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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000366046.89571.24
AJN Reports

The Clinical Nurse Leader

Nelson, Roxanne BSN, RN

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An update on the controversial nursing role.

In 2003, the American Association of Colleges of Nursing (AACN) declared its intention to develop "a new nursing professional with generalist practice"—the clinical nurse leader (CNL). When AJN first reported on the new role (AJN Reports, December 2005), opinions on whether the CNL was needed varied.

Now, seven years after the AACN's declaration, the first graduates of the CNL pilot programs have been in the workforce and the project has grown to include more than 100 universities and more than 200 participating clinical sites.

"One institutionally based report shows that we now have 732 graduates of CNL or postmaster's programs," says Joan Stanley, PhD, RN, CRNP, the AACN's senior director of education policy. And according to an annual survey that was completed in August 2008, there are now 1,650 students enrolled in CNL programs nationwide.

What is a CNL? The CNL is the first new nursing leadership role to be introduced in decades, and according to the AACN's definition (, the master's degree–prepared CNL "designs, implements, and evaluates client care by coordinating, delegating, and supervising the care provided by the health care team, including licensed nurses, technicians, and other health professionals." The CNL should ideally be prepared for clinical leadership in all types of health care settings and to manage "microsystems of care"—small groups of clinicians who regularly work together with specific populations. But as with anything brand new, putting the theory into practice is fraught with challenges, and there are inevitably growing pains.

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Acceptance of the CNL is still uneven. Although some leaders, organizations, and institutions have enthusiastically accepted the CNL, others remain unconvinced.

Embracing the CNL. According to Stanley, the Veterans Affairs (VA) facilities have, by and large, embraced the initiative and are actively recruiting CNLs into practice. "The VA hopes to implement the CNL across all settings by 2014," she says. "They've been employing CNLs for several years now, including some of the earliest graduates, and the numbers are growing."

Dan O'Neal, GCNS-BC, CNL, an evidence-based practice specialist at the James A. Haley Veterans' Hospital in Tampa, Florida, said of CNLs, "We can't hire them fast enough. We plan to place them in all outpatient and inpatient settings. We find that CNLs are very good at working collaboratively and reliably with other groups and can put evidence together to design a care map."

"It's difficult to predict how quickly the role will grow," Stanley adds, "but we have institutions that are interested and that are exploring the use of CNLs."

Indeed, other facilities have begun using them, particularly those CNLs who participated in the pilot project. At Maine Medical Center in Portland, there are currently eight certified CNLs working on units right now, and four others who are enrolled in a CNL program will be employed when they complete their degrees. "We'll have a CNL on almost every unit at our hospital when the four nurses finish the program," says Nina Swan, MSN, RN, CNL, a graduate of the pilot program in 2007 who works on the hospital's cardiology unit.

Skeptics abound. Some leaders remain unconvinced that the CNL is needed at this time. In the March 2005 issue of the Journal of Nursing Education, Marianne Ditomassi, MSN, MBA, RN, executive director of Patient Care Services Operations at Massachusetts General Hospital, coauthored an editorial expressing concern about overlap between the role of the CNL and that of the clinical nurse specialist (CNS). Almost five years later, Ditomassi remains unconvinced that the creation of the CNL is the right strategy for advancing the profession of nursing.

"From the vantage point of a model agency for the role of CNS," says Ditomassi, "I have yet to see evidence that the CNL and the CNS are anything but redundant, in terms of existing clinical and administrative roles; if the CNL role is implemented, it can contribute to further role confusion and conflict within the discipline."

The National Association of Clinical Nurse Specialists (NACNS) issued a position paper in 2004, stating that "the proposed competencies of the new nurse [the CNL] duplicate the competencies of the CNS" and maintaining that such changes would only serve to disenfranchise the CNS. In an updated version of the paper issued a year later, many of those concerns remained.

The NACNS hasn't officially updated its position statement on the issue, according to the organization's chief executive officer, Christine Carson Filipovich MSN, RN, because the NACNS hasn't conducted any research on the CNL. "In some locations," she says, "there continues to be concern about a role that can be perceived as similar to or even overlapping the CNS role. There's evidence that there are clear differences between the two roles, but the concern is how things unfold at a local level."

Melanie Duffy, MSN, RN, CCRN, CCNS, a critical care CNS at PinnacleHealth System in Harrisburg, Pennsylvania, and president of the NACNS, agreed that there's still some concern over the duplication of roles. She also notes that so far, the use of CNLs appears to be limited. "In my area, we're not seeing them at all," she says. "We're still not seeing that much of a demand."

Working together. Although Stanley acknowledges that there are still concerns about the two roles, she believes that they're surmountable. "I think there's still discussion at the national level, but at the local level they're working together," she says. "The roles complement one another, and I haven't heard of any real problems."

At the Portland, Oregon, VA Medical Center, Kelly Goudreau, DSN, RN, CNS, says that even though there's a potential for conflict and confusion, the center has worked out a system in which the two roles complement each other. "The CNS works on systems-level problems within a specialty, while the CNL is unit based," she says. "There are clear distinctions between the two roles, at least at our facility, but we don't see that happening yet throughout the VA. We're hoping that it will."

Marylou Nesbitt, APRN-BC, AOCN, an oncology CNS at Maine Medical Center, also finds the two roles to be collaborative. "We've had CNS's for more than 30 years," she says. "The CNL role is evolving, but there's good synergy between the two. Role clarity is a common topic for us. Initially the CNS and CNL groups met monthly to provide mutual support, and now they meet quarterly. This ongoing communication has resulted in clear role delineation and a strong sense of collegiality."

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One of the primary reasons for developing the CNL role was to improve the quality of patient care. Stanley says that there are plans to conduct an aggregate study but that, until then, they're looking at individual hospitals and comparing data from year to year. She says that although comprehensive data haven't yet been released, preliminary research has been encouraging.

"Hospitals employing CNLs have reported improvements in core CMS [Centers for Medicare and Medicaid Services] measures, such as decreases in the numbers of falls and pressure ulcers," she says. "There's also greater RN and physician satisfaction."

RN retention is also improving, according to Stanley. "Many RNs were burned out and wanted to leave, but having the CNL is empowering them and helping them address the issues they didn't have the time or energy for," she says. "The CNL is helping to put innovation and changes in place and to address care quality and patient safety."

Roxanne Nelson, BSN, RN

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