The Clinical Nurse Leader (CNL) role is a relatively new role in nursing. The CNL was first conceptualized in 2005 by the American Association of Colleges of Nursing (AACN) along with the Institute of Medicine (IOM; now National Academy of Medicine) with an aim to improve quality of health care while controlling costs.1–3 The AACN sees the CNL as a team leader at the microsystem level who incorporates knowledge about the organization and the environment into bedside care delivery. Because the CNL is relatively new, there is a lack of formal tracking of certified CNLs over time.4 This article describes a follow-up study of CNL graduates.
The CNL is prepared at the master's level as an advanced generalist nurse who provides and leads care at the point of care to individuals and groups or populations in all settings in which health care is delivered. The complexity of health care systems today demands an increased focus on improving outcomes with knowledge of quality measures and safety assessment. The CNL oversees the lateral integration of care for a distinct group of patients and may actively provide direct patient care in complex situations. The CNL puts evidence-based practice into action to ensure that patients benefit from the latest innovations in care delivery. The CNL collects and evaluates patient outcomes, assesses cohort risk, and has the decision-making authority to change care plans when necessary. This clinician functions as part of an interprofessional team by communicating, planning, and implementing care directly with other health care professionals, including physicians, pharmacists, social workers, clinical nurse specialists, and nurse practitioners.5
The CNL is a new type of nurse that has become increasingly popular. Currently over 8000 nurses have earned CNL certification. In 2007, there were only 379 certified CNLs, and 10 years later there were up to 6199 CNLs.6 This growth has been fueled by an associated growth in CNL programs offered at schools of nursing. There are currently over 100 CNL programs available across the United States. These programs offer several models and different entry points for the CNL. The majority of CNL nursing programs are direct-entry or second-degree programs designed for those with degrees in other fields interested in becoming nurses, but there are also CNL programs designed for experienced nurses, those with associate degree in nursing (ADN) and bachelor of science in nursing (BSN) degrees, to earn a master's degree in nursing with a focus on quality and safety.
Currently, most programs track benchmarks and end-of-program evaluation data such as graduation rates, initial employment data, National Council Licensure Examination (NCLEX) pass rates, CNL certification pass rates, end-of program student surveys, and initial employment information. A review of the literature revealed several studies that have been conducted exploring the CNL role and transition into practice; however, sample sizes are often small,7,8 are limited to the first few years after graduation,8 are focused only on CNL certified nurses,9 or use primarily qualitative methods.8,10 Thus there are still gaps in available knowledge.
The aim of this study was to describe the transition experience of CNLs 2 to 10 years after graduation to assess career trajectory, and explore self-reported satisfaction with work, life, and educational preparation as well as to solicit suggestions for improvement.
This descriptive study used a cross-sectional survey design. To assess the success of graduates and describe their career path, the research team conducted an online survey of 109 CNL alumni from one university's classes of 2007 to 2017.
Setting and sample
In 2005, the university developed its CNL generalist master's curriculum for students with baccalaureate degrees in other fields and graduated the first cohort in 2007. This CNL program was among the first in the country; it was the first in the Commonwealth and the only program in Virginia to offer Model C (master's program designed for individuals with a baccalaureate degree in another discipline). The program has since added Model A (master's program designed for BSN graduates) and Model D (master's program designed for ADN graduates with a baccalaureate degree in another field). At the completion of the program, students are eligible to sit for the national CNL certification examination.
The program is an accelerated full-time, 24-month program that leads to a master of science in nursing (MSN). Core courses are required in pathophysiology, pharmacology, and physical assessment, as well as leadership courses in care environment management, ethics, and research (75 total credits). A full complement of clinical courses and clinical experiences are offered primarily in 1:1 preceptorships as well as some small group experiences with a full range of patient populations (pediatric, adult, and geriatric), illnesses (chronic and acute), and environments (inpatient, intensive care, outpatient, and transition-to-home care) and can include global opportunities. This CNL program has over 400 alumni since the first class graduated in 2007.
The sample pool was derived from a contact list obtained from the nursing alumni office. Participants included alumni from across the United States. Eligible participants graduating from 2007 to 2017, with a known email address, were sent an email invitation between January to February 2020 with a password-protected link to the online survey. One email reminder was sent a week after the initial invitation. The response rate for the survey was 35%; 109 CNL graduates completed the survey out of 314 invited to participate (304 active email addresses). Typical response rates to online surveys range from 20% to 30%.11 Because this was a convenience sample based on those who read their email and agreed to participate, no estimates of theoretical sampling error can be calculated.
Data were collected through a custom-designed online survey that could be completed in 5 to 30 minutes with minimum participant burden. Questions were developed based on a review of previous research, reviewed for face validity by a panel of experts, pilot tested, and refined. University institutional review board review and approval was received, and this survey was designated as exempt. Participation was voluntary, and respondents had the option to skip any questions. The survey consisted of 30 items that included basic demographic information, questions about career as well as graduates' satisfaction with educational preparation, and measures of satisfaction with life. A few open-ended items were included. Demographic information included age and gender. Career information included queries about their first job, their current job, salary range, location, and job responsibilities. They were asked whether they were still practicing as a nurse, full- or part-time, and about any additional degrees, education, or certifications earned after completing the CNL program. They were also asked about student loan debt.
Several measures of satisfaction were used. Satisfaction with life was measured with the 5-item Satisfaction with Life Scale (SWLS).12 The SWLS is designed to measure a person's global self-assessment of life satisfaction. Scores range from 5 to 35. It is a well-established, valid, and reliable instrument. Cronbach's α coefficients have been reported at 0.79 to 0.89.13
Overall satisfaction with the decision to become a nurse was measured with 1 item (5-point Likert scale from very dissatisfied to very satisfied) along with an open-ended follow-up question. Satisfaction with educational preparation was measured with 1 item (a 5-point Likert scale; agree-disagree). CNL graduates were asked to respond to the statement, “My education prepared me well for my career.” Open-ended follow-up questions allowed for comments and suggestions.
The Net Promoter Score (NPS) was also used to assess satisfaction with educational preparation. The NPS measures willingness to recommend a product or service to others. The NPS measures overall satisfaction and loyalty to the brand and can be a leading indicator for growth. On this single item, respondents were asked: on a scale of 0 to 10, how likely are you to recommend this CNL program to a friend or colleague, followed by an open-ended question, why? Ratings can be divided into 3 categories: promoters (9 or 10 rating), passives (7 or 8 rating), and detractors (0-6 rating).14
Statistical analysis was performed using Statistical Package for the Social Sciences software (SPSS Statistics for Windows, Version 27, Armonk, New York: IBM Corp). Descriptive statistics were used to describe the demographic characteristics and career trajectory of participants. Additional psychometric analysis was conducted on applicable survey items. For qualitative data and text answers to open-ended questions, a basic content analysis was conducted. Flexible coding was used. Phrases were identified and hand-coded by each researcher. Categories, general trends, and common patterns were identified, shared with the team, and discussed until agreement was reached. Then content was reanalyzed to reassess the coding scheme and to identify any missed text.15
There were 109 respondents in this survey. Demographics and characteristics are displayed in the Supplemental Digital Content Table (available at: https://links.lww.com/JNCQ/A966). The current age of respondents ranged from 26 to 64 years (mean = 37, SD = 8.23). Most (76%) identified as female, 22% male, 2% transgender or other. Years since graduation ranged 2 to 10 years (mean = 7.18, SD = 2.95). The majority of respondents were from the classes of 2013 to 2016, approximately 4 to 7 years post-graduation.
Educational background, career trajectory, and life satisfaction
The majority (40%) of these CNL students left a full-time career to begin nursing school; 33% were recent college graduates when they entered the CNL program. Prior degrees and work experience varied widely: patient care assistant, emergency medical technician, teacher, carpenter, statistician, Chaplin, legal assistant, sales manager, research assistant, and more.
Many of the graduates (36%) became CNL certified after graduation, and over 90% held some kind of specialty certification. A large percentage (38%) have gone on to earn additional degrees after completing the CNL program (NP, DNP, PhD, nurse anesthetist, and DrPh). When asked about student loan debt, many (23%) reported less than $5000 in student debt upon graduation; however, approximately 50% had over $30 000 and up to $90 000 in student debt.
To begin to describe their career trajectory, the survey asked about their first job after graduation. Most described their entry role as a bedside RN or entry-level clinician, in a variety of settings. The Model A or D RN-CNL graduates with nursing experience (n = 9) often went on to a variety of different roles after graduation (clinical faculty, manager, coordinator, etc). A full 30% reported that they are still working at their first employer at 2 to 10 years after graduation. Another 40% worked at their first employer for 1 to 2 years and then moved on to another job.
Current work setting, roles, and responsibilities
The overwhelming majority (95%) are still working full- or part-time in nursing. While these graduates are now spread around the country, the majority are working in Virginia, Texas, and California (see the Supplemental Digital Content Figure, available at: https://links.lww.com/JNCQ/A967). Over 30% were still working at the same hospital where they had many of their clinical rotations as a student. Most of these CNLs are still at the bedside in a variety of roles. Several unique roles were mentioned: Director of Nursing Education, Well-Being Officer, and Research Coordinator for study of drug resistant tuberculosis in South Africa.
Salary and career satisfaction
The majority of respondents (61%) reported an annual income between $50 000 and $100 000. Another 10% reported an annual income over $125 000. Career satisfaction was high (mean = 4.3, SD = 0.84). When asked about satisfaction with the decision to become a nurse, the overwhelming majority (over 90%) were satisfied or extremely satisfied with their decision to become a nurse; only 6% were dissatisfied. Many positive themes were noted in participant comments: “Being a nurse and being able to care for patients and their families, is a great honor. Nursing is a great field, not only because it is rewarding, but also due to the flexible schedule, opportunities for advancement, and wide variety of career paths.” Another participant noted: “This is the most gratifying job/career I can imagine. Even though there are quite stressful moments (or entire shifts), my job and all of its finite details have great meaning. No two days are alike. I love the moment-by-moment critical thinking, working with a team, helping colleagues.”
However, some negative themes were also noted: “The demands on nurses in our health care system continue to increase (a do more with less mentality) which causes moral distress when you cannot properly care for your patient. It is also physically and mentally exhausting to be a bedside RN.” Another common theme related to the lack of designated CNL roles: “I wish more hospital systems, especially in the south, had CNL roles, so I recommend reaching out to more health systems to advocate for the role.”
Satisfaction with educational preparation
The overwhelming majority (89%) were satisfied or extremely satisfied with their educational preparation. The NPS ranged from 4 to 10 with a mean of 8.14 (SD = 1.5). Most respondents scored as promoters; some were neutral or passive; and approximately 10% scored as detractors in relation to recommending the CNL program to others. Open-ended responses after the NPS score revealed several themes: volume of clinical hours, including the benefits of the 1:1 preceptorship model; development of critical thinking and problem-solving skills; focus on evidence-based practice, systems thinking, and change management; and the ability to assess, think, and evaluate. Many responses highlighted themes related to leadership and problem-solving: “The CNL program taught me how to recognize and appreciate excellent leadership.” Being able to see the big picture was another theme: “Understanding how hospital systems work—it has a bigger impact on day-to-day life as a nurse than we'd like to admit.” Many participants reflected on their education in a positive way: “I didn't appreciate the CNL courses as much as I should have at the time. The approach to data analysis and problem-solving is something I use and enjoy the most about my career as a nurse.”
Suggestions for improvement from graduates
Relatively few shortcomings were outlined (there were only 11 total responses to this question, compared with 55 earlier). Important themes included not using the CNL specialty in their current role, the minimal number of dedicated CNL positions at some hospital systems, and the overall cost of the program plus related expenses resulting in burdensome student loans.
The SWLS scores from these CNL respondents ranged from 14 to 31, with a mean of 24.9 (SD = 5.67). The highest possible score on the SWLS is 35. The majority (82%) reported currently being satisfied or extremely satisfied with their lives; 2 respondents were not satisfied.
This survey provides detailed information about one school's cohort of CNL graduates 2 to 10 years after graduation. The aim was to describe the transition experience and career trajectory and satisfaction with work, life, and educational preparation. Overall, these graduates were happy, successful, and satisfied with their decision to become a nurse. These data were collected just prior to the COVID-19 pandemic. The health care and nursing context has changed considerably since then, but these data provide a prepandemic baseline.
At the time of this survey, the average nursing salary was $75 510 per year, with a range of $58 000 to $106 000/year.16,17 This is in line with the survey findings. Of note, the CNL graduates seemed to gravitate to areas in the northeast and west with higher nursing salaries. National data suggest that some of the highest concentration of CNLs are working in California and Texas.6
The majority of the respondents stayed with their first employer at least 2 to 5 years, and many were still working with their first employer suggesting a strong retention rate. The national average new graduate RN turnover has been reported at 23.9% to 26.8%; the turnover costs to hospitals range from $20 561 to $67 100 per nurse.18–20
Most of these CNL graduates were working at the bedside, but few were in identified CNL roles. This lack of CNL designated roles has been noted in other studies8,9,21–23 A large percentage of these respondents continued their education and were in advanced practice, nurse practitioner, and educator roles. These findings are similar to those of Clavo-Hall et al.22,23 We also noted low CNL certification rates among these survey respondents. The addition of more CNL-designated roles and employer-provided incentives might encourage more CNL education, certification, and retention in CNL roles.
Satisfaction with Life Scale scores in this sample were high. According to Diener et al24 most people in the high scoring range (25-39) find life enjoyable and state that work, family, friends, leisure, and personal development are going well. The SWLS scores in this sample were slightly higher than those found in other studies of nurses.25,26 This may reflect the strong focus on resilience, healthy work environment, and self-care at this school.27,28
Soliciting survey data and qualitative feedback about the student experience helped us generate recommendations for potential enhancements moving forward. Respondents reported high satisfaction with their educational preparation and these graduates recognized they had a strong foundation that helped launch them into their nursing career. They also appreciated the CNL capstone project, and the relationship with faculty throughout the program, as well as the consistent focus on systems level thinking and evidence-based practice.
These respondents reported challenges experienced in the program and the survey responses highlighted several opportunities for improvement. As is the case in higher education, financial concerns remain an issue for students. This has been reported in other studies of CNL graduates.8 More opportunities for financial assistance are clearly needed. Part-time study has come up as a possibility to address financial concerns and to make the program more accessible for nontraditional students, including a growing student-parent population. In addition, policies to support graduate education tuition assistance and loan forgiveness could help rebuild the nursing workforce post-pandemic. Student loan repayment may also be a valuable recruitment tool for hospitals trying to attract CNLs and other types of nurses.
This was a single survey in time, and there is potential for self-report, social desirability, and other types of bias. Results may not be representative of the full population or generalizable beyond the respondents. However, this survey could serve as a pilot for future longitudinal studies with larger samples and could be a potential model for other schools or organizations. The Commission on Nurse Certification surveys CNLs around the country, but additional research in other samples across different schools and programs could add to that initial data. More qualitative data could also add richness and depth to the existing survey results.
More CNL designated roles are clearly needed to allow these graduates to practice to their fullest potential. This initial data can be leveraged to help educate health systems to the opportunities to optimize outcomes with CNL-prepared graduates in quality, safety, and systems thinking. Hospital systems may find that hiring these CNL graduates is a good investment because based on these survey results, their retention rates appear high, and they are able to take on leadership roles fairly quickly. Providing clinical sites, preceptors, and tuition assistance for CNL students may serve as valuable recruitment strategies for hospital systems across the country.
This work has implications not only for this program but also for CNL education and for nursing practice overall. These findings add to the body of knowledge about the CNL role and overall understanding of the CNL initiative. The findings may be of particular interest for current and prospective students, educators, accrediting bodies, policy makers, and employers as well as current and future donors and funding agencies. More information is clearly needed, but sharing this preliminary data is helpful in building the business case for CNLs.
1. American Association of Colleges of Nursing. White paper on the education and role of the clinical nurse leader. Published 2007. Accessed March 12, 2020. http://www.aacn.nche.edu/publications/white-papers/ClinicalNurseLeader.pdf
2. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (US); 2001.
3. Institute of Medicine (US) Committee on the Health Professions Education Summit, Greiner AC, Knebel E, eds. Health Professions Education: A Bridge to Quality. National Academies Press (US); 2003.
4. Bender M, Holmes D. Reconciling nursing's art and science dualism: toward a processual logic of nursing. Nurs Inq. 2019;26(3):e12293. doi:10.1111/nin.12293
5. American Association of Colleges of Nursing. Working Statement Comparing the Clinical Nurse Leader and Clinical Nurse Specialist Roles: Similarities, Differences and Complementarities. Published 2004. Accessed March 12, 2020. https://ons.confex.com/ons/2018/mediafile/ExtendedAbstract/Session1615/CNL%20vs%20CNS%20ComparisonTable.pdf
6. American Association of Colleges of Nursing. CNC annual report: transform, lead, experience! Published 2020. Accessed September 6, 2021. https://www.aacnnursing.org/Portals/42/CNC/CNC-Annual-Report-FY2020.pdf
7. Shatto B, Meyer G, Delicath TA. The transition to practice of Direct Entry Clinical Nurse Leader graduates. Nurse Educ Pract. 2016;19:97–103. doi:10.1016/j.nepr.2016.05.008
8. Shatto B, L'Ecuyer K, Meyer G, Shagavah A, Mooney E. Experiences of master's prepared clinical nurse leaders at three years post-graduation. J Prof Nurs. 2019;35(1):51–56. doi:10.1016/j.profnurse.2018.06.001
9. Gilmartin MJ. Variations in clinical nurse leaders' confidence with performing the core role functions. J Prof Nurs. 2014;30(4):307–316. doi:10.1016/j.profnurs.2013.11.002
10. Bombard E, Chapman K, Doyle M, Wright DK, Shippee-Rice RV, Kasik DR. Answering the question, “what is a clinical nurse leader?”: transition experience of four direct-entry master's students. J Prof Nurs. 2010;26(6):332–340. doi:10.1016/j.profnurs.2010.04.001
11. Dillman D, Smyth J, Christian L. Internet, Mail, and Mixed-Mode Surveys. Wiley; 2009.
12. Diener E, Emmons RA, Larsen RJ, Griffin S. The Satisfaction
With Life Scale. J Pers Assess. 1985;49(1):71–75. doi:10.1207/s15327752jpa4901_13
13. Pavot W, Diener E. Review of the Satisfaction
With Life Scale. Psychol Assess. 1993;5(2):164–172. doi:10.1037/1040-3518.104.22.168
14. Reichheld F, Markey R. The Ultimate Question 2.0. Harvard Business Review Press; 2011.
15. Krippendorff K. Content Analysis: An Introduction to Its Methodology. 3rd ed. Sage Publications; 2018.
16. Forbes. Here's How Much Nurses Make in Every State. Published 2019. Accessed September 6, 2021. https://www.forbes.com/sites/andrewdepietro/2019/10/31/nurses-salary-state/?sh=50fd8115215a
17. US Bureau of Labor Statistics. Occupational outlook handbook: registered nurses. Published 2020. Accessed September 6, 2021. https://www.bls.gov/ooh/healthcare/registered-nurses.htm
18. NSI Nursing Solutions, Inc. NSI national health care retention & RN staffing report. Published 2021. Accessed February 26, 2022. https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf
19. Li Y, Jones CB. A literature review of nursing turnover costs. J Nurs Man. 2013;21(3):405–418. doi:10.1111/j.1365-2834.2012.01411.x
20. Meyer GC, Shatto BC. The clinical nurse leader and the gritty environment. J Nurs Care Qual. 2022;37(2):101–102. doi:10.1097/NCQ.0000000000000598
21. Bender M, Williams M, Su W. Diffusion of nurse-led healthcare innovation: describing certified clinical nurse leader integration into care delivery. J Nurs Adm. 2016;46(7/8):400–407. doi:10.1097/NNA.0000000000000365
22. Clavo-Hall JA, Bender M, Harvath TA. Roles enacted by clinical nurse leaders across the healthcare spectrum: a systematic literature review. J Prof Nurs. 2018;34(4):259–268. doi:10.1016/j.profnurs.2017.11.007
23. Commission on Nurse Certification. Clinical nurse leader CNL 2016 job analysis. Published 2016. Accessed September 6, 2021. https://www.aacnnursing.org/Portals/42/CNL/2016-CNL-Job-Analysis-Final-Report.pdf
24. Diener E, Tamir M, Scollon CN. Happiness, life satisfaction
, and fulfillment: the social psychology of subjective well-being. In: VanLange PAM, ed. Bridging Social Psychology: Benefits of Transdisciplinary Approaches. Lawrence Erlbaum Associates Publishers; 2006:319–324.
25. Uchmanowicz I, Witczak I, Rypicz Ł, et al. A new approach to the prevention of nursing care rationing: cross-sectional study on positive orientation. J Nurs Manag. 2021;29(2):317–325. doi:10.1111/jonm.13156
26. Zakeri MA, Hossini Rafsanjanipoor SM, Zakeri M, Dehghan M. The relationship between frontline nurses' psychosocial status, satisfaction
with life and resilience during the prevalence of COVID-19 disease. Nurs Open. 2021;8(4):1829–1839. doi:10.1002/nop2.832
27. Fontaine DK, Koh EH, Carroll T. Promoting a healthy workplace for nursing faculty and staff. Nurs Clin North Am. 2012;47(4):557–566. doi:10.1016/j.cnur.2012.07.008
28. Harmon RB, DeGennaro G, Norling M, Kennedy C, Fontaine D. Implementing healthy work environment standards in an academic workplace: an update. J Prof Nurs. 2018;34(1):20–24. doi:10.1016/j.profnurs.2017.06.001