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Original Articles

Implementation of the Clinical Nurse Leader Role in the Veterans Health Administration

Miltner, Rebecca S. PhD, RN, CNL, NEA-BC; Haddock, Kathlyn Sue PhD, RN, FAAN; Patrician, Patricia A. PhD, RN, FAAN; Williams, Marjory PhD, RN, NEA-BC

Author Information
doi: 10.1097/NAQ.0000000000000428

Abstract

THE AMERICAN ASSOCIATION of Colleges of Nursing, in partnership with stakeholders across a variety of health care organizations including the Veterans Health Administration (VHA), developed the Clinical Nurse Leader (CNL) role to meet the system needs for strong clinical leadership across all settings prepared to implement evidence-based practice and quality improvement strategies within a microsystem of care.1 The VHA led implementation of the CNL role nationally.2 The stated goals were to improve cost/financial outcomes (length of stay, patient flow, readmissions, and registered nurse [RN] turnover), increase patient satisfaction, increase staff satisfaction and retention, improve quality and internal processes (medication management, patient safety, and hospital-acquired infections), and facilitate practice model transformation including evidence-based practice and collaborative, interdisciplinary practice.3,4

After a decade of CNL role implementation, the VHA supported this evaluation to determine the current state, the successes, the challenges, and the fidelity to the original intent of the role. The authors used the Centers for Disease Control and Prevention Framework for Program Evaluation to engage various stakeholders and review information about the current state of the CNL initiative within the VHA.5 Preliminary conversations with stakeholders at various levels suggested large variation in the role implementation across facilities, as well as varying levels of satisfaction with how the role was utilized in the facility. These initial interviews with stakeholders indicated the lack of a shared mental model of the CNL role by nursing staff, CNLs, managers, and executive leaders that complicated the evaluation process. To address this confusion, the evaluation team decided to use the fundamental aspects of CNL practice as outlined by the Competencies and Curricular Expectations for CNL Education and Practice1 as the standard to guide the evaluation of CNL practice in the VHA.

EVALUATION PLAN

A logic model was created to focus this complex evaluation (Figure 1) and identify key data sources for the evaluation design (see Supplemental Material 1, available at: http://links.lww.com/NAQ/A3). The CNL Initiative is a multilevel program with inputs, activities, and outcomes at the VHA level, at the local facility level, and at the nursing unit level. Theorized possible elements of each of these components at each level are detailed in Supplemental Material 2 (available at: http://links.lww.com/NAQ/A4). Inputs are generally the structural components of the CNL program and include strategic and operational plans, leadership support, and resource allocation at the VHA and facility levels as well as the leadership support and availability of qualified CNLs at the unit level. There are a variety of activities at all levels of the organization needed to develop, support, and sustain the program. These activities include communication of goals and objectives, management (human resources) processes, partnerships with internal and external groups, and ongoing evaluation. At the unit level where the CNL is embedded, the activities consist primarily of CNL role activities.

Figure 1.
Figure 1.:
CNL operational logic model with evaluation components.

Finally, incorporating the CNL role into care delivery at the unit level is reported to improve a range of outcomes including patient experience, quality-of-care measures (falls, pressure ulcers, etc), and staff satisfaction.2,6–9 Other nursing leadership transformation outcomes may include increased staff engagement, evidence-based interventions and practices, and improved interprofessional teamwork and collaboration. The VHA system inputs and activities drive the facility inputs and activities, which, in turn, drive the unit-level inputs and activities. Patient- and nurse-sensitive outcomes arise from unit activities and may be aggregated at the facility and system levels. There may be other outcomes important to the organization at the facility and system levels such as practice transformation and recognized expertise.

The team used mixed methods to evaluate the state of the CNL initiative, including effectiveness of the role. There were 10 proposed evaluation activities. Qualitative data from early interviews and the fundamental aspects of CNL practice1 were used to develop and field 2 key informant surveys. One survey, the Facility Gap Analysis, was directed toward chief nurse executives (CNEs) at all VHA facilities. In addition, CNEs were asked about current and future operational plans related to CNL implementation at their facility. The second survey, the CNL Survey, was directed at VHA RNs who completed a CNL graduate program, were certified as a CNL, or were currently enrolled in a CNL graduate program. This survey also included demographic and educational preparation questions as well as some open-ended questions about outcomes and projects.

Invitations to participate in the Facility Gap Analysis Survey were sent through the REDCap survey application to VHA nurse leaders identified through the national Nurse Executive e-mail group. A total of 102 facility responses were received from the 142 facilities solicited. Three of these responding facilities were smaller units of a larger health care system and not included in the usual 142 facilities. These were added to our list for a total of 145 facilities. The final facility response rate was 70.3% (102/145).

Similarly, invitations to participate in the CNL Survey were sent to a total of 561 VHA nurses identified as having CNL education and/or certification or graduate students in CNL programs. CNLs were identified from the Fall 2014 CNL Directory list as well as identified by other survey participants. A total of 284 surveys were returned for a 50.6% response rate.

The qualitative evaluation activities included semistructured interviews of CNLs, facility nursing leaders, and national leaders associated with the CNL program. Phone interviews were recorded and transcribed. The CNL listserv e-mail traffic for 6 months was examined as well as the job postings for CNL positions in USAJobs.gov for 4 months. Information was recorded about dedicated educational funds (Veterans Affairs National Education for Employees Program-CNL [VANEEP-CNL]) provided over the last 4 fiscal years. We also completed 5 visits to sites with CNLs in place and traveled to the 2015 CNL Summit in Orlando, Florida. The purpose of these site visits was to use comparative case study methods (eg, interviews of key personnel, clinical observations, and local project and data review) to supplement the Facility Gap Analysis and the CNL Survey data. Finally, we compiled nursing-sensitive indicators at the facility level including nursing work environment (practice environment scale), patient experience/satisfaction, nurse turnover, pressure injury (hospital-acquired pressure injury of 2+ or greater), and hospital-acquired infection rates. Large qualitative and quantitative datasets were generated from these evaluation activities.

RESULTS

Facility gap analysis survey (nurse leader respondents)

Sixty-nine (67.6%) of the nurse leaders reported designated CNLs in their facility. These nurse leaders reported a total of 244.5 CNL positions in the facilities with 143 filled (58.5%) and 71 vacant (29%). They also reported that 34 (13.9%) of the positions were filled by nurses who were not certified as CNLs.

Nurse leaders specifically listed 234 positions by service area. These positions were predominantly in acute care services, but 53 were in outpatient areas or long-term care settings called community living centers (Table 1). Nurse leaders were asked about facilitators for CNL implementation at their facility. The most common facilitators were nursing leadership support and unit leadership support. Senior facility leadership was mentioned by 46% of respondents (Figure 2).

Figure 2.
Figure 2.:
Facilitators to CNL implementation.
Table 1. - Current and Planned Expansion of CNL Positions Reported by Facility Nurse Leaders (CNEs)
Service Group Number of Current CNL Positions (% Reported) Planned Expansion (% Reported)
Acute care 158 (67.5%) 104 (48.6%)
Community living center 33 (14.1%) 35 (16.4%)
Outpatient care 20 (8.6%) 41 (19.2%)
Other (ED, Perioperative, spinal cord injury) 23 (9.8%) 34 (15.9%)
Abbreviations: CNL, Clinical Nurse Leader; ED, emergency department.

Table 2. - Service Group of Primary Work Area(s)a
Service Group All Respondents n (%) Working as CNL n (%)
Acute care (medical, surgical, ICU) 148 (50.5) 69 (65.7)
Emergency department, perioperative, spinal cord injury 30 (10.2) 12 (11.4)
Community living center 33 (11.3) 20 (19.1)
Outpatient care 82 (28.0) 9 (8.6)
Abbreviations: CNL, Clinical Nurse Leader; ICU, intensive care unit.
aAll respondents are more than 284, as some respondents identified multiple work areas. Working as CNL is more than 105, as some respondents identified multiple work areas.

Barriers to CNL implementation were also identified. Over half of the respondents reported that insufficient budgeted positions full-time equivalent employee (54.9%) and a limited supply of CNLs in the local area (53.9%) were barriers to implementation (Figure 3). In some of our initial conversations with stakeholders, CNL retention was a problem expressed by CNLs, nurse executives, and national leaders. In the Facility Gap Analysis Survey, 34 (33.3%) nurse leaders reported CNLs leaving designated positions in the last 2 years, with a total of 67 losses. The primary reason for leaving the CNL position was promotion (37.3%), followed by inadequate fit for the positon (19.4%). Another 23.9% left the facility and/or the VHA for unknown reasons.

Figure 3.
Figure 3.:
Barriers to CNL implementation.

CNL survey

Most CNL survey respondents (73.4%) were certified through the Commission on Nurse Certification as a CNL. Most of the remaining respondents were students enrolled in CNL programs who were not yet eligible for certification. Nurse participants reported their current roles as CNL (37%), Staff Nurse (22.9%) and other (e.g. educator, charge nurse, quality or safety role) (27.8%). Most reported working in acute care settings (Table 2).

There were no system wide outcomes identified for CNL practice focus, so outcomes were chosen by individual CNLs and/or their local organization leaders. The most common outcome measure was falls (74.3%), followed by hospital-acquired infections (64.7%), pressure injury (63.8%), and patient satisfaction (58.1%). Other reported outcomes included restraints and clinic-specific measures.

Lack of orientation was reported by many of the stakeholders in the first phase of the evaluation. Nurse executives reported orientation elements were general nursing orientation (59.8%) and staff nurse orientation (49%) followed by shadowing another CNL at the facility (43.1%), training modules (32.4%), and shadowing a CNL at another facility (16.7%). In CNL interviews and during site visits, very few CNLs reported structured orientation processes specific to the CNL role. In the CNL Survey, CNLs were asked an open-ended question about their orientation. Their responses were coded as no orientation, unstructured, or formal orientation. The majority reported unstructured (46.7%) or no formal orientation (38.1%).

CNL work functions

One key component of the evaluation plan was to understand the mental model(s) concerning CNL practice. Both nurse leaders and CNLs were asked about role functions in their respective surveys. Both groups rated clinical leadership at the point of care and team leadership as the most common role functions (Table 3). At the other end, both groups rated staff nurse duties and management duties as less common functions. Both groups rated staff education as the first or second most common role function.

Table 3. - CNL Role Functions
CNE Rankings of CNL Work—Rate the Frequency That the following Work Functions Are Performed for the Typical CNL Practicing in Your Facility Role Function Reporting Common/Most Frequent CNL Rankings of CNL Work—How Much Time Did You Spend in Each of the Following? Role Function Report ≥25% of Time
Staff educationa 86.2% Clinical leadership at the point of care 59.3%
Clinical leadership at the point of care 81.8% Staff educationa 48.6%
Nursing team leader 81.5% Interprofessional team leader 40.8%
Evidence-based practice work 78.1% Nursing team leader 38.8%
Advocacy 76.5% Identification and collection of care outcomes 33.0%
Interprofessional team leader 75.3% System-level worka 33.0%
Risk anticipation 66.2% Care coordination 32.0%
Identification and collection of care outcomes 64.6% Advocacy 31.7%
Improve quality and safety 63.6% Evidence-based practice work 31.1%
Care coordination 60.0% Improve quality and safety 30.1%
System-level worka 53.9% Risk anticipation 24.3%
Information management 46.9% Information management 18.4%
Resource stewardship 36.0% Resource stewardship 16.6%
Staff RN assignmenta 12.3% Management dutiesa 15.6%
Management dutiesa 4.6% Staff RN assignmenta 10.7%
Abbreviations: CNL, Clinical Nurse Leader; RN, registered nurse.
aThese role functions are not identified by the AACN1 as fundamental aspects of the CNL role.

Job description analysis

Sixteen jobs posted on USAJobs.gov for CNLs from September to December 2014. Facilities in 13 states posted CNL positions (Arizona, California, Florida, Illinois, Kansas, Massachusetts, Michigan, Missouri, North Carolina, New Hampshire, Oklahoma, Tennessee, and Texas). Positions were posted for a range of units/patient populations including acute care (medical/surgical and ICU), mental health, emergency department, spinal cord injury, and hospice. Analysis of the postings showed a wide variation in the wording of the job description. The only component of the 10 fundamental aspects of the CNL role consistently mentioned was clinical leadership at the point of care.

VANEEP-CNL

The Office of Nursing Service reported 124 nurses were funded specifically for a CNL master's program from 2012 through October 2015. The total amount of approved funding through VANEEP-CNL was $2 459 740. In the Facility Gap Analysis Survey, we asked nurse leaders about VANEEP-CNL utilization. They reported a total of 104 staff members who used these funds, but in almost 60% of reporting facilities, staff did not use these funds. Almost 40% of CNL Survey respondents reported using VANEEP funding. Of those respondents who received VANEEP funding, only 43.5% reported currently working in a CNL position.

Nursing-sensitive indicators

The evaluators planned to use facility and unit-level data including nurse job satisfaction, patient experience, pressure injury process and outcomes measures, falls, hospital-acquired conditions, and personnel data (turnover and injuries) and link to specific facilities and unit. The evaluation teams were unable to link data at the unit level for several reasons including the limited number of respondents for the CNL survey who identified as working in CNL roles and the inability to obtain unit-level data for all nursing-sensitive indicators except pressure injury data. Therefore, the evaluation team examined facility-level data for sites (n = 23) responding to the organizational survey who indicated higher levels of CNL implementation (3 or more CNL positions filled with high congruence with CNL role functions). This group was compared with the Facility Gap Analysis Survey responders who reported no CNL implementation. Independent sample t tests showed no difference between the higher CNL implementation group and the no CNL implementation group except for ventilator-associated pneumonia (Table 4).

Table 4. - Comparison of Nursing Care–Sensitive Indicators Between Higher and No CNL Implementation Groups
Indicator Higher Implementation Mean (SD) No Implementation Mean (SD) t Statistic (P Value)
Catheter-associated urinary tract infection 1.438 (1.0460) 1.243 (1.1350) −0.563 (0.575)
Central line–associated bloodstream infection 0.665 (0.4536) 0.617 (0.6045) −0.280 (0.781)
Ventilator-associated pneumonia 0.369 (0.8035) 1.407 (2.2315) 1.038 (0.001)
PES-Participation 2.526 (0.1266) 2.614 (0.1227) 2.245 (0.088)
PES-Quality 2.872 (0.0989) 2.892 (0.0889) 0.658 (0.515)
PES-RN Manager 2.751 (0.1297) 2.787 (0.1302) 0.892 (0.378)
PES-Staffing 2.535 (0.1364) 2.428 (0.1302) −0.171 (0.865)
PES-RN/MD Relations 2.923 (0.1288) 2.929 (0.750) 0.176 (0.861)
IT support 2.970 (0.0955) 2.961 (0.1045) −0.291 (0.773)
Overall job satisfaction 3.493 (0.1998) 3.526 (0.2043) 0.507 (0.615)
FY2015 QTR 1 HAPU rate 0.846 (0.6378) 1.160 (0.7689) 1.384 (0.176)
Nursing staff regrettable turnover rate 1.578 (0.5271) 1.322 (0.5344) 1.330 (0.134)
SHEP: composite scoresa
Nurse communication 93.377 (2.8217) 94.937 (2.6051) 1.828 (0.074)
Responsiveness 88.027 88.253 0.130 (0.897)
Pain management 87.714 89.869 1.502 (0.141)
Shared decision-making 73.859 74.737 0.583 (0.563)
Care transition 49.114 50.837 1.229 (0.227)
Abbreviations: FY, financial year; HAPU, hospital-acquired pressure ulcer; PES, practice environment scale; QTR, quarter; SHEP, Survey of Healthcare Experience of Patients (US VA).
aNo individual questions were significantly different, so only composite scores are displayed.

LIMITATIONS

This evaluation was completed over 1 year and had some challenges. First, we were unable to link clinical and system outcome data directly to CNL role implementation because of changes in data availability and, more importantly, the lack of role fidelity across the system and even within facilities. The second limitation was the number of field observations. We originally planned for 8 site visits, but system issues prevented us from completing all 8, thus we only conducted 5 site visits.

DISCUSSION

The VA is recognized as the leader in implementation of the CNL role.2,4 However, introducing the CNL into health care microsystems to improve all levels of patient and system outcomes is a complex intervention, and it was not evident that sufficient attention to this complexity was given to effectively implement the role on a national scale. Structures and processes necessary for successful implementation of this new role were not addressed in a systematic manner.

At the national VHA (macrosystem) level, considerable resources (inputs) were provided for this implementation. This included visionary leadership committed to implementing the role on a broad scale, inclusion in the Office of Nursing Services strategic plan, funding for education and training, and, after recognition of need, funding for multiple years of a consultation service (CNL Implementation and Evaluation Service) to assist the field in implementation. However, no monies were earmarked to specifically add CNL positions directly to the facilities, so facilities who implemented the role generally carved those positions out of existing resources. In addition, there was less support for the role and role implementation among nonnursing leaders at the higher levels of the VHA. This set the stage for other challenges to the implementation.

National VHA activities were less defined and several key system-wide supports for role implementation were missing that could have facilitated implementation across the VHA including foundational human resource tools such as standardized job descriptions, appropriate administrative guidance for nursing standards boards, specialized pay scale, and identified measures of successful implementation of the role. In addition, there was no formalized orientation structure for new CNLs entering this challenging role. The VHA is known for highly structured and comprehensive employee training programs, yet for this new role it was missing, contributing to role confusion for nursing staff and leaders.

While theoretically decentralizing the CNL roles and responsibilities allowed flexibility to provide leadership at the individual unit (microsystem), it increased confusion among stakeholders at all levels of the VHA. Explicitly calling the CNL a “staff nurse” role also added to the lack of role clarity. The VHA Chief Nursing Officer (CNO) promoted the role as a staff nurse role with a direct patient care assignment expecting it to be better accepted in the system than another “add on” role. But she reported that her view of the patient care assignment was conceptualized more broadly as a member of the nursing care team at the point of care, with a focus on leading and creating efficiencies and improvements of care day to day and for the future. However, this conceptualization was interpreted in many different ways from a traditional RN staff nurse patient care assignment with 1 day per week/pay period allocated for “CNL work” to the CNL rarely taking a traditional patient assignment. This created a lack of standardization of the role with resulting low fidelity of the CNL as an intervention to improve quality at the point of care.

The lack of evaluative metrics and concurrent CNL evaluation data was detrimental to building support, which limited the ability of facility leaders to justify additional CNL positions. The metrics needed to demonstrate the value of this leadership role are unquestionably challenging to ascertain. Current nursing-sensitive indicators may not be sensitive to the work of CNLs, due in part to the diffusion of the role and lack of focused work processes that specifically address the key indicators of importance to the VHA. For CNLs working in nonacute areas, this is even more difficult as there are not well-defined indicators for nursing practice in outpatient areas. Most of the accepted nursing-sensitive patient outcomes are (fortunately) rare events. The patient experience and nurse job satisfaction data have low variability. New indicators need to be identified to best reflect the outcomes CNL practice.

Examination of facility-level inputs and activities shows there are pockets of exemplary CNL practice within the VHA and the majority of CNOs are supportive of role. However, CNOs are challenged by both the limitations of local resources and an inadequate supply of qualified CNLs in certain geographic regions. While there are over 100 CNL programs across the country, some only admit prelicensure students as an accelerated entry-level program. Most others are distance accessible, and leaders reported concerns about the quality of these programs. Unfortunately, we also heard CNL-prepared nurses bemoan the ability to find a CNL position in their facility and in their desired unit, while senior nurse leaders were frustrated by the lack of qualified applicants for their job postings. While some of the CNLs we talked with had relocated for CNL positions, most of the ones who were looking for a position stated they were not willing to relocate due to family responsibilities.

The lack of role clarity contributes to a lack of shared mental model of the role between CNL and other unit nurse leaders. Evaluators observed nurse manager-CNL dyads who built dynamic partnerships that facilitated a favorable practice environment with staff engaged in both excellent patient care and other professional activities such as including quality and safety work. Several nurse managers told us that having the CNL on the unit focusing on clinical oversight “made their lives easier.” But many CNLs reported issues with both the reporting structure of their position and their ability to work at the full scope of their CNL education and training. In our logic model, the unit-level activities were represented by the CNL role implementation. As previously discussed, each CNL defined the role differently, and there are large discrepancies in the shared mental model of the role across all levels of the VHA, including at the unit level.

The site visits and interviews provided some important insights into effective CNL practice. CNL practice with an emphasis on clinical leadership at the point of care holds promise for improving the quality of nursing care. This clinical expertise by a nurse within the microsystem who has advanced problem-solving skills and systems competencies cannot only anticipate and mitigate risk, improve care processes and patient outcomes, but can also improve team function across nursing and interprofessional teams. These practice elements need further exploration and a mechanism to capture meaningful process and outcome measures to assess the effectiveness of this role. More than 500 CNLs within the VHA should be recognized as a potential catalyst for transformation in clinical nursing care.

RECOMMENDATIONS

This evaluation suggests the CNL initiative had not yet accomplished the stated goals to improve cost and financial outcomes, increase patient satisfaction, increase staff satisfaction and retention, improve quality and internal processes, and facilitate practice model transformation including evidence-based practice and collaborative, interdisciplinary practice across the system. There are observed clinical practices within the VHA and externally that serve as exemplars for developing a care delivery model that could achieve these goals and offer potential paths to move this role forward. With these in mind, we make the following recommendations.

First, there needs to be standardization in the role to achieve facility and system-level improvement. The fundamental aspects of the role outlined by the American Association of Colleges of Nursing1 were generally supported by both leaders at multiple levels in the system and also the CNLs working in the role. However, how that role is operationalized currently has wide variation. Standardization needs to be of sufficient detail that a novice CNL has enough structure to move into the role knowing what should be done, but also offer enough flexibility to adjust to meet the needs of the specific microsystem and/or patient population (eg, medical-surgical units, intensive care units, primary care, or long-term care).

Second, there needs to be a process for an overall assessment and preparation of the environment prior to adding the CNL position to the care delivery model in a particular microsystem. At a minimum, consideration should be given to the current staffing model structure and the knowledge of the nurse manager about the role. The formal reporting relationships for the CNL is also important; within the facility, does the CNL report to the microsystem manager or to nurse leaders at the department of nursing level? This evaluation did not find that one model more effective than another, but each depends on shared mental models and support for the role.

Third, the widely used indicators to measure inpatient nursing care quality may not be sensitive to CNL practice. The patient outcome indicators are generally rare events and may not reflect the lateral integration of care and risk mitigation that standardized CNL practice provides. This is yet another opportunity for the VHA to continue to innovate nursing care nationally.

The VHA led the development and testing of this new nursing role. The system needs expert clinicians at the point of care who can improve nursing practice variation within microsystems. There are over 500 VHA nurses who identify as a CNL or CNL student. They are an invaluable resource that must be acknowledged and used to the full scope of their education and training. However, the CNL role needs a more focused, standardized implementation and the system needs an improved infrastructure to both support and evaluate the role as the VHA continues to lead the nation in innovative practice models to transform care for Veterans.

REFERENCES

1. American Association of Colleges of Nursing. Competencies and curricular expectations for Clinical Nurse Leader education & practice. http://www.aacn.nche.edu/publications/white-papers/cnl. Published 2013. Accessed December 5, 2019.
2. Ott KM, Haddock KS, Fox SE, et al. The Clinical Nurse Leader: impact on practice outcomes in the Veterans Health Administration. Nurs Econ. 2009;27(6):363–370, 383.
3. Office of Nursing Service (ONS). Clinical Nurse Leader information page. https://www.va.gov/NURSING/practice/cnl.asp. Accessed December 5, 2019.
4. Williams M, Avolio AE, Ott KM, Miltner RS. Promoting a strategic approach to Clinical Nurse Leader practice integration. Nurs Adm Q. 2016;40(1):24–32.
5. Centers for Disease Control and Prevention. A framework for program evaluation. https://www.cdc.gov/eval/framework/index.htm. Accessed December 5, 2019.
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8. Polancich S, Coiner S, Barber R, et al. Applying the PDSA framework to examine the use of the Clinical Nurse Leader to evaluate pressure ulcer reporting. J Nurs Care Qual. 2017;32(4):293–300.
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Keywords:

Clinical Nurse Leader; nursing care models; program evaluation; Veterans Health

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