According to the American Association of Colleges of Nursing (AACN):
The clinical nurse leader (CNL) is a leader in the health care delivery system across all settings in which health care is delivered, not just the acute care setting. The implementation of the CNL role, however, will vary across settings. The CNL role is not one of administration or management. The CNL functions within a microsystem and assumes accountability for healthcare outcomes for a specific group of clients within a unit or setting through the assimilation and application of research-based information to design, implement, and evaluate client plans of care. The CNL is a provider and a manager of care at the point of care to individuals and cohorts. The 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 (American Association of Colleges of Nursing, 2007b, pp. 6).
The Institute of Medicine (IOM) series of reports beginning in 1999 exposed increasing numbers of medical errors; diminishing quality of health care and inadequate use of resources. The reports prompted persuasive recommendations supporting curriculum reform and alteration of the workplace to ensure safe patient care from additional stakeholders and organizations such as the Joint Commission and American Hospital Association (AACN, 2007b).
In response to the call for changes in nursing education, licensure, credentialing, and practice, the AACN developed two task forces to examine the issues surrounding the need for changes which included developing models that would propel quality nursing into the future; examine the pros and cons of the models; recommend competencies and the role of future nurse leaders (Long, 2003).
The first white paper released by AACN described the role, education, values, and competencies of the CNL (AACN, 2004). From 2004 to 2006, the CNL initiative was advanced through outreach to stakeholders, such as the American Organization of Nurse Executives (AONE) to develop curriculum and begin implementation of a pilot program. By 2007, many clinical nurse leaders had been integrated into workforce settings such as the Veterans Health Administration (Ott et al., 2009). In addition, evaluation of the programs, resources and other tools were developed and disseminated. Evaluation of the CNL has been considered an important component (AACN, 2007b).
In 2007, AACN expanded the white paper to include graduation from a Master’s program integrated with specific competencies required for graduates of the CNL program and the framework for required curriculum components; as well as clinical experiences and a formal end of program clinical immersion, which would prepare CNL graduates for certification. The AACN has been clear that although the CNL education program culminates with a master’s degree and includes advanced nursing knowledge and skills, a CNL does not meet the criteria to practice as an advanced practice nurse. Five educational models for the CNL have been developed since 2007, with research pending (AACN, 2007a).
Examination of the impact of the CNL on cost savings; patient outcomes; and improving patient and staff satisfaction is being developed, implemented, and results evaluated.
Evidence in support of financial benefits and improved patient outcomes related to the use of CNLs at the point of care has been noted in research. In an investigation of seven Veterans Administration Medical Centers, Ott et al. (2009) examined data from areas identified by individual CNL(s) in one of three quantitative domains including external peer review data, administrative goals, or clinical complications. Overall, domains including but not limited to nursing hours per patient, cancellation rates for procedures, pressure ulcers, patient falls, discharge teaching and ventilator-associated pneumonia demonstrated cost savings and improved outcomes pre and post CNL implementation. The authors noted limitations of using data from individual CNL(s) and their associated facility rather than a compilation of national data, and the need for additional research using a valid tool for data collection to improve reliability and validity as well as centralizing outcome documentation to support CNL practice across all settings (Ott et al., 2009). Additional research supportive of the CNL in other settings is not available at this time.
Stanley et al. examined the implementation of the CNL through a naturalistic lens using national patient safety goals as domains. Although the results demonstrated improved outcomes post CNL implementation, the authors concluded that the results were valuable for increasing awareness of the role and future research directed at outcome evaluation. The authors suggest a review by stakeholders of all initiatives including the work of the Institute for Health Initiatives (IHI) and the Robert Wood Johnson Foundation funded Quality and Safety Education for Nurses (http://www.qsen.org) to ensure knowledge of all opportunities to improve patient safety and outcomes (Stanley, et al., 2008).
Although the CNL has been embraced by some organizations, others remain unconvinced or silent regarding the need for an additional role (Nelson, 2010). To address concerns raised within the nursing community and academia, AACN (2004) released a document on the similarities, differences and the areas the roles overlap between the clinical nurse leader and clinical nurse specialist. Conferences, teleconferences, and webinars are available through the AACN website at http://www.aacn.nche.edu/cnl/professional-development/teleconferences-webinars, which provides valuable information regarding the education, implementation, evaluation, and evolution of the CNL role. The AACN (2011) uses these opportunities to support the CNL role and gather information supportive of the role.
Complexities existing within the current health system include population diversity, employee shortages, and financial struggles compounded by external factors that demand greater transparency. Clear delineation regarding the roles of advanced practice nurses are necessary to avoid confusion by patients and mistrust by other staff (Bombard et al., 2010).
Support is needed for a well-educated and competent nursing staff able to meet these demands and collaborate with other professionals to advance health care for all individuals across the lifespan, all of which are reinforced within the IOM’s Future of Nursing (2010) recommendations. To ensure collaboration and safe care for the public, registered nurses have a responsibility to remain knowledgeable regarding emerging roles within the healthcare system.
To ensure that the role of the clinical nurse leader is supported and used appropriately within the clinical setting, NYSNA recommends that
NYSNA will explore and present evidence regarding how health care organizations and the National Council of State Board of Nursing have established the value of the clinical nurse leader role, and how health care delivery systems will financially support implementation of the role.
Note: The use of the term “patient or client” anywhere in this document is intended to be generic and refers to the recipient of nursing care.
Approved by the NYSNA Board of Directors November 16, 2011. Prepared and reviewed by the Council on Nursing Practice August 19, 2011.
American Association of Colleges of Nursing. (2004). Working paper on the role of the clinical nurse leader (revised June 2004). Retrieved from http://www.aacn.nche.edu/Publications/docs/CNL6-04.DOC
American Association of Colleges of Nursing. (2007a). Clinical Nurse Leader℠ education models being implemented by schools of nursing. Retrieved from http://www.aacn.nche.edu/CNL/pdf/CNLEdModels.pdf
American Association of Colleges of Nursing. (2007b). White paper on the education and role of the Clinical Nurse Leader™ (revised July 2007). Retrieved from http://www.aacn.nche.edu/publications/white-papers/ClinicalNurseLeader.pdf
American Association of Colleges of Nursing. (2011). CNL teleconferences and webinars. Retrieved from http://www.aacn.nche.edu/cnl/professionaldevelopment/teleconferences-webinars
American Operating Room Nurse. (2006). AORN white paper: Clinical nurse leader. Retrieved from http://www.aorn.org/docs/assets/F2DD79C6-A207-7FF3- 631E7597738D778F/Ref_Clinical_Nurse_Leader_-_REVISED__2_.pdf
Bombard, E., Chapman, K., Doyle, M., Wright, D. K., Shipee-Rice, R.V., Kasik, D. R. (2010). Answering the question, “What is a clinical nurse leader?” Transition experience of four direct-entry master’s students. Journal of Professional Nursing, 26(6), 332-340.
Institutes of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
Long, K. A. (2003). Clinical Nurse Leader. Retrieved from http://www.aacn.nche.edu/CNL/history.htm
Ott, K. M., Haddock, K. S., Fox, S. E., Shinn, J. K., Walters, S. E., Hardin, J W., Durand, K., & Harris, J. L. (2009). Clinical nurse leader℠: Impact on practice outcomes in the Veterans Health Administration. Nursing Economic$, 27(6), 363-383.
National Association of Clinical Nurse Specialists. (2005). NACNS update on the clinical nurse leader. Retrieved from http://www.nacns.org/LinkClick.aspx?fileticket=3%2bip4nbDLho%3d&tabid=116
Nelson, R. (2010). The clinical nurse leader: An update on the controversial nursing role. AJN, American Journal of Nursing. doi: 10.1097/01.NAJ.0000366046.89571.24
Stanley, J. M., Gannon, J., Gabuat, J., Hartranft, S., Adams, N., Mayes, C., Shouse, G. M., Edwards, B. A., & Burch, D. (2008). The clinical nurse leader: A catalyst for improving quality and patient safety. Journal of Nursing Management, 16, 614-622.
For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.