CNLs Influence Outcomes at the Bedside and Beyond

Health care coordination is incredibly complex. It is becoming increasingly challenging to integrate new practices and technologies, while addressing the need to improve patient care outcomes. It’s been more than two decades since The Institute of Medicine’s (IOM) 1999 landmark report, To Err Is Human: Building a Safer Health System, revealed that medical errors accounted for more deaths than motor vehicle accidents, breast cancer or acquired immunodeficiency syndrome. Further, nearly half the expenses caused by these medical events are preventable (Kershaw, 2011). While there has been consistent progress, the U.S. health care system continues to prove insufficient compared to other nations’ outcome measure performance (Gonzalo & Singh, 2019). The clinical nurse leader (CNL) role was thoughtfully developed to address this gap. In fact, a 2011 IOM report identified the CNL as “one of the most transformational roles” in nursing (Hulett & Shatto, 2021).

Developing the CNL role

The CNL role was first defined and developed by the American Association of Colleges of Nursing in 2003, with the first CNLs receiving certification in 2007. The CNL is a master’s-prepared clinical leader with advanced education, training and professional competencies. The expertise of the CNL can be applied to any health care setting and the role is highly adaptable to individual site or specialty needs (Ott et al., 2019). CNLs are intended to work alongside other front-line clinicians to facilitate the lateral integration of care. Educated in continuous process improvement, CNLs take action to implement evidenced-based practice, analyze patient outcomes and perform risk assessments, while working directly at the bedside to establish patient and family rapport. The Veteran’s Health Administration became early adopters and advocates for the CNL role and were the first to publish robust outcome metrics validating the cost savings, waste reduction and quality care improvements that the CNLs could bring (Ott et al., 2019). Since that time, the number of CNLs and CNL positions in health care systems has increased, but it remains an underutilized role. 

At Shirley Ryan AbilityLab, we began integrating the CNL role into the structure of our nursing team in 2014. We initially conceived of the CNL as a bedside leader with equal time and focus on direct patient care and unit-level outcomes. Protected administrative time dedicated to quality improvement activities would make up approximately half of the CNL’s worked hours. This time is intended to be spent on the unit in close proximity to patients and clinical staff. The remainder of their time would be spent working at the bedside in a traditional staff nurse capacity. As our patient census increased over the years, we identified an increased need for CNL support. In response, protected administrative time now accounts for between 50% and 100% of the CNL’s time. This varies based on individual unit census and needs. The key feature of the role is bedside engagement; the CNL meets patients and nursing staff where they are. 

Value of CNL investment

CNLs are trained to manage outcomes including falls, pressure injuries, hospital-acquired infections, readmissions, patient satisfaction, resource management and staff satisfaction and retention (Hulett & Shatto, 2021). CNLs can assess trends and patterns in ways front-line nurses often cannot. Bedside nurses are running at a mile a minute. Many are novices in their practice, with some learning nursing skills in simulation at the height of a pandemic. At the same time, these novices are encountering some of the most critical staffing challenges health care has seen in our practicing generation.
 CNLs can help these nurses develop critical thinking skills, perform risk assessments and adopt a model of proactive prevention instead of reactive damage control. It is not always reasonable to expect seasoned bedside nurses to consider big picture outcomes at the unit or facility level when they are trying to keep their heads above water and perform bedside duties. Providing high-quality care to the patient in front of them is the priority. While unit-level managers or department directors are responsible for monitoring and responding to quality outcomes data, these leaders may not be optimally positioned to understand the full context necessary to achieve sustainable improvements. CNLs view the care team’s approach holistically, holding the perspective of a direct caregiver and a systems leader simultaneously. They successfully bridge the gap between patient care and clinical leadership. They function as unit practice experts and outcome managers (Hulett & Shatto, 2021), advising and partnering with hospital leadership on evidenced-based directives while incorporating individual unit needs. Their unique role maintains a close relationship with the interdisciplinary front-line clinicians, patients, families and administrators, which affords a well-rounded perspective of both bottom-up and top-down expectations surrounding performance. 

CNLs are powerful change agents, models of behavior and advocates when it comes to adopting new policies or practice changes. CNL-led efforts at other facilities have resulted in improved adherence to medication administration standards (Santana, 2021), decreased fall rates and associated costs (Votruba et al., 2016), decreased rates of ventilator-associated pneumonia and decreased surgical complications (Ott et al., 2019) just to name a few examples. 

Nurse managers and executive nursing leaders at Shirley Ryan AbilityLab have come to view CNLs as invaluable. Our CNLs collaborate with staff to troubleshoot obstacles and identify realistic goals surrounding process and outcomes improvements. They maintain a pulse on the unit and adjust their approach to problems in real time. This is accomplished by participating in interdisciplinary and nursing-specific team huddles and safety rounds. CNLs also have discussions with unit stakeholders, observing day-to-day practice and reviewing unit-level quality and safety data. Through the collaborative efforts of CNLs, Shirley Ryan AbiltyLab implemented fall prevention strategies resulting in a 31% decrease in hospital-wide fall rates from 2020 through 2023. Fall prevention presents unique challenges in the acute inpatient rehabilitation setting, as we prioritize early mobility in a population of patients at high risk of falling due to physical and/or cognitive disabilities. Many hospitals struggled with fall rates during the pandemic due to staff shortages, lack of family presence, burnout and infection control precautions that limited staff time at the bedside. Attaining such a drastic decrease in fall rate during a pandemic is just one example of the innovative problem-solving that a group of determined CNLs can offer.

Recruitment and professional development 

External recruitment of CNLs can be challenging. While most states have at least one school of nursing offering CNL preparation, the availability of CNL programs varies considerably from one region to another. At Shirley Ryan AbilityLab, we found success combining external recruitment of CNLs with internal development programs. In Illinois, several schools of nursing offer direct entry to practice MSN programs that include preparation for CNL certification within their curriculums. For external recruitment, we have partnered with these programs to offer clinical immersion experiences for their students. This exposes more future CNLs to our facility and to the specialty practice of rehabilitation nursing, and allows us to recruit new graduate nurses who have shown promising performance. Shirley Ryan AbilityLab has recruited multiple CNLs in this fashion. This strategy requires a long-term investment, as new graduate CNLs are not fully prepared to function as unit-based leaders until they have achieved a proficient level of practice in the role of bedside nurse. We found that internal development strategies also were necessary for optimal succession planning for the CNL role. To address this need, we developed a professional growth plan with tracks for both BSN- and MSN-prepared staff nurses interested in pursuing CNL certification. Staff members pursuing this plan remain in their current roles while they are provided dedicated time without a patient assignment to begin performing select aspects of the CNL role in an interim capacity. At the same time, they receive mentoring from a seasoned CNL or other appropriate nurse leader. The employee is reimbursed for the cost of the certification upon passing their examination and is then able to apply for formal promotion into any open CNL role. The flexibility of this approach has greatly improved succession planning for CNL roles, allowing us to achieve a 0% vacancy rate. When a role does become available, we are able to identify quality candidates and fill the role quickly. Since we first piloted the defined CNL role in 2014, CNLs have been successfully integrated across all adult inpatient units. The one- and two-year retention rates for the role are 100% and 73%, respectively. Over half of all nurses hired into the role over the past 10 years remain employed with the organization. 

With advanced education and training and a keen eye for identifying improvement needs, it is no surprise CNLs are remarkably productive clinicians who tend to seek out professional challenges early in their careers. Providing CNLs with a pathway to continued professional growth will amplify their skills and allow them to practice to their full potential. At Shirley Ryan AbilityLab, CNLs regularly spearhead quality improvement initiatives, manage small- and large-scale projects and are deeply engaged in our shared governance structure. These individuals make excellent candidates for other leadership positions. The unit-level CNL role has turned out to be a key succession planning pipeline for full-time clinical quality coordinator roles at our facility. Four of our unit CNLs have been promoted into this role in recent years, taking their expertise from the microsystem to the macrosystem level. Other roles filled by CNLs at our facility include charge nurse, clinical instructor and principal investigator for nurse-led research projects. 

A path forward

The CNL role is still not widely adopted at many health care facilities. As CNL numbers increase, they are filling a variety of roles outside of formally designated CNL positions (Clavo et al., 2018). At Shirley Ryan AbilityLab, CNL-prepared nurses have thrived both within and outside of the dedicated CNL role. A systematic review of CNL literature showed CNLs function in roles including research, academic faculty, case management, clinical director and staff nurse (Clavo-Hall et al., 2018). However, if organizations do not define CNL responsibilities and provide adequate protected time to address these priorities, it is not possible to realize the CNL’s full potential. Consider the gaps in care your facility. Where are outcomes not matching up to expectations? Where can cost savings be realized? What kinds of errors are reported most frequently? A CNL might be just what you need to address these problems in a way that makes sense to both executive leadership and front-line staff. 

References 
Clavo-Hall, J. A., Bender, M., & Harvath, T. A. (2018). Roles enacted by clinical nurse leaders across the healthcare spectrum: A systematic literature review. Journal of Professional Nursing : Official journal of the American Association of Colleges of Nursing, 34(4):259-268. https://pubmed.ncbi.nlm.nih.gov/30055677

Gonzalo, J. D., & Singh, M. K.  (2019). Building systems citizenship in health professions education: The continued call for health systems science curricula. Patient Safety Network. https://psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems 

History of the CNL. American Association of Colleges of Nursing. (n.d.). https://www.aacnnursing.org/our-initiatives/education-practice/clinical-nurse-leader/cnl-certification/about/history

Hulett, B., & Shatto, B. (2021). Clinical nurse leaders. Nursing Management, 52(8), 49–51. https://doi.org/10.1097/01.numa.0000758712.33132.83 

Kershaw, B. (2011). The Future of Nursing – leading change, advancing HealthInstitute of Medicine of the National Academies (USA). Nursing Standard, 26(7), 31–31. https://doi.org/10.7748/ns.26.7.31.s40 

Ott, K. M., Haddock, K. S., Fox, S. E., Shinn, J. K., Walters, S. E., Hardin, J. W., Duran, K., & Harris, J. L. (2009). The clinical nurse leader: Impact on practice outcomes in the Veterans Health Administration. Nursing Economics, 27(6):363-370, 383. https://pubmed.ncbi.nlm.nih.gov/20050486/ 

Santana, B. (2021). CNL and CNS collaboration to improve stroke patient population quality of care. Journal of Nursing Care Quality, 36(3): 241. https://doi.org/10.1097/NCQ.0000000000000549 

Votruba, L., Graham, B., Wisinski, J., & Syed, A. (2016). Video monitoring to reduce falls and patient companion costs for adult inpatients. Nursing Economics, 34(4):185-189. https://pubmed.ncbi.nlm.nih.gov/29975024/

ABOUT THE AUTHORS

Kristen Gracz, MSN, RN, CNL, is the clinical quality coordinator at Shirley Ryan AbilityLab in Chicago. 

Katherine Earnest, MSN, RN, CNML, is the director of nursing research at Shirley Ryan AbilityLab in Chicago.