Team concepts

A portrait of the bedside: Clinical nurse leaders complete the picture By Karen Schilling-Broderick, MSN, RN, CCRN

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ave your fall rates decreased over the last few months? Is there a recent decline in your healthcare-associated infection (HAI) rates? Are your staff and patient satisfaction scores higher than in the last survey? If so, chances are there’s a clinical nurse leader (CNL) participating in safety and quality improvement measures on your unit. This evolving leadership role is becoming increasingly popular with hospitals as healthcare reform moves us to a focus on patient outcomes. In 1999, the Institute of Medicine issued a report on medical errors and the fragmentation of our healthcare system across the continuum.1 This report detailed how fragile our quality of care is and the affect it has on hospital reimbursement and the future of our patients. In 2004, the American Association of Colleges of Nursing (AACN) held a national discussion with nurse executives on what the profession could do to help alleviate this issue. The result was the development of a leadership role with a focus on the bedside and within a specific microsystem population. This role was the CNL.

Nursing care, fragmented Critical care patients are generally the sickest in the hospital. These patients are evaluated by multiple healthcare workers usually working self-sufficiently. Sometimes, multiple consults for specialty services occur with little or no communication from one specialty to another. Fragmented care can cause a patient more harm because it puts them at an increased risk for adverse reactions, infections, and other potential medical errors. The possibility for a longer length of stay and increased expenses also plays a role in the fragmentation of healthcare.2 10 November 2013 • Nursing Management

When speaking with a family member, how many shift-to-shift nursing reports have you received only to discover that pertinent information was missing? Between chronic illnesses, such as diabetes and heart failure, and routine surgeries, such as knee and hip replacements, a patient’s current and past medical history is more complex than ever. Not every clinical nurse has the time to scour a medical record to figure out the complexities of a patient’s condition. However, in critical care, having the correct clinical information about a patient is essential to providing quality care. The CNL knows the patient’s story. CNLs assist with bridging the gap between healthcare providers, decreasing the fragmentation of care. Being available on a continuous basis, the CNL serves as a liaison between clinical nurses and physicians within the multidisciplinary team. Putting the pieces in place In 2007, the AACN published the White Paper on the Education and Role of the Clinical Nurse Leader.3 This paper outlined the role of CNLs, including a list of leadership skills they possess, such as delegating, supervising, and evaluating clinical nurses and other ancillary staff members at the bedside. Using theory- and research-based data in the planning, implementation, and evaluation of patient care, the CNL has the autonomy and authority to adjust the nursing care plan if the patient’s condition changes. The CNL addresses quality improvement processes and introduces a culture of safety, which is an alltime high priority for today’s healthcare systems. The CNL is educated at the master’s degree level, practicing at the point of care in any microsystem setting. Individuals at this stage are equipped to assume a clinical supervisory role. Bringing a unique level of expertise to the lateral integration of care, multidisciplinary communication, quality improvement, implementation of evidencebased practice, and patient advocacy, the CNL provides leadership and mentorship among nurse colleagues.4 The CNL working on a nursing unit www.nursingmanagement.com

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Team concepts follows a special cohort of patients, collaborating with the clinical nurse to prevent fragmentation of care. During patient care rounds, the clinical nurse presents his or her patient case, covering the care provided and addressing the necessary quality components while being supported by the CNL. Practicing at the microsystem level, the CNL is accountable for the care outcomes of a specific patient population. In critical care, for example, the CNL may focus on intubated and septic patients. By focusing on this group, the CNL can concentrate on ventilator-associated pneumonia and central line-associated bloodstream infection prevention strategies, along with length of stay in the ICU. Besides influencing quality improvement and averting potential medical errors, the CNL can also help entice a new group of leaders into the profession by mentoring new nurses. The CNL is an expert, a mentor, and, most of all, a colleague. Over time, this will strengthen the profession by showing an institution’s commitment to nursing and patient care.5 Aligning outcomes CNLs all over the country are proving their “worth.” For example, at a large facility in the northeast, the critical care CNLs have decreased their patients’ length of stay in the ICU by almost 18% by focusing on early interventions using the discharge plan.6 By concentrating on the discharge plan from the beginning of the patient’s admission and including the families, there has been improved teamwork among staff members and care fragmentation has decreased.7 Another major benefit of this leadership role is improved patient and family satisfaction. Families feel their loved ones are safe with an expert nurse overseeing the quality of care being given. Clinical nurses may feel www.nursingmanagement.com

less stressed and overwhelmed with their assignment knowing the CNL is assisting with any family issues at hand. Other benefits include having a better understanding of good fiscal stewardship and the safety of a healthy work environment.2 Improved patient care and quality indicators, such as a decrease in fall rates, pressure ulcers, and HAIs, are just a few of the key outcomes that the CNL focuses on in specific patient populations. Providing new and updated evidence-based practices for fall prevention helps the clinical nurse deliver quality care. Hourly rounding with toileting and comfort care are prevention strategies to keep patients safe while in the hospital. Morning nursing assessments completed by the CNL and the clinical nurse together help focus on pressure ulcer prevention and HAIs. A complete unit With the focus on a specific patient population, the CNL delivers expert care and education at the bedside. Nurse managers are then able to complete their main responsibility: managing the unit. The nurse manager is responsible for the overall clinical, operational, and fiscal management of the unit, and the CNL supports the nurse manager clinically and works very closely with staff members.2 Nurse managers can depend on the CNL to speak the high-reliability language of safety and quality initiatives. CNLs transform care at the bedside similar to the model most hospitals are adopting. The Transforming Care at the Bedside model engages frontline staff and hospital leadership to make improvements in four areas: quality and safety, healthy work environments, the family experience, and the healthcare team.8 Having a CNL to identify flaws, avoid mishaps, and quickly address system imperfections in real-time can avert negative adverse

events. The rest is a domino effect. High-quality outcomes and safety improvements lead to a healthier work environment, a better patient/family experience, and a cohesive healthcare delivery team. The nursing profession was on the right track when it developed this leadership role. The CNL is a valuable addition to any nursing unit and part of the foundation of delivering quality care. By collecting and reporting data, whether it’s patient satisfaction scores, financial metrics, or other pertinent quality indicator measurements, the CNL uses best practice, evidence-based protocols to deliver quality care. NM

REFERENCES 1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 1999. 2. Sheets M, Bonnah B, Kareivis J, Abraham P, Sweeney M, Strauss J. CNLs make a difference. Nursing. 2012;42(8):54-58. 3. American Association of Colleges of Nursing. The white paper on the education and role of the clinical nurse leader. http:// www.nursing.vanderbilt.edu/msn/pdf/cm_ AACN_CNL.pdf. 4. Stanley JM, Gannon J, Gabuat J, et al. The clinical nurse leader: a catalyst for improving quality and patient safety. J Nurs Manag. 2008;16(5):614-622. 5. Begun JW, Tornabeni J, White KR. Opportunities for improving patient care through lateral integration: the clinical nurse leader. J Healthc Manag. 2006;51(1):19-25. 6. Poulin-Tabor D, Quirk RL, Wilson L, et al. Pioneering a new role: the beginning, current practice and future of the Clinical Nurse Leader. J Nurs Manag. 2008;16(5):623-628. 7. Sherman RO. Lessons in innovation: role transition experiences of clinical nurse leaders. J Nurs Adm. 2010;40(12):547-554. 8. Needleman J, Hassmiller S. The role of nurses in improving hospital quality and efficiency: real world results. Health Aff (Millwood). 2009;28(4):w625-w633. Karen Schilling-Broderick is a critical care clinical nurse leader at Middlesex Hospital in Middletown, Conn. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NUMA.0000436368.07022.f5

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A portrait of the bedside: clinical nurse leaders complete the picture.

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