Variations in Clinical Nurse Leaders’ Confidence with Performing the Core Role Functions Mattia J. Gilmartin RN,PhD PII: DOI: Reference:
S8755-7223(13)00188-9 doi: 10.1016/j.profnurs.2013.11.002 YJPNU 800
To appear in:
Journal of Professional Nursing
Please cite this article as: Gilmartin, M.J., Variations in Clinical Nurse Leaders’ Confidence with Performing the Core Role Functions, Journal of Professional Nursing (2013), doi: 10.1016/j.profnurs.2013.11.002
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Variations in Clinical Nurse Leaders’ Confidence with Performing the Core Role Functions
Mattia J. Gilmartin RN, PhD
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Senior Research Scientist
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New York University College of Nursing 726 Broadway 10th floor
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New York, NY. 10003 Tel: 212-992-7128
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Email: [email protected]
This study was supported by a grant from the American Nurses Foundation/Nurses in Staff Development. 2010-090, M. J. Gilmartin, RN, PhD, Principal Investigator.
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Variations in Clinical Nurse Leaders®’ Confidence with Performing the Core Role Functions
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Abstract Background: CNL practice, by definition, requires individuals to make career transitions.
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CNLs must adjust to their new work role and responsibilities and doing so also entails individual
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adjustment. Prior work has not examined the role of individual-level factors in effective CNL
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role transition.
Aim: This study contributes to CNL implementation efforts by developing understanding of
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personal and contextual factors that explain variation in individuals’ levels of self-confidence
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with performing the key functions of the CNL role.
Design and Methods: Data were gathered using a cross-sectional survey from a national sample
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of RNs certified as CNLs. Respondents’ perceptions of their confidence in performing CNL role competencies were measured with the Clinical Nurse Leader Self-Efficacy Scale (CNLSES)
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(Gilmartin & Nokes, in press). The CNLSES is a thirty-five item state-specific self-efficacy scale
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with established measurement properties that assesses nurses’ perceptions of their ability to function effectively as a CNL. Demographic data were also collected. Data were analyzed
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using a general linear regression model (GLM). Results: One hundred and forty-seven certified CNLs participated in the survey. Results indicate that respondents vary in their confidence with performing the nine role competencies associated with CNL practice. Results from regression analyses also show that respondents’ confidence in their abilities to carry out the core functions associated with the CNL role varied significantly across geographic region, organizational type and by CNL graduate program model.
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Conclusions: The results of this study show important differences in CNLs’ levels of selfconfidence with the core competencies of their role. As a result, it may be important to develop
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targeted career transition interventions to gain the full benefit of CNL practice.
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Variations in Clinical Nurse Leaders®’ Confidence with Performing the Core Role Functions
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Introduced in 2004, the Clinical Nurse Leader (CNL®) is the first new nursing role in more than thirty years (American Association of Colleges of Nursing, 2007). The goal of the
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CNL role is to return expert clinicians to the point of care to strengthen the nursing professions’ contributions to improve the quality, safety and outcomes of health care in the United States. The
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hallmark of CNL practice is the management of client centered care and clinical excellence at the
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point of care (AACN, 2007; Reid & Dennison, 2012; Ott et al., 2009; Hix, McKeon & Walters, 2009).
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Unlike other masters prepared roles in nursing, the CNL is an advanced generalist with unit-level responsibility. Because of their generalist orientation, the scope of CNL practice
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complements that of the front-line nurse manager, on the one hand, and the nurse practitioner
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and clinical nurse specialist, on the other (AACN, 2007). Graduate education for the CNL role extends the direct care skills acquired at the baccalaureate level to build competence in the area
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of policy and organizations, outcomes management, nursing leadership and care management (ANCC, 2007). CNLs are educated to assume responsibility for interdisciplinary care coordination; managing clinical outcomes, with a particular focus on promoting health and preventing disease in populations; and implementing clinical quality improvement and risk management programs within the context of a clinical unit. To promote the diffusion of the CNL role in both academic and practice settings, the American Association of Colleges of Nursing (AACN) specified the development of CNL program curricula; clinical and didactic experiences required for certification as a CNL; and academic-service partnerships to serve as a mechanism for each partner to initiate the CNL role,
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with the goal of hiring CNL program graduates into formal CNL positions at the partner organization (Stanley, Hoiting, Burton, Harris & Norman, 2007). The White Paper on the
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Education and Role of the Clinical Nurse Leader (2007) outlined these requirements, that also
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are described elsewhere (Bartels & Bednash, 2005; Stanley, Hoiting, Burton, Harris & Norman, 2007; Torabeni & Miller, 2008).
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Although clinical practicum experiences are a common feature of nursing education
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programs, the role transition experience for individuals pursuing the CNL role differ in important ways from experiences provided in other graduate programs in nursing. Ideally, CNL education
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and transition to practice occur within the context of an academic-service partnership (AACN, 2007). The academic-service-partnership model serves to promote CNL role implementation by
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aligning academic and organizational goals; each partner is committed to educating and
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employing nurses to lead and manage clinical improvement initiatives. CNL students complete between 400 and 500 clinical contact hours during the program, 300 to 400 of which are
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structured as an immersion experience in the CNL role with a dedicated preceptor and a faculty
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partner over a ten to fifteen week period (AACN, 2007). During the immersion experience, students have the option to select a new clinical practice area for the practicum experience as a means to promote transitions into a new practice area after graduation (Bombard, Chapman, Dole, Wright, Shippee-Rice & Kasik, 2010). Prior studies examining the transition experiences of nurses pioneering the CNL role provide important information regarding organizational factors that promote or hinder the adoption of the CNL role in clinical settings (Sherman, 2010; Stanton, Lammon & Williams, 2011; Moore & Leahy, 2012; Bombard et al., 2010). Two recent qualitative studies suggest that
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the CNL role is implemented differently across organizations and practice areas (Stanton et al., 2011; Sherman, 2011).
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The purpose of this study is to develop understanding of factors that account for variation
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in individuals’ self-efficacy in the CNL role. This study contributes to CNL implementation efforts by developing understanding of personal and contextual factors that explain variation in
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individuals’ levels of self-confidence with performing the key functions of the CNL role.
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Understanding differences in CNLs’ levels of self-confidence with the core competencies of the role will provide important information to develop targeted career transition interventions to gain
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the full benefit of CNL practice.
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Role Transitions of Clinical Nurse Leaders
CNL practice, by definition, requires individuals to make career transitions that require
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adjustment to new professional work roles and responsibilities. Doing so also entails individual
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adjustment. Prior research suggests that experienced nurses moving into advanced practice roles
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experience difficulty during role transition because they are expected to function at a higher, more independent, practice level than previously demonstrated in traditional staff nurse roles (Jones, 2005; Sherman, 2010). More generally, an individual’s ability to build a successful career is based on her or his ability to transition to increasingly complex work roles (Nicholson, 1984; Ashforth & Saks, 1995). Work role transitions entail two interdependent adjustment processes: personal development and role development. Personal development includes cognitive and psychological changes in knowledge, skills, confidence, and work identity; motivation for feedback to improve work performance and prior professional socialization experiences. In contrast, role development is reflected in the design of the job within a specific organizational content.
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Managers are typically responsible for attending to the required changes in organizational systems, structures, reporting relationships, politics, culture and resources needed to promote the
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adoption of a new work role (Nicholson, 1984; Edwards, 2008). In sum, the extent to which an
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individual is able to successfully transition to a new work role is predicated on personal characteristics that make her or him well suited for the job, on the one hand, and changes in
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organizational content and job design to promote person-job fit, on the other (Ashforth & Saks,
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1995; Stephens, 1994; Edwards, 2008).
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Self-confidence is an important factor associated with successful role transitions. Selfconfidence is an attitude that enables individuals to have positive, yet realistic, views of
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themselves and their situations. Self-confident people trust their own abilities, have a general sense of control in their lives, and believe that, within reason, they will be able to do what they
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wish, plan, and expect (Stakjovic & Luthans, 1998). Prior research establishes that self-
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confidence is an important factor associated with a number of important work outcomes including successful career transitions, job satisfaction, job performance, and voluntary turnover
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(Stakjovic & Luthans, 1998; Judge, Erez & Bono, 1998). Variations in nurses’ self-confidence associated with transitioning into the CNL role is likely to be influenced by a number of personal and contextual factors. First, because nursing is a contextually situated practice, prior exposure to a particular clinical problem or practice situation builds competence and confidence in the ability to respond appropriately to similar situations (Benner, 2009; Tanner, 2006). Recent analyses of the content of RNs’ daily work suggest that nurses do not have the time for care planning and coordination activities (Lucero, Lake & Aiken, 2009; Chow, 2008), lack skills either to assess the quality of care or integrate evidence into clinical decision making (Kovner, Brewer, Yingrengreung & Fairchild, 2010), or
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work in organizations that have been slow to adopt quality and process improvement techniques into daily routines (Watcher, 2010). Thus, even though many CNLs are experienced staff nurses,
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their exposure to, and confidence with, the core activities of the CNL role may be limited.
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Similarly, experience in the CNL role is likely to affect nurses’ self-confidence in their abilities
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to perform the role competencies.
Second, educational preparation may affect nurses’ self-confidence with performing the
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core functions of the CNL role. CNL program curricula conform to the Institute of Medicine’s
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recommendations to promote clinicians’ effectiveness in complex organizational settings (Committee on the Quality of Health Care in America, 2001). There are currently five
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educational entry points for CNL practice. These include a traditional master’s program for individuals with a bachelor’s degree in nursing, including a small subset of programs offering
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master’s credits for a post-BSN residency program; a direct-master’s entry option for individuals
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with a bachelor’s degree in another field; RN-MSN program designed for individuals with associate degrees in nursing; and a post-master’s certificate option for individuals with master’s
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preparation in another area of study. Currently, more than 50 percent of CNLs are graduates of the direct master’s entry programs, or Model C programs (AACN, 2012). Research on direct master’s entry programs suggests that non-nurse college graduates successfully develop into advance practice registered nurses (APRNs) and certified nurse midwives (CNMs) (Pellico, Terrill, White & Rico, 2012). As noted previously, the care planning, outcomes management and process improvement skills associated with CNL practice may represent new practice competencies for most CNL program graduates. Therefore, graduates from the Model C direct graduate entry programs are likely to
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be as confident in their abilities to carry out the core functions of the CNL role as nurses prepared for the CNL role designed for individuals with a prior nursing education.
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Third, organizational context may shape individuals’ perceptions of their ability to perform the CNL role competencies. According to the AACN, more than 200 health care
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organizations in the United States have partnered with schools of nursing to adopt the CNL role (AACN, 2012). The CNL role has been implemented in a variety of settings, including for-profit
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and not-for-profit hospitals, and most notably, Veteran’s Health Administration health system
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(Ott, Haddock, Fox, Shinn, Walter, et al. 2009; VA Strategic Plan, 2009), Differences in organizational ownership, mission and strategy, including the maturity of
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quality improvement programs (Watcher, 2010) and nursing practice models are likely to shape the environment for CNL practice that, in turn, will influence nurses’ perceptions of their ability
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to perform the core functions of the CNL role. Thus, CNLs’ perceptions of their confidence with
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carrying out the role competencies are likely to vary by organizational context.
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Finally, geographic location may also influence nurses’ perceptions of their confidence with carrying out the CNL role functions. CNLs from regions with a larger concentration of CNL programs and organization that have adopted the role are likely to be more confident in their abilities to function in the CNL role because there is a community of practice for learning and consultation. Design and Methods I gathered cross-sectional survey data from a national sample of registered nurses who passed the national CNL certification exam administered by the Commission for Nurse Certification (CNC), an autonomous arm of the AACN.
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Sample. The population (n=1378) of registered nurses certified as CNLs in March of 2011 received an invitation to participate in the study sent to the email address listed in the CNC
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database. The invitation included a link to the CNLSES survey that was created and managed
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using the Qualtrics survey software (Qualtrics.com). The CNLSES survey was open from March to September 2011. Eligible participants received three emailed reminders sent at six week
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intervals until the survey site was closed. The study was reviewed and approved by the
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Institutional Review Board at ABC University.
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Instruments and Variables. Respondents’ perceptions of their confidence in performing practice competencies associated with the CNL role were measured with the Clinical Nurse Leader Self-
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Efficacy Scale (CNLSES) (Gilmartin & Nokes, in press). The CNLSES is a thirty-five item state-specific self-efficacy scale that assesses nurses’ perceptions of their ability to function
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effectively as a CNL. The CNLSES items are presented in Table 1. Based on Bandura’s (2006)
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well-established survey assessment of self-efficacy, the CNLSES assess individuals’ confidence in performing thirty-five CNL role competencies using a 5 point Likert scale (1= not at all
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confident through 5= extremely confident). Respondents rated their self-confidence in performing each of the thirty-five role activities on the day that they completed the CNLSES survey. Because the survey was sent to all certified CNLs, respondents serving as program faculty were asked to rate their self-confidence in teaching each of the thirty-five CNL practice competencies. The CNLSES reflects the AACN’s prescribed CNL practice competencies in the domains of 1). nursing leadership: to actively manage care coordination activities; 2). clinical outcomes management: to promote evidence based practice and data-based clinical decision making; and, 3). care environment management: to promote clinical quality and safety (AACN, 2007). The
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nine indices in the CNLSES are 1). population based care (9 items, α .93); 2). care planning (6 items, α .93); 3). unit-based strategic leadership (4 items, α .89); 4). managing financial
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resources (6 items, α .92); 5). team management (2 items, α .83); 6). continuing education (2
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items, α .91); 7). mobilizing others (3 items, α .86); 8). professional leader (1 item, N/A), and; 9). mentor (2 items, α .98). For example, a question from the population-based care index is: “In
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your practice as a CNL how confident are you that you can translate clinical research to improve
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practice routines.” A question from the unit-based strategic leadership index is: “In your practice as a CNL how confident are you that you can apply the organization’s strategic plan to guide
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practice on your unit?”
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Dependent Variables.
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---------------Insert Table 1 around here -----------------
Clinical Nurse Leader Role Competencies. The nine role competencies associated with CNL
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practice is the dependent variable. Predictor Variables
1) Experience as a Clinical Nurse Leader. Measured as the time employed as a Clinical Nurse Leader in years and months. 2) Graduate Program Model. There are five types of master’s degree programs preparing Clinical Nurse Leaders recognized by the AACN. These include: Program Model A designed for graduates holding a bachelor’s of science degree in nursing (BS); Program Model B designed for BS graduates that includes a post-BS residency that awards master’s credit; Program Model C designed for individuals with a bachelor’s degree in another discipline
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(i.e., direct master’s entry program); Program Model D designed for associate degree graduates (RN-MSN program); Program Model E awarding a post-master’s certificate for
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individuals with a master’s degree in nursing in another area of study. These data were
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collapsed into the categories: Model A that included responses from those attending both
as the referent group in the regression models.
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Model A and B programs; Model C programs; the Model D, E and N/A categories were used
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3) Year Graduated from CNL program. Measured as the year graduated from a CNL program
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4) Years of Experience in Nursing. Measured as the calendar year graduated from a basic nursing education program to become a registered nurse.
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5) Organizational Ownership. Organizational ownership was measured in one of four
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categories: for-profit, not-for-profit, public and Veteran’s Administration. The VA was used as the referent group in the regression models because it is an early adopter of the CNL role.
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The not-for-profit and public ownership categories were merged into one category for
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regression analysis.
6) Employed in a position with a CNL title. Measured as a binary Yes/No categorical variable. CNL job title = 1; No or Not Applicable = 0. Respondents working as CNL program faculty were included in the No or Not Applicable category. 7) Geographic region. Measured as a categorical variable using the United States Census regions. Collapsed into four regions: Midwest, Northeast, South and West. The Western region was used as the referent group in the regression model. Data Analysis
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Data were analyzed using a general linear regression model (GLM) to account for the use of a dependent variable measured on an ordinal scale with predictor variables measured on
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categorical, interval, and ordinal scales. I checked for potential multicollinearity among the
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predictor variables and found none. Analyses were conducted using Statistical Analysis
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Software (SAS) version 9.1. Results
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One hundred and ninety seven (n=197) surveys were returned. Of the returned surveys,
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50 had missing data for all the items, suggesting that respondents activated the survey link and decided not to complete the survey after it was launched. These 50 cases with missing data for all
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questions were deleted from the data set, leaving a final sample of 147 cases and a response rate of 9.4% (147 respondents/1378 eligible participants). This response rate compares reasonably
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well with the rate obtained for the Commission for Nurse Certification’s 2011 job analysis
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survey (258 respondents/1560 eligible participants; 16.7% response rate) (Tan, 2011). So as to maintain statistical power, the 22 respondents serving as CNL program faculty were retained in
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the analytic sample. I conducted analyses comparing the characteristics of respondents to the population of CNLs; results from these analyses (reported below) indicate that the sample largely represents the CNL population. . Sample. The respondents are predominately female (93% of respondents); hold a Bachelor’s of Science degree (BS) as their first degree in nursing (69% of respondents) and have an average of 19.9 years (s.d. =12.24 years) of experience in nursing. Fifty-five percent of the respondents attended a Model A CNL program, a master’s degree program designed for graduates with a bachelor’s degree in nursing, with nearly 50% of the respondents graduating from a CNL program in 2009 or 2010. Twenty-one percent of the respondents work for the U.S.
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Department of Veteran’s Affairs and 32% of respondents live in the Midwestern region of the
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United States. The demographic characteristics of the respondents are reported in Table 2.
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The sample of respondents is largely representative of the population of CNLs, according
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to AACN data, with a slight over-representation of respondents from the Midwest region of the United States. According to 2012 AACN data, there are 28 CNL programs in this region,
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representing approximately 28% of the total number of CNL programs. For the employment setting, the VA is over represented in the sample as compared to the
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proportion of VA hospitals in the population of US hospitals. This is expected because the VA
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has been an early adopter of the CNL role, with a national strategic agenda to integrate CNLs at each facility across the national network of one hundred and fifty three VA hospitals by 2016
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(Veterans’ Administration, 2009). This sample has a larger percentage of male respondents than
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the general RN population (9% in the CNL sample versus 5% in the 2008 RN population survey estimates). As expected, due to the direct master’s entry CNL program model, the sample has a larger percentage of nurses prepared with a master’s degree as their initial education for entering the profession, than the general nursing population. According to the 2008 RN Population Survey, 13, 235 individuals or 0.4 % of the RN population hold a master’s degree as their initial educational preparation (US Department HHS, 2008). --------------------------Insert Table 3 around here -----------------------------Respondent’s confidence with performing the CNL role competencies.
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Table 3 shows results from the GLM regression models. Overall, 7 of 9 models were statistically significant, accounting for 14-28% of the variation. Respondents’ demonstrated
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variation in their confidence with performing the nine role competencies associated with CNL
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practice measured by the CNLSES. The mean score and standard deviation for each of the nine dependent variables suggests that not all respondents were equally confident in their abilities to
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perform the CNL role competencies. Respondents’ were least confident in their abilities to
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function as a unit-based strategic leader (mean = 3.55, s.d.=0.508) and most confident in their abilities to develop and implement a total plan of care for individual clients (mean=4.20, s.d. =
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0.703).
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Experience in the CNL role. Experience in the CNL role was a significant predictor for two of the nine role competencies. Respondents with longer experience as a CNL were more
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confident in performing the role functions associated with unit-based strategic leadership and
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assuring the continuing education of unit staff than other respondents. Educational Preparation . Graduates from the Model A and B CNL master’s programs
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designed for individuals with a bachelor’s degree in nursing were less confident in performing care planning or serving as mentors for other CNLs, as compared to respondents graduating from the D and E model programs or those serving as program faculty. Respondents graduating from the direct master’s entry Program Model C, designed for individuals with a bachelor’s degree in another field, were less confident in performing seven of the nine role competencies associated with the CNL role. Compared to others, the Model C program graduates were less confident in performing activities associated with population based care; care planning; unit-based strategic leadership; team management; continuing education; mobilizing others and serving as a mentor to other CNLs.
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Organizational Type. CNLs working in for-profit organizations were less confident in their team management abilities than the respondents working in the VA organizations. In
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comparison, CNLs working in not-for profit or public hospitals were more confident in their
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abilities related to ensuring the continuing education of the nursing staff and serving as a mentor
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to other CNLs than respondents employed in other organizations.
Position using the skills of a CNL. Respondents who did not hold a formal job title of
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CNL, but used the knowledge and skills associated with CNL practice, were more confident in
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their abilities to effectively manage the care team than respondents employed in a formal CNL position.
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Geographic Region. Respondents reported differences in their confidence to carry out the CNL role competencies that varied by geographic region. Respondents employed in the
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Midwestern region of the United States were more confident in performing the care planning
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activities and ensuring the continuing education of unit staff than other respondents/respondents
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from the Western region (referent group). At the same time, respondents from the Midwestern region were less confident in their abilities to function effectively as a unit-based strategic leader than other respondents. Respondents from the Northeastern region of the United States were more confident in their abilities to perform effectively in the population-based care, continuing education, mobilizing others and mentoring role competencies than other respondents. Finally, respondents living in the Southern region of the United States were less confident in their unit based strategic leadership abilities on the one hand, and more confident in their abilities to ensure the continuing education of unit staff than other respondents, on the other.
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Discussion The findings from this study have implications for research, education and practice to
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inform strategies that promote effective role transitions to gain the full benefit of CNL practice.
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Using self-report data from a national sample of nurses certified as CNLs, this study adds to the literature on the implementation of the CNL role by empirically identifying personal and
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contextual factors that explain variation in individuals’ levels of self-confidence in performing
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for research on CNL role implementation.
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the key functions of the CNL role. The results of this study point to a number of new avenues
Psychological Factors. The findings from this study extend prior work on the role that
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psychological factors play in the day-to-day work performance of nurses pursuing careers as CNLs (Dzurec, Allchin, Engler, Szarlan, Polifroni & Brewer, 2006). In particular, self-
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confidence is an important psychological factor associated with successful career transitions
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(Stakjovic & Luthans, 1998; Stephens, 1994), and my results show how self-confidence varies among CNLs. There has been only one other prior study of the role of psychological factors
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associated with CNL performance: Dzurec and colleagues (2006) examined data from a sample of direct master’s entry CNL students and found that, in comparison to traditional undergraduate nursing students, the CNL students were less depressed, less fatigued and more pessimistic in their outlook. Future studies should extend the work above by including key measures of individual characteristics such as the as the Big 5 Personality traits (i.e., extraversion, agreeableness, conscientiousness, emotional stability, and openness) (McCrae & Costa, 1987); core selfevaluation traits (i.e.: self-esteem, generalized self-efficacy, locus of control, and emotional stability) (Judge & Bono, 2001), or openness to change (Oreg, 2003).
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Educational preparation to become a CNL. Contrary to expectations, respondents who graduated from, direct graduate entry Model C programs had low levels of confidence in
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performing seven of the nine competencies associated with the CNL role as compared to
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graduates of other program models. According to data from the Commission for Nursing Certification, there are currently 913 graduates from Model C programs, comprising
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approximately 56% of the CNL population (ANCC, 2012). This result suggests the need for a
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focused intervention and career transition strategy to bolster self-confidence in this group of
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CNLs.
Master’s entry programs in nursing, usually completed in three years of study are
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designed for individuals with a degree in another field who are entering nursing as a career change. First developed in the 1960s (Pellico et al., 2012) these programs seek to reduce the time
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it takes to produce new nurses with the goal of meeting the national demand for advanced
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practice nurses. Pellico and colleagues’ (2012) recent integrated review of graduate entry programs in nursing suggests that non-nurse college graduates successfully develop into APRNs
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and CNMs. This evidence bodes well for graduates of the Model C CNL programs. Although the literature suggests that individuals do successfully transition into new nursing roles, understanding of the career transition process for direct master’s entry graduates is limited. It is important to note that the current research on the transitions of non-nurse master’s entry to practice graduates focuses on the well-established advanced practice RN and Certified Nurse Midwife nursing roles. Respondents’ relative low levels of self-confidence may be related to the development of the CNL role, rather than the personal adjustment component associated with career transitions. That is, given the newness of the CNL role and the lack of knowledge on the part of other nurses, health professionals and managers regarding the scope of practice and
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potential benefits to patients and the organization (Sherman, 2010; Moore & Leahy, 2012), CNLs may be placed in a situation of justifying the CNL role and their credentials to function in
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the role, a situation that is likely to diminish self-confidence. More research focused on the
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direct-graduate entry to practice group of CNLs is warranted to understand the relationship of personal adjustment and role development on the career transitions of non-nurses into a high
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profile clinical leadership position.
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Organizational Context. Results from this study suggest that organizational ownership is
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associated with CNLs’ confidence in performing difference aspects of the role. Ownership is a variable that researchers commonly use as a proxy for an organization’s mission, values, and
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strategy (Reuf & Scott, 1998). Differences in organizational ownership may be related to variation in the goals of CNL practice, which, in turn, may affect CNLs’ confidence in their
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ability to achieve these goals. For example, the Chief Nurse Officer that adopts the CNL role to
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improve performance and reimbursement rates associated with the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) (Center for Medicare
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Services, U.S. Department Health and Human Services, 2010) core measures and nurse sensitive outcomes will design the CNL role differently than the Chief Nurse Officer who seeks to improve staff engagement and nurse-physician communication and collaboration. Future research examining relationships between organizational ownership and CNL selfefficacy should develop understanding of the mechanisms associated with CNLs’ confidence in performing their core role functions. Similarly, future studies should include key variables not only to account for the nursing practice environment, but also organizational strategy and performance as important contextual factors that may account for variations in the design of the
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CNL role, and by extension, a determinant of an individual’s confidence in performing the core role functions (Nicholson, 1984; Stephens, 1994).
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Another aspect of the organizational context that merits further study is the content and structure of CNL academic-service partnerships used to formalize and institutionalize the CNL
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role (De Geest, Dobbels, Schonfeld, Duerinckx, Sveinbjarnardottir & Denjaerynck, 2013). According to the AACN (2007), the purpose of academic-service partnerships is to promote the
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rapid diffusion and adoption of the CNL role into practice settings. In the ideal model, the
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academic partner is responsible for ensuring that graduates possess the knowledge, skills and abilities to effectively lead care coordination, quality improvement and clinical outcome
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management activities. In turn, the service partner is responsible for creating a receptive environment for CNL practice by attending to changes in organizational systems and structures;
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including role descriptions, reporting relationships, staff education, and performance
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expectations (Smith & Dabbs, 2007; AACN CNL Tool Kit, no date).
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More than fifty percent of the respondents participating in this study do not hold a job title of CNL, suggesting that they are employed in organizations that have not formally adopted the CNL role. More work to understand the nature of the academic-service partnership that are both committed to the CNL initiative and aligned to educate and employ nurses as CNLs will be important to understand the adoption and diffusion of the CNL role over time and across organizations. CNL Job Title. Interestingly, holding a formal job title of CNL was not a significant predictor of respondent’s confidence with performing core competencies associated with the CNL role. This finding provides some evidence supporting a shift away from conceptualizing the
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CNL as a formal unit-based role with responsibilities for microsystem functioning to conceptualizing the core knowledge associated with CNL practice as a skill set with applications
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to a range of existing positions with responsibility for clinical quality, safety and performance
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improvement. More research is needed to understand differences in the practice patterns and the associated self-confidence with the role competencies of nurses employed in formal CNL
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positions with those who bring new knowledge of leadership, outcomes management and
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performance improvement gained through graduate education as a CNL to other clinical or
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management positions.
Regional differences. The results suggest that CNL’s confidence with performing the key
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competencies associated with the role vary by geographic region. For example, respondents working in the Northeastern region of the United States were more confident in their abilities to
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perform the population based care, continuing education for unit staff, mobilizing others and the
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mentoring functions associated with the CNL role than others. In comparison, respondents from the Midwest region of the United States were more confident in their abilities for care planning
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and ensuring continuing education for staff, but were less confident in their abilities to function as a unit-level strategic leader than other respondents. These findings point to local variations within communities of practice that warrant further study. Faculty self-confidence. More research is needed on CNL program faculty members’ confidence with teaching the core role competencies. To date, no studies have examined faculty members’ mastery of the key knowledge and skills associated with CNL practice. Quality improvement, patient safety, and organizational performance are relatively new content in the educational curricula of the health professions (Institute of Medicine, 2001; 2003; Cronenwett, Sherwood, Barnsteiner, Disch, Johnson, et al., 2007). Because CNL program faculty are on the
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forefront of educating a new generation nurses as point-of-care quality and safety clinicians (Reid & Dennison, 2012), there are likely to be variations in faculty confidence with teaching the
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prescribed curriculum outlined in the Clinical Nurse Leader White Paper (2007). For example,
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nurse faculty may be very confident with teaching advanced care planning and risk reduction strategies, because the nursing process is an important foundation for professional practice and a
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core element of undergraduate and graduate curricula. In comparison, nurse faculty may have
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less exposure and familiarity with teaching CNLs how to assess unit (microsystem) performance and to develop a successful change management plan focused on improving a particular practice
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problem (McKeon, Norris, Web, Hix, Ramsey & Jacobs, 2009). More research focusing on CNL faculty would be useful to understand the contributions of faculty expertise to the personal
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development aspect of the work role transitions of their students.
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Person by Environment Interaction Effects. Finally, my results point to a number of new
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avenues for research examining interactions among both personal characteristics and the organizational environment that may affect nurses’ transitions into the high profile CNL role.
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For instance, consider the relationships among personality, work experience and organizational support for the CNL role. It may be that an expert staff nurse with a strong belief in his ability to control his future (i.e., high internal locus of control) working in a hospital with a formal CNL academic-service partnership may be more confident in his abilities to function in the CNL role than a less experienced nurse, who believes that her career is in the hands of others (i.e., high external locus of control), despite working in a hospital with a formal CNL partnership. New studies with larger sample sizes should focus on understanding how personal and organization characteristics interact to promote or hinder nurses’ transitions into the CNL role.
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Limitations
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Of the population of certified CNLs, the final sample of respondents is relatively small. Despite this limitation, the sample reflects the demographic characteristics of the population of
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nurses credentialed as CNLs. Further, the response rate is acceptable for a non-solicited on-line survey (Cook, Heath &Thompson, 2000) and is similar to the response rate for the recent CNL
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job analysis survey conducted by the Commission on Nurse Certification during approximately
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the same time period that this survey was in the field (Tan, 2011). Conclusions
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This study contributes to the literature on the implementation of the CNL role by identifying key variables associated with the personal adjustment and role development involved
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in successful career transitions to the CNL role. Respondents’ confidence in their ability to carry
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out the core functions associated with the CNL role varied across practice competency, geographic region, and organizational type and by the type of graduate program model attended
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to become a CNL. This evidence can be used by nurse managers and program faculty to develop targeted interventions to bolster CNL’s self-confidence in performing the core competencies associated with their role. Because self-confidence is an important predictor of successful career transitions, it is important to understand variations in CNLs’ confidence in their ability to function in the role to promote the overall performance, job satisfaction and retention of the nurses pioneering this innovative clinical leadership role.
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Edwards, J.R. (2008). Person-environment fit in organizations: An assessment of theoretical
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Hix, C., McKeon, L., & Walters, S. (2009). Clinical Nurse Leader impact on Clinical Microsystem outcomes. Journal of Nursing Administration, 39(2), 71-76. doi:
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McCrae, R.R., & Costa, P.T. (1987). Validation of the five-factor model of personality across
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McKeon, L.M., Norris, T.L., Webb, S., Hix, C. Ramsey, G., & Jacob, S.R. (2009). Teaching Clinical Nurse Leaders how to diagnose clinical microsystems. Journal of Professional
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Moore, L.W. & Leahy, C. (2012). Implementing the new clinical nurse leader role with gleaning
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Oreg, S. (2003). Resistance to change: Developing an individual difference scale. Journal of
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Harris, J.L. (2009). The clinical nurse leader ®: Impact on practice outcomes in the Veterans Health Administration. Nursing Economics, 27 (6), 363-373. Pellico, L.H, Terrill, E., White, P., & Rico, J. (2012). Integrative review of graduate entry programs in nursing. Journal of Nursing Education, 51(1), 29-37. doi: 10.3928/01484834-20111130-01. Accessed July 28, 2012. Poulin-Tabor, D., Quirk, R.L., Wilson, L., Orff, S., Gallant, P., Swan, N., et al. (2008). Pioneering a new role: The beginning, current practice and future of the clinical nurse leader. Journal of Nursing Management, 16, 623-628.
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Reid, K., & Dennison, P., (2012). "The Clinical Nurse Leader (CNL)®: Point-of-Care Safety Clinician" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 3, Manuscript 4.
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Leaders. Journal of Nursing Administration, 49(12), 547-554.
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Stakjovic , A.D. & Luthans, F. (1998). Self- efficacy and work-related performance: A meta-
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Stanley, J.M., Hoiting, T., Burton, D., Harris, J., & Norman, L. (2007). Implementing innovation through education-practice partnerships. Nursing Outlook, 55(2), 67-73. Stanton, M.P, Lammon, C.A., & William, E.S. (2011). The Clinical Nurse Leader: A comparative study of the American Association of Colleges of Nursing vision to role implementation. Journal of Professional Nursing, 27(2), 78-83. Stephens, G. K. (1994). Crossing internal career boundaries: The state of research on subjective career transitions. Journal of Management, 20(2), 479-501.
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Tan, R.J.B. (2011). Job analysis summary report 2011. Commission for Nurse Certification, Washington, D.C.
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Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.
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Tornabeni, J. & Miller, J.F. (2008). The power of partnership to shape the future of nursing: The evolution of the clinical nurse leader. Journal of Nursing Management, 16(5), 608-613.
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Table 1: The Clinical Nurse Leader Self-Efficacy Scale
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Index 1 “Population based care” (α = .93)
1. Acquire information about the population through information systems
3. Identify population-level health problems
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2. Seek knowledge about specific populations from the research literature
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4. Use information systems to track population-level health problems 5. Resolve population-level health problems
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6. Translate clinical research to improve practice routines 7. Review unit performance to project risks to client safety
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8. Review unit performance to project risks to quality of care
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9. Incorporate evidence based practice changes into clinical information technology systems
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Index 2 “Care planning” ( α = .93)
1. Assume accountability for the welfare of client populations served on your unit
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2. Identify client population risk based on a comprehensive assessment 3. Collaborate with cohorts of clients to design a total plan of care 4. Collaborate with clients in gaining their endorsement for the total plan of care 5. Consult appropriately with other health professionals to design a total plan of care for your clients 6. Advocate effectively on behalf of the client with the intervention team Index 3 “Unit-based strategic leadership” (α = .89) 1. Represent your unit on organizational committees 2. Know the organization’s mission 3. Apply the organization’s strategic plan to guide practice on your unit
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4. Practice in accordance with the values of the organization Index 4 “Managing financial resources” ( α = .92)
3. Use technology to reduce costs
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2. Identify opportunities for cost savings on your unit
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1. Identify waste on your unit
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4. Identify opportunities for revenue enhancement to benefit clients
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5. Create proposals to modify your unit using alternative business models 6. Create proposals to modify unit incorporating return of investment (ROI) analyses
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Index 5 “Team management” ( α = .83) 1. Meet regularly with intervention team
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2. Evaluate the intervention team’s performance with achieving patient care outcome goals
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Index 6 “Continuing education” ( α = .91) 1. Assure the continuing education of the team members
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2. Educate your unit’s staff on innovative practices
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Index 7* “Mobilizing others” ( α = .86) 1. Appropriately deploy human resources to improve outcomes 2. Mobilize managers to deploy resources 3. Mobilize informal leaders to deploy resources Index 8 “Professional leader” (α = NA) 1. Act as leader in relevant professional organizations Index 9 “Mentor” (α = .98) 1. Mentor other CNL™s 2. Act as a preceptor for other CNL™s *Items in this factor failed to reach the .600 threshold for item loading. These items should be subjected to further testing.
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Gender Male n=9 (6.62%) Female n=127 (93.3%) Age Mean= 46.07 years S.D. = 10.93 (Min 25 - Max 70) Educational Preparation to Enter Nursing Diploma n=18 (12.4 %); Associate Degree n=31 (21.3%); Bachelor Degree n=61 (47.5%); Master Degree n=27 (18.6 %) Years since graduating from basic nursing program Range 1962-2001. Mean =19.91 S.D. = 12.24 CNL Program Model Model A n=79 (55.2%); Model B n=6 (4.20%); Model C n=25 (17.5%); Model D n=2 (1.40%); Model E n=2 (1.40%); Not applicable n=24 (16.78%) Year graduated from CNL program 2005 n=1 (.72%); 2006 n=3 (2.17%); 2007 n=19 (13.7%); 2008 n=15 (11%); 2009 n=32 (23%); 2010 n=37 (27%); 2011 n=9 (7%); NA n=22 (16%) Geographic Region New England n=12 (8.2 %)
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Table 2: Respondent Demographics
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New York-New Jersey n=11 (7.6%) Mid-Atlantic n=14 (9.6%) Southeast n=26 (18 %) Midwest n=46 (32%) Southwest n=3 (2.7%) Mountain-Plains n=5 (3.5 %) Western n=28 (19.3%) Organization Type For-profit n=10 (6.9%) Not-for-profit n=90 (62%) Public n=14 (9.6%) Veteran Affairs n=31 (21.3%) Job title of CNL Yes n=57 (39%) No n=79 (55%) Not Applicable n=9 (6.21) CNL Faculty Yes n = 22 (15%) No n = 121 (85%)
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Table 3: Respondents’ Confidence in Performing the CNL Role Competencies
Region NE Region S
R2 for Model F Value Pr > F
Team Mgmt 4.095 0.796
0.0888 0.0116
4.166 0.838
Mobliz Others 3.673 0.864
Prof Lead 4.176 0.919
Mentor 4.011 0.902
0.1065 0.0545
-0.6796 0.0201
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-0.2875 0.1271
-1.5526 0.0001
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---0.7898 0.5624 0.8858 0.0084 0.0590 0.0048
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---0.5206 0.7593 0.5035 0.0488 0.0035 0.0079
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Finan Resou 3.602 0.902
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Strat Lead 3.553 0.508
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Type HCO not profit/ public CNL Title NO/NA Region MW
Care Plan 4.200 0.703
-0.4598 0.1200 0.3182 0.0876
0.43182 0.0834
0.2443 0.1016
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Mean SD Variables Experience as CNL Program Type A&B Model Program Type C Model Year Complete CNL program Year Complete Basic RN Type HCO for-profit
Pop Care 4.004 0.704
0.3464 -0.0601 0.1506 0.2619
0.3558 0.1034 -0.2316 0.0811
0.3796 0.0751 0.8017 0.5535 0.0014 0.032 0.5612 0.0081
0.1427 0.2357 0.1885 N/S
0.1996 0.2806 0.1970
1.83 3.39 2.56 0.0556 0.0004 0.0061
2.74 4.29 0.0033
S8755-7223(13)00188-9 doi: 10.1016/j.profnurs.2013.11.002 YJPNU 800
To appear in:
Journal of Professional Nursing
Please cite this article as: Gilmartin, M.J., Variations in Clinical Nurse Leaders’ Confidence with Performing the Core Role Functions, Journal of Professional Nursing (2013), doi: 10.1016/j.profnurs.2013.11.002
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Variations in Clinical Nurse Leaders’ Confidence with Performing the Core Role Functions
Mattia J. Gilmartin RN, PhD
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Senior Research Scientist
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New York University College of Nursing 726 Broadway 10th floor
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New York, NY. 10003 Tel: 212-992-7128
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Email: [email protected]
This study was supported by a grant from the American Nurses Foundation/Nurses in Staff Development. 2010-090, M. J. Gilmartin, RN, PhD, Principal Investigator.
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Variations in Clinical Nurse Leaders®’ Confidence with Performing the Core Role Functions
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Abstract Background: CNL practice, by definition, requires individuals to make career transitions.
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CNLs must adjust to their new work role and responsibilities and doing so also entails individual
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adjustment. Prior work has not examined the role of individual-level factors in effective CNL
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role transition.
Aim: This study contributes to CNL implementation efforts by developing understanding of
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personal and contextual factors that explain variation in individuals’ levels of self-confidence
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with performing the key functions of the CNL role.
Design and Methods: Data were gathered using a cross-sectional survey from a national sample
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of RNs certified as CNLs. Respondents’ perceptions of their confidence in performing CNL role competencies were measured with the Clinical Nurse Leader Self-Efficacy Scale (CNLSES)
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(Gilmartin & Nokes, in press). The CNLSES is a thirty-five item state-specific self-efficacy scale
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with established measurement properties that assesses nurses’ perceptions of their ability to function effectively as a CNL. Demographic data were also collected. Data were analyzed
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using a general linear regression model (GLM). Results: One hundred and forty-seven certified CNLs participated in the survey. Results indicate that respondents vary in their confidence with performing the nine role competencies associated with CNL practice. Results from regression analyses also show that respondents’ confidence in their abilities to carry out the core functions associated with the CNL role varied significantly across geographic region, organizational type and by CNL graduate program model.
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Conclusions: The results of this study show important differences in CNLs’ levels of selfconfidence with the core competencies of their role. As a result, it may be important to develop
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targeted career transition interventions to gain the full benefit of CNL practice.
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Variations in Clinical Nurse Leaders®’ Confidence with Performing the Core Role Functions
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Introduced in 2004, the Clinical Nurse Leader (CNL®) is the first new nursing role in more than thirty years (American Association of Colleges of Nursing, 2007). The goal of the
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CNL role is to return expert clinicians to the point of care to strengthen the nursing professions’ contributions to improve the quality, safety and outcomes of health care in the United States. The
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hallmark of CNL practice is the management of client centered care and clinical excellence at the
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point of care (AACN, 2007; Reid & Dennison, 2012; Ott et al., 2009; Hix, McKeon & Walters, 2009).
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Unlike other masters prepared roles in nursing, the CNL is an advanced generalist with unit-level responsibility. Because of their generalist orientation, the scope of CNL practice
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complements that of the front-line nurse manager, on the one hand, and the nurse practitioner
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and clinical nurse specialist, on the other (AACN, 2007). Graduate education for the CNL role extends the direct care skills acquired at the baccalaureate level to build competence in the area
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of policy and organizations, outcomes management, nursing leadership and care management (ANCC, 2007). CNLs are educated to assume responsibility for interdisciplinary care coordination; managing clinical outcomes, with a particular focus on promoting health and preventing disease in populations; and implementing clinical quality improvement and risk management programs within the context of a clinical unit. To promote the diffusion of the CNL role in both academic and practice settings, the American Association of Colleges of Nursing (AACN) specified the development of CNL program curricula; clinical and didactic experiences required for certification as a CNL; and academic-service partnerships to serve as a mechanism for each partner to initiate the CNL role,
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with the goal of hiring CNL program graduates into formal CNL positions at the partner organization (Stanley, Hoiting, Burton, Harris & Norman, 2007). The White Paper on the
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Education and Role of the Clinical Nurse Leader (2007) outlined these requirements, that also
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are described elsewhere (Bartels & Bednash, 2005; Stanley, Hoiting, Burton, Harris & Norman, 2007; Torabeni & Miller, 2008).
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Although clinical practicum experiences are a common feature of nursing education
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programs, the role transition experience for individuals pursuing the CNL role differ in important ways from experiences provided in other graduate programs in nursing. Ideally, CNL education
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and transition to practice occur within the context of an academic-service partnership (AACN, 2007). The academic-service-partnership model serves to promote CNL role implementation by
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aligning academic and organizational goals; each partner is committed to educating and
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employing nurses to lead and manage clinical improvement initiatives. CNL students complete between 400 and 500 clinical contact hours during the program, 300 to 400 of which are
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structured as an immersion experience in the CNL role with a dedicated preceptor and a faculty
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partner over a ten to fifteen week period (AACN, 2007). During the immersion experience, students have the option to select a new clinical practice area for the practicum experience as a means to promote transitions into a new practice area after graduation (Bombard, Chapman, Dole, Wright, Shippee-Rice & Kasik, 2010). Prior studies examining the transition experiences of nurses pioneering the CNL role provide important information regarding organizational factors that promote or hinder the adoption of the CNL role in clinical settings (Sherman, 2010; Stanton, Lammon & Williams, 2011; Moore & Leahy, 2012; Bombard et al., 2010). Two recent qualitative studies suggest that
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the CNL role is implemented differently across organizations and practice areas (Stanton et al., 2011; Sherman, 2011).
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The purpose of this study is to develop understanding of factors that account for variation
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in individuals’ self-efficacy in the CNL role. This study contributes to CNL implementation efforts by developing understanding of personal and contextual factors that explain variation in
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individuals’ levels of self-confidence with performing the key functions of the CNL role.
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Understanding differences in CNLs’ levels of self-confidence with the core competencies of the role will provide important information to develop targeted career transition interventions to gain
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the full benefit of CNL practice.
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Role Transitions of Clinical Nurse Leaders
CNL practice, by definition, requires individuals to make career transitions that require
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adjustment to new professional work roles and responsibilities. Doing so also entails individual
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adjustment. Prior research suggests that experienced nurses moving into advanced practice roles
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experience difficulty during role transition because they are expected to function at a higher, more independent, practice level than previously demonstrated in traditional staff nurse roles (Jones, 2005; Sherman, 2010). More generally, an individual’s ability to build a successful career is based on her or his ability to transition to increasingly complex work roles (Nicholson, 1984; Ashforth & Saks, 1995). Work role transitions entail two interdependent adjustment processes: personal development and role development. Personal development includes cognitive and psychological changes in knowledge, skills, confidence, and work identity; motivation for feedback to improve work performance and prior professional socialization experiences. In contrast, role development is reflected in the design of the job within a specific organizational content.
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Managers are typically responsible for attending to the required changes in organizational systems, structures, reporting relationships, politics, culture and resources needed to promote the
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adoption of a new work role (Nicholson, 1984; Edwards, 2008). In sum, the extent to which an
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individual is able to successfully transition to a new work role is predicated on personal characteristics that make her or him well suited for the job, on the one hand, and changes in
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organizational content and job design to promote person-job fit, on the other (Ashforth & Saks,
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1995; Stephens, 1994; Edwards, 2008).
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Self-confidence is an important factor associated with successful role transitions. Selfconfidence is an attitude that enables individuals to have positive, yet realistic, views of
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themselves and their situations. Self-confident people trust their own abilities, have a general sense of control in their lives, and believe that, within reason, they will be able to do what they
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wish, plan, and expect (Stakjovic & Luthans, 1998). Prior research establishes that self-
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confidence is an important factor associated with a number of important work outcomes including successful career transitions, job satisfaction, job performance, and voluntary turnover
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(Stakjovic & Luthans, 1998; Judge, Erez & Bono, 1998). Variations in nurses’ self-confidence associated with transitioning into the CNL role is likely to be influenced by a number of personal and contextual factors. First, because nursing is a contextually situated practice, prior exposure to a particular clinical problem or practice situation builds competence and confidence in the ability to respond appropriately to similar situations (Benner, 2009; Tanner, 2006). Recent analyses of the content of RNs’ daily work suggest that nurses do not have the time for care planning and coordination activities (Lucero, Lake & Aiken, 2009; Chow, 2008), lack skills either to assess the quality of care or integrate evidence into clinical decision making (Kovner, Brewer, Yingrengreung & Fairchild, 2010), or
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work in organizations that have been slow to adopt quality and process improvement techniques into daily routines (Watcher, 2010). Thus, even though many CNLs are experienced staff nurses,
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their exposure to, and confidence with, the core activities of the CNL role may be limited.
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Similarly, experience in the CNL role is likely to affect nurses’ self-confidence in their abilities
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to perform the role competencies.
Second, educational preparation may affect nurses’ self-confidence with performing the
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core functions of the CNL role. CNL program curricula conform to the Institute of Medicine’s
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recommendations to promote clinicians’ effectiveness in complex organizational settings (Committee on the Quality of Health Care in America, 2001). There are currently five
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educational entry points for CNL practice. These include a traditional master’s program for individuals with a bachelor’s degree in nursing, including a small subset of programs offering
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master’s credits for a post-BSN residency program; a direct-master’s entry option for individuals
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with a bachelor’s degree in another field; RN-MSN program designed for individuals with associate degrees in nursing; and a post-master’s certificate option for individuals with master’s
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preparation in another area of study. Currently, more than 50 percent of CNLs are graduates of the direct master’s entry programs, or Model C programs (AACN, 2012). Research on direct master’s entry programs suggests that non-nurse college graduates successfully develop into advance practice registered nurses (APRNs) and certified nurse midwives (CNMs) (Pellico, Terrill, White & Rico, 2012). As noted previously, the care planning, outcomes management and process improvement skills associated with CNL practice may represent new practice competencies for most CNL program graduates. Therefore, graduates from the Model C direct graduate entry programs are likely to
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be as confident in their abilities to carry out the core functions of the CNL role as nurses prepared for the CNL role designed for individuals with a prior nursing education.
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Third, organizational context may shape individuals’ perceptions of their ability to perform the CNL role competencies. According to the AACN, more than 200 health care
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organizations in the United States have partnered with schools of nursing to adopt the CNL role (AACN, 2012). The CNL role has been implemented in a variety of settings, including for-profit
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and not-for-profit hospitals, and most notably, Veteran’s Health Administration health system
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(Ott, Haddock, Fox, Shinn, Walter, et al. 2009; VA Strategic Plan, 2009), Differences in organizational ownership, mission and strategy, including the maturity of
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quality improvement programs (Watcher, 2010) and nursing practice models are likely to shape the environment for CNL practice that, in turn, will influence nurses’ perceptions of their ability
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to perform the core functions of the CNL role. Thus, CNLs’ perceptions of their confidence with
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carrying out the role competencies are likely to vary by organizational context.
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Finally, geographic location may also influence nurses’ perceptions of their confidence with carrying out the CNL role functions. CNLs from regions with a larger concentration of CNL programs and organization that have adopted the role are likely to be more confident in their abilities to function in the CNL role because there is a community of practice for learning and consultation. Design and Methods I gathered cross-sectional survey data from a national sample of registered nurses who passed the national CNL certification exam administered by the Commission for Nurse Certification (CNC), an autonomous arm of the AACN.
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Sample. The population (n=1378) of registered nurses certified as CNLs in March of 2011 received an invitation to participate in the study sent to the email address listed in the CNC
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database. The invitation included a link to the CNLSES survey that was created and managed
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using the Qualtrics survey software (Qualtrics.com). The CNLSES survey was open from March to September 2011. Eligible participants received three emailed reminders sent at six week
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intervals until the survey site was closed. The study was reviewed and approved by the
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Institutional Review Board at ABC University.
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Instruments and Variables. Respondents’ perceptions of their confidence in performing practice competencies associated with the CNL role were measured with the Clinical Nurse Leader Self-
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Efficacy Scale (CNLSES) (Gilmartin & Nokes, in press). The CNLSES is a thirty-five item state-specific self-efficacy scale that assesses nurses’ perceptions of their ability to function
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effectively as a CNL. The CNLSES items are presented in Table 1. Based on Bandura’s (2006)
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well-established survey assessment of self-efficacy, the CNLSES assess individuals’ confidence in performing thirty-five CNL role competencies using a 5 point Likert scale (1= not at all
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confident through 5= extremely confident). Respondents rated their self-confidence in performing each of the thirty-five role activities on the day that they completed the CNLSES survey. Because the survey was sent to all certified CNLs, respondents serving as program faculty were asked to rate their self-confidence in teaching each of the thirty-five CNL practice competencies. The CNLSES reflects the AACN’s prescribed CNL practice competencies in the domains of 1). nursing leadership: to actively manage care coordination activities; 2). clinical outcomes management: to promote evidence based practice and data-based clinical decision making; and, 3). care environment management: to promote clinical quality and safety (AACN, 2007). The
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nine indices in the CNLSES are 1). population based care (9 items, α .93); 2). care planning (6 items, α .93); 3). unit-based strategic leadership (4 items, α .89); 4). managing financial
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resources (6 items, α .92); 5). team management (2 items, α .83); 6). continuing education (2
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items, α .91); 7). mobilizing others (3 items, α .86); 8). professional leader (1 item, N/A), and; 9). mentor (2 items, α .98). For example, a question from the population-based care index is: “In
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your practice as a CNL how confident are you that you can translate clinical research to improve
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practice routines.” A question from the unit-based strategic leadership index is: “In your practice as a CNL how confident are you that you can apply the organization’s strategic plan to guide
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practice on your unit?”
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Dependent Variables.
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---------------Insert Table 1 around here -----------------
Clinical Nurse Leader Role Competencies. The nine role competencies associated with CNL
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practice is the dependent variable. Predictor Variables
1) Experience as a Clinical Nurse Leader. Measured as the time employed as a Clinical Nurse Leader in years and months. 2) Graduate Program Model. There are five types of master’s degree programs preparing Clinical Nurse Leaders recognized by the AACN. These include: Program Model A designed for graduates holding a bachelor’s of science degree in nursing (BS); Program Model B designed for BS graduates that includes a post-BS residency that awards master’s credit; Program Model C designed for individuals with a bachelor’s degree in another discipline
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(i.e., direct master’s entry program); Program Model D designed for associate degree graduates (RN-MSN program); Program Model E awarding a post-master’s certificate for
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individuals with a master’s degree in nursing in another area of study. These data were
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collapsed into the categories: Model A that included responses from those attending both
as the referent group in the regression models.
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Model A and B programs; Model C programs; the Model D, E and N/A categories were used
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3) Year Graduated from CNL program. Measured as the year graduated from a CNL program
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4) Years of Experience in Nursing. Measured as the calendar year graduated from a basic nursing education program to become a registered nurse.
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5) Organizational Ownership. Organizational ownership was measured in one of four
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categories: for-profit, not-for-profit, public and Veteran’s Administration. The VA was used as the referent group in the regression models because it is an early adopter of the CNL role.
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The not-for-profit and public ownership categories were merged into one category for
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regression analysis.
6) Employed in a position with a CNL title. Measured as a binary Yes/No categorical variable. CNL job title = 1; No or Not Applicable = 0. Respondents working as CNL program faculty were included in the No or Not Applicable category. 7) Geographic region. Measured as a categorical variable using the United States Census regions. Collapsed into four regions: Midwest, Northeast, South and West. The Western region was used as the referent group in the regression model. Data Analysis
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Data were analyzed using a general linear regression model (GLM) to account for the use of a dependent variable measured on an ordinal scale with predictor variables measured on
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categorical, interval, and ordinal scales. I checked for potential multicollinearity among the
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predictor variables and found none. Analyses were conducted using Statistical Analysis
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Software (SAS) version 9.1. Results
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One hundred and ninety seven (n=197) surveys were returned. Of the returned surveys,
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50 had missing data for all the items, suggesting that respondents activated the survey link and decided not to complete the survey after it was launched. These 50 cases with missing data for all
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questions were deleted from the data set, leaving a final sample of 147 cases and a response rate of 9.4% (147 respondents/1378 eligible participants). This response rate compares reasonably
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well with the rate obtained for the Commission for Nurse Certification’s 2011 job analysis
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survey (258 respondents/1560 eligible participants; 16.7% response rate) (Tan, 2011). So as to maintain statistical power, the 22 respondents serving as CNL program faculty were retained in
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the analytic sample. I conducted analyses comparing the characteristics of respondents to the population of CNLs; results from these analyses (reported below) indicate that the sample largely represents the CNL population. . Sample. The respondents are predominately female (93% of respondents); hold a Bachelor’s of Science degree (BS) as their first degree in nursing (69% of respondents) and have an average of 19.9 years (s.d. =12.24 years) of experience in nursing. Fifty-five percent of the respondents attended a Model A CNL program, a master’s degree program designed for graduates with a bachelor’s degree in nursing, with nearly 50% of the respondents graduating from a CNL program in 2009 or 2010. Twenty-one percent of the respondents work for the U.S.
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Department of Veteran’s Affairs and 32% of respondents live in the Midwestern region of the
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--------------------------Insert Table 2 around here ------------------------------
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United States. The demographic characteristics of the respondents are reported in Table 2.
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The sample of respondents is largely representative of the population of CNLs, according
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to AACN data, with a slight over-representation of respondents from the Midwest region of the United States. According to 2012 AACN data, there are 28 CNL programs in this region,
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representing approximately 28% of the total number of CNL programs. For the employment setting, the VA is over represented in the sample as compared to the
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proportion of VA hospitals in the population of US hospitals. This is expected because the VA
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has been an early adopter of the CNL role, with a national strategic agenda to integrate CNLs at each facility across the national network of one hundred and fifty three VA hospitals by 2016
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(Veterans’ Administration, 2009). This sample has a larger percentage of male respondents than
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the general RN population (9% in the CNL sample versus 5% in the 2008 RN population survey estimates). As expected, due to the direct master’s entry CNL program model, the sample has a larger percentage of nurses prepared with a master’s degree as their initial education for entering the profession, than the general nursing population. According to the 2008 RN Population Survey, 13, 235 individuals or 0.4 % of the RN population hold a master’s degree as their initial educational preparation (US Department HHS, 2008). --------------------------Insert Table 3 around here -----------------------------Respondent’s confidence with performing the CNL role competencies.
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Table 3 shows results from the GLM regression models. Overall, 7 of 9 models were statistically significant, accounting for 14-28% of the variation. Respondents’ demonstrated
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variation in their confidence with performing the nine role competencies associated with CNL
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practice measured by the CNLSES. The mean score and standard deviation for each of the nine dependent variables suggests that not all respondents were equally confident in their abilities to
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perform the CNL role competencies. Respondents’ were least confident in their abilities to
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function as a unit-based strategic leader (mean = 3.55, s.d.=0.508) and most confident in their abilities to develop and implement a total plan of care for individual clients (mean=4.20, s.d. =
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0.703).
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Experience in the CNL role. Experience in the CNL role was a significant predictor for two of the nine role competencies. Respondents with longer experience as a CNL were more
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confident in performing the role functions associated with unit-based strategic leadership and
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assuring the continuing education of unit staff than other respondents. Educational Preparation . Graduates from the Model A and B CNL master’s programs
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designed for individuals with a bachelor’s degree in nursing were less confident in performing care planning or serving as mentors for other CNLs, as compared to respondents graduating from the D and E model programs or those serving as program faculty. Respondents graduating from the direct master’s entry Program Model C, designed for individuals with a bachelor’s degree in another field, were less confident in performing seven of the nine role competencies associated with the CNL role. Compared to others, the Model C program graduates were less confident in performing activities associated with population based care; care planning; unit-based strategic leadership; team management; continuing education; mobilizing others and serving as a mentor to other CNLs.
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Organizational Type. CNLs working in for-profit organizations were less confident in their team management abilities than the respondents working in the VA organizations. In
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comparison, CNLs working in not-for profit or public hospitals were more confident in their
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abilities related to ensuring the continuing education of the nursing staff and serving as a mentor
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to other CNLs than respondents employed in other organizations.
Position using the skills of a CNL. Respondents who did not hold a formal job title of
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CNL, but used the knowledge and skills associated with CNL practice, were more confident in
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their abilities to effectively manage the care team than respondents employed in a formal CNL position.
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Geographic Region. Respondents reported differences in their confidence to carry out the CNL role competencies that varied by geographic region. Respondents employed in the
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Midwestern region of the United States were more confident in performing the care planning
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activities and ensuring the continuing education of unit staff than other respondents/respondents
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from the Western region (referent group). At the same time, respondents from the Midwestern region were less confident in their abilities to function effectively as a unit-based strategic leader than other respondents. Respondents from the Northeastern region of the United States were more confident in their abilities to perform effectively in the population-based care, continuing education, mobilizing others and mentoring role competencies than other respondents. Finally, respondents living in the Southern region of the United States were less confident in their unit based strategic leadership abilities on the one hand, and more confident in their abilities to ensure the continuing education of unit staff than other respondents, on the other.
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Discussion The findings from this study have implications for research, education and practice to
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inform strategies that promote effective role transitions to gain the full benefit of CNL practice.
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Using self-report data from a national sample of nurses certified as CNLs, this study adds to the literature on the implementation of the CNL role by empirically identifying personal and
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contextual factors that explain variation in individuals’ levels of self-confidence in performing
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for research on CNL role implementation.
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the key functions of the CNL role. The results of this study point to a number of new avenues
Psychological Factors. The findings from this study extend prior work on the role that
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psychological factors play in the day-to-day work performance of nurses pursuing careers as CNLs (Dzurec, Allchin, Engler, Szarlan, Polifroni & Brewer, 2006). In particular, self-
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confidence is an important psychological factor associated with successful career transitions
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(Stakjovic & Luthans, 1998; Stephens, 1994), and my results show how self-confidence varies among CNLs. There has been only one other prior study of the role of psychological factors
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associated with CNL performance: Dzurec and colleagues (2006) examined data from a sample of direct master’s entry CNL students and found that, in comparison to traditional undergraduate nursing students, the CNL students were less depressed, less fatigued and more pessimistic in their outlook. Future studies should extend the work above by including key measures of individual characteristics such as the as the Big 5 Personality traits (i.e., extraversion, agreeableness, conscientiousness, emotional stability, and openness) (McCrae & Costa, 1987); core selfevaluation traits (i.e.: self-esteem, generalized self-efficacy, locus of control, and emotional stability) (Judge & Bono, 2001), or openness to change (Oreg, 2003).
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Educational preparation to become a CNL. Contrary to expectations, respondents who graduated from, direct graduate entry Model C programs had low levels of confidence in
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performing seven of the nine competencies associated with the CNL role as compared to
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graduates of other program models. According to data from the Commission for Nursing Certification, there are currently 913 graduates from Model C programs, comprising
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approximately 56% of the CNL population (ANCC, 2012). This result suggests the need for a
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focused intervention and career transition strategy to bolster self-confidence in this group of
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CNLs.
Master’s entry programs in nursing, usually completed in three years of study are
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designed for individuals with a degree in another field who are entering nursing as a career change. First developed in the 1960s (Pellico et al., 2012) these programs seek to reduce the time
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it takes to produce new nurses with the goal of meeting the national demand for advanced
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practice nurses. Pellico and colleagues’ (2012) recent integrated review of graduate entry programs in nursing suggests that non-nurse college graduates successfully develop into APRNs
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and CNMs. This evidence bodes well for graduates of the Model C CNL programs. Although the literature suggests that individuals do successfully transition into new nursing roles, understanding of the career transition process for direct master’s entry graduates is limited. It is important to note that the current research on the transitions of non-nurse master’s entry to practice graduates focuses on the well-established advanced practice RN and Certified Nurse Midwife nursing roles. Respondents’ relative low levels of self-confidence may be related to the development of the CNL role, rather than the personal adjustment component associated with career transitions. That is, given the newness of the CNL role and the lack of knowledge on the part of other nurses, health professionals and managers regarding the scope of practice and
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potential benefits to patients and the organization (Sherman, 2010; Moore & Leahy, 2012), CNLs may be placed in a situation of justifying the CNL role and their credentials to function in
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the role, a situation that is likely to diminish self-confidence. More research focused on the
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direct-graduate entry to practice group of CNLs is warranted to understand the relationship of personal adjustment and role development on the career transitions of non-nurses into a high
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profile clinical leadership position.
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Organizational Context. Results from this study suggest that organizational ownership is
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associated with CNLs’ confidence in performing difference aspects of the role. Ownership is a variable that researchers commonly use as a proxy for an organization’s mission, values, and
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strategy (Reuf & Scott, 1998). Differences in organizational ownership may be related to variation in the goals of CNL practice, which, in turn, may affect CNLs’ confidence in their
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ability to achieve these goals. For example, the Chief Nurse Officer that adopts the CNL role to
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improve performance and reimbursement rates associated with the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) (Center for Medicare
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Services, U.S. Department Health and Human Services, 2010) core measures and nurse sensitive outcomes will design the CNL role differently than the Chief Nurse Officer who seeks to improve staff engagement and nurse-physician communication and collaboration. Future research examining relationships between organizational ownership and CNL selfefficacy should develop understanding of the mechanisms associated with CNLs’ confidence in performing their core role functions. Similarly, future studies should include key variables not only to account for the nursing practice environment, but also organizational strategy and performance as important contextual factors that may account for variations in the design of the
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CNL role, and by extension, a determinant of an individual’s confidence in performing the core role functions (Nicholson, 1984; Stephens, 1994).
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Another aspect of the organizational context that merits further study is the content and structure of CNL academic-service partnerships used to formalize and institutionalize the CNL
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role (De Geest, Dobbels, Schonfeld, Duerinckx, Sveinbjarnardottir & Denjaerynck, 2013). According to the AACN (2007), the purpose of academic-service partnerships is to promote the
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rapid diffusion and adoption of the CNL role into practice settings. In the ideal model, the
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academic partner is responsible for ensuring that graduates possess the knowledge, skills and abilities to effectively lead care coordination, quality improvement and clinical outcome
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management activities. In turn, the service partner is responsible for creating a receptive environment for CNL practice by attending to changes in organizational systems and structures;
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including role descriptions, reporting relationships, staff education, and performance
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expectations (Smith & Dabbs, 2007; AACN CNL Tool Kit, no date).
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More than fifty percent of the respondents participating in this study do not hold a job title of CNL, suggesting that they are employed in organizations that have not formally adopted the CNL role. More work to understand the nature of the academic-service partnership that are both committed to the CNL initiative and aligned to educate and employ nurses as CNLs will be important to understand the adoption and diffusion of the CNL role over time and across organizations. CNL Job Title. Interestingly, holding a formal job title of CNL was not a significant predictor of respondent’s confidence with performing core competencies associated with the CNL role. This finding provides some evidence supporting a shift away from conceptualizing the
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CNL as a formal unit-based role with responsibilities for microsystem functioning to conceptualizing the core knowledge associated with CNL practice as a skill set with applications
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to a range of existing positions with responsibility for clinical quality, safety and performance
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improvement. More research is needed to understand differences in the practice patterns and the associated self-confidence with the role competencies of nurses employed in formal CNL
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positions with those who bring new knowledge of leadership, outcomes management and
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performance improvement gained through graduate education as a CNL to other clinical or
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management positions.
Regional differences. The results suggest that CNL’s confidence with performing the key
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competencies associated with the role vary by geographic region. For example, respondents working in the Northeastern region of the United States were more confident in their abilities to
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perform the population based care, continuing education for unit staff, mobilizing others and the
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mentoring functions associated with the CNL role than others. In comparison, respondents from the Midwest region of the United States were more confident in their abilities for care planning
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and ensuring continuing education for staff, but were less confident in their abilities to function as a unit-level strategic leader than other respondents. These findings point to local variations within communities of practice that warrant further study. Faculty self-confidence. More research is needed on CNL program faculty members’ confidence with teaching the core role competencies. To date, no studies have examined faculty members’ mastery of the key knowledge and skills associated with CNL practice. Quality improvement, patient safety, and organizational performance are relatively new content in the educational curricula of the health professions (Institute of Medicine, 2001; 2003; Cronenwett, Sherwood, Barnsteiner, Disch, Johnson, et al., 2007). Because CNL program faculty are on the
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forefront of educating a new generation nurses as point-of-care quality and safety clinicians (Reid & Dennison, 2012), there are likely to be variations in faculty confidence with teaching the
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prescribed curriculum outlined in the Clinical Nurse Leader White Paper (2007). For example,
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nurse faculty may be very confident with teaching advanced care planning and risk reduction strategies, because the nursing process is an important foundation for professional practice and a
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core element of undergraduate and graduate curricula. In comparison, nurse faculty may have
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less exposure and familiarity with teaching CNLs how to assess unit (microsystem) performance and to develop a successful change management plan focused on improving a particular practice
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problem (McKeon, Norris, Web, Hix, Ramsey & Jacobs, 2009). More research focusing on CNL faculty would be useful to understand the contributions of faculty expertise to the personal
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development aspect of the work role transitions of their students.
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Person by Environment Interaction Effects. Finally, my results point to a number of new
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avenues for research examining interactions among both personal characteristics and the organizational environment that may affect nurses’ transitions into the high profile CNL role.
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For instance, consider the relationships among personality, work experience and organizational support for the CNL role. It may be that an expert staff nurse with a strong belief in his ability to control his future (i.e., high internal locus of control) working in a hospital with a formal CNL academic-service partnership may be more confident in his abilities to function in the CNL role than a less experienced nurse, who believes that her career is in the hands of others (i.e., high external locus of control), despite working in a hospital with a formal CNL partnership. New studies with larger sample sizes should focus on understanding how personal and organization characteristics interact to promote or hinder nurses’ transitions into the CNL role.
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Limitations
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Of the population of certified CNLs, the final sample of respondents is relatively small. Despite this limitation, the sample reflects the demographic characteristics of the population of
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nurses credentialed as CNLs. Further, the response rate is acceptable for a non-solicited on-line survey (Cook, Heath &Thompson, 2000) and is similar to the response rate for the recent CNL
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job analysis survey conducted by the Commission on Nurse Certification during approximately
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the same time period that this survey was in the field (Tan, 2011). Conclusions
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This study contributes to the literature on the implementation of the CNL role by identifying key variables associated with the personal adjustment and role development involved
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in successful career transitions to the CNL role. Respondents’ confidence in their ability to carry
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out the core functions associated with the CNL role varied across practice competency, geographic region, and organizational type and by the type of graduate program model attended
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to become a CNL. This evidence can be used by nurse managers and program faculty to develop targeted interventions to bolster CNL’s self-confidence in performing the core competencies associated with their role. Because self-confidence is an important predictor of successful career transitions, it is important to understand variations in CNLs’ confidence in their ability to function in the role to promote the overall performance, job satisfaction and retention of the nurses pioneering this innovative clinical leadership role.
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Table 1: The Clinical Nurse Leader Self-Efficacy Scale
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Index 1 “Population based care” (α = .93)
1. Acquire information about the population through information systems
3. Identify population-level health problems
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2. Seek knowledge about specific populations from the research literature
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4. Use information systems to track population-level health problems 5. Resolve population-level health problems
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6. Translate clinical research to improve practice routines 7. Review unit performance to project risks to client safety
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8. Review unit performance to project risks to quality of care
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9. Incorporate evidence based practice changes into clinical information technology systems
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Index 2 “Care planning” ( α = .93)
1. Assume accountability for the welfare of client populations served on your unit
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2. Identify client population risk based on a comprehensive assessment 3. Collaborate with cohorts of clients to design a total plan of care 4. Collaborate with clients in gaining their endorsement for the total plan of care 5. Consult appropriately with other health professionals to design a total plan of care for your clients 6. Advocate effectively on behalf of the client with the intervention team Index 3 “Unit-based strategic leadership” (α = .89) 1. Represent your unit on organizational committees 2. Know the organization’s mission 3. Apply the organization’s strategic plan to guide practice on your unit
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4. Practice in accordance with the values of the organization Index 4 “Managing financial resources” ( α = .92)
3. Use technology to reduce costs
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2. Identify opportunities for cost savings on your unit
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1. Identify waste on your unit
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4. Identify opportunities for revenue enhancement to benefit clients
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5. Create proposals to modify your unit using alternative business models 6. Create proposals to modify unit incorporating return of investment (ROI) analyses
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Index 5 “Team management” ( α = .83) 1. Meet regularly with intervention team
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2. Evaluate the intervention team’s performance with achieving patient care outcome goals
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Index 6 “Continuing education” ( α = .91) 1. Assure the continuing education of the team members
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2. Educate your unit’s staff on innovative practices
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Index 7* “Mobilizing others” ( α = .86) 1. Appropriately deploy human resources to improve outcomes 2. Mobilize managers to deploy resources 3. Mobilize informal leaders to deploy resources Index 8 “Professional leader” (α = NA) 1. Act as leader in relevant professional organizations Index 9 “Mentor” (α = .98) 1. Mentor other CNL™s 2. Act as a preceptor for other CNL™s *Items in this factor failed to reach the .600 threshold for item loading. These items should be subjected to further testing.
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Gender Male n=9 (6.62%) Female n=127 (93.3%) Age Mean= 46.07 years S.D. = 10.93 (Min 25 - Max 70) Educational Preparation to Enter Nursing Diploma n=18 (12.4 %); Associate Degree n=31 (21.3%); Bachelor Degree n=61 (47.5%); Master Degree n=27 (18.6 %) Years since graduating from basic nursing program Range 1962-2001. Mean =19.91 S.D. = 12.24 CNL Program Model Model A n=79 (55.2%); Model B n=6 (4.20%); Model C n=25 (17.5%); Model D n=2 (1.40%); Model E n=2 (1.40%); Not applicable n=24 (16.78%) Year graduated from CNL program 2005 n=1 (.72%); 2006 n=3 (2.17%); 2007 n=19 (13.7%); 2008 n=15 (11%); 2009 n=32 (23%); 2010 n=37 (27%); 2011 n=9 (7%); NA n=22 (16%) Geographic Region New England n=12 (8.2 %)
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Table 2: Respondent Demographics
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New York-New Jersey n=11 (7.6%) Mid-Atlantic n=14 (9.6%) Southeast n=26 (18 %) Midwest n=46 (32%) Southwest n=3 (2.7%) Mountain-Plains n=5 (3.5 %) Western n=28 (19.3%) Organization Type For-profit n=10 (6.9%) Not-for-profit n=90 (62%) Public n=14 (9.6%) Veteran Affairs n=31 (21.3%) Job title of CNL Yes n=57 (39%) No n=79 (55%) Not Applicable n=9 (6.21) CNL Faculty Yes n = 22 (15%) No n = 121 (85%)
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Table 3: Respondents’ Confidence in Performing the CNL Role Competencies
Region NE Region S
R2 for Model F Value Pr > F
Team Mgmt 4.095 0.796
0.0888 0.0116
4.166 0.838
Mobliz Others 3.673 0.864
Prof Lead 4.176 0.919
Mentor 4.011 0.902
0.1065 0.0545
-0.6796 0.0201
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-0.2875 0.1271
-1.5526 0.0001
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---0.7898 0.5624 0.8858 0.0084 0.0590 0.0048
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---0.5206 0.7593 0.5035 0.0488 0.0035 0.0079
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Finan Resou 3.602 0.902
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Strat Lead 3.553 0.508
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Type HCO not profit/ public CNL Title NO/NA Region MW
Care Plan 4.200 0.703
-0.4598 0.1200 0.3182 0.0876
0.43182 0.0834
0.2443 0.1016
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Mean SD Variables Experience as CNL Program Type A&B Model Program Type C Model Year Complete CNL program Year Complete Basic RN Type HCO for-profit
Pop Care 4.004 0.704
0.3464 -0.0601 0.1506 0.2619
0.3558 0.1034 -0.2316 0.0811
0.3796 0.0751 0.8017 0.5535 0.0014 0.032 0.5612 0.0081
0.1427 0.2357 0.1885 N/S
0.1996 0.2806 0.1970
1.83 3.39 2.56 0.0556 0.0004 0.0061
2.74 4.29 0.0033
