Clinical Nurse Leader Role Implementing

Clinical Nurse Leader Role

Implementing the Clinical Nurse Leader Role in the Women's and Children's Department

The recently emerging role of Clinical Nurse Leader has come under extreme scrutinty by both the promoters of the position and the detractors. Developed as a further educational and training program to Clinical Nurse Specialist, Clinical Nurse Leader has the fundamental duty of coordinating the various components and personnel in a department. These duties will be analyzed in relation to the Women and Children's departments in hospitals.

Prevalence in Nursing

Theoretical/Conceptual Underpinnings

Project Description

Project Components

Community Contributions

Implementing the Clinical Nurse Leader Role in the Women's and Children's Department

Introduction

The recently emerging role of Clinical Nurse Leader has come under extreme scrutinty by both the promoters of the position and the detractors. The American Association of Colleges of Nurses (AACN) have created this new role in nursing as a natural progression of the changing roles and the diverse challenges that are confronting the medical profession in the new millennium in essence this new position was developed as further extension of an educational and training program to Clinical Nurse Specialist, Clinical Nurse Leader has the fundamental duty of coordinating the various components and personnel in a department. The Clinical Nurse Leader supervises the delivery of nursing care provided by professional and support nursing staff on any designated unit. This position ensure that care is provided in a manner consistent both with the medical profession ethically and professionally, as well as establishing clear guidelines in represented by the particular hospital or institution code of ethics. (Staff Nurses, 2007) These duties will be analyzed in relation to the Women and Children's departments in hospitals.

While a charge nurse has the responsibility to supervise primarily the nursing staff and other supporting staff, the Clinical Nurse Leader has the added responsibility of analyzing the other professional staff members involved on the floor, doctors, anesthesiologists, etc. To validate their performance and behavior is within the guidelines previously specified. While this position is not directly 9in charge of these professional, it is responsible to assure that the care being given on all levels is not only appropriate and consistent with good medical attention, but that it also meets the ethical and moral guidelines of the hospital and the medial profession at large.

These are critical feature in all departments, but ther are of an extreme concern in the various departments of women and children's care such as OB/GYN Emergency Room and Triage area, Labor & Delivery Suites, Labor & Delivery Recovery, Antepartum, Postpartum (Mother Baby), Several Newborn Intensive Care Units (NICU), and Gynecology Oncology. The Clinical Nurse Leader will be analyzed in general and then how it specially applies to the Women and Children's departments.

Purpose of the Study

There have been significant changes in the medical profession over the past decade. Aside from the many technological advancements there has also been a need to curtail medical costs in light of the current healthcare crisis and to also supplement the lack of doctors and other skilled staff that is becoming a concern. The creation and adoption of the position of Clinical Nurse leader is a necessary role to help to fill some of the gaps in the higher skilled care, while still maintain and perhaps even improving upon the level and consistency of care that is necessary in the are of Women and Children's department in hospitals.

The American Association of Colleges of Nurses (AACN) that have the potential to significantly change nursing education and practice from master's degree to the doctor's degree. The AACN proposed the development of a new nursing role, that is, the clinical nurse leader (CNL), in 2003. A CNL will require a master's degree in nursing and will have to design, implement and evaluate client care by coordinating, delegating and supervising the care provided by the health care team, including licensed nurses, technicians and other health professionals. Some nursing leaders and organizations have embraced it, but others have questioned its validity and usefulness. (Nelson, 2005, 24)

Significance of the Problem

While there is an increasing need for supervisory care in the nursing profession, there is an ever-present need in Women and Children's departments for consistency of care.

In a study entitled, a Controlled Trial of Nurse Practitioners in Neonatal Intensive Care, preformed in 1996, even then the authors already cite two prevalent factors that are contributing to the need there as well as in other departments of these units that contribute to the increasing need of Clinical Nurse Leaders as well as other supervisory staff:

The first is the reduction in the availability of pediatric residents, and the second is the increasing survival rate of smaller, sicker infants. These factors will not change in the foreseeable future; if anything, resident shortages will increase, as will the technological capacity to treat tiny, critically ill infants. Therefore, our study is highly relevant to current problems in the delivery of neonatal intensive care. Health care planners can now move forward confident that the process of care, parent satisfaction, and patient outcomes will be comparable with those achieved with current mechanisms of neonatal health care delivery. (Mitchell-DiCenso & Guyatt, 1996, p. 1143)

This need was initially halted by the lack of Medicare reimbursement for these positions, but recently the guidelines have been reviewed and Clinical Nurse Leaders as well as other staff are now under the Medicare reimbursement umbrella in most states. (Lego, 1998) Given the fact that most hospitals have been forced to cut down on staff, it make sense to attempt to incorporate some of these duties into one single position responsible the maintaining a standard level of care for the hospital and these departments. These cuts have hit hospitals throughout the nation, none have been spared the need to curtail budgets and have been forced to work with less qualified staff coming on board.

Prevalence in Nursing

Currently this position is gaining more interest in both the medical profession as wel as the administrative side of the spectrum. Proving itself both to be clinically advantageous and cost effective at the same time.

Perhaps we are watching the start of an evolution. An iterative process that is bringing the pendulum of masters-level nursing back to the center. National movements are calling for the development of a generalist masters-prepared nurse, the Clinical Nurse Leader degree (AACN, 2003). Discussions of a nursing practice doctorate are increasingly gaining favor (AACN, 2004). The blurred line may be the start of the movement towards expanding the impact of nurses on the total health of individuals. But before we get there, I still need us to talk about where the line is. (Mccabe, 2005, p. 88)

The line that Mccabe is referring to is that between the practice of nursing and the new clinical supervisory element that is being added to this position. Clearly there are still positions and roles to be ironed out but clearly this is becoming a more predominant need in the nursing as well as the medial profession as a whole.

For instance, one of the most difficult supervisory items that a floor charge nurse must do is attempt to schedule and distribute the workload of the floor properly. This has many variables and is also often a political mission as well as a strategic organizational mission. The charge nurse on the floor of the unit is often placed in difficult positions, having to decide not only how to distribute the workload, but to whom, and who was the most qualified as well as who may need to take on more responsibility. This particular supervision always is an attempt to balance education of staff with the proper allocation of the workload. She must also try and maintain a fair balance as perceived by the LPN's as to their assigned duties and amount of work they are given so as not to appear to be favoring or ignoring anyone. A good supervisor takes into account not only the needs of the patients, but the needs of those they are supervising as well.

Theoretical/Conceptual Underpinnings

It is important to realize the nursing, as in all medical related profession, continues to expand and grow both with the scientific and technical advances as well as having a need to adapt, change and grow along with the current cultural and economic environment. Nurse practitioner have now become commonplace and no longer treated as a perhaps second rate level of care. They have filled an important gap, that same gap is appearing in hospitals and in particular in the departments of Women and Children's units.

A in light of the expanding role of professional nurses in health care settings today, it is imperative that they acquire the leadership skills necessary to influence positively this dynamic and uncertain environment. These skills are vital for them to make an impact, considering the powerful relationship between leadership strength and influence. One characteristic of effective leaders is attainment of for- mal preparation and educational credentials in addition to work and life experience. The American Association of Colleges of Nursing (AACN) and the Council on Graduate Education for Administration in Nursing (AACN, 1996; Dienemann & Aroian, 1995) operationally define the professional nurse as one who has been prepared with a minimum of a baccalaureate or higher degree in nursing. (Feldman & Greenberg, 2005, p. 219)

These were necessary requirement in the 90's. Now in an ever increasing age of need for more highly educated professional, the Clinical Nurse Leader armed with a Master's degree or better, is more adapted to handle a wide range of situations and create a fulcrum from which to balance all the staff in a given unit.

Literature Review

Clinical Nurse Leader

Kennedy, M.S.. (2004) Introducing the Clinical Nurse Leader. American Journal of Nursing, 104 (10), 22.

This article is a report regarding the decisions calling for a new role for nurses. The American Association of Colleges of Nursing (AACN), held an extraordinary January 2004 meeting to take action regarding recommendations of its Task Force on Education and Regulation for Professional Nursing Practice,. The result was that they passed a resolution calling for a "new nursing professional for generalist practice," (2004, 22) the clinical nurse leader (CNL), This position would be required to hold a minimum of a masters degrees. Although the AACN views the role of the CNL as different from that of the clinical nurse specialist, the National Association of Clinical Nurse Specialists does not and this has become a political hot bed of controversy regarding the roles that each play in the leadership of a department.

Mccabe, S. (2005). I Don't See No Line. Perspectives in Psychiatric Care, 41(2), 79-88

Although mainly concerned with Opsychitric care Mccabe's article assists with the understand of the CNL position as it is evolving into the new practice of medicine as well as keeping a well educated staff present in the hospitals setting without relying solely on interns and doctors for that level of care.

Perhaps we are watching the start of an evolution. An iterative process that is bringing the pendulum of masters-level nursing back to the center. National movements are calling for the development of a generalist masters-prepared nurse, the Clinical Nurse Leader degree (AACN, 2003). Discussions of a nursing practice doctorate are increasingly gaining favor (AACN, 2004). (Mccabe, 2005, p. 88)

He does note that the lines may be a little blurred at the start of the movement towards increasing the effect that a nurses may have on the overall health of patients. He does emphasize that the lines do need to be drawn between such level of supervision as charge nurses, LPN, RN and so on so that there is no misunderstanding along the way.

Mccabe, S., & Burman, M.E. (2006). A Tale of Two APNs: Addressing Blurred Practice Boundaries in APN Practice. Perspectives in Psychiatric Care, 42(1), 3-19

Here Mccabe with Burnam further address the confusion over the roles and the myriad titlesl that have appeared in the nursing community as well as the often less evident but significant confusing issue in practice, that of blurred supervisory boundaries as indicated in the previous article..

It would seem that, given the alphabet soup asserting specialization in APNs, the scope and boundaries of their specific roles would be clear. But they are not. The boundaries of APN practice are increasingly blurred, enough so that many of us are unable "to see the line" that forms the boundary of our professional practice in the real world of clinical care. (Mccabe & Burman, 2006, p. 3)

Nursing has started to evolve down a path of what appear to be extremes,. While there are very clear and succinct specialization on the one hand there is also the "decreasing specialization on the other hand with the development of the clinical nurse leader (CNL) degree" (2006, p. 16). The further development in educational priorities for nursing has also led an increase in nurses earning a doctorate in nursing practice (DNP). This further heightens the discussions of roles, standards and practices as well as what constitutes the core of APN practice.

Until we can provide an answer to the question of whether or not our artificially derived roles produce the most efficacious outcomes, we will not know where the APN future lies, nor how to best grow our science and identity. (Mccabe & Burman, 2006, p. 18)

Nelson, R. (2005)T he Clinical Nurse Leader -- Needed or Not? American Journal of Nursing, 105 (12) 24-25,

The main focus of this article is a report which explores the initiative of the American Association of Colleges of Nurses (AACN) which has the potential to change the nurses role in supervision and education creating the need for minimally a master degree as well as a doctoral degree.

The AACN proposed the development of a new nursing role, that is, the clinical nurse leader (CNL), in 2003. A CNL will require a master's degree in nursing and will have to design, implement and evaluate client care by coordinating, delegating and supervising the care provided by the health care team, including licensed nurses, technicians and other health professionals. Some nursing leaders and organizations have embraced it, but others have questioned its validity and usefulness. (2005, p. 25)

Education

Feldman, H.R. & Greenberg, M.J. (Eds.). (2005). Educating Nurses for Leadership. New York: Springer.

Feldman and Greenburg have written a seminal book on the topic of supervision and nursing tht help to expand and explain the necessary educational components of this evolving field. There are many types of systems and truing for this field, however, the authors promote the use of the case method:

using real life case studies in the classroom and clinical set- tings (Ashby, 1999; Wilson & Porter-O'Grady, 1999). This complex and progressive learning is a continuous process that occurs throughout one's career (Aroian, Meservey, & Crockett, 1996; Grossman & Valiga, 2000; Wilson & Porter-O'Grady, 1999). (Feldman & Greenberg, 2005, p. 6)

The authors realize that not all case studies can cover all scenarios so there have been many improvements by nursing broads and colleges to create clinical scenarios based on specific events to attempt to broaden their educational venues. For a clinical nurse leader this is crucial since there will be more to that role than merely facts and prescriptions, but also necessary will be the ability to cope with various multi-dimensional situations.

Leadership skills, such as visioning, strategic planning, embracing diversity, fostering interprofessional relationships, and networking, take on critical significance for the rural nurse, physician, or public health professional. These professionals are often alone or part of a small team of experts available within a geographic region. To succeed in improving health, professionals must be able to work together effectively and collaborate with community members in a mean- ingful way. The community-based (Feldman & Greenberg, 2005, p. 192)

In the current environment of the medial profession it is imperative that the person in the role of professional nurses acquire the leadership skills necessary to positively influence this new and constantly chaining environment.

These skills are vital for them to make an impact, considering the powerful relationship between leadership strength and influence. One characteristic of effective leaders is attainment of for- mal preparation and educational credentials in addition to work and life experience. (Feldman & Greenberg, 2005, p. 219)

Staff Nurses. (2007). Nursingworld.org. Retrieved February 15, 2009, from American Nurses Association Web site: http://nursingworld.org/EspeciallyForYou/stafftesting.aspx

Clinical nurse leader general

This site provided a great deal of general insight and information into the postion of clinical nurse leader that is already in place. The Registered Nurse / Clinical Leader supervises the delivery of nursing care provided by professional and support nursing staff on a designated unit. The Registered Nurse / Clinical Leader prescribes, coordinates and delegates care utilizing the nursing process which is integrated into the multidisciplinary treatment team plan of care. The Registered Nurse / Clinical Leader is accountable for nursing care activities on a shift basis and is responsible for promoting and enhancing professional nursing practice on the unit.

Women & Children Care

Knorr, R.S., Condon, S.K., Dwyer, F.M., & Hoffman, D.F. (2004). Tracking Pediatric Asthma: The Massachusetts Experience Using School Health Records. Environmental Health Perspectives, 112(14), 1424-1439.

This article concerned a specific case study regarding pediatric asthma and the various and complex needs of the patient from diagnosis to maintenance. It involved a survey of children with asthma in grade k to 8 Academic year in the Massachusetts public school system. The schools in the Essential School Health Service (ESHS) program are required to have a full-time master's-prepared district nurse leader coordinating the health activities of that district's schools.

The target population included 958 public schools in 173 cities and towns (111 school districts) serving more than 395,000 children, or approximately 57% of Massachusetts's K-8 students.

Mitchell-DiCenso, a. And Guyatt, G. (1996) a Controlled Trial of Nurse Practitioners Ii Neonatal Intensive Care / Pediatrics 98 (6), 1143.

The article by Mitchell-DiCenso and Guyatt reviews the economic reasoning behind using Nurse practitioners, Nurse Leaders, etc. In the neonatal department of a hospital. While in a perfect word economics should always be the last resort in providing adequate heatlh care, the authors are practical and review the findings by comparing nurse leaders in charge vs. internists and pediatric residents. There are two major factors at play in these decisions. One is the fact that there are fewer and fewer pediatric residents available in both the Undited States and Canada. This shortage is one of the reasons that Clinical Nurse Leader is becoming a more important presence on the department floor. The second is the increasing survival rate of smaller and smaller premature infants in the neonatal ward.

These factors will not change in the foreseeable future; if anything, resident shortages will increase, as will the technological capacity to treat tiny, critically ill infants. Therefore, our study is highly relevant to current problems in the delivery of neonatal intensive care. Health care planners can now move forward with the wider use of CNS/NPs, confident that the process of care, parent satisfaction, and patient outcomes will be comparable with those achieved with current mechanisms of neonatal health care delivery. (1996, p. 1143)

The report concluded that when comparing Nurse Leader teams with pediatric resident teams, the results in level of care were similar for all tested measures of performance.

The authors believe that these conclusions support the use of Clinical Nurse Leader teams as an alternative to pediatric resident teams in delivering the necessary care to critically ill neonates.

Perkins, B.B. (2004). The Medical Delivery Business: Health Reform, Childbirth, and the Economic Order. New Brunswick, NJ: Rutgers University Press.

The author provides an excellent overview of the medical profession in both health care and economic aspects, focusing specifically on Childbirth, Women and Children's care. Especially relevant is the formation of surgical and other teams within the department. It is interesting to note that doctors often parceled out the actual patient recovery care to non-medical team members:

surgical specialties took the lead in developing teams of medical and nonmedical personnel. As a president of the American College of Surgeons later noted, "surgeons operated with trained assistants as a team. The classic picture of Agnew in his clinic depicts an anesthetist, a surgical assistant, a nurse, and an orderly, all performing specific functions.".... Relationship with the patient often became one of the parceled-out tasks. "It is not unusual," an academic obstetrician-gynecologist observed in 1918, "to hear an operator say of the patient under the anesthetic, 'this is the first time I have examined the patient.'" (Perkins, 2004, p. 30)