Clinical Nurse Leader Role in Women's and Children's Care

Introduction

The recently emerging role of the Clinical Nurse Leader has come under intense scrutiny by both proponents of the position and its detractors. The American Association of Colleges of Nursing (AACN) created this new role as a natural progression of the changing responsibilities and diverse challenges confronting the medical profession in the new millennium. In essence, this position was developed as a further extension of an educational and training program beyond the Clinical Nurse Specialist. The Clinical Nurse Leader has the fundamental duty of coordinating the various components and personnel within 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 ensures that care is provided in a manner consistent with both the ethical and professional standards of the medical profession, while also establishing clear guidelines as represented by the particular hospital or institution's code of ethics (Staff Nurses, 2007). These duties will be analyzed in relation to Women's and Children's departments in hospitals.

While a charge nurse bears responsibility primarily for supervising nursing and support staff, the Clinical Nurse Leader carries the added responsibility of evaluating other professional staff members on the floor — including physicians and anesthesiologists — to validate that their performance and behavior fall within the previously specified guidelines. While this position is not directly in charge of those professionals, it is responsible for ensuring that care delivered at all levels is not only appropriate and consistent with sound medical practice, but also meets the ethical and moral guidelines of the hospital and the medical profession at large.

These are critical features in all hospital departments, but they are of extreme concern in the various areas that make up Women's and Children's care, such as the OB/GYN Emergency Room and Triage area, Labor and Delivery Suites, Labor and Delivery Recovery, Antepartum, Postpartum (Mother Baby), Neonatal Intensive Care Units (NICU), and Gynecology Oncology. The Clinical Nurse Leader role will be examined both generally and in terms of how it specifically applies to Women's and Children's departments.

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 ongoing healthcare crisis and to address the growing shortage of physicians and other skilled staff. The creation and adoption of the Clinical Nurse Leader position is a necessary step toward filling some of the gaps in higher-skilled care, while maintaining — and perhaps even improving — the level and consistency of care required in Women's and Children's departments in hospitals.

The AACN has proposed changes that have the potential to significantly reshape nursing education and practice, from the master's degree level to the doctoral level. The AACN formally proposed the development of a new nursing role — the Clinical Nurse Leader (CNL) — in 2003. A CNL requires a master's degree in nursing and must 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 this role, but others have questioned its validity and usefulness (Nelson, 2005, p. 24).

While there is an increasing need for supervisory capacity within the nursing profession broadly, Women's and Children's departments face a particularly acute need for consistency of care. In a study entitled "A Controlled Trial of Nurse Practitioners in Neonatal Intensive Care," conducted in 1996, the authors identify two prevalent factors that were already then contributing to the need for greater supervisory staffing in neonatal and related units:

"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 constrained by the lack of Medicare reimbursement for these positions, but the guidelines have since been reviewed and Clinical Nurse Leaders, along with other advanced practice staff, are now covered under the Medicare reimbursement umbrella in most states (Lego, 1998). Given that most hospitals have been forced to reduce staffing levels, it makes sense to consolidate certain duties into a single position responsible for maintaining a standard level of care. These budget cuts have affected hospitals throughout the nation, forcing many to work with less-experienced staff.

Prevalence in Nursing

The Clinical Nurse Leader position is currently attracting growing interest from both the medical profession and hospital administration, proving itself to be simultaneously clinically advantageous and cost-effective.

As McCabe (2005) observes: "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." (p. 88)

The line McCabe refers to is that between the practice of nursing and the new clinical supervisory element being added to this role. Clearly there are still boundaries and responsibilities to be clarified, but the Clinical Nurse Leader is becoming an increasingly prominent necessity in both the nursing and medical professions.

One of the most challenging supervisory tasks for a floor charge nurse is scheduling and distributing the unit's workload appropriately. This involves many variables and is both a political and strategic organizational mission. The charge nurse is often placed in difficult positions — deciding not only how to distribute the workload, but to whom, and who is most qualified, while also considering who may be ready to take on greater responsibility. This supervision always seeks to balance staff development with the appropriate allocation of duties. A charge nurse must also maintain a perceived fair balance among LPNs regarding their assigned tasks, so as not to appear to favor or overlook anyone. A skilled supervisor takes into account not only the needs of patients, but also the needs of those they supervise.

Theoretical and Conceptual Underpinnings

It is important to recognize that nursing, like all medical-related professions, continues to expand and grow — both with scientific and technical advances and in response to shifting cultural and economic environments. Nurse practitioners have now become commonplace and are no longer regarded as a second-tier level of care. They have filled an important gap, and that same gap is now appearing in hospitals, particularly in Women's and Children's units.

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 positively influence this dynamic and uncertain environment. These skills are vital for making an impact, given the powerful relationship between leadership strength and influence. One characteristic of effective leaders is the attainment of formal preparation and educational credentials in addition to work and life experience. The AACN and the Council on Graduate Education for Administration in Nursing 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 the necessary requirements in the 1990s. Now, in an era of increasing demand for highly educated professionals, the Clinical Nurse Leader — armed with a master's degree or beyond — is better equipped to handle a wide range of situations and to serve as a fulcrum balancing all staff within a given unit.