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It’s a first — nurse representatives of health care facilities and academia working together, developing a new nursing role, adding finishing touches to curricula. The scene at Sonoma State University is occurring across the country, as clinical nurse leader (CNL) pilot programs approach their inaugurals.

The increasing complexity of health care and numerous reports of unsafe and inadequate patient care prompted the American Association of Colleges of Nursing’s (AACN) concerns about nursing education and practice and health care delivery systems.

“The health care system is fragmented, with groups of providers focusing on what each does,” says AACN Executive Director Geraldine (Polly) Bednash, RN, PhD, FAAN. “We need a new dynamic for care delivery, a different way for providers to work together and interact.” Last year, AACN requested proposals for partnerships of academia with health care to redesign systems for the CNL, a role that would “integrate health care delivery systems and move them forward,” says Bednash.

What’s in a name?

“CNLs are lateral integrators of those they work with across the spectrum of providers,” Bednash adds. RNs who are interested in master’s-level education and want to remain at the patient point of care might find their niche in the CNL role. CNLs are generalists who coordinate the care of a distinct group of patients and put evidence-based practice into action.

After completing the educational part of the program (which may last from 12 to 15 months if completed full time) and a residency either during or after course work, CNL graduates will be eligible to sit for the certification exam developed under AACN auspices.

Unlike nurse managers who determine how hospital units function, CNLs drive patient care. They have decision-making authority to design, implement, evaluate, and change patient care plans. In hospital settings, CNLs are unit-based caregivers who work with the interdisciplinary team, including clinical nurse specialists.

“Typically, CNSs work with patient populations across units, at multiple points of care,” says Cathy Rick, RN, CNAA, FACHE, chief nursing officer, Veterans Health Administration, Washington. “Unit-based CNLs’ accountability lies in influencing and facilitating rather than being responsible for systems thinking and planning,” she says.

Though AACN and a group of nurse leaders in CNS practice and education worked together on a statement that compared and differentiated the CNL and CNS roles, the National Association of Clinical Nurse Specialists (NACNS) voiced concerns. In its Position Statement on the CNL, NACNS says the proposed CNL competencies “are an overlaying of the baccalaureate essentials on knowledge and competencies of the CNS, and continued efforts to implement this new nurse proposal will disenfranchise CNLs.” NACNS also says that “proposing this new nurse as either a replacement for or duplication of baccalaureate entry-level nurses who provide direct clinical care at a time of severe nurse shortage is a questionable use of scarce educational resources.”

Background check

Even before AACN issued a call for partnerships, practice-setting leaders began designing CNL-type roles in response to need. Staff nurses were dissatisfied because they wanted to shape — not just provide — care, says Rick. AACN’s proposal for partnerships between academia and practice would solidify the new CNL role. Rick encouraged at least one facility in the 21 VA integrated service networks across the U.S. to participate in the pilot; nearly 50 have joined.

In the midst of redesign, Inova Health System, Falls Church, Va., looked at better ways to deliver care through team coordinators, BSN-prepared nurses with many task similarities to CNLs.

“We were looking for someone to be an integrator on the unit and oversee responsibility for coordination of care, mentoring, and leadership of new staff,” says Karen Drenkard, RN, MSN, CNAA, Inova’s vice president of nursing and chief nurse executive. Drenkard served on the AACN’s Reaction to the CNL White Paper Committee. In conjunction with George Mason University, Fairfax, Va., Inova is piloting the CNL program in September, encouraging staff participation in CNL master’s degree preparation.

At Inova, Drenkard envisions functional responsibilities threaded through the CNL role. As unit outcome managers, CNLs understand, collect, and benchmark outcome data. To assess patient risk for developing pressure sores, they may teach new RNs how to use the Braden Scale for Predicting Pressure Sore Risk. They work with colleagues to collect and compile skin sensitivity data on patients and use data results to uncover patients’ skin problems, create solutions, and work with staff to provide better patient skin care.

“CNLs are resources to help staff on the unit understand the bigger health care picture and their part in it,” says Drenkard.

Different faces

The CNL role is evolving at 83 partnerships across the country. “The partnership model will look different in different settings,” says Rose Sherman, RN, EdD, CNAA, director of the Nursing Leadership Institute and assistant professor of nursing at the Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton. In Palm Beach County, in addition to seven hospitals, the school of nursing is partnering with the Palm Beach County School District, the 11th-largest school system east of the Mississippi.