Developing a Clinical Nurse Leader Practice Model

Transcription

1 Developing a Clinical Nurse Leader Practice Model An Interpretive Synthesis Miriam Bender, PhD RN

2 Background The American health care system as currently structured, is characterized by fragmented care delivery systems lacking formal interdisciplinary collaborative processes Consequences include errors in clinical practice and preventable adverse patient outcomes, such as increased mortality, morbidity, readmission rates, lengths of stay, and care costs Professional, policy and educational organizations have recognized the need to transform the healthcare workplace to better provide safe, patient centered, and team oriented care

3 Clinical Nurse Leader Initiative In response to this need, the American Association of Colleges of Nursing (AACN) spearheaded the development of the Clinical Nurse Leader (CNL) 2003 first White Paper published Educational and competency requirements 2004 initiated nationwide pilot demonstrations Funded in part by AHRQ The CNL is theorized to provide clinical leadership at the point of practice to promote and sustain crossdisciplinary collaborative practice and improve care quality.

4 Clinical Nurse Leader Evidence Evidence of effectiveness Positive: Consistent improvement in quality care standards and patient safety outcomes wherever the CNL has been implemented and documented Negative: weak evidence base, consisting primarily of case study design or single microsystem analyses An important finding across reports was that the CNL is not yet clearly defined in terms of fundamental leadership activities and responsibilities necessary to facilitate outcomes This lack of practice clarity limits the ability to articulate, implement, and measure CNL specific practice and outcomes

5 Objective and Methods The purpose of this research was to clarify CNL practice components contributing to improved quality care standards and patient safety outcomes Interpretive synthesis design was used to integrate diverse CNL practice narratives (research reports, articles, webinars, conference abstracts, etc.) into a coherent understanding of CNL practice Grounded theory analytical approach was used to empirically derive a CNL Practice Model that clarifies practice domains and components

6 Report Category CNL practice reports and narratives Qualitative/mixed methods study Quantitative study Explanatory/editorial Journalism Description of Category Documents including journal articles, webinars, job analyses, case studies and implementation reports that describe some aspect of CNL implementation and practice Studies describing the experience of practicing CNLs using qualitative methods, including investigator-designed survey data used for descriptive and qualitative analysis Descriptive, survey or quasi-experimental studies examining the CNL role using inferential statistical analysis to quantify results Documents describing the vision, history, rationale, educational competency development, and/or editorial commentary about the CNL, but do not provide information on the role in action Short, informative briefs introducing or commenting on the role in general but do not provide information on the role in action Total Count Included in Synthesis 30 Yes 8 Yes 3 Yes 38 No 43 No Not about CNL role Reports that were not actually about the CNL 16 No Total Conference Abstract Category QI (quality improvement) CNL-initiated QI project 122 Yes Implementation/outcomes Describes the need for and implementation of CNL(s), sometimes with outcomes 54 Yes Educational methods Describes methods to educate/train CNLs, including developing partnerships with clinical organizations and 39 Yes placing CNLs into practice Immersion methods Describes clinical immersion experience of CNL students, including how they were operationalized into the 20 Yes organizational setting How CNL can be utilized Describes how and why CNL can be utilized 9 Yes CNL experience Description/analysis of CNL personal experience 7 Yes Quantitative/survey study Cross-sectional survey method investigating some aspect of CNL practice 3 Yes Total

7 CNL Practice Model

8 Data Saturation CNL Practice Domain Percent of reports/abstracts domain codes found in Preparation for CNL practice 79% Structure of CNL practice 79% Continuous Leadership 93% Outcomes of CNL practice 86% Acceptance 62%

9 CNL = Continuous Leadership The heart of CNL practice involves developing relationships across professions to promote and manage information exchange, shared decision making, and effective care processes at the point of practice Components of continuous leadership include: Being a source of constant communication/information Strengthening inter professional relationships Team creation Supporting staff engagement Shifting focus from person to process All components have evidence supporting effectiveness The innovation is workflow responsibility for continuous leadership May be more effective than episodic training, especially in organizations with less leadership across levels

10 CNL Practice Model How does the model align with current theories of healthcare delivery and improvement? How do these domains interact to produce successful CNL practice and improved outcomes?

11 CNL Practice: Multi Level Intervention Healthcare System Level Assumed Drivers of Change Approaches to Change CNL Practice Model Larger system, Policy Environment Organization Group Individual Reimbursement regulatory policy Structure Strategy Cooperation Coordination Shared knowledge Knowledge Skills Expertise Accreditation Public reporting Evidence based practice Continuous Quality Improvement Organization structure development Knowledge management Team development Task redesign Guideline, protocol, pathway implementation Education Feedback Leadership development Preparation for CNL Practice Need for reporting outcome improvement Structure of CNL Practice Care structure redesign Outcomes based Competency driven Continuous Leadership Communication Relationship building Team creation Staff engagement Person to process Acceptance Exposure, feedback Outcome of CNL Practice Better work environment, care quality, nursing visibility Adapted from Ferlie, E. B., & Shortell, S. M. (2001); Shortell, S. M. (2004)

12 AHRQ: Patient Safety Model context Implementation process theory Moderators of patient safety practices Patient safety problem Patient safety practice Beneficial safety outcomes A Patient Safety Practice (PSP) is a type of process or structure whose application reduces the probability of adverse events Complex interventions targeting varying system levels Context is important when determining generalizability

13 CNL Practice = Patient Safety Practice? Context Implementation process Theory Preparation for CNL practice Structure of CNL practice Acceptance Moderators of patient safety practices Patient safety problem 5 for the price of 1 CNL Practice: Continuous Leadership Communication Interdisciplinary relationships Teamwork Staff support Shift focus from person to process Outcomes

14 Conclusions The empirically derived CNL practice model proposes five domains that interact to produce the structure, function, and outcomes of CNL practice Clarifies CNL practice components Differentiates them from existing nursing roles Proposes mechanisms by which a CNL integrated care delivery system can improve healthcare quality The model can be helpful to organizations contemplating CNL implementation Care delivery redesign as patient safety practice Target multilevel domains for success

15 Implications The synthesis highlights CNL practice as a nurseled intervention that can promote and sustain healthy interdisciplinary care environments Consistent with the IOM Initiative on the Future of Nursing Strategic Plan to capitalize on the contributions of nurses to quality care and the benefits of nurse led models of care for improving healthcare delivery Provides a solid basis for future research Confirm domains across a wider sample of microsystems Valid measures of CNL practice domains Further investigation into microsystem clinical leadership How do perceptions of collaborative practice form in differing disciplines and how do they come to be shared Continuous leadership and acceptance domains

16 Thank You! Questions?