Clinical Nurse Leader Integrated Care Delivery to Improve Care Quality: Factors Influencing Perceived Success.

The Institute of Medicine's (IOM) report The Future of Nursing: Leading Change, Advancing Health challenged the nursing profession to become full partners in redesigning healthcare delivery (IOM, 2011). Nurses comprise the largest sector of the healthcare workforce and are leading innovations in the reorganization of nursing knowledge and practice at the front lines of care to consistently achieve safe and high-quality patient care (Dubois et al., 2013; McSherry & Douglas, 2011; Naylor, 2012). One innovative nursing care delivery model (CDM) spreading across America (Williams & Bender, 2015) and abroad (Dermody, 2015) integrates certified clinical nurse leaders (CNLs) into microsystem, or point-of-care, delivery with the goal of changing practice dynamics to improve care quality and safety.Study PurposeDespite growing evidence of improved care environment and quality outcomes associated with the redesign of microsystem care delivery to incorporate CNL practice, there is limited knowledge about organization and implementation factors that influence successful CNL practice and outcomes. As part of a larger research effort validating an explanatory model of CNL-integrated care delivery, the purpose of this study was to examine the relationship between CNL organization, implementation, and CNL practice success as perceived by diverse stakeholders involved in a CNL initiative. Specific aims were to identify relevant CNL organization and implementation factors and measure the influence of operationalized factors on perceived CNL success.Literature ReviewNursing Care DeliveryNursing CDMs delineate the organization and implementation of nursing services, including specific nursing roles, such as nurse practitioner, staff nurse, and charge nurse, and the deployment of these roles into daily practice, such as staffing patterns and skill mix (Minnick et al., 2007; Shirey, 2008). The specific ways nursing roles and practices are organized and deployed within practice environments is becoming increasingly recognized as an important determinant of overall nursing effectiveness (Djukic et al., 2013; Duffield, Roche, Dimitrelis, Homer, & Buchan, 2014; Yakusheva, Stevens, Wholey, & Frick, 2014). Current efforts are focused on how nursing knowledge and practice can best be leveraged to produce effective care delivery and consistently achieve care quality and improved patient outcomes (Joynt & Kimball, 2008; Tran, Johnson, Fernandez, & Jones, 2010). A recent Cochrane review concluded there is no strong evidence favoring traditional CDMs such as team or primary nursing, yet highlighted the fact that specialized nursing roles integrated into care delivery may improve patient outcomes (Butler et al., 2011).CNL-Integrated Nursing Care DeliveryThe CNL initiative was launched in 2003 by the American Association of Colleges of Nursing (AACN) to promote an innovative new model for nursing care delivery (AACN, 2007). Original CNL initiative stakeholders included health system and policy organization leaders along with education faculty, who worked together to develop a master's-level CNL nursing curriculum advancing end competencies in clinical leadership, care environment management, and clinical outcomes management (Stanley, Hoiting, Burton, Harris, & Norman, 2007). A subsequent task force facilitated the development of practice-education partnerships across the country to pilot the education of CNLs and their integration into health system's CDMs (Begun, Tornabeni, & White, 2006). Recent studies have advanced understanding of CNL practice, which is not about placing an "extra set of hands" into existing models of care, but a highly systematic process of microsystem care delivery redesign to structure CNL competencies (clinical leadership, care environment management, and clinical outcomes management) into a workflow that establishes and maintains multimodal communication channels, multiprofessional relationship building, teamwork, and staff engagement, which together improve microsystem care dynamics to achieve consistent quality and safety outcomes (Bender, 2015, 2016). …