Clinical Nurse Leadership in the Critical Care Setting Karen S. Broderick, MSN, RN, CCRN Clinical Nurse Leader for Critical Care Middlesex Hospital January 2014

Objectives Define the role of the CNL Define the role of the CNL Discuss current CNL initiatives Discuss current CNL initiatives Understand the relationship to patient safety and quality improvement Understand the relationship to patient safety and quality improvement Where are we now? Where are we now?

Question asked in 2003 What does the nursing profession need to be able to do to meet the needs of the current and future healthcare system??

The Answer A Clinical Nurse Leader: This nursing role function as a Masters- prepared generalist providing and managing care at the point of care to patients, individuals, and families…….along with the authority, autonomy and initiative to design and implement care, the CNL is accountable for improving individual care outcomes and care processes in a quality, cost- effective manner.

CNL role AACN- February 2007: White Paper on the Education and Role of the Clinical Nurse Leader AACN- February 2007: White Paper on the Education and Role of the Clinical Nurse Leader There is a documented need for the CNL role in assuring quality and cost effectiveness of nursing care There is a documented need for the CNL role in assuring quality and cost effectiveness of nursing care Education: Master’s prepared – generalist Education: Master’s prepared – generalist –Not specific like a CNS or APRN –Does not have prescriptive authority

What does a CNL do? Depends on the setting Depends on the setting Patient population Patient population Staff resources Staff resources The role continues to evolve through education and practice but the emphasis is on patient safety, QI, lateral integration of care, interprofessional communication and EBP implementation The role continues to evolve through education and practice but the emphasis is on patient safety, QI, lateral integration of care, interprofessional communication and EBP implementation

The CNL is: Leader in decisions for clinical interventions Leader in decisions for clinical interventions Works at the point of care and is primarily unit based and ideally in conjunction with a DNP Works at the point of care and is primarily unit based and ideally in conjunction with a DNP A professional within an interdisciplinary care environment- peers and collaborators with knowledge and skill for negotiated care expectations (i.e. recommendations for care) A professional within an interdisciplinary care environment- peers and collaborators with knowledge and skill for negotiated care expectations (i.e. recommendations for care) 2 year implementation period minimum 2 year implementation period minimum

Lateral integration of care for a specified group of patients -Intubated/ Sepsis patients Clinician Clinician –may actively provide direct patient care in complex situations –emphasis on health promotions and risk reduction Outcomes manager Outcomes manager –Responsibility for the ongoing assessment of the plan of care. –Has the decision-making authority to change care plans if necessary –Accountability for evaluation and improvement in point-of-care outcomes

A major component of the CNL role centers on fostering and sustaining a culture of safety for the patients and families entrusted into their care (Reid & Dennison, 2011) A major component of the CNL role centers on fostering and sustaining a culture of safety for the patients and families entrusted into their care (Reid & Dennison, 2011)

The CNL is not: A direct care RN or charge RN A direct care RN or charge RN An administrator or manager An administrator or manager A Nursing Supervisor or Case Manager A Nursing Supervisor or Case Manager An APRN/NP/Clinical Nurse Specialist An APRN/NP/Clinical Nurse Specialist

CNL Evidence-Based Outcomes Evidence reported in the literature continues to grow: Evidence reported in the literature continues to grow: –Improved patient, MD and RN satisfaction scores –Improved NDNQI scores –Improved core measures, decreasing HAIs, falls, restraint usage, etc. –Improved coordination of care and decreased fragmentation of care esp with nursing handoff reports –Decreased LOS

So where are we now? Patient Safety Quality Improvement Handoff Communication

CNL Role Initiated

% of BGMs < 180 mg/dl in CCU Intubated/Septic patients May 2012 – Oct 2013 CNL role initiated BGM focus

CCU Daily Goals To be revised to better fit our quality and safety indicators To be revised to better fit our quality and safety indicators Night staff fills out part of the goals sheet Night staff fills out part of the goals sheet Followed up by the day staff and presented during rounds report Followed up by the day staff and presented during rounds report –MDs follow the format as well to make sure components are addressed and not missed CNL and Intensivist collaborate on patients daily and PRN

Thank you ! Thank you !

References AACN (2007). White Paper on the Education and Role of the Clinical Nurse Leader. Retrieved from eader07.pdf AACN (2007). White Paper on the Education and Role of the Clinical Nurse Leader. Retrieved from eader07.pdf eader07.pdf eader07.pdf Broderick, Karen Schilling (2013). A portrait at the bedside: clinical nurse leaders complete the picture. Nursing Management, 44(11), Broderick, Karen Schilling (2013). A portrait at the bedside: clinical nurse leaders complete the picture. Nursing Management, 44(11), Poulin-Tabor, D., Quirk, R.L., Wilson, L, Orff, S., Gallant, P., Swan, N., & Manchester, N. (2008). Pioneering a new role: the beginning, current practice and future of the Clinical Nurse Leader. Journal of Nursing Management, 16, Poulin-Tabor, D., Quirk, R.L., Wilson, L, Orff, S., Gallant, P., Swan, N., & Manchester, N. (2008). Pioneering a new role: the beginning, current practice and future of the Clinical Nurse Leader. Journal of Nursing Management, 16, Reid,. K., Dennison, P., (September 30, 2011) "The Clinical Nurse Leader (CNL)®: Point-of-Care Safety Clinician" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 3, Manuscript 4. Reid,. K., Dennison, P., (September 30, 2011) "The Clinical Nurse Leader (CNL)®: Point-of-Care Safety Clinician" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 3, Manuscript 4.