1. Clinical Nurse Leader Impact on Microsystem Care Quality Miriam Bender PhD(c), MSN, RN, CNL National State of the Science Congress on Nursing Research September 14, 2012 Washington DC

2. Study Background The current fragmented healthcare system, characterized by a lack of collaborative, patient-centered care processes, creates significant barriers to providing quality patient care. The clinical nurse leader (CNL) provides clinical leadership at the point-of-practice to maintain cross- disciplinary collaborative processes that lead to integrated quality care Patient satisfaction is an important health outcome, providing a valid measure of quality of care received CNL Impact on Microsystem Care Quality

3. CNL Framework CNL new nursing role, developed by the American Association of Colleges of Nursing (AACN) Education and competency framework described through the AACN CNL white paper (2007) CNL is masters prepared RN Certified (not licensed) by examination through the Commission on Nursing Certification (CNC) Implemented across the US, but remains untested in many ways CNL Impact on Microsystem Care Quality

4. CNL Framework CNL Impact on Microsystem Care Quality

5. Study Aim and Design Aim: Empirically quantify patient satisfaction with multiple dimensions of care before and after CNL implementation, compared to a control unit. Study Design: Short interrupted time series (ITS) Time frame: 22 months total (10 months pre, 12 months post) CNL Impact on Microsystem Care Quality

6. Setting Intervention unit: 26-bed high-acuity progressive care unit in a 119-bed urban academic hospital State-mandated staffing ratios in place Patient population includes complex surgical-oncology, cardiac, pulmonary, bone marrow transplant (BMT), and neurology patients. RN staff work 12-hour, 3-day weeks Medical teams rotated every 2 weeks Control unit: high-acuity oncology and BMT unit Similar patient population and staffing ratios Same staffing/turnover schedule Oncology physicians and nurse practitioners round on both units CNL Impact on Microsystem Care Quality

7. CNL Intervention Two CNLs, each responsible for 13 patients, Monday-Friday from 7-3:30 CNL system responsibilities Physician team rounding structure; skin and fall rounds; standardized interdisciplinary care plans; quality improvement project facilitation; quality data tracking; and facilitation of a unit-based shared governance counsel CNL staff responsibilities Nursing and ancillary staff rounds; assisting staff RNs with hands-on complex care needs; facilitating accurate and complete documentation in interdisciplinary care plans; and ensuring all disciplines and the patient had a voice in the decision-making process regarding complex care goals CNL patient responsibilities Multiple daily patient rounds; daily review patient data for inclusion into the care plan and review with interdisciplinary staff during rounds. CNL Impact on Microsystem Care Quality

8. Measures Press Ganey survey instrument Acceptable validity evaluated via focus group data obtained from both patients and providers Reliability reported as Cronbach’s alphas ranging from.86 to.92 Scores = Percent of patients answering 5 on a 5-point Likert- type scale (1= ‘very poor’ to 5 = ‘very good’) with: Overall satisfaction with Admission and Discharge experience Overall satisfaction with Nursing and Physician care Overall satisfaction with Nursing-Specific indicators: Skill of the RN RN kept you informed Attention to special needs Attention to requests CNL Impact on Microsystem Care Quality

9. Analysis Time series analysis program (Borckardt et al. 2008) Level Change: intervention’s association with a change in outcomes Reported as Pearson’s r Phase Effect: intervention’s trend over time Reported as Pearson’s r association of data fitting a predetermined trend model CNL Impact on Microsystem Care Quality

10. ITS Analysis CNL Impact on Microsystem Care Quality

11. Results CNL Impact on Microsystem Care Quality

12. Results No significant change in control data throughout study time frame. CNL Impact on Microsystem Care Quality Admission scores

13. Results Press Ganey MeasureLevel Change: Pearson’s r Association of CNL intervention with a change in outcome Admission0.63* Discharge0.33 Physician0.31 Nursing care0.75† Skill level0.83† Keeping patients informed0.70† Attention to requests0.68† Attention to special needs0.47* * p <.05 † p <=.01 CNL Impact on Microsystem Care Quality

14. Results Press Ganey MeasurePhase Effect: Pearson’s r Immediate, sustained improvement Continuous improvement Admission0.450.60* Discharge0.270.07 Physician0.220.15 Nursing care0.69†0.63* Skill level0.78†0.79† Keeping patients informed0.55*0.52* Attention to requests 0.55* * Attention to special needs0.45*0.39 * p <.05 † p <=.01 CNL Impact on Microsystem Care Quality

15. Discussion Improvements in Nursing and Admission scores correspond with CNL accountability for improving care coordination and interdisciplinary collaboration structures and processes Ongoing collaboration with staff RNs, admitting physicians, and ancillary staff such as case management, respiratory therapy, and pharmacy Role modeling professional practice on a daily basis Convenient source of information about policy standards and evidence-based clinical practice CNL Impact on Microsystem Care Quality

16. Discussion Organizational structures not amenable to reform during study time frame may have influenced physician and discharge outcomes Biweekly physician team rotation Resident physician discharge order writing Additional work creating improved discharge processes and engaging patients with their physician teams is needed CNL Impact on Microsystem Care Quality

17. Implications The Institute of Medicine’s report on the Future of Nursing (2010) emphasizes the need to reconceptualize nursing practice FON highlights the CNL role as an innovative strategy for restructuring care delivery systems to improve care quality The CNL is a new model for nursing practice, yet remains untested in many ways. This study provides empirical evidence of a positive, sustained correlation between CNL-integrated care model and quality patient outcomes. CNL Impact on Microsystem Care Quality