Clinical Nurse Leaders: A Revolutionary Change
Monday, Jul 15, 2019
CNL students
In May 2019, Lander University graduates 13 students from its Master of Science in Nursing - Clinical Nurse Leader program. 
CNL students pictured above, L-R: Stephanie Ahn, Virginia Dean,  
Amy Leigh Logan, Joshua Eidson, Tonya Williams, Jessica Kelly,  
Portia Bluford-Briggs and Stephanie Lewis. Photo by Laura Brown

In the spring of 1959, Sylvia Brooks got up from her seat, walked across a small stage, and received her associate’s degree in nursing from what was then Lander College.

It was a major moment, because the young Brooks was the first graduate in the school’s first nursing class – two years after the college had begun the Self Memorial Division of Nursing, a two-year program for qualified applicants.

But, in May 2019, 13 nursing students from Lander University will walk across a much bigger stage and become the largest graduating class of a Master of Science in Nursing program that qualifies each of them to sit for the Clinical Nurse Leader (CNL®) certification, a new health care designation designed to improve patient care and safety.

Their milestone marks a signature achievement of a CNL partnership established in 2017 between Lander and nearby Self Regional Healthcare (SRH).

And, more than just graduating a new class of nurses, this partnership not only represents a revolutionary era of U.S. health care, it puts Lander on the forefront of every CNL nursing program in South Carolina.

“We are currently the only school in the state to have a CNL partnership with an area health care system,” said Dr. Holisa Wharton, dean of Lander’s William Preston Turner School of Nursing. “The 13 members of this class are our largest CNL class to date, and the program they have just completed stands to serve as the model for every future CNL partnership in South Carolina.”

CNL – A New Nurse

Despite its newness to Lander and Self Regional, the concept of the Clinical Nurse Leader originated in 1999 with the American Association of Colleges of Nursing (AACN).

AACN officers were concerned over a new report by the Institute of Medicine (“To Err is Human: Building a Safer Health System”), which estimated that 44,000 to 98,000 Americans were dying each year due to errors in health care.

The Institute urged health care systems to reorient their efforts to reduce these errors and improve patient safety.

From this recommendation, an AACN task force developed the model of a "New Nurse" graduate – one that would be educated beyond a four-year program, with a new professional credential and new scope of practice.

This model soon became the blueprint for the CNL – serving in the role of an advanced generalist nurse, applying their clinical knowledge at any point of care where needed, but without having to specialize in one or more specific areas of medicine, like an Advanced Practice Registered Nurse.

This kind of care would allow other nurses to spend more time in specialty areas, such as surgery, ambulatory, neonatal, oncology and research, and ostomy, which involves the treatment of patients with acute and chronic wounds.

“We were at a crossroads in health care,” said Dr. Joan Stanley, Chief Academic Officer with the AACN, and a chief proponent of the national CNL initiative. “Nursing shortages were increasing, and patient care was not as stellar as we thought it could be. We wanted the ‘New Nurse’ model to help us answer these concerns.”

It was the first new role to the nursing profession in 35 years – and when the AACN convened a meeting in June 2004 to discuss next steps in the initiative, 77 schools of nursing and their partner health agencies committed to working together to implement this new model of care delivery. 

Texas Health Resources, Maine Medical Center, Carolinas Medical Center in Charlotte, N.C., and the U.S. Department of Veterans Affairs were among the first pilot programs.

From their efforts, the first set of CNL curricular standards was estab-lished in 2006, with the first CNL degrees conferred in 2007.

Both Lander and USC Upstate began their own CNL programs in 2014 – the first two in South Carolina.

And, by 2016, the CNL initiative had mushroomed to more than 190 health care agencies and 90 universities across the U.S.

“We’ve been tracking CNL graduates since 2005,” said Robert Rosseter, chief communications officer with the AACN, “and through 2018, more than 11,000 nursing students have graduated from master's- level CNL programs.”

Stanley added that this figure is expected to go much higher in the next decade because “the entire health care system has said they need nurses with a CNL skillset to address the gaps in patient care and patient safety.”

Keeping an eye on CNL progress were Lander nursing professors Dr. Holisa Wharton and Dr. Liz McDowell.

When they attended the February 2017 AACN-CNL Summit and Research Symposium in Atlanta, Ga., they learned that many U.S. health care systems with CNL partnerships had shown vast improvements in patient outcomes and safety.

McDowell and Wharton saw the potential to shift the university’s CNL program into a higher gear – and shortly after returning from the symposium, they met with Dr. Linda Russell, senior vice president and Chief Nursing Officer at Self Regional, to see if Lander and SRH could form its own CNL partnership program.

“We saw many future benefits in the idea,” Russell said, “and it was also a way of taking our original partnership from 1957 to a higher level.”

In the next eight months of planning, 17 nurses at SRH were approached to be in the pilot class. As an incentive, SRH agreed to pay a large portion of their education, to allow them to continue working fulltime with minimal financial burden.

And shortly after 10 of the 17 nurses became CNL-interns in August 2018, Wharton, McDowell, and Russell knew they had something special.

“We’ve already seen evidence that this first team of CNLs has improved the quality and safety of our patient care,” Russell said.  “And, we believe they will lead to increased nurse satisfaction and physician satisfaction. So, in terms of us providing Greenwood with better health care, we recognize that it’s a new day.”

So new, in fact, that many of the 10 Lander CNLs often find it hard to explain what their new role is all about.

Bridging Gaps in Patient Care

CNL nurse Jessica Kelly, for example, can tell you about bedside care, hospital safety procedures and rapid responses when patients become unstable.

But ask her to explain her role as a CNL …

“It’s been my biggest challenge,” Kelly said. “But, in a nutshell, I help bridge gaps in patient care.”

Bridging this gap means Kelly now serves SRH in many points of care, such as:

  • reviewing patient charts daily and assisting nurses in documentation and goals of patient care for that day; 
  • assisting the nursing staff with preventive measures, and in critical patient areas, such as inserting IVs and Foley catheters into the bladder to drain urine;
  • monitoring the need for central lines and other devices that put patients at high risk for infection; and
  • coordinating interdisciplinary care rounds with nurses to help determine patient needs. 

“I think CNLs are important on any health care level,” Kelly said. “And soon, I hope I can tell people I’m a CNL without hearing, ‘What does a CNL do?’”

Denting the Shortage

Such confidence could soon face a critical test, as the AACN expects many U.S. health care systems to experience a sizable nurs-ing shortage.

For example, in 2007, the American Hospital Association estimated that U.S. hospitals were understaffed by approximately 16,000 nurses.

The Health Resources and Services Administration in Rockville, Md., projected this shortage to surpass the one-million mark by 2020.

But, Lander clinical instructor William Maxwell Clegg said that CNL partnerships are an obvious way to dent this shortage, because of their “multiple advantages.”

“CNLs are true bedside nurses – they have the time to visit each patient under their care,” Clegg, who also graduates from the CNL program in May, said. “They can save hospitals millions of dollars by keeping patients safe, and helping them feel more involved in their health care decisions, which increases patient satisfaction.”

And Suzanne Vaughn, director of nursing quality at SRH, added that the CNL partnership demonstrates this dedication.

“Collaboration between us and Lander is a top priority for furthering our CNL program,” Vaughn said. “In the past two years, we have witnessed a culture change for the better, related to perceptions of how the CNL program benefits our patients and our entire health care team.”

CNL Confidence – Near and Far

Whether large or small, CNL partnerships around the country have led to a number of improved health care outcomes, including these three:

Tennessee Valley Healthcare System (TVHS)​

An early pilot for the CNL initiative, TVHS operates across Tennessee and parts of northern Kentucky. In 2007, TVHS officials reported these CNL-related outcomes:​

  • a 40 percent decrease in patient returns to critical care.
  • an 18 percent decrease in critical care days.
  • a decrease in central catheter line infections, from 179 per year to 0 per year. This achievement netted the system a savings of $500,000.​

University of Virginia

In 2011, a CNL student at UVA was noted by Dr. Kathryn Reid for “Bundling Up Clostridium Difficile,” a bacterium that infects humans and other animals, causing diarrhea and inflammation of the colon. The CNL’s efforts in a local intensive care unit reduced the bacterium rate from an average of 10 cases per month to 0 cases for a three-month period.

Rush Oak Park Hospital – Chicago, Ill.

Rush Oak began its CNL program in 2012 under the direction of Denise Wienand. In 2015, Wienand authored "Implementing the Clinical Nurse Leader Role,” in which she noted a decrease in the average length of stay from 5.73 days to 4.85 days.

Since then we’ve improved to a rate of 3.58 days, our 30-day all-cause readmission rate has decreased from 12 per-cent to 7.8 percent, and staff satisfaction has also increased,” said Wienand, “all because of our addition of CNLs.”

 

It is these kinds of outcomes that Self Regional hopes to see from their CNLs.

“Hospitals are now seeking out CNL students,” said Dr. John Paguntalan, a ’97 Lander alumnus and nurse practitioner at SRH. “The growth of our CNL program lies in the success of CNLs improving measurable health outcomes that are effective, efficient and sustainable.”

It’s a challenge that Jessica Kelly, Amy Leigh Logan and  CNL-to-be Angela Smith are ready to embrace – in the same spirit Sylvia Brooks did in 1959, when she and other members of that year’s class set Lander’s nursing wheels in motion.

“I’m so glad I was part of this first CNL partnership program,” said Smith, a surgical floor nurse at Self Regional. “I think my training will allow me to be a better educator, leader and patient advocate – and I am proud to be a CNL!”

 

This story is featured in the Spring 2019 edition of Lander Magazine. Read more, including profiles of several CNL graduates and students, at www.lander.edu/magazine.