Clinical Nurse Leader--a new nursing role.

In 2004, a new role in nursing, the Clinical Nurse Leader (CNL), was introduced by the American Association of Colleges of Nursing (AACN). Department of Veterans Affairs Tennessee Valley Healthcare System (VATVHS), in partnership with Vanderbilt University School of Nursing began a pilot program to introduce the CNL role to VATVHS. I was asked by Dr. James Harris, the then Associate Director of Patient Care Services at VATVHS, to work in this pilot program and implement the CNL role in the outpatient Gastroenterology area where I currently served as a staff nurse. This did not mean taking on a new job, but incorporating the Clinical Nurse Leader role into my existing role as staff nurse.

I was given the AACN White Paper which defined the role as follows: A clinician, outcomes manager, client advocate, educator, information manager, system analyst/risk anticipator, team manager, member of a profession and that of being a lifelong learner. I related to each of these roles, and I had worked part or all them during my 20 years of being a nurse. I decided to accept the position and to learn more about it.

The Clinical Nurse Leader role requires a master's or post-master's certificate in Clinical Management. In accepting this role, I knew I would have to return to school at Vanderbilt University School of Nursing. I completed the MSN program in Critical Care in 1993 at VUSN. Now at 53 years old, the challenge in front of me was to return to school and earn a post-master's certificate in Clinical Management. The CNL role inspired me so much that I eagerly accepted the challenge with myself and returned to school.

My biggest concern was how would I be able to manage work and school? I did not want to give up my position or work part-time. I discovered that in the clinical/educational partnership between VUSN and VATVHS the Clinical Management program at Vanderbilt allowed students to incorporate their clinical rotations directly into their current work practice site. This allowed me to maintain my current position and begin my CNL role as a student, while giving me the benefit of implementing freshly gained nursing principles into daily practice. This made a huge difference in beginning my CNL role, as I was able to design and implement process improvements at my clinical work site during my clinical nursing rotations while working directly with a Vanderbilt Clinical Management professor. I later discovered this to be a unique quality of Vanderbilt's School of Nursing program that was developed as a result of both the VATVHS and VUSN participating in the AACN CNL partnership pilot program.

I was educated to use research to define and solve practice problems, to look beyond the obvious outcomes and to work to discover the true essence of practice problems. Through research, I learned to define problems on the unit by analyzing decreased patient satisfaction scores, the nurse turnover rate, staff morale, and increasing stress levels. I worked within the practice environment and studied how problems were being solved daily and how the flow through the GI lab was affected by other variables within the unit itself. I evaluated how happy staff were with the way problems were being addressed by management and how their work performance was affected by their overall satisfaction with their work environment.

The building block of the CNL role is in microsystem process development and improvement. One of the processes I immediately began working on was a high No-Show/Cancellation rate in the Gastroenterology (GI) lab. Based on my initial Needs Assessment, I found that the GI Lab in 2004 and 2005 had a high No-Show/Cancellation rate at approximately 30%. Using the concepts gained from the CNL program, in one year of working with the staff, we were able to decrease this rate to a 14% yearly average. The educational training taught me how to implement microsystem process changes using Evidence Based Practice principles. The AACN White Paper guided me in coordinating the principles I learned from advanced practice nursing education with current standards in clinical practice. In doing this, I worked collaboratively with the Medical Director of the VATVHS Gastroenterology Lab, and the Nurse Manager of the GI Lab, to implement microsystem process changes that not only reduced our No-Show Cancellation rate, but improved the overall nursing care delivered at the bedside.

As the CNL, I provided education and process redesign at the unit level united with the facility's need for cost-effectiveness and efficiency in the work environment. The nursing staff displayed an overall increase in their job performance along with enhancing their own professional development. Their daily work achievements or accomplishments were not being fully recognized prior to the introduction of the CNL role in the GI Lab and are now nationally known. Their achievements have been used to enhance their own job performance evaluations and their accomplishments have increased their own personal awareness of nursing professionalism. As I began monitoring the work performance based on the changes implemented in my CNL practice, I created poster presentations highlighting the staff's work improvements, increased job performance and enhanced patient care outcomes, while being a part of delivering daily nursing care at the bedside.

It is the goal of the VA system that by 2016 the CNL role will be implemented in every VA facility and will be working in partnerships with institutions of higher educational programs in nursing just as VATVHS and Vanderbilt University School of nursing are currently doing now.

In 2006 as the CNL title became a registered trademark nursing title, I received a recognition award by Central Nursing Office of the Veteran Affairs for being one of the first nurses to successfully implement the CNL role in an outpatient area. Later that year, the CNLs at VATVHS were recognized by the Robert Wood Johnson Foundation as a team of CNL's implementing successfully a new role in nursing at VATVHS.

My long-term goal is to return to school to further my education in a Doctorate of Nursing Practice Program this fall to further improve and build upon my role. Being a CNL has made me realize how badly graduate education is needed at the bedside and I feel I must increase my knowledge base to fulfill this need. One thing I have observed is how much the CNL role has contributed greatly to joining together education and practice. VATVHS and Vanderbilt School of Nursing working together has proved to me that VATVHS is no longer just a training ground for physicians, but one for nurses as well.

Conclusion

I can't begin to tell you what a difference the CNL role has made to my life. When you return to school to gain more education you are often forced to work in administrative roles away from patient care due to your higher education level training. I wanted to remain involved in patient care, practicing at an advanced nursing level, and sharing my knowledge where I felt it would do the most good-at the bedside.

This is what the Clinical Nurse Leader role is all about and why I am so proud of being a part of pioneering the implementation of this new role in nursing. Thanks to the facility I work in, the Tennessee Valley Healthcare System, partnering with my educational facility, Vanderbilt University School of Nursing, I am able to practice my dream job of being an advanced practice nurse at the bedside, delivering high-quality nursing care to my honored patients, the United States American Veterans.

by Paula Miller MSN, RN, CNL

Paula Miller, MSN, RN, CNL, was recognized by the VA system for being the first Clinical Nurse Leader to introduce the program into the outpatient area. Miller has also worked with the American Association of Colleges of Nursing (AACN) and VA Central Office in Washington to implement the program in Nashville.