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Creating innovative clinical nurse leader practicum experiences through academic and practice partnerships.

ABSTRACT

Introduction. The new Clinical Nurse Leader (CNL) nursing role was developed to meet the complex health care needs of patients, families, and health care systems.

Case Presentation. This article describes the process used by nurse leaders at the University of Alabama at Birmingham School of Nursing and Hospital to develop Hodel C CNL practicum courses, recruit and prepare clinical preceptors, prepare clinical microsystems for CNL students, and develop additional practice partnerships throughout the region.

Management and Outcome. Critical to the success of the CNL role is a dynamic partnership between academic and practice leaders. The partnership allows faculty to develop curricula that are relevant and responsive to the rapidly changing health cate system. Clinical leaders become more aware of trends and issues in nursing education.

Discussion. Continued growth and success of the CNL role is largely dependent on the ability of faculty and practice partners to collaborate on innovative educational programs and models of care delivery.

Key Words Nursing Education--Clinical Nurse Leader Academic-Practice Partnership--Practicum

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MORE THAN A DECADE AGO, THE INSTITUTE OF MEDICINE (IOM) PUBLISHED THE LANDMARK REPORT TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM, REVEALING INEFFICIENCIES OF THE UNITED STATES HEALTH CARE SYSTEM (IOM, 2000). Although the health care system excels in its capacity to treat serious illness (Kenagy, Berwick, & Shore, 1999), medical errors, fragmentation, and inequity are prevalent and, often, place patients at unnecessary risk. Significant improvements in patient safety and quality have been accomplished during the last 10 years, but much remains to be done (Elhauge, 2010).

The "indispensable" role of the professional nurse in ensuring patient safety and care quality is well established (IOM, 2004). But, as a profession, nursing is experiencing unprecedented challenges (Donley, 2005) likely to have significant implications for how nurses are educated as well as how nursing care is delivered (Benner, Sutphen, Leonard, & Day, 2010). New models of tare, using a novel nursing role, are needed to ensure the delivery of efficient, effective health tare (Joynt & Kimball, 2004).

Recognizing the capacity of nurses to assume a leadership role in improving quality and safety in the health tare system, the American Academy of Colleges of Nursing (AACN) has partnered with leaders in the health care system to develop a new nursing role known as the clinical nurse leader (CNL) (AACN, 2007). CNLs are educationally prepared to provide the point-of-care clinical leadership needed to guide the interdisciplinary team in the delivery of care consistent with the needs of patients, families, and health care systems. To successfully fulfill the nursing covenant with the public, professional nurses must be educationally and experientially prepared to: a) assume clinical leadership roles, b) implement evidence-based practice, c) evaluate health care system and patient health outcomes, d) accept personal responsibility for their professional practice, e) advocate for patients and the nursing profession, and f) ensure that care provided within the microsystem is culturally appropriate and relevant (AACN, 2007). The success of a CNL educational program to prepare graduates to fulfill this covenant is largely dependent on the presence of a dynamic partnership between academia and practice (Tornabeni & Miller, 2008), ensuring the development of meaningful and innovative clinical immersion experiences (Harris & Roussel, 2010).

This article describes the process used by nurse leaders within an academic health care center in Alabama to develop Model C CNL practicum courses, recruit and prepare clinical preceptors, and develop additional practice partnerships throughout the region. The article also discusses clinical microsystems for CNL students. In contrast to the traditional "top down" approach, the microsystem assessment framework has been developed for use on the "front line" of care in efforts to improve health care quality and safety (Microsystem Academy, 2009). Because quality, safety, and cost outcomes are produced from activities occurring within the microsystem, improvement in the larger health care system (macrosystem) is dependent on achieving optimal microsystem performance.

Model C CNL Program Responding to the community's need to increase the number of highly educated nurses ar the point of care, the University of Alabama at Birmingham (UAB) School of Nursing (SON) formed a partnership with nursing leadership at the UAB Hospital to develop a Model C CNL program. The Model C program is designed to prepare an individual with a baccalaureate degree in another field to enter the nursing profession as a master's-prepared nurse (AACN, 2007). The SON Model C CNL program is composed of the accelerated master's in nursing practice (AMNP, pre-licensure phase) and the CNL phases. Following the successful completion of the three-semester AMNP phase, students are eligible to sit for the NCLEX-RN[R] (licensure is a requirement for participation in the CNL phase of the program). The curriculum in the four-semester CNL phase of the program is designed to prepare students to successfully function in the nine roles of the beginning CNL and to become eligible for CNL certification.

Kolb's (1984) experiential learning model and the Microsystem Assessment Framework (Microsystem Academy, 2009) were used to guide the creation of practicum learning experiences. Consistent with AACN guidelines (2007), student practicum experiences include the following elements: a) full immersion into the CNL role within the microsystem, b) ongoing opportunities to develop technical skills and professional knowledge, c) opportunities to form interpersonal relationships with unit leaders and health care professionals required to function as a leader within the microsystem, and d) practicum placement, occurring only within microsystems in which interdisciplinary care is embedded.

Preparing Students A major component of the CNL practicum experience includes the development and implementation of a safety and/or quality project specific to the needs of each student's assigned clinical microsystem. However, successful initiatives at the microsystem level require knowledge of the unique context of the environment, known only to those working within the microsystem on a regular basis (Batalden & Davidoff, 2007). To facilitate development of the clinical knowledge, skills, and professional relationships needed to successfully lead the microsystem assessment process (Lansberg, 2007), students are assigned to one clinical microsystem with one primary preceptor for all three CNL practicum courses (one year). Experiential learning is supported through clinical experience, reflection, conceptualization, and active experimentation over the one-year time span (Kolb, Corrigan, & Donaldson, 1999).

In the first clinical semester (90 contact hours), course work guides students to primarily focus on five of the nine CNL role functions: clinician, member of a profession, team manager, outcomes manager, and lifelong learner. To support the development of clinical skills, students spend 40 hours directly working with an expert nurse to develop an understanding of care delivery within the microsystem and how the expert nurse communicates (verbally and in writing), delegates, plans and prioritizes care, and provides nursing leadership within the clinical setting. This is a critical component for Model C students with limited clinical nursing experience.

During the remaining 50 hours, students begin the microsystem assessment (Godfrey, Nelson, & Batalden, 2005) by completing three steps: a) organize a lead team, b) conduct the assessment, and c) make a diagnosis (i.e., identify an opportunity to improve quality, safety, or both). Through this process, students learn to access and interpret information vital to assessing the performance of the microsystem, such as employee and patient satisfaction, and compare it with national benchmarks. Leading the interdisciplinary team supports the development of leadership, communication, and conflict-management skills. Collaboratively, the preceptor, faculty, and students will identify other relevant quality and safety activities in which participation may be beneficial, such as a root-cause analysis or joining an existing quality improvement committee.

In the second clinical semester (90 contact hours), the primary focus is on the remaining four roles (advocate, educator, information manager, and risk analyst); however, the students continue to strengthen their knowledge of and skills in the five roles presented in the previous semester. Students spend an additional 40 hours with an expert clinician, develop staff and patient educational materials, and continue to participate in other agreed-upon quality and safety activities. The fourth step of the microsystem assessment is completed as students lead an interprofessional team in the creation of an evidence-based protocol to "treat" the microsystem for the need identified in the third step of the assessment. A detailed plan for protocol implementation and evaluation is also developed.

The goal of the SON CNL capstone practicum experience is that it more closely resemble future graduates' first CNL position rather than students' last practicum course. During the final semester, students spend 300 hours fully immersed within the microsystem, functioning in all nine roles of the beginning CNL. Students also implement the evidence-based intervention developed in the previous semester, collect preliminary outcome data, and make needed changes to the protocol. A plan to enhance sustainability of successful interventions within the microsystem is created.

Preparing Clinical Preceptors The mentorship provided by the clinical preceptor is critical to student success. By facilitating socialization into the nursing profession (Henderson, Fox, & Malko-Nyhan, 2006) and sharing clinical knowledge and expertise (Heffernan, Heffernan, Brosnan, & Brown, 2009), preceptors can create a unique clinical learning environment that supports the development of confidence and competence in clinical practice.

As the CNL role is relatively new, identifying preceptors educationally prepared as CNLs is not always possible. Potential preceptors are identified through chief nursing officer (CNO) referral, faculty recruitment, and self-selection. We found that potential preceptors often experienced confusion with both the CNL role and their role as a CNL student preceptor. To better communicate the CNL preceptor role, a conceptual model was created from a review of the literature and an analysis of the AACN description of the CNL (2007) as well as preceptor guidelines (AACN, 2006). (See Figure.)

A true education-practice partnership requires ongoing dialogue between academic and practice partners (Stanley, Hoiting, Burton, Harris, & Norman, 2007). To meet the ongoing informational needs of clinical preceptors and faculty during the practicum, educational sessions are held at the beginning of each semester to discuss course content, assignments, and clinical practicum student expectations. Through this interaction, faculty members can frequently assess student performance, determine the adequacy of theory course content to prepare students to practice in the CNL roles, and verify that assignments are relevant within the complex and rapidly changing health care system. At the end of each semester, preceptors are asked to provide information about their experience as a preceptor and how their experience and practicum courses could be improved.

Preparing the Community Full microsystem support of the student in the CNL role is a required component of the practicum experience (AACN, 2007). However, many health care professionals within the microsystem are not familiar with the CNL role or the microsystem assessment framework, which limits their ability to be supportive. To provide an introduction to the CNL role, CNL educational preparation, and the microsystem assessment framework, one-hour information sessions offering continuing education units are held for all health care professionals in all practice roles (e.g., unit secretaries, nursing assistants) within our partnering microsystems. Following participation, many health care professionals verbalized that they now understand the CNL role. We believe these formal information sessions are critical to gaining full support of the CNL role by health care professionals within the microsystem.

Within the UAB SON, many faculty were unfamiliar with the Model C CNL program. To provide faculty with a foundational understanding, a nationally recognized CNL champion led one-hour information sessions. The Model C CNL curriculum was also presented and discussed at faculty organization and curriculum committee meetings.

Each year, the UAB SON offers a daylong symposium dedicated solely to advancing the role of the CNL in the region. During its first year, the content of the symposium was primarily focused on advancing knowledge of CNL education and the CNL role within the health care community. Future symposiums will primarily focus on disseminating information about the impact of the CNL on health care outcomes (patient, family, and microsystem) and incorporating the CNL role into the practice setting. Nurse leaders (e.g., CNOs, nurse managers, unit educators) and faculty throughout the region are invited to attend these daylong continuing education events free of charge.

Challenges PREPARING THE MODEL C CNL STUDENT The transition from nursing student to nursing graduate to competent registered nurse is challenging (Duchscher, 2008, 2009). As Model C CNL students begin new jobs within the practice setting as novice nurses, they are also required to simultaneously assume a clinical leadership position as nursing school graduates. Nearly all students initially demonstrated a significant difficulty adapting to the two very different practice roles. An additional challenge for these students was fulfilling practicum requirements while participating in daily mandatory "new nurse" orientation.

Research to determine the need for a required practice (i.e., nursing experience) component prior to beginning independent graduate student CNL practicum course work is needed. At a minimum, the curriculum should include content on the transition from nursing student to RN, socialization into the professional nursing role, health care systems, and interprofessional communication prior to starting a practicum experience.

Again, limited awareness of the CNL role within the health care community presents a challenge. Students are encouraged to have an "elevator speech" ready as a response to frequent questions posed about the CNL role. Students should also be prepared to respond to questions from other master's-prepared nurses concerning the viability of the CNL and the ability of novice nurses to be engaged in a graduate-level education program preparing them to be clinical leaders. Finally, the lack of CNL positions in the region is a concern for students. A fear of being unable to secure a CNL position following graduation leads some to consider transferring to more established MSN programs.

PREPARING THE PRECEPTOR Overall, we have had great success with non-CNL preceptors. However, lack of personal experience, exposure, or both to the CNL role may create uncertainty in the preceptor's ability to facilitate needed clinical experiences and serve as a role model. Non-CNL preceptors may require additional support and affirmation when they precept CNL students compared to when they precept students educated in their same practice role.

Preceptors make a 12-month commitment to the CNL students. On a few occasions, life events for the preceptor (e.g., relocation, promotion) or poor preceptor-student fit have necessitated the transfer of a student's practicum to another preceptor, unit, or both. If possible, students are reassigned to a new preceptor in the same unit; however, if this is not possible, then the student is assigned to a new preceptor in a new unit within the same institution to minimize possible disruption of the student's practicum experience. When transferring a student practicum to a new unit, the student is partnered with a peer on a larger or more complex unit, allowing the transferred student to utilize data collected during the microsystem assessment performed by their peers.

Preceptors have expressed difficulty providing clinical feedback on student performance. This difficulty most often occurs due to unrealistic expectations of the preceptor, student, or both with regard to the student's ability to fully function in all nine roles of the beginning CNL by the middle of the first practicum course. Active faculty guidance during formative and summative clinical evaluations was beneficial in helping both students and preceptors identify realistic benchmarks for clinical role performance.

PREPARING THE COMMUNITY Implementation of the Model C CNL program created concern among faculty members about the appropriateness of preparing novice nurses as clinical leaders. Discussions of the realistic employment outcomes of Model C CNL students (the necessity of working at least two years in a staff nurse role prior to applying for a CNL role position) have been helpful, but many faculty remain tentative with their approvals.

At the time we began our program, we had no CNL-prepared faculty. Those selected to lead CNL program development had educational and experiential backgrounds as nurse administrators, outcomes managers, and clinical nurse specialists, necessitating rapid acculturation of the knowledge and skills needed in the CNL faculty role. Faculty members also found that teaching strategies had to be adapted to provide the level of support needed to help novice nurses progress in a graduate nursing-leadership program.

Expanding CNL Practicum Opportunities To expand clinical practicum opportunities, faculty within the CNL program visited the CNO at each hospital in the region. Faculty and CNOs had the opportunity to discuss the evolution of the CNL role, competencies and skills, and the educational program for Model C CNL students at UAB SON. The nature of the student's microsystem assessment and the fact that the evidence-based intervention was more than just an academic requirement but instead was a microsystem-specific and sustainable improvement in quality or patient safety were particularly meaningful to CNOs. Each CNO was asked the following questions: Would the skills and competencies of the CNL be valuable to your institution? How do you envision the CNL role being implemented at your institution? Would you be willing to serve on the UAB SON CNL Advisory Council? Would you support the placement of CNL students ar your institution? All CNOs provided positive responses to each question.

Another effective initiative to expand practicum opportunities was the appointment of reimbursed CNL coordinators at selected area hospitals to serve as practice partners for the CNL program. Because each appointed CNL coordinator was also currently within a nursing leadership role within the organization, they were able to facilitate practicum experiences for CNL students, identify and recommend appropriate preceptors, and champion the CNL role. The first CNL coordinator was appointed at a major practice partner of the UAB Hospital. In the next two years, a CNL coordinator was selected for the Veterans' Affairs Medical Center and St. Vincent's Hospital, both in Birmingham.

Formation of an Advisory Council Recognizing the need for sustained programmatic leadership from nurse practice leaders within the region, an advisory council was created. Using Ott's (2010) recommendations for the formation of advisory councils, practice partner leaders (CNOs or their designee), CNL faculty members, consultants to the CNL program, CNLs from the community, and CNL student representatives were invited to attend an initial meeting. This group formed a charter to clearly delineate the purpose of the Advisory Council, membership and leadership, reporting structure, and the meeting schedule. The purpose of the council was determined to be: a) provide a forum for the collaborative exchange of ideas for the preparation of CNLs at the UAB SON, b) assist in the planning, implementation, and evaluation of CNL practica, and c) explore opportunities for practice and academic partners to facilitate the promotion of excellence and achievement for new CNLs in the region. It was further determined that the Advisory Council would be co-chaired by a CNL faculty member and a practice partner representative. It would meet biannually and report directly to the UAB associate dean for academic affairs.

Conclusion Nationally, nursing schools have successfully prepared CNL graduates to have a significant impact within the microsystem. Implementation of the CNL role has demonstrated improved organizational and patient health outcomes (Bowcutt, Wall, & Goolsby, 2006; Gabuat, Hihon, Kinnaird, & Sherman, 2008; Smith, Manfredi, Hagos, Drummond-Huth, & Moore, 2006; Tachibana & Nelson-Peterson, 2007). However, continued growth and success of the CNL role in the practice setting is largely dependent on the ability of faculty members and practice partners to unite and develop innovative educational programs and design models of care delivery while incorporating the CNL role (Stanley et al., 2007). The partnership developed to create innovative CNL practicum courses may also provide the needed knowledge, skills, and leadership to develop innovative care-delivery models.

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Angela Jukkala, PhD, RN, CNL, CNE, is associate professor, University of Alabama at Birmingham School of Nursing. Rebecca Greenwood, PhD, RN, is an adjunct faculty member, University of Alabama at Birmingham. Terry Motes, MPA, RN, NEA-BC, is a nurse manager, University of Alabama at Birmingham Hospital. Velinda Block, DNP, RN, NEA-BC, is chief nursing officer, University of Alabama at Birmingham Hospital. For more information, contact Dr. Jukkala at jukkalaa@uab.edu.
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Title Annotation:CLINICAL NURSE LEADER
Author:Jukkala, Angela; Greenwood, Rebecca; Motes, Terry; Block, Velinda
Publication:Nursing Education Perspectives
Article Type:Report
Geographic Code:1USA
Date:May 1, 2013
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