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Pilot Program: Clinical Nurse Leader


Specializes in Gerontological, cardiac, med-surg, peds. Has 16 years experience.

This is a new direct entry level Masters prepared nurse.



Clinical Nurse Leader Role Moves into Pilot Phase

By Debra Wood, RN, contributor

Establishment of a new nursing position has moved closer to reality as 78 education and workplace partnerships launch pilot projects to pioneer the clinical nurse leader role and shape a new care delivery model.

"We have to radically change the way nursing care is delivered in the hospital and develop our caregiving around the role vs. just throwing another position onto the practice site," said Jolene Tornabeni, RN, FACHE, FAAN, chairperson of the American Association of Colleges of Nursing (AACN) Clinical Nurse Leader Implementation Task Force. "The clinical nurse leader is a generalized role of being a leader of a group of caregivers."

The task force has intentionally left some ambiguity about the position, so pilot sites will have flexibility to flesh out how a master's prepared clinical nurse leader will function in practice settings. Most of the clinical nurse leaders will work in acute-care hospitals but some will hold positions in ambulatory-care clinics.

Torabeni envisions the clinical nurse leader as the "go-to person" on a unit, someone who oversees care of 12 to 16 patients, but does not carry out nursing tasks. This leader will make suggestions, perhaps consult with a clinical nurse specialist or bring in other disciplines to help manage a complicated patient.

"Our world in health care has changed and care has become so complex," said Geraldine (Polly) Bednash, Ph.D., RN, FAAN, executive director of AACN. "We need someone at the point of care to serve as an expert clinician to lead other people giving hands on care."

The clinical nurse leader will stay a step removed from daily caregiving and focus on the bigger picture. This nurse will champion innovations that improve patient outcomes, ensure quality care and reduce health care costs as well as integrate emerging science into practice, according to the AACN vision statement.

"I think they have to have a financial return," Torabeni said.

In many regards, this position resembles the nurse manager role of the 1970s. But as nurse managers assumed more responsibility for the business and human relations side of unit operations, they ceased making rounds or honing in on patients' clinical concerns.

The clinical nurse leader will give back to nursing units a clinical management role and continuity between shifts. Nurse managers will maintain their financial and staffing duties.

"It's key to design a model that works in partnership with the registered nurses. We don't want to minimize what they are contributing or doing," said Marge Wiggins, RN, MBA, vice president of nursing at Maine Medical Center, a partner facility in Portland, and a member of the implementation task force.

Nursing leaders from Maine Medical in conjunction with the University of South Maine are meeting to develop a new delivery model and will rewrite job descriptions to redefine what everyone on the nursing team does. They also plan to change processes and eliminate system failures that waste nursing time before launching the clinical nurse leader role.

"Nurses are working so fast and hard," Wiggins said. "The stress is overwhelming. The system is broken."

The pilot programs will span 18 to 24 months. The master's curriculum will include courses in conflict resolution and leadership skills as well as physiology and science.

"We have great hope it's a highly skilled individual who is going to have a cram-packed curriculum that will teach system thinking, outcome management and complexity of care, and look at risk and populations at risk," Wiggins said.

Some sites will train second-degree people to become nurses who will immediately move into clinical nurse leader roles. But Torabeni expects that will not become the norm.

The role should appeal to nurses who enjoy working at the bedside but want to further their careers, gain more education and assume more responsibility, without leaving clinical care.

Nearly 120 nurses at Providence St. Vincent Medical Center, in Portland, Oregon, expressed interest in returning to school to pursue the new role when the health system announced plans to pilot the program. Providence Health System will provide financial support for about a dozen nurses completing coursework at the University of Portland.

"We had a huge response," said Traci Hoiting, RN, MS, ACNP-C, director of nursing quality & education at Providence St. Vincent. "The folks I have talked to about this role are so excited."

Providence Health System plans to pilot the clinical nurse leaders on certain units throughout its Oregon network of hospitals.

"One of the challenges for the first group is we need to look for alternative mentors, because there isn't somebody else already in a clinical nurse leader role to help them with their development," Hoiting said. "We have to be careful in structuring it, so folks in the role feel well supported from peers and administration."

Hoiting, who also serves on the implementation task force, views the clinical nurse leader as a positive step for nursing and an opportunity to rethink how the profession structure's care delivery. With the 78 partnerships free to create and experiment, more than one model may emerge for leaders to evaluate or try.

Torabeni hopes the partnerships will serve as a nucleus to galvanize additional support for transforming the care delivery model into one that nurses find more rewarding.

"Is this a magic bullet? I hope it is," Torabeni said. "We're talking about revolutionizing how nurses function. We need to make sure we stay with it long enough that it sticks."

© 2004. AMN Healthcare, Inc. All Rights Reserved.


Specializes in Gerontological, cardiac, med-surg, peds. Has 16 years experience.



March 14, 2004

Citing a need to focus education on preparation of nurses capable of addressing the health care dilemmas of the future, the American Association of Colleges of Nursing (AACN) proposes a new entry level master's prepared nurse. This new entry level nurse is proposed to target current and future leadership needs in all levels and types of health care settings and to implement outcomes-based practice, to improve quality, and to create/ manage systems of care.

The new nurse role - labeled the Clinical Nurse Leader - is conceptualized based on 10 assumptions, 3 core competencies, 7 knowledge competencies and 3 role competencies. No data are offered to support this conceptualization.

The National Association of Clinical Nurse Specialists (NACNS) monitored the progress of this proposal since it came into the public domain May 2003. Recently AACN's Board of Directors approved master's preparation for the new nurse. The move to master's education heightened existing concerns by NACNS members and the clinical nurse specialist (CNS) community at large. In response, NACNS conducted a systematic analysis of the competencies of the new nurse. The analysis was based on a comparison of competencies described in the Working Paper on the Role of the Clinical Nurse Leader (AACN, 2003) with competencies described in NACNS's Statement on Clinical Nurse Specialist Practice and Education (NACNS, 2004). Rationale for this comparison is that the CNS is a recognized a clinical leader and expert at managing clinical outcomes (ANA, 2004). The knowledge and competencies described in the working paper were also compared with The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 1998) because the proposed new role is an entry point into nursing practice.

The results of the comparison demonstrate that the proposed new nurse is an overlaying of the baccalaureate essentials on knowledge and competencies of the CNS. From this comparison, it is NACNS's opinion that the proposed competencies of the new nurse duplicate the competencies of the CNS. Additionally, it is NACNS's position that a clinical leader with systems level responsibilities cannot be prepared at the baccalaureate level; to be a leader requires competencies in the direct patient care level at the baccalaureate level upon which the master's preparation builds to prepare a clinical leader. CNS competencies build on baccalaureate competencies, therefore, the graduate degree awarded by programs preparing CNSs are focused entirely on advanced nursing practice. NACNS questions the ability of a master's program to include both the competencies needed for entry into practice and the competencies to practice in a leadership/advanced role as described in the working paper.

For AACN to propose this new nurse as either a replacement for or duplication of baccalaureate entry-level nurses who provide direct clinical care at a time of severe nurse shortage is a questionable use of scarce educational resources. The current number of CNSs is inadequate to provide the needed clinical leadership. Continued efforts to implement this new nurse proposal will disenfranchise clinical nurse specialists, a role that has been providing leadership to meet the needs of health care of the public for the past 50 years. This new nurse role should not progress to implementation. Rather than spending scarce financial and faculty resources on developing this new role when there is a national shortage of nurses, including CNSs, the nursing profession would be better served to support baccalaureate nursing and CNS programs.

NACNS acknowledges that baccalaureate nurses are in need of clinical mentoring and practice support and believes that CNSs are prepared to provide that support. NACNS is eager to collaborate with baccalaureate

programs/health care agencies to develop mechanisms to enhance the actualization of baccalaureate leadership competencies. In addition, NACNS is interested in discussing with AACN and other organizations opportunities for supporting and strengthening CNS programs.


National Association of Clinical Nurse Specialists (2004). Statement on clinical nurse specialist practice and education. Harrisburg, PA:author.

American Nurses Association (2004). Scope and standards of practice. Washington, DC:Nursesbooks.org.

American Association of Colleges of Nursing (1998). The essentials of baccalaureate education for professional nursing practice.Washington, DC, author.

American Association of Colleges of Nursing (2004). Working paper on the role of the clinical nurse leader. American Association of Colleges of Nursing. Retrieved March 15, 2004 from http://www.aacn.nche.edu.

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