Preparing the Way for the Clinical Nurse Leader, A Work site program Final for submission

Running head: PREPARING THE WAY FOR THE CLINICAL NURSE LEADER 1

Abstract

The Clinical nurse leader (CNL) is the first new nursing role in 40 years. The CNL is a

nursing created position developed by the American Association of Colleges of Nursing (AACN)

in 2003. As a CNL I was asked to design a work site curriculum for a major university.

Designing a CNL curriculum differs from other nursing specialties because AACN and

practicing partners contribute to the success of this role. In addition to gaining support from the

university, commitment from a practicing health care partner is essential before proceeding with

this initiative. The first step in creating the curriculum design is to determine the community’s

readiness and need for this type of program. In this paper I will outline the steps taken to develop

a work site CNL program. When planning a curriculum for the CNL the graduate needs to meet

the requirements of the AACN and pass a certification exam after completing the program. A

capstone project and clinical immersion hours must be met prior to sitting for this exam. My

experience as a CNL influenced the curriculum design as well as my personal education in

graduate school. This work site program was tailored to meet the specific requirements of a large

university with multiple healthcare affiliations.

Key words: Clinical Nurse Leader, Educational partnerships, Curriculum design


The Clinical Nurse Leader (CNL) role is a new visionary nursing role developed by the

American Association of Colleges of Nursing (AACN) in 2003. In the AACN Spring annual

meeting it was reported that 90 schools of nursing and 190 health care institutions were

participating in the CNL pilot (AACN, 2006a). In this paper a proposal for a CNL program is

suggested guiding the decision whether or not to become part of this national AACN initiative.

The University is part of a large health care system and this cutting edge role could advance

professional nursing practice in this geographical area. The innovative idea for a CNL work site

program came from a university faculty advisor. Presently a successful master’s degree program

is already established at this partner site. Creating a work site program has many advantages and

is a great fit for the CNL partnership. Developing a CNL program requires a strong commitment

from practicing health care partners and the educational partners to succeed. The AACN

provides guidance and direction to the education and practice partner as they pilot the CNL

program. This CNL curriculum design is influenced by existing university requirements for

Masters Education, the AACN, and the practice partner’s resources. It takes planning, tenacity,

and stakeholder support to pioneer this program. In this paper I will expound on the steps taken

to lay the foundation for a CNL program at a major university.

Brief Introduction of the CNL role

The CNL is a new nursing role created by the American association of colleges of nursing

(AACN). The CNL is a patient advocate who practices in the clinical setting at the point of care.

The roots of this new role began to emerge in response to critical issues linked to our current

fragmented health care systems. The nursing shortage, increasing medical errors, call for

evidence based practices, an aging population, and projected future societal health care needs are

only some of the issues which precipitated this role. Although it seems as though the CNL


emerged out of nowhere it was the product of many years of planning and collaboration. In 2003

the first draft of the white paper defining the role of the CNL was published and subsequently

revised in 2007 (AACN, 2007). The CNL role captures skills needed to fill the gaps in our

current nursing practice. This role provides leadership and empowerment needed to propel our

profession forward into the future. This role embraces change which is essential for growth in

our current practice settings.

It is apparent that the CNL role is one answer to meet the nursing demands of the 21st century

but will it prevail? The success of the CNL role teeters on the approval and recognition of this

role by nursing administration, nurse colleagues, practice, education and service partners.

Sherman (2008) reported “A unique feature of the project was an AACN requirement that

universities and colleges interested in offering the CNL curriculum had to engage a service

partner” (p. 236). The service partner is complementary providing a niche in the institution for

the CNL to practice and expand this role. Practice partners’ create a job description, salary

incentive, tuition reimbursement, and oftentimes flexible work schedules while the student

attends college. Chief nursing officers and nursing administrators are vital to the successful

implementation of this role. The CNL cannot navigate change without strong administrative

support. Mentoring for the CNL role begins in college and continues after graduation to sustain

the momentum for this new role. The CNL will transition into this role during the clinical

immersion. Nursing colleagues will learn about this role by word of mouth and as it unfolds in

the clinical setting. The role as nurse generalist varies in each clinical site and may differ in

implementation across settings. For nursing colleagues to embrace the CNL they need to

understand the value of this role to nursing practice. In contrast to engage practice partners

requires demonstration of outcomes which appeal to the business.


The CNL role takes time to develop and transform clinical practice. The educational partner

is crucial to the success of the CNL project as they provide an environment to practice core

competencies vital to this evolving new role.

Engaging Partners

One of the unique challenges to developing a CNL curriculum is that the program cannot

exist without a practice partner. And it must demonstrate business value to the key stakeholders.

Can a practice partner be persuaded to join forces with an academic institution to develop the

CNL role? Developing the CNL role requires strong leadership, academic creativity, and

tenacity. The first step prior to adopting the CNL curriculum plan is to determine the community

need and student interest. Keating (2006) recommends “A needs assessment ensures the

relevance of the program to a community need and its eventual financial viability” (p. 108). It

would be irresponsible to not evaluate the projected financial costs for the university and

partners. The work site program was selected because full time employees of this healthcare

institution receive tuition reimbursement. I met with the Chief nursing officers (CNO) of two

healthcare institutions to introduce the CNL role and determine interest for participating as a

practice partner. Both healthcare institutions were selected because of their affiliation with the

University. Neither CNO seemed to have prior exposure to this role. One chief nursing officer

expressed interest in piloting the CNL role but requested additional evidence to support the value

of this role. I also attended a university sponsored educational information session at this work

site where some students expressed interest in the CNL role. In the course of my employment I

casually discussed the CNL role orienting physicians, colleagues, and administration. Several

colleagues at this work site are enrolled in my Doctorate of nursing practice program and I

introduced them to the role through classroom discussion and presentations. One way to prepare


an organization for a new nursing role is through education. I provided a nursing presentation

titled The Clinical Nurse Leader for the current Masters degree students enrolled in the work site

program which was well received. I realized that in this large medical complex with three major

hospitals in close proximity to one another that I was the only CNL employed in this area.

Although, not for long because one of the major hospitals in this area has recently partnered with

another university to join the CNL initiative (X, personal communication, September, 9, 2009).

Gaining buy in from key stakeholders is one of the most important steps to achieve before

adopting a CNL program. Once a University–stakeholder partnership is achieved the secondary

goal of finding interested student candidates will follow. Stanley (2007) found “Factors that must

be taken into account when considering any potential partnership include such things as the

location, availability, public or private status of potential partners, competition from other

sources for resources, funding, and decision-making processes and philosophy of both parties”

(p. 69). The CNO who agreed to pilot the CNL in a few clinical units shares a nursing

philosophy which is in alignment with the School of Nursing. Now that a partner has accepted

the challenge to pioneer this role it is reasonable to plan the curriculum.

Planning the Curriculum

I contacted the AACN to determine what steps were needed to form a CNL educational

partnership. I contacted Dr. Joan Stanley who is the AACN Senior Director of Education policy

at AACN for guidance and permission to proceed in the development of a CNL program. Dr.

Stanley directed me to the AACN web site to download the CNL toolkit, curriculum framework,

and Whitepaper (J. M. Stanley, personal communication, July 13, 2009). Preparing a CNL

curriculum design requires methodical detailed planning. Educational partners are challenged to

develop a graduate program within the parameters of the AACN guidelines. The AACN (2006b)


curriculum framework outlines detailed academic requirements necessary to fulfill the

competencies for the CNL role. Tailoring the CNL curriculum to meet the AACN guidelines,

and finding faculty to implement this new role requires creative innovative across-the-board

planning. It is a challenge to create a curriculum to meet these imposing standards.The Clinical

nurse leader conceptual framework can serve as a guide when planning the CNL curriculum

(Maag, Bucccheri, Capella, and Jennings, 2006). I met frequently with Dr. X. university faculty

advisor who informed me that several university courses must be built into the curriculum as

they are required core courses. Roche, Demartinis, and Henneman (2009) caution “Programs that

requied mainly existing course work, with a CNL immersion course to integrate all the CNL

competencies, could fall into the trap of merely tweaking an existing program” (p. 103). For this

reason I felt that the curriculum should include core courses which would incorporate all the

elements of the CNL as outlined by AACN. The courses were designed to follow a sequential

pattern of learning building upon each successive course. Young and Paterson (2007) found

“The design of instruction should logically flow from the other major elements of the

curriculum”. Students are required to complete an evidenced based capstone project. Partners can

be instrumental in offering suggestions for capstone projects and the outcomes will be of mutual

benefit to the organization. The clinical immersion experience was planned for the last semester

as it is hoped that the employee will smoothly transition into this role at that time. Planned

seminars will accompany the capstone and clinical immersion to render support and guidance to

students. It is hoped that clinical preceptors will develop bonds with the students and provide

future mentorship as the role evolves. Once the university agrees to proceed with this program

the next step in this process is to design the course syllabus with the entire curriculum team. It is

suggested that the course syllabus include all the essentail curriculum elements of the CNL.


Students will be eligible to take the CNL certification exam at the conclusion of the program if

the capstone, clinical immersion, and core curriculum competencies have been met.

Curriculum design

Curriculum design was developed using the AACN Curriculum framework (AACN, 2006a) .

The goal was to develop a curriculum model which fits the current part time nursing on site

program at the University affliated healthcare center. The reasons to pilot the CNL at a work site

are (a) employer tuition plan, (b) convenient location for partners, (c) convenient class hours for

employees, and (d) ability to transition into existing curriculum. The length of the program

would be sequential part-time study for two years. The GRE would be exempt as in the existing

work site program. This program would provide 30 nursing credits.

The curriculum is designed for students to sequentially complete the courses. A CNL course

is offered every semester with the exception of the Spring semesters. Threading CNL concepts

thoughout each course is suggested to provide opportunities to embrace this role. The practice

immersion and capstone will include seminar face to face meetings throughout these semesters.

Opportunities to prepare for the CNL exam will be interwoven into the courses. The informatics

course is ideal for providing an opportunity to practice the CNL simulation style exam on line.

Threading exams similar to the CNL certification exam throughout this program will help

students to succeed in passing this test.


Curriculum Sample

Fall # 1 NUR 645 (MSN) CNL Core # 1 Introduction to the role & core competencies

*NUR 644 (MSN) Leadership and Professional Development in Nursing

Spring # 1 *NUR 608 (MSN) Concepts for Advanced Practice for the CNL

*NUR 630 (MSN) Research Methods & Evidenced-based Practice

Summer #1 NUR 650 (MSN) Capstone with seminar (100 hours)

Fall # 2 *NUR 612 (MSN) Physiology/Pathophysicology for Advanced Practice

NUR 646 (MSN) CNL Core # 2 Informatics, Global & Health Disparities

Spring # 2 *NUR 613 (MSN) Advanced Health Assessment

NUR 647 (MSN) Healthcare systems Finance, Economics, and Politics

Summer# 2 NUR 649 (MSN) Clinical Immersion with Seminar (300 hours)

*Core courses required for the Masters Education program

Development of a work site CNL program

Developing a work site CNL program requires commitment from the practicing partners to

provide classroom space, job creation, and students. The worksite setting will require

technology to support class lectures as well as possible IT support if equipment malfunctions. In


addition University faculty must be flexible to teach courses outside of the university setting and

at flexible times. The advantages for a work site CNL program are numerous as this degree is

based on the premise that practice partners benefit with improved patient outcomes, cost savings,

and employee satisfaction. The worksite environment offers opportunities for the partners to

contribute to the educational program tailoring it to address individual institutional needs. The

geographical location for this University work site nursing program provides opportunities to

recruit students from several major healthcare institutions. The university is affiliated with

several of these institutions which can potentially lead to new practice partners. A major benefit

to the work site program is student networking and brainstorming which undoubtedly will

improve patient outcomes. The CNL can lead the way to create a professional nursing think tank

for the practice partner.

Drawbacks

A work site setting may be difficult to attend for students who live and work outside of the

practicing partners’ geographical area. Students may miss out on the university campus

experience. The practicing partner will be expected to offer job placement at the completion of

this program which may cause shifts in staffing. The work site partner may wish to pilot the

program before they officially make a decision to adopt it thus not making a full commitment.

Changes in administration can affect the commitment to this new role. Will the new

administration share the enthusiasm for this clinical practice model? The class size will require at

least twelve to fifteen students per cohort to demonstrate cost effectiveness. Can this particular

work setting accommodate all of these students into CNL positions after graduation? Gabuat,

Hilton, Kinnaird, and Sherman (2008) reported “Designing the curriculum was not as

challenging as planning for the incorporation of a new role into the practice setting” (p. 303). It


is after graduation that many challenges may arise as students establish this new nursing role.

Additional faculty time and resources are needed to guide the practice partner and students as

they move forward with this initiative.

Challenges for the CNL

As a Clinical nurse leader I have experienced firsthand the challenges faced with introducing

this new role into the healthcare community. In my university setting and amongst my colleagues

the clinical nurse leader was a foreign concept. In my attempts to advocate and describe this role

I was met with opposition. Pioneering the CNL role is challenging at my work site because I am

the only clinical nurse leader. I am not currently working as a CNL in my facility because this

job description does not exist. Creating a new nursing job description for students is essential to

the success of this new role. Healthcare systems facing financial constraints may be reluctant to

add another nursing role. Goudreau (2008) raises strong concerns that CNLs too could be

considered at risk for extinction when fiscal solvency threatens the healthcare institution. Nurses

have been historically oppressed as a professional group (Roberts, 2006). Are healthcare

institutions ready for empowered professional nurse leaders? Roberts (2006) found that

“Freedom comes from rejecting the negative images of one’s own culture and replacing it with a

sense of pride in the group’s characteristics and abilities” (p. 24). The CNL is challenged to be

the change to lead nursing out of oppression.

Conclusion

The Clinical nurse leader partnership provides a clinical ladder for nurses who desire to

remain at the point of care. The CNL benefits all partners as it provides a model for excellence

in patient care. The CNL role is designed to meet current and future health care challenges.


The AACN offers guidelines, education and support for partners who pilot this new nursing

position. Joint commission and other regulatory agencies have a vested interest in this role as it

promotes safe practice. The CNL is a nurse generalist who can adapt to any clinical setting. The

CNL is complementary to other nursing roles and supports interdisciplinary teamwork. A work

site designed currriculum will benefit the student, university and practice partner.

The university and health care partner mutually contribute to the education of the CNL

student. The work site program offers value to both education and institution as they work

together to meet the demands of a rapidly changing fragmented health care system. Nursing

excellence, creative solutions, safe patient care, cohesive interdisciplianary teams and

empowerment will result. Most importantly CNL leaders redirect nursing focus back to the

patient, family, community, and health care system. The CNL practices the art of nursing whilst

demonstrating core nursing values at the point of care. Caring empowered nurse leaders can help

the nursing profession advance into the 21st century.


References

American Association of Colleges of Nursing (AACN). (2006a). Update on the Clinical Nurse

Leader. PowerPoint presented at the AACN Spring Annual Meeting, March 2006,

Washington, DC. Retrieved from http://www.aacn.nche.edu/CNL/tkmats.htm

American Association of Colleges of Nursing (AACN), (2006b). Preparing graduates for

practice as a Clinical Nurse Leader draft curriculum framework. Retrieved from

http://www.aacn.nche.edu/CNL/pdf/currlefrmwk.pdf

American Association of Colleges of Nursing (AACN). (2007). White paper on the education

and role of the Clinical Nurse Leader. Retrieved from

http://www.aacn.nche.edu/Publications/Whitepapers/CNL2-07.pdf

American Association of Colleges of Nursing Clinical Nurse Leader Tool Kit Retrieved from

http://www.aacn.nche.edu/CNL/tkmats.htm

Gabuat, J., Hilton, N., Kinnaird, L. S., & Sherman, R. O. (2008). Implementing the clinical

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http://www.aacn.nche.edu/CNL/pdf/currlefrmwk.pdf

http://www.aacn.nche.edu/CNL/tkmats.htm


Goudreau, K. A. (2008). Confusion, concern, or complimentary function: The overlapping roles

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Harris, J. L., & Roussel, L. (2010). Initiating and sustaining the clinical nurse leader role, A

practical guide. Sudbury, MA: Jones and Bartlett.

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Lippincott Williams & Wilkins.

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& Wolf, K. A. (Eds.), A history of nursing ideas (pp. 24-25).

Sudbury, MA: Jones and Bartlett.

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Preparing the Way for the Clinical Nurse Leader, A Work site program Final for submission

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