Empirical Evidence of Theorized Clinical Nurse Leader Integrated Care Delivery Model Domains

2.50
Hdl Handle:
http://hdl.handle.net/10755/621602
Category:
Full-text
Format:
Text-based Document
Type:
Presentation
Level of Evidence:
N/A
Research Approach:
N/A
Title:
Empirical Evidence of Theorized Clinical Nurse Leader Integrated Care Delivery Model Domains
Other Titles:
Promoting Interprofessional Teams
Author(s):
Spiva, Elizabeth; Bender, Miriam; Su, Wei; Hites, Lisle
Lead Author STTI Affiliation:
Mu Phi
Author Details:
Elizabeth Spiva, PhD, MSN, BSN, RN, Professional Experience: LeeAnna currently serves as executive director at WellStar Health System. She is an active mentor and educator promoting research and evidence-based practice (EBP) to staff, including oversight of the Nursing Research Fellowship. She is principal investigator of multiple research studies in progress, and a member of WellStar’s Nursing Research Committee, Kennesaw State University’s (KSU) Institutional Review Board and the Annual Evidence-Based Practice Conference planning committee. She also serves as co-chair of the KSU and WellStar Academic Service partnership. In addition, LeeAnna supports Clinical Research including Clinical Trials and other research related programs at WellStar. She holds an adjunct faculty position at KSU WellStar School of Nursing and is an active member of various professional organizations. LeeAnna has presented and published more than 100 publications and presentations. Author Summary: LeeAnna Spiva is an accomplished Nurse Leader in both Healthcare and Academia with a proven success leading teams and achieving outcomes. She is actively involved with the system's Clinical Nurse Leader (CNL) initiative, serves on national CNL charter, developed a reliable/valid tool to measure staff satisfaction with the CNL role and most recent collaborated with Dr. Miriam Bender at the University of California, Irvine to assess CNL implementation at WellStar.
Abstract:

Background: The National Academy of Medicine acknowledges healthcare delivery redesign and innovative models of care are essential for improving care quality and safety (Institute of Medicine, 2011). Registered nurses (RN) comprise the largest healthcare workforce in the United States and are in a vital position to shape clinical microsystems into spaces where interdisciplinary teams work together to deliver high quality patient care. The evidence for nursing presence to reduce patient mortality and morbidity is robust (Aiken et al., 2011; Needleman et al., 2011) How nursing practice should best be organized and implemented to consistently achieve quality outcomes is less clear (Needleman, 2015) Preliminary data support a new nursing model, Clinical Nurse Leader integrated care delivery, as an effective approach to redesigning microsystem nursing care delivery to achieve consistent quality outcomes. A recently validated conceptual model describes domains of organizational readiness and structuring that are necessary for CNL integrated care delivery to be successful and produce quality and safety outcomes (Bender, 2014). Confirmatory factor analysis and structural equation modeling validated the measurement (a CNL Practice Survey) and model structure (Bender et al., in press). The validated model provides a framework to assess CNL-integrated care delivery and practice across diverse care settings, and better understand how model domains have been operationalized in health systems with CNL initiatives. The model domains include Readiness (for CNL-integrated care delivery), Structuring (of CNL-integrated care delivery), CNL Practice (communication, relationship building, teamwork, supporting staff engagement), Outcomes (improved microsystem care dynamics and quality/safety outcomes), and Value (The CNL is perceived by clinicians and administrators as adding value to the ways care is delivered).

Purpose: The study purpose was to assess the presence of and specify the operationalization of model domains at one health system with active CNLs in its hospitals and ambulatory practice.

Methods: The setting was a health system comprised of four affiliated hospitals and an ambulatory practice that launched its CNL initiatives in 2011. The health system partnered with a local university to educate RN employees who expressed interest in the CNL role, and covered 100% of employee’s tuition. The university provided the curriculum and classes were conducted at the healthcare system. Employees signed a 2-year commitment to CNL positions after graduation. A mixed methods design was used to (a) measure the presence of conceptual model domains after the health system’s CNL rollout and (b) compare observed operationalization components to the hypothesized components derived from the CNL practice model. All employees involved in the system’s CNL initiative were eligible to take the electronically administered CNL Practice Survey. A purposeful sample of this population was approached to participate in interviews and focus groups conducted on-site or via telephone. Survey data were exported from Qualtrics into SPSS 22 and analyzed using descriptive statistics. Interview/focus group data were analyzed using deductive and inductive qualitative content analyses. Qualitative data were mapped to the professional role from which the data was generated to enable descriptive analysis of coding variation. Qualitative data was first coded onto the existing CNL practice model domains and components. Data coded onto model components were then inductively analyzed to derive categories corresponding to the system’s operationalization of model domains/components. Findings were mapped back onto the model to confirm or not, theorized patterns and identify any new or emerging patterns.

Findings: There were 209 valid surveys analyzed and 57 interviews conducted, including patients, nurse leaders, unit managers, clinical RNs, advanced practice RNs, physicians, CNLs, clinical nurse specialists and clinical educators. Survey data confirmed health system settings operationalized all model domains and components to a greater or lesser extent, and confirmed associations between model domains. As for CNL practice itself, 38% of respondents reported CNLs practiced on one unit; 23% reported CNL practice on more than one unit; 16% in administration; and 22% of respondents did not know where CNLs spent most of their time. In terms of consistent practice, 44% of respondents reported CNLs activities were performed consistently, 24% reported consistency for a portion of the workweek, and 23% didn't know. The average overall health system success score for the CNL initiative was 76% (out of 100, SD 23). CNLs reported a slightly greater success rate of 80% (SD 17). In terms of the CNL practice model, all locations scored lowest in the “Readiness for CNL integrated care delivery” (70%, SD 21), and highest in the “CNL Practice” domain (79%, SD 25). Qualitative data confirmed all CNL care delivery model domains were present. Nurse leaders and unit managers provided the most coded information about Readiness for and Structuring of the CNL-integrated care delivery model. Patients and physicians provided the most information about actual CNL practices. Patients, physicians and clinical RNs provided the most information about the care delivery model’s outcomes. Physicians also had the most to say about the care model’s value. Clear expectations for CNL practice, system-wide yet tailored education about the care delivery redesign, and CNL readiness for practice were the top implementation strategies. Structuring of care delivery redesign included changes in evaluation, reporting and communication structures, with the main focus for CNL workflow at the microsystem level. Outcomes were operationalized as engagement with and enactment/consistency of best practices, CNL professional growth, process and not task thinking, and shared understandings of care processes. Value was operationalized as trust in CNLs and an assumption that their practice is a necessary function of microsystem care delivery. Value did not emerge if there was ambiguity about expectations for practice or when CNLs were not visible in the microsystem, supporting the theorized model pathway.

Discussion: Findings indicate the empirical operational category that most concretely linked the concepts Readiness through Structuring to Practice and Value was ‘clarity on expected practice.’ Clarity of CNL functions within a care delivery microsystem was consequential to CNL readiness for practice, system-wide education to orient clinicians and leaders to the new care delivery model, administrative reporting, communication and evaluation practices, CNL workflow and activities, and perceived outcomes and value of the care delivery model. Furthermore, there was a learning curve to perceiving the care model as beneficial and valuable. For example, it was only as small wins were achieved improving and stabilizing care processes over time that “stability allowed different [positive] aspects [of the care delivery model] to be seen.” The findings suggest a transformation in understanding of nursing practice, from a traditional focus on patients or particular processes (discharges, education) towards an active clinical practice holistically focused on microsystem care processes. This ‘microsystem nursing practice’ entails patients, staff, other professionals, resources, policies, existing routines and cultures, and aims to catalyze improvement through relationships, communication, team building and supporting engagement. It does this via a CNL workflow that for many at first appears simply “wrong,” for example not having a patient assignment, but over time is considered part of “the woven thread” of microsystem care, the outcome of which one director powerfully articulated as the entire microsystem team knowing “what works in the clinical flow so quality is happening at the same time as practice.”

Conclusion: The findings provide preliminary empirical confirmation of the CNL practice model and greater clarity and specification of how health system settings have operationalized model domains within their local contexts. The next step is to compare identified operationalization characteristics against other health system’s CNL initiatives to determine: (a) the extent to which operationalization varies (or not) across contexts; (b) how context influences variation; and (c) the effects on outcomes. Results will drive progress in measuring and comparing CNL practice in a standardized way across diverse care settings. This systematic, theory-informed program of research has great potential to produce the evidence needed to ensure transferability to health systems considering care delivery redesign, including implementation strategies that facilitate adoption and success.

Keywords:
care delivery model; clinical nurse leader; innovation
Repository Posting Date:
29-Jun-2017
Date of Publication:
29-Jun-2017
Other Identifiers:
INRC17J14
Conference Date:
2017
Conference Name:
28th International Nursing Research Congress
Conference Host:
Sigma Theta Tau International
Conference Location:
Dublin, Ireland
Description:
Event Theme: Influencing Global Health Through the Advancement of Nursing Scholarship

Full metadata record

DC FieldValue Language
dc.language.isoen_USen
dc.type.categoryFull-texten
dc.formatText-based Documenten
dc.typePresentationen
dc.evidence.levelN/Aen
dc.research.approachN/Aen
dc.titleEmpirical Evidence of Theorized Clinical Nurse Leader Integrated Care Delivery Model Domainsen_US
dc.title.alternativePromoting Interprofessional Teamsen
dc.contributor.authorSpiva, Elizabethen
dc.contributor.authorBender, Miriamen
dc.contributor.authorSu, Weien
dc.contributor.authorHites, Lisleen
dc.contributor.departmentMu Phien
dc.author.detailsElizabeth Spiva, PhD, MSN, BSN, RN, Professional Experience: LeeAnna currently serves as executive director at WellStar Health System. She is an active mentor and educator promoting research and evidence-based practice (EBP) to staff, including oversight of the Nursing Research Fellowship. She is principal investigator of multiple research studies in progress, and a member of WellStar’s Nursing Research Committee, Kennesaw State University’s (KSU) Institutional Review Board and the Annual Evidence-Based Practice Conference planning committee. She also serves as co-chair of the KSU and WellStar Academic Service partnership. In addition, LeeAnna supports Clinical Research including Clinical Trials and other research related programs at WellStar. She holds an adjunct faculty position at KSU WellStar School of Nursing and is an active member of various professional organizations. LeeAnna has presented and published more than 100 publications and presentations. Author Summary: LeeAnna Spiva is an accomplished Nurse Leader in both Healthcare and Academia with a proven success leading teams and achieving outcomes. She is actively involved with the system's Clinical Nurse Leader (CNL) initiative, serves on national CNL charter, developed a reliable/valid tool to measure staff satisfaction with the CNL role and most recent collaborated with Dr. Miriam Bender at the University of California, Irvine to assess CNL implementation at WellStar.en
dc.identifier.urihttp://hdl.handle.net/10755/621602-
dc.description.abstract<p><span>Background: The National Academy of Medicine acknowledges healthcare delivery redesign and innovative models of care are essential for improving care quality and safety (Institute of Medicine, 2011). Registered nurses (RN) comprise the largest healthcare workforce in the United States and are in a vital position to shape clinical microsystems into spaces where interdisciplinary teams work together to deliver high quality patient care. The evidence for nursing presence to reduce patient mortality and morbidity is robust (Aiken et al., 2011; Needleman et al., 2011) How nursing practice should best be organized and implemented to consistently achieve quality outcomes is less clear (Needleman, 2015) Preliminary data support a new nursing model, Clinical Nurse Leader integrated care delivery, as an effective approach to redesigning microsystem nursing care delivery to achieve consistent quality outcomes. A recently validated conceptual model describes domains of organizational readiness and structuring that are necessary for CNL integrated care delivery to be successful and produce quality and safety outcomes (Bender, 2014). Confirmatory factor analysis and structural equation modeling validated the measurement (a CNL Practice Survey) and model structure (Bender et al., in press). The validated model provides a framework to assess CNL-integrated care delivery and practice across diverse care settings, and better understand how model domains have been operationalized in health systems with CNL initiatives. The model domains include Readiness (for CNL-integrated care delivery), Structuring (of CNL-integrated care delivery), CNL Practice (communication, relationship building, teamwork, supporting staff engagement), Outcomes (improved microsystem care dynamics and quality/safety outcomes), and Value (The CNL is perceived by clinicians and administrators as adding value to the ways care is delivered).</p> <p>Purpose: The study purpose was to assess the presence of and specify the operationalization of model domains at one health system with active CNLs in its hospitals and ambulatory practice.</p> <p>Methods: The setting was a health system comprised of four affiliated hospitals and an ambulatory practice that launched its CNL initiatives in 2011.<strong> </strong>The health system partnered with a local university to educate RN employees who expressed interest in the CNL role, and covered 100% of employee’s tuition. The university provided the curriculum and classes were conducted at the healthcare system. Employees signed a 2-year commitment to CNL positions after graduation. A mixed methods design was used to (a) measure the presence of conceptual model domains after the health system’s CNL rollout and (b) compare observed operationalization components to the hypothesized components derived from the CNL practice model. All employees involved in the system’s CNL initiative were eligible to take the electronically administered CNL Practice Survey. A purposeful sample of this population was approached to participate in interviews and focus groups conducted on-site or via telephone. Survey data were exported from Qualtrics into SPSS 22 and analyzed using descriptive statistics. Interview/focus group data were analyzed using deductive and inductive qualitative content analyses. Qualitative data were mapped to the professional role from which the data was generated to enable descriptive analysis of coding variation. Qualitative data was first coded onto the existing CNL practice model domains and components. Data coded onto model components were then inductively analyzed to derive categories corresponding to the system’s operationalization of model domains/components. Findings were mapped back onto the model to confirm or not, theorized patterns and identify any new or emerging patterns.</p> <p>Findings: There were 209 valid surveys analyzed and 57 interviews conducted, including patients, nurse leaders, unit managers, clinical RNs, advanced practice RNs, physicians, CNLs, clinical nurse specialists and clinical educators. Survey data confirmed health system settings operationalized all model domains and components to a greater or lesser extent, and confirmed associations between model domains. As for CNL practice itself, 38% of respondents reported CNLs practiced on one unit; 23% reported CNL practice on more than one unit; 16% in administration; and 22% of respondents did not know where CNLs spent most of their time. In terms of consistent practice, 44% of respondents reported CNLs activities were performed consistently, 24% reported consistency for a portion of the workweek, and 23% didn't know. The average overall health system success score for the CNL initiative was 76% (out of 100, SD 23). CNLs reported a slightly greater success rate of 80% (SD 17). In terms of the CNL practice model, all locations scored lowest in the “Readiness for CNL integrated care delivery” (70%, SD 21), and highest in the “CNL Practice” domain (79%, SD 25). Qualitative data confirmed all CNL care delivery model domains were present. Nurse leaders and unit managers provided the most coded information about Readiness for and Structuring of the CNL-integrated care delivery model. Patients and physicians provided the most information about actual CNL practices. Patients, physicians and clinical RNs provided the most information about the care delivery model’s outcomes. Physicians also had the most to say about the care model’s value. Clear expectations for CNL practice, system-wide yet tailored education about the care delivery redesign, and CNL readiness for practice were the top implementation strategies. Structuring of care delivery redesign included changes in evaluation, reporting and communication structures, with the main focus for CNL workflow at the microsystem level. Outcomes were operationalized as engagement with and enactment/consistency of best practices, CNL professional growth, process and not task thinking, and shared understandings of care processes. Value was operationalized as trust in CNLs and an assumption that their practice is a necessary function of microsystem care delivery. Value did not emerge if there was ambiguity about expectations for practice or when CNLs were not visible in the microsystem, supporting the theorized model pathway.</p> <p>Discussion: Findings indicate the empirical operational category that most concretely linked the concepts Readiness through Structuring to Practice and Value was ‘clarity on expected practice.’ Clarity of CNL functions within a care delivery microsystem was consequential to CNL readiness for practice, system-wide education to orient clinicians and leaders to the new care delivery model, administrative reporting, communication and evaluation practices, CNL workflow and activities, and perceived outcomes and value of the care delivery model. Furthermore, there was a learning curve to perceiving the care model as beneficial and valuable. For example, it was only as small wins were achieved improving and stabilizing care processes over time that “stability allowed different [positive] aspects [of the care delivery model] to be seen.” The findings suggest a transformation in understanding of nursing practice, from a traditional focus on patients or particular processes (discharges, education) towards an active clinical practice holistically focused on microsystem care processes. This ‘microsystem nursing practice’ entails patients, staff, other professionals, resources, policies, existing routines and cultures, and aims to catalyze improvement through relationships, communication, team building and supporting engagement. It does this via a CNL workflow that for many at first appears simply “wrong,” for example not having a patient assignment, but over time is considered part of “the woven thread” of microsystem care, the outcome of which one director powerfully articulated as the entire microsystem team knowing “what works in the clinical flow so quality is happening at the same time as practice.”</p> <p>Conclusion: The findings provide preliminary empirical confirmation of the CNL practice model and greater clarity and specification of how health system settings have operationalized model domains within their local contexts. The next step is to compare identified operationalization characteristics against other health system’s CNL initiatives to determine: (a) the extent to which operationalization varies (or not) across contexts; (b) how context influences variation; and (c) the effects on outcomes. Results will drive progress in measuring and comparing CNL practice in a standardized way across diverse care settings. This systematic, theory-informed program of research has great potential to produce the evidence needed to ensure transferability to health systems considering care delivery redesign, including implementation strategies that facilitate adoption and success.</p>en
dc.subjectcare delivery modelen
dc.subjectclinical nurse leaderen
dc.subjectinnovationen
dc.date.available2017-06-29T17:03:02Z-
dc.date.issued2017-06-29-
dc.date.accessioned2017-06-29T17:03:02Z-
dc.conference.date2017en
dc.conference.name28th International Nursing Research Congressen
dc.conference.hostSigma Theta Tau Internationalen
dc.conference.locationDublin, Irelanden
dc.descriptionEvent Theme: Influencing Global Health Through the Advancement of Nursing Scholarshipen
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