Bridging the Gap in Care for Children Through the Clinical Nurse Leader

Erin L. O'Grady, Brigit VanGraafeiland

Disclosures

Pediatr Nurs. 2012;38(3):155-158, 167. 

In This Article

CNL Duties in Improving Quality of Care

The CNL can be used to improve overall quality by eliminating some of the gaps previously mentioned. For example, if a family can have a "go-to person" who is always at the center of care, then questions can be more easily answered, and there may be less waiting time between procedures. The ultimate outcome may not change, but the family may feel more at ease, and the child may be more quickly discharged, returning to where he or she feels more comfortable. Even in settings in which a patient navigator program has been established, patients and families are often new to the illness process and receiving assistance from a team member whom they can trust and use at their convenience.

CNLs have the unique characteristic of being both bedside nurses and leaders. By combining the information gathered as a bedside nurse and their skills as leaders, these practitioners can serve as the team leader and "go-to person" at the center of family focused care. CNLs can work at the unit level, filling gaps in the entirety of care, and can implement evidencebased practice to improve quality of care. They can serve as trusted team members whose guidance and recommendations for care are driven by their coordination skills and constant interactions with health care professionals, patients, and families. CNLs can do this through their specified roles as team manager, educator, client advocate, clinician, outcomes manager, information manager, and lifelong learner.

Team Manager

One important role of the CNL is to serve as the team manager within the health care microsystem. As technology advances and health care professionals learn to work together more efficiently, hospital length of stay becomes shorter, which means that more treatment occurs during a short period of time. Additionally, much care is being delivered in a home environment where the family needs complex discharge education. Community hospital average length of stay has steadily decreased from 7.6 days in 1981 to 5.6 days in 2005 (American Hospital Association [AHA], 2007). Because of these busy stays, patients need a team manager now more than ever to coordinate complex acute and chronic conditions This is especially important for children because the treatment plans need to include the entire family, and at times, also the school system.

CNLs can help coordinate an evidence- based care plan that includes members from an interdisciplinary team. The role of team manager is important for care coordination, and is optimal because the nurse will most likely interact with multiple members of the family, provide continuity of care, and be at the bedside more than other professionals. According to Hollingsworth, Chisholm, Giles, Cordell, and Nelson (1998), nurses in the emergency department spend significantly more time on personal activities than physicians, there fore making them an optimal team manager. Further, according to Hendrich, Chow, Skierczynski, and Lu (2008), care coordination is the third most time-consuming task involved in medical-surgical nursing practice. Therefore, CNLs can provide oversight for patient care laterally and over a period of time to coordinate care for the entire patient experience. The CNL can help promote overall health by serving as centralized coordinators who are familiar with the medical interventions and patient needs. One example of the CNL's role of team manger is to conduct multidisciplinary meetings to include the family and patient.

As an effective team manager, the CNL can help improve interdisciplinary relationships by helping disciplines see their interdependencies so everyone has the same goals and care can be clustered to avoid fatigue and burden on patients and families. Although the main goal is to decrease fatigue and burden on families, coordination may also decrease burden on professionals if they are able to more easily share ideas and results, thereby eliminating some repeated research or studies. This coordination role extends outside the inpatient hospital setting because it is important for nurses to coordinate with primary care providers and school nurses, thereby improving the gaps in communication. Additionally, a team leader role will ensure that resources are properly used. A nursing team leader will also help ensure that tasks are properly delegated. Should problems or disagreements arise, CNLs can use their critical thinking skills to plan for the most effective actions for the entire interdisciplinary team.

A team managerial role will provide congruency for the patient and a familiar face to the family. Simply being present throughout care will allow the patient and family more time to ask questions and provide the family with a sense of commitment to the entirety of care. Continuity across the care continuum will help keep clients well informed and allow them to participate in planning their care.

Educator

CNLs can serve as educators by providing information and education throughout the entirety of care through appropriate teaching principles, materials, and technologies. Further, education can be coordinated with other professionals so all information is covered and no discrepancies in teaching exist. Some professionals may be better able to educate patients in some instances, so an overseer of care can address this issue in education. For example, a child life specialist may be better able to prepare a child for a procedure. By incorporating better coordination, CNLs can help assess teaching methods that have worked or not worked in the past and share this with others for future educational purposes with that family. The CNL as an educator is also optimal in explaining how different interventions affect each other and are linked. Being an educator may help decrease parental anxiety and allow parents to focus more on helping their child through treatment.

As educators, CNLs provide information through multiple resour ces because parents and children acquire their information from a variety of means, such as health care providers, other parents, books, pamphlets handouts, Internet, newspapers, television, and conferences (Moore & Beckwitt, 2006). Lastly, CNLs should promote the application of research into education for patients and families. This is especially important because advancements in technology and medical treatment have given patients and families access to information that is not always reliable.

Client Advocate

Being an advocate for patients is an important role that the CNL can play to help bridge gaps in current practice. As stated earlier, parents often feel advocacy is missing in the care of their children (Clarke, 2006). Research has shown that parents of children with a chronic illness were happier with their family member's care when health care providers gave clear information, and communicated directly and with sensitivity with children when applicable (Mack et al., 2005). However, families often felt they lacked the necessary education for treatment, so it is important for CNLs to advocate for these actions for the client.

Being a client advocate alleviates some of the pressure families may feel to provide their loved ones with the best care. When CNLs provide care, they are in optimal positions to be client advocates because they can see the larger picture and can work with multiple members of the team. For example, CNLs are in an important position to advocate for services, such as hospice, because the nurse most likely has a constant connection with the family and may be the most trusted member of the team. Again, this example goes back to the idea of the CNL serving as a "constant face" for the family and health care team because of the CNL's duty as care coordinator. Families may not be able to discern when an advocate is needed, so it is important for CNLs to advocate in these instances. CNLs may also challenge actions that may not be in the best interest of the child. Open communication is especially important in advocacy, and as the care coordinator, the CNL should have established a good rapport with the entire team. This is also important when communicating the family's wishes to the entire health care team. As advocates, CNLs should focus on maximizing quality of life and maintaining optimal functioning for the patient and family.

Being an advocate may entail advocating for policies that may affect family members of the sick child. For example, research has shown that mothers who care for children with cancer exert a great deal of energy and time in their efforts (Clarke, Fletcher, & Schneider, 2005). These researchers documented a suggestion for more research on the home health practices of mothers and establishment of "suitable family leave policies for mothers" of children with cancer (Clarke et al., 2005, p. 372). Conducting this research may help alleviate gaps in care related to caregiver strains. Lastly, an advocacy role may also require CNLs to advocate for the profession and the interdisciplinary team.

Clinician

To help eliminate some gaps in care, CNLs serve as bedside clinicians, who provide evidence-based care across the continuum. Providing psychosocial support throughout the entirety of care is important and may involve listening longer, recommending help from another interdisciplinary team member, providing information, and recommending group therapy sessions or any other appropriate measure. Because CNLs serve as team managers, they should be able to assess which learning and coping approaches have helped in the past and use them for further needs. Additionally, because of the CNL's constant presence, the patient and family will hopefully become closer to them and be more willing and open to talk about psychological impacts of disease. CNLs are involved in all levels of care, can plan ahead and identify interventions (which may prevent future complications), and focus on health promotion. As informed clinicians, CNLs should also identify potential and actual ethical issues that may arise from care for children with acute or chronic illness. The CNL serves as a nurse but extends to the role of managing the micro-system involved in the patient's and family's care.

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