A Day in the Life of a Clinical Nurse Leader

Linda L. Borns, MS, RN, CCRN, CNL

Disclosures

October 18, 2017

My Day as a Clinical Nurse Leader

I'm a clinical nurse leader (CNL®). (If you've never heard of the CNL role, it's a master's-prepared registered nurse [RN], equipped for comprehensive practice across the continuum of care within any healthcare setting. (For more information, see The Clinical Nurse Leader Role.)

The microsystem in which I've practiced since 2009 is a 24-bed medical telemetry/oncology unit. I oversee the clinical care of all 24 patients on the unit.

On a typical day, the first thing I do is touch base with night-shift and day-shift nursing staff members to see whether they have any concerns or questions, especially any concerns about the patients.

Each day, we hold a multidisciplinary discharge planning meeting. This meeting is attended by acute care CNLs, social workers, and physicians; utilization managers; staff nurses, community health nurses, physical medicine and rehabilitation nurses; and a chaplain. Discharge needs are discussed, and plans and recommendations are made by each discipline. This is where I prioritize my time, determining which discharges will be the most complex—which patients will most need my attention and involvement in the discharge process.

A complex patient is at risk of "falling through the cracks" with respect to follow-up care, and therefore is at risk for early readmission to the hospital. Complex discharges might include the following:

  • A patient with congestive heart failure (CHF). I assist the staff to ensure that CHF education is provided to the patient and family, ensure that a follow-up CHF clinic appointment is scheduled, and make arrangements for any necessary equipment at home (such as a scale).

  • A patient with chronic obstructive pulmonary disease. I determine whether the patient knows how to appropriately use an inhaler, and arrange for close follow-up to prevent readmission.

  • A patient with newly diagnosed diabetes mellitus. I perform diabetes teaching and arrange follow-up in the diabetes clinic, as well as additional classes, as needed.

  • A patient who needs a meeting with family members to discuss the goals of care, including the need for hospice or palliative care, as appropriate.

After the multidisciplinary team discharge meeting, I return to the unit and conduct rounds to take a snapshot of what is going on with the patients. I collaborate with the nursing staff to answer their questions about plans of care or other concerns.

The Microsystem and Beyond

As the unit's CNL, I am involved in many activities and projects, and serve on many committees. Some of these activities are closely tied to the microsystem, and others expand to areas elsewhere in the facility. Still, I try to maintain as my primary focus the patients and the staff of the unit. For example, one of my regular roles is as a mentor to unit RNs on evidence-based practice projects.

An important function of the CNL is to measure patient outcomes. Here's a partial list of projects that I have worked on, sometimes with other CNLs, to monitor and improve patient outcomes:

  • A method of increasing compliance with alcohol screening, which improved alcohol screening dramatically.

  • Stroke education in acute care.

  • A hospital-acquired pressure injury prevention protocol, which led to increased accuracy in pressure injury staging, better skin documentation, and improved pressure ulcer prevention. Our staff training was done with simulation, which enhanced the staff learning experience.

  • A falls training program involving simulation to improve fall prevention, awareness, and documentation. This led to a reduction in major injuries from falls and increased compliance with post-fall huddle documentation.

  • A point-prevalence survey for catheter-association urinary tract infection (CAUTI) and staff training to increase awareness, reduce the CAUTI rate, and update staff on evidence-based practices to prevent CAUTI. This resulted in a reduction in facility CAUTI rates.

  • Implementation of a multidisciplinary discharge meeting with shared documentation between CNL and social workers. This improved our multidisciplinary discharge planning documentation.

I often advocate for the role of the CNL. I led a group of CNLs from around the country in preparing a toolkit for CNL orientation, which I now maintain and keep up to date. I also gave a presentation at a local conference to spread the word about the value of CNLs.

What I've Learned as a CNL

Being a new CNL can be tough for many reasons. As a relatively new role in nursing, you might be the first CNL to fill the position on a particular unit. The staff nurses and others on the unit may never have worked with a CNL before, and don't know what to expect of you or how you fit into the unit culture. Are you a manager—someone to keep at arm's length and be suspicious of? As the only CNL, you may have no peers on the unit to show you the ropes, or to consult with when carving out your own role.

Here are my tips for new CNLs:

  • Build your network. Have a "go-to" person in every department, if possible. I wouldn't be able to do my job without the bridges I have built with such people as quality management staff, the computer application coordinators, patient education coordinator, and many more. They help me get my job done, and they often call on me for clinical expertise as well.

  • Have your "elevator speech" ready at all times. Don't be shy about telling everyone what a CNL does. We have to spread the word and market our role. Never miss an opportunity to tell someone about CNLs.

  • Don't be afraid to pave your CNL road. Start small and gain the trust of your microsystem staff. Once the staff and the nurse manager start seeing what you bring to the table, they will say, "I don't know how we survived without a CNL."

  • Successful implementation of the CNL role starts with leadership. Many facilities that have been successful with CNL implementation have a group of CNLs who report to a nurse executive who supports and understands the CNL role.

  • If you feel like you are being pulled too far away from the microsystem, spend some time talking to the patients in your microsystem. The patients are why we do what we do.

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