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.
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