Integrated Care and the Role of the Certified Nurse Leader
In 1999 the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System. The report concluded that preventable medical errors within our healthcare system lead to as many as 98,000 deaths per year. Perhaps even more importantly, the report noted that most errors are systemic failures that are not due to unqualified or negligent individual healthcare providers.
Since then there has been a shift in the culture of American healthcare. A culture once dominated by top-down finger-pointing, we are now starting to examine the way our system functions. Why does this matter? Because finger-pointing promotes a culture in which fear of judgment and disciplinary action inhibits individuals from identifying mistakes and because finger-pointing focuses on events in the past, thereby thwarting learning experiences. It shuts down any innovation or creativity that involves even a hint of constructive risk taking.
To Err Is Human examined healthcare practices that increased the risk of error. The IOM evaluated healthcare facilities with the lowest and the highest preventable error rates. It found that some of the safest hospitals were those that emphasized communications and teamwork instead of retribution and strict observance of and adherence to a medical hierarchy.
Inter-professional teamwork and communications were found to reduce preventable errors, reduce the cost of healthcare, and improve patient and staff satisfaction. As a result, we now have medical “extensivists,” healthcare homes, stepped care, and healthcare teams. New ideas for integrated care are abundant. All too often, however, no one is at the helm — at least no one whose job is to be the one person overseeing the big picture and bringing everything together. In systems functioning like an orchestra without a conductor, we trudge on. We continue to play our own instruments well, following sheets of the same music. We can see one another, and we can hear one another. Most of the time, we even pull off a convincing performance.
But there is more than an aesthetic difference between a convincing performance and a professionally conducted one. Similarly, the success of integrated care depends on a level of leadership requiring medical knowledge and experience, communications skills, risk assessment and reduction strategies, and outcome analysis, all integrated with strengths in advocacy and education. Sound like anyone you know? The Institute of Medicine thought so and turned, naturally, to nursing.
The Future of Nursing, a 2011 Institute of Medicine report, called on the nursing profession to lead change in healthcare. Nursing is well positioned to take on this responsibility and, in response, has supported the emergence of the role of the Clinical Nurse Leader (CNL). The CNL is a master’s-level competency-based nursing specialty new to the nursing profession that has been recognized by the American Association of Colleges of Nurses (AACN). The AACN Commission on Nurse Certification offers Certified Nurse Leader certification by examination.
To meet higher-quality health and safety standards, CNLs are charged with improving outcomes by looking at how all moving parts in healthcare come together. By including evidence-based practice, considering resources and environment, and directing the healthcare team, a CNL can also improve group cohesion, facilitate team communications, improve staff and patient satisfaction, and boost quality indicators.
The inconsistency of the CNL role implementation to date has made determining its impact on outcomes difficult. We might not yet be able to quantify precisely what the significance of a CNL could be, but, I suspect, we will know it when we see it.