A clinical nurse leader is a master’s-educated nurse who serves as a dedicated organizer of patient care, collaborating with interdisciplinary care teams and hospital support services, drawing insights from clinical staff, and through billing analysis and data collection to ensure the highest possible level of care in any individual case.
Clinical nursing leadership is an exciting new role for registered nurses that takes the strengths of the nursing profession and uses them to take on some of the biggest challenges in modern healthcare.
Those challenges boil down to two critical points: patient safety and the quality of healthcare outcomes. The field of medicine has advanced so fast that it has started to outstrip something that has always made nursing unique: a holistic, patient-centric approach to care.
The CNL role may be unique among all nursing jobs. The need for it was seen by nurses, defined by nurses, and put in place by nurses.
In 1999, the Institute of Medicine published a report titled To Err is Human: Building a Safer Health System. Part of a larger project launched the year before to study the quality of healthcare in America, To Err dove into the hushed-up reality of medical errors leading to further harm or death among patients.
The sobering finding of To Err is Human was that preventable medical errors were causing the death of between 44,000 and nearly 100,000 Americans each year.
With so many specialties and different departments in the modern healthcare organization, it can be easy for patient needs to fall through the cracks. Errors of communication were leading to incorrect amputations, removal of the wrong organs in surgery, and frequent drug dosing and toxicity errors.
The American Association of Colleges of Nursing formed two task forces to study the problem. And their primary solution rests on the shoulders of the newly created role of clinical nurse leader.
- Why Clinical Nurse Leaders Are Vital to the Future of American Healthcare
- Creating a Culture of Safety is The Role of The Clinical Nurse Leader
- Clinical Nurse Leader Roles and Responsibilities
- Education and Degree Options for Clinical Nurse Leaders
- Clinical Nurse Leader Programs
- Achieving CNL Certification
- CNL Salary Expectations
- CNL Resources For Boosting Career Outcomes Along With Patient Safety
Why Clinical Nurse Leaders Are Vital to the Future of American Healthcare
Systems theory is relatively new to healthcare, but it’s a field that has made important contributions to other complex industries and processes ranging from aviation to nuclear power over the years.
The fundamental premise of the field is that complicated systems can produce unexpected outcomes.
Systems Thinking in Nursing Has Its Roots In Some Unlikely Places
In aviation, the recognition of systems theory began on October 30, 1935 with the fatal crash of experimental Boeing prototype NX13372 at Wright Field in Ohio.
The plane was the first test of what was about to become the famed, World War II-winning B-17 Flying Fortress bomber. It was the most complex aircraft ever built at the time, able to fly higher, farther, faster, and with a bigger payload than anything else in the skies.
To do all that, it had four engines, advanced hydraulics, and an array of flight control systems that took two pilots and an engineer to manage. The pilots of NX 13372 were highly experienced and experts on those systems, but they crashed for a simple reason: they forgot to flip some switches to unlock two important controls before takeoff.
The B-17 project might have ended there, but engineers realized there wasn’t really a problem with either the plane or the pilots. Instead, the entire system for starting up, operating, and flying the plane had to be matched to human capabilities. No person could remember or coordinate so much stuff under so much pressure.
The humble take-off checklist was created. A co-pilot would go down a piece of paper with the required steps on it, both pilots verifying that each step was completed before the next. And today, jumbo jets carrying millions of people and billions in cargo overhead each year do so with a superb safety record.
Science produces new findings all the time about how the human body functions and how disease and injury affects it. New techniques and treatments in a wide array of specialty areas are constantly under development. Each of those discoveries and innovations may be complicated in and of themselves. When you put them together though, the complexity skyrockets.
Specialists may not always know exactly what other specialists are doing or how the combination of treatments may interact in a given case. Doctors prescribe drugs with potentially harmful interactions. Nurses may become confused whose responsibility it is to ensure the patient took a certain pill.
This is what complexity looks like in medicine, and it leads to mistakes that can kill.
Creating a Culture of Safety is The Role of The Clinical Nurse Leader
The role of clinical nurse leader came from the idea that a practicing clinical nurse would be in the best position to monitor and shape this culture at the point of care.
The CNL job is not designed around sitting in an office in some remote executive building, not about reviewing case notes months after the fact, but as a practical practitioner who both understands the challenges of day-to-day patient care and appreciates the data and statistics revealing gaps in safety. CNLs are experienced registered nurses who have first-hand knowledge of patient care processes, but who are given the training and the discretion to focus on creating a culture of safety in the healthcare workplace.
The CNL role is distinct from other advanced practice clinical roles. Clinical nurse leaders are responsible for designing, implementing and evaluating client care by coordinating, delegating and supervising the care provided by a healthcare team at the clinical level. That’s opposed to the administrative level, as is the case with other nursing leadership roles. Clinical nurse leaders use evidence-based practice to ensure that patients receive the best care. They make full use of the latest innovations in care delivery.
Clinical nurse leaders are part of an interdisciplinary team of physicians, pharmacists, social workers, nurse practitioners, and clinical nurse specialists, all working together to plan and implement the most effective medical care.
The following responsibilities routinely fall to clinical nurse leaders:
- Facilitating collaborative care for patients
- Providing mentoring to nursing staff
- Establishing and overseeing a healthy working environment
- Collecting and evaluating patient risks, outcomes, and care plans
- Coordinating direct care activities among nursing staff
- Providing lateral integration of healthcare services
As a clinician with expert practice skills and additional knowledge beyond the average RN, the role of clinical nurse leaders is unique and far-reaching. They work both within the clinical setting and outside of it in roles like:
- Clinician – Provide direct patient care across the lifespan and across all populations, with an emphasis on health promotion and risk reduction services.
- Outcomes Manager – Integrating information and data to survey overall success rates and advising clinicians on adjustments that lead to better healthcare outcomes among patients.
- Client Advocate – Ensures that clients, families, and communities are well-informed, serves as an advocate for both the nursing profession and the healthcare team for the patient.
- Educator – Make use of all available technology to teach clients and healthcare professionals using evidence-based principles and strategies.
- Information Manager – Uses information systems and technology to identify trends in outcomes and identify risk points and success strategies for healthcare quality teams.
- Systems Analyst/Risk Anticipator – Review client care delivery quality and anticipate risks in an effort to prevent medical error.
- Team Manager – Delegate and manage nursing resources and serve as a leader and partner of the interdisciplinary healthcare team.
Clinical Nurse Leader Roles and Responsibilities
Clinical nurse leaders work in a wide variety of different types of facilities and healthcare specializations, but their roles and responsibilities are remarkably similar across the spectrum. That’s because the goal of the CNL is always to improve patient safety and outcomes through observation, analysis, and communication.
As a CNL, you can expect to spend most of your time on tasks such as:
- Collaboration and coordination – CNLs are at the center of organizing and monitoring individual patient care in complex healthcare environments. They are responsible for keeping track of what is happening and making sure the necessary care is delivered. Because they don’t deliver all that care themselves, that means much of their time is spent getting other specialists and providers working on the same track. You can expect a lot of stand-up meetings by patient beds, at nursing stations, or in exam rooms. You’ll make a lot of phone calls and do a lot of chart reviews to keep up with procedures. And you’ll consult with all those other providers to get their perspectives and build them into your knowledge base about both individual patients and patient populations generally to aid your coordination.
- Systems design and implementation – Like checklists in aviation, the greater part of patient safety emerging from CNL practice will come from the systems you design to automate and make fail-safe clinical procedures. Your specialized training will give you perspectives on the common risk or failure points. When you spot them, you’ll have the tools you need to design patient care processes and systems that may be simple, but can have tremendous impact on routine care and positive patient outcomes.
- Risk analysis – In order to design those systems, clinical nurse leaders have to have a fine appreciation of the wide array of risks in a healthcare environment. There are always trade-offs and calculations to make… weighing the cost of expensive procedures against unlikely outcomes, deciding whether a hefty investment in personal protective equipment outweighs putting the money into improved ventilation systems. CNLs are a vital part of those analyses, using their advanced knowledge and clinical evidence to help make the best patient care and safety decisions possible.
- Leadership and management – None of the other elements on this list of tasks are possible without strong leadership and management skills. CNLs may have great authority in their roles, but other times their effectiveness comes from persuasion. You’ll need to learn to set an example and how to manage and organize people effectively instead of just ordering them around. The best outcomes are developed when your staff is fully committed to the same vision of safety and success that you have. Motivation is a key component of the CNL position.
- Patient advocacy – CNLs are ultimately an advocate for patients, even in jobs where they have little direct patient contact. The position was designed as a voice for individual patient safety. Whether you are out on the clinic floor monitoring nursing care processes or sitting in a conference room talking about scrub color choices with some executive committee, you are expected to speak up for what the best practices will be for patient health and welfare. The role also requires the moral courage and conviction to speak out even when other leaders or the majority of practitioners are against you.
- Knowledge sourcing and distribution – CNLs practice evidence-based versions of all of the above tasks. That requires collecting and distributing that evidence to back up their leadership and ideas. Much of the job is spent keeping current on studies and best practices in whatever your chosen field of medicine is. You will need to synthesize the various results and apply them to your place of business, whether it’s a rural clinic or a busy urban intensive care unit. You have the hard job of taking the data and information you find and adapting it to the styles and procedures already in place in your area, then using it to convince other staff to change how they work to make for the best possible patient outcomes.
Since CNL positions are still relatively new, you should bring a lot of flexibility to the table. Different organizations will structure the job differently, and you may also be engaged in related work like participating on safety and ethics committees, or acting in a managerial capacity. The beauty of the job is that you can continue to define it in the ways necessary to protect patient safety.
Education and Degree Options for Clinical Nurse Leaders
Not just anyone can step up into the CNL role. Even with years of experience, there is advanced knowledge that you need to really understand how healthcare systems fit together and how to improve clinical outcomes. That means earning a master’s degree in nursing (MSN) at a minimum.
AACN decided that a master’s degree is necessary because the CNL must bring a high level of clinical competence and knowledge to the nursing team.
The AACN lists 157 qualified CNL degree and post-graduate certificate programs available around the country as of 2021.
The multi-faceted role of the CNL requires a multi-faceted education. As such, the AACN Board recognizes the key components of the CNL education to include:
- A liberal background in the arts and sciences
- Professional values, core competencies
- Core knowledge
- Role development.
Although becoming a CNL requires a master’s degree or higher, it starts during your undergraduate studies in nursing.
To meet the criteria for CNL certification through the AACN, graduates must have content mastery at the undergraduate level in:
- Anatomy and physiology
- Healthcare Policy
You won’t find that kind of training in associate’s degree programs, even though they qualify you as an RN. That makes a BSN, or Bachelor of Science in Nursing, your first stop on the path to clinical nurse leadership. You will find, however, that there are certain types of CNL master’s programs designed to bridge knowledge and skills from the ADN level all the way to the master’s level, effectively including the key elements of a bachelor’s program. Any nurse can become a CNL.
Clinical Nurse Leader Programs: Post-Master’s Certificate Online and Other Education and Degree Options
The American Association of Colleges of Nursing (AACN) Board defines a CNL as a generalist clinician educated at the master’s degree level or higher.
Most CNLs come to the field after gaining experience working as an RN, so your university education is probably going to be way back in the rear-view mirror by the time you start considering getting advanced training in clinical nurse leadership.
Your education at the graduate level will build on both the technical knowledge you built up as an undergrad as well as the practical, first-hand experienced you earned as a nurse. But there are many different paths you can follow to get that CNL education.
What Are The CNL Program Models Available?
The Commission on Nurse Certification (CNC) of the AACN defines five different possible models for CNL programs to follow. Each of them gives you the same essential coursework and preparation for the job. But all of them are aimed at nurses in different phases of their career with different entry points into the profession of nursing.
- Model A – Master’s degree programs designed for BSN graduates
- Model B – Master’s degree programs designed for BSN graduates and includes a post-BSN residency awarding graduate credits
- Model C – Master’s degree programs designed for individuals who earned a bachelor’s degree in a field other than nursing
- Model D – Master’s degree programs designed for ADN graduates (bridge programs)
- Model E – Post-master’s certificate program for individuals who have already earned an MSN degree in another field of study
These different categories give nurses from all different levels of experience and clinical backgrounds a full range of options for getting the education needed to become a qualified CNL.
What Kinds of Courses Do You Have to Study to Become a Clinical Nurse Leader?
In order to make it onto that CNC-approved program list, every CNL degree or post-graduate certificate has to include the right kind of coursework and experiential training to qualify.
Clinical nurse leadership programs are designed to build upon the direct-care nursing skills developed through an undergraduate degree program. Once you get to the graduate level, you’ll then be ready to hit the ground running with studies of policy and organization, outcomes management, nursing leadership, and care management.
Clinical nurse leader programs must prepare graduates to demonstrate achievement in the following core competencies:
- Practice Background – CNL programs have to teach or validate a basic science and humanities education that fuels community and science-based approaches to practice, supports diversity and social justice, and incorporates ethical reasoning and the holistic principles of nursing.
- Organizational and Systems Leadership – Training in business and economic principles helps future CNLs weigh possible quality and safety interventions. These courses teach not just managerial and leadership skills, but the kind of organizational understanding that allows CNLs to become effective change agents even in steep bureaucratic hierarchies.
- Quality Improvement and Safety – This coursework starts off with training in how to evaluate and analyze information gathering processes and systems to ensure you are getting the right data to base your decisions on. From there, you’ll look at specific quality-improvement systems and examine how integrated systems can be made highly reliable with the right types of cultural and quality controls.
- Translating and Integrating Scholarship Into Practice – Not only will you study the latest findings and evidence to understand how it impacts healthcare quality, but you will also look at how CNLs have to continually study and incorporate new findings into practices. These courses will give you the tools to analyze new evidence and how to evaluate and present it to other audiences to support your patient safety efforts.
- Informatics and Healthcare Technologies – Information technology is an important support for CNL practices, and you’ll learn how those systems work and how to get the most out of them. You’ll also learn about the privacy and ethical pitfalls of those systems. Finally, you’ll study how other healthcare technologies can be used to promote safety and improve outcomes.
- Health Policy and Advocacy – CNLs aren’t given a crown and scepter when they are hired. The job involves winning over staff and executives and creating a culture of safety, not giving orders from on high. These courses will teach you the art of performing advocacy work and the importance of shifting healthcare policy to help do the heavy lifting of creating safe environments.
- Interprofessional Collaboration – Similarly, CNLs don’t only work with nursing staff. You will have courses in how to interact with both healthcare and business staff and how they impact quality outcomes in different environments.
- Clinical Prevention and Population Health – Prevention is always a tough sell because the outcomes are seen only in their absence; infections that didn’t happen, procedures that didn’t go wrong. You will study how sometimes population-level policies and culturally-adept prevention services can make your job effective by getting ahead of problems before they ever happen.
Additionally, graduate-level content must include (most CNL programs will offer this content in three, separate, graduate-level courses):
- Health Assessment
All CNL programs designate clinical mentors (preceptors) for each CNL student. That kind of person-to-person training is key in developing the kind of skills you will need on the job.
All CNL education programs have to meet clear and extensive clinical experience requirements. Students must complete a total of 400 clinical contact hours within the formal CNL program. Of these clinical contact hours, at least 300 must be an immersive experience in the CNL role in a practice environment that allows development of the full range of CNL skills.
What Are the Master’s and Doctoral Degree Options For Qualifying as a Nurse Practitioner?
Most CNL programs are a concentration option in a traditional MSN degree program. The core components of the program are identical to those you would encounter while earning a Master of Science in Nursing as a path to advanced practice licensure, or to become a nursing administrator. You can find those degrees in both full and part-time formats, either online or in traditional brick and mortar classrooms.
But there are also CNL education options at the most advanced level in nursing, the doctoral level. The DNP, or Doctor of Nursing Practice, is the terminal degree in nursing practice, a path that can take four or five years to complete but gives you the ultimate training in effective research, treatment, and leadership options.
A DNP-level CNL will be at the top of the field in training and evidence-based practice skills and can expect to take roles at high levels in any healthcare organization.
Should You Choose a Post-Master’s Certificate for CNL Certification?
CNLs have to hold master’s degrees, but they don’t always get that master’s degree specifically to become a CNL. In some cases, they will have already earned an MSN or even a DNP with other specialties in mind.
In these cases, a post-master’s certificate can fill in the gap for the required educational components of CNL certification without sending you back to school for a whole new degree.
These programs include all the same material from a regular master’s-level CNL program, but skip the content you would already have studied in a regular MSN. That means they dive down into the CNC-required coursework immediately, and can be completed in just over a year of full-time study. That makes them a faster and less expensive option if you already hold an MSN.
A certificate is different from the CNL certification that you will eventually earn in this field. The post-master’s certificate is simply a mark of your education. It indicates that you have taken all the equivalent classes that you would have received in a master’s or doctoral CNL program, building on your previous MSN degree.
As you’ll see in a moment, CNL certification offers a broader qualification of your total skills and knowledge in the field.
How Important is Accreditation in CNL Education?
If you are going to all the trouble of taking two years or more of graduate-level education in order to become an effective clinical nurse leader, you definitely want to make sure you’re getting the right education for the job. That’s where accreditation comes in, validating programs to make sure they have the appropriate coursework and the right instructors and resources to give you what you need.
For CNL students, there are actually two different levels of validation to think about.
First, your MSN or DNP program itself needs to hold specialty accreditation through either the Accreditation Commission for Education in Nursing (ACEN) or the Commission on Collegiate Nursing Education (CCNE). That’s identical to the accreditation you would look for in any nursing program.
But you also need to make sure the degree has the stamp of approval from CNC. Although not an official accreditation, CNC approves programs that have the right coursework to qualify you for the CNL certification exam.
Is an Online CNL Program Just as Good as Traditional Degree Options?
The question of online or traditional has definitely been put to rest by the COVID-19 pandemic. Online programs have definitely been proven the equal of traditional on-campus education in terms of outcomes, respect, and information.
Moreover, online programs offer a lot of advantages that traditional degrees just can’t match. Almost all CNL students are coming to the degree after healthy careers working as RNs. That means you have professional and often personal obligations that you just can’t put on a shelf for two years to go back to school.
Online degrees and post-master’s certificates allow you to shift your coursework around your lifestyle. You can put your priorities where they need to be at any particular time of day. If that means hitting soccer practice and then studying in bed later, you get that option.
Of course, with practical on-site experience a required part of these programs, none of them are entirely online. But most online schools have a great track record of getting local clinical options lined up for you to keep your studies convenient.
Achieving CNL Certification
Clinical nurse leaders are certified by the AACN’s Commission on Nurse Certification (CNC). The Clinical Nurse Leader (CNL) Certification is the industry-standard recognition of your qualifications as a CNL, offered by the same organization that created the concept. That makes it a pretty rock solid credential to hold if you are pursuing a career as a CNL.
Although you are not technically required to hold CNL certification in order to serve as a Clinical Nurse Leader, you’ll find it a lot easier to get those jobs once you have it. And many organizations list CNL certification among the job requirements for the position.
CNL and Clinical Nurse Leader are registered marks of AACN, and no one who has not received official certification is allowed to refer to themselves using those terms.
There are a number of requirements to fill to become certified, even after you have gotten the right education in the field.
1. Become a Registered Nurse
For most CNL candidates, this step is really just a formality. You’ve probably been an RN for years already by the time you are looking at becoming a CNL. But it is an official requirement in order to sit for the CNL examination. You also must not currently be undergoing any investigation or disciplinary action from your state nursing board.
In some cases, though, you may have allowed your license to lapse or you may be on a fast-track and haven’t actually earned it yet. CNC allows CNL candidates to sit for the CNL exam prior to passing the NCLEX-RN, but withholds CNL certification until you’ve actually received your registered nursing license.
2. Taking and Passing the Official CNL Examination
The CNL Examination is a 140-question, multiple-choice test you will need to take and pass in order to become certified. It’s offered by CNC through Prometric testing centers, where it is offered by computer and must become completed within three hours. Tests are offered in four different exam windows through the year, designed to line up with end-of-term at universities. The cost of the exam is $425.
In order to be eligible to sit for the exam, you’ll first need to complete either an accredited graduate degree or post-graduate degree program, or be in the final term of completing that program.
The questions cover all the different areas of CNL expertise that your education went through. They are weighted by percentage of questions involved on the test:
- Nursing Leadership – 32%
- Clinical Outcomes Management – 23%
- Care Environment Management – 45%
The minimum passing score is 350 on a weighted scale.
3. Apply For Your CNL Certification
Once you have passed the exam, you have to apply for and meet a number of other qualifications before you can actually be certified. To qualify for CNL certification, applicants must:
- Hold a current RN license in the United States or one of its territories
- Hold a master’s degree or higher from an institution that is accredited by a nursing school accreditation agency recognized by the U.S. Department of Education and that prepares students with the competencies defined by the AACN
- Complete a minimum of 400 clinical hours within their formal CNL education program
- Complete a minimum of 300 clinical hours in a clinical immersion experience in the CNL role (this can be a part of the 400 total clinical hours)
CNL Salary Expectations
Because a CNL is a relatively new nursing role, up-to-date statistics regarding CNL salary expectations are not readily available. The Bureau of Labor Statistics (BLS), which collects data on all American occupations and compensation, does not separately track the CNL role.
You can make some good guesses from the BLS data that is available for RNs, however. The average registered nurse in the U.S. in 2020 made $75,330. But those in the top ten percent, which would fit the profile for highly education clinical nurse leaders, brought in more than $116,230.
That’s also in line with another category in which CNLs can fit, which is medical and health services managers. The median 2020 salary in that occupation was $104,280. Even better, BLS projects a job growth rate of 32 percent between 2019 and 2029, blowing other fields out of the water.
That makes for a bright, well-paid future for CNLs.
2020 US Bureau of Labor Statistics salary figures and job market trends for registered nurses represent national data not school specific information. Conditions in your area may vary. Data accessed August 2021.
CNL Resources For Boosting Career Outcomes Along With Patient Safety
During your education as a CNL, something that will get drummed into you is the need for constant quality improvement in the healthcare environment. But it’s not really just the healthcare environment that needs that kind of ongoing assessment and improvement. It’s also your own knowledge and skills. As the medical community continues to grow, and treatments and technology change, you need to stay up to date on the latest and greatest in order to do your job well.
That means looking back to that community and using the resources that other clinicians and CNLs make available or design to offer continuing education. These organizations are some of your best bets for keeping up with the state of the art in clinical nursing leadership:
- Clinical Nurse Leader Association – The dedicated international association for clinical nurse leaders offers networking and educational opportunities, together with a superb mentorship program that allows you to either get direct individual guidance from an experienced nurse leader or to give back to the community by offering your own wealth of experience once you are established.
- American Association of Colleges of Nursing – AACN is the organization that really got the ball rolling for the CNL position and remains one of the best resources for anyone interested in becoming a clinical nurse leader. You’ll find educational resources, references, and all the important information you need to become a certified CNL here.
- Department of Veteran’s Affairs Clinical Nurse Leader Initiative – As one of the earliest and largest adopters of the CNL role, the VA has developed an extensive and practical initiative for creating CNL positions and integrating them into daily operations in major healthcare systems.