The clinical nurse leader (CNL) designation was first proposed by the American Association of Colleges of Nursing (AACN) to address many of the issues facing today’s healthcare system, including patient safety and quality of care.
A report published by the Institute of Medicine in 1999, aptly titled To Err is Human: Building a Safer Health System, was by itself a partial impetus for the idea behind developing and clearly defining the CNL role within the sphere of advanced clinical nursing practice. The sobering report provided a great deal of insight into the frequency of preventable medical errors, including data drawn from two separate studies that showed between 44,000 and 98,000 Americans die every year as a result of medical errors.
In the years that followed, the AACN formed two task forces made up of leaders from the practice environment: One to identify solutions for improving the quality of patient care, and the other to prepare nurses with the skills and knowledge required to thrive in present-day and future healthcare systems. Through years of research and much discussion within the medical community, a clear definition of the CNL role began to emerge. By 2007, graduate programs and national certification were available specific to the clinical nurse leader role. According to a 2012 report published by the AACN, to date, more than 1,000 CNLs have been certified since the inception of the role in 2007.
The CNL role is distinct from other advanced practice clinical roles, as 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, as 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, making 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.
Although CNLs must be educated in advanced nursing knowledge, it must be noted that they do not meet the criteria for the advance nursing scope of practice, meaning they are limited in terms of clinical duties they may perform while providing direct patient care. However, 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 advanced practice skills and knowledge, but serving in a role that is based in leadership, the role of clinical nurse leaders is unique and far-reaching, both within the clinical setting, and outside of it:
- Clinician – provide care across the lifespan and across all populations, with an emphasis on health promotion and risk reduction services
- Outcomes Manager – integrate information and data to better ensure optimal client outcomes
- Client Advocate – ensure that clients, families, and communities are well-informed, serving as advocates for both the nursing profession and the healthcare team
- Educator – make use of all available technology to teach clients and healthcare professionals using evidence-based principles and strategies
- Information Manager – use information systems and technology to improve healthcare outcomes
- 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
- Member of a Profession – acquire the latest knowledge and skills to change healthcare practices and outcomes
- Lifelong Learner – recognize the value of the pursuit of new knowledge and skills.
Education and Degree Options
The American Association of Colleges of Nursing (AACN) Board defines a CNL as a generalist clinician who possesses an education at the master’s degree level or higher. The Board notes 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 has reported that 85 CNL programs are now available in 34 states, as well as in Puerto Rico.
The AACN Board notes that the multi-faceted role of the CNL requires a multi-faceted education. As such, they recognize the key components of the CNL education to include a liberal background in the arts and sciences, professional values, core competencies, core knowledge, and role development. Graduates of clinical nurse leader programs will be skilled in clinical leadership for a specific practice setting.
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
Additionally, graduate-level content must include (although not a requirement, most CNL programs will offer this content in three, separate, graduate-level courses:
- Health Assessment
Clinical nurse leader programs must prepare graduates to demonstrate achievement in the following core competencies:
- Quality Improvement
- Interdisciplinary Team Care
- Patient-Centered Care
- Evidence-Based Practice
- The Utilization of Informatics
All CNL programs will designate clinical mentors (preceptors) for each CNL student. The AACN further advises that all graduate-level CNL curriculum and clinical immersion experience be completed within a 12-15 month timeframe (3 semesters or 4 quarters).
Clinical nurse leadership programs are designed to build upon the direct-care nursing skills developed through an undergraduate degree program. As such, the graduate-level curriculum will be focused on policy and organization, outcomes management, nursing leadership, and care management.
The AACN Board notes that the following major threads must be present throughout clinical nurse leader curriculum:
- Critical Thinking/Clinical Decision Making
- Human Diversity/Cultural Competence
- Global Healthcare
- Professional Development in the CNL Role
- Nursing Technology and Resource Management
- Professional Values, Including Social Justice
The AACN has also set forth clear and definitive terms for CNL clinical experiences that must be included in CNL education programs. Students must complete a total of 400 to 500 clinical contact hours within the formal CNL program. Of these clinical contact hours, at least 300 to 400 must be an immersive experience in the CNL role over a 10 to 15-week time frame, involving a designated clinical preceptor and a faculty partner. The CNL program’s immersion experience must include weekly opportunities with fellow CNL students, faculty and mentors so as to allow the CNL to discuss issues and assess experiences within the CNL role. The immersion experience exposes students to a greater depth and breadth of practice than the clinical experiences, and though emersion hours count towards total clinical hour requirements, it is considered separate from the clinical component.
Upon the completion of a formal CNL education program and clinical experience, a CNL is then eligible to take the AACN Clinical Nurse Leader (CNL) Certification examination. The CNL certification program is managed by the Commission on Nurse Certification (CNC), which is an arm of the AACN, and is governed by the CNC Board of Commissioners.
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. However, the Bureau of Labor Statistics, Occupational Outlook Handbook 2010, reported that the median pay for medical and health service managers and healthcare executives was $84,270 per year in 2010. The top 10 percent of earners earned an average of $144,880. The Bureau of Labor Statistics also noted that employment for medical and health services manager is expected to grow by 22 percent from 2010 to 2020 – faster than the average for all other occupations.
The Bureau of Labor Statistics’ (BLS) Occupational Employment and Wages report for 2011 showed that the mean annual wage for medical and health services managers was $96,030 in 2011, and the top 10 percent of earners in this field earned an average annual salary of $147,890. These year over year comparative figures show an increase in compensation that aligns with increasing demand.