Refining And Validating A Cnl Practice Model As The Basis For

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Refining and validating a CNL Practice Model as the basis for testing in practice Miriam Bender, PhD RN Assistant Professor Program in Nursing Science University of California, Irvine [email protected] Introduction A collaborative CNL research project designed to…. – Grow and sustain the clinical nurse leader initiative – Shift the focus from pioneering innovation to evidence-driven integration into healthcare delivery 2 Who was Involved? • Principal Investigator: Miriam Bender PhD RN, Assistant Professor, University of California, Irvine • Co-PI: Marjory William PhD RN, Program Director, Clinical Nurse Leader Implementation & Evaluation Service, Office of Nursing Services (at the time of the study), Central Texas Veterans Health Care System, Temple TX • Co-investigator: Lisle Hites PhD, Assistant Professor and Director of the Evaluation And Assessment Unit, Center For The Study Of Community Health, University Of Alabama, Birmingham • Co-investigator (Data Analysis): Wei Su PhD, Program Manager, Evaluation and Assessment Unit, School of Public Health, University of Alabama at Birmingham 3 CNL Expert Panel 4 Why focus on nursing care delivery? • Nurses can shape clinical microsystems into spaces where the multiprofessional healthcare team work together to deliver safe and high quality patient care • There is however surprisingly little evidence to guide the organization nursing care delivery – Conflicting evidence regarding basic elements such as staffing in relation to outcomes • The organization of nursing care delivery may influence microsystem care quality and safety as much if not more than RN staffing alone • A recent Cochrane review concluded that while there is no strong evidence favoring one care delivery model over another, specialized nursing roles integrated into care delivery models may improve patient outcomes 5 CNL-integrated nursing care delivery • An innovative nursing model that integrates certified Clinical Nurse Leaders (CNL) into microsystem care delivery – Master’s-level nursing curriculum – CNL certification for practice • Commission on Nurse Certification (CNC) • Accredited (in NDNQI) 6 CNL: Unique Orientation to Practice The environment becomes a targeted domain of clinical practice Current CNL Evidence • 15 case reports describing the development, implementation and outcomes of CNL practice in federal, community nonprofit, and forprofit settings – NHPPD, staff/physician/patient satisfaction, care process efficiencies, LOS, falls, discharge teaching, sitter hours, pressure ulcers, turnover, CLABSI, CAUTI, VAP, transfusion rates, interdisciplinary communication/collaboration • 2 cross-section correlation studies associating CNL practice with improved nurse satisfaction, turnover and leadership practices • 2 short interrupted time series studies quantifying significant correlations between CNL implementation and improved care environment and quality outcomes – Multiple aspects of patient experience, turnover, NHPPD 8 CNL Evidence Gap • What precisely is CNL practice?? • If we can’t define ‘it,’ we can’t measure ‘it,’ and we cant link ‘it’ to the outcomes we are seeing Fifty-two percent of participants believed that the biggest challenge to the CNL role implementation was a lack of role clarity. This finding is of concern especially when coupled with the finding that 39% of participants believed that the success of the role hinges upon a more structured description and understanding of the role Bender, 2014, p. 110 Moore & Leahy, 2012, p. 143 Despite preliminary evidence supporting the CNL as an innovative new nursing role capable of consistently improving care quality wherever it is implemented, CNLs are still struggling to define the role to themselves and to the health care spectrum at large. Although the AACN CNL White Paper provides a concise model for CNL educational curriculum and end competencies, there is a compelling need for further research to substantively delineate the CNL role in practice, define care delivery structures and processes that influence CNL integration, and develop indicators capable of capturing CNL-specific contributions to improved care quality 9 Closing the Evidence Gap • Multi-staged research, 2010-2015 • Sequential mixed methods design • Research question: What is CNL practice? 10 Stage 1: 2010-2013 Develop CNL Practice Model Qualitative methods: Interpretive synthesis and grounded theory analysis of extant CNL literature Product: a CNL Practice model that identifies fundamental domains and components of CNL practice • Bender PhD research – Synthesized all published literature on the CNL – Presented at CNL summit, Academy Health – Interest from Linda Roussel, Tricia Thomas and Micki Williams! Stage 1 Model 12 Stage 2: 2013-2014 Develop CNL Practice Model Refine CNL Practice Model Qualitative methods: Interpretive synthesis and grounded theory analysis of extant CNL literature Qualitative methods: Focus group and Delphi methods to refine CNL Product: a CNL Practice model practice domains and that identifies fundamental domains and components of CNL components reflecting clinical and administrative perspectives practice Product: A CNL Practice model that expresses refined domains and components of CNL practice • Collaborative research with expert panel – Biweekly teleconferences – Refined domains and components, one by one – Delphi process of consensus for refined CNL practice model Stage 2 Model 14 What changed? • Components clarified • Removal of ‘shift focus from person to process’ • • • This is a reason for our work, not an outcome Pathway more linear • Direct path from Readying to Outcomes Transformation of ‘acceptance’ domain • • Lack of evidence (potential mechanism of action?) Removal of ‘nursing brought to forefront of healthcare redesign’ • • • Notice ‘fuzzy’ boundary for acceptance Where/how is this happening remains unclear Acceptance more specified as ‘integration’ • • • Administrative and social ‘Where’ defined to be at all stages Still don’t know how 15 Stage 3: 2014-2015 Develop CNL Practice Model Refine CNL Practice Model Qualitative methods: Interpretive synthesis and grounded theory analysis of extant CNL literature Qualitative methods: Focus group and Delphi methods to refine CNL Product: a CNL Practice model practice domains and that identifies fundamental domains and components of CNL components reflecting clinical and administrative perspectives practice Product: A CNL Practice model that expresses refined domains and components of CNL practice • CNC funded – Item writing, consensus on content – Survey administration – Survey data analysis Validate CNL Practice Model Quantitative methods: Survey development, content validation of survey, survey administration, confirmatory factor analysis and structural equation modeling of survey results Product: an empirically validated model for CNL implementation and practice that is credible, dependable and transferrable to a wide range of organizational contexts. Importance of Survey Items • Survey items express components and domains of the CNL practice model – They are concrete representations of abstract concepts • Cant measure “continuous clinical leadership” like you can a blood pressure • So, created survey items that ‘express’ continuous clinical leadership and can be measured: i.e. the responses to the items • Items combined represent the ‘latent variable’ continuous clinical leadership Items for communication Latent variable (theory) Continuous clinical leadership Items for relationships Items for teams Items for engagement observed variable (survey items) 17 Survey Procedures • Survey pretested with CNL students – N=36 – Do the items read well, are they easily understood? – 36 items revised based on pretest • Survey transformed to Qualtrics platform • Electronic survey available 1/22/15-4/30/15 18 Survey Participation 19 Survey Data Analysis • Did 3 separate analyses – Descriptive analysis – Certified CNL demographics » JONA paper, in review at this time – Inferential analysis – CNL initiative demographics (organization, implementation) – Organization and implementation factors associated with perceived success » JNS paper, in review at this time – Model validation analysis – Reported today….. 20 Model Validation • Two-phase process – Validate the measurement structure – Confirmatory factor analysis – Confirm the pattern of observed variables (the items) in the model aligns with theory – i.e. do the items do a good job of measuring what we hypothesize they are measuring? – Validate the model structure – Structural equation modeling – Verify the hypothesized relationships in the model – i.e. does the data fit our theory of CNL practice? 21 First Round Results • Good fit indices but: • Too complex with non significant pathways • Low coefficients for hypothesized pathways 22 Interim Analysis • Acceptance? Integration? – What is this concept?? Where does it belong in the model?? • Reviewed the survey items very closely – Concept more fruitfully labeled ‘value’ • value encompasses both acceptance and integration! – Value can only come after CNL practice has been implemented and outcomes achieved! • i.e. domain should be placed AFTER outcomes – HUGE AHA MOMENT!! 23 Final Validated Model • Parsimonious model with good FIT – The data fit the theory well – The fit indices are acceptable for publication: no one will argue – People agreed with the model • ALL pathways are significant – The hypothesized pathway direction is correct, from readiness to value • Strong coefficients that align with theory – The data confirm the hypothesized relationships between domains 24 Final Validated Model Readiness for CNLintegrated care delivery Understand care delivery gaps Consensus CNL practice can close gaps Organization level implementation strategy Structuring CNLintegrated care delivery Microsystem level structuring CNL level competency structuring CNL level workflow structuring CNL Practice Continuous Clinical Leadership Outcomes of CNLintegrated care delivery Value Facilitate effective ongoing communication Strengthen intra and interprofessional relationships Create and sustain teams Support staff engagement Improved care environments Improved care quality outcomes The CNL is perceived by clinicians and administrators as adding value to the ways care is delivered 25 Final Validated Model Readiness for CNLintegrated care delivery Understand care delivery gaps Consensus CNL practice can close gaps Organization level implementation strategy Structuring CNLintegrated care delivery Microsystem level structuring CNL level competency structuring CNL level workflow structuring CNL Practice Continuous Clinical Leadership Outcomes of CNLintegrated care delivery Value Facilitate effective ongoing communication Strengthen intra and interprofessional relationships Create and sustain teams Support staff engagement Improved care environments Improved care quality outcomes The CNL is perceived by clinicians and administrators as adding value to the ways care is delivered 26 Implications • Testable CNL model and validated measurement tool • How much readiness is enough to get CNLs into practice? • How much structuring is necessary for CNL practice? • How much CNL practice is occurring in any particular microsystem? • How much CNL practice is needed for outcomes? • Does value help CNL growth and sustainment? • What is the cost associated with each domain? – i.e. can do a cost analysis! 27 Future Research • Implementation-practice-effectiveness research – Measure and link implementation, practice, and significant improvement in outcomes – The model provides a framework to link outcomes specifically to CNL practice – Have not been able to do this before! – Replication across health systems • What works, or doesn’t, where? • What domain/component clusters are sufficient/necessary for success? • Results provide evidence for CNL practice AND data for improvement – Goal: Further specify the model – Goal: Generate evidence for practice – Goal: Toolkit for new/better CNL practice at health systems across the nation 28 Continuing the Journey • Formalize the collaborative research process to accomplish CNL initiative goals – CNL Practice-Education-Research Collaborative • National collaborative with diverse professional stakeholders – Practice, policy, research, education, multi-disciplinary • Central hub for CNL research questions, funding, conduct, dissemination – Research questions come from stakeholders – Health systems become ongoing CNL research laboratories – Resources to ensure research rigor and comparability across systems Contact me if interested or would like more info… 29 Thank you! Feedback? Questions? [email protected] 30