Skip Navigation
Service Delivery Innovation Profile

Creation of Unit-Based, Clinically Focused Nurse Leader Position Expedites Discharge, Improves Quality, and Reduces Turnover


Tab for The Profile
Comments
(2)
   

Snapshot

Summary

Lakeland Regional Medical Center developed a new unit-based nurse leadership position, the clinical resource nurse, who ensures continuity of care, facilitates interdisciplinary care planning, serves as a physician liaison, encourages adherence to evidence-based practices, and mentors and coaches less experienced nurses. Data from a pilot unit show that the program has led to more timely discharges, fewer facility-acquired pressure ulcers and falls, lower nurse turnover, and higher patient, nurse, and physician satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of key process and outcome measures including patient discharge, patient fall rates, and patient/physician satisfaction.
begin do

Developing Organizations

Lakeland Regional Medical Center
end do

Date First Implemented

2006
The initial pilot test was conducted on a 48-bed cardiac step-down unit and occurred in July 2006.

Problem Addressed

Hospitals face a number of internal and external challenges, including increased scrutiny by external agencies. These challenges could potentially be met by nurse leaders with a highly clinical focus; yet, most hospitals do not have such nurse leaders, as traditional delivery systems do not support this role.
  • Many challenges in nursing care: Like many hospitals, Lakeland Regional Medical Center faced a number of practical challenges related to nursing, including a shortage of personnel, high turnover, an aging workforce, and the need to ensure the following: better continuity of care across shifts, the availability of nursing leaders at the point of care, mentoring of less experienced nurses, and adherence to evidence-based nursing practices.1
  • Increased scrutiny of nursing quality: Hospital quality of care is now being measured nationally with indicators that are highly sensitive to the quality of nursing care, including the 34 "core measures" defined by the Centers for Medicare & Medicaid Services (CMS).2
  • Unrealized potential of clinical nurse leaders: Nursing leaders focused solely on clinical care (rather than administrative tasks) can promote care coordination and adherence to evidence-based practices. Although this can lead to better performance on CMS and other quality measures, relatively few hospitals have created this type of position.

What They Did

Back to Top

Description of the Innovative Activity

Lakeland Regional Medical Center developed a new unit-based nurse leadership position, the clinical resource nurse, who ensures continuity of care, facilitates interdisciplinary care planning, serves as a physician liaison, encourages adherence to evidence-based practices, and mentors and coaches less experienced nurses. These nurses have only clinical (rather than administrative) duties. Key roles and responsibilities related to this new position include the following:
  • Flexible shifts: Clinical resource nurses work Monday through Friday; hours are flexible based on patient care needs.
  • General roles and responsibilities: The clinical resource nurse has a number of general roles and responsibilities, as outlined below:
    • Liaison with providers and patient/family: The nurse acts as a liaison among physicians, patients/families, and allied clinicians, serving as a daily presence who can monitor patient health status and communicate needs across providers.
    • Promoting adherence to evidence-based practice: The nurse serves as a clinical expert who promotes adherence to evidence-based practice. To that end, the clinical resource nurse is responsible for being aware of all evidence-based hospital initiatives (e.g., practices and protocols related to heart failure care, prevention of falls and urinary tract infections, and wound prevention and care) and ensuring that those initiatives are implemented at the bedside. To fulfill this role, the nurse reviews patient charts and talks to patients to ensure they receive appropriate care. (See bullet on daily patient care activities below for more details.)
    • Documenting provision of care: The clinical resource nurse works with nurses and doctors to ensure that the provision of all services included in CMS core measures are documented appropriately in patient charts.
    • Coaching and mentoring: The clinical resource nurse serves as an informal mentor, coach, and educator for new and existing unit-based nurses. As issues arise with patients, the clinical resource nurse will speak with unit nurses about how to improve care delivery. The clinical resource nurse also encourages unit nurses with associate (2-year) degrees to take advantage of hospital incentives (including tuition reimbursement, paid time off to pursue education, and increased compensation once higher education status is obtained) by pursuing baccalaureate nursing education and certification through the American Association of Critical Care Nurses.
  • Specific daily patient care activities: As part of the roles and responsibilities outlined above, the clinical resource nurse leads and/or participates in several critical patient care-related activities each day, as described below:
    • Huddles: The clinical resource nurse and unit nurses hold a "huddle" at the start of the morning shift (7 a.m.). (Unit nurses hold a similar huddle at the start of the evening shift as well.) The conversation focuses on unit-specific issues, such as updated fall rates and other data, new protocols, and other topics pertinent to daily patient care.
    • Walking rounds to each patient: After the morning huddle, the clinical resource nurse and the charge nurse walk around the unit, quickly visiting each patient to obtain a "snapshot" of his or her health status and needs.
    • Rounding to review care plans: The clinical resource nurse and a social worker lead half-hour “lightning rounds” each weekday morning at 9 a.m. to review the care plan for each patient; coach nurses on the care steps required; and outline discharge planning, documentation, and education needs. Other participants include registered nurses, the nursing manager, and utilization review personnel. During rounds, participants identify barriers to care steps that the clinical resource nurse can help overcome (e.g., by holding necessary discussions with physicians or patients/family members). This process helps the clinical resource nurse to organize his or her tasks for the day.
    • Patient followup: After the rounds, the clinical resource nurse follows up with patients and families regarding their concerns and addresses any care delivery tasks highlighted during rounding.
    • Discharge planning: Clinical resource nurses manage discharge planning in conjunction with social workers and utilization review staff. (The hospital does not have dedicated discharge planning staff.) This role involves ensuring that coordinated, appropriate care steps occur so that patient discharge is expedited and, for more complex patients, facilitating, coordinating, and sometimes providing discharge planning and education services.

Context of the Innovation

Lakeland Regional Medical Center, a 751-bed, not-for-profit community medical center in Lakeland, FL, handles approximately 70,000 inpatient discharges annually. In 2005, nurse administrators began brainstorming about how to retain the hospital's most experienced nurses and to ensure that some of these nurses continued to provide patient care rather than moving on to administrative positions. These discussions led to the development of the clinical resource nurse position.

Did It Work?

Back to Top

Results

Data from a pilot unit show that the creation of the clinical resource nurse position has led to more timely discharges, fewer facility-acquired pressure ulcers and falls, lower nurse turnover, and higher patient, nurse, and physician satisfaction; data from other units where the program has been adopted are not available.
  • More timely discharges: Before implementation, roughly 20 percent of all patients on the unit were discharged each day. By 2009, this figure had risen to between 35 and 50 percent.
  • Fewer pressure ulcers and falls: Between mid-2008 and mid-2009 (after program implementation), the pilot unit experienced no hospital-acquired pressure ulcers; while unit-specific data from before implementation are not available, the hospital-wide rate was approximately 13 percent in December 2007. In 2008, the pilot unit experienced 3.25 patient falls per 1,000 patients, down from 4.14 in 2005, before program implementation.
  • Lower nurse turnover, higher satisfaction: Among the 57 registered nurses and 8 licensed practical nurses on the unit, nurse turnover on the pilot unit was 2.13 percent in 2008, down from a much higher level before program implementation (exact data are unavailable). Anecdotal reports suggest that nurse satisfaction has increased since the new position was created.
  • Higher patient and physician satisfaction: Patient satisfaction on the pilot unit has been consistently higher than for the hospital as a whole (as measured by Press Ganey surveys). In addition, the patient satisfaction rating on the pilot unit has increased since program implementation, from 83.3 in 2005 to 85.8 in 2008. Physician satisfaction on the pilot unit was 1.1 in 2009, compared with 2 in 2005 (note: the hospital uses a 1 to 5 scale, with lower figures representing higher levels of satisfaction).
  • More nurses pursuing additional education: Before program implementation, only 11 nurses on the pilot unit had a baccalaureate degree. Since the creation of the new position, roughly 10 additional unit nurses have enrolled in a 4-year bachelor's of nursing program, while approximately 5 baccalaureate nurses have enrolled in a master's-level program.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of key process and outcome measures including patient discharge, patient fall rates, and patient/physician satisfaction.

How They Did It

Back to Top

Planning and Development Process

Key elements in the planning and development process included the following:
  • Forming a task force: A task force including the chief nurse executive, director of nursing, director of national practice and governance, nurse managers, and staff nurses met to review current nursing roles and promotion pathways, with a view toward better leveraging resources given the nursing shortage and the need to maintain nursing experience at the bedside. The idea of creating the clinical resource nurse position evolved from these group discussions.
  • Selecting the pilot unit: The task force selected the cardiac stepdown unit to serve as a pilot unit, largely because this unit had very low levels of employee satisfaction. This unit was also selected because of the nursing skill mix (75 percent registered nurses and 25 percent licensed practical nurses).
  • Developing the role and redefining workload: The director of nursing and the nurse manager of the pilot unit designed the requirements, roles, responsibilities, and workflow components (e.g., huddles, walkarounds) for the new position. They also redesigned the nursing care model so the creation of the new position would not require the addition of new staff. To accomplish this, the patient load for registered nurses was increased from five to six patients, with certain responsibilities traditionally handled by these nurses (e.g., discharge planning) being shifted to the clinical resource nurse. In addition, existing patient care assistants received training on transporting and monitoring patients, while licensed practical nurses received training on how to administer medications and treatments.
  • Educating pilot unit staff: The director of nursing and the nurse manager educated pilot unit staff on the new role and work processes and on how this new role could help the unit. At the same time, nurse leaders addressed any staff concerns, such as streamlining laborious charting requirements and removing barriers to work processes that resulted from certain interactions with other departments. Because the clinical resource nurse role adoption was really about changing the culture, the American Association of Critical Care Nurses' Healthy Work Environment concepts served as a key foundation for the education process.
  • Filling the new positions: Existing nurses were encouraged to apply for the three clinical resource nurse positions that were created as part of the pilot test.
  • Program expansion: Based on the success of the initial pilot, the program was expanded to other areas of the hospital, including an oncology unit, cardiac unit, medical/surgical unit, and general medicine unit. Roughly 200 beds are now covered by a clinical resource nurse.

Resources Used and Skills Needed

  • Staffing: The cardiac stepdown unit currently employs 10 licensed staff nurses plus 2 clinical resource nurses. The 10 licensed staff nurses must include at least 8 registered nurses each day; the other 2 positions can be filled either by 2 registered nurses or 2 licensed practical nurses. In total, the hospital employs eight clinical resource nurses, each of whom previously served as a staff nurse. As described earlier, the program required the hiring of no incremental staff because of the shift in responsibilities. Clinical resource nurses must have at least 5 years of clinical experience, along with a bachelor's degree in nursing (or they can be enrolled in such a program). Ideally, 1 clinical resource nurse should be responsible for 24 patients; on larger units, the presence of a charge nurse may allow for a larger patient load.
  • Costs: Startup costs were $140,000 (see Funding Sources for more details). Data on ongoing program costs, which consist primarily of the incremental salary and benefits for the clinical resource nurses, are unavailable.
begin fsxml

Funding Sources

Lakeland Regional Medical Center; Lakeland Regional Medical Center Foundation
The Lakeland Regional Medical Center Foundation provided a $140,000 grant to cover startup costs, including the salary differential for the three initial clinical resource nurses (because their promotion from staff nurse was accompanied by a salary increase not included in the unit's annual budget). Salaries for these positions are now included in the annual budget of the units in which they work.end fs

Tools and Other Resources

Information about the American Association of Critical Care Nurses' (AACN) Healthy Work Environment Initiative can be found at: http://www.aacn.org/WD/HWE/Content/hwehome.pcms?menu=Community.

Adoption Considerations

Back to Top

Getting Started with This Innovation

  • Expect (and address) resistance to change: Nurse leaders must be prepared to spend significant time alleviating anxiety about the new position among unit-based nurses. Adopting the clinical resource nurse role requires significant culture change.
  • Emphasize potential benefits: Staff nurses will respond more positively if they understand the potential benefits for various stakeholder groups, including improvements in patient care and higher satisfaction among nurses, physicians, and patients/families.

Sustaining This Innovation

  • Be open to conversation: Nurse leaders should be responsive to staff concerns and should change processes accordingly.
  • Share outcomes: Sharing data demonstrating the positive impact of the program on patient care, physician and patient satisfaction, and nurse turnover should convince unit nurses to continue supporting the program and may encourage some to seek a promotion to the level of clinical resource nurse.

More Information

Back to Top

Contact the Innovator

Virginia Smith
Manager, B5 Unit
Lakeland Regional Medical Center
1324 Lakeland Hills Boulevard
Lakeland, FL 33805
(863) 687-1244
E-mail: virginia.smith@lrmc.com

Jackie Yon, ARNP, MS, CCRN, CCNS
Associate Vice President, Nursing Services
Lakeland Regional Medical Center
1324 Lakeland Hills Boulevard
Lakeland, FL 33805
(863) 687-1153
E-mail: jackie.yon@lrmc.com

Innovator Disclosures

Ms. Smith and Ms. Yon have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Recognition

In 2009, ADVANCE for Nurses magazine recognized the pilot unit nursing team at Lakeland Regional Medical Center as Best in Adaptability among Florida hospitals. Recognitions are awarded to nursing teams who have demonstrated ability to adapt to challenges or changes. More information on this recognition is available at: http://nursing.advanceweb.com/Web-Extras/Online-Extras/Best-Nursing-Team-2013-FAQ-3.aspx.

References/Related Articles

Adams RW. LRMC nurses' innovations pay off with Best in Florida award. The Ledger. 17 May 2009. Available at: http://www.theledger.com/article/20090517/NEWS/905179946?tc=ar.

Footnotes

1 Interview with Virginia Smith and Jackie Yon, August 21, 2009.
2 Stanley JM, Gannon J, Gabuat J, et al. The clinical nurse leader: a catalyst for improving quality and patient safety. J Nurs Manage. 2008;16(5):614-22. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: January 20, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 17, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.