Project Summary
A significant number of patients are harmed or die every year because of unsafe, inappropriate or inadequate
healthcare delivery. The Agency for HealthCare Research and Quality has identified Registered Nurses (RNs)
as a patient safety strategy for reducing patient mortality and morbidity. However, variability in research
findings indicate the relationship is not as simple as `more nurses = better outcomes'. Despite the fact that RNs
are the largest health workforce component, with identified potential to improve patient safety, currently no
evidence-based frontline RN care model exists. The long-term goal of this research is to generate critical
knowledge that enables wide-spread implementation and sustained utilization of evidence-based frontline RN
care models that maximize the quality and safety of care received. One emerging model highlighted by policy
makers and increasingly taken up by health systems across the nation is the Clinical Nurse Leader (CNL) care
model. The purpose of this study is to estimate the CNL care model's effectiveness in impacting better care
and better health. It leverages a natural experiment in 66 clinical care units in 9 hospitals across 5 states (GA,
TX, MI, NC, IL) that are integrating CNLs into their frontline nursing care delivery model. A hybrid type II
implementation-effectiveness study will be used to accomplish the following aims. Aim 1. Evaluate the effect of
CNL-integrated care delivery on changes in nationally endorsed and standardized quality and safety outcomes
including patient satisfaction, infection rates, falls, LOS, and readmissions. Quasi-experimental interrupted time
series (ITS) design using regression methods to evaluate outcome change for individual units. A meta-analysis
implementing multilevel random effects models will provide combined unit-specific and overall estimates of
effect size for each outcome. All analysis will control for pre-intervention trends, seasonality, temporal
dependence, and unit-level demographics. Aim 2. Identify characteristics of CNL implementation that are
sufficient and necessary to achieve outcomes. Already collected data (surveys, interviews) will be used to
identify, characterize, and measure CNL implementation in each clinical unit. Qualitative Comparative Analysis
will be used to identify CNL implementation and practice characteristics that are consistently present in units
with improved outcomes (sufficient conditions) and thresholds that must be in place for outcomes to occur
(necessary conditions). By leveraging sophisticated analytic methods that capture the dynamic
interdependency of contextual factors in nursing practice, this study will be the first to examine nursing as an
organizational strategy to increase care quality and safety, to measure its effectiveness, and provide specific
`recipes' of successful CNL care model configurations that health systems can match to their needs to achieve
intended quality and safety outcomes.