Nurses are often promoted or hired into leadership positions without the benefit of a formal orientation to their new leadership positions. The challenge of navigating the various expectations of the role of clinical nurse leader (CNL) such as fiscal ownership, staffing patterns, payroll, and disciplinary action process can be overwhelming. The lack of a formalized orientation process and an identified nurse leader to function as a mentor can contribute to the novice CNL feeling unsupported and overwhelmed. The purpose of this project was to identify, develop, and evaluate a CNL orientation manual, outline, and program for newly appointed CNLs. The desired outcome for this doctor of nursing practice project was the education and preparation of CNLs who will navigate the various facets of the role and retain their positions longterm. The Association of Nurse Executives nurse leader model was used to guide the project. A panel of 5 CNL experts evaluated the manual outline and content using a 5-question Likert scale survey. Findings indicated 100% of the participants agreed or strongly agreed with the importance of the topics covered and 80% agreed with the content covered in the manual outline. The project is expected to promote positive social change by preparing new CNLs to meet the requirements of leadership positions.

The purpose of this study was to explore the relationship of the Clinical Nurse Leader (CNL) (AACN) role with the variables of work related stress, quality of life, job satisfaction and anticipated turnover of acute care nurses. Participants included registered nurses (RNs) (N= 94) in Florida recruited from 3 (not for profit) Magnet hospitals in the Tampa Bay Florida area. An ex post facto design was used to test the hypotheses of this study; independent t-tests compared RN’s responses on survey tools measuring work-related stress, quality of life, job satisfaction, and anticipated turnover. Multiple regression analysis was used to examine the interrelationships among these variables. RNs (N=94) completed five survey instruments, including a researcher-developed demographic form. The results of the study showed Aim1 which explored work- related stress did not show any statistical difference between the two groups. Aim 2 which explored job satisfaction and quality of life did not show a difference in the two groups when total scores were analyzed. However, the mental health subscale of the Sf-36(quality of life) was significant ( p=.021), and the general health subscale of the Sf-36 trended toward the CNL group reporting better general health (p=.080). This study revealed that Aim 3 which explored anticipated turnover was statistically significant (p=.047). Standard multiple regression showed a significant relationship existed between CNLs, work related stress and anticipated turnover. The significance of implementation of the CNL role in decreasing turnover through a relationship with these variables may have an important impact on the nursing profession. Specifically, economic implications in reducing turnover that bear further exploration and improving the nursing work environment. This research is the first study to explore the CNL role in relation to these variables.

A major focus in nursing education is on the judgement of clinical performance, and it is a complex process due to the diverse nature of nursing practice. Difficulties in the development of valid and reliable assessment measures in nursing competency continue to pose a challenge in nursing education. A holistic approach in the assessment of competency comprises knowledge, skills and professional attitudes, wherein the notion of competency incorporates professional judgement and management skills in the clinical situation. Therefore, the thesis aims to develop a holistic clinical assessment tool with a reasonable level of validity and reliability to meet the needs of clinical education. The conceptual framework underlying this research is formed by establishing a theoretical connection between the practice of learning, and of pedagogy and assessment. This research consists of five studies. In Study I, a systematic review was conducted to explore the current assessment practices and tools for nursing undergraduates. In Studies II, III and IV, a qualitative approach with focus group discussions was adopted to explore the views of final-year undergraduate nursing students, preceptors, clinical nurse leaders and academics on the clinical assessment. Based on the multiple perspectives, it therefore addresses concerns in clinical assessment. In Study V, a holistic clinical assessment tool was developed, for which a psychometric testing was conducted. The systematic review indicated that limited studies adequately evaluate the psychometric properties of the assessment instrument. The qualitative studies have raised an awareness of professional and educational issues in relation to clinical assessment. Workload, time, availability of resources, adequate preparation of preceptors, and availability of valid and reliable clinical assessment tools were deemed to influence the quality of students’ clinical learning and assessment. In addition, the presence of support systems and formal educational programs for preceptors influenced their preparation and self-confidence. Nursing leaderships in hospitals and educational institutions have a joint responsibility in shaping the holistic clinical learning environment and making holistic clinical assessment for students. The involvement of all stakeholders in the development of a valid and reliable assessment tool for clinical competency is also essential to the process. The Holistic Clinical Assessment Tool (HCAT) was developed by the author based on the systematic review, qualitative findings and the core competencies of registered nurse from the professional nursing boards. The HCAT consists of 4 domains and 36 assessment items. Furthermore, testing of the psychometric properties indicated that the HCAT has satisfactory content validity, construct validity, internal consistency and test-retest reliability. In conclusion, the HCAT is meritorious in that it carries the potential to be used as a valid measure to evaluate clinical competency in nursing students, and provide specific and ongoing feedback to enhance the students’ holistic clinical learning experience. The HCAT not only functions as a tool for self-reflection for the students, but also guides the preceptors in clinical teaching and assessment. In addition, the HCAT can be used for peer-assessment and feedback. It is imperative that the clinical and academic institutions establish various levels of ongoing support for both students and preceptors in the process of clinical assessment.

In an era of value based purchasing and healthcare reform, hospitals face the challenge of delivering high quality care in an environment of diminishing resources. This performance improvement project describes the use of master’s prepared nurses on medical surgical units to improve quality and patient satisfaction. The setting was five medical surgical units in a 200+ bed hospital in the southeastern United States. Declining resources necessitated an increase in the nurse to patient ratios on the units (from 5:1 to 6:1). The project involved the modification of the model of care through the change in nurse/patient ratios and the addition of master’s prepared nurses to coordinate and supplement the care of the staff RNs for complex patients. While inconclusive, the literature review confirmed the impact of master’s prepared nurses on quality metrics and did not conclusively confirm that delivering high quality, safe care was not possible with nurse/patient ratios of 1:6. The goal of the project was to determine if the presence of the master’s prepared nurse could mitigate the changes in ratios and produce high quality and satisfaction outcomes. Measures of success were drawn from archived standardized quality measures in the realms of service (HCAHPS questions), patient safety (CABSI, HAPU) and quality outcomes (core measures and 30 day readmissions). The project design was a retrospective, one-group pre-post design looking at two six-month intervals—before and after project implementation. Results demonstrated sustained or improved quality in six of ten measures. Highest positive impact was in readmissions and nurse sensitive indicators. The most negative results were in patient satisfaction. Modifying the model of care is an iterative process requiring continued evaluation and changes to improve outcomes. Results of this project supported the further evaluation of staffing and expansion of the number of master’s prepared nurses on medical surgical units.