Predictors of Clinical Nurse Leader implementation success across a national sample of settings: A Bayesian multilevel modeling analysis.

INTRODUCTION: The Clinical Nurse Leader (CNL) care model is a different way of organizing frontline nursing care delivery in contrast to the traditional "staff nurse" model and is increasingly being adopted by health systems across the United States and abroad. However, variability in implementation and outcomes has been noted across health settings. AIM: A recently validated CNL Practice Model provides an explanatory pathway for CNL model integration into practice. The purpose of this study was to identify and compare patterns of empirical correspondence to the CNL Practice Model and predict their influence on implementation success. METHODS: We conducted a secondary analysis of a 2015 national-level study with clinicians and administrators involved with CNL initiatives in their health system. A psychometrically validated CNL Practice Survey was used to collect data measuring the presence (0%-100%) of the five domains of the CNL Practice Model (organizational readiness, CNL structuring, CNL practices, outcomes, and value) and one measure of CNL implementation success. We modeled the complex hierarchical structure of the data using a Bayesian multilevel regression mixed modeling approach. A zero-one-inflated beta distribution, a mixture of Bernoulli distributions for the minimum and maximum responses and a beta distribution for the responses between the minimum and maximum, was used to fit success ratings in the model. RESULTS: A total of 920 participants responded, 540 (59%) provided success scores. The model captured ratings skewed toward upper bound, while also adequately modeling data between the minimum and maximum values. The Bayesian model converged and gave estimates for all hierarchical parameters, which would likely have failed to converge in a pure maximum likelihood framework. The variability around success score across CNL Practice Model element ratings was greatest at the component level, 0.29 (0.18-0.48), compared to either the domain level, 0.16 (0.01-0.54), or the item level, 0.09 (0.01-0.17). The components most predictive of implementation success were (a) consensus CNL model can close gaps, (b) organization level implementation strategy, and (c) alignment of empirical CNL microsystem level structuring to the model's conceptualization. CONCLUSIONS: Findings provide further empirical evidence to support the explanatory pathway proposed by the CNL Practice Model and identified specific organizational readiness and CNL workflow structures that are critical antecedents predictive of CNL practice manifestation and production of expected outcomes. Findings indicate actionable implementation evidence that can be successfully adopted across real-world healthcare settings to achieve safer and higher quality patient care. CLINICAL RELEVANCE: CNL integrated care delivery is a frontline nursing care model that is being increasingly adopted by health systems across the United States and abroad. However, variability in CNL implementation and outcomes has been noted across health settings, limiting its evidence base. Findings of this study contribute a better understanding about the variability of CNL practice and outcomes found in the literature and contribute empirical and conceptual clarity about the relationships between modes of CNL implementation and successful adoption in healthcare settings.

What constitutes philosophical activity in nursing? Toward a definition of nursing philosophy based on an interpretive synthesis of the recent literature.

Nursing claims a significant history of engaging philosophical inquiry. To better understand the rationale for this engagement, and what nursing understands itself to achieve through philosophical inquiry, we conducted an interpretive synthesis of the recent nursing literature to identify what nurses are doing when they say they are doing philosophy. The overarching finding was that while vanishingly few articles articulated any definition of philosophy, the synthesis showed how nursing considers philosophical engagement a generative mode for asking and answering questions in/for nursing. Whatever aspects of nursing were focused on in these articles, and they were myriad, philosophy was invoked as an appropriate modality to work through that aspect rigorously, critically, and with an expectation that something "knowledgeable" would result from the effort. Based on the synthesis, we conclude that nursing philosophy could be considered a specific modality of nursing practice by which nursing is both done and delineated, a discursive practice in which we continually assess and explore and adapt and advance our understanding of the discipline in service to advancing our unique efficacy. This definition of "nursing philosophy" provides an opening for further inquiry helping to illuminate its functionalities and potentialities for outputs that can facilitate rigorous practice, education, and scholarship.

Factors Influencing Implementation Success of the Clinical Nurse Leader Care Delivery Model: Findings From a National-Level Mixed-Methods Study.

BACKGROUND: The clinical nurse leader (CNL) care model has existed since 2007. However, there is limited understanding how the model can best be implemented. PURPOSE: A validated CNL Practice Survey measuring domains theorized to influence CNL implementation was used to examine the link between CNL domains and CNL implementation success. METHODS: Mixed methods were used to analyze data from a nationwide 2015 survey administered to clinicians and administrators involved in CNL initiatives. RESULTS: Of total respondents (n = 920), 543 (59%) provided success scores, with 349 (38%) providing comments. Respondents with negative comments gave significantly lower average CNL success scores. The majority of negative comments mapped onto Readiness and Structuring domains, providing details of barriers to CNL implementation success. CONCLUSIONS: Findings provide information about structural domains that can be strategically targeted to better prepare settings for CNL implementation and success.

A response to Michael Clinton's On Bender's orientation to models: Towards a philosophical debate on covering laws, theory, emergence and mechanisms in nursing science.

My purpose in this short response to Clinton's interesting article On Bender's orientation to models: Towards a philosophical debate on covering laws, theory, emergence and mechanisms in nursing science, which is published in this issue, is not to provide any counterargument to Clinton's interpretation of my own argument; readers are welcome to interrogate both articles at their leisure and make their own conclusions. What I will do instead is provide a brief critical assessment of my own (il)logic re bringing in the notion of mechanism as conceived by Machamer, Darden and Craver into an argument for models versus theories as a carrier of nursing knowledge.

The role of philosophy in the development and practice of nursing: Past, present and future.

This article summarizes a virtual live-streamed panel event that occurred in August 2020 and was cosponsored by the International Philosophy of Nursing Society (IPONS) and the University of California, Irvine's Center for Nursing Philosophy. The event consisted of a series of three self-contained panel discussions focusing on the past, present and future of IPONS and was moderated by the current Chair of IPONS, Catherine Green. The first panel discussion explored the history of IPONS and the journal Nursing Philosophy. The second panel involved a reflection on the challenges of doing nursing philosophy in a research-intensive context of a Canadian university and the history and current movements in nursing philosophy in the Nordic countries. The final panel involved presentations on the future potential for philosophy in/and for nursing, the critical connections between nursing philosophy and nursing theory, dismantling racism in nursing and the potential for process philosophy to help explore nursing's unique efficacy in creating possibilities for health. The panels were followed by a lively Q&A session with participants, of which there were 252 registrants from across the globe. The event underscored the wide and diverse interests of nurses in philosophical discussion and the need for more virtual events and other connective modalities bringing nurses together to discuss and analyze the value and potential of philosophy to better understand and advance nursing theory and practice.

Relationships within MOMS Orange County care coordinated home visitation perinatal program.

PURPOSE: The study aimed to examine how registered nurses (RNs) and paraprofessional home visitors (PHVs) work together as a team to care for underserved perinatal women in a coordinated home visitation program. DESIGN AND METHODS: Qualitative methods were used to understand the perspectives of three RNs and twenty PHVs who worked at MOMS Orange County, a community-based perinatal health program. Individual one-on-one interviews were administered with the RNs and focus groups with the PHVs. Qualitative content analysis was conducted to synthesize themes. RESULTS: RNs perceived themselves as educators, mentors, and supervisors. PHVs thought of themselves as supporters, coaches, and advocates. Interdependence and proactive communication were favorable characteristics of the relationship in which RNs trained PHVs to provide health education. The positive interactions between RNs and PHVs appeared to enhance the client-healthcare provider connection. CONCLUSIONS: Our study is one of the first to describe relationships and communication patterns among the healthcare team in a coordinated home visitation program in the United States. Future studies should examine how additional members of the team, including clients and healthcare providers, view their experiences with a home visitation program.

Relationship of Time of Injury Marijuana Exposure and Traumatic Brain Injury: A Systematic Review.

BACKGROUND: Traumatic brain injury (TBI) is a significant nursing concern, as it is a leading cause of mortality, morbidity, and disability in the United States. Notably, up to 51% of all TBI patients have substance use exposure at the time of injury. Marijuana remains the most widely used illicit drug in the United States. However, little is known about marijuana exposure and TBI incidence and severity, particularly at the time of injury. METHODS: A systematic literature review was conducted following PRISMA guidelines in PubMed to determine the relationship between marijuana exposure and TBI severity.Heterogeneity of study designs, concepts, samples, and variables in included studies precluded a meta-analysis. Hence, a descriptive analysis of findings was conducted. RESULTS: The search yielded 939 studies, of which eight met inclusion criteria. Only one study found a connection between positive marijuana toxicology screen and mortality outcomes in TBI patients. There was significant variation in how marijuana exposure was defined, conceptualized, and operationalized in the other studies. CONCLUSIONS: This review identified the need for larger, better-designed studies to address the significant knowledge gap about the relationship between marijuana use and its influence on TBI. Data and knowledge derived from such studies can help inform policy and aid in the development of nursing interventions that target prevention and increase awareness of TBI risk when under the influence of marijuana.

Assessing health care interventions via an interrupted time series model: Study power and design considerations.

The delivery and assessment of quality health care is complex with many interacting and interdependent components. In terms of research design and statistical analysis, this complexity and interdependency makes it difficult to assess the true impact of interventions designed to improve patient health care outcomes. Interrupted time series (ITS) is a quasi-experimental design developed for inferring the effectiveness of a health policy intervention while accounting for temporal dependence within a single system or unit. Current standardized ITS methods do not simultaneously analyze data for several units nor are there methods to test for the existence of a change point and to assess statistical power for study planning purposes in this context. To address this limitation, we propose the "Robust Multiple ITS" (R-MITS) model, appropriate for multiunit ITS data, that allows for inference regarding the estimation of a global change point across units in the presence of a potentially lagged (or anticipatory) treatment effect. Under the R-MITS model, one can formally test for the existence of a change point and estimate the time delay between the formal intervention implementation and the over-all-unit intervention effect. We conducted empirical simulation studies to assess the type one error rate of the testing procedure, power for detecting specified change-point alternatives, and accuracy of the proposed estimating methodology. R-MITS is illustrated by analyzing patient satisfaction data from a hospital that implemented and evaluated a new care delivery model in multiple units.

Advancing the use of organization theory in implementation science.

Healthcare settings and systems have been slow to adopt and implement many effective cancer prevention and control interventions. Understanding the factors that determine successful implementation is essential to accelerating the translation of effective interventions into practice. Many scholars have studied the determinants of implementation, and much of this research has been guided by the Consolidated Framework for Implementation Research (CFIR). The CFIR categorizes implementation determinants at five levels (characteristics of the intervention, inner setting, individual, processes, and outer setting). Of these five levels, determinants at the level of the outer setting are the least developed. Extensive research in fields other than healthcare suggest that determinants at the level of the outer setting (e.g., funding streams, contracting practices, and public policy) play a central role in shaping when and how an organization implements new structures and practices. Thus, a more comprehensive understanding of outer-setting determinants is critical to efforts to accelerate the implementation of effective cancer control interventions. The Cancer Prevention and Control Research Network (CPCRN) created a cross-center workgroup to review organizational theories and begin to contribute to the creation of a future framework of constructs related to outer setting determinants. In this paper, we report findings from the review of three organizational theories: Institutional Theory, Transaction Cost Economics, and Contingency Theory. To demonstrate the applicability of this work to implementation science and practice, we have applied findings to three case studies of CPCRN researchers' efforts to implement colorectal cancer screening interventions in Federally Qualified Health Centers.

System- and Unit-Level Care Quality Outcome Improvements After Integrating Clinical Nurse Leaders Into Frontline Care Delivery.

OBJECTIVE: This study determined whether 1 health system's frontline nursing model redesign to integrate clinical nurse leaders (CNLs) improved care quality and outcome score consistency. METHODS: Interrupted time-series design was used to measure patient satisfaction with 7 metrics before and after formally integrating CNLs into a Michigan healthcare system. Analysis generated estimates of quality outcome: a) change point; b) level change; and c) variance, pre-post implementation. RESULTS: The lowest-performing unit showed significant increases in quality scores, but there were no significant increases at the hospital level. Quality metric consistency increased significantly for every indicator at the hospital and unit level. CONCLUSIONS: To our knowledge, this is the 1st study quantifying quality outcome consistency before and after nursing care delivery redesign with CNLs. The significant improvement suggests the CNL care model is associated with production of stable clinical microsystem practices that help to reduce clinical variability, thus improving care quality.

Reconciling nursing's art and science dualism: Toward a processual logic of nursing.

There is an enduring debate in nursing regarding the art-science dualism, involving an articulation of two distinct 'kinds' of disciplinary knowledge: objective/scientific and subjective/artistic. Nursing identifies both as necessary, yet unbridgeable, which creates problems in constructing a coherent disciplinary knowledge base. We describe how this problem arises based on an ontological assumption of two different kinds of 'stuff' in the world: that with essential determinate properties and that without essential properties. We experiment with a solution by ontologically understanding the world as made from a single kind: That the most irreducible element of the world is process, in that reality is a continuous construction whereby subject and object are products, not independent constituents, of reality. Process philosophy overcomes nursing's ontological bifurcation and enables nursing's art-science dualism to be re-conceptualized as a cohesive logic of skilled reality production. An unavoidable implication of a process turn in nursing philosophy is that the disciplinary goal no longer becomes a privileged 'body of knowledge' that authorizes, which has always been a defining challenge in nursing. Rather, and more productively perhaps, the aim is for greater sophistication and plurality in its ongoing commitment to attuning to reality in ways that shape disciplinary attainment.

Clinical Nurse Leader Knowledge Production to Quality Improvement in a Seamless Trajectory: A Participatory Research Approach.

BACKGROUND: Health systems are actively implementing Clinical Nurse Leader (CNL)-integrated care delivery across the United States. PROBLEM: However, the CNL model is a complex health care intervention, making it difficult to generate evidence of effectiveness using traditional research frameworks. APPROACH: Participatory research is a growing alternative to traditional research frameworks, emphasizing partnership with target community members in all phases of research activities. This article describes a system-based participatory study that leveraged academic and practice knowledge to conduct research that was feasible and relevant, and which produced findings that were easily translated into systematic action by the health system. OUTCOMES: Study data were used to produce improvements in the health system's CNL onboarding process, role differentiation, performance, recruitment, and growth plus development. CONCLUSIONS: A participatory approach can be used in future CNL studies, providing a framework for research efforts and potentially speeding up CNL evidence generation and utilization in practice.

Advancing the clinical nurse leader model through academic-practice-policy partnership.

The nursing profession is tasked with identifying and evaluating models of care with potential to add value to health care delivery. In consideration of this goal, we describe the Clinical Nurse Leader (CNL) initiative and the activities of a national-level CNL research collaborative. The CNL initiative, launched by the American Association of Colleges of Nursing in collaboration with education and healthcare leaders, has delineated CNL education curriculum and practice competencies, and fostered the creation of academic-practice-policy partnerships to pilot CNL integration into frontline nursing care delivery. The partnership has evolved into an Agency for Healthcare Research and Quality affiliate practice-based research network, the CNL Research Collaborative, which links research, policy, education, and practice stakeholders to advance the CNL evidence base. We summarize foundational CNLRC research to explain CNL practice, quantify CNL effectiveness, and bring clarity to how CNLs can be implemented to consistently influence care, quality, and safety.

Re-conceptualizing the nursing metaparadigm: Articulating the philosophical ontology of the nursing discipline that orients inquiry and practice.

Jacqueline Fawcett's nursing metaparadigm-the domains of person, health, environment, and nursing-remains popular in nursing curricula, despite having been repeatedly challenged as a logical philosophy of nursing. Fawcett appropriated the word "metaparadigm" (indirectly) from Margaret Masterman and Thomas Kuhn as a devise that allowed her to organize then-current areas of nursing interest into a philosophical "hierarchy of knowledge," and thereby claim nursing inquiry and practice as rigorously "scientific." Scholars have consistently rejected the logic of Fawcett's metaparadigm, but have not yet proposed a substantially agreed-upon alternative. Through an analysis of articles introducing and critiquing Fawcett's metaparadigm, I argue for a re-conceptualized metaparadigm that articulates nursing's ontology. What exists for the nursing discipline are not already-demarcated metaparadigm domains, but rather interdependent, dynamic relations that constitute people, including nurses, in their health/environment circumstance. The nursing discipline aims to skillfully access this dynamic relationality as the basis for action and reflection to produce both positive health trajectories and knowledge that facilitates future action and reflection. Further inquiry into the onto-epistemology of nursing will produce a more robust understanding of nursing practice, science, and philosophy, and clarify its unique contribution to health and healthcare.

Developing the Clinical Nurse Leader Survey Instrument: A Modified Delphi Study.

Clinical nurse leader (CNL)-integrated care delivery is an emerging nursing model, with growing adoption in diverse health systems. To generate a robust evidence base for this promising nursing model, it is necessary to measure CNL practice to explicitly link it to observed quality and safety outcome improvements. This study used a modified Delphi approach with an expert CNL panel to develop and test the face, content, and construct validity of the CNL Practice Survey instrument.

Organising nursing practice into care models that catalyse quality: A clinical nurse leader case study.

AIMS: To determine the power of a conceptual clinical nurse leader practice model to explain the care model's enactment and trajectory in real world settings. BACKGROUND: How nursing, organised into specific models of care, functions as an organisational strategy for quality is not well specified. Clinical nurse leader integrated care delivery is one emerging model with growing adoption. A recently validated clinical nurse leader practice model conceptualizes the care model's characteristics and hypothesizes their mechanisms of action. METHODS: Pattern matching case study design and mixed methods were used to determine how the care model's constructs were operationalized in one regional United States health system that integrated clinical nurse leaders into their care delivery system in 2010. RESULTS: The findings confirmed the empirical presence of all clinical nurse leader practice model constructs and provided a rich description of how the health system operationalized the constructs in practice. The findings support the hypothesized model pathway from Clinical Nurse Leader structuring to Clinical Nurse Leader practice and outcomes. CONCLUSION: The findings indicate analytic generalizability of the clinical nurse leader practice model. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing practice organised to focus on microsystem care processes can catalyse multidisciplinary engagement with, and consistent enactment of, quality practices. The model has great potential for transferability across diverse health systems.

Models versus theories as a primary carrier of nursing knowledge: A philosophical argument.

Theories and models are not equivalent. I argue that an orientation towards models as a primary carrier of nursing knowledge overcomes many ongoing challenges in philosophy of nursing science, including the theory-practice divide and the paradoxical pursuit of predictive theories in a discipline that is defined by process and a commitment to the non-reducibility of the health/care experience. Scientific models describe and explain the dynamics of specific phenomenon. This is distinct from theory, which is traditionally defined as propositions that explain and/or predict the world. The philosophical case has been made against theoretical universalism, showing that a theory can be true in its domain, but that no domain is universal. Subsequently, philosophers focused on scientific models argued that they do the work of defining the boundary conditions-the domain(s)-of a theory. Further analysis has shown the ways models can be constructed and function independent of theory, meaning models can comprise distinct, autonomous "carriers of scientific knowledge." Models are viewed as representations of the active dynamics, or mechanisms, of a phenomenon. Mechanisms are entities and activities organized such that they are productive of regular changes. Importantly, mechanisms are by definition not static: change may alter the mechanism and thereby alter or create entirely new phenomena. Orienting away from theory, and towards models, focuses scholarly activity on dynamics and change. This makes models arguably critical to nursing science, enabling the production of actionable knowledge about the dynamics of process and change in health/care. I briefly explore the implications for nursing-and health/care-knowledge and practice.