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.

Using a handheld UV device for disinfection in the patient care environment: A descriptive qualitative study.

Frontline nurses play a critical role in the prevention of healthcare-acquired infections (HAIs) through daily practices of hand hygiene and decontamination of surfaces. Despite these practices, environmental contamination and HAIs persist. Emerging use of UV light at wavelengths safe for human exposure provides additional strategies for disinfecting the patient care environment. The purpose of this qualitative study is to explore frontline nursing feedback regarding a novel handheld UV device prototype. A convenience sample of nurses were invited to participate in facilitated individual or small group discussions led by one member of the research team. Thematic analysis of discussion transcripts was completed by two members of the research team. Sixteen registered nurses participated. Four themes found in the study were time considerations, complexity, safety (patient and nurse), and characteristics of technology to improve patient care. Findings suggest that while nursing staff are willing to use technology, it must be considered valuable to patient care and should not hinder the provision of care. Inclusion of inputs from nursing staff for development of technology identifies potential barriers to acceptance and use in the practice environment.

A pilot of a veteran suicide prevention learning collaborative among community organizations: Initial results and outcomes.

INTRODUCTION: Veteran suicide remains an ongoing public health concern in need of fresh, community-based initiatives. The Department of Veterans Affairs (VA) has built an enterprise-wide integrated behavioral health system that has pioneered numerous suicide prevention methods. However, most Veterans receive healthcare outside the VA, from organizations that may not be equipped to address Veteran suicide risk. One solution is implementing a VA/community suicide prevention learning collaborative to support organizations in implementing suicide prevention best practices for Veterans. Although learning collaboratives have a history of supporting improved patient safety in healthcare systems, to our knowledge, none have focused on Veteran suicide prevention. METHOD: The current quality improvement project sought to pilot a VA/community suicide prevention learning collaborative in the broader Denver and Colorado Springs areas with 13 organizations that served, interacted with, or employed Veterans. RESULTS: The collaborative had a large footprint in the region, with organizations interacting with over 24,000 community members and over 5000 Veterans. Organizations implemented 92 Veteran suicide prevention program components within a 16-month period. Overall, the learning collaborative made significant strides in Veteran suicide prevention. CONCLUSION: Findings suggest that this method facilitates rapid implementation of Veteran suicide prevention practices and may be promising for accelerating uptake within communities.

Efficacy of a filtered far-UVC handheld disinfection device in reducing the microbial bioburden of hospital surfaces.

BACKGROUND: The filtered far-UV-C (FFUV) handheld disinfection device is a small portable device that emits far UV-C at 222 nm. The objective of this study was to evaluate the device's ability to kill microbial pathogens on hospital surfaces and compare it to manual disinfection using germicidal sodium hypochlorite wipes. METHODS: A total of 344 observations (4 observations from 86 objects' surfaces) were sampled with 2 paired samples per surface: a pre- and a post-sodium hypochlorite and FFUV sample. The results were analyzed via a Bayesian multilevel negative binomial regression model. RESULTS: The estimated mean colony counts for the sodium hypochlorite control and treatment groups were 20.5 (95% uncertainty interval: 11.7-36.0) and 0.1 (0.0-0.2) colony forming units (CFUs), respectively. The FFUV control and treatment groups had mean colony counts of 22.2 (12.5-40.1) and 4.1 (2.3-7.2) CFUs. The sodium hypochlorite group and the FFUV group had an estimated 99.4% (99.0%-99.7%) and 81.4% (76.2%-85.7%) reduction in colony counts, respectively. CONCLUSIONS: The FFUV handheld device effectively reduced the microbial bioburden on surfaces in the health care setting. The major benefit of FFUV is likely seen when manual disinfection is not possible or when supplementing cleaners or disinfectants with the low-level disinfection properties.

Assessment of microbial bioburden on portable medical equipment in a hospital setting.

Objectives: Although routine disinfection of portable medical equipment is required in most hospitals, frontline staff may not be able to disinfect portable medical equipment at a rate that adequately maintains low bioburden on high-use equipment. This study quantified bioburden over an extended time period for two types of portable medical equipment, workstations on wheels and vitals machines, across three hospital wards. Methods: Bioburden was quantified via press plate samples taken from high touch surfaces on 10 workstations on wheels and 5 vitals machines on each of 3 medical surgical units. The samples were taken at three timepoints each day over a 4-week period, with random rotation of timepoints and portable medical equipment, such that frontline staff were not aware at which timepoint their portable medical equipment would be sampled. The mean bioburden from the different locations and portable medical equipment was estimated and compared with Bayesian multilevel negative binomial regression models. Results: Model estimated mean colony counts (95% credible interval) were 14.4 (7.7-26.7) for vitals machines and 29.2 (16.1-51.1) for workstations on wheels. For the workstations on wheel, colony counts were lower on the mouse, 0.22 (0.16-0.29), tray, 0.29 (0.22, 0.38), and keyboard, 0.43 (0.32-0.55), when compared to the arm, as assessed by incident rate ratios. Conclusions: Although routine disinfection is required, bioburden is still present across portable medical equipment on a variety of surfaces. The difference in bioburden levels among surfaces likely reflects differences in touch patterns for the different portable medical equipment and surfaces on the portable medical equipment. Although the association of portable medical equipment bioburden to healthcare-associated infection transmission was not assessed, this study provides evidence for the potential of portable medical equipment as a vector for healthcare-associated infection transmission despite hospital disinfection requirements.

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.

Effect of a "feedback prompt" from a disinfection tracking system on portable medical equipment disinfection.

BACKGROUND: Portable medical equipment (PME) may contribute to transmission of multidrug-resistant organisms without proper disinfection. We studied whether a Disinfection Tracking System (DTS) with feedback prompt, attached to PME, can increase the frequency of PME disinfection. METHODS: DTS devices were placed on 10 workstations-on-wheels (WOWs) and 5 vitals machine (VM). After a 25 day "screen-off" period, the DTS device screens were turned on to display the number of hours since the last recorded disinfection event for a 42 day period. We used a Bayesian multilevel zero-inflated negative binomial model to compare the number of events in the display "screen-off" to the "screen-on" period. RESULTS: During the "screen-off" period, there were 1.26 and 0.49 mean disinfection events and during the "screen-on" period, there were 1.76 and 0.50 mean disinfection events for WOWs and VM, respectively, per day. The model estimated mean events per device per day in the the "screen-on" period for WOW's were 1.32 (1.10 - 1.57) times greater than those in the "screen-off" period and the "screen-on" period for VM devices was 1.37 (0.89 - 2.01) times greater than those in the "screen-off" period. CONCLUSIONS: The rate of disinfection events for WOWs increased following the implementation of the DTS feedback prompt.

Frontline Nurse Feedback During the Development of a System to Track Cleaning of Portable Medical Equipment.

As part of the development and testing of an innovative technology for tracking disinfection of portable medical equipment, end-user feedback was obtained during an initial trial on two acute care hospital units. The disinfection tracking device was installed on the computers-on-wheels and vital signs machines. Each device had the capability of detecting a cleaning event, reporting the event to an online database, and displaying the time since last cleaning event on a visual display. End-user feedback regarding functionality, usefulness of information provided, and impact on workflow was obtained by survey and facilitated group discussions. Seventeen frontline nurses completed the anonymous survey, and 22 participated in the facilitated group discussions. End users found the system functionally easy to use and the information about time since last cleaning useful and reported minimum disruption of workflow. Functionality of the system was confirmed by consistency between recorded and self-reported cleaning patterns. Managers found the data on cleaning of portable medical equipment helpful in validating compliance with hospital equipment cleaning policy. Frontline staff expressed appreciation for technology that helps them and improves outcomes but also discussed concerns about the potential for technology that creates extra work and disruption in the busy frontline nursing care delivery environment. Nurses were appreciative of opportunities to provide feedback and input into efforts to develop and introduce technology. Recorded cleaning events coincided with self-reported equipment cleaning patterns and illustrated that the device efficiently collects information deemed useful by the end user.

Capturing portable medical equipment disinfection data via an automated novel disinfection tracking system.

BACKGROUND: Portable Medical Equipment (PME) such as workstations-on-wheels (WOWs) and vital signs machines (VMs) have been linked to healthcare-associated infections. Routine visual monitoring of PME disinfection is difficult. An automated Disinfection Tracking System (DTS) was used to record and report the number of disinfection events of PME in a hospital setting. METHODS: The study was conducted in 2 acute-care units for 25-days to determine the pattern of recorded events from DTS on PME. Devices record disinfection events as moisture events and automatically store on a central database. DTS devices with "screen-on" feedback and "screen-off" devices with no display were placed on 10 WOWs and 5 VMs on separate units. RESULTS: A total of 421 moisture events were recorded for the "screen-on" and 345 for the "screen-off", during the 25-day implementation period on the 2 different hospital units. The highest number of events occurred between 6:00am-7:00am, with 69 & 75 moisture events recorded for Units 1 and 2, respectively. CONCLUSIONS: The pattern of disinfection events for WOWs and VMs demonstrated that most events occurred regularly at the times corresponding with nursing shift change. The DTS has the potential to continuously record, and report data related to PME disinfection.

A study protocol to evaluate the implementation and effectiveness of the Clinical Nurse Leader Care Model in improving quality and safety outcomes.

AIMS: Patients are harmed or die every year because of unsafe, inappropriate or inadequate healthcare delivery. Registered Nurses are a recognized patient safety strategy. However, variability in research findings indicate the relationship is not as simple as "more nurses=better outcomes." Hence, currently there exists no evidence-based frontline nursing care model. One emerging model is the Clinical Nurse Leader care model. DESIGN: This Hybrid Type II Implementation-Effectiveness study will evaluate the effect of the care model on standardized quality and safety outcomes and identify implementation characteristics that are sufficient and necessary to achieve outcomes. METHODS: This study leverages a natural experiment in 66 clinical care units in nine hospitals across five states in the United States that have implemented the Clinical Nurse Leader care model. RESULTS: Findings will elucidate Registered Nurse's mechanisms of action as organized into frontline models of care and link actions to improved care quality and safety.

Developing Effective Senior Nurse Leaders: The Impact of an Advanced Leadership Initiative.

OBJECTIVE: The aim of this study was to measure structural empowerment (SE) and capture short-term changes in perception for senior nurse leaders before and after a formal development experience. BACKGROUND: The body of literature related to SE in senior nurse leaders is limited. Applying the SE concept to senior levels of nursing leadership provides a vehicle to impact nurse leader retention and ultimately the organization beyond singular units. METHODS: The Advanced Leadership Program (ALP) was designed in collaboration with the American Nurses Association to support personal and professional development for senior nurse leaders. The sample included 28 participants from the United States and the United Kingdom over a 6-month period. RESULTS: The effect of the intervention was seen in the postintervention survey rating SE higher in 5 of 7 domains as compared with the preintervention survey, reduction in overall turnover, and improvements in patient experience scores. Additionally, the participants evaluated the program in top categories, and comments were highly positive around peer support, improved working relationships, and expectations. CONCLUSION: The ALP has shown promise in strengthening SE for senior nurse leaders by supporting leadership skill development, follow-up training, and peer network development.

The Veterans Affairs Patient Safety Center of Inquiry-Suicide Prevention Collaborative: Creating Novel Approaches to Suicide Prevention Among Veterans Receiving Community Services.

BACKGROUND: While the US Department of Veterans Affairs has made significant strides to prevent veteran suicide, efforts have largely targeted veterans actively engaged in and eligible for Veterans Health Administration (VHA) care, which is consistent with the VHA mission. The majority of veterans are not enrolled in VHA care, and many are ineligible for services. Veterans not connected to VHA have experienced an increase in suicides in recent years. OBSERVATIONS: Since 2018, VHA National Center for Patient Safety has funded the Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), which has worked to develop, implement, and evaluate practical solutions aimed at curbing the rising suicide rate among veterans not receiving VHA care. PSCI-SPC has 3 guiding objectives: (1) Develop and test a collaborative, organizational structure to connect VHA and community organizations, such as national, local, public, private, nonprofit, and academic partners who provide high-quality and timely health care; (2) Build and test a learning collaborative to facilitate sharing of VHA suicide prevention best practices with community partners to increase availability, consistency, and quality of mental health services for all veterans; and (3) Implement, test, and refine a novel program to provide affordable suicide prevention interventions to veterans with mental health needs, regardless of their use of, or eligibility for, VHA services. This paper details the current progress for this demonstration project. As these objectives are met, PSCI-SPC will create and disseminate products to support broad implementation of these practices to other VA medical centers and the communities they are embedded in. CONCLUSIONS: PSCI-SPC seeks to fill an important gap in veteran health care by serving as a national clinical innovation and dissemination center for best practices in suicide prevention for veterans who receive care in their communities.

Efficacy of pulsed-xenon ultraviolet light on reduction of Mycobacterium fortuitum.

OBJECTIVES: Hospitals and healthcare facilities rely largely on isolation and environmental disinfection to prevent transmission of pathogens. The use of no-touch technology is an accepted practice for environmental decontamination in medical care facilities, but little has been published about the effect of ultraviolet light generated by a portable pulsed-xenon device use on Mycobacteria. We used Mycobacterium fortuitum which is more resistant to ultraviolet radiation and less virulent than Mycobacterium tuberculosis, to determine the effectiveness of portable pulsed-xenon devices on Mycobacterium in a laboratory environment. METHODS: To determine the effectiveness of pulsed-xenon devices, we measured the bactericidal effect of pulsed-xenon devices on Mycobacterium fortuitum. RESULTS: In five separate experiments irradiating an average of 106 organisms, the mean (standard deviation) log-kill at 5 min was 3.98 (0.60), at 10 min was 4.96 (0.42), and at 15 min was 5.64 (0.52). CONCLUSIONS: Our results demonstrate that using pulsed-xenon devices is a highly effective modality to reduce microbial counts with this relatively ultraviolet germicidal irradiation-resistant mycobacterium in a time-dependent manner.

Clade-specific variation in susceptibility of Candida auris to broad-spectrum ultraviolet C light (UV-C).

BACKGROUND: Candida auris is an emerging and often multidrug-resistant fungal pathogen with an exceptional ability to persist on hospital surfaces. These surfaces can act as a potential source of transmission. Therefore, effective disinfection strategies are urgently needed. We investigated the efficacy of ultraviolet C light (UV-C) disinfection for C. auris isolates belonging to 4 different clades. METHODS: In vitro testing of C. auris isolates was conducted using 106 colony-forming units (CFU) spread on 20-mm diameter steel carriers and exposed to a broad-spectrum UV-C light source for 10, 20, and 30 minutes at a 1.5 m (5 feet) distance. Post-UV survivors on the coupons were subsequently plated. Colony counts and log reductions were recorded, calculated, and compared to untreated control carriers. Identification of all isolates were confirmed by MALDI-TOF and morphology was visualized by microscopy. RESULTS: We observed an increased susceptibility of C. auris to UV-C in 8 isolates belonging to clades I, II and IV with increasing UV exposure time. The range of log kill (0.8-1.19) was highest for these isolates at 30 minutes. But relatively no change in log kill (0.04-0.35) with increasing time in isolates belonging to clade III were noted. Interestingly, C. auris isolates susceptible to UV-C were mostly nonaggregating, but the isolates that were more resistant to UV exposure formed aggregates. CONCLUSIONS: Our study suggests variability in susceptibility to UV-C of C. auris isolates belonging to different clades. More studies are needed to assess whether a cumulative impact of prolonged UV-C exposure provides additional benefit.

Effectiveness of Copper-Impregnated Solid Surfaces on Lowering Microbial Bio-Burden Levels in an Acute Care Hospital.

BACKGROUND: Microbial bio-burden on high-touch surfaces in patient rooms may lead to acquisition of health care-associated infections in acute care hospitals. This study examined the effect of a novel copper-impregnated solid material (16%-20% copper oxide in a polymer-based resin) on bacterial contamination on high-touch surfaces in patient rooms in an acute care hospital. METHODS: Five high-touch surfaces were sampled for aerobic bacterial colonies (ABCs) 3 times per day over a 3-day period in 16 rooms with copper installed and 16 rooms with standard noncopper laminate installed on high-touch surfaces. A Bayesian multilevel negative binomial regression model was used to compare ABC plate counts from copper-impregnated surfaces with standard hospital laminate surfaces. RESULTS: The mean and median (interquartile range [IQR]) ABC counts from copper-impregnated surfaces were 25.5 and 11 (4-27), and for standard hospital laminate surfaces they were 60.5 and 29 (10-74.3). The negative binomial regression model-estimated incidence rate for ABC counts on plates taken from copper-impregnated surfaces was 0.40 (0.21-0.70) times the incidence rate of ABC counts on plates taken from standard hospital laminate surfaces. CONCLUSIONS: Copper-impregnated solid surfaces may reduce the level of microbial contamination on high-touch surfaces in patient rooms in the acute care environment, as our study demonstrated a decline in microbial bio-burden on samples taken from copper-impregnated compared with standard hospital laminate high-touch surfaces.

Implementation of the Clinical Nurse Leader Role in the Veterans Health Administration.

The Veterans Health Administration (VHA) led implementation of the Clinical Nurse Leader (CNL) role nationally with the goal to meet system needs for strong clinical leadership across all settings. After a decade of CNL role implementation, the VHA supported this evaluation to determine the current state, the successes, the challenges, and the fidelity to the original intent of the role. The team used mixed methods to evaluate the state of the CNL initiative. Ten evaluation activities were undertaken including a facility survey directed toward chief nurse executives at all VHA facilities, and a second survey directed at registered nurses who completed a CNL graduate program, were certified as a CNL, or were currently enrolled in a CNL graduate program. The evaluation results suggest the CNL initiative had not yet accomplished the stated goals to improve cost and financial outcomes, increase patient satisfaction, increase staff satisfaction and retention, improve quality and internal processes, and facilitate practice model transformation including evidence-based practice and collaborative, interdisciplinary practice across the system. Observed CNL practices within the VHA could serve as exemplars for developing a care delivery model that could achieve these goals and offer potential paths to move this role forward.

A clinical nurse leader competency framework: Concept mapping competencies across policy documents.

To ensure Clinical Nurse Leaders (CNL) are prepared to function to the full scope of their master's level education, the American Association of Colleges of Nursing published a 2007 White Paper and a 2013 update articulating expected end-of-education and CNL practice competencies. The Commission on Nurse Certification published a CNL job analysis in 2016, which identified a core set of knowledge, skills, and abilities for entry-level practicing CNLs, as the basis for the CNL certification exam. While all share core themes, the language and organization of competencies differs across the three policy documents, resulting in potential ambiguity about expected CNL knowledge and practices, and how they differ from other nursing roles. This effort identified, analyzed and synthesized CNL education and practice concepts listed in each document to refine understanding about CNL competencies and harmonize concepts across documents. The product of this effort is a cohesive CNL competency framework that aligns across the education-to-practice trajectory. The CNL competency framework can be used to guide CNL curriculum and certification review, and may have use in implementing and evaluating CNL practice integration.

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.