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Clinical Nurse Leader Portfolio Zane J. Muthamia N266, Healthcare Systems/Organizations University of California, Los Angeles

!"#$#!%"&$'()*&"*%+*(&,-(./-"#-& & I. Zanes Elevator Speech: The iconic image of the nurse as a female taskmaster, an expert only in following directions from her male doctor boss, emptying bedpans, and performing blood pressure readings is taking its place alongside tape decks and the Soviet Union as

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very last century. The American Association of the Colleges of Nursing (AACN) is at the forefront of working together with leaders from the practice environment to set forth new education standards for nurses working in various domains. The Clinical Nurse Leader (CNL) role is one that emerged organically in the practice setting what is truly new is the naming of it, and the setting out of a formalized educational path to become a CNL. Delimiting the functions of the CNL is somewhat complex, because CNLs by definition must be flexible and the role is adaptable to a multitude of care settings; however, a few core characteristics most likely will hold across the board: CNLs are quality-oriented, focused both on delivering the best patientcentered care and improving resource use within the health care organization (e.g., funding, manpower, technology); CNLs heavily utilize critical thinking skills and rely on evidence-based practice in decision-making; finally, CNLs are to oversee the lateral integration of care for a distinct group of patients--- fancy, I think, for saying that the CNL will see to it that no patient of hers is lost in the shuffle of the process of obtaining the best patient-centered care. CNLs are the trouble-shooters of their unitnot managers or administrators formally, but utilizing leadership, team-building and organizational skills to unify the multi-faceted care-provider team and streamlining health care services delivery. The role is being implemented steadily by more organizations since its formal introduction by the AACN in 2007, markedly more so by health care organizations in the South and Eastern United States and most notably, nationally, by the largest heath care organization in the nation, the United States Veterans Affairs (VA, for short). Thirty-seven states offer masters CNL programs, which focus on producing advanced clinicians with formal training in fourteen competencies that will give them the tools and knowledge base to bring any organization (lucky enough to have them) up a notch in improving health care outcomes. (AACN, 2007).

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Zanes Nursing Philosophy: My personal philosophy of nursing is taking on its shape as a result of ideas that stem from three distinct sources or perspectives: my experiences as an uninsured, first generation American youth from a disadvantaged family; the current informational flood and intellectual refocusing that I am enjoying in the MECN program as an about-face career-changer; and as a recently insured, comparatively affluent wife/graduate student with some of the best health insurance coverage around. Without going into detail here, suffice it to say that for most of my life, I have been living with very skewed and misinformed ideas about what providing and receiving good healthcare consists of, as well as what the true cost of unhealthy lifestyle choices is. From only three short quarters of nursing school, my nursing philosophy is wholly centered on educating and empowering individuals and families to truly become partners in shaping their health-related destiny. A nursing intervention accompanied by minimal time and effort on patient education is of about as much use for the long term as giving a homeless person a few dollars: it very well might provide some instant relief of the problem, but does nothing to facilitate life-altering change. This is closely related to my commitment to being a thorough patient-advocate that really listens to what the patient wants to accomplish and what sort of health outcomes they value.

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Critical Thinking: Critical thinking underlies independent and interdependent decisionmaking. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and

N465A, Foundational Concepts for Tertiary Prevention and Care of Medical-Surgical Patients and Families. Using SBAR; writing nursing care plans as a CNL; NCLEX style exam questions. A particularly condensed (and very effective) day of learning was spent at Charles Drew

!"#$#!%"&$'()*&"*%+*(&,-(./-"#-& & creativity. Critical thinking includes the ability to use evidence gathered through personal experiences and through the research of others in evaluating and designing models and plans of care.

>& University in the simulation lab. Teams of roughly eight students participated in role-play exercises that required both quick and critical thinking. N250A, Ethical Issues, Social Justice, and History of Nursing. A structural element of the course was collaboration and teamwork, and self-reflection on ones own team working skills was inevitable and very useful. We learned to address complex social justice and ethical issues from a multitude of theoretical perspectives. N250A, Ethical Issues, Social Justice, and History of Nursing. Numerous collaborative projects enhanced communication skills through role-play, writing a CNL issue brief, and PowerPoint presentations. N260, Secondary Prevention. A critical component of the course includes two clinical case reports in which we utilize the Unites States Preventive Services Task Force (USPSTF) iPad application to conduct recommended secondary prevention screenings. The collaborative evidencebased screening video case presentation requires teamwork, working with technology and clearly communicating the goals and challenges facing a specific preventive screening process to the viewer.

Communication: Communication is a complex, ongoing, interactive process and forms the basis for building interpersonal relationships. Communication includes critical listening, critical reading, and quantitative literacy, as well as oral, nonverbal, and written communication skills. Communication requires the effective use of a wide range of media, including not only face-to-face interactions, but also rapidly evolving technological modalities. Further, communication includes effectiveness in-group interactions, particularly in taskoriented, convergent, and divergent group situations. Communication requires the acquisition of skills necessary to interact and collaborate with other members of the interdisciplinary health care team as well as to develop a therapeutic alliance with the client. Assessment: Assessment skills form the foundation of evidence-based practice. Assessment includes gathering information about the health status of the client, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings, evaluating and managing individual care outcomes. Assessment also includes understanding the family, community, or population and using data from organizations and systems in planning and delivering care. The analysis of systems and outcomes datasets to anticipate individual client risk and improve quality of care delivery is another critical form of assessment.

All N465 series courses and corresponding clinical internships, which provide the ground floor of our clinical foundation for medical surgical nursing with 465B focusing oh the gerontological population. Future courses (and corresponding clinical internships): N461, Mental Health, N462, Maternity, N.464, Pediatrics. N269, Quality Improvement and PopulationBased Quality of Service: this course will hone how to assess and improve the quality of care at the population level.

!"#$#!%"&$'()*&"*%+*(&,-(./-"#-& & Nursing Technology and Resource Management: Acquisition and use of client care technology and nursing procedures are required for the delivery of nursing care. While the CNL must understand the principles related to and be adept at performing skills, major roles will include teaching, delegating, and supervising the performance of skilled tasks by others and behaviors of others. Consequently, graduates must approach their understanding and use of skills in a sophisticated theoretical and analytic manner. The application of nursing science and client care technology is necessary to perform nursing procedures. The acquisition of new skills is an ongoing component of health care and nursing care delivery and will depend on the practice setting, specialty area of practice, and the development of new knowledge and technologies. Health Promotion, Risk Reduction, and Disease Prevention: The CNL must have a strong theoretical foundation in health promotion, illness prevention and maintenance of the clients (individual, family, group or community) function in health and illness. Health promotion and disease prevention is an integral part of nursing practice. Illness and Disease Management: Illness and disease management requires knowledge about pharmacology, pathophysiology of disease, and assessment and management of symptoms across the lifespan with particular emphasis on the chronicity and sequelae of illness. Also, knowledge about the social, physical, psychological, and spiritual responses of the individual and family or caregiver to disease and illness is required. The goal is to maximize the quality of life and maintain optimal level of functioning throughout the course of illness, including end of life. The CNL uses case management skills and principles to provide and supervise continuous care within specific episodes and across episodes of illness and disease. Information and Health Care Technologies: Information technology includes traditional and

?& All N465 series courses and corresponding clinical internships, which provide the ground floor of our clinical foundation for medical surgical nursing with 465B focusing oh the gerontological population. Future courses (and corresponding clinical internships): N461, Mental Health, N462, Maternity, N.464, Pediatrics. We gain hands-on experience with hospital and health network-wide informatics systems and resources, including patient/caregiver teaching materials. N204, Research Design and Critique. Although perhaps not an overt objective of the course, students learn to navigate the wide world of nursing and medical journalsmaking the search for the latest on evidence-based practice and the newest technologies more approachable.

N260, Secondary Prevention: this course focuses on identifying both modifiable and non-modifiable risk factors an individual may have and the screening tools that are recommended by the USPSTF.

N225 A&B, Advanced Pharmacology; N230 A&B, Advanced Pathophysiology; the N465 series and corresponding clinical internships; N461, Mental Health, N462, Maternity, N.464, Pediatrics and clinical internships. Pathophysiology and pharmacology courses provide us with the foundation for recognizing, naming and treating disease; the 465 series , N461, N462 and N463 give us the opportunity to put what weve learned into practice. Future course N465D, Human Responses to Critical Illness, will emphasize the unique aspects of nursing at the end of life.

N204, Research Design and Critique. Although perhaps not an overt objective of the course,

!"#$#!%"&$'()*&"*%+*(&,-(./-"#-& & developing methods of discovering, retrieving, and using information in nursing practice. Knowledge of and effective use of information technology is necessary for evidence-based practice and for effective, appropriate health teaching. The use of technology is critical for the documentation and evaluation of client care outcomes.

@& students learn to navigate the wide world of nursing and medical journalsmaking the search for the latest on evidence-based practice and the newest technologies more approachable. N260, Secondary Prevention. A critical component of the course includes two clinical case reports in which we utilize the Unites States Preventive Services Task Force (USPSTF) iPad application to conduct recommended secondary prevention screenings. All N465 series courses and corresponding clinical internships, which provide the ground floor of our clinical foundation for medical surgical nursing with 465B focusing oh the gerontological population. Future courses (and corresponding clinical internships): N461, Mental Health, N462, Maternity, N.464, Pediatrics. We gain hands-on experience with hospital and health network-wide informatics systems and resources, including patient/caregiver teaching materials N250, Ethical Issues, Social Justice, and History of Nursing. This incredible course brought to light the multitude of social justice and ethical issues that surround nursing practice on every scale, from private the sphere of one-on-one, practitionerpatient relations to the global arena.

Ethics: Ethics includes values, codes, and principles that govern decisions in nursing practice, conduct, and relationships. Skill and knowledge in resolving conflicts related to role obligations and personal beliefs are necessary. The CNL is able to identify potential and actual ethical issues arising from practice and help clients and other health care providers address such issues; therefore, knowledge of ethics and ethical decision-making is critical. The CNL serves as a client advocate within the health care delivery and policy systems. In addition, the CNL interfaces between the client and the health care delivery system to protect the rights of clients and to effect quality outcomes Human Diversity: Human diversity includes understanding the ways cultural, ethnic, socioeconomic, linguistic, religious, and lifestyle variations are expressed. The CNL is able to apply knowledge of the effects these variations have on health status and response to health care. The CNL is well prepared to care for the aging population and to help all individuals and families make decisions about life-extending technologies and treatments within the context of their values, as well as physical, emotional, and spiritual health

N250, Ethical Issues, Social Justice, and History of NursingSix slides in seven minutes was a collaborative assignment that focused on addressing the needs of a special needs population that I think it is fair to say that each and every class in the MECN program has hit upon this subject area at one time or anothereven pathophysiology, because Dr. BBJ shared stories about her experiences doing emergency relief in Haiti after the earthquake of 2010. Our class itself is very diverse, with every continent represented in the student body. I myself am multi-

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A& lingual and a dual citizen (U.S and E.U.). I speak fluent English and Latvian and conversational Spanish and Italian. I am proud to say that the MECN program addresses diversity every day. N250, Ethical Issues, Social Justice, and History of Nursing. This course draws attention to the disparities in access to healthcare around the world and avenues for improvement. Global Action in Nursing (GAIN) student organization: the club hosts numerous lectures each quarter that feature guest speakers that are heavily involved in global healthcare.

Global Health Care: Global health care knowledge includes an understanding of the implications of living with transportation and information technology that link all parts of the world. Information about the effects of the global community on such areas as disease transmission, health policy, and health care economics is required. Global health care also includes an understanding of and ability to share information with health care providers across disciplines, cultures, and geographic boundaries. Health Care Systems and Policy: Knowledge of health care systems includes an understanding of the organization and environment in which nursing and health care is provided. Health care policy shapes health care systems and helps determine accessibility, accountability, and affordability. The CNL has an understanding of the economies of care, a beginning understanding of business principles, and an understanding of how to work within and affect change in systems.

N266, Healthcare Systems/Organizations. As future CNLs, we are learning about the very complex world of our immense health care system and the imminent transformation that awaits it with the coming of the Affordable Care Act. We are building a knowledge base about US health care systems and policy that will enable us to best serve our patients and help us improve policy wherever we will work. Read the AACN white paper on the CNL role. N250, Ethical Issues, Social Justice, and History of Nursing. CNL brief assignment. Future course, N267, Healthcare Policy will stress how policy impacts clinical practice and healthcare delivery. Future course: N467, Clinical Internship: Integration. I believe that our immersion quarter will give us the biggest opportunity to develop these skills. We will work as a part of a multidimensional team and assess, diagnose, plan, implement, and evaluate plans of care. I see this competency as one we will get to practice very much in our immersion. In my personal life, I am also becoming increasingly involved in designing and coordinating my mothers care, who is transitioning into the final stages of Alzheimers Disease. This is a competency in which I will grow throughout my career.

Provider and Manager of Care: The CNL uses theory and research-based knowledge in the design, coordination, and evaluation of the delivery of client care. The CNL is a leader in the interdisciplinary health care team in the planning, delivery, and evaluation of clientfocused care. Designer/Manager/Coordinator of Care: The CNL takes primary responsibility for the design, coordination, and management of health care across the lifespan and in all types of health care settings. The CNL provides and coordinates comprehensive care for clients: individuals, families, groups, and communities,

!"#$#!%"&$'()*&"*%+*(&,-(./-"#-& & in multiple and varied settings. Using information from numerous sources, the CNL guides the client through the health care system. Skills essential to this role development are communication, collaboration, negotiation, delegation, coordination, and evaluation of interdisciplinary work, and the application, design and evaluation of outcome-based practice models. Member of a Profession: The CNL has an understanding of the role and responsibilities of a professional and leader in the health care delivery system, as well as knowledge and experiences that encourage the embracing of lifelong learning, the incorporation of professionalism into practice, and identification with the values of the profession. The CNL is responsible for the professional presentation of self. In addition, a critical component of the CNL role is the development and mentoring of the next generation of professionals.

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GSNA Community Outreach MECN I Representative and Outreach Chair; GAIN member; AACN member; Institute for Health Care Improvement Certifications: Introduction to Patient Safety and Fundamentals of Patient Safety. Expected RN licensure 2014; expected CNL and Public Health Nurse certification Fall, 2014. LACUSC Emergency Medical Services Department Volunteer 2010. Independent Action: collaborated with two other classmates to initiate dialogue between the Assistant Deans of UCLA-SON and our cohort to address mounting concerns regarding work overload during Winter 2013 quarter. Our intervention culminated with positive results that benefitted the cohort (and taking action felt great).

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American Association of Colleges of Nursing (AACN). (2007). White paper on the education and role of the clinical nurse leader, 23. Retrieved from www.aacn.nche.edu

Begun, J.W., Tornabeni J., White K.R. (2006). Opportunities for improving patient care through lateral integration: the clinical nurse leader. Journal of Healthcare Management, 51 (1), 19-25. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16479747

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