The Eight-Stage Process to Creating Major Change:
Clinical Nurse LeaderSM
An Emerging Role for Nursing in the 21st Century
The CNL was developed by the American Association of Colleges of Nursing (AACN) in
response to complexities of health care environments, the need to ensure safety and high
standards at the point of service, as well as to meet diverse client and health care environment
needs. The CNL is prepared as a master's prepared generalist accountable for clinical and health
care environment outcomes. The Clinical Nurse Leader (CNL) is a leader across all settings at
the microsystem level (patient unit, community zip code area, school setting, nursing home
specific area, etc). The CNL oversees care coordination of a distinct group of patients, is a
resource for clinical decision making and serves as a lateral integrator of care. This clinical
leader puts evidence-based practice into action to ensure that patients benefit from the latest
innovations in care delivery. The CNL collects and evaluates patient outcomes, assesses cohort
risk, and has the decision-making authority to change care plans when necessary. This clinician
functions as part of an interdisciplinary team by communicating, planning, and implementing
care directly with other health care professionals, including physicians, pharmacists, social
workers, therapists, clinical nurse specialists, and nurse practitioners. The CNL is a leader in the
health care delivery system across all settings in which health care is delivered, not just the acute
care setting. Implementation of this role will vary across settings.
Competencies and clinical learning experiences for CNL students are specified for each of the
following CNL role components: client advocate, member of a profession, team manager,
information manager, systems analyst/risk anticipator, clinician, outcomes manager, educator,
and life long learner. The CNL designs and directs care within a microsystem ensuring best
practices are brought to the point of service and patients/clients receive timely cost efficient care.
Lateral integration of services is key. The CNL is accountable for clinical and care environment
outcomes as well as influencing work environments so as to increase nurse retention. The
framework for the curriculum for the CNL includes the domains of leadership, clinical outcomes
management, and care environment management. The curriculum guide can be accessed here. The CNL role is fully
described in AACN's determination on the role of the Clinical Nurse Leader (2004).
Incorporating the CNL requires a transformation in practice. Specifics of the process of this
transformation may be unique to each institution. Resistance is inherent in any major change so
patience and perseverance are key leadership attributes in implementing this new role. Kotter
(1996) suggests that the first four steps in the transformation process help defrost a hardened
status quo. Phases five to seven introduce new practices. The last stage grounds the changes;
makes them "stick."
Stage I. Establishing a Sense of Urgency
Stage II. Creating the Guiding Coalition
Stage III. Developing a Vision and Strategy
Stage IV. Communicating the Change Vision
Stage V. Empowering Board-Based Action
Stage VI. Generating Short-Term Wins
Stage VII. Consolidating Gains and Producing More Change
Stage VIII. Anchoring New Approaches in the Culture