Q1 2016 Insights: How Hospitals Can Fill the Gaps Left by CNL Training

Key Takeaways: 
  1. In the rapidly evolving healthcare industry, the clinical nurse leader (CNL) will play a pivotal role in implementing new strategies, coordinating care, and leading change.
  2. Although CNLs are well prepared for managing patient care, research indicates that many lack the soft skills and technology acumen needed to excel in this dynamic environment.
  3. Providers should reassess their training programs and look to best practices outside of the industry to ensure their CNLs are well equipped to tackle the challenges ahead.

As the front line of healthcare, nurses have only grown in importance. The role has become ever more complex in recent years, however: nurses today must have not only the skills to administer care but also an understanding of how their actions contribute to their provider’s efficiency and outcomes. In addition, the advent of a more patient-centric approach means that nurses are increasingly the face of care and a vital element of a provider’s reputation. In recognition of the evolving healthcare landscape and its unique challenges, the American Association of Colleges of Nursing (AACN) developed the clinical nurse leader (CNL) role in 2003, the first new nursing occupation since the nurse practitioner role was defined in the 1960s. The AACN laid out seven essential competencies for CNLs and has developed curriculum guidelines to promote their development.[1]

The CNL role was designed to bring a generalist perspective to particular clinical specialties as well as a specialist lens to process improvement, efficiency, and management. CNLs coordinate care within a discrete unit, integrate technology and innovations in care approaches, and provide care to patients in complex situations. Many providers have committed funding for nurses interested in pursuing additional training and certification to become a CNL. Despite these efforts and the rigor of the AACN curriculum, the sheer range of skills needed to excel in this position has resulted in a skills gap for many CNLs. Indeed, the Strayer@Work Skills Index highlights areas where CNLs typically fall short—particularly in soft management skills and technology. Providers seeking to address this issue should look to other industries and incorporate best practices on professional development in these areas.


Since the introduction of the CNL role in 2003, the healthcare industry has undergone a tectonic shift. Although the industry was behind the curve in integrating technology into its operations, it has been rapidly making up ground. In 2009, the American Recovery and Reinvestment Act (ARRA) authorized $34 billion to drive the adoption of certified electronic medical records (EMRs), leading providers to incorporate an unprecedented degree of digital technology into their operations.[2] Continued technological advancements, such as the growing ubiquity of the tablet, have presented new opportunities for practitioners to go digital. Further, the proliferation of wearable devices and sensors has the potential to alter everything from patient intake to monitoring and treatment regimens.

The underlying care model is also being reassessed. The passage of the Patient Protection and Affordable Care Act of 2010 (Obamacare) has, among other things, placed a greater emphasis on efficiency, costs, and patient outcomes. Payers and providers are experimenting with a range of strategies, such as outcomes-based payment structures, to improve care quality while reducing costs. On the consumer side, patients are exerting more control over their care choices, including gathering more information on providers.

CNLs are at the epicenter of many of these issues: they are tasked with implementing strategies, which have an impact on decision-making processes and the coordination of care. Further, they are responsible for redesigning processes to enable greater efficiency and using technology to support care delivery. In this capacity, CNLs function as lead change agents by communicating new processes and protocols, connecting care delivery to the organization’s high-level goals, and administering training programs for other nurses.


This environment has put a premium on two areas—inter-professional collaboration and technology. CNLs with these capabilities are in short supply at a time when qualified leaders have never been more critical.


The AACN outlines the skills CNLs need to “create an understanding and appreciation among healthcare team members of similarities and differences in role characteristics and contributions of nursing and other team members.” However, a recent study by the State of Rhode Island indicated that healthcare employers overwhelmingly perceive nursing candidates to be lacking soft management skills such as conflict resolution, listening, and teamwork, among others. The study highlighted the lack of emphasis on soft skills in most healthcare curriculums as the source of the problem. The Strayer@Work Skills Index indicates a significant shortfall among the demand for candidates with these soft skills and the supply of qualified talent.



The CNL curriculum includes a focus on the application of information technology, analytics, and evaluation methods to support operational improvements, patient diagnosis and monitoring, and process efficiency. However, the rapid pace of technology changes, initiatives to adopt EMRs, and implementation and management of ICD-10 [5] seem to play a huge role in the skills gap in healthcare. CNLs must become conversant in new technologies and understand how to apply them to support care delivery, but the Skills Index found a shortage of candidates with the required level of expertise in analysis (53 percent) and process improvement (31 percent), two skills for which technology is an integral component.


The industry shortfall in the areas of inter-professional collaboration and technology presents some fundamental challenges for healthcare providers and their employees. Since these skills are also essential elements for organizations outside of healthcare, clinicians who are seeking effective training programs might look to other industries for greater insight. For example, companies across industries still use Toyota’s lean production techniques as a touchstone for process redesign and efficiency improvements. Healthcare executives could take a similar approach by adopting best practices on leadership and management. On technology, providers might seek to mirror tech-savvy companies that have used software tools to gain greater visibility into their operations. To capture the greatest benefit, executives should take a holistic approach to ensure that CNLs have the requisite skills in technology, process redesign, and management.

By addressing these issues, healthcare executives can ensure that their investment in training delivers the expected impact. Getting it right will pay off for nurses at all levels as well as for the patients they serve.

1. Competencies and Curricular Expectations for Clinical Nurse Leader SM Education and Practice, AACN, October 2013.
2. https://healthit.ahrq.gov/key-topics/electronic-medical-record-systems
3. Rhode Island’s Healthcare Workforce: Assessing the skills gap and providing recommendations to meet industry needs, Governor’s Workforce Board Healthcare Industry Partners, 2014.
4. Include url to page on Index and methodology
5. An international classification of diseases developed by the World Health Organization.