Examining the Relationship Between Differing Implementation Patterns of an Evidence-Informed Frontline Nursing Care Model and Implementation Success in a National-Level Study.

Introduction: The Clinical Nurse Leader (CNL) care model, which is increasingly being adopted by health systems across the United States and abroad, is a different way of organizing frontline nursing care delivery, in contrast to traditional "staff nurse ratio" models. However, variability in implementation and outcomes has been noted across health settings. Aim: A psychometrically validated CNL care model survey instrument operationalizes a complex implementation pathway that leads to improved care quality outcomes. The purpose of this study was to identify implementation patterns in 66 clinical units across 9 hospitals in 5 states and examine their relation to implementation success. Methods: The survey was administered between 2016 and 2019 to a national sample of administrators/clinicians involved in CNL care model implementation. The survey measures presence of the five domains of the model and implementation success. We analyzed the complex hierarchical structure of the data using a Bayesian framework. Results: 1265 participants responded, and 1223 (97%) provided success and rating scores. The analysis estimated CNL care model elements best discriminating between lower and higher implementation success. Outcome domain survey item scores were most consistently predictive of implementation success. In terms of Readiness and Structuring and CNL Practice, discrete patterns emerged, suggesting efficacious pathways toward improved care environments and care quality. Conclusions: Findings describe specific CNL care model organizational readiness and unit-level workflow implementation patterns that drive CNL practices and the production of expected outcomes, including positive work environments. The research provides actionable implementation and outcome evidence about a different way to organize nursing knowledge and practice into a care model that can be successfully adopted within real-world healthcare settings to achieve improved care environments and higher quality patient care.