Earning a master's degree is a great way to advance your nursing career. With several concentrations to choose from, it's important to find a program that supports your interests. If you want to remain connected to patient care, you enjoy teamwork and collaboration, and you love the variety that comes with working across specialties, the MSN clinical nurse leader degree is right for you.
By furthering your education as a clinical nurse leader (CNL), you'll approach patient care from a big-picture perspective. You'll embark on a leadership career to support frontline nurses and streamline care delivery. Exploring an MSN – CNL degree is the first step, and there's lots to consider as you weigh your options. Follow the links below if you're curious about your future role as a clinical nurse leader, you want to learn more about job prospects, or you want to explore what it's like to study online.
What Does a Clinical Nurse Leader Do?
Clinical nurse leaders are advanced generalists and care coordinators. Because CNLs directly impact patient outcomes in multiple healthcare settings, they must stay current when it comes to medical innovation and best practices for care. That means CNLs are lifelong learners. They rely on evidence-based practice, monitor patient outcomes and adjust as needed. By taking a big-picture approach, clinical nurse leaders create and implement care plans across both patient cohorts and interprofessional teams.
From transitions of care to risk assessment and quality improvement, CNLs operate as leaders at the point of care. They work closely with healthcare professionals while also serving as advocates for patients and their families. CNLs routinely collaborate with pharmacists and physicians, nurses, clinical nurse specialists, social workers and nurse practitioners. Ultimately, CNLs are "stop-gap" professionals. They reduce fragmentation of care in an increasingly complex healthcare system.
Are CNLs the Same As Nurse Practitioners?
Clinical nurse leaders and nurse practitioners are both master's-prepared RNs, but they attend different degree programs, take part in uniquely tailored clinical rotations, and pass different certification exams. In fact, CNLs set themselves apart from all four advanced practice nurses (APRNs). Nurse practitioners, clinical nurse specialists, certified nurse anesthetists and certified nurse midwives are all trained for a specific practice area. APRNs may have more autonomy in their practice, but they're also confined to a given specialty. Clinical nurse leaders, on the other hand, are advanced generalists. CNLs work collaboratively and serve as team leaders, and their clinical practice is exceedingly flexible.
What's the Difference between a Clinical Nurse Leader and Clinical Nurse Manager?
You might assume that CNLs and clinical nurse managers have similar duties, but there are several key differences. CNLs are MSN-prepared nurses, while nurse managers are typically BSN-prepared. Clinical nurse leaders are focused on patient care integration and interprofessional collaboration. Nurse managers, however, are tasked with balancing clinical, administrative and operational functions. CNLs work across units and patient cohorts, while nurse managers are assigned to a specific unit or group of units. These distinctions, between both educational attainment and day-to-day responsibilities, lead to vastly different incomes. According to ZipRecruiter (May 2019), the average annual salary for CNLs is $106,821. The average salary for nurse managers is $79,699.
How Do I Become a Clinical Nurse Leader?
If you're already a BSN-prepared nurse with one to two years of clinical experience, you meet the basic admission requirements for an MSN degree. All clinical nurse leaders are MSN-prepared and educated through an eligible CNL program, such as the University of Louisiana Monroe's online MSN with clinical nurse leader concentration. Eligible CNL programs must be approved by the American Association of Colleges of Nursing (AACN). Curriculum and rotation guidelines set by the AACN ensure that all approved programs provide you with the necessary skills and knowledge to pass your CNL certification exam and embark on a successful career as an advanced generalist.
What Is Clinical Nurse Leader Certification?
CNL certification, like your nursing license, is issued after you pass the certification exam and successfully complete your educational program. CNLs-in-training may apply for examination as soon as they enter the final semester of their approved CNL program.
Exams and certification are administered by the Commission on Nurse Certification (CNC), an autonomous arm of the AACN. The computer-based, multiple-choice CNL exam is designed to confirm core competencies in nursing leadership, clinical outcomes management and care environment management. When the time comes, there are several resources to help you prepare, including a test outline and practice test. Additional resources, including an exam review course and sample questions, are also available.
Spotlight on Medical Error: The Call for a New Role in Nursing
Between 2003 and 2004, the AACN formally called for the creation of the CNL role, filling a sizeable gap in healthcare. The CNL is the first nursing position developed in almost 40 years, following the introduction of nurse practitioners in 1965. Clinical nurse leaders, the AACN reasoned, are needed to address the increasing complexity of healthcare and healthcare delivery systems.
The AACN's recommendation was largely a response to the 1999 Institute of Medicine (IOM) report "To Err is Human: Building a Safer Health System." The report, which examines preventable medical errors from a systemic perspective, cited fragmented care delivery as a significant weak point. The IOM (now known as the National Academy of Medicine) explained that patients in hospitals are seen by multiple specialists and nurses each day. Under these circumstances, the lack of a coordinating force increases the likelihood of medical error. A 2016 study issued by Johns Hopkins University reveals that medical error is the third-leading cause of death in the United States. The CNL, then, is an essential role. By facilitating direct and cohesive care, clinical nurse leaders don't just improve patient outcomes — they save lives.
Learn more about our MSN CNL online program
What Will I Learn in an MSN – CNL Degree Program?
Whether you choose to study online or on campus, you'll learn everything you need to apply clinical management strategies and oversee the integration of care across your unit or patient cohort. As a CNL-in-training, you'll implement evidence-based practice to ensure that all patients are receiving the best possible care. You'll become familiar with regulatory issues, global health issues, and the specific needs of vulnerable populations. CNL studies additionally include advanced physical assessment, advanced pharmacology and advanced pathophysiology.
As part of their degree plan, CNLs-in-training complete a minimum of 400 clinical practice hours, 300 of which consist of an immersive experience to allow for full implementation of CNL competencies. Through your practice experiences, you'll become adept at risk management, ethical decision-making, strategic planning, economic management, organizational efficiency and quality improvement. In other words, you'll become an expert in point-of-care leadership.
Students are able to identify and apply course concepts and objectives as evidenced by discussions, presentations and … paper submissions.
What Courses Will I Take for My MSN – CNL Degree?
No matter which school you choose, courses for your MSN – CNL cover leadership, evidence-based practice, pharmacology, pathophysiology, health assessment, healthcare policy and ethics, among other offerings. CNL programs tend to fall between 35 and 45 credit hours, and many include practicums within this framework. With course-based practicums, you can take part in clinical hours while also earning course credit.
The online clinical nurse leader program at ULM consists of 15 courses totaling 38 credit hours. Five courses include clinical practicum hours. Research II (below) also includes a research practicum:
- Advanced Nursing Theory
- Advanced Pathophysiology
- Health Policy & Global Health
- Advanced Physical Assessment
- Biology of Aging
- Advanced Pharmacology
- Research I: Evidence-Based Practice
- Personnel and Organizational Management*
- Personnel and Organizational Management II*
- Quality Improvement & Patient Safety*
- Health Care Law and Ethical Decision Making
- Research II: Utilizing Research in Practice
- Economics & Finance*
- Economics & Finance II*
- Social Gerontology
*Includes clinical practicum hours.
Are Online Courses As Rigorous As On-campus Courses?
Online or on campus, accredited and AACN-approved CNL programs prepare you for a successful career as a clinical nurse leader. In an article about online education myths, U.S. News & World Report found that studying online is just as challenging as on campus. In some cases, the online format may be a more effective educational delivery method for students and instructors alike. Forbes cited a U.S. Department of Education study to explain that there's no significant difference in quality between online and traditional classroom education. Ultimately, the main difference comes down to flexibility and convenience.
Are Online MSN Programs Accredited?
Reputable MSN programs are endorsed through both university accreditation and program accreditation. That's the case regardless of format (online or on campus). Nursing programs hold accreditation from the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission for Education in Nursing (ACEN), and both are equally respected. Universities with regional accreditation, however, enjoy a better reputation than those with national accreditation. In addition to these credentials, any MSN with a clinical nurse leader concentration must be approved by the AACN.
The University of Louisiana Monroe's online MSN – CNL is an AACN-approved program with CCNE accreditation. ULM is regionally accredited by the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC).
What Are the Admission Requirements for an MSN – CNL?
When it comes to a Master of Science in Nursing with Clinical Nurse Leader concentration, an active and unencumbered RN license, one to two years of RN experience, a BSN and a minimum grade point average (GPA) are all basic requirements set by admissions boards. Some programs may require letters of recommendation, a nursing philosophy statement and/or GRE scores. Short for Graduate Record Examinations, the GRE is a standardized test much like the SAT or ACT. All three tests help assess the likelihood of academic success, but where the SAT and ACT apply to undergraduate students, the GRE applies to graduate students.
At ULM, applicants for their master's in nursing with a clinical nurse leader concentration are considered holistically. While you must be a legal resident of Louisiana, Texas or California to enroll, graduates may practice in any state. In addition to your RN license and BSN, you'll need at least two years of clinical nursing experience. If you have a cumulative GPA between 2.2 and 2.7, you'll need to take the GRE. If your GPA is 2.8 or higher, the GRE requirement is waived.
Are There Clinical Rotations for an Online MSN – CNL Degree?
All CNLs-in-training must complete at least 400 clinical hours, with 300 of those earmarked for immersive CNL experience. With immersive hours, you'll practice competencies for your future role as a certified clinical nurse leader. Recommended practice experiences range from evidence-based quality improvement projects to patient cohort assessments. Practice modules aside, it's important to confirm clinical hour guidelines with your chosen university. That's because clinical nurse leader programs often require more than the AACN minimum. Some CNL programs call for as many 660 clinical hours.
CNL students enrolled at ULM complete 413 clinical hours on their path to graduation.
How Do Online MSN Students Complete Their Clinicals?
Protocols vary from university to university, but many online students select a clinical site convenient to their home or place of work. (Some sites require a clinical affiliation agreement with your university, so be sure to check before deciding on a location.) After choosing a site, CNLs-in-training also select a preceptor who is a healthcare professional with an MSN-level education or higher. Sites and preceptors are then approved by faculty members or academic advisors. Once the approval process is complete, online students document their clinical practice experience. Preceptors simply sign and verify student documentation.
ULM adheres to the process noted above. Faculty members work with each student to ensure site and preceptor approval.
Will My School Help Me Find a Preceptor?
Many MSN students are able to find their own preceptors through their healthcare network. However, sometimes students do need help. The level of assistance in this area will vary by school and program. If a ULM MSN CNL online student is unable to find their own preceptor, ULM can help. Don't let the concern of finding an approved preceptor hold you back – assistance is available.
Am I Allowed to Complete My CNL Clinicals at Work?
CNLs-in-training get the most out of their learning experience by working with an unfamiliar patient cohort in an unfamiliar clinical environment. That's why some universities don't allow you to complete clinical hours at your place of work. Others allow it with a few important restrictions. No matter which option is available, CNLs-in-training aren't compensated for clinical hours.
The MSN – CNL program at the University of Louisiana Monroe does allow for employer-based clinicals, but practice hours must take place outside of your assigned floor or unit. Completing hours away from your unit ensures educational integrity. It also sets a clear boundary between your regular duties and your practice experience.
What Can I Do With My MSN – CNL?
The MSN – CNL is specifically designed for clinical nurse leader certification, and most graduates go on to work as clinical nurse leaders. However, there is also flexibility with the degree. Based on their March 2019 professional assessment, the CNC reported that clinical nurse leaders work in multiple sectors of healthcare:
- Acute Care Inpatient: 61.33%
- Other (including Addiction Recovery, Oncology, Orthopedics, Research, Behavioral Health, Informatics, Infection Control, etc.): 11.66%
- School of Nursing/University Health: 11.21%
- Outpatient Clinic or Surgery: 7.86%
- Nursing Home/Long-term Care/Sub-acute Care: 2.6%
- Community/Public Health: 1.67%
- Home Health: 1.2%
- Physician Practice: 1.12%
- Hospice: 0.85%
- Nurse-managed Practice: 0.47%
CNLs are able to switch units and patient cohorts throughout their career, even if they don't change industry sectors. That's one of the major benefits of an advanced generalist degree. You're not committed to a single discipline. Perhaps that's why career retention for CNLs is so high. The CNC reports that of the 7,156 nurses who've earned their CNL certification since it became available in 2006, 83.72% remain active clinical nurse leaders. While some of the remaining 16.28% may have switched careers, some have also retired. Some may have gone on to earn a doctorate, allowing their license to lapse after transitioning into research or college-level instruction.
Learn more about our MSN CNL online program
How Much Do Clinical Nurse Leaders Make?
Income for clinical nurse leaders is much higher than it is for BSN-prepared nurses. According to ZipRecruiter (May 2019), the average annual salary for CNLs is $106,801 The average salary for BSN RNs is $81,832. Average income, however, varies by state. That's mostly due to fluctuations in the cost of living, not to mention supply and demand within local labor markets. To get a better idea of how CNL and BSN RN salaries stack up by state, check out the chart below.
|State||Average CNL Salary||Average BSN RN Salary|
What's the Career Outlook for Clinical Nurse Leaders?
The career outlook for CNLs is bright, and that's due to a number of factors:
- As healthcare increases in complexity, the need for CNLs increases as well.
- The CNL is a relatively new profession, which leaves room for growth.
- Outlooks for the entire healthcare industry are positive, and CNLs benefit as a result.
According to the U.S. Bureau of Labor Statistics (BLS), employment of all healthcare occupations is set to expand at a rate of 18% between 2016 and 2026, adding an estimated 2.4 million jobs over the same period. Much of this growth comes from an aging population's increasing healthcare needs. Clinical nurse leaders stand to benefit from the increasing complexity of care delivery systems as well. Drilling down within healthcare, the BLS expects the medical and health services managers job category will grow 20% between 2016 and 2026, adding 72,100 jobs. This bodes well for clinical nurse leaders who fall in the same category.
Clinical nurse leaders in the South, including Louisiana and Texas, are particularly well-positioned to benefit from sector growth. The regional distribution of CNL certifications often reflects local industry demand, and the South tops the list with 2,305 certified clinical nurse leaders. While the Midwest is home to 1,927 certified CNLs, the West is a close third at 1,856.
CNLs by Region
Number of nurses who earned the CNL between 2006 and March 2019. Data provided by the Commission on Nurse Certification.
The Veterans Health Administration (VHA), is another key driver when it comes to positive career outlooks for CNLs. In 2011, the VHA's Office of Nursing Affairs announced its CNL Nurse Leader Spread Plan Initiative. This initiative was created to bring clinical nurse leaders to all points of care in the VHA system With 170 medical centers and 1,063 outpatient locations across the country, that's a significant goal. In fact, the VHA is America's largest nursing employer, and they're leading the charge in CNL implementation. That's because clinical nurse leaders play an important role in improved patient outcomes.
Spotlight on Patient Outcomes
CNLs first entered the workforce in 2006 and 2007. Studies on their impact have been conducted ever since. A pilot CNL project conducted by the Veterans Affairs Tennessee Valley Healthcare System tracked patient outcomes by hospital unit, with notably positive results. In acute medical unit, the readmission rate for patients with a primary diagnosis of heart failure fell by 2.4%. RN time spent per patient per day increased by nearly 11% as well. In the intensive care unit, length of stay for heart failure patients was reduced by 27%. The acute surgical unit also saw positive results. Patient falls dropped by 50%, and post-surgical infection rates plummeted by 38%.
While research is still in its early phases, several hospital-led assessments indicate that CNLs improve patient outcomes, patient satisfaction and staff satisfaction. The Online Journal of Issues in Nursing cites multiple studies in support of this claim. A year after introducing the CNL role, one hospital reported a 67% reduction in the fall with injury rate, zero instances of sustained pressure ulcers, a decrease in staff turnover and an increase in patient satisfaction. Another hospital's 6-month pilot study revealed that the implementation of the CNL role improved satisfaction rates for nurses, physicians and patients. The same hospital also reported a 38% drop in the use of patient restraints and a 9% decrease in length of hospital stay. Other positive outcomes included a drop in the use of temporary staff, fewer falls, and a reduced incidence of failure to rescue.
Collectively, multiple CNL-impact studies have shown massive decreases in hospital acquired infections, as well as improvements in discharge instructions, more efficient utilization of operating rooms, and drops in surgical cancellation. By working with clinical staff, providing support and assessment, making referrals, and completing rounds with interdisciplinary teams, CNLs play a key role in reducing hospital costs. For instance, a 2013 Journal of Nursing Management article correlates the utility of the CNL skill set in a community hospital with a four-year savings of $1,000,000 on long-term ventilation rounds.
Will Employers Care If I Earned My MSN – CNL Online?
According to U.S. News & World Report, employers are most concerned about whether your degree program is properly accredited and administered by a reputable university. Some may even value your online degree because it speaks to your time management skills. About one in six students study entirely online, and many employers are accustomed to hiring online graduates as a result. While online students are increasingly common, there's no discernable difference between an online MSN – CNL diploma and an on-campus degree. In fact, many employers won't know you studied online unless they become familiar with your program. These considerations aside, your clinical hours mostly take place in a healthcare setting, so you'll have plenty of real-world experience by the time you begin your job search.
What's the Tuition for an MSN – CNL?
Several factors determine your out-of-pocket expenses, and tuition varies widely across programs. Public universities, for instance, are state-funded, so they often cost less than private institutions. Online degrees also tend to cost less than on-campus degrees. That's because they don't come with facility usage and other overhead costs. These guidelines, however, aren't set in stone, and expenses aren't necessarily straightforward. Some universities add exorbitant fees. Others don't. On top of all that, some CNL degree programs consist of as few as 33 credit hours. Others consist of as many as 49. These fluctuations will impact your expenses.
The table below compares pricing structures for CNL programs in Louisiana, Texas and California:
|School||Price Per Credit Hour||Type of Institution||Online||On-Campus||Fees||Program Credit Hours|
|Texas Christian University (TCU)||$1,630 to $1,710||Private||100%||0%||Not included in price||33|
|Western University (California)||$921 to $1,138||Private||95%||5%||Not included in price||49|
|LSU New Orleans||$398||Public||0%||100%||Not included in price||37|
|University of Louisiana Monroe||$365.79||Public||100%||0%||Included in price||38|
*Prices taken from university websites
Are Online Students Eligible for Financial Aid?
You're eligible for federal financial aid as long as your program is accredited and you're enrolled for six-credit hours each semester. That's the case whether you study online or not. You can check out additional federal aid eligibility requirements and fill out the Free Application for Federal Student Aid (FAFSA) online.
Once you've completed your FAFSA, it's a good idea to explore grants and scholarships. Unlike federal loans, you don't have to pay them back. There are several scholarships meant just for nurses, and the AACN also features a tailored scholarship and financial aid guide. The AACN guide even includes nursing loan forgiveness programs, which typically pay down some of your student debt when you agree to work in a high-need area.
Another funding option may come from your employer, as many hospitals offer tuition reimbursement for nurses. Like loan forgiveness, this benefit often comes with a service agreement, and employers may ask you to commit to your workplace for a set period of time in exchange for reimbursement.
What If I Have Outstanding Federal Loans?
As long as your current debt remains under a set limit, you're eligible for additional federal loans. Your existing loans, however, must be in good standing. If they're not, you'll need to resolve your default status first. Assuming you're good to go, the next thing you'll want to do is look into loan deferment. This allows you to suspend payments on your existing federal loans. Make sure you're enrolled for at least six credit hours each semester to maintain your deferment.
Can I Apply My Military Education Benefits to an Online Degree?
Yes. You can apply your military education benefits as long as your program is approved by the U.S. Department of Veterans Affairs. Accredited universities are typically eligible, and you can always confirm approval status through the VA's website.
The University of Louisiana Monroe is dedicated in its efforts to support military and veteran students. You can apply for benefits through ULM's Office of Veterans Affairs, or you can speak to an enrollment specialist at 1-800-917-3236.
How Long Will It Take to Earn My MSN – CNL Online?
That depends on how many courses you take each semester. Some online degree plans include accelerated course schedules, which split semesters in half. Even if you're only taking one class at a time in an accelerated program, you'll still complete two courses over a single semester. Clinical hours are another factor in your timeline to graduation, so it's important to select a location and preceptor that fit your busy schedule.
Many CNL programs take a minimum of two years to complete, but ULM students can graduate in as few as 20 months thanks to the school's accelerated course structure.
Can I Keep Working While I Get My CNL Degree?
Yes. One of the main benefits of online study is flexibility, which means you can complete course modules and assignments on your timeline. That means your coursework fits around your job and your family, not the other way around. For CNLs-in-training, maintaining your nursing career comes with the added bonus of real-time implementation. In other words, you can practice your newfound skills and knowledge whenever you're at work.
I always have the adult working student in mind when I plan the course, deadlines, due dates, etc.
How Many Hours a Week Do I Need to Study?
Online students should plan to set aside 10 to 14 hours per week for each 3-credit course. This estimate includes your "in-class" activities, time set aside for viewing video lectures, participating in course modules, and engaging in class discussions with your professor and fellow students. You'll spend the remaining six to nine hours on assigned reading, studying and assignments.
Students enrolled in ULM's clinical nurse leader program never have to take two clinical or practicum courses at once. This policy gives busy nurses the time they need to successfully manage work, personal life, coursework and clinical hours.
Plan to spend about two hours every day on school work: reading, studying and preparing assignments.
How Do I Attend Classes Online?
Courses and course materials are administered through a Learning Management System (LMS), which is basically a virtual classroom. Whether you're enrolled online or on campus, many students will encounter an LMS like Canvas, Moodle or Blackboard. These web-based systems allow you to log in and access your course list. From there, you click into the course you want to enter. Once you're inside your course, you'll find links to course materials and course modules, class forums for discussion, and upload options for course assignments. As with any new website, it may take a few moments to become familiar with the layout, but after that, you'll know your way around.
ULM students can access tech support through the Help Desk at 318-342-3333 or firstname.lastname@example.org.
What Kind of Technology Do I Need?
A reliable computer and internet connection are pretty much all you need. You're good to go as long as your computer can execute basic functions, including internet browsing and word processing, creating spreadsheets and presentations, viewing videos, and uploading and downloading files. Since the LMS is web-based, you can also access your courses through your phone or tablet.
Do My Online Professors Have Clinical Experience?
It's common practice for professors teaching at the graduate level to hold doctoral degrees, and that's true no matter the discipline. Advanced nursing programs often require some measure of clinical background, so your CNL professors typically have clinical experience. They understand the challenges that come with balancing your career and education, and they also understand the joys and travails of nursing.
Every professor and instructor at ULM is an experienced clinician. Many chose to become college-level instructors to share their expertise and further their profession.
"I want to help future nurses feel equipped to deliver high-quality healthcare and achieve positive outcomes for patient populations. To 'give back' to nursing a little of what this career has afforded me over the last 45 years." – Dr. Rhonda Hensley, Associate Director of Graduate Nursing at ULM
How Will I Interact With My Professors and Fellow Students?
You'll interact with both through LMS class discussion forums. You may even find yourself participating in online group projects with your classmates. Professors are also available to students via email or phone, and some can be reached through text or video chat.
Are Online Students Allowed to Use the Library?
Many universities allow for this feature, and e-books are often available to online students. Since research databases have migrated online, you'll be able to access relevant articles and studies 24 hours a day, seven days a week. On-campus students rely on this feature as well.
In addition to e-book and database access, some universities provide research assistance to online students. CNLs-in-training at ULM can find online support through the Ask a Librarian service.
Why Should I Choose ULM for My Degree?
The South remains the top region for clinical nurse leaders, and demand in Louisiana is particularly high. ULM developed its master's CNL program in response to that demand, and it was the first university in Louisiana to do so. While other schools in the state have followed suit, ULM is currently the only institution with a 100% online option.
When Can I Enroll?
Learn more about our MSN CNL online program!
American Association of Colleges of Nursing (AACN):
Additional Exam Resources
Certified Clinical Nurse Leader Talking Points: Published Outcomes of the Clinical Nurse Leader
The Clinical Nurse Leader Role: A Pilot Evaluation by an Early Adopter
CNL Frequently Asked Questions
Prepare for the Exam
Recommended Practice Experiences
Scholarships & Financial Aid
Working Statement Comparing the Clinical Nurse Leaders and Nurse Manager Roles: Similarities, Differences and Complementarities
U.S. News & World Report:
7 Myths About Online Education
10 Things Employers Think About Your Online Degree
U.S. Department of Education:
Am I Eligible for Deferment?
Am I Eligible to Receive Financial Aid?
Evaluation of Evidence-Based Practices in Online Learning: A Meta-Analysis and Review of Online Learning Studies
Free Application for Federal Student Aid (FAFSA)
Getting Out of Default
How Much Can I Borrow?
Average Salary of Clinical Nurse Leader Jobs
Average Salary of Nurse Manager Jobs
Average Salary of RN BSN Jobs
What Is the Average Clinical Nurse Leader Salary by State
What Is the Average RN BSN Salary by State