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Scholar's Report

Travel: International observation of clinical nurse leaders - The clinical nurse leader & quality improvement role. The study tour included visits to New-York, Washington DC & Nottingham University Hospital.

2016/74 - Alison Smart


Motivation/problem statement:  Globally, the quality of healthcare is under scrutiny, with various inquiries reporting on pockets of poor care in the clinical setting resulting at times with poor quality of care. This has been simultaneous with shifting demographics of healthcare, increased pressures on the health care system coupled with staff shortages. A global consensus, of a requirement for effective clinical leadership during this transformation has been key. In Scotland, there are initiatives for the emerging clinical nurse leaders however not compulsory. Clinical nurse leaders are at the forefront of healthcare and with adequate resources, skills and knowledge are well placed to improve the quality of care of our patients. High quality care, safety and evidence based practice are the words often employed to describe a new role in the USA, Clinical Nurse Leader (CNL). The introduction of the role as a masters trained nurse with particular knowledge and skills has reported measurable quality improvements.


The study tour aimed to,

 1: Observe CNL trained staff within the USA and to gain an insight and working knowledge of the CNL & quality improvement.

2: Explore any challenges or opportunities of the introduction of the new CNL role

3: Develop new ways of working as a clinical nurse leader and adopt these into clinical practice in NHS Lothian.


An observational approach was employed for the study tour. New-York Presbyterian, Columbia & Veterans Health Administration, James J. Peters V.A medical centre was visited. The visits, comprised of observation of the CNL in roles within both clinical attachments, this was followed up with formal nursing leaders and forums to explore any observations further. Unstructured interviews were carried out with academics and students involved in the CNL programme at the School of Health & Nursing studies at Georgetown University. A post study tour visit to Nottingham University Hospitals will be carried out to gain an insight into clinical nursing leadership in an NHS England hospital. Ultimately, three key themes of the study tour will be presented and recommendations for clinical nurse leadership within NHS Lothian will be outlined.


The clinical nurse leader is a valuable asset to both the clinical and non-clinical team. The international findings, in relation to the clinical nurse leader role within the USA illustrated the RN Clinical Nurse Leader (CNL) is an advanced generalist who directs and can provide comprehensive, preventative & wellness care as well as the spectrum of acute episodic care, chronic and end of life to our patients. The CNL serves as a leader, mentor and consultant to healthcare staff. The CNL is an accredited role within the USA and consists of an 18 month post-graduate course, comprised of both a practical and academic nature where the student carries out various modules and acts as a change agent within the clinical environment.

Quality improvement is a key aspect of the CNL roles and responsibilities, the CNL’s promoted an environment that embraced knowledge, innovations and improvement. This was facilitated by the knowledge and skills acquired during the Clinical Nurse Leader Masters programme. Staff engagement, collaboration & preparation were the three key themes identified that contributed to the CNL in improving the quality patient care. Limitations of role ambiguity and lack of CNL posts within the practice environments, were two of the main challenges clinical and academic nurses communicated.


The CNL is an important MDT team member, with the knowledge, skills and passion to be change agents within a service at a microsystem level. The clinical nurse leader is an emerging role within the USA, created as a direct result from evidence of the challenges and pressures within Healthcare in the USA. The CNL is an advanced generalist, educated to Master’s degree level. The role has produced measurable outcomes in hospitals throughout the USA. There is a desire for a role out of the roll to continue, however role ambiguity exsists and has lead to some difficulty in implementation of the role. Staff engagement, Collaboration & preparation are the three key themes identified which facilitated the CNL in improving the quality of care. Staff engagement is required to be on the agenda from the clinical areas to the board room coupled with collaboration of the interdisciplinary team to facilitate the transformation of healthcare. Preparation & investment in our clinical nurse leaders within NHS Scotland is important to see measurable improvement in the quality of patient care.