Monday 10th September 2012
By Gwen Marples, Senior Research Assistant at the Centre for Health Community and Education Studies (CHESs), Northumbria University.
Constraints and challenges within the NHS require the nursing profession to articulate and measure the nature and impact of nursing work. Nurses are being asked to justify their roles in terms of ‘value for money’ as deepening pressure on finite financial resources seeks to further constrain health service provision.
The role of the cancer clinical nurse specialist (CNS) is outlined within cancer nursing literature, but there is little that unpicks the role and teases out ‘hidden’ work that cannot be easily measured. Workforce reviews have challenged the position of the CNS, with specialist nurses being moved to less specialised positions.
Communicating the role of the CNS to commissioners requires compiling and presenting quantitative and qualitative data in a meaningful way to showcase the complexity, diversity and effectiveness of the work.
The advent of the specialist nursing role
The concept of specialist clinical nursing was first referred to in 1900. Reiter subsequently suggested the term ‘nurse clinician’ as a way of referring to nurses in advanced and specialist roles.
The specialist nurse role emerged in the UK during the 1970s; initially employed within primary care settings, many roles are now located within secondary and tertiary settings, including cancer care.
Details of a census of the advanced and specialist cancer workforce in England, Wales and Northern Ireland recorded a total of 2,309. Four specialist and advanced posts in England (89% response rate), 204 posts in Wales (66% response rate) and 43.4 posts in Northern Ireland (100% response rate).
Building on earlier census work, further work relating specifically to the English workforce was commissioned by the National Cancer Action Team (NCAT) supported by the Workforce Review Team. Findings provide details of the ratio of cancer specialist nurses (all job titles) to the incidence of cancer in all 28 English cancer networks revealing variance in the provision of specialist nursesupport by tumour type and geographical location. It’s intended that the document be used by commissioners to benchmark the provision of specialist nursing within geographical localities.
UK health policy has influenced health service reform and has had an impact on the development of advanced nursing practice. Such policy developments have allowed for a re-conceptualisation of professional roles, offering opportunities for the delivery of new and innovative approaches to nurse-led services.
The CNS role
The importance of the role is clearly articulated in the academic literature and in government reports. ‘Specialist nurses are involved in all aspects of a patient’s cancer journey, from diagnosis and treatment, through supportive and palliative care to survival’. The report Tackling Cancer states that ‘cancer care should be regarded as a specialist service evolving around the patient, carers and the multidisciplinary team (MDT)’.
While fully acknowledging the value of the CNS and its contribution to the transformation of cancer services, suggestion is made that the role is ‘frequently nebulous or poorly defined’, a situation that hampers any potential contribution of the role to cancer services.
Identifying the contribution
Patients, colleagues and others greatly value input from CNS [10,11] and the cancer CNS is regarded as having an important role to play in improving the experience of people diagnosed with cancer. There are, however, two areas of confusion: terminology and collaboration. Terminology Within the profession and in academic literature, there has been ‘the introduction of a plethora of specialist posts with unclear or inconsistent titles ... which has led to confusion and conflict about the roles of the expert practitioner’, with titles being used interchangeably.
The Nursing and Midwifery Council (NMC) states that ‘advanced nursing practise is an umbrella term which is used to describe a number of specialist roles including clinical nurse specialist and nurse practitioner’. Currently no accepted standardisation exists for the level of academic qualification needed or the level of competency required to perform such roles. As such, the NMC are seeking to take steps to regulate advanced nursing practice and to ensure that advanced practitioners are recorded on the register and possess the required competences.
The Royal College of Nursing (RCN) offers a summary of its current position on the advanced practitioner role using the term ‘nurse practitioner’ throughout the document, and outlining the RCN domains and competences for advanced nursepractitioners.
NCAT provides the following definition of a CNS: ‘... registered nurses who have graduate level nursing preparation and who would usually be expected to be prepared at Master’s level. They are clinical experts in evidence-based nursing practice within a specialty area. Their specialty may be focused on a population (eg young people), type of cancer (eg palliative care), type of problem (eg lymphoedema), type of treatment (eg chemotherapy) or tumour type (eg lung cancer)’.
Working within this definition, Macmillan CNSs would be regarded as advanced practitioners because they possess specialist skills in relation to cancer and palliative care. However the above report notes that ‘whilst many CNSs may function at an advanced level of practice, this level of practice is not common to all, thus the title of clinical nurse specialist does not in itself indicate that the nurse is an “advanced practitioner”.’
Cancer CNSs are essential members of the MDT who are able to work in collaboration with other professionals in and across primary and secondary/tertiary settings. CNSs are seen as having influence and credibility across the care pathway and have a potential cohesive role in both a) the improvement of cancer care overall and in b) the configuration of cancer services.With little quantifiable published research examining the work of the CNS in the UK, ‘the nature of specialist nursing remains ambiguous’ Consequently, it remains difficult to capture and measure the essence of this collaborative work and its impact particularly in a way that is meaningful to commissioners.
Improvements in cancer services will need to be delivered to more patients with less financial resources. Given that workload data collection isn’t standardised across specialties or settings, we can’t meaningfully describe or accurately measure what CNSs do within their working day.
A number of approaches have been proposed to evaluate the role of the specialist practitioner; concept mapping, computer modelling[2,17] audit. None of these fully explore the role of the specialist nurse and any impact on patient care. A major problem is isolating the effects of the nurse and attributing patient outcomes to their contribution. The Pandora computer model may have the potential to cost the value of specialist nurses. The Patient Reported Outcomes Measures Programme shifts away from recording activities to requiring patients to self-report health outcomes. This may also be an approach worth considering.
There are significant gaps in the literature around the development of new tools or the application of existing tools to meet the needs of commissioners of cancer services. Cancer prevalence is anticipated to increase by 3.2% per year. It’s recommended that strong consideration be given to both the maintaining and strengthening of specialist nursing support for people with cancer and there is now guidance that everyone with cancer should have access to a specialist key worker. There is also is implicit value placed on the role of the CNS by patients, carers and fellow healthcare professionals.
In view of these factors, serious consideration needs to be made as to whether this continuing preoccupation with role justification, particularly in terms of ‘value for money’, is now somewhat outdated. It may now be time to think about whether resources would be better focussed on the effective deployment of cancer CNSs and innovative service improvement.
National Cancer Patient Experience Survey, DH, 2010
This survey showed the positive impact of having a clinical nurse specialist can have on a patient’s experience of care. You can download the survey from the Department of Health website.
One to one support for cancer patients, DH, 2010
This report is an independent analysis of the value of one-to-one support roles provided by CNSs and other staff for people with cancer. Download from the Department of Health website [PDF, 490kb].
Clinical Nurse Specialists in Cancer Care; Provision, Proportion and Performance, NCAT, 2010
A census of the cancer specialist nurse workforce in England 2010. Download from the NCAT website [PDF, 440kb].
About the author
Gwen has extensive experience in health-related research and evaluation projects. She has worked in teaching and assessment of students in higher education. Past projects include a Policy Appraisal and Health/Health Impact Assessment project and the evaluation of several local Sure Start programmes. Gwen now works with Dr Karen Roberts, Macmillan Reader, on a gynaecological oncology survivorship project.
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