Clinical nurse specialists: towards a definition

The number of nurses with titles such as clinical nurse specialist and nurse practitioner is increasing. In the context of chronic nurse shortages it is important that all nursing roles are reviewed to ensure the most efficient and effective use of staff, but there is no clear agreement on the competencies expected of nurses using these titles (UKCC, 1998).

The title 'registered nurse' is protected in law, but the titles 'clinical nurse specialist' and 'nurse practitioner' are not.

In East Somerset NHS Trust, as in other trusts across the country, CNS posts are developed mainly by medical staff, rather than as part of strategic multidisciplinary workforce planning. These developments are piecemeal, with wide variations in the knowledge and the qualifications expected of post-holders.

For this reason a project group was set up to clarify the situation, providing a model that could be used by other trusts facing similar difficulties.

The project group
The aim of the project group was to produce recommendations, which would then be made to the trust board, that could be used as a blueprint by all managers and consultants when creating new CNS/NP posts. Minimum qualifications, future educational requirements and the pay for new posts would be clearly defined, offering a framework within which those already employed would be able to develop with appropriate support.

The project group included a nurse manager, two medical consultants, specialist nurses and a community nurse. Its terms of reference were to:

- Define the roles of CNSs and NPs and their place in the organisation;

- Examine the scope of the two roles;

- Consider issues of preparation and qualification at appointment, and educational needs;

- Identify ways of measuring competencies;

- Develop core job descriptions.

The group met a number of times - debates were lively and occasionally tense, particularly regarding the interpretation of the scope of the two different roles - and a draft report was produced for wider circulation in the trust.

Once the report had been finalised, a statement and definition of the roles, preparation, education and competencies was presented to the trust board and ratified.

Core requirements of the CNS role
Reviewing the plethora of CNS definitions available, the project group decided that the role should include clinical practice, consultancy, teaching and the application of relevant nursing research (see box).

Nursing is fast becoming an all-graduate profession to meet the requirements of modern health care. Most new entrants to the profession are educated to diploma level and many have degrees.

The group decided that all new CNSs should be educated to degree level. In view of the practice expertise required, they should be RNs with a minimum of five years experience at senior staff nurse level - that is, at a minimum of E grade. They should also have extensive experience in the relevant clinical area, hold an appropriate clinical ENB course (where available) and a recognised practice teaching qualification, such as the ENB 998 or equivalent.

New CNSs appointed by the trust who do not have a degree must, as part of their contract, obtain a degree related to health care within three years of taking up the post. Funding and study leave are provided. Until they gain a degree the trust has recommended that their title should be 'sister in specialist care' - 'sister in breast care', for example - with the post graded at F. On obtaining a degree the post will be regraded to G and the title CNS applied.

Maintaining competence
Protected study leave of five days a year allows CNSs to attend appropriate conferences, providing an opportunity to network with other nurse specialists, and study privately. To enable this, arrangements have been made for extra support in the clinical area, such as locum cover and the development of link nurses.

In addition to the five training days, each CNS needs time to participate in research. Nurses may choose to incorporate this into their studies for a master's degree or to participate in the work of national or regional committees.

To enable CNSs to develop a strategic overview and look at local issues, the trust provides two additional days every year. Time is ring-fenced to ensure that they take part in clinical supervision, which is essential to monitor their competency and allow time for reflection.

Assessment of competence
The trust supports a model of clinical supervision that focuses on the domains of nursing practice and the 10 key characteristics of expert practice (Benner, 1984; ENB, 1995). This model is used as a focus for reflection and discussion between professionals and acts as a structure for clinical supervision sessions, enabling practitioners to identify their level of competence and set goals for future development.

The CNS must choose an accredited supervisor who has university-level skills in facilitating reflective practice. Regular supervision sessions are scheduled to fit into work time, with a minimum of four sessions a year.

While acknowledging that clinical supervision is a confidential process, the outcomes of supervision sessions are used to inform the process of individual development and review, where CNSs and their managers set goals to achieve inservice development priorities and business plan objectives. Acknowledging training and development needs in this way means that they can be formally supported. This also enables the development of expertise that can be measured and recorded.

The individual development and review process is also used to ensure that an annual review of any extended scopes of practice is carried out. Expertise development is recorded in the practitioner's professional portfolio and in reflective diaries to support their UKCC reregistration.

Conclusion
Research studies are increasingly recommending a strategic approach to the development of new nursing roles (Read, 1999). Maximising scarce nursing resources will depend on the development of robust, organisation-wide processes to ensure that the full potential of all nurses is realised.

Extensive internal consultation and discussion on the role of the CNS have resulted in a recommendation that the creation of new roles, such as CNS posts, should be agreed with the directors of nursing and personnel. The grade for CNS should be G or, in exceptional cases, H.

Those currently in post with 'specialist' in their job title should continue, but those who do not have a first degree should be encouraged to gain one within five years. All CNSs should have their practice regularly reviewed through the use of clinical supervision and individual development and review.

To maximise its impact, the CNS role at East Somerset NHS Trust has focused essentially on teaching and developing the knowledge and skills of ward and community nurses, enabling them to deliver the highest standards of holistic care for patients.

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