Ward duties put specialist nurse roles at risk

11 May 2010 | By Clare Lomas

Trusts that send clinical nurse specialists back to the wards could be putting the future of the clinical nurse specialist role at risk, Nursing Times had been told.

Last week an investigation by Nursing Times revealed hospital trusts across England were requiring clinical nurse specialists to undertake general ward duties outside of their specialist role.

A similar pattern is emerging in Scotland, where NHS Greater Glasgow and Clyde now requires clinical nurse specialists to work one day a week on acute wards.

The move has sparked concern from nurse union leaders, who say it creates “real issues” about the role of the clinical nurse specialist and nurses’ career prospects.

Royal College of Nursing head of policy development and implementation Howard Catton said trusts need to be clear about their rationale for asking nurse specialists to undertake general ward duties.

“My concern is whether this is being driven by the need for efficiency savings and workforce flexibility, or whether it is being driven by patient need and clinical demand,” he said.

“There is a concern that nurses may not be as attracted to specialist nursing roles in the future if there is the impression that when times get tough they will be asked to step back from these roles,” he said.

Unison head of nursing Gail Adams said it was “highly appropriate and highly relevant” that clinical nurse specialists undertook ward duties if the purpose was to maintain clinical skills and help pass on knowledge to others.

But she said using nurse specialists as an “additional pair of hands” was unacceptable and could lead to the role being undermined.

“We will lose their clinical expertise because their [specialist] knowledge will become more distant,” she told Nursing Times.

“In addition to this, they will become frustrated that they are not being given the authority or ability to do the job they have been trained to do and they may vote with their feet,” she said.

The cost effectiveness of clinical nurse specialists is coming under increasing scrutiny, with many trusts looking closely at the roles in response to budget pressures.

Independent nurse consultant in rheumatology Sue Oliver told Nursing Times it was vital clinical nurse specialists kept accurate and up to date records of their work so they could prove their worth to directors of nursing and commissioners.

Readers' comments (20)

Anonymous | 11-May-2010 4:46 pm
I work in a mental health trust...lets really be honest like most other things in nursing it is all dependent on how focused the person is on patient care to how good they are as a specialist nurse.........if we take mental healthcare for example a CNS will take a smaller caseload than a functional CPN, have clients that are unique case studies and high probability of recovery....the rest is left to the nurses they cant help have a "dig at" for not doing things from their point of view.
CNS spend much of their time in meetings, doing admin and presenting what other nurses are doing to third parties and not so often using direct patient contact as a way of filling their contracted hours.
Like lots of posts in nursing it seems that these sorts of positions exsist to reward nurses for their hard slog on wards, and when analysed it dosent have much use as they are not there to help staff reach new levels of practice and be knowledgeable of best practice (although they should be) but just to critique the contribution other people make.
There will be people replying with lots of justifications of these posts and say we do this, we do that etc...but I dont care, from my perspective its just another layer of management sitting in their ivory tower that think hands on ward work is somehow beneath them now they ve "made it".
fair play that they have to get back to basics and rediscover what patients need.
Theres a beautiful model of nuirsing that barker describes of asking identifying with the patient, asking them what they want and lastly doing it..does that make me a CNS for doing no more than that?
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Anonymous | 11-May-2010 8:05 pm
Problem with the persons not the role - the the money often comes from a separate source of funding.... Let's apoint a CNS or two with the cash we got. There is no CNS factory producing CNS of verifyable quality. Some are truly excellent, others not so. NMC light years behind the wave have done nothing to ensure the quality either.

BUT please don't equate patient contact time as the ultimate measure of a professionals value. It's idiotic.
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Anonymous | 11-May-2010 8:33 pm
idiotic? is nursing about looking after people...its idiotic to suggest nursing is contact and your obviously one of them
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Anonymous | 11-May-2010 9:55 pm
Anonymous | 11-May-2010 8:33 pm.

CNS the clue is in the title. Guess it would mean spending some time educating other nurses maybe some medical staff, improving standards of care, writing protocols, liasing with other professionals at a strategic level. Not all best measured by patient contact time as an indicator of value you think?
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Sandra Joyce Powell | 12-May-2010 8:47 am
my feeling on this situation is that the clinical nurse specialist will have the ability to observe the wards to ensure that the care of the patients is at its most efficient,it will also give them the opportunity of having one day a week when they can wind down a little from the very their very demanding role and perform the duties of a ward nurse. If i were in their shoes i would grab this opportunity with both hands .assuming of course they are not expected to day a drop in pay for that one day. let us not forget we are nurses who care but we all have mortgages and lives to pay for.
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Anonymous | 12-May-2010 9:27 am
Well, well, well....it's getting interesting. Finances and bottom line, those are the most driving forces in all healthcare. I never understand why nurses think any different. Specialist nurses often find it difficult to measure outcomes, and so it will be hard to justify the higher salary when wards or depts are struggling.
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Anonymous | 12-May-2010 11:40 am
I think this is a great idea - there has been much de-skilling of nursing staff over the years. At one time nurses had to deal with whatever arose on the ward and knew what to do without having to call on someone who is a 'specialist'. From what I can see there has been too much fragmentation of the job and this might help to put it back together again along with some continuity of care with patients knowing who is looking after them.
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Anonymous | 12-May-2010 4:36 pm
the situation is not any different from what is happening in Ghana. specialist nurses are being sent back to the ward to play the role of general nurses and the rationale sometimes is shortage of staff. come to talk of salary increment, the salary remains the same in exception of nurse anaesthesiologist and a medical assistant. it's terrible.
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Anonymous | 12-May-2010 7:45 pm
Oh dear, again nurses are at each others throats again. This is not about CNS's verses Ward Nurses and who provides the best care. BOTH provide care and BOTH complement each other. NEITHER can function without the other. CNS's are required to provide specialista dvice and knowledge that is not available on the wards, to manage caseloads that would swamp wards, prevent admissions, reduce admisions, enhance patient care, educate ward staff and take some of the pressure of the wards. CNS's are often in meetings, redefining healthboard strategies, working on care plans and coordinating patient care.

As a CNS I have a caseload of over 600 patients - each of these requires different skils, and odten as a CNS i am the patients point of contact for advice, support and problem solving. When on a ward could a patient phone up for advice and spend thirty or forty minutes speaking with a dedicated professional. As a CNS i coordinate admissions, arrange discharges and prevent / reduce readmissions to hospital. Thois could not be done within a ward environment.

And WHO will pick up the patients and jobs that are not done for that day the CNS's are on the wards!

Contrary to the management viewpoint - putting CNS's back to the ward will not Reduce admissions, enhance care, reduce costs and enhance education. Rather it will increase readmissions, increase costs, reduce care and detract from education to ward staff.
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Anonymous | 13-May-2010 8:47 am
This is a very very interesting little debate ongoing here! I think what it really shows is a total lack of understanding in the main part of the clinical nurse specialist role. I am a nurse consultant in Tissue Viability and my role begins and ends very much at a ward level, 50% of my time is clinical and I have to fight quite hard to maintain that. The strategic element of the role cannot be undervalued - would we have the equipment to care for our patients without that part of the role? I think not. I already work alongside nurses at ward level the aim being to upskill, but I am not a pair of hands - I am there to physically care for patients with the nurses and help them in terms of providing expertise and education but also increasingly helping nurses prioritise patient care. I champion the fundamentals of care and I appear to be having an increasing role in expediting patient discharge from hospital. We are in a changing and challanging healthcare climate we need to be together and not against each other, equally nurse specialism in this country needs to step up and show its worth, the system Pandora should be FREELY AVAILABLE this IT system clearly demonstrates the value of nurse specialism. Are we asking our medical colleagues to act as F2's - now there is a real debate and a potential cost efficiency!
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Anonymous | 13-May-2010 4:11 pm
Specialist Nurses need to pass on their knowledge and also keep in touch with real nursing. One day a week wont kill them unless its the day they go off early shopping
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Anonymous | 14-May-2010 8:37 am
I knew this would happen CNS justifying what they think they do?......i'l put money on it that most people's experiences are that they are uncontactable, i personally have never recieved any "training" from one and never known how to refer someone on to a CNS.....all i have ever seen are blindly obvious assessment tools introduced by them that they dont actually explain, otherwise I really can't think of one occassion in the last five years I have seen something measurable that a CNS has put into place that has been of actual use to people who arent well. Id love to hear someone with a different expereince opposed to a CNS assuring me that isnt the case and lsiting the many things they do.
Im glad in hard times they are expected to work harder for less reward, like everone else.
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Anonymous | 15-May-2010 2:19 pm
This is so sad! I have been nursing for 30yrs and have seen many different changes in the health service, and from different points of view, not all bad. Many yrs ago patients were having to wait for treatments, but once the were admitted, nurses were able to spend good quality time with them. Now, although patients are seen and treatment started so much sooner, 2wks from GP referral, who is there to support them and their carers once they are on the roller coaster? Nurses on the wards are under a great deal of stress, shortage of staff, lack of resources ect. And as much as they want to they haven't got the time to spend explaining,going over again the diagnosis, holding hands for an hour, due to the busyness and demands of the ward. Since becoming a CNS I feel its the best job I have had. Being able to give my full attention to my patients and carers, they have my contact details and know they can ring any time, they know that they won't be waiting to speak to someone who knows who they are, or having to go through their history of their illness again. Going to meetings with other specialities allows the treatments to be streamlined and enhances the service. There is only me in my speciality and I liase with other trusts to plan patient’s care. My hours do not start,’ at the beginning of a shift' nor does it end after a specific number of hours or when the new shift takes over. I am often at work waiting for patients and carers come home from work to speak to them. I am there as a resource, and educator, counsellor and facilitator not just for my patients but also for other members of the nursing teams I visit and work. Taking on this role has far from 'deskilled' me, in fact I have learned new skills and knowledge, no not just policies, but actual hands on! Plus I still know how to make a bed and do bed baths,monitor and record blood pressures the old fashion way and press a button way, take patients to theatres and plan their care. I can only think that those of you who are opposed to CNS's, haven’t had the opportunity to see how they are enhancing and aiding the very busy ward nurses by providing a life belt and crutch for not just the patients but the nurses too.
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Anonymous | 17-May-2010 12:20 pm
We need to start supporting each other and stop this fighting. Can you not see it is exactly what the government wants to take our mind of the main focus!! Anyone who works for the NHS will know if it was not for the patients and our commitment in wanting to make a difference we would have left years ago. If anyone can say hand on their hearts our patients receive the care and attention they deserve then get rid of the CNS, but I am sure you will agree they don't! As a CNS my patients and their care is the most important aspect of my job and it's because I am a specialist in my field I am able to deal with the problems others can't. Oh yes forgot to say when I am not seeing patients I am writing policies, procedures, responding to NPSA alerts, teaching and training on extended role, leading a link nurse service for the trust etc etc. Do I need to say more? Nurses run the NHS and we need to stick together and tell this government where they can stick their reductions in nursing care!!
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Anonymous | 17-May-2010 2:53 pm
strange not one person who is not a cns has defended things?....might well do a good job, but is this not the problem that nobody knows what it is?

people before title again? i know too many stuck up CNS who really do see themselves above people who aren't very well....what sort of a person can be comfortable sat at a computer knowing 10 yards away a ward is short staffed and a fellow human being is in a bed of wee and poo. Thats what upsets me and until I see that as different I have no sympathy what so ever and hope you enjoy your essential work for as long as it lasts.
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Anonymous | 17-May-2010 2:55 pm
Id love to see a CNS take a bollocking for not getting a policy wrote, missing a meeting at the expense of putting the patient first at that given time.......that would get respect.
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Cornelia Walsh | 18-May-2010 1:49 pm
I am a psychiatric nurse working just outside of Boston, MA, USA. We use Clinical Specialists in many areas of our hospital (though not on my unit) and actually have trouble recruiting them, esp.in mental health.
I think they serve an important educational need for staff nurses, esp. as our education department is being reduced in staff.
I so wish nurses could all work together and get along.. there is so much in-fighting and non-support.. why is that?? We are all in this to care for patients, to work together to improve health care delivery.
We all have important roles that compliment each other.. what do we need to bring some harmony to this profession?
The way the economy around the world is going, we should be joining together to defend our profession, not spend time fighting amongst ourselves.
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Anonymous | 25-May-2010 12:18 pm
I agree I have worked with CNSs who do think they above everyone else but I have also worked with ones who provide an essential service and have helped with getting complex patients discharged.
This is horrible seeing nurse against nurse; why don't we all stick together rather than be "happy" that another nurse is at risk. Where is the caring aspect there? Yes CNSs should work on wards but not just in times of crisis but on regular basis maybe 2 - 3 shifts a month to ensure if things such as epidemic occurs they are ward ready to assist.
I have seen nurses on wards thinking they do not need to call a specialist in and causing more problems. The same goes for GPs who think they do not need to refer patients to see a consultant.
I see many CNSs now doing the things that doctors did many years ago so are used now to cut costs of employing doctors.
Complaints from wards tend to come because patients have not had specialist treatment. I don't know what I don't know so am happy to refer the complex cases to those who do.
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Anonymous | 25-May-2010 4:35 pm
its not nurse vs nurse, it those who value patients above themselves the good CNS are the ones who are already decent human beings...but give someone an offic, a title and they show themselves to be what they always were......I hate the tories being in government, i really do...but if it gets people back doing what they were supposed to do by being there for the poorly person il be happy as anything that things are going back right again
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Anonymous | 11-Dec-2010 8:52 pm
It is a shame that it is time again to have a go at specialist nurses. At least as a specialist nurse you see both sides as you have also been a ward based nurse. The bottom line ought to be that we are all there for patients. Most don't mind hard work and like to keep up to date with clinical skills on wards. Once you have tried a CNS role you tend to have a much different view. Lots of CNSs love their jobs but the burn out rate is high. It is especially hard to be told you need to justify your salary! The role is hard to quantify as often you keep patients out of hospitals..
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