The benefits of the clinical nurse specialist role to patient care are not always clear. A trust developed a database to analyse their workload and contribution
Elizabeth Keenan, MSc, BSc, RGN, is clinical nurse specialist in spasticity management, The National Hospital for Neurology and Neurosurgery; Kay Eaton, MSc, RGN, is consultant nurse, cancer and supportive care; Sheila Adam, MSc, BNurs, RGN, is head of nursing; all at University College London Hospitals Foundation Trust.
Keenan E et al (2010) Using a database to demonstrate the clinical nurse specialist’s contribution to patient care. Nursing Times; 106: 22, early online publication.
Specialist nurse roles appear to be under threat in the UK and the role of the clinical nurse specialist has been subject scrutiny recently.
A trust developed a database to enable data on CNS workload and contribution to patient care to be collected and analysed. This showed the components of the role and the clear benefits to patient care.
Keywords Clinical nurse specialist, Workload, Role
- This article has been double-blind peer reviewed
An accurate way to sample CNSs’ work, produced from five months of Pandora CNS data from an acute inner city trust, provides an excellent insight into the work of the CNS in cancer and surgery.
More accurate reporting on activity is needed, with more time spent untangling events, considering the work completed and the dimensions covered, which is often so innate in many CNSs’ daily activity.
By coding activity and printing reports, CNSs can see the elements of their work, highlight the “bottlenecks” and introduce changes in clinical practice.
The cancer reform strategy (Department of Health, 2007a) set out a commitment to establish a new NHS cancer patient experience survey programme to monitor national progress and to use the findings to drive quality improvements locally. This is in line with the government’s vision, outlined in the NHS next stage review (DH, 2008a), which stated that patient experience should be one of the guiding principles of the NHS. Tackling variations in the quality of care and giving patients more information and choice were key themes in this report.
Implicit within this is the contribution of the clinical nurse specialist (CNS) role to delivering this vision. The DH (2007a) said CNSs have a valuable role across different elements of patient management and support, carrying out a range of functions including: technical aspects of care; information provision; emotional support; and care coordination.
Many policy documents argue that personalising care is essential to ensure patients receive care that is tailored to them (DH, 2007a; 2007b).
The first annual report on the cancer reform strategy (DH, 2008b) explored new models of care and focused on:
- Testing new ideas to reduce length of stay;
- Avoiding emergency admissions;
- Considering care delivery in the most appropriate setting;
- Developing models of care that improve quality and value patients’ time.
Many of these strands are common components of the CNS role. The evidence of how valuable this role can be to patient outcomes is well understood and documented, highlighted in the chapter on survivorship in the cancer reform strategy (DH, 2007a). This discusses living with and beyond cancer, a theme which is further developed in the National Cancer Survivorship Initiative’s vision (DH et al, 2010).
However, specialist nurse roles appear to be under threat in the UK due to financial pressures in the NHS (Tarrant et al, 2008). The CNS role has been subject to scrutiny within clinical areas as it appears less clear to external examination (although not to patients) and a relative “luxury” when compared with ward based nurses (Neate, 2006).
In order to address this and make explicit the work of the CNS, a Structured Query Language interrelational database called Pandora.. Pandora was developed by Tony Lezard of North London Cancer Network and Alison Leary, then Macmillan lecturer in oncology at University College London Hospital, with support from NHS Innovations London. The purpose was to design a tool that would help collect data to support and demonstrate the complexity and connectivity of the CNS role (Leary, 2007). The software was supported by NHS Innovations London and its development for commercial distribution started in March 2008.
What is Pandora?
Pandora is a database designed to articulate the complexity of the CNS role (Leary et al, 2008). It does this by collecting data in various forms including narratives which may be subjected to content analysis for example (Leary, 2007).
The CNS role in the UK has evolved over the last three decades and debate still continues over its definition. However, the Nursing and Midwifery Council (2007) said there are four key themes: advanced clinical/professional practice; facilitating learning; leadership/ management; and research practice. These appear to be common in the literature, which generally report the key elements of the CNS role as clinical practice, education, management/consultation and research (Ball, 2005; Hamric and Spross, 1989). While these components are prescriptive, it is considered to be approximately representative (Leary et al, 2008).
However, the Pandora research showed further hidden elements connecting the impact of CNS work to patient and organisational outcomes (Leary et al, 2008) (Box 1). Pandora was initially piloted at the trust in 2007 among a group of volunteer CNSs and after a successful phase, it was agreed that its use should be part of all CNS roles.
Box 1. What the Pandora database collects
- Event number -this allocated by the Pandora programme-it is a sequential number
- Time interval - of the event - how long each event took
- Event context - the context of the event is usually the “where and how” it happened, such as by telephone or in the outpatient department.
- Emotional effort of the event- this is subjective and at the CNS’s discretion
- Interventions - this gives options to choose from that are subdivided into a further drop down menu
- Event form - the “why and how it happened”. For example, although an “admin” intervention may have been carried out, it may take a clinical form (dictating a letter would take the form of clinical expertise), whereas typing a standard template letter would take the form of “admin”
- Outcome - the outcome of the event
- Target contribution - the contribution to national “outcomes”, such as the 18 week wait target
- Narrative – section for free text describing the event (no confidential information to be written)
Source: Leary et al (2008)
Introducing Pandora at the trust
To facilitate the rollout of the Pandora database, an e-learning tool was developed (Fig 1). All CNSs at the trust were required to complete this in order to be able to access Pandora. E-learning was considered to be the most convenient and accessible method of training, allowing CNSs to complete it when it was most suitable for them. A unique training log-in was emailed from the information, communications and technology (ICT) team to each CNS and training took about 20 minutes to complete.
The training helped them to navigate their way around the database using scenarios to demonstrate how an event could be coded under the key dimensions. On completion, each CNS emailed Pandora and received their own unique password and username. The database could be accessed via the internet so activity could be inputted from any location within the trust at a convenient time.
No confidential information was placed on the database and CNSs were reminded of this at various stages during data collection. Following completion, a crib sheet with the dimensions and drop down options can be printed and carried so that data can be collected during clinical time and loaded onto their Pandora account. Each CNS was encouraged to collect on different days across the working week, ideally two days per month, so that the data could accurately reflect their workload. On each day that data is collected, ideally CNSs needed to collect 20-30 events to ensure the data was representative (Leary, 2007). Using Pandora An interrelational database for Clinical Nurse Specialists (an unpublished guideline from UCLH).
CNS work in cancer and surgery
Data was collected from a group of 18 CNSs working in cancer and surgery at the trust over five months. They collected different weekdays to reflect their workload accurately. The report was collected over a short period, the aim being to generate a report to feed back to this group of CNSs. The data presented below describes this activity, which was validated and further explained by the CNSs themselves at a nursing meeting in December 2009. This allowed for validation and further explanation of the data through discussion and reflection with the group.
Unsurprisingly the majority of CNSs’ time was coded under clinical activity. Much of this was physical and psychological assessments taking about one hour to complete (Fig 2).
Physical work encompassed: physical, general and specialist symptom control, performing specialist and routine procedures and making recommendations to other multidisciplinary teams. This was expected due to the multi-professional nature of cancer and the importance of multidisciplinary working, guided by the Manual of Cancer Services Standards (DH, 2001). These assessments were completed in both outpatient and inpatient departments as well as over the telephone and were coded low to medium on the emotional effort scale.
When examining the drop down elements selected during psychological assessment, CNSs coded that most of their time was spent managing anxiety, supporting patients and families with clinical choices and dealing with distressed patients and relatives.
Communication of significant news to patients and relatives was coded as a smaller percentage of their time. While activity was coded in all interventions, the majority of time was spent undertaking clinical (63%) and administrative activity (30%), with less time coded under educational and professional development (4%), consultancy (2%), research and audit (1%) (Fig 3).
A significant amount of overall time was taken up by administrative tasks (Fig 4). While many of these tasks were completed over 15-30 minutes, a small number took over two hours.
The majority of administrative tasks consisted of coordinating clinical notes, ensuring correct results were available, checking emails and making calls to patients and other multidisciplinary team members. Less administrative time was coded under dictating, typing and faxing letters. On reflection with the CNS group they indicated that they coded their activity as predominantly clinical and failed to see that for the clinical intervention to be performed, a number of administrative steps need to occur. After this discussion, the CNS group felt they should examine their workload more closely and code every step/event in the future.
There appeared to be differences in the breadth and depth of the CNS role, with some practitioners managing and completing a ward round where they reviewed and dressed wounds, while others were involved in completing a Macmillan grant application and others in acting as advisors on the North London cancer network.
The majority of workload associated with this group of CNSs involved following up on telephone calls and reviewing patients in outpatient and inpatient settings.
Rescue and brokering work
Evident in the data with this group was that a significant amount of time was spent organising patients’ pathway: chasing medical notes, ensuring blood results and biopsy results were present along with other completed investigations. CNSs were anticipating the pathway of care before patients’ attendance, usually in the outpatient setting, by coordinating a particular procedure or liaising and coordinating with the necessary multidisciplinary team before, during and after patient review. It appeared that many were spending a significant amount of their time “brokering” and doing “rescue work” (Leary et al, 2008).
These terms describe how a CNS may negotiate a particular pathway for a patient, ensuring the best possible outcome at a particular time. “Rescue work” is based on Silber et al’s (1992) work, which explored what would happen if a situation was not rescued. While many practitioners did not code their activity under “rescue work” in their narratives, there are clear examples of this and it is an important element of CNS work (Leary et al, 2008).
CNS narratives gave examples of their “rescue work”, describing situations where there was prevention of unscheduled care, as admissions were prevented by CNS coordinating a pathway of appropriate care in a home setting. This ensured that patients could be seen locally, by their GP, providing a shared protocol of care and best possible outcome for patients. Understandably, emotional effort under the psychological dimension was significantly higher than in others, with many events coded as medium to exceptionally high. This is a subjective scale but it seemed to be reflected in the qualitative narratives (Fig 5).
Qualitative workload data
While the quantitative data demonstrates the percentage of time CNSs were spending on a key dimension, the qualitative data gives enormous insight into the level of “intimacy” they have with patients and relatives at a traumatic time in their lives.
There were five pages of narratives and these were pooled and analysed to identify some common themes (Box 2). The strongest themes were:
- Communication/health promotion;
- Rescue work;
- Advocacy work;
- Helping patients with clinical choices at time of diagnosis;
- Psychological support work that CNSs were providing for this patient group.
One narrative describes how the CNS “spent time with a patient whose mother is dying whilst he is undergoing chemotherapy. Explored his feelings of anger towards her for abandoning him when he needs her most”.
Another CNS described how they “talked through the choices that had been made by the team and acknowledged difficulties in dealing with an unknown outcome for the family”.
Another described their role with a “complex discharge” in a “patient with high anxiety and distress” where there was discussion with the patient regarding the “palliative phase of disease”.
Many of these themes concur with work by Tarrant et al (2008), which found that patients with prostate cancer valued input from a specialist nurse. Equally, the evidence of how valuable a CNS role can be to patient outcomes is highlighted in the cancer reform strategy’s chapter on living with and beyond cancer (DH, 2007a) and the National Cancer Survivorship Initiative’s vision (DH et al, 2010).
Interestingly, research by the Picker Institute Europe (Coulter, 2005) identified key aspects of healthcare that patients consider important:
- Fast access to reliable health advice;
- Effective treatment delivered by trusted professionals;
- Involvement in decisions and respect for preferences;
- Clear, comprehensible information and support for self-care;
- Continuity of care;
- Emotional support and support for family and carers.
Many of these key aspects appear to overlap with the aspects coded by CNSs in their qualitative narratives in caring for this patient group.
The Pandora database has clearly demonstrated the complexity and multiplicity of components of the CNS role and its impact on patients.
Box 2. Themes from the narratives
- Supporting family and children during cancer
- Providing information
- Planning treatment
- Empowering patients
- Encouraging self-management
- Liaising with ward staff, social services
- Liaising with hospice care
- Liaising with community teams
- Liaising with palliative care
Admission and discharge planning
- Ordering tests
- Admission planning
- Obtaining Biopsy results
- Explaining treatment options (such as pelvic floor exercise)
- Complex diagnosis, symptom management
- Dealing with treatment questions
- Explaining choices in surgery
- Chasing notes
- Ward rounds
- Wound assessments and procedures
- Continuing care, and liaising with support organisations
- Patient management outside normal service
- Organising shared care
- Arranging a prosthesis
- Helping patients to deal with issues with body image
- Discussing hair loss and ensuring appropriate pain relief
- Providing reassurance for distressed patients
- Rescue work; preventing admission
- Helping patients to explore feelings such as the grieving process and feelings of abandonment
- Supporting patients to deal with bereavement, end of life issues, complex emotional difficulties
- To arrange a demonstration or for more information on Pandora contact NHS Innovations London at www.nhsinnovationslondon.com/contact-us/
We would like to Tony Lezard North London Cancer Network and Alison Leary then Macmillan lecturer in oncology at UCLH with support from NHS Innovations London .We would also like to thank the cancer and surgery CNSs for their contribution to the article and Louise Boden, chief nurse, for her continuous support; all based at UCLH.
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