Background: The clinical nurse specialist (CNS) role aims to improve patient care and develop services. Gaining the views of service users is a vital part of the role.
Aim: To evaluate CNS services provided to children and their families in a paediatric trust.
Method: A group of CNSs in a surgical directorate undertook an audit. We used an adapted 15-item questionnaire with three groups: parents/carers and children/adolescents in two different age groups. A total of 156 responses were returned.
Results and discussion: Parents, children and young people reported high levels of satisfaction with the nurses. Parents highlighted their good communication skills and high level of professionalism, as well as their being approachable, knowledgeable and understanding. Those areas identified less positively by parents and children included accessibility, equity of service provision and variable information resources.
Conclusion: This audit showed that one-to-one contact between children, families and the nurses was considered by service users to be the most valuable part of CNS work.
McArthur, L., Flynn, A. (2008) Evaluating the clinical nurse specialist role in child health. This is an extended version of the article published in Nursing Times; 104: 33, 28-29.
Liz McArthur, MSc, BSc, RSCN, is clinical nurse specialist in paediatric pain and sedation; Alison Flynn, BA, RN (child), RGN, is clinical nurse specialist in ENT; both at Alder Hey Children’s NHS Foundation Trust, Liverpool.
The clinical nurse specialist (CNS) role focuses on improving patient care and developing clinical services, often within specialist areas. CNS roles demonstrate a high degree of professional competence, skill and teamwork in both generalist and specialist areas of practice. Many CNSs are considered leaders within their own specialties, initiating care and making treatment decisions (Raja-Jones, 2002).
Changes to professional working patterns have facilitated the advancement of nursing practice. These include a shift between the boundaries of medical and nursing care and policies such as the Working Time Directive (Office of Public Sector Information, 1989, amended 2003). As a result, CNS roles have flourished over the last decade in the UK, alongside other advanced roles (Department of Health, 2000; DH, 1999; Read et al, 2001; Castledine, 1998). The government launched several documents including Liberating the Talents (DH, 2002), which allowed nurses to use their skills and knowledge to improve patient services.
Although a concise and legislative agreement of the CNS role does not exist, several key areas are identified in the literature. These include: expert clinical competence; education; research; critical thinking skills; and resource and time management expertise (Henderson, 2004; Raja-Jones, 2002). Local development of a policy for advanced, specialist and consultant nursing roles has helped clarify expectations in our organisation while also offering a clear career pathway.
Clinical nurse specialists are clinical experts directly involved in improving patient care and staff development. These roles link professional practice to evidence-based outcomes at patient, specialty and organisational levels (LaSala et al, 2007). Therefore CNS roles focus on ensuring and improving the effectiveness, efficiency and, most importantly, the quality of services delivered, matched against patient experience.
Often CNS roles have been associated with entrepreneurial characteristics, ranging from visionary leaders and innovators, developing creative practice to negotiator and self-motivated and autonomous practitioner (Dayhoff and Moore, 2003). A recent grounded theory study by Austin et al (2006) examined the challenges these nurses experienced when developing services. The findings suggested they were considered the main drivers in developing and evaluating services. Substantial groundwork has been established measuring outcomes of the CNS role. Their practice has been shown to improve quality, safety and cost-effectiveness of patient care (Fulton and Baldwin, 2004).
Consequently, CNS roles promote the development, implementation and evaluation of care delivered to patients in primary and acute care. Organisational and national care priorities are matched alongside patient needs, and service delivery and outcomes are measured against the overarching goal of promoting quality care. Quality can be evaluated from listening to and acknowledging the experiences of service users. A pivotal part of the CNS role is to seek service users’ views. In our evaluation we explored the views of children, young people and parents across the surgical directorate. Improving services for children is a key part of government policy (DH and Department for Education and Skills, 2004; DfES, 2003).
Background to the study
In 2007 a group of clinical nurse specialists based in the surgical directorate of a paediatric trust undertook an audit to evaluate the services they provided to children and their families. The audit was also prompted by increasing requirements for systems to ensure service users’ views are heard and acted on (DH, 2004; DH, 2003). The trust is also committed to an ongoing consultation process (child and family friendly hospital – CHAFF). The inclusion of children and young people is imperative in service evaluation and design. We recognise and value the families’ keen awareness of their healthcare needs. Informal discussions also highlighted the interest and enthusiasm parents and children had about being involved in the evaluation.
Clinical nurse specialists representing a diverse surgical patient workload (see below) meet monthly to discuss ways of advancing their roles and improving services.
Specialties represented are:
- Tissue viability;
- Stoma care;
- Ear, nose and throat;
- Cardiac and anticoagulation;
- Laser therapy;
- Pain and sedation;
It was during these meetings that an audit was suggested and we agreed to proceed with the project.
We reviewed questionnaires available for this type of audit. The Commission for Health Improvement (now the Healthcare Commission) had produced The Experience of Service Questionnaire Handbook (ESQ) survey (2000). It is a 15-item self-completion questionnaire that assesses users’ views of services in terms of accessibility, humanity of care, organisation of care and the environment. The commission introduced it as a method to assess child and adolescent mental health services (CAMHS) as part of a clinical governance review.
The hospital’s psychology department was involved in piloting the work and continues to use it to evaluate its service. The CAMHS questionnaire comprised three distinct components: parent/carer; young people aged 11–15; and young people aged 16–18. For our project, we adapted the age ranges in line with the work already undertaken by our psychology department. This resulted in a wider age range of children being included in the study (9-11 years, over 12 and parents/carers).
Before the evaluation started, we contacted the audit department and the project was logged on their database. This process enabled us to secure design, administrative and analysis support. Stamped, self-addressed envelopes were supplied with each questionnaire, which were returned to the audit department.
The trust’s patient and service-user group oversaw the process. This group ensures that any survey undertaken within the trust involving patients and/or families is methodologically sound and does not replicate existing work. It also ensures that outcome data is acted on.
Patient selection for the audit proved to be difficult. After discussion, we decided that each specialty would nominate the previous 50 children and/or families they had seen in the last six months. This ensured the families had recent contact with the service and that possible bias in selection was avoided. These lists were then sent to the coordinator within the group. Some families were seen by more than one service due to the complexity of their needs and some children had died.
We carried out cross-referencing of all names submitted to ensure that we did not send out questionnaires which would be duplicated or cause distress. Each one was modified accordingly for the population we were seeking views from. However, once the final list had been compiled a final number was not noted, which meant that we could not calculate the response rate. This omission was only noticed once the forms had been sent out.
The closed responses (yes, sometimes, no, don’t know) from the 15 questions were subjected to simple descriptive statistical analysis. The section of the questionnaire that allowed free text was explored thematically.
Parents reported satisfaction >90% with nurses’ knowledge, skills and multidisciplinary working, while children and young people reported 83-97% satisfaction. For a summary of the results, see Table 1 below.
Number of responses:
- Parents/carers = 115
- Children aged 9-11 years = 12
- Young people aged 12 and over = 29
Table 1. Summary of survey results
|Number returned||CNS very hepful||CNS listened||Accessible at a time always convenient for child and family||Explanation given and was knowledgeable||Continue to need access to and value service|
|12 years +||29||87%||97%||62%||90%||90%|
This group found the nurses’ care effective and accessible, and the nurses were available.
Quotes from participants:
‘I was spoken to as a young adult.’
‘It was very satisfactory.’
‘When I needed help it was always there, even if I just phone for help.’
‘Excellent service, all nurses, consultants, porters. They were kind, helpful and funny. I always got seen straightaway.’
Young people aged 12 and over
This group found the nurses explained things, listened and related to their problems. They were also good at problem-solving, helpful and friendly, and involved the young people in aspects of their care.
Quotes from participants:
‘I was given a choice in the care I got, my views were listened to and taken into account.’
‘Someone to talk to and listen to and someone who understands my body.’
‘Sometimes I was unable to see or speak to the nurse when I need to because she was busy.’
‘Nurse specialists are like tech people and provide a human element of care.’
In accordance with recent studies, the clinical nurse specialists in our audit appeared to be considered as ‘good nurses’ (Brady, 2008). They possessed skills and demonstrated all the characteristics suggested by Brady (2008), which included good communication skills, knowledge, trustworthiness, awareness of safety, humour and professionalism.
This group found there were many aspects to the care provided by the CNS, which we have ranked in order of priority (Box 1).
Box 1. Aspects of CNS care ranked in order of importance
Other comments from parents and carers included the following:
‘Always felt the team was available for us outside clinic hours - nurses used a range of incentives to motivate… to make their treatment more bearable.’
‘Excellent communication with the nurse specialists on a personal and professional level - the nurse made sure that mine and my child’s emotional and physical needs were met with trust and compassion.’
‘It has been consistent, supportive and informative through a very difficult time in our lives.’
Many lessons were learnt from the project. Parents and children reported high levels of satisfaction with CNS services. However, they identified the following areas less positively: accessibility, equity of service provision, variable information resources and administrative issues. These will be examined by individual services and the group to see how best to address them.
Changes that have already been put in place range from simple ones, such as producing uniform business cards, to setting up transitional clinics, improving care by using pathways and updating information. We also felt that involvement of some families would help us in implementing change and ensure that developments remain focused on their needs.
After completing the audit, the group met to discuss problems that had arisen during the process. As the audit is to be a regular event we explored how the tool, recruitment, evaluation and dissemination of findings should be addressed and improved on. We also discussed how we could improve the audit process, following implementation of changes to practice identified:
- Stricter control on documenting numbers of questionnaires sent out;
- It would have been helpful to find out how many of each group were involved in the audit;
- Involvement of patients and their families in the design of the questionnaire, as we felt some questions were too similar in nature and the format was not very child-friendly.
Disseminating the results
The audit was presented at ‘Grand Rounds’ in the hospital. This is a weekly educational event, which enables the multi-professional team to present topics, innovations and case histories. We made a poster presentation at the RCN research conference in Liverpool in April 2008, and within the trust the results will be published in the hospital newspaper. We are asking a group of families who were involved in the audit to meet with us to discuss the findings and how best to implement changes identified.
On the issue of frequency of repeat audits, the group decided that a reaudit should take place every 3-4 years. This is because it will take some time for changes to filter down to children and their families.
All those who took part in the audit felt it was an ambitious project but recognised the importance of having their services evaluated by families who used them. This audit showed that the most important part of our work - one-to-one contact between children, families and clinical nurse specialists – was considered by service users to be the most valuable. These nurses are a valuable resource delivering high-quality care and are important members of the healthcare team in our trust.
Implications for practice
- Listening to children, young people and their families and acting on the results should be built into service evaluation.
- Audit provides a vehicle to enable practitioners to evaluate their services.
- Clinical nurse specialists provide information, education and a service that is accessible to children, young people and their families.
- Service evaluation can in itself be a learning experience for practitioners.
We would like to thank the following people for their help with this audit (all of whom are employed by Alder Hey Children’s NHS Foundation Trust): Caroline Sanders, Frances Dooley, Jennie Craske, Pat Coldicutt, Rose Davies, Alison Lee, Mary Murray and team, Carole Boken, Cath Gorst, Joan Grogan, Doreen Williams and the audit department, The patient and service-users group. We would also like to thank all the children and families who took part in the audit.
Austin, L. et al (2006) Clinical nurse specialists as entrepreneurs; constrained or liberated. Journal of Clinical Nursing; 15: 1540-1549.
Brady, M. (2008) Children’s views of the ‘good’ nurse. RCN Annual International Nursing Research Conference, Abstract 5.4.2, 59. April, 2008, Liverpool.
Castledine, G. (1998) Clinical specialists in nursing in the UK: the early years. In: Castledine, G., McGee, P. (eds). Advanced and Specialist Nursing Practice. Oxford: Blackwell Publishing.
Commission for Health Improvement (2000) The Experience of Service Questionnaire Handbook. www.healthcarecommission.org.uk
Dayhoff, N., Moore, P.S. (2003) You don’t have to leave your hospital system to be an entrepreneur. Clinical Nurse Specialist; 17: 1, 22-24.
Department for Education and Skills (2003) Every Child Matters. www.everychildmatters.gov.uk
Department of Health, Department for Education and Skills (2004) The National Service Framework for Children, Young People and Maternity Services: Core Standards. www.dh.gov.uk
Department of Health (2004) Standards for Better Health: Health Care Standards for Services under the NHS.www.dh.gov.uk
Department of Health (2003) Getting the Right Start: National Service Framework for Children, Young People and Maternity Services: Standard for Hospital Services. www.dh.gov.uk
Department of Health (2002) Liberating the Talents: Helping Primary Care Trusts and Nurses to Deliver the NHS Plan. www.dh.gov.uk
Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. www.dh.gov.uk
Department of Health (1999) Making A Difference: Strengthening their Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. www.dh.gov.uk
Fulton, J., Baldwin, K. (2004) An annotated bibliography reflecting CNS practice and outcomes. Clinical Nurse Specialist; 18: 21-39.
Henderson, S. (2004) The role of the clinical nurse specialist in medical-surgical nursing. MedSurg Nursing; 13: 1, 38-41.
Office of Public Sector Information (2003) The Working Time (Amendment) Regulations (2003) Statutory Instrument 2003 No 1684. www.opsi.gov.uk
Raja-Jones, H. (2002) Role boundaries – research nurse or clinical nurse specialist? A literature review. Journal of Clinical Nursing; 11: 415-420.
Read, S. et al (2001) Exploring New Roles in Practice. Final Report. Sheffield: School of Health and Related Research, University of Sheffield.
LaSala, C.A. et al (2007) The role of the clinical nurse specialist in promoting evidenced based practice and effecting positive patient outcomes. Journal of Continuing Education in Nursing; 38: 6, 262-270.