In 2015 the Independent Cancer Taskforce published its recommendations on the strategic direction of cancer services in England.1 This document was quite explicit in its acknowledgement of the crucial role played by clinical nurse specialists (CNSs) and recommended that their numbers should be increased.
There had already been a significant growth in the numbers of CNSs in oncology over the previous two decades2 but this continued build up is not keeping pace with the steady increase in cancer incidence in the UK. This is despite evidence which strongly suggests that the CNSs make a significant impact on the quality of patient care and that they have demonstrated their cost effectiveness.3
The benefits that the existing CNS workforce can deliver are additionally undermined by the tendency of some trusts to redeploy CNSs into routine, non-specialist work in an effort to compensate for nursing shortages elsewhere. This is despite the recommendation of the Cancer Reform Strategy,4 that it is essential that the critical roles of the clinical nurse specialists in information delivery, communication and coordination of care are supported.
The role of the cancer CNS
The National Cancer Action Team (NCAT) described the CNS as a nurse who demonstrates high level skills in clinical practice and programme management, as well as developing practice and offering leadership.5 Their more detailed definition (see Resources section) acknowledges the growth of increasingly complex roles, which include proactive case management and the provision of psychological support and specialist symptom control. It highlights the importance of providing information to patients regarding their disease, its treatment and facilitating their clinical choices.
However, NCAT acknowledges that there are a variety of job titles with 78% of cancer specialist nurses holding the CNS title. Other titles include consultant nurse, advanced nurse practitioner and nurse specialist. Few would dispute that this is confusing and that role clarification is needed.6
This lack of clarity means that it is difficult to gain any consistency or nationwide agreement on the qualifications and qualities that are required by specialist nurses. The Royal College of Nursing proposes that clinical nurse specialists and nurse practitioners should be educated to degree level, have acquired specialist knowledge, skills, competencies and experience and be in possession of a number of key role components.7
This is not dissimilar to the view of cancer charity Macmillan that clinical nurse specialists should possess a first level degree and have completed postgraduate learning. Additionally, they should be clinical experts within a specialist field such as palliative care or specific cancer types.3
This reflects the reality of practice so far as the majority of CNSs focus on the treatment and care delivered to people in one distinct disease group. Breast care, colorectal cancers and urology represent the largest areas of activity in this regard.5 Alternatively, the CNS may work with one particular population group such as children, or concentrate on one specific treatment approach. Thus there are a growing number of CNSs throughout the UK who specialise in the treatment and care of the chemotherapy patient.
Although there is frequently a distinctive focus to their role, the remit of the CNS also includes leadership, educational, developmental and advocacy components. In many respects the CNS is very well placed to offer guidance and direction in the provision of care, act as a resource to others and empower the person with cancer. This is because they work in day-to-day practice, can influence care delivery organisation and systems, work closely with other members of the multi-professional team and can reach clearly defined groups of patients with improvement approaches.
The influence of the CNS can extend to other parts of the care continuum. Although most cancer CNSs are based in the acute sector, many will have close links with primary care. This is particularly important as this sector assumes a much more prominent role in the support of the person with cancer. This is perhaps best seen in the empowerment of those living with and beyond cancer, particularly as they are supported in adapting to life following the experience of prolonged and aggressive multimodal anticancer therapy, which is characterised by significant acute and long-term toxicities.
CNS provision
Not every person with cancer in the UK has access to a CNS. The provision of CNS care is very uneven in terms of geographical spread, with a marked degree of variance depending on location. Disease type also influences CNS provision. Breast cancer is the disease grouping that offers the greatest number of CNSs, followed by urology and colorectal cancer. Other disease groupings have little or no CNS cover. This is a matter of particular concern given that the CNS workforce is not expanding quickly enough to keep pace with a 3.2% annual growth of cancer incidence.5
Many of the CNS roles in current cancer nursing practice have been developed and initially funded by Macmillan cancer charity. The common practice is that Macmillan will provide ‘pump prime’ funding for a post. This usually lasts three years or less before a partner organisation (usually a Trust) assumes total responsibility for the role. The name Macmillan is often integrated into the job title and is retained even after the charity ceases to fund the post. In 2014 Macmillan funded 3,500 nursing posts in the UK – most of these were at CNS level.3
The value of the CNS
The cancer pathway can be complex, lengthy and disjointed, involving a wide variety of healthcare professionals in a range of care settings. The evidence would suggest that the current models of care are not fully meeting the needs of those affected by cancer and that there is a need for greater CNS input in order to optimise the quality of care and the efficacy of treatment. This will ultimately depend upon an individually tailored approach to care and empowerment of the individual is fundamental to this.
This is best realised through person-centred approaches to care. The central tenet behind person-centred care is ensuring that the needs and goals of the individual become central to the process of care.8 This requires the CNS to work with each person’s definition of their situation and to support people to participate in decision-making. The value of this can be seen in the analysis of the contribution that the cancer CNS makes to the quality of care. The national cancer patient experience survey in England demonstrates that people affected by cancer value the support and input of the CNS.9 Patients who have been allocated a CNS have been shown to be more positive about their experience of care, while CNSs are viewed as playing a valuable role in decision making and are regarded as trusted sources of information.3
Analysis of the work of the CNS has highlighted the cost effectiveness of the role. This is shown through a reduction in treatment costs, an increase in efficiency of care delivery and the facilitation of innovative practice. In practical terms CNSs contribute to a reduction in the rate of emergency admissions, the length of hospital stays, the volume of follow-up appointments, and the number of medical consultations. They also provide support so that people with cancer can be cared for in a place of their choice.3
Additionally, the CNS is a key player in many of the changes that are taking place in the NHS including personalised care planning, effective discharge planning, rapid access diagnostics and the provision of advice and information tailored to the patients needs.
The CNS role in oncology continues to evolve notably in those aspects of treatment and care that were formally undertaken by medical staff. These roles can include treatment review and follow up and are increasingly enhanced by the inclusion of non-medical prescribing.7 The close collaboration with the members of the multi-professional team is a common characteristic of the CNS role and they frequently undertake the role of key worker or care navigator.
The way forward
Few would dispute that these are challenging times for everybody involved in the provision of healthcare. Yet the future also offers considerable opportunities for nurses to develop their practice, strengthen their influence and contribute more fully to the quality of care.
In order to take advantage of these opportunities cancer CNSs need to consider a number of factors that affect their practice. Firstly, there is no agreed standard of skill and knowledge against what the practice of CNSs might be gauged. There is a need for a competency framework, national standards and a system of clinical appraisals that can offer transparency of practice and safeguards to both nurses and patients. Secondly, role developments and nurse-led clinics have often been ad hoc and poorly evaluated – there is a need for robust evidence of the effectiveness of CNSs and their impact on patient care. Thirdly, they need to articulate the scope and depth of their role more effectively and address the marked inequities in the provision of CNSs. This is given added urgency by rapid developments in cancer treatment and care. CNSs are already contributing to innovations in clinical practice such as acute oncology, personalised medicine, immunotherapy and targeted therapies.
Conclusion
There seems to be general unanimity that cancer CNSs make a valuable contribution to the quality and effectiveness of cancer treatment and care. Despite this, their numbers and availability are inadequate to meet the growing demand for their input. This is frequently compounded by poor utilisation of their knowledge, skills and experience.
Nonetheless there is significant potential in the role and it must be in the interests of all, particularly the person with cancer, that this is realised.
Resources
NHS cancer reform strategy – nhs.uk/NHSEngland/NSF/Documents/Cancer%20Reform%20Strategy.pdf
References
1. Independent Cancer Taskforce. Achieving world class cancer outcomes: A strategy for England 2015-2020. cancerresearchuk.org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf (accessed 22 October 2015).
2. Leary A, Mak V, Trevatt P. The variance in distribution of cancer nurse specialists in England. British Journal of Nursing 2011;20(4):228-230
3. Macmillan Impact Briefs. Cancer Clinical Nurse Specialist. macmillan.org.uk/impactbriefs (accessed 22 October 2015).
4. Department of Health. Cancer Reform Strategy. nhs.uk/NHSEngland/NSF/Documents/Cancer%20Reform%20Strategy.pdf (accessed 22 October 2015).
5. National Cancer Action Team. Quality in Nursing Excellence in Cancer Care: The Contribution of the Clinical Nurse Specialist, 2010. macmillan.org.uk/Documents/AboutUs/Commissioners/ExcellenceinCancerCaretheContributionoftheClinicalNurseSpecialist.pdf (accessed 22 October 2015).
6. Farrell C, Molassiotis A, Beaver K, Heaven C. Exploring the scope of oncology specialist nurses’ practice in the UK. European Journal of Oncology Nursing 2011;15(2):160-166.
7. Royal College of Nursing. Specialist nurses make a difference. RCN Policy Unit; Policy briefing 14/2009 rcn.org.uk/__data/assets/pdf_file/0006/588669/14.09_Specialist_Nurses_Make_a_Difference.pdf (accessed 22 October 2015).
8. Draper J, Tetley J. The importance of person-centred approaches to nursing care. open.edu/openlearn/body-mind/health/nursing/the-importance-person-centred-approaches-nursing-care (accessed 22 October 2015).
9. NHS England. Cancer Patient Experience Survey 2014. quality-health.co.uk/surveys/national-cancer-patient-experience-survey (accessed 22 October 2015).
