Art & science | role review

A trust-wide review of clinical nurse specialists’ productivity Helen Balsdon and Susan Wilkinson describe a trust’s internal review to assess whether nursing resources were being used effectively Correspondence susan.wilkinson@addenbrookes. nhs.uk Helen Balsdon is divisional lead nurse, cancer division (oncology) Susan Wilkinson is divisional lead nurse for surgery (surgical division) Both at Addenbrooke’s Hospital, Cambridge Date of submission January 17 2014 Date of acceptance March 3 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nm.rcnpublishing.com

Abstract The contribution made by clinical nurse specialists (CNSs) to patient care needs to be understood fully to provide assurance of effective use of resources. However, CNS roles are often poorly understood and not easily articulated. Due to the diversity of these roles, robust reviews of performance and economic benefits can be regarded as time consuming and resource intense, and many organisations enlist external agencies to clarify the contribution to care made by their CNSs. This article gives an overview of a Cambridge University Hospitals NHS Foundation Trust internal review of CNS roles without the support of an external agency. The review provided assurance that this group of nurses is being used effectively and identified opportunities to use the role in different ways to increase effectiveness. Keywords Clinical nurse specialist, role review, nurse-led practice, patient pathways THE NHS is under pressure to improve care while keeping associated costs low (Vidall et al 2011). Nursing is one of the largest staff groups in the health service, so it has to account for how many of the finite resources are allocated. Although direct nursing care and ward establishments are being reviewed, there is likely to be an increase in the number of nurses at ward level rather than a reduction (Royal College of Nursing (RCN) 2010a, Francis 2013). Many NHS organisations are exploring innovative ways to deliver patient-focused services that make the best possible use of the nursing workforce,

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including autonomous nurse-led clinical activity, for example by clinical nurse specialists (CNSs). But, even though the contribution to patient care by CNSs is well documented and considered vital, it is one of the least understood nursing roles (Department of Health (DH) 2007, Keenan et al 2010, National Cancer Action Team 2010, RCN 2010b). Reviews of CNS roles over the past few years have tended to focus on their qualitative contribution to holistic patient care (Norton et al 2012), which has done little to define their quantitative financial contributions, such as through admission avoidance and reduced length of stay. In addition, CNSs have affected medical roles, for example by taking on work in areas such as clinics that were previously medically led. However, CNSs still find it difficult to define what they do and make this definition widely known (Leary 2011). A census of cancer nurse specialists, for example, revealed that not only those outside the profession but also some nurse leaders found it difficult to identify the functions of the CNS role (Leary 2011, Vidall et al 2011, Norton et al 2012). Information technology programmes have been developed to help senior managers and nurse leaders understand the CNS role better, by calculating optimum caseload and quantifying CNS contributions to care, particularly in cancer services. One of these programmes, ALEXA (DH 2012), was developed by the Quality in Nursing Group of the National Cancer Action Team, the responsibilities of which are now held by NHS Improving Quality, in an attempt to address April 2014 | Volume 21 | Number 1 33

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Art & science | role review

the huge variation in CNS caseload and provide meaningful patient access to CNSs. ALEXA is a mathematical tool that quantifies the ratio of CNS posts required to support caseloads. However, while such tools can help to identify optimum caseloads, they do not identify productivity outputs or contextualise the CNS role in multidisciplinary teams. It is likely that this is why the role has been under so much scrutiny over the past decade by senior managers and nurse leaders, particularly when financial pressures have been high (Smy et al 2011, Norton et al 2012).

Local context Cambridge University Hospitals NHS Foundation Trust (CUH) is a large teaching hospital site and tertiary referral centre for patients with a wide range of conditions. In November 2012, health service regulator Monitor raised formal concerns about CUH’s financial viability, board performance and breach of several targets relating to cancer treatment and emergency care waiting times. These breaches meant the trust had to put in place rapidly an executive-level taskforce to improve performance. One component of the initiative was to review the organisation’s 34 April 2014 | Volume 21 | Number 1

workforce, and the review of CNSs was part of the nursing productivity workstream. At this time, there were 286.89 whole time equivalent (WTE) CNSs in the trust across 24 teams of specialties, as well as stand-alone posts, with a headcount of 339 including part-time staff. Castille and Robinson (2011) had identified that the trust had more CNSs than similar-sized NHS organisations but nevertheless the number of CNSs and their roles in the trust had continued to grow. The development of CNSs since they were introduced at CUH in the late 1980s has not only helped reduce junior doctors’ hours, but also provided nurses with more varied career structures and extended their knowledge and expertise (Castledine 2003). Historically CNSs have outlined and set their own agendas for training and development rather than there being generic objectives, skills and knowledge. It used to be common practice in the trust, for example, to have band 7 specialist nurse posts to support new consultant appointments so that CNSs often developed their roles according to needs and wishes rather than more strategically agreed service requirements. This resulted in the number of these roles increasing with little consistency in how they developed, equity of caseload, knowledge and skills, decision making or level of autonomy.

Specialist productivity The trust’s nurse specialist productivity workstream has been running since 2011, a year before the Monitor review. The main driver was the need to identify ways to save money, and an initial assessment by external reviewers suggested there was an opportunity to make a 10% saving in this work group; however this was an overall figure without detail. Over a two-year period from 2011 to 2013, several issues were identified by internal and external reviewers, such as differing caseloads, levels of autonomy and service delivery, and measures were taken accordingly. These included the compilation of a comprehensive list of CNSs in post, the drawing up of standardised job descriptions for bands 6, 7 and 8a CNSs, and the provision of administrative support. A baseline understanding of CNSs’ financial contribution to the trust was also completed to identify nurse-led activity that generates income. However, despite this work, the turnaround team, comprising internal and external personnel, continued to suggest that the ‘opportunity of a 10% saving’ had still to be realised, so a subsequent external review quantified and costed patient NURSING MANAGEMENT

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pathways and contact time using data provided and presented by the CNSs or team leaders. This process proved useful if the activity being measured was led by nurses, because nurse-led activity could be tracked through the hospital system clearly. However, the approach was limited where CNSs managed complex, longitudinal pathways or where they focused on pathways co-ordination, support and advice, much of which is provided in outside clinics and is therefore not formally coded or recorded. When the results of the review were made available, it became apparent to senior nurse leaders that it had been flawed by inconsistencies in the trust’s clinical divisions and across the organisation. Discussions among senior nurses identified various possible reasons for this, including: ■■ The external review team having to take the information presented to them by postholders at face value. ■■ Lack of understanding about the organisation and how it operates to deliver the services in which the nurses worked. ■■ Lack of consideration of the role of CNSs in the context of interdisciplinary teams. ■■ An inability to capture CNS activity on the hospital information system consistently, which meant robust activity data, especially relating to phone calls, was limited. ■■ A reliance on the nurses’ ability to ‘sell’ what they do, and how they do it, to the reviewers. ■■ The review was undertaken quickly, over about two days, which limited how much time individuals had with the review team. ■■ Inconsistency of which internal staff were on the review team. Table 1

Example of timetable that records work of clinical nurse specialists CNS 1

Mon

Tues

Faced with the limitations and inconsistencies of the external review, and the continued pressure to deliver a consistent assessment of the CNS workforce, the trust agreed to a robust internal review. Two lead nurses, both of whom had previously held CNS posts, were appointed to lead this work and were released from their roles part time for four weeks to complete the project. They used a straightforward, practical approach that involved triangulation of various information sources, including postholder-written job plans, cross-referencing timetables of CNSs’ working in teams to identify duplication, and activity data collected by questioning postholders’ line managers. Table 1 gives an example of the timetable used and Box 1 (page 36) lists some of the questions asked by reviewers. Information sources included the hospital patient records system, clinic templates and any audit reports produced by services. This approach enabled clear and consistent gathering of quantitative and qualitative supporting evidence, which was validated by the clinical directors and lead nurses for each specialty. The information was used to build a picture of the CNSs’ workload and understand their roles in relation to service needs; if further clarification was required, it was discussed with the postholder. The work was undertaken with senior managers, usually line managers, the service clinical directors and a nurse if the line manager in each case was not a nurse. This enabled questioning and discussion about how each of the services use the CNS role, and the level of clinical decision making CNSs are required to perform to deliver the services. It also identified the level of role autonomy so that the review could consider banding of the postholders to ensure trust-wide consistency.

CNS 2

CNS 3

AM

Nurse-led clinic (five return Management of patient patients hotline

Support consultant clinic (key worker)

PM

Ward round to facilitate nurse-led discharge

Ward round

Nurse-led new patient clinic (six patients)

AM PM

Weds

AM PM

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Art & science | role review Box 1 Examples of questions that are used in the review process ■■ What is the structure of the team and what staff does it have? ■■ What does each nurse in the team do day by day? ■■ What is the case load? ■■ What are the cross-cover arrangements? So what happens when the postholder goes on leave? ■■ Is there administrative support? ■■ Tell us about the types of decisions the postholder makes in day-to-day practice? This approach also ensured that service leaders and senior clinicians were part of the review process early, and discussion about the roles and how the services use them meant that managers and clinicians could critically evaluate their services’ needs and how the CNSs contributed toward these, and explore different ways of working to enhance or maximise use of the role if deficits were identified. Although the CNS postholders provided job plans and other supporting information such as patient pathways, policies written and educational qualifications, these were not included in the discussions with managers and clinicians. This was a decision based on the need for an objective approach and in recognition of the fact that this group of nurses had already been subjected to a number of reviews; it was considered that emotions were at risk of clouding objectivity. The specialist nurses had already provided the required information in the earlier reviews and been involved in the processes, and this information was available to the authors and managers. Where necessary, details were clarified with the CNSs directly. The findings were presented to divisional management teams, comprising divisional directors, divisional lead nurses and the divisional associate directors of operations, to review and assess the risk of any opportunities for different ways of working, increasing productivity and the potential savings that were identified. The outcomes were then presented to a scrutiny panel, which included executive directors, to authorise the divisional plans.

Findings The methodology was consistent and replicable for teams of CNSs and for single postholders, so all 339 CNS roles were reviewed using this approach over a four-week period. The review identified widespread examples of high-quality contributions to care and innovative practice delivered by CNSs across the organisation. Examples include nurse-led 36 April 2014 | Volume 21 | Number 1

two-week-wait cancer referral clinics, where many patients are managed solely by CNSs, nurse-led rapid access services and telephone triaging. Many CNSs used nurse prescribing, clinical assessment and other skills to develop services and improve specialist nurse-led practice, and in many cases CNSs were the leaders and directors of patient care. The review also identified several unique roles, many of which reflect the high-volume tertiary services provided in the trust that have resulted from centralisation. The roles include allergy, lysosomal and oncological management. It also identified a range of opportunities for making potential savings or, at least, reconfiguring services to increase productivity. These were mainly found: in teams that had several CNSs and where there was multiple duplication; where there was significant overlap as different teams covered different parts of patient pathways; and where there was a high volume of tasks that could be undertaken easily by more junior nurses or healthcare support workers, as they required limited decision making by registered nurses or were administrative.

Discussion The role of the CNS has evolved over the past 20 years and is expected to continue to do so because pushing the boundaries remains essential to developing expert and innovative nursing practice. However, it is vital that the roles evolve in line with service needs as well as with personal and professional development of postholders. Some specialist nurses and managers can find it challenging to articulate the contribution that CNSs make to patient care, especially when the clinics or services are not specifically nurse-led. To ensure the role is easily understood and translated, all nurses must overcome this barrier, which will require support from senior nurses in organisations. In addition, trust information systems should ensure that all staff, including CNSs, can record activity and quantitative service data that can support triangulation of multiple sources of information, by which productivity gains related to any nursing post can be measured. The internal review showed that it is possible to use local nursing expertise to review nursing services and equity of banding of postholders across an organisation. However, to achieve this, the methodology must be clear and easily replicable across different specialties and different posts. There should also be a small number of reviewers involved who are given time to focus on this work over a specified time. NURSING MANAGEMENT

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Reviewing many roles quickly kept the momentum going and supported constant comparison between the reviewers as they were immersed in the project, particularly in relation to banding. Engagement of managers and senior professionals early in the process was also critical to the success of the review. This piece of work was not, however, without challenges. Overcoming pre-conceptions that the reviewers were going to ‘slash and burn’ CNS posts with no consideration of service requirements was crucial before starting the process. Other challenges included: ■■ Defensive attitudes of staff who perceived the purpose was only to deliver cost savings and head count reduction with no understanding of the CNS role and contribution to care. ■■ Paternalistic attitudes of medical colleagues, as demonstrated by comments about ‘my’ nurse and letters of support from CNSs’ medical colleagues about the nurse rather than the post. ■■ Concurrent change processes. ■■ Difficult decision making. ■■ Role development beyond what the post requires. ■■ Change of chief nurse at the trust during the review. It was also challenging to review the role of one staff group, that of the CNS, in isolation from the rest of the multidisciplinary teams as they all contribute to services. Ideally the whole multidisciplinary team in each service should be reviewed together, although this would require whole-system re-design of the method.

Conclusion The review provided insight into the autonomous nurse-led services across the trust, and went some way to explain why CUH had a higher-than-

average WTE CNS workforce compared with other organisations. For example, consider the nurseled two-week-wait referral clinics to support local and national cancer campaigns; these were not nurse-led services in other organisations when benchmarking was carried out. A number of recommendations came out of the project, including the need to: review other roles such as speech and language therapists, and research nurses; examine where there are clear links across patient pathways; and look at where there are multiple nurses involved at different stages in patients’ pathways. A sustainable future for CNS roles requires nurses and their managers to be able to articulate clearly their contribution to care, and ensure effective use of the role in meeting service needs and the ability to demonstrate value for money, particularly in relation to patient safety and quality of care (Leary 2011). As a result of this review, the trust has agreed to annual CNS job planning that incorporates service needs and includes the collation of qualitative and quantitative data. Job plans will be reviewed and agreed by the lead nurse in each service area, which should provide CNSs and their managers with core information to enable them to articulate their contribution to care. The internal review identified real and informed opportunities for savings and quantifiable productivity gains without compromising patient care, as opposed to a ‘blanket’ percentage cut. This suggests that organisations need not depend always on external consultancies to review their nursing workforce. The methodology could be applied to other non-ward based nursing roles, such as practice development and research nurses.

Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared

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Keenan E, Eaton K, Adam S (2010) Using a database to demonstrate the clinical nurse specialists contribution to patient care. Nursing Times. 106, 22, 14-17. Leary A (2011) Proving your worth. Nursing Standard. 25, 31, 62-66.

Department of Health (2007) Cancer Reform Strategy. tinyurl.com/lsroyda (Last accessed: March 4 2014.)

Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry; Executive Summary. tinyurl.com/bkgyem7 (Last accessed: March 7 2014.)

Department of Health (2012) ALEXA Caseload Tool: User Guide. DH, London.

National Cancer Action Team (2010) Excellence in Cancer Care: The Contribution of the Clinical

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Nurse Specialist. NCAT, London. tinyurl. com/6wz3w25 (Last accessed: March 4 2014.) Norton C, Sigsworth J, Heywood S et al (2012) An investigation into the activities of the clinical nurse specialist. Nursing Standard. 26, 30, 42-50. Royal College of Nursing (2010a) Guidance on Safe Nurse Staffing Levels in the UK. RCN, London.

Smy J, Young A, Barlow H (2011) Making clinical nurse specialists make more of an impact. Health Services Journal Online. tinyurl.com/oqgf3go (Last accessed: March 4 2014.) Vidall C, Barlow H, Crowe M et al (2011) Clinical nurse specialists: essential resource for an effective NHS. British Journal of Nursing (Oncology Supplement). 20, 17, S23-27.

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A trust-wide review of clinical nurse specialists' productivity.

The contribution made by clinical nurse specialists (CNSs) to patient care needs to be understood fully to provide assurance of effective use of resou...
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