Comprehensive Notes on the Clinical Nurse Specialist Role in Cancer Care

Evaluation of the Clinical Nurse Specialist (CNS) Role in Cancer Care

Introduction to Advanced Nursing Practice

• Evolution of Nursing Practice: There has been expanding international interest in extending nursing practice beyond initial registration, leading to advanced nursing roles. The nurse's role has evolved over the past two decades due to factors such as developments in healthcare delivery, financial constraints, and increasing service user expectations (Furlong & Smith, 2005; East et al., 2015).

• Clinical Nurse Specialist (CNS) Role: A commonly identified category of Advanced Practice Nursing is the Clinical Nurse Specialist (CNS) role (East et al., 2015; International Council of Nurses, 2020), which has been evolving for over 20 years (Balsdon & Wilkinson, 2014).

• Definition of CNS: A CNS is an Advanced Practice Nurse who provides expert clinical advice and care based on established diagnoses in specialist clinical fields of practice (International Council of Nurses, 2020, p. 6).

• Global Presence: The CNS role is embedded in healthcare services in many European countries, Asia, Canada, and the USA, while other countries are just beginning to develop it (Fulton, 2018).

• Multifaceted Responsibilities: CNS responsibilities are diverse across settings, including:

  • Management of care (Leary & Baxter, 2014).

  • Management of patient caseloads (Vidall et al., 2011).

  • Information and support provision.

  • Teaching, audit, research, and service development (Farrell et al., 2011).

  • Leadership and educational components (Henry, 2015).

• Example of Role Diversity (Rheumatology): The CNS role in rheumatology was found to be approximately:

  • Clinical: $67\%$

  • Administration: $21\%$

  • Educational: $6\%$

  • Research: $4\%$

  • Consultation: $2\%$ (Royal College of Nursing, 2010).

• Challenges of Versatility: This versatility can lead to role ambiguity, misinterpretation of function, and improper use (Glover et al., 2006). Managers may perceive the CNS role as an 'unaffordable luxury' (Vidall et al., 2011, p. S23).

• Recognized Success: Despite challenges, the CNS role is considered a success in modern healthcare (Smy et al., 2011), recognized for its expertise in healthcare quality and positive patient outcomes (Fulton et al., 2016).

• Positive Patient Outcomes: Reported related to:

  • Alleviation of suffering.

  • Assessing and meeting informational needs.

  • Rescue work (e.g., related to drug toxicity).

  • Meeting psychological needs.

  • Access to knowledgeable professionals (Royal College of Nursing, 2010).

• Impact on Patient Experience and Productivity: Growing evidence highlights the CNS role's difference in improving patient experience and increasing productivity (Baxter & Leary, 2011; Macmillan Cancer Support 2015a).

• Cost Efficiencies and Savings (UK NHS): Investment in CNS roles can generate efficiencies and cost savings for the NHS in the UK (Vidall et al., 2011). In 2010, the cancer CNS model of one-to-one specialist care was estimated to reduce the net cost of cancer care in England by approximately $\$19\text{ million}$ per year (Frontier Economics, 2010).

• Role in Oncology (UK NHS): In oncology, CNSs are crucial for effective implementation of initiatives to improve cancer services (National Cancer Action Team, 2010).

  • Quicker Diagnosis and Treatment: Specialist nurses are essential for meeting targets in quicker diagnosis and treatment (Corner, 2003).

  • Early Issue Identification: Their specialist nature and key worker role enable them to quickly identify emerging issues requiring medical attention, facilitating care planning and avoiding emergency admissions (National Cancer Action Team, 2010).

  • Reduced Avoidable Admissions: A workload analysis for lung cancer CNSs showed a reduction in avoidable admissions for non-acute problems from four to a mean of $0.3$ per month (Baxter & Leary, 2011).

• Need for Evaluation: Despite evidence of positive impact, the full value of the CNS role is not always realized, and current models may not fully meet cancer patients' needs (Vidall et al., 2011; Macmillan Cancer Support 2015a).

  • Challenges in Evaluation: Difficult to define and quantify the variety of needs met by CNSs (Royal College of Nursing, 2009).

  • Critical Importance: Understanding the effectiveness of the CNS role on patient outcomes in cancer care remains critical (Fulton et al., 2016; Glover et al., 2006).

  • Data Collection: Essential to gather data on clinical outcomes to robustly demonstrate the CNS role's contribution to healthcare (Smy et al., 2011).

  • Ensuring Effective Resource Use: Full understanding of CNS contribution is needed to assure effective use of resources, especially with ICN guidelines (Balsdon & Wilkinson, 2014; International Council of Nurses, 2020).

• Aims of the Integrative Literature Review:

  • Primary Aim: To collate research evaluating outcomes associated with the role of the CNS in cancer care.

  • Secondary Aim: To clarify the components of the CNS role in cancer care from the included papers.

Methodology of the Review

• Approach: An integrative literature review adopted a systematic approach.

  • Rationale for Integrative Approach: Chosen to address review aims by providing a framework for a comprehensive review, allowing inclusion of both experimental and non-experimental research (Whittemore & Knafl, 2005).

• Five-Stage Framework (Whittemore & Knafl, 2005):

  1. Problem identification.

  2. Literature search.

  3. Data evaluation.

  4. Data analysis.

  5. Presentation.

• Data Analysis Approach: Involved an iterative process of constant comparison of extracted data to identify themes and deviances.

  • Four stages of systematic data analysis:

    1. Data Reduction: Used a classification system for diverse methodologies, followed by data extraction and coding.

    2. Data Display: Developed charts for comparing data from primary sources.

    3. Data Comparison: Iterative examination of data displays to identify patterns, themes, or relationships.

    4. Conclusion Drawing and Verification: Interpretation of patterns to a higher level of abstraction, identifying commonalities and variations.

• Audit Trail: Maintained throughout the process.

Search Method

• Databases: Four databases were selected: Cinahl, Medline, PubMed, and Cochrane Library.

• Key Search Terms: Developed after an initial literature review and adapted for the primary aim. Linked with AND/OR Boolean operators:

  • (a) Clinical nurse specialist, Specialist nurse, Nurse specialist, Specialist practice nurse, Advanced practice nurse.

  • (b) outcome, effect, impact, Evaluat*.

  • (c) cancer, oncology.

• Independent Searches & Consensus: Database searches were completed independently by the three authors, who then reached a consensus on included papers.

• Supplementary Searches: Reference lists of included papers and grey literature were also searched.

Inclusion and Exclusion Criteria

• Timeframe: Limited to January $2009$ to July $2019$ for recent research.

• Language: English language only.

• Exclusion Reasons:

  • Research not related to the primary aim.

  • Research evaluating other healthcare professionals in addition to the CNS.

  • Papers not published in English.

  • Research evaluating other interventions unrelated to the CNS role.

Data Extraction and Quality Appraisal

• Data Extraction: Relevant data was extracted using a standardized form (HK) and independently reviewed (MD and OMcS).

  • Extracted Data: Country, setting, study objective, study design, population, sample size, intervention description, outcome measures, results, and relevance.

• Quality Appraisal: Methodological rigor of each paper was assessed using relevant Critical Appraisal Checklists from the Joanna Briggs Institute (2020).

  • Rating: Studies were rated as weak, moderate, or strong based on design and methodology.

Results of the Literature Search

• Initial Identification: $688$ papers identified from four databases (July 2019); no additional papers from reference lists or grey literature.

• Duplicates Removed: $168$ duplicates removed, leaving $520$ records.

• Title/Abstract Review: $520$ records screened; $468$ identified as not relevant.

• Full-Text Review: $52$ full-text papers reviewed; $38$ further excluded.

• Included Papers: $14$ eligible research papers included in the review (Figure 1).

Methodological Characteristics

• Countries Represented:

  • UK: $n=9$

  • Australia and New Zealand: $n=1$

  • Denmark: $n=1$

  • Ireland: $n=1$

  • Netherlands: $n=1$

  • South Korea: $n=1$

• Cancer Diagnoses: Included a range of cancers ($n=3$), breast cancer ($n=5$), colorectal cancer ($n=1$), gastric cancer ($n=1$), gynaecological cancer ($n=1$), hepatobiliary and pancreatic cancer ($n=1$), lung cancer ($n=1$), and prostate cancer ($n=1$).

• Research Designs:

  • Quantitative: $7$

  • Qualitative: $3$

  • Mixed Methods: $2$

  • Audit: $1$

  • Multiple Case Study: $1$

• Perspectives Included:

  • Patients: $12$

  • Carers: $1$

  • Healthcare Professionals: $3$

  • CNS: $3$

Methodological Rigour

• Assessment (Joanna Briggs Institute, 2020):

  • Strong: $5$ studies

  • Moderate: $8$ studies

  • Weak: $1$ study

Findings: Primary and Secondary Aims

The primary aim was to evaluate outcomes associated with the CNS role in cancer care. Evaluations were predominantly positive, focusing on six key areas: psychological, information, clinical, service delivery, patient satisfaction, and cost-effective outcomes. The secondary aim was to identify CNS role components: psychological support, education and information, clinical contribution, and service delivery.

Psychological Outcomes

• Predominantly Positive Evaluation: The CNS role was positively evaluated for providing psychological support to cancer patients and their carers.

  • Emotional Support: Individuals in areas with higher specialist nurse staffing were more likely to report receiving enough emotional support (Griffiths et al., 2013). (Sample size: $67,713$; observational study, no causal inference).

  • Valued Support: Individuals with prostate cancer valued the psychological support offered by CNSs (Ream et al., 2009). (Mixed methods study: $4$ CNSs, $19$ colleagues, $40$ men).

  • Increased Discussion Opportunities: For breast cancer patients, opportunities to discuss worries/concerns increased from $71\%$ (pre-CNS) to $82\%$ (post-CNS) (Hardie & Leary, 2010).

  • No Difference in Anxiety: A randomized equivalence study comparing telephone consultation with a CNS vs. face-to-face with a medical doctor found no difference in anxiety levels for breast cancer patients (Beaver et al., 2009).

  • Confidante Role for Carers: Bereaved carers felt at ease discussing concerns with the CNS, leading to anxiety relief (Borland et al., 2014).

• Negative Finding: One mixed-methods study reported lowest satisfaction from breast cancer patients regarding emotional support, specifically lack of information about potential emotional changes (Droog et al., 2014).

• Supporting Studies: Three quantitative, two mixed methods, and one qualitative study.

  • Methodological Rigour: Two strong (Griffiths et al., 2013; Beaver et al., 2009), three moderate, one weak.

• CNS Role Components (Secondary Aim):

  • Reassurance: CNSs provide reassurance to patients (e.g., colorectal cancer) (Jeyarajah et al., 2009).

  • Holistic and Supportive Approach: CNSs view cancer in the context of the person's whole life, not just symptoms (Griffiths et al., 2013).

  • Emotional Support in Challenging Scenarios: Provide emotional support and reassurance when sharing test results (prostate cancer, Ream et al., 2009) and to women with gynaecological cancers and their families (Cook et al., 2019).

  • Confidante for Carers: Act as confidantes for bereaved carers who don't want to burden family (Borland et al., 2014).

Information Outcomes

• Improved Knowledge and Understanding: The CNS role, especially in providing information and education, leads to improvements in patient knowledge.

  • Diagnosis and Investigations: An audit showed CNSs improved awareness of diagnosis and provided better information on investigations and timelines for hepatobiliary and pancreatic cancer patients (Pollard et al., 2010).

  • Enhanced Access to Information: Both prostate cancer patients and CNSs reported CNSs improved access to information (Ream et al., 2009).

  • Breast Self-Examination Education: CNS-provided education significantly increased self-reported frequency of breast self-examination after a breast cancer diagnosis (Visser et al., 2015).

    • Limitations: Small sample size ($29$ completing questionnaires) and data limited to three months post-intervention, restricting generalizability and long-term implications.

  • Financial Information for Carers: Bereaved carers valued CNSs for information on financial matters (Borland et al., 2014).

• Negative Findings/Challenges:

  • No Difference in Information Provision: One cross-sectional study found no significant differences in patients reporting receiving the 'right amount of information' between areas with high vs. low specialist nurse staffing (Griffiths et al., 2013). CNSs attributed this to staff shortages and role ambiguity.

  • Lack of Nutritional Information: $59\%$ of breast cancer patients in a mixed-methods study reported not receiving enough information on nutritional needs from CNSs (Droog et al., 2014).

• Supporting Studies: Two quantitative, two mixed methods, one qualitative, and one audit.

  • Methodological Rigour: One strong, five moderate.

• CNS Role Components (Secondary Aim):

  • Education Providers: CNSs serve as educators for patients with prostate, colorectal, and hepatobiliary/pancreatic cancers.

  • Support for Carers: Carers also benefit from information provided by CNSs (Borland et al., 2014).

Clinical Outcomes

• Improved Symptom Management: The CNS role positively impacts clinical outcomes, especially symptom management.

  • Pain and Fatigue Reduction, Quality of Life Increase: A quantitative study showed CNS interventions diminished pain and fatigue intensity scores and increased health-related quality of life for cancer patients undergoing chemotherapy (Kim, 2011).

    • Study Details: Longitudinal study, $112$ participants ($n=65$ experimental, $n=47$ control) at baseline and after two chemotherapy sessions, capturing long-term effects. No significant effects on anxiety or ER visits.

  • Symptom Management and Prescribing: Lung Cancer CNSs were found to support better management of symptoms and swift, accurate prescribing (Tod et al., 2015). (Multiple case study: $4$ CNSs, $24$ clinicians).

  • Nurse-Led Clinics Improve Symptom Management: A prospective study highlighted nurse-led clinics vastly improved symptom management for colorectal cancer patients, though outcome measures weren't specified (Jeyarajah et al., 2009).

  • Support for Chemotherapy Side Effects: Patients with breast cancer in Trusts with fewer patients per specialist nurse were more likely to report good support for chemotherapy side effect control (Griffiths et al., 2013).

  • Equivalence to Consultant Care: A quantitative study randomized pelvic cancer patients into usual care, nurse-led algorithmic care, or consultant-led algorithmic care. Symptom improvement was similar in nurse and consultant arms over six months for gastric cancer patients (Jordan et al., 2017).

  • No Difference in Investigations/Recurrence: No differences were found between nurse-led and traditional medical consultation groups in terms of clinical investigations ordered or time to detection of recurrences for low-to-moderate risk breast cancer patients (Beaver et al., 2009).

• Supporting Studies: Four quantitative, one mixed methods, and one multiple case study.

  • Methodological Rigour: Four strong, two moderate.

• CNS Role Components (Secondary Aim):

  • Direct Care: Clinical CNS roles involve providing direct patient care, particularly improving symptom management.

  • Specific Symptoms: Improvements reported in breathlessness, pain, and fatigue (Kim, 2011; Tod et al., 2015).

Service Delivery Outcomes

• Positive Impact on Service Delivery: The CNS role positively impacts service delivery, including continuity of care, patient advocacy, and increased access to services.

  • Continuity of Care: Continuity with the same breast care nurse and the trusting relationship improved service delivery experience for breast cancer patients (Beaver et al., 2010).

  • Accessible Point of Contact: Prostate cancer patients reported CNSs as a continuous, accessible point of contact, providing a personal approach in an otherwise impersonal service (Ream et al., 2009).

  • Ease of Contact: High specialist nurse staffing levels were associated with better patient experiences, such as being given a specialist nurse's name and finding them easy to contact (Griffiths et al., 2013).

  • Patient Advocacy: CNSs' value in advocating for patients was acknowledged by CNSs, prostate cancer patients (Ream et al., 2009), and hepatobiliary/pancreatic cancer patients (Pollard et al., 2010).

  • Ease of Access to Services: Cancer patients reported CNSs positively affected their ease of access to services (Kim, 2011).

  • Access to Additional Services: Bereaved carers reported CNSs improved timely access to additional services, such as medical consultants (Borland et al., 2014).

    • Recall Bias Consideration: Study recruited $7$ participants (one female), time from bereavement ranged from $3$ months to $2.5$ years, potential for recall bias.

• Positive Evaluation by Clinical Colleagues:

  • Eased Pressure on Medical Staff: Medical consultants reported CNSs eased pressure by running nurse-led clinics for prostate cancer patients (Ream et al., 2009).

  • **

Findings: Primary and Secondary Aims

The integrative literature review investigated two primary aims:

1. Primary Aim: To collate research evaluating outcomes associated with the role of the CNS in cancer care.

   • Overall Evaluation: Outcomes were predominantly positive, focusing on six key areas:

     • Psychological Outcomes: Positively evaluated for providing psychological support. Individuals with higher specialist nurse staffing reported receiving more emotional support ($67,713$ sample size) (Griffiths et al., 2013). Prostate cancer patients valued CNS psychological support (Ream et al., 2009). Breast cancer patients (pre-CNS $71\%$ to post-CNS $82\%$) saw increased opportunities to discuss worries (Hardie & Leary, 2010). Bereaved carers found CNSs acted as confidantes and reduced anxiety (Borland et al., 2014).

     • Information Outcomes: Led to improvements in patient knowledge and understanding. CNSs improved awareness of diagnosis and information on investigations for hepatobiliary and pancreatic cancer patients (Pollard et al., 2010). Prostate cancer patients reported enhanced access to information (Ream et al., 2009). CNS-provided education significantly increased breast self-examination frequency for breast cancer patients (Visser et al., 2015).

     • Clinical Outcomes: Positively impacted, especially symptom management. CNS interventions diminished pain and fatigue intensity scores and increased health-related quality of life for cancer patients undergoing chemotherapy ($n=112$ participants) (Kim, 2011). Lung Cancer CNSs supported better symptom management and prescribing (Tod et al., 2015). Nurse-led clinics vastly improved symptom management for colorectal cancer patients (Jeyarajah et al., 2009).

     • Service Delivery Outcomes: Positively impacted, including continuity of care, patient advocacy, and increased access to services. Continuity with breast care nurses improved service experience (Beaver et al., 2010). CNSs provided an accessible, continuous point of contact for prostate cancer patients (Ream et al., 2009). High specialist nurse staffing levels were associated with better patient experiences regarding ease of contact (Griffiths et al., 2013). CNSs were acknowledged for patient advocacy by patients and healthcare professionals alike (Ream et al., 2009; Pollard et al., 2010).

     • Patient Satisfaction Outcomes: Generally improved patient satisfaction.

     • Cost-Effective Outcomes: Investment in CNS roles can generate efficiencies and cost savings for the NHS in the UK; the cancer CNS model was estimated to reduce the net cost of cancer care in England by approximately $\$19\text{ million}$ per year (Frontier Economics, 2010).

2. Secondary Aim: To clarify the components of the CNS role in cancer care from the included papers.

   • Key Components Identified:

     • Psychological Support: Providing reassurance, holistic care, and emotional support in challenging scenarios, and acting as confidantes for carers.

     • Education and Information: Serving as educators for patients across various cancer types and providing support for carers, including financial information.

     • Clinical Contribution: Direct patient care, particularly improving symptom management (e.g., breathlessness, pain, fatigue), and supporting prompt prescribing.

     • Service Delivery: Enhancing continuity of care, acting as an accessible point of contact, advocating for patients, and facilitating access to additional services, while also easing pressure on medical staff.