Undervalued, overworked and misunderstood: survey highlights challenges facing specialist nursing

With the number of people living with long-term conditions on the rise in the UK, the role of the CNS is more important than ever: but is the NHS missing what makes specialist nursing special?

A survey of nurses across Oyster Healthcare Communications’ four Clinical Communities found 40% are expected to cover the wards when their hospital enters operational difficulties, 85% work unpaid overtime, 26.5% have to take annual leave to attend educational events and 40% have suffered work-related stress in the last year. Of the 142 nurses who took part, 90% said their trust had no form of succession planning in place.

It’s hard to overstate the impact a specialist nurse can have on the life of someone living with a chronic condition.

Report after report has reinforced the importance of Clinical Nurse Specialists (CNS) in the management of just about every long-term condition and life-changing disease. They are highly educated in their therapy area, a constant source of support and work over and beyond the call of duty simply because they care.

Despite all this, they could soon become an endangered species, according to more than 140 nurses who answered a Clinical Communities survey. At the very moment the NHS is calling upon itself to become more patient centred, reduce emergency admissions and help people manage their own long-term conditions, it is placing under threat the very mechanism to achieve this: the CNS.

Justify your existence

We surveyed the nurses across our four Clinical Communities, IBD Today, Liver Today, MS Today and Blood Club, and found a sea of discontent and low morale brought on by a (seemingly) never-ending need to “justify your own existence”.

Of the nurses who took part, 40% said they had suffered work-related stress in the last year and 85% said they regularly worked unpaid overtime, ranging from one to more than 15 hours each week.

Their responses provide evidence that the role of the CNS is misunderstood, undervalued and beset by issues of lone working.

Dr Alison Leary is a professor of healthcare and workforce modelling and has been working to promote specialist nurses for the last decade.

She said: “The reason specialist nursing evolved in the first place is unmet need. Across specialisms, nurses do the things other colleagues don’t: case management, brokering, getting people to see the right people at the right time – they run services, they manage caseloads – without them, it would be disastrous.

“They are experts. In any other safety-critical profession you keep your experts on the front line and that’s what should be happening in healthcare.”

What is a specialist nurse?

There is a basic misunderstanding around what the role entails, demonstrated by the 40% who said they were expected to cover the wards when their hospital entered operational difficulties.

Specialist nurses are highly trained, highly educated healthcare professionals who work autonomously to build their service and manage their, often inflated, caseload. They do everything a doctor would do and more. In our survey, 40% even prescribed drugs.

Chief Executive of the British Liver Trust, Andrew Langford, is a nurse by training, and said our survey demonstrated a “large-scale undervaluing of the role”.

“There is still a stigma of what a nurse is compared to other healthcare professionals, particularly doctors, and there is an undervaluing of the holistic range of issues specialist nurses can cover, particularly mental health issues linked to the condition,” he said.

Invaluable, holistic care

“Specialist nurses provide an invaluable service to patients. They provide the holistic care that many other HCPs do not: not because they don’t want to but because it’s not part of their role.”

More than half, 56%, of our sample, work alone, and 52% of those say their services are suspended when they are ill or on holiday.

“This puts no value on the services whatsoever. It says we will have them 45 weeks of the year, and heaven help those patients who fall ill when the nurse is not around,” Andrew said.

Karen Bennett, Macmillan Haematology CNS at Barts Health NHS Trust, and Blood Club Clinical Editor, said working alone also meant there were limited opportunities to develop services.

“I would love to be able to share my service with another CNS. My service is suspended when I am on leave, so I give out my private mobile. I take a couple of calls because people need to be pointed in the right direction,” she said.

Professor Leary, who has developed the Apollo Nursing Resource, a website carrying realms of support and resources for specialist nurses, said this was not rare.

‘Virtue script’

“The way specialist nursing is treated is a reflection of nursing not being valued,” she said.

“Nursing relies on the ‘virtue script’ about being a nice, kind person, but what underlines nursing care is knowledge and skills, and nurses often sell themselves short.”

Collecting the evidence needed to do that is often a double-edged sword, however. The nurses we work with tell of a continual merry-go-round of proving yourself that is both exhausting and demoralising.

In our survey, almost 70% said they had been asked to justify their role though data collection, yet only 16% had been given the support they needed to do that.

“We need to be more confident in voicing what we do and the positive impact it has on patient care. Unfortunately, this does not always come naturally,” said Fiona Fry, Chair of the British Association for the Study of the Liver’s Nurse Forum.

“As nurse specialists, we have very clear job plans and keep robust data on activity within our services. Despite this, we are often required to justify our roles, which leads to increased pressure and often leaves the nurse or team feeling insecure and demoralised.”

Generating evidence

The MS Trust runs the innovative GEMSS (Generating Evidence in Multiple Sclerosis Services) programme, teaching nurses how to catalogue their caseload and record their work.

“This is really important because people with MS reported the person they go to most about their condition is their MS nurse. The MS nurses are the hub of the specialist networks, and they fulfil a really important expert role that helps people with MS cope,” said Geraldine Mynors, GEMSS Programme Manager.

The picture, she said, was “not as gloomy as this survey suggests”.

“The MS Trust was aware back in 2010/11 of a big need to increase the number of MS specialist nurse posts, and since then, lots have come into being,” she said.

Despite that, a report the charity published last year, Defining the Value of Specialist Nursing, identified a UK-wide shortfall of 62 MS nurses.

It is a misunderstanding of the role that leaves specialist nursing vulnerable to cost cutting.

“We are an expensive group on the face of it, but when you look closer we are very good value for money,” said Fiona, who is also Clinical Editor of Oyster’s Liver Today Clinical Community.

The majority of our sample, 95 of the 142, said they were at Band Seven on the NHS pay scale, putting their salary at somewhere between £30,000 and £40,000.

Compare that to the average Band Five nurse, earning between £21,000 and £25,000, and you see how the CNS role can look expensive on paper, making them a target for the bean counters.

Investing in quality care

The truth is specialist nurses save money. Most will run telephone and/or email helplines: they are the first point of call for their patients.

As such, they help avoid complications that might otherwise have resulted in costly hospital admissions, they answer questions that might otherwise necessitate a consultant appointment, they help their patients learn to manage their condition independently, freeing up countless resources and saving cold, hard cash.

Aileen Fraser is one of Royal College of Nursing’s representatives on the British Society of Gastroenterology’s Inflammatory Bowel Disease Committee ­– last year, her service tariffed far more than it cost the University Hospitals Bristol NHS Foundation Trust.

“I know that because I collected the data: it is not difficult to do and everybody needs to be doing it,” she said.

“Everyone who calls themselves a specialist nurse and who runs a specialist service needs to be putting annual reports together. Once you have done it and been able to set a figure on how much you are bringing in or the savings being made by reducing visits to GPs and emergency departments.”

“Central cog”

Everyone in the health service is supposedly working towards the NHS Five Year plan. This document puts reducing emergency hospital admissions and improving quality of life for people with long-term conditions among its top priorities – this is the bread and butter of what specialist nurses do, day in day out.

Anyone who knows the NHS knows it operates like a living organism, driven forward by the passion and capabilities of the self-made clusters of its cells – the men and women who work within it.

And central to this is the army of clinical nurse specialists.

“We are the central cog in the wheel: we take an overview of the specialism and of the service from the individual patient’s point of view.

“We need to stand up and let people know what we are doing. We have specialist training and specialist skills to offer and we need to make sure everyone knows what we are doing,” said Aileen.

For more information on providing bespoke education and support programmes for specialist nurses in your therapy area, contact Oyster Healthcare Communications on 01273 601996 or email us at mail@oysterhc.co.uk


Nurse response survey

Published on: September 28, 2015