The impact of expanding the numbers of clinical nurse specialists in cancer care: a United Kingdom case study

The impact of expanding the numbers of clinical nurse specialists in cancer care: a United Kingdom case study Alison Hill

In the last few years there has been an increase in the number of clinical nurse specialists (CNSs) working in cancer care throughout the UK. This paper examines the issues raised by the proliferation of site-specif|c cancer CNS posts, developed to give a ‘nursing lead’ for a particular tumour type.The issues common to all CNS posts are exacerbated when a number of specialists are involved in the cancer journey, causing potential fragmentation and confusion. Key issues need to be addressed if the role is to remain credible, and ensure clarity for patients and the multiprofessional team.These include role clarif|cation, sensitive integration, interface with other cancer CNSs and the multiprofessional team, evaluation, cost, education and training, recruitment and succession planning and the ‘career cul-de-sac’. Cancer nursing’s response to these challenges will set the professional agenda for education, training and future models of service delivery. # 2000 Harcourt Publishers Ltd Keywords: clinical nurse specialist, role evaluation, cancer care, organization of care Die Auswirkungen einer gr˛sseren Anzahl klinischer Pflegespezialisten in der Krebspflege: Fallstudie Vereinigtes K˛nigreich In den letzten Jahren haben wir imVereinigten K˛nigreich eine h˛here Anzahl von klinischen Plegespezialisten (CNSs) fˇr die Krebspflege erlebt. Dieses Papier befasst sich mit den Problemen, die sich auf Grund der gestiegenen Zahl von standortspezif|schen Krebs CNS ArbeitsplÌtzen, die als pflegefˇhrend fˇr einen bestimmtenTumortypen entwickelt wurden, ergeben. Diese fˇr alle CNS-Posten gleichermassen geltenden Probleme treten verschÌrft auf, wenn eine Anzahl von Spezialisten an der Krebsreise beteiligt sind und sind Ursache potentieller Fragmentierung und Verwirrung.Wenn diese Rolle glaubwˇrdig bleiben soll und fˇr den Patienten und das multiprofessionelleTeam Klarheit sicherstellen soll, mˇssen wichtige Fragen beantwortet werden. Diese umfassen Klarstellung der Rolle, einfˇhlsame Integration, Schnittstelle zu anderen Krebs CNS und zum multiprofessionellenTeam, Auswertung, Kosten, Bildung und Ausbildung, Rekruitierung, Nachfolgeplanung und die ‘Sackgasse fˇr die Karriere’. Die Antwort der Krebspflege auf diese Herausforderungen wird das Programm fˇr Bildung, Ausbildung und zukˇnftige Modelle der PflegetÌtigkeit bestimmen.

Alison Hill, MSc, RGN, Nurse Consultant, SouthThames Macmillan Cancer Relief, 3 Angel Walk, Hammersmith, London W6 9HX, UK Correspondence and o¡print requests to: Alison Hill

El impacto del aumento del nu¤mero de especialistas en enfermer|¤ a cl|¤ nica en la esfera de la atencio¤n del ca¤ncer: estudio de casos del Reino Unido En los u¤ltimos a•os se ha registrado un aumento en el nu¤mero de especialistas en enfermer|¤ a cl|¤ nica (EEC) dedicados a la atencio¤n del ca¤ncer en todo el Reino Unido. Este trabajo examina las dif|cultades que suscita la proliferacto¤n de cargos EEC de atencio¤n del ca¤ncer espec|¤ f|cos de determinados emplazamientos, desarrollados para proporcionar una‘‘ventaja de enfermer|¤ a’’en un tipo particular de tumor. Las dif|cultades comunes a todos los cargos EEC se ven exacerbadas cuando varios especialistas esta¤n involucrados en el tratamiento del ca¤ncer, ocasionando confusio¤n y fragmentacio¤n potencial. Es necesario resolver dif|cultades clave para que la funcio¤n conserve su credibilidad, y asegurarse de que haya claridad para los pacientes y el equipo multiprofesional. Entre ellas se cuentan la aclaracio¤n de funciones, integracio¤n sensible, contacto can otros EEC de atencio¤n del ca¤ncer y el equipo multiprofesional, evaluacio¤n, costo, educacio¤n y formacio¤n, contratacio¤n y planif|cacio¤n de la sucesio¤n y el ‘‘callejo¤n sin salida de la carrera’’. La reaccio¤n de la enfermer|¤ a de atencio¤n del ca¤ncer ante estos retos determinara¤ el temario profesional para la educacio¤n, formacio¤n y futuros modelos de suministro de atencio¤n.

INTRODUCTION In the last 20 years the number of possible nursing roles have increased, with a specialist or

European Journal of Oncology Nursing 4 (4), 219^226 # 2000 Harcourt Publishers Ltd doi:10.1054/ejon.2000.0061, available online at http://www.idealibrary.com on

advanced role more common in both acute and community settings. Such roles have a number of titles, for example advanced practitioner, clinical nurse specialist (CNS), nurse consultant, nurse

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clinician or simply nurse specialist. For the purposes of this paper the term CNS will be used to describe these roles, despite their differences and the fact that each will reflect, to a greater or lesser extent, the original CNS model. The original CNS model for practice originated in the USA with the advent of advanced clinical roles (Dyson 1997). The role encompassed the following components: clinical practice, education, management, research and clinical leadership, but had little impact in the UK until the introduction of a new clinical grading structure in 1986 (Bousfield 1997). Since then the model has been adapted and such roles have increased in response to external factors and changes in service delivery. There are now CNS roles in virtually every area of nursing practice, some with particular technical skills and others following a population-based model. All have developed the profession into new areas and enabled individuals to enhance practice to the benefit of patients and health care in general. It could be argued that these roles are of particular importance in cancer nursing where the increased complexity of treatments and the need to provide information and support have led to many innovative approaches to care. For example, some new nursing roles have arisen from the need to provide a service for a particular tumour type or treatment modality. In 1995 the Department of Health published a report into the organization of cancer services, A Policy Framework for Commissioning Cancer Services, advised by Dr Calman and Dr Hine. The Calman–Hine Report, as it is more commonly known, has an emphasis on access to specialist services, equity, information, support and seamless care which has accelerated the process of change. In many instances this has led to an increase in tumour site-specialist nursing posts, as these have been seen as key to these types of quality developments. Often such roles are developed to give a nursing lead for a particular cancer and to ensure that specific national guidelines are met (National Health Service Executive 1996, 1997, 1998). This paper identifies and examines the emerging issues for cancer nursing in the UK as more site-specific cancer nurse roles are developed and require integration into the workforce and ongoing evaluation. These roles are also important in view of the changes in the nursing profession in the UK, where there is a move towards new and innovative roles along with the realization that sensitive development will ensure appropriate and timely education and training for the individual nurse, and an increased understanding within the profession as to the specific nature of the role. In the UK cancer nursing can European Journal of Oncology Nursing 4 (4), 219^226

therefore be seen to be in a period of transition with specific challenges confronting specialist nurses.

CURRENT ISSUES AFFECTING CANCER NURSING In the UK the first cancer site-specific role to be introduced was in breast care resulting from the recommendations of the Forrest Report (1987), which identified the value of screening to detect early breast cancer and the contribution of a specialist breast nurse in providing information and support to women from diagnosis and throughout treatment. Following the success of these posts, many felt that similar cancer specialist nurses could provide support in a number of specialist areas within oncology, leading to an adhoc development of some sitespecific roles for nurses. Palliative care has also become established as a specialty and in many areas has been a nurse-led innovation, with nurses developing skills in symptom management and support, to be followed at a later date by a multiprofessional team (Dunlop & Hockley 1990). Many of the current CNS roles in palliative care overlap with oncology and might be seen in the context of cancer support, particularly in the acute sector where patients undergo palliative interventions and treatment. The focus of palliative care has also changed with earlier referrals and potential involvement from diagnosis onwards. This model of ongoing support can conflict with that of the population approach of the site-specialist nurse (National Hospice Council 1998).

Recent legislation In the UK there have been a number of changes within the nursing profession over the last few years, reflecting changes in the wider health arena and the need for nursing to adapt to meet new and different challenges. The issue of a graduate profession in nursing and specialization throughout all areas of health have led to a greater emphasis on the role of ongoing education, especially in the light of new technology, treatment patterns and the changing epidemiological mix in society as a whole. It is within this context that the developments within cancer nursing need to be viewed. There are three key pieces of recent legislation which impact on the role of the site-specialist cancer nurse. As has already been mentioned, the recent reorganization of cancer services through the Calman–Hine Report (1995) has led to the realization that investment in an infrastructure is required in relation to all three cancer settings outlined in the report – the specialist cancer

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centre, the unit offering treatments for common cancers and the community. As the report has an emphasis on equity, access and patient choice, the CNS role can be seen as key in developing these aspects of care. The cross-boundary working needed for seamless care between the three settings and the holistic model advocated in the report will also rely heavily on CNS skills. The recent UK Government White Paper on the future organization and structure for health care, The New NHS. Modern. Dependable (1997), outlined a commitment to specialist nursing roles and to specialist nurses who are able to offer cross-boundary working. Within this document are new targets for cancer care, reflecting the Government’s commitment to improving outcomes for cancer patients, in particular the unnecessary delays at diagnosis and in accessing specialist treatment. The first cancer to be targeted in this way is breast cancer, with a 2-week waiting time proposed from first presentation to referral to a specialist team. This type of target will be introduced across all cancers, leading to better outcomes for patients but also adding to the pressure on providers of cancer services. The other major change contained in this White Paper is the formation of Primary Care Groups (PCGs). These are local commissioning groups comprising General Practitioners (GPs), a nursing and social service representative and a lay person who will purchase services for their local population, usually of about 10 000 people. Although working initially to a Health Authorityled Health Improvement Programme (HIMP), these PCGs will be very influential in determining spending priorities for their local area. From April 2000 these groups will also be able to apply for Primary Care Trust status, where they will have the total budget from the Health Authority, accountability and the ability to employ their own staff. This type of development will have far-reaching implications and may well affect the roles of those existing CNS in cancer and palliative care working in the community and may also result in the development of new CNS roles. More recently, the Green Paper, Our Healthier Nation (1998), has demonstrated the current Government’s commitment to prevention, screening, early diagnosis and a population approach to cancer care using a public health model, and this may lead to further opportunities for cancer nurses in screening and early diagnostic work.

The Specialist Practice Debate Over the last decade there has been an increased interest on the part of the regulatory body for nursing in the UK – the United Kingdom Central Council for Nursing, Midwifery, and

Health Visiting (UKCC) – in the concept of specialist or advanced practice. This in part reflects the changes in health care and the increased professionalization of nursing in a changing climate, but also reflects the realization that new ways of working and new models of practice are required to meet these challenges. In particular, there has been interest in identifying the skills and knowledge required to practice at an advanced level, reflecting the need to control and regulate practitioners to inform and protect the public (UKCC 1997). A lack of clarity has led to many different models, and a resulting discrepancy in terminology, pay and grading of advanced practice roles. It has also led to a degree of confusion for professionals and the public. In the UK, nursing has always valued and promoted the need for those with advanced skills and experience to remain in clinical practice (RCN 1981). From a new clinical grading structure in 1989 to the sentiments expressed in the documents The Scope of Professional Practice (UKCC 1992) and The Extended Role (EL 92 38), the emphasis has been on new and extended parameters for practice to enable and give incentives for experienced nurses to maintain their clinical role. With these new skills nurses take responsibility, and become accountable, for their actions. Therefore, the above papers were reactive in nature, enabling the development of new nursing skills as a reaction to external factors, without addressing the issue of the level of knowledge or experience required. Many of these roles developed as a result of these guidelines from the UKCC have enabled nurses to provide aspects of care otherwise provided by doctors or other professionals, therefore providing a more cohesive service (Belcher & Shurpin 1995). Currently the UKCC is undertaking a Consultation Exercise (1998) on this higher level of practice in order to determine how the profession wishes to develop this important area of nursing, and aims to provide a mechanism whereby individual practitioners will be able to register as specialists. Not all those currently regarding themselves as specialists will wish to embark on this process and many practitioners will not fulfill the requirements laid down by the UKCC. Therefore, in summary, an increasing number of specialist roles in nursing, combined with the requirements of the Calman–Hine Report (1995), have accelerated the current situation in cancer nursing, resulting in large numbers of tumourspecific, site-specific or role-specific specialist nurses. A number of issues arise out of this which will be discussed within the context of: . Operational service needs . The strategic dimension of future service delivery . Professional issues. European Journal of Oncology Nursing 4 (4), 219^226

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OPERATIONAL ISSUES Environment The organizational environment within which a CNS is employed is critical to the success or failure of the service (Welch-McCaffery 1986). Where a new member joins an established specialist team there can be an easier transition to the specialist role, and a degree of collegiate support. However, a site-specialist may work alone in a department where there may be little understanding of the role and little peer-group support, leading to a sense of professional isolation (Bousfield 1997). This needs to be balanced against the positive feeling of being able to work closely with a small multiprofessional team and directly influence patient care. Being outside the hierarchy or, put another way, an ‘organizational anomaly’ (Paulen 1985) can also lead to a more creative approach to the role and lead to working relationships with a wider variety of professional colleagues (Nash 1990). However, the issue of professional nursing support is key in maintaining a nursing focus. This can cause problems in smaller units where there are few cancer nurses and a lack of understanding about the role, function and the needs of the CNS. This can lead to a clinician-led model with an emphasis on clinical work, to the detriment of other role components (Dyson 1997). A foundation in nursing will ensure that the agendas of other professionals who may not understand the role do not dictate the agenda to be followed by individual nurses.

Recruitment Many environmental issues can be addressed during the pre-recruitment stage when needs assessment and accurate mapping of local service provision will ensure that there is a ‘discrete’ nursing role with the breadth and influence required for a CNS. The National Health Service Executive (NHSE) guidelines for the management of specific tumours (1996, 1997, 1998) have led to new roles being developed to provide nursing leadership, and a need to fulfill the guidelines. However, such leads can be achieved in various ways and there is a need to think creatively to avoid duplication and unnecessary expenditure on new, expensive CNS posts. This is also of particular significance to the current nursing shortage in the UK (Department of Health 1999) where there are few nurses who can fulfill some of these roles, and potential employers will be competing in a limited market. Education and recruitment are inter-related, with a need to develop succession planning and ensure equal access to the education required to become a CNS, particularly in some geographical areas European Journal of Oncology Nursing 4 (4), 219^226

where there are shortages. Recruiting the right nurses is vital as these roles are key to practice development and quality initiatives, and development of a skilled workforce. However, the current vogue for academic qualifications has resulted in less emphasis on experience, personal maturity and the ability to work with a variety of professional and non-professional staff. These skills are important where a CNS is working in a more isolated site-specialist role and will need to function in an autonomous manner with little overt support.

Career ‘cul-de sac’ The original intention of the revised clinical grading structure in the UK in 1989 was to encourage and reward nurses who remained in clinical practice. More leadership and experience were required in the clinical areas and one mechanism for addressing this issue was to develop more CNS roles with their mix of advanced clinical practice, education and clinical leadership. However, little thought has been given to the future career progression of nurses in such roles. In many parts of the country a CNS may be the most senior cancer or palliative care nurse based in a hospital or community area, making changing or progressing within the specialty difficult. In their study into the stress experienced by CNSs in cancer care, Dunne and Jenkins (1992) identified that inability to move or progress was a major cause of stress in many nurses. In order to attract nurses into the specialty at a time of shortage there needs to be a clear and attractive career structure, and the role of the CNS is pivotal to this thinking. Recent developments within the profession may well help to address some of these issues; last year Prime Minister Tony Blair announced the creation of a new type and grade of nursing role, the consultant nurse. The UK Department of Health Strategy for Nursing (1999), entitled ‘Making a Difference’, suggests that nurse consultants will have responsibility in four main areas – expert practice, professional leadership, consultancy, education and development, and practice and service development linked to evaluation and research. At least 50% of their time will be clinical in direct patient contact and hospital and community areas will be able to determine how many consultant nurses they wish to employ. In response to this initiative, the Royal College of Nursing, the main professional forum for nurses in the UK, is planning to set up a pilot scheme to develop this new and innovative role. It may be that the advanced practice required for a CNS will provide a preparation for this role and alleviate some of the current career issues. However, there are still a number of uncertainties about the consultant nurse and

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the preparation for such nurses has yet to be identified (Healey 1999).

Workload management The model for the role of the site-specific cancer nurse is in breast care, where nurses have been extremely successful in influencing both nursing and medical practice (Watson et al. 1988, Garvican et al. 1998). Many breast cancer patients need short-term interventions and the size of an active patient caseload can remain small. This may be different in urology or colorectal cancers where prognosis can be less predictable; even with consultancy and caseload management the ‘chronicity’ of an increasing number of cancers could lead to a disproportionate increase in the clinical component of the specialist nurses role, with a need to ensure that both direct and indirect methods of working are employed to benefit the largest number of patients (Webber 1996). It would appear from discussion and review of these roles that sitespecialist nurses have a larger clinical role than more established posts in palliative care who have moved to a ‘consultancy model’ of working. However, this may change as the newer roles become established and confidence increases. Referral and discharge criteria are an important component, as where clinical workloads are high other parts of the role can be neglected (Nash 1990). However, there will be increasing numbers of patients who require rehabilitation and ongoing support, particularly those who survive for longer periods and who have the potential to become anxious cancer survivors. Other unforeseen problems can occur with site specialization. For example, those working with lung cancer patients will mainly encounter patients with an extremely poor prognosis, difficult symptoms, complex socio-economic and legal factors to assess, and associated stigma. The cumulative effect on the CNS of this type of patient needs to be considered when developing new roles, with particular stressors requiring appropriate support mechanisms and links with palliative care services.

Interprofessional and intraprofessional issues Many authors have observed that role boundaries are a key issues for any CNS (Dunne & Jenkins 1992, Dunlop & Hockley 1990, Webber 1994). Nash (1990) identified the threat to others posed by any new post and possible misunderstandings about what the new post will provide. This can be especially difficult if previous posts have been in palliative care and the new role is focused on early diagnostic or treatment work. Close working relationships and joint protocols

are essential to ensure that all patients who require the services of a specialist nurse are receiving an appropriate service, while avoiding confusion and duplication. Communication, liaison and an awareness of the different cancer CNS roles are integral to the success of a specialist cancer nursing team. No one CNS has ‘ownership’ of any particular group of patients (Nash 1990).

Relationships with palliative care One of the areas causing the most concern is the relationship with palliative care services (Hospice Bulletin Summer 1998). Here the issue is clouded by the difficulties some clinicians in palliative medicine have understanding the role of a sitespecialist nurse. Many palliative teams have always offered a service for patients at any stage in their disease and feel that this is compromised by additional site-specialist nurses. The Calman– Hine Report (1995) encourages early integration of palliative care into cancer services and for many practitioners this reflects the holistic approach required in palliative care. With increased specialization this will be a challenge to practitioners as the knowledge and psychosocial skills required to support patients having active management have similarities with those required in palliative care. However, up-to-date information on treatments may require a different knowledge base. One solution might be more focussed and formalized liaison to avoid potential fragmentation. Some palliative care teams are, as individual members, taking on a more site-specialist role, where each will take the lead for different cancer types. This has the advantage of reducing the number of liaison points, ensuring that patients are not ‘lost’ due to confusion or fragmentation and enables the development of new skills in relation to particular tumour types (National Hospice Council 1998).

STRATEGIC ISSUES Previously the impetus for many cancer nurse specialists has come from emotionally charged local situations, rather than a more empirical approach using population data or needs mapping. However, the Calman–Hine Report (1995) has given providers the opportunity to plan provision of cancer services to ensure access and equity, one of the report’s founding principles. This type of planning requires both a regional and UK perspective and the identification of different and appropriate methods of care delivery and the implications that such strategic work will have for the nursing infrastructure. European Journal of Oncology Nursing 4 (4), 219^226

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There will also need to be an understanding that the areas where there has been little investment in cancer nursing are the cancer units. These are the smaller local hospitals treating people with common cancers, rather than those requiring specialist treatments such as radiotherapy. There is also an indication that primary care providers will need more specialist skills as patients spend longer periods of time at home during their cancer treatments. Planning will also highlight both the deficits in suitably trained nurses and the educational requirements to prepare such nurses (The Cancer Collaboration 1997).

Educational issues The future training and education for cancer specialist nurses is still uncertain. Recent reports have stressed the need to identify the type and numbers of nurses required (RCN 1996, Cancer Collaboration 1998), and there is a national problem in identifying how many nurses have cancer qualifications and whether they are currently in practice in a specialist area. This is particularly difficult to identify in the community where many are working as generic community nurses (Closs et al. 1997). However, changing service requirements have made this a complex task, exacerbated by the current problems in general nursing recruitment. It is clear that there will need to be a range of nurses who have been educated in cancer nursing to a variety of levels, including generic cancer care, those working in specialist areas and CNS or advanced level nurses. The recent discussion on the Higher level of practice has fuelled the idea that the CNS is synonymous with the requirements of the proposed higher level. All those aiming for the higher level of practice will need graduate education (UKCC 1997) and be able to demonstrate specific expertise, ensuring clinical credibility. However, there is some evidence that not all current CNS posts are operating at such a level, particularly site-specialists. This may be due to the evolving nature of the role, but also the confusion surrounding the definition of a CNS. Some of the current site-specialists follow a predominantly ‘medical model’ with priority given to clinical work, and less emphasis on other role components, leading to an excellent service for patients but not affecting education and practice development within their given area. The education required for these clinical roles may need to be different. However, the single most important issue is the lack of suitably qualified candidates to fill site-specialist posts, leading in some instances to the appointment of inadequately prepared candidates, which may contribute to the above European Journal of Oncology Nursing 4 (4), 219^226

situation where an inexperienced nurse may not understand the depth and breadth of the role. The particular skills needed for a CNS are often difficult to acquire within the traditional nursing hierarchy and this has led to suggestions that ‘training posts’ could be developed to enable skilled clinical nurses to observe while working in an established specialist team. Clinical knowledge is rarely the issue; it is the conceptual model of CNS practice and the attendant professional issues which nurses often lack. This is particularly important for the more isolated sitespecialist post where there may be a lack of role models either in, or local to, their employer. In these situations networks of site-specialists need to set up fora to ensure that new nurses have experienced mentors and are able to identify how the CNS model can be adapted to their specific practice area. There is also the potential for conflict where new professional identities are being developed as it may be appropriate for nurses to join other professionals for the purposes of education and study, leading to potential misunderstandings about the role of nursing in the future and increased concern about boundaries (Colquhoun 1997).

Evaluation The role of the specialist nurse is notoriously difficult to audit and evaluate (Hamric & Spross 1989) due to the diversity of tasks contained within the role. It is especially difficult to assess contributions made which are indirect and involve collaborating with, or empowering, others (Webber 1994). As cost constraints become more important, the need to demonstrate the value of a specialist has never been greater. There have been some recent attempts to evaluate the role (Luthbert & Webber 1995, Macmillan Cancer Relief in progress) but although there is a great deal of anecdotal evidence, there has been a lack of concrete work in this important area (Department of Health (DoH) 1999). As many of the original CNS roles in cancer care were in the palliative care arena this may reflect the reluctance of professionals to evaluate care in such a sensitive area. As has previously been discussed, the White Paper on health (1997) has affirmed the need for all health-care providers to contribute to evaluation and to ensure that all interventions are based on research-based evidence, and this has been followed more recently by A First Class Service: Quality in the NHS. This document sets out the UK Government’s commitment to monitoring the quality of care through national service frameworks. The Calman–Hine Report (1995) can be seen as the first of these. The development of the National Institute of Clinical

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Effectiveness (NICE) will bring a national perspective and the development of the concept of Clinical Governance, with its emphasis on organizations which create quality in all areas of work, will impact on all health-care providers. For many site-specialists, the recent guidance from the working group at the NHSE on breast, colorectal and lung cancers (1996, 1997, 1998) will assist them in evaluating practice as part of the multiprofessional team. However, there is an urgent need to identify a model for evaluation of the role itself, which takes into account the inherent complexities and the local variation (DoH 1999).

PROFESSIONAL ISSUES

UKCC (1997, 1998), that the level at which the practitioner operates identifies the specialist, and there is a difference between a nurse practicing in a specialty and a specialist nurse. However, there are arguments for the American model where a specific education programme is the only route to specialist practice. This might appear exclusive but has the advantage of clarity for patients and professionals, and at a time where recruitment is a problem it also gives a clear career pathway to newly qualified nurses and an incentive to undertake further study or professional development. Clarification of the situation is an urgent professional issue and if achieved will enhance the standing of nurses and consolidate their position in the health-care hierarchy.

Sub-specialization Following the model outlined in the Calman– Hine Report (1995), clinical oncologists and cancer surgeons are adopting site-specialization and sub-specialization as the research has demonstrated that patients have better outcomes when treated by a specialist team (NHSE 1996, 1997, 1998). As cancer care becomes more complex it seems inevitable that there will be further specialization. However, when applied to nursing there are some professional concerns, as it could lead to an in-depth knowledge of a very small area of practice, which may militate against the breadth and influence required for the other components of the CNS role. Skills are not as easily divided as in medicine, and there are arguments for both the site-specific and the more generic model. A larger number of nurses involved with each patient could lead to fragmentation of care in an area where there are already a number of professionals involved. Many patients appreciate seeing the same CNS throughout their treatment, as they will see many different doctors, and this type of personal approach may be lost with increased specialization.

Regulation/Control The title CNS conveys different meanings inside and outside the profession, and the resulting lack of clarity affects the credibility of the individual and the role itself. The development of large numbers of site-specialist nurses gives a ‘visibility’ to this type of nursing role, and the public are entitled to know what the skills and education of that nurse will be. This situation is especially true in cancer, which has led the way in terms of CNS roles. It could be argued that it can be more helpful to identify the knowledge, skills and attitudes required rather than a specific role. This type of thinking underpins the stance of the

CONCLUSION In conclusion, there are key areas for cancer nurses in the UK to debate, as there are advantages and disadvantages in the development of site-specialist cancer nurses. There is little doubt that an individual working with a specific cancer population will ensure a greater level of information and support from the time of diagnosis onwards. However, there are issues which have yet to be resolved in terms of the level of practice required, the educational background of the nurse and the relationship with other nursing colleagues and the multiprofessional team. Each new role needs to be integrated into current service provision avoiding difficulties with boundaries. Feelings of threat must not compromise the support and peer group cohesion required for a successful cancer care team. Financial constraints limit all health-care activity and the role of the CNS is no exception. It is therefore important that evaluation of all sitespecialist posts is undertaken as a matter of priority, to ensue that changes and adaptations to the original model can be made as service needs alter or are refined, and to demonstrate the added value of CNS practice in the cancer setting.

ACKNOWLEDGEMENT The content of this paper is based on a presentation given by the author at the Royal College of Nursing Cancer Nursing Conference in Jersey, November 1998.

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