This article explores the roles of the clinical nurse specialists (CNS) in one setting in Ireland, namely intellectual disability nursing. In 1998 the Report of the Commission on Nursing: A blueprint for the future recommended the establishment of the National Council for the Professional Development of Nursing and Midwifery (NCNM). It also recognised the need to ‘promote intellectual disability nursing as a career’ (Government of Ireland 1998, 172). The establishment of the NCNM and the issuing, by the Council, of the definition for clinical nurse specialism, allowed the development of the specialist nurse in Ireland to formally begin, particularly in the area of intellectual disability nursing. Since then a number of nurses working in the area of intellectual disability have been recognised as clinical nurse specialists (CNS) by the NCNM.
Following the establishment of the National Council for the Professional Development of Nursing and Midwifery and the issuing of a clear definition for clinical nurse specialist, a report was commissioned to explore the clinical nurse specialist and advanced practice in intellectual disability nursing. The report, Proposed framework for the development of clinical specialism and advanced practice in intellectual disability nursing, was published in 2002. It identified clear pathways for the clinical nurse specialist in the intellectual disability area. This report further aided the development of specialist nursing in intellectual disability by its publication.
The report’s clear recommendations included specific suggestions relating to education, but also advice that the ‘clinical career pathway for intellectual disability nursing be incorporated into all seven broad bands of nursing and midwifery recognised by the Report of the Commission on Nursing 1998’ (DoHC, 2002). The bands suggested by the Commission, transverse all nursing disciplines and included such areas as high dependency, community, rehabilitation etc—all areas where clients with intellectual disability may be found at different times as they move along the healthcare continuum. It continues echoing the Commission report in listing themes or areas of practice where the clinical nurse specialist in intellectual disability could specialise. It was a long but not exhaustive list and, similar to the Commission, it included such areas as sensory development, assistive technology, health promotion, care of the elderly person etc. Clinical career pathways were suggested in these practice areas as the report highlights that the work of the clinical nurse specialist in intellectual disability is varied and incorporates such roles as educator, clinical leader, consultant and researcher (DoHC, 2002).
The 2002 report went on to state ‘the value and contribution of specialist roles to client care should not be underestimated…. Clinical nurse specialists are ideally positioned to provide specialist direct care services to clients and their families. These clinical specialists are in a position to proactively respond to client needs and identify current and future service requirements’ (DHC, 2002, 21). This clear recognition of the possible benefits for the clients gives added incentive and encouragement for nurses working at this specialist level in intellectual disability.
The potential benefits were further recognised and clearly outlined in the report by the Eastern Regional Health Authority. It stated, ‘The development of the clinical focus of the role of the nurse in a specific area of practice along with the integration of nursing research and audit in intellectual disability nursing services and the provision of a clinical career pathway will assist in Intellectual Disability Services significantly increasing treatment options and quality of care’ (Eastern Regional Health Authority, 2002, 32). The development of these varied posts in intellectual disability clinical nurse specialism were seen as likely to aid and assist intellectual disability clients where clearly the potential benefits for the clients is recognised.
The NCNM has worked to develop clinical nurse specialism in intellectual disability nursing. In the Council’s study exploring the effectiveness of the clinical nurse specialist, it noted that the establishment of further clinical nurse specialist posts within intellectual disability services is highly desirable. At that time there was 105 recognised clinical nurse specialists intellectual disability posts (NCNM, 2004, 46). In March 2006 there were a total of 116 clinical nurse specialists in intellectual disability recognised by the NCNM (see Table 2). They are spread over the various Health Service Executive areas, but are predominately based in the Eastern Region, with the second largest number in the Southern region. These figures show an increase of 11.5% from the 2004 figures, with the number growing.
The various reports mentioned identified areas of practice in which the clinical nurse specialist in intellectual disability nursing may be active, but they did not explore the roles or competencies which have been outlined by the NCNM as:
- Clinical Focus
- Patient/Client Advocate
- Education and Training
- Audit and Research and
As the NCNM states, these individual competencies ‘are shared by all nurses who practise at specialist level’ (NCNM, 2004a, 10). The activities of the clinical nurse specialist in these individual roles have rarely been explored. A small study in 2005 in the Irish healthcare setting has attempted to do this and the study results raised issues in research, education of colleagues and education of clients and families.
The NCNM definition gives clear guidelines for research. ‘The specialist nurse or midwife will participate in nursing research and audit’ (NCNM, 2004a). The identification of this role is further echoed in the study of Hurlimann et al. (2001) which examined clinical nurse specialist roles and clearly identified ‘researcher’ as very much part of the clinical nurse specialist’s work. When questioned about conducting research related to the specialist area and/or other areas of nursing practice, the responses showed a variety of activity, with only 13% on average involved in research. Clearly this appears to be an area where the clinical nurse specialist is not very active and further investigation is warranted to explore this issue.
Education of colleagues is considered a key role of the clinical nurse specialist’s work. Reid-Priest (1989) describes education as a ‘traditional part’ of the role. The clinical nurse specialist educates at a number of levels: patients, staff, family/carers and student nurses. Miller (1995) sees the need for the educator component as ‘immense’ and Henderson (2004) concurs and points out that clinical nurse specialists will also need to educate others about their specialist role as well as education relating to their specialist area of practice. It is clearly an area where the clinical nurse specialists are very active.
Working with clients and families has always been a key part of intellectual disability nursing. This continues as the nurse specialises and advances practice. However, activity in this area is varied considering the many diverse care settings and distinct abilities of the clients with intellectual disability.
The role of the CNS is growing in importance. There are some clear roles identified for the nurse who advances or wishes to advance along this clinical career pathway in intellectual disability nursing. Humphries (1999) believes that clinical nurse specialists have the potential to have a major impact on the future development of healthcare. A clinical nurse specialist in intellectual disability care needs to be active in many roles.
This study explored the roles of clinical nurse specialists (CNS) in one setting in Ireland. The study is limited in size and location. The fact that it was not carried out in a specific area of intellectual disability care restricts its findings, but highlights some interesting factors, such as the active role of the CNS in education, and the limited evidence of a research role. The study demonstrates room for further exploration in this area.
A larger study of the total population of all clinical nurse specialists in Ireland is currently being carried out. Questionnaires have already been distributed to all clinical nurse specialists on the NCNM register. Following this, it should be possible to specifically report findings relating to the active roles of the clinical nurse specialists in intellectual disability. It is hoped the findings from the bigger study can contribute to the future growth and development of the clinical nurse specialist’s role, particularly in the area of intellectual disability where there are an increasing number of nurses following this career pathway