In the past, many experienced and highly capable nurses were promoted into management, leaving the clinical field. The role of clinical nurse specialist (CNS) was developed to retain experienced nurses in clinical practice and to offer a clear structure for the formal recognition of nursing expertise. Despite the increasing prevalence of clinical nurse specialists, the role remains poorly understood within services. The Nursing Council defines the five core competencies of the clinical nurse specialist: clinical practice, education and training, consultancy, audit and research, and advocacy.
Within the field of challenging behaviour, if the clinical nurse specialist is to have a positive impact on a service, all the core competencies must be in place. The time spent on a specific competency will fluctuate, depending on factors such as caseload, deadlines, changes in clinical practice and the structure of a service.
Approximately 50 per cent of the CNS role is clinical, i.e. directed around the clinical caseload and the management of it. This involves developing a referral system that contains basic information on the presenting problem. This can be done through the use of a quality-of-life questionnaire carried out pre- and post-intervention. This is vital to gauge quality-of-life outcomes for the person, rather then just focusing on clinical effect. It also involves carrying out in-depth analysis of the presenting problems and developing interventions or support plans to aid the person, and staff and family, to manage the challenging behaviour.
The CNS brings a package of skills from his/her educational background and area of specialism, as well as from years of working at the coalface. This combination of skills allows a CNS to be alert to the possible predisposing factors to any challenging behaviour (such as an underlying medical problem). Failure to accurately diagnose health problems can lead to inadequate treatment and incorrect supports for the person. For instance, aggression may be the first indication that a person is in the early stages of Alzheimer’s disease. If behavioural supports are the only treatment provided, it may compound the problem, leading to increased levels of confusion, low self-esteem and aggression. The CNS, as a key member of any multidisciplinary team, will play a central role in the assessment of the person who is displaying challenging behaviour.
When the role of the CNS was first developed, unit staff depended on the CNS to carry out assessments, develop support plans and provide maintenance strategies. This has continued to change as the role of the CNS has developed.
Education and training
This occurs around three areas:
- frontline staff of all disciplines
- nurses and professionals in other disciplines
- families and their home-support workers.
Training and Education is a vital role of the CNS and one that is often neglected or goes unrecognised. Initially, when I started in the role, education took place around an individual case or referral. My role was training staff in the specifics of the individual’s case. This continues and has expanded into planned focused training for specific groups of staff.
The CNS has a role in educating other professionals who are also involved in providing medical treatment or other supports for a person with intellectual disability and challenging behaviour. The experience of the care that a person who displays challenging behaviour receives can often depend on their behaviour. Other health professionals can be left feeling confused and fearful owing to a lack of understanding of the behaviour being displayed. Educating staff from other disciplines regarding the communicative function of behaviour is vital to ensure that good clear diagnoses can be made. To address this issue the CNS must develop links with other professionals and offer training and education workshops.
The final area is training for families and family support staff. Research (Dunlop and Fox,1996) has shown that behavioural supports have the greatest impact when developed before the challenging behaviour becomes ingrained and multifunctional.
As a consultant, the CNS employs an interactional process between professionals. The CNS is consulted by staff who seek assistance in relation to a problem. Which generally refers to the treatment or management of a client. The goal of the consultant is to improve the person’s skills in handling current issues and to empower them to enhance their capacity to resolve similar issues in the future. The consultant’s responsibility lies in assisting with problem solving, rather than dictating solutions.
What does this look like on the ground? One of the ways the CNS can encourage and empower staff is through the development of behaviour support groups. The purpose of the behaviour support group is to:
- support staff who are working with clients who engage in challenging behaviour,
- develop and encourage an atmosphere and language that are proactive and non-aversive,
- update staff on new developments and research,
- development of ongoing review of support plans, and
- track data for research.
These measures ensure that staff are empowered, supported and able to develop skills by learning from each other in such a way that the required behavioural supports are maintained for the individual.
Audit and research
The CNS role in auditing and research can help to develop practice within a service by reviewing and evaluating current practice, promoting new ideas, and incorporating research findings into clinical practice. There are three areas of research and auditing that a CNS is involved in:
- reading about and publicising the latest research in the field,
- tracking and auditing behaviour support plans and reporting on the results, and
- incorporating individuals’ long-term goals into service plans.
This involves advocating for and with the client and ensuring that the long-term goals and wishes of the person are placed into service plans for development. The CNS-advocate can also act as an advocate by inputting into service policy and development.
The CNS has a crucial role in service advancement by developing policies that emphasise behavioural change, rather then just behavioural management. Behavioural supports act as a prosthesis for the person—if the prosthesis is removed, the challenging behaviour will return. It is incumbent on a CNS that they are involved in policy development to ensure that meaningful outcomes for individuals with challenging behaviour are maintained and embedded in service development.
Finally, the CNS must be clear on his/her role and develop all five competencies within the area of challenging behaviour?. The CNS firstly focuses on improving the person’s repertoire of behaviours and skills and the person’s quality of life. To support and maintain behavioural change, the CNS develops strategies for supporting families and staff through training and support groups. As frontline staff and families become more proficient with supporting behavioural change, the CNS in behaviour will need to adapt and change to suit the increasing knowledge of staff and families . The role should not remain static, but should be flexible in order to meet changing demands and service needs, but also to service needs.