Clinical nurse specialists (CNS) in cancer perform a range of complex activities, including the management of care. However, they often report a high administrative burden for services, which makes providing expert nursing care challenging. Administrative work for a service can be seen as a priority for non-nurses, yet a high administrative burden allows less time for complex nursing care. A London trust admitted a mean of four lung cancer patients per month for symptom control in progressive disease or end-of-life care, with a mean stay of 6 days. This was often a default location: the acute hospital was not always the patient's preferred place of care for end of life. The CNS negotiated away the administrative burden, which occupied 38% of their working time, and adopted standard proactive case management in line with national standards. The CNS were also able to build a collaborative relationship with others, such as local GPs and community palliative care teams. Their proactive and vigilant case management resulted in fewer admissions for non-acute problems: a mean of four emergency admissions per month fell to a mean of fewer than one (0.3). For this service, the mean length of emergency admission was 6 days, so a reduction in the admission rate represented a significant saving in bed days (266 a year) and a higher rate of achieving the preferred place of end-of-life care. In conclusion, CNS who practise proactive case management and refocus services in line with best practice represent a good return on investment (ROI).
Keywords: Admission avoidance; Clinical nurse specialists; Outcomes; Value.