Guidance

Clinical nurse specialists in breast screening

Updated 16 December 2019

1. Role and definition of the clinical nurse specialist in breast screening

The clinical nurse specialist role as described by the Royal College of Nursing (CNS) is:

• an important contact for women throughout the assessment process
• a professional resource for colleagues and the wider primary care team
• an important member of the multidisciplinary team (MDT) in the screening service

The CNS provides:

• specialist support for women recalled to assessment
• specialist nursing advice and education

The CNS is accountable for their own professional practice in accordance with the Nursing and Midwifery Council (NMC) code.

The role of the CNS in breast screening is to manage and alleviate any anxiety and distress experienced by women, particularly when recalled for assessment.

To achieve this the CNS will provide appropriate, high-quality information to women and help them understand it so they can make a more informed choice about treatment options.

They must deliver this care and information in a sensitive and caring manner which preserves the dignity of women. They should hold discussions at an appropriate time with due regard to women’s emotional, physical, social and educational needs.

The CNS role has 4 main components, which are:

The CNS should assess each woman’s level of anxiety at an early stage and offer support throughout the assessment process and while she awaits her result.

By recognising those at increased risk and helping to manage their anxiety and distress during the pre-diagnostic phase, the CNS can anticipate some of the problems that may arise when a woman is diagnosed with breast cancer as described in the October 2012 report jointly commissioned by Cancer Research UK and the Department of Health. This helps women who are diagnosed with cancer and those who return to the routine recall for screening protocol.

The National Cancer Patient Experience Survey (2014) found that the CNS can have a profound and positive impact on a woman’s experience and eventual outcomes.

Appendix 1 lists the mandatory requirements for the CNS role along with the evidence that should be collected for audit, quality assurance (QA) and potential research purposes.

1.1 Role of the CNS in the MDT

The CNS is a core member of the MDT. They should play a crucial role in improving the overall quality of the screening service by:

• acting as the woman’s advocate throughout her assessment process
• sharing information about her psychological, emotional, social and physical wellbeing
• identifying women who may need additional specialist support
• gaining a clear understanding of treatment options and supporting women in any treatment decisions
• obtaining a definitive, authorised diagnosis from the MDT (see section 2.5 below)

Section 2.3 of the breast screening service specification requires all services to produce mandatory single definitive MDT records. Records should be available for all normal, benign and malignant cases. The CNS should not produce their own notes from the MDT meeting.

1.2 Reducing anxiety associated with further investigation

Most women who are recalled to assessment, experience some psychological consequences whether the ultimate outcome of assessment is normal, benign or malignant.

Evidence shows that women can experience significant distress at every stage of the screening process, including the time between receiving the recall letter and attending the recall appointment. Undergoing a biopsy deepens the level of anxiety women experience. They may remain concerned about their health for some time after such a procedure. Consequently, a recall to assessment has been shown to adversely affect a woman’s future attendance at screening appointments, as described in the report, Psychological consequences of false-positive screening mammograms in the UK.

Over the whole assessment process, women who eventually receive a return to routine screening outcome may experience a similar level of anxiety and distress to those who are referred for treatment.

The period of uncertainty between invitation for further investigation and receiving the results of that investigation can be highly stressful, particularly for women who have had a biopsy.

The role of the CNS is to reduce the adverse effect of this anxiety by supporting all women through the recall process.

1.3 Clinical practice

Women who have received a recall to assessment letter and are waiting for further tests and diagnosis can experience considerable anxiety. See Cancer Nursing Practice feature. All letters and leaflets sent to women who are recalled should clearly state how they can contact a CNS for further information and support.

The CNS should be able to:

• help women cope with the uncertainties of the situation
• answer questions about the assessment process

The CNS should attend any pre-assessment briefing and have access to the patient notes so they can deal with woman’s queries about the reason for recall. The CNS must meet women at the start of the assessment process and plays a significant role in this process by:

• evaluating a woman’s level of anxiety at an early stage
• offering the appropriate support

The CNS should make sure the woman gets the follow-up and personalised support she needs while waiting for a diagnosis.

It is really important that a CNS sees women after any biopsy procedure. This is to make sure that the woman fully understands what has been discussed with the health professional carrying out the biopsy and can ask questions. Women should leave the clinic with an appointment for their biopsy results.

Women who have had a benign outcome may also experience uncertainty and may need further reassurance. They should be given written information regarding their screening outcome. Patients who are returned to routine screening following assessment should also know how to contact a CNS if they want further information or reassurance.

Present when cancer diagnosis is given

Association of Breast Surgery (ABS) and National Institute for Health and Care Excellence (NICE) guidelines for surgeons state that a CNS should be present to support a woman when she is given a diagnosis of cancer at the results clinic. The CNS will then provide the ongoing support and information that the woman needs.

The CNS should be aware of the woman’s current, and history of, anxiety or depression. They should explore any current or recent life or health crises that may indicate she needs more specific support. Relevant support, information, education and advice must be provided. The CNS should signpost the woman to support from other organisations or refer to professionals as appropriate. This will depend on local support mechanisms available which may be accessed via the trust or GP.

Women’s accessibility to the CNS

Women should have timely access to telephone support and information from a CNS from the time they receive a recall for assessment letter. The CNS must have access to the woman’s clinical record so they know the reason for recall and can outline the assessment process.

The service should provide CNS telephone contact details on:

• assessment appointment letters
• assessment leaflets
• discharge from assessment letters
• relevant patient information leaflets, such as biopsy leaflets
• the screening service website

Alternative contact details should be available to women, including a generic screening office email address for those who cannot use a telephone.

1.4 Information requirements

The CNS should be involved in the development and review of any written information sent to women participating in breast screening. This includes communications relating to recall to assessment and biopsy procedures. The CNS should review all written information at least annually to incorporate new evidence and best practice.

The CNS must keep up to date with new advances, evidence and advice from sources such as:

• Breast Cancer Now
• Breast Cancer Care
• Cancer Research UK
• Macmillan
• NHS.UK

The breast screening host trust or other provider organisation must approve all information produced by the CNS.

All written or verbal information resources provided by the CNS should give women up-to-date, evidence-based information. This should include clinical management and treatment options throughout the screening recall process, supporting the decision-making process and helping the woman make an informed choice.

The CNS should establish clear lines of communication with other clinical nurse specialists working with the treating teams to make sure there is effective handover and continuity of care.

Information regarding diagnosis and treatment options should:

• be provided in a timely manner
• enable women to make informed decisions about treatment and care

The CNS should encourage all women to participate in the decision-making process relating to their care and should be involved in discussions with the woman regarding treatment options during the decision-making process. See 2015 article published in Breast Cancer Management.

The CNS must keep clear and accurate records and there must be established systems for documenting their work in line with NMC guidance and trust policy. This will ensure that accurate data is available for audit, QA and research.

The CNS should keep appropriate nursing records. They should make sure that data relating to the screening assessment process is retained on a woman’s screening record until they can be recorded on the national breast screening system (NBSS) database.

The CNS documentation for each case should include evidence of:

• contact with the woman (see appendix 2)
• informal psychological assessment
• verbal and written information provided to the woman

The CNS should initiate and participate in:

• audits relating to women’s experience of the assessment process
• other clinical audits relating to the care pathway for women in screening

Providing information on participation in trials

When participating in research, the CNS must make sure that women have enough information to make an informed choice regarding current research trials.

1.5 Educating peers and stakeholders

The CNS must respond to the educational needs of nurses engaging in the screening programme. This can include:

• communication skills
• information and support for the screening and assessment process
• the role of the CNS in screening and health promotion

The CNS must also be aware of the educational needs of those involved in breast screening and breast care or oncology. This includes:

• medical staff
• radiographers
• assistant practitioners
• students
• GPs
• community care staff

They should also be prepared to provide advice on nursing and other relevant aspects of the NHS breast screening programme (BSP) to external bodies such as:

• patient associations
• service user groups
• voluntary groups

1.6 Health promotion

There is a growing body of evidence demonstrating the effectiveness of lifestyle behaviour change approaches. As a frontline member of staff, the CNS has the opportunity to recognise appropriate times and situations to engage with individuals and help them on the pathway to improving overall health and wellbeing.

The CNS should initiate and actively participate in health promotion activities that are relevant to women’s health, specifically those relating to breast screening and breast health.

2. Resourcing, management and support for the CNS service

The number of clinical nurse specialists required depends on several factors. There should be an absolute minimum of 0.1 whole time equivalent CNS staff per 10,000 screening population to fulfil the clinical element of the role, specifically in the assessment clinic.

The CNS must be provided with adequate resources to ensure a continuing and effective service, including appropriate cover for absence. Resource planning should include cover by another qualified CNS for annual leave and training and development.

This does not include other aspects of the role such as:

• results clinics
• audit and research
• teaching
• training
• duty of candour or disclosure of audit consultations
• any extended or advanced practice duties
• administration time associated with the role
• any work undertaken as part of symptomatic practice

2.1 Line management

A lead nurse for breast screening should be appointed for each trust providing breast screening assessment.

There must be clear professional lines of accountability through nursing services within the host trust or provider. There must also be clear lines of clinical reporting within the screening service through to the director of breast screening.

The CNS should generate and contribute to clinical standards, guidelines, and protocols within the screening service, particularly those that relate to the care pathway for women. The CNS should be a core member of the breast screening management team.

2.2 Facilities

The CNS must be present during the assessment clinic, and must have access to a dedicated non-clinical room for private consultations. The CNS’s manager must provide other necessary resources, including:

• an office
• a phone with voicemail
• a computer
• a page or bleep (if appropriate)
• identified dedicated clerical support

2.3 Training and development

The CNS must be a registered general nurse (RGN) with relevant post-registration qualifications and experience. Post-registration qualifications should include:

• a breast care nursing course (at least 15 credits at first degree level or equivalent)
• an appropriate first degree
• advanced communication skills training

The CNS must:

• have an annual performance appraisal and the opportunity to complete annual continuing professional development (CPD), in accordance with local protocols
• have access to effective reflective practice or clinical supervision as well as psychological and peer support agreed with their line manager during appraisal
• be aware of their responsibilities in relation to clinical governance, risk management and information governance
• be able to analyse research findings relevant to breast screening and breast cancer, including those relating to treatment options and psychological care
• participate in research and be able to evaluate outcomes to ensure that clinical practice, protocols and standards of care are evidence-based
• participate in annual reviews or planning days based on the performance outcomes of the service

2.4 Management role

The CNS:

• is a core member of the breast screening team
• must be aware on their responsibilities in relation to clinical governance, risk management and information governance
• generates and contributes to clinical standards, guidelines and protocols within the screening service, particularly those relating to the care pathway for women
• participates in annual reviews based on the performance outcomes of the service
• ensures confidentiality in relation to women’s records in line with the general data protection regulation (GDPR)
• is accountable for their own professional practice in accordance with the code of professional conduct produced by the NMC

2.5 Extended roles

If a CNS chooses to take an extended role within the breast screening service they must:

• have undertaken accredited training
• work within clear protocols and guidelines, as ratified by their employer
• be aware of their responsibilities as a health professional
• be appropriately mentored and supervised
• audit their own work

Extended roles can encompass a wide variety of subjects, including health promotion, uptake initiatives and management of the woman’s pathway. Two of the most common extended roles are outlined below.

Giving benign results face-to-face or by telephone

NHS BSP policy guidelines recommend that all results are given in person. However, providing benign results by telephone as part of the extended CNS role is now established practice in most services. There is still some concern about the impact this might have on patient anxiety, as previous research published in the Journal of public health medicine has shown that women with a benign result frequently experience ongoing anxiety.

Services providing benign results by telephone must have adequate resources to take account of the predicted number of benign results each year and that each call can take between 5 and 10 minutes.

CNS staff giving benign results will require a telephone and a quiet dedicated time for such calls. Guidelines for giving benign results by telephone should be agreed locally, with women given the option of attending in person if they would prefer. There must be local guidance and protocols validated as part of the quality management system that specifies the process for giving women benign results. This must comply with the national service specification.

Disclosure of audit (including duty of candour) interviews

A CNS should always be present to support women during any disclosure of audit process. An experienced CNS in breast screening should undertake this highly specialised extended role.

More guidance about disclosure of audit and duty of candour (DoC) is available along with specialist e-learning. Any CNS involved in the disclosure of audit consultation must complete DoC e-learning.

Advanced practice

Advanced practice is distinct from the CNS role and is a level of practice characterised by a high level of autonomy. It requires a master’s level award or equivalent that encompasses:

• clinical practice
• management and leadership
• education and research
• demonstrations of both core and area-specific competence

A CNS trained as an advanced practitioner may support the service in:

• giving malignant results
• performing breast examinations
• performing fine needle aspiration cytology and core biopsies
• prescribing (as appropriate to screening)
• image reading

The advanced practitioner nurse must:

• be aware of their responsibilities as a health professional
• have undertaken accredited training
• work within clear protocols and guidelines as ratified by their employing organisation
• be appropriately mentored and supervised
• have their competency signed off by a mentor

3. Quality assurance and audit framework

The CNS must be available for any planned QA visit and provide appropriate information required for the review. They will support the CNS pathway element of provider functions reviewed by the screening quality assurance service (SQAS) as detailed in Appendix A of the programme specific operating model.

3.1 Regional level

The nursing professional clinical advisor (PCA) audits nursing practice in the breast screening service at the regional level, and participates in QA visits to assess professional nursing performance. This incorporates:

• patient experience
• information giving (formal and informal)
• patient pathway (including pre-QA visits to services)
• patient advocacy
• adherence to national guidance

The lead CNS should attend the annual screening meeting arranged by SQAS.

Regional meetings should discuss:

• local audit findings (presentations and outcomes)
• national programme updates
• incident reporting
• trial updates
• matters relating to breast nursing practice (research or educational)

3.2 Local level

All breast screening services should have a nominated CNS who leads for breast screening and assessment and is the identified point of contact for all queries relating to nursing within screening practice. This position should be involved in operational management meetings on a regular basis within the screening service. This should include representation at commissioning programme board meetings when issues relating to patient pathway or user experience are discussed.

The CNS should initiate and participate in audits relating to women’s experience of the assessment process and should participate in other clinical audits relating to the care pathway for women in screening. An assessment survey is available in Appendix 3 to evaluate the level of client satisfaction of nursing in the assessment clinic. This should be undertaken once every screening round. The NHS BSP recommends that the CNS contact their trust audit team for support in this activity and to offer guidance on survey sample size. This should be presented at the local programme board meeting and made available to the regional meetings and QA visits.