Reducing variations in clinical nurse educator roles: a service improvement project standardising roles and career pathways

Across the UK, there are wide variations in registered nurse job titles, job person specifications, role expectations and pay bands within the nursing workforce.

Leary et al (2017) examined variations in the job titles of nurses working in specialisms in the UK. From the available published studies (n=17 960) they found 595 different job titles. Similarly, there is evidence of 35 variations in clinical nurse educator (CNE) job titles and different expectations of CNE roles across the UK (Sprinks, 2015).

In 2014, the first UK Clinical Nurse Educator Network (CNEnet) was founded. Survey feedback from CNEnet's 235 members identified: variations between organisations in how CNEs work; inconsistencies in job descriptions; and the lack of a national framework or career progression pathway for CNEs in the UK (Sprinks, 2015).

The role

UK CNEs are usually registered nurses employed by NHS organisations, not universities, to ensure staff receive essential training and support in clinical practice (Sprinks, 2015). The role of the CNE is multifaceted and encompasses a variety of responsibilities and role expectations, such as:

• Promoting evidence-based nursing practice (Penz and Bassendowski, 2006; Hampson et al, 2017)
• Assisting in the development of policies and procedures, and mentoring (Milner et al, 2005; Hampson et al, 2017)
• Acting as a role model and change agent (Strickland and O'Leary-Kelley, 2009), and enacting leadership (Adelman-Mullally et al, 2013)
• Driving practice change through engagement in professional forums, research and scholarship (Sayers et al, 2015)
• Providing support and education to clinical staff and students to improve their professional practice (Hampson et al, 2017)
• Fostering research-based clinical practice and professional growth through lifelong learning (Petrova and Camilleri, 2015); narrowing the theory-practice gap (Rowe, 2008)
• Acting as a link between universities and practice environments to support student nurses (Jowett and McMullan, 2007; Hampson et al, 2017).

While the CNE role is a global one, there is a lack of research evaluating its implementation and effectiveness. Three evaluative UK studies examining perceptions of the CNE role suggest it is valued by staff and students (Jowett and McMullan, 2007; Matthew-Maich et al, 2015; Hampson et al, 2017).

Matthew-Maich et al (2015) provide the largest evaluative study examining student perceptions of UK nurse educators in clinical practice. Online surveys were completed by nursing students (n=511) to examine their perceptions of what makes an effective nurse educator in the clinical practice setting and the influence of effective teaching on student experiences. Findings indicated that effective CNEs foster positive experiences, motivation, meaningful learning and success. CNEs were perceived to be person centred, professional, passionate and positive, and helped students achieve success using active strategies.

Similarly, findings from local evaluations of newly implemented clinical educator posts identified that practice educators are a vital link between university and practice environments (Jowett and McMullan, 2007) and that CNEs enhanced the learning experiences of pre-registration nursing and allied health students during clinical placements (Hampson et al, 2017). Senior CNEs are also working with universities to develop and run in-house accredited level 7 courses to strengthen collaborative working to meet the needs of clinical staff to follow their academic pathways.

Need for research

It is evident there is limited research evaluating the implementation and impact of CNE roles in clinical practice. CNE roles in the UK are subject to different interpretations by UK employers and there are no nationally standardised CNE job titles, job descriptions and person specifications in the UK (Sprinks, 2015).

This is an important role, but one that takes a variety of forms in different settings, none of which have been rigorously evaluated.

This service improvement project gathered both quantitative and qualitative data to provide a rich description of the CNE role within one large acute hospital trust and developed an intervention (the job plan), which addressed some of the role ambiguities and associated tensions.

Service improvement project

Objectives

Initiated and led by the divisional education lead, the service improvement project presented here took place from September 2017 to September 2018 and involved a review of CNE roles across a division in a UK NHS hospital trust. Service evaluation included a collaborative review of CNE job titles, job descriptions and job plans, as well as focus group interviews, to examine CNEs' and senior nurses' perceptions of the CNE role. Data collection took place over a 4-week period and fed into the standardisation of CNE job titles, job descriptions and job plans, which promoted a unified approach to the CNE role across the division.

Key project objectives included the following:

• To review and analyse existing CNE roles, job titles, job descriptions and job plans
• To review perceptions of the CNE role across the hospital division from the perspective of matrons, senior nurses and current CNEs
• To develop, standardise, implement and evaluate new CNE job titles, job descriptions and job plans.
• To develop and implement clear career pathways for CNEs.

Authorisation process

Authorisation for the project was sought from the divisional nurse, divisional senior management team and matrons. The implementation of new CNE job titles, descriptions and profiles adhered to trust policies and standards.

Following authorisation, an email was sent to all matrons and CNEs explaining the aims, objectives, risks and benefits of the project. Two risks were identified: traditional resistance to change; and misinterpretation by CNEs that their job was under threat. These were mitigated by a strong, clear message that everyone's job was secure and that the review could potentially help CNEs to be more efficient and effective in their role.

There was an expectation that all CNEs' job titles, descriptions and plans needed to be submitted as part of the evaluative review across the division. However, participants could opt out of focus group interviews at any time without giving a reason and all those taking part were assured of their anonymity throughout the project and while the findings were being written up.

The collaborative communication methods already established within senior nurse and CNE meetings allowed project data to be shared with the divisional nurse, divisional education lead, divisional recruitment and retention lead as well as the matrons, which helped inform ongoing decision-making. Informed by the review findings, the divisional education lead was authorised to standardise and implement new CNE roles in agreement with the divisional matrons.

Methods

Review of job titles, job descriptions and job plans

All CNEs in the four directorates of the division were asked to submit their current job title, job description and job plans for evaluation. They also stated the number of hours spent working in each component of the role. Findings from this quantitative review provided topic guides for the focus group interviews. Managers were interviewed for their perspectives on the role, and the data they provided were compared and contrasted with information from role holders to identify similarities and differences in view.

Role-specific headings and the percentage of time each CNE spent in the different parts of their role informed which areas were key within the current job description templates.

CNEs and matrons were contacted by email to establish the number of hours CNEs spent per week performing educational, developmental, clinical, managerial and administrative duties. Cross-referencing details from nurse managers and CNEs helped to further verify and validate data, for example where different definition of duties were given by a manager and a CNE.

The trust's existing nursing job description templates adhered to the Agenda for Change grading and pay system for NHS staff (NHS Employers, 2019) and national generic job profiles produced from a national job evaluation group (NHS Employers, 2021).

Review findings

The hospital division is split into four directorates and each directorate is split further into several specialist areas. Table 1 shows the variations in job titles, descriptions and plans of CNEs by directorate before the review. The directorates within the division are anonymised using letters (A, B, C and D) and each CNE by numbering. This is the structure of the division in the trust being reviewed, which may differ from structures that are in place in other trusts.

After the evaluative review was completed, it became evident that there were variations in job titles and job plans across the division. Two CNE job titles were used—practice development nurse (PDN) or clinical practice educator (CPE). Two areas used the title PDN for a band 7 role, while other areas aligned a PDN to band 6. A similar picture is found across the UK, with CNE job titles aligned to a variety of bands.

Clinical (direct patient care) duties within CNE job plans ranged across the division from an average of 10% to 80% of contracted hours per week.

Focus group interviews

Data from focus group interviews were captured during established regular monthly senior nurse and nurse educator meetings to capture CNEs' (n=12) and senior nurses' (n=11) perceptions of the CNE role. CNEs and nurse managers were asked semistructured questions, such as:

• What CNE job titles and roles do you have in your area?
• What range of duties/role(s) do CNEs undertake in your area?
• How much time do CNEs spend on administration on average a week?
• What percentage of time do CNEs spend on educational, developmental, clinical, managerial and administrative duties?
• Do you feel the role of the CNE meets the needs of staff and your service? Individuals who stated ‘no’ were asked to provide details.

CNEs were also asked about the support offered to them in the role.

Examples of comments made during focus group interviews are shown in Table 2.

The narrative data from different focus groups within the study was transcribed and coded electronically and analysed separately by a senior nurse and a nurse academic. These data informed the development of the new and structured job descriptions and job plans (Tables 3 and 4).

Themes from focus groups

The formation of themes and categories using comparative content analysis informed theoretical interpretations (Creswell and Creswell, 2018). Three key themes were identified from the coding of narrative data as follows:

• The importance and need for CNEs
• Variations in roles: job titles, job descriptions and/or job plans
• Lack of academic support and career progression for CNEs.

Example themes from CNE responses during focus group interviews are presented in Table 2.

A dominant theme was the need for more clarity around job titles and job plans, from both the perspective of a CNE who may feel ‘pulled’ between different aspects of their role, and the perspectives of staff who may not understand what a CNE is doing on an administration day. The majority of CNEs called for more academic preparation and career guidance to support their future progression. All CNEs and matrons highlighted the importance of the CNE role to staff development which, in turn, impacts the quality of patient care.

Implementation of the findings and lessons

Standardising roles: job titles, descriptions and plans

After the study's findings were presented and discussed at senior nurse meetings, standardised job titles and job plans covering band 5 to band 7 were approved by the divisional nurse and matrons and implemented by senior nurses. Three new CNE job titles were created and aligned to different bands as follows:

• Band 5 associate clinical practice educator (ACPE) to act as a developmental education post for experienced band 5 staff
• Band 6 clinical practice educator (CPE) to deliver staff education and training in practice
• Band 7 practice development and education lead to manage and lead education.

The new standardised job plans relating to each role are presented in Tables 3 and 4. Table 5 shows the percentage of administration and clinical time associated with each CNE role. The academic qualifications and professional experience required were aligned to each band (Table 6). The job descriptions were then revised in line with these.

The human resources team ensured the new job descriptions adhered to trust policies and were banded correctly. They also provided ongoing advice and support during the transition phase as the new job plans were being implemented for current staff. CNEs who were already in post were fully supportive of changes to their role as there was no downgrading of staff and many received an increase in their administration time.

Career advice and support

All CNEs were offered one-to-one career advice and support from the divisional recruitment and retention lead. These sessions were guided by band 5–8 career progression tables that align individuals' professional experience and academic development with a clinical, education, research or specialist nursing pathway (Forde-Johnston, 2020).

Since implementation, five CNEs have completed a postgraduate certificate in teaching in higher education and are considering an MSc in the field of nursing education. This has inspired other CNEs to do something similar because elements of their role each year include completing a training needs analysis, providing career development advice and managing continuous professional development funding.

Evaluations

Increased numbers of CNE roles

Evaluative verbal feedback was obtained from 100% of CNEs, 95% of matrons and 90% of senior nurses through senior nurse and nurse educator meetings 3–6 months after implementation. Feedback was overwhelmingly positive and there was evidence of senior nurses seeking more support from CNEs in a wider range of service areas following the implementation of new job titles and plans.

The number of CNE positions in the division increased from 12 originally to 17 after implementation. To create CNE posts, with the support of the divisional management team, managers moved unfilled band 5 vacancies over to new CNE positions. Within 6 months of implementation, three new band 5 ACPEs (in a directorate that had initially planned to have only one) and two band 6 CPEs were appointed.

It was clear these developments were partially enabled by managers being able to be flexible with their staffing budgets as they had unfilled vacancies.

Retaining staff through career pathways

Feedback from 90% of nurse managers and 100% of CNEs suggested that CNEs were happier in their role and more likely to stay in post after the new CNE career pathways were implemented. The matron and senior nurses in one directorate suggested that the new job profiles and career pathways helped attract band 5 applicants to previously vacant posts.

Matrons agreed to support all CNEs to complete their postgraduate certificate in teaching in higher education as part of their career development. All CNEs stated they felt more motivated to start academic courses, master's degrees and/or doctorates in the future. After implementation, five of the existing CPEs started a postgraduate certificate in teaching in higher education, two completed MSc degrees they had started, and two senior members of the education team started a doctor of education programme.

This project has helped raise the profile of CNE roles within the division, improved CNE morale and made CNEs proud and able to celebrate their job as nurses.

Future evaluation

Although initial feedback from matrons and CNEs in this one division of one trust was positive, further review is needed to evaluate the long-term impact and effectiveness of CNE roles and education career pathways both locally and across the UK.

The value of more standardised and better understood CNE roles across all trusts, perhaps leading to its better recognition as a specialisation in its own right, needs to be assessed.

Reviewing future recruitment and retention rates may help inform future CNE: staff ratios. Clinical staff being supported by CNEs should also be included in future reviews to evaluate the effectiveness of CNE roles in practice.

Conclusion

This service improvement project demonstrates that a standardised approach to the implementation of CNE job titles, job descriptions and job plans across a UK NHS hospital trust division can be achieved with the support of a unified senior nursing team.

Although the CNE job titles and plans presented may not be wholly transferable to other UK health and social care environments, insights gained from the methodology employed may inform future service improvement projects in other trusts.

There is a need for more evaluative service improvement projects and research studies to examine the implementation and effectiveness of CNE roles in the UK.

The importance of career advisory sessions aligned to clear career pathways should not be underestimated, as nurses are more likely to stay in a role if they can envisage their future career progression. Staff need to feel that they belong and are valued, empowered and enabled to do their job with pride.

KEY POINTS

• There is considerable variation in clinical nurse educator (CNE) job titles, job descriptions and job plans between hospitals in the UK
• Aligning a career pathway with nursing bands may increase staff motivation and help retain employees
• A standardised implementation of CNE roles requires a collaborative team approach
• The long-term impact and effectiveness of CNE roles needs to be further evaluated across the UK

CPD reflective questions

• Why do you think that clinical nurse educators (CNEs) have variable job titles and job descriptions across the UK?
• Review the number and types of clinical education roles where you work; are the job titles and job descriptions similar or different between services?
• What would be the impact of increasing the number of CNE roles across services?
• What are the potential risks of not evaluating the role of clinical practice educators?