This occupational standard and end-point assessment plan has been updated to align to the Nursing and Midwifery Council's 2022 Standards of proficiency. The latest agreed version is called ST1419 Community nurse specialist practitioner (NMC 2022). ST0709 version 1.1 will be available until 31 August 2024 for new starts.
Caring for patients with a wide range of health conditions.
This occupation is found in health care. District Nurses work with adults of all ages and communities. They work across numerous different organisations and settings for example; primary care, social care, third sector organisations, hospitals including mental health, hospices, prisons and other community services to ensure that patients get the right care, at the right time, every time.
The broad purpose of the occupation is work with individuals and populations. This can mean working with people in their own home (which could be an individual’s house, a care home, a hostel, a prison, hotels etc.), a healthcare setting e.g. GP practice, hospital, hospice etc. or even the streets in the case of the homeless population. District Nurses assess and care for patients with a wide range of health conditions and are accountable for a large varied complex caseload where they prioritise care, assess risk, prescribe medication, dressings and appliances in accordance with legislation, manage changing local demands which require very careful oversight and case management. They plan, provide and monitor complex community nursing care and services. They manage a caseload of complex patients and families/carers, either with long-term conditions over a protracted period or those with acute short episodes of care, by leading a clinical team who often work in isolation without immediate and direct access to medical advice. They influence and lead change management initiatives within the service, for example, new ways of working, new models of care.
They are responsible for delivery of care across a 24 hour period 365 days a year anticipating problems and crises and proactively planning to prevent unnecessary hospital admission and facilitating timely discharge across a range of patient pathways e.g. end of life care, tissue viability etc.
In their daily work, an employee in this occupation interacts with patients, their carer’s and relatives and a wide variety of health and social care professionals including GP’s, social workers and hospital staff. District Nurses work with adults of all ages and communities. They work across numerous different organisations and settings for example; primary care, social care, third sector organisations, hospitals including mental health, hospices, prisons and other community services to ensure that patients get the right care, at the right time, every time. An employee in this occupation will be responsible for their own work as an autonomous, independent practitioner, whilst contributing and leading collaborative work with other health and care professionals. In addition the occupation will be responsible for a caseload of patients and the team responsible for delivering care to that caseload.
It is a requirement of the Nursing and Midwifery Council (NMC) that those training to become a District Nurse are already registered nurses on Part 1 of the NMC register
| Duty | Criteria for measuring performance | KSBs |
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Duty 1 Provide advanced case management for people with highly complex unpredictable needs including those nearing and at the end of their lives. |
Plan and implement effective case management strategies Asses, plan, implement and evaluate safe and effective care to the caseload and individuals |
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Duty 2 Holistically assess heath needs and make diagnostic decisions for people, including those nearing and at the end of their lives with highly complex unpredictable needs. |
Effectively assess the physical and mental health needs of individuals and make decisions to support the needs of individuals Work effectively with individuals, groups, health professionals and stakeholders |
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Duty 3 Lead a team to manage a complex, dynamic and unpredictable caseload. |
Implement effective organisational strategies Provide effective leadership and manage the team through change Maintain accurate records to inform service delivery |
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Duty 4 Take responsibility and accountability for care delivery, anticipatory care planning to avoid unnecessary admission and facilitate timely discharge. |
Conduct effective workload and workforce planning to meet identified needs | |
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Duty 5 Promote health education and self-care to individuals’ to achieve their health outcomes. |
Facilitate health promotion Identify resources required to deliver the strategy Refer individuals to correct services |
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Duty 6 Proactively lead, engage, challenge and empower the team in quality assurance, service improvement and change management. |
Effectively project manage service improvement and change Maintain audit requirements of the service Ensure teams engage in quality improvement activity Contribute to the development of effective business cases to support change |
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Duty 7 Develop practice to respond to the public and community health needs. |
Effectively collect and interpret data on health and wellbeing Provide evidenced based care to individuals, groups and communities |
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Duty 8 Participate in and undertake research and evaluation to improve care and services for the people and communities. |
Conduct and implement effective research Communicate the outcomes of data analysis and research Advance district nursing practice through research, audit and feedback |
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Duty 9 Develop and implement risk assessment and management strategies taking into account people’s views, choices and responsibilities, whilst promoting safeguarding of individuals, carers and staff. |
Deploy and evidence effective risk management strategies Minimise risk to all service users Carry out effective risk based approaches |
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Duty 10 Manage increasing demands on the service, deliver and manage change to meet the evolving shape of services through flexibility, innovation, strategic and operational clinical leadership. |
Implement effective organisational strategies Provide effective leadership and manage the team through change Maintain accurate records to inform service delivery |
K1: The complex causes, signs, symptoms and impact of interacting physical and mental health conditions
Back to Duty
K2: The principles of delivering and evaluating safe and effective palliative and end of life care including the principles of managing symptoms and involving carers
Back to Duty
K3: The principles, concepts and theories of evidence-based therapeutic interventions
Back to Duty
K4: How to apply the principles of case management
Back to Duty
K5: The principles of risk stratification
Back to Duty
K6: How to recognise, manage and evaluate the deterioration of patients in order to decide effective anticipatory care
Back to Duty
K7: The principles of managing long term conditions and interactions between long term conditions
Back to Duty
K8: The complex risks to patients in transition between services
Back to Duty
K9: How to use assessment and decision making models and proactive case management for effective care planning
Back to Duty
K10: Advanced communication skills to develop therapeutic relationships
Back to Duty
K11: The principles of advocacy and acting as the patients advocate in complex situations whilst also respecting the patient’s autonomy and ensuring ethical principles are upheld
Back to Duty
K12: The local and national policies, regulatory frameworks and guidelines for care e.g. prescribing
Back to Duty
K13: Pharmacotherapeutics relative to your scope of practice
Back to Duty
K14: The range of advanced physical, psychological and population based assessment methods and the application of pathophysiology to underpin assessment and diagnosis
Back to Duty
K15: The principles of social prescribing
Back to Duty
K16: The strategies and methodologies for effective teaching, learning and staff development
Back to Duty
K17: The local and national policies and procedures within your role and the NMC code
Back to Duty
K18: The principles and concepts of accountability in the role of District Nurse team leader and how to delegate responsibility
Back to Duty
K19: The theories, techniques and models of leadership, management and team working and how these can be applied across professional boundaries in health and social care
Back to Duty
K20: The principles of workload and workforce planning and application to practice including when to make the case for service changes
Back to Duty
K21: How to avoid unnecessary admission and facilitate timely discharge when there are many interacting factors
Back to Duty
K22: The range of appropriate places of care and how to facilitate and justify access to these
Back to Duty
K23: The principles of consent and capacity in relation to the mental capacity act and deprivation of liberties
Back to Duty
K24: Core assessment skills to assess mental wellbeing within the scope of the role and the limits of competence
Back to Duty
K25: The theories, methods and principles of health promotion and prevention
Back to Duty
K26: The range of advanced health promotion tools available for use
Back to Duty
K27: The theories, methods and principles underpinning self-care e.g. motivational interviewing and advanced communication skills
Back to Duty
K28: The theories, methods and principles of quality assurance, service improvement and change management
Back to Duty
K29: How to formulate specialist business cases for service change and improvement
Back to Duty
K30: How to apply the audit process and change management theories related to district nursing practice
Back to Duty
K31: How to critically analyse, interpret and evaluate data and information
Back to Duty
K32: How to foster a culture of openness and learning
Back to Duty
K33: The theories, methods and principles of leadership
Back to Duty
K34: How to use the public health outcomes framework
Back to Duty
K35: How to critically analyse, interpret and evaluate wider public health and demographic data
Back to Duty
K36: How to create a community profile
Back to Duty
K37: The complex range of evaluation and audit methods used in clinical practice
Back to Duty
K38: Critical appraisal techniques and how to apply them to clinical practice
Back to Duty
K39: The service evaluation and improvement methodology
Back to Duty
K40: Research methodology and how to implement research
Back to Duty
K41: The range of evidence-based strategies to manage risk in clinical practice and in relation to the different environments a district nurse works within
Back to Duty
K42: The cost benefit and individual analysis of the risks, taking account of individual’s views and responsibilities
Back to Duty
K43: Relevant safeguarding policies and procedures
Back to Duty
K44: How to apply the principles of confidentiality and information sharing policies
Back to Duty
K45: How to influence and the importance of political awareness
Back to Duty
K46: The principles of resilience and how this is built within yourself and others
Back to Duty
S1: Manage a caseload of patients in a variety of community settings using a person centred approach including implementation of risk stratification and case management strategies to determine those at most risk of poor health outcomes
Back to Duty
S2: Use specialised skills to work collaboratively with the patient and the multidisciplinary team, to improve anticipatory care, self-management, facilitate timely discharges and reduce avoidable hospital admissions to enable care to be delivered closer to, or at home
Back to Duty
S3: Manage and co-ordinate programmes of care, for individuals with complex acute and long term conditions, striving to make the patient journey seamless between mental and physical health care, hospital and community services and between primary and community care
Back to Duty
S4: Assess when a referral is required and maintain overall responsibility for the management and co-ordination of care
Back to Duty
S5: Manage the delivery of service whilst critically evaluating the capacity and demand and being mindful of patient and staff safety
Back to Duty
S6: Autonomously assess the complex health needs of people, families and other informal carers to formulate care plans, anticipatory care and care packages
Back to Duty
S7: Appropriately manage problems and make decisions in partnership with people, families and other informal carers using advanced communication skills
Back to Duty
S8: Use evidence based physical and clinical assessments of individuals with complex health care needs to make accurate diagnostic decisions, including prescribing
Back to Duty
S9: Lead and support the clinical team to provide community nursing interventions in a range of settings
Back to Duty
S10: Manage clear lines of accountability for the assurance of clinical governance and care quality
Back to Duty
S11: Manage the district nursing team within regulatory, professional, legal, ethical and policy frameworks ensuring staff feel valued and developed
Back to Duty
S12: Critically analyse, act on and evaluate trends and demands on the district nursing service to inform workload and workforce planning
Back to Duty
S13: Work with other services, teams and colleagues to support fewer unnecessary admissions and facilitate timely discharges
Back to Duty
S14: Assess and identify the mental capacity of people
Back to Duty
S15: Use specialised skills to work in partnership with individuals, formal and informal carers and other services to promote health education, self-care and patient-led care, to maximise the individual’s independence and understanding of their condition(s)
Back to Duty
S16: Critically analyse, interpret and evaluate complex data and information to improve patient care
Back to Duty
S17: Determine and use specialised skills to influence and negotiate the development of operational plans for the service
Back to Duty
S18: Lead a team to deliver service improvement and change management that involves many interacting factors
Back to Duty
S19: Quality assure services and make service improvements
Back to Duty
S20: Determine and use specialised skills to influence and negotiate the development of public health initiatives
Back to Duty
S21: Collaborate with other agencies to analyse and evaluate public health principles, priorities and practice and implement these policies
Back to Duty
S22: Participate in the collation of a community profile to understand local assets
Back to Duty
S23: Utilise position within the organisation to influence position of community nursing teams in the provision of care for communities under their umbrella
Back to Duty
S24: Engage in research activity and develop evidence-based strategies to enhance the quality, safety, productivity and value for money of health and care
Back to Duty
S25: Lead improvements to care service delivery through the implementation of research findings, best practice, outcome of audits and patient feedback
Back to Duty
S26: Critically assess and evaluate risk using a variety of specialised tools across a broad spectrum of often interrelated and unpredictable situations, including staff, and people within their home environments
Back to Duty
S27: Formulate and implement risk assessment and management strategies that take account of people’s views and responsibilities, whilst promoting patient and staff safety and preventing avoidable harm to individuals, carers and staff
Back to Duty
S28: Ensure all staff are able to recognise vulnerability of adults and children and understand their responsibilities and those of other organisations in terms of safeguarding legislation, policies and procedures
Back to Duty
S29: Lead the service change required to deliver services and evaluate the outcome
Back to Duty
S30: Develop, support and train the team to meet new and evolving requirements in patient care
Back to Duty
B1: Treat people with dignity at all times
Back to Duty
B2: Respect people’s diversity, beliefs, culture and individual needs
Back to Duty
B3: Show respect and empathy for patients, their families and carer’s and those you work with at all times
Back to Duty
B4: Be adaptable, reliable and consistent and have the courage to challenge areas of concern
Back to Duty
B5: Show flexibility, self-awareness and emotional intelligence when dealing with patients, carers, teams and self
Back to Duty
B6: Act as a positive role model for staff and teams
Back to Duty
| High Level Qualification |
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PG Diploma for District Nursing with integrated independent prescribing at Level 7 Level: 7 (non-degree qualification) |
This standard aligns with the following professional recognition:
This is a regulated occupation.
Nursing and Midwifery Council
Training provider must be approved by regulator body
7
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| Version | Change detail | Earliest start date | Latest start date |
|---|---|---|---|
| 1.1 | Funding band and end-point assessment plan revised | 24/11/2021 | 31/08/2024 |
| 1.0 | Retired | 30/09/2019 | 23/11/2021 |
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