Interested in a simple Skills Scan and Learning Progress Tracker tool for the District nurse standard?
Knowledge
K1: The complex causes, signs, symptoms and impact of interacting physical and mental health conditions
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
K3: The principles, concepts and theories of evidence-based therapeutic interventions
K4: How to apply the principles of case management
K5: The principles of risk stratification
K6: How to recognise, manage and evaluate the deterioration of patients in order to decide effective anticipatory care
K7: The principles of managing long term conditions and interactions between long term conditions
K8: The complex risks to patients in transition between services
K9: How to use assessment and decision making models and proactive case management for effective care planning
K10: Advanced communication skills to develop therapeutic relationships
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
K12: The local and national policies, regulatory frameworks and guidelines for care e.g. prescribing
K13: Pharmacotherapeutics relative to your scope of practice
K14: The range of advanced physical, psychological and population based assessment methods and the application of pathophysiology to underpin assessment and diagnosis
K15: The principles of social prescribing
K16: The strategies and methodologies for effective teaching, learning and staff development
K17: The local and national policies and procedures within your role and the NMC code
K18: The principles and concepts of accountability in the role of District Nurse team leader and how to delegate responsibility
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
K20: The principles of workload and workforce planning and application to practice including when to make the case for service changes
K21: How to avoid unnecessary admission and facilitate timely discharge when there are many interacting factors
K22: The range of appropriate places of care and how to facilitate and justify access to these
K23: The principles of consent and capacity in relation to the mental capacity act and deprivation of liberties
K24: Core assessment skills to assess mental wellbeing within the scope of the role and the limits of competence
K25: The theories, methods and principles of health promotion and prevention
K26: The range of advanced health promotion tools available for use
K27: The theories, methods and principles underpinning self-care e.g. motivational interviewing and advanced communication skills
K28: The theories, methods and principles of quality assurance, service improvement and change management
K29: How to formulate specialist business cases for service change and improvement
K30: How to apply the audit process and change management theories related to district nursing practice
K31: How to critically analyse, interpret and evaluate data and information
K32: How to foster a culture of openness and learning
K33: The theories, methods and principles of leadership
K34: How to use the public health outcomes framework
K35: How to critically analyse, interpret and evaluate wider public health and demographic data
K36: How to create a community profile
K37: The complex range of evaluation and audit methods used in clinical practice
K38: Critical appraisal techniques and how to apply them to clinical practice
K39: The service evaluation and improvement methodology
K40: Research methodology and how to implement research
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
K42: The cost benefit and individual analysis of the risks, taking account of individual’s views and responsibilities
K43: Relevant safeguarding policies and procedures
K44: How to apply the principles of confidentiality and information sharing policies
K45: How to influence and the importance of political awareness
K46: The principles of resilience and how this is built within yourself and others
Skills
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
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
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
S4: Assess when a referral is required and maintain overall responsibility for the management and co-ordination of care
S5: Manage the delivery of service whilst critically evaluating the capacity and demand and being mindful of patient and staff safety
S6: Autonomously assess the complex health needs of people, families and other informal carers to formulate care plans, anticipatory care and care packages
S7: Appropriately manage problems and make decisions in partnership with people, families and other informal carers using advanced communication skills
S8: Use evidence based physical and clinical assessments of individuals with complex health care needs to make accurate diagnostic decisions, including prescribing
S9: Lead and support the clinical team to provide community nursing interventions in a range of settings
S10: Manage clear lines of accountability for the assurance of clinical governance and care quality
S11: Manage the district nursing team within regulatory, professional, legal, ethical and policy frameworks ensuring staff feel valued and developed
S12: Critically analyse, act on and evaluate trends and demands on the district nursing service to inform workload and workforce planning
S13: Work with other services, teams and colleagues to support fewer unnecessary admissions and facilitate timely discharges
S14: Assess and identify the mental capacity of people
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)
S16: Critically analyse, interpret and evaluate complex data and information to improve patient care
S17: Determine and use specialised skills to influence and negotiate the development of operational plans for the service
S18: Lead a team to deliver service improvement and change management that involves many interacting factors
S19: Quality assure services and make service improvements
S20: Determine and use specialised skills to influence and negotiate the development of public health initiatives
S21: Collaborate with other agencies to analyse and evaluate public health principles, priorities and practice and implement these policies
S22: Participate in the collation of a community profile to understand local assets
S23: Utilise position within the organisation to influence position of community nursing teams in the provision of care for communities under their umbrella
S24: Engage in research activity and develop evidence-based strategies to enhance the quality, safety, productivity and value for money of health and care
S25: Lead improvements to care service delivery through the implementation of research findings, best practice, outcome of audits and patient feedback
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
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
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
S29: Lead the service change required to deliver services and evaluate the outcome
S30: Develop, support and train the team to meet new and evolving requirements in patient care
Behaviours
B1: Treat people with dignity at all times
B2: Respect people’s diversity, beliefs, culture and individual needs
B3: Show respect and empathy for patients, their families and carer’s and those you work with at all times
B4: Be adaptable, reliable and consistent and have the courage to challenge areas of concern
B5: Show flexibility, self-awareness and emotional intelligence when dealing with patients, carers, teams and self
B6: Act as a positive role model for staff and teams
Duty 1
DUTY: Provide advanced case management for people with highly complex unpredictable needs including those nearing and at the end of their lives.
CRITERIA FOR MEASURING PERFORMANCE: Plan and implement effective case management strategiesAsses, plan, implement and evaluate safe and effective care to the caseload and individuals
K1
K2
K3
K4
K5
K6
K7
K8
S1
S2
S3
S4
S5
B1
B2
B3
B4
B5
B6
Duty 2
DUTY: 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.
CRITERIA FOR MEASURING PERFORMANCE: Effectively assess the physical and mental health needs of individuals and make decisions to support the needs of individualsWork effectively with individuals, groups, health professionals and stakeholders
K9
K10
K11
K12
K13
K14
K15
S6
S7
S8
B1
B2
B3
B4
B5
B6
Duty 3
DUTY: Lead a team to manage a complex, dynamic and unpredictable caseload.
CRITERIA FOR MEASURING PERFORMANCE: Implement effective organisational strategies Provide effective leadership and manage the team through changeMaintain accurate records to inform service delivery
K16
K17
K18
K19
S9
S10
S11
B1
B2
B3
B4
B5
Duty 4
DUTY: Take responsibility and accountability for care delivery, anticipatory care planning to avoid unnecessary admission and facilitate timely discharge.
CRITERIA FOR MEASURING PERFORMANCE: Conduct effective workload and workforce planning to meet identified needs
K20
K21
K22
S12
S13
B1
B2
B3
B4
B5
B6
Duty 5
DUTY: Promote health education and self-care to individuals’ to achieve their health outcomes.
CRITERIA FOR MEASURING PERFORMANCE: Facilitate health promotionIdentify resources required to deliver the strategyRefer individuals to correct services
K23
K24
K25
K26
K27
S14
S15
B1
B2
B3
B4
B5
Duty 6
DUTY: Proactively lead, engage, challenge and empower the team in quality assurance, service improvement and change management.
CRITERIA FOR MEASURING PERFORMANCE: Effectively project manage service improvement and changeMaintain audit requirements of the serviceEnsure teams engage in quality improvement activityContribute to the development of effective business cases to support change
K28
K29
K30
K31
K32
K33
S16
S17
S18
S19
B1
B2
B3
B4
B5
B6
Duty 7
DUTY: Develop practice to respond to the public and community health needs.
CRITERIA FOR MEASURING PERFORMANCE: Effectively collect and interpret data on health and wellbeingProvide evidenced based care to individuals, groups and communities
K34
K35
K36
S20
S21
S22
S23
B1
B2
B3
B4
B5
Duty 8
DUTY: Participate in and undertake research and evaluation to improve care and services for the people and communities.
CRITERIA FOR MEASURING PERFORMANCE: Conduct and implement effective research Communicate the outcomes of data analysis and researchAdvance district nursing practice through research, audit and feedback
K37
K38
K39
K40
S24
S25
B1
B2
B3
B4
B5
Duty 9
DUTY: 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.
CRITERIA FOR MEASURING PERFORMANCE: Deploy and evidence effective risk management strategiesMinimise risk to all service usersCarry out effective risk based approaches
K41
K42
K43
K44
S26
S27
S28
B1
B2
B3
B4
B5
Duty 10
DUTY: 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.
CRITERIA FOR MEASURING PERFORMANCE: Implement effective organisational strategies Provide effective leadership and manage the team through changeMaintain accurate records to inform service delivery
