Developing the general practice nursing role in integrated community nursing teams

Works under direction and instruction from registered professionals

Supervision may be remote or direct

Carries out repetitive, routine and familiar tasks during their working day

Through experience and instruction, develops an awareness of what is normal concerning their patients'/clients' wellbeing and reports that which is outwith normal to registered professionals

Can communicate both routine and sensitive information to patients, clients, relatives and staff

Is able to problem-solve related to the task at hand

As a co-producer, works with patients/clients with varying levels of dependence; at times, they may be considered a 'lone worker' and as such carries out and undertakes familiar tasks with minimum supervision

Is able to recognise patients'/clients' response to care and recognises the basic care needs of patients/clients

Undertakes delegated well defined routine clinical and non-clinical duties within limits of competency

Supports patients, carers and the wider team

Develops organisational and time-management skills

Supports patients learning around lifestyle

At all times, acts under the delegation and supervision of a registered practitioner

Makes non-complex decisions and reports these back to assist patient care evaluation

Works on their own initiative within their role remit, which consists of delegated tasks

Plans and prioritises their own work tasks and activities

In some circumstances, spends more time with patients/clients post-assessment than registered staff and is able to report to registered practitioners regarding patient/client progress

Shows awareness of patient advocacy and wider patient/client issues (such as home concerns)

Ensures confidentiality

Understands and is able to carry out reflective practice

Recognises risk in relation to care provision

Has a generalised knowledge and understanding of their job role and related tasks. Is further developed than a HCSW

Has a broad skill-base related to their practice

Possesses an awareness and relative understanding of what is normal concerning their patients'/clients' wellbeing and reports that which is outwith normal to registered professionals

Following an initial assessment of the patient/client by the registered practitioner, and under guidance and supervision while following set protocols and procedures, carries out routine elements of assessment to enhance the patient/client journey

Regularly communicates routine and sensitive information to patients, clients, relatives and staff

Has an awareness of subtle cues concerning patient/client wellbeing and responds to/takes action concerning common symptoms within agreed protocols and guidelines pertinent to their work area

General workload is likely to increase in complexity where familiar but not routine tasks are delegated to them

Recognises risk in relation to care provision and further develops risk assessment skills

Shows awareness of patient advocacy and wider patient/client issues; recognises and understands role boundaries and limitations

At all times, acts under the delegation and supervision of a registered practitioner

Supervises and assesses HCSWs of a lower grade and takes a role in supporting students and other health and social care staff

Is expected to participate in running groups and activities, giving help and support to registered colleagues

Supports and acts as a role model to HCSWs

Is able to problem-solve and take action regarding patient/client care through an awareness of policy and legislation

Works on their own initiative within their role remit, which may involve more advanced clinical skills and tasks than a HCSW, dependent on the area and site of their work

Role remit consists of delegated tasks and duties that they plan and prioritise in consultation with registered practitioners

Has developed organisational and time-management skills

At times, may be considered a 'lone worker' and as such carries out and undertakes familiar tasks with minimum supervision

Reports back to assist in broader service development and quality-assurance activities

Understands and is able to carry out reflective practice

As a co-producer, works with patients/clients with varying levels of dependence

Supports patients/clients with a wide range of conditions to understand and where possible take on self-management of their condition

Possesses clinical assessment skills

Delivers anticipatory and preventative care

Prescribes and works to patient group directives

Undertakes risk assessment

Assesses patients, taking into account their physical, mental and social states alongside the impact of their environment and social support available to them

Negotiates care plans with patients and the wider multidisciplinary team (MDT) that are person-centred and focused on self-care with clear objectives, using a range of assessment tools pertinent to the patient's needs to inform the assessment and assess risk for patients and staff

Articulates risk and strategy for risk assessment and management

Has knowledge of a broad range of conditions, local care pathways and evidence-based management experienced by patients in community and general practice settings (this includes long-term conditions and common mental illnesses, frailty and palliative care)

Has an understanding of the presentations of multiple pathology, depression, anxiety states, frailty and delirium

Has knowledge of the management of uncomplicated symptoms in patients/clients with palliative or terminal care needs and enhanced communication skills to confidently manage uncertainty

Ensures information is recorded objectively and reported back to the general practice team and wider MDT

Can plan ahead for potential scenarios to ensure anticipatory care needs are understood and met

Recognises signs of deterioration in patients and refers appropriately to ensure patient safety and avoid hospital admission

Collaborates effectively with other members of the multidisciplinary team or other agencies involved in the patient's care

Has the ability to recognise the patient's health beliefs and adapts behaviour-change approaches to enable self-management using extended brief interventions

Utilises a range of IT applications and technology where appropriate

Utilises critical thinking to explore and analyse evidence, cases and situations in practice

Draws on a range of sources in making judgements guided by senior colleagues within defined policies, procedures and protocols

Supervises experienced or qualified staff and students

Facilitates students and others to develop their experience

Has the ability to reflect on practice and utilise clinical supervision and other development opportunities and support

Has emotional intelligence and the ability to support staff at levels 2, 3 and 4 to debrief and reflect on difficult situations experienced to improve learning and enhance self-awareness

Provides effective mentorship for nursing students and maintains a supportive learning environment with a range of learning opportunities

Shows creativity in developing learning materials for patients and adapting care to support individual needs in patients

Co-ordinates the management of a defined group of patients, as delegated

Plans, implements and evaluates programmes of care to meet individual health needs

Has the ability to prioritise a delegated workload and effectively manage time and work effectively within the team

Has knowledge of resource management to ensure care is clinically effective and signposted to the patient and family, ensuring principles of confidentiality and disclosure are maintained

Recognises personal accountability and responsibility to monitor and evaluate care to ensure optimal practice

Participates in personal development, appraisal and development of other team members and the links between organisation and team goals

Has the ability to recognise poor performance and take appropriate measures

Acts up when appropriate

Assists the lead general practice nurse, or appropriate other, in undertaking and reviewing population needs, assessments and community profiles or other data in general practice that reflect the demographics within broader public health issues within the local community and general practice populations

Demonstrates leadership through appropriate delegation and supervision of non-registered staff

Contributes to quality-assurance processes and service development

Participates in educational audit

Contributes to review of impact of NMaHP interventions on the wider individual/patient experience

Has the ability to articulate the evidence underpinning patients' care plans and interventions

Has the ability to source evidence and appraise it to underpin practice

Recognises any ethical implications of audit, research, clinical trials or service-user involvement strategies

Uses opportunities to suggest improvements to services or introduction of other innovations or evidence

Engages actively in data collection for quality assurance and takes responsibility for ongoing evaluation of delegated care

Uses a range of clinical assessment skills, including:

history-taking, physical examination, cognitive assessment and an approach that fosters a bio-psychosocial model

critical thinking and clinical decision-making

making objective and appropriate referrals

Is an V300 non-medical prescriber

Delivers palliative care

Delivers care and support planning and anticipatory care

Role-models the values, behaviours and interactions expected, and ensures patient, family and carer feedback support these in practice

Understands public health, including health inequalities, epidemiology and prevention

Utilises a range of skills related to e-health and technology to enable care, and support self-management

Understands and supports mental health and wellbeing

Provides assessment, support, advice and, if appropriate, management of women's health and men's health issues

Manages minor illness and triage

Assesses and manages long-term conditions

Monitors laboratory results, arranging follow-up where appropriate

Identifies and supports the achievement of learning needs of individuals/teams in response to service need and personal development planning

Evaluates the effectiveness of educational interventions

Participates in teaching and student selection in higher education institutions and/or other education organisations

Uses established models of supervision, mentorship and coaching

Contributes to the creation of an effective learning environment, ensuring learning opportunities for students

Participates in educational audit

Works effectively across professional and agency boundaries

Provides leadership for quality improvement and service development and improvement to enhance people's wellbeing and experiences of health care

Actively contributes to a variety of professional networks, such as managed knowledge networks

Recognises early signs of poor performance and takes appropriate measures to address concerns

Contributes to the development of local guidelines and policy where appropriate at cluster, regional and national levels

Provides leadership around integrated working, risk management, handling of complaints and feedback

Supports staff through change, including building resilience in self and others

Demonstrates advanced communication skills, including motivational interviewing and negotiation

Has knowledge regarding sources of evidence

Has the ability to generate, manage and utilise data

Has the ability to critically examine research, including:

its application to clinical practice

facilitating and participating in research

dissemination, where appropriate

Delivers population surveillance and interventions to improve community and individual health and wellbeing

Provides measurement of effectiveness of care

Has responsibility for specific areas of service delivery

Has in-depth expertise in long-term condition assessment, including comprehensive clinical examination to address highly complex health needs and physical and mental health assessment

Is an V300 non-medical prescriber

Has freedom and authority to request diagnostic investigations and interpret and analyse results

Acts on the results to inform diagnosis and optimise treatment and management outcomes

Implements non-pharmacological-related interventions/therapies, dependent on situation and technical requirements of care

Utilises new knowledge in innovative ways and takes responsibility for developing and changing practice in complex and sometimes unpredictable environments

Recognises the complexity of operating in multi-agency environments and the need for interdependent decision-making

Supports patients and carers to manage their medicines and undertakes medicine management reviews when required

Manages/supervises work of others

Provides training support and supervision of staff

Delivers advanced practice through educational development and delivery

Acts as an experienced work-based learning educator/assessor by providing advice to other practitioners

Designs, plans, implements and evaluates learning and development programmes

Engages with education providers to contribute to curriculum development and teaching

Takes a lead role in ensuring the application of standards and guidelines that underpin a quality learning experience

Analyses the range of factors that influence learning

Advises service/education providers on capability and capacity for student experience

Provides strong and effective leadership across professional and organisational teams/boundaries

Leads or contributes to general practice clusters and health policy development and implementation

Advises others on evidence-informed complex community nursing issues

Critically reviews team performance and uses results to enhance own and team-member working

Provides strong and effective leadership across professional and organisational team boundaries

Actively encourages involvement of service users to influence and improve person-centred care

Ensures organisational objectives are reflected in personal and team objectives

Establishes, leads and supports a variety of professional networks with peers across professional groups

Ensures the delivery of evidence-informed care and participates/leads practice development

Leads innovation and quality improvement

Is a role model for the wider team by creating a positive research culture

Utilises skills and knowledge of staff to support or undertake research/quality-improvement activity, such as audit and evaluation

Identifies, promotes, embeds and monitors the measurement of outcomes relevant to area of practice, using findings to enhance practice

Provides differential diagnoses

Has responsibility for specific areas of service delivery

Undertakes advanced-level assessment, including comprehensive clinical examination to address highly complex health needs and physical and mental health assessment

Is an V300 non-medical prescriber

Takes account of managing clinical risk in dealing with undifferentiated client groups across the age spectrum

Has freedom and authority to request diagnostic investigations and interpret and analyse results

Acts on the results to inform diagnosis and optimise treatment and management outcomes

Formulates an action plan for the treatment of the patient, synthesising clinical information based on the patient's presentation, history, clinical assessment and findings from relevant investigations, using appropriate evidence-based practice

Implements non-pharmacological-related interventions/therapies, dependent on situation and technical requirements of care

Has the freedom and authority to admit and discharge from identified clinical areas

Utilises new knowledge in innovative ways and takes responsibility for developing and changing practice in complex and sometimes unpredictable environments

Recognises the complexity of operating in multi-agency environments and the need for interdependent decision-making

Manages/supervises work of others

Provides training support and supervision of staff

Delivers advanced practice through educational development and delivery

Acts as an experienced work-based learning educator/assessor by providing advice to other practitioners

Designs, plans, implements and evaluates learning and development programmes

Engages with education providers to contribute to curriculum development and teaching

Takes a lead role in ensuring the application of standards and guidelines that underpin a quality learning experience

Analyses the range of factors that influence learning

Advises service/education providers on capability and capacity for student experience

Provides strong and effective leadership across professional and organisational teams/boundaries

Leads or contributes to community nursing and health policy development and implementation

Practices with autonomy by virtue of advanced knowledge and skills

Advises others on evidence-informed complex community nursing issues

Critically reviews team performance and uses results to enhance own and team-member working

Provides strong and effective leadership across professional and organisational team boundaries

Actively encourages involvement of service users to influence and improve person-centred care

Ensures organisational objectives are reflected in personal and team objectives

Establishes, leads and supports a variety of professional networks with peers across professional groups

Ensures the delivery of evidence-informed care and participates/leads practice development

Leads innovation and quality improvement

Is a role model for the wider team by creating a positive research culture

Utilises skills and knowledge of staff to support or undertake research/quality-improvement activity, such as audit and evaluation

Identifies, promotes, embeds and monitors the measurement of outcomes relevant to area of practice, using findings to enhance practice