In this guide
All registered nurses with a community nursing specialist practice qualification take the lead in providing evidence based, person-centred and safe interventions, in the context of the specific client groups and settings within their intended field of SPQ practice.
They are able to initiate and deliver a range of care and treatment that can be supportive, curative, symptom relieving or palliative. They ensure that the care they provide or delegate is flexible, dynamic and is of a consistently high standard.
They are independently able to undertake a range of interventions to positively impact a person’s health and wellbeing, and to manage complete episodes of care in relation to their intended field of SPQ practice.
They can communicate complex information in a way that supports, advocates for, enables and seeks to maximise the involvement of people, their families, carers or nominated person. They support people to make decisions and choices about their care and treatment, taking into account
the benefits and opportunities for supported self-management, and any risks.
They work in partnership with people, peers and interdisciplinary and interagency colleagues to assess the impact of care on an ongoing basis, including supporting and managing transition between services. They evaluate the care outcomes and whether planned interventions continue
to be effective and in line with the wishes, preferences and desired outcomes of the person receiving care, which may change over time.
Outcomes
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Registered nurses with this qualification in their intended field of practice, will be able to:
4.1autonomously manage and evaluate complex episodes of care from referral to service and admission, to discharge from caseload, or referral to other appropriate services or agencies
4.2assess and manage transition of people to other services or agencies, proactively collaborating with colleagues of other disciplines and agencies to find solutions to mitigate any risks
4.3agree and negotiate with the person and where necessary their family, carer or nominated person, the implications of delegation of any aspect of their care to an alternative person
4.4recognise reduced concordance, changes in motivation or dissatisfaction with the care and treatment plan, and work in partnership with people to influence and negotiate any revisions to the plan
4.5proactively engage with, and effectively advocate for, people using services provided by other professionals or agencies to identify and find solutions where there is inconsistency, disagreement or conflict
4.6initiate a range of evidence-based care and treatment, including care, therapeutic interventions and social prescribing, that may be supportive, curative, symptom relieving or palliative
4.7safely and effectively manage complex medicines administration, optimisation and medicines reconciliation, and continually evaluate to ensure optimum effectiveness
4.8evaluate and adjust plans to ensure adequate safeguards for people when they are vulnerable
4.9maintain therapeutic relationships with people, their families and/or carers throughout the episode of care and treatment, and actively address any differing views
4.10understand and apply a range of techniques to educate people, their families, carers or nominated persons about their condition, treatment and care, to promote independence and confidence in supported self care and self-management
4.11work in partnership with people, their families, carers and other members of the team to continuously monitor and evaluate the care and treatment provided
4.12include people and their families or carers in making decisions about their care and mitigate any risks as a result of changes in a person’s mental and physical health, their living environment, or social arrangements
4.13make autonomous decisions in challenging and unpredictable situations, and be able to take appropriate action to assess and manage risk
4.14work with people and where appropriate their families, carers or nominated person to agree and provide evidence-based person-centred nursing care for those who are dying or near to the end of life
4.15sensitively accommodate the preferences, beliefs, cultural requirements and wishes of the deceased and people who are bereaved
4.16clearly explain and accurately record the rationale for decisions, actions taken and resulting outcomes either in writing, or using digital technology, which can be shared with the person, their family, carers, nominated person and interdisciplinary and interagency teams.
