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Changing practice

Supporting staff nurses to train as community specialist district nurse practitioners


Band 5 staff nurses often need targeted training to make the transition to specialist practitioners. A trust set up a course to prepare candidates for degree study


Lorraine Elliott, PGCert, BSc, RN, is clinical practice lead, NHS Blackburn with Darwen.


Elliott L(2010) Supporting staff nurses to train as community specialist district nurse practitioners. Nursing Times; 106: 15, early online publication.

The removal of district nurses from the Nursing and Midwifery Council’s recognised specialist practitioner list has resulted in many employers not commissioning district nurse courses and a lack of clarity about the skills required to be a team leader.

This article discusses a practice development initiative to support learning through a practice based competency programme, to develop skills of local staff members.

Keywords District nursing, Community specialist practitioners, Training

  • This article has been double-blind peer reviewed



Practice points

  • As this development programme received positive feedback and constructive evaluation, this approach to role development and competency based practice learning could be trialled in other trusts and clinical areas. This would enable a smooth transition from the staff nurse to specialist role, with opportunity to “practise” the role under guided supervision and clinical/professional support.
  • The programme supports the values of The Queen’s Nursing Institute (2009) by using district nurses’ leadership and strategic skills through continuous professional development and service improvement projects.




Many primary care trusts face major challenges in enabling nurses to continue their professional development while maintaining staffing levels to ensure high quality care.  

The volume of district nursing work makes it a significant part of the health service. It is also crucial that district nurses can respond to patients’ needs in a proactive way.

Nursing in the home is fundamentally different to nursing in other settings and district nurses are experts in their field. Its key elements are expert assessment and care and the need to work with the whole family and carers as a unit. Historically, these services have been diluted, with reduced leadership opportunities and a lack of recognition of the value of the specialist qualification (The Queen’s Nursing Institute, 2009).

Longley et al (2007) argued there is a lack of definition of career pathways in advanced and specialist nursing roles and educational preparation programmes. However, the Knowledge and Skills Framework (Department of Health, 2004) is attempting to address work based learning and development and the setting of standards in the healthcare workforce. This development programme aims to redress the balance of work based learning, career development and competency development, in addition to raising the profile of the district nurse specialist practitioner role.

Programme aims

The remit of “growing your own staff” is attractive due to their knowledge of local communities and practice populations. However, some staff have had difficulties in meeting the requirements of community specialist practice interviews, which do not enable them to demonstrate their strengths and understanding of the district nursing role. The aim of the competency framework in this programme is to give staff a clear understanding of the district nurse role, with the advantage of being guided and supported through a learning process, ideally in the year before undertaking the specialist practitioner degree.

Students benefit from being exposed to mentors, practice teachers and teachers who have developed themselves to a higher standard, in both academic and clinical settings (Nursing and Midwifery Council, 2006). The mentors on this programme have completed further academic study and are excellent role models.

The project

The initiative was prompted by a decline in the numbers applying for district nursing sister posts. Following a discussion with the clinical practice lead and head of service, band 7 team leaders were consulted and a competency framework was designed.

The removal of district nurses from the recognised specialist practitioner NMC list has impacted significantly on district nursing, resulting in many employers not commissioning district nurse specialist practitioner courses, with course provision now potentially reduced. This could contribute to a lack of clarity on the skills required to be a district nurse team leader/caseload holder, resulting in role dilution. Since competency based practice learning can enable standardisation, the competencies were devised and adapted in line with best practice from the NMC specialist standards for health visitors/school nurses. They were developed with a view to staff completing them under supervision from the district nurse specialist practitioner.

The programme was designed to run over 10 months and included key elements of the district nurse role including:

  • Health needs assessment;
  • Complex assessments;
  • Leadership;
  • Change management;
  • Risk management;
  • Teaching and learning.

Criteria for selection were at least two years’ community experience, previous level 3 study and a requirement to go forward to complete the specialist practitioner degree in the following year. Six staff members expressed interest in the posts out of a total of around 50 and four were recruited following interviews.

Learners were supported by a district nurse mentor, who worked alongside them for at least 20% of the week until the competencies were completed.  

The staff being developed met monthly with the clinical practice lead to undertake supervised practice visits, alongside monthly action learning sets and facilitated teaching sessions. The clinical practice lead had overall responsibility for the programme’s design, coordination, delivery and evaluation.


At the end of the initial phase of the programme, mentors and development staff were asked to complete an evaluation form. The results were interpreted using a Likert scale ranging from strongly satisfied (5) to strongly dissatisfied (1).

The results were plotted in a graph to show how the feedback between mentors and participants compared. Fig 1 shows the satisfaction levels between the two groups.

The formal evaluation was undertaken in July 2009 through consultation with development staff, mentors and the operational manager. An evaluation tool was designed to critically appraise the programme’s strengths and limitations for future planning. Verbal feedback from both staff and team leaders has been extremely positive, indicating that staff are practising at a more advanced level than in their previous roles and have significantly developed skills in critical thinking and clinical decision making. They have also been exposed to and participated in leadership and change management strategies and developed the necessary skills to manage large neighbourhood teams. From observation in practice and feedback from mentors, this project has demonstrated the challenge required to create a positive learning environment for both teachers and students. Establishing a shared vision, with opportunities to meet learning outcomes in a limited time frame, is crucial when dealing with workload constraints. All involved have recognised the programme’s benefit and value to direct patient care, service delivery and improvement.


Three out of four staff have completed the competency programme; due to illness the fourth is due to complete later. Two out of four have since gained a place on the community specialist practitioner (CSP) degree course which started in September 2009.

One of the problems encountered during the programme is that as it ran from November 2008 until August 2009, the CSP interviews took place in May before its completion. For the two candidates who were unsuccessful at these interviews, it left them feeling disappointed and considering going back to their previous staff nurse role without completing the remaining competencies. To encourage them to complete these they have been given the option of completing them in a reduced timeframe or remaining on the programme until the end date. On reflection it would have been more beneficial to run the programme alongside an academic year.

This programme has enabled four selected staff to complete practice role based competencies with the support and supervision of district nurse specialist practitioner mentors and a clinical practice lead/ practice teacher. While we recognise that this is a small scale practice development, it is a step in the right direction in providing staff with opportunities to develop their skills while gaining an insight into the role of the specialist practitioner.

The use of a competency framework that focuses on role based learning can be replicated or adapted in other areas such as school nursing and health visiting. However, learners and facilitators will require time and professional support in order for them to complete the competencies within the expected timeframe. Within the district nursing service, continuous quality assurance and commitment has been maintained through the support of four district nurse mentors, a coordinator/practice teacher, clinical development adviser, operational manager and head of service. Staff development and improvement has been clearly demonstrated in practice.


The band 5 development role is an exciting initiative for district nursing practice with a clear career development pathway for those who aspire to be a district nurse. It also provides opportunities for district nurses to lead on practice improvement and service development and makes use of their leadership and strategic skills. The development role also raises the profile of district nurses’ role by demonstrating the skills and competence required to practise as a district nurse.

Locally the development role has resulted in an increase in staff wanting to go on to undertake the community specialist practitioner degree and as a result of this the programme will be repeated with four more staff in the second year. The band 5 development role is an excellent example of service improvement as it provides staff with the skills and knowledge they need to prepare them for the CSP degree.



  • The programme originated with a “grow your own” philosophy, as it was recognised that it is often too big a leap for many to go from staff nurse to community specialist practitioner (CSP) student.
  • The competency based framework was devised to give staff a structured understanding of the district nurse role and to prepare them with the skills and knowledge they need in the year before undertaking the CSP degree.



We would like to thank operational manager Rachel Sagar, acting operational manager Fiona Bentham, head of service Jane Pemberton and all staff in the community nursing service – provider service unit.



Readers' comments (7)

  • Martin Gray

    Is this new role supposed to qualify these nurses as health visitors and school nurses as well, or just manage the district nurse team?

    And why is it that the nursing profession believe that having a management qualification, taken as part of a degree or on its own, makes those nurses good managers?

    What is sadly lacking here is the recognition that specialist roles require a high level of practical experience within those roles, you can't learn everything from books and short clinical observation/supervision sessions. Management particularly is not learned from books and lectures; people that make good leaders have to have the personal qualities to do so. There are far too many people in management positions that have no idea of how to lead a team but are good at paperwork, which is one reason why the NHS is in such a mess.

    However, on a more positive note, I think it is fantastic that a career pathway for community nurses has been developed as it can only encourage those that want to move onwards and upwards int their development.
    But please, don't try and tell me that these District Nurse Specialist Practitioner is going to include such specialisms as health visiting, school nursing and midwifery. These are areas that require nurses dedicated to those, not a generic district nursing qualification.

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  • "Nursing in the home is fundamentally different to nursing in other settings and district nurses are experts in their field."

    You lost me after that sentence. What could be really useful was that if 3 or 4 years of nurse education - I don't care what you call it , degree, certificate, diploma - the newly qualified nurse actually had some relevant and well developed physical assessment skills and confidence to get on with the job.

    Personally, when I'm a old gimmer I want someone with 10 years experience in ITU to come and change my dressings and give me an injection, forget the 'specialist' community nurse.

    And your wrong Martin, ANY management training would be of use to nurses expected to do management.

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  • I do like this idea of 'Grow your Own' though, as in grow a set, grow a spine, grow some moral courage, grow a body of knowledge useful for the job in hand, since the vacuum of nurse education in the U.K. provides a ready medium for 'growing your own', indeed. I sincerely hope this concept catches on.

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  • When the first Anonymous is an 'old gimmer', she/he will find an ITU nurse with 10 years experience will be far less helpful and effective at planning and delivering the care of her/his leg ulcers than a District Nurse/Specialist Practitioner with 3 years community experience. (Ask any ITU nurse what they know about leg ulcers).

    Over time, all nurses develop skills and experience appropriate to the needs of their clients and area of practice. In the Community this includes extensive Tissue Viability knowledge, supporting patients with Long Term Conditions and Palliative Care. We may not be as High Tech as the ITU staff, but we still give IVs, manage Chemotherapy, PEG tubes, set up and manage syringe drivers and actively participate in decision making about appropriate dose adjustments for palliative care.

    We cannot develop these skills without good leadership and managers; the Course includes management modules to help develop the skills we started with but as observed, only more experience (in a supportive environment) will allow people to become good managers.

    And yes it is great that this area has developed some career pathway for its community nurses.

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  • Personally i would prefer a District nurse not an ITU nurse visiting me!

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  • I think it is ridiculous to read that district nurses has been removed from the list of the NMC specialist nurses. The health visitors, school nurse and the district nurse, all went through the same rigorous specialist course pathway. In fact the skills and knowledge pathway of district nurses is more broad than that of their schhool nurse and health vistor colleague. Doest anyone know the reason why the district nurses have been removed

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  • In response to martin grey, I think you will find that district nurses have more experience across a broader aspect of care delivery than any other nurse and to suggest that they are not on par with 'a specialist such as a health visitor' then your sadly mistaken. District nurses complete their specialist qualification along side health visitors but they only get 9 months to complete it not like the health visitors who get 12 month and also before applying for the course you have to have at least 2 years community experience however for a health visitor you can apply as a newly qualified nurse! I will put this question to you, if someone in your family became unwell and wanted to stay at home would you want the district nurse to visit who could help with symptom control or would you prefer a health visitor who would talk about a healthier life style? I know which one I would want!

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