Practice Nurse Competencies - Hypertension-Specific

Hypertension (high blood pressure) is a prevalent long-term condition managed in general practice. Nurses often play a central role in screening, diagnosing, educating, and monitoring hypertensive patients. The following competencies are specific to hypertension management, built on the general competencies (see Practice Nurse Competencies), and likewise have gradations from basic to advanced practice.

Diagnosis of Hypertension

Knowledge and Skills: The nurse must accurately identify and confirm hypertension according to national guidelines:

• Blood Pressure Measurement: Perform blood pressure (BP) measurements correctly and consistently. This includes using validated equipment, selecting the correct cuff size, and measuring in the appropriate position. Nurses should follow NICE guidance to measure BP in both arms at first visit (to check for any significant inter-arm difference). They must also recognize when to do manual BP measurement (for example, if an automated reading is high or irregular) and use proper technique for manual auscultation.

  • Foundation: nurse can conduct BP checks under supervision, ensuring proper procedure;

  • Proficient: nurse independently performs clinic BP and can instruct patients on home monitoring;

  • Advanced: nurse might run hypertension screening clinics, teach others, and calibrate/validate BP devices.

  • Assessment: Use a Direct Observation of Procedural Skills (DOPS) – the nurse is observed taking a BP on a patient. The assessor checks that they followed protocol (rested the patient, took two readings, etc.) and correctly documented the readings.

• Diagnostic Criteria: Understand and apply the diagnostic thresholds for hypertension. According to NICE, a clinic reading of ≥140/90 mmHg (for adults under 80) or ≥150/90 mmHg (for age 80+) is considered high and should be confirmed with out-of-office measurements (High blood pressure - NHS). Nurses must know to arrange ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to confirm a diagnosis if clinic BP is elevated (to rule out white-coat effect). They should recognize the definitions of Stage 1 hypertension (e.g. home/ABPM average ≥135/85 mmHg) and Stage 2 (home/ABPM ≥150/95 mmHg) and the concept of severe hypertension (≥180/120 mmHg) (High blood pressure - NHS),

  • Foundation: the nurse knows the threshold numbers and follows GP instructions to arrange confirmation tests;

  • Proficient: the nurse can independently initiate the ABPM/HBPM process, explain it to patients, and identify results that meet diagnostic criteria;

  • Advanced: a nurse prescriber or practitioner may diagnose hypertension themselves, interpret patterns (e.g. isolated ambulatory hypertension) and decide on immediate actions.

  • Assessment: Case study or scenario – given a patient with BP readings, the nurse should state whether it meets criteria for diagnosis and what next step is needed. Chart audits can check if the nurse appropriately requested ABPM for borderline readings. Knowledge can be tested with questions like “What is Stage 2 hypertension threshold on home readings?” (Expected answer: ≥150/95).

• Secondary Causes & Urgent Recognition: Be alert to signs of secondary hypertension or hypertensive emergencies. Competent nurses know basic causes (e.g. if a young patient has very high BP, consider secondary causes like kidney disease or coarctation) and will refer to a GP for further investigation. They must also recognize red flags: a BP ≥180/120 with acute symptoms (like headache, vision changes, chest pain) or retinal hemorrhages indicates possible accelerated (malignant) hypertension requiring same-day specialist referral (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE).

  • Foundation: nurse might simply flag very high readings to the GP immediately;

  • Proficient: nurse triages the urgency – e.g. checking for symptoms or organ damage signs and advising an urgent GP review;

  • Advanced: nurse initiates emergency management (such as arranging admission as per protocol) even before GP evaluation if needed.

  • Assessment: Scenario-based questions can be used (e.g. “You take a BP of 210/130 and the patient has headaches and blurred vision – what do you do?” Expected: recognize this as an emergency, alert GP or call 999 according to local policy (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE)). Documentation audits can verify that in such cases the nurse took appropriate action (documenting symptoms, informing the doctor promptly, etc.).

Treatment Protocols

Once hypertension is diagnosed, nurses (especially those who are prescribers or managing long-term conditions clinics) need competencies in current treatment guidelines:

• Initiation Criteria: Understand when lifestyle measures alone are sufficient and when medication should be initiated. NICE guidelines state that for Stage 1 hypertension, drug treatment is indicated if the patient is under 80 and has a 10-year cardiovascular risk ≥10% or evidence of target organ damage, diabetes, or existing cardiovascular/kidney disease; all patients with Stage 2 hypertension (BP ≥160/100 clinic) should be offered drug therapy ( Diagnosis and management of hypertension in adults: NICE guideline update 2019 - PMC ). A competent nurse incorporates these criteria into care: e.g. performing a QRISK3 calculation and checking for organ damage (blood tests for renal function, checking for LVH on ECG, etc.) as part of the assessment.

  • Foundation: knows that not everyone with raised BP gets pills immediately and will defer to GP or protocol for who qualifies.

  • Proficient: can explain to a patient why they need medication (e.g. “because your risk is high at 20% over 10 years, treatment is recommended” ( Diagnosis and management of hypertension in adults: NICE guideline update 2019 - PMC )) and ensure the preliminary tests are done.

  • Advanced: nurse prescriber could independently decide to start an antihypertensive according to protocol and arrange follow-up labs as needed.

  • Assessment: Review of practice against guidelines – for instance, an audit of hypertensive patients to see if those with BP in the Stage 1 range were appropriately evaluated for risk and only started on drugs if criteria met. A case-based discussion could cover a scenario of a patient with mild hypertension to see if the nurse knows whether to recommend meds or just lifestyle.

• Pharmacological Management: Know the NICE-recommended first-line and add-on therapies for hypertension and apply them or advise accordingly. According to NICE (NG136), first-line choice depends on age and ethnicity: “Offer a calcium-channel blocker (CCB) to adults starting step 1 treatment who are aged 55 or over, or of Black African/Caribbean origin (without diabetes)” – otherwise, for younger (<55, not Black) patients, an ACE inhibitor (or angiotensin receptor blocker, ARB) is first-line (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE). If the first drug doesn’t control BP, the step 2 is to combine two classes (e.g. ACEi + CCB, or ACEi + thiazide diuretic) (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE). Nurses need a working knowledge of this stepped approach so they can support medication titration in GP management plans.

  • Foundation: nurse might simply know the names of common blood pressure drugs and check patient understanding;

  • Proficient: nurse is expected to have deeper knowledge of classes (ACE-i, CCB, diuretics, etc.), their common side effects, and be able to follow a GP’s plan or a patient group directive for titration.

  • Advanced: nurse (especially nurse prescribers or specialists) can independently adjust medications per protocol, e.g. adding a diuretic if on dual therapy not at target, and will be familiar with more complex regimens (such as resistant hypertension requiring a fourth drug).

  • Assessment: Medication knowledge can be assessed via a test or case discussion (e.g. “The patient is on ramipril 5mg and amlodipine 10mg but BP is still high, what might be added next according to NICE?” – expecting: a thiazide-like diuretic, if no contraindication (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE)). Also, direct observation or supervised clinics can ensure the nurse safely uses independent prescribing (if qualified), and an audit of their prescribing or treatment plans can confirm adherence to NICE protocols.

• Medication Management and Safety: Ensure safe prescribing and monitoring. Competent practice includes checking for drug interactions (e.g. understanding that certain decongestants can raise BP), ensuring required blood tests are done (such as renal function and electrolytes within a few weeks of starting an ACE inhibitor or diuretic), and adjusting treatment if side effects occur (like recognizing and reporting a cough from an ACE inhibitor and suggesting an ARB alternative). Nurses should reinforce medication adherence and advise patients on what to do if doses are missed or if they develop side effects.

  • Assessment criteria: Chart reviews can verify that appropriate monitoring took place (e.g. U&E blood test ordered after starting an ACE-I), and patient questionnaires can confirm the nurse educated them about their medications. A simulated counseling session might be used to see if the nurse appropriately explains a new prescription (covering purpose, how to take it, and side effects to watch for).

Patient Education

Effective patient education is a cornerstone of hypertension management – patients who understand their condition and treatment are more likely to achieve control. Nurses in general practice often take the lead in educating and empowering patients:

• Hypertension Knowledge Transfer: Explain to patients what hypertension is and why it matters. A competent nurse can translate medical information into clear, accessible terms (e.g. calling high BP a “silent risk” that can damage organs over time). They should communicate the potential health risks of uncontrolled hypertension – such as stroke, heart disease, kidney damage, and others (High blood pressure - NHS) – in a motivating but sensitive way. Patients should understand their BP targets (for example, <140/90 mmHg for most under 80 years (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE)) and the benefits of reaching control.

  • Foundation: nurse might use prepared leaflets or stick to basic facts when educating.

  • Proficient: nurse tailors the discussion to the individual’s situation (for instance, emphasizing stroke prevention if the patient has a strong family history) and checks the patient’s understanding (teach-back technique).

  • Advanced: nurse could design educational workshops (e.g. a “Blood Pressure Clinic” group class), or lead initiatives like home BP monitoring training sessions, demonstrating a high level of communication skill and content knowledge.

  • Assessment: Review of educational materials the nurse provides (are they up to date and NICE-aligned?). Observing a consultation or role-play where the nurse explains hypertension to a new patient – the assessor can tick if the nurse covered key points (what BP numbers mean, why treatment/lifestyle is needed, etc.) and responded well to patient questions. Patient feedback can also be telling: do patients report that the nurse’s explanations are clear and helpful?

• Self-Management Support: Encourage patient involvement and self-care. This includes training patients in how to monitor their BP at home if they choose (and ensuring they know how to use a home monitor correctly), advising them to keep a BP diary, and involving them in decision-making (shared decision making per NHS principles). Nurses should be aware of programs like the NHS England “BP@Home” initiative supporting home monitoring (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE) and help patients participate (for example, by enrolling suitable patients and providing them guidance on technique and targets (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE)). Additionally, nurses can introduce tools like patient decision aids for hypertension (NICE provides these) to help patients weigh pros/cons of medications.

  • Assessment: A possible criterion is whether the nurse routinely offers or discusses home BP monitoring with appropriate patients – this can be audited from records (e.g. mention of home readings). Another is review of how the nurse documents education: good practice is to note “discussed nature of hypertension and importance of adherence/lifestyle changes – patient verbalised understanding.” Consistent documentation of these discussions indicates the nurse is actively educating patients.

• Communication & Health Coaching: Use coaching techniques to motivate behavior change. Hypertension often requires long-term lifestyle and medication adherence, so nurses benefit from skills like motivational interviewing and setting SMART goals with patients (e.g. “Let’s aim to reduce your salt intake over the next month; how confident are you that you can do that?”). At higher competency levels, nurses might obtain qualifications in health coaching or signpost patients to structured education programs.

  • Assessment: Qualitative observation of how the nurse engages a patient in behavior change conversation. For instance, an assessor could look for the nurse asking open-ended questions (“What do you know about high blood pressure?”), showing active listening, and using positive reinforcement. Outcomes like improved patient adherence or satisfaction could also be indirect evidence of effective patient education by the nurse.

Lifestyle Intervention

Lifestyle modification is the first-line intervention for managing hypertension and reducing cardiovascular risk. Nurses should be proficient in promoting and supporting healthy lifestyle changes, in line with NHS advice and NICE recommendations:

• Diet and Nutrition: Advise on a healthy, balanced diet rich in fruits, vegetables, and low-fat products, similar to the DASH diet principles. Emphasize reducing salt intake – patients should “avoid adding salt to meals and cut down on salty foods” (High blood pressure - NHS), as even a moderate reduction in salt can lower BP. Nurses should know the NHS recommendation of aiming for <6g of salt per day for adults. They should also counsel on limiting foods high in saturated fat (for overall cardiovascular health).

  • Foundation: nurse provides general diet handouts and encourages patients to follow them.

  • Proficient: nurse can have a more detailed discussion – for example, reviewing a patient’s dietary habits and suggesting specific swaps (like seasoning with herbs instead of salt, or choosing low-sodium options).

  • Advanced: nurse might coordinate with or refer to a dietitian for complex cases (e.g. patients with obesity or renal issues) and follow up on dietary changes in subsequent visits.

  • Assessment: Could include asking the nurse to perform a brief dietary assessment and advice session in a simulated scenario. The content of their advice can be checked against NICE lifestyle guidelines. Documentation review: does the nurse consistently document dietary advice given to hypertensive patients?

• Physical Activity and Weight Management: Encourage regular exercise – at least 150 minutes of moderate exercise per week (such as brisk walking) as per NHS guidelines (High blood pressure - NHS). Also discuss weight management: if the patient is overweight, even a 5-10% weight loss can significantly improve BP. Nurses should be able to calculate BMI and explain what is a healthy range. They might set incremental exercise goals or refer patients to local exercise referral schemes or weight loss programs (e.g. NHS Better Health resources (High blood pressure - NHS)).

  • Foundation: nurses should advise exercise appropriate to the patient’s ability,

  • Proficient & Advanced: higher-level nurse might develop a tailored plan in collaboration with the patient (taking into account comorbidities like arthritis) and follow up progress.

  • Assessment: Perhaps use a case reflection – e.g., ask the nurse to describe how they managed a patient who needed to lose weight for BP control, looking for elements of effective goal-setting and follow-up. Checking referrals made (if any) to exercise or weight management services in the nurse’s patient cohort is another objective measure.

• Alcohol and Smoking Cessation: Advise on moderating alcohol intake (keep within ≤14 units/week and spread out the drinking) (High blood pressure - NHS) and support smoking cessation. Smoking doesn’t directly cause hypertension, but it hugely increases overall cardiovascular risk; thus a practice nurse should always address smoking status. Competent nurses can provide brief interventions for smoking cessation and refer to local cessation services or prescribe nicotine replacement if qualified. They also warn about excessive caffeine intake as it can raise BP transiently (High blood pressure - NHS).

  • Assessment: Auditing whether all hypertensive patients have a documented smoking status and that smokers have been offered cessation support can be an indicator. In supervision, one might ensure the nurse knows the recommended alcohol limits and can counsel accordingly. Role-play could be used to see how the nurse approaches a conversation about cutting down alcohol with a patient who drinks above guidelines.

• Holistic Lifestyle Support: Nurses should adopt a “make every contact count” approach – reinforcing lifestyle advice at every suitable opportunity, and customizing it to the individual’s circumstances and culture. For example, discussing stress management or sleep if relevant (while not primary causes of hypertension, they affect overall health). At advanced levels, nurses might initiate or lead group sessions (e.g. “Healthy Heart” classes) or quality improvement projects to increase lifestyle intervention uptake among practice patients. Notably, NICE emphasizes giving “regular lifestyle advice, including diet and exercise, to all patients with suspected or diagnosed hypertension” ( Diagnosis and management of hypertension in adults: NICE guideline update 2019 - PMC ) as part of routine care, so this should be ingrained in practice at all levels.

  • Assessment: This can be part of routine performance review – e.g., supervisors checking that lifestyle advice is not a one-off at diagnosis but ongoing. Patient surveys might ask if they recall receiving advice on diet and exercise from the practice, reflecting the nurse’s impact.

2.5 Ongoing Monitoring and Management

Hypertension requires long-term follow-up. Nurses often coordinate routine monitoring and support adherence to management plans:

• Follow-Up Scheduling: Ensure patients have appropriate follow-up appointments to monitor BP and adjust treatment. After medication changes, a review in about 4 weeks is typical to check efficacy and tolerability (as per NICE guidance). Once stable, at least annual reviews are recommended for all hypertension patients (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE). A competent nurse sets up recall systems (often using electronic alerts or registers) so that no patient “falls through the cracks.”

• Foundation: nurse relies on prompts in the system and recalls set by others;

• Proficient: nurse proactively calls patients in for reviews (for example, running a search for those overdue) and can independently perform the review;

• Advanced: nurse might manage the entire hypertension recall program for the practice and ensure QOF targets (e.g. percentage of patients with BP controlled) are met.

• Assessment: Monitor the practice’s recall system for how well it’s maintained – if the nurse is responsible for it, measures like percentage of hypertensive patients seen in the last year can reflect performance. During appraisal, ask the nurse how they keep track of follow-ups or to show evidence of their recall workflow.

• Clinical Review and Adjustment: Conduct blood pressure review consultations. In these, the nurse checks BP (clinic reading, and home readings if available), inquires about symptoms (like dizziness that might indicate hypotension or side effects), assesses medication adherence, and reinforces lifestyle advice. They then take appropriate action: if BP is above target, ensure an action plan (GP review for med adjustment or if an independent prescriber, adjust medication per protocol); if BP at target, provide positive feedback and plan next review. According to NICE, at each step before intensifying treatment, one should “discuss with the person if they are taking their medicine as prescribed and support adherence” (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE) – nurses must be adept at assessing adherence in a non-judgmental way and problem-solving any barriers (e.g. simplifying dosing schedules or managing side effects).

  • Foundation: nurse might do the measurements and basic questions then refer to the GP for decisions.

  • Proficient: will make recommendations or implement protocol-driven adjustments (e.g. titrating dose if within an agreed range), and involve the GP for complex issues.

  • Advanced: nurse practitioner could independently run a hypertension clinic, adjusting medication under agreed guidelines and only referring difficult cases.

  • Assessment: Direct observation or audit of a sample of hypertension review appointments done by the nurse. The assessor can check if appropriate actions were taken for elevated readings and if adherence was checked. For instance, if a patient’s BP was high and the nurse simply rebooked without any intervention or discussion, that would be a gap at proficient level. Conversely, a note that “medication compliance reviewed, patient admits missing doses; counselled on using a pill organizer; will recheck BP in 2 weeks” shows competent management. This can be cross-checked with patient outcomes (does the patient’s BP improve at next visit, indicating effective intervention?).

• Coordination of Care: Work with the GP and other professionals for comprehensive care. Nurses should know when to escalate or refer: e.g., if BP remains uncontrolled on three drugs (possible resistant hypertension), suggest evaluation by a specialist; if there are atypical findings (like declining kidney function), ensure the GP is aware to adjust treatment. They also support medication reviews (often annual, possibly with a pharmacist) to deprescribe unnecessary drugs or optimize therapy. In hypertensive patients with comorbidities (diabetes, heart failure), the nurse must coordinate care (for example, making sure the patient’s diabetic reviews and BP reviews are aligned, or that any changes cardiology made to meds are updated in the GP record).

  • Assessment: During performance review, the supervisor might check that the nurse appropriately flags patients meeting criteria for referral (e.g., documented a plan to refer to nephrology for a young patient with severe HTN). Also, review of communication – e.g., did the nurse communicate with the GP or pharmacist about a patient’s side effect concerns? Effective coordination often shows up in meeting notes or patient records.