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Detailed job description and main responsibilities

Key Responsibilities and Duties

 

1. To provide face to face nursing care, assessing, planning, implementing and evaluating care and treatment for housebound service users with complex physical, psychological and social needs.

 

2. Managing and co-ordinating a caseload of service users with complex physical health needs that require multi-systems health assessment; have multiple co-morbidities and may have social and mental health needs that influence their treatment plans. This may at times include co-ordination of MDT meetings.

 

3. To work closely with the service users, their carer’s and families ensuring that they have the tools to manage and monitor their own condition where appropriate and have robust management plans in place to recognise deterioration and access appropriate care.

 

4. Have an understanding of the demographics and population profile of their attached PCN/locality. Acting as a key stakeholder working with system partners to ensure the physical health needs of the population are met and work to prevent unnecessary admissions to hospital.

 

 

5. Collaborate with the Operational Lead in developing training and practice. Providing support, mentorship and assessment of pre and post-registration nurses within the team, to develop their competence and skills. Including induction and preceptorship of new staff.

 

6. Provide consistency through collaborative clinical leadership to their team with Professional Leads across the care group. Embedding a learning culture underpinned evidence based practice.

 

7. Takes a lead in specialist areas and complex caseload management, providing advice and support to others to undertake community nursing care, including but not limited to:

 

• Promoting independence/self-management
• Maintaining safety including/safeguarding awareness/incident reporting
• Improvement in health and wellbeing including mental health
• Interventions in disease/condition management
• Prevention and reducing of health inequalities
• Admission avoidance including frequently users of acute services
• Supported early discharge from hospital (appropriate to the service)
• Case management/ treatment /care plans
• Palliative and end of life care
• Complex decision making
• Management of complex wounds

 

 

8. Will utilise a range of available and emerging technology to support the service user to manage and monitor their condition; including virtual consultations and remote monitoring.

 

9. To monitor the skill mix in the team to enable safe delegation of nursing care in line with NMC guidance. Working closely with the operational lead for the team to support effective workforce planning.

 

10. The post holder will participate in service developments as a member of the community nursing team and wider primary care network, and will be a key stakeholder in the development of place based partnership working.

 

11. Oversee the caseload to improve the quality of care for patients, ensuring that this is driven by patient outcomes and feedback; evidence based clinical practice that supports the national quality agenda. Ensuring actions of the caseload review process are carried out.

 

12. Work in collaboration with Operational and General Managers providing clinical expertise and decision making support as part of the leadership team to ensure best practice and patient safety are be maintained.

 

13. There will be no responsibility for finances other than to make efficient use of resources and to consider cost effectiveness when developing treatment plans and prescribing medication.

 

Systems and equipment

 

14. Maintain accurate contemporaneous records and data collection through daily use of a range of electronic clinical systems e.g. EMIS; Safeguard; Microsoft Office Suite. Adhering to information governance standards; legal and professional requirements are maintained at all times. Ensuring that clinical systems are used effectively within their team.

 

15. Responsible for ensuring actions are carried out by themselves and their team where safety alerts are issued regarding equipment or medications used by the service.

 

16. Maintain an awareness of assistive technology available to support service users to manage their condition.

 

 

Decisions and judgements

 

17. To work autonomously as an experienced nurse using enhanced clinical expertise to assess; plan and evaluate care. Critically evaluate current evidence; clinical guidelines; policies and SOPs to support clinical decision making.

 

18. To evaluate and make decisions about treatment options taking into account both theoretical and therapeutic models and highly complex factors ascertained through holistic assessment and history taking.

 

19. Formulate plans of care and negotiate the implementation of such plans and the sharing of complex, sensitive, confidential, and at times contentious information e.g. explaining diagnosis and treatment plans; discussing disease progression and prognosis.

 

20. To contribute to the development, evaluation and monitoring of the service’s operational policies; objectives and standards. Utilising research, business intelligence data and audit.

 

21. Support and complete investigations and reports including clinical incident management; root cause analysis; coroners’ reports and serious incident investigations. Using clinical experience and judgment to review the findings of these investigations and make recommendations where appropriate. Leading on the development, learning and actions for their team following formal investigations and reports.

 

22. To exercise autonomous professional responsibility for the assessment, treatment and discharge of service users on their caseload.

 

23. Prioritising competing demands responding to unplanned aspects of the role using innovative problem solving techniques and clinical decision making for example rescheduling or cancelling planned visits to complete urgent visits.

 

24. To be able to access, critically appraise and apply relevant information/ knowledge in clinical practice. Utilising evidence-based literature and research to support practice in individual work and work with other team members.

 

25. To positively promote and act as a role model for community nursing.

 

26. Be actively participate in the receipt of, and delivery of clinical and managerial supervisor in line with Trust policies.

 

27. Implement, review and maintain Trust Policies and Procedures and propose changes to working practices and pathways where appropriate and relevant to the service.

 

28. Will have an awareness of the resources required to deliver the service; utilising a range of quality improvement tools to implement and review effective working practices.

 

29. Will have responsibility for the safety and maintenance of IT and clinical equipment that they utilise to carry out the role.

 

Communication and relationships

 

30. Communicate sensitive diagnosis and treatment related information with service users and their families, utilising highly developed communication skills to overcome barriers to understanding.

 

31. Establish therapeutic relationships with service users and families/carers, and implement evidence based therapeutic interventions with appropriate boundaries in accordance with professional code of conduct.

 

32. To work with individuals and carers who may find it difficult to engage with the service or aspects of the service resulting in none concordance, decision against advice or challenging behaviour.

 

33. As a senior nurse, work collaboratively with practitioners from the MDT, service users and families to communicate clinical decisions, clinical rationales and treatment plans.

 

34. Ensure that all members of the multi-disciplinary team, service users and appropriate others are kept informed and up to date about changes to a service users care or condition.

 

35. To produce treatment plans that are timely, relevant, accurate, evaluated, dated, signed, legible and objective, and communicate these to other relevant agencies. These must be in keeping with best practice guidance and evidence based practice.

 

36. To support patients, families and carers on the DN caseload to self-manage or share the care of their condition. Ensuring that clear parameters are set and agreed for escalation.

 

37. To develop and maintain close links with the multi-disciplinary team, working in partnership with general practitioners and practice nurses to optimise treatment pathways.

 

38. To identify own training/educational needs and those of the team as part of the supervision and appraisal process. Attain and maintain an agreed level of expertise through ongoing training and development.

 

39. To provide clinical leadership to their team ensuring that effective governance structure in place. Using a range of communication styles and channels as appropriate to the task.

 

Physical demands of the job

 

40. The post holder will be expected to implement highly developed physical skills pertinent to the area of specialism daily, for example, such as de-escalation skills, driving, manual handling, and skills relevant to professional role.

 

41. Standard keyboard skills required for inputting data onto EMIS; report writing; research etc.

 

42. Undertaking physical health assessments with patients, including chest auscultation; obtaining samples, wound swabs and venepuncture.

 

43. Using specific equipment e.g. hoists, sliding equipment, etc.

 

44. Required to carry nursing and IT equipment when visiting service users homes.

 

45. Frequent travel across the PCN area, with occasional travel across the county of Staffordshire.