About this role
Job summary
The Registered Nurse appointed will be responsible for providing a domiciliary and practiced based care in the City Health area for the coordination, management and monitoring of the care of housebound patients with long-term chronic illness (for example heart disease, COPD and diabetes).
Through a structured programme of monitoring the primary focus of this role will be on service quality, through specialist assessments and reviews of health care needs, the optimisation of care where co-morbidity exists, maximising wellbeing, self-empowerment, and quality of life.
The Chronic Conditions nurse will be an expert generalist whose role will involve providing advanced chronic disease management care in the community setting. The post holder will work autonomously in patients homes and in primary care premises, to co-ordinate the care needs of those patients on the caseload.
The Chronic Conditions Nurse will work in collaboration with partner organisations and other professionals to ensure patients health care needs are met appropriately and hospital admissions are reduced.
Main duties of the job
The Chronic Conditions Nurse will:
Assess patients, plan and implement care, provide specialist advice to both patients and healthcare colleagues and act as a resource for other community nurses.
Maintain comprehensive and contemporaneous records for each patient in line with SBUHB, NMC and local policy, liaising closely with the patients GP and the Practices own specialist nurses where needed.
Undertake relevant Risk Assessments associated with this role and working environments as indicated in the SBUHB Health and Safety Policies and Risk Management Strategy, and act on any findings in a timely manner.
Undertake an initial patient assessment including the taking of a comprehensive history, perform a comprehensive and systematic physical examination and establish baseline data to inform the development of a specialised, individual and comprehensive care plan.
Consider signs and symptoms, direct patient tests, laboratory tests results, and other measures to function when reviewing the condition of the patient.
Collaborate across the wider team to plan and implement treatment for acute illness/injury/chronic illness as required.
Monitor indicators of chronic disease, anticipating possible decline and proactively managing this to enhance well-being, and to maintain independence.
Undertake minor illness clinics within cluster practices within own scope of practice.
Be accountable for own professional actions; not directly supervised.
About us
The practice has been established since 1870 and had multiple locations over the years to adapt to growing demand before finding a place on the Kingsway in 1993 with its own parking facilities underneath. The practice benefits from a stable and consistent team across clinical and non-clinical roles. Each GP has a lead role to play in the practice which assists in the success of the practice achieving excellent QAIF standards and access standards. The Kingsway Surgery will act as the base for this role but they will serve all 8 practices in the City Cluster. The City Health Cluster Network has agreed to deploy funding to address potential health inequalities amongst housebound patients and those with limited mobility/support living in the Network area through improving access to nurse-led chronic disease monitoring in the patients home. The Chronic Conditions Nurse role will be attached to City Health Cluster Network to lead this Chronic Conditions housebound service for Cluster wide patients.
Job description Job responsibilities
Care Co-ordination
Integrate care across all care settings, preventing duplication, fragmentation and delay occurring as patients move between care settings.
Build relationships across professional and organisational boundaries, breaking down barriers and smoothing the patient journey.
Work with other Health Care Professionals to monitor, manage and treat Chronic Conditions, including non-drug based treatment methods, utilising robust management plans in line with national and local policies and patient needs.
Assess, plan, implement and evaluate individual treatment plans for patients with Chronic Conditions and working collaboratively with practices within the designated cluster to maintain quality patient care for housebound patients.
Review medication for therapeutic effectiveness within your scope of practice and in collaboration with a GP or non-medical prescriber. Ensure national and local policies are adhered to when devising or amending treatment plans.
Assist in planning, co-ordinating and supervising the workload of junior nursing staff and HCSWs associated with the Chronic Conditions Management service.
Participate as a key member of the multidisciplinary team through development of collaborative and innovative practice.
Communication
Be able to communicate effectively will all patients, colleagues and associated stakeholders, and support and encourage patient/carer interventions and education.
Enable and support integration of patients wishes into care planning for both current and future care needs.
Disseminate information throughout the multidisciplinary team, taking into account the need for confidentiality.
Be able to discuss highly sensitive and complex information with patients, relatives/carers and colleagues offering empathy and reassurance.
Respect cultural and language difficulties and address communication barriers in a positive non-discriminatorymanner
Communicate in a manner which is easily understood by patients and their relatives.
Safely and effectively use all relevant forms of communication such as oral, written and electronic formats.
Ensure practice IT systems are kept updated with accurate patient information.
Education and Training
Be responsible for highlighting any identified personal educational and training needs to Cluster and Health Board Line Managers. Ensure all training and educational needs are discussed within your annual appraisal.
Empower patients and carers to evaluate possible treatment options as their disease progresses, and evaluate relative benefits and burdens of these options.
Be responsible for ensuring appropriate delegation of tasks to Health Care Support Workers and Registered Nurses in line with their scope of practice.
Participate in the development of the teams knowledge about disease processes and treatments.
Play an active role in disseminating knowledge about chronic disease and its management within primary care, mentoring new Primary Care nurses as required and supporting education of other primary care colleagues.
Provide learning opportunities in the clinical setting that support the wider primary care team. Undertake formal teaching sessions for organisations, students and staff groups where possible.
Provide learning opportunities for wider Swansea health and social care community to improve the awareness of chronic conditions and the needs of people with chronic conditions.
Continue to develop own expert clinical competence in line with evidence based practice.
Leadership and Management
Ensure the SBUHB Values are adopted and adhered to at all times.
Take responsibility for the day-to-day operational management of the Chronic Conditions Management service for identified housebound patients within the designated Cluster.
Monitor, audit and evaluate clinical effectiveness in accordance with SBUHB policies and procedures.
To be a clinical resource for members of the healthcare team, providing advice and assisting with treatment and provision of care.
Comment on policies, procedures and guidelines pertinent to this role, ensuring they are implemented, monitored and updated as necessary.
Promote effective team working, disseminating knowledge and skills as necessary.
Support changes in service delivery in accordance with evidence-based standards and policies.
Act as an advocate at all times, both for patients and the service. Take a lead role in advocating for the patient in order to obtain optimal treatment and symptom control, thereby improving quality of life.
Support the clinical governance strategy as a means of improving the service to patients and staff.
Professional
Work within the NMC Code of Conduct at all times.
Remain updated and ensure that clinical practice is evidence based.
Maintain Professional Registration and Revalidation.
Maintain a personal development plan and professional portfolio.
Adhere to consent and confidentiality requirements.
Contribute to the appraisal process, providing feedback on performance.
Escalate any concerns/ issues to the GP Leads and Health Board Line Manager where needed.
Responsibilities for Information Resources
Scrutinise professional record keeping in line with NMC professional standards.
Input, review and process data using accurate READ codes to ensure easy and accurate retrieval for monitoring and audit processes.
Manage information searches using evidence based clinical resources to retrieve relevant information for patients and others on specific conditions.
Understand the responsibility of self and others regarding the Freedom of Information Act.
Equality and Diversity
Ensure the promotion of equality and diversity and a non-discriminatory culture.
Treat all service users, families, carers and colleagues with dignity & respect.
Act as a role model in the observance of equality and diversity good practice.
Accept the rights of individuals to choose/participate in their care or to refuse care.
Person Specification
Qualifications Essential
Registered Nurse - currently registered with the NMC Hold a first degree in Nursing studies Evidence of Diploma or higher level training in Chronic Conditions Management (or equivalent) Evidence of ongoing, relevant CPD Understanding of clinical audit Knowledge of Professional Nursing agenda, Clinical Governance and Quality and Safety Knowledge of national policies, guidance and standards relevant to this role
Desirable
Clinical assessment module ECDL Level 3 POVA Mentorship qualification
Experience Essential
Clinically credible with experience of multi-disciplinary working Extensive experience of working within Primary Care and/or Community services Post registration Nursing experience Knowledge and experience of managing patients with Chronic Conditions
Desirable
Service improvement experience Experience of nurse triage/workload prioritisation Mentorship and teaching experience
Skills/Other Essential
Excellent communication skills, both verbal and written Clinical skills relevant to Chronic Conditions Management Able to establish good working relationships with internal and external stakeholders Able to work effectively as an autonomous practitioner and member of a team to achieve outcomes and deadlines Able to prioritise and manage service workload, balancing short term unpredictable demands with long term objectives Good IT skills and understanding of General Practice computer systems Shows empathy and compassion towards others. Sees and treats others as individuals. Treats people with dignity and respect. Shows resilience, adaptability and flexible approach as situations arise and positivity when times are tough. Shows respect for others views and appreciate others inputs and encourage colleagues to display our values. Motivated to use initiative to recognise problems and seek solutions whilst understanding the importance of empowering and enabling others (patients, families, colleagues). Friendly and helpful disposition, awareness of how our own and others behaviours impact on peoples experiences and the organisations reputation. Willing to seek out learning, give and accept constructive feedback and committed to continuous improvement. Consistently exhibits a positive attitude and respect for others. Evidence of drive, enthusiasm and commitment. Displays a positive and constructive attitude Ability to travel within geographical area to meet the needs of this role. Able to work hours flexibly when needed.
Desirable
Ability to speak Welsh Change Management, Service Improvement experience Experience of implementing protocols and clinical guidelines Audit experience
Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Certificate of Sponsorship Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details Employer name GP Practice in Wales
Address Kingsway Surgery
37 The Kingsway
Swansea
SA1 5LF
United Kingdom
Employer's website https://gpwales.co.uk (Opens in a new tab)