Job Description

Key Responsibilities:

The post holder will use their assessment and diagnostic skills to assess and treat patients. The post holder will be an experienced nurse, collaborating with colleagues from primary care, community and secondary care, as appropriate. The post holder will be based at a primary care site and will routinely visit patients in their own homes; they may at times be expected to work in other settings, e.g. clinic setting.

The post holder will:

be a Registered Nurse with experience of working in a relevant field, e.g. primary care, frailty or community elderly care alongside other colleagues, support the team and delegate work to the care coordinators and social prescriber as appropriate act as a role model be responsible for undertaking comprehensive geriatric health assessments, physical examination and ordering relevant tests for patients use enhanced clinical decision making and assessment skills, coordinate care planning and initiate referrals to diagnostics for appropriate tests for this population promote the team and work as part of an MDT with external stakeholders such as acute frailty team specialist community services voluntary sector organisations social services & local authority, to develop new ways of working use networking skills to bring diverse stakeholders together to develop a single, integrated, community team around each individual Clinical Practice: Be professionally and legally accountable for all work undertaken and to practice at an enhanced level of professional autonomy and accountability that is within national guidelines and that of the NMC Code of Conduct. Provide clinical leadership and maintain credibility through practice and professional update. Act as a role model Ensure high quality care through provision of evidence-based practice.



Act as an expert clinician and resource for patients, families, and staff. Admit, discharge or transfer patients to and from the service as their needs require. Undertake enhanced clinical assessments of patients referred to the service to enable prompt assessment, diagnosis and treatment according to agreed policies, protocols and guidelines. Clinically examine and assess patient needs from a physiological, psychological and social perspective and plan clinical care accordingly.



Provide and request appropriate diagnostic and/or therapeutic interventions to provide a holistic assessment of the client group. Maintain and develop own repertoire of enhanced clinical assessment skills including physical examination, comprehensive geriatric assessment, assessment of continence, mental health screening, memory assessment, nutritional status, falls assessment, tissue viability screening, mental capacity assessment. Facilitate the further development of clinical skills for all staff caring for patients. Ensure self and staff are provided with adequate protection if exposed to body fluids, odours and infections.



Be aware of needs and ensure that staff, patients and relatives use personal protection equipment provided and adhere to local policies in relation to health and safety and infection, prevention and control. Support staff as required in the management of challenging situations. Complete documentation relating to patient care and ensure that staff maintain and update documentation as changes occur according to local policy. Encourage staff through role modelling to apply critical thinking through the process of clinical assessment of patients or problem solving.



Follow this process through the planning and evaluation stages of patient care and to effectively document this process in the patient records. Liaise and work closely with relevant multi-disciplinary team members, including General Practitioners, social prescribers, ARRS therapists, volunteers, social workers, community specialists and acute partners in the provision of a professional service Provide support for anxious patients and/or relatives demonstrating empathy and understanding in a professional manner. Provide empathetic support when involved in the process of giving patients and/or relatives bad news; for example, informing patients/relatives of changes of condition. To lead on proactive Advanced Care Planning as necessary in an empathetic and collaborative manner, attending to the priorities and preferences of patients and their loved ones.



To identify when people are approaching the end of life, undertake palliative care assessment and develop universal care plans (UCP). Prioritise, organise and manage own workload in a manner that maintains and promotes quality. Assist in further development of the service and wider organisational strategies. Take responsibility for own learning and performance including participating in clinical supervision and acting as a role model, as well as continuous preparation for annual personal appraisal and development review.



Contribute to the development of local guidelines, protocols and standards. Education and Development: It is the responsibility of the employee to comply with all organisational and statutory mandatory requirements (eg. health and safety, infection control, equality and diversity, confidentiality, safeguarding adults and children, information governance) and to complete the required training. It is the responsibility of the employee to comply with all organisational and statutory mandatory requirements (eg.



health and safety, infection control, equality and diversity, confidentiality, safeguarding adults and children, information governance) and to complete the required training. Engages in annual appraisal, developing objectives to inform a Personal Development Plan, which may include 360-degree appraisal and use of patient feedback. Maintain own personal and professional development through education, training and networking. Undertake education and training that is appropriate to the role of Enhanced Nurse, as identified in Professional Development Plan.



Contribute to the training of staff, using informal and formal teaching sessions, and promote reflective practice initiatives in the clinical setting. Contribute to the development and updating of resource and teaching packs for use by patients and/or staff in the clinical and education settings. Disseminate innovative practice through conference presentations or journal publications both nationally and internationally. Record objectives and updates, including maintaining a portfolio of evidence to support achievements.

Communication:

The post holder will require the skills necessary to provide and receive information which is highly complex and sensitive in its nature. Communicate with other health care professionals and address interface issues within primary, community and secondary care to ensure consistent and accurate transfer of information relating to patient care. Promote multi-disciplinary working to deliver effective and appropriate services; provide advice to service providers, independent contractors and other relevant stakeholders. To demonstrate excellent communication skills with colleagues and patients and to deliver teaching programmes Participate in the review and development of clinical policies and identify improvements to service provision To organise, lead and contribute to multi-disciplinary team meetings; discussing own and others input around client needs ensuring a well-coordinated care plan/service provision.



Work closely, and demonstrate empathy with clients, carers and their families to agree decision making relevant to care management particularly where barriers to understanding exist. Employ excellent written and verbal communication skills. Demonstrate skills in motivating clients and/or carers to engage in the care process. Apply negotiation skills in the management of conflict across a range of situations.



Deal with initial complaints sensitively, avoiding escalation where possible. Form productive relationships with others who may be under stress and/or have difficulty with their communication.