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Detailed job description and main responsibilities

Clinical Practice

The post holder will be aligned to a Place Based Team and be clinically responsible for the diagnosing, prescribing, planning and evaluation of care, ensuring provision of high standards of care to patients and their families within the community. They will work as part of an Integrated Team, working within and across professional and organisational boundaries.

The post holder will be a practitioner who can demonstrate a broad range of competencies and is able to adapt to a wide variety of clinical circumstances. They will be part of a community team where their proven ability to make high level clinical decisions will aid patient outcomes.

Providing highly developed clinical leadership for all patients on the Community Nursing caseload through advanced level autonomous practice including taking managed risks, for example where the patient is kept at home, rather than hospital or hospice admittance as would previously been the practice.

Provide highly specialist clinical leadership for patients on the caseload and work collaboratively with all professionals, carers and relatives to gain a deep understanding of all aspects of the patient’s physical, emotional and social situation. This includes physical examination and detailed history taking, diagnosis, prescribing, planning and evaluation of care.

Provide highly specialist clinical leadership for the development and maintenance of personalised care plans for patients on the community nursing caseload, based on the full assessment of medical, nursing and care needs. This includes preventative measures and anticipation of future needs.

Order investigations and tests and interpret and act on results, using clinical guidelines and policies to support clinical decision-making.

Maintain competence in prescribing according to level of prescribing qualification i.e. Independent Prescriber and participate in regular continuing professional development in relation to the role.

Prescribe medication in accordance with the local Non-medical Prescribing Policy, and local and national prescribing guidance. It is expected that all prescribers will prescribe within the limits of their individual competence.

Liaise with other agencies, including the voluntary sector, to mobilise resources to meet patient needs and to support them at home securing additional support as required.

Act as a resource for the PBT and community teams, providing teaching and education to them as required.

To promote new research, innovation and evidence to support quality improvements and evidence based practice within the team.

Clinically lead by example showing a high level of motivation and a positive attitude.

Carry out regular reviews of the caseload with the Caseload Holder to maintain oversite and identify patients who are not progressing towards expected health outcomes.

Support teams, individual clinicians and patients with recommendations regarding individualised treatment plans.

Provide care interventions and higher level assessments for patients with highly complex conditions to ensure that patients achieve their optimum level of wellness.

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Autonomous Clinical Practice

To take a comprehensive history, perform a systematic physical examination and establish baseline data to inform the development of a comprehensive care plan.

Utilise highly specialist assessment, planning, treatment and evaluation skills appropriate to Routine Pathway.

Analyse signs and symptoms, laboratory tests, investigations and other measures of function in formulating a diagnosis.

Use highly complex analytical and problem solving skills in unpredictable situations.

Provide evidence-based treatment plans based on sound clinical decision making, including the unique presentation of illness and response to treatment of patients on the community nursing caseload.

Collaborate with the multi-disciplinary team to plan and implement treatment for acute illness/injury/chronic illness as required, using skills in nurse prescribing and medicines management.

Negotiate, collaborate and support individuals and families to make sometimes difficult decisions about plans of care by empowering them to decide on the most appropriate course of action.

Ensure a robust process is in place to review care and treatment plans.

Take a leading role in auditing and monitoring all components of care delivery.

Review and develop clinical competency as required to support clinical practice, participating in ongoing personal development of self and of others.

Ensure all clinical records are kept in line with SWUF and NMC guidelines.

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Communication

Establish the dynamic process of understanding, reflecting, active listening and checking understanding, thus developing a therapeutic relationship with patients and their carers.

Enable and support patients as active partners in the care planning process for present and future needs.

Dissemination of information throughout the multidisciplinary team, taking into account the patient’s right of confidentiality.

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Education

Utilise communication skills and knowledge to promote patients and families abilities to make informed decisions and participate in care planning.

Participate in the development of the teams’ knowledge for Routine Care Pathways.

Work alongside team managers to support staff in clinical examinations and assessments unfamiliar to them.

Continue to develop own expert practice.

Critically evaluate research and educate the team to ensure that this theory is integrated into practice.

Role model and support staff to ensure that they are clinically competent to undertake new complex skills which are maintained to ensure that patients receive the highest possible standards of care in the most appropriate environment as close to home as possible, preferably in their own home if that is their express wish.

Delivering educational sessions regarding benefits of supervision, quality improvement and Learning from Experience sessions.

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Leadership

Contribute to the development of clinical policies, procedures and guidelines ensuring they are implemented and monitored.

Participate in the clinical appraisal process, providing feedback on performance.

Participate and lead on the embedding of regular clinical and safeguarding supervision for all appropriate staff.

Contribute to the recruitment and selection process.

Act with colleagues to identify clinical development needs within the service.

Act as an advocate at all times for both patients and the service.

Be a role model for other clinical members of the team, taking an active role in ensuring staff are safe in clinical practice, work with team managers to risk assess areas of practice, reporting to senior staff with education/training plans to aid the mitigation of risk as required.

Embed activities within the community team to achieve organisational quality priorities.

Deliver clinical supervision and undertake supervision for own practice.

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Professional

Work within the NMC Code of Conduct.

Remain updated and ensure that clinical practice is evidence based.

Have a personal development plan and professional portfolio.

Access regular clinical supervision.

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Freedom to Act

The post is a clinically autonomous one and the post holder is expected to manage their caseload and the care of their patients independently recognising the limits of their knowledge and experience and seeking help and support appropriately.

Undertake and lead on quality improvement initiatives.

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Working Conditions

Based within SWUFT District Nurse Place Based Team within Routine Care Pathway working mainly in patient’s place of residence.

Carrying light cases and other equipment.

Computer based work and data inputting.

Car driving.

Expected to deal with difficult situations on a regular basis.

Working in patients own home.