Chronic Disease Practice Nurse

Job responsibilities

Responsibilities

Your responsibilities will include:

- Deliver high-quality chronic disease management clinics, supporting the practices within Yeovil to achieve QOF, DES, and other clinical targets for conditions including COPD, Asthma, Heart Failure, and Diabetes.

- Take a leading role in delivering innovative group chronic disease clinics to enhance patient care and engagement.

- Provide expert advice and support to patients, including medication reviews and lifestyle advice.

- Support the delivery of adult vaccination programmes throughout the year, including flu and COVID-19 vaccinations.

- Provide chronic disease reviews within care homes and patients own homes as required.

- Apply infection control measures in line with local and national guidelines.

- Maintain accurate and comprehensive patient records on EMIS in accordance with NMC guidelines.

- Work in accordance with PGDs and support HCAs working to PSDs for vaccination delivery.

- Collaborate effectively with other members of the primary healthcare team.

- Maintain and update standard operating procedures (SOPs) and policies within own area of work.

- Provide cover for colleagues as required and coordinate with the PCN Manager to address any staffing shortages.

Communication

- Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment

- Communicate with and support patients and their families who are receiving bad news

- Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating

- Anticipate barriers to communication and take action to improve communication

- Maintain effective communication within the PCN environment and with external stakeholders

- Act as an advocate for patients and colleagues

- Ensure awareness of sources of support and guidance and provide information in an acceptable format to all patients, recognising any difficulties and referring where appropriate

Delivering a quality service

- Recognise and work within own competence and professional code of conduct as regulated by the NMC

- Produce accurate, contemporaneous and complete records of patient consultation, consistent with legislation, policies and procedures

- Prioritise, organise and manage own workload in a manner that maintains and promotes quality

- Deliver care according to NSF, NICE guidelines and evidence-based care

- Assess effectiveness of care delivery through self and peer review, benchmarking and formal evaluation

- Initiate and participate in the maintenance of quality governance systems and processes across the organisation and its activities

- In partnership with other clinical teams, collaborate on improving the quality of health care responding to local and national policies and initiatives as appropriate

- Evaluate patients response to health care provision and the effectiveness of care

- Support and participate in shared learning across the PCN and wider organisation

- Understand and apply legal issues that support the identification of vulnerable and abused children and adults, and be aware of statutory child/vulnerable patients health procedures and local guidance

- Working with PCN management to ensure the whole team have skills and knowledge regarding domestic violence, vulnerable adults, substance abuse and addictive behaviour. Provide guidance and support to ensure appropriate referral if required

Leadership personal and people development

- Take responsibility for own learning and performance including participating in clinical supervision and acting as a positive role model

- Support staff development in order to maximise potential

- Enlist support and influence stakeholders and decision-makers in order to bring about new developments in the provision of services

- Contribute to the development of local guidelines, protocols and standards

- Maintain active involvement in the planning and processes of PCN commissioning or similar initiatives

Team working

- Work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working

- Delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence

- Create clear referral mechanisms to meet patient need

- Prioritise own workload and ensure effective time-management strategies are embedded within the culture of the team

- Work effectively with others to clearly define values, direction and policies impacting upon care delivery

- Work effectively with Care Home teams to develop and maintain relationships and create clear lines of communication.

- Discuss, highlight and work with the team to create opportunities to improve patient care

- Manage and lead on the delivery of specifically identified services or projects as agreed with the PCN management team

- Agree plans and outcomes by which to measure success

Clinical Governance

- Identify risk issues that impact on peoples health or social care needs.

- Take appropriate action to the significance of the risk and consistent with protection procedures, applying protection procedures, following lone worker procedure.

- Demonstrate effective team working inclusive of all relevant professionals.

- Report all accidents / incidents, and all ill health, failings in equipment and / or environment to line managers.

- Contribute towards audit and data collection as required.

- Once assessed as competent will be accountable for their own practice within their area of responsibility when identified and agreed with the line manager.

- Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities.

- Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.

- Work with the Clinical Lead to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present.

Miscellaneous

- Work as part of the team to seek feedback, continually improve the service and contribute to business planning.

- Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.

- Duties may vary from time to time, without changing the general character of the post or the level of responsibility.

Confidentiality:

- In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately

- In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carer(s), PCN Hub staff and other healthcare workers. They may also have access to information relating to the PCN as a business organisation. All such information from any source is to be regarded as strictly confidential

- Information relating to patients, carers, colleagues, other healthcare workers or the business of the PCN may only be divulged to authorised persons in accordance with the PCN policies and procedures relating to confidentiality and the protection of personal and sensitive data

Health & safety:

The post-holder must comply at all times with the PCNs Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System.

Equality and diversity:

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

- Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with PCN procedures and policies, and current legislation

- Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues

- Behaving in a manner that is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings priorities and rights.

The role will be contracted under Symphony HealthCare services on behalf of Yeovil Primary Care Network

Qualifications

Essential

• Registered Nurse, NMC Registered
• Membership of a professional body

Desirable

• Previous experience as a practice nurse
• Minimum 3 years post registration
• Non-medical prescribing qualification

Experience

Essential

• Experience in minimum of two long term conditions
• Previous experience in Primary Care minimum 3 years
• Compiling protocols and clinical guidelines
• Experience of prioritising own workload in a busy working environment

Personal Qualities and Attributes/ Other

Essential

• Must hold valid driving licence and own means of transport
• Self-directed practitioner
• Highly motivated
• Flexibility
• Enthusiasm
• Team player
• Ability to work across boundaries

Knowledge & Skills

Essential

• Management of patients with Chronic diseases
• Clinical examination skills
• Accountability of own role and other roles in a nurse-led service
• Local and national health policy
• Change management
• Clinical governance issues in primary care
• Communication skills, both written and verbal
• Communication of difficult messages to patients and families
• Negotiation and conflict management skills
• Change management
• Resource management

Desirable

• Understanding of Primary Care Networks and network Direct Enhanced Service
• Knowledge of public health issues
• Experience of working within Care Homes or with patients with complex needs
• Clinical leadership skills

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).