Job responsibilities
JOB SUMMARY
The
Neighbourhood Teams District Nurse will:-
Adapt and provide a wide range
of nursing care in home and community based settings
Be accountable for assessing, planning, implementing and
evaluating care for patients and managing unpredictable
situations flexibly and responsively ensuring this is of a high standard.
Have the flexibility and skill set, with appropriate
training, to work across planned and crisis pathways, supporting patients to
remain well in their own homes, or long-term place of residence and / or
prevent hospital admission.
Be responsible for the management of generic caseload and
clinic clients, coordinating care, whether anticipated or
unscheduled, with individuals and their families, through acute illness, long
term and multiple health challenges and at the end of life;
Have ongoing management of
people with multiple pathology and long term conditions whose mobility is
impaired;
Lead and managing a team to
deliver care in the home and community.
Prescribe
according to assessed need from within the nurse prescribing formulary.
Participate
with the training of learners.
Work in an integrated and
partnership way with primary, secondary, social care, the independent and
voluntary sector and others to improve the health and care of individuals,
families and communities, particularly the most vulnerable.
KEY RESULT AREAS:
1.1 Clinical
Care
Demonstrate a broad range of specialist
district nursing clinical expertise that supports high quality person-centred
care for the caseload population in a variety of community settings.
Use appropriate physical and clinical
examination skills to undertake the assessment of individuals with complex
health care needs or those presenting with more acute illnesses, using a range
of evidence based assessment tools and consultation models.
Assess the health related needs of families and
other informal carers, developing therapeutic relationships and using creative
problem solving that enables shared decision making for the development of care
plans, anticipatory care and delivery of care packages.
Supervise the delivery of person centred care
plans by the district nursing team ensuring regular evaluation of care and
develop systems to support staff interventions and care quality.
Support all staff to use tools to identify
changes in health status and maximise the skills of the District Nurse to
support complex assessment where the patient is showing signs of deteriorating
health or new symptoms.
Assess when additional expertise is necessary
and make objective and appropriate referrals, whilst maintaining overall
responsibility for management and co-ordination of care.
Ensure clear lines of accountability with
respect to delegation, supervision and mechanisms for the assurance of clinical
and care governance including antimicrobial stewardship.
Source and utilise eHealth technology and technology
assisted learning systems to support self-care and improve efficiency and
effectiveness of the Neighbourhood Teams service
Work collaboratively with others to identify
individuals who would benefit from further ongoing support and management
within Neighbourhood Teams or wider support.
Promote the mental health and well-being of
people and carers in conjunction with mental health professionals and GPs,
identifying needs and mental capacity, using recognised assessment and referral
pathways and best interest decision making and providing appropriate emotional
support.
Where appropriate, undertake the case
management of people with complex needs, with the support of the
multidisciplinary team, to improve anticipatory care, self-management,
facilitate timely discharges and reduce avoidable hospital admissions to enable
care to be delivered closer to, or at home.
Assess and evaluate risk using a variety of
tools across a broad spectrum of often unpredictable situations, including
staff, and people within their home environments.
Develop and implement risk management
strategies that take account of peoples views and responsibilities, whilst
promoting patient and staff safety and preventing avoidable harm to
individuals, carers and staff.
Work in partnership with individuals, formal
and informal carers and other services to promote the concept of self-care and
patient-led care where possible, providing appropriate education and support to
maximise the individuals independence and understanding of their condition(s)
in achieving their health outcomes.
Analyse and use appropriate approaches to
support the individuals health and well-being and promote self-care in
addressing their short or long term health conditions.
Support the team to facilitate behaviour
change interventions for individuals.
Explore and apply the principles of effective
collaboration within a multi-agency, multi-professional context facilitating
integration of health and social care and services, ensuring person-centred
care is co-ordinated and anticipated across the whole of the persons journey.
Demonstrate advanced communication skills
engaging and involving people and their carers that foster therapeutic
relationships and enable confident management of complex interpersonal issues
and conflicts between individuals, carers and members of the caring team.
Prescribe from the appropriate formulary
relevant to the type of prescribing being undertaken, following assessment of
patient need and according to legislative frameworks and local policy.
Use opportunities to identify and build the principles of
making every contact count into clinical practice and use opportunities to
raise lifestyle issues.
Demonstrate a see and treat approach to patient care.
1.2 Leadership and Operational Management
Contribute to public health initiatives and
surveillance, working from an assets-based approach that enables and supports
people to maximise their health and well-being at home, increasing their
self-efficacy and contributing to community developments.
Lead, support, clinically supervise, manage and
appraise a mixed skill/discipline team to provide community nursing
interventions in a range of settings to meet known and anticipatory needs,
appraising those staff reporting directly to the District Nurse whilst
retaining accountability for the caseload and work of the team.
Enable other team members to appraise, support
and develop others in the team and develop strategies for addressing poor
practice.
Manage the district nursing team within
regulatory, professional, legal, ethical and policy frameworks ensuring staff
feel valued and developed.
Facilitate an analytical approach to the safe
and effective distribution of workload through delegation, empowerment and
education which recognises skills, regulatory parameters and the changing
nature of district nursing whilst establishing and maintaining the continuity
of caring relationships.
Lead, manage, monitor and analyse clinical
caseloads, workload and team capacity to assure safe staffing levels in care
delivery, using effective resource and budgetary management.
Manage and co-ordinate programmes of care, for
individuals with acute and long term conditions, ensuring their patient journey
is seamless between mental and physical health care, hospital and community
services and between primary and community care.
Collaborate with other agencies to
evaluate public health principles, priorities and practice and implement these
policies in the context of the district nursing service and the needs of the
local community.
Participate in the collation of a community
profile, nurturing networks that support the delivery of locally relevant
resources for health improvement and analysing and adapting practice in
response to this.
Articulate the role and unique contribution of
the district nursing service in meeting health care needs of the population in
the community and the evidence that supports this in local areas.
Ensure all staff are able to recognise
vulnerability of adults and children and understand their responsibilities and
those of other organisations in terms of safeguarding legislation, policies and
procedures.
Use knowledge and awareness of social,
political and economic policies and drivers to analyse how these may impact on
district nursing services and the wider health care community. Where
appropriate participate in organisational responses and use this knowledge when
advocating for people or resources.
Record
all client contacts and activities accurately and contemporaneously maintaining
accurate records and statistical returns as required by the Trust via SystmOne
and monitor SytmOne usage within your team.
Participate in
clinical supervision on a regular basis with a designated person.
To be aware of
and act in accordance with Trust Clinical Standards and Guidelines and the NMC
Code of Conduct and Guidelines.
Contribute to the development, collation,
monitoring and evaluation of data relating to service improvement and
development, quality assurance, quality improvement and governance, reporting
incidents and developments related to district nursing ensuring that learning
from these, where appropriate, is disseminated to a wider audience to improve
patient care.
For full details of the role please see the supporting documents attached.
