Long Term Condition Practice Nurse

Purpose To work as part of a multidisciplinary team to enable service delivery and management of high quality evidence based care to meet the health and social care needs of the practice population. Job Summary Assess, plan, develop, implement and evaluate treatment programmes that promote health and well being Assess, plan, implement and evaluate individual treatment plans for patients with a known long term condition Proactively identify, diagnose and manage treatment plans for patients at risk of developing a long-term condition as appropriate Work with other health care professionals to diagnose, monitor, manage and treat long-term conditions, including non-drug-based treatment methods using a management plan, and in line with national and local policies and practice needs Review medication for therapeutic effectiveness, appropriate to patient needs and in accordance with evidence-based practice and national and practice protocols Work with patients in order to support adherence to prescribed treatments Provide information and advice on prescribed or over-the-counter medication on medication regimens, side-effects and interactions Prioritise health problems and intervene appropriately to assist the patient in complex, urgent or emergency situations, including initiation of effective emergency care Support patients to adopt health promotion strategies that promote patients to live healthily, and apply principles of self-care Recognise, assess and refer patients presenting with mental health problems Implement vaccination and immunisation programmes Advise, support and administer vaccinations where appropriate for patients travelling abroad Promote and deliver evidence-based care for patients presenting with aural conditions Meet the needs of patients presenting for chronic/opportunistic wound care Communication Demonstrate sensitive communication styles to ensure patients are fully informed and consent to treatment Communicate and support patients receiving complex and sensitive information to patients including unwanted pregnancy, bereavement counselling and mental health. 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 Estimate and maintain effective communication with individuals and groups within the practice environment and with external stakeholders Act as an advocate when representing patients and colleagues 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 local and national evidence-based care Assess effectiveness of care delivery through self and peer review, benchmarking and formal evaluation Participate in the maintenance of quality governance systems and processes across the practice Utilise the audit cycle as a means of evaluating the quality of the work of self and the team, implementing improvements where required Collaborate on improving the quality of health care in partnership with other clinical teams, responding to local and national policies and initiatives as appropriate Evaluate the patients response to health care provision and the effectiveness of care Support and participate in shared learning across the practice and wider organisation Participate in the management and review of patient complaints, and identify learning from clinical incidents and near-miss events using a structured framework Assess the impact of policy implementation on care delivery Participate in the performance monitoring review of the team, providing feedback as appropriate Understand and apply legal policy that supports the identification of vulnerable and abused children and adults, being aware of statutory child/vulnerable adult health procedure and local guidance Work within policies regarding family violence, vulnerable adults, substance abuse and addictive behaviour, and refer as appropriate Leadership personal and people development Take responsibility for own development learning and performance including participating in clinical supervision and acting as a positive role model Support the development of others in order to maximise potential Actively promote the workplace as a learning environment, encouraging everyone to learn from each other and from external good practice Encourage others to make realistic self-assessment of their application of knowledge and skills, challenging any complacency and actions that are not in the interest of the public and/or users of services Act as a clinical leader in the delivery of practice nurse services to patients, ensuring that the needs of the patient are the priority Participate in planning and implementing changes within the area of care and responsibility Work with practice management to ensure sufficient staff of appropriate ability, quality and skill-mix are available to meet current and future service delivery Contribute and participate in the development of local guidelines, protocols and standards Participate in the planning and engagement of practice-based commissioning or similar initiatives Ensure awareness of sources of support and guidance (eg PALS), and provide information in an acceptable format to all patients, recognising any difficulties and referring where appropriate Promote the role of the senior practice nurse in the provision of care Team working Understand own role and scope, and identify how this may develop over time 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 assessing competence Ensure clear referral mechanisms are in place 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 Participate in team activities that create opportunities to improve patient care Participate in and support local projects as agreed with the practice management team Management of risk Manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients Monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety and security legislation, policies, procedures and guidelines Ensure safe storage, rotation and disposal of vaccines and drugs is undertaken. Where appropriate, oversee the monitoring, stock control and documentation of controlled drug usage according to legal requirements Undertake mandatory and statutory training Apply infection control measures within the practice according to local and national guidelines Apply policies that reduce environmental health risks, are culturally sensitive and increase access to health care for all Participate in the local implementation strategies that are aligned to the values and culture of general practice Utilising information Use technology as an aid to management in planning, implementation and monitoring, presenting and communicating information Review and process data using accurate Read codes about patients in order to ensure easy and accurate retrieval for monitoring and audit processes Manage information searches using the internet and local library databases, for example, the retrieval of relevant information for patients on their condition Understand own and others responsibility to the individual organisation regarding the Freedom of Information Act Collate, analyse and present clinical data and information to the team using appropriate charts and/or graphs to enhance care Learning and development Act as mentor to students, assessing competence against set standards as requested and if appropriately qualified Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments Assess own learning needs and undertake learning as appropriate Make effective use of learning opportunities within and outside the workplace, evaluating their effectiveness and feeding back relevant information Provide an educational role to patients, carers, families and colleagues in an environment that facilitates learning Equality and diversity Identify patterns of discrimination, take action to overcome this, and promote diversity and quality of opportunity Enable others to promote equality and diversity in a non-discriminatory culture Support people who need assistance in exercising their rights Monitor and evaluate adherence to local chaperoning policies Act as a role model in good practice relating to equality and diversity Accept the rights of individuals to choose their care providers, participate in care and refuse care. Assist patients from marginalised groups to access quality care. Job description Job responsibilities Purpose To work as part of a multidisciplinary team to enable service delivery and management of high quality evidence based care to meet the health and social care needs of the practice population. Job Summary Assess, plan, develop, implement and evaluate treatment programmes that promote health and well being Assess, plan, implement and evaluate individual treatment plans for patients with a known long term condition Proactively identify, diagnose and manage treatment plans for patients at risk of developing a long-term condition as appropriate Work with other health care professionals to diagnose, monitor, manage and treat long-term conditions, including non-drug-based treatment methods using a management plan, and in line with national and local policies and practice needs Review medication for therapeutic effectiveness, appropriate to patient needs and in accordance with evidence-based practice and national and practice protocols Work with patients in order to support adherence to prescribed treatments Provide information and advice on prescribed or over-the-counter medication on medication regimens, side-effects and interactions Prioritise health problems and intervene appropriately to assist the patient in complex, urgent or emergency situations, including initiation of effective emergency care Support patients to adopt health promotion strategies that promote patients to live healthily, and apply principles of self-care Recognise, assess and refer patients presenting with mental health problems Implement vaccination and immunisation programmes Advise, support and administer vaccinations where appropriate for patients travelling abroad Promote and deliver evidence-based care for patients presenting with aural conditions Meet the needs of patients presenting for chronic/opportunistic wound care Communication Demonstrate sensitive communication styles to ensure patients are fully informed and consent to treatment Communicate and support patients receiving complex and sensitive information to patients including unwanted pregnancy, bereavement counselling and mental health. 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 Estimate and maintain effective communication with individuals and groups within the practice environment and with external stakeholders Act as an advocate when representing patients and colleagues 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 local and national evidence-based care Assess effectiveness of care delivery through self and peer review, benchmarking and formal evaluation Participate in the maintenance of quality governance systems and processes across the practice Utilise the audit cycle as a means of evaluating the quality of the work of self and the team, implementing improvements where required Collaborate on improving the quality of health care in partnership with other clinical teams, responding to local and national policies and initiatives as appropriate Evaluate the patients response to health care provision and the effectiveness of care Support and participate in shared learning across the practice and wider organisation Participate in the management and review of patient complaints, and identify learning from clinical incidents and near-miss events using a structured framework Assess the impact of policy implementation on care delivery Participate in the performance monitoring review of the team, providing feedback as appropriate Understand and apply legal policy that supports the identification of vulnerable and abused children and adults, being aware of statutory child/vulnerable adult health procedure and local guidance Work within policies regarding family violence, vulnerable adults, substance abuse and addictive behaviour, and refer as appropriate Leadership personal and people development Take responsibility for own development learning and performance including participating in clinical supervision and acting as a positive role model Support the development of others in order to maximise potential Actively promote the workplace as a learning environment, encouraging everyone to learn from each other and from external good practice Encourage others to make realistic self-assessment of their application of knowledge and skills, challenging any complacency and actions that are not in the interest of the public and/or users of services Act as a clinical leader in the delivery of practice nurse services to patients, ensuring that the needs of the patient are the priority Participate in planning and implementing changes within the area of care and responsibility Work with practice management to ensure sufficient staff of appropriate ability, quality and skill-mix are available to meet current and future service delivery Contribute and participate in the development of local guidelines, protocols and standards Participate in the planning and engagement of practice-based commissioning or similar initiatives Ensure awareness of sources of support and guidance (eg PALS), and provide information in an acceptable format to all patients, recognising any difficulties and referring where appropriate Promote the role of the senior practice nurse in the provision of care Team working Understand own role and scope, and identify how this may develop over time 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 assessing competence Ensure clear referral mechanisms are in place 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 Participate in team activities that create opportunities to improve patient care Participate in and support local projects as agreed with the practice management team Management of risk Manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients Monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety and security legislation, policies, procedures and guidelines Ensure safe storage, rotation and disposal of vaccines and drugs is undertaken. Where appropriate, oversee the monitoring, stock control and documentation of controlled drug usage according to legal requirements Undertake mandatory and statutory training Apply infection control measures within the practice according to local and national guidelines Apply policies that reduce environmental health risks, are culturally sensitive and increase access to health care for all Participate in the local implementation strategies that are aligned to the values and culture of general practice Utilising information Use technology as an aid to management in planning, implementation and monitoring, presenting and communicating information Review and process data using accurate Read codes about patients in order to ensure easy and accurate retrieval for monitoring and audit processes Manage information searches using the internet and local library databases, for example, the retrieval of relevant information for patients on their condition Understand own and others responsibility to the individual organisation regarding the Freedom of Information Act Collate, analyse and present clinical data and information to the team using appropriate charts and/or graphs to enhance care Learning and development Act as mentor to students, assessing competence against set standards as requested and if appropriately qualified Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments Assess own learning needs and undertake learning as appropriate Make effective use of learning opportunities within and outside the workplace, evaluating their effectiveness and feeding back relevant information Provide an educational role to patients, carers, families and colleagues in an environment that facilitates learning Equality and diversity Identify patterns of discrimination, take action to overcome this, and promote diversity and quality of opportunity Enable others to promote equality and diversity in a non-discriminatory culture Support people who need assistance in exercising their rights Monitor and evaluate adherence to local chaperoning policies Act as a role model in good practice relating to equality and diversity Accept the rights of individuals to choose their care providers, participate in care and refuse care. Assist patients from marginalised groups to access quality care.