Senior Registered Nurse Community

Job responsibilities

PHYLLIS TUCKWELL

JOB DESCRIPTION

POST: Senior Registered Nurse Hospice at Home

ACCOUNTABLE TO: Designated Lead within Community Services

Job Purpose and Summary:

To work as a proactive member of the Phyllis Tuckwell (PT) multidisciplinary Hospice at Home team. This requires working with patients, families and carers known to the PT Community teams in their usual place of residence which includes home or care home, and as outpatients.

The role involves holistic assessment and identification of patient needs, decision making and care planning alongside other MDT colleagues at PT and community partners. It involves strong assessment skills, implementation of a management plan and evaluation to ensure that responsive high-quality, nursing care and support is available for patients, their families, and carers.

The role requires, symptom management, communication and psychological skills, medication management and administration, organisational, leadership and people management skills. Patient safety and practice development are elements of the role.

The role involves:

• Providing a face-to-face service of planned visits and a responsive service to people with palliative care needs in an unstable phase of illness, or with rapidly changing needs.
• Proactive planning for people in the last phase of life to maximise quality of life and live as fully as possible.
• Caseload management.
• Rotating into a co-ordination function as required.
• Working with colleagues to ensure the process of receiving and responding to referrals, to professional and patient enquiries, workload prioritisation, and timely response to clinical need.

Where appropriate, the role will be required to work across services including the inpatient unit, in response to patient needs.

Responsibilities:

1.0 Clinical

a. To assess, plan, co-ordinate, implement and evaluate palliative care interventions based on an agreed plan of care that supports quality and timely care delivered to the patient and family or carer

b.To be proactive in response to referrals and patient needs

c. To ensure that care is centred around the person, family and their carer and that effectiveness, clinical safety and a joint approach with community nursing colleagues underpins PT practice.

d. To work with the Team Leads to co-ordinate an effective nursing service ensuring the highest standards of nursing care are provided to patients, families and carers.

e. To undertake face to face and telephone holistic assessments to assess patient need and arrange appropriate follow up and interventions, in accordance with identified needs and the role of other health care professionals.

f. To act as a resource and support to palliative care colleagues through giving advice, information, support, and education.

g. To work alongside PT multi-professional team to ensure high standards are maintained and constantly re-evaluated to provide high quality individualised care.

h. To liaise with other healthcare professionals to ensure effective continuity of care irrespective of the care setting.

i. To manage workload of patients under the supervision and direction of the key worker, ensuring patient safety and the principles of clinical governance are at the centre of all care.

j. To provide optimal symptom management, psychological and emotional support to patients, their families, and carers.

k. To assess the patients changing needs, liaising with other PT specialists or external partners to support patient or family needs as appropriate, for end of life care at home, or in the In-Patient Unit.

l. To take on, where appropriate, responsibilities for a specific clinical area, proactively seeking to improve knowledge and practice in the specified area and disseminating best practice.

m. To work with colleagues to assess their clinical competencies as appropriate, providing training and support.

n. To attend and contribute to clinical multidisciplinary meetings.

2.0 Professional

a. To contribute to team cohesion, through ongoing supportive relationships and consideration of colleagues.

b. To make autonomous decisions whilst acting the patients best interests, and also recognise own limitations.

c. To work in accordance with NMC Code of Practice.

d. To represent Phyllis Tuckwell in the general public arena, and occasionally give educational talks ensuring that the reputation of PT is maintained and enhanced.

e. To ensure patient records are properly maintained in accordance with NMC guidelines and PT policies.

f. To develop an area of expertise and act as a resource for the multi-professional PT team.

g. To participate in, and contribute to, inter-hospice meetings.

h. To maintain professional links with other health and social care agencies.

i. To identify and work to mitigate risks, and report accidents or incidents in a timely way, ensuring appropriate action and the optimum safety and wellbeing of patients, their families and colleagues

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