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Community Health Nurse

1. JOB IDENTIFICATION

Job Title: Community Health Nurse (CHN)

Responsible to (insert job title): Advance Practitioner

Department(s):

Directorate:

Operating Division:

Job Reference:

No of Job Holders:

Last Update (insert date):

2. JOB PURPOSE

The Community Health Nurse (CHN) will contribute to the national health service agenda through the application of research evidence based practice to enable patients and the public to improve and sustain their health and well being. The CHN provides a clinical and professional leadership role and is responsible for the delivery of high quality rights based care and interventions to the population across a geographical /GP practice area. The post holder will be the single point of contact to community nursing services and has a strong co-ordinating role within the nursing team and other services. The CHN will promote the development of an integrated team working approach aiming to provide maximum benefit to children and young people, adults, carers, families and communities.

This will be achieved by working within the seven core elements of nursing in the community; Working directly with individuals and carers, adopting public health approaches to protecting the public, co-ordinating services, supporting self care, multi-disciplinary and multi-agency team working, meeting the health needs of communities and supporting anticipatory care. It will be further enhanced by using a proactive approach to promoting health and wellbeing, detection and prevention of vulnerability, preventing illness, reacting and responding to existing or potential ill health issues and contributing to reduction in unplanned hospital admissions.

3. DIMENSIONS

The post holder will be accountable and responsible for the clinical and professional leadership of the Community Health Nursing Team (CHNT) in a defined geographical / GP aligned area.

The post- holder will assess, plan, co-ordinate and deliver programmes of care to individual children and young people, adults, families, carers and communities within the area. The post holder will work in diverse and varied context and settings as part of a multi-disciplinary and multi-agency team.

The post-holder will collaborate with a wide range of statutory, voluntary and private organisations to maximise the nursing contribution in health improvement, patient and public protection, planning and delivery of nursing care and interventions to children and young people, families, carers and communities.

Population health profile to include

Ø Number of practices, AHPs and any Community Hospitals, Care Homes and Social Care/specialist ……..

Ø Number and mix of staff within team………….

Ø Budget size and responsibilities…………………..

Ø Participate in the activity of the CHP……

Ø Number of schools………

4. ORGANISATIONAL POSITION

-

Advanced Practitioner

CHN

Community Staff Nurses

CHP/LHP

Operational

structure

Health Care Support Workers



*Example only to be shaped to local structures

5. ROLE OF DEPARTMENT

The Community Health Nursing Team forms part of the services provided by (name of CHP) Community Health Partnership. (Name of CHP). The CHP covers (describe the area)…………


The CHP provides services to around ……………….. people across ………… square miles and includes:

………………………………………………………………………………………………………………………..

The main functions and objectives of the Community Health Nursing service are to:

Ø To contribute to the seven core elements of nursing in the community

Ø Assess, anticipate, identify, promote and maintain the health needs of the local population in partnership with colleagues, individuals, families, carers and the local community in a variety of settings.

Ø Collaboratively plan with stakeholders and implement and deliver care, treatment and early interventions as assessed.

Ø Evaluate outcomes of planned programmes of care and support

This will be addressed by a public health approach to the health and well being of children and young people,

adults, families, carers and communities within a robust clinical governance framework in line with local and national

priorities and standards.

6. KEY RESULT AREAS

Leadership and Management:

Responsible for the professional and clinical leadership of the Community Health Nursing Team (CHNT) in order to provide efficient and effective community nursing services to a defined population.

Leads, prioritises and delegates workload and responsibility within the team in order to address the nursing health

needs of children and young people, adults, families, carers and communities.

Works collaboratively and acts as a resource to specialist health services, social care colleagues, voluntary, private sector, and the community to:

  • Promote health and well being and contribute to meeting local and national health targets
  • Prevent ill health
  • Prevent, detect and where necessary protect vulnerable children, young people and adults

Influences policy development to maximise societal health and well being.

Responsible for staff appraisal and PDP in line with the KSF framework, address performance management issues, provides and participates in clinical supervision of staff and addresses performance issues.

Co-ordinates programmes of learning for a variety of learners within the community nursing setting

Participates in the recruitment and selection of the community health nursing team to influence the composition of the team to ensure the required skills mix meet local need.

Health Needs Assessment

Assesses, plans implements and evaluates care for children, young people, adults, carers and families who will benefit from clinical case management due to long term conditions, palliative and terminal care and complex needs requiring individualised packages of care.

Responsible for ensuring the delivery of a universal child health programme

Lead on a range of activities that will contribute to improving physical and mental health and well being, promotes capacity and capability to self care and parent and ensures that the most vulnerable children and young people, adults, families and carers are targeted and protected through early intervention in line with local and national policies.

Contributes to the reduction in unplanned hospital admissions and facilitates early discharge by anticipating care needs, providing early clinical interventions for ill health, supporting self care initiatives and working collaboratively with carers and other health, social and voluntary care providers.

Works collaboratively with the health improvement team within the organisation /CHP in the health needs assessment of the population. Identifies and plans priorities for the CHNT to address that will contribute to reducing health inequalities and prevention of social inclusion.

Proactively engages with people with multiple and complex needs, not registered with a GP who are less likely to seek health care in an unplanned or emergency situation.

Practice Development :

Develops and facilitates practice through effective utilisation and integration of research evidence based practice into the practice setting

Influences the development of best practice in community health nursing


Demonstrates and delivers highly skilled clinical and public health interventions and be an advisor and educator and mentor to the CHNT and a variety of learners.

Co-ordinates and supports staff in their teaching of a learners in the community working in collaboration with education providers and other stakeholders

Ensures specialist expertise is accessed when required and care shared with those who have the specific skills,

facilitating opportunities for the team to learn from this expertise.

Clinical Governance

Assist the development of practice through effective utilisation and integration of current research evidence into practice setting, implementing, monitoring evidence based policies, procedures and protocols and acting as a change agent when appropriate.

Develops and encourages a culture of continuous practice that improves quality by ensuring continuous review and development of practice and through involvement in service redesign through risk assessment, clinic audit, patient feedback and reflection on practice by self and other members of the team.

Works within the health protection policy agenda and is responsible for ensuring compliance with legislation, policies and protocols e.g. infection control, health and safety, risk management and critical incident reporting and analysis, assessing and managing actual and potential risks to health and well-being of patients and staff.

Identifies issues of poor practice and takes appropriate action to safeguard and protect patients, public and communities.

Ensures high standard of record keeping in accordance with NMC, national legislation and local standards, facilitating effective communication with multi-professional and multi-agency team.

Patient and Public Experience:

Promote a culture of person centred care by empowering and engaging children, young people, adults, families, carers and communities in joint decision making in service delivery, developments.

Lead the community health nursing team to provide children, young people, adults, families, carers and communities with the best care, treatment, interventions and support for health improvement and well being based on the most recent research evidence available.

Responsible for ensuring the planning and co-ordination of CHNT services including signposting and referring individuals, families, carers and communities to the most appropriate services and agencies.

Identifies opportunities to further develop high quality community nursing services by ensuring there are effective systems in place to ascertain patient and public experience / feedback and complaints are managed in line with organisational policy including actions from the learning.

Acts as an advocate for children, young people, adults and carers to support and empower them to make informed decisions and choices.

7a. EQUIPMENT AND MACHINERY and use

Insert as appropriate to work area

Examples:

Child Development assessment /equipment and charts

Scales, hearing equipment, Doppler, Leicester Height Measures, Urinalysis, Vision charts, Specimens, digital camera,

Toys play equipment

Aids and adaptations

Mobile hoists, Beds, rails, lever, wheelchairs, pressure relieving equipment, trolley's, commodes

Treatment equipment

needles and syringes/ drivers

7b. SYSTEMS

  • Community Health Nurse Team Assessment tools and records
  • Joint assessment tools and records with social work and other partners
  • Personally generated notes
  • Electronic and paper record systems
  • Activity recording systems - ISD
  • Workload and staffing profiles
  • Analysis and input SPARRA data
  • Clinical, financial and staff governance audit tools
  • Patient group directives
  • National prescribing centre
  • E-LIBRARY
  • ScotPHO website
  • Intranet

8. ASSIGNMENT AND REVIEW OF WORK

The post holder will be responsible for the day-to day prioritisation and organisation of their work and delegation to the team.

The post holder will work within the seven core elements of nursing in the community to respond to the needs of the local population, taking into account the priorities of the NHS Board, CHP and those expressed by the public.

The Advanced Practitioner and local operational manager will be responsible for agreeing key objectives, reviewing performance and supporting professional development.

Workload will be generated by individual, families and community need, self referral, GP's, hospital teams, other health care professionals and other agencies based in the community

9. DECISIONS AND JUDGEMENTS

Highly skilled in interpretation of health needs assessment and interpretation of complex information often

where acute health and/or social circumstances are present and determines when to refer to other professionals

and /or specialist services.

Exercises a high level of autonomy and independence in clinical decision making and utilises the support of

relevant tools and local and national policies to inform decisions and apply clinical judgements in terms of

competing priorities within a complex changing environment

Negotiates, collaborates and supports individuals and families to make sometimes difficult decision about

plans of care by empowering them to decide the most appropriate course of action.

Makes informed decisions on how to respond where the protection of vulnerable children, young people and

adults may be required, in accordance with local and national policies and guidelines and make decisions with

guidance from child protection advisor or vulnerable adult's officer as required.

Prioritises and delegates team activity on a day-to-day basis across the seven elements of practice.

Co-ordinates and supervises nursing team and takes remedial action as required to resolve issues / staff problems within own team.

Supports professional development of team members.

Challenges other agencies in decision making and judgement where appropriate.

10. MOST CHALLENGING/DIFFICULT PARTS OF THE JOB

  • Being able to co-ordinate and deliver and develop a new nursing role whilst maintaining high quality care in a range of settings
  • Assessing and developing plans to address the health needs of people in complex care situations.
  • Being able to co-ordinate high quality care in a range of settings and balance conflicting priorities in addressing the health challenges of the community
  • Change management, management of people, facilitating good performance and conduct
  • Co-ordinating complex care packages with colleagues in other health, and social and educational services
  • Complex case conference for vulnerable children and adults.
  • Working with vulnerable people and their families
  • Meeting health challenges and inequalities of the community
  • Ensuring a proactive way of working within finite resources allocated
  • High level of knowledge and expertise for the post
  • Dealing with complex, sensitive or contentious situations
  • Remote and rural working
  • Lone working

11. COMMUNICATIONS AND RELATIONSHIPS

Internal

Primary Health Care Team

CHP/LHP staff

Specialist Services

Child Protection Services

Vulnerable Adults Services

Child and Young people Health Services

Midwifery Services

Mental Health

Learning Disability Services

Allied Health Professionals

Health improvement Team

Addiction Services

Community hospitals

Nurse Director/s

NHS QIS

Acute Directorates

occupational Health Service

HR dept

NES

Health Scotland

External

Higher Education Institutes

Local Authorities (Social work, Education and Housing

Individuals, families, communities

Immigration

Church groups

Counselling services/Brook advisory

Community Groups and organisations

Professional organisations and representatives

Other health and social care providers e.g nursing homes, Nurseries, Family centres

12. PHYSICAL, MENTAL, EMOTIONAL AND ENVIRONMENTAL DEMANDS OF THE JOB

Physical:

Moving and handling of individuals and equipments such as hoists and wheelchairs

Risk assess a range of working environments and ensure safe working environment for self and staff

Restrictive movement in environments in terms of some clinical interventions e.g kneel

Fine motor skills and dexterity such as syringes as needles

Driving

IT

Exposure to body fluids

Mental

Dealing with urgent and life threatening conditions

Variety of assessment approaches and interpretation of findings sometimes complex

Concentration and decision making in terms of competing demands and priorities.

Lone working in the community, risk assessment, concentration in driving in a variety of environments

Ability to calculate drug dosages and prescribe safely and effectively

Ability to organise and manage workforce and workload

Writing prolonged reports

Administration of medications

Negotiation and influencing skills

Motivating others

Descalation of volatile situation

conflict management

Interpret data and use findings to inform service delivery

Dealing with challenging behaviour

Concentration to deal with highly complex facts or situations requiring analysis, interpretation and comparison of a range of options

Dealing with changing resource provision

Challenging poor performance

Emotional

Individual , family, community and team dynamics

Supporting in terms of individual, family and community crisis/ major incident/ poor diagnosis and prognosis

Advocating for patients

Supporting staff

Supporting and enabling self care when individuals, family and community may not be motivated to do so

Coping with unpleasant surroundings and environments,

Coping with management of complaints

Providing episodes of care that challenge individual beliefs and values

Caring for terminally ill

Balancing the support for carers with the protection of vulnerable groups

Bereavement

Environmental

smoking in homes,

pets,

ergonomics

13. KNOWLEDGE, TRAINING AND EXPERIENCE REQUIRED TO DO THE JOB

Qualifications:

Registered Practitioner

Community nursing Qualification

1st Degree

Training and Experience:

5 years post registration experience, at least 3 at community specialist level

Recent experience of working within a community setting

Independent Nurse Prescriber

Mandatory training such as moving and handling, child protection

Evidence of relevant on-going professional development

Experience of working in collaboration with other professionals across

organisational boundaries.

Experience or working with children and young people, adults, families, carers and communities

Experience of developing and implementing creative/complex packages

.

Knowledge and Skills:

Knowledge and skills to lead a community health nursing team

Capable in a range of clinical skills

Ability to direct and coordinate programmes of care working collaborative and autonomously.

Knowledge and skills to work in a collaborative manner with other key stakeholders

Knowledge and ability to interpret and apply public health agenda and research based evidence in all aspects of community health nursing practice.

Knowledge and understanding of policy and guideline implementation, review, monitoring and evaluation

Knowledge and understanding of involvement of patient and public in service delivery, development and design

Knowledge, understanding and experience of service improvement and redesign and managing change

Basic IT skills

Ability to demonstrate effective verbal and written communication.

Decision making and prioritisation

Clinical audit

Presentation

Problem solving skills

Teaching, supervising, mentoring and supporting junior staff

Car driver

Page updated: Tuesday, April 15, 2008