Community Clinical Nurse Specialist - Palliative Care

Detailed job description and main responsibilities

Expertise & Excellence in Clinical Practice

Deliver evidence-based personalised and compassionate care which places quality at the heart of Specialist Palliative Care practice.  Care will be responsive to individual needs and reflect current local protocols and national guidelines.

Act as the key accessible professional for the MDT proactively managing a clinical caseload for at least 70% of the role.  This will necessitate high levels of autonomy and advocacy, using analytical and judgemental skills in undertaking differential diagnosis to ensure the delivery of appropriate care.

Work as an autonomous practitioner providing an expert level of care, developing own and others knowledge within Specialist Palliative Care.

Manage a caseload of patients and prioritise workload to meet patient and service need.

Use and apply technical knowledge of the Specialist Palliative Care to define, oversee and personalise care pathways for individuals through holistic needs assessment, planning and evaluation of care and all care interventions.

Effectively manages pathways of care, adapting to patients’ emerging needs by ensuring a planned and co-ordinated approach to care, supporting enhanced recovery and reducing inappropriate admissions to improve patient experience and safety.

Receive and act upon referrals directly from health care professionals and makes referrals to other team members and specialist departments as necessary to ensure optimal quality of care.

Act as a patient advocate to facilitate the process of shared decision making in respect to health, choice of treatment and care.  Use interpersonal and communication skills where there may be significant barriers in order to build confidence.  Ensure that patients’ individual needs are expressed and valued and individual care plans are understood.

Advise on the complex disease and symptom management for Specialist Palliative Care patients in both inpatient and outpatient settings.  Evaluate response to interventions and advise on the adaptation of management.

Work autonomously in the development and delivery of nurse led or parallel clinics in line with National guidance and local service need.

Act as a resource providing clinical expertise, specialist advice and support across service boundaries to ensure optimum liaison and co-ordination of care.

Undertake clinical competencies relevant to this specialist service to demonstrate expertise in extended nursing roles.

Actively integrates theory and practice.

Contribute to weekend on call service for Specialist Palliative Care Team. 

Management & Leadership

Act as a role model demonstrating high standards of holistic care and provide expert clinical leadership to others across the organisation.

Supervise the patient caseloads of more junior members of the nursing team assuming overall responsibility where applicable.

Lead and line manage junior members of the team of specialist nurses including responsibility for annual appraisal where applicable.

Embed public and patient involvement within the sphere of practice.

Determine measurable outcomes for the service and demonstrate continuous evaluation of practice making changes where necessary.

Contribute to lead on elements of the clinical governance agenda.

Participate in operational and strategic planning for the development and delivery of Specialist Palliative Care Services.  Implement service improvements and efficiencies.

Attend Trust senior nurse meetings and contribute to the agenda and the strategic nursing vision.

Represent the Trust by contributing to and participating in meetings locally, regional and nationally relating to the speciality.

Lead or contribute to annual service review and write annual report to reflect service activity and development.

Communication

Take personal responsibility for ensuring effective communication between all service providers.

Act as a role model for excellent advanced communication skills and expertise.  Demonstrate advanced empathetic interpersonal and communication skills. This will involve frequently imparting significant news or supporting patients and carers during and following such consultations.

Effectively and sensitively communicate highly complex and sensitive information to emotionally distressed patients and family/carers at key points along the care pathway on a frequent basis.

As a core member of the MDT provide professional advice.

Refer to other health professionals and outside agencies to ensure optimum care and ongoing support for individual patients/carers, and to ensure the seamless transition from primary to secondary care appropriate to patients’ individual needs and circumstance.

Maintain links with local and national organisations, which support the care of patients within this speciality.

Education

Identify and use advanced educational strategies to deliver complex information to patients and carers.

Influence the development of other professionals by leading or contributing to Trust wide specialist education and training.

Deliver formal and informal teaching initiatives as part of the Trust’s education strategy as agreed with the appropriate senior nurse to ensure practice development, staff empowerment and improved care for patients.

Act as a mentor/clinical supervisor as appropriate.

Take personal responsibility for life-long learning and personal development through clinical supervision and appraisal.  Actively engages with learning and development opportunities needed to work as an advanced practitioner and take appropriate action to ensure these needs are met.

Contribute to promoting educational links with local providers of higher education and deliver lectures on a range of courses.

Quality, Audit, Innovation & Research

Develop written patient information and use existing appropriate resources to inform users, according to individually assessed need.

Work within the NMC code of professional conduct.

Influence and develop policy and clinical guidelines to support the specialist service.

Collaborate with other MDT members to develop and update multi-professional Trust operational policies and guidelines.

Maintain patient records and ensure an effective documentation system to reflect the activity and delivery of specialist nursing care.

Promote the service and clinical excellence by publishing and presenting innovations, audit and research locally and nationally.

Use creative reasoning, experience and vision to advance care.

Develop new skills in response to emerging knowledge and techniques.

Instigate and manage change within a complex environment.

Maintain membership and attendance at national and local forums to network and debate issues to inform the specialist nursing role and service delivery.

Collate and record quantitative and qualitative data to provide evidence of productivity, outcomes and quality through audit and research.

Identify and conduct clinical audit in own specialist area.

Participate in clinical research relevant to practice area.

Develop links and system to seek the views of patient and carers to ensure service development is in line with user need.