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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 homeless health 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 the speciality.

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

Use and apply technical knowledge of the speciality and treatment 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 (& other stakeholders involved with the homeless population) and make 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 patients within the speciality in both inpatient and outpatient settings.  Evaluate response to interventions and advise on the adaptation of management.

Empower patients to self-manage their condition, undertaking risk stratification to determine those who can self-manage following education, those who will need guided support to self-manage and those who will need ongoing face-to-face support.

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

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.  Assess and effectively manage individual psychological reactions to diagnosis, treatment and associated side effects of including Homeless Health.

Actively integrates theory and practice.

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 (Homeless Health CSWs) of the team of specialist nurses including responsibility for annual appraisal where applicable.

Manage budgets as necessary.

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 the specialist service.  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 in supporting, informing and advising patients and carers through diagnosis, treatment, disease progression, prognosis and supportive and palliative care where applicable.  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 to All partner agencies during weekly MDT meetings, including relevant  council charities and statutory bodies complying with consent, GDPR and confidentiality and liaise with Street outreach team members

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.

Lead the development of patient-focused education including training to support self-management and health promotion activities.

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.

Demonstrate knowledge of current clinical trials available to patients within the speciality.  Work in collaboration with the Trust Research and Development Team to support clinical trials for patients.

Contribute to the identification of patients eligible for trial entry.  Provide support to patients considering entry to clinical trials in relation to informed consent and advocacy.

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

Additional Responsibilities

 Need to access locations where patients may reside or visit, i.e charity/local authority led initiatives where patients may congregate.

Will participate in Audits and liaise with public health staff

Participate in public health initiatives including vaccination clinics, BBV screening, general health assessments, wellbeing clinics.

To maintain strong desire to develop service and to be resilient to negative attitudes within this patient cohort