Registered Nurse, Primary Care - (Multi-site) - EAST Region

Detailed Overview

In accordance with the British Columbia College of Nurses and Midwives (BCCNM) standards of practice and the Mission and Values of Fraser Health, works collaboratively and as a member of an inter-professional team to provide direct patient care to clients of the Urgent Primary Care Centre ( UPCC , "UPCS" or Centre ) or Primary Care Clinic, which provides both timely and longitudinal primary care to unattached and attached vulnerable clients.

• Provides initial client consultation, assessment, coaching and teaching, health promotion and intervention, client care services and follow-up based on the client's needs, urgency of request and best practices, to ensure clients, families and caregivers are provided with ease of access to timely, person-centred, continuous and culturally safe quality health services;
• facilitates and manages client transitions across the healthcare continuum to optimize recovery and adapts to changes in the client's condition to minimize avoidable admission to healthcare facilities;

collaborates and ensures linkages with acute, primary and community care healthcare providers including the client's primary care provider (Nurse Practitioner, Physician, other specialists) and family supports regarding client care planning to facilitate the flow of information through a variety of settings including FH and non-FH community services.

• Provides client and family-centered care through a trauma-informed approach and evidence-informed practice; establishes a dignifying, purposeful and trusting relationship with clients, promoting self-determination and independence;
• encourages knowledge exchange in day-to day activities, and empowers clients and natural supports to engage and connect within their communities;
• ensures clients and their family members are supported in navigating the health care system. Responsibilities Provides direct nursing care to clients receiving scheduled or urgent / timely primary care;
• assesses clients and collects information from a variety of sources using skills of observation, communication, data review and physical assessment;

makes a nursing diagnosis of the client's condition and determines whether the condition can be improved or resolved by an appropriate nursing intervention or through interventions and collaboration with other clinical staff.

Processes physician or nurse practitioner orders by initiating unit standing orders, administering medications, carrying out treatments and monitoring and documenting the effects.

Establishes a therapeutic relationship with the client through the use of interpersonal and interviewing techniques, in person and / or over the telephone, to ensure the client's choice and autonomy in decision-making and care planning including the client's right to dignity and privacy.

• Screens referrals, provides individualized client assessments, inter-professional care planning and interventions when appropriate and referral services for clients with multiple complex conditions;
• assists clients to achieve an optimal level of function by facilitating timely and appropriate health services and utilizing a variety of resources and services;

collaborates with the primary care provider, client, the family / supports / caregivers, other health care professionals, clinics, hospitals and other community resources to identify and resolve client care issues and coordinate the integration of care and services.

Develops a comprehensive shared client care plan, in collaboration with the inter-professional team, primary care provider, client and / or family, other healthcare providers and / or referring clinics;

facilitates and supports the transition of the client care plan to the primary / community care provider and / or community agencies.

• Provides direct planned and unplanned client care and identifies other care services required in accordance with applicable guidelines, policies and evidence-based best practice;
• provides comprehensive explanations of care to the client and family, as appropriate. Reviews client care plans, in collaboration with the inter-professional team / primary care provider to determine timing and referral to other services and / or interventions to improve client outcomes;
• initiates, monitors and evaluates the appropriateness and effectiveness of the short and long term care plan to meet specific client goals;

develops next steps in collaboration with the client and family; develops and supports a transition process for achieving client care goals across the care continuum.

• Discusses clinical findings with client / family, in collaboration with the inter-professional team to develops action plans and sets goals directed at clinical needs, self -management, self-care and improved health-related quality of life;
• accesses system information and resources to review client data such as medical history, progress notes, consultation reports, lab reports and incorporates findings into the care plan;

plans, organizes and establishes priorities by using resources effectively and efficiently; responds to unanticipated events and / or changing client or service assignment needs, as needed.

Supports clients and their families clinic visits by providing information through their decision-making process regarding treatment options;

advocates on behalf of the client / family to support their choices and needs and provides direct care to client as they transition to another program, service or healthcare provider.

• Arranges and participates in outreach nursing care to clients in their home setting or suitable alternative, as required;
• performs nursing functions such as assessment, determining physical and mental status, and evaluating response to medications administered;

formulates and explains plan of care to client / family or supportive care persons and provides advice to the client and / or caregiver about available community resources.

Provides health counselling to clients including education, self-management, self-monitoring and wellness / health promotion / prevention through a combination of clinic, telephone or home / outreach visits;

assesses the learning needs of individuals, providing and explaining techniques and equipment, and evaluates the overall effectiveness of the selected teaching methods and outcomes of learning.

Maintains clinical records such as intake screens, client assessments, clinical interventions, treatment formulations, care plans and progress notes;

maintains statistical information on clients in accordance with established policies, standards, and procedures. Maintains professional practice growth, knowledge and expertise to reflect current standards of practice by reviewing relevant literature, attending educational workshops and in-services, consulting and networking with other health care professionals.

Participates in department quality improvement and risk management activities by identifying client care issues and collecting data;

participates in research opportunities, as required. Participates in the orientation and ongoing education of nursing staff and students by providing information and acting as a preceptor as appropriate.

Provides input in the development and revision of standards of care, policies and procedures and advocates for improvements in clinical practice, health care and health care services;

participates in the development, implementation and evaluation of quality improvement initiatives within the program by providing recommendations to the Manager.

Performs other related duties, as assigned. Qualifications Education and Experience Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).

One year recent related clinical experience in acute care, urgent / emergency care or related clinical area including assessing and treating children, youth and adults in an acute or community / outpatient care setting, or an equivalent combination of education, training and experience.

Valid BC Drivers license and access to a personal vehicle for business related purposes, as required. Skills and Abilities Demonstrated ability to complete initial and ongoing client assessments and provide nursing care through therapeutic interventions Demonstrated ability to communicate effectively, both verbally and in writing Demonstrated ability to integrate and evaluate pertinent data from multiple sources to problem-solve effectively Knowledge of broad health care services, community resources agencies and their role in providing a continuum of care Ability to promote client-focused care including sensitivity to diverse cultures and preferences Ability to independently manage and prioritize clients with diverse healthcare issues Ability to teach clients and others about topics essential to health care, health promotion and care self-management using care management principles Ability to work effectively in a dynamic environment with changing priorities Ability to work independently and as a member of an interprofessional team Ability to operate related equipment including applicable software applications Physical ability to perform the duties of the position