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Detailed job description and main responsibilities

Communication

1.         Attend relevant internal and external meetings as required to communicate the performance of the service. 

2.         Attend multidisciplinary team meetings, including co-chair of local heart failure steering group.

3.         Acts as a patients’ advocate in issues concerning their care.

4.         Communicate effectively with patients, relatives and healthcare professionals, including consultants and clinical nurse specialists working in this field. To share knowledge and experience through networking.

5.         Communicate life-changing issues such as medical complications or palliation to patients and provide support to patients and their families.

6.         Discuss complex therapies with patients to allow informed consent.

7.         Refer patients with complex issues and challenging behaviour for psychological care.

8.         Provide written and verbal reports to GPs and other members of the multidisciplinary team regarding treatment changes and recommended management of care.  Communicate results of tests results to patients and GPs.

9.      Support verbal communication by providing written educational material to patients, carers and healthcare professional to ensure understanding of complex issues. Build patients knowledge, skills and confidence to self –manage.  

10.      Utilise the interpreting service for patients with language barrier.

11.      Maintain accurate records regarding all patient contacts, including telephone consultations.

12.      Seek opportunities to publicise and promote the service.

13.      Collaborate with secondary and primary care teams using local tools for holistic care planning, to enhance patient care and avoid unnecessary delay in referral and treatment.

14.      Refer patients who are vulnerable and need ongoing support to GPs, practice nurses, community nurses, social workers and intermediate care service. Ensure patients are aware of contact points.

Service Delivery and Improvement

1.         Actively contribute to setting and monitoring standards in nursing practice and service provision with respect to specialist heart failure care. Using innovation develop patient pathways that reflect contemporary heart failure care.

2.         Keep up to date with current research and evidence-based practice by attending relevant meetings, courses and seminars. Responsible for sharing knowledge with other professionals and team to influence better care and outcomes for patients.

3.         Critically analyse methodology and results of research and apply to future clinical practice where appropriate.

4.         In collaboration with UHSussex research department, develop, participate in and encourage research pertaining to area of specialism, and assist in changing practice related to evidence based research findings.

5.         Collect audit data in line with local and national requirements (e.g. National Heart Failure audit). Independently undertake service audit or local protocol audits according to service need.

6.         Work with the heart failure team to analyse data available and contribute to the publication and dissemination of results.

7.         Implement NICE quality standards, contributing to gap analyses where required.

8.      Participate in local clinical governance programmes.

9.      Respond and take appropriate action relating to hazard notification regarding products and equipment.

10.      Inform manager of any untoward incident or accident and ensure that appropriate investigation, corrective action and documentation takes place. Complete the DATIX procedure, in accordance with the Trust Policy. 

11.      Adhere to all local standard operating procedures and policies.

People Management and Development

1.         Utilise opportunities for teaching junior nursing and medical staff as part the daily clinical work

2.         Provide formal teaching to the MDT – nurses, doctors, allied health professionals, as required

3.         To share knowledge and experience through networking

4.         Work collaboratively with the heart failure specialist nurses to deliver independent and shared care to the heart failure nurse caseload where required

5.         In conjunction with local community heart failure specialist nurses, deliver education to GP’s and Practice Nurses in order to support primary care management of heart failure patients. This will include the education required for Practice Nurse heart failure uptitration clinics.

6.         Establish links with educational providers (e.g. University and School of Nursing and Midwifery), providing maximum learning opportunities in this field. By doing so facilitate the planning and delivery of educational programmes (both practical and theoretical) to healthcare professionals relating to specialist area.

Patient Care Delivery

1.         To work as an autonomous practitioner, liaising with all members of the multidisciplinary team in order to provide clinical expertise, emotional and psychological support and education to heart failure patients and their carers. These patients are at high risk of complications, deterioration, hospital admission, disease progression and death.

2.         Provides specialist care to inpatients, outpatients, ambulatory care and virtual ward patients as per local service development.

3.         Receive referrals of patients who require heart failure nurse specialist input. Manage this caseload in hospital bringing those requiring specialist heart failure management for discussion at the MDT and for review on the heart failure ward round.

4.         Provide heart failure education, discharge advice and appropriate onward referral for heart failure nurse care, or follow up in the nurse-led clinic.

5.         Lead on the organisation of the Heart Failure MDT and Heart Failure ward round.

6.         Participate in the heart failure ward round, identifying patients for review and providing specialist nurse input.

7.         Provide specialist heart failure advice across the RSCH site

8.         Develop effective relationships and team working with community heart failure specialist nurses in order to deliver a smooth patient pathway of admissions avoidance / reduction in length of hospital stay / readmission prevention.

9.         Contribute to end of life care, referring to Palliative Care as required.

10.      Provide telephone advice, education and triage (telemedicine) as appropriate for patients, carers and health care professionals who request help or support, to manage changes in a patient’s condition early in order to reduce the risk of unnecessary hospital admission.

11.      Use data from cardiac devices, such as congestion alerts, to support advanced clinical assessment and decision making.

12.      Use advanced specialist nursing skills (e.g. physical assessment) to independently  assess, plan, implement and evaluate care delivered to own caseload of patients within a nurse led clinic.

13.      Plan care, education, investigations and treatment of patients ensuring effective evaluation and review of the process. 

14.      Ensure full and accurate records of relevant information are documented in the patients' medical notes and communicated to the GP.

15.      Maintain a knowledge base that reflects contemporary issues and therefore be able to autonomously select and apply evidence-based treatment.

16.      Provide support to patients with other psychological and emotional challenges, referring them for psychological care as necessary.

17.      Assess, develop, implement and evaluate care which meets the needs of the individual patient, involving their carers or relatives.

18.      Participate in the expansion of nursing practice using local protocols and non-medical prescribing.

19.      Undertake an occasional home visit to support virtual ward specialist care where needed.

20.      Refer patients for cardiac rehabilitation as part of their holistic care, considering the use of virtual programmes.

21.      Act as professional lead and role model providing advice and support to all staff working in the field to promote best practice, including: medical students, nurses, and doctors in the out-patient and in-patient settings.

Learning and Development

1.         The post holder is accountable for their own practice and should take every reasonable opportunity to sustain and improve their knowledge and professional competence.

2.         Attend mandatory and statutory training as required.

3.         Attend relevant education, training and study days as required.

4.         Ensure that practice is in accordance with the NMC Code of Professional Conduct and other appropriate NMC and statutory guidelines.

5.         Maintain own professional development and identify ongoing learning needs in accordance with annual performance review and regular clinical supervision, thereby creating a personal development plan.

6.         Attend relevant educational activities, conferences and training programs to maintain an appropriate level of clinical expertise in line with the professional code of conduct.

Please see Job Description and Person Specification for full details.