Practice Nurse with Chronic Disease Management

Assess, plan, implement and evaluate treatment

programmes and individual care plans, including for patients with, or at risk

of developing, a long-term condition

Work with other health professionals to diagnose,

monitor and manage long-term conditions in line with national and local

guidance

Prioritise and respond to urgent or complex

presentations, including initiating emergency care where needed

Support patients to adopt health-promoting behaviours

and self-care strategies

Deliver vaccination and immunisation programmes for

adults and children

Provide core general practice nursing procedures,

including wound care, cervical screening, contraception advice, travel health

and phlebotomy

Job Description: Practice Nurse and Chronic Disease Management

Post: Practice Nurse,

General Practice and Chronic Disease Management

Accountable to: Lead

Nurse, and ultimately the Watlington Leadership Team

Purpose: To deliver

high-quality general practice nursing to our whole practice population, with a

particular focus on the proactive management of chronic diseases such as

diabetes, COPD, asthma and cardiovascular disease, alongside preventative

health.

The post holder delivers the

full range of general practice nursing, from acute presentations and health

promotion to the structured, evidence-based management of patients living with

chronic diseases, including diabetes, COPD, asthma, hypertension and coronary

heart disease. As an autonomous practitioner, they are responsible for the care

they deliver and are expected to demonstrate sound clinical decision-making,

including in running dedicated chronic disease clinics and reviews. They work

collaboratively within the wider practice team to meet patient needs and

support the delivery of our policies and procedures.

Clinical Practice

Assess, plan, implement and evaluate treatment

programmes and individual care plans, including for patients with, or at risk

of developing, a long-term condition

Work with other health professionals to diagnose,

monitor and manage long-term conditions in line with national and local

guidance

Prioritise and respond to urgent or complex

presentations, including initiating emergency care where needed

Support patients to adopt health-promoting behaviours

and self-care strategies

Deliver vaccination and immunisation programmes for

adults and children

Provide core general practice nursing procedures,

including wound care, cervical screening, contraception advice, travel health

and phlebotomy

Long-Term Condition and

Chronic Disease Management

Run structured clinics and annual reviews for patients

with chronic diseases, such as diabetes, COPD, asthma, hypertension, coronary

heart disease and chronic kidney disease, in line with NICE guidance and local

care pathways

Develop and agree personalised care plans and

self-management goals with patients, reviewing and adjusting these as their

condition changes

Initiate, titrate and review medicines for long-term

conditions within your competence and any Patient Group Directions or Patient

Specific Directions, referring to a prescriber where needed

Support patients to self-manage their condition,

including use of home monitoring equipment, action plans and lifestyle change

Maintain accurate long-term condition registers and

contribute to the practice's performance against QOF and other quality

frameworks

Recognise signs of deteriorating or poorly controlled

chronic disease and escalate promptly to a GP, the wider multidisciplinary team

or secondary care as appropriate

Health, Safety and

Infection Control

Follow and promote infection control procedures,

including hand hygiene, specimen handling, waste segregation, decontamination

and management of sharps or spillage incidents

Apply the principles of the cold chain and ensure safe

storage, rotation and disposal of vaccines and medicines

Maintain awareness of first aid and resuscitation

procedures, and act on them as needed

Follow workplace health and safety policies, including

fire procedures and safe use of equipment

Identify and manage risks from microbiological and

chemical hazards in the working environment (COSHH)

Communication

Communicate sensitively and effectively with patients

and carers, adapting your approach to different needs, backgrounds and levels

of understanding

Anticipate and address barriers to communication

Act as an advocate for patients and colleagues where

appropriate

Quality and Governance

Work within your competence and the NMC Code of

Professional Conduct

Keep accurate, timely patient records in line with

legislation and our policies

Deliver care in line with NICE guidance and the best

available evidence

Take part in audit, self and peer review, and quality

improvement activity, implementing changes where needed

Contribute to shared learning, and to the review of

complaints, incidents and near misses

Understand and apply safeguarding procedures for

vulnerable children and adults

Team Working

Understand your own role and how it may develop, and

work flexibly to support the wider team

Delegate safely and appropriately, and ensure clear

referral pathways are in place

Manage your own workload and time effectively

Equality and Diversity

Promote equality and diversity, and challenge discrimination

where you see it

Support patients in exercising their right to choose,

participate in, or decline care

Apply chaperoning policy and support patients from

marginalised groups to access quality care

Information Governance

Record patient information accurately and promptly,

using SNOMED CT codes correctly to support monitoring and audit

Maintain confidentiality of information about patients,

colleagues and the practice, and take appropriate precautions when sharing

information

Attribute

Essential

Registered

General Nurse, currently registered with the NMC

Educated

to a good general standard

We are a small,

friendly, semi-rural practice with 6,500 patients looking for a practice nurse with chronic disease management experience.

Experience