Registered Nurse System Navigator - Queens University

Within the Department of Family Medicine, the Queen’s Family Health Team (QFHT), Belleville site provides primary health services to rostered patients while modeling safe, efficient and collaborative clinical processes to the Family Medicine residents in the Belleville/Quinte site. Reporting to the Program Manager, the incumbent is responsible for establishing patient and education services and programs as a member of the interdisciplinary health team, and in accordance with the accepted clinical practice guidelines of the College of Nurses of Ontario (CNO).

Reporting to the Program Manager, the incumbent will work collaboratively with the Belleville family physicians and other members of the health care team to provide nursing care and to support the training of medical residents and other learners. The Registered Nurse (RN) plans, develops, implements and evaluates programs and services and performs clinical skills where appropriate. The incumbent will also engage in medically/socially complex patients by identifying socio-economic barriers, improving the patient/family experience in navigating the system and supporting patients/families to receive their care at home.

To view the full job description, please visit our Careers page. 

KEY RESPONSIBILITIES:

• Provide direct and indirect chronic disease care, health promotion, screening and disease prevention care and education to patients. Make clinical decisions and exercises judgement about the care provided to patients.
• Complete individual patient assessments, identify and address the patients’ needs.
• Provide teaching to patients. Evaluate patient comprehension and compliance to a care plan. Involve patients in decisions about their own health, identify barriers to better health and planning ways to overcome barriers.
• Develop and deliver educational sessions to patient and family groups.
• Document patient health history, assessments, interventions and plans in the electronic medical record.
• Collaborate with other health care providers in the planning, development and evaluation of programs and services, such as chronic disease self-management programs. Contributes to quality improvement projects.
• Conduct patient assessments and counselling; including social assessment of context of the health problem (e.g. housing, financial, family crises).
• Conduct home visits and community outreach visits when appropriate.
• Maintain confidentiality in all aspects of patient, staff and organization information.
• Collaborate with physicians, residents and allied health professionals.
• Contribute to the education of family medicine residents and other interdisciplinary learners regarding the role of the Registered Nurse System Navigator.
• Maintain and develop professional competence through ongoing professional development.
• Prepare program reports and promote awareness of clinical programs as required.
• Support the delivery of coordinated care for the highest users of the health system accordingly to a defined definition.
• Main point of contact for the patient/family in navigating the health system.
• Integrate system thinking/planning between transition points in care with the goal of a seamless patient experience.
• Undertake other duties and/or special projects as assigned in support of the unit.

REQUIRED QUALIFICATIONS:

• Baccalaureate Degree in Nursing from a recognized University or equivalent.
• Current RN Registration with the CNO with a entitled to practice with no restrictions status.
• Minimum of five (5) years’ experience preferably in a community and/or primary care setting.
• BCLS Certificate.
• Teaching experience will be considered an asset.
• Valid Province of Ontario Class G driver’s license and access to reliable vehicle required.
• Satisfactory Criminal Records Check and Vulnerable Sector Screening required.
• Consideration may be given to an equivalent combination of education and experience.

SPECIAL SKILLS:

• Knowledge and proficiency in current, evidenced-based methods and practices of primary care nursing services.
• Proficient in the use of computer/technology (Word, Outlook, internet) including prior experience and knowledge of electronic medical records.
• Excellent verbal and written communication and interpersonal skills.
• In depth knowledge of the local health service delivery and community based services.
• Leadership skills.
• Ability to work both independently and effectively in an interdisciplinary team environment.
• Ability to prioritize, manage time effectively and be flexible in a busy clinic environment.
• Ability to be flexible and creative to develop strategies to meet the needs of a diverse patient, family and provider population.
• Knowledge of relevant legislative requirements, eg. Children’s Aid, Privacy.

DECISION MAKING

Make decisions regularly regarding patient care within the legal scope of practice of the
profession, including but not limited to:

• Provide wellness care, including developing and monitoring treatment/care plans, utilize screening and assessment tools.
• Provide individual and group counseling, support and education services.
• Monitor patients with stable chronic disease conditions, such as hypertension.
• Determine effective strategies for providing services, educational programs and support to patients, families, family medicine residents and students.
• Conduct social assessment of patients; determines needs required to resolve social issues.
• Provide services to patients deciding on a treatment/care plan. Determines services available to connect patients to the appropriate community services and programs.
• Make decisions and communicates with appropriate health team members to ensure a smooth transition of patient care between hospital and community resource.

Please apply online at:
https://clients.njoyn.com/CL4/xweb/xweb.asp?clid=74827&page=jobdetails&jobid=J1025-0288&BRID=EX429156&SBDID=21474&LANG=1.