POSITION SUMMARY
The attending NP works with residents, family/caregivers, and the health care team in the development, implementation and evaluation of the resident's plan of care; provides leadership and mentorship to the Home's staff to enhance their knowledge, assessment skills and ability to care for residents in place; and leads and collaborates in research, education and evidence-based practice initiatives to optimize resident, Home and health system outcomes.
MAJOR RESPONSIBILITIES
Provide comprehensive primary care to residents (including Substitute Decision-Makers (SDMs) as appropriate) as part of the multidisciplinary health care team.
Increase the continuity of care through collaboration, consultation and referral as appropriate:
Collaborate and consult with attending physicians, the DOC, nursing department staff, multidisciplinary team members and external resources regarding resident plan of care
Assist, support, guide and provide consultation to the DOC, registered nursing staff and multidisciplinary team members regarding challenging clinical situations
Make referrals to specialized consultants, services and other health providers
Accept referrals from multidisciplinary team members.
Perform a person-centred health assessment of residents on admission, annually, and as needed (including quarterly medication reviews).
Conduct person-centred comprehensive health histories.
Engage in regular dialogue with the resident about their care plan.
Participate in resident care conferences.
Order or perform appropriate screening and diagnostic investigations, interpret results, and provide follow-up care.
Diagnose acute and chronic health conditions.
Manage the care of residents by providing pharmacological, complementary or counselling interventions, and perform procedures within the NP scope of practice.
Advocate for and provide palliative and end-of-life care.
Document clinical data, assessment findings, diagnoses, plans of care, therapeutic interventions, resident responses and clinical rationale in a timely and accurate manner.
Utilize communication and counselling skills to engage residents in dialogue to determine what is important to them for health and quality of life, and to provide person-focused health education.
Collaborate with the resident to develop a person-centred plan of care.
Provide outreach and transitional services to residents who return to the community.
Liaise with discharge planning services for hospitalized residents to ensure a smooth transition back to the Home.
Participate in providing after hours and on-call coverage in accordance with the Home's on-call policy.
Identify, develop and implement practice innovations in collaboration with the Home's senior leadership team.
Provide leadership and involve the multidisciplinary team in quality improvement initiatives.
Provide leadership in developing and implementing strategies to optimize the integration of illness and injury prevention, health promotion, health maintenance, rehabilitation and restorative care activities.
Provide formal and informal teaching and coaching in the management of clinical care to multidisciplinary team members, serving as a resource person, educator and role model, and contributing to the performance appraisals of registered nursing staff.
Identify and implement research-based innovations for improving resident care.
Collaborate with members of the multidisciplinary team or community to identify research opportunities and to conduct or support research.
QUALIFICATIONS
Current College of Nurses of Ontario registration in the Extended Class (EC) as an NP (adult) or NP (primary health care) required.
Master's Degree in Nursing/Nurse Practitioner (MN-NP) or Masters of Science in Nursing with successful completion of a post Master's Nurse Practitioner Diploma from a recognized school of graduate studies required.
Minimum 2 years of relevant experience in either home/community care, acute care, chronic disease management, health promotion, palliative care or mental health.
The ability to work independently in an autonomous and self-directed manner within the NP scope of practice.
Demonstrated clinical leadership experience to manage complex patient and family needs in complex settings with need to liaise with multidisciplinary team and primary care providers.
Critical thinking, problem solving and analytical skills to navigate challenging situations.
Ability to be flexible and adaptable with excellent organizational skills.
Excellent interpersonal and communication skills.
Ability to work in a team environment.
Vulnerable sector check (current).
Post-graduate education and experience in gerontology is an asset.
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