Job Descriptions

Purpose of the Post

The purpose of this Clinical Nurse Specialist (General) post is to:

Deliver care in line with the five core concepts of the role set out
in the Framework for the Establishment of Clinical Nurse Specialist Posts, 4th edition,
National Council for the Professional Development of Nursing and Midwifery
(NCNM) 2008. The
concepts are:

• Clinical Focus

• Patient/Client Advocate

• Education and Training

• Audit and Research

• Consultant

The role of the Clinical Nurse Specialist, Older People Services is
to ensure that his/her knowledge and skills in gerontology are utilised
effectively and efficiently to facilitate and provision of an equitable and
quality client focused service that enhances the health status of that
population.

The post holder will have a pivotal role in meeting the
psychological, emotional and informational needs of patients with aged related
issues, their families and significant others

He/she will be a key member of the inter-disciplinary clinical team
responsible for the care of this patients group.

The CNS (Residential Care Facilities Older Persons Liaison) post is
part of a broader integrated care team where RCF outreach is supported. The CNS will contribute to the improvement of
the health care experience and outcomes of older people who are resident in
RCFs.

Caseload

Clinical Nurse Specialist (Older Persons General) will focus
initially on the patient group Older People

Work closely and clinically liaise with the Advanced Nurse
Practitioner.

The CNS (Residential Care Facilities Older Persons
Liaison) will work closely with the integrated care consultant geriatrician and
Integrated Care Team for Older people (ICTOP) to implement care pathways that
supports the needs of older people in Residential Care Facilities (Public &
Private). The role will work across acute hospital and RCFs with an outreach /
inreach function.

Details of Service/Background to the
post

The Galway/Roscommon/Mayo areas have unique service provision
challenges with many of our population living in rurally isolated and
geographically dispersed locations. The Saolta region has an older population
compared with the national average (15.4% versus 13.4%) and the Saolta group
has committed to working closely with their CHW community colleagues to change
the model of care for older people with less reliance on acute admissions. The
population of Galway aged over 65 will increase to almost 70,000 and the
population of Mayo to almost 33,488 by 2031. Those aged over 80 years will
double. The integrated care service for older people will serve a population of
322,602 (258,058 Galway City and County) and (130,507 Mayo) of which more than
15% are aged over 65 years.

In 2018 initial funding (ICPOP) supported the
development of an Ambulatory Hub (Day Hospital) in Moneen Primary Care Centre.
The hub provided comprehensive geriatric assessment to older patients referred
from the Emergency Department (HomeFirst) and from the Orthopaedic department
(IHFD). An integrated governance structure was established with stakeholders
from Acute (MUH) and Community Healthcare West (Social Care and Primary Care)
and a model of integrated working developed.

There also was the development of the pilot Galway Integrated Care
for Older Persons (GICOP) Programme. The initial pilot GICOP team was funded on
a temporary basis from the Slaintecare Integrated Fund. It also established a
governance structure which now underpins all development around integrated
specialist geriatric care comprising of stakeholders from the acute setting
(Saolta) and the community setting Community Healthcare West (CHW)
incorporating representation from the three counties/areas of Galway, Mayo and
Roscommon.Within the framework of the ICPOP,
opportunity now exists to operationalise integrated care In Mayo Galway and
Roscommon, Acute and Social Care. Spanning the acute and community services,
the integrated model includes many key elements including support for acute
frailty pathways, expedited assessment for frail older persons presenting to
ED, GP or AMAU through specialist ambulatory hub for older people and rapid
access to support ongoing care in the community including access to allocated
community rehabilitation beds. The model is in keeping with the shared vision
of the ICPOP. It aligns to the key principles of the National Integrated Care
Programme such that the service will be truly patient centric and integrated
with the community to support the older person in so far as is reasonably
possible in their own home and using supported community pathways to reduce
need for avoidable hospital care where appropriate.

This significant programme of reform is underway in Services for
Older Persons and Chronic Disease supported by the strategic direction set out
under Sláintecare, the Enhanced Community Care business case, HSE Corporate
Plan, National Service Plan (2021) and the National Clinical Programmes. The
Enhanced Community Care Reform Programme is focused on the transformation of
community care with an emphasis on establishing Community Health Networks and
Specialist Community Teams working within Ambulatory Community Hubs. These plan
and organise services for a defined population, enables integrated care to be
implemented and thus allows a shifting the focus away from acute hospitals
towards a new model of specialist care in the community. The redesign of services
allow new pathways to be developed between hospitals, community services,
primary care, health & wellbeing and voluntary sectors to develop new
networks of care for Older People and people with Chronic Disease

The investment in an Enhanced Community Care Model will be delivered
on a phased basis, with a view to national coverage being achieved within a 2
to 3 year period. Three priority areas have been identified as follows;

1. Structural
   reform with Community Health Networks (CHNs) becoming the basic building
   blocks for the organisation, management and delivery of community services
   across the country.


2. Creating
   specialist ambulatory care hubs within the community for the management of
   chronic disease and older people with complex needs.


3. Scaling
   Integrated Care for older people and chronic disease through the
   recruitment of specialist integrated care teams across the care pathway
   including Frailty at the Front Door Teams.

The Older Persons/Chronic Disease Service
Model sets out the end to end service architecture for the identification and
management of people living with chronic disease and frail older adults with
complex care needs.

The focus on an end-to-end pathway, includes specialist
care community hubs, that will act as a focal point for accelerating integrated
care by;

• Providing a point
  of access


• Acting as a team
  base


• Enabling services
  to be integrated


• Allowing care to be
  coordinated


• Acting as a focal
  point for older person/chronic disease services and their development

This is intended to;

• Case manage care at
  or near home


• Prevent admissions
  to acute hospitals where it is safe and appropriate to do so


• Support early
  discharge from acute or secondary inpatient care where admission is
  unavoidable.


• For patients who
  require admission, the emphasis is on minimising hospital stays and
  improving outcomes, with post discharge support for people in the
  community and in their own homes.

A shared local governance structure across Acute
hospital and CHO ensures the development of a fully integrated service and
end-to-end pathway.

The ECC Model is underpinned by a set of key principles
including:

• Eighty percent of
  services delivered in Primary Care are through the Community Healthcare
  Networks.


• Identifying and
  building health needs assessments at a Network level (approximate
  population of 50,000) based on a population health planning approach i.e.
  population stratification thereby ensuring the right people get the right
  service based on the complexity of their health care needs.


• Utilisation of a
  whole system approach to integrating care based on person centred
  community models, while promoting self-care in the community.


• Learning from and
  delivering services based on best practice models in the community and the
  extensive work of the integrated care clinical programmes particularly in
  Older Persons and Chronic Disease services


• Availability of a
  timely response to early presentations of identified conditions and the
  ability to manage appropriate levels of complexity related to it.


• Resources applied
  intensively in a targeted manner to a defined population, implementing
  best practice models of care to demonstrate the delivery of specific
  outcomes and sustainable services


• The need to
  frontload investment, coupled with reform to strengthen community
  services.


• The need to embed
  preventative approach into all services.

Principal Duties and Responsibilities

The post holder’s practice is based on the five core
concepts of Clinical Nurse Specialist (Older Persons General) role as defined
by the NCNM 4th edition (2008) in
order to fulfil the role. The concepts are:

• Clinical Focus

• Patient/Client Advocate

• Education and Training

• Audit and Research

• Consultant

Clinical
Focus

The Clinical Nurse Specialist, Older People Service,
will have a strong patient focus whereby the specialty defines itself as
nursing and subscribes to the overall purpose, functions and ethical standards
of nursing / midwifery. The clinical practice role may be divided into direct
and indirect care. Direct care comprises the assessment, planning, delivery and
evaluation of care to the patient, family and/or carer. Indirect care relates
to activities that influence and support the provision of direct care. Clinical Nurse Specialist, Older People Services
will:

Direct
Care

• Provide a specialist nursing
  service for patients with age related conditions who require support and
  treatment through the continuum of care


•  


• Undertake comprehensive patient assessment to include
  physical, psychological, social and spiritual elements of care using best
  evidence based practice in gerontology.


• Use the outcomes of patient assessment to develop and
  implement plans of care/case management in conjunction with the
  multi-disciplinary team (MDT) and the patient, family and/or carer as
  appropriate.


• Monitor and evaluate the patient’s response to
  treatment and amend the plan of care accordingly in conjunction with the
  MDT and patient, family and/or carer as appropriate.


• Make alterations in the management of patient’s
  condition in collaboration with the MDT and the patient in line with
  agreed pathways and policies, procedures, protocols and guidelines
  (PPPG’s).


• Accept appropriate referrals from MDT colleagues.


• Co-ordinate investigations, treatment therapies and
  patient follow-up.


• Communicate with patients, family and /or carer as
  appropriate, to assess patient’s needs and provide relevant support,
  information, education, advice and counselling as required.


• Where appropriate work collaboratively with MDT
  colleagues across Primary and Secondary Care to provide a seamless service
  delivery to the patient, family and/or carer as appropriate.


• Participate in medication reconciliation taking
  cognisance of poly-pharmacy and support medical and pharmacy staff with
  medication reviews and medication management.


• Identify and promote specific symptom management
  strategies as well as the identification of triggers which may cause
  exacerbation of symptoms. Provide patients with appropriate
  self-management strategies and escalation pathways.


• Manage nurse led clinics with MDT
  input.
  


• Identify health promotion priorities for the patient,
  family and/or carer and support patient self-care in line with best
  evidence. This will include the provision of educational and health
  promotion material which is comprehensive, easy to understand and meets
  patient’s needs.

Indirect Care

• Identify and agree appropriate referral pathways for
  patients with age related conditions.


• Participate in case review with MDT colleagues.


• Use a case management approach to patients with
  complex needs in collaboration with MDT in both Primary and Secondary Care
  as appropriate.


• Take a proactive role in the formulation and provision
  of evidence based PPPGs relating to Older Persons care.


• Take a lead role in ensuring the service for patients
  with age related condition is in line with best practice guidelines and
  the Safer Better Healthcare Standards (HIQA, 2012).

Patient/Client Advocate

• Communicate, negotiate and represent patient’s family
  and/or carer values and decisions in relation to their condition in
  collaboration with MDT colleagues in both Primary and Secondary
  Care as
  appropriate.


• Develop and support the concept of advocacy,
  particularly in relation to patient participation in decision making,
  thereby enabling informed choice of treatment options


• Respect and maintain the privacy, dignity and
  confidentiality of the patient, family and/or carer.


• Establish, maintain and improve procedures for
  collaboration and cooperation between Acute Services,
  Primary Care, Residential Facilitiesand Voluntary Organisations as appropriate.


• Proactively challenge any interaction which fails to
  deliver a quality service to patients.

Education & Training:

The Clinical Nurse Specialist, Older People Services will:

• Maintain clinical competence in patient management
  within Older Persons Nursing, keeping up-to-date with relevant research to
  ensure the implementation of evidence based practice.


• Provide the patient, family and/or carer with
  appropriate information and other supportive interventions to increase
  their knowledge, skill and confidence in managing their condition.


• Contribute to the design,
  development and implementation of education programmes and resources for
  the patient, family and/or carer in relation to Older Persons care thus
  empowering them to self-manage their condition.


• Provide mentorship and preceptorship for Nursing
  colleagues as appropriate.


• Participate in training programmes for Nursing, MDT
  colleagues and key stakeholders as appropriate.


• Create exchange of learning
  opportunities within the MDT in relation to evidence based care delivery
  through journal clubs, conferences etc.


• Develop and maintain links with Regional Centres for
  Nursing & Midwifery Education (RCNMEs), the Nursing and Midwifery
  Planning and Development Units (NMPDUs) and relevant third level Higher
  Education Institutes (HEIs) in the design, development and delivery of
  educational programmes in gerontology care.


• Be responsible for addressing own continuing
  professional development needs

Eligibility Criteria

Qualifications and/ or experience

Candidates must have at the latest
date of application: -

1. Statutory
   Registration, Professional Qualifications, Experience, etc

(a)

i)   Be a registered nurse on
the active Register of Nurses or Midwives held     by An    
Bord Altranais agus Cnáimhseachais na hÉireann (Nursing and Midwifery
Board     of     Ireland) or be eligible to be so
registered.

And

ii)   Be registered in the
General division of the register of Nurses and Midwives.

Skills, competencies and/or knowledge

Professional
Knowledge

The Clinical Nurse Specialist will:

• Practice in accordance with
  relevant legislation and with regard to The Scope of Nursing &
  Midwifery Practice Framework (Nursing and Midwifery Board of Ireland,
  2015) and the Code of Professional Conduct and Ethics for Registered
  Nurses and Registered Midwives (Nursing and Midwifery Board of Ireland,
  2014).

• Maintain a high standard of
  professional behaviour and be professionally accountable for
  actions/omissions. Take measures to develop and maintain the competences
  required for professional practice.

• Adhere to the Nursing &
  Midwifery values of Care, Compassion and Commitment (DoH, 2016).

• Adhere to national, regional
  and local HSE PPPGs.

• Adhere to relevant legislation
  and regulation.

• Adhere to appropriate lines of
  authority within the nurse/midwife management structure.

Clinical Nurse Specialist (Older
Person General) will Demonstrate:

• An in-depth knowledge of the
  role of the Clinical Nurse Specialist (Older Person General).

• In-depth knowledge of the
  pathophysiology of Older Persons/ Gerontology.

• The ability to undertake a
  comprehensive assessment of the patient with (frailty) including taking an
  accurate history of their condition and presenting problem.

• The ability to employ
  appropriate diagnostic interventions and quality of life scales to support
  clinical decision making to support clinical decision making and the
  patients’ self- management planning.

• The ability to formulate a plan
  of care based on findings and evidence-based standards of care and
  practice guidelines.

• The ability to follow up and
  evaluate a plan of care.

• Knowledge of health promotion
  principles / coaching / self-management strategies that will enable people
  to take greater control over decisions and actions that affect their
  health and wellbeing.

• An understanding of the
  principles of clinical governance and risk management as they apply
  directly to the Clinical Nurse Specialist role and the wider health
  service.

• Evidence of teaching in the
  clinical area.

• A working knowledge of audit
  and research processes.

• Evidence of computer skills
  including use of Microsoft Word, Excel, Email, PowerPoint

The
CNS. Residential Care Facilities Older Persons Liaison will demonstrate:

• In-depth knowledge of the role of the CNS. Residential Care
  Facilities Older Persons Liaison.


• In-depth knowledge of the pathophysiology of ageing.


• The ability to undertake a comprehensive geriatric assessment of
  the resident, including taking an accurate history of their condition and
  presenting problem.


• The ability to employ appropriate diagnostic interventions
  including the use of validated assessment tools e.g. frailty, delirium,
  cognition) to support clinical decision making and the residents’
  integrated care plan.


• The ability to formulate an integrated care plan based on findings
  and evidence based standards of care and practice guidelines.


• The ability to follow up and evaluate the agreed integrated care
  plan.


• Knowledge of health promotion principles/coaching/self-management
  strategies that will enable people to take greater control over decisions
  and actions that affect their health and wellbeing.


• An understanding of the principles of clinical governance and risk
  management as they apply directly to the CNS. role and the wider health
  service.


• Evidence of teaching in the clinical area.


• A working knowledge of audit and research processes.


• Evidence of computer skills including use of Microsoft Word,
  Excel, E-mail, PowerPoint.


• Engage with telehealth and communication platforms for delivery of
  patient care.

Communication
and Interpersonal Skills.

Demonstrate:

• Effective communication skills.

• Ability to build and maintain relationships particularly in the
context of MDT working.

• Ability to present information in a clear and concise manner.

• Ability to manage groups through the learning process.

• Ability to provide constructive feedback to encourage future
learning.

• Effective presentation skills.

Organisation
and Management Skills:

Demonstrate:

• Evidence of effective
  organisational skills including awareness of appropriate resource
  management.

• Ability to attain designated
  targets, manage deadlines and multiple tasks.

• Ability to be self-directed,
  work on own initiative.

• A willingness to be flexible in
  response to changing local/organisational requirements.

Building
& Maintaining Relationships including Team and Leadership skills

Demonstrate:

• Leadership, change management
  and team management skills including the ability to work with MDT
  colleagues.

Commitment
to providing a quality service:

Demonstrate:

• Awareness and respect for the
  patient’s views in relation to their care.

• Evidence of providing quality
  improvement programmes.

• Evidence of conducting audit.

• Evidence of motivation by
  ongoing professional development.

Analysing
and Decision Making

Demonstrate:

Effective analytical, problem solving and decision-making skills.

Skills

Experience

• 1 year