UNVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

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1 COR JOB SCRPTON Title: irectorate: Board/corporate function: Senior ischarge Nurse Queen Square Specialist Band: 7 Responsible to: ccountable to: Hours: Location: Matron Chief Nurse 37.5 per week UCH UNVRSTY COLLG LONON HOSPTLS NHS FOUNTON TRUST University College London Hospitals NHS Foundation Trust (UCLH), situated in the West nd of London, is one of the largest NHS trusts in the United Kingdom and provides first class acute and specialist services both locally and to patients from throughout the UK and abroad. The new state-of-the-art University College Hospital which opened in 2005, is the focal point of the Trust alongside six cutting-edge specialist hospitals. UCLH was one of the first trusts to gain foundation status. The Trust has an international reputation and a tradition of innovation. Our excellence in research and development was recognised in ecember 2006 when it was announced that, in partnership with University College London (UCL), we would be one of the country s five comprehensive biomedical research centres. longside our relationship with the world leading UCL and Royal Free medical school, we enjoy close links with London South Bank and City universities offering the very best in training and education. CLNCL BOR We are dedicated to the diagnosis and treatment of many complex illnesses. UCLH specialises in women s health and the treatment of cancer, cardiac, infection, neurological, gastrointestinal and oral disease. t has world class support services including critical care, imaging, nuclear medicine and pathology. VSON Core J/PS Band 7 ntegrated care nurse 1

2 The Queen Square ivision comprises of the National Hospital for Neurology and Neurosurgery (NHNN) and the Royal London Hospital for ntegrated Medicine (RLHM) and is the largest division within the Specialist Hospitals Board. The NHNN is an internationally renowned hospital for clinical practice and world-class clinical research in neurosciences. t is also closely associated with the nstitute of Neurology (ON). Together, NHNN and ON are regarded as the premier neurosciences centre in the UK. n addition to Neurology and Neurosurgery, the NHNN provides comprehensive services in Neuro-rehabilitation, Neuro- Critical Care and Neuro-Psychiatry. The NHNN receives secondary, tertiary and quaternary referrals from across the UK and internationally. JOB PURPOS The ischarge nurse will play an integral role in the reduction of Length of Stay and the management and facilitation of complex discharges within Queen Square The post will specialise in the care of people admitted with Neurological, Neurosurgical and Stoke diagnosis and will demonstrate a high level of expertise in this specialty. The post holder will actively contribute to the Length of Stay strategy across the Trust and will play a key role in delivering the single point of access and the discharge care bundle within their speciality area. This post will be responsible for reducing Length of stay and developing integrated care pathways with the ntegrated Care Nurse for QS. The objectives for this position will be set on the basis of 30% specialty specific and 70% corporate objectives. The ischarge nurse for will: dentify patients who can go home earlier (supported by the hospital at home team) Lead on delivering the discharge care bundle to all patients within their specialty nsure safe and adequate discharge of patients in conjunction with the therapy team Lead on ensuring all patients prepared pre discharge as part of the discharge care bundle The post holder will be the key-worker / key-contact for targeted patient groups and will work along side therapy and social care teams. Work in a collaborative approach with the multidisciplinary team to provide a comprehensive patient focused service. Lead on delivering appropriate CQUNs within their specialty area Work as a key member of the Trust wide Readmission Prevention and ischarge Team. Lead on ensuring appropriate outcome data is collected to measure the effectiveness of discharge planning work. ncluding ToC submissions The ischarge nurse will lead on proactively identifying patients who will have complex discharge prior to admission to hospital and will develop, coordinate and manage care both within the Trust and in the community to prevent elayed Transfer of Care. The post-holder is also expected to facilitate the development of other nurses in order to benefit patient care and to be an educational resource to all members of the trust wide multidisciplinary MT regarding practice in the provision of care. Nurses working at an advanced level will: 1. Practice autonomously and be self-directed Core J/PS Band 7 ntegrated care nurse 2

3 2. Undertake assessment of individuals using a range of different assessment methods, which may include physical examination, ordering and interpreting diagnostic tests or advanced health needs assessment 3. raw on a diverse range of knowledge in their decision-making to determine evidence-based therapeutic interventions 4. ctively seek and participate in peer review of their own practice 5. ppropriately define the boundaries of their practice 6. Promote and participate in the implementation of the UCLH Nursing & Midwifery strategy MNSONS The role will provide nurse specialist support to the readmission prevention programme and the integrated care strategy within Neurosciences and across the Trust. Key working relationships with all members of the multi-professional team, including nursing and medical staff, allied health professionals and support workers. This post will have close links and work collaboratively with the integrated discharge team (hospital at home, homeless team, alcohol and drugs team, discharge team, rapid response and rapid discharge team) within the Trust. SPCLTY Responsible for the nursing management of targeted patient groups prone to readmission, also responsible to provide an expert specialist nursing service for people with specialist needs. To be responsible that the discharge care bundle is implemented across their ward/speciality To develop and manage hot clinics as appropriate/required Participate in the integrated on call rota to provide out of hours advice to patients (not necessarily from specialist area) and to support the single point of access To develop patient owned care plans and contingency plans for patients To lead the management and provision of telephone nurse led clinics for elective and emergency discharges To support the single point of access and to be the key-worker / key-contact for targeted patient groups Lead in the development, implementation and evaluation of integrated care pathways, patient information and systems of multidisciplinary documentation. To provide expert nursing advice and support to patients, their families and other healthcare professionals. To ensure continuity of a high standard of evidence based nursing care, assessing health, health related and nursing needs of patients, their families and other carers by identifying and initiating appropriate steps for effective care. To be actively involved with in-patient care, liaising with ward staff to ensure high quality nursing care Core J/PS Band 7 ntegrated care nurse 3

4 To work as part of a team to provide a seamless service through the development of enhanced Multidisciplinary team (MT) processes and communication To ensure all care is given in accordance with agreed protocols. To work in close collaboration with primary care, local community, social services, paramedics and voluntary organisations. Liaise with social services, community teams, mental health services and GPs to ensure smooth and co-ordinated pathway home/interim/intermediate care Utilise and develop communication links between primary and secondary care to ensure continuity of patient care and safe transfer. Lead on implementing appropriate CQUNs within their specialty area Promote the uptake of community services, in particular ntermediate care services to enable patients to be supported/rehabilitated safely in their own home/community facility for as long as possible. nsure ischarge summary is sent with the patient and sent to the GP CONTONS OF SRVC: Hours: 37.5 hours per week (adapted to meet the needs of the service) Shifts: TBC KY RSULT RS CLNCL PRCTC Monitor and maintain health, safety and security of self and others in own work area through ensuring own and others knowledge of relevant local / national policies and procedures, and that these are adhered to Work according to the NMC Code of Professional Conduct and relevant professional standards and guidelines ct as a role model in promoting peoples equality, diversity and rights through ensuring that own and others practice is the best interests of users Receive direct referrals within the speciality and to provide expert assessment of patients needs Work in partnership with nurses and other health professionals to address people s health needs through planning and delivering interventions which are based on best practice and clinical judgement elegate and refer to other practitioners when this will improve health outcomes or when risks and needs are beyond own competence and scope of practice Support patients in the delivery of care and meeting their health and wellbeing needs by providing expert advice and information, promoting their wishes and beliefs and addressing their concerns Core J/PS Band 7 ntegrated care nurse 4

5 Promote peoples equity, diversity and rights, through ensuring that own and others practice is in the best interests of patients Monitor and review the effectiveness of interventions with the patient and colleagues and modify this to meet changing needs and established goals of care. UCTON/RSRCH dentify objectives for own professional development which reflect local and national service needs, including the CNO 10 key roles ct as a resource to others in developing and improving knowledge and skills in clinical practice, through acting as an assessor, teacher and facilitator Contribute to the development of practice knowledge within the speciality through internal and external presentation and publication. Promote a learning environment through identifying opportunities and seeking resources required for own and others learning Provide specialist input to post-registration courses and professional development programmes. Reflect on own practice through clinical supervision / mentorship and to act as a clinical supervisor / mentor to others Maintain own and others awareness of relevant research evidence related to the speciality and work with others in applying this to practice. dentify areas of potential research relating to the speciality and to participate in relevant research activities evelop evidence based standards, policies and guidelines at a local, network and national level to improve the practice of own and other professions valuate clinical effectiveness within the speciality, identifying poor quality and a plan for quality improvement Support quality improvement through offering advice and support to others Take part in reflection and appropriate learning from practice, in order to maintain and develop competence and performance CONSULTNCY/COLLBORTON evelop and maintain others awareness of role within the speciality, the organisation and local networks and maintain mechanisms for contact and referral Review and evaluate services collaboratively with own and other professions and users, identifying areas for service development Facilitate service changes collaboratively with the multi-disciplinary team to make best use of resources, improve practice and health outcomes in line with local and national best practice. Core J/PS Band 7 ntegrated care nurse 5

6 Promote and facilitate the implementation of the UCLH Nursing and Midwifery strategy, Core Standards and UCLH top 10 objectives Lead in the implementation of national policy and practice initiatives and to implement these at a local level within the speciality Provide expert advice and support to colleagues internally and externally within speciality nsure that appropriate information is disseminated within the speciality, the organisation and within external agencies and forums. evelop and maintain partnership working with other practitioners, local and national bodies and forums dentify, develop and sustain mechanisms to support patient involvement and feedback. LRSHP Participate in developing a shared vision of the service and work with the multidisciplinary team, organisation and external agencies to achieve this Negotiate and agree with individuals, groups and other practitioners outcomes, roles and responsibilities, and action to be taken to develop resources, services and facilities Maintain appropriate channels and styles of communication to meet the needs of patients, relatives and carers, managers, peers and other professions / agencies. mploy effective decision making skills to address complex issues and use effective change management skills to implement these Use effective prioritisation, problem solving and delegation skills to manage time effectively stablish networks with other specialists at a local, national and international level, to exchange and enhance knowledge and expertise. Maintain a peer network of support, information and learning with other nurse specialists within the organisation General dhere to the UCLH Service Commitment "Putting Patients First" and adopt a professional approach to customer care at all times Comply with the Trust s qual Opportunities Policy and treat staff, patients, colleagues and potential employees with dignity and respect at all times Take personal responsibility for promoting a safe environment and safe patient care by identifying areas of risk and following the ncident, Serious ncidents and Near Misses reporting policy and procedure Take personal responsibility for ensuring that UCLH resources are used efficiently and with minimum wastage, and to comply with the Trust's Standing Financial nstructions (SFs) Core J/PS Band 7 ntegrated care nurse 6

7 Comply with Trust policies for personal and patient safety and for prevention of healthcare-associated infection (HC); this includes a requirement for rigorous and consistent compliance with Trust policies for hand hygiene, use of personal protective equipment and safe disposal of sharps n accordance with the Trust's responsibilities under the Civil Contingencies ct 2004 to undertake work and alternative duties as reasonably directed at variable locations in the event of and for the duration of a significant internal incident, major incident or pandemic Be aware of and adhere to all Trust policies and procedures, the Health and Safety at Work ct and the ata Protection ct Maintain confidentiality at all times Other These guidelines are provided to assist in the performance of the contract but are not a condition of the contract. The job description is not intended to be exhaustive and it is likely that duties may be altered from time to time in the light of changing circumstances and after consultation with the post-holder. ll staff will be regularly assessed on their knowledge, skills and behaviour, and application of all aspects of the job description, in line with the Trust s Personal evelopment Review (PR) process. Staff will also be expected to work according to the Nursing and Midwifery Council and code of professional practice and relevant professional guidelines. Core J/PS Band 7 ntegrated care nurse 7

8 KSF Outline for Band 7 Nurse: ischarge nurse (Levels 1 & 2) KSF imension, Level and ndicator imen - sion Numb er imension Foundation Gateway ( Subset Outline) Second Gateway ( Full Outline) Level ndicators Level ndicators Core imension Specific imension 1 Communication 4 ll 4 ll 2 Personal and People evelopment 3 ll 4 ll 3 Health, Safety and Security 3 ll 4 ll 4 Service mprovement 2 ll 3 ll 5 Quality 3 ll 3 ll 6 quality and iversity 3 ll 3 ll HLTH N WLLBNG HWB1 Promotion of health and wellbeing and 2 ll 3 ll prevention of adverse effects to health and wellbeing HWB5 Provision of care to meet health and 4 ll 4 ll wellbeing needs HWB6 ssessment and treatment planning 3 ll 4 ll NFORMTON N KNOWLG K2 nformation collection and analysis 2 ll 3 ll GNRL G1 Learning and development 3 ll 3 ll July 2008 Core J/PS Band 7 ntegrated care nurse 8

9 Person Specification Post: ischarge nurse Band 7 (Higher Level Practice 1&2) Candidate s Name: * Subset Outline (SO) Higher Level Practice 1 (HLP1) Full Outline - (FO) Higher Level Practice 2 (HLP2) *ssential / esirable / HOW WLL CRTR B SSSS? ()PPLCTON / (T) TST / () NTRVW / (R) RFRNCS RQURMNTS * / How assess ed Me t Not Met VNC TO SUPPORT SSSSMNT 1. Qualifications/xperience a. Registered Nurse b. Relevant post-registration programme c. Teaching/ssessment programme d. Completed/completing Masters egree (HLP2) (FO) e. relevant post registration experience in same specialty (HLP1), (SO) f. Honours egree in Nursing, midwifery, research or ethics (HLP1), (SO) g. Leadership development programme (HLP2) h. Management development programme (HLP2) 2. Clinical Practice a. emonstrates up to date knowledge and expertise in the specialty b. vidence of developing & leading nurse led clinics / services (HLP2) c. vidence of ability to work collaboratively (HLP1) / autonomously (HLP2) d. Knowledge of key professional issues and NMC guidelines relating to professional practice / / 3. ducation / Research a. vidence of continuing professional development b. Previous experience of formal & informal teaching of patients & staff. c. xperience of applying research evidence to clinical practice d. Skills in critical analysis and application of research to practice (HLP2) e. Previous experience of developing standards, guidelines and policies / / / / Core J/PS Band 7 ischarge nurse ecember

10 f. Previous experience in audit and evaluation of practice / services g. xperience in acting as a clinical supervisor and mentor h. Published articles / poster presentations 4. Consultancy / collaboration a. Commitment to ongoing implementation of the Trust nursing & midwifery strategy, Core Standards, CNO 10 key roles and relevant NSF s. b. emonstrates commitment to multidisciplinary working c. ble to work across organisational and professional boundaries d. ble to negotiate effectively with different disciplines (HLP2) e. Understanding of relevant national strategy / policy and how this relates to the service 5. Leadership a. emonstrates a clear vision of the role and service. b. ecision making skills c. ble to resolve complex problems (HLP2) d. ble to initiate, sustain and evaluate change. e. ffective communicator, in writing, verbally & electronically f. Presentation skills g. Keyboard and word processing skills 6. Other Requirements a. Previous experience in budgetary management b. Commitment to maintaining own fitness for practice through maintaining a personal portfolio of competencies c. Understanding of appropriate health and safety legislation d. Understanding of equal opportunities e. Commitment to principles of best practice in Customer Care f. nnovative approach to service delivery g. bility to manage change h. xperience in developing service strategies 7. Specific requirements * Contents of this section must be Core J/PS Band 7 ischarge nurse ecember 2013 / / / / / / 10

11 approved by ivisional Senior Nurse Shortlist: Yes / No Reason: Signatures: Offer Post: Yes / No Reason: Signatures: Core J/PS Band 7 ischarge nurse ecember