Geriatric Nurse Clinician

Detailed Overview

In accordance with the British Columbia College of Nurses and Midwives (BCCNM) standards of practice and the Mission and Values of Fraser Health, the Geriatric Nurse Clinician utilizes evidence-informed practice to provide consultation and clinical expertise related to care for the older adults. Role models direct care skills to staff and students, performs gerontological nursing assessments and ongoing evaluation of older adults with complex care needs, and provides information and education to staff and/or patients/families.

Participates in research, policy, quality improvement, and risk management activities. The Nurse Clinician perform in-reach and outreach services; home and community visits and may be required to work at multiple sites across Fraser Health. Responsibilities Demonstrates expertise and provides clinical leadership in evidence-informed practice; reviews literature, consults with experts, collaborates with members of the interprofessional team, evaluates clinical practice, recommends changes to existing standards to the Manager, and participates on regional and provincial committees related to care for older adults.

Role models direct patient care skills to staff and students related to older adults and provides just in time education at the point of care required to ensure optimal care Coaches, mentors and provides information utilizing clinical evidence, policy (e.g. clinical decision support tools), literature and resources, and education theory. Performs comprehensive gerontological nursing assessment to older adults who present with complex care needs;

intervenes as needed, and evaluates outcomes of these interventions. Collaborates with the interprofessional team to develop/support development of individualized care plans, ongoing evaluation of the care plan. Discusses clinical findings with client/family, in collaboration with the interprofessional team to develop action plans and set goals directed at clinical needs, self-management, self-care and improved health related quality of life; accesses system information and resources to review client data such as medical history, progress notes, consultation reports, lab reports, and incorporates findings into the care plan;

plans, organizes and establishes priorities by using resources effectively and efficiently; responds to unanticipated events and/or changing client or service assignment needs, as needed. May provide in-reach support to acute care teams with appropriate and timely discharge and/or transfer of patients home or to alternate care settings Arranges rapid referral to Geriatricians, and the coordination of referrals and linkages to appropriate community resources including Older Adult programs such as the Specialized Seniors Clinics.

Provides health counseling to clients/families including education, self-management, self-monitoring and wellness/health promotion/prevention through a combination of clinic, telephone or home visits; collaborates with the other healthcare professionals in the clinics, community programs and services to facilitate the follow of information through a variety of settings within the primary & community care network. Maintains clinical records such as intake screens, patient/client assessments, clinical interventions, treatment formulations, care plans and progress notes;

maintains statistical information on patient/client in accordance with established policies, standards, and procedures. Determines education requirements that meet clinical and learner needs, in collaboration with the Manager/Director/Clinical Nurse Educator/Clinical Nurse Specialist; completes learning needs assessments of individuals or groups to assist in the determination of the learning requirements and their objectives. Arranges and/or provides preceptorships and mentorships for staff and students regarding older adult health care, as appropriate.

Develops and revises education tools/plans on the basis of identified learner needs, chart audits, patient outcomes, and introduction of new/revised clinical decision support tools or scope(s) of practice/roles/functions. Plans and schedules education activities and maintains a system for tracking attendance; maintains related statistics. Delivers learner-centered education to individuals or groups of staff and patient/families through methods such as coaching, conducting presentations, facilitating groups, and providing lectures.

Evaluates effectiveness of education programs and consultations to ensure older adult care/learning needs are met and to determine opportunities for improvement; maintains related reports. Collaborates with other practice leaders to provide leadership, consultation and performance support to clinical staff, employed student nurses and students to assess, plan, implement and evaluate care. Supports staff to plan and carry out patient/family education about discharge planning, illness prevention and health promotion.

Participates in…