L Clinical Nurse Specialist Diabetes Service

Purpose of the Post

The purpose of this Clinical Nurse Specialist (Diabetes) 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.

Caseload

Adults attending Galway University Hospitals with a diagnosis of Diabetes

Principal Duties and Responsibilities

The post holder’s practice is based on the five core concepts of the CNS 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

· Clinical Nurse Specialist (Diabetes) 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.

· 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.

Direct Care

The Clinical Nurse Specialist in Diabetes will:

· Provide a specialist nursing service for patients with a diagnosis of diabetes 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 diabetes care.

· 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 Multidisciplinary team 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

The Clinical Nurse Specialist in Diabetes will:

• Identify and agree appropriate referral pathways for patients with diabetes.
• 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 diabetic care.
• Take a lead role in ensuring the service for patients with diabetes is in line with best practice guidelines and the Safer Better Healthcare Standards (HIQA, 2012).

Patient/Client Advocate

The Clinical Nurse Specialist in Diabetes will:

• 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 and Voluntary Organisations as appropriate.
• Proactively challenge any interaction which fails to deliver a quality service to patients.

Education & Training:

The Clinical Nurse Specialist in Diabetes will:

• Maintain clinical competence in patient management within Diabetic 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 diabetes.
• Contribute to the design, development and implementation of education programmes and resources for the patient, family and/or carer in relation to diabetes 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 diabetic 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 diabetic care.
• Be responsible for addressing own continuing professional development needs

Audit & Research:

The Clinical Nurse Specialist in Diabetes will:

· Establish and maintain a register of patients with diabetes within Clinical Nurse Specialist Caseload.

· Maintain a record of clinically relevant data aligned to National Key Performance Indicators (KPl's) as directed and advised by the DON.

· Identify, initiate and conduct Nursing and MDT audit and research projects relevant to the area of practice.

· Identify, critically analyse, disseminate and integrate best evidence relating to diabetic care into practice.

· Contribute to nursing research on all aspects of diabetic care.

· Use the outcomes of audit to improve service provision.

· Contribute to service planning and budgetary processes through use of audit data and specialist knowledge.

· Monitor, access, utilise and disseminate current relevant research to advise and ensure the provision of informed evidence based practice.

Audit expected outcomes including:

· Collate data which will provide evidence of the effectiveness of Clinical Nurse Specialist (Diabetes) interventions undertaken 3 or 4 - Refer to the National Council for the Professional Development of Nursing and Nursing final report.

· Evaluation of Clinical Nurse and Midwife Specialist and Advanced Nurse and Midwife.

· Practitioner roles in Ireland (SCAPE Report, 2010) and refer to the National KPI’S associated with the speciality. They should have a clinical Nursing focus as well as a breakdown of activity - patients seen and treated.

· Evaluate audit results and research findings to identify areas for quality improvement in collaboration with nursing management and MDT colleagues (Primary and Secondary Care).

Consultant:

The Clinical Nurse Specialist in Diabetes Service will:

• Provide leadership in clinical practice and act as a resource and role model for diabetes practice.
• Generate and contribute to the development of clinical standards and guidelines and support implementation.
• Use specialist knowledge to support and enhance generalist nursing practice.
• Develop collaborative working relationships with local Clinical Nurse Specialist (Diabetes)'s/Registered Advanced Midwife Practitioner/MDT colleagues as appropriate, developing person centred care pathways to promote the integrated model of care delivery with the support of the Director of Nursing, attend integrated care planning meetings as required
• Where appropriate develop and maintain relationships with specialist services in voluntary organisations which support patients in the community.
• Liaise with other health service providers in the development and on-going delivery of the National Clinical Programme model of care.

Network with other Clinical Nurse Specialist (Diabetes)'s in related professional associations

The above Job Description is not intended to be a comprehensive list of all duties involved and consequently, the post holder may be required to perform other duties as appropriate to the post which may be assigned to him/her from time to time and to contribute to the development of the post while in office.

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