Job Description: Practice Nurse and Chronic Disease Management
Post: Practice Nurse, General Practice and Chronic Disease Management
Accountable to: Lead Nurse, and ultimately the Watlington Leadership Team
Purpose: To deliver high-quality general practice nursing to our whole practice population, with a particular focus on the proactive management of chronic diseases such as diabetes, COPD, asthma and cardiovascular disease, alongside preventative health.

Job Summary
The post holder delivers the full range of general practice nursing, from acute presentations and health promotion to the structured, evidence-based management of patients living with chronic diseases, including diabetes, COPD, asthma, hypertension and coronary heart disease. As an autonomous practitioner, they are responsible for the care they deliver and are expected to demonstrate sound clinical decision-making, including in running dedicated chronic disease clinics and reviews. They work collaboratively within the wider practice team to meet patient needs and support the delivery of our policies and procedures.

Key Responsibilities
Clinical Practice

• Assess, plan, implement and evaluate treatment programmes and individual care plans, including for patients with, or at risk of developing, a long-term condition
• Work with other health professionals to diagnose, monitor and manage long-term conditions in line with national and local guidance
• Prioritise and respond to urgent or complex presentations, including initiating emergency care where needed
• Support patients to adopt health-promoting behaviours and self-care strategies
• Deliver vaccination and immunisation programmes for adults and children
• Provide core general practice nursing procedures, including wound care, cervical screening, contraception advice, travel health and phlebotomy

Long-Term Condition and Chronic Disease Management

• Run structured clinics and annual reviews for patients with chronic diseases, such as diabetes, COPD, asthma, hypertension, coronary heart disease and chronic kidney disease, in line with NICE guidance and local care pathways
• Develop and agree personalised care plans and self-management goals with patients, reviewing and adjusting these as their condition changes
• Initiate, titrate and review medicines for long-term conditions within your competence and any Patient Group Directions or Patient Specific Directions, referring to a prescriber where needed
• Support patients to self-manage their condition, including use of home monitoring equipment, action plans and lifestyle change
• Maintain accurate long-term condition registers and contribute to the practice's performance against QOF and other quality frameworks
• Recognise signs of deteriorating or poorly controlled chronic disease and escalate promptly to a GP, the wider multidisciplinary team or secondary care as appropriate

Health, Safety and Infection Control

• Follow and promote infection control procedures, including hand hygiene, specimen handling, waste segregation, decontamination and management of sharps or spillage incidents
• Apply the principles of the cold chain and ensure safe storage, rotation and disposal of vaccines and medicines
• Maintain awareness of first aid and resuscitation procedures, and act on them as needed
• Follow workplace health and safety policies, including fire procedures and safe use of equipment
• Identify and manage risks from microbiological and chemical hazards in the working environment (COSHH)

Communication

• Communicate sensitively and effectively with patients and carers, adapting your approach to different needs, backgrounds and levels of understanding
• Anticipate and address barriers to communication
• Act as an advocate for patients and colleagues where appropriate

Quality and Governance

• Work within your competence and the NMC Code of Professional Conduct
• Keep accurate, timely patient records in line with legislation and our policies
• Deliver care in line with NICE guidance and the best available evidence
• Take part in audit, self and peer review, and quality improvement activity, implementing changes where needed
• Contribute to shared learning, and to the review of complaints, incidents and near misses
• Understand and apply safeguarding procedures for vulnerable children and adults

Team Working

• Understand your own role and how it may develop, and work flexibly to support the wider team
• Delegate safely and appropriately, and ensure clear referral pathways are in place
• Manage your own workload and time effectively

Equality and Diversity

• Promote equality and diversity, and challenge discrimination where you see it
• Support patients in exercising their right to choose, participate in, or decline care
• Apply chaperoning policy and support patients from marginalised groups to access quality care

Information Governance

• Record patient information accurately and promptly, using SNOMED CT codes correctly to support monitoring and audit
• Maintain confidentiality of information about patients, colleagues and the practice, and take appropriate precautions when sharing information

Person Specification
Attribute
Essential

• Registered General Nurse, currently registered with the NMC
• Educated to a good general standard
• Evidence of ongoing continuing professional development
• Understanding of practice nursing
• Competent in the nursing skills required for the post
• Sound understanding of patient confidentiality and information governance
• Knowledge of evidence-based management of chronic diseases such as diabetes, COPD, asthma and cardiovascular disease
• Working in accordance with the NMC Code of Professional Conduct
• Working as part of an integrated, multi-skilled team
• Experience of dealing with the public and patients
• Experience providing care for patients with chronic diseases or long-term conditions
• Good communication and observation skills
• Flexible, adaptable and hard-working
• Sensitive towards others
• Committed to personal development and acquiring new skills
• Able to maintain confidentiality
• Excellent verbal and written communication skills
• Able to think and plan ahead, using own initiative
• Flexible working hours
• Professional demeanour
• Competent and confident use of IT

Desirable

• Primary care experience
• Evidence of work-based study
• Basic Life support training
• Experience running long term condition or chronic disease clinics

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Applicants must have current UK professional registration. For further information please see NHS Careers website.