Paediatric Complex Care and Transitional Flow Coordinator

Job overview

As an experienced paediatric nurse, the post holder will lead on the development and delivery of a Transition Service for children and young people and work collaboratively to map and implement multi-speciality pathways of care for children transitioning into adult services and those with complex needs.

The post holder will work in line with national guidance to understand current service provision for transition within each speciality. They will build and maintain professional partnerships across adult and paediatric services to ensure the delivery of effective, safe and efficient transition pathways for patients.  Models of care will primarily be across the following specialities:  Epilepsy, gastroenterology, endocrinology, and respiratory.

The role will involve developing and delivering joint outpatient clinics to support the transition of care.  Central to this work will be to improve young people’s experience of transition by hearing the CYP voice and that of their families by developing partnerships with them alongside their professional team and empowering them to lead in their care.

The post holder will also lead on the oversight of the inpatient provision of care to 16 and 17 year olds across the organisation, ensuring there is oversight and in reach support to these young people admitted to the hospital in adult areas.

Using their Paediatric knowledge and skills the post holder will support children and their families with complex care needs.

Main duties of the job

As a Paediatric Nurse Specialist, the post will work within the Paediatric team to ensure that children with Complex care needs have equal access to services. Working within the Multidisciplinary team to enable improved pathway between the different divisions and facilitating access to services with external providers through collaborative working.

The position has key responsibilities in improving access to Adult services and establishing pathways of care for safe and effective transition of care.

Detailed job description and main responsibilities

• Understands the business of each of the departments, wards and speciality services
• Understanding of the local and national nursing agenda
• Understanding of relevant national service guidance pertinent to the service
• Awareness of Royal Surrey County Hospital NHS Foundation Trust guidelines and policies
• Understanding of organistional structures within the Trust and those for the important relationships external to the Trust
• Commitment to clinical audit, research and evidence-based practice
• Awareness of budget management
• Awareness of Human resources policies and guidance as pertinent to the management and leadership of the clinical team
• Knowledge and understanding of current issues in health and social care
• Awareness of, and engagement with the regional system providers and healthcare organisations across the region

Clinical Practice

• Provide visible clinical leadership and acts as a role model to the nursing and wider team by delivering high quality compassionate care as an expert practitioner
• Promote and maintain positive working relationships between all staff, internal and external to the Trust, involved in the care of patients
• Work at an advanced level of practice autonomously and self-directed
• Work to optimise health and wellbeing, demonstrate autonomous decision making related to comprehensive history taking and physical assessment of patients.
• Plan, prioritise and manage complete episodes of care, working in partnership with others, delegating and referring as appropriate to optimise health outcomes and resource use, providing direct support to patients and clients
• Devising negotiating, implementing, supervising and reviewing individual treatment plans in collaboration with service users, family and carers
• Draw upon an appropriate range of multi-agency and inter-professional resources in their practice
• Ensure that documentation standards are maintained in accordance with NMC and RSFT guidelines, whether written or computerised
• Promote a high standard of advanced specialist nursing by initiating and coordinating the assessment, planning, delivery and evaluation of the holistic needs of patients/families through evidence-based practice following agreed policies, protocols and guidelines
• Practice a high standard of communication including highly sensitive and complex information to develop and sustain partnership working with individuals, groups, communities and agencies.
• Balance clinical risk and clinical decision making against context
• Help to set, monitor and seek to continuously improve standards and the quality of patient care, including those standards defined in local and national guidance
• Maintain a safe working environment
• Ensure the safe use and efficient management of equipment and supplies
• Promote compassionate evidence-based practice, wherever possible
• Act in such a way that safeguards the health and wellbeing of children and vulnerable adults at all times
• Is familiar with and adheres to the RSFT safeguarding policies.
• Act in accordance to the Nursing and Midwifery Council’s Code: Professional Standards Practice and Behaviour
• Fulfils the requirements as directed by the Nursing and Midwifery Council to maintain and revalidate registration

Leadership and Service Development

• Collaborate with the multi professional team to develop a shared vision of the service.
• Work collaboratively with colleagues to develop effective documentation, pathways, protocols and guidelines for care
• Identify gaps in the coordination of transitional care and liaise with both adult and paediatric services to promote a seamless MDT approach to transition
• Demonstrate a commitment to share expertise and disseminate information
• Contribute to the development of the teams and the service to continuously improve patient care
• Participate in implementing national standards and frameworks at a local level.
• Network locally, regionally, nationally and internationally and seek opportunities to develop the transition nurse role
• Use effective change management skills to initiate and implement service and practice development, making the best use of resources to improve practice and health outcomes
• Participate in the selection, interviewing, appraisal and professional development of team members
• Maintain involvement and active input in multidisciplinary meetings and appropriate local bodies / forums to contribute to practice and service development
• Support and inspire staff to provide efficient, effective, safe, quality care to patients
• Deliver a positive patient experience
• Promote the building of effective teams and collaboration between teams
• Support the senior sister / charge nurse to investigate and respond to accidents, complaints, untoward incidents and other significant events
• Support in the delivery of an effective, safe, quality service within budgetary envelope
• Raise and respond to concerns with regards to risk, danger, malpractice or wrongdoing by following the Trust whistle blowing policy and supporting processes

Quality Improvement

• Through the use of audit, local research, metrics and feedback continually seek to identify practice that needs improvement. Implement and evaluate any resultant improvement plan
• Plan, develop and evaluate methods and processes for gathering, analysing, interpreting and presenting data and information to support service development and improvement
• Support the implementation and use of innovative software or techniques to support service improvement and development, for example Quality Improvement tools
• Actively coordinate and promote patient involvement and feedback within service improvements to promote a positive patient experience
• Evaluate clinical practice in relation to its evidence base and clinical effectiveness including policy and guidance
• Identify areas of risk and poor quality, and address these through appropriate governance structures and forums
• Maintain and sustain the momentum of improvements until they are firmly embedded into the values and culture of the clinical area
• Participate and actively seek peer review in practice and sound evidence for assurance purposes

Educational

• Develop and maintain a peer network of support, information and learning with other Lead Nurses at a local and National level.
• Contribute to the development and acquisition of specialist knowledge and skills to enhance and extend the practice of other nurses and health care professionals within the service and beyond
• Identify and address the educational needs of patients, families, carers and staff involved in the delivery of this service.
• Participate in personal appraisal and mandatory training at the required time periods
• Support and facilitate re-validation for registered nursing staff, and self.
• Promote a learning and development culture to improve staff skills, knowledge and competence
• Contribute to relevant educational programmes and in house study days.
• Promote a positive learning environment within the clinical area to support the development of knowledge and skills in learners.
• Support and facilitate work-based inter-professional learning

Freedom to Act

• To be professionally and legally responsible and accountable for all aspects of your work including the management of patients in your care.