Spinal Outreach and Community Liaison Clinical Nurse Specialist

Job overview

To perform autonomous outreach visits to newly referred spinal cord injury (SCI) patients to assess their clinical needs and to ensure that expert clinical knowledge and specialist spinal injury care is shared with all referring hospitals (non-specialist in SCI), in particular the Major Trauma Centres (MTCs) for London.

To empower spinal injury outpatients to live successfully in the community by promoting their independence, self-reliance and self-esteem, and participate in the lifetime surveillance and support service for patients with spinal cord injuries, throughout the Southeast of England.

Main duties of the job

• To work autonomously as a Specialist SCI Nurse in the non-specialist referring hospitals, community settings and nurse led clinics to effectively deliver expert nursing advice and education for professionals, patients, and their family members on spinal cord injury. To deliver an advanced, highly specialised spinal outreach service for people with a new SCI that are not in a specialist SCI Centre. To provide teaching and training for non-specialist multidisciplinary teams (MDTs) in hospitals and community settings to enable them to care for the SCI patient. To ensure that patients and their families are fully informed and supported by providing clinical and psychological support. To establish clear lines of communication within the non-specialist teams at MTCs, other referring hospitals and community teams. To link with non-specialist teams to increase knowledge and facilitate the care of this patient group to help reduce avoidable complications by training and management strategies. To maintain effective ongoing liaison with hospital teams and community. To represent the London Spinal Cord Injury Centre (LSCIC) and the Royal National Orthopaedic Hospital (RNOH) at conferences and on other forums. To assist in co-ordinating the admission of patients from referring hospitals or from the community to the London Spinal Cord Injury Centre for their rehabilitation.

Detailed job description and main responsibilities

SPECIFIC DUTIES AND RESPONSIBILITIES

CLINICAL

• Ø  To facilitate communication between MTCs / non-specialist referring hospitals / community teams and the specialist SCI team at the RNOH. Ø  To work with the referring MDT and community team key staff members to maintain a robust specialist service. Ø  To provide specialist advice and support via a nurse led telephone service, nurse led clinics as well as follow up support through the email referral system. Ø  To travel to MTCs, non-specialist referring hospitals and Community settings in order to provide expert clinical knowledge and skills through various teaching strategies to members of the MDTs caring for patients with a newly acquired spinal cord injury and as required patients with long standing SCI. Ø  To contribute proactively to the decision-making process when planning care or organising transfer/admission arrangements to the LSCIC. Ø  To work with and support senior clinical staff at the non-specialist referring hospitals and community teams in identifying areas where changes in practice are required and also where opportunities exist for improving the treatment and support of patients. Ø  To assess the care needs of patients, their families and carers in non-specialist referring hospitals and the community by identifying and initiating appropriate steps for effective care within the current setting. Ø  To share responsibility with the other members of the Spinal Outreach and Community Liaison Teams for patient caseload.  To ensure all patients have an accurate plan of care which reflects the assessment undertaken and incorporates the issues and recommendations made with clear documentation in the patient’s electronic health records - EPIC Ø  To provide information for the specialist spinal MDT admission meetings, ensuring all patients are reviewed and presented to the team at RNOH when updating the waiting list. Ø  To deliver a seamless service through the development of clinical protocols and strategies both here at the RNOH and at non-specialist referring hospitals to ensure the continuity and uphold the standard of specialist spinal cord injury care whilst ensuring equity of access to the service at The London Spinal Cord Injury Centre. Ø  To ensure all specialist spinal cord injury care is provided in accordance with agreed local and national specialist protocols. Ø  To follow up spinal outreach patients at non-specialist referring hospitals via face-to-face visit, telephone or video conference and ensure all relevant information is available for review to enable patients to make an informed choice about their treatment. Ø  To maintain a nationally agreed mechanism for referral from the non-specialist referring hospitals to the highly specialist members of the Spinal Outreach Team. Ø  To assist the non-specialist referring hospitals in collaboration with the RNOH to develop, implement, evaluate and choose the correct nationally agreed integrated care pathway that best meets the patients predicted specialist journey. Ø  To actively involve key stakeholders, including non-specialist referring teams, Spinal Injuries Association (SIA) and patients, in supplying information and feedback about their experience of the current spinal outreach service, community liaison and contributing suggestions for future improvements. Ø  To evaluate patients’ social, psychological and physical wellbeing and refer to colleagues and other disciplines as appropriate. Ø  To negotiate with community professionals for provision of specialist equipment. Ø  To provide ad-hoc follow-up in the community and attend community meetings as necessary. Ø  To provide support (written and verbal) for patients living in the community and their community teams. Ø  To ensure accurate and confidential records are kept up to date for all patients on EPIC. Ø  To attend departmental staff support sessions. Ø  To provide support to the Rehabilitation Consultants and their teams in their Outpatient Clinics and support the use of EPIC including MyCare app for advanced accurate communication. Ø  To continually act as a role model to achieve excellence in nursing practice.

EDUCATION AND RESEARCH

• Ø  To utilise every opportunity to ensure that own skills and knowledge are regularly updated. Ø  In collaboration with other team members, design a formal teaching package for acute hospitals and for community professionals in relation to spinal cord injury and review and update as necessary. Ø  To provide education to outpatients in their own homes where necessary. Ø  To ensure all patients at the non-specialist referring hospitals and community teams are fully informed of the risks and benefits of treatments suggested by the Spinal Outreach / Community Liaison Team, contributing to the process of informed consent. Ø  To produce and provide all patients at non-specialist referring hospitals with printed information relevant to their unique injury regarding their treatment in accordance with the non-specialist Trusts policies. This can include website addresses and email contact details. Ø  To supervise and participate in the delivery of programmes of education and training at the non-specialist referring hospitals and in community teams. Ø  To contribute to the development of specialist nursing practices within the teams at the non-specialist referring hospitals and community teams. Ø  To attend relevant meetings and spinal related conferences as agreed by your direct Line Manager at the LSCIC, ensuring that you are fully conversant with current issues both national and international. Ø  To promote and facilitate evidence-based practice and clinical audit within the non-specialist referring hospitals, raising the profile of the RNOH and enhancing the contribution of MDT work to patient care. Ø  To participate in and assist with any appropriate / relevant RNOH Trust approved research projects conducted within the outreach department. Ø  To undertake audit and evaluation of the specialist Spinal Outreach and Community Liaison team at the RNOH with a view to presenting at appropriate forums, both at the RNOH or elsewhere.

MANAGEMENT

• Ø  To promote patient focused care programmes within the rehabilitation process and maintain effective communication channels with the multi-disciplinary team. Ø  Together with the Case Managers, facilitate an effective and efficient approach to the rehabilitation and reintegration of spinal cord injured patients. Ø  Work in conjunction with other team members to develop a comprehensive service for our outpatients. Ø  Contribute towards monitoring, evaluation and development of the service provided by the department. Ø  To ensure that formal reporting systems and recording of adverse incidents are carried out in line with RNOH Trust policy or the policies of the non-specialist referring hospitals when reviewing patient risk factors when outside a specialist SCIC. Ø  To utilise and maintain information and technology systems to assist with audit, to provide regular activity analysis reports and provide the information required for the Administrator to input into various databases and activity logs. Ø  To participate in the evaluation of the Spinal Outreach Service and Community Liaison in terms of clinical effectiveness, clinical excellence and future planning.

PERSONAL PROFESSIONAL DEVELOPMENT

• Ø  To achieve a range of clinical spinal cord and other nursing related competencies as required to fulfil this highly specialist, skilled role. Ø  To keep up to date with current literature and research in the speciality by presenting to the RNOH MDT and assisting in the production of audits. Ø  To maintain your own personal and professional development through mandatory training and active participation in regular IPRs / PDPs. Ø  To keep up to date with NMC, relevant specialist faculty and hospital guidelines and protocols. Ø  To adhere to the NMC Code of Professional conduct working within and accepting responsibility for maintaining agreed levels of competence for yourself and others that you encounter.

SPECIAL REQUIREMENTS:

• Ø  The post holder is required to hold a full driving licence and to have access to a vehicle in order to carry out visits outside of the hospital as necessary to perform his / her duties. Ø  The post-holder is required to act autonomously at a level of advanced practice. Ø  The post-holder is required to maintain an understanding and overview of health and social care issues.