Indigenous Community Health Nurse

Fraser Health•Surrey, BC

39d•$41 - $60

About The Position

In accordance with the British Columbia College of Nurses and Midwives (BCCNM) scope of practice, standards of practice and the Mission and Values of Fraser Health, works collaboratively as a member of an interprofessional team to provide direct patient care for clinical practice within the Aboriginal Health program. The role of the Indigenous Community Health Nurse is to partner with and complement that of the family physician or nurse practitioner. Provides initial client consultation, assessment, triage, coaching and teaching, health promotion and intervention, client care services and follow-up based on the client's needs, urgency of request and best practices, to ensure clients, families and caregivers are provided with ease of access to timely, person-centred, continuous and culturally safe quality health services. Care may be provided in the clinic setting, over the phone, or in the community setting. Facilitates and manages client transitions across the healthcare continuum to optimize health and well-being and adapts to changes in the client's condition to minimize avoidable admission to healthcare facilities; collaborates with the client and ensures linkages with acute, primary and community care healthcare providers including the client's primary care provider (Nurse Practitioner, Physician), other specialists and family supports with respect to client care planning to facilitate the flow of information through a variety of settings including FH and non-FH community services. Provides client and family-centered care through a trauma-informed approach and evidence-informed practice. Establishes a dignifying, purposeful and trusting relationship with clients, promoting self-determination and independence. Encourages knowledge exchange in day-to day activities, and empowers clients to engage and connect within their communities. Ensures clients and their family members are supported in navigating the health care system.

Requirements

Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).
One (1) year recent related clinical experience including assessing and treating children, youth and adults in an acute or community/outpatient care setting or an equivalent combination of education, training and experience.
Immunization additional education completed and up to date.
Valid BC Drivers license and access to a personal vehicle for business related purposes.
Demonstrated ability to complete initial and ongoing client assessments and provide nursing care through therapeutic interventions
Broad knowledge of immunization and related reactions and contraindications.
Demonstrated ability to administer injections and recognize adverse reactions
Demonstrated ability to communicate effectively, both verbally and in writing
Demonstrated ability to integrate and evaluate pertinent data from multiple sources to problem-solve effectively
Knowledge of broad health care services, community resources agencies and their role in providing a continuum of care
Comprehensive knowledge of Aboriginal health approaches, protocol, cultural practices, and community resources and agencies.
Ability to deliver culturally sensitive services to Aboriginal populations.
Knowledge of common chronic diseases, effects of aging on health, infection control approaches, and primary care competencies
Knowledge of adult guardianship act and related acts for children and reporting processes
Knowledge of basic wound care assessment and treatments
Ability to promote client-focused care including sensitivity to diverse cultures and preferences and utilization of harm reduction strategies
Ability to independently manage and prioritize clients with diverse healthcare issues
Ability to teach clients and others about topics essential to health care, health promotion and care self-management using care management principles
Ability to work effectively in a dynamic environment with changing priorities
Ability to work independently and as a member of an interprofessional team
Ability to operate related equipment including applicable software applications
Physical ability to perform the duties of the position

Responsibilities

Provides direct nursing care to clients receiving scheduled or urgent/timely care.
Assesses clients and collects information from a variety of sources using skills of observation, communication, data review and physical assessment.
Triages and makes a nursing diagnosis of the client's condition and determines whether the condition can be improved or resolved by an appropriate nursing intervention or through interventions and collaboration with other clinical staff and primary care provider.
Assists the Physician/NP and other team members with urgent and emergent care as necessary.
Performs a comprehensive and focused health assessment that includes health history and complete physical evaluation; considers the patient's psychosocial, emotional, ethnic, cultural and spiritual dimension of health, the client's goals for health, including a thorough medication assessment and best possible medication history, and his or her understanding of their health/illness experience and how their daily life is affected.
Processes physician or nurse practitioner orders through methods such as administering medications, carrying out treatments and monitoring and documenting the effects.
Immunizes clients against vaccine preventable disease in accordance with the BCCDC scope of practice and applicable policies and procedures.
Conducts immunization clinics by assessing immunization needs, transporting vaccines, setting up work stations, establishing informed consent, preparing and administering injections and observing and responding to reactions such as fainting and anaphylaxis to ensure client safety.
Ensures cold chain procedures are followed in accordance with policies and procedures.
Advises client about possible adverse reactions and contraindications and provides after care instructions and related documentation.
Answers immunization related questions as required.
Participates in quality improvement, risk management activities, research and special projects in collaboration with relevant personnel by methods such as collecting data, interpreting data and providing input for further analysis, as required.
Provides formal presentations and educational programs for selected population groups via telephone, one-on-one and group in a clinical, school, community and outreach settings; provides collegial sharing of information to staff for the purpose of enhancing knowledge of Aboriginal cultures and health beliefs; provides information on services available in the community for Aboriginal people; participates in committees that integrate Aboriginal Health with hospital and community programs by providing input and addressing Aboriginal Health issues.
Performs nursing procedures within their scope of practice and their own level of competency both independently and in an assisting role with the Physician/NP.
Establishes a therapeutic relationship with the client through the use of interpersonal and interviewing techniques, in person and/or over the telephone, to ensure the client's choice and autonomy in decision-making and care planning including the client's right to dignity and privacy.
Screens referrals, provides individualized client assessments, including mental health and substance use screening, and contributes to interprofessional care planning and clinical interventions.
When appropriate collaborates and refers to specialized services for clients with multiple complex conditions; assists clients to achieve an optimal level of function by facilitating timely and appropriate health services (e.g. public health, mental health & substance use, social services) and utilizing a variety of resources and services; collaborates with the primary care provider, client, the family/supports/caregivers, other health care professionals, clinics, hospitals and other community resources to identify and resolve client care issues and coordinate the integration of care and services.
Coordinates care for clients by collaborating with interprofessional care team, developing, implementing, maintaining and adjusting comprehensive treatment plans based on client needs and best practices, administering prescribed medications, and monitoring and assessing clients' mental state, response to medications and efficacy of treatment plan to ensure optimum use of resources and to facilitate client centred care
Arranges and participates in outreach nursing care to clients in their home setting, primary care setting, or suitable alternative including individuals who are homeless or at risk of homelessness performing nursing functions such as assessing substance use/dependence, determining physical and mental status, monitoring withdrawal symptoms and evaluating response to medications administered; formulate and explain plan of care to client/family or supportive care persons; transport and/or accompany clients to physician appointments for assessment to determine suitability for program or to designated safe bed for withdrawal management support
Develops a comprehensive shared client care plan, in collaboration with the interprofessional team, client and/or family, other healthcare providers and/or referring clinics which includes health promotion, illness prevention, rehabilitation, chronic disease management, and/or palliative approaches; facilitates and supports the transition of the client care plan to the primary/community care provider and/or community agencies.
Provides direct planned and unplanned client care and identifies other care services required in accordance with applicable guidelines, policies and evidence-based best practice; informs and educates clients and families and provides comprehensive explanations of care to the client and family and checks for understanding, as appropriate.
Reviews client care plans, in collaboration with the interprofessional team/primary care provider to determine timing and referral to other services and/or interventions to improve client outcomes; initiates, monitors and evaluates the appropriateness and effectiveness of the short and long term care plan to meet specific client goals; develops next steps in collaboration with the client and family; develops and supports a transition process for achieving client care goals across the care continuum.
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, 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; monitors and evaluates the plan of care and responds to unanticipated events and/or changing client or service assignment needs, as needed.
Supports clients and their families' clinic visits by providing information through their decision-making process regarding treatment options; advocates on behalf of the client/family to support their choices and needs and provides direct care to client as they transition to another program, service or healthcare provider.
Provides health counselling to clients including education, self-management, self-monitoring and wellness/health promotion/prevention through a combination of clinic, telephone or home/outreach visits; assesses the learning needs of individuals, providing and explaining techniques and equipment, and evaluates the overall effectiveness of the selected teaching methods and outcomes of learning.
Maintains clinical records such as intake screens, client assessments, clinical interventions, medication documentation, care plans and progress notes; maintains statistical information on clients in accordance with established policies, standards, and procedures.
As required based on the local community model, makes decisions on client specific direct care tasks; assigns direct client care tasks to Community Health Workers and when appropriate delegates client specific direct care tasks to Community Health Workers; provides in-home demonstrations and training to standards of practice for assigned and delegated client specific tasks; ensures that the Community Health Worker has the necessary knowledge, skills and support to perform the delegated tasks within the clearly defined limits.
Maintains professional practice growth, knowledge and expertise to reflect current standards of practice by reviewing relevant literature, attending educational workshops and in-services, consulting and networking with other health care professionals based on own learning needs.
Acts in an advocacy capacity to represent Aboriginal Health to medical staff and other service providers, and to community agencies and their staff by maintaining up to date knowledge of Aboriginal Health
Provides input in the development and revision of standards of care, policies and procedures and advocates for improvements in clinical practice, health care and health care services; participates in the development, implementation and evaluation of quality improvement initiatives within the program by providing recommendations to the Manager.
Performs other related duties as assigned.