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Fraser Health

Public health authority operating hospitals

Community Health Nurse

Nursing & Frontline Patient CareConfirmed live in the last 24 hours
Full-timeLangley, BC, CanadaCA$41.42 - CA$59.52 /hrIn-person

About the Job

Requirements

  • Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives.
  • One year of recent related clinical experience assessing and treating complex geriatric and/or adult patients with chronic health conditions in an acute or community/outpatient care setting, including recent experience in care and discharge planning, or an equivalent combination of education, training and experience.
  • A valid British Columbia driver's license and access to a personal vehicle for business-related purposes.
  • Demonstrated knowledge, skills and competence in gerontology and in supporting adults living with complex frailty and chronic illnesses.
  • Ability to complete initial and ongoing client assessments and provide nursing care through therapeutic interventions.
  • Ability to communicate effectively, verbally and in writing.
  • Ability to integrate and evaluate relevant data from multiple sources to solve problems effectively.
  • Knowledge of broad health care services, community resource agencies, and their roles in providing a continuum of care.
  • Ability to promote client-focused care with sensitivity to diverse cultures and preferences.
  • Ability to independently manage and prioritize clients with diverse healthcare issues.
  • Ability to teach clients and others about 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

  • Establish a therapeutic relationship with clients using interpersonal and interviewing techniques, in person or by telephone, to support their choice and autonomy in decision-making and care planning, including their rights to dignity and privacy.
  • Screen referrals; provide individualized client assessments, interprofessional care planning and interventions, including clinical care when appropriate, and referral services for clients with multiple complex chronic conditions; help clients achieve an optimal level of function through timely and appropriate health services and resources; and collaborate with primary care providers, clients, families, supports, caregivers, health professionals, clinics, hospitals, and community resources to resolve care issues and coordinate integrated care and services.
  • Develop comprehensive shared patient/client care plans with the interprofessional team, primary care provider, client and/or family, other health care providers, and referring clinics; facilitate and support transition of the care plan to the referring source, primary/community care provider, and/or community agencies.
  • Provide direct client care and identify other required care services in accordance with applicable guidelines, policies, and evidence-based best practice; explain care comprehensively to clients and families as appropriate.
  • As required by the local community model, make decisions about client-specific direct care tasks; assign and, when appropriate, delegate tasks to Community Health Workers; demonstrate and train them in assigned and delegated tasks according to practice standards; ensure they have the knowledge, skills, and support to perform delegated tasks within defined limits; and collaborate with the Community Health Nurse–Licensed Practical Nurse in monitoring delegated tasks.
  • Facilitate care conferences with the interprofessional team and primary care provider to review care plans and determine timing and referrals for services or interventions; initiate, monitor, and evaluate care-plan appropriateness and effectiveness; develop next steps with clients and families; and support transitions across the care continuum, including discharge or transfer as required.
  • Discuss clinical findings with clients and families in collaboration with the interprofessional team; develop action plans and goals addressing clinical needs, self-management, self-care, and health-related quality of life; review client data such as medical history, progress notes, consultation reports, and laboratory reports and incorporate findings into care plans; prioritize and use resources effectively; and respond to unanticipated events or changing client or service-assignment needs.
  • Support clients and families before, during, and after interprofessional conferences and clinic visits by providing information for treatment-option decisions; advocate for their choices and needs; and provide direct care in clinic, community, or home settings as they transition to another program, service, or health care provider.
  • Arrange and participate in joint home visits with clients and/or families and other health professionals as required; advise clients and caregivers about available community resources.
  • Provide health counselling, education, self-management, self-monitoring, and wellness, health-promotion, and prevention support through clinic, telephone, or home visits; collaborate with health professionals in clinics and community programs and services to facilitate information flow across primary and community care settings.
  • Maintain clinical records, including intake screens, client assessments, clinical interventions, treatment formulations, care plans, and progress notes; maintain client statistical information in accordance with established policies, standards, and procedures.
  • Maintain professional practice growth, knowledge, and expertise in accordance with current standards by reviewing relevant literature, attending educational workshops and in-services, and consulting and networking with health professionals.
  • Participate in departmental quality-improvement and risk-management activities by identifying client-care issues and collecting data; participate in research opportunities as required.
  • Participate in the orientation and ongoing education of nursing staff and students by providing information and acting as a preceptor as appropriate.
  • Provide input into the development and revision of standards of care, policies, and procedures; advocate for improvements in clinical practice and health care services; and participate in developing, implementing, and evaluating program quality-improvement initiatives by providing recommendations to the Manager.
  • Perform other related duties as assigned.

About the Company

Fraser Health

Public health authority operating hospitals

Fraser Health is a Canadian health authority that provides health services to about 1.8 million people in British Columbia. It operates 12 hospitals, including major trauma centers, as well as outpatient care and surgery centers, and offers services in residential care, public health, home health, and mental health. It employs more than 40,000 staff, medical staff, and volunteers who coordinate care across hospitals, clinics, and community settings to ensure patients receive the right care at the right time. Its goal is to keep communities healthy by delivering accessible, high-quality care and by creating good workplaces for its employees and volunteers.

Company size
10,001+
Company stage
Grant
Total funding
$20K
Headquarters
Surrey, Canada
Founded
2001

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