Practice Nurse and Chronic Disease Management

We are seeking a motivated Practice Nurse with Chronic Disease Management experience to join our friendly, forward-thinking team for 30.5 hours per week. This is an excellent opportunity for a skilled practice nurse who is passionate about delivering high-quality, patient-centred care and working autonomously within a supportive environment.

The proposed working hours are as follows:

Monday 8.30am - 1pm

Tuesday 8.30am - 1pm

Wednesday 8.30am - 6pm

Thursday 8.30am - 6pm

Friday 8.30am - 1pm

With ability to cover sickness or annual leave., 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, 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., 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., 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

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 stufy

Basic Life support training

Experience running long term condition or chronic disease clinics

We are a small, friendly, semi-rural practice with 6,500 patients looking for a practice nurse with chronic disease management experience.