Practice Nurse - Chronic Disease Management and Minor Illness

Job purpose To provide protected, effective and person-centred general practice nursing care, with a particular focus on diabetes and chronic disease management. The post-holder will undertake structured reviews, support patients to manage their health and contribute to agreed core practice nursing services. The post-holder will work autonomously within professional competence, practice policies and agreed clinical pathways, while collaborating with the wider primary care team. Diabetes care and reviews Undertake diabetes checks, interim monitoring and structured nurse-led diabetes reviews in accordance with current guidance, practice protocols and individual competence. Take a relevant clinical history and assess symptoms, lifestyle, self-management, medicines adherence and risk factors. Undertake or arrange appropriate monitoring, including blood pressure, weight or BMI, foot screening, urinalysis and review of relevant blood and urine results. Provide patient education, lifestyle advice, personalised care planning and support for self-management. Recognise abnormal findings, deterioration or potential complications and refer or escalate appropriately. Maintain accurate records and clinical coding. Contribute to diabetes recall systems, QOF, clinical audit and quality improvement. Wider chronic disease management Undertake structured reviews and ongoing monitoring for other long-term conditions according to competence, including asthma, COPD, hypertension and cardiovascular disease. Assess treatment effectiveness, medicines adherence, relevant observations and investigation results. Agree personalised management plans, promote shared decision-making and support patients to manage their conditions. Identify patients requiring follow-up, additional investigation,



referral or medical review. Contribute to prevention, screening, recall systems, QOF and work to reduce health inequalities. Core practice nursing and prevention Provide evidence-based health promotion and lifestyle advice, including smoking cessation, diet, physical activity and cardiovascular risk reduction. Undertake agreed practice nursing duties according to competence and service need. Duties may include immunisations, injections, wound assessment and care, cervical screening, venepuncture, ECGs, spirometry and physiological observations. Use patient group directions and other authorised medicines processes safely and within professional and organisational requirements. Recognise findings that require urgent review and obtain appropriate clinical support. Clinical governance and patient safety Practise in accordance with the NMC Code, relevant legislation, evidence-based guidance, practice policies and professional scope of practice. Maintain accurate, complete and contemporaneous electronic patient records. Use appropriate clinical coding and templates. Comply with safeguarding, infection prevention and control, confidentiality, information governance, medicines and vaccine management, cold-chain and health and safety requirements. Report incidents, significant events, risks, complaints and equipment concerns promptly. Participate in learning from incidents and quality-improvement activity. Recognise personal limitations,



seek advice when required and work within demonstrated competence. Teamwork and service development Work collaboratively with GPs, nurses, healthcare assistants, pharmacists, administrative colleagues, Primary Care Network staff and other health and care professionals. Communicate sensitively and effectively with patients, carers and colleagues, adapting communication where required. Contribute to clinical meetings, audit, protocol development, service review and quality-improvement activity. Support colleagues and learners appropriately, including delegation and supervision within competence. Use appointments, equipment, clinical supplies and other practice resources responsibly. Professional development Maintain NMC registration, revalidation and an up-to-date professional portfolio. Participate in appraisal, mandatory training, clinical supervision and continuing professional development relevant to the role. Maintain and develop competence in diabetes, chronic disease management and agreed core practice nursing duties. Reflect on practice and use feedback, audit and learning events to improve patient care. Working relationships The post-holder will work with GP Partners, salaried GPs, the Lead Practice Nurse, Practice Manager, practice nurses, healthcare assistants, clinical pharmacists, administrative and reception colleagues, Primary Care Network staff, community and secondary care services, patients and carers. General This job description describes the main responsibilities of the post and is not exhaustive. It may be reviewed with the post-holder to reflect service development, provided that any changes remain appropriate to the role, contracted hours and the post-holders demonstrated competence.

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📌 Practice Nurse - Chronic Disease Management and Minor Illness (Shire of Northampton)
🏢 Allscreens Nationwide
📍 Shire of Northampton