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Position Description

Nurse Specialist (RN)
 Full Time
Reporting to:
Executive Director
July 31st 2009

The Nurse Specialist (RN) is a specialist in a geriatric care and is responsible for the planning, coordination and delivery of services to patients who are seniors and their families and caregivers. Working in collaboration with an interdisciplinary team, the Nurse Specialist (RN) will share expertise and knowledge of health promotion and disease prevention, helping to connect patients with appropriate services and professionals.
The Nurse Specialist (RN) is to practice within the scope and according to the standards of practice as outlined in the following documents:
·         College of Nurses of Ontario’s “Practice Standards” (
·         Nursing Act (1991) and
·         Regulated Health Professionals Act (1991)

·         Develops a tool to assist team members in identification and referral of appropriate patients.
·         Screens, prioritizes and processes client referrals to the designated program (s).
·         Coordinates the assessment of health status and its impact on client/family coping, with the Family Physician.
·         Reviews client clinical information obtained through physician referral, laboratory reports and health records.
·         Conducts consultations with clients/family to obtain relevant information and assess client/family learning needs.
·         In partnership, conducts assessments of a community, group or population in relation to their health learning needs and capacity using appropriate tools and resources.
·         In collaboration with Family Physicians and other members of the interdisciplinary team, develops and discusses appropriate individualized care plan with the client/family/caregiver based on best practices.
·         Based on evidence and best practice and in partnership with other community partners, collaborates in development of goals and objectives, services and activities outcome measures and evaluation for community, group or population programming.
·         Reviews current literature/resources to support preparation of education materials and tools.
·         Works in collaboration with interdisciplinary team to safely and effectively provide appropriate primary care to clients.
·         Provides ongoing case management for patients identified as at risk and enrolled in a specialist service or program.
·         Collaborates with the Family Physician and/or specialist consultants to deliver effective primary health care to the clients enrolled in the specialized program.
·         Recommends and adapts teaching to the client’s identified health needs, revising treatment protocols as required.
·         Facilitates educational sessions and activities using the principles of adult learning.
·         Participates in community capacity building activities as opportunities arise or are created.
·         Documents using client health record, refers to other resources and arranges follow-up as necessary.
·         Evaluates effectiveness of care plan by assessing client/family comprehension and compliance to the care plan, reviewing clinical, behavioural and learning outcomes.
·         Identifies key performance indicators for consultation, participates in the measurement of these indicators.
·         Participates in the evaluation of outcomes of group, population or community programming and its effectiveness.
·         Prepares monthly statistical reports for the Ministry of Health and Long-Term Care, Local Health Integration Network and the FHT.
Team Development
·         Works effectively within an interdisciplinary team, in varied practice settings, to improve access to primary care for the residents of Wellington County. The “client” may be an individual, a family, a target group or a community.
·         Provides case study consultation, conducts in-services and workshops for team members, other health professionals and community partners, as appropriate.
·         Promotes awareness of the Corporation’s services and programs.
·         Actively participates in staff, team and committee meetings as appropriate.
·         Provides leadership and mentorship to registered nurse students that enter the FHT on a placement. Participates in the education of other health professional students.
·         Participates in the development, planning and evaluation of treatment, education, counselling and health promotion activities of the FHT.
Professional Development
·         Maintains and develops professional competence through ongoing professional development. Fully participates in the Quality Assurance Program of the College of Nurses of Ontario.
·         Stays current and aware of opportunities to implement new, evidenced-based methods of client assessment, treatment and programming
·         Participates in self-directed learning to ensure that practice remains relevant by attending professional conferences, e-learning and journal reviews.
·         Participates on interdisciplinary committees to promote professional/ interpersonal development.
·         Participates in clinical projects/studies as required.
·         Communicates effectively with health care team members to create a cohesive team and seamless services to the community including using electronic messaging, and accessing Electronic Medical Records remotely.
·         Communicates effectively with all clients, families, peers, other health care professionals and community partners.
·         Participates in interdisciplinary meetings as required.
Related Duties
·         Models the values and philosophy of the Corporation;
·         Exhibits a commitment to life-long learning;
·         Maintains confidentiality of team, personnel and client information;
·         Facilitates appropriate in-house and external education sessions;
·         Supports student rotations and internships for all allied health professionals;
·         Assists with planning and attends special events; and
·         Performs other associated duties as required.

·         Baccalaureate of Science in Nursing required, Master of Science in Nursing preferred.
·         Current registration with the College of Nurses of Ontario required.
·         CNA Gerontological Nursing Certification preferred
·         Current membership with RNAO preferred.
·         Basic CPR certification.
·         Current Ontario Drivers’ License.
·         Demonstrated experience in Community and/or Primary Care Setting.
·         Demonstrated experience or additional certification in the specialty area.
·         Team player – demonstrated ability to engage in truly collaborative practice with Interprofessional colleagues both across the FHT multi-disciplinary members and the physician office teams
·         Flexibility and creative problem solving in order to create and deliver responsive, effective and accountable services and systems for the organization and for the individual patient and their family and the community.
·         Knowledge and proficiency in current, evidence-based methods and practices of primary care delivery, with an emphasis on health promotion and risk reduction.
·         Superior leadership, organization, research, evaluation, time management, communication and interpersonal skills.
·         Proficiency in the use of the computer hardware and software, particularly in Microsoft Word, Excel, Outlook and electronic medical records..
·         Desire and ability to update knowledge and skills through various means including technology-based opportunities, courses, workshops and conferences.
·         Multi-tasking skills related to the delivery of efficient primary care including the ability to share information and teach while treating a patient.
·         Excellent verbal and written communication skills.
·         Exhibit an ability to be open and non-judgmental.
·         Knowledge of the goals and structure of the organization, the policies and procedures and the programmes.
Computer, printer, scanner, fax, photocopier, telephone, AV equipment including video projection unit, telemedicine equipment, hand-held assessment tools, various teaching aids. Some specialized clinical equipment dependant on role – pulse oximeter, stethoscope, blood pressure monitoring equipment.

Executive Director
Ministry of Health & Long-Term Care
Associated Family Health Organization Physicians (and staff of the FHO)
Waterloo Wellington Local Health Integration Network
Contracted Professional Staff
Community Health and Social Services Agencies
Employees, including allied health professionals and administrative staff
Non-Government Organizations
Contracted administrative support
Professional Associations, College of Nurses of Ontario
Drop in associated staff e.g. CCAC Case Managers, Seniors At Risk Coordinator and Trellis staff (especially from the Specialized Geriatric Services Team), Alzheimer’s Society First Link Coordinator
Groves Memorial Community Hospital – especially GEM nursing staff and discharge coordination staff
Peers, Other FHT Nurse Specialists
Service Providers and Vendors

Moderate: The position requires minimal physical effort and the workday comprises roughly of equal amounts of standing and sitting, with frequent position changes.  The position may entail visits to patients in the community setting and in hospital requiring driving and potential exposure to hazardous surroundings. This position may involve routine exposure to persons with contagious or infectious illnesses and requires constant attention to infection control procedures.
The Nurse Specialist (RN) must be able to make decisions based on the best information and evidence that is available. This position requires the RN to exhibit creativity and exceptional problem solving skills. The RN may frequently be exposed to circumstances that involve unpredictable emotions and behaviours.
Participates in the planning of a set budget. May participate in the expenditure of resources as planned.
Poor decisions and/or omissions can impact harmfully on client health. The level of impact could range from very low to extremely high.
Poor interpersonal skills could impact negatively on relations with staff, community partners, clients and public. The level of impact could range from low to moderate.
FHT Clinics – Fergus, Elora, Arthur
The work environment will primarily be in well-lit, well-ventilated clinic areas that are furnished ergonomically. Exam rooms will be well equipped and supplied. Office space is shared.
FHT Satellite or Outreach Sites
Environment may vary depending on location. Ergonomics, health and safety of the RN will be an important consideration when the location is furnished and equipped. It may be required to bring some requisite equipment and supplies when reporting to work in these environments.
In Home Visits
The RN may be required to provide primary care within the confines of a client’s home. These environments are not assessed before hand and it is the responsibility of the RN to assess the environment for health and safety risks. It is the policy of the FHT that no employee is exposed to second-hand smoke.
Due to the collaborative nature of this position, the RN will be required to attend meetings at other organizations offices and visit patients in other institutional settings such as local hospitals and long term care facilities. Staff must follow the policies and procedures of the locations they are visiting and must be officially recognized by the host organization if providing care.   Travel may be required between sites and client homes. Travel related to the fulfillment of this position description will be reimbursed.
The Nurse Specialist (RN) reports to the Executive Director. In clinical matters, the RN collaborates with physicians and other FHT members to provide the most efficient, appropriate primary care to a client of the FHT. The RN collaborates with other community health partners to deliver appropriate services and programs to the community.
All FHT salaries are determined by the MOHLTC pay grids for primary care and are therefore non negotiable. Hourly rates for this position are from $27.71 to $33.39 ($54,035 to $65,103 for a full-time position providing 1950 hours per annum -based on a weekly paid attendance of 37.5 hours). Benefits include vacation of 4 weeks per year for full-time staff, education allowance of up to $750, Group Life Insurance, Accidental Death and Dismemberment, Long Term Disability and Short Term Disability, Medical, Vision, Drugs and Dental Plans and Statutory Benefits as required by law, such as CPP and EI and participation in a Registered Retirement Savings Plan with employer matched contributions up to 5% of salary. The overall benefits package equates to an average of 20% of base salary.