SAMPLE ROLE DESCRIPTION FOR REGISTERED NURSE IN FAMILY PRACTICE

FOR ADAPTATION TO YOUR PRIMARY CARE PRACTICE

Preamble

This document describes the potential roles for nurses in primary care. Registered
nurses can use this document as a guide; however, not all roles may be appropriate
depending on the practice environment and the nurses level of competence. Please
adapt for your practice setting as needed.

JOB SUMMARY

The role of the registered nurse (RN) in family practice partners with and complements that of
the family physician. The registered nurse follows the patient through all stages of growth and
development, through degrees of wellness and illness, from one setting to another,
collaborating with other RNs, physicians and expert providers in various settings. The
registered nurse provides holistic assessments and creates linkages with appropriate
community resources.

The RN works in partnership with the family physician(s) and other members of the health-
care team to provide care to the entire patient population. The RN focuses on providing
assessment, screening, healthy lifestyle support, education and chronic disease management
with a goal of improving health outcomes and facilitating access to services.

KEY DUTIES

A. Health assessment
Each interaction with a patient offers an opportunity to complete a comprehensive assessment
of the presenting problem as well as a complete assessment of the health status, risks and
opportunities that can affect long-term health. This may be completed during one visit or over
a series of visits depending on the circumstances and should be updated in the patients record
on a regular basis.

The registered nurse:

o Obtains a history of the presenting health issue(s).
o Performs a comprehensive and focused health assessment that includes health history
and complete physical evaluation; considers the patients psychosocial, emotional,
ethnic, cultural and spiritual dimensions of health, including his or her understanding of
their health/illness experience and how their daily life is affected.
o Uses and adapts assessment tools and techniques based on the patients unique needs.
o Assesses the presence of or the need for advanced care directives or do not
resuscitate documents.
o Completes and documents a thorough medication assessment, including over-the-
counter medications, alternative medications, intolerances and allergies.
o Maintains an accurate list of all current medications by reviewing at each visit and
assessing adherence
o Assesses access to medications and treatment by determining health coverage.
o Documents health assessment and clinical data in visit note and patient profile or
summary as appropriate.
 o Synthesizes health assessment information and uses critical thinking and clinical
reasoning skills to identify health concerns and potential screening issues.
o Applies recognized clinical practice guidelines and best practices to screening,
monitoring, and assessment of patients physical and emotional well-being.
o Incorporates objective findings such as laboratory and diagnostic findings, specialist
reports and past history in a comprehensive assessment.
o Provides telephone and in-person triage according to established practice protocol

B. Health-care management and therapeutic interventions

The registered nurse provides care and management for patients with a wide range of health
issues. As an integral member of the health team, RNs provide care for complex patients and
those that require extra time and attention to develop a plan of care.

The registered nurse:

o Initiates and/or contributes to the development of a health plan in collaboration with
the patient and other members of the interdisciplinary team.
o Encourages maximum independence and accountability for self-care.
o Recognizes the need for and initiates effective interventions and treatments.
o Discusses treatment options with patients and involves them in decision-making and
self management.
o Assists and supports patients with implementation of the health plan including
interventions and diagnostic testing. This may involve setting up supports such as
medication delivery/adherence programs for medications, assisting with transportation,
arranging in-home care, etc.
o Determines the need for and initiates consultations with other services and health-care
providers in a timely and supportive manner.
o Monitors, evaluates and adjusts the health plan based on effectiveness of interventions
and/or changes in condition or environment, in collaboration with the patient and team
members.
o Provides telephone care, follow-up and consultation. Documents this care in patient
record or according to agency policy.
o Informs and educates patients regarding the meaning and implications of test results
and interventions.
o Counsels patients on drug therapies, side-effects and interactions.
o Counsels and guides patients on symptom management, health maintenance and
rehabilitation strategies, as well as risk factors and lifestyle changes.
o Co-ordinates services and care with the patient to ensure continuity and follow-up.
o Initiates or participates in patient care case conferences to ensure co-ordinated,
comprehensive and holistic services.
o Provides care in collaboration with family physician for patients in long-term care or
assisted living, including home visits as required.
o Documents accurate and pertinent patient information in a timely manner, including
maintaining a comprehensive health summary or patient profile.
o Prepares prescriptions for signing or facilitates the ordering of medications according to
practice policy. (Please confirm with your provincial/territorial professional college or
association that this practice is within the scope of nursing practice in your province or
territory.)
o Completes necessary documents to access medications or treatments that are
exceptions to formulary.
o Communicates with secondary and tertiary providers to ensure the continuity of care.
o Networks with community agencies and groups.
o Completes referrals or consults, lab requisitions*, and diagnostic requisitions*.
 o Completes insurance, Workers Compensation Board documents or other forms.
o Monitors and maintains infection control practices according to established standards.

Examples of types of interventions can include: lifestyle counselling, chronic disease management,
medication management, referrals or links to community resources, wound care, suture/staple removal*,
insulin starts, specimen collection, INR adjustment*, injections, dressing changes, immunizations*, co-
ordinating services, ear syringing*, wart treatment*, foot care*, assisting with procedures, etc.

In some provinces the following interventions are also possible with appropriate documentation or use of
best practice guidelines. Please check with your provincial college or association to ensure that these
interventions are approved:

o Recommending over-the-counter medication

o Prescribing contraceptives or other medications
o Adjusting insulin doses
o Suturing minor lacerations
o INR management (adjustment of warfarin)

* May be subject to provincial college or association standards of practice or scope of practice guidelines
(link to http://www.cna-aiic.ca/CNA/practice/scope/default_e.aspx) or require additional education or
documentation such as medical directives.or best practice guidelines

C. Health education
The registered nurse provides education that is responsive to the needs of the patient to
optimize health, enhance understanding of health status, and engage the patient in managing
their own health while anticipating challenges and barriers.

The registered nurse:

o Assesses health education requirements and readiness of the patient as a component
of an overall health assessment.
o Assesses current knowledge, education and literacy levels, social supports, learning
preferences and other factors that may affect the education approach and plan.
o Acquires, develops, and evaluates teaching materials and tools, with consideration for
cultural, language, physical, intellectual, and environmental factors.
o Employs education strategies and motivational interviewing skills to support behaviour
changes to enhance health (e.g., smoking cessation, physical activity, and healthy
eating).
o Provides education related to healthy living, prevention of injury, illness and
communicable diseases, care and treatment, individual and family adjustments, and
support systems as appropriate to the patient situation.
o Engages patients in education regarding chronic illnesses such as diabetes, chronic
obstructive pulmonary disease, hypertension, cardiac disease, cancer, and chronic
pain.
o Utilizes all health-care encounters as an opportunity to identify educational needs and
provide health education (e.g., immunizations, screening, health lifestyle, smoking)
o Develops and provides a variety of educational approaches to address health topics,
including individual and group sessions, and offers these in a variety of settings to
enhance accessibility.
o Uses a variety of communication strategies, e.g., written, verbal, non-verbal, visual,
Internet, and group education.
 o Creates or advocates for an environment that facilitates patients learning and
maximizes their participation and control in meeting their health-care goals.

Examples of areas of health education that can be provided: diabetes, cholesterol, COPD, hypertension,
insulin starts, cardiovascular health, medications, inhaler use, sexual health counselling, smoking cessation,
health screening, community resources, nutrition, medication, tests and procedures, INR education, etc.

D. Health promotion and prevention of illness, injury and complications

Screening and monitoring is completed to ensure early identification of health issues and
complications associated with chronic or communicable diseases. The RN can play a key role in
the prevention of illness and promotion of health by ensuring screening mechanisms are in
place and patient-management of health is encouraged.

The registered nurse:

o Plans to prevent the onset of health issues and minimize complications arising from
disease.
o Assesses the community for strengths and opportunities to enhance health and
monitors trends that may have an impact on health. This may be done in conjunction
with the community health nurse or other community health providers.
o Conducts risk assessments in collaboration with the patient and other service providers
and develops appropriate health plans to promote health and prevent illness and
complications.
o Assesses the immunization status of all patients and ensures immunizations are
current.
o Plans and participates in a strategy to recall patients for monitoring and screening
(e.g., planned recall for diabetes, cervical screening, hypertension)
o Builds on patient and community resources in planning health promotion and illness
prevention strategies.
o Collaborates with patients, interdisciplinary teams and communities to develop,
implement and evaluate health promotion and illness prevention programs.
o Provides and co-ordinates screening for health issues such as diabetes, hypertension,
cholesterol, cancer screening, cardiovascular health, mental health, cognitive function
and osteoporosis.
o Provides counseling on health promotion and illness prevention strategies.
o Assists and supports the patient in life transitions, including palliation and death.
o Works as a navigator to ensure the appropriate referrals and connections to other
services and programs that would enable the patient to achieve their health goals.
o Monitors patient progress with respect to risk reduction and self management plans.
o Participates in the maintenance of an accurate comprehensive health record.
o Documents according to standards for completing electronic medical records where
applicable.

E. Professional role and responsibility

The registered nurse works in an ever-changing environment and, as such, invests
considerable time in maintaining their professional expertise and maintaining a strong
evidence-based approach. The RN acquires and maintains a comprehensive understanding of
health and social services as well as referral processes, including diagnostic services,
specialists, hospital care, rehabilitation and support programs, educational programs, and
community-based health agencies. They are also involved in many initiatives aimed at
improving the health-care practice, identifying risk and safety issues and facilitating resolution.
They are strong and visible role models for their profession.
The registered nurse:
o Recognizes personal attitudes, beliefs, feelings and values about health in their
interactions with patients and their families.
o Maintains and applies evidence-based knowledge to the nursing process.
o Leads or participates in research initiatives.
o Leads or participates in conference presentations.
o Demonstrates the ability to reflect on personal and team practice through a systematic
evaluation of professional competencies, acceptability, quality, efficiency, and
effectiveness of practice.
o Participates in the development, implementation, and maintenance of medical
directives, and policies and procedures that guide practice.
o Uses research findings and evidence to guide the delivery of services.
o Seeks professional development opportunities consistent with current primary care
practice, new and emerging issues, changing needs of patient populations, and
research.
o Advances primary care nursing through participation in professional development and
practice development activities, mentoring students, orientating staff and participating
in research and quality assurance initiatives.
o Provides supervision, mentorship, orientation, observational and teaching opportunities
to students ensuring that program goals and objectives are met.
o Demonstrates leadership in areas such as chronic disease management, reproductive
health, shared care models, safety and health.
o Participates in relevant meetings and committees.
o Establishes and maintains effective professional relationships and partnerships with
other organizations to benefit system integration, efficient service utilization, effective
collaboration and optimal patient care
o Identifies and collects performance and quality improvement data and initiates or
participates in a process to address identified issues.
o Completes documentation, accurate statistical data, and reports.
o Participates or leads quality improvement programs or initiatives in the practice.
o Maintains a membership with professional organizations and interest groups.
 STATEMENT OF (MINIMUM) QUALIFICATIONS

Education: Baccalaureate degree in nursing or diploma entry registered nurse

Current CPR and BCLS

Experience:
Minimum of five years experience as a registered nurse

Certificate/ Current nursing registration with the provincial/territorial professional college

Licence: or association

Knowledge: Knowledge of primary health care and the social determinants of health
Knowledge of concepts of health promotion, disease prevention,
behaviour change counselling, program planning, individual and group
counselling
Knowledge and awareness related to cultural competence
Nursing care knowledge related to primary care/community
health/chronic disease management
Knowledge of the principles of the Stanford model of self management
Understanding of the principles of collaboration
In-depth knowledge of health assessment and interventions in the family
practice context
Knowledge of acts or legislation that govern practice:
o Personal Health Information Protection Act
o Protection for Persons in Care Act
o Mental health act
o Workplace Hazardous Material Information System (WHMIS)
o Principles of routine practices (universal precautions)
o Child protection act

Competencies/ Ability to work independently and be self-directed

Skills & Ability to work well with other health-care professionals
Abilities: Ability to delegate care appropriately
Ability to be an effective change agent
Effective organizational, critical thinking, problem-solving and decision-
making skills
Excellent communication skills and ability to adapt communication styles
to meet the needs of patients, health team members and community
partners

Desirable Completion of a post entry primary health care/family practice nurse

Qualifications: education program
Certification in the administration of immunizations (or demonstration of
competency)
Specialty certification
Experience working in a family practice, community or primary health
care setting
Experience in working within a collaborative interdisciplinary team
Experience in a variety of clinical areas
Language: English
French
 Sign language
Other ____________________
Desirable Key Other primary care teams and nurses in family practice
Relationships: Other professional team members within centre and in the community
(e.g., public health, home care, pharmacists)
Community resources (e.g., community health boards, community groups
or centres, local service clubs)
Health-care institutions and specialty programs
Long-term care or nursing care facilities
Education facilities, including schools, colleges, and universities
Other: If home visiting or community work is part of the nursing role, a valid drivers
licence and access to a vehicle may be required