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Registered Nurse Transition Care Unit

Humber River Regional Hospital

This is a Full-time position in Victoria, BC posted July 18, 2021.

Position Profile Join our interprofessional team as we provide strong patient centered care in a dynamic, rapidly changing environment where we drive for change and innovation.

At Humber River Hospital’s Nephrology Program, we by utlilize a chronic disease prevention and management (CDPM) and self-management approach and philosophy, as the Program continues to achieve the deliverables under the Ontario Renal Network, and strives to achieve the targets of the Ontario Renal Plan II: Empower and support patients to be active in their care Integrate patient care throughout the kidney care journey Improve patient access to kidney care As we continue to advance our patient centred Nephrology Porgram, we have an exciting opportunity for a Registered Nurse to work in our Transition Care Unit .

The goal of the TCU is to provide a venue for patient engagement, psycho-social and emotional support, education, and comprehensive renal management.

Patients and their family will receive specialized care and a sequential delivery of services in an effort to bring about a positive experience in selecting a renal replacement treatment.

The Registered Nurse is responsible for addressing the needs of a unique patient population.

Using a case managed approach, the Registered Nurse coordinates the dialysis services for patients residing in their homes and congregate living.

The Nurse will assess, educate, and train patients, family, and external service providers on independently performing the hemodialysis treatments in the community.

The Nurse working in the Transition care unit Program will take a comprehensive approach to providing care for dialysis patients living at Home.

As an integral team member of the Nephrology Program, there is an opportunity to participate within the program by utilizing a chronic disease prevention and management (CDPM) and self-management approach and philosophy, as the Program continues to achieve the deliverables under the Ontario Renal Network, and strives to achieve the targets of the Ontario Renal Plan III.

Do you have strong strong communication skills with a clear patient focus, ability to manage execution, and find creative solutions to potential barriers for patient success at home?

If you answered yes to any of the questions above, we invite you to read the details below and apply to this exciting career opportunity at Humber River Hospital.

Reporting Relationship: Manager, Transition Care and Home Dialysis Program Hiring Salary Range : $33.90-$48.53 Position Responsibilities: Performing all aspects of the patient’s dialysis care and support, both within the Hospital and the community, within the Registered Nurse’s scope of practice Train, monitor, and support service providers in providing Home dialysis to patients where necessary, and identifying and addressing any gaps in the provider’s knowledge, skill or ability Maintain quality assurance by monitoring the dialysis quality and patient outcomes Facilitate patients transitions of care between the hospital and Home Facilitate the communication between the program and Home dialysis Team Coordinate the multidisciplinary clinic visits as per the guidelines within relevant Standards of Care Initiation of kidney transplant work up and referral services for patients who are interested in pursuing a living donor kidney transplant Demonstrating a commitment to ongoing professional development within an evolving field Provide ongoing assessment, education, training, guidance and decision support for patients/families and support service providers as it relates to independent dialysis, including addressing any inquiries or troubleshooting Engage the interdisciplinary team in a collaborative approach to professional practice issues and acts in the role of liaison between all members who participate in the care of the patient and their family Apply relevant research to clinical practice using critical thinking and decision making; utilizing research/evidence based information to recommend nursing interventions Perform home visits as part of the transition process to home dialysis, equipment set up, and monitoring of the first treatment outside the hospital in tandem with the Renal Technician.

Communicate, collaborate, and coordinate services with vendors including, but not limited to, Fresenius Medical and NxStage Requirements: Registered and in good standing with the College of Nurses of Ontario BLS Provider certified required Dialysis experience using various machines (NxStage, Baxter AK, and Fresenius 5008S) is preferred Experience in case management and working independently within both hospital and community settings Demonstrated proficiency in adult education, teaching and developing training plans for patients, families, and community partners Exceptional written and verbal communication is a requirement Proficiency in using Microsoft office (Word, Outlook, Power Point and Excel) Exceptional physical assessment skills, high degree of critical thinking, and clinical nursing knowledge required Ability to address a broad range of psychosocial needs Ability to establish positive therapeutic relationships with patients and families Demonstrated commitment to quality improvement, service improvement, and commitment to continuous learning Exceptional interpersonal skills, compassion and emotional intelligence, and cultural competence required in order to effectively work with a diverse and vulnerable patient population Ability to work in an effective and collaborative manner with all members of the multidisciplinary team including external business and community partners Demonstrated excellent organizational skills Ability to be flexible and effective within a dynamic and complex clinical environment Demonstrates exceptional clinical documentation practices Demonstrates fiscal responsibility Demonstrated understanding of and commitment to Humber’s comprehensive safety programs and practices, including staff, patients and environmental safety, and participation in regular in-services and continuous education as it relates to the role Excellent attendance record Access to reliable transportation for home and community visits The ideal candidate is strong in patient centered care in a dynamic, rapidly changing environment and should be ready to drive change and innovation.

We require a person with strong communication skills with a clear patient focus.

This candidate has the ability to manage execution, find creative solutions to potential barriers for patient success at home and fosters teamwork and cooperation.

Hours of work: Available to work rotating shifts including weekends, day and evening shifts.

Employee Group: ONA Location: Church Why Humber?

Why Now?

Humber River Hospital is on an exciting transformation journey of redefining patient care as we leverage the most advanced technologies to enhance all aspects of delivering high-quality, safe care.

We continue to build a people-centered workplace with excellent staff and physician engagement by hiring passionate, diverse and inclusive healthcare professionals.

People who care and live our values of Compassion , Professionalism and Respect .

People who are committed to making a positive difference.

We are a Studer Group hospital, focused on building our evidence-based leadership practice and hardwiring a culture that WOWs.


Because at Humber River Hospital, we know it’s our people and our ability to innovate that allows us to consistently deliver a great patient experience and the best quality outcomes.

After all, we are the hospital that believes exceptional carehealthier community .

This description has been designed to indicate the general nature and level of work performed by the employee within this position.

However, the actual responsibilities, duties, qualifications and experience may vary.

Employee may perform other related duties as required to meet the ongoing needs of the organization.

Information contained in this job posting/description is subject to change.

Humber River Hospital is committed to inclusion and diversity.

We believe that diversity drives our culture of innovation.

By bringing together a variety of different perspectives, it fuels our creative thinking, generates new ideas and creates solutions designed to address tomorrow’s healthcare challenges today.

We take pride in providing professional development and career advancement opportunities for our employees including minorities, women, veterans and individuals with physical and developmental disabilities.

We also provide accommodation to applicants and all of our employees
– from hire to retire.

Let us know what we can do to help you be successful during your recruitment experience at Humber River Hospital.

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