The Registered Nurse is responsible for providing clinical oversight, nursing guidance and health-related coordination across Supporting Your Independence participant services.

Support Plan Review, Development and Distribution

• Regularly review participant support plans and care plans to ensure health and clinical information remains current, accurate and reflective of the participant’s individual needs.
• Develop, update and contribute to participant health-related care plans, nursing plans, risk management strategies and clinical protocols.
• Review support plans and care plans following hospital admissions, medical appointments, changes in diagnosis, medication changes, incidents or significant changes in participant presentation.
• Ensure relevant clinical recommendations are incorporated into participant support documentation.
• Coordinate the distribution of updated support plans, care plans and clinical documentation to relevant employees and management.
• Clearly communicate when plans have been updated and identify any changes requiring immediate implementation.
• Ensure superseded clinical instructions are removed or appropriately archived to reduce the risk of employees working from outdated information.

Participant Routine Development and Review

• Develop and review participant routines in consultation with participants, management, employees and relevant health professionals.
• Ensure routines appropriately incorporate health, medication, nutrition, hydration, continence, bowel management, sleep, mobility, personal care and other clinical considerations.
• Update routines where participant needs or clinical recommendations change.
• Ensure routine changes are clearly communicated to employees and management.
• Provide practical guidance to employees regarding how clinical requirements are incorporated into the participant’s everyday routine.
• Monitor whether established routines continue to meet participant needs and escalate concerns where changes are required.

Clinical Assessments and Monitoring

• Undertake nursing assessments as required to identify participant health needs, risks and changes in presentation.
• Conduct ongoing clinical reviews based on participant needs and identified risks.
• Assess areas including, where relevant:
• skin integrity and wound management;
• continence;
• bowel management;
• nutrition and hydration;
• mobility;
• respiratory health;
• seizure management;
• diabetes management;
• catheter care;
• medication management;
• pressure care;
• swallowing and aspiration risks;
• pain;
• sleep;
• infection risks; and
• general deterioration or changes in health status.
• Document assessment findings and develop appropriate recommendations, actions and escalation pathways.
• Identify clinical risks requiring GP, specialist, hospital or allied health intervention.

Specialist and Medical Appointment Attendance

• Attend specialist, GP, hospital and allied health appointments where clinical representation or nursing input is required.
• Prepare relevant clinical information and participant documentation prior to appointments.
• Provide treating practitioners with accurate information regarding the participant’s current presentation, routines, medication, incidents and support requirements.
• Seek clarification of medical recommendations where required to ensure instructions can be safely implemented within the participant’s support environment.
• Document appointment outcomes and clinical recommendations.
• Communicate relevant outcomes to management, support workers and participants where appropriate.
• Ensure recommendations arising from appointments are incorporated into relevant participant plans, routines and clinical documentation.

Clinical Communication

• Act as a central clinical communication point between participants, employees, management and external health professionals.
• Ensure significant clinical information is communicated promptly, accurately and through appropriate organisational communication channels.
• Provide clear written instructions for employees where clinical requirements change.
• Translate complex medical or clinical information into practical instructions suitable for implementation by support workers.
• Participate in participant reviews, stakeholder meetings, case conferences and clinical discussions where required.
• Escalate significant health concerns to management and appropriate health professionals.
• Maintain appropriate professional boundaries and confidentiality when communicating participant health information.

Medication Management and Changes

• Review participant medication information and medication administration documentation.
• Ensure medication information available to employees is consistent with current prescribing instructions and pharmacy documentation.
• Communicate medication changes promptly to relevant employees and management.
• Ensure changes including:
• commencement of medication;
• cessation of medication;
• dosage changes;
• administration time changes;
• PRN medication instructions;
• short-course medications;
• medication administration requirements; and
• medication-related monitoring requirements are clearly documented and communicated.
• Liaise with pharmacies, medical practitioners and management regarding medication discrepancies or clarification requirements.
• Support the safe transition of medication information following hospital admission or discharge.
• Review medication incidents or errors and provide clinical recommendations regarding follow-up actions.
• Provide clinical guidance to employees regarding medication administration within their authorised scope and organisational procedures.
• Develop and implement PRN protocols for all PRN medication, creams and the like.

Polypharmacy and Medication Reviews

• Ensure annual polypharmacy reviews are completed for each participant
• Ensure interim polypharmacy reviews are completed for each participant where there is significant medication of health condition changes.
• Coordinate and support medication reviews with participants, GPs, specialists, pharmacists and other relevant practitioners.
• Monitor for reported or observed medication-related concerns including sedation, behavioural changes, mobility changes, appetite changes, constipation, dizziness or other potential adverse effects.
• Escalate concerns regarding possible medication interactions or side effects to the appropriate prescribing practitioner or pharmacist.
• Support regular medication reviews for participants receiving multiple medications.
• Ensure recommendations resulting from medication reviews are reflected within participant support plans and care plans communicated to the support team.

Clinical Guidance to Employees

• Provide accessible clinical guidance and support to support workers and management.
• Assist employees to understand participant-specific health conditions and clinical requirements.
• Provide clinical direction regarding changes in participant presentation and appropriate escalation pathways.
• Develop practical clinical guidance documents, instructions and resources where required.
• Support employees to recognise early signs of deterioration or changes in participant health.
• Reinforce when employees should contact the Registered Nurse, management, GP, specialist, Healthdirect, emergency services or other appropriate services.
• Provide education and clarification regarding participant-specific clinical procedures.
• Ensure employees understand the importance of accurate documentation, observations and escalation.

Health Deterioration and Clinical Escalation

• Review reported changes in participant health or presentation and provide appropriate clinical guidance.
• Assist management and support workers in determining appropriate escalation pathways.
• Review clinical incidents and identify whether further assessment, treatment, monitoring or plan changes are required.
• Ensure post-hospital and post-emergency department recommendations are appropriately implemented.
• Support participants following hospital discharge by reviewing discharge documentation, medications and follow-up requirements.
• Coordinate required follow-up appointments, assessments or monitoring.

High Intensity Supports

• Provide clinical oversight for participants receiving High Intensity Daily Personal Activities where applicable.
• Contribute to the development and review of participant-specific high-intensity support plans and care plans.
• Ensure instructions clearly outline participant risks, procedures, monitoring requirements and escalation processes.
• Support competency-based training and assessment processes where relevant to nursing scope and organisational requirements.
• Monitor ongoing implementation of high-intensity support requirements and recommend changes where necessary.

Clinical Documentation and Record Keeping

• Maintain clear, accurate and timely clinical documentation.
• Ensure clinical recommendations, assessments and communications are recorded within appropriate participant records.
• Review health-related documentation for accuracy and consistency.
• Ensure clinical records support continuity of care between employees, management and external healthcare providers.
• Maintain confidentiality and appropriate handling of participant health information.

Training and Education

• Provide participant-specific clinical education and guidance to employees.
• Assist with identifying training needs arising from participant health conditions or changes in support requirements.
• Develop or contribute to training materials, clinical guides and competency resources.
• Participate in employee induction and refresher training where clinical content is required.
• Provide education following significant clinical incidents or changes in participant care requirements.

Clinical Governance and Continuous Improvement

• Contribute to Supporting Your Independence’s clinical governance and quality improvement systems.
• Identify trends, recurring concerns or areas where participant clinical supports could be strengthened.
• Participate in reviews of clinical incidents, medication incidents and health-related risks.
• Recommend improvements to clinical systems, documentation, procedures and communication pathways.
• Support management to maintain safe and consistent health-related practices across participant services.