The posting
The Staff Nurse (Community Health) provides professional nursing care and clinical support to clients with particular focus on post-discharge care, chronic diseases, frailty, chronicorgan failure and complex medical conditions. The role bridges hospital, primary care and community-based services through nursing assessment, care planning, monitoring, care coordination, health education, risk identification and timely escalation. The Staff Nurse also contributes professional nursing input to preventive health, ageing-in-place and integrated community care initiatives.
Responsibilities: -
Clinical & Community Nursing
- Conduct comprehensive nursing assessments in home, community and centre-based settings, including physical, functional, cognitive, psychosocial, caregiver and environmental needs.
- Develop, implement, review and update individualised nursing care plans within professional scope and organizational protocols.
- Support transition from hospital to home, including post-discharge assessment, monitoring, care coordination and timely escalation for clients with chronic diseases, chronic organ failure and complex medical conditions.
- Monitor chronic conditions, frailty, dementia, medication adherence and other clinical risks, and recognize early signs of deterioration.
- Provide appropriate nursing interventions, health education, self-management support and caregiver guidance within the Staff Nurse's scope of practice.
- Conduct medication reconciliation, identify medication adherence or safety concerns and escalate appropriately to the relevant healthcare professional.
- Conduct home visits where nursing assessment or clinical judgement is required, assess patient, caregiver and home risks, and initiate appropriate healthcare or social-care referrals.
- Identify clients at risk of deterioration, falls, frailty, poor disease control, caregiver stress, repeated hospital utilisation or other adverse health outcomes and facilitate appropriate intervention or escalation.
- Maintain accurate nursing assessments, care plans, clinical notes, case updates, escalation records and other documentation requiring nursing accountability.
Clinical Capability, Governance & Quality
- Provide clinical guidance and training to Community Carers, volunteers and non-clinical staff on health monitoring, warning signs, safety considerations and appropriate escalation procedures.
- Participate in multidisciplinary case discussions and case reviews where nursing input is required.
- Contribute nursing expertise to the development and review of clinical workflows, protocols and escalation procedures.
- Participate in incident reviews, clinical risk management and quality improvement activities relevant to nursing and community care.
- Maintain professional practice in accordance with Singapore Nursing Board requirements, organisational policies and applicable clinical governance standards.
Community Health Programmes & Outreach
- Provide nursing and clinical input to community health programmes, preventive health initiatives, screenings and outreach activities.
- Conduct or support health education, screening, risk identification and appropriate follow-up or referral arising from community health activities.
- Advise on clinical, health, mobility, frailty, dementia and safety considerations where programmes involve clients or other vulnerable participants.
- Support community-based activities where nursing presence or clinical expertise adds value to participant health, safety or wellbeing.
- Participate in occasional weekend or after-hours activities where nursing or clinical presence is reasonably required.
Requirements: -
- Minimum Diploma in Nursing from a recognised institution.
- Registered with the Singapore Nursing Board (SNB) with a valid Practising Certificate.
- At least 5 years of relevant nursing experience, preferably including medical-surgical, community nursing, home care, transitional care, primary care or eldercare experience.
- Experience supporting older adults with frailty, dementia, chronic diseases, chronic organ failure, post-discharge needs and/or complex medical conditions would be advantageous.
- Able to conduct home visits independently, exercise sound nursing judgement, recognise clinical deterioration and escalate appropriately.
- Familiarity with community care services, care coordination and multidisciplinary working would be advantageous.
- Strong communication and collaboration skills with clients, caregivers and multidisciplinary/community partners.
- Able to translate clinical knowledge into practical guidance for caregivers and non-clinical staff.
- Comfortable with relevant clinical documentation systems, MS365 and digital tools.
