Staff Nurse (Community Health)

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.