Description
SUMMARY OF THE POSITION
A person who assumes responsibility for a range of nursing care based on the bio-psycho-social needs of the patients or groups of patients entrusted to their care. They assess the patient's health status, determine and ensure the implementation of the nursing care plan and treatment plan. They initiate and provide nursing and medical care and treatments to maintain and restore health and prevent illness. They may prescribe laboratory tests, treatments, products, medications, and dressings in the areas of wound care and public health, in accordance with applicable regulations.
They plan, deliver, and evaluate education for patients, their families, and groups of people. They participate in research aimed at promoting health and preventing disease.
SPECIFIC FUNCTIONS
The Care Team Nurse delivers holistic, evidence-informed, and person-centered care within an interdisciplinary team, promoting health, preventing disease, and ensuring coordinated, continuous care across the lifespan. Integrating physical, psychological, social, cultural, and spiritual dimensions, the nurse fosters therapeutic relationships, advocates for equity and client self-management, and supports informed decision-making. Through collaboration, accurate documentation, and evidence-based practice, the nurse enhances accessibility, quality, and population health outcomes while contributing to continuous improvement in care delivery.
• Provides preventive care through evidence-based screenings (cancer, diabetes, cardiovascular risks), immunizations, CE-CLE screening, and lifestyle counselling (nutrition, activity, sleep, substance use);
• Delivers integrated chronic disease management for conditions such as diabetes, hypertension, COPD, CKD, and heart failure through assessment, monitoring, medication support, and client education to promote self-management;
• Conducts mental health assessments, provides supportive interventions, maintains therapeutic relationships, and coordinates with mental health professionals for specialized follow-up;
• Offers pediatric, sexual, and elder care: ensures child immunizations and growth monitoring, provides sexual health counselling (contraception, STBBI, pregnancy options), and performs functional and cognitive assessments for older adults, including dementia-related support;
• Addresses minor non-urgent issues through focused assessment, triage, guidance, and referral, ensuring timely and continuous care;
• Ensures seamless communication and coordination across healthcare professionals and settings to support continuity of care;
• Manages referrals, results follow-up, and documentation while applying standardized protocols and maintaining accurate clinical data;
• Conducts comprehensive biopsychosocial assessments, develops and adapts individualized care plans, and advocates for client needs and equitable service access;
• Promotes self-management, health literacy, and empowerment through education and collaboration;
• Uses data-driven panel management to identify care gaps, perform proactive follow-up, participate in team huddles, and align interventions with population health goals;
• Maintains reliable EMR documentation and contributes to ongoing quality improvement and evidence-informed practice;
• Performs any other related duties as required.
REQUIREMENTS
Education and Experience:
• Must be a member of the Ordre des infirmières et infirmiers du Québec (OIIQ).
• Two (2) years of diverse experience as a nurse in direct client care
Knowledge and Abilities:
• Strong interpersonal skills and experience in interdisciplinary teamwork and case management;
• Knowledge of Cree culture, social issues in Eeyou Istchee, and sensitivity to cultural diversity;
• Solid understanding of chronic diseases, strong clinical assessment, and critical thinking abilities;
• Excellent therapeutic communication, listening, and counselling skills;
• Ability to handle stress, adapt to change, and work in new environments;
• Self-directed, proactive, and accountable in managing responsibilities;
• Capacity for observation, analysis, synthesis, and problem-solving;
• Competent in EMR systems, data-driven decision-making, and motivational interviewing;
• Commitment to evidence-informed practice, ethical standards, and continuous improvement;
• Demonstrates empathy, cultural openness, and respect in all interactions.
Language:
• Fluent in English;
• Fluency in Cree or French is an asset.
Other:
• A skill-based test may be required;
• This position includes on call duty periods;
• Based in a Community Medical Center within an interdisciplinary team; may include outreach or community activities, with regular hours and flexibility for client or program needs.
