Organization: Red Deer Primary Care Network (RDPCN)
Location: Red Deer Primary Care Network (RDPCN) Patient’s Medical Home and Primary Clinic
A. Position Summary
As a key member of the Red Deer Primary Care Network (RDPCN) team, the Primary Care Registered Nurse (PCRN) provides complex and comprehensive, person-centred nursing care within the Patient Medical Home (PMH). Acting as a specialty generalist, the PCRN delivers primary nursing care across the lifespan in collaboration with primary care providers (PCPs). In this largely autonomous role, employees have significant independence in their daily work within a clear framework of support, coaching, and accountability.
The PCRN in this role functions as a Generalist, providing care across a wide range of patient needs with the following Specialty Focused role that require specialized education and/or experience:
- Complex and Comprehensive Care
- Certified Diabetes Educator (Certified Diabetes Educator Certification (CDE) Required)
This position also provides opportunities for professional growth, allowing RNs to expand into other areas of clinical focus based on patient population needs, organizational priorities, and individual interests or expertise.
B. Generalist Role Competencies and Skills
Core Competencies (apply to all PCRNs)
Interdisciplinary Team Member
- Fosters collaboration and teamwork across the health system.
- Provides patient-centred care in partnership with PCPs and other providers.
- Acts as a clinical resource, promote PCN services, and support education.
- Builds strong relationships to ensure continuity and integrated patient support.
Communication & Professional Relationships
- Communicates respectfully and effectively with patients, families, and health professionals.
- Uses evidence-informed approaches to support patient goals.
- Builds health literacy, self-advocacy, and resilience for patients and care partners.
Continuous Quality Improvement
- Contributes to service development, monitoring, and evaluation using best practices and data.
- Adheres to policies while promoting a culture of safety and continuous improvement.
- Integrates relevant research and evidence-informed practices to strengthen clinical decision-making in primary care.
- Reflects on professional practice regularly and through annual Future Focus conversation with leadership to set goals and a plan for the following year.
Health Promotion & Prevention
- Promotes wellness and prevention through patient education, screening, early detection, and technology-supported programs.
- Empowers patients to actively participate in their health and well-being.
Comprehensive, Patient-Centered Care & Case Management
- Delivers care guided by primary health care principles.
- Assesses and addresses complex physical, psychological, social, cultural, and equity-related needs.
- Develops and adapts individualized care plans using strategies such as motivational interviewing.
- Demonstrates cultural sensitivity and awareness, acknowledging the influence of diverse cultural backgrounds - including Indigenous ways of knowing - on the determinants of health.
- Maintains accurate documentation, confidentiality, and ethical standards.
Navigation and Referral
- Supports patients in accessing and navigating the health system.
- Facilitates continuity, smooth care transitions, and appropriate referrals.
- Connects patients to resources, programs, and community services.
- Educates patients on self-management tools and technology-supported programs.
Skills (apply to all PCRNs)
- Able to adapt, develop new skills, and apply evidence-based practice.
- Works effectively both independently and within a team environment.
- Thrives in a complex, unstructured, and dynamic setting.
- Demonstrates initiative, problem-solving skills, and flexibility.
- Strong communication, organizational, and critical thinking skills.
- Proficient with electronic medical records and Microsoft Teams.
- Strong knowledge of clinical prevention and management strategies, including patient education.
- Skilled in motivational interviewing, behaviour change support, and self-management coaching.
C. Specialty Competencies
Complex & Comprehensive Care
Typical Referrals Include: Diabetes, Cognitive Screening, Weight Management, Frailty, Malnutrition, Tobacco Reduction/Cessation, Asthma, COPD, Hypertension, Dyslipidemia, Metabolic Dysfunction-Associated Steatotic Liver Disease, Complex Care Plan and General Navigation
Generalist Competencies and Skills
- as listed in Generalist Competency section
Interdisciplinary team member
- Serves as a resource to team members in supporting patients with complex and comprehensive care needs.
Education and Health Promotion
- Provides education on self-management: nutrition, physical activity, medication, monitoring, and prevention of complications.
Continuous Quality Improvement
- Participates in Complex Care Team Meetings and PCN Community of Practices for strategic planning and CQI.
- Contributes to Complex & Comprehensive Care pathways development.
Health Promotion & Prevention
- Promotes wellness and prevention through patient education, screening, early detection, risk reduction strategies and technology-supported programs.
- Empowers patients across the lifespan to actively participate in their health and well-being.
Comprehensive, Patient-Centred Care & Case Management
- Conducts holistic assessments, including history, physical parameters, psychosocial factors, and chronic disease-related risks.
- Provides case management for patients with multiple or complex chronic conditions.
- Collaborates with PCPs, specialists, and interdisciplinary team members to optimize care plans and support patients at risk for or living with chronic conditions.
- Monitors patient progress, identifies barriers, and adjusts interventions as needed.
- Delivers individualized education, counselling, and support to enhance patient understanding, self-management, and quality of life.
- Participates in interdisciplinary case reviews and contributes to the development of evidence-based care pathways
Clinical Procedures
- Performs capillary blood glucose, , interstitial blood glucose monitoring via continuous glucose monitoring, blood pressure monitoring, and foot assessments.
Navigation and Referral
- Connects patients with chronic and complex conditions to community resources and supports.
Certified Diabetes Educator
Typical Referrals Include: Medication Management of Type 2 Diabetes. Complex Type 2.
Note: Maintain currency Certified Diabetes Educator Certification (CDE) required
Generalist Competencies and Skills
- as listed in Generalist Competency section
Interdisciplinary team member
- Serves as a resource to team members in supporting patients with Type 2 Diabetes.
- Provides consultation, mentorship, and capacity-building support to colleagues, strengthening diabetes knowledge and management across the team.
Education and Health Promotion
- Provide advanced education on self-management: nutrition, physical activity, medication, monitoring, and prevention of complications.
- Contributes to group education programs and community outreach events to enhance diabetes awareness and prevention.
Continuous Quality Improvement
- Participates in Complex Care Team Meetings and PCN Community of Practices for strategic planning and CQI.
- Contributes to Complex & Comprehensive Care pathways development.
Comprehensive, Patient-Centred Care & Case Management
- Conducts holistic assessments, including history, physical parameters, psychosocial factors, and diabetes-related risks.
- Develops, implements, and monitors individualized diabetes care plans.
- Supports initiation/titration of medications under collaborative protocols.
- Monitors progress, identify barriers, and adjust care.
Clinical Procedures
- Performs capillary blood glucose testing, interstitial glucose measurement with continuous glucose monitoring, blood pressure monitoring, and foot assessments.
Navigation and Referral
- Triages diabetes referrals.
- Connects patients with PCN and community programs.
- Facilitates referrals to specialty services (endocrinology, ophthalmology, podiatry).
E. Qualifications
Education
- Bachelor of Science in Nursing (BScN) or. Bachelor of Nursing (BN). PCRNs without a baccalaureate currently working in this position would be exempt.
- Current registration and good standing with the College of Registered Nurses of Alberta (CRNA) with annual proof of registration.
- Certified Diabetes Educator (CDE) designation required for CDE-assigned roles.
Experience
- Minimum five years of experience preferred in a similar role within primary care or community health.
Monday to Friday (8:30 am to 4:30 pm)
1.0 FTE (38.75 hours per week)
