Position Position: Palliative Nurse Navigator (1.0 FTE) Reports To: Manager Specialized Programs

Position Summary As a key member of the Couchiching Family Health Team (CFHT), and an integral part of an interdisciplinary health care team, you will deliver nursing care in accordance with FHT policies and professional practice standards. The Palliative Nurse Navigator is a specialist in palliative care and is responsible for the planning, coordination and delivery of palliative and end of life care to patients and their families and caregivers. Working in collaboration with an interdisciplinary team, the Palliative Nurse Navigator will provide clinical and educational support and facilitate care connections across the health care sectors for clients requiring palliative care in the community. As well, you will provide expert clinical palliative leadership to support seamless, integrated care delivery. The Palliative Nurse Navigator will apply an anti-oppressive lens in supporting diverse patients, including those facing systemic barriers.

Why Join Us Join a collaborative, team-based primary care environment focused on improving access and continuity of care in the community, and be part of a progressive organization advancing Ontario Health’s Primary Care for All initiative.

Roles and Responsibilities

Screen, prioritize and process client referrals

Consult with Primary Care Practitioners and specialists and review client clinical information obtained through the Primary Care Practitioner and client health records

Provide client-centred case management, including assessment, service coordination, and evaluation, and a direct report to the Primary Care Practitioner, specialist involved in client’s care

Link with community resources, particularly supportive care and palliative care facilities and services and share information to provide the best experience for the client

In collaboration with the Primary Care Practitioner and other members of the interdisciplinary team, develop and discuss an appropriate individualized care plan with the client/family/caregiver based on best practice

Recommend and teach client’s treatment protocols and education as required

Liaise with other palliative care providers within the circle of care at palliative care rounds and provide home visits as required for integrated care delivery, adhering to the CFHT Home Visit Policy Guidelines

Palliative pain assessment and management to assist Most Responsible Primary Care Practitioner (MRPCPs) with treating pain effectively in the palliative and end of life setting in the home. Suggest and support the MRPCP with appropriate directions in order to properly treat pain

Indication to MRPCP what the patient’s current Palliative Performance Scale (PPS)



is to alert the MRPCP to any changes that may need to be addressed to help improve Quality of Life (QOL)

Implementing Edmonton Symptom Assessment Scale (ESAS) with every patient encounter to provide the MRPCP with an indication of what symptoms are paramount for the patient at any given time and assist the MRPCP with the appropriate treatment and avoid hospitalization

Actively participate in staff, team and committee meetings, if appropriate

Participate in the development, planning and evaluation of treatment, education, counselling and health promotion activities of the FHT

Promotion Activities of the FHT

Of note: The CFHT palliative care coordinator does not routinely administer symptomatic medications; however, in circumstances where a patient is experiencing significant symptoms that may be managed using medications contained within the Pain and Symptom Relief Kit available in the home, the CFHT palliative care nurse may, based on clinical knowledge, skill, and judgement and within scope of practice, administer these medications in accordance with orders provided by the most responsible primary care provider (MRPCP). All interventions must be documented in the medical record accordingly.

Work in compliance with Health and Safety laws adhering to safe work practices and procedures established by the CFHT

Other duties as required

Organizational Nursing Support

Adapt to the staffing needs of the CFHT by assisting with Nursing responsibilities in other CFHT programs and services as required

Reporting

Prepare quarterly reports and monitor daily statistical data to ensure statistics are reported to the Ministry of Health in a timely fashion

Accurate and timely documentation into the Electronic Medical Record as per the CFHT Documentation Policy. Given the changing nature of health status within the Palliative Patient, however, priority must be given to recording details of sessions and documentation must be completed within 24 hours of the appointment.

Professional Development

Maintain and develop professional competence through ongoing professional development

Stay current and aware of opportunities to implement new, evidence-based methods of client assessment, treatment and programming

Maintain and upgrade knowledge and skills

Participate in clinical projects as required

Education/Specific Job Requirements

Current Basic Cardiac Life Support





Current membership and in good standing with the College of Nurses of Ontario (CNO)

Current membership in Registered Nurses Association of Ontario (RNAO) preferred

Demonstrated understanding of client-centred case management, including assessment, service coordination, and evaluation

Demonstrated and comprehensive understanding of ethical decision-making principles, palliative care philosophy, and quality end of life care planning

Demonstrated working knowledge of community resources, particularly supportive care and palliative care facilities and services

Demonstrated evidence of sound organizational, prioritization, and conflict management skills with the ability to work well in stressful situations

Excellent communication, negotiation, teaching and interpersonal skills with the ability to work well with patients, families, all levels of staff and the community

Demonstrated ability to work well autonomously

Maintain confidentiality in accordance with the Municipal Freedom of Information and Protection of Privacy Act

Flexible to meet additional responsibilities as program demands

Positive attendance and work record essential

Able to work flexible hours including evenings if required

It is a condition of employment that you receive the necessary vaccinations to protect against infection of COVID-19, or any similar infectious diseases, which may be recommended by governmental and publichealth authorities from time to time

Experience

Demonstrated clinical competence in nursing practice with 3-5 years recent experience working in a palliative care/oncology/hospice setting. Preference will be given to those candidates with foundations in oncology courses and CNA Palliative/Hospice Care certification

Highly experienced with physical assessment as well as competence in emotional assessment to assist MRPCP with developing an appropriate plan of care as per patient wishes

Relevant community-based or lived experience working with palliative clients, their families, and/or caregivers may be considered an asset

The Couchiching Family Health Team supports diversity, equity and a workplace free from harassment and discrimination. The CFHT is committed to an inclusive, barrier-free recruitment and selection process and workplace. If you are contacted to participate in our recruitment process, please advise the interview coordinator of any accommodations. The CFHT has an Accommodation Policy and Procedure to ensure you have access to a fair and equitable process. While we thank all applicants, only those contacted for an interview will be acknowledged.

Please submit cover letter and resume including position title in subject line to: [email protected].

Only those selected for an interview will be contacted.

Reviewed: Feb 2025

Revised: June 2026

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📌 Palliative Nurse Navigator (Winnipeg)
🏢 Couchiching Family Health Team
📍 Winnipeg