Registered Nurse – Primary Care Nurse Clinician (PCNC) Role : Role: Registered Nurse – Primary Care Nurse Clinician (PCNC)

FTE/Status: 1.0 FTE (Full-Time, Contract)

Salary Range: $41.56 – $43.23

Reports to: Manager, Qualified Practice & Integrated Care About Us : The Guelph Family Health Team is a not-for-profit, interdisciplinary primary care organization providing comprehensive, team-based care to the community of Guelph and surrounding areas. Our team works collaboratively to improve patient access, health outcomes, and system sustainability through innovative and integrated primary care services.

Position Summary : The Registered Nurse in the role of Primary Care Nurse Clinician (PCNC) works as part of an interdisciplinary team to provide knowledgeable, holistic, and comprehensive patient care with a focus on health promotion, chronic disease prevention and management, access, and system navigation. Patient education and motivational interviewing are central to this role. Working collaboratively with primary health care providers and the interdisciplinary team, the PCNC assesses, plans, coordinates, and delivers services to support patients in optimizing their health and wellness.

Care is provided at the individual, group, and interdisciplinary level and includes supporting patients and families with education, self-management, and navigation of the health care system.

Key Responsibilities

- Assess patients’ holistic health care needs using evidence-based screening and assessment tools and identify health-related goals, learning needs, readiness,



and potential barriers to lifestyle modification.
- Collaborate with patients, families, and the interdisciplinary team to develop and evaluate individualized care plans, with a focus on determinants of health and supporting patient self-management.
- Provide health education, chronic disease management, care, and treatment within the Registered Nurse scope of practice, independently, collaboratively, or under appropriately authorized delegated acts.
- Provide care through multiple formats, including virtual, telephone, and in-person care, and use current evidence, resources, and clinical guidelines to support patients and families.
- Support patients and families in navigating the health care system and collaborate with community partners to support individual and group programming.
- Accurately document assessments, interventions, and patient outcomes in the medical record.
- Develop and deliver health education programs and resources for patients, families, community members, interdisciplinary team members, and partners.
- Evaluate group, population, and community programming and contribute to health promotion activities.
- Provide education, consultation, mentorship,



and knowledge sharing to team members, health professionals, community partners, nursing students, and new Registered Nursing staff, as appropriate.
- Participate actively in staff, team, and committee meetings and contribute to the development, planning, and evaluation of health promotion activities at Guelph Family Health Team.
- Maintain ongoing professional development and remain current with primary care practice, emerging issues, changing population needs, and research.

Qualifications

- Baccalaureate of Science in Nursing.
- Maintains a certificate of competence from the College of Nurses of Ontario.
- Minimum of three (3) years of medical/surgical and/or community experience.
- Ability to function in a full-scope RN role within a collaborative and interdisciplinary primary care setting.
- Strong working knowledge of chronic disease management.
- Excellent patient education and coaching skills to support patient self-management.
- Self-directed with strong health system navigation capabilities.
- Strong organizational skills with the ability to work across multiple settings.
- Knowledge of community social and health partners is considered an asset.
- Commitment to ongoing learning and professional development. Guelph FHT is committed to diversity, equity, and inclusion and welcome all qualified applicants to join our team. We accommodate people with disabilities throughout the recruitment and selection process; Please advise Human Resources in advance if an accommodation is required.

📌 Registered Nurse – Primary Care Nurse Clinician (Full-Time, Contract) (Guelph)
🏢 Guelph FHT
📍 Guelph