POSITION SUMMARY / PURPOSE
Incumbents of this position are professional Registered Nurses that utilize the nursing process (assessment, planning, intervention, documentation, and evaluation) to provide direct and indirect patient care based on area(s) assigned, addressing the age appropriate needs of all patients. Follows nursing department philosophies, policies and procedures to develop unique education and care plans for each patient and provide appropriate education and support for family members. Utilizes judgment, knowledge, and understanding of patient and family needs when directing ancillary staff. Responsible for ensuring customer satisfaction (patient, family, physician, others), maintaining patient confidentiality and being sensitive to the age specific patient needs for comfort, privacy and generalized care.
ESSENTIAL FUNCTIONS
Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients.
Performs all responsibilities/duties required by the Unit as defined in the scope of service, to ensure that the unique nature of the client is addressed. This includes, but is not limited to the age of the client served.
Performs admission assessment within twenty four hours of admission or in accordance with specific unit standards.
Identifies and documents patient’s plan of care within eight hours of admission.
Identifies and documents patient/family/significant other teaching needs upon admission.
Identifies discharge planning needs of patient/family/significant other in collaboration with Case Manager.
Verification of patient identity is conducted following hospital procedure.
Identifies priorities and executes nursing care appropriately.
Develops, discusses, and communicates a plan of care for each patient, in collaboration with the healthcare team and including the patient/family/significant other in order to address all identified needs.
Plan of care will include interventions and discharge outcomes for each identified problem.
Demonstrates the skills and judgment necessary to implement the medical plan of care, nursing interventions, and procedures as necessary for the care of the patient.
Demonstrates knowledge of policies and procedures for administering, transcribing, and recording medications.
Demonstrates knowledge of commonly used medications and their action, dose, and side effects.
Observes the five “rights” (R’s) for administering meds: right patient, right drug, right dose, right method, and right time.
Demonstrates proper procedures in all methods of medication administration, including documentation.
Administers blood and blood products following policy and procedures, if applicable.
Initiates and maintains IV access according to policy and procedures, if applicable.
Demonstrates knowledge of policies and procedures for Pyxis stations, if applicable.
Assesses and documents IV site per unit standard, if applicable.
Per unit standards, evaluates the identified problems, care provided and patient’s responses are reassessed to meet patient and family needs to ensure overall quality of care delivered.
Reassessment of plan of care is done on an ongoing basis, until outcomes are met or discharge.
Based on reassessment, plan of care will remain the same or be modified to meet the patient/significant other’s identified needs.
Documents outcomes of patient care.
Assesses the patient’s/significant other’s response to teaching plan in order to evaluate the effectiveness of the plan.
Maintains up‑to‑date and accurate documentation of nursing care provided to ensure the integration of information for use by the healthcare team, to ensure quality care.
Interagency communication referral forms are complete and accurate.
Nursing assessment is complete and documented per unit standard.
Discharge plan and documentation accurately reflects patient and/or significant other’s ability to manage care after discharge. Referrals are made based on identified needs.
Maintains current knowledge/certification/licensure per Hospital policy. Pursues professional growth and development. Attends all required Safety Training programs and can describe his/her responsibilities related to general safety, department/service safety, and specific job‑related hazards.
Practices within legal boundaries of nurse practice act and according to Hospital policy and procedures.
Attends Hospital sponsored training programs as required by department.
Maintains CPR certification.
Attends continuing education programs in order to maintain certification.
Completes Mandatory Health stream Education.
Operates assigned equipment and performs all procedures in a safe manner as instructed.
Maintains work area and equipment in condition required by department standards.
Demonstrates proper body mechanics in all functions.
Completes identified unit specific competencies.
Functions as a role model for current and new staff.
Facilitates problem resolution among peers.
Demonstrates a constructive approach during all interactions with staff and nurse manager.
Accepts assignment as preceptor for new staff.
Demonstrates willingness to assume charge nurse role as required.
Based on patient care needs and skills of caregiver, delegates responsibilities accordingly.
Follows the Hospital Exposure Control Plans/Blood borne and Airborne Pathogens.
Demonstrates knowledge of techniques, procedures, and correct use of protective barrier equipment.
Ensures a safe environment by instituting appropriate control measures.
Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
Interacts with all of the above in a considerate, helpful, and courteous manner. Fosters mature professional relationships with fellow employees in a courteous, friendly manner as measured by management observation and peer input.
Maintains professional composure and confidence during stressful situations.
Conducts all work activities with respect for rights and wishes of patients, visitors, families, and fellow employees.
Maintains confidentiality of all hospital and patient information at all times as observed by peers and management.
Presents neat appearance in proper attire and identification as required by the position, department, and policy.
Continuously displays a positive attitude within the department and across departmental lines to contribute to the overall customer service program in place.
Maintains open communication using appropriate chain of command regarding issues.
Promotes effective working relations and works effectively as part of a department/unit team inter- and intradepartmental to facilitate the department’s/unit’s ability to meet its goals and objectives.
Participates in staff meetings as determined by department Director/staff manager.
Supports the Hospital’s mission, policies and procedures through attendance and participation at committee meetings, if applicable.
Utilizes automated system to communicate inter- and intradepartmental, as appropriate.
Completes work assignments on time/readily accepts assignments. Reports to work on time and is at work as scheduled.
Culture of Caring: Displays and upholds CHH core values of dignity, compassion, service excellence, community and integrity. Consistently demonstrates caring for patients, for one another, and for the organization they are part of, and contributes to building trust, pride and camaraderie.
Participates in quality and performance improvement activities as assigned by department Director/staff manager. Brings ideas forward to improve quality of care delivered in department.
JOB KNOWLEDGE, SKILL REQUIREMENTS, AND DESIRED ATTRIBUTES
Handles multiple priorities, independent discretion/decision making, manages stress appropriately, works alone effectively, works in close proximity to others and/or in a distracting environment, works with others effectively. Demonstrate skills in reading, writing, be able to communicate effectively. Must have strong organizational skills and ability to problem solve. Must have ability to work collaboratively with physician, nursing team and patient.
Demonstrates ability to use computer technology, electronic medical records specific to the units.
