Summary
Provides direct
and indirect patient care on the Med/Surg unit. Communicates with Physicians/Nurse
Manager/co-workers, as appropriate about changes in patient’s clinical
condition, including results of diagnostic studies and symptomology. Able to respond quickly and accurately to
changes in condition or response to treatment. Able to perform general nursing
duties in all departments with adequate supervision. Participates in
performance improvement and CQI activities. May also function in the role of
Charge Nurse under the supervision of the Director of Inpatient Services.
Communicates on behalf of the patient (patient advocate); care provided
reflects the mission, ethics and goals of the facility, as well as the focus
statement the department.
Essential Duties and Responsibilities
- Monitors and supervises patient care, including
diet and physical activities. Communicates appropriately and clearly to
departmental charge nurse or director, co-workers, and physicians.
- Prepare patients for and assists with
examinations or treatments or procedures to assist physicians.
- Performs a head-to-toe assessment on all
patients and reassessments as per policy.
Able to interpret data about the patient’s status in order to identify
the care needed.
- Adequately assess and reassess pain. Utilizes appropriate pain management
techniques. Educates the patient and
families regarding pain management.
- Perform waived testing (point-of-care testing),
draw blood for lab testing as needed, interpret results and take appropriate
actions per Clinical Laboratory’s and the patient care unit’s policies and
procedures.
- Makes decisions reflecting knowledge of facts,
knowledge of diseases/surgical conditions, care required and good judgment.
Identifies physical symptoms and changes, reports changes to surgeon/ physician,
and initiates appropriate actions.
- Knowledge of medications and IV fluids and
their correct administration, based on age of the patient and the patient’s
clinical condition. Administers medications safely using the five medication
rights and reduces the potential for medical errors.
- Knowledge in maintenance and care of central /
PICC line.
- Knowledge of cardiac monitoring and can
identify dysrhythmias, notifies physician of changes, treat appropriately based
of facility protocol.
- Able to perform the techniques of
cardiopulmonary resuscitation accurately and effectively.
- Performs patient care in an environment that
optimizes patient safety and reduces the likelihood of medical/health care
errors.
- Ability to formulate an individualized plan of
care, modify patient treatment plans as indicated by patients’ responses and
conditions and evaluate overall plan daily for effectiveness. Involves
patient/family in plan of care.
- Keeps abreast of changing techniques in nursing
and maintains a high level of expertise in patient care.
- Ability to be flexible, organized, and function
under stressful situations.
- Assists in emergency nursing procedures
necessary for prompt control of changes in patient’s physical condition.
- Treats patients and their families with respect
and dignity, maintains an environment that provides the patient and family
feelings of safety and security, practices good guest relations.
- Maintains a good working relationship and
effective communication both within the department and with other departments
for the benefit of the patient. Consults other departments as appropriate to
provide for an interdisciplinary approach of meeting patient needs.
- Ensures completion of documentation, including
but not limited to, H/P, consents, handoff communications tool, medication
administration, pre-anesthetic questionnaire, medication reconciliation form,
and allergies.
- Practices economical use of equipment and
supplies, informs proper authority of discrepancies.
- Provides education to staff on performance
improvement. Ability to provide in-service training for unit staff members,
participates in guidance and educational program.
- Demonstrates ability to perform treatments and
provide services to level of licensure.
Charge Nurse Responsibilities
- Updates Table for Inpatient Log Census.
- Completes Patient Classification Form to assure
efficient staffing levels and patient assignments.
- Verifies that temperature logs completed.
- Oversee all staff on the Med Surg Unit.
- Follows protocol for admitting a patient and
activation of call team.
- Initiates emergency response protocol.
- Effectively communicates pertinent issues with
Med/Surg Director.
- Supervises dietary after hours.
- Follows up on consults and outstanding orders.
- Follows protocol for patient transfers.
- In charge of room assignments, assists with
admits and discharges and ensures minimal delays in patient treatment.
Core Competencies
Action
Orientation - Targets and achieves results, overcomes obstacles, accepts
responsibility, establishes standards and responsibilities, creates a
results-oriented environment, and follows through on actions.
Communications
- Communicates well both verbally and in writing. Effectively conveys and
shares information and ideas with others. Listens carefully and understands
various viewpoints. Presents ideas clearly and concisely and understands
relevant detail in presented information.
Creativity/Innovation
- Generates novel ideas and develops or improves existing and new systems that
challenge the status quo, takes risks, and encourages innovation.
Critical
Judgment - Possesses the ability to define issues and focus on achieving
workable solutions. Consistently does the right thing by performing with
reliability.
Customer
Orientation - Listens to customers, builds customer confidence, increases
customer satisfaction, ensures commitments are met, sets appropriate customer
expectations, and responds to customer needs.
Interpersonal
Skills - Effectively and productively engages with others and establishes
trust, credibility, and confidence with others.
Leadership
- Motivates, empowers, inspires, collaborates with, and encourages others.
Builds consensus when appropriate. Focuses team members on common goals.
Teamwork
- Knows when and how to attract, develop, reward, and utilize teams to optimize
results. Acts to build trust, inspire enthusiasm, encourage others, and help
resolve conflicts and develop consensus in creating high-performance teams.
Professional Requirements
- Meets dress code standards; adheres to dress
code policy.
- Completes annual education requirements.
- Maintains regulatory requirements.
- Maintains patient confidentiality at all times.
- Reports to work on time and as scheduled,
completes work within designated time.
- Wears identification while on duty, uses
computerized punch time system correctly.
- Completes in-services and returns in a timely
fashion.
- Attends annual review and department
inservices, as scheduled.
- Attends monthly staff meetings.
- Represents the organization in a positive and
professional manner.
- Actively participates in performance
improvement and continuous quality improvement (CQI) activities.
- Complies with all organizational policies
regarding ethical business practices.
- Communicates the mission, ethics and goals of
the hospital, as well as the focus statement of the department.
- Promotes professional growth of subordinates by
sharing knowledge and/or directing them to sources if information appropriate
to given situation. Utilizes journals, books, etc. to learn and/or improve new
techniques and equipment.
- Assists other staff members in performing any
duty that enhances the delivery of patient care.
- Critical Care experience preferred.
Advanced Orthopedic and Spine
Certification Requirements
(CR.1c) As part
of the Advanced Orthopedic and Spine Certification, at a minimum, the Program
direct-care staff, must have eight (8) hours of education specific to the
Program scope, initially, and at least annually thereafter.
(CR.1e) As part
of the Advanced Orthopedic and Spine Certification, staff possess adaptability
to processes as related to up-to-date best practices, collaboration between
departments, compliance with protocols/processes, communication, cooperation
and exceptional customer service.
Within 90 days
of hire or, if currently employed, within 90 days of signing the job
description, must adhere to:
- Orientation of Advanced Orthopedic and Spine
Certification.
- In compliance with the Program education
requirements.
- Completed department specific competencies.
Regulatory Requirements
- Graduate of accredited school of nursing
- Current state Registered Nurse Licensure,
within state of practice
- Current BLS and ACLS certification
- PALS
certification recommended
Skills
Ability to communicate effectively in English,
both verbally and in writing.
Basic
computer knowledge.
Physical Demands
The physical
demands described here are representative of those that must be met by an
employee to successfully perform the essential functions of this job. While
performing the duties of this job, the employee is regularly required to talk
and hear. This position is very active and requires repetitive motions, standing,
walking, bending, kneeling and stooping all day. The employee must frequently
lift or move items weighing up to 50 pounds.
