The following information is designed to outline the functions and position requirements of this job. It does not identify all tasks that may be expected, nor address the performance standards that must be maintained.
General Position Summary:
This is a leadership position accountable for the quality of nursing services delivered to their unit. Oversees that staff assess, plan, implement, evaluate and document nursing care of patients in accordance with facility and departmental policies and in accordance with standards of professional nursing practice. The Nursing Clinical Leader utilizes specialized knowledge, judgment, and nursing skills necessary to assess data and plan, provide and evaluate care appropriate to the physical and developmental age of patients on his or her assigned unit. Summit Healthcare core values, Service Standards, promotion of Patient Safety Standards and support of healing environment are exhibited in all aspects of the Nursing Clinical Leader’s performance.
Essential Functions / Major Responsibilities:
Supervises staffing and scheduling needs of the unit
Makes patient care assignments based on the acuity of the patient and number and experience of staff scheduled for the shift.
Coordinates changes in staffing throughout shift.
Collaborates with Administrative Shift Coordinator/One-Call Nurse to make patient bed assignments when applicable.
Assures adequate staffing for next shift including finding coverage for sick calls, etc.
Completes all assigned departmental specific paperwork
Oversees Unit operations, patient safety.
Enters Quantros reports, medication issues, shift activity, patient and family satisfaction issues, physician issues, acuity reports, outpatient observation charge sheets (if applicable), pharmacy supply requisitions (as indicated), and LPN oversight documentation and data collection tools.
Participates in performance improvement data collection and chart review.
Supervises Personnel
Supervises staff performance and initiates critical conversations as needed.
Communicates issues and concerns to department director.
Intervenes and provides resources in critical and crisis situations.
Mediates issues between staff members, physicians, and patient/family members.
Oversees compliance with staff hourly rounding and bedside shift report
Monitors appropriate hand off of care
Researches and communicates to Department Director issues related to Quantros reports, medication issues, patient and physician complaints, and concerns identified by ancillary departments.
Mentors, coaches and develops staff.
Oversees the efficient functioning of the nursing care in the department.
Participates in employee evaluation processes.
Participates in leadership development activities.
Ensures code carts and emergency equipment is checked and functional.
Leads hospital/department initiatives as directed by department director, such as:
Monitors Bedside Shift Report
Participates in Staff Rounding for Outcomes
Monitors AIDET
Assesses patient physical, psychological, social, spiritual, educational, developmental, cultural and discharge planning needs for assigned patients and oversees activities for all other patients on unit.
Reviews patient initial interview and initial assessment with patient/family, assures completion within appropriate time frame.
Reviews available information obtained by other health care team members.
Reviews diagnostics and laboratory data and reports abnormal results to the physician(s) and other appropriate caregivers.
Completes assessment and reassessment according to patient need and as outlined in policy and Standards of Care.
Formulates a plan of care, including the discharge plan, utilizing assessment data, patient, family and health team input for assigned patients and oversees activities for all other patients on unit.
Initiates a plan of care based on patient-specific needs, assessment, data and the medical plan of care.
Goals for patient are realistic, measurable, and developed in conjunction with the patient/family.
Considers the physical, cultural, psychosocial, spiritual, age-specific, and educational needs of the patient and family in the plan of care, advocating for and supporting the patient’s rights.
Responsible for optimal patient flow through the department.
Collaborates with members of the multidisciplinary team.
Reviews and revises the plan of care to reflect changing patient needs based on evaluation of the patient’s status.
Implements the plan of care through direct patient care, coordination, delegation and supervision of the activities of the unit staff.
Provides care based on physician orders and the nursing plan of care, in compliance with policies and procedures, standards of care, and regulatory agency requirements.
Promotes continuity of care by accurately and completely communicating to other caregivers the status of patients for whom care is provided.
Assures all team members practice within their scope of care.
Evaluates the patient’s and family’s response to care and teaching and revise the plan of care as needed for assigned patients and oversees activities for all other patients on unit.
Evaluates patient progress toward goals and expected outcomes in collaboration with other health care team members.
Evaluates patient’s response and the effectiveness of patient teaching. Documents assessment, planning, implementation, and evaluation in the patient record for assigned patients and oversees activities for all other patients on unit.
Documentation is legible, timely and in accordance with policy.
Documentation reflects objective/subjective data, nursing intervention and patient’s response to treatment
Reviews and notes physician’s orders accurately and in a timely manner.
Promotes professional development within delivery of care.
Maintains clinical performance competencies appropriate to the area worked as demonstrated through annual validations
Participates in and attends internal and external educational in-services for continuing/ongoing education, including, but not limited to leadership training.
Incorporates, supports, and participates in concepts of shared leadership at both departmental and organizational level.
Utilizes evidence based practice or research within clinical practice. Actively participates in performance/quality improvement processes including national nursing quality indicators.
Interacts and participates in the education/orientation of hospital personnel, patients, students, families and visitors. Promotes/supports growth of others.
Seeks opportunities for growth in the profession of nursing such as participation in professional nursing organizations and/or attaining specialty certification pertinent to the area in which they work.
Displays proper behaviors that reflect the SHINE Behavior Standards.
Promotes the Patient Safety Standards as a core value of the organization.
Secondary Functions:
· Participates in greater than or equal to 75% of all department staff meetings, unit leadership meetings, and NCL/ASC meetings.
· Participates in hospital wide informational meetings and inservices, hospital wide forums, and seminars.
· Reviews department and hospitalwide policies and procedures annually.
· All other duties as assigned.
Additional Responsibilities:
· Completes all tasks as expressed in the Skills Delineation List.
Job Scope:
This job involves:
· May assist other nursing units within scope of training.
· Recurring work situations with occasional variations from the norm.
· A moderate to high level of complexity.
· Operation from established and well-known procedures.
· Performance of duties under moderate supervision.
· Assigned to be “On-Call” for emergency back-up as needed.
Supervisory Responsibility:
· Delegates appropriately and provides nursing supervision in the provision of care to patients by other licensed nurses and other personnel.
Interpersonal Contacts:
Contacts:
· Are normally made with others both inside and outside the hospital.
· Are usually made with own department staff and supervisor as well as with other departments or locations.
· Frequently contain confidential/sensitive information necessitating discretion at all times.
· Are usually face-to-face, with some contact by telephone and e-mail.
· Are usually with patients, with some physician contact.
Specific Job Skills & Mental Activities:
This position requires general nursing skills and knowledge of general office equipment (including the nurse call system, telephone system, fax machine, copy machine, computer, and commonly used hospital programs) as well as excellent computer communication, critical thinking, problem solving, leadership, supervisory, interpersonal skills, basic math skills, and the ability to exercise independent judgment skills when necessary. This position also requires knowledge of hospital equipment and programs, including all Hospital Information Systems and department specific equipment. This position requires self-direction and self-motivation. Must be able to read, write, speak, and understand English.
Physical Demands & Job Conditions:
Exert up to 100 lbs. of force occasionally, and/or up to 50 lbs. of force frequently, and/or up to 20 lbs. of force constantly to move objects. The worker is subject to on-call status, contact with chemicals, contact with infectious fluids, heavy lifting, constant standing, and encounters with upset/disturbed individuals.
Physical motions include finger dexterity, standing, walking, stooping, crawling, talking, reaching, feeling, sitting, bending, kneeling, climbing, grasping, listening/hearing, handling, lifting up to 50-100 pounds with assistance, and repetitive motions of the hands, wrists, and feet.
This is a safety sensitive position.
OSHA Exposure Category:
Involves exposure to blood, body fluids, or tissues.
