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Job Summary
Provides clinical direction for all aspects of patient care in an acute inpatient setting, fostering patient/family centered care. Demonstrates clinical competency utilizing evidence-based practices/research in all areas of the nursing process: assessment, planning, implementation, evaluation and outcomes. Incorporates knowledge of safety protocols, cost containment and quality improvement throughout the nursing process. Identifies patient, unit and organizational priorities and incorporates into the nursing process.
Adheres to all compliance and policy/procedures of the organization including, but not limited to: licensure renewal, assigned training, employee health screenings, time and attendance policy, dress code policy, patient confidentiality, infection control, medication administration. Demonstrates knowledge of regulatory agency requirements (TJC, SC DPH, CMS). Provides care within the scope of the South Carolina Nurse Practice Act.
The acute inpatient setting may require staff to be scheduled for a weekend, holiday, and on-call work.
Accountabilities
Assessments:
- Collects data and completes nursing assessment utilizing appropriate area and/or age-specific standards/policies and tools. Completes appropriate forms. Assesses and recognizes subtle or actual changes in patients' status and patient response to intervention. Identifies nursing priorities for patient plan of care based on nursing assessment (and other data as appropriate). Validates these priorities with healthcare team members and documents appropriately.
Planning/Outcomes:
- Develops an individual plan of care based on the age and assessed needs of the patient. Develops the plan in collaboration with the patient and/or family, the physician, and other members of the interdisciplinary health care team. Updates the plan based on changes in the patient's condition and communicates changes in the plan to other members of the team.
- Identifies realistic and measurable goals and outcomes to be attained prior to discharge. Validates these with the patient and/or family.
- Demonstrates respect for the patient's/family cultural, spiritual, and belief system in planning for care.
- Includes planning for discharge to assure continuity of care and a smooth transition post-discharge from one level of care to another (to include appropriate referrals).
Implementation:
- Provides direct care to assigned patients consistent with the established nursing plan.
- Performs specific tasks based on organizational, departmental and/or unit policies and procedures within the RN scope of practice.
- Delegates nursing tasks as appropriate to members of the healthcare team, developing written assignments (if appropriate) and ensures completion of assigned tasks.
- Monitors quality of care delivered on a continual basis; ensures appropriate surveillance of assigned patients.
- Provides care based on patient and unit priorities, coordinating and organizing tasks as appropriate, utilizing known resources internal and external to the unit. Incorporates cost containment principles into nursing care.
- Assumes responsibility for patient safety by maintaining a safe environment to include awareness of safety procedures, protocols and adherence to patient care standards.
- Utilizes appropriate technology in daily practice.
- Utilizes performance indicators to collect data, monitor quality and effectiveness while providing nursing care. Completes assigned hospital/unit performance improvement monitoring (audits).
Evaluation:
- Based on assessment/reassessment of patient response to interventions, evaluates plan of care for effectiveness, documents progress toward expected outcomes, and revises plan of care as needed. Reports changes in patient condition and refers unresolved problems to appropriate healthcare team members. Discusses outcomes with peers (via shift to shift report) and with other healthcare team members. Evaluates opportunities for quality improvement; based upon evaluation, incorporates performance improvement recommendations into the plan of care as appropriate.
Patient Family Education/Teaching:
Identifies/assesses patient/family learning needs and teaches accordingly by:
- using language and terminology that the patient/family is familiar with
- providing examples to clarify ideas
- implementing and evaluating teaching plan (encourages patient/family involvement/participation)
- Micromedex utilization
- Computer resources
Communicates the patient/family's need for education/teaching to others in the healthcare continuum.
Professional Accountability:
- Evaluates own nursing practice in relation to professional practice standard guidelines, state statutes, policies, procedures, rules/regulations and current specific knowledge. Takes personal accountability for maintaining competency through education and professional activities to promote the healthcare of the community. Maintains professional licensure and completes required mandatory education in a timely manner. Reflects on identified areas of strength that offer opportunity for improvement.
- Ensures that written documentation and oral communication focuses on pertinent information to support meeting patient/family care needs.
- Serves as the patient's advocate and coordinator of care, working collaboratively with the physician(s) and other members of the healthcare team.
Supervisory/Management Responsibility
This is a non-management job that will report to a supervisor, manager, director, or executive.
Minimum Requirements
Associate's Degree in Nursing. BSN preferred.
Two years experience as a registered nurse.
Required Licensure/Registrations/Certifications
Licensed to practice as a Registered Nurse in South Carolina
In Lieu Of The Above Minimum Requirements
N/A
Work Shift
Night (United States of America)
Location
Richland
Facility
1510 Richland Hospital
Department
15106501 Richland Central Staffing Office
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