Description
Summary:
Responsible for patient assessment, patient care planning, and provision of quality nursing care to an assigned group of patients for a defined work period. Provides direction and supervision to LVN/LPNs, nursing assistants, unit secretaries, and other clinical/clerical associates. By assignment, may function as a charge nurse for the unit. Involves provision of patient care/service to older adolescents, young adults, adults, geriatric and pediatric patients.
Responsibilities
- Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
- Patient Care Planning
- Develops a comprehensive nursing care plan which addresses all significant needs and problems identified through nursing assessment.
- Prepares nursing elements of the interdisciplinary care plan prior to the initial team conference.
- Reviews and updates nursing care plan and collaborates with team members as changes occur.
- Patient Care Provision
- Implements patient care as planned in nursing care plan and interdisciplinary care plan.
- Sets priorities based on knowledge of patient acuity and patient needs.
- Provides safe and therapeutic care and seeks resources when appropriate.
- Safely performs and accurately documents procedures, consistent with established nursing policy and procedure.
- Patient Care Evaluation
- Evaluates patient response to interventions and attainment of goals in collaboration with interdisciplinary team.
- Evaluates progress toward nursing goals and revises goals as needed on a weekly basis.
- Completes nursing progress note for assigned patients on a daily basis.
- Completes nursing flow sheets for assigned patients on a daily basis.
- Teaching
- Evaluates education needs of patient and significant others and documents their response to teaching.
- Utilizes, adapts, and revises teaching resources to meet patient education needs.
- Explains procedures, tests, and disease process to patients and families as needed.
- Acts as role model for health care students and other team members.
- Acts as preceptor to assigned orientees.
- Assists in the orientation of new staff by sharing knowledge and experience.
- Patient Care Communication
- Reports and documents accurately and concisely to appropriate persons the patient's condition.
- Maintains patient confidentiality.
- Applies basic verbal and nonverbal skills to maintain open, effective communication among care team members, patients, and significant others.
- Encourages direct discussion between staff members when differences occur and seeks assistance to arbitrate differences as needed.
- Gives and accepts constructive feedback appropriately.
- Identifies actual and potentially unsafe patient care practices, reports them in the designated manner, and suggests alternatives.
CORE COMPETENCIES
Standard I: Utilizes the Nursing Process
- Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural,
- Spiritual, and development needs of patient and families
- Communicates findings to appropriate healthcare team members
- Develops and uses a specific plan of care and modifies it to meet individual patient
- needs using evidence-based practice. Implements patient care and therapeutic
- procedures; monitors and documents progression of treatment and teaching goals
- Evaluates the care and treatment(s) provided to the patient and the patient response to
- the care and treatment(s). Performs timely reassessment and documentation
- Must be able to perform unit specific competencies based on the specific patient care need for designated unit's patient population
Standard II. Patient Throughput & Patient Flow Process
- Anticipates and plans for admission/discharge/transfer needs to facilitate patient flow
- Utilizes appropriate systems of communication and tools to facilitate the discharge process
- Coaches on tools and techniques for checking, cross checking and validating orders to ensure accuracy
Standard III. Unit Operations
- Plans, directs, and evaluates the overall nursing care and functions in a particular nursing unit during an assigned shift
- Demonstrates good stewardship in proper use and maintenance of equipment and Supplies
- Assesses departmental staffing needs; actively participates in resourcing efforts.
- Educates and trains others on the operations, ethics, and regulations within the industry
Standard IV. Safe Practice/Quality Care/Regulations
- Incorporates patient safety practices/guidelines to promote a safe environment resulting in positive patient outcomes
- Demonstrates accountability for nursing research and quality improvement activities
- Provides evidence-based nursing care
- Communicates patient information effectively across the continuum of care
- Educates and trains others on the operations, ethics, and regulations within the industry.
- Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities
TECHNICAL COMPETENCIES
Clinical Policies and Standards
- Follows a specific set of standards and associated clinical procedures
- Analyzes policy and standards documentation and ensures organizational compliance
- Provides feedback for improvement of procedures
- Assists in the development and implementation of specific procedures
- Works with control and monitoring mechanisms, tools and techniques
Health Information Documentation
- Shares experiences with maintaining paper and electronic patient documentation
- Walk through the steps and procedures for receiving, validating and updating patient records
- Describes the flow of information between various stations or units
- Discusses the functions, features and document flow of electronic documentation
- Transcribes verbal orders; explains techniques for ensuring their accuracy
- Explains health information documentation best practices and their rationale across health care practices
Medical Equipment
- Describes experience with basic medical equipment used in own unit or facility
- Uses standard diagnostic tools and techniques to resolves common equipment problems
- Educates patients about the appropriate use of home medical equipment
- Ensures that all equipment and related supplies are in proper working order prior to use to ensure patient safety
- Inspects, troubleshoots and evaluates incoming equipment
Medical Order Processing
- Shares experiences with processing medical orders for one or more groups of patients or conditions
- Describes functions and features of the system used to enter, validate, update and forward medical orders
- Discusses common errors, their sources and procedures for correcting
- Explains considerations for entering and following standing orders
- Differentiates between standing orders and preprinted orders and considerations for each
Patient Chart Reading and Interpretation
- Describes experiences in reading and interpreting patient charts for patients on unit and under own care
- Reviews patients’ charts for completion and accuracy; identifies and alerts to mistakes or omissions
- Recognizes unexpected readings and alerts nursing or medical staff
- Relates examples of mis-readings or misinterpretations and lessons learned
- Reviews, discusses and validates own interpretation with others
Patient Safety
- Shares experiences with ensuring safety for one or more patient groups or settings
- Explains key features of safety guidelines and procedures for those groups and settings
- Listens and responds to safety inquiries from patients and family members
- Recognizes and addresses physiological and psychological signs of problems
- Describes considerations for patients who can cause to harm to self, versus harm to others
- Utilizes appropriate systems to document misses and near misses, participates in immediate investigating, analysis and reporting in real time
Education/Skills
Job Requirements:
- Bachelor of Science Degree in Nursing, preferred
Experience
- Six months to a year of experience as a licensed RN or holder of an active GN permit
Licenses, Registrations, or Certifications
- BLS required
- RN License in state of employment or compact
- Graduate Nurse Permit
- Associates with an unsuccessful licensure application or on the 75th day following the effective date of the temporary permit; will be transferred to another position within CHRISTUS Health
Work Schedule
7PM - 7AM
Work Type
Full Time
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