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

Job Requirements:

Education/Skills

• 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 Type:

Full Time