RN-Med / Surg-Charge-Nights

Job Description

Job Description

1. Clinical Judgment : Using clinical reasoning, conducts accurate clinical assessments according to practice standards. Identifies and prioritizes patient and family needs. Develops, implements and evaluates the nursing plan of care. Modifies plan to meet clinical outcomes.

2. Clinical Inquiry : Systematically evaluates the quality and effectiveness of nursing practice, including, but not limited to, nursing sensitive indicators. Supports evidence-based practice changes through research utilization and experiential learning. Participates in quality / performance improvement initiatives.

3. Caring Practices : Creates a compassionate, supportive, safe and therapeutic environment for patients, families and staff. Develops therapeutic relationships with patient and family and maintains appropriate boundaries. Manages both emotional and physical pain with the aim of promoting comfort and healing and preventing unnecessary suffering

4. Response to Diversity : Recognizes, appreciates and incorporates a patient's and family's unique differences, such as culture, spiritual beliefs, gender, race, ethnicity, lifestyle, socioeconomic status, age, and values, into an individualized plan of care.

5. Advocacy and Moral Agency : Preserves and protects the confidentiality, autonomy, dignity and rights of patient and family and represents their concerns. Creates an individualized plan that accurately reflects patient and family values and goals. Identifies and helps resolve ethical and clinical concerns.

6. Facilitation of Learning : Facilitates learning for patients and families, nursing staff, other members of the health care team and community; integrating appropriate education throughout the continuum of care to help them participate and / or make informed decisions about their health care and treatments, including health promotion and disease prevention. Assesses and documents learning needs and outcomes.

7. Collaboration : Works collaboratively and interdependently with colleagues and community to develop and implement an integrated plan of care. Open and sensitive to all team members' unique contributions. Delegates tasks and care to appropriate staff and ensures timely follow-up.

8. Systems Thinking : Uses strategies and available resources for problem-solving for patients, family and staff. Recognizes that resources are limited and considers factors related to safety, effectiveness and efficiency in planning and delivering patient care.

9. Professionalism : Improves nursing practice and the work environment through participating in shared governance and decision-making processes and meaningfully recognizing the contributions of others. Participates in the staffing process from education and planning to evaluation. Identifies personal goals and commits to ongoing professional growth through continuing education, networking with professional colleagues, membership and involvement in professional nursing organizations, self-study, professional reading, certification etc.. Contributes to the professional development of peers, colleagues and others.

10. Assesses patient physical, psychological, social, spiritual, educational, developmental, and cultural and discharge planning needs. Reviews patient history and physical with patient / family and assures completion within appropriate timeframe. 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 reassessments according to patient need and as outlined in policy.

11. Formulates a plan of care , including the discharge plan, utilizing assessment data and patient, family and health team input. 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 in the plan of are. Plans care in collaboration 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.

12. Implements the plan of care through direct patient care, coordination, delegation and supervision of the activities of the health care team. 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. Delegates appropriately, and provides nursing supervision in the provision of care to patients by other licensed nurses and other personnel. Promotes continuity of care by accurately and completely communicating to other caregivers the status of patients for whom care is provided.

13. Evaluates the patient's and family's response to care and teaching, and revises the plan of care as needed. Evaluates patient progress towards goals and expected outcomes in collaboration with other health care team members. Evaluates patient's response and the effectiveness of patient teaching.

14. Documents assessment , planning, implementation and evaluation in the patient record. Documentation is legible, timely and in accordance with policy. Documentation reflects objective / subjective data, nursing interventions and patient's response to treatment. Notes physician orders accurately and in a timely manner.

15. Provides care based on the best evidence available and may participate in research activities within clinical practice. Participates in unit or facility shared leadership. Interacts and participates in the education, role development, and orientation of facility personnel, patients, students, families and visitors. Promotes / supports growth of others through precepting and mentoring when appropriate.

16. Any other duties assigned as needed to help drive our Mission and abide by our organizations values.