Job Description
Job Description
Job Overview
This role involves managing personalized, outcome-focused nursing care by employing the nursing process. The position entails delivering care, treatment, and services through effective coordination and execution of various processes, including assessment, care planning, and implementation, all in line with the organization's policies and procedures.
Key Responsibilities
- Medication Administration
- Exhibits understanding of and adheres to organizational policies regarding the administration, transcription, and documentation of medications.
- Completes the medication reconciliation process in accordance with established policies.
- Follows proper procedures for documenting narcotic administration, verifying counts, managing waste per policy, and resolving discrepancies.
- Care Planning and Documentation
- Creates, reviews, and communicates a prioritized list of patient issues and care plans.
- Develops, assesses, and updates individualized care plans, documenting outcomes accordingly.
- Conducts admission assessments within 8 hours, identifying and recording educational needs for patients and families upon admission and throughout their stay.
- Continuously assesses and identifies care requirements within established nursing practices.
- Documents all patient care in compliance with nursing policies, unit standards, disease processes, and nurse-sensitive indicators.
- Evaluates and documents patient comfort levels using appropriate pain scales and responses to both pharmacological and non-pharmacological interventions.
- Advocates for patients and families, seeking assistance when they cannot represent themselves.
- Addresses ethical concerns with the clinical team and seeks resources to aid in ethical decision-making.
- Communicates daily plans through updates on a whiteboard at the start of each shift.
- Facilitates discharge or transfer processes aiming for completion by 12:00 PM, addressing any barriers through the appropriate channels.
- Safety and Quality Assurance
- Confirms patient identity using two identifiers before any invasive procedures, including time-outs, and documents the verification of the correct patient, procedure, site, equipment, and consent.
- Adheres to CDC hand hygiene guidelines and universal precautions, utilizing personal protective equipment and disposing of hazardous materials properly.
- Ensures the environment consistently meets regulatory standards.
- Understands individual roles and responsibilities during hospital codes and emergency situations.
- Professional Growth
- Takes responsibility for personal professional development by integrating evidence-based practices, research, and performance improvement into nursing activities.
- Obtains a minimum of 5 contact hours annually in relevant practice areas.
- Operates within the legal framework of the Nurse Practice Act and supervises licensed and unlicensed personnel as needed.
- Demonstrates the ability to accept and respond constructively to feedback and suggestions for improvement.
- Fosters professional relationships with colleagues across disciplines to create a supportive work environment.
- Employs critical thinking to analyze problems, evaluate solutions, and communicate effectively through the appropriate channels.
- Stays informed about updates to hospital policies and procedures.
- Technology Utilization
- Accesses organizational systems to review emails, training materials, and other resources relevant to the nursing role.
- Utilizes required software applications in accordance with departmental standards.
- Understands operational procedures during system downtimes.
- Compliance
- Operates within the legal, regulatory, and ethical standards pertinent to the position.
- Adheres to applicable policies and procedures.
- Protects the privacy and security of patient information, complying with relevant privacy policies.
- Reports potential compliance issues to appropriate management personnel.
- Completes mandatory education related to compliance, privacy, and security programs.
- Patient and Family-Centered Care
- Shows respect for the values, preferences, and needs expressed by patients and their families.
- Recognizes patients and families as integral members of the healthcare team.
- Collaborates with patients and families in planning, implementing, and evaluating care based on their preferences.
- Encourages family presence and participation at all times, respecting patient preferences.
- Age and Cultural Competence
- Possesses knowledge and awareness of age and cultural considerations.
- Takes into account the unique needs of each individual during interactions.
- Delivers care with sensitivity to diverse populations.
- Effectively utilizes resources such as interpreter services and online tools to enhance care delivery.
Minimum Education
Graduation from an accredited School of Nursing is required.
Preferred Work Experience
Prior experience as an Acute Care RN is preferred.
Required Licenses and Certifications
Registered Nurse (RN) license is mandatory.
Depending on the department, certifications such as Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Emergency Response Training, Neonatal Resuscitation Program (NRP), Pediatric Advanced Life Support (PALS), Trauma Nurse Core Course (TNCC), and Trauma Care After Resuscitation (TCAR) may be necessary.
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