DescriptionSummary:
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 PlanningDevelops 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 ProvisionImplements 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 EvaluationEvaluates 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. TeachingEvaluates 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 COMPETENCIESStandard I: Utilizes the Nursing Process
Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural, Spiritual, and development needs of patient and familiesCommunicates findings to appropriate healthcare team membersDevelops 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 goalsEvaluates the care and treatment(s) provided to the patient and the patient response to the care and treatment(s). Performs timely reassessment and documentationMust 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 flowUtilizes appropriate systems of communication and tools to facilitate the discharge processCoaches 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 shiftDemonstrates good stewardship in proper use and maintenance of equipment and SuppliesAssesses 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 outcomesDemonstrates accountability for nursing research and quality improvement activitiesProvides evidence-based nursing careCommunicates patient information effectively across the continuum of careEducates 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 COMPETENCIESClinical Policies and Standards
Follows a specific set of standards and associated clinical proceduresAnalyzes policy and standards documentation and ensures organizational complianceProvides feedback for improvement of proceduresAssists in the development and implementation of specific proceduresWorks with control and monitoring mechanisms, tools and techniques
Health Information Documentation
Shares experiences with maintaining paper and electronic patient documentationWalk through the steps and procedures for receiving, validating and updating patient recordsDescribes the flow of information between various stations or unitsDiscusses the functions, features and document flow of electronic documentationTranscribes verbal orders; explains techniques for ensuring their accuracyExplains 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 facilityUses standard diagnostic tools and techniques to resolves common equipment problemsEducates patients about the appropriate use of home medical equipmentEnsures that all equipment and related supplies are in proper working order prior to use to ensure patient safetyInspects, troubleshoots and evaluates incoming equipment
Medical Order Processing
Shares experiences with processing medical orders for one or more groups of patients or conditionsDescribes functions and features of the system used to enter, validate, update and forward medical ordersDiscusses common errors, their sources and procedures for correctingExplains considerations for entering and following standing ordersDifferentiates 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 careReviews patients’ charts for completion and accuracy; identifies and alerts to mistakes or omissionsRecognizes unexpected readings and alerts nursing or medical staffRelates examples of mis-readings or misinterpretations and lessons learnedReviews, discusses and validates own interpretation with others
Patient Safety
Shares experiences with ensuring safety for one or more patient groups or settingsExplains key features of safety guidelines and procedures for those groups and settingsListens and responds to safety inquiries from patients and family membersRecognizes and addresses physiological and psychological signs of problemsDescribes considerations for patients who can cause to harm to self, versus harm to othersUtilizes appropriate systems to document misses and near misses, participates in immediate investigating, analysis and reporting in real time
Requirements:
Bachelor of Science Degree in Nursing, preferred. Six months to a year of experience as a licensed RN or holder of an active GN permit. BLS requiredRN License in state of employment or compactGraduate Nurse PermitAssociates 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:
TBD
Work Type:
Full Time
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