The Registered Nurse is a clinical practitioner who coordinates and implements patient care specific to the age and type of patient population served on the assigned units. She/he ensures that quality care is provided in an efficient and safe manner, consistent with the unit's standards of care. She/he demonstrates performance consistent with the mission, vision and goals of the unit and organization; remains flexible to changing systems; is expected to demonstrate quality and effectiveness in work habits and clinical practice; and treats patients, families, staff and physicians with respect and consideration.
Patient Care Management and Clinical Judgment: Develops, interprets, implements, evaluates and documents a plan of care for each patient using the nursing process, specific to the age and type of patients served. Demonstrates effective decision-making and critical thinking skills coupled with nursing skills acquired through a process of integrating formal and experiential knowledge. Safely performs and documents nursing interventions consistent with nursing care standards and division/department policies.
Collects, interprets and documents basic level data. Performs initial physiological, educational, and psychosocial assessments as per protocols/standards for admission, and daily during shift assessments while applying effective interviewing skills to elicit information from the patient and/or significant other that is necessary to establish the plan of care. Implements appropriate interventions in a timely manner.
Functions to identify patient needs and problems (biophysical, cognitive, developmental, emotional, socio-cultural, spiritual) supported by assessment data, and establishes priorities reflective of the patient's age specific needs.
Demonstrates effective interpersonal communication skills with staff and other health are team members (i.e. discharge planning rounds, multidisciplinary rounds, report).
Collaborates with patient and other health care team members to develop a comprehensive plan of care/pathway.
Initiates and takes an active role in discharge planning inclusive of identifying referrals to appropriate community agencies.
Implements and follows clinical practice standards of care (such as plans, pathways, protocols, flow charts, algorithms, etc.) for all patient populations cared for on the unit.
Interprets and implements physician's orders in a timely manner.
Establishes appropriate priorities for delivery of patient care and implements nursing actions in an appropriate time frame; assures that supplies and equipment are available for patient care.
Anticipates and acts on potential predictable needs (such as pain management, skin management, etc.) and/or problems, in a timely manner.
Demonstrates accountability for ongoing awareness of the status of assigned patients.
Appropriately delegates nursing tasks to team members and consistently follows up to ensure and evaluate the outcomes. Identifies and reports unsafe practices and/or procedures related to patient care.
Evaluates and modifies the multidisciplinary plan of care based on observable responses of the patient and attainment of patient outcomes each shift as evidenced by documentation. Assures problems are reviewed and revised as appropriate.
Demonstrates competent technical skills for a specific patient population (see Unit Specific competencies, structure standards, procedure, protocols and policies).
Demonstrates knowledge and skills to provide care appropriate to the age of the patients on the assigned unit as described in the unit/area/department/policies/procedures and/or standards/competencies.
Communication, Collaboration, Advocacy and Diversity: Communicates relevant patient information. Incorporates differences (individual, cultural, spiritual, gender, race, ethnicity, disability, lifestyle, family configuration, socioeconomic status, age, values and alternative medicine) into the provision of care, involving patient, family and members of the healthcare team.
Communicates in a clear, concise, understandable manner appropriate to the development stage of the patient. Identifies verbal and non-verbal communication problems of the patient and/or significant other. Demonstrates the ability to utilize a variety of communication methods (i.e. sign language, foreign language, story boards, etc.) to collaborate with patient, family health care team members.
Communicates accurate information/plan of care to the physician, patient, family and/or patient care team (i.e. shift to shift report, unit to unit report, data to physician, and/or in multidisciplinary rounds). Performs as liaison to patient/family to ensure participation in care.
Communicates with other team members concerning changes in patient condition with accurate/timely information to ensure continuity of patient care.
Documents nursing care activities/completion of plan of care/pathway and patient response to interventions consistent with nursing care standards with 100% completion rate to ensure completeness of care.
Assesses and considers the impact of diversity on the individual's/family care
Facilitator of Learning: Communicates knowledge and facilitates patient/family/community and staff learning.
Utilizes standardized educational programs/protocols to educate patient/family (teaching packets, other resources).
Adapts educational programs to patient/family readiness/level of understanding/age/development.
Identifies patient/family education as an important component of delivery of care and documents educational instruction on the appropriate forms.
Evaluates patients' response to education and documents appropriately.
Documents discharge teaching/referral information given to patient with 100% completion.
Participates in annual unit needs assessment to identify topics for continuing education.
Caring Practices: Treats everyone in a caring professional manner to foster a positive image and instill confidence in the care received. Demonstrates behaviors (vigilance, engagement, responsiveness) which are responsive to the uniqueness of the patient and family and create a compassionate and therapeutic environment with the aim of promoting conform and preventing unnecessary suffering.
Respects the rights and dignity of all patients, which includes but is not limited to, the following:
Provides and maintains privacy (i.e. Draws curtains, covers patient's body, always knocks on door before entering, etc.).
Functions as a resource to visitors, physicians and patients. Acknowledges patients, physicians and visitors by making appropriate visual contact and tone of voice. Interacts in a courteous and friendly manner.
Introduces self by name and title during first contact with patient and explains role.
Orients patient and family to environment/routines.
Explains procedures to be performed to minimize patient anxiety.
Recognizes patient/family concerns surrounding hospitalization, diagnosis, prognosis, treatment
and terminal care (if appropriate) and provides appropriate reassurances. Answers patient questions when appropriate; refers patients to appropriate personnel to ensure patient satisfaction. Listens effectively.
Explains Hospital and departmental policies and procedures in order to gain patient understanding
and cooperation. Responds to patient requests in a timely manner and lets the patient/family know if there are going to be delays.
Respects patient confidentiality by giving information only to those individuals who are authorized and have a need to know; never discusses patients in public areas.
Keeps discussions of personal issues out of patient/family and public areas (i.e. Personal plans, jokes, loud laughter).
Represents the patient when the patient cannot represent self; aware of patient/family rights and encourages them to speak/represent themselves.
Aware of ethical conflicts that may surface throughout the patient's hospitalization and utilizes appropriate resources (i.e. Ethics Committee).
Interacts with the patient/family as a unique individual/family; tailors caring practices to the individuality of patient/family. Allows patient/family to individualize environment when possible (i.e. rituals, pictures, ceremonies, etc.).
Appropriately resolves customer concerns in a prompt and effective manner. Gives clear, accurate information to help them or refers them to people who can help them.
Facilitates patient flow/movement.
Provides timely and efficient assistance to physician staff as requested.
Maintains as safe and orderly patient care environment.
Professional Practices, Innovation, Intuition, Integrity: Demonstrates commitment to the organizational/departmental missions, vision, goals and objectives by incorporating the organization's values into his/her daily work.
Functions as a dependable team member, seeks assistance as needed or offers unsolicited help to others. Contributes to cohesive group relationships; uses open communication to identify and resolve problems within or outside of the department, in an appropriate, timely manner.
Graduate of an accredited school of nursing with a Bachelor's of Science in Nursing preferred.
Ten (10), Education contact hours required annually, excluding mandatory hospital education requirements.
Ability to demonstrate knowledge of the principles of growth and development over the life span.
Ability to assess data reflective of the patient's requirements relative to his or her age-specific needs.
Knowledgeable and sensitive to patient's rights in the delivery of care.
Communicates in a clear, concise manner appropriate to the developmental stage of the population served.
Ability to learn and use computer systems in order to manage patient information.
Dimensions Health Care