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 One

CHRISTUS

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 CommunicationReports 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 ProcessUses 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 patientneeds using evidence-based practice.

Implements patient care and therapeuticprocedures; monitors and documents progression of treatment and teaching goalsEvaluates the care and treatment(s) provided to the patient and the patient response tothe 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 populationStandard II.Patient Throughput & Patient Flow ProcessAnticipates 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 accuracyStandard III.Unit OperationsPlans, 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 industryStandard IV.Safe Practice/Quality Care/RegulationsIncorporates 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 StandardsFollows 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 techniquesHealth Information DocumentationShares 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 practicesMedical EquipmentDescribes 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 equipmentMedical Order ProcessingShares 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 eachPatient Chart Reading and InterpretationDescribes 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 othersPatient SafetyShares 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

Job Requirements:

Education/SkillsBachelor of Science Degree in Nursing, preferredExperience0-1 years of nursing experience preferredLicenses, Registrations, or CertificationsBLS 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

HealthIn accordance with the

CHRISTUS

Health License, Certification and Registration Verification Policy, all Associates are required to obtain the required certifications for their respective positions within the designated time frame.

Work Schedule:

3 Days - 12

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