RN-Med/Surg All Types

The Registered Nurse is a professional practitioner who assesses, manages, directs, and provides nursing care care activities during the patient’s hospital stay and coordinates planning with other disciplines utilizing a patient/customer driven approach.

POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIA

Essential Functions: The following are essential job accountabilities and performance criteria:

1) Performs comprehensive nursing assessment/reassessment.

Criteria

A) Performs age-appropriate admission assessment or transfer assessment. Obtains input from family/guardian when appropriate.

B) Accurately and completely documents findings.

C) Performs assessment of post-op/post-invasive procedure patients.

D) Assesses and documents education and discharge needs of patient and family on admission and throughout hospitalization.

E) Provides patient reassessment documenting pertinent observations according to the patient plan of care, changes in condition, status and/or diagnosis, response to care, procedures, etc., and standards of care.

2) Establishes, coordinates and evaluates a plan of care based on analysis of assessment data, patient diagnosis, lab data, tests, procedures, physician orders, protocols and standards of care and other information as relevant.

Criteria

A)Identifies short and long term goals based on patient care needs.

B)Formulates nursing interventions to achieve desired patient outcome.

C) Incorporates disease specific evidenced based practice into nursing care plan and other documentation

3)Provides and documents nursing interventions based on assessed patient needs, plan of care, and changes in patient status.

Criteria

A) Collaborates with appropriate health team members for coordination of daily plan of care for assigned patients.

B) Provides, coordinates and communicates patient care, including accurate Handoff Communication Reports.

C) Administers and documents medications accurately according to policies and procedures.

D) Monitors, maintains and documents accurate IV fluids and parenteral nutrition according to policies and procedures.

E) Completes referrals as indicated by assessment data.

F) Requests consultation for special needs, equipment, or information for patient and/or family.

G) Provides patient/family education and discharge planning per documentation guidelines and protocol.

H) Clarifies all physician orders as warranted.

I) Acknowledges and implements physician orders in an accurate and timely manner as evidenced by documentation in the medical record.

J) Assists physician with procedures/treatments as requested or delegates to Care Partner as appropriate.

K) Documents “Readback” for all telephone/verbal orders.

L) Takes telephone/verbal orders only in emergency situations.

M) Recognizes changes in patient’s condition and takes appropriate nursing actions.

N) Involves the family/guardian when providing care and in decision-making as appropriate.

O) Recognizes risks for patient and takes appropriate action.

P) Incorporates use of Infection Control practices in daily care.

4) Documents and or communicates nursing care and or changes in patient condition.

Criteria

A) Performs and documents ongoing evaluation of effectiveness of care based on assessment data, nursing interventions, patient response to medications, treatments and procedures.

B) Evaluates and documents effectiveness of patient/family education.

C) Evaluates plan of care and modifies as indicated in “A” above.

D) Recognizes significant changes in patient’s clinical parameters and reports immediately to physician and others as indicated.

E) Identifies problems, gathers pertinent data, suggests solutions, communicates using appropriate lines of authority, and works toward problem resolution.

F) Reports variation from care/treatment following the occurrence reporting policy and procedures.

5)Specialized Care: Provides specialized care to patients at high risk for injury.

Criteria

A) Restraint Care

1. Initiates/evaluates alternatives to restraint prior to application

2.Applies restraints consistent with the approved procedure.

3. Monitors and assesses patient’s response throughout the restraint period at the appropriate intervals.

4. Provides specified patient care (toileting, skin care, hydration, feeding, etc.) on a timely basis.

5. Provides consultation for peers to determine alternatives to restraints and 1:1 observation.

6. Documents restraint use and associated care thoroughly.

B) Pain Management

1. Assess patient for presence of pain on admission and during assessments/reassessments.

2. Incorporates patient’s cultural/spiritual beliefs regarding pain into pain management plan.

3. Implement pain management techniques. Focus on prevention rather than treatment.

4. Include patient and/or family members in developing a pain management plan.

5. Consider other methods of pain control when developing plan of care: massage, repositioning, immobilization, and music therapy.

C) Abuse Assessment

1. Is aware of abuse recognition criteria and incorporates it into assessments.

2. Reports signs of possible abuse/neglect to the Administrative Director of Behavioral Health, physician, Risk Management and Social Work.

3. Takes appropriate action to support patient safety when signs of abuse are noted.

6) Demonstrates accountability for own professional practice.

Criteria

A) Adheres to all quality and performance standards, policies, procedures, protocols when implementing clinical and technical aspects of care.

1. Participates in learning experiences that increases professional competence.

B) Demonstrates appropriate technical and cognitive skills for area of practice.

C) Maintains currency in all hospital/unit information, communication, policies and procedures.

1. Attends staff meetings/reviews minutes when absent

2. Participates in Committee(s), Shared Governance, Work Team(s), in a leadership and or in membership role

3. Reviews Hospital/Nursing publications

4. Keeps up to date with policies and procedures

5. Participates and or keeps up to date with Shared Governance and Unit Based Practice Council activities and information. Contributes to requests for feedback.

D) Demonstrates ability to change and adapt to changing work demands

1. Responds positively to change

2. Provides assistance and support to peers, co-workers and other team members

3.Adapts positively to changes in unplanned work load and job demands

7) Ability to relate to coworkers in a professional and appropriate manner.

Criteria

A) Orients and/or precepts new employees when required.

B) Participates in and maintains a collaborative team approach toward work.

C) Functions as a resource person to co-workers, patients/families, medical staff and other members of the health care team.

D) Effectively assumes and delegates care and other activities to the appropriate team member.

E) Redirects clinical staff when the medical plan of care is altered.

F) Communicates the plan of care to be followed on each individual patient in a precise and professional manner.

G) Responsible for the supervision and teaching of students/new staff nurses.

8) Safety/Infection Control: Performs job in accordance with safety and infection control policies.

Criteria

A) Practices standard precautions and disposes of hazardous wastes per established guidelines.

B) Maintains a safe, clean, comfortable, and therapeutic environment for patients/families/employees in accordance to hospital standards.

1. Maintains clutter free environment.

2. Follows hand hygiene procedures.

3. Utilizes Safe Patient Handling techniques and equipment.

4. Keeps personal conversations/background noise to a minimum.

5. Adheres to dress code.

C) Reports risk management concerns using eSRM.

D) Assumes responsibility for completing all annual mandatory requirements:

1. Maintains current license and certifications

2. Maintain up to date BLS and HI

3. Annual TB Screening and Influenza vaccination

4. Annual Ethics Training (Initial Ethics, if new employee)

5. Annual Safety Training

6. Required Information Security course

7. Required Abuse & Neglect course

8. Annual Blood Borne Pathogens training (if required)

9. Coursework as assigned for .edu

10. Annual competency

11. Age/Population specific competency (if applicable)

12. orientation competency (if new hire)

13. Service Specific

E) Reports variations from care/treatment following the occurrence reporting policy and procedure.

9) Service: Provides service excellence to the customers of Saint Louis University Hospital by delivering timely, high quality care in a courteous and respectful manner.

Criteria

A)Demonstrates care and courtesy

1. Provides prompt, respectful, courteous service.

2. Meets physical, spiritual, psychological and emotional needs of patients and families.

3.Works with other members of the health care team to see that call lights are answered promptly.

4. Apologizes for mix-up and delay.

B) Communicates effectively and maintains confidentiality

1. Listens to staff/patient/family concerns and addresses needs.

2. Explains procedures and all education in a manner that staff/patient/family understand.

3. Allows time for questions.

C) Demonstrates competence and collaboration

1. Provides accurate handoff reports.

2. Provides quality care in accordance to standards.

3. Shares knowledge with other departments to facilitate work flow and continuity.

D) Provides cost effect services

1. Uses resources wisely.

2. Recommends changes in practice that increases efficiency and minimizes waste.

E) Ensures that customer satisfaction is maintained through the use of the “Principles and Commitments” of the hospital AIDET and “One Mission, One Spirit”.

10) Incorporates Performance Improvement and Evidenced Based Practice into individual professional practice.

Criteria

A) Assist in developing and implementing nursing unit goals.

B) Remains current with evidenced based practice initiatives.

C) Identifies opportunities for improvement, participates in data collection when requested, suggests solutions, communicates using appropriate lines of authority and works toward problem resolution.

D) Participates in the performance/process improvement process.

1. Assists in developing unit based Performance Improvement and action plans.

2. Leads a performance improvement team when requested

3. Contributes to data collection

4. Participates in evaluation of Performance Improvement results.

E) Participates in nursing research activities.

F) Participates in Departmental and Hospital Performance Improvement activities when warranted.

G) Participates in occurrence reviews

H) Contributes to the maintenance/improvement of all nursing quality indicators.

11) Age Appropriate Care: Provides age-appropriate care to: _____Adult _____Geriatric

Criteria

A) Demonstrates knowledge and skills of normal growth & development necessary to provide services to the age of the patient served by the department.

B)Demonstrates ability to assess and interpret age specific data to identify patient needs.

C) Utilizes communication skills necessary to interpret age specific responses to service and interaction.

D) Involves family or significant other in decision making related to services provided.

E)Demonstrates ability to provide service needed for the age groups routinely served by the department assigned.

12) Cost Effective Services

Criteria

A) Uses resources efficiently.

B) Recommends change in practice that increase efficiency and minimize waste.

C) Documents chargeable supplies and equipment used to provide care.

D) Prioritizes responsibilities and completes work on time.

E) Utilizes non-clinical time in a constructive manner, i.e. completing chart audits, .edu, mandatory education requirements.

DISCLAIMER: Performs other related duties as assigned or requested.

Job Specifications

MINIMUM EDUCATION: RN licensure in the State of Missouri

WORKING CONDITIONS: May be exposed to the risk of blood borne diseases. Exposure to unpleasant elements (accidents, injuries, and illness). Subject to varying and unpredictable situations. Handles emergency and crisis situations. Subject to irregular hours.

PHYSICAL REQUIREMENTS: Occasional prolonged standing/walking. Occasionally lifts, positions, pushes and/or transfers patients. Occasional reaching, stooping, bending, kneeling, crouching.

Employee___________________________________________Date____________

Supervisor__________________________________________Date_____________

Department Director __________________________________Date_____________

Administration________________________________________Date_____________

The above statements are intended to describe the general nature and level of work being performed. They are not to be construed, as an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. An individual working in their job classification must also perform specific tasks upon request by supervisor personnel. Furthermore, the duties and responsibilities for this job classification are subject to change at the discretion of the medical center.

Practice Agreement

For Nursing Staff

Please read the below standards and expectations.

Standard (I understand that . . .)

Our patients deserve care that sets the standard for excellence and meets the needs of each and every patient whose care is our primary purpose and mission. (Quality)

Expectations (So I will . . .)

Achieve Excellence in Infection Control By:

• Isolating per policy
• Consistently adhering to proper infection control practices and I will educate patients and visitors of the same.
• Taking responsibility to read, learn, follow, enforce and remain up to date on Saint Louis University Hospital policies and procedures.
• Practicing excellent hand washing technique – Wash or gel my hands when going into and coming out of patient rooms and between glove use, especial when it relates to dressing changes, suctioning, etc.
• Change dressings when they need to be changed now rather than later and maintain all invasive lines as directed by policy.
• Vaccinate per policy.
• Notify my supervisor if I see anyone or anything that puts my patient at risk.
• Utilizing safe practices during crisis situations (i.e. codes) and transport to other departments, e.g. masks, 02 tanks.

Achieve Excellence in Nursing Practice By:

• Contributing in a positive way to the functioning of the patient care team.
• Taking an active role in practice development through participation in unit based and hospital committees.
• Ensuring that documentation of patient care is consistently thorough and legible.
• Rounding with a purpose on each patient.
• Modeling practice excellence to new employees.
• Ensuring that licensure, certifications, and other mandatory requirements are completed within assigned deadlines.

Own and Respect My Environment By:

• Maintaining proper care of and treat all equipment with respect (clean up after using the microwave, not hit the walls with beds etc.).
• Maintaining a neat , clean and organized work environment.
• Keeping the nursing station, bathroom, and break room neat and clean.
• Leaving my patent’s room in good order, with supplies in place, and ready for the next shift and my work area in the same condition as I would like to see when I return.
• If I see something out of order I will pick it up, fix it, or call to have it repaired. I will not assume that someone else will do it.
• Giving hand-off report to another nurse before I leave the unit with another patient or for any other errand.

Standard (I understand that . . .)

Treating my colleagues, our patients, visitors, and business partners with respect and dignity is necessary to create an environment where excellence in caring and nursing practice can thrive. (People)

Expectations (So I will . . .)

• Show empathy to every patient and communicate my commitment to assist in their comfort, safety, and restoration to health.
• Demonstrate my respect to my colleagues and co-condition and concerns, mentoring new employees, resolving conflicts constructively, and proactively scheduling shifts to meet unit needs.
• Come to work with a positive attitude.
• Offer constructive criticism to co-workers when addressing concerns, praising in public and criticizing in private when necessary.
• Be part of the solution not part of the problem.
• Not complain to or complain in front of my patients/families and staff (i.e. too busy or short staffed, no lunch).
• Follow up on patient concerns every time to the appropriate person.
• Respond promptly to patient requests.
• Always refer to physicians as Dr. ____.
• Make sure that my patients are checked at least every ___ 1 hour ___ 30 minutes ___ 15 minutes per clinical standard and as appropriate.

Standard (I understand that . . )

Patients and their families are scared and vulnerable. It is my responsibility to communicate through verbal and non-vernal means that I am here to help. (Service)

Expectations (So I will . . .)

• Introduce myself to all my patients and family members.
• Take time to tell them what to expect and keep them informed.
• Answer lights promptly to meet a patient’s needs and prevent patient falls.
• Respect the patient’s privacy and modesty – close curtains, cover patient, reduce traffic in patient’s room during procedures.
• Explain all procedures, test, medications and monitoring equipment, etc to each patient and discuss plan of care for the day/shift with patient and family.
• Be compassionate and empathetic to their concerns at all times.

The intent of this agreement is not to provide a complete list of job responsibilities. Its intent rather is to be a positive statement of concrete actions which will ensure that nursing practice at Saint Louis University Hospital sets the benchmark for excellence in service, quality, and people.

As a member of the nursing staff at Saint Louis University Hospital, I understand that on behalf of my hospital, our patients and my co-workers I will conduct myself according to this agreement at all times.

Staff Signature __________________________________________ Print Name ___________________________________________ Date _______________

Manager Signature _________________________________________ Print Name _________________________________________ Date ______________

2/16/09

Associated topics: ambulatory, bsn, care unit, hospice, maternal, mhb, nurse clinical, psychiatric, registered nurse, staff nurse

Tagged as: Ambulatory, Bsn, Care Unit, Hospice, Maternal, Mhb, Nurse Clinical, Psychiatric, Registered Nurse, Staff Nurse