Reporting to the Nursing Director or Manager and according to the established policies, procedures, nursing standards of care and practice, and the direction of the medical staff, renders competent, humane, individualized care to every patient and their family. Utilizes the nursing process to assess, plan, implement and evaluate the delivery of individual patient care to facilitate continuity of care through the continuum. Provides age and developmentally appropriate care to adult and geriatric patients. Complies with all RML hospital and departmental policies.
PRINCIPAL DUTIES & RESPONSIBILITIES:
Exemplifies the RML REACH (Service Excellence) culture by demonstrating respect, excellence, appreciation, concern and honor in all interactions with patients, families and co-workers, and as identified in departmental and hospital wide behavioral expectations.
Maintains accountability for the overall care management of assigned patients. Accepts and responds to written and verbal physician orders, coordinates and participates in emergency and “code” situations, performs cardio-pulmonary resuscitation, performs clinical assessments, administers and monitors patients’ response to medications, blood products and nutritional support, and performs complex patient treatments.
Demonstrates clinical competence by consistently applying the nursing process, and performs within the scope of practice of the registered nurse in the State of Illinois. Responsible for maintaining nursing knowledge and skills appropriate to the specific clinical population for whom the nurse is providing care (treatments, medications, equipment, etc.) Obtains necessary information prior to implementing new or unfamiliar care practices, or responsibly declines to provide care and notifies supervisor until able to obtain the appropriate skill.
Assesses patients’ progress in accordance with established goals and initiates appropriate actions; documents according to established standards and reports information regarding patient’s condition and interventions performed (e.g., medications given, treatments performed, etc.) to all appropriate individuals. Notifies physician and documents significant changes in patient condition. Provides a complete and thorough report to the next shift. Documents completely and timely in the Meditech system.
Works in a team environment with the Patient Care Technicians and Respiratory Therapists to plan and provide patient centered care. Works closely with other disciplines to define an individualized plan of care and relevant interventions, correlated with medical and team care goals. Provides input to organized “staffing” meetings to discuss patient progress and revise goals, as requested. Revises patient’s plan of care based upon changes in patient’s status, needs, and unexpected outcomes.
Works closely with other disciplines and the care coordinator to ensure timely interventions and education that lead the patient and family to readiness for discharge.
Demonstrates the organizational skills and the ability to direct others in the planning and delivery of patient care. Supervises the work of the LPN, as assigned, and the PCT. Gives clear direction to PCT at the beginning of the shift on work to be accomplished, and collaborates with PCT throughout the shift to ensure completion. Provides guidance and direction to other team members and notifies department manager of apparent break in providing the expected standard of care, or of observations indicating potential educational needs of co-workers.
Executes the medical treatment plan by implementing physician orders. Seeks clarification or consultation on any unclear or questionable order by consulting with the ordering physician or on-call physician after hours, prior to implementation. If question is not resolved, nurse refers question to Clinical Supervisor, Nursing Director/Manager or Chief Nursing Officer as necessary for resolution.
Maintains the basic human rights and confidentiality of each patient, family and significant others in providing information and in delivering patient care. Is aware of and complies with applicable regulations and laws related to healthcare workers and the care of hospitalized patients, such as abuse reporting. Recognizes and complies with patients’ rights to have pain assessed and managed.
Observes and reports the emotional and spiritual needs of patients and assists in providing and obtaining appropriate supportive care to patients and their families, especially in end of life circumstances. In collaboration with the physician, evaluates and implements strategies to effectively manage patient’s comfort.
D emonstrates appropriate psychosocial interventions based on patients’ age and developmental status. Facilitates patient/family participation in self-care tasks as appropriate for each patient’s age, developmental status and level of functioning.
Evaluates environmental safety and promotes a safe patient care environment that is based on each patient’s age, developmental status and level of functioning. Implements all relevant patient safety initiatives, including but not limited to: consistently uses two forms of patient identification prior to medication administration, treatment, and procedures; responds to call lights and alarms and provides appropriate intervention; follows restraint policy and uses minimally restrictive devices; implements falls prevention precautions; ensures frequent rounding, and complies with swallowing and skin breakdown precautions, etc.
Demonstrates knowledge of and consistently adheres to all infection control and transmission prevention precautions. Ensures that other healthcare workers and visitors are aware of and use the personal protective equipment required to appropriately interact with the patients under the nurse’s care.
Participates in department quality improvement and performance improvement activities, especially including opportunities to promote patient safety. Notes areas for improvement in day to day department operations or patient care practices, and brings to the attention of department director/manager. Actively participates in the educational development of healthcare students and participates in the formal and informal education of other team members.
Maintains effective colleague relationships with other members of the health care team through consistently professional and respectful communications.
Identifies own learning and professional development needs and seeks opportunities within and outside of RML to meet these needs. Actively participates in staff meetings and continuing education activities. Provides information and feedback to other staff members on related clinical and professional topics. Meets all employee requirements including but not limited to: license renewal, TB testing, CPR, General Annual Review and Annual Clinical Validation, and performance evaluation, by demonstrating completion, or participating in the required activity prior to the expiration or due date.
Participates in welcoming, orientation and precepting of new team members, and orients and serves as resource to temporary (agency) personnel.
Is responsible for supporting a safe work environment for self and others, by reporting unsafe conditions, and by using appropriate safe work practices such as proper body mechanics and applicable safety devices (patient lift and transfer equipment, safety needles and sharps disposal, PPE, etc.) Complies with Employee Health Service policies regarding illness and injury.
Maintains confidentiality of the patient’s medical information verbally, on-line and in print. Complies with all hospital policies related to computer use and system security. Complies with HIPAA requirements.
JOB REQUIREMENTS AND CHARACTERISTICS
Skills and Abilities
The analytical ability necessary to assess patient conditions and utilize the nursing process and professional judgment to provide comprehensive care to patients.
The interpersonal skills necessary to positively interact with patients, families, physicians, and other members of the health care team.
The physical ability for almost constant standing, walking, lifting, and moving patients and patient care equipment.
The ability to perform effectively under the pressure of stressful and /or emergency situations.
The clinical and technical skills to work with high technology equipment and computers.
The ability to work in a team setting to provide patient centered care.
Knowledge and Experience
Competence documented by references based on nursing experience and education.
Recent acute hospital experience with complex medical patients preferred, including:
- Ventilator experience
- Wound care experience
- Acute rehabilitation or restorative experience
- Critical care experience
License & Certifications
Diploma, AA, AS or Bachelors degree in nursing from an accredited nursing school.
Current Illinois registered nurse license.
Bachelor’s degree preferred.
Work is performed in a patient care environment
The above statements are intended to describe the general nature and level of the work being performed by people assigned this job. They are not exhaustive lists of all duties, responsibilities, knowledge, skills, abilities, and working conditions associated with it.
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