Steward Health Care
The Staff Nurse is an individual who holds ultimate responsibility for direct and indirect nursing care through the utilization of the nursing process. The Staff Nurse provides individualized, goal-directed nursing care through use of the nursing process and practices within the guidelines of the Nurse Practice Act and the Standards, Policies and Procedures of Carney Hospital. He/she reports to the Clinical Manager or designee.
EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:
Graduate of an accredited School of Nursing
Current registration in the Commonwealth of Massachusetts
Current BLS Certification
Demonstrated proficiency in acute care nursing, knowledge and skills
KEY RESPONSIBILITIES: Assess and diagnose patient and family problems in order to provide quality care to assigned patients. Complete patient assessment data within 8 hours of admission or in accordance with specific unit standard. Identify and document nursing diagnosis/problem list on patient plan of care within 8 hours of admission. Identify and document patient/family/significant other teaching needs upon admission (including barriers/strategies/outcomes). Identify discharge planning needs of patient/family/significant other at time of admission. Identify and anticipate needs of patient/family as they move through the hospitalization process. Develop, discuss and communicate a realistic problem list (plan of care) for each patient, in collaboration with each patient/family/significant other in order to address all identified needs/or in accordance with specific unit standards. • Plan of care includes nursing diagnosis/problem list statement for each identified problem • Develop patient/family/significant other teaching and discharge plans that are driven by the needs of patient/family. Demonstrate the skills and judgement necessary to implement medical plan of care, nursing interventions and procedures as necessary for the care of the patient. • Demonstrate knowledge of Carney Hospital policies and procedures/protocols for administering, transcribing and recording medications. • Demonstrate knowledge of commonly used meds: action, dose and side effects. • Observe 5 R’s for administering meds: - right patient - right drug - right dose - right method - right time • Demonstrate proper procedures in all methods of medication administration. • Monitor patients response and intervene appropriately. • Provide effective pain management to include: - accurate assessment using 0-10 pain scale - documentation of location, character and duration - timely appropriate interventions - timely reassessment and intervention. • Administer blood and blood products following Carney Hospital policy and procedures. • Document narcotics use according to Carney Hospital policy and procedure. • Assess, maintain and document IV access according to Carney Hospital policy and procedures. • Identify patients at risk for falls and implement fall prevention program as appropriate. • Deliver culturally competent care being sensitive to issues related to culture, race, gender, sexual orientation, and socio-economic class. • Provide emotional support to the patient/family. • Consider patient’s spiritual needs and appropriately consult Spiritual Care Services. • Effectively teach the patient/family about the disease, disease process, procedures, medications, food drug interactions, activity progression and when to call M.D. Re-evaluate the identified problems, care provided, and outcomes in order to meet patient and family needs and assure overall quality of care delivered. • Reassessments of plan of care is done every 24 hours and as patient condition warrants/or at each patient visit. • Assess the patient/significant other’s response to teaching plan in order to evaluate the effectiveness of plan. • Based on reassessment, plan of care remains the same or is modified to meet the patient/significant other’s identified needs. • Contribute knowledge and information and be open to the knowledge and assessment of others, thus enabling the team to develop an integrated approach to patient care. Maintain up-to-date and accurate documentation of nursing care provided to ensure the integration of information for use by the healthcare team. • Each identified problem is addressed using flow sheet or progress note every 24 hours. • Patient teaching record is completed to include barriers, teaching method and learning outcome. • Flow sheets and I&O sheets are accurate and signed with name and title each shift. • Medication administration record reflects full signature and title of nurse administering med, time given, reason for omission, and site for injection (if applicable). • Discharge plan accurately reflects patient and/or family’s ability to manage care after discharge. • Referrals are made based on identified needs. • Interagency communication referral forms (Pg. 2) are complete and accurate. Demonstrate ability to use critical thinking skills in all aspects of practice. • Collate and integrate multiple sources of data. • Recognize the limits of clinical judgment and seek interdisciplinary collaboration and consultation. • Maintain a global grasp of situations, and utilize nursing skills acquired through a process of integrating formal and experiential knowledge. • Function appropriately during medical emergencies. Maintain current knowledge/certification/licensure. • Practice within legal boundaries of nurse practice act and according to Carney Hospital policies and procedures. • Attend continuing education programs in order to maintain licensure. • Attend Carney Hospital sponsored skills programs as required by department. Function as a role model for current and new staff. • Facilitate problem resolution among peers as observed by Clinical Manager and peers. • Demonstrate a constructive approach towards the organization during all interactions with staff and nurse manager. • Role model the core values. • Seek opportunities to act as preceptor/teacher/mentor. Perform competently in fulfilling job responsibilities as required by the Division. • Maintain all unit based competencies. • Demonstrate knowledge of procedures/theories of PCA and epidural pain management modalities. • Demonstrate knowledge of procedures/theories of capillary blood glucose testing. • Demonstrate knowledge of Carney Hospital restraint policy. • Demonstrate ability to use computer system. Direct other licensed and non-licensed personnel in the provision of care to patients as assigned. • Demonstrate willingness to assume charge nurse role as required. • Delegate responsibility based on patient care needs, skills and competence of the caregiver. Assume all other duties and responsibilities as necessary. • Identify and/or assume activities relative to the developmental needs of the unit and the nursing department. • Demonstrate dependability/flexibility in meeting scheduling needs of the unit and Hospital. • Maintain professional composure and confidence during stressful situations. • Maintain open communication using appropriate chain of command regarding issues. • Seek opportunities to participate in decision making regarding standards, policies, practice and/or education. • Demonstrate knowledge and principles of Performance Improvement works as a team member to achieve Performance Improvement. • Participate in a minimum of 50% of staff meetings. • Demonstrate respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment. 1. Commit to recognize and respect cultural diversity for all customers (internal and external). 2. Communicate effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed. • Perform other duties as assigned.
#J-18808-Ljbffr
KEY RESPONSIBILITIES: Assess and diagnose patient and family problems in order to provide quality care to assigned patients. Complete patient assessment data within 8 hours of admission or in accordance with specific unit standard. Identify and document nursing diagnosis/problem list on patient plan of care within 8 hours of admission. Identify and document patient/family/significant other teaching needs upon admission (including barriers/strategies/outcomes). Identify discharge planning needs of patient/family/significant other at time of admission. Identify and anticipate needs of patient/family as they move through the hospitalization process. Develop, discuss and communicate a realistic problem list (plan of care) for each patient, in collaboration with each patient/family/significant other in order to address all identified needs/or in accordance with specific unit standards. • Plan of care includes nursing diagnosis/problem list statement for each identified problem • Develop patient/family/significant other teaching and discharge plans that are driven by the needs of patient/family. Demonstrate the skills and judgement necessary to implement medical plan of care, nursing interventions and procedures as necessary for the care of the patient. • Demonstrate knowledge of Carney Hospital policies and procedures/protocols for administering, transcribing and recording medications. • Demonstrate knowledge of commonly used meds: action, dose and side effects. • Observe 5 R’s for administering meds: - right patient - right drug - right dose - right method - right time • Demonstrate proper procedures in all methods of medication administration. • Monitor patients response and intervene appropriately. • Provide effective pain management to include: - accurate assessment using 0-10 pain scale - documentation of location, character and duration - timely appropriate interventions - timely reassessment and intervention. • Administer blood and blood products following Carney Hospital policy and procedures. • Document narcotics use according to Carney Hospital policy and procedure. • Assess, maintain and document IV access according to Carney Hospital policy and procedures. • Identify patients at risk for falls and implement fall prevention program as appropriate. • Deliver culturally competent care being sensitive to issues related to culture, race, gender, sexual orientation, and socio-economic class. • Provide emotional support to the patient/family. • Consider patient’s spiritual needs and appropriately consult Spiritual Care Services. • Effectively teach the patient/family about the disease, disease process, procedures, medications, food drug interactions, activity progression and when to call M.D. Re-evaluate the identified problems, care provided, and outcomes in order to meet patient and family needs and assure overall quality of care delivered. • Reassessments of plan of care is done every 24 hours and as patient condition warrants/or at each patient visit. • Assess the patient/significant other’s response to teaching plan in order to evaluate the effectiveness of plan. • Based on reassessment, plan of care remains the same or is modified to meet the patient/significant other’s identified needs. • Contribute knowledge and information and be open to the knowledge and assessment of others, thus enabling the team to develop an integrated approach to patient care. Maintain up-to-date and accurate documentation of nursing care provided to ensure the integration of information for use by the healthcare team. • Each identified problem is addressed using flow sheet or progress note every 24 hours. • Patient teaching record is completed to include barriers, teaching method and learning outcome. • Flow sheets and I&O sheets are accurate and signed with name and title each shift. • Medication administration record reflects full signature and title of nurse administering med, time given, reason for omission, and site for injection (if applicable). • Discharge plan accurately reflects patient and/or family’s ability to manage care after discharge. • Referrals are made based on identified needs. • Interagency communication referral forms (Pg. 2) are complete and accurate. Demonstrate ability to use critical thinking skills in all aspects of practice. • Collate and integrate multiple sources of data. • Recognize the limits of clinical judgment and seek interdisciplinary collaboration and consultation. • Maintain a global grasp of situations, and utilize nursing skills acquired through a process of integrating formal and experiential knowledge. • Function appropriately during medical emergencies. Maintain current knowledge/certification/licensure. • Practice within legal boundaries of nurse practice act and according to Carney Hospital policies and procedures. • Attend continuing education programs in order to maintain licensure. • Attend Carney Hospital sponsored skills programs as required by department. Function as a role model for current and new staff. • Facilitate problem resolution among peers as observed by Clinical Manager and peers. • Demonstrate a constructive approach towards the organization during all interactions with staff and nurse manager. • Role model the core values. • Seek opportunities to act as preceptor/teacher/mentor. Perform competently in fulfilling job responsibilities as required by the Division. • Maintain all unit based competencies. • Demonstrate knowledge of procedures/theories of PCA and epidural pain management modalities. • Demonstrate knowledge of procedures/theories of capillary blood glucose testing. • Demonstrate knowledge of Carney Hospital restraint policy. • Demonstrate ability to use computer system. Direct other licensed and non-licensed personnel in the provision of care to patients as assigned. • Demonstrate willingness to assume charge nurse role as required. • Delegate responsibility based on patient care needs, skills and competence of the caregiver. Assume all other duties and responsibilities as necessary. • Identify and/or assume activities relative to the developmental needs of the unit and the nursing department. • Demonstrate dependability/flexibility in meeting scheduling needs of the unit and Hospital. • Maintain professional composure and confidence during stressful situations. • Maintain open communication using appropriate chain of command regarding issues. • Seek opportunities to participate in decision making regarding standards, policies, practice and/or education. • Demonstrate knowledge and principles of Performance Improvement works as a team member to achieve Performance Improvement. • Participate in a minimum of 50% of staff meetings. • Demonstrate respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment. 1. Commit to recognize and respect cultural diversity for all customers (internal and external). 2. Communicate effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed. • Perform other duties as assigned.
#J-18808-Ljbffr