Registered Nurse - Medsurge

Description

ORGANIZATIONAL DESCRIPTION

The Registered Nurse (RN) performs those activities for which the RN has been prepared through education and training. The RN provides nursing supervision in the planning for and provision of nursing care to patients and directs and evaluates care given by other licensed nurses and personnel and within scope of practice. The RN provides education, assesses needs, plans for, implements, evaluates and documents care being provided by nursing staff to each patient. The RN is responsible both for nursing care directly provided by that nurse and the care provided by others under her/his supervision.

INTERACTION

Primarily Interacts with: administration, physicians, employees, clinical and non-clinical departments, patients, visitors, and volunteers.

PRIMARY FUNCTIONS

• Utilize the nursing process by demonstrating appropriate assessment, planning, implementation, and evaluation of the patient's care. 
• Assess the patient; collect and document the patient's current health status and medical history. Complete and/or review Admission Data Record as defined by policy. Make accurate and ongoing assessment of patient's status and respond appropriately.
• Plan/Implement; set priorities for nursing actions in a logical sequence according to patient's needs and formulate a plan of care by the appropriate selection of Nurse Practice Standards. 
• The Plan of Care is initiated on patient admission based on all aspects of the initial assessment. Plan includes physiological, psychosocial, and environmental factors: patient/significant other education and patient discharge planning. 
• Evaluate; perform ongoing assessment and revise plan of care based on new data and patient's condition. 
• Document accurate and ongoing assessment of patient status. Document patient care which reflects nursing intervention, patient response to care provided, patient needs, problems, capabilities, limitations, and progress toward goals. Documentation includes evidence of appropriate patient/significant other teaching, and the understanding of these instructions is noted in the medical record. 
• Communicate with the physician regarding patient needs, the nursing assessments, and recommendations.
• Collaborate with other nurses and health team members to ensure the patient's wellbeing.
• Teach patient/significant other appropriate health information in a timely manner and share written informational material.
• Perform direct patient care, utilizing established procedures, policies, and standards as evidenced by client/staff feedback and Operations Coordinator observation.  
• Administer medications according to policy and procedure
• Administer IV's according to policy and procedure. 
• Observe and document patient's response to pertinent medications. 
• Demonstrate ability and appropriate technical skills when administering treatments and procedures in accordance with physician's orders and policy and procedure (done within a timely manner). 
• Demonstrate necessary skills and knowledge to provide care for patients according to policy and procedure. 
• Demonstrate necessary skills and knowledge to provide care for patients according to division/unit specific competencies. 
• Demonstrate ability to handle emergency situations in a prompt, precise, and professional manner. 
• Provide personal patient care to provide comfort and well-being to the patient, acknowledging physiological and psychological needs.
• Perform indirect patient care, utilizing established procedures, policies, and standards.
• Give a thorough, concise report at change of shift.
• Demonstrate accurate and timely documentation according to hospital policy.
• Maintain a clean, neat, and safe environment for patient and staff according to policy and procedure.
• Demonstrate correct and safe technique in the use of equipment according to specific product information. 
• Follow appropriate procedure for obtaining and returning or cleaning/disposing of equipment and supplies. 
• Assist patients, family members or other clients with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.
• Answer and refer telephone calls or other inquires to ensure accurate and timely communications are facilitated. 
• Systematically evaluate the quality and effectiveness of nursing practice.
• Participate in quality of care activities as appropriate to the individual’s position, education, and practice environment.
• Utilize the results of quality of care activities to initiate changes in practice. 
• Utilize the results of quality of care activities to initiate changes throughout the health care delivery system, as appropriate.
• Evaluate his/her own nursing practice in relation to professional practice standards and relevant statues and regulations.
• Engage in performance appraisal on a regular basis, identifying areas of strength as well as areas for professional/practice development.
• Seek constructive feedback regarding his/her own practice.
• Take action to achieve goals identified during performance appraisal.
• Acquire and maintain current knowledge in nursing practice.
• Participate in ongoing education activities related to clinical knowledge and professional issues.
• Seek experiences to maintain clinical skills.
• Seek knowledge and skills appropriate to the practice setting.
• Demonstrate an integration of knowledge and clinical competence.
• Contribute to the professional development of peers, colleagues, and others.
• Share knowledge and skills with colleagues and others.
• Provide peers with constructive feedback regarding their practice.
• Mentor novice nurses and those new to the specialty.
• Contribute to an environment that is conducive to clinical education of nursing students, as appropriate.
• Decision and actions on behalf of patients are determined in an ethical manner.
• Assume the role of patient advocate.
• Deliver care in a nonjudgmental and nondiscriminatory manner that is sensitive to diversity.
• Deliver care in a manner that preserves/protects patient autonomy, dignity, and rights.
• Collaborate with the patient’s significant others, and health care providers in providing patient care.
• Communicate with the patient’s significant others and health care providers regarding patient care and nursing’s role in the provision of care.
• Maintain confidentiality consistent with the rules and regulations of state and federal government.
• Consult with health care providers for patient care, as needed.
• Make referrals, including provisions for continuity of care, as needed.
• Consider factors relating to safety, effectiveness, and cost in planning and delivering patient care.
• Promote a safe and therapeutic environment for the recipients and providers of nursing care.
• Integrate components of the nursing process: assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
• Individualize care and set priorities to address the patient’s physical, psychological, educational, and social needs.
• Articulate the plan of care to other members of the health care team to promote collaborative efforts in achieving outcomes.
• Document the integrated components of the nursing process to show responses to interventions.
• Foster the development, regular review, and revision of evidence-based practice guidelines and organizational policies and procedures.
• Participate in the integration of caring into the practice environment.
• Demonstrate maturity and accountability for job performance. Support the philosophy, objectives and goals of the department and assesses areas of personal and professional growth.
• Demonstrate good judgment and analytical ability in preparing work for review.
• Promote confidence and uses complete discretion when discussing information.
• Maintain calm and effective behavior during stressful situations.
• Inspire confidence from callers, visitors, co-workers by remaining well informed and prepared at all times.
• Attentive to detail, record keeping and required paperwork inherent to the position.
• Demonstrate effective delegation skills.
• Complete assignments accurately and on time.
• Willingly accept assignments to special projects.
• Adjust personal schedule to complete assignments. 
• Maintain assigned equipment, reports malfunction and orders services as necessary.
• Responsible for charging of supplies utilized.
• Participate in the required continuing education programs, including safety storm, and utilizes the information in area(s) of practice as evidenced by attendance records or certificates.
• Participate in performance improvement activities, including data collection, development of indicators, and evaluation criteria.
• Float to other areas as assigned with the proper orientation to these areas; respond to floating requests with a positive attitude.
• Demonstrate adherence to infection control policies as evidenced by in-service attendance records and employee practices. Notifies the Infection Control Practitioner of real or potential exposures.
• Demonstrate knowledge of OSHA regulations. Comply with OSHA regulations regarding Blood borne Pathogens Exposure Control Plan. Comply with OSHA regulations regarding TB Exposure Control plan.
• Demonstrate knowledge of the Hazardous Waste Management Plan. Appropriately segregate waste at the point of origin. Discard waste in appropriate bags, receptacles, etc.
• Demonstrate adherence to the safety policies as evidenced by in-service attendance records and employee practices.
• Demonstrate an understanding of fire drills, internal/external disaster plans and procedures, and evacuation procedures as evidenced by in-service records and participation in drills.
• Demonstrate adherence to risk management policies as evidenced by in-service attendance records and employee practices. Submit incident reports according to hospital policy.
• Notifies the Risk Manager of incidents involving injury or having the potential for injury.
• Provide exemplary customer service.
• Maintain confidentiality and compliance with HIPAA.
• Cooperate with other personnel to achieve departmental objectives and maintain good employee relations, inter-departmental objectives and infection control policies.
• Cordially demonstrate timeliness and professionalism in appearance, communications, and actions during all interactions and with all individuals and entities.
• Solve practical problems, dealing with a variety of issues, and interpret a variety of instructions furnished in written and oral form.
• Attend meetings as required.
• Perform other duties as requested or assigned.

Requirements

ABILITY TO USE EQUIPMENT, TOOLS, MATERIALS, MACHINES: Computer, telephone, facsimile machine, copier, scanner, printer, calculator and other standard office equipment. Blood Pressure Cuffs, stethoscope, syringes, IV pumps, feeding pumps, beds, scales, lifts, hyper/hypothermia units, glucose monitors, PCA pumps, suction equipment, ventilators, crash cart, miscellaneous medical equipment and DME.

EDUCATION/EXPERIENCE/SKILLS/ABILITIES

Education:

• Associate degree in nursing required; bachelor degree in nursing preferred
• Valid RN license in Texas
• BLS/ACLS/PALS or ENPC

Experience:

• One year nursing experience preferred.

Personal Job-Related Skills / Abilities:

• Must be committed to quality and patient safety at all times.
• Excellent command / highly proficient in spoken and written English; bilingual in Spanish preferred.
• Basic computer skills, including but not limited to: Microsoft Office, electronic medical documentation, and email.
• Must be effective at adjusting to change, prioritizing duties, handling stress and effectively communicating face-to-face and/or over the telephone.
• Must be able to work independently, and flexibly, and as a part of a multidisciplinary team.
• Must be able to manage several interruptions throughout the shift.
• Must have strong interpersonal and communication skills, verbal and written.
• Must have strong time management skills.
• Must be able to work under pressure while interacting in a helpful, courteous manner with a high degree of patient contact.
• Sufficient hearing, vision and dexterity to perform duties safely.

Physical and Mental Requirements:

Physical:     

Activity Up to %

• Walking: 80   
• Squatting: 50 
• Standing: 80   
• Pulling: 25 
• Kneeling: 50   
• Reaching: 50 
• Sitting: 20   
• Lifting up to 50 lbs: 25 
• Pushing: 25  
• Wrist/Finger Movements: 90 
• Bending: 50   
• Climbing: 5    

Mental:     

• Stress Level Moderate to High 

Individual position core competencies:

• Quality
• Service Excellence
• Compassion
• Professionalism
• Fiscal Responsibility

Required education within first 60 days (if employee is from outside organization).

• GrahamRMC Orientation
• Department Orientation

Continuing/Annual Education and Training:

• As needed to maintain certification/ licensure of position
• BLS/ACLS
• Falling Star Program
• Safety Storm Program

Supervision

Employees Supervised: __No__ 

ADA REQUIREMENTS

Each category is grouped under a percentage rating based on the frequency the condition is expected to occur.

Frequency of Condition 1-33% 34-66% 67%+

1-33% 

• Extreme Heat
• Extreme Cold
• Extreme Swings in Temperature 
• Extreme Noise 
• Working Outdoors
• Mechanical Hazards
• Electrical Hazards
• Explosive Hazards
• Fume/Odor Hazards
• Dust/Mite Hazards
• Chemical Hazards
• Toxic Waste Hazards
• Radiation Hazards
• Wet Hazards
• Heights
• Other Conditions

67%+

• Working Indoors

OSHA Classification:

Identify with a check the OSHA Job Category that describes this job. The intent is to enhance worker protection by identifying any risk in the performance of routine and reasonably anticipated job-related functions.

__X__ Category I: Tasks that involve exposure to blood, body fluids or tissues.

All procedures or other job-related tasks involve an inherent potential for mucous membrane or skin contact with blood, body fluids or tissues or a potential for spills or splashes of them are Category I tasks. Use of appropriate protective measures, such as gloves, masks, goggles, and gown are required for every employee engaged in Category I tasks.

_____ Category II: Tasks that involve no exposure to blood, body fluids or tissues but employment may require performing unplanned Category I tasks.

The normal work routine involves no exposure to blood, body fluids or tissues, but exposure may be required as a condition of employment. Appropriate protective measure, such as gloves, masks, goggles, and gown are readily available to every employee engaged in Category II tasks.

_____ Category III: Tasks that involve no exposure to blood, body fluids or tissues and Category I tasks are not a condition of employment.

The normal work routine involves no exposure to blood, body fluids or tissues (although situations can be imagined or hypothesized under which anyone, anywhere might encounter potential exposure to body fluids). Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency medical care or first-aid or to be potentially exposed in some other way. Tasks that involve handling implements or utensils, use of public or shared bathroom facilities or telephone and personal contacts such as handshaking are Category III tasks.

ADDITIONAL INFORMATION

The employee will demonstrate continuous commitment to the maintenance of a clean and safe work environment that is compliant with applicable regulatory agency requirements. The employee will follow established infection control procedures.

The employee will ensure the effective and safe use of all equipment used in his/her activities, if applicable.

The competence of the employee in performing his/her job duties is evaluated during orientation to his/her position and will be demonstrated, maintained, and improved on an ongoing basis. The employee will adhere to the assigned schedule and report to work on-time.

The employee shall abide by the requirements set forth in the Code of Conduct and report suspected violations of the Code of Conduct.

The employee will recognize, appreciate and incorporate an employee’s, patient's and patient’s family's unique differences, such as culture, spiritual beliefs, gender, race, ethnicity, lifestyle, socioeconomic status, age, and values, into an individualized plan of care or plan of action.

The statements contained in this position description reflect the general duties considered necessary to describe the principal functions of the job as identified, and shall not be considered a detailed description of all the work requirements that may be inherent in the position. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

The job description does not constitute a contract of employment and the company or employee may exercise its employment-at-will rights at any time.