Registered Nurse Acute - Day Shift

Description This job description is a record of the essential functions of the listed job. The job description provides the employee, CEO, Human Resources, applicants, and other agencies with a clear understanding of the job, where it fits into the organization, and the skill and work requirements in relation to other jobs. Jobs are always changing to some degree and the existence of the approved job description is not intended to limit normal change and growth. The facility will make reasonable accommodations to otherwise qualified individuals who are capable of performing the essential functions of the job with or without reasonable accommodation.

Requirements

POPULATION SERVED The position involves direct patient care for a population of patients between the ages of 18 and older for inpatient care and between the ages of 0 and older for emergency services. Age specific experience and/or special training and/or expertise is required to serve this population.

Position Summary

Using independent and interdependent judgement, the Registered Nurse (RN) in compliance with the state of California, Title 22 Nursing Service maintains the delivery of quality care by assuring the nursing care plan is followed. In collaboration with the provider, the RN assures implementation of the assessment plan, evaluation, and follows up the plan of care for the patient population. POSITION QUALIFICATIONS This position requires a valid temporary or permanent CA State Registered Nurse License. The individual must have strong interpersonal skills, the ability to manage multiple priorities, be dedicated to the provision of quality patient care, and use sound judgement in decision-making. Basic Life Support (BLS) certification required upon hire. Advanced cardiac life support (ACLS) certification required Upon Hire. Pediatric Advanced Life Support (PALS) certification required within 1 months of hire if working in Emergency Department. Trauma nursing core course preferred if working in the Emergency Department but not required. Ability to maintain assigned work hours: Requires endurance to perform tasks over long periods of work hours. The duties and responsibilities are listed below. It is the expectation of the institution that the employee be able to demonstrate competency in each area. It is the duty of the institution to provide orientation and performance evaluation in each area stated.

Duties and Responsibilities

I. RESPONSIBILITIES TO THE PATIENT 1) Initiates an on-going systematic assessment of the physical, emotional, social, educational, and functional needs of the patient/family through interview, observation, and physical examination. a) Receives admissions and/or transfers to the unit. b) Completes nursing admission notes within 24 hours. 2) Interprets assessment data and information to develop a nursing care plan which contains problem identification, nursing diagnosis, nursing orders, approaches, interventions, short/long term goals, and discharge planning. a) Develops nursing care plan utilizing nursing diagnosis b) Assesses safety and fall risk levels for patients 3) Teaches and counsels patients/families, and makes referrals to appropriate resource personnel when needed. a) Documents patient, family, and significant other teaching 4) Participates as a productive member of the interdisciplinary team in assessment, planning, implementation and evaluation of rehabilitation goals. 5) Assures that medical orders are transcribed and processed accurately, and integrates the medical care plan into the provision of nursing care. 6) Assures that medication/I.V. administration is correct and according to the established nursing policies and procedures. a) Looks up unfamiliar medications b) Processes medication orders c) Administers medications as ordered d) Evaluates effectiveness of PRN medications e) Verbalizes process for self-administered medications f) Verbalizes patient education on identified medications g) Verbalizes standing orders h) Verbalizes policy and procedure for maintenance and care of central line catheters i) Administers I.V. drugs 7) Provides for personal and environmental safety in accordance with hospital and nursing policies and procedures 8) Demonstrates skills in handling emergency and life-threatening situations a) Locates and uses crash cart items b) Calls Code Blue and Medical Emergency c) Initiates CPR d) Follows P&P and POLST 9) Assures that documents in the medical record are complete, factual, accurate and timely. a) Documents materials and equipment used. b) Verbalizes method to noting orders. c) Documents discharge in chart. d) Initiates and updates care plan as appropriate. e) Provides discharge instructions. f) Completes interagency transfer form. 10) Provides nursing care to meet patient needs: a) Performs a complete head-to-toe assessment of each assigned patient per shift using proper documentation tools. b) Acts promptly on changes in patient condition, utilizing SBAR method c) Reviews lab and test results, notifying physician of abnormal and critical results d) Performs wound care in accordance with policy, utilizing proper documentation tools. e) Performs basic ventilator management and trouble-shooting. II. RESPONSIBILITIES TO UNIT STAFF 1) Provides direction and leadership in patient care to assigned personnel. a) Acts as a team leader. b) Makes assignments for team. 2) Prioritizes activities and plans for effective use of time and staff in meeting patient needs. 3) Communicates the plan of nursing care for each patient through reports, conferences, rounds, and patient care records. a) Shift to shift report and shift huddle with aides b) Delegates tasks to aides; monitors to make sure delegated tasks are completed appropriately. 4) Demonstrates responsibility for the teaching of staff in areas of new techniques, policies and procedures. a) Preceptor 5) Participates in the quality improvement activities of nursing. a) Attends appropriate meetings. 6) Communicates identified learning needs of self and others to the DON/CNO. 7) Assists the DON/CNO in the orientation of new staff. 8) Adheres to established policies and procedures of the hospital and Nursing Department. 9) Actively participates on nursing committees. 10) Performs other duties as assigned or requested. III. RESPONSIBILITIES TO SELF 1) Evaluates own performance and seeks opportunities for growth and expansion of skills 2) Takes initiative in upgrading and maintaining skills necessary to provide quality care to patients and leadership to assigned staff. 3) Acquires continuing education sufficient to maintain licensure and certification a) Maintains current nursing licensure b) Provides Human Resources and DON/CNO with a copy of current nursing license. c) Maintains required competencies d) Completes assigned program tracks assigned by DON/CNO/Education Facilitator. e) Completes appropriate level of Clinical Advancement within established timeframes 4) Membership in appropriate professional organizations. 5) Assumes responsibility for maintaining/enhancing physical health and alleviating stress a) Attendance 6) Demonstrates competency in a variety of nursing skills as demonstrated and evaluated on at lease an annual basis. a) Attends annual skills fair 7) Displays a “customer service” attitude toward patients, visitors, and other staff members at all times. a) Demonstrates basic telephone skills (how to answer, place on hold, and transfer a call.) b) Utilizes intercom and demonstrates how to page physicians or others on call. 8) Abides by all safety, infection control, and other guidelines as required. a) Follows guidelines for caring for patients in isolation b) Utilizes hand-washing techniques c) Cleans equipment between patient usage. d) Reports personal symptoms of suspected illness or contagious disease to the Employee Health Nurse. e) Demonstrated knowledge of universal blood and body fluid precautions 9) Promotes an ethic of continuous quality improvement in all matters associated with the position, and documents specific quality improvement implementation. 10) Performs all other tasks and duties as may be assigned. 11) Provides a level of competency to treat patients 0 and older. a) Pediatric: a. Involves family and or care provider in all aspects of procedures assessment or care. b. Identifies learning strategies that are age appropriate. b) Adults: a. Involves them with care planning by meeting any needs they identify during assessment. b. Identifies their normal patterns of living and strives to attain them c) Geriatric: a. Strives to obtain understanding by speaking distinctly and moving slowly. b. Involves family as much as possible IV. DRESSES AND PRESENTS SELF IN A PROFESSIONAL MANNER AT ALL TIMES. ADHERENCE TO THE DRESS CODE POLICY IS REQUIRED. V. WEARS HOSPITAL ISSUED NAMETAG AT ALL TIMES WHILE ON DUTY VI. CONDUCTS SELF ETHICALLY AT ALL TIMES. VII. UPHOLDS ALL SERVICE STANDARDS 1) Safety- We do no harm and create an error-free environment. a) Follow environment of care plan b) Follow established clinical practices c) Routine assessment of the environment for high risks with immediate correction (look for dangerous things and fix them; identify high risk issues and fix them) d) Pay attention to detail 2) Communication- We engage our customers in exchanging clear, timely and accurate information. a) Listen carefully b) Ensure understanding of treatment and services c) Timely follow-up on commitments d) Constantly learn about the customers and identify their needs 3) Courtesy- We treat everyone with respect, social sensitivity and professionalism. a) We acknowledge our customers with a smile and treat them as welcomed guests b) Listen to our customers c) Look at each interaction as an opportunity to promote courtesy with our customers d) We treat each other as we treat our guests e) We strive to exceed our customers expectations 4) Presentation- We provide a positive customer experience through the appearance of our environment and employees. a) Maintain a clean and organized environment, including workspaces b) Control hospital odors c) All employees are compliant with the dress code d) All employees communicate in a professional and courteous manner, including body language e) Protect the privacy of patients f) Maintain a quiet atmosphere 5) Efficiency- We use resources appropriately to benefit the customer and the organization. a) Availability, assessment and application of resources b) Do it right the first time c) Pay attention to details d) Save steps through planning e) Timely responses WORKPLACE BEHAVIORS I. RESULTS ORIENTATION – Meets current objectives and positions the organization for future growth. Completes daily tasks and assignments and processes large volumes of work associated with the operation of the department. II. SOCIAL SENSITIVITY - Builds positive relationships based on respect for others. Demonstrates a helpful, positive attitude. Maintains effective communication with peers, medical staff, patients, visitors, and families. III. QUALITY OUTCOMES – Meets and exceeds expectations of internal and external customers. All organizational and departmental standards regarding quality of performance are met. Demonstrates a strong commitment to confidentiality. Participates in quality improvement programs as directed. IV. SAFE WORKING ENVIRONMENT – Demonstrates an awareness of and adherence to safety and legal requirements established at the facility with an emphasis on maintaining a safe environment for all persons working in the facility. A. Accident/Injury Reporting – Reports any accidents, injuries, and unsafe equipment and conditions to supervisor by the end of the shift. B. Unsafe Conditions – Immediately reports and corrects, if possible, unsafe conditions or equipment. C. Workplace Standards – Compiles with relevant regulations, standards and policies governing safe workplace environment (OSHA, Accreditation, etc.) D. Safety Techniques – Maintains current knowledge of all aspects of the facility’s safety program by attending safety-related training as mandated upon hire and thereafter as required by facility. E. Modified Work – Accepts modified work assignments after receiving the physician’s release to return to work following an accident/ injury. F. Follows Prescribed/Recommended Treatment – Follows the prescribed/recommended treatment given by treating physician(s) after an accident/injury. V. EDUCATION – Participates in required Inservice and educational programs on an ongoing basis. VI. ATTENDANCE AND PUNCTUALITY – Follows all facility guidelines outlining standards of attendance and punctuality. Responsible for reporting to and completing work at assigned times.