Registered Nurse (RN)-Acute Care, Vascular Access Team, PRN, Various

Provides clinical direction for all aspects of patient care in an acute inpatient setting, fostering patient/family centered care.

Demonstrates clinical competency utilizing evidence based practices/research in all areas of the nursing process: assessment, planning, implementation, evaluation and outcomes.

Consults with clinical advisor and/or peers as appropriate.Adheres to all compliance and policy/procedures of the organization including, but not limited to: licensure renewal, assigned training, employee health screenings, time and attendance policy, dress code policy, patient confidentiality, infection control, medication administration.

Demonstrates knowledge of regulatory agency requirements (JCAHO, DHEC, CMS).

Provides care within the scope of the South Carolina Nurse Practice Act.

The acute inpatient setting usually requires staff to be scheduled for a significant amount of shift, weekend, holiday and on-call work.

Accountabilities

Assessment - Collects data and completes nursing assessment utilizing appropriate area and/or age specific standards/policies and tools. Assesses and recognizes subtle or actual changes in patients' condition and patient response to intervention. Identifies nursing priorities for the interdisciplinary plan of care based on nursing assessment (and other data as appropriate). Validates these priorities with healthcare team members and documents appropriately. - 20%

Planning & Outcomes - Develops an age appropriate, culturally sensitive, individualized plan of care that reflects current evidence based practice, the assessed needs of the patient/family and addresses continuity of care. Makes appropriate referrals based upon assessment (eg. skin, nutrition, social services). Develops the plan in collaboration with the patient/family, the physician, and other members of the interdisciplinary healthcare team to derive measurable outcomes from diagnoses that are culturally appropriate, realistic and attainable; validates goals with the patient/family and documents appropriately. Updates the plan based on changes in the patient's condition; communicates changes in the plan to other members of the team. Plans for discharge begin at the time of admission to assure continuity of care and a smooth transition post discharge from one level of care to another (eg. medication lists to assist with reconciliation, appropriate referrals, etc.) - 15%

Implementation - Provides direct care to assigned patients in a safe, timely, appropriate and cost effective manner; consistent with the established plan of care and identified patient priorities. Performs specific tasks based on organizational, departmental and/or unit policies/ procedures within the nurses' scope of practice; utilizing known resources and appropriate technology internal/external to the unit (per evidence based practice). Delegates nursing tasks as appropriate to members of the healthcare team, developing written assignments (as appropriate); ensures completion of assigned tasks. Ensures appropriate surveillance of assigned patients; monitors quality of care delivered. Ensures smooth, safe hand-offs of assigned patients to other departments and/or caregivers (eg. shift report, transfer to diagnostic areas or to another unit, etc.). Assumes responsibility for patient safety by maintaining a safe environment to include awareness of safety procedures, protocols and adherence to patient care standards (infection control, medication administration, restraints, etc.). Utilizes performance indicators to collect data, monitor quality and effectiveness while providing nursing care. Completes assigned hospital/unit performance improvement monitoring (audits). -20%

Evaluation - Based on assessment/reassessment of patient response to interventions, evaluates plan of care for effectiveness, documents progress toward expected outcomes, and revises plan of care as needed. Reports changes in patient condition and refers unresolved problems to appropriate healthcare team members. Discusses outcomes with peers (via shift to shift report) and with other healthcare team members. Evaluates opportunities for quality improvement; based upon evaluation, incorporates performance improvement recommendations into the plan of care as appropriate. - 15%

Patient/Family Education/Teaching - Identifies/assesses patient/family learning needs and teaches accordingly by:

using language and terminology that the patient/family is familiar with

providing examples to clarify ideas

encouraging patient/family involvement in implementing and evaluating teaching plan

utilizing appropriate resources (eg. written tools, computer aides, Micromedix, etc.) Communicates the patient/family's need for education/teaching to others in the healthcare continuum, utilizing resources within the interdisciplinary healthcare team as necessary. 15%

Professional Accountability - Evaluates own nursing practice in relation to professional practice standard guidelines, state statutes, policies, procedures, rules/regulations and current specific knowledge. Takes personal accountability for maintaining competency through education and professional activities to promote the healthcare of the community. Maintains professional licensure and completes required mandatory education in a timely manner. Reflects on identified areas of strength that offer opportunity for improvement. Ensures that written documentation and oral communication focuses on pertinent information to support meeting patient/family care needs. Serves as the patient's advocate and coordinator of care, working collaboratively with the physician(s) and other members of the healthcare team. - 15%