The Registered Nurse BSN embodies the attributes of the Relationship Based Care model and performs to PPM core functions. Under the direction of the department leadership, consistently reflects the mission, vision, and values of NM, adheres to the State of Illinois Nurse Practice Act, the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Responsibilities:
Relationship to Patient/Family and Community
Care Coordination
- Performs a comprehensive assessment on all assigned patients as evidenced by completed documentation.
- Communicates changes in patient’s condition promptly.
- Utilizes appropriate nursing diagnosis and data from the assessment to derive realistic outcomes and documents them as measurable goals on the plan of care; modifies care plan, if indicated, in order to identify realistic patient goals.
- Identifies and prioritizes patient needs and/or nursing diagnosis for patients and documents.
- Collaborates with patient, family, and other members of the health care team when planning patient care and documents accordingly. Assesses patients with regard to discharge planning and makes the appropriate referrals as necessary.
- Evaluates and documents the patient response to nursing interventions and alters the plan of care as necessary.
- Assesses patients with regard to discharge planning and makes the appropriate referrals as necessary, including palliative care.
- Assures a completed discharge instructions, medication reconciliation and provide information to patient/family regarding the use of the patient portal and other pertinent resources.
Patient Education/Ethic and Diversity
- Supports patient/family/spiritual/cultural needs when assessing the patient and family needs for teaching; identifies the patient's learning level and readiness, and documents education record.
- Utilizes the teach back methodology for advancing patient education about medication side effects and new medication education.
- Utilizes and distributes Krames for patient education /clinical condition.
- Utilizes culture vision as a resource in care planning and delivery.
- Treats patients, families and staff in a caring manner with respect and dignity.
- Acknowledges and values the contributions of patient’s significant others as an integral part of the plan of care.
- Adheres to ethical standards of practice.
- Calls for an ethics consult when appropriate.
EBP and Research
- Implements nursing interventions consistent with the established plan of care based on evidenced based care.
- Maintains and advances the professional image and science of nursing and the practice of professional nursing through use of best available evidence utilizing resources such as Ovid/Joanna Briggs, Up to Date, Culture Vision, and other reliable sources of evidence.
- Demonstrates active involvement in clinical LADDER project or process improvement at the unit/organization level.
Healing Safe Environment
- Demonstrates safe medication administration through the use of bar coding
- Promotes and strives to protect the health, safety and rights of the patient
- Conveys complete, timely, and accurate information at bedside shift report/hand-off
- Rounds hourly in collaboration with patient care technician
- Protects patients by maintaining a safe environment of excellence
- Demonstrates innovation and participation in meeting unit based and organizational quality metrics on the exceptional care dashboard
- Ensures clinical practice excellence that focuses on preventing pressure ulcers, falls, CAUTI’s and central line infections (as appropriate to area of practice).
- Participates as a unit safety facilitator or as identified resource for quality initiatives as requested
- Participates in unit huddles
Relationship to Colleagues
Shared Leadership
- Oversees and directs the work of patient care or support techs; maintains overall accountability for the care of assigned patients.
- Demonstrates effective interpersonal skills in leading and directing others; deals with conflict directly and appropriately.
- Demonstrates proficiency in the charge nurse/preceptor role when assigned; assumes responsibility for coordinating patient care for the entire unit.
- Takes the clinical lead when patient’s condition changes and confers with the primary care physician about the appropriate treatment plan or the need to transfer to the appropriate level of care.
- Serves as a resource and role model for new staff, students, and other system personnel
- Assists with precepting, unit orientation, and mentoring as requested.
- Participates in the peer evaluation process by providing feedback to colleagues on a regular basis, and through participation in clinical case peer review.
- Works collaboratively with all hospital services to responsibly accomplish daily work and maintain an environment of excellence.
- Identifies barriers to effective clinical practice and communicates to nursing leadership and practice operations council.
Resource Utilization
- Ensures an appropriate level of care order is documented in the EMR for all admissions.
- Understands and adheres to the charging of supplies.
- Participates in any value based unit/organizational initiative.
- Demonstrates a personal commitment to decreasing utilization overtime hours.
Use of Technology
- Assures all electronic and paper documentation is complete.
- Utilizes the guardrails for the Alaris pump.
- Understands physiologic monitoring and the implications to drive changes to clinical management of the patient.
- Utilizes the bed management system
- Identifies new technologies for unit, hospital or system use.
- Participates in CEOC activities for the advancement and optimization of the medical record as requested.
Relationship to Self
Professional Practice
- Attends internal professional development offerings i.e. Schwartz Rounds, Nursing Grand Rounds.
- Obtains certification in the nursing specialty of practice.
- Demonstrates accountability for his/her professional practice-competencies, ELM learning, dress code adherence
- Participates in professional organization through membership, leadership, or committee work
- Takes assigned lunch breaks.