Site: Cooley Dickinson Hospital, Inc.
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Job Summary
Summary
The Registered Nurse is responsible for delivering patient care through the nursing process of assessment, diagnosing, planning, implementation, and evaluation. The Registered Nurse directs and coordinates all nursing care for patients based on established clinical nursing practice standards and collaborates with other professional disciplines to ensure effective and efficient patient care delivery and the achievement of desired patient outcomes.
This position is part of the Massachusetts Nurses Association Bargaining Unit at Cooley Dickinson Hospital.
This position reports to the Nurse Manager/Director and operates within established organizational and departmental policies and procedures.
Does this position require Patient Care?
Yes
Essential Functions
-Must be able to effectively interact appropriately to an individual’s intellectual level and physical ability with infant, pediatric, adolescent, adult and geriatric patients.
-Deliver nursing care according to the standards of care defined within the American Nurses Association (ANA) Standards of Clinical Practice.
-Collect patient health data during admission process and throughout the patient’s stay.
-Determine the priority of data collection based on the patient’s immediate condition or needs.
-Collect pertinent data using appropriate assessment techniques.
-Involve the patient, significant others and health care providers in data collection when appropriate.
-Ensure that the data collection process is systematic and ongoing.
-Document relevant data in the medical record according to hospital standards.
-Analyze the assessment data in determining diagnoses/patient problems.
-Derive diagnoses/patient problems from the assessment data.
-Validate diagnoses/patient problems with the patient, significant others, and health care providers when possible.
-Document diagnoses/patient problems in a manner that facilitates the determination of expected outcomes and plan of care.
-Identify expected outcomes individualized to the patient.
-Derive outcomes from the diagnoses/patient problems.
-Document outcomes as measurable goals.
-Formulate outcomes mutually with the patient and health care providers, when possible.
-Ensure outcomes are realistic and attainable in relation to the patient’s present and potential capabilities and resources available.
-Ensure outcomes provide direction for continuity of care.
-Develop a plan of care that prescribes interventions to attain expected outcomes.
-Individualize the plan to the patient’s condition or needs.
-Develop the plan with the patient, significant other, and health care providers, when appropriate.
-Ensure the plan reflects current nursing practice.
-Document the plan according to hospital standards.
-Provide for continuity of care in the plan.
-Implement the interventions identified in the plan of care.
-Interpret and implement physician’s orders accurately, safely, and within established time expectations.
-Calculate and administer medications safely.
-Administer Point of Care testing, such as glucose monitoring, bladder scans and urine dipsticks (Childbirth Center only). Establish interventions that are consistent with the plan of care.
-Implement interventions in a safe and appropriate manner.
-Document interventions according to hospital standards.
-Evaluate the patient’s progress toward attainment of outcomes.
-Ensure evaluation is systematic and ongoing.
-Document patient’s response to interventions according to hospital standards.
-Evaluate the effectiveness of interventions in relation to outcomes.
-Utilize ongoing assessment data to revise diagnoses/patient problems, outcomes, and the plan of care, as needed.
-Document revisions in the diagnoses/patient problems, outcomes, and the plan of care according to hospital standards.
-Involve the patient, significant others, and health care providers in the evaluation process, when appropriate.
-Formulate a discharge plan.
-Begin discharge plan at patient’s admission.
-Contribute to, update, and communicate plan throughout hospitalization.
-Collaborate with the patient, significant others, and health care providers to efficiently utilize resources throughout hospitalization and facilitate appropriate discharge.
-Document the discharge plan according to hospital standards.
-Assess patient/family learning needs and facilitate the education process.
-Identify patient/family’s willingness and readiness to learn.
-Investigate barriers to patient/family education and develop plan to alleviate barriers in learning process.
-Develop and implement individualized patient teaching plans using appropriate patient education resources, including Care Notes.
-Adjust teaching strategies based on age appropriateness, cultural, and gender issues.
-Incorporate patient/family understanding into practice.
-Utilize education strategies to manage transitions across the continuum of care.
-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, including:
-Identification of aspects of care important for quality monitoring.
-Identification of indicators used to monitor quality and effectiveness of nursing care.
-Collection of data to monitor quality and effectiveness of nursing care.
-Analysis of quality data to identify opportunities for improving care.
-Formulation of recommendations to improve nursing care or patient outcomes.
-Implementation of activities to enhance the quality of nursing practice.
-Acquire, maintain, and apply current knowledge in nursing practice.
-Participate in and create a culture that recognizes and supports the development of professional nursing practice at CDHC.
-Attend educational programs and other activities in order to meet licensure and regulatory compliance, as well as to keep current in nursing practice.
-Share new information from educational programs with other staff members.
-Attend all mandatory in-services, staff meetings and committee meetings.
-Seek opportunities to contribute to the organization’s success, such as participating voluntarily on committees or quality improvement initiatives.
-Collaborate with the Nurse Manager/Director to establish annual goals for upgrading own practice and act independently to accomplish goals.
-Assist with the identification of needs for unit in-service activities.
-Contribute to development of in-service activities as appropriate.
-Meet all hospital-wide and department-specific annual retraining and competency requirements.
-Provide leadership to unit as assigned.
-Assume charge nurse/group leader responsibilities at request of Nurse Manager/Director or designee.
-Coordinate assignments based on patient’s needs, staff skills, and available resources to promote continuity of care.
-Identify priorities for patient care and unit activities.
-Serve as a resource person to other staff members.
-Follow-up on issues/suggestions raised by patients or other disciplines to facilitate and/or improve patient care.
-Communicate effectively regarding issues of patient care.
-Relate complete and pertinent information when processing patient/unit issues.
-Act as a patient advocate regarding patient’s physical, psycho-social, and spiritual needs.
-Initiate/participate in unit and department projects to improve systems for delivery of patient care.
-Act as a preceptor and assist in orientation of new personnel.
-Establish priorities, organize, and delegate work assignments accordingly.
-Cooperate with instructors to provide quality clinical learning experiences for affiliating students.
-Provide peers and other staff members with constructive feedback regarding their practice.
-Be open to constructive feedback from peers and other staff members.
-Seek available resources to help formulate ethical decisions.
-Maintain established hospital and departmental policies and procedures, objectives, confidentiality, quality improvement program, compliance, safety, infection control, and environmenta