Job DescriptionSummary
Manages individualized,outcome oriented nursing care through the use of the nursingprocess. Provides care, treatment and services through thesuccessful coordination and completion of a series of processesthat include assessment, planning care, providing care, inaccordance with departmental and hospital policies andprocedures
JobDescription
1.Medication Administration
a. Demonstrates knowledge of and follows SSH policies andprocedures for administering, transcribing, and recordingmedications.
b. Completes medicationreconciliation process following SSH policy and procedure.
c. Demonstrates proper procedure for thedocumentation of narcotic withdrawal, administration, verifiescount, wastes per policy and resolves narcotic discrepancy.
2. Plan ofcare/Documentation/Patient Family Centered Care/Patient ExperienceDevelops, discusses, and communicates a prioritized problemlist/plan of care for eachpatient.
a. Develop,evaluate and update individualized plan of care for patient anddocuments outcomes.
b. Initiating admissionassessment within 8 hours of admissions, identifies and documentspatient/family/significant other teaching needs upon admission andthroughout hospitalization.
c. Continuesassessment/reassessment and identifies care needs withinestablished nursing practice.
d. Documentsall patient care following the department of nursing policy, unitbased standards, disease processes (CHF, PNA vaccines) and nursesensitive indicators (falls, skin, CAUTI)
e.Assess/reassesses and documents patient's level of comfortutilizing the appropriate pain scale and the patient's response toeach intervention both pharmacological and non-pharmacological perSouth Shore Hospital policy.
f. Works onbehalf of patient/family. Seeks help to represent patient/familywhen they are unable to represent themselves.
g. Raises ethical questions and concerns with clinical team.Seeks available resources to help formulate and understand ethicaldecisions.
h. Actively communicates plan ofday via white board updating every shift.
i.Facilitates discharge/transfer by goal of 12:00pm, communicatesbarriers utilizing chain of command.
3. Safety/Quality - Foster's a "Culture of Safety"through personal ownership and commitment to a safeenvironment.
a. Verifiespatient identification with two identifiers prior to the start ofany invasive procedure, including "time out", administration ofcare, medications, labeled specimen's an documents confirming thecorrect patient, procedure, site, equipment and consent.
b. Complies with the current CDC hand hygieneguidelines through proper handwashing. Adheres to universalprecautions, makes appropriate use of personal protective equipmentat all times and appropriately disposes of hazardous materials.Maintains awareness of MSDS sheets and how to access.
c. Ensures environment meets regulatoryrequirements at all times.
d. Understandsand is able to demonstrate individual roles and responsibilities inthe event of hospital codes/emergency preparedness.
4. Professional Development:Assumes overall responsibility for own professional development byincorporating evidenced-based practice, research, and performanceimprovement initiatives as a part of ongoing nursingpractice.
a. Obtains atleast 5 contact hours per year in area of practice.
b. Practices within the legal boundaries of MANurse Practice Act. Directs other licenses and non-licensedpersonnel as assigned.
c. Displays theability to accept and respond appropriately to feedback andrecommendations for change.
d. Demonstratesprofessional working relationships with colleagues from alldisciplines to promote a positive/encouraging workplace.
e. Critical Thinking: analyzes causes of problems,identifies and evaluates alternative solutions, and selectsappropriate solution, and communicates appropriately andeffectively utilizing chain of command.
f.Accountable for being informed about changes in hospital policy andprocedure.
5.Technology: Utilizes technological solutions to work processes andpractices.
a. Access LotusNotes to review email, learning management and other resources asapplicable to RN role.
b. Utilizes softwareapplications required by department and unit standards.
c. Accountable to understand how to operate indowntime.
6. Compliance
a. Works within legal, regulatory and ethical standardsrelevant to the position.
b. Complies withapplicable policies and procedures.
c.Safeguards the privacy and security of patient information. Theemployee compiles will policies and procedures relating to SSH'sprivacy and security programs.
d. Bringspotential compliance issues to a manager, supervisor, director orVP.
e. Complies with the mandatory educationrequirements of the compliance, privacy and securityprograms.
7. Patientand Family Centered Care
a.Conveys respect for values, preferences, and expressed needs of thepatient and family.
b. Recognizes thepatient, and family according to patient preferences, as importantmembers of the health care team.
c.Collaborates with the patient, and family according to patientpreferences, in planning, implementing, and evaluating care.
d. Welcomes the presence and participation offamily members at all times according to patient preferences,regardless of rounds, change of shift, or other events onunit.
8. Age &Culture
a. Possesses ageand cultural knowledge and awareness.
b.Considers the individual needs of each person with whom theyinteract.
c. Interacts with sensitivity inthe delivery of care/services of diverse populations asneeded.
d. Effectively utilizes resources toprovide care/services - such as, interpreter services and on-linesources.
Minimum Education -Preferred
Graduate of an accredited School ofNursing
Minimum Work Experience
Previous Acute Care RN experiencepreferred
RequiredLicenses/Certifications
RN- RegisteredNurse
Dependingon department Basic Life Support (BLS) Certification, AdvancedCardiac Life Support (ACLS) Certification, Emergency ResponseTraining Certification, Neonatal Resuscitation Program (NRP)Certification, Pediatric Advanced Life Support (PALS), Trauma NurseCore Course (TNCC), Trauma Care After Resuscitation (TCAR)Certification may berequired