Staff Nurse-Tower A8 - VIP Wing

Responsibilities

• Assessment and Diagnosis: Collects and analyzes assessment data to determine diagnosis/issues:  Assesses comprehensive data including but not limited to physical, psychosocial, emotional, cognitive, and spiritual needs and interprets assessment information to derive the diagnosis or issues as defined by the patient's condition.  Uses evidence-based assessment techniques and instruments in collecting data and validates the diagnosis or issue with the patient, family and healthcare team members as appropriate.  Prioritizes the data and information collected based on patient's immediate condition or anticipated needs and identifies potential risks or barriers to the patient's health or safety.  Documents the data and information collected in compliance with established guidelines and reflective of the needs of the patient. • Planning and Outcomes Identification: Identifies expected outcomes and develops a plan that address health promotion, health restoration and health maintenance to attain expected outcomes.  Involves patient, family and healthcare team members in formulating a culturally appropriate individualized plan of care.  Applies evidence-based nursing practices in developing the individualized plan of care to attain expected outcomes and continuity of care.  Modifies the individualized plan of care according to the ongoing assessment and reevaluation of the patient's response, status, and outcome indicators.  Documents the expected outcomes as measurable goals in a manner that uses standardized language or recognized terminology.
• Implementation and Coordination of Care Delivery:  Implements the plan of care in partnership with the patient, family and healthcare team members in a timely manner utilizing evidence-based interventions and treatments specific to the needs of the patient.  Performs treatments and procedures according to established procedural guidelines and protocols.  Administers medications according to organization policies and procedures.  Ensures that all components of the individualized plan of care, including modifications, are documented in the patient’s health record.  Communicates relevant information across all levels of care and organizations.  Demonstrates a working knowledge of resource consumption and practices within a costeffective framework. • Health teaching and health promotion:  Utilizes teaching strategies appropriate to the individual patient's condition and learning needs.  Uses health promotion to support patients and families in developing skills that promote, maintain, or restore healthy lifestyles and self-management support.  Seeks opportunities for feedback and evaluation of the effectiveness of the strategies used, including teach back.  Ensures that all components of the health education, relevant to the clinical condition, is documented in the patient health record. • Evaluation: Evaluates progress toward attainment of outcomes.  Evaluates the patient/family's understanding of and response to the plan of care.  Utilizes systematic and ongoing assessment data to revise nursing diagnoses, outcomes, and the plan of care.  Involves the patient, family and healthcare team members in the evaluation process.  Provides a comprehensive clinical handover/report as required to ensure patient safety.  Attends patient care rounds, communicates, and updates the attending healthcare provider on changes in the patient’s condition.  Communicates with the patient care team about ongoing changes in patient’s plan of care and unit activity  Documents the reassessment of patient status; patient and family participation and understanding; and the rationale for any revision in the plan of care. • Evidence-based Practice and Research: Integrates evidence and research findings into practice.  Utilizes current evidence-based nursing knowledge, including research findings, to guide and evaluate practice.  Participates in evidence-based and research activities at various levels appropriate to the nurse's level of education and position.  Shares evidence-based and research findings with healthcare team members.  Participates in performance improvement projects for the evaluation and improvement of clinical practice • Leadership: Demonstrates leadership behaviors in practice settings, across the profession, and in the community.  Functions as a professional role model promoting a positive, team-based, organized, and safe work environment.  Coordinates and supervises delegated activities to assure completion and serve as a resource for other healthcare team members  Demonstrates critical thinking in priority setting and decision making in response to patient needs.  Pursues informal and formal leadership opportunities  Participates actively in organizational shared decision-making situations that improve the nursing practice, organizational performance, and outcomes.  Supervises practical nurses and junior staff and student nurses to ensure the provision of safe and effective patient care. Accountabilities • Applies the principles of professional codes of ethics that ensure individual rights in all areas of Practice: • Maintains a professional and therapeutic nurse-patient relationship and serves as a patient advocate assisting patients and families in developing skills for self-advocacy. • Speaks up to question healthcare practices as appropriate for safety and quality improvement. • Discloses any observed illegal or incompetent practices and decisions made by potentially impaired health care staff per organizational policy. • Evaluates own nursing practice in relation to professional practice standards and guidelines, rules and regulations. • Considers factors related to effectiveness, cost, environmental health, and impact on practice and organization. • Utilizes current resources related to standards of care, policies and procedures, and patient needs. • Navigates and utilizes electronic resources for information retrieval, communication, and documentation. • Evaluates factors related to patient safety, effectiveness, availability, and cost when determining practice options. • Promotes a practice environment that reduces environmental health risks for staff. • Communicates environmental health risks and exposure reduction strategies to healthcare consumers, families, colleagues, and communities. • Demonstrates a commitment to continuous learning and education for self and others and mentors healthcare team members for the advancement of nursing practices, the profession, and quality healthcare. • Oversees and responds to all levels of emergencies according to the organizations policies and procedures.