JOB TITLE: Registered Nurse
REPORTS TO: Director of Nursing
SUPERVISES: Milieu
EXEMPTION STATUS: Non-exempt
POSITION SUMMARY: The Registered Nurse is responsible for the overall assessment, implementation of treatment, and evaluation of quality clinical services for children, adolescent, adult and geriatric patients. He/she has direct responsibility for the provision of nursing care. Carries out “other duties” as assigned
ENVIRONMENTAL CONDITIONS: General office environment, computer and other office equipment
Physical Requirements: Ability to communicate verbally and in writing. Repetitive motion for typing and manual dexterity to access filing systems. Push, pull and lift up to 40 pounds. Intermittent sitting, standing, walking, bending and stooping. Drug and alcohol free as evidenced by negative results of post-offer, pre-employment urine drug screen.
FUNCTIONS:
Essential Functions:
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Demonstrates competency in prioritization, delegation, and coordination when functioning as Charge Nurse on a unit. Fills out assignment sheets effectively. Assigns responsibility for the provision of various aspects of care which is reflective of the complexity of nursing care required and the competence of available staff, considers the following in making/revising patient care assignments:
- The patient’s status
- The environment in which nursing care is provided.
- The competence of the nursing staff members who are to provide the care.
- The degree of supervision required.
- The complexity of the assessment required by the patient.
- Relevant infection control and safety issues.
- Assures compliance of all staff on unit with levels of observation, patient checks/flow sheets, meal monitors, enuresis logs, other tracking forms, and patient check-ins.
- Understands and assures adherence by all staff to unit program structure (i.e. point system, limit-setting system, rules, schedule, etc.) on all units. (If works nights, understands and assures adherence to proper procedures for billing, chart breakdown, precautions and census, chart building, report, filing, vital signs, etc.).
- Actively manages the milieu, ensures that seclusion and/or restraint are minimized and only utilized as a last resort for patent safety. Directs the effective and timely implementation of milieu tools
- Demonstrates the knowledge and skill necessary to provide care and services for the following age specific patient groups:
- Children 4-12 years of age.
- Adolescents 13-17 years of age.
- Adults 18-64 years of age.
- Geriatrics 65 years and older.
- Completes Nursing Admission Assessment within 8 hours of admission and determines nursing needs to serve as the baseline for development of the patient’s initial plan of care. Includes consideration of biophysical, psychosocial, spiritual, environmental, pain level, self-care, educational, and discharge planning factors in the admission assessment. Writes initial treatment plan based on data gathered from the admission assessment. Assesses safety risk of every new admission, assures appropriate level of observation and starts protocol as indicated.
- Demonstrates knowledge of normal dosages, actions and interactions with foods and other drugs, side effects and routes of administration. Provides ongoing medication education during medication administration.
- Questions unusual dosages or routes of administration of medications, clarifies with physician/pharmacist. Questions prescribing doctor when concerns or problems with medications arise.
- Documents response to PRN medication administration. Assesses the patient’s pain level utilizing the numeric pain scale, demonstrating knowledge of pain management principles. Documents pain level before and after the administration of PRN pain medication.
- Completes any appropriate follow-up documentation related to medication administration/events.
- Monitors and interprets vital functions and findings and correlates with patient condition.
- Bases patient care/treatment decisions on identified patient needs and clinical treatment priorities.
- Completes at least 50% of regular in-services through in-person attendance or by video in a timely fashion and 100% of mandatory in-services by in-person attendance or video. Is up-to-date on competencies and staff development requirements. Attends at least 50 % of departmental and unit staff meetings. Is responsible for reading the minutes of meeting not attended on base unit.
- Checks personal mail folder daily and returns requested policies for review promptly. Initials Communication Book daily. Takes initiative to write entries in the Communication Book to facilitate improved functioning and adherence to policies on the unit as needed.Other Functions
- Provides shift supervision, guidance, support, and corrective actions on issues of immediate concern with Mental Health Workers, LPNs, and Unit Clerks. Follows-up and addresses complaints/and or problem issues and gives useful feedback in a timely manner.
- Ensures Infection Control, Safety and Risk Management policies are consistently followed on the units. Demonstrates safety as a priority and promotes a safe environment for patients, families, visitors, and staff. Identifies potential safety issues and takes effective action to reduce the risk.
- Proficient with effective inter-shift communication, assuring that Kardex and Jots are updated each shift, patient assignment board is updated and taping a full change of shift report using the Kardex and Jots.
- Collaborates effectively with physicians and other clinical disciplines in making decisions regarding each patient’s need for nursing care. Gives a full nursing report using the Kardex and Jots in Staffing. Assures that pertinent milieu management issues are addressed in staffing. Provides nursing care consistent with the therapies of other disciplines.
- Enters active medical problems and nursing interventions on the multidisciplinary treatment plan. Updates progress on medical problems during treatment plan reviews.
- Involves the patient and/or significant other in the patient’s care as appropriate. Consistently documents education on Multidisciplinary Pt/Family Education Record throughout the patient’s hospitalization. Intervenes appropriately in unusual and complex patient/family situations.
- Proficient at crisis de-escalation, positive early crisis intervention, and providing supervision in potential CPIs. Completes Seclusion/Restraint paperwork accurately and timely.
- Completes daily check-ins with assigned patients. Uses therapeutic communication techniques when interacting with patients. Gives patients additional assignments relating to their treatment plan problems.
- Documentation is appropriate, specific, and objective. Documentation shows evidence of assessment, intervention, teaching per treatment plan and protocol, and patient’s response. Documents chart notes on shift summaries. Ensures that documentation meets policies, procedures, standards and laws.
- Has completed in-service on “Safety Assessments and Therapeutic Communication”. Performs safety assessments on all patients with high-risk issues prior to or during hospitalization and accurately completes the suicide assessment forms for these patients. Uses therapeutic communication to establish rapport when assessing safety risk. Assures that every patient is at appropriate level of observation to maintain his or her safety.
- Consistently starts Protocols (suicide, assaultive, sexual, and fall) when indicated, gives patient a copy, and writes the start date in the doctor’s orders and Kardex. Assures that staff assists patients to work on Protocols as tolerated by patient each shift. Writes progress on Protocols in doctor’s orders and Jots. Writes completed date in Kardex and puts completed copy of Protocol in the front part of the doctor’s orders section of the chart.
- Regularly leads and co-leads health management/psychoeducational groups to assist patients in improving or regaining previous coping skills, fostering mental health, improving self-care activities and improving medication management. Understands and demonstrates the principles of leading groups (introductions, group rules, warm-up, psychoeducational content, wrap-up.)
- Performs procedures/treatments in a timely manner and in accordance with physician orders and nursing policies and procedures. Proficient at order transcriptions, chart checks, EKGs, and assuring completion of consults/labs. Has a low rate of transcription errors and chart deficiency.
- Functions promptly and effectively in codes, emergencies or other stressful patient situations.
- Proficient at coordinating effective discharge processes. Assesses patient readiness for discharge and related teaching needs or referral. Provides patient and family education necessary to promote continuity of care and optimal patient outcomes after discharge.
- Practices safe nursing care in accordance with the Wyoming Board of Nursing, Nurse Practice Act.
- Transcribes, administers, and documents medications accordingly per hospital policies and safe practice. Uses at least two identifiers (picture and birth date) before administering medications. Triple checks the 5 rights of medication administration. Assures that medication is not cheeked or palmed by patients. Has a low rate of medication errors.
- Follows absenteeism policy, unscheduled absences are minimal. Volunteers for overtime when staffing emergencies arise.
- Wears identification while on duty, uses punch time system correctly. Punches out and in for breaks. Fills out a missing break slip for every break not taken and forwards to Nursing Management for signature.
Values and Commitment
- Protects confidentiality of patients and peers.
- Participates in PI activities as assigned.
- Promotes enthusiasm, dedication, and self-motivation.
- Provides compassionate nursing care with special attention to comfort and well being of the patient and his/her family/ SO.
Fulfills Professional Conduct
- Treats patients, families, visitors, and peers with respect.
- Maintains positive attitude. Volunteers for and has a positive attitude when needed on another floor or unit. Promotes positive teamwork.
- Orients new staff and provides guidance in an effective and supportive manner.
- Refrains from gossip.
- Offers problem-solving ideas.
- Strives for professional excellence.
- Demonstrates high standards of personal appearance.
- Identifies a need, develops, and implements in-service education at least once a year.
- Adheres to policies and procedures.
Facilitates An Effective Communication Process
- Maintains a communication pattern that promotes collegiality.
- Identifies self and clarifies role to patient, family, staff, physicians, students and other disciplines.
- Recognizes and responds appropriately to verbal and non-verbal cues.
- Communicates effectively with all members of the health care team in a timely manner by:
- Asserting self with tact
- Supporting collaboration
- Maintaining open communication
- Offering suggestions and criticisms constructively
- Asking questions and sharing information during treatment planning sessions
- Using appropriate chain of command.
- Relates complete and pertinent information in verbal and written communication.
- Initiates and maintains open and effective communication with physicians, the multidisciplinary team members and other department associates as evidenced by improved patient outcomes.
- Demonstrates appropriate communication skills by sharing, clarifying, reflecting and interpreting.
- Acts as a liaison to the patient/parent or guardian by providing accurate and timely information to ensure patient/parent or guardian participation in care. Consistently documents patient/family education on the Multidisciplinary Patient/Family Teaching Record during and after admission and addresses barriers to learning.
Demonstrates Understanding of Patient Rights and Delivers Care in Accordance with Policies and Procedures Regarding:
- Patient confidentiality.
- Appropriate boundaries.
- Advance directives.
- Informed consent.
- Personal privacy.
- Patient values and beliefs.
- Resolution of patient complaints/dissatisfaction.
- Addressing ethical issues.
- Restraints/Seclusion.
- In the absence of Nursing Management, monitors and adjusts staffing to fit the census and acuity for current and next shift. Works with other Charge Nurses to assure adequate staffing all over the hospital. Promotes effective teamwork between units and floors.
REQUIREMENTS: Must be 21 years of age and hold a Wyoming Registered Nursing License. Prefer Bachelor’s Degree in Nursing. One year of experience in psychiatric acute care, residential care, partial care or equivalent is preferred, but will train Graduate Nurses. Must have knowledge of developmental tasks of children, adolescent, adult and geriatric patients and apply knowledge in assessment and planning of care.
Source: Indeed.com
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