Responsible for patient assessment, patient care planning, and provision of quality nursing care to an assigned group of patients for a defined work period. Provides direction and supervision to LVN/LPNs, nursing assistants, unit secretaries, and other clinical/clerical associates. By assignment, may function as a charge nurse for the unit. Involves provision of patient care/service to older adolescents, young adults, adults, geriatric and pediatric patients.

Responsibilities:

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
Patient Care Planning
Develops a comprehensive nursing care plan which addresses all significant needs and problems identified through nursing assessment.
Prepares nursing elements of the interdisciplinary care plan prior to the initial team conference.
Reviews and updates nursing care plan and collaborates with team members as changes occur.
Patient Care Provision
Implements patient care as planned in nursing care plan and interdisciplinary care plan.
Sets priorities based on knowledge of patient acuity and patient needs.
Provides safe and therapeutic care and seeks resources when appropriate.
Safely performs and accurately documents procedures, consistent with established nursing policy and procedure.
Patient Care Evaluation
Evaluates patient response to interventions and attainment of goals in collaboration with interdisciplinary team.
Evaluates progress toward nursing goals and revises goals as needed on a weekly basis.
Completes nursing progress note for assigned patients on a daily basis.
Completes nursing flow sheets for assigned patients on a daily basis.
Teaching
Evaluates education needs of patient and significant others and documents their response to teaching.
Utilizes, adapts, and revises teaching resources to meet patient education needs.
Explains procedures, tests, and disease process to patients and families as needed.
Acts as role model for health care students and other team members.
Acts as preceptor to assigned orientees.
Assists in the orientation of new staff by sharing knowledge and experience.
Patient Care Communication
Reports and documents accurately and concisely to appropriate persons the patient's condition.
Maintains patient confidentiality.
Applies basic verbal and nonverbal skills to maintain open, effective communication among care team members, patients, and significant others.
Encourages direct discussion between staff members when differences occur and seeks assistance to arbitrate differences as needed.
Gives and accepts constructive feedback appropriately.
Identifies actual and potentially unsafe patient care practices, reports them in the designated manner, and suggests alternatives.

CORE COMPETENCIES

Standard I: Utilizes the Nursing Process

Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural,
Spiritual, and development needs of patient and families
Communicates findings to appropriate healthcare team members
Develops and uses a specific plan of care and modifies it to meet individual patient
needs using evidence-based practice. Implements patient care and therapeutic
procedures; monitors and documents progression of treatment and teaching goals
Evaluates the care and treatment(s) provided to the patient and the patient response to
the care and treatment(s). Performs timely reassessment and documentation
Must be able to perform unit specific competencies based on the specific patient care need for designated unit's patient population