| Location | Weymouth, MA |
Job Description Summary
Manages individualized, goal-directed nursing care through use of the nursing process and the principles of primary nursing in accordance with departmental and Hospital policies and procedures.
Job Description
ESSENTIAL FUNCTIONS
1 - Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients.
a - Performs admission assessment within 8 hours of admission or in accordance with specific unit standards.
b - Identifies and documents nursing diagnosis on patients plan of care within 8 hours of admission.
c - Identifies and documents patient/family/significant other teaching needs upon admission.
d - Identifies and documents patient/family/significant other teaching needs upon admission.
2 -Develops, discusses and communicates a realistic problem list (plan of care) for each patient, in collaboration with each patient/family/significant other in order to address all identified needs.
a - Plan of care will include nursing diagnosis statement for each identified problem.
b - Develops patient/family/significant other teaching and discharge plan as per unit standard.
3 - Demonstrates the skills and judgment necessary to implement medical plan of care, nursing interventions and procedures as necessary for the care of the patient.
a - Demonstrates knowledge of SSH&EC policies and procedures for administering, transcribing and recording medications.
b - Demonstrates knowledge of commonly used meds: action, dose, and side effects.
c - *Observes 5 R's for administering meds:
*right patient
*right drug
*right dose
*right method
*right time
d - *Demonstrates proper procedures in all methods of medication administration.
e - Administers blood and blood products following SSH&EC policy and procedures.
f - Initiates and maintains IV access according to SSH&EC policy and procedures.
g - Assesses and documents IV site q8o or per unit standard.
4 - Evaluates the identified problems, care provided and patient's responses are reassessed in order to meet patient and family needs to assure overall quality of care delivered.
a - Reassessment of plan of care is done every 24 hours or per unit standard.
b - Assesses the patient/significant other's response to teaching plan in order to evaluate the effectiveness of the plan.
c - Based on reassessment, plan of care will remain the same or be modified to meet the patient/significant other's identified needs.
5 - Maintains up-to-date and accurate documentation of nursing care provided to assure the integration of information for use by the healthcare team, in order to assure quality care.
a - Flow sheets and I & O sheets must be accurate and signed with name and title each shift.
b - Medication administration record must reflect full signature and title of nurse administering med, time given, reason for omission, and site for injection (if applicable).
c - Discharge plan and documentation includes patient and/or significant other's ability to manage care after discharge.
d - Referrals are made based on identified needs.
e - Interagency communication referral forms (pg. 2) are complete and accurate.
f - Demonstrates use of narcotics according to Hospital policy and procedure.
6 - Maintains current knowledge/certification/licensure.
a - Practices within legal boundaries of nurse practice act and according to Hospital policy and procedures.
b - Attends continuing education programs in order to maintain licensure. Obtains at least 5 contact hours per year in your area of practice.
c - Attends Hospital sponsored training programs as required by department.
7 - Functions as a role model for current and new staff.
a - Accepts assignment as preceptor for new staff.
b - Facilitates problem resolution among peers as observed by Nurse Manager and peers.
c - Demonstrates a constructive approach during all interactions with staff and Nurse Manager towards the organization
8 - Assumes responsibility for daily personnel assignment/monitoring patient care and overall unit activities in accordance with established standards.
a - Prepares assignments based on patient acuity, skill mix, and primary nursing model.
b - Assumes a lower acuity/workload.
c - Serves as a clinical resource to all staff members.
d - Identifies clinical and patient satisfaction issues, and communicates pertinent patient and unit information to the Nurse Manager.
9 - Effectively performs managerial responsibilities.
a - Assesses overall staffing needs of the unit based on patient census and workload.
b - Collaborates with the Nurse Manager to provide feedback for performance evaluations.
c - Meets with staff to review performance evaluations if required.
d - Represents Nurse Manager at clinical meetings as needed.
e - Reconciles payroll under the direction or absence of the Nurse Manager.
f - Assumes responsibility for the day–to–day operations of the unit in the absence of the Nurse Manager.
10 - Demonstrates leadership behaviors in a professional manner.
a - Communicates in a constructive manner with colleagues to decrease conflict and promote teamwork.
b - Recognizes and explores own impact on others.
c - Utilizes problem solving techniques to prevent conflict and promote team development.
d - Demonstrates initiative in pursuing own professional development.
e - Guides and assists other staff members in growth and development; i.e., resource, preceptor, role model, conducts conferences.
11 - Directs other licensed and non-licensed personnel in the provision of care to patients.
a - Based on patient care needs and skills of caregiver, delegates responsibilities accordingly.
b - Assignment sheets are made out with the appropriate coverage for LPN's and non–licensed
personnel.
c - Is a member of a shared management council and/or Hospital committee.
12 - Performs selected managerial duties as delegated by the Nurse Manager.
a - Under direction of Nurse Manager, prepares staffing schedules that meet unit standards.
b - Attends meetings in absence of Nurse Manager, as required.
13 - Assumes all other duties and responsibilities as necessary.
a - Identifies and/or assumes activities relative to the developmental needs of the unit and Hospital.
b - Demonstrates dependability/flexibility in meeting scheduling needs of the unit and Hospital.
c - Participates in CQI activities as assigned by the CQI Representative.
14 - Embraces technological solutions to work processes and practices.
15 - Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment.
a - Prior to the start of any invasive procedures, a final verification to confirm the correct patient, procedure, site, and information is done.
b - Abbreviations on the hospital DO NOT USE list are adhered to, an evidence through ongoing concurrent medical record review.
c - Prior to use of any intravenous infusion pump assures free flow protection is in place.
d - Verifies patient according to policy prior to administration of care/procedures/medications.
e - Follows approved procedure for verifying MD orders including a verbal readback to the licensed independent practitioner after receiving a telephone order.
f - Complies with the current CDC hand hygiene guidelines through proper handwashing , as observed by nurse manager and peers.
g - Assures that alarms are activated with appropriate settings and are sufficiently audible.
h - Assesses and periodically reassesses each patient’s risk of falling utilizing the approved fall risk assessment tool, according to policy.
i - Consistently follows the South Shore Hospital policy to mark surgical sites.
j - Adheres to current process for identification and follow up of crucial values.
a - Makes appropriate use of personal protective equipment at all times.
b - Adheres to respiratory etiquette guidelines.
c - Adheres to universal precautions.
d - Appropriately disposes of hazardous materials.
e - Adheres to electrical safety guidelines.
1 - Technology and Learning
a - Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.
b - Embraces technological advances that allow us to communicate information effectively and efficiently based on role
JOB REQUIREMENTS
Minimum Education - Preferred
Graduation from an accredited school of Nursing.
Minimum Work Experience
Experience as an acute care nurse. PACU experience.
Required Classes/Skills -
PALS or ENPC - Pediatric Advanced Life Support or Emergency Nursing Pediatric Course
ACLS
Required additional Knowledge, and Abilities
Demonstrated proficiency in acute care nursing knowledge and skills.