Job Description

Assists patients with activities of daily living, provides basic nursing care to non-acutely ill patients and assists in Maintenance of a safe and clean environment under the direction and supervision of the Registered Nurse in charge of the team and/or unit. Demonstrates competency in performing delegated functions and or treatments. Demonstrates ability to identify changes occurring in the patients’ conditions and reports these to the appropriate team members. Demonstrates professional attitude with accountability for role performance. Performs RN duties under direct supervision of RN with validation of competencies from school checkoff list.

Essential Functions

Patient assessment:
Obtains and documents nursing history from the patient and/or significant other that is comprehensive of present condition and prior problems.
Performs basic assessment of the patient, indicating adequate knowledge of anatomy, physiology, and pathology.
Records vital signs, notes changes, and pursues more-specific investigation as needed.
Makes pertinent observation, using language that correctly describes body parts and functions, and draws logical conclusions which direct formation of nursing care plan.
Identifies abnormal diagnostic data and shows a fundamental understanding of its implications by reporting information to the physician and others caring for the patient, and by incorporating information in the nursing care plan.

Nursing care plan:
Uses assessment information to develop a care plan before the end of duty time that communicates enough information for incoming personnel to adequately care for the patient.
Reviews and develops care plans for assigned patients.
Includes the patient and his or her family in planning care, establishing priorities, and setting goals.

Plan implementation:
Uses care plans as a basis for providing safe and therapeutic care to patients.
Consistently follows established standards, policies, and procedures in providing nursing care.
Accepts accountability for clinical care of assigned patients, including supervision of nonprofessional personnel.
Communicates with the patient and his or her family and other members of the health care team in carrying out the goals of the care plan.
Indicates an understanding of the roles of other health-care team members in patient care and incorporates their input into the care plan.
Performs competently those technical skills considered basic to the type of care given on that unit.
Identifies patient teaching needs and provides elementary instructions for the patient and his or her family.
Notes discharge planning elements and incorporates these in care plans, demonstrating an awareness of community care available after discharge.
Responds appropriately in urgent and/or emergency situations.

Evaluation:
Evaluates and notes the individual patient's response to nursing care defined in the nursing care plan and medical records.
Participates in the evaluation of nursing care given to groups of patients.
Identifies strengths and weaknesses of nursing care systems.

Leadership:
Supports standards of nursing care through adherence to existing policies and procedures.
Supervises care given by nonprofessional personnel, providing instruction as needed.
Regularly attends unit conferences and makes recommendations for improvement in patient care via the patient care conference and unit conference.
Participates in peer review as appropriate to the unit and Department of Nursing.

Education:
Assumes responsibility for professional growth by current reading and attendance at educational programs and unit conference.
Assists in teaching individual patients and patients in groups in established programs.
Seeks guidance when encountering nursing procedures and responsibilities that have not been mastered.
Acquires minimum of ten (10) hours of continuing education per year in nursing practice.

Organizational Expectations

Provides a positive and professional representation of the organization.

Promotes culture of safety for patients and employees through proper identification, reporting, documentation, and prevention.

Maintains hospital standards for a clean and quiet patient environment to maintain a positive patient care experience.

Maintains competency and knowledge of current standards of practice, trends, and developments in related scope of job role or practice.

Adheres to infection-control policies and protocols, medication administration and storage procedures, and controlled substance regulations.

Participates in ongoing quality improvement activities.

Maintains compliance with organization’s policies, as well as established practices, protocols, and procedures of the position, department, and applicable professional standards.

Complies with organizational and regulatory policies for handling confidential patient information.

Demonstrates excellent customer service through his/her attitude and actions, consistent with the standards contained in the Vision, Mission, and Values of the organization.

Adheres to professional standards, hospital policies and procedures, federal, state, and local requirements, and TJC standards and/or standards from other accrediting bodies.

Actively participates in Foundation Safety Behavior Tools and Tactics such as Briefs, Debriefs Huddles, Learning Board Activities. Executive patient Safety Rounds and report of unanticipated and untended patient events regardless of whether there is harm.

Provide effective mentoring
Be loyal to the absent
Always manage up
Consistent use of AIDET and 5 P's
Uphold the facilities Standards of Performance

Job Requirements

Minimum Education
High school graduate or equivalent. Be in final year of RN degree program.
Final year of RN degree program.
BLS Certification or obtain within 90 days of hire.

Minimum Work Experience
Minimum of six (6) months' recent experience in a hospital setting.

Required Skills
Demonstrated proficiency of 50 percent of the skills required for Level II.

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