Provides nursing care via the nursing process and data analysis for the development, implementation and evaluation of nursing care. Interviews patient to obtain pertinent medical and surgical history, current medications, treatment plan and preparation for examination. Performs age specific assessments to collect pertinent data. Identifies needs based on knowledge of growth and development of adolescents, adults and geriatric patients, records initial database and ongoing assessment pre-, intra-, and post-procedure. Consistently recognizes and acts upon subtle changes in patient status, anticipating their needs while collaborating with the health care team. Develops and documents plan of care from assessment data including discharge planning in collaboration with the patient, significant others, and health care providers. Implements interventions in a manner to maintain patient dignity, privacy, confidentiality and safety. Defines measurable outcomes based on database and ongoing evaluations of patient response to interventions. Identifies variances to expected outcomes and intervenes to optimize outcomes. Involves patient, significant others, and health care providers in the evaluation process. (i.e. Patient satisfaction surveys, follow-up calls and CQI). Assists the patient and significant others in identifying and securing appropriate services and educational opportunities available to address health-related needs while providing emotional and psychological support to patients and family. ( i.e.: Referrals, Consults, Lab and Radiology Services, Support Groups and teaching materials). Demonstrates advanced competencies and critical thinking skills in day to day practice. Educates staff regarding the nursing process, and the use of clinical pathways as a collaborative practice and interdisciplinary care tool.
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Establishes a caring and therapeutic nurse/healthcare team/patient/significant other relationships. Recognizes communication barriers, identifies resources and establishes plans to resolve barriers to communication. Demonstrates respect for diversity and cultural differences in patient/significant others related to age, ethnicity, gender, religion, socioeconomics, education, personality, or other unique variable.Formulate individualized plans to address individual needs related to diversity, cultural difference or other unique variables. Advocates for the patient/significant other. Demonstrates skillful responses to customer needs based on particular context of the situation. Provides education to staff related to the patient/nurse relationship.
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Supports an environment of evidence based practice/research/quality improvement. Demonstrates knowledge of Shared Governance accountabilities and principles, supports department shared governance council directly as a council member or indirectly by keeping informed of council activities/supporting council decisions, brings forth issues to council. Demonstrates knowledge of how to access online resources containing policies, procedures, standards, and additional resources. Participates in QI/EBP/Research activities to support departmental goals and initiatives. Demonstrates understanding of resource management and implements opportunities. Collects QI/EBP/Research data and participates in analysis and action plan development, incorporates changes into practice. Participates in ongoing activities to meet and adhere to regulatory standards (TJC, DFS, OSHA). Analyzes QI data and suggests action plans, incorporates changes into practice and coaches and mentors others to do so. Recognizes opportunities for QI processes, participates in design and implementation of QI processes.
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Supervises other members of the team. Contributes to a supportive and healthy work environment. Holds self and others accountable for complying with policies, procedures and standards including dress code and attendance. Provides input into and supports the precepting and mentoring process. Delegates appropriate tasks to support staff, ensures completion of delegated tasks and provides feedback as needed. Demonstrates team spirit and collegiality. Supervises select personnel in performance/patient care. Participates in preceptor development courses. Collaborates with other RN3s and RN4s to identify, initiate, and evaluate teambuilding strategies. Recognized as a resource/facilitator for precepting, mentoring, delegating, team building. Independently performs charge duties.
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Demonstrates personal accountability and effective conflict resolution/negotiation skills. Demonstrates appropriate use of universal precautions and use of personal protective equipment. Maintains safe environment and responds appropriately to emergencies and safety hazards. Promotes positive, supportive, and professional work environment free of disruptive behavior. Practices, in all professional relationships, with compassion and respect for the inherent dignity, worth and uniqueness of every individual. Follows Chain of Command for assistance with issues related to unresolved/problem-solving and/or conflict resolution. Provides, seeks and receives constructive feedback. Provides peer to peer feedback and seeks mediation as necessary. Facilitates building and preserving collaborative and respectful relationships. Adheres to maintenance requirements for the professional nurse advancement program.
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