RN- Medical Surgical (4th Floor)

Under the general direction of the Unit Supervisor for the Medical/Surgical/Telemetry Unit the Registered Nurse is responsible for professional nursing care and related assistance to adolescent, young adult, middle adult, and older adult patients admitted for medical/surgical problems. The Registered Nurse utilizes the nursing process in ensuring safe and competent quality patient care. The Registered Nurse supports the medical care of patients under the direction of the Medical Staff pursuant to the mission and objectives of the hospital. The Registered Nurse provides leadership by working cooperatively with ancillary nursing and other patient care team personnel in maintaining standards for professional nursing practice in the clinical setting. The Registered Nurse provides direction to Licensed Vocational Nurses and unlicensed assistive personnel in providing patient care. The Registered Nurse must be able to assess his/her own learning needs to enhance personal and professional development. The Registered Nurse will increase knowledge and skills related to patient care by attending workshops, formal classes, seminars and inservices. Actual duties and responsibilities may vary depending on assigned area.

Staff in this job category is responsible for consideration of development issues of patients in each of the following age groups identified.

________Infancy (Birth to Eighteen (18) Months)

________Toddlers (Eighteen (18) Months to 3 Years)

________ Preschool (Age 3 to Age 6)

________ School Age (Age 6 to Age 12)

___X____ Adolescent (Age 12 to Age 18)

___X__ __Young Adult (Age 18 to Age 40)

___X____ Middle Adult (Age 40 to Age 65)

___ X____ Older Adult (Age 65 and Over)

III. PERFORMANCE COMPETENCIES:

A. ADMINISTRATIVE COMPETENCIES

1. Employee reflects HCA values and a sensitivity to HCA ethics and compliance principals in his/her daily activities.

a. Adheres to policies on appropriate access

b. Respects patient confidentiality

c. Uphold code of conduct

d. Conforms to hospital dress code for nursing department.

e. Arrives to work on time and initiates work in a timely manner.

d. Willing to adjust personal schedule in case of workload fluctuations or departmental needs.

2. Patient Care Responsibilities

a. Assesses, plans, develops, implements and evaluates care of a specific patient population.

b. Develops Plans of Care with realistic goals:

1. Obtains informative, accurate and concise nursing assessment.

2. Demonstrates an understanding of the nursing process.

3. Identifies patient problems, symptoms, and psychosocial needs.

4. Utilizes clinical experience and knowledge to anticipate potential patient care problems and/or emergencies and makes provisions to meet them.

5. Validates data obtained by others by reviewing plan of care and admission assessment for a specific patient population.

6. Interprets diagnostic data and incorporates it in the Plan of Care.

7. Plans, implements, sets priorities, and performs direct care or delegates responsibility and collaborates with physicians and other health care team members.

8. Makes nursing rounds and revises plan of care for specific patient population based on observation, changing needs of the patient, and available data obtained by other members of the health care team, patient, and significant other.

9. Works with patient’s significant other and appropriate members of health care team and/or community agencies to plan for discharge.

c. Performs procedures basic to the general well being of the patient.

1. Performs nursing skills and can consistently state the rationale underlying these skills.

2. Assesses patient needs continuously in order to perform appropriate nursing interventions and documents in appropriate place.

3. Identifies unsafe patient care practices and assumes responsibility for intervention. Documents where appropriate

4. Demonstrates awareness of and understands the consequences of nursing actions and legalities.

5. Assists physicians in performing examinations, treatments, and procedures.

d. Accurately and safely administers medications and records according to nursing policy.

e. Accurately and safely administers I.V. Therapy and records according to Nursing Policy.

f. Investigates all unfamiliar procedures, techniques and medications (purpose, methods, and side effects) before carrying them out.

g. Demonstrates knowledge of epidemiology principles in order to maintain a safe and aesthetic environment.

h. Assesses patients understanding of disease process and procedures.

i. Prioritizes and organizes care to be given to each patient, using patient input when possible.

j. Completes work within acceptable time limits.

k. Makes best use of time during shift.

l. Performs several tasks simultaneously during peak workload situations.

m. Demonstrates a thorough knowledge of work practices, emergency procedures, and personal protective equipment to protect from exposure to chemical, radiation, and infectious hazards.

n. Assumes responsibility for own communications and communicates through appropriate channels.

1. Records informative, accurate and concise nursing observations and reports observations to appropriate person.

2. Receives physician’s orders either written or via telephone. Records and carries out the orders.

3. Keeps immediate supervisor informed of patient care problems.

4. Interacts and communicates appropriately and effectively with other departments and coordinates patient schedules based on the needs of the individual patient.

5. Interacts and communicates effectively with health care team to keep them informed of changes in patients condition and/or the plan of care.

6. Interacts and communicates appropriately and effectively with medical staff.

7. Gives organized, pertinent report in a timely manner.

8. Assumes responsibility for discussing, clarifying and/or questioning medical therapy through effective communication with physicians.

e. Teaches patients and/or significant other about disease process and treatment plan.

1. Plans teaching strategies in conjunction with the health care team to meet individual needs that involve the patient and/or significant other.

2. Implements and/or assists others to implement the planned teaching strategies.

3. Evaluates, revises and documents the teaching strategies in relation to the response of patient and/or significant others.

2. Leadership Responsibilities:

a. Demonstrates leadership ability by planning, implementing, evaluating, and coordinating the activities of a group as delegated.

b. Satisfactorily functions as a Team Leader or Team Member.

c. Functions as a charge person after satisfactory completion of charge orientation.

d. Makes recommendations for assigning personnel to provide for patient care during assigned shift.

e. Acts as a resource person and gives assistance to staff in performance of their duties.

f. Evaluates nursing and patient care goals.

g. Participates in multidisciplinary patient care conferences.

h. Follows through with assignments, informs supervisor of an inability to complete task.

i. Consults supervisor during light workload situations for additional assignments or independently seeks tasks needing to be done.

j. Willing to adjust personal schedule in case of workload fluctuations or other departmental needs.

3. Professional Growth Responsibilities:

a. Attends hospital and unit inservices as required and maintains continuing education based on licensure requirements.

b. Maintains current BLS certification.

c. Knows the philosophy, policies, guidelines, and protocols of the hospital, nursing department, and own unit and participates in evaluation and revision of same.

d. Participates in unit process improvement activities.l

B. TECHNICAL COMPETENCIES

1. Ensures implementation of operational standards which promotes the maintenance of patient’s rights including:

a. Informed consent

b. Clarification of patients expectations

c. Explanation of treatment process

d. Maintenance of confidentiality of patient information

e. Advanced Directives--Do Not Resuscitate

f. Organ procurement program

g. Ethical considerations

h. Handling of patient complaints

I. Maintenance of patient privacy

j. Religious and cultural beliefs

k. Recognizing and reporting suspected abuse or neglect

l. Reports malfunctioning equipment to Manager/designee and labels, secures, and documents appropriately.

2. Obtains records and exchanges information in behalf of the patient.

a. Performs patient assessments in accordance of operational guidelines with documentation of these assessments as a basis for planning of each patient’s care.

1. Assessments are performed utilizing appropriate techniques for data collection and data analysis to make decisions regarding patient care or treatment within a scope of responsibility.

2. Reassessments are performed with each patient contact with notification of responsible practitioner when significant changes are noted in patient’s condition.

3. Patient’s developmental age, educational needs, normal physiologic changes associated with the aging process will be considered with assessment and reassessment.

b. Formulates a plan of care for each patient based on age specific criteria, nursing diagnosis, and identified needs derived from patient assessments.

c. Delegates nursing care activities to members of the nursing team based on patient care needs and competencies of available nursing staff.

d. Validates documentation of all required elements of patient care.

e. Communicates information appropriately with medical staff and other members of the health care team to promote continuity of care and attainment of patient expected outcomes.

1. Ensures that all information is appropriately communicated to responsible staff in any receiving facility when a patient is transferred including both verbal and transmission of medical records.

2. Ensures that all information is appropriately communicated to nursing personnel in receiving units when a patient is

transferred for ongoing care to include provision of all medical records.

3. Performs patient care activities proficiently.

a. Provides health care teaching to the patient, family, or significant other with documentation of this teaching with a focus on immediate care needs and preparation for transfer to another nursing setting when applicable.

1. Adapts teaching to the age, developmental level, and cognition state of each patient to promote maximum understanding.

2. When barriers to learning are identified, ensures that a responsible adult is provided with this information.

b. Encourages patient or family to make decisions regarding their care when appropriate.

c. Assists patient in recognizing and coping with psychological stresses related to acute illness and possible consequences of the illness for future health status.

d. Facilitates patient self care when appropriate.

e. Performs technical skills proficiently in accordance with policies and procedures.

f. Safely and effectively utilizes equipment in the provision of patient care. Demonstrates knowledge and skill in the following areas.

1. High risk medication procedure

2. Invasive procedures

3. High risk equipment

4. Code Blue response

4. Bases professional actions on clinical judgement.

a. Adapts patient care to individual patient needs.

b. Recognizes own limitations and errors with corrective actions taken when indicated.

c. Utilizes available inservice programs and other self-directed learning activities to enhance professional nursing practice.

C. INTERACTIVE COMPETENCIES

1. Maintains own personal growth through appropriate organizations, workshops, seminars, and other education endeavors.

2. Actively participates in hospital and departmental committees and group meetings with a focus on improving the quality of patient care.

3. Communicates effectively with staff and management members maintaining harmonious relationships.

4. Readily accepts re-assignment of duties from Unit Supervisor/Designee when department priorities change.

5. Consistently checks with other staff members and assists them when needed.

6. Maintains awareness of current developments and trends in nursing practice as appropriate to the provision of nursing care.

IV. EDUCATION / EXPERIENCE REQUIREMENTS

A. Current licensure in Texas or an approved compact state as a Registered Nurse

B. Current BCLS course completion (American Heart Association Health Care Provider required).

C. ACLS preferred.

V. PHYSICAL DEMANDS

A. Physical Activity: D.O.T. Strength Rating: H.

B. Working Hazards or Risks - routine hazards and risks involved in performing nursing activities, including potential exposure to infectious processes, potential exposure to hazardous substances, potential musculoskeletal injuries.

C. OSHA Blood Borne Risk Category I.