The staff Registered Nurse (RN) is a professional caregiver who assumes responsibility and accountability for a group of patients for a designated time frame and provides care to these patients via therapeutic use of self, the nursing process, and other health care team members. In addition, the staff RN contributes to the management of the unit by monitoring unit activities and developing staff.

JOB SPECIFIC ACTIVITIES:

1. Implements measures to promote a safe environment for patients and others.

• Follows nursing safety standards in the delivery of patient care.
• Follows approved policies and procedures for infection control.
• Follows policies and procedures for "high risk for falls" and "restraints".
• Identifies, reports, and appropriately intervenes in safety hazards.
• Practices universal precautions by appropriate disposal of waste, hazardous waste, sharps, and wearing personal protective equipment.
• Keeps patient rooms and other common patient areas free from potential hazards.
• Participates in the quality/safety improvement efforts by identifying need for improvement, collecting data, developing plan for improvement and evaluating change.

2. Respects the patient's right to privacy by protecting confidential information unless obligated or allowed by law to disclose the information.

• Follows policies and procedures for "no information patients".
• Awareness of conversations held at nursing stations.
• No participation in conversations outside patient care environment.

3. Assessment of patients -- Utilizes the knowledge, skills, and judgment of the professional nurse in administering direct patient care by appropriately assessing the patient to promote optimal levels of wellness and documents finding according to policy and procedure.

• Consistently obtains ongoing histories on all patients using multiple resources as needed.
• Identifies changes in the patient's condition, problems and follows through by adapting the plan of care to meet changing needs.
• Incorporates pathophysiology and assessment skills into particular area of clinical practice.
• Demonstrates increased awareness of psychosocial needs of patient / family.
• Provides shift report according to unit guidelines.
• Assesses the learning needs of the patient and family.

4. Planning of Care -- Plan nursing care based on nursing assessment, diagnosis, medical treatments, and patient's / family's level of understanding and documents according to policy and procedure.

• Formulates an individualized plan of care based on initial and on-going assessment.
• Utilizes diagnostic data, medical orders and nursing assessment to plan care.
• Documents plan of care to reflect the patient's understanding of disease process and jointly identifies needs.
• Plan of care reflects teaching, physiological, psychosocial, and discharge needs.

5. Implementation of Plan of Care -- Provides nursing care that promotes the patient's optimal level of wellness and documents care provided according to policy and procedure.

• Prioritizes & organizes care so that tasks are completed within a specific (or appropriate) time period.
• Demonstrates competence in the performance of nursing skills and skills relevant to area of practice.
• Demonstrates ability for appropriate intervention for abnormal clinical / laboratory findings.
• Sets priorities for care of patients based on acuity and / or patient / family preference.
• Safely performs and documents nursing procedures required by patient assignment consistent with scientific principles of nursing and the organization's policy and procedure.
• Consults with, utilizes and makes referrals to health care team members, case managers, and community agencies to provide continuity of care.
• Explains tests, procedures, and disease process to patient / family.

6. Evaluation of Patient of Care -- Demonstrates the ability to appropriately evaluate the patient and the effects of the plan of care and documents according to policy and procedure.

• Reviews patient's progress toward achievement of expected outcomes.
• Maintains accountability for the care of assigned patients.
• Reports on the effectiveness of nursing care and medical therapies, which focus on patient progress.
• Reports on the effectiveness of patient / family teaching.
• Solicits & documents patient / family ability to verbalize implications of illness & expectations for this hospitalization.
• Participates in patient care rounds and conferences.

7. Demonstrates leadership abilities and qualities.

• Demonstrates ability to act with initiative and practice independently.
• Maintains accountability for the care of assigned patients.
• Identifies potential and actual problems, recommends solutions and intervenes appropriately.
• Monitors care provided by other personnel.
• Evaluates overall unit situations in determining staffing needs of the on-coming shift.
• Participates in staff education by actively assisting in orientation of new staff and students, and assisting in the development of educational programs.

• High school graduate or equivalent.
• Associates or Bachelors degree in Nursing.
• Current licensure as a Registered Nurse.
• BCLS Certification.
• Ability to communicate effectively, both verbally and in writing.
• Basic computer knowledge.
• Minumum of 2 years of pediatric experience in an acute hospital setting