Assessment, treatment and patient care responsibilities are delivered with a knowledge of patient growth and development and are appropriate to the ages of the patients served.

ASSESSMENT

Identifies and documents initial observation and assessment of the patient's needs for immediate nursing action.

Systematically and accurately assesses nursing needs of the patient in order to detect pertinent changes in the clinical picture.

Identifies appropriate foci of patient needs related to addiction/health.

Selects, plans, evaluates, and documents care based on this assessment.

Assesses, intervenes, and documents appropriately to meet patient's health, educational, psychosocial, and discharge planning needs.

Initiates appropriate referrals to other departments, services, and/or outside agencies for patient care.

DIRECT PATIENT CARE

Gives comprehensive patient care.

Initiates and follows through with patient and family teaching.

Consults with program leadership regarding significant changes in patient's condition.

Collaborates with all members of the health care team.

Communicates relevant patient care information on shift to shift report.

Utilizes patient care standards in clinical practice.

Documents pertinent information regarding patient's response to treatment and progression toward goals in patient's chart.

Completes Admission/Transfer Summary Sheet and/or Discharge Summary.

Seeks clarification of physician's orders that are unclear or inappropriate.

Interprets clinical data and notifies the physician promptly if immediate changes in management are indicated.

Administers medications in compliance with policies and procedures.

Gives injections to patients as ordered by the attending psychiatrist.

Titrates medication as per physician's prescriptives, protocols, and standard.

Provides individual health related counseling

Carries caseload of up to 12 cases.

Provides group therapy sessions

Provides case management up to 12 cases.

Provides discharge planning.

Assures that the practice of nursing by the registered professional nurse is centered around the New Jersey Nurse Practice Act defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive of life and well-being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician.

Diagnoses in the context of nursing practice by identification and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing care as evidenced by the psychiatric and medical problems identified on the treatment plan.

Selects and performs therapeutic measures essential to providing quality care as evidenced by identified nursing goals and actions on the interdisciplinary treatment plan.

Responsible for the nature and quality of all nursing care including the assessment of the nursing needs, the plan of nursing care (within the interdisciplinary treatment plan) the implementation, and the monitoring and evaluation of the plan. The RN delegates selected nursing tasks (as deemed appropriate in the BHS division) in the implementation of the plan of care to MHA.

The RN delegates select nursing tasks to MHA’s, the RN shall be responsible for exercising that degree of judgment and knowledge reasonably expected to assure that proper delegation has been made. A registered professional nurse may not delegate the performance of a nursing task to persons who have not been adequately prepared by verifiable training and education. No task may be delegated which is within the scope of nursing practice.

The RN upholds the Code of Ethics for Nursing established by the American Nurses Association, which is a statement of the moral obligations and duties of every individual who enters the nursing profession.

The RN in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems as evidenced by observation of the RN with 1:1 interactions and group leadership with patients.

The RN’s primary commitment is to the patient, the recipient of nursing services, and that the interdisciplinary treatment plan reflects uniqueness.

The RN promotes, advocates for and strives to protect the health, safety and rights of patients by assuring that the patient is knowledgeable of the patient rights on admission and throughout his/her hospital stay.

The RN is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.

The RN owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence and to continue personal and professional growth.

The RN delivers primary mental health care as outlined in the Standards of Psychiatric Mental Health Clinical Nursing Practice written by the American Nurses Association.

The RN performs intakes including physical and psychosocial assessments on new admissions completing the nursing assessment form fully, renders diagnostic and dispositional judgments, and facilitating the patient’s movement in their hospital stay.

The RN utilizes skills and resources to foster the restoration of individual patient’s previous adaptive abilities and allows for the acquisition of new ones.

The RN maintains all aspects of a therapeutic milieu, which will facilitate the patient’s potential growth and change. Evidenced by nursing group skills and milieu management during emergencies and on a daily basis.

The RN will comfort, guide, and set limits to make use of the patient’s experience of daily living to help them move from dependent to more independent modes of behavior.

The RN employs psychobiological interventions which include various emergency procedures and standard nursing measures such as relaxation techniques, medication education, nutrition / diet regulation, exercise and rest schedules, monitoring response to medication, and other somatic treatments including monitoring the patient’s responses to psychobiological interventions and the overall treatment program.

Provides direct crisis intervention services to patients in crisis and that the appropriate interventions are used as evidenced by observation of staff during Team 20 and Dr. Strong emergency codes.

SAFETY

Checks to ensure that emergency equipment is on hand and in good working order.

Recognizes and reports malfunction or failure of equipment used in the area to Biomedical Engineering; takes appropriate action to repair/replace such equipment (e.g. cardiac monitors, defibrillators, suction apparatus, pumps, O₂ tank).

INDIRECT PATIENT CARE ACTIVITIES

Participates in patient care rounds by presenting findings on patients.

Applies principles of infection control and safety.

Assists in the orientation of new personnel.

Provides clinical supervision of LPNs, Nursing Attendants, MHAs and other ancillary staff.

Understands and adheres to the Medical Center’s Code of Conduct.

Familiar with the Medical Center’s Mission, Vision, and Values Statements.

Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental, and infection control standards; promotes adherence to Patient Bill of Rights.

Customer Service: respect, flexibility, knowledge, confidence, professionalism, pleasant attitude, patience, and helpfulness. All responses should be timely, professional, caring, and respectful in accordance with Customer Service Performance expectations.

OTHER JOB DUTIES

Orients patient's family to new environment; develops rapport with patient's family.

Assists in data collection and analysis of Quality Assurance/CQI monitors; participates in implementation of follow up action.

Effectively utilizes the hospital computer system as it pertains to job responsibilities and in accordance with hospital policy.

Participates actively on Quality Improvement committees as assigned.

Assists other personnel as needed.

Keeps up-to-date with current trends pertinent to area of assignment.

Participates in continuing education activities; attends scheduled in-service programs; shares information gained at conferences with colleagues.

Performs other related duties as required.

BASIC COMPETENCIES

Education:

Graduation from accredited school of Nursing.

Current NJ licensure as RN.

Certification in Addiction or Psychiatric Mental Health Nursing preferred.

Experience:

Minimum of 2 years experience working with the Substance Abuse population.

Knowledge and understanding of the disease of Addiction and Behavioral Health issues.

Must have experience in facilitating and understand the dynamics in a group situation.

Case Management experience and certification preferred.

Skills:

Clinical nursing skills for a RN.

BLS Required

Good oral and written communication skills.

Good interpersonal skills.

Speaks, reads and writes English to the extent required by the position.