JOB SUMMARY: Performs the nursing process through assessment, planning, intervention and evaluation of safe therapeutic care for patients overt and covert needs and/or complications of treatment during employee assigned shift. Employee will individualize patient care based upon age appropriate and developmental needs. Should be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients on the employee’s unit. Provides direction to ancillary members of the healthcare team. A Staff Nurse I has less than one year of experience in an acute care facility in the last five years. Employee will successfully complete Staff Nurse I orientation within 6 months and be promoted to Staff Nurse II

PERFORMANCE DIMENSIONS AND TASKS

Essential Function

1. Collects and documents data about patients through the following methods:
a. Interviews the patient or other significant source and completes appropriate history/assessment information on patient’s clinical record within two hours of admission
b. Legibly documents symptoms that indicate risk on clinical record in a legible manner
c. Incorporates nursing diagnostic data into written assessment.
d. Documents information form family, other nurses and physicians in the written assessment.
2. Documents patient problems requiring nursing interaction.
a. Documents identified problems using nursing diagnosis including patient teaching needs and discharge planning on patient’s clinical record.
3. Develops and contributes to a plan of nursing action based on existing problems and obtainable patient response.
a. Develops and contributes to the nursing care plan using nursing process.
b. Records patient response on care plan and clinical record
c. Incorporates medical plan of care when developing nursing care plan
4. Utilizes resources (patient, family, nurses, physicians, and written material) to formulate the written plan of care
a. Uses resources when formulating a written plan of care and involves patient and family in care plan formation.
5. Communicates the plan of care by using methods that include action plans, goals and time frames.
a. Updates Kardex and care plans using Nursing diagnosis and outcome criteria.
b. Aware of time frames when carrying out medical/nursing plan of care
c. Uses shift report to communicate changes and response to care.
d. Documents patient responses in patient records
6. Implements safe therapeutic care for patients.
a. Documents and sets priorities for care of patients based on acuity, need, or patient preference.
b. Safely performs and documents nursing interventions required by the patient assignment consistent with research-based principles and MMHS policy
c. Carries out and documents the medical and nursing care plans for said patients and coordinates patient care activities with nurses and physicians and other healthcare team members
d. In response to information/data indicative of acute risk and documents the action.
e. Seeks out appropriate resources.
f. Explains tests, procedures, and disease process to patient/family. Follows through with teaching plan about information by instructing patient/family and skills essential to understanding and coping with illness and for the promotion of optimal health and as it applies to the discharge process.
g. Assesses patient/family level of understanding and documents on clinical records.
h. Participates effectively in Code procedures.
i. Ensures that patient is reassessed, as status requires.
7. Participates in the evaluation and review of patient care.
a. Evaluates the effectiveness of nursing interventions in relation to intended goal.
b. Participates in patient care conferences.
c. Documents patient response to care in Nurses notes
d. Revises patient care plans based on evaluation of effectiveness of interventions.
8. Participates in staff teaching and development
a. Provides both formal and informal teaching activities to promote staff education/knowledge.
b. Communicates identified learning needs of others to resources able to meet learner’s needs.
9. Policies and procedures.
a. Is knowledgeable of, follows and directs others to follow MMHS policies and procedures and nursing unit protocols.
b. Administers medications safely and accurately following existing department procedures.
c. Maintains principles and procedures of intravenous therapy.
d. Follows Infection Control policies/procedures, i.e., prescribed hand-washing and universal precautions.
e. Recognizes and communicates to proper authority ethical and legal issues relative to patient care. Completes notification forms according to protocol and notifies appropriate personnel. Applies principles of prevention and safety for patients and staff.
f. Uses mechanical equipment correctly and appropriately as outlined in the Nursing Procedure Manual. Detects faulty equipment and notifies appropriate person for repairs.
10. Problem solving
a. Utilizes the steps of problem solving to resolve identified patient related problems.
b. Reports unit related problems using the supervisory communication structure.
11. Gathers, disseminates and communicates pertinent information.
a. Completes clinical assignments in a timely fashion including maintenance of equipment and supplies necessary for provision of patient care through next shift.
• Medication stock
• Medical/Surgical supplies
• Linen
• Maintains safe, therapeutic, physical environment.
b. Completes non-clinical assignments, tasks, and projects within a pre-established agreed upon time frame.
c. Prioritizes own workload relative to patient care
d. Attends and participates in staff meetings
e. Obtains information presented in staff meetings.

12. Reviews communication/information book every shift.
a. Participates in nursing unit goal setting, (e.g. computer assisted instruction – CAI)
b. Attends mandatory inservice programs.
c. Participates in committee work as requested.
d. Maintains cost containment efforts by:
• Prudent use of supplies and equipment
• Charging supplies appropriately.
13. Maintains professional responsibilities to enhance personal growth
a. Understands and functions within the scope of the California nurse Practice Act.
b. Keeps all licenses and certificates current.
c. Plans for personal change and growth based on evaluation and feedback.
d. Participates in setting measurable goals for performance
e. Acquires knowledge or experience to meet goals.
f. Complies with annual skills update as required.
14. Performs other duties as assigned.
a. Performs other duties within capabilities as assigned by Manager.

QUALIFICATIONS

Education: Graduate of an Accredited School of Nursing
Skills Requirements: IV competency completed within 1 month

Licensing Requirements: Current California RN License or Interim Permit (IP) License*
*California RN License must be obtained within 6 months of hire
Current AHA BLS for healthcare providers required.
Dysrhythmia interpretation proficiency by the end of orientation to the department.
AHA ACLS and PALS are required upon completion of orientation to Med/Surg Unit

Language Requirements: Bilingual (English/Spanish) preferred.

Physical Demands: Must be able to sit for 2 hours and stand/walk for 4 hours or more per day. Must be able to reach overhead and lift/carry up to 50 pounds. Moderate exposure to hazardous waste and materials.

Special Considerations: Will be dealing with patients age 0 to 120 years

Special Demands: Ability to work well with others and to perform a variety of assigned duties.

DISCLAIMER: The preceding job description has been designed to indicate the general nature and level of work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.