Summary:

The competent Nurse, in the same or similar clinical setting, practices independently and demonstrates an awareness of all relevant aspects of a situation. Provides routine and complex care, with the ability to on long-range goals or plans. Continues to develop the ability to cope with and manage contingencies of clinical nursing. Makes appropriate assignments and delegates to other care providers as a means to help manage the clinical situation.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Consistent with the ANA Scope and Standards of Practice, provides nursing care utilizing the nursing process, including assessment, diagnosis, planning, intervention and evaluation for assigned patients
• Addresses increasingly complex psychological, emotional, cultural, and social needs of patient and families in accordance with their level of practice
• Using the appropriate protocol, administers medications and treatments; monitors for side-effects and effectiveness of the treatment prescribed
• Documents patient history, symptoms, medication, and care given
• Assess learning needs and provides education to patients, family members and/or care givers; identify issues and resources

CORE COMPETENCIES
Standard I: Utilizes the Nursing Process
• Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural,
• Spiritual, and development needs of patient and families
• Communicates findings to appropriate healthcare team members
• Develops and uses a specific plan of care and modifies it to meet individual patient needs using evidence-based practice.
• Implements patient care and therapeutic procedures; monitors and documents progression of treatment and teaching goals
• Evaluates the care and treatment(s) provided to the patient and the patient response to the care and treatment(s).
• Performs timely reassessment and documentation
• Must be able to perform unit-specific competencies based on the specific patient care need for the designated unit's patient population

Standard II. Patient Throughput & Patient Flow Process
• Anticipates and plans for admission/discharge/transfer needs to facilitate patient flow
• Utilizes appropriate systems of communication and tools to facilitate the discharge process
• Coaches on tools and techniques for checking, cross checking and validating orders to ensure accuracy.

Standard III. Unit Operations
• Plans, directs, and evaluates the overall nursing care and functions in a particular nursing unit during an assigned shift
• Demonstrates good stewardship in proper use and maintenance of equipment and Supplies
• Assesses departmental staffing needs; actively participates in resourcing efforts.
• Educates and trains others on the operations, ethics, and regulations within the industry.

Standard IV. Safe Practice/Quality Care/Regulations
• Incorporates patient safety practices/guidelines to promote a safe environment resulting in positive patient outcomes
• Demonstrates accountability for nursing research and quality improvement activities
• Provides evidence-based nursing care
• Communicates patient information effectively across the continuum of care
• Educates and trains others on the operations, ethics, and regulations within the industry.
• Knowledge of federal, state and local healthcare-related laws and regulations; ability to comply with these in healthcare practices and activities.

TECHNICAL COMPETENCIES
Clinical Policies and Standards
• Follows a specific set of standards and associated clinical procedures
• Analyzes policy and standards documentation and ensures organizational compliance
• Provides feedback for improvement of procedures
• Assists in the development and implementation of specific procedures
• Works with control and monitoring mechanisms, tools and techniques

Health Information Documentation
• Shares experiences with maintaining paper and electronic patient documentation
• Walk through the steps and procedures for receiving, validating and updating patient records
• Describes the flow of information between various stations or units
• Discusses the functions, features and document flow of electronic documentation
• Transcribes verbal orders; explains techniques for ensuring their accuracy
• Explains health information documentation best practices and their rationale across health care practices.

Medical Equipment
• Describes experience with basic medical equipment used in own unit or facility
• Uses standard diagnostic tools and techniques to resolves common equipment problems
• Educates patients about the appropriate use of home medical equipment
• Ensures that all equipment and related supplies are in proper working order prior to use to ensure patient safety
• Inspects, troubleshoots and evaluates incoming equipment

Medical Order Processing
• Shares experiences with processing medical orders for one or more groups of patients or conditions
• Describes functions and features of the system used to enter, validate, update and forward medical orders
• Discusses common errors, their sources and procedures for correcting
• Explains considerations for entering and following standing orders
• Differentiates between standing orders and preprinted orders and considerations for each

Patient Chart Reading and Interpretation
• Describes experiences in reading and interpreting patient charts for patients on unit and under own care
• Reviews patients’ charts for completion and accuracy; identifies and alerts to mistakes or omissions
• Recognizes unexpected readings and alerts nursing or medical staff
• Relates examples of mis-readings or misinterpretations and lessons learned
• Reviews, discusses and validates own interpretation with others

Patient Safety
• Shares experiences with ensuring safety for one or more patient groups or settings
• Explains key features of safety guidelines and procedures for those groups and settings
• Listens and responds to safety inquiries from patients and family members
• Recognizes and addresses physiological and psychological signs of problems
• Describes considerations for patients who can cause to harm to self, versus harm to others
• Utilizes appropriate systems to document misses and near misses, participates in immediate investigating, analysis and reporting in real-time.

Requirements:

• Bachelor of Science Degree in Nursing, preferred.
• 1 year of experience i