Registered Nurse

Job Title: Registered Nurse

Job Type: Full time or part time

Department: Nursing Service, Hospital

Position Summary

The registered nurse in acute care must adhere to the RN legal scope of practice. The RN role is responsible for utilizing the nursing process to provide quality, competent nursing care in the acute care setting to patients, families, and significant others. Performs under direct supervision of the CNO and Assistant Director of Patient Care Services. Provides direct nursing care to the patients and supervises daily nursing activities performed by Licensed Practical Nurses and certified nursing assistants. Such care and supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations. This role must work collaboratively with other team members, physicians, and healthcare workers to deliver quality care. Must understand and use nursing process, must be able to critically think and be self-directed to manage patient care. Must be able to effectively delegate, collaborate, and negotiate with team members. Must handle stressful situations effectively. Must be able to patient teach, be able to communicate effectively with patients, family, physicians, and other providers. When students are providing patient care, treatment, and/or services as part of their training any or all employees may be asked to supervise employees.

Education/Experience

RN – Graduate from an American College of Nursing or National League for Nursing accredited college of nursing. Current South Dakota RN license is required, or multi state licensure privileges.

Required Credentials (Licensure, Certification, or Registration)

Current RN license to practice in the State of South Dakota or multi-state licensure privileges. BLS, ACLS, NRP required. TNCC recommended.

Employment Variables

Normal working hours are twelve-hour shifts, Sunday through Saturday, including holidays. Occasionally may need to work beyond normal shift as the workload necessitates. May be exposed to communicable or infectious disease, hazardous materials, and injury from performance of assigned duties. Subject to multiple sensory and environmental stressors. Initial Tuberculosis (TB) test and drug screening is required by Winner Regional Health. Rubella titer will also be drawn upon hire and immunization is required if no past exposure or indication of immunization.

Required to wear name tag provided by WRH and to follow the dress code of WRH.

Job Knowledge and Skills

Ability to read, write, speak, and understand the English language. Excellent oral and written communication skills. Ability to deal with people in a professional manner. Knowledge of nursing and medical practices, procedures, laws, regulations, and guidelines that pertain to acute care.

Direct Supervisor

Chief Nursing Officer

PART II: CODE OF CONDUCT

Honesty

We will do the right thing at all times, even if it is difficult, maintaining strong, ethical practices. We protect the confidentiality of others, including patients, staff and the facility as a whole. We will take responsibility for our actions.

Expertise

We will demonstrate superior judgment, training and skill, at all times, demonstrating professionalism while doing so. We will perform all aspects of our job to the best of our ability, utilizing all resources and tools available.

Approachability

We will be non-judgmental, friendly, and open and willing to listen to everyone we come into contact with while performing our duties. We are humble and learn from others.

Respect

We will be understanding and sensitive to others’ feelings; caring and responding in a manner that sets them at ease, keeping the situation in perspective without minimizing others’ feelings or reactions. We will listen to others with full attention in a sincere, civil fashion, being careful not to be judgmental of the speaker. We maintain composure when facing conflict and avoid jumping to conclusions and defaming another’s name.

Teamwork

We willingly work together with a common approach, trusting and supporting members of our organization, using our skills and resources, sharing information to achieve a common aim.

PART III: ESSENTIAL FUNCTIONS

Essential functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable. Following are the essential functions of the job, along with the corresponding performance standards.

Function

Explanation

Assessment

Collects and organizes pertinent patient assessment data. Seeks information from patient, family, health care providers and environment on an ongoing basis.

Diagnosis

Analyzes assessment data to identify expected outcomes unique to the patient. Expected outcomes are mutually formulated with patient, family and health care team. Formulates measurable expected outcomes using standards of care as guides. Identifies expected outcomes which are realistic in respect to patients present and potential capabilities.

Identification of Outcomes

Develops plan of care consistent with assessment data. Involves patient, family and healthcare providers to identify outcomes. Incorporates cultural needs/diversity in individualized patient outcome identification. Defines outcomes with attainable timeframes. Documents outcomes as measurable goals

Database Data

Validates abstracted data against the medical record and enters additional data elements as appropriate. Utilizes critical thinking while completing the abstract for recognition of data elements requiring follow-up.

Planning

Develops a plan to provide direct nursing care to attain outcomes. Individualizes plan based upon identified patient needs, such as economic impact, cultural concerns. Prioritizes implementation of diagnoses and interventions based on patient condition. Utilizes standardized terminology to communicate to others.

Implementation

Implements the interventions identified in the plan of care. Carries out interventions in a safe and timely manner. Incorporates evidenced-based treatments in care of patient. Uses resources and collaborates with others to implement plan. Documents intervention implementation, noting exceptions/modifications.

Evaluation

Evaluates the patient’s progress toward attainment of outcomes. Utilizes an organized ongoing process to determine outcome attainment based on the plan of care. Includes patient, family, health care providers involved in patient care in evaluation process. Documents evaluation findings. Utilizes evaluation data to revise as necessary, diagnoses, outcome, and plan and implementation process. Communicates results to patient and those involved in care.

Quality of Care

Documents in a responsible, accountable and ethical manner.

Duties and Responsibilities

Provide leadership in accordance with organizational and departmental goals and objectives. Assists with orientation of new personnel. Reports appropriately to the PCC infractions of policy. Provides documentation regarding infractions. Assumes responsibility for safety and comfort of the patients. Respects patient right to privacy. Monitors utilization of equipment and usage of supplies to assure quality patient care and remain cost effective. Keeps PCC and Nursing Service Administrator informed of equipment failures and nursing unit needs. Knows emergency procedures for fire, internal/external disaster plans, codes, etc., and participates in drills. Performs appropriately in emergency/crises situations. Supports patient care policies and procedures. Works collaboratively with the Medical Staff to coordinate patient care. Utilizes and promotes familiarization with quality assurance standards. Organizes patient care and ensures continuity of care based on knowledge of clinical nursing needs relating to the physical, spiritual and psychological needs of the patient. Provides written assessment of the patient from admission through discharge utilizing the nursing process. Demonstrates clinical competence by being responsible for knowledge of theories, principles, policies, procedures and legal implications of patient care. Serves as a clinical resource person and assists nursing personnel in assessing patient/family status to plan nursing care. Communicates with family and health professionals regarding care to the patients; provides educational and teaching efforts directed to patients and their families. Implements medical plan of care by transcribing and carrying out physician orders in a timely manner. Documents nursing interventions, patient response, effectiveness, complications, etc., utilizing appropriate charting method. Gives pertinent shift report utilizing the nursing care plan. Promotes open communication within the unit and with other units and departments. Settles differences with others in non-threatening, non-judgmental fashion. Acts as a resource person regarding patient care. Assumes responsibility for PCC position when designated. Cooperate with clinical instructors in providing nursing students clinical experience. Assumes responsibility for professional and self-development. Attends meetings, in-services and workshops to enrich personal and professional knowledge. Provides timely and proper notification for absences and paid personal leave. Finds a replacement when necessary. No unexcused absences or excessive tardiness. Knows emergency procedures for fire, internal/external disaster plans, codes, etc. and participates in drills. Verbally supportive of Winner Regional Health and the Sanford Health Network. Participates on committees and/or is involved in special projects of Winner Regional Health. Provides for patient, resident, employee, and visitor safety through preventative measures. Identifies hazards and reports incidents. Utilizes and adheres to appropriate precautions/techniques with hazardous chemicals, blood and body fluids, medical waste and/or equipment. Satisfactory attendance at department meetings (50% attendance meets expectations). Is cross-trained to other areas/positions/departments to provide assistance when needed.

Patient Safety

Washes hands well before and after patient care and proper use of waterless hand soap. Ensures that all patients have the correct armband. Checks physician order with patient’s armband prior to medications, treatments, or procedures. Reviews, compiles, records and reports accurate information/ data for the improvement of patient care and safety. Listens to the patient and follows up on concerns.

Transportation of Supplies and Patients

Checks at least two patient identifiers (preferably by asking patient to state name and date of birth and verifies the information by comparing two identifiers on patient ID armband) to match the correct patient with the correct procedure ordered prior to transporting the patient. Verifies patient by match of armband and chart. Seeks information from healthcare team important to the continued safe care of patient. (e.g., fall risk status, infection control precautions, code status, etc.). This information is then accurately communicated to next provider(s) of care.

Collegiality

Contributes to the professional development of peers, colleagues and others. Shares knowledge and skills with others (patient care conference, meeting presentations, precept/mentoring). Provides peer feedback in constructive manner. Engages in direct one-to-one communication. Interacts with peers and colleagues to enhance performance. Contributes in a positive manner to the environment, making conducive to education and learning

PART IV: COMPLIANCE

Compliance

Must comply with the Corporate Compliance Policy and all laws, rules, regulations and standards of conduct relating to the position. The employee has a duty to report any suspected violations of the law or the standards of conduct to the Compliance Officer or the Chief Executive Officer.

PART V: PHYSICAL AND MENTAL REQUIREMENTS

General Activity

In a regular workday, employee may

Sit

1/2

Hours at a time; up to

1-1.5

Hours during the day

Stand

1