The Registered Nurse (RN) is accountable for providing a restorative healing experience for the patient and the patient’s support systems in transformational partnership with the Clinical Manager and the interdisciplinary team. As an accountable professional, the Registered Nurse exercises autonomy (the right to undertake a specified action), authority (the power to implement action), and control (the ability to enforce the action in an ongoing and consistent manner) in order to ensure these excellent patient outcomes. Professional accountability is expressed in five areas: practice, quality assurance, competence, research, and resource management.

RESPONSIBILITIES

• Patient Assessment - Demonstrates autonomy in practice by performing a thorough and ongoing holistic nursing assessment, including appropriate admission assessment of patient and patient support systems. Upon admission, the RN identifies, prioritizes and documents current and potential problems in developing an individualized plan of care that addresses needs and concerns. Develops appropriate interventions and desired outcomes for key problems with the goal of positive and effective patient outcomes. Evaluates problems based on patient condition and per policy.
• Patient Care/Discharge Planning - Nurses are accountable for their own practice in the coordination of care. The RN will collaborate with patient, patient support systems, and appropriate health care team members, to meet the patient’s present needs, discharge needs and outcomes identified for key problems. Implements a plan of care upon admission or within 24 hours of admission. Recognizing that interdisciplinary decision-making is essential, the RN initiates interdisciplinary referrals upon admission and as needed. The RN facilitates the evaluation, revision and documentation of the patient’s plan of care on a regular and on-going basis.
• Teaching - The RN is empowered to exercise independent judgment and critical thinking skills to process information on the plan of care to provide individualized, ongoing teaching to patient and patient support systems throughout the continuum of care. Teaching is a vital component of nursing care. The RN uses current, evidence-based practice when teaching patients and support systems.
• Communication - As a professional, the RN demonstrates mutual respect and collaboration when communicating with the interdisciplinary health care team. Communication is a two-way process in which the RN mindfully utilizes effective communication skills such as active listening, relationship building and assertive communication techniques. The RN conveys a strong sense of advocacy and protects patient rights. The RN strives to create high performance teams by providing the teams with an overall positive, inclusive sense of support.
• Treatment/ Procedures - As the essential provider of healthcare, the RN performs all treatments and procedures in accordance with established evidence-based policies, procedures and patient care Standards. The RN collaborates with the MD and all members of the health care team in the performance of these tasks.
• Documentation – The RN accurately, efficiently, and in a timely fashion, documents pertinent patient information Utilizing the nursing process on all required forms or fields/ screens to ensure that patient information is collected and communicated effectively to ensure excellent patient outcomes.
• Medication Administration – The RN provides all aspects of the medication process including: assessment, administration, monitoring, and evaluation of the patient’s response to the medication. The RN teaches the patient and the patient support system regarding the safe use of medications and initiates referrals to Pharmacy as needed.
• Quality Performance and Improvement (QPI) - Actively participates in the QPI process to achieve excellent patient outcomes and improved processes. Participation in QPI includes the development of the QPI plans by identifying actual or potential problems, collecting data, analyzing the results, implementing corrective action plans and sustaining improvements. The RN actively participates in maintaining and improving the Culture of Patient Safety.
• Delegation to and Development of Co-workers - The RN accurately delegates aspects of patient care to the LPN, CNA, and other ancillary personnel according to their Scope of Practice, job description, individual competence and patient needs. The RN supervises the provision of this care by clearly communicating the right task in the right circumstance to the right individual, while being available to provide the right direction and supervision. The RN orients, precepts, mentors, teaches and fosters the development of co-workers from Novice to Expert.
• Unit Specific Competencies - See Attached.

QUALIFICATIONS/REQUIREMENTS

EXPERIENCE

• Basic knowledge of nursing theory and practice. Knowledge of appropriate technology and practice standards for area of responsibility. Demonstrates sound clinical skills; knowledge of Hospital structure, objectives and standards of practice, positive communication skills.

EDUCATION

• Graduate of an accredited school of nursing, currently licensed in the State of New York, or permittee. Membership in a professional organization suggested.

LICENSES/CERTIFICATIONS

• New York State Registered Nurse license required, or permittee.

OTHER

• Meets the crtieria for Level II for CAP Program.