RN - L&D

Duties

• Involves the patient and family psychosocial, spiritual, emotional, population specific, and diversity needs in care assessment.
• Constructs and implements the plan of care using nursing knowledge and skill.
• Integrates direct and indirect patient care activities related to the diagnosis and co-morbidities.
• Coordinates the implementation of the interdisciplinary plan of care for assigned patients.
• Develops goals, treatment plans, and discharge plans that meet individual patient/family needs.
• Consistently completes hourly rounds with purpose to strengthen nurse communication, improve safety, and anticipate patient needs (i.e. pain, re-positioning, toileting).
• Rounds with purpose including pro-actively evaluating the environment to ensure it is patient friendly and patient safe.
• Collaborates with the patient’s designated care partner to meet the educational, physical, psychological, and spiritual needs of the patient.
• Actively participates in bedside report (as appropriate) to ease anxiety and address important points of care, concerns, and progress with the patient/family.
• Provides patients with caregiver name and contact information each shift.
• Provides care that is respectful of and responsive to the patient values in clinical decision making.
• Supports and informs the patient and family of hospital specific components of the Patient Centered Care Delivery model.
• Acts with integrity, consistency, and respect for differing views.
• Assumes role of team member, charge nurse or team leader based on the need and/or situation.
• Follows communication practices that minimize risks associated with handoffs among providers, and across transitions in care utilizing the SBAR process.
• Leads or participates in the design and implementation of systems that support effective teamwork.
• Empowers contributions of others who play a role in helping patients/families achieve health goals.
• Solicits input from other team members to improve individual, as well as team, performance.
• Initiates actions to resolve conflict.

Evidence Based Practice

• Demonstrates the ability to formulate questions that address clinical issues.
• Demonstrates proficiency in completing an evidence-based practice literature search.
• Analyzes best evidence to address a clinical question.
• Translates evidence into clinical practice through the consistent use of knowledge and evidence.
• Utilizes clinical reasoning and knowledge based on evidence-based practice outcomes and research studies as the basis for decision making and comprehensive patient care.
• Demonstrates quality through accurate documentation of the nursing process in a responsible, accountable manner.
• Demonstrates quality through accurate documentation of core measures and concurrent use of tools and resources to ensure high compliance is achieved (core measure checklist, double checks, etc.).
• Utilizes the results of quality improvement activities to initiate changes in nursing practice and care delivery.
• Understands and analyzes unit metrics to understand how individual practice, continuing education, and process improvement is necessary to improve the quality of practice.
• Participates in efforts to minimize cost and eliminate waste and unnecessary duplication.
• Utilizes policies, procedures, and evidence-based guidelines to improve the quality of practice.
• Participates in interdisciplinary teams to evaluate clinical care or services.
• Demonstrates competent clinical skills, critical thinking, and nursing judgment.

Safety

• Follows facility policies and procedures to promote patient safety (i.e. safe medication administration, equipment safety practices, radiation safety, fire prevention, etc).
• Reports errors (facility and unit) to promote analysis of errors and design of prevention or system improvements.
• Utilizes appropriate patient safety strategies to prevent human errors (checklists, forced functions, software calculations, mandatory fields, etc.).
• Demonstrates effective use of technology and standardized practices to promote safety.
• Navigates the patient's electronic health record to accurately enter and locate appropriate information.
• Demonstrates sound judgment to increase or decrease the frequency of data collection based upon the patient's clinical condition and data trends.
• Incorporates patient data from multiple sources to identify problems and assure timely and appropriate intervention.
• Ensures the confidentiality and security of patient information while advocating for and involving the patient as appropriate.
• Participates in the collection of data to support nursing research and evidence based nursing practice.
• Maximizes the capabilities of the electronic clinical information system to enhance clinical decision and care planning.

Autonomy

• Makes discretionary patient care decisions/interventions independently within the scope of practice (selects a course of action consistent with the patient’s needs and is accountable for decisions).
• Is self-directed and decision oriented.
• Practices interdependently, utilizing the skills and observations of team members appropriately.
• Practices with respect and dignity and advocates for the patient.
• Facilitates problem resolution among peers and unlicensed team members when behaviors and decisions are not within the range of expected actions.
• Prioritizes and delegates care appropriately.
• Evaluates changes in the patient condition and reports significant findings to the physician.
• Involves all disciplines, patient & family to coordinate effective medical and nursing interventions including rescue to achieve positive outcomes.