Description Summary: Responsible for patient assessment, patient care planning, and provision of quality nursing care to an assigned group of patients for a defined work period. Provides direction and supervision to LVN/LPNs, nursing assistants, unit secretaries, and other clinical/clerical associates. By assignment, may function as a charge nurse for the unit. Involves provision of patient care/service to older adolescents, young adults, adults, geriatric and pediatric patients. Responsibilities: Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders. Patient Care Planning Develops a comprehensive nursing care plan which addresses all significant needs and problems identified through nursing assessment. Prepares nursing elements of the interdisciplinary care plan prior to the initial team conference. Reviews and updates nursing care plan and collaborates with team members as changes occur. Patient Care Provision Implements patient care as planned in nursing care plan and interdisciplinary care plan. Sets priorities based on knowledge of patient acuity and patient needs. Provides safe and therapeutic care and seeks resources when appropriate. Safely performs and accurately documents procedures, consistent with established nursing policy and procedure. Patient Care Evaluation Evaluates patient response to interventions and attainment of goals in collaboration with interdisciplinary team. Evaluates progress toward nursing goals and revises goals as needed on a weekly basis. Completes nursing progress note for assigned patients on a daily basis. Completes nursing flow sheets for assigned patients on a daily basis. Teaching Evaluates education needs of patient and significant others and documents their response to teaching. Utilizes, adapts, and revises teaching resources to meet patient education needs. Explains procedures, tests, and disease process to patients and families as needed. Acts as role model for health care students and other team members. Acts as preceptor to assigned orientees. Assists in the orientation of new staff by sharing knowledge and experience. Patient Care Communication Reports and documents accurately and concisely to appropriate persons the patient's condition. Maintains patient confidentiality. Applies basic verbal and nonverbal skills to maintain open, effective communication among care team members, patients, and significant others. Encourages direct discussion between staff members when differences occur and seeks assistance to arbitrate differences as needed. Gives and accepts constructive feedback appropriately. Identifies actual and potentially unsafe patient care practices, reports them in the designated manner, and suggests alternatives. 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 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 Job Requirements: Education/Skills Bachelor of Science Degree in Nursing, preferred Experience Six months to a year of experience as a licensed RN or holder of an active GN permit Licenses, Registrations, or Certifications BLS required RN License in state of employment or compact Graduate Nurse Permit Associates with an unsuccessful licensure application or on the 75th day following the effective date of the temporary permit; will be transferred to another position within CHRISTUS Health Work Schedule: TBD Work Type: Full Time EEO is the law - click below for more information: https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf We endeavor to make this site accessible to any and all users. 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