• | The registered nurse systematically and continuously collects and assesses data in collaboration with the multidisciplinary team to provide therapeutic care with the patient and family. |
• | Establishes an in-depth data base by assessing the behavioral and physiologic status of the patient utilizing interview, observation, physical examination, and other available data. |
• | Establishes individualized patient goals in consultation with the patient family and health care team. |
• | Integrates nursing interventions into the multidisciplinary plan of care, incorporating appropriate standards of care and practice and patient outcomes. |
• | Incorporates discharge/home care planning into the multidisciplinary plan of care on an ongoing basis. |
• | Implements safe, competent, and efficient patient care within policies, procedures and standards, and interventions related to the care of patients served within the diagnostic and therapy center (i.e. sedation, day treatment, “campground” six bed procedural area). |
• | Sets priorities adapting to changing patient and unit/clinic situations. In response to data indicating urgent and/or emergent risk to patient, initiates action to reduce or correct risk. |
• | Assumes responsibility and accountability for effectively managing nursing care of individual patients as a team member. |
• | Documents the nursing process to reflect a comprehensive and integrated approach to patient care. |
• | Documents information which leads to insights or the solutions of unusual patient problems. |
• | Evaluates patient's responses to care based on effectiveness of nursing interventions/actions in relationship to established outcomes and consults with Medical Staff, Care Team Leader, Case Manager, and/or Nurse Practitioner regarding clinical variances and recommended changes to the plan of care. |
• | Identifies learning needs of patients/families and teaches by adapting standard information to provide individualized and comprehensive teaching-learning. Utilizes the resources of the Teaching-Learning Center as appropriate to meet identified patient, family and/or caregiver needs. |
• | Performance measures:
· Assesses physical and psychosocial needs of patients and families.
· Implements appropriate nursing intervention.
· Analyzes patient data and uses this to provide appropriate nursing care.
· Assesses patient needs and analyses patient data to make appropriate changes in patient care.
· Works proactively and throughout patient/family stay to assure to assure timely discharge.
· Evaluates patient/family responses to nursing interventions.
· Takes time every shift to determine patient/family needs, wants and priorities.
· Answers call/lights within 5 minutes and appropriately meets patient/family needs directly or through delegation.
· Answers any patient call/light and meets patient needs.
· Is flexible and responsible to accommodate physical and emotional needs.
· Is courteous to patients, families, visitors, and staff.
· Looks for ways to improve service.
· Addresses patient/family by preferred name.
· Introduces self and explains role to patient/visitor with a friendly smile.
· Participates in quality improvement efforts of unit, including working to achieve unit benchmarks.
· Delivers care in an organized, efficient manner, with attention to ensuring that all therapies and procedures start on time.
· Demonstrates positive professional attitude toward job.
· Dresses in a professional, neat manner.
· Provides patient/family with complete information and explains procedures in ways they can understand.
· Explains typical events and common patient responses for patient diagnosis
· Documents per hospital standard to assure continuity of care.
· Maintains patient, family, visitor and personal safety.
· Appropriately implements patient plan of care
· Completes competency check list from annual review. |
• | The registered nurse considers factors related to safety, effectiveness, and cost in planning and delivering care. He/she demonstrates knowledge of UWHC health care delivery system as multidisciplinary and multifaceted with a variety of entry and access points along the care continuum. |
• | Contributes to and supports the effective management of the unit/clinic. |
• | Incorporates standards of practice, clinical practice protocols, benchmarks, etc. into practice in order to maximize clinical effectiveness. |
• | Acts to facilitate cost control in use of material resources. |
• | Acts to facilitate cost controls in the use of human resources. |
• | Effectively utilizes technology to support practice and efficiencies in care delivery. |
• | Performance measures:
· Adheres to attendance policy.
· Implements practice protocols relevant to patient population i.e. pain scale, fall risk, |
• | The registered nurse collaborates with the patient, family, significant others, and health care providers in providing patient care. Delegates and supervises care in accordance with nurse practice acts and professional nursing role. |
• | Initiates multidisciplinary collaboration to positively impact the outcomes of health provided. |
• | Collaborates with Case Manager, Nurse Manager, and Care Team Leader in the provision of patient and family care. |
• | Communicates effectively with patients, families, professionals, supportive personnel and others. |
• | Initiates steps to support and enhance the patient's and family’s responsibility and self-determination in decision-making concerning health, treatment and well-being. |
• | Involves the individual patient/family in identification of requirements/perceptions of learning needs and preparation to assume self-care on discharge. |
• | Develops, maintains, and terminates therapeutic relationships with patients and families. |
• | Participates in unit/clinic and/or departmental shared governance structure in order to improve care. |
• | Performance measures:
· Participates in meeting Nursing Unit Patient Satisfaction Goal.
· Considers patient privacy a priority and maintains confidentiality.
· Always demonstrates a "how can I help?" versus "it is not my job" attitude.
· Attends 50% of staff meetings, at a minimum.
· Works with patient, family and healthcare team to achieve mutual goals.
· Offers assistance to coworkers.
· Makes a point to welcome new employees and assists in making them comfortable.
· Demonstrates positive working relationships with other departments.
· Assists less experienced nurses to evaluate and implement approaches to patient care.
· Appropriately delegates to team members.
· Facilitates multidisciplinary resolution of issues.
· Contributes to achieving unit goals.
· Provides respectful communication toward and about patients/families.
· Listens attentively to patients/families and healthcare team.
· Utilizes effective verbal and nonverbal techniques with patients, families and healthcare team.
· Demonstrates accountability for obtaining unit/organization information.
· Provides communication to coworkers. |
• | The registered nurse's decisions and actions with patients and families are determined in an ethical manner. |
• | Demonstrates sensitivity to the values of self and others. |
• | Participates in activities designed to broaden ethical decision-making skills. |
• | Integrates personal values with UWHC Mission and Nursing Vision and Aspiration Statements. |
• | Involves patient/family in plan of care incorporating their cultural, spiritual and other belief systems. |
• | Performance measures:
· Respects differences in culture, values, lifestyle, coping skills and healthcare practices.
· Integrates personal values with UWHC mission and nursing vision.
· Maintains confidentiality of password when accessing computer and medication cabinets.
· Seeks available resources for value conflicts and ethical issues. |
• | The registered nurse uses research findings in practice. |
• | Participates in organizational quality improvement activities. |
• | Identifies recurring clinical practice issues and contributes to the development of specific plans to address identified issues. |
• | Demonstrates knowledge of research findings related to clinical specialty. |
• | Reads reports of research studies and contributes to discussions about their relevance to care of the pediatrics patient. |
• | Performance measures:
· Participates in activities that support the advancement of nursing practice through literature, professional organizations, research, committee participations, etc.
· Consistently uses new knowledge, technology and research in practice. |
• | The registered nurse acquires and maintains current knowledge in nursing practice and assumes responsibility of the professional development of self, other nursing staff, and students. |
• | Evaluates own performance and that of peers and other nursing staff in relation to standards. |
• | Demonstrates an awareness of elements in own performance needing further development and seeks opportunities to improve. |
• | Contributes to the learning experiences of students and orientees in cooperation with the instructor and other staff. |
• | Performance measures:
· Meets all mandatory education requirements.
· Serves as a preceptor when appropriate to staff or students.
· Obtains at least 4 hours of professional continuing education each year (excluding mandatory). |
• | The registered nurse communicates in a professional, effective, timely manner. |
• | Communicates effectively, both written and orally. |
• | Uses approved abbreviations, professional language and language skills, (grammar, spelling, format) in written and spoken communication. |
• | Reads documentation, (e.g. preop patient assessment, patient admission form, critical pathways, and progress notes) in a timely manner. |
• | Addresses conflict with interdisciplinary staff in a direct, honest, non-confrontational manner. |