PROVIDES AGE SPECIFIC DIRECT PATIENT CARE ACCORDING TO UNIT SCOPE OF SERVICE

Demonstrates the knowledge and skills necessary to provide service appropriate to the age of the patient.

Assesses Patients

1. Collects and documents data about patients commonly seen on the unit through the following methods:
a. Completes the admission record consistent with policies and interviews patient/significant others to complete health history.
b. Documents overt signs and symptoms that indicate risk situations.
c. Documents physical assessment findings consistent with unit standards.
d. Assesses each patient and significant others at the time of admission to identify individual criteria for discharge.

2. Utilizes resources to assess patients with conditions that are new, unfamiliar, or not commonly seen on the unit.
3. Interprets overt assessment data to determine when patient is at acute physiological and/or psychosocial risk.
4. Establishes and documents a database through the use of assessment skills.
5. Identifies patient/significant other learning needs.

Develops a Plan of Care
1. Develops, with guidance, a plan of nursing action based on an evaluation of existing patient problems, expected patient response, and the interdisciplinary plan of care, and realistic goals/outcomes utilizing appropriate human (e.g. patient, significant others, other disciplines) and material resources to meet bio-psycho-social and developmental needs.
2. Communicates the plan of care by using methods that include diagnosis, orders, short and long term goals/outcomes, and time frames.
3. Plans and implements individualized nursing care/appropriate care path and teaching plans for patients, families and/or significant others.
4. Documentation of patient care reflects the following characteristics:
a. is precise and well-organized
b. is individualized to meet patient needs
c. is goal/outcome directed
d. clear priorities of care are established
e. is reviewed and revised according to the patient¿s condition
f. individualizes patient education to reflect individual maturational level.

Implements Patient Care
STATEMENT: ACCEPTS ACCOUNTABILITY IN ACCORDANCE WITH THE NURSE PRACTICE ACT.

1. Provides individualized direct patient care within established PCMH policies and procedures and PCMH nursing philosophy.

2. Provides a therapeutic environment for patient care.
a. Consistently assesses the therapeutic quality of the nurse-patient relationship.
b. Does not allow personal feelings to interfere with the delivery of patient care or the maintenance of therapeutic relationships.
c. Demonstrates the ability to recognize when personal conflicts have the potential to interfere with therapeutic relationships.
d. Accepts accountability for nursing care of his/her patients.

3. Provides safe, therapeutic care for assigned patient in accordance with the nursing policies and procedures.

4. Implements nursing care as directed by the patient plan of care. Modifies plan of care to assure continuity of care.

5. Reports changing patient status that affects unit staffing needs to charge nurse.

6. Utilizes an interdisciplinary approach in implementing and coordinating nursing care and sets priorities for care of patients based on acuity.

7. Safely performs and documents the nursing procedures required by the patient assignment consistent with physician¿s orders and following PCMH policy and procedure. Promotes safety awareness on the unit. (See Unit Competencies)

8. Seeks out resources when in difficult or new situations.

9. Conscientious of cost containment in all nursing practice activities.

10. Teach and documents patient education based on nursing assessment to meet identified learning needs of patient and/or significant other(s).

11. Demonstrates appropriate use of equipment and takes initiative to ensure the cleaning, replacing or repairing as necessary.

Evaluates and Revises Patient Care

1. Evaluates the patient¿s physical and emotional response to care recognizing pharmacological and physiologic response variations:
a. among the young, middle-aged and elderly patients.
b. between pediatric and adult patients.
2. Evaluates patient and/or significant other(s) response to care based on a continuing assessment and assists with revisions as needed.
3. Documents the patient¿s overt response to care using unit specific guidelines.
4. Documents and revises patient plan of care daily based on evaluation of effectiveness of interventions and achievement of patient care goals/outcomes.
5. When questioned, gives rationale for action/inaction based on one or more of the following:
a. scientific principle
b. proven practice/experience
c. research findings
d. legal implications
6. Attends patient care conferences and/or rounds.

PARTICIPATES IN QUALITY IMPROVEMENT (QI) ACTIVITIES

1. Changes practice behavior as a result of QI data.
2. Identifies opportunities for improvement.
3. Participates in problem resolution activities.
4. Participates in data collection per unit QI plan.
5. Demonstrates understanding and documentation of variances.

PARTICIPATES IN EDUCATION OF SELF AND OTHERS

1. Identifies learning needs and contracts with coaches and/or manager to achieve learning goals.
2. Maintains core and divisional/unit-based competencies as described in the divisional competency plan.
3. Attends staff development programs as identified by self, preceptor and/or Manager.
4. Fulfills mandatory educational requirements annually, which include but are not limited to:
a. JCAHO competency
b. OSHA competency
c. Corporate Compliance/Code of Conduct
d. BLS Health Care Provider
e. Unit-Specific Skills
f. Occupational Health Screening
5. Maintains a record of participation in all professional and educational activities.
6. Presents professional image for student learning.
7. Serves as a resource to students by supervising patient care as appropriate.
8. Shares knowledge gained through continuing education activities.
9. Functions as clinical coach as appropriate following clinical coach guidelines.

Provides Leadership

1. Policies and Procedures
a. Follows hospital policies and procedures and unit protocols.
b. Supports the philosophy of nursing and the organizational structure.
c. Familiar with job descriptions and legal implications of role.
2. Delegation and Supervision
a. Delegation process is implemented safely and effectively to produce positive health outcomes.
b. Can serve as a relief charge nurse for assigned shift following orientation
to charge nurse role.
c. Adapts to changing patient care and unit situations.
3. Problem-Solving
a. Utilizes the steps of problem-solving to resolve identified patient-related problems.
b. Reports unit-related problems using the appropriate chain of command.
4. Interpersonal Relations and Communication
a. Listens to the ideas, opinions and feelings of others.
b. Uses communication (interpersonal) strategies with individual patients, families, and
staff that result in achievement of intended outcomes.
c. Gives and receives constructive feedback with regard to behavior that is related to the
achievement of:
1) patient care objectives
2) unit objectives
3) Patient Care Services objectives
d. Works effectively with others in a team approach.
e. Does not allow personal feelings to interfere with the delivery of patient care or the
maintenance of therapeutic relationships.
f. Demonstrates the ability to recognize when personal conflicts have the potential to
interfere with therapeutic relationships.
5. Unit, Department and Hospital Contributors
a. Attends unit staff meetings.
b. Responsible for information presented in staff meetings.
c. Reviews unit goals.
d. Practices cost-effective use of personnel, equipment, and supplies.
e. Demonstrates flexibility in scheduling to meet unit and service needs.
6. Demonstrates Service Excellence behaviors, demonstrates Cultural Attributes.
7. Demonstrates appropriate application of nursing management systems (e.g. T&A, WinPFS, One Staff, QS.)

Demonstrates Support of Research

1. Demonstrates support of research in clinical nursing practice through active participation in the collection of data for identified research projects.

MAINTAINS QUALIFICATIONS:

1. Personal
a. Demonstrates evidence of:
1) effective communication skills
2) initiative
3) problem-solving skills
4) accountability
5) flexibility
6) stress management
b. Demonstrates and understanding and support of the philosophy and objectives of PCMH.
2. Professional
a. Demonstrates competency in basic nursing practice and mastery in the use of nursing process.
b. Current RN licensure in the state of North Carolina or temporary North Carolina
licensure or meet requirements to hold RN licensure in a compact state.

BSN or ADN and current NC RN licensure required.

Prior experience or preferred interest in Behavioral Health /Psych strongly preferred.

It is the goal of Vidant Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

Vidant Health is an Equal Opportunity Employer. EOE/AA Applications for Vidant Health and its subsidiary corporate entities are accepted and employees are chosen for employment without regard to race, color, gender, religion, age, national origin, marital status, citizenship, veteran status, or disability.