The Registered Nurse holds shift accountability for providing care to Medical Surgical patients by utilizing the Nursing Process in accordance with the state Nurse Practice Act and Hospital policy and procedures. The registered nurse demonstrates critical thinking skills, scientific judgement and leadership in the anticipation and planning for safe delivery of care; maintains clinical competencies through continuing education; delegates patient care priorities commensurate with the education and experience of the staff available; provides direction and supervision of assigned personnel delivering patient care.
STANDARD I – Customer Service/Communication/Interpersonal Skills
- Strives to exceed expectations of internal and external customers: Patients, families, physicians, colleagues, visitors and
- Demonstrates appropriate communication skills in all
- Interacts with others in a spirit of teamwork and
- Anticipates and provides resolution to issues based on the needs and expectations of our customers. Channels concerns appropriately through chain of command; deals with conflict appropriately, timely and
- Treats others with respect at all times; maintains a work environment free of harassment, hostility, threats or
STANDARD II – Job Knowledge/Productivity/Initiative
- Maintains certifications, education and development appropriate for
- Completes position responsibilities by following established guidelines and protocols within the appropriate time
- Demonstrates a thorough knowledge of work practices/responsibilities/establishing priorities and roles in emergency
- Demonstrates self-direction, flexibility, professional development and willingness to master new skills.
- Has the ability to accept and act upon suggestions for improved
- Completes all requires orientation and annual updates as appropriate to clinical
- Knowledgeable of standards of practice as outlined in professional practice organizations related to clinical
STANDARD III – PWMS/Hospital/Department Policies & Procedures
- Supports, implements and ensures compliance with all PWS/Hospital and regulatory/accrediting agency standards, regulations and policies and
- Ensures accuracy, timeliness and completeness of documentation and work performed per Hospital
- Utilizes appropriate resources and hospital policies as the “standard of care” for positive patient outcomes.
STANDARD IV – Organizational Ethics/Improving Organizational Performance
- Supports PWS and Hospital’s mission, vision and
- Conduct reflects PWS values; accepts the responsibility to act with absolute integrity, work as a unified team, learn and transfer that knowledge across the continuum, have accountability to all that we serve, and treat everyone with dignity and
- Demonstrates compliance with the Ethics and Compliance Program, policies, directives and Code of Conduct
- Maintains privacy and confidentiality of patient, client, employees and organizational information in verbal, written and electronic form. Limit access to information on a job-related need to know basis. Complies with PWS/Hospitals risk management program-timely/accurate occurrence reporting. Demonstrates understanding and involvement with Performance
STANDARD V – Position Specific Essential Performance Criteria
Performs position specific job functions at an acceptable level with minimal direction. Primary responsibilities for a Medical Surgical Nurse encompass but not intended to be all-inclusive;
- Patient Rights – Demonstrating awareness and respect for the patient/family/significant others dignity and values; identifies cultural and religious needs, emotional and language barriers, physical, cognitive, psychological and educational limitations. Knowledgeable of patient’s rights, advanced directives, consents, protection of patient security, privacy and confidentiality in all aspects of
- Assessment - Completes assessment/reassessment in accordance with Hospital policy, standards and patient care needs as it relates to; Admission, transfer, discharge, pain management, risk to fall, skin integrity, interventions, signs and symptoms of abuse, changes in patients condition, abnormal lab/radiology values and the notification to physician, identification of patient needs requiring intervention of other team members, surgical procedures and end of life care needs. Knowledgeable of documentation systems utilized to chart patient’s assessment/reassessments, interventions, medication utilization and supply
- Care of the Patient – Develops, implements, updates, evaluates and revises as appropriate an interdisciplinary age-specific patient plan of care; based on continuous assessment/re-assessment and interpretation of all available patient data – to meet the identified patient care goals for a Medical Surgical Demonstrates accuracy in administration, monitoring and documentation of medications, treatments, IV therapies, modalities and blood products according to Hospital policies. Able to recognize the need for and use of designated equipment in resuscitation efforts.
- Patient/Family Education - Utilizes a collaborative and interdisciplinary process to provide initial and ongoing teaching based on assessed learning needs, abilities, preferences and Provides patients with explanations of all procedures, medications and treatments – documents teaching per hospital policy. Ensures patient/family teaching occurs across the continuum of care and discharge planning includes specific teaching which ensures the patient is prepared for discharge and prevents re-admissions due to lack of education provided.
Continuum of Care - Assess, collaborate and coordinate meeting patient’s care needs during transition from shift to shift, transfer and upon discharge. Ensures continuity of care by participating in patient transfers, utilizing communication tools when handing off communication, completing required forms for transfers to other units or facilities and nurse to nurse report. Ensures that discharge planning/processes provides for continuing care based on the assessed needs of the patient; provide clear time/action specific discharge instructions in clear understandable terminology.