Job Description Summary

Manages individualized, outcome oriented nursing care through the use of the nursing process. Provides care, treatment and services through the successful coordination and completion of a series of processes that include assessment, planning care, providing care, in accordance with departmental and hospital policies and procedures

Job Description

1. Medication Administration

a. Demonstrates knowledge of and follows SSH policies and procedures for administering, transcribing, and recording medications.

b. Completes medication reconciliation process following SSH policy and procedure.

c. Demonstrates proper procedure for the documentation of narcotic withdrawal, administration, verifies count, wastes per policy and resolves narcotic discrepancy.

2. Plan of care/Documentation/Patient Family Centered Care/Patient Experience Develops, discusses, and communicates a prioritized problem list/plan of care for each patient.

a. Develop, evaluate and update individualized plan of care for patient and documents outcomes.

b. Initiating admission assessment within 8 hours of admissions, identifies and documents patient/family/significant other teaching needs upon admission and throughout hospitalization.

c. Continues assessment/reassessment and identifies care needs within established nursing practice.

d. Documents all patient care following the department of nursing policy, unit based standards, disease processes (CHF, PNA vaccines) and nurse sensitive indicators (falls, skin, CAUTI)

e. Assess/reassesses and documents patient's level of comfort utilizing the appropriate pain scale and the patient's response to each intervention both pharmacological and non-pharmacological per South Shore Hospital policy.

f. Works on behalf of patient /family. Seeks help to represent patient/family when they are unable to represent themselves.

g. Raises ethical questions and concerns with clinical team. Seeks available resources to help formulate and understand ethical decisions.

h. Actively communicates plan of day via white board updating every shift.

i. Facilitates discharge/transfer by goal of 12:00pm, communicates barriers utilizing chain of command.

3. Safety/Quality - Foster's a "Culture of Safety" through personal ownership and commitment to a safe environment.

a. Verifies patient identification with two identifiers prior to the start of any invasive procedure, including "time out", administration of care, medications, labeled specimen's an documents confirming the correct patient, procedure, site, equipment and consent.

b. Complies with the current CDC hand hygiene guidelines through proper handwashing. Adheres to universal precautions, makes appropriate use of personal protective equipment at all times and appropriately disposes of hazardous materials. Maintains awareness of MSDS sheets and how to access.

c. Ensures environment meets regulatory requirements at all times.

d. Understands and is able to demonstrate individual roles and responsibilities in the event of hospital codes/emergency preparedness.

4. Professional Development: Assumes overall responsibility for own professional development by incorporating evidenced-based practice, research, and performance improvement initiatives as a part of ongoing nursing practice.

a. Obtains at least 5 contact hours per year in area of practice.

b. Practices within the legal boundaries of MA Nurse Practice Act. Directs other licenses and non-licensed personnel as assigned.

c. Displays the ability to accept and respond appropriately to feedback and recommendations for change.

d. Demonstrates professional working relationships with colleagues from all disciplines to promote a positive/encouraging workplace.

e. Critical Thinking: analyzes causes of problems, identifies and evaluates alternative solutions, and selects appropriate solution, and communicates appropriately and effectively utilizing chain of command.

f. Accountable for being informed about changes in hospital policy and procedure.

5. Technology: Utilizes technological solutions to work processes and practices.

a. Access Lotus Notes to review email, learning management and other resources as applicable to RN role.

b. Utilizes software applications required by department and unit standards.

c. Accountable to understand how to operate in downtime.

6. Compliance

a. Works within legal, regulatory and ethical standards relevant to the position.

b. Complies with applicable policies and procedures.

c. Safeguards the privacy and security of patient information. The employee compiles will policies and procedures relating to SSH’s privacy and security programs.

d. Brings potential compliance issues to a manager, supervisor, director or VP.

e. Complies with the mandatory education requirements of the compliance, privacy and security programs.

7. Patient and Family Centered Care

a. Conveys respect for values, preferences, and expressed needs of the patient and family.

b. Recognizes the patient, and family according to patient preferences, as important members of the health care team.

c. Collaborates with the patient, and family according to patient preferences, in planning, implementing, and evaluating care.

d. Welcomes the presence and participation of family members at all times according to patient preferences, regardless of rounds, change of shift, or other events on unit.

8. Age & Culture

a. Possesses age and cultural knowledge and awareness.

b. Considers the individual needs of each person with whom they interact.

c. Interacts with sensitivity in the delivery of care/services of diverse populations as needed.

d. Effectively utilizes resources to provide care/services - such as, interpreter services and on-line sources.

Minimum Education - Preferred
Graduate of an accredited School of Nursing
Minimum Work Experience
Previous Acute Care RN experience preferred

Required Licenses/Certifications

RN - Registered Nurse

Depending on department Basic Life Support (BLS) Certification, Advanced Cardiac Life Support (ACLS) Certification, Emergency Response Training Certification, Neonatal Resuscitation Program (NRP) Certification, Pediatric Advanced Life Support (PALS), Trauma Nurse Core Course (TNCC), Trauma Care After Resuscitation (TCAR) Certification may be required