• Performs initial and ongoing assessment of the patient, utilizing appropriate data (i.e. physical, psychological, educational and risk-screen data appropriate for the chronological / developmental age of the patient).
• Demonstrates clinical judgment in responding to priority patient needs.
• Communicates and documents assessment of patient with the interdisciplinary team. Utilizes all available resources in order to meet the needs of the patient and family.
• Develops and documents plan of care, treatment and services which is individualized and appropriate for the patient needs, strengths, limitations and goals.
• Includes the interdisciplinary health team as needed.
• Demonstrates effective communication with the patient / family and interdisciplinary team.
• Provides care, treatment and services in collaboration with interdisciplinary health team.
• Maintains an appropriate nurse-patient relationship.
• Complies with organizational policies, procedures and protocols including policies governing safety, medication administration and documentation.
• Initiates and documents education plan for the patient and family based on identified learning.
• Evaluates, communicates and documents patient responses to care.
• Revises plan of care based on ongoing evaluations and updates documentation appropriately.
• Ensures the patient and family receives / understands education / training specific to their needs and abilities using the teach back method for evaluation and documents appropriately.
Demonstrates Compassion, Leadership and Professionalism:
• Confidently leads the care delivery team through effective communication, collaboration and leadership.
• Assumes responsibility and accountability on the unit / patient care team.
• Demonstrates the ability to work collaboratively with others.
• Demonstrates knowledge of legal aspects of nursing as evidenced by documentation and professional behaviors.
• Delegates appropriate responsibilities to assigned nurses and ancillary staff.
• Demonstrates ability to manage job related stressors and constructive feedback during intra/interdepartmental relations.
• Demonstrates flexibility in meeting staffing needs throughout the organization.
• Participates in problem-solving activities at the unit level by identifying the problem and collaboratively working toward resolution.
• Provides input regarding protocols, policies and procedures to immediate supervisor.
• Provides training / precepting for new team members on the unit.
Performance Improvement / Evidence Based Practice / Research:
• Demonstrates knowledge of evidence-based practice within practice area and identifies opportunities for performance improvement.
• Participates and utilizes the performance improvement process to improve clinical practice.
• Completes at least one clinical research utilization (CRU) form for submission to Nursing Research Department utilizing a research article from the last 5 years from research performed in the United States.
• Completes a minimum of 5 nationally approved contact hours (CNE or CEU) per year.
• Completes mandatory in-services and health screens in timely manner.
• Maintains Basic Life Support (BLS) certification.