The Nursing Process
Assessment - Demonstrates the nursing skills to complete a holistic assessment of the patient’s physical, psychosocial, spiritual, and education needs utilizing The Christ Hospital Professional Practice Model.
1. Understands signs and symptoms and data related to the patient’s presenting needs and actual or potential nursing diagnosis.
2. Recognizes and appropriately reports to the physician and charge RN pertinent abnormal data and changes in the patient’s condition.
3. Utilizes appropriate handoff methods to collaborate with other healthcare team members to communicate pertinent data regarding patient’s physiological and psychological data.
4. Assesses patient, family, and environment for safety risks, proactively seeks out and performs safety initiatives.
Diagnosis and Planning - Utilizes collected data to establish and prioritize a list of actual, and potential, individualized patient problems and needs.
1. Prepares, coordinates, and revises multidisciplinary plan of care in collaboration with the patient and family to be supportive of the TCH model of care/Patient and Family Centered care. For each problem a measurable goal is set.
2. Communicates the plan of care utilizing SBAR and handoff processes with all team members.
3. Establish priorities of care, discusses plan of care during shift report, and participates in care conferences.
4. Initiates discharge planning upon admission, makes appropriate referrals consistent with the anticipated length of stay.
Implementation – The method of providing evidence based, quality care is based on assessed needs and standards of care while adhering to hospital policy and procedures to achieve set goals.
1. Performs and delegates nursing actions based on appropriate orders demonstrates critical thinking and accountability for appropriate implementation.
2. Provides ongoing, individualized holistic patient and family education based on needs and plan of care in collaboration with the multidisciplinary team.
3. Demonstrates critical thinking upon review of physician orders, making appropriate referrals, & contacts other health team professionals.
4. Responds to emergency situations that require an immediate, controlled precision in a skillful manner.
5. Implements measures to prevent contamination and/or transmission of disease to include the use of appropriate protective devices and equipment to prevent injury and maintain a safe environment.
Evaluation – Continuously evaluates nursing practice related to the plan of care in relation to the standards of care established through evidence-based literature and standards established by professional organization that have been built into order sets in the electronic medical record, the individual plan of care, and patient outcomes and goals.
1. Evaluates effectiveness of nursing care interventions, adjusts or continues with plan of care based on patient and family response.
2. Maintains continuity of care by continuous evaluation during ”handoff” report, rounding, and upon transfers to other specialty units and post care facilities.
Documentation
Nursing process is accurately and concisely documented in the patient’s electronic medical record reflecting the plan of care as implemented by the patient, family, and multidisciplinary team.
Documents information in a timely manner, according to hospital policy, to include the plan of care, accurate updates, teaching and the patients’ and family response to care.
Leadership and Professional Development
Demonstrates leadership skills such as the ability to motivate, educate, delegate, and mentor peers and other members of the healthcare team while effectively managing the care of patients and family members.
Assumes responsibility and accountability for professional growth and development. Contributes to the professional development of peers, colleagues, and others.
1. Participates in 75% of staff meetings and 75% of council meetings as appropriate.
2. Participates in unit based activities/initiatives for performance improvement, evidence based projects, and research as needed.
3. Participates in council activities and task forces to improve competencies of self, co-workers, and staff members related to patient care.
4. Supports self and peers in professional growth and development utilizing resources and opportunities within and outside of The Christ Hospital.
5. Participates in self and peer review activities to include the positive recognition of peers and staff on a regular basis.
6. Acts as a resource, educator and preceptor for multidisciplinary team members, staff and nursing students, continuously evaluating and documenting competency. .
7. Maintains competency in POC (point of care) testing for unit specific nursing practice.
8. The following are strongly encouraged:
a. Participation in the professional advancement program.
b. Certification specific to work area of professional practice when eligible.
c. Participation in chosen professional organizations and conferences.
d. Participation in development and maintenance of research activities.
e. Participation in community service activities.
Employee Responsibilities
Complies with organization and department policies and required training.
Completes all educational requirements to maintain competency related to specific population of patient and/or regulatory agencies (Healthstream education 100% on-time completion and attendance for annual education day).
Submits required tests and paperwork in a timely manner without management interventions.
Attendance
Follows the time and attendance policy; reports to work on time, maintains a good attendance record, has badge and uses it to clock in and out, makes requests for tie off as far in advance as possible, etc.
