Job Description

OPTS, Registered Nurse

POSITION SUMMARY

Responsible for designing and implementing the plan of care for an assigned group of patients. Uses the nursing process to assure the performance of direct care activities required to provide and maintain individualized quality patient care. Specific areas of responsibility, whether providing total patient care or functioning as a team leader, include; performance of treatments, assessment of patients and development of an individualized care plan of care based upon the nursing process, provision of patient education, maintenance of a record of care provided and ensuring that comfort measures are provided. Actively participates in performance improvement program of department. This position will be primarily working with a chronically mentally ill through rehabilitating adult to geriatric patient population in a manner that demonstrates an understanding of the functional and/or developmental age of the individual served.

MAJOR RESPONSIBILITIES

SERVICE PERFORMANCE

Greets/acknowledges customers warmly, with a smile, and immediately when they enter department/unit/area. Asks how the customer may be helped with interest and concern. Listens attentively, does not interrupt. Accepts ownership and takes action to resolve customer needs and/or concerns. Is attentive and responsive to the expectations of physicians, co-workers and direct reports. Is generous in acknowledging a job well done. Uses words and behaviors that express consideration, concern and respect. Facilitates and holds staff accountable for meeting department customer service standards in the performance of duties. Utilizes telephone skills effectively. Keeps all private information about staff or patients confidential. Meets or exceeds customer service improvement targets as demonstrated by dashboards, etc. VALUE ADDED – INCREASES WORTH OF SERVICE TO MISSION COMMUNITY HOSPITAL Participates in marketing activities of the Hospital including but not limited to committees/task forces, speaking engagements, conducting tours, Hospital sponsored health fairs. Participates in staff recognition activities in ways that reward behaviors reflecting positively on Mission Community Hospital. Serves as an active participant in departmental, interdepartmental, multi-department or house-wide process improvement forums/task forces/committees. Offers and implements solutions to challenges/problems. Assists with development-related activities including fund raising programs & activities. Participates in departmental activities / projects and contributes recommendations and/or assists in implementing new or revised processes/procedures that improve work efficiency and/or enhanced service. Identifies, independently, departmental work to be done and/or coworkers needing assistance (beyond regular job responsibilities) and actively meets the need(s). Supports department efforts dedicated to business growth. Attends/participates in activities that contribute to professional growth and development in ways that enhances value to the organization.

LEADERSHIP

Assists assigned staff and other patient care team members in completing care efficiently, effectively and safely. Utilizes and role models participant decision making. Provides coaching and supervision when deficiencies are noted Is continuously aware of changing priorities and resource availability and proactively removes roadblocks and prevents problems. Utilizes competent interpersonal skills and conflict resolution technique. Delegates tasks within the scope of practice, skills and abilities of patient care team members. Assures appropriate completion/documentation of unit logs, quality control measures and participation in/compliance with performance improvement activities/projects. Role models and fosters high quality and continuous excellence in patient care. Conducts rounds with assigned team members to assess the care being given and that patient needs/expectations are met. Promotes an environment in which the patient care team is motivated to work cooperatively toward common outcomes. Collaborates with staff regarding physician notification. Role models and assures compliance by patient care team members with hospital policies, procedures, standards of care, accreditation and regulatory standards. Maintains an efficient and cost effective, work environment. Precepts students, new hires, unit floats and registry personnel to promote a positive development and patient care experience for patients, the staff, and the unit.

PATIENT CARE

Assesses The Physical, Psycho-Social, Spiritual, Cultural, Functional, High Risk and Discharge Needs Of The Patient And Family. Completes admission assessment/triage, history and physical on all assigned patients per department/unit policy. Completes patient transfer assessment within one hour of receiving patients or per unit policy. Identifies psychosocial, spiritual, learning and discharge planning needs. Performs assigned patient reassessment that is age specific and relevant to patient’s needs/diagnosis per patient condition/unit policy. Completes assessment and instruction upon discharge per unit policy. Recognizes and reports abnormal diagnostic data. Identifies predicable patient problems. Identifies low volume/high risk patient problems and anticipates less predictable problems. Recognizes the relationship between physiological, psychological and environmental factors and their affect on the patient/family. Identifies current patient/family coping mechanisms and their effectiveness. Identifies patient/family support systems and their effectiveness. Recognizes need for other resources to assist in the assessment of needs and notifies appropriate members. Collaborates with resources for assessment as needed, i.e., social services, physical therapy, dietary, etc. Develops, implements and evaluates a nursing and treatment team plan of care for the patient/family. Determines and prioritizes patient problems, expected outcome and discharge planning. Formulates plan of care that demonstrates knowledge of age specific needs, conditions, and measurable interventions, including diagnostic process and expected diagnostic values for high volume cases. Utilizes input from the patient/family and/or significant other. Integrates the medical plan of care in the patient’s nursing and treatment team plan of care. Utilizes existing standards of care in formulating the plan. Formulates plan of care that demonstrates knowledge of complex patient conditions and specific to the patient’s age. Revises/updates plan In collaboration with others Communicates plan of care effectively to other staff members, physicians and interdisciplinary healthcare team members. Coordinates nursing care with other disciplines involved. Consults with other members of the healthcare team to maximize problem identification and appropriate interventions towards a positive patient outcome. Actively participates in interdisciplinary care conferences. Provides for the education of the patient/family. Independently assesses learning needs of assigned patients and seeks assistance in identifying/meeting complex learning needs. Incorporates teaching into the plan of care and performs the teaching for routine patient populations. Performs teaching for complex patient problems. Implements instructions for patients/families/significant others about the illness, management of the illness and after discharge care using resources and referrals as necessary. Teaches others involved in the care of the patient and family with complex problems. Evaluates teaching plan and revises in relation to patient and/or family response/input. Evaluates need for further instruction based on patient/family response/ input; seeks assistance when appropriate. Documents patient and/or family response/input. Documents patient and/or family response and progress toward goals in compliance with plan of care and practice standards. Implements and/or directs/supervises the nursing interventions identified in the plan of care towards accomplishing defined goals. Provides basic patient care independently and implements physician orders safely for high volume diagnoses. Ensures physician’s orders are transcribed correctly and carried out in a timely manner. Reports and seeks immediate assistance in life threatening situations. Identifies life threatening situations, initiates and coordinates appropriate nursing interventions. Keeps work area neat and uncluttered; removes, cleans and returns equipment and supplies as appropriate. Documents nursing interventions, patient response, effectiveness and complications in DARE format or per unit policy. Communicates information to physician and co-workers in timely manner. Responds appropriately to usual and abnormal diagnostic data and documents interventions. Identifies and implements alternative interventions to achieve expected outcomes; involves and solicits feedback from patient and/or significant others. Recognizes subtle changes and trends and identifies abnormal deviations in signs, symptoms, vital signs; interprets these with respect to the patient’s condition and age and takes appropriate action. Suggests appropriate interventions for abnormal findings utilizing clinical assessment of the patient and critical thinking. Communicates rationale for interventions to assigned staff and other healthcare team members. Evaluates the effectiveness of the nursing interventions identified in the plan of care towards accomplishing defined goals. Evaluates, by direct observation, the effectiveness of interventions based on the plan of care and expected outcomes. Evaluates the effectiveness of interventions based on psychosocial, age, cultural, religious and educational influences; seeks assistance when necessary. Revises patient’s plan of care to reflect changes in patient needs or lack of progress in response to planned interventions. Demonstrates the ability to safely and competently perform tasks and procedures according to hospital policy and procedure. Assists physician/staff with basic clinical procedures. Differentiates between patient complications and equipment malfunction. Sets up/prepares for procedures less frequently done and assists the physician effectively. Facilitates appropriate/efficient utilization of resources. Follows appropriate Code notification procedures. Functions in a Code situation quickly and calmly Effectively prioritizes clinical interventions and care. Understands actions, side-effects, contra-indications of drugs. Follows five “rights” of medication administration. Documents medications, including narcotics, according to appropriate standards of care and policy and procedure. Questions medication and notifies appropriate physician, supervisor and/or pharmacy when the medication, the dose, the frequency, or the route may be harmful to the patient. Detects and reports medication or treatment errors according to policy. Identifies drug/drug, drug/food interactions and notifies physician and pharmacy. Monitors for desired effect of medications/treatments. Obtains necessary training prior to initial equipment use. Assures equipment is in operating order prior to use. Uses equipment in accordance with manufacturer’s operating instructions.

QUALIFICATIONS

General Requirements Current license to practice professional nursing in the state of California. Prefer minimum one-year psychiatric care experience. BLS Additional Requirements Mental Health: MAB, PART or CPI certified BSN preferred. Experienced with L.P.S. Patients Rights Knowledge of Psychiatric Medications, D.S.M.4

PHYSICAL DEMAND ANALYSIS

PHYSICAL REQUIREMENTS:

Ability to negotiate physical environment with safety

VISUAL REQUIREMENTS:

Ability to translate and understand written communications and negotiate physical environment with safety.

HEARING REQUIREMENTS:

Ability to understand and translate auditory communications with safety

WORKING CONDITIONS:

Office working conditions: Normal Patient Care Areas: With safety precautions

Job Tags

Full time, Work at office, Immediate start,

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