Registered Nurse- Preop/PACU

%

of time

Essential Function (Yes/No )

Key Responsibilities

(To be completed by Supervisor)

25

Y

CLINICAL KNOWLEDGE/SKILLS MANAGEMENT

1. Clinical Knowledge

2. Integrates evidence-based nursing theory, research, and practical knowledge in patient care delivery.

3. Maintains knowledge base consistent with new technology, procedures, and interventions specific to patient groups and their families.

4. Assesses, plans, implements, and evaluates appropriate interventions for a patient's current, changing, or potential clinical status.

5. Understands the effects of local, regional, sedation and general anesthesia.

6. Clinical Skill

7. Performs priority technical procedures required by the area/department assignment and does so safely, legally, effectively, and efficiently.

8. Utilizes computer technology for and maintains confidentiality of data collection, documentation, communication, and research.

9. IV proficiency.

10. Ability to recover patients from general anesthesia, regional anesthesia, and local anesthesia.

11. Experience and competency in procedural sedation.

12. Ability to circulate in a procedural sedation case.

13. Clinical Organization

14. Utilizes the nursing process in providing care for a group of patients in accordance with all Department Policies and Procedures.

15. Establishes and/or revises priorities for job/patient care activities based on acuity, resource availability, patient/family preference, and scheduled procedures.

16. Seeks consultation, supervision, and/or assistance when unable to perform procedures effectively, safely, or independently.

17. Patient Care Management

18. Functions as patient advocate and facilitates patient/family participation in decisions regarding their care.

19. Directs others in the delivery of patient care, as appropriate and holds staff accountable for completion of delegated tasks.

20. Participates collaboratively as a team member to achieve desired patient care outcomes.

21. Initiates or maintains interventions to assure continuity of safe/effective care for patients:

- between units

- between shifts

- within hospitalization period

- prior to admission and/or discharge

- among contacts in the health care agencies

25

NURSING PROCESS/DOCUMENTATION

Meets the Department of Nursing Documentation Standards by utilizing the nursing process as evidenced by documentation of the following

1. Assessment

2. Completes a nursing history that includes patient and family medical history, psychosocial, cultural factors, nutritional and special needs of the patient's physical status within department timeframes.

3. Completes an ongoing pain assessment and management plan, as needed.

4. Assesses discharge and teaching needs at the time of admission and throughout each episode of care, utilizing Aldrete criteria for procedure & sedation patients and discharge criteria.

5. Planning

6. Uses the nursing assessment and other appropriate resources to formulate a multi-disciplinary care plan.

7. Revises the multi-disciplinary care plan according to the current condition and changing needs of the patient.

8. In response to data indicating potential or actual risk to individual’s health, initiates action to correct, reduce or prevent the risk.

9. Provides and documents a rationale for actions or decisions based on scientific principles, standards of nursing practice, previous experience, and/or clinical judgment.

10. Implementing

11. Prepares patients for and instructs them about specific diagnostic and therapeutic procedures and treatments.

12. Performs patient care procedures required by scope of clinical assignment and in accordance with the Department and unit policy and procedures.

13. Responds and participates in the management of emergency clinical issues.

14. Administers medications and blood components safely as needed.

15. Performs waived laboratory testing and participates in quality checks according to departmental policy.

16. Provides age-appropriate care and interventions for ages served:

adult adolescent geriatric

1. Evaluating

2. Documents patient outcomes and responses to nursing interventions.

3. Utilizes theoretical knowledge and clinical skill to develop alternate nursing approaches to patient and family care.

4. Provides post-procedure/surgery instructions to patient and significant other.

5. Makes post-operative phone calls and documents. Calls are targeted to be made no later than 24 hours post-surgery. Alerts attending surgeon immediately to any concerns and issues that are identified during the call.

6. Teaching

7. Identifies patient, family, and/or patient caregiver's learning needs and potential barriers to learning.

8. Identifies patient, family, and/or patient caregiver's teaching interventions specific to patient’s diagnosis and ability to learn, collaborating with other disciplines as appropriate.

9. Involves patient, family, and/or the patient’s caregiver in teaching.

10. Evaluates the patient, family, and/or patient caregiver's response to teaching.

30

COMMUNICATION

1. Responds to the emotional needs of patients and families by demonstrating a sensitivity to their socio-cultural dynamics.

2. Interacts with patients, families, and staff in a supportive, calm, and therapeutic manner.

3. Demonstrates courtesy, common sense and follow through in all telephone communications, maintaining the telephone standards established by the Medical Center.

4. Listens respectfully to the ideas, opinions, and feelings of others.

5. Demonstrates sensitivity, respect, tact, and diplomacy in all interactions.

6. Expresses and accepts constructive feedback with a focus on positive outcome.

7. Demonstrates knowledge and effective use of conflict resolution techniques.

8. Utilizes appropriate chain of command in problem resolution, as identified in the organizational chart and Administrative Manual.

10

PROFESSIONALISM

1. Professional Development

2. Completes annual performance evaluation in accordance with departmental policies and unit practice.

3. Identifies and meets own educational needs to enhance area of practice.

4. Work Related Policies

5. Maintains current California RN license, BLS and ACLS and specialty certification and presents proof prior to expiration, per policy.

6. Meets annual review requirements

7. Meets physical examination and PPD or chest exam requirements.

8. Meets work schedule commitment.

9. Follows departmental guidelines regarding attendance.

10. Maintains flexibility in relation to patient assignment, shift assignment and work assignment.

11. Adheres to dress code, including appropriate identification.

12. Complies with unit-related policies.

13. Knowledgeable about and complies with all applicable infection control, health and safety policies and procedures as implemented by the Department and the Medical Center.

14. Professional Responsibility

15. Participates in Nursing QI and/or Performance Improvement activities.

16. Complies with activities mandated by JCAHO/Title 22.

17. Maintains knowledge of and adheres to established clinical and administrative policies and procedures.

18. Ensures protection of patient rights and confidentiality in all interactions.

19. Participates in patient care/ethics conferences, as appropriate.

20. Supports Medical Center cost containment efforts.

21. Attends and participates in at least 50% of staff meetings.

22. Reads meeting minutes and other department communications and integrates information into practice.

23. Participates in research activities to enhance patient care as appropriate.

10

LEADERSHIP

1. Uses an Effective Approach with Patient and Unit-related Problems

2. Identifies actual and potential problems and participates in formulation/implementation of a plan for resolution of problems using appropriate resources.

3. Reports unresolved patient and unit-related problems to appropriate individual(s) and/or department.

4. Acts as a resource to other staff members in problem identification/resolution and current issues in own clinical area.

5. Delegates duties and guides personnel in patient care delivery to ensure safe and individualized patient care.

   1. Fosters a Collaborative Approach to Patient and Staff-related Issues

6. Acts as a reliable and approachable role model/mentor for staff and students at a level appropriate to own stage of professional development.

7. Recognizes and utilizes talents and strengths of staff members to improve care of patients.

8. Delegates to and supervises PSA’s, other support staff, students and other personnel as appropriate for their scope of practice.

9. Participates in orientation of new and supplemental staff and in implementation of unit orientation program.

10. Performs the role of charge nurse in accordance with Departmental and unit-based policy.

100%

(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)