RN Internal Medicine (02041)

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, coordinating cross continuum care and assessing outcomes of interventions in accordance with system, departmental and ambulatory policies and procedures.This role provides clinically-based, risk reducing care and coordination that facilitates the delivery of cost-effective quality healthcare along the continuum. It directly interfaces with physicians, care managers, health care teams, patients and their caregivers to achieve desired patient outcomes. Excellent communication skills, both written and verbal, a commitment to coaching patients on health promoting behaviors, and an ability to listen and assimilate complex clinical information are required in the role. The ability to work autonomously and in teams is essential. Participation in quality improvement efforts, research and evaluation processes related to the management of patient care is integral to the role.

Job Description

ESSENTIAL FUNCTIONS

1 - Medication Administration

a - *Demonstrates knowledge of and follows SSH policies and procedures for administering and documenting medications.

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

c - *Demonstrates safe procedures for the safe administration of medication and vaccines.

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

a - Develops, evaluates and updates individualized plan for patient and documents outcomes.

b – Initiates patient outreach, identifies and documents patient/family/significant other needs and makes appropriate interventions, evaluating outcomes of interventions.

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

d - Documents all patient care following the department of nursing policy, department-based standards, disease processes (CHF, PNA vaccines) and nurse sensitive indicators (falls, safety risk, isolation, etc.)

e - Assess/reassesses and documents patient's response to each intervention both pharmacological and non-pharmacological per South Shore Health and ambulatory policies and procedures.

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 and collaborates with health team members: primary care, specialty care, and ancillary providers and departments.

i - Facilitates care across the continuum to insure patient needs are met in the right setting and at the right time.

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 procedure, including "time out", administration of care, medications, labeled specimen's and 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 ambulatory 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 policy and procedure.

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

a – Accesses Outlook, Epic, HealthStream and Workday to review email, learning management and other resources as applicable to RN role.

b - Utilizes software applications required by health system, nursing and department 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 through chain of command.

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.

8 Age & Culture

a - Possesses and practices age and cultural knowledge and awareness.

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

c - Interacts with sensitivity and inclusion 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.

9 - Technology and Learning

a - Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

b - Embraces technological advances that allow us to communicate information effectively and efficiently based on role.

UNIT / DEPARTMENT SPECIFIC JOB FUNCTIONS

1 - Demonstrates as part of daily work experience the Aspects of Caring including but not limited to accountability and respect to our patients and colleagues.

2 - Demonstrates professional working relationships with colleagues to promote a positive/encouraging workplace.

3 - Consistently advocates for, facilitates, and implements principles of positive patient experience including caring, kindness and service.

4- Communicates plan of care to patient and family. Goals are:

a. Keep the patient and family informed

b. Provide information to patient and family about condition / treatment

c. Include the patient/family in care plan decisions

d. Communicate to patients and families in terminology they can understand.

JOB REQUIREMENTS

Minimum Education - Preferred

Graduate of an accredited School of Nursing, BSN preferred

Minimum Work Experience

Previous Ambulatory Care RN experience preferred

Required Licenses / Registrations

RN - Registered Nurse

Required Classes/Skills -

BLS – Basic Life Support

Required additional Knowledge, and Abilities

Demonstrated proficiency in ambulatory care nursing, knowledge, and skills

Excellent verbal and written communication skills required.
Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
Basic computer skills required.

Demonstrated skills in the areas of: communication (verbal and written), interdisciplinary collaboration, creative problem solving, and critical thinking.

Knowledge of health system and community resources preferred.