The clinical nurse coordinates and performs a variety of nursing care procedures for patients of all ages, requiring professional knowledge and consideration of specific patient conditions and treatments; and the ability to work independently in completing assignments. Guidelines include provider’s orders; standards of care, nursing policies and procedures manuals, hospital policies, and nursing duties include support to individuals of all ages and their families.

Clinical decisions are made independently during the scheduled shift; maintains complete accountability for all actions taken. Consults with the appropriate manager/supervisor and/or ancillary department in difficult situations requiring additional input or resources. Able to react in a calm manner and make sound nursing judgments in an emergent situation. Accountable for proper delegation and supervision of CNA/Tech.

Key Essential Functions and Accountabilities of the Job

• Promotes the SEARHC Seven Standards of Excellence; implements safe, therapeutic and efficient care for patients with needs due to multisystem disease and/or complications of treatment using appropriate infection control measures; sets priorities for care of patients based on acuity and/or patients’ preference; anticipates potential problems; adapts to change in the area by setting priorities for emergencies; changes in patient status and unusual occurrences; initiates, manages and documents the nursing procedures consistent with scientific principle and departmental policy; demonstrates knowledge of equipment use; accurately administers age-specific medications and therapeutics; carries out the medical and nursing care plan and coordinates patient care activities with physicians and other healthcare team members; initiates action to reduce, correct or prevent immediate, ongoing or potential risks to the patient; facilitates healing by providing nursing care that is individualized, goal oriented, based on scientific principles and the nursing process; seeks out resources when beyond the scope of skill, knowledge or experience, explains tests, procedures and disease process to patient/significant others; follows through on nursing care plans by teaching and demonstrating skills essential for understanding and coping with illness and promoting optimal health; communicates and interacts with patient/significant others in a positive and supportive way; provides counseling using emotional, intellectual and psychological supports and utilizes other healthcare professionals in dealing with psychosocial problems if needed; takes steps to decrease stress and/or increase effectiveness of coping mechanisms of patient/significant others; evaluates patient’s progress or lack of progress towards goals, directing new goal setting and implementing revised patient care plans as directed by reassessment; documents the patient’s response to care; closes out patient care plan by discharge (with instructions) or has in place an after care plan to meet the patient’s needs.  Assures confidentiality of patient information.

• Accomplishes nursing assessment through interviewing, observation and nursing process; obtains, interprets and applies age-related (pediatric, adult and geriatric) patient information terms of cognitive, physical, emotional and normal growth/development needs of the patient; completes thorough Nursing Admission Databases/initial patient assessment; documents assessment findings that are consistent with other providers and include review of body systems, laboratory results, diagnostic findings, chart reviews and inter disciplinary input; identifies problems and nursing diagnosis by recognizing the impact of health problems on patients and families; distinguishes between normal and abnormal assessments in order to identify patient capabilities and limitations including psychosocial risks, utilizes resources to assess patients with conditions that are new, unfamiliar or not commonly seen.  Shall perform duties as assigned and ensure quality patient care despite the situation encountered, be it routine or emergent.  Develops and contributes to a plan of nursing action based on existing and potential patient problems and obtainable patient responses which are mutually acceptable to the healthcare team; transcribes and notes physician orders accurately, utilizes past experience to provide a range of options for nursing care; initiates patient care plans using patient care standards; addresses identified nursing diagnosis and coordinates the plan with the healthcare team by using methods that include interventions, goals and time frames; utilizes resources to formulate a written plan of care; documents reassessments which include laboratory results, diagnostic findings, interdisciplinary notes and documented patient observations; gives shift report according to guidelines.  Other duties as assigned.

• Imparts educational knowledge to develop skills to enhance decision making and promote understanding by interacting with patients, family, staff and community; engages in ongoing evaluation of the effectiveness of teaching in terms of patient understanding and behavioral outcomes; organizes and participates in patient care conferences as applicable; identifies staff, patient and family needs and develops a plan for education and/or makes appropriate referrals; develops/implements educational programs and learning aids in the department (i.e. in-services, special projects, learning aides, patient care standards); documents education accurately and completely; provides discharge patient information; participate in in-services and educational programs in the department, hospital and/or community as assigned;  ACLS, PALS, TNCC/ATCN, and NRP certified (depending on specialty area) within the first 6 months of employment and bi-annually thereafter; completes all mandatory training and competency checks; utilizes opportunities for incidental teaching with staff members.

• Communicates with staff, patients, significant others and other members of the healthcare team in a way that is supportive, constructive and positive;  gives feedback to other staff and healthcare team members in regard to behavior that does not support achievement; assists in the orientation of new staff, travelers and students by sharing knowledge, experience and verbal encouragement; guides others in choosing nursing intervention, developing skills and applying knowledge; follows and directs others to follow corporate, hospital and departmental policies, procedures and patient care standards; supports the area and overall Nursing services mission by assigning staff to productive tasks and floating to other units as needed; provides input regarding the need for change in policies, procedures and patient care standards able to perform as Contact RN leading assigned RNs and CNAs and accomplishes all assigned patient care and area support activities during the shift.

• Attends and participates in at least 50% of departmental staff meetings; applies information presented in staff meetings; participates in unit goal setting; complies with area and departmental scheduling guidelines; initiates discussion with nurse manager regarding area or department issues; completes annual competencies, evaluation material, maintains certification sand licensure; complies with dress code; refers un-resolved problems with patients/visitors/co-workers to Nurse Manager or Administrative Manager for resolution, addresses employee concerns consistent with Human Resources policy.