Assists patients with activities of daily living, provides basic nursing care to non-acutely ill patients, and assists in maintaining a safe and clean environment under the supervision of the Registered Nurse (RN). Demonstrates competency in delegated functions and treatments, and can identify changes in patient conditions, reporting them appropriately. Performs RN duties under direct supervision, validated by a school checkoff list.
Essential Functions
- Patient assessment :
- Obtains and documents comprehensive nursing history from the patient and/or significant other.
- Performs basic patient assessments, demonstrating knowledge of anatomy, physiology, and pathology.
- Records vital signs, notes changes, and investigates as needed.
- Makes pertinent observations, describes body parts and functions accurately, and draws logical conclusions for care planning.
- Identifies abnormal diagnostic data, reports to physicians, and incorporates findings into the care plan.
- Develops a care plan using assessment data before shift end to ensure continuity of care.
Care Plan Development and Implementation
- Reviews and develops care plans for assigned patients, involving patients and families in planning and goal setting.
- Uses care plans to provide safe, therapeutic care, following standards and policies.
- Assumes accountability for clinical care, including supervision of nonprofessional staff.
- Communicates effectively with patients, families, and healthcare team members.
- Incorporates input from team members into the care plan.
- Performs basic technical skills relevant to the unit's care needs.
- Identifies patient teaching needs and provides elementary instructions.
- Notes discharge planning elements and integrates them into the care plan, considering community resources.
- Responds appropriately to urgent and emergency situations.
Evaluation :
- Evaluates patient responses to nursing care and documents outcomes.
- Participates in evaluating nursing care for groups of patients.
- Identifies strengths and weaknesses in nursing care systems.
Leadership :
- Supports nursing standards by adhering to policies and procedures.
- Supervises care provided by nonprofessional personnel, offering guidance as needed.
- Attends unit conferences and contributes suggestions for improvement.
- Participates in peer review processes.
Education :
- Engages in professional development through reading, educational programs, and conferences.
- Assists in teaching patients and groups within established programs.
- Seeks guidance for unfamiliar procedures and responsibilities.
- Completes at least 10 hours of continuing education annually.
Organizational Expectations
- Represents the organization positively and professionally.
- Promotes a safety culture through proper identification, reporting, and prevention.
- Maintains a clean, quiet patient environment to enhance care experience.
- Stays current with standards, trends, and developments in nursing practice.
- Follows infection control, medication, and controlled substance policies.
- Participates in quality improvement activities.
- Ensures compliance with organizational policies and professional standards.
- Handles confidential patient information appropriately.
- Provides excellent customer service aligned with organizational values.
- Adheres to all relevant policies, procedures, and standards, including accreditation requirements.
- Participates in safety initiatives and reports patient safety events.
- Demonstrates loyalty, manages up, and consistently uses AIDET and 5 P's communication tools.
- Upholds facility standards of performance.
Qualifications :
- High school diploma or equivalent; final year of RN program.
- BLS certification or obtain within 90 days of hire.
- At least six months of recent hospital experience.
- Proficiency in 50% of Level II skills required.