Under general supervision, utilizes the nursing process of assessment, planning, implementation and evaluation, and theoretical/clinical skills in the promotion/maintenance of health. Incorporates evidence-based nursing practices consistent with national standards and which support quality outcomes. Assumes responsibility and accountability for the quality of nursing care. Directs the plan of care while maintaining professionalism.
Essential Job Functions
• Supports and models behaviors consistent with Billings Clinic's and facility's mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
• Utilizing a holistic approach and evidence-based nursing practices, incorporates the nursing process into the goal-directed plan of care for the patient. Collaborates with the interdisciplinary care team to execute a plan of care appropriate to the needs of the patients.
• Ensures complete, accurate and timely entry into patient medical record as indicated by patient condition and documentation guidelines, consistent with departmental policies and procedures.
• Adheres to facility's safety standards, policies and practices. Anticipates and identifies problems and safety issues, then initiates appropriate action.
• Maintains appropriate skill/knowledge and application of relevant and commonly used equipment specific to area, pharmacology and laboratory values based on disease process or physiological status.
• Utilizes evidence-based practice, supported by nursing research, within specialty area.
• Utilizes performance improvement principles to assess and improve the quality of patient care.
• Takes responsibility for own professional growth and development needs; meets all system/departmental educational requirements.
• Demonstrates collaborative, supportive, and caring behaviors in communication with patient's families, visitors, and the interdisciplinary care team.
• Consideration is given to the appropriateness of care based on the population specific needs of the patient.
• Performs other duties as assigned or needed to meet the needs of the department/organization.
• In collaboration with the Trauma Registrar, supports the trauma registry for the purpose of performance improvement by measuring and evaluating plans to improve both the processes of care and the outcome. Facilitates in designing the registry to facilitate performance improvement activities, trend reports, and research while protecting confidentiality.
• Helps coordinate trauma care management utilizing effective communication across the continuum of trauma care, including helping develop clinical protocols/practice management guidelines, monitoring care of in-hospital patients, serving as a resource for clinical practice, and discharge planning.
• Identifies multidisciplinary opportunities for improvement in a timely manner and assists team members with problem resolution through plan development, implementation and evaluation.
• Conducts multidisciplinary rounds to ensure that comprehensive, multidisciplinary collaboration of trauma care occurs with the patient, family, physicians and other health care providers. Identifies fragmentation/duplication and assists the team in defining effective utilization of resources
• Provides and supports trauma education for Billings Clinic staff and assists in inter-facility and regional staff development. Participates in case review, Trauma M&M, Trauma Committee, Trauma Case conference, ERTAC and STCC.
• Aids in teaching Stop the Bleed, ENPC, TNCC, TEAM course, and Trauma nurse classes, and hospital and regional trauma education
• Serves as a resource and role model in implementation of professional nursing practice in the clinical setting and provides bedside care for trauma patients as needed.
• Identifies need and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency environmental, employee or patient safety standards relevant to job performance. Identifies and anticipates problems and safety issues and initiates appropriate action.
Knowledge, Skills, and Abilities
• Common policies and procedures, both organizational and departmental • Code of Business Conduct
• Corporate Compliance Program
• HIPAA and confidentiality requirements
• Customer service techniques and Personal Service Excellence (PSE) skills
• Regulatory standards (i.e., State Survey, OSHA, Patient Safety Standards, etc.)
• Computers and electronic applications
• Nursing practices, planning and assessment within scope of practice
• American Nurses Association (ANA) Code of Ethics
• Patient safety standards
• Interpersonal communication
• Collection and analysis of information to develop evidence-based plans of care related to specific interventions and goals.
• Incorporate population specific needs into all aspects of communication and patient care; scope of services provided will encompass age groups ranging from infant through geriatric
• Communicate clearly and effectively, both verbal and written
• Utilize time management concepts and maximize time effectively
• Work effectively with interdisciplinary care team
• Give attention to detail when planning and performing professional nursing care, resolving patient care problems and dealing with patients and their families, while working with frequent interruptions and competing priorities
• Respond calmly and professionally when dealing with difficult or emergency situations
• Maintain flexibility to adapt to a variety of workload assignments
• Lift, push and pull 50 pounds unassisted
• COMPLEXITY & DIFFICULTY:
• Resourcefulness in dealing with emergency situations
• May be required to work on various areas of the CAH/RHC for varying periods of time
• Practices within the scope of RN licensure
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