Involves the patient and family psychosocial, spiritual, emotional, population specific, and diversity needs in care assessment.
Constructs and implements the plan of care using nursing knowledge and skill. Integrates direct and indirect patient care activities related to the diagnosis and co-morbidities.
Coordinates the implementation of the interdisciplinary plan of care for assigned patients. Develops goals, treatment plans, and discharge plans that meet individual patient/family needs.
Consistently completes hourly rounds with purpose to strengthen nurse communication, improve safety, and anticipate patient needs (i.e. pain, re-positioning, toileting). Rounds with purpose including pro-actively evaluating the environment to ensure it is patient friendly and patient safe.
Collaborates with the patientâ€™s designated care partner to meet the educational, physical, psychological, and spiritual needs of the patient.
Actively participates in bedside report (as appropriate) to ease anxiety and address important points of care, concerns, and progress with the patient/family.
Provides patients with caregiver name and contact information each shift.
Provides care that is respectful of and responsive to the patient values in clinical decision making.
Supports and informs the patient and family of hospital specific components of the Patient Centered Care Delivery model. Examples may include informing the family of open medical record policy, supports open family visitation, family presence during resuscitation and other invasive procedures and promotes a quiet environment.
Acts with integrity, consistency, and respect for differing views.
Assumes role of team member, charge nurse or team leader based on the need and/or situation.
Follows communication practices that minimize risks associated with handoffs among providers, and across transitions in care utilizing the SBAR process.
Leads or participates in the design and implementation of systems that support effective teamwork.
Empowers contributions of others who play a role in helping patients/families achieve health goals.
Solicits input from other team members to improve individual, as well as team, performance.
Initiates actions to resolve conflict.
Demonstrates the ability to formulate questions that address clinical issues.
Demonstrates proficiency in completing an evidence-based practice literature search.
Analyzes best evidence to address a clinical question.
Translates evidence into clinical practice through the consistent use of knowledge and evidence.
Utilizes clinical reasoning and knowledge based on evidence-based practice outcomes and research studies as the basis for decision making and comprehensive patient care.
Demonstrates quality through accurate documentation of the nursing process in a responsible, accountable manner.
Demonstrates quality through accurate documentation of core measures and concurrent use of tools and resources to ensure high compliance is achieved (core measure checklist, double checks, etc.).
Utilizes the results of quality improvement activities to initiate changes in nursing practice and care delivery.
Understands and analyzes unit metrics to understand how individual practice, continuing education, and process improvement is necessary to improve the quality of practice.
Participates in efforts to minimize cost and eliminate waste and unnecessary duplication.
Utilizes policies, procedures, and evidence-based guidelines to improve the quality of practice.
Participates in interdisciplinary teams to evaluate clinical care or services.
Demonstrates competent clinical skills, critical thinking, and nursing judgment.
Follows facility policies and procedures to promote patient safety (i.e. safe medication administration, equipment safety practices, radiation safety, fire prevention, etc).
Reports errors (facility and unit) to promote analysis of errors and design of prevention or system improvements.
Utilizes appropriate patient safety strategies to prevent human errors (checklists, forced functions, software calculations, mandatory fields, etc.).
Demonstrates effective use of technology and standardized practices to promote safety.
Navigates the patient's electronic health record to accurately enter and locate appropriate information.
Demonstrates sound judgment to increase or decrease the frequency of data collection based upon the patient's clinical condition and data trends.
Incorporates patient data from multiple sources to identify problems and assure timely and appropriate intervention.
Ensures the confidentiality and security of patient information while advocating for and involving the patient as appropriate.
Participates in the collection of data to support nursing research and evidence based nursing practice.
Maximizes the capabilities of the electronic clinical information system to enhance clinical decision and care planning.
Makes discretionary patient care decisions/interventions independently within the scope of practice (selects a course of action consistent with the patientâ€™s needs and is accountable for decisions).Â Is self-directed and decision oriented.
Practices interdependently, utilizing the skills and observations of team members appropriately.
Practices with respect and dignity and advocates for the patient.
Facilitates problem resolution among peers and unlicensed team members when behaviors and decisions are not within the range of expected actions.
Prioritizes and delegates care appropriately.Â
Evaluates changes in the patient condition and reports significant findings to the physician. Involves all disciplines, patient & family to coordinate effective medical and nursing interventions including rescue to achieve positive outcomes.