Clinical Nurse Leader (Med/Surg 3N)

Overview

To facilitate culturally sensitive patient care from pre-admission to post discharge by managing, coordinating and monitoring resources to achieve optimal clinical outcomes, resource utilization and quality service.  Assists the Nurse Manager in planning and supervising the overall operation of the assigned nursing unit on a 24-hour basis. Functions as a clinical resource and educator to unit/department staff members in area of expertise.  Works within the department and as a part CentraState management team to operationalize the patient care and service goals and objectives established by senior management. Bases clinical decisions on evidence-based practice in nursing to achieve desirable outcomes.  A patient focused care model utilizing a multidisciplinary approach is used as the method to deliver patient care in the department. Takes a patient assignment when necessary.

Responsibilities

• Assists the Department Head in the continuing effort made by the department to improve the quality of patient care and services.
• Provides considerate respectful care focused upon the patients' individual needs.
• Provides considerate respectful care focused upon the patients' individual needs.
• Demonstrates the ability to obtain information and interpret information in terms of the needs of the age of the patients cared for. Demonstrates an understanding of the range of care needed based on the age of the patients cared for. Successfully completes life-span education as appropriate.
• Successfully completes life-span education as appropriate.
• Obtains a complete nursing history and baseline assessment that is systematic, consistent, and continuous. This assessment is communicated effectively and documented.
• Appropriately analyzes health status data to determine nursing diagnosis and needs for appropriate nursing care, medical intervention or services of other clinical professionals.
• Identifies patient problems and formulates nursing diagnosis according to physical, psychological, spiritual/cultural and educational needs in conjunction with a multi-disciplinary approach.
• Consistently includes patient and family in the development of an individualized plan of care.
• Administers medications as needed following CSHS policies and manufacturer's instructions.
• Takes immediate and appropriate actions in the event of a medication variance occurrence.
• Attends and participates in the multi-disciplinary discharge planning meetings and identifies the need for further services following discharge.
• Provides appropriate education based upon teaching plan.
• Conducts unit based education programs on a routine basis in collaboration with professional development.
• Meets standards for documentation regarding patient education.
• Documents results of patient assessment, nursing diagnosis, care plan nursing interventions and evaluation and patient progress in Medical Records, Nursing Standards of Care/Practice for the specific patient type.
• Recognizes changes in patient condition and/or emergencies situations and takes immediate and appropriate actions.
• Delegates components of care to non-professional caregivers as appropriate and evaluates outcomes.
• Makes decisions that demonstrate knowledge of nursing practice. Utilizes sound nursing judgment in clinical and patient care management situations.
• Demonstrates critical thinking skills in the care of patients and in the coordination of care to assure the achievement of maximum outcome.
• Develops new clinical pathways, monitors patient progress on current clinical pathways, reviews variances with Patient Care Reviewers, reviews variances from Quality Management with Nurse Manager, staff and reports to Nursing Quality Council.
• Follows the clinical progress of all patients. Participates in the development of unit protocols as needed.
• Conducts unit conferences to discuss quality issues and quality improvement strategies.
• Quality Referrals - unit based, follows up on nursing referrals, investigates problem, develops action plan, reviews with Nurse Manager, responds to Quality Management in writing, implements action plan.
• Follows up on patient complaints or concerns, keeps Nurse Manager informed.
• Provides or coordinates in-services to staff six times per year or as needed to address unit specific needs.
• Monitors appropriate usage of specialty and Zonaire beds.
• Administers chemotherapy as necessary, or when 1-1 nursing care or high dose regimes are ordered.
• Conducts and assists with performance evaluations, disciplinary actions, and work performance plans.
• Collects, analyzes quality data: Nursing P.I
• Collects, analyzes, develops action plans and reports quality initiatives for the Oncology departm