Job Title: Surgery RN

Department: Surgery

PART I: POSITION OVERVIEW

Position Summary:

The Surgery RN must adhere to the RN legal scope of practice. The Surgery RN is responsible for utilizing the nursing process to provide individualized nursing care. The nurse in this role is expected to assess and provide competent, safe care for surgical patients. The nurse works collaboratively with other interdisciplinary team members. The nurse has the knowledge of and utilizes age related patient protocols relating to physical and psychological needs of patients aged from adolescence to geriatrics. The nurse must respect and maintain confidentiality at all times. The nurse assumes responsibility for the outcome of nursing care during a specific work period. The nurse in this role must have excellent clinical, communication, and critical thinking skills.

When students are providing patient care, treatment, and/or services as part of their training, any/all employees may be asked to supervise the students.

Education/Experience:

Graduation from a NLN or AACN accredited nursing program is required. Current South Dakota RN license is required, or multi state licensure privileges.

Required Credentials (Licensure, Certification, or Registration):

ACLS, NALS, NRP, ACLS,BLS, and NRP required. Current RN license to practice in the State of South Dakota or multi-state licensure privileges

Employment Variables:

This department is open 7 days a week, 24 hours a day, 365 days a year. Scheduled work hours will vary dependent on patient needs. This includes overtime, call, nights, days, weekends and holidays. May be exposed to communicable or infectious disease, hazardous materials, and injury from performance of assigned duties. Subject to multiple sensory and environmental stressors. Initial Tuberculosis (TB) test and drug screening is required by Winner Regional Health. Rubella titer will also be drawn upon hire and immunization is required if no past exposure or indication of immunization.

Required to wear name tag provided by WRH and to follow the dress code of WRH.

Job Knowledge and Skills:

Ability to read, write, speak and understand the English language. Excellent oral and written communication skills. Ability to deal with people in a professional manner. Leadership or supervisory experience. Knowledge of nursing and medical practices, procedures, laws, regulations and guidelines that pertain to acute care.

Direct Supervisor:

Surgery Supervisor

PART II: CODE OF CONDUCT

Honesty

We will do the right thing at all times, even if it is difficult, maintaining strong, ethical practices. We protect the confidentiality of others, including patients, staff and the facility as a whole. We will take responsibility for our actions.

Expertise

We will demonstrate superior judgment, training and skill, at all times, demonstrating professionalism while doing so. We will perform all aspects of our job to the best of our ability, utilizing all resources and tools available.

Approachability

We will be non-judgmental, friendly, and open and willing to listen to everyone we come into contact with while performing our duties. We are humble and learn from others.

Respect

We will be understanding and sensitive to others’ feelings; caring and responding in a manner that sets them at ease, keeping the situation in perspective without minimizing others’ feelings or reactions. We will listen to others with full attention in a sincere, civil fashion, being careful not to be judgmental of the speaker. We maintain composure when facing conflict and avoid jumping to conclusions and defaming another’s name.

Teamwork

We willingly work together with a common approach, trusting and supporting members of our organization, using our skills and resources, sharing information to achieve a common aim.

PART III: ESSENTIAL FUNCTIONS

Essential functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable. Following are the essential functions of the job, along with the corresponding performance standards.

Assessment

Collects and organizes pertinent patient assessment data. Seeks information from patient, family, health care providers and environment on an ongoing basis. Uses established assessment forms to document assessment of patient's emotional, spiritual and physical care needs. Completes admission assessment within time frame identified in admission policy.

Diagnosis

Analyzes assessment data to identify expected outcomes unique to the patient. Expected outcomes are mutually formulated with patient, family and health care team. Formulates measurable expected outcomes using patient profile, pathways and standards of care as guides. Identifies expected outcomes which are realistic in respect to patient's present and potential capabilities.

Identification of Outcomes

Develops plan of care consistent with assessment data. Involves patient, family and healthcare providers to identify outcomes. Incorporates cultural needs/diversity in individualized patient outcome identification. Defines outcomes with attainable timeframes. Documents outcomes as measurable goals

Planning

Develops a plan to provide direct nursing care to attain outcomes. Individualizes plan based upon identified patient needs, such as economic impact, cultural concerns. Prioritizes implementation of diagnoses and interventions based on patient condition. Utilizes standardized terminology to communicate to others

Implementation

Implements the interventions identified in the plan of care. Carries out interventions in a safe and timely manner. Incorporates evidenced-based treatments in care of patient. Uses resources and collaborates with others to implement plan. Documents intervention implementation, noting exceptions/modifications

Evaluation

Evaluates the patient’s progress toward attainment of outcomes. Utilizes an organized ongoing process to determine outcome attainment based on the plan of care. Includes patient, family, health care providers involved in patient care in evaluation process. Documents evaluation findings. Utilizes evaluation data to revise as necessary, diagnoses, outcome, plan and implementation process. Communicates results to patient and those involved in care

Quality of Care

Systemically evaluates the quality and effectiveness of nursing practice. Documents in a responsible, accountable and ethical manner. Uses results of quality improvement activities to initiate change. Implements creativity and innovation to improve care delivery.

Education

Acquires and maintains current knowledge in nursing practice. Participates in ongoing educational related activities. Demonstrates commitment to lifelong learning. Seeks experiences to maintain skills and competence for role performance. Maintains records to support competency and lifelong learning

Collegiality

Contributes to the professional development of peers, colleagues and others. Shares knowledge and skills with others (patient conference, meeting presentations, precept/mentoring). Provides peer feedback in constructive manner. Engages in direct one-to-one communication. Interacts with peers and colleagues to enhance performance. Contributes in a positive manner to the environment, making conducive to education and learning

Transportation of Supplies and Patients

Checks at least two patient identifiers (preferably by asking patient to state name and date of birth and verifies the information by comparing two identifiers on patient ID armband) to match the correct patient with the correct procedure ordered prior to transporting the patient. Verifies patient by match of armband and chart. Notifies patient's nurse/caregiver that the patient is leaving for procedure/surgery (handoff communication) prior to leaving nursing department with patient. Seeks information from healthcare team important to the continued safe care of patient prior to transporting patient (e.g., fall risk status, infection control precautions, code status, etc.). This information is then accurately communicated to next provider(s) of care.

Duties and Responsibilities

Provides leadership and direction in accordance with organizational and departmental goals and objectives. Assists with professional orientation, growth and development of nursing staff through identification of needs and encouraging educational efforts. Counsels employees and, as necessary, reports appropriately to the OR supervisor infractions of policy; provides documentation for the OR supervisor regarding counseling and infractions. Teaches and directs other nursing personnel and provides for maximum utilization of their skills and abilities. Inspires team work. Organizes and prioritizes effectively. Keeps OR supervisor informed of reportable situations and OR needs. Performs appropriately in emergency/crisis situations. Provides input and supports patient care policies and procedures for the nursing department. Works with Medical Staff and other personnel to coordinate medical and nursing management of patient care. Supervises nursing activities related to patient care during the perioperative period and follows standards for accurate reporting and recording of patient’s symptoms, reactions and progress. Evaluates patient care through assessment, planning, intervention, re-evaluation, written documentation, observation and comparison to establish standards of care. Serves as a clinical resource person and assists nursing personnel in assessing patient/family status to plan nursing care. Functions within the limits of South Dakota Nurse Practice Act. Implements medical plan of care by transcribing and carrying out physician orders in a timely manner. Documents nursing interventions, patient response, effectiveness, complications, etc., utilizing appropriate charting methods. Communicates pertinent information to anesthesia, physicians, and nursing service. Promotes open communication and maintains a good working relationship within the unit, with medical staff, and with other units and departments. Assumes responsibility for OR supervisor when designated. Cooperates with clinical instructors in providing nursing student’s clinical experience. Recognizes areas of personal strengths and limitations of self and seeks supervision of own actions when necessary. Is cross-trained to other areas/positions/departments to provide assistance when needed. Provides timely and proper notification for absences and paid personal leave. Finds a replacement when necessary. No unexcused absences or excessive tardiness. Knows emergency procedures for fire, internal/external disaster plans, codes, etc., and participates in drills. Participates on committees and/or is involved in special projects of Winner Regional Health. Utilizes and adheres to appropriate precautions/techniques with hazardous chemicals, blood and body fluids, medical waste and/or equipment. Satisfactory attendance at department meetings (50% attendance meets expectation).

PART IV: COMPLIANCE

Compliance

Must comply with the Corporate Compliance Policy and all laws, rules, regulations and standards of conduct relating to the position. The employee has a duty to report any suspected violations of the law or the standards of conduct to the Compliance Officer or the Chief Executive Officer.

PART V: PHYSICAL AND MENTAL REQUIREMENTS

General Activity

In a regular workday, employee may:

Sit

1/2

Hours at a time; up to

1-1.5

Hours during the day

Stand

1

Hours at a time; up to

3-4.5

Hours during the day

Walk

1

Hours at a time; up to

4-6

Hours during the day

Motion

Employee is required: (In terms of a regular workday, "Occasionally" equals 1% to 33%, "Frequently" 34% to 66%, "Continuously", greater than 67 %.)

Bend/Stoop

Kneel, Duration 30 sec

Squat

Balance

Crawl, Distance

Twist

Climb, Height

Keyboarding/Mousing

Reach above shoulder level

Physical Demand

Employee’s job requires he/she carry and lift loads from the floor, from 12 inches from the floor, to shoulder height and overhead. Employee’s job requires a pushing/pulling force to move a load (not the weight of the load).

Physical Demand Classification:

Carrying/lifting weight and pushing/pulling force:

Occasionally

Frequently

Constantly

Sensory Requirements:

Yes/No

Explanation (if Yes)

Speech

Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.

Need to continuously communicate with patients and co-workers.

Vision (VDT)

Are there specific vision requirements for the job?

Need to accurately measure intake and output; work with multiple tubes, drains, monitoring equipment, etc. Must be able to visually assess patients, including color recognition.

Hearing

Ability to receive detailed information through oral communications, and to make fine discriminations in sound; i.e., making fine adjustments on machine parts, using a telephone, taking blood pressures.

Need to continuously hear instructions from co-workers, requests from patients. Need to hear BP readings, assess by auscultation.

Environmental Factors

Yes/No

Explanation (if Yes)

Working on unprotected heights

Being around moving machinery

X-ray machines

Exposure to marked changes in temperature and humidity

Driving automotive equipment

Wearing personal protective equipment

Patient care

Exposure to atmospheric conditions (i.e. fumes, dust, odors, mists, gases, or poor ventilation)

Helicopter fumes

Exposure to extreme noise or vibration

Crying babies, Moms

Exposure to blood, body fluids and waste

Patient care

Exposure to radiation

X-rays, radium

Exposure to other hazards (i.e. mechanical, electrical, burns, or explosives)

Chemicals

Emotional/Psychological Factors

Yes/No

Explanation (if Yes)

Stress: Exposed to stressful situations

Dealing with patients, families and others who may be very stressed. Working with a variety of co-workers at one time. Has high accountability for tasks performed.

Concentration: Must be able to concentrate on work tasks amidst distractions.

Work must be done accurately. Mistakes may be harmful to patient outcomes.

Must exert self-control.

Due to stressful situations, must maintain composure in order to get work done. Will give directions and take directions from multiple sources.

PART VI: JOB RELATIONSHIPS

Supervises

No supervisory responsibilities

Supervisory responsibility

# Direct Reports:

# Indirect Reports:

Age of Patient Populations Served

Neonates: 1-30 days

Infant: 30 days - 1 yr

Children: 1- 12 yrs

Adolescents: 13- 18 yrs

Adults: 19- 70 yrs

Geriatrics: 70 yrs

All

Not applicable

Internal Contacts

Patients

Providers: (i.e. Physicians, Therapists, Social Workers)

Staff: (i.e. clinical and administrative support staff)

Volunteers

Others:

External Contacts

Patients

Families/Significant Others

Providers

Vendors

Community and Health Agencies

Regulatory agencies

Other: Job Applicants