RN Surgical and Stepdown
Company: SSM Health
Location: Saint Louis
Posted on: May 6, 2021
POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIAEssential
Functions: The following are essential job accountabilities and
performance criteria: 1) Performs comprehensive nursing
assessment/reassessment. CriteriaA) Performs age-appropriate
admission assessment or transfer assessment. Obtains input from
family/guardian when appropriate.B) Accurately and completely
documents findings.C) Performs assessment of post-op/post-invasive
procedure patients.D) Assesses and documents education and
discharge needs of patient and family on admission and throughout
hospitalization.E) Provides patient reassessment documenting
pertinent observations according to the patient plan of care,
changes in condition, status and/or diagnosis, response to care,
procedures, etc., and standards of care. 2) Establishes,
coordinates and evaluates a plan of care based on analysis of
assessment data, patient diagnosis, lab data, tests, procedures,
physician orders, protocols and standards of care and other
information as relevant. CriteriaA)Identifies short and long term
goals based on patient care needs.B)Formulates nursing
interventions to achieve desired patient outcome.C) Incorporates
disease specific evidenced based practice into nursing care plan
and other documentation3)Provides and documents nursing
interventions based on assessed patient needs, plan of care, and
changes in patient status.CriteriaA) Collaborates with appropriate
health team members for coordination of daily plan of care for
assigned patients. B) Provides, coordinates and communicates
patient care, including accurate Handoff Communication Reports. C)
Administers and documents medications accurately according to
policies and procedures. D) Monitors, maintains and documents
accurate IV fluids and parenteral nutrition according to policies
and procedures. E) Completes referrals as indicated by assessment
data. F) Requests consultation for special needs, equipment, or
information for patient and/or family. G) Provides patient/family
education and discharge planning per documentation guidelines and
protocol.H) Clarifies all physician orders as warranted. I)
Acknowledges and implements physician orders in an accurate and
timely manner as evidenced by documentation in the medical record.
J) Assists physician with procedures/treatments as requested or
delegates to Care Partner as appropriate. K) Documents "Readback"
for all telephone/verbal orders. L) Takes telephone/verbal orders
only in emergency situations. M) Recognizes changes in patient's
condition and takes appropriate nursing actions. N) Involves the
family/guardian when providing care and in decision-making as
appropriate. O) Recognizes risks for patient and takes appropriate
action. P) Incorporates use of Infection Control practices in daily
care. 4) Documents and or communicates nursing care and or changes
in patient condition. CriteriaA) Performs and documents ongoing
evaluation of effectiveness of care based on assessment data,
nursing interventions, patient response to medications, treatments
and procedures. B) Evaluates and documents effectiveness of
patient/family education. C) Evaluates plan of care and modifies as
indicated in "A" above. D) Recognizes significant changes in
patient's clinical parameters and reports immediately to physician
and others as indicated. E) Identifies problems, gathers pertinent
data, suggests solutions, communicates using appropriate lines of
authority, and works toward problem resolution. F) Reports
variation from care/treatment following the occurrence reporting
policy and procedures. 5)Specialized Care: Provides specialized
care to patients at high risk for injury.CriteriaA) Restraint
Care1. Initiates/evaluates alternatives to restraint prior to
application2.Applies restraints consistent with the approved
procedure.3. Monitors and assesses patient's response throughout
the restraint period at the appropriate intervals. 4. Provides
specified patient care (toileting, skin care, hydration, feeding,
etc.) on a timely basis. 5. Provides consultation for peers to
determine alternatives to restraints and 1:1 observation. 6.
Documents restraint use and associated care thoroughly.B) Pain
Management 1. Assess patient for presence of pain on admission and
during assessments/reassessments. 2. Incorporates patient's
cultural/spiritual beliefs regarding pain into pain management
plan. 3. Implement pain management techniques. Focus on prevention
rather than treatment. 4. Include patient and/or family members in
developing a pain management plan. 5. Consider other methods of
pain control when developing plan of care: massage, repositioning,
immobilization, and music therapy.C) Abuse Assessment 1. Is aware
of abuse recognition criteria and incorporates it into assessments.
2. Reports signs of possible abuse/neglect to the Administrative
Director of Behavioral Health, physician, Risk Management and
Social Work. 3. Takes appropriate action to support patient safety
when signs of abuse are noted.6) Demonstrates accountability for
own professional practice. CriteriaA) Adheres to all quality and
performance standards, policies, procedures, protocols when
implementing clinical and technical aspects of care. 1.
Participates in learning experiences that increases professional
competence.B) Demonstrates appropriate technical and cognitive
skills for area of practice.C) Maintains currency in all
hospital/unit information, communication, policies and procedures.
1. Attends staff meetings/reviews minutes when absent 2.
Participates in Committee(s), Shared Governance, Work Team(s), in a
leadership and or in membership role 3. Reviews Hospital/Nursing
publications 4. Keeps up to date with policies and procedures 5.
Participates and or keeps up to date with Shared Governance and
Unit Based Practice Council activities and information. Contributes
to requests for feedback.D) Demonstrates ability to change and
adapt to changing work demands 1. Responds positively to change 2.
Provides assistance and support to peers, co-workers and other team
members3.Adapts positively to changes in unplanned work load and
job demands7) Ability to relate to coworkers in a professional and
appropriate manner. CriteriaA) Orients and/or precepts new
employees when required.B) Participates in and maintains a
collaborative team approach toward work. C) Functions as a resource
person to co-workers, patients/families, medical staff and other
members of the health care team. D) Effectively assumes and
delegates care and other activities to the appropriate team member.
E) Redirects clinical staff when the medical plan of care is
altered. F) Communicates the plan of care to be followed on each
individual patient in a precise and professional manner. G)
Responsible for the supervision and teaching of students/new staff
nurses. 8) Safety/Infection Control: Performs job in accordance
with safety and infection control policies. CriteriaA) Practices
standard precautions and disposes of hazardous wastes per
established guidelines. B) Maintains a safe, clean, comfortable,
and therapeutic environment for patients/families/employees in
accordance to hospital standards. 1. Maintains clutter free
environment. 2. Follows hand hygiene procedures. 3. Utilizes Safe
Patient Handling techniques and equipment. 4. Keeps personal
conversations/background noise to a minimum. 5. Adheres to dress
code. C) Reports risk management concerns using eSRM. D) Assumes
responsibility for completing all annual mandatory requirements: 1.
Maintains current license and certifications 2. Maintain up to date
BLS and HI 3. Annual TB Screening and Influenza vaccination 4.
Annual Ethics Training (Initial Ethics, if new employee) 5. Annual
Safety Training 6. Required Information Security course7. Required
Abuse & Neglect course 8. Annual Blood Borne Pathogens training (if
required) 9. Coursework as assigned for .edu 10. Annual competency
11. Age/Population specific competency (if applicable) 12.
orientation competency (if new hire) 13. Service Specific E)
Reports variations from care/treatment following the occurrence
reporting policy and procedure. 9) Service: Provides service
excellence to the customers of Saint Louis University Hospital by
delivering timely, high quality care in a courteous and respectful
manner. CriteriaA)Demonstrates care and courtesy1. Provides prompt,
respectful, courteous service. 2. Meets physical, spiritual,
psychological and emotional needs of patients and families. 3.Works
with other members of the health care team to see that call lights
are answered promptly. 4. Apologizes for mix-up and delay. B)
Communicates effectively and maintains confidentiality 1. Listens
to staff/patient/family concerns and addresses needs.2. Explains
procedures and all education in a manner that staff/patient/family
understand. 3. Allows time for questions. C) Demonstrates
competence and collaboration 1. Provides accurate handoff reports.
2. Provides quality care in accordance to standards. 3. Shares
knowledge with other departments to facilitate work flow and
continuity. D) Provides cost effect services 1. Uses resources
wisely. 2. Recommends changes in practice that increases efficiency
and minimizes waste. E) Ensures that customer satisfaction is
maintained through the use of the "Principles and Commitments" of
the hospital AIDET and "One Mission, One Spirit".10) Incorporates
Performance Improvement and Evidenced Based Practice into
individual professional practice. CriteriaA) Assist in developing
and implementing nursing unit goals. B) Remains current with
evidenced based practice initiatives. C) Identifies opportunities
for improvement, participates in data collection when requested,
suggests solutions, communicates using appropriate lines of
authority and works toward problem resolution. D) Participates in
the performance/process improvement process. 1. Assists in
developing unit based Performance Improvement and action plans. 2.
Leads a performance improvement team when requested 3. Contributes
to data collection 4. Participates in evaluation of Performance
Improvement results. E) Participates in nursing research
activities. F) Participates in Departmental and Hospital
Performance Improvement activities when warranted. G) Participates
in occurrence reviews H) Contributes to the maintenance/improvement
of all nursing quality indicators. 11) Age Appropriate Care:
Provides age-appropriate care to: _____Adult _____Geriatric
CriteriaA) Demonstrates knowledge and skills of normal growth &
development necessary to provide services to the age of the patient
served by the department.B)Demonstrates ability to assess and
interpret age specific data to identify patient needs.C) Utilizes
communication skills necessary to interpret age specific responses
to service and interaction. D) Involves family or significant other
in decision making related to services provided. E)Demonstrates
ability to provide service needed for the age groups routinely
served by the department assigned. 12) Cost Effective Services
CriteriaA) Uses resources efficiently. B) Recommends change in
practice that increase efficiency and minimize waste. C) Documents
chargeable supplies and equipment used to provide care. D)
Prioritizes responsibilities and completes work on time. E)
Utilizes non-clinical time in a constructive manner, i.e.
completing chart audits, .edu, mandatory education
requirements.DISCLAIMER: Performs other related duties as assigned
or requested. Job SpecificationsMINIMUM EDUCATION: RN licensure in
the State of Missouri, or new graduate of accredited school of
nursing and must obtain licensure within 90 days of graduation.
WORKING CONDITIONS: May be exposed to the risk of blood borne
diseases. Exposure to unpleasant elements (accidents, injuries, and
illness). Subject to varying and unpredictable situations. Handles
emergency and crisis situations. Subject to irregular hours.
PHYSICAL REQUIREMENTS: Occasional prolonged standing/walking.
Occasionally lifts, positions, pushes and/or transfers patients.
Occasional reaching, stooping, bending, kneeling, crouching.
The above statements are intended to describe the general nature
and level of work being performed. They are not to be construed, as
an exhaustive list of all duties, responsibilities, and skills
required of personnel so classified. An individual working in their
job classification must also perform specific tasks upon request by
supervisor personnel. Furthermore, the duties and responsibilities
for this job classification are subject to change at the discretion
of the medical center.Practice AgreementFor Nursing StaffPlease
read the below standards and expectations. Standard (I understand
that . . .)Our patients deserve care that sets the standard for
excellence and meets the needs of each and every patient whose care
is our primary purpose and mission. (Quality)Expectations (So I
will . . .)Achieve Excellence in Infection Control By:
- Isolating per policy
- Consistently adhering to proper infection control practices and
I will educate patients and visitors of the same.
- Taking responsibility to read, learn, follow, enforce and
remain up to date on Saint Louis University Hospital policies and
- Practicing excellent hand washing technique - Wash or gel my
hands when going into and coming out of patient rooms and between
glove use, especial when it relates to dressing changes,
- Change dressings when they need to be changed now rather than
later and maintain all invasive lines as directed by policy.
- Vaccinate per policy.
- Notify my supervisor if I see anyone or anything that puts my
patient at risk.
- Utilizing safe practices during crisis situations (i.e. codes)
and transport to other departments, e.g. masks, 02 tanks.?Achieve
Excellence in Nursing Practice By:
- Contributing in a positive way to the functioning of the
patient care team.
- Taking an active role in practice development through
participation in unit based and hospital committees.
- Ensuring that documentation of patient care is consistently
thorough and legible.
- Rounding with a purpose on each patient.
- Modeling practice excellence to new employees.
- Ensuring that licensure, certifications, and other mandatory
requirements are completed within assigned deadlines.?Own and
Respect My Environment By:
- Maintaining proper care of and treat all equipment with respect
(clean up after using the microwave, not hit the walls with beds
- Maintaining a neat , clean and organized work environment.
- Keeping the nursing station, bathroom, and break room neat and
- Leaving my patent's room in good order, with supplies in place,
and ready for the next shift and my work area in the same condition
as I would like to see when I return.
- If I see something out of order I will pick it up, fix it, or
call to have it repaired. I will not assume that someone else will
- Giving hand-off report to another nurse before I leave the unit
with another patient or for any other errand. Standard (I
understand that . . .)Treating my colleagues, our patients,
visitors, and business partners with respect and dignity is
necessary to create an environment where excellence in caring and
nursing practice can thrive. (People)Expectations (So I will . . .)
- Show empathy to every patient and communicate my commitment to
assist in their comfort, safety, and restoration to health.
- Demonstrate my respect to my colleagues and co-condition and
concerns, mentoring new employees, resolving conflicts
constructively, and proactively scheduling shifts to meet unit
- Come to work with a positive attitude.
- Offer constructive criticism to co-workers when addressing
concerns, praising in public and criticizing in private when
- Be part of the solution not part of the problem.
- Not complain to or complain in front of my patients/families
and staff (i.e. too busy or short staffed, no lunch).
- Follow up on patient concerns every time to the appropriate
- Respond promptly to patient requests.
- Always refer to physicians as Dr. ____.
- Make sure that my patients are checked at least every ___ 1
hour ___ 30 minutes ___ 15 minutes per clinical standard and as
appropriate.Standard (I understand that . . )?Patients and their
families are scared and vulnerable. It is my responsibility to
communicate through verbal and non-vernal means that I am here to
help. (Service)Expectations (So I will . . .)
- Introduce myself to all my patients and family members.
- Take time to tell them what to expect and keep them
- Answer lights promptly to meet a patient's needs and prevent
- Respect the patient's privacy and modesty - close curtains,
cover patient, reduce traffic in patient's room during
- Explain all procedures, test, medications and monitoring
equipment, etc to each patient and discuss plan of care for the
day/shift with patient and family.
- Be compassionate and empathetic to their concerns at all
times.?The intent of this agreement is not to provide a complete
list of job responsibilities. Its intent rather is to be a positive
statement of concrete actions which will ensure that nursing
practice at Saint Louis University Hospital sets the benchmark for
excellence in service, quality, and people. As a member of the
nursing staff at Saint Louis University Hospital, I understand that
on behalf of my hospital, our patients and my co-workers I will
conduct myself according to this agreement at all times. Staff
Signature __________________________________________ Print Name
_________________________________________ Print Name
Keywords: SSM Health, St. Louis , RN Surgical and Stepdown, Healthcare , Saint Louis, Missouri
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