JOB TITLE: REGISTERED NURSE

JOB CODE: 30420

DEFINITION: This is professional nursing work at a Commonwealth facility. An employee in this class performs as a charge nurse, staff nurse or an assessment coordinator providing nursing care and treatment services in a Commonwealth facility for individuals with a mental or physical injury or illness, dysfunctional behavior and/or a developmental disability. As charge nurse, the employee directs and coordinates the delivery of nursing care and treatment for individuals in patient or resident care and treatment area(s), ward(s), unit(s) or living area(s), usually on the evening or night shift. Charge nurses make assessments and decisions in regard to staff utilization and supplies and equipment needs. Charge nurse supervises paraprofessional and/or non-professional nursing direct care personnel assigned to their patient or resident care and treatment area(s), ward(s), unit(s) or living area(s); and ensures that the coordination of services, coverage of services, and maintenance of records is accomplished. The assessment coordinator develops, implements, and evaluates individualized nursing care and treatment plans for residents of a Commonwealth Veterans Home facility; directs, evaluates, and coordinates the delivery of nursing care and treatment with members of the nursing staff and interdisciplinary teams; meets with family and residents to assess residents' condition and completes documentation as required by federal and state regulations. The staff nurse is responsible for providing professional nursing care and treatment services in a patient or resident care area or in a medical clinic in the Youth Development Center (YDC) system, a State Correctional Institution, at Thaddeus Stevens College of Technology or Scotland School for Veterans Children; or may be responsible for a nursing specialty care area, such as, infection control or quality assurance/improvement/risk management activities. Work assignments are received in the form of oral or written instructions and employees exercise independent judgment in the application of professional nursing practices. Work is reviewed and evaluated by a Registered Nurse Supervisor, physician or dentist through observation, review of reports and conferences for quality and adherence to established standards in the application of professional nursing practices. Work may be administratively reviewed by another professional supervisor. EXAMPLES OF WORK:

• Assesses individuals' physical, psychosocial and/or mental health status.

• Determines immediate and long-range nursing care and treatment plans, goals, staff utilization, supply and equipment needs.

• Assigns and directs the work efforts of assigned paraprofessional and non-professional nursing direct care personnel.

• Coordinates services, coverage of services and maintenance of records.

• Administers prescribed medications and treatments and takes physician's orders.

• Monitors nursing care through observation and review of charts, records, and reports.

• Updates nursing care charts, records, and reports.

• Develops, recommends, and directs changes in the administration of nursing care and treatment methods and plans.

• Reviews, monitors, reports, and develops corrective action plans for nursing department procedures and nursing staff performance in a nursing specialty care area.

• Provides and/or assists with the provision of complete nursing care and treatment in a medical clinic.

• Assists a clinic physician with scheduling and conducting physical examinations.

• Assists a clinic physician with providing emergency health care coordination services for individuals and/or for facility employees.

• Compiles, reviews, monitors, and interprets nursing database.

• Evaluates nursing care and treatment plans.

• Observes, interprets, records and reports symptoms, vital signs and the effects of pharmacological agents and therapeutic treatments to shift supervisor.

• Provides guidance to paraprofessional and non-professional nursing direct care staff in implementing, reviewing, and modifying nursing care plans.

• Coordinates nursing infection control and quality assurance/improvement/risk management procedures and pre-discharge planning efforts.

• Directs the delivery of Individual Habilitation Programs (IHP), training and habilitation services.

• Integrates the various aspects of the comprehensive IHP.

• Records individual's progress in meeting IHP program objectives.

• Initiates periodic reviews of each individual's IHP plan of care.

• Provides nursing expertise to the Interdisciplinary Treatment Team.

• Participates in developing, implementing, evaluating, and modifying comprehensive individualized care and treatment plans.

• Plans and coordinates the activities of the assigned nursing care staff and the resources of other disciplines as part of the Interdisciplinary Treatment Team.

• Organizes and conducts, or co-conducts, with other professional disciplines, various treatment modalities.

• Positions, moves, and/or lifts non-ambulatory individuals with assistance, as needed, to assist them with daily living and physical treatment activities.

• Develops and maintains a therapeutic milieu and a safe and sanitary environment.

• Develops and provides training, guidance, and counseling to patient's families on health promotion and maintenance.

• Participates in nursing and facility committee activities.

• Identifies nursing direct care staffs' learning needs

• Makes staff development and training recommendations.

• Orients new employees to the policies and procedures, rules and regulations of the nursing department and the health care facility.

• Provides on-the-job training for paraprofessional and non-professional nursing care personnel.

• Participates in staff development programs to further enhance professional nursing skills.

• Prepares probationary, interim, and annual performance evaluations on paraprofessional and non-professional nursing staff.

• Participates in counseling and the disciplinary process for paraprofessional and non-professional nursing staff.

• Prepares and submits records and reports as required in accordance with rules, regulations, and operating practices.

• Reviews pre-entrance physicals and documents medical concerns and needs of students for provision of appropriate services.

• Communicates to faculty and staff special medical needs or restrictions of students who have supplied written permission for treatment.

• Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of the theories, practices, and methodologies of professional nursing.

• Knowledge of the principles and practices involved in organizing and directing the work of others in providing nursing care and treatment.

• Knowledge of therapeutic and adverse effects of pharmacological agents and medical treatments.

• Knowledge of the human anatomy and physiology.

• Knowledge of hospital dietetics and personal hygiene.

• Knowledge of the principles and methodologies of quality nursing practices.

• Ability to apply professional nursing practices, techniques, methodologies, and standards.

• Ability to direct, instruct, guide, and lead paraprofessional and non- professional nursing direct care staff.

• Ability to develop and implement a comprehensive nursing care and treatment plan in accordance with the prescribed medical, psychiatric and/or psychosocial regimen.

• Ability to promote and maintain continuity of care and treatment within a medica clinic, or in a patient care area(s), ward(s), unit(s) and/or living area(s).

• Ability to make independent judgments in relation to the nursing care of individuals and in resolving life threatening health problems.

• Ability to plan and assess immediate and long-term nursing care goals and objectives for individuals in patient care area(s), ward(s), and/or living area(s).

• Ability to insure that staffing levels are proper for the nursing care and treatment needs of the individuals.

• Ability to plan and coordinate activities of the nursing direct care staff with resources of other disciplines.

• Ability to assess training, educational and staff development needs of nursing care staff and staff development programs.

• Ability to provide guidance and on-the-job training and recommend additional training or continuing education.

• Ability to establish and maintain effective communications with individuals, their family members, and other members of the health care system.

• Ability to position, move, lift and/or transfer non-ambulatory with assistance, as needed.

• Ability to identify actual or potential health and safety hazards.

• Ability to evaluate patterns and trends in the nursing care and health care system.

• Ability to administer prescribed medications and treatment.

• Ability to observe, interpret, document, and report individual's symptoms, vital signs, and reactions/responses.

• Ability to demonstrate competence in specialty nursing care and treatment areas, as appropriate.

• Ability to apply professional nursing concepts, techniques, and procedures to the care and treatment of individuals.

• Ability to develop and maintain effective working relationships with employees of the health care facility.

• Ability to prepare and maintain records and reports.

• Ability to participate in staff development, in-service and out-service training and/or continuing education courses.

• Ability to express ideas clearly and concisely, both orally and in writing.

SPECIAL REQUIREMENTS:

• All positions require active authorization to practice as a Registered Nurse in Pennsylvania.

• All employees possessing an active temporary practice permit must obtain licensure as a Registered Nurse within the one (1) year period defined by the Pennsylvania State Board of Nursing.