Behavioral Health RN - Inpatient - PTI

Job Title:         Analenisgi Inpatient Registered Nurse

Job Code:         RN AI

Department:         Analenisgi Inpatient

Division:          Nursing

Salary Level:          NE13

Reports to:          Behavioral Health Nurse Manager

Last Revised:         September 2021

Job Summary  

The incumbent performs nursing procedures for patients of all ages independently within the framework of established policy within the Analenisgi Inpatient Department. The Registered Nurse is a licensed professional nurse responsible for assessment of patients, development, implementation and evaluation of a patient plan of care; administration of therapeutic measures; teaching and counseling of patients and families; and participating in the development of nursing policies and procedures and quality assurance standards. The Registered Nurse is responsible for the delivery of comprehensive health care to patients of all ages, utilizing standards of care and practice, policies, protocols, and procedures. The purpose of the work is to perform the full range of the nursing process from assessment to evaluation. The work affects the physical and psychosocial well-being of the patients and their families.  

Essential Duties and Responsibilities  

•    Utilizes best practice models to identify, incorporate or develop best practices for behavioral health including psychiatry medication management and medication-assisted treatment with buprenorphine and methadone. Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies. 

•    Manages assignments by addressing and resolving acute care needs and chronic care needs through a team based approach.  

•    Incumbent will be responsible assisting the psychiatry and medication-assisted treatment medical providers in management of patients that results in meeting facility, national, and regulatory quality indicators within the Analenisgi Inpatient unit.

•    Coordinates and follows up on patients placed in outside behavioral health settings, (inpatient psychiatric hospitals, residential treatment centers, etc.) Emphasis is placed on ensuring treatment notes are available to the appropriate behavioral health and medical providers in timely manner.  

•    Provides standard nursing care for patients throughout the age continuum.  

•    Develops, implements and evaluates care plans when in the appropriate setting. 

•    Promotes health care outcomes with currently accepted clinical practice guidelines.  

•    Provides patient education, advice, and information on health assessment, disease processes, medications, treatment plans and available community resources.  

•    Assesses patient needs using established clinical guidelines, protocols, and pathways.  

•    Provides appropriate follow up as directed or per established guidelines.  

•    Provides nursing care in accordance with established nursing care standards, participates in routine and specialty clinics, curative, rehabilitative, and preventive nursing care. On rare occasions may be required to participate in emergency medical care or psychiatric crisis.  

•    Complete appropriate screening upon admission to the Analenisgi Inpatient unit or when appropriate that include but are not limited to screenings regarding tobacco product use, Alcohol consumption, domestic violence, illicit substance use, suicidality, and the PHQ-9 when appropriate.

•    Responds to patient questions about medication adjustments.  Coordinates with the Analenisgi Inpatient medical provider when appropriate for medication requests or needed provider orders and contacts the medical provider when any questions or concerns. . 

•    Assist medical provider in ensuring there is appropriate management of psychotropic medications including, but not limited to, metabolic monitoring, AIMS testing, and therapeutic lab levels. 

•    Supervise and facilitate same day medication administration of buprenorphine and methadone on the Analenisgi Inpatient unit per facility policy. 

•    Coordinate with medication-assisted treatment and psychiatry nursing staff for patient discharge plans and to coordinate follow-up care.

•    Provide appropriate patient education such as but not limited to the use of naloxone rescue kits and other harm reduction based practices and answer patient questions as necessary.

•    Work to ensure effective utilization of behavioral health resources through efficient scheduling and patient management practices. 

•    The incumbent will be evaluated annually on his/her ability to identify, assess, analyze, and evaluate data and solve problems through the CIH Performance Appraisal System.  

•    Performs ongoing nursing assessment by actively participating in the determination of meeting the nursing care needs based upon collection and interpretation of data relevant to the health status of the patient.  

•    Collects data from relevant sources (patient, family, or caregiver) regarding the biological, psychological, social and cultural factors that might influence and impact the health status of the individual.  

•    Collects data through observations of appearance and behavior, measurements of physical structure and physiological function, and other information in an effort to place consultations and/or referrals to the correct internal and external resources (Nutrition, Tsali Manor, etc.).  

•    Interprets data, recognizes existing relationships between data collected and the client’s health status and treatment regimen, and determines the client’s need for immediate nursing interventions.  

•    Reviews the patient’s health records and health summary, interviewing patients and family members, documenting the chief complaints, medical history, physical and clinical findings, identifying learning needs of the patient and family, and determining priority of care required. Assessment for health prevention, health promotion, restorative, and health maintenance needs is emphasized.  

•    The nurse will plan patient care according to individual assessed patient needs and established hospital policies and procedures.  

•    Functions as charge nurse when assigned by the Behavioral Health Nurse Manager or designee; assigns nursing staff according to staff competency and patient complexity and provides technical supervision for staff members, including reviewing procedures; anticipates problems and acts to resolve problems.  

•    Develops individualized plan of care with input from the patient, patient’s family, therapists, targeted case managers, and anyone else the patient requests to be included for those patients considered “high risk.” 

•    Initiates individualized plan of care based on assessment of the patient for specific illnesses, injuries, and diseases and human behavior while adhering to appropriate standards of care.  

•    Develops expected patient outcomes that are observable and within an adequate time frame, and are congruent with the patient’s present and potential physical capabilities and behavioral patterns. 

•    Implements nursing care according to the established health care plan.  

•    May be required to change work schedule to assist in covering for periodic “late clinics” or early morning supervised medication administration of buprenorphine and methadone. This may also include coverage for weekend supervised medication administration dosing times. May be subject to on-call and callback.  

•    May be required to rotate between nursing departments including Inpatient, Analenisgi Inpatient, Kanvwotiyi Residential Treatment Facility, Satellite Clinics, the Emergency Department, and other areas that require nursing coverage within the CIH healthcare system. Participates in cross training of services within the nursing department at the discretion of the Behavioral Health Nurse Manager.

•    Performs nursing interventions including, but not limited to:  

o    Detects changes in the patient’s condition and takes appropriate action.  

o    Recognizes, identifies and interprets serious situations and immediately decides proper action. 

o    Initiates appropriate resuscitative measures in an emergency situation.  

o    Initiates appropriate action when safety measures are required to protect patients.  

o    Documents observations, nursing interventions, patient progress, needs, treatments, diagnoses, possible side effects of treatment, teaching, patient response, effectiveness, complications and communicates information to the physician, co-workers and other health personnel.  

o    Administers and documents medications per manufacturer guidelines, hospital policy and established protocols and according to State Board of Nursing regulations. Documents all known drug allergies on the medical record and according to protocol.  

o    Assures that all medications, treatments and tests are done appropriately and in a timely manner, detects, and reports medication errors.  

o    Provides counseling, teaching, and anticipatory guidance to patients and families on preventive, curative and rehabilitation measures involved in health care. Documents all patient education activities within the patients/family’s level of understanding.  

o    Provides guidance, leadership, and training to other nursing personnel and behavioral health support staff.  

o    Coordinates health care needs through referrals to support services, community, and tribal resources to promote continuity of care.  

o    Maintains a safe environment through the practice of Universal Precautions and Body Substance Isolation, medical waste/chemical management and containment. Isolates infected patients. Cleans patient contact areas and equipment according to policies and OSHA regulations.  

o    Participates in the development and implementation of performance improvement activities. Identifies and reports risk management issues.  

o    Assumes responsibility for the adequacy and appropriateness of supplies and ensures proper functioning of all medical equipment. Maintains cleanliness and orderliness of work areas.  

o    Promotes patient advocacy and confidentiality.  

•    Serves on Committees as appointed.  

•    Maintains and promotes positive and constructive communications and activities within Nursing services, other departments, tribal, and community agencies for purposes of coordinating and understanding of goals and objectives relevant to the population served.  

•    Functions appropriately during disasters.  

•    Updates and maintains currency/competency in nursing practices and standards by attending training and in-services.  

•    Evaluates patient care provided.  

•    Directly observes and evaluates patient care.  

•    Revises nursing care to reflect changes in patient needs.  

•    Documents nursing care and patient progress according to hospital policy.  

•    Participates in ongoing nursing quality assurance program.  

•    May be necessary to work when Administrative leave is granted if patient care would be compromised.

•    Other duties as assigned. 

Education/Experience/Minimum Qualifications  

•    Associate’s Degree in nursing from an accredited program required.

•    Bachelor’s Degree in nursing from an accredited program preferred.  

•    Two years of behavioral health nursing experience preferred.  

•    Valid Registered Nurse license within the state of North Carolina.  

•    Current Basic Life Support (BLS) required.  

•    Must obtain Advanced Cardiac Life Support (ACLS) within 6 months of date of hire.

•    Must have a valid North Carolina driver’s license.  

•    Proficiency rated at 2 years for a new graduate to reach the journeyman’s level.  

Job Knowledge  

•    Knowledge of principles, practices, techniques, and theories of professional nursing in order to  plan and provide nursing care to meet the physical, emotional, spiritual, and socio-cultural needs  of patients of all ages; specifically, Infancy (Birth-1 year), Toddler and Early Childhood (2  years), Latency (6-9 years), Preadolescence (10-12 years), Early Adolescence (13-15 years),  Adolescence (16-20 years), Adult (21-64 years), and Elderly (65- years).  

•    Knowledge of the nursing process and its application to clinical practice.  

•    Knowledge of the biological aspects of the disease process and illness in order to recognize complications and therapeutic interventions required. 

•    Knowledge of medications and dosages in order to recognize desired effects, side effects, and complications of their use.  

•    Knowledge and ability to analyze the results of various medical procedures and translate into appropriate nursing interventions.  

•    Knowledge and ability to independently plan, manage, and organize work in order to meet priorities, accomplish work within established time frames and work in stressful situations.  

•    Knowledge of the occupational functions of multi-disciplinary health care team.  

•    Knowledge of the culture and medical health profile of the patient population.  

•    Knowledge and ability to teach and counsel patient/family on health maintenance and disease prevention.  

•    Knowledge of available health care programs and community resources.  

•    Knowledge of processes and procedures for establishing, revising, continually monitoring, and evaluating standards for the practice of nursing.  

•    Knowledge and skills in operating specialized medical equipment, such as, monitoring devises suction pumps, oxygen equipment, etc. 

•    Knowledge of problem oriented medical record methods.  

•    Knowledge of legal and ethical aspects of nursing.  

Complexity of Duties  

The RN role requires flexibility and the ability to lead team members who possess a variety of personalities. The RN role necessitates the incumbent to always maintain a high level of integrity, poise, and control. The nurse provides a full range of comprehensive nursing care that includes assessing patient needs, development of a plan of care, administration of medications and therapeutic measures, operation of specialized medical equipment, evaluation of the plan of care to ensure that the physical and psychosocial needs of the patient are met and counseling and teaching of patient and families. The nurse must recognize and respond appropriately to patient conditions that deviate from normal and identify, analyze, and report on causative factors and reactions. Guidelines consist of professional standards of practice as determined by the nurse practice act, nursing and medical policy and procedures, standing orders, and hospital and agency policies. Complies also with federal, state, accrediting and local regulations. These guidelines are not always specifically applicable to the individual patient or situation and independent judgment is required in selecting the most appropriate guideline, and applying the intent of the guideline to the specific situation at hand. The nurse receives assistance from the Nurse Manager with difficult or unusual problems.  

Supervision Received  

The nurse independently plans, schedules, and provides nursing care in coordination with the medical care plan and attempts to solve problems only within established procedures. This is done under the supervision of the Nurse Manager. The work is evaluated for technical soundness and adherence to professional standards.  

Responsibility for Accuracy  

The incumbent has a positive effect upon the recovery of the patient, is responsible for following policies and procedures, which serve as hospital guidelines, and prevents errors from occurring. Errors can have a negative patient outcome since the incumbent’s performance affects the health, recovery, and rehabilitation of patients, and the quality of care provided. Evaluations and observations are used to modify and develop clinically appropriate treatment plans. Work can be verified or checked by the immediate supervisor, other health care providers or systems checks but usually the responsibility for accuracy relies solely on the incumbent.  

Contact with Others  

Contacts are with patients, families, hospital personnel, and community agencies. Contacts with patients, families, and hospital personnel are to exchange, provide, and obtain information concerning the patient’s physical and psychosocial health care problems, and needs. The nurse uses teaching and counseling methods to influence and motivate patient and family behavior. Contacts with other health care or related disciplines within the hospital are for the purpose of collaboration and consultation. Tact, courtesy, and professional conduct are required to maintain positive working relationships. Utmost sensitivity and confidentiality is required when dealing with patients and families.  

Confidential Data  

The incumbent has access to highly confidential patient medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and all other pertinent information that comes to his/her attention or knowledge. The Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action.  

Mental/Visual/Physical Environment  

Work in the various services within the nursing department is mostly sedentary, yet requires walking, standing, bending, pushing, and lifting in helping patients to and from beds, wheelchairs, and stretchers. These same activities are required in moving equipment and medical supplies. Will be subject to frequent interruptions requiring varied responses, which can cause distractions therefore, the incumbent must possess the ability to differentiate and prioritize many tasks at once.  

Work Environment 

Must be flexible in working hours. Work is performed in the clinic setting, which is responsible for treating patients with a wide variety of medical problems. Incumbent may be exposed to communicable diseases. Incumbent is required to comply with Employee Health Program guidelines including current immunization status of identified communicable diseases and safety precautions are sometimes necessary, such as use of personal protective equipment as required by hospital policy. The work environment involves moderate risks of exposure to infectious disease, radiation, electrical hazards, irritant chemicals and explosive gases.  

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.