Employment

Job Summary

The incumbent performs nursing procedures for patients of all ages independently within the framework of established policy within the behavioral health 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.

Job Description

• Utilizes best practice models to identify, incorporate or develop best practices for behavioral health including psychiatry medication management, buprenorphine clinic and pain clinic. Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies.
• Manages panel by addressing and resolving acute care needs and chronic care needs through a team based approach.
• Incumbent will be responsible assisting the psychiatry and buprenorphine, and other medical providers in management of patients that results in meeting facility, national, and regulatory quality indicators.
• 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 behavioral health provider timely.
• Participates in the continued development of the role of case management in the behavioral health setting.
• Provides standard nursing care for patients throughout the age continuum.
• Develops implements and evaluates care plans.
• 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 care.
• Screen for psychiatry medication management visits with vitals and standard measures, such as PHQ 9 when appropriate.
• Respond to phone calls regarding medication questions and refill requests.  Send orders to physician when appropriate and contact the physician when any questions or concerns.
• Contact patients for same day drug screens and pill counts when necessary.
• Assist psychiatric provider in ensuring there is appropriate management of psychotropic medications including, but not limited to, metabolic monitoring, aims testing, and therapeutic lab levels.
• Supervise same day medication administration of buprenorphine and methadone per CIHA policies and procedures.
• Work to ensure effective utilization of psychiatric 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 CIHA performance appraisal system.
• Performs ongoing 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 client.
• 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 outpatient administrator; 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, 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.”
• May be subject to on-call and callback.
• May be required to rotate between nursing departments including inpatient, satellite clinics, and the emergency department. Participates in cross training of services within the nursing department.
• Performs nursing interventions including, but not limited to:

• Detects changes in the patient’s condition and takes appropriate action.
• Recognizes, identifies and interprets serious situations and immediately decides proper action.
• Initiates appropriate resuscitative measures in an emergency situation.
• Initiates appropriate action when safety measures are required to protect patients.
• 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.
• 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.
• Assures that all medications, treatments and tests are done appropriately and in a timely manner, detects, and reports medication errors.
• 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.
• Provides guidance, leadership, and training to other nursing personnel and behavioral health support staff.
• Coordinates health care needs through referrals to support services, community, and tribal resources to promote continuity of care.
• 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.
• Participates in the development and implementation of performance improvement activities. Identifies and reports risk management issues.
• Assumes responsibility for the adequacy and appropriateness of supplies and ensures proper functioning of all medical equipment. Maintains cleanliness and orderliness of work areas.
• 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

• Associates degree in nursing from an accredited program required.

• Bachelor’s degree in nursing from an accredited program preferred.
• Two years of 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 hire for nursing staff primarily assigned to Kanvwotiyi.
• Must have a valid North Carolina driver’s license.