Graduate of an accredited nursing school. Must possess a current license to practice nursing in the state of practice. Minimum of one (1) year of experience in general nursing practice, hospice experience and/or palliative, end of life care preferred. Should have good communication skills, ability to work well with others, function well under pressure, and function independently. Must comply with the standards outlined in the Nurse Practice Act.
REPORT TO: Patient Care Manager/Branch Manager
Knowledge and Competency:
Must demonstrate basic knowledge of all procedures included in the Registered Nurse description. Must have the ability to follow instructions from the physician, nursing supervisor and other professional staff. Ability to communicate effectively with managers, patients, families and co-workers. Must be able to assess safety of home situations for self, patients, and other staff members, including physical and psychological dangers. Must have the ability to effectively cope with patients, families and all others with varying backgrounds, socioeconomic conditions, and value judgments.
Maintains confidentiality of information relating to the patient and family. Will discuss only those aspects necessary to the care and treatment of patient and family with those directly involved in the patient’s care.
JOB RESPONSIBILITIES (includes but not limited to the following):
- Provides skilled nursing services in accordance with the orders of a physician and under a plan of care in a patient’s home. Has the responsibility for the observation, assessment, nursing diagnosis, counsel, care and health teaching of the hospice patient and family.
- Performs, completes and documents initial and ongoing assessment of the impact of the terminal diagnosis on the patient’s physical, functional, psychosocial and environmental needs and activities of daily living including:
- Risk for pathological grief
- Cultural and spiritual implications
- Verbal and non-verbal communication patterns
- Initiates IDT Plan of Care with consultation from the basic IDT members, attending physician and medical director. Reviews and revises the plan as necessary.
- Determines the scope and frequency of services needed based on acuity and patient/family needs.
- Applies specific criteria for admission and re-certification to hospice care to establish appropriate levels of care and the patient’s eligibility.
- Assesses the ability of the caregiver to meet the patient’s immediate needs upon admission and throughout care. Shall evaluate and document the appropriateness and ability of the patient or family member’s administration of medications.
- Completes all required consent, election and notification paperwork.
- Evaluates the effects of the care given and regularly reevaluates the patient’s nursing needs.
- Provides those services requiring substantial specialized nursing skill based on the physician’s orders and the nursing diagnosis related to palliative and end-of-life care. Examples of such services include, but are not limited to; appropriate preventive and rehabilitative nursing procedures, physical assessment, managing discomfort and providing symptom relief, patient and family teaching, urinary catheter insertion and care, venipuncture and administration of IV fluids or medications, sterile and nonsterile dressing changes.
- Counsels the patient and his/her family regarding the disease process including self-care techniques, end-of-life care and the processes for dealing with issues of ethical concern.
- Dietary counseling, when identified in the plan of care.
- Reviews medication use with the patient and/or family and provides medication information, counseling and education when appropriate.
- Uses the case management approach and acts as the coordinator of the interdisciplinary team in order to maintain the proper linkages with a continuum of care.
- When a patient is a facility resident, will coordinate the implementation of the plan of care with the facility and will respond to questions and concerns from the nursing facility.
- Informs the attending physician, medical director and other personnel of changes in the patient’s needs and outcomes of intervention.
- Makes referrals to other agencies or services as needed.
- Prepares clinical and progress notes on the relevant and specialized nursing services he/she provides.
- Submits documentation per agency policy.
- Participates in Clinical Record Reviews.
- Participates in in-service programs and staff meetings including provision of specialized hospice training to other staff, family members and informal caregivers to insure adequate care.
- Directs the activities of the licensed practical nurse.
- Shall make at least monthly on-site visits to assess that the licensed practical nurse is routinely providing nursing services in accordance with the plan of care and documents this visit and assessment.
- Shall participate in being available to the licensed practical nurse at least by phone during the hours that the licensed practical nurse is providing services or is on call.
- Shall develop a written aide assignment based upon the patient’s/family’s needs when home health aide services are provided.
- Shall visit the home at least every two weeks, when aide services are provided. The visit shall include an assessment of the aide services and relationship issues. Documents to show that the aide is providing services in accordance with the plan of care and/or makes revision to the aides plan of care as needed. When an aide is permanently assigned to a hospice facility as opposed to a specific hospice patient, the every two week supervisory requirement does not apply.
- Evaluates own needs for support and using identified system(s) to meet the need.
- Other duties as assigned by management.Physical Demands: Must be able to complete all physical demands of the job, which may include, but not be limited to: the ability to lift and transfer patients, carry supplies, and read normal typewritten print. Have corrected vision and hearing within normal range and have manual dexterity with normal range of motion of all extremities. May be requested to work weekends, holidays, and occasional overtime. Must be able to work alone without usual support systems immediately available in acute care settings. Must have the ability to deal with abrupt schedule changes and to maintain objectivity in coping with the stress of working with acute, chronic and terminally ill patients.