Assesses comprehensive data including but not limited to physical, psychosocial, emotional, cognitive, and spiritual needs and interprets assessment information to derive the diagnosis or issues as defined by the patient’s condition. Uses evidence-based assessment techniques and instruments in collecting data and validates the diagnosis or issue with the patient, family and healthcare team members as appropriate. Prioritizes the data and information collected based on patient’s immediate condition or anticipated needs and identifies potential risks or barriers to the patient’s health or safety. Documents the data and information collected in compliance with established guidelines and reflective of the needs of the patient.

Involves patient, family and healthcare team members in formulating a culturally appropriate individualized plan of care and identifies expected outcomes based on nursing assessment and diagnosis. Applies evidence-based nursing practices in developing the individualized plan of care to attain expected outcomes and continuity of care. Modifies the individualized plan of care according to the ongoing assessment and reevaluation of the patient’s response, status, and outcome indicators. Documents the expected outcomes as measurable goals and the plan in a manner that uses standardized language or recognized terminology

Implements the plan of care in partnership with the patient, family and healthcare team members in a timely manner utilizing evidence-based interventions and treatments specific to the needs of the patient. Prioritizes interventions based on patient’s condition, preferences, situation, or anticipated needs and performs clinical treatments and procedures according to established procedural guidelines and protocols. Demonstrates compassionate behaviors of acceptance, caring and empathy for the patient and family. .Ensures that all components of the individualized plan of care, including modifications, are documented in the patient health record. Communicates relevant information through hand offs across levels of care and organizations.

Utilizes teaching strategies appropriate to the individual patient’s condition and learning needs. Uses health promotion to support patients and families in developing skills that promote, maintain, or restore healthy lifestyles and self-management support. Maintains a safe, clean, and organized environment for the patient, families and staff. Seeks opportunities for feedback and evaluation of the effectiveness of the strategies used, including teach back.

Evaluates the patient/family’s understanding of and response to the plan of care. Utilizes systematic and ongoing assessment data to revise nursing diagnoses, outcomes, and the plan of care. Involves the patient, family and healthcare team members in the evaluation process. Documents the reassessment of patient status; patient and family participation and understanding; and the rationale for any revision in the plan of care.

Maintains a professional and therapeutic nurse-patient relationship and serves as a patient advocate assisting patients and families in developing skills for self-advocacy. Listens to patient care concerns and practice issues and communicates information to appropriate healthcare team members and documents in a timely manner. Speaks up to question healthcare practices as appropriate for safety and quality improvement. Utilizes available resources to help formulate ethical decisions. Discloses any observed illegal or incompetent practices and decisions made by potentially impaired health care staff per organizational policy.

Utilizes current evidence-based nursing knowledge, including research findings, to guide and evaluate practice. Participates in evidence-based and research activities at various levels appropriate to the nurse’s level of education and position. Shares evidence-based and research findings with healthcare team members.

Demonstrates a commitment to continuous learning and education for self and others and mentors healthcare team members for the advancement of nursing practices, the profession, and quality healthcare. Functions as a professional role model promoting a positive, team-based, organized, and safe work environment. Coordinates and supervises delegated activities to assure completion and serve as a resource for other healthcare team members. Demonstrates critical thinking in priority setting and decision making in response to patient needs. Pursues informal and formal leadership opportunities. Participates actively in organizational shared decision making situations that improve the nursing practice, organizational performance, and outcomes. Assumes overall responsibility for managing all aspects of the nursing process and coordinating nursing care.

Utilizes current resources related to standards of care, policies and procedures, and patient needs. Navigates and utilizes electronic resources for information retrieval, communication, and documentation. Evaluates factors related to patient safety, effectiveness, availability, and cost when determining practice options. Responds to workload changes and patient needs effectively. Promotes a practice environment that reduces environmental health risks for staff. Assesses the practice environment for factors such as sound, odor, noise, and light that threaten health/safety. Advocates for the judicious and evidence-based use of products in health care. Communicates environmental health risks and exposure reduction strategies to healthcare consumers, families, colleagues, and communities. Evidence of competencies specific to area of practice are up to date.