·Clinical Knowledge and Practice
Maintains professional knowledge and clinical ability sufficient to provide evaluation and treatment of complex patients in one or more specialty areas. Interprets relevant clinical data and is an active participant on the medical decision making care team. Ensures comprehensive and complex healthcare needs (medical, psychosocial and economic), are continually monitored and addressed. Monitors and routinely updates the patient's status on the national registry waiting list. Remains current on clinical policy, guidelines and regulatory changes. Maintains current knowledge of transplant center outcomes and performance standards.
·Family Centered Care
Advocates for the patient and family as they navigate through the complex healthcare setting by providing resources and coordinating care. Empowers patient and family to actively participate in family centered rounds and medical decision making. Empowers the patient and family to problem solve and become independent in managing care for the transplant patient in the home setting. Develops a plan in conjunction with the multidisciplinary team to prepare and support the adolescent transplant patient in self-management of their chronic illness. Facilitates/coordinates the process of transfer of care to an adult transplant center.
Provides individualized patient/family education throughout all phases of care and provides an ongoing assessment of the effectiveness of education provided. Plans, conducts, and evaluates educational materials and activities provided for patients and families in response to educational needs. Educates candidate/family about the evaluation process, regulations, allocation, pre transplant listing phase, transplant process, donor/recipient confidentiality, post-operative transplant care, symptoms and surveillance of infection and rejection, risk and benefit of immunizations, potential financial issues and candidate/family responsibility throughout the transplant process. Assesses candidate and family educational deficits of transplant process. Reinforces education and follow up requirements needed for successful outcome.
Maintains thorough, accurate, and timely electronic documentation of all patient encounters to ensure safe transitions between all transplant specific phases of care. Communicates effectively with patients, family and multidisciplinary team members, as well as referring and primary care provider and consultants regarding patient clinical findings and plan of care within a timely manner. Maintains/ensures communication with patient, referring physician, payors or other health care providers throughout the transplant process. Collaborates with nursing staff, social work and other health care providers to establish and implement patient care plan according to current standards of care.
Participate in, contribute to and promote continuing education around transplant and care of the transplant patient. Participates in improvement initiatives and projects within the institution. Serves as a resource to internal and external organizations to provide specific education appropriate to the needs of transplant professionals. Maintains current knowledge of and complies with institutional policies and procedures. Demonstrates knowledge/understanding of current regulatory oversight requirements for transplant centers including active participation in ongoing survey readiness and site visit process. Maintains current knowledge of transplant center outcomes and performance standards. Maintains knowledge of regulatory requirements for the transplant center and ensures required documentation is completed. Maintains knowledge of guidelines and standards and acts as a resource for internal and external health care providers.
·Transplant Referral and Evaluation
Facilitates/coordinates evaluation and listing of potential transplant candidate. Identifies requirements and provides oversight of the candidate evaluation process. Interprets serological results and their implications for transplant. Gathers and communicates serological results and blood type in accordance with regulatory requirements. Identifies possible co-morbidities and absolute and relative contraindications for potential transplant recipients. Functions as candidate advocate by applying knowledge of growth, development, educational and cultural background during candidate/family interactions. Collects and evaluates medical, psychosocial and financial data for review by transplant team. Communicates with referring physician, other care providers, payors and transplant team members regarding the candidate status and evaluation outcome. Provides data to regulatory bodies for listing statistics.
Monitor and coordinate care of the candidate awaiting transplantation. Ensures monitoring per transplant center specific standards. Identifies and responds to the psychosocial and economic needs of the transplant candidate during the pre-transplant period. Exhibits ability to maintain and update candidate listing status per regulatory regulations. Identifies the need for candidate re-evaluation and initiates process when appropriate. Acts as a resource for internal and external health care providers.
·Peri Operative Period
Participates in transplant process according to specific standards. Shares pertinent information about the intended recipient including ABO compatibility with the transplant team. Facilitates admission or transfer of patient to the transplant facility. Notifies transplant team of pending medical and/or surgical procedure. Remove transplant recipient from list according to regulatory guidelines. Provides outcome specifics to regulatory bodies for donor family follow up.
Demonstrates understanding of post-transplant management including medications, complications, interventions and discharge planning. Coordinate the care of the transplant recipient in the outpatient setting to achieve optimal physical, social and emotional rehabilitation. Identifies complications and considers interventions with the transplant team. Coordinates/ensures discharge planning to provide for continuity of care. Assess recipient's compliance with medication and medical regimen and collaborates with transplant team to attain and maintain compliance. Collects and reviews data pertinent to recipient health (and if applicable the organ function) with transplant physician. Communicates adjustments in patient plan of care and drug transplant therapy as ordered by medical providers. Arranges for consults, diagnostic testing, and hospitalization when indicated. Coordinates emergent evaluation of transplant recipient when indicated. Assists in the reporting required data to regulatory bodies.
·Communication - Advanced
Effective verbal and interpersonal communication skills.
Demonstrates professional skills in the assessment, planning, execution and evaluation of treatment plans for the transplant patient.
Facilitates/coordinates evaluation and listing for potential candidates.
Exhibits knowledge and ability to facilitate the transplant process at the time of transplant. Understands post-transplant management, including medications, complications, interventions and discharge planning. Knowledge of regulatory policies and listing requirements.
Work well as a member of an interdisciplinary team.
Relates to diverse age and demographic backgrounds.
·Patient Growth and Development
Professional knowledge of the growth and development process of pediatric and adult patients and clients.
Competency in basic nursing practices and skills.
Adapts to stressful or crisis situations; identifying strengths and weaknesses and seeking appropriate resources.
Possesses interest and willingness to broaden knowledge and skills in nursing practice.
Demonstrates enthusiasm in providing family-centered care.
Capable of bending, lifting and standing; demonstrates physical ability to perform necessary tasks.