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GENERAL DESCRIPTION

Accountable for providing professional nursing care to patients within a hospital unit, adhering to hospital policies and nursing services principles, policies, and procedures to ensure high-quality care practiced. 

JOB DESCRIPTION

ORGANIZATION AND MANAGEMENT 

1.      Adherence to nursing care vision, mission, goals and objectives, aligns with the scope of nursing services, and performs shift duties as assigned by the Unit Manager to ensure high quality care rendered.  

2.      Notifies the unit manager of any changes in the situation that could impact the standards of care. 

3.      Providing high-quality care to patients in urgent situations, managing ambulance transfers, ensuring patient safety, and ensuring continuity of care during transitions to and from healthcare facilities. 

4.      Conduct patient triaging by performing detailed examinations, documenting abnormalities, informing the attending physician, and prioritizing care based on patient history to ensure prompt and effective treatment. 

5.      Identifying and collaborating with doctors and team members to manage life-threatening conditions and effectively communicating with relevant professionals to ensure optimal patient care. 

6.      Performing phlebotomy and intravenous infusions for patients, administering medications, dressing changes, and assisting with simple surgical procedures as directed by medical officers or consultants, ensuring patient safety.  

7.      Assist with patient admission and discharge procedures, scheduling specialist clinic appointments, handling death cases with respect, and ensuring safe transfer to the mortuary. 

8.      Obtains and handovers a report of patient progress, ensuring all doctor's orders are followed before changing or over taking shifts and notifying any incidents or problems encountered. 

9.      Visit patients in the unit with team members to assess conditions, re-plan nursing care, and determine nursing priorities based on patient needs and staff availability. 

10.   Provides personalized, holistic patient care using the nursing process approach, maintaining accurate documentation in patient folders, and promptly reporting any abnormal findings to relevant doctors or consultants. 

11.   Providing emotional support and accompanying doctors while doing rounds, as well as assisting in procedures as needed. 

12.   Executing the doctor's orders, coordinating with team members related to patients’ treatment, and fostering effective communication with all disciplines, patients, and relatives to ensure patient satisfaction. 

13.   Actively participates in the health education of patients and their families in the ward as well as unit meetings, dialogue sessions, and hospital activities. 

14.   Provide clear, compassionate, and culturally sensitive communication with patients, ensuring their understanding of their condition, treatment options, and care plan in a comprehensive manner. 

15.   Collaborate with the unit manager in administration, setting care standards, and fulfilling duties in the absence of the unit manager, while also carrying out assigned tasks and providing feedback. 

16.   Charge accurately, incorporating charges for equipment and consumable items into the patient's charges and verifying their completeness. 

17.   Inspect and document the supply of sterile packs to ensure the integrity of the packaging and maintain an adequate supply of unit stock from CSSS. 

HUMAN RESOURCE AND DEVELOPMENT 

1.      Accountable for personal and professional growth keeps up to date with professional change by maintaining mandatory learning hours. 

2.      Executes continuous professional development through annual competency evaluations and privileges every 3 years and is proficient in performing cannulations and medication calculations. 

3.      Participates and contributes to the teaching program of the unit / ward and orientation of new members of staff to the ward routine. 

4.      Engage in the supervision of staff, which includes: 

·       Assistant Nurses, Midwives, and Care Assistants and student nurses assigned to the unit for their clinical experience to achieve the clinical attachment objectives.  

5.      Collaborates with the unit manager to evaluate staff performance, provide constructive feedback, and optimize staff, supply, and service utilization for efficient resource allocation and coordination with consultants for effective bed management. 

6.      Participate and contribute to the development and maintenance of the nursing process, ensuring effective patient care and documentation. 

7.      Participates in research initiatives and advocates for quality improvement through evidence-based practice. 

POLICIES AND PROCEDURES 

1.      Participates in the review and revision of nursing policies, procedures, and work instructions, providing valuable insights, promoting best practices for optimal patient care, and continuously improving the process.  

2.      Inspect the DDA drugs with the previous shift's nurse in charge and adhere to hospital policies and procedures in medication care, custody, and administration. 

3.      Checks daily and audits resuscitation trolley periodically as scheduled. 

4.      Promotes infection prevention and control by ensuring staff follow protocols, implementing surveillance activities, and demonstrating commitment through personal involvement. 

5.      Maintain confidentiality of patient’s personal and medical history 

FACILITIES AND EQUIPMENT 

1.      Operates and maintains specialized equipment in a unit, guiding new staff on the use of it and maintaining accurate records. 

2.      Collaborate with the unit manager to maintain equipment, medical supplies, consumable items, and drugs, ensuring proper functioning, service according to the PPM schedule, and adequate stock and linen supply.  

3.      Notify biomedical personnel of faulty equipment and assist in maintaining instruments and equipment through proper cleaning, handling, disinfection, and usage. 

4.      Participate in a quarterly stock count with the finance staff. 

SAFETY AND QUALITY IMPROVEMENT ACTIVITIES 

1.      Participate in and support activities aimed at the continuous improvement of nursing services, including quality assurance, infection control, and fire and safety programs. 

2.      Conduct thorough investigations, root cause analyses, appropriate response actions, and timely completion of incident reports within the stipulated timeframe. 

3.      Collaborate with unit manager to collect and evaluate clinical and administrative data, participate in hospital-wide surveys like MSQH, JCI, IMS and etc. for continuous quality improvement efforts. 

4.      Participate and contribute to the Baby Friendly Hospital Initiative certification, with a focus on promoting exclusive breastfeeding. 

5.      Adhere to the Occupational Safety and Health Act and Regulations 1994, which mandate reasonable work care, employer cooperation, protective equipment use, patient safety goals, World Alliance recommendations, patient and family rights policies, standard people practice, 5S activities. 

JOB REQUIREMENT

Education: 

• Registered with Nursing Board of Malaysia with a valid license to practice as a Registered Nurse. 

Skills & Competencies: 

• Possess certifications in BLS, ACLS, and ATLS

Special skills are required. 

• Proficient in writing and conversing in English and Bahasa Malaysia. 

• Microsoft office literacy 

Personal attributes  

• Have interpersonal and communication skills. 

• Critical thinking and problem-solving skills 

• Caring, honest, and responsible workers 

• Willingness to work on schedule hours, shift and weekends, public holidays and anytime called during an emergency. 

• Passionate and commitment to patient centered care and continuous quality improvement. 

• High integrity, patience, and high attention to details.