Job Description

GENERAL DESCRIPTION

Accountable for providing professional nursing care to patients within an assigned hospital unit, in accordance with hospital policies and procedures, as well as the established principles and practices of Nursing Services, to ensure the delivery of safe and high-quality patient care.

JOB DESCRIPTION

1. ORGANISATION AND MANAGEMENT

1. Provide nursing care in accordance with the organisation's Vision and Mission Statements, Goals and Objectives, within the scope of Nursing Services, and perform shift duties as assigned by the Unit Manager to ensure high-quality patient care.
2. Inform the Unit Manager of any changes in circumstances that may affect the standard of patient care.
3. Receive and provide patient handover reports, ensuring a clear understanding of patients' progress, completion of doctors' orders before the end of each shift, and communication of any incidents or problems encountered.
4. Conduct patient rounds with team members to assess patients' conditions, review and re-plan nursing care, and determine nursing priorities based on patient needs and staff availability.
5. Provide individualised and holistic nursing care using the Nursing Process approach, ensuring accurate and timely documentation in patients' medical records and promptly reporting abnormal findings to the relevant doctors or consultants.
6. Provide appropriate nursing care to infants and young children, while effectively communicating with and managing challenging situations involving patients and their families.
7. Conduct regular nursing rounds to identify patients' additional needs and provide emotional support. Accompany doctors during ward rounds and assist with medical procedures when required.
8. Carry out doctors' orders, coordinate patient care activities with team members, and maintain effective communication with all healthcare disciplines, patients and their relatives to achieve optimal patient satisfaction.
9. Actively participate in providing health education to patients and their families, as well as unit meetings, dialogue sessions and hospital activities.
10. Provide clear, compassionate and culturally sensitive communication to ensure patients and their families understand their medical conditions, treatment options and care plans.
11. Assist the Unit Manager in unit administration, establishing patient care standards and carrying out the Unit Manager's responsibilities in their absence, as directed. Perform assigned duties, provide feedback and coordinate with consultants on effective bed management.
12. Ensure all equipment and consumable items used are correctly charged to patients' accounts and verify that all charges are complete.
13. Inspect and document the supply of sterile packs received from Central Sterile Supply Services (CSSS), ensure packaging integrity and maintain adequate unit stock levels.

2. HUMAN RESOURCE AND DEVELOPMENT

1. Take responsibility for personal and professional development by keeping up to date with changes in nursing practices and fulfilling mandatory learning hours.
2. Participate in continuous professional development through annual competency assessments and professional privileges renewal every three years. Demonstrate competency in general calculations and medication calculations.
3. Participate in and contribute to the unit's teaching programmes and the orientation of new staff members to ward routines and procedures.
4. Supervise and guide the following personnel assigned to the unit:

• Fresh graduate Registered Nurses.
• Assistant Nurses.
• Midwives.
• Care Assistants.
• Student Nurses undertaking clinical attachments.

1. Ensure the above personnel receive appropriate guidance and supervision to achieve their clinical attachment and learning objectives.
2. Collaborate with the Unit Manager in evaluating staff performance, providing constructive feedback and optimising the utilisation of staff, supplies and services to ensure effective resource allocation and bed management.
3. Participate in the development and maintenance of the Nursing Process to ensure effective patient care and proper nursing documentation.
4. Participate in research initiatives and promote continuous quality improvement through evidence-based nursing practices.

3. POLICIES AND PROCEDURES

1. Participate in reviewing and revising nursing policies, procedures and work instructions to promote best practices, improve patient care and support continuous service improvement.
2. Check psychotropic drugs together with the Nurse in Charge from the previous shift and ensure compliance with hospital policies and procedures relating to medication management, safekeeping and administration.
3. Check the resuscitation trolley daily and conduct periodic audits according to the established schedule.
4. Promote infection prevention and control by ensuring compliance with established protocols, participating in surveillance activities and demonstrating personal commitment to infection control practices.
5. Maintain the confidentiality of patients' personal information and medical records at all times.

4. FACILITIES AND EQUIPMENT

1. Operate and maintain specialised equipment within the unit, provide guidance to new staff on its proper use and maintain accurate equipment records.
2. Collaborate with the Unit Manager to ensure adequate availability and proper maintenance of equipment, medical supplies, consumable items, medications and linen.
3. Ensure equipment is functioning properly and serviced according to the Planned Preventive Maintenance (PPM) schedule.
4. Report faulty equipment to the Biomedical Engineering Department and assist in maintaining instruments and equipment through proper cleaning, handling, disinfection and usage.
5. Participate in quarterly stock counts together with the Finance Department.

5. SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

1. Participate in and support activities aimed at continuously improving Nursing Services, including quality assurance, infection prevention and control, and fire and safety programmes.
2. Conduct appropriate incident investigations and root cause analyses, implement necessary corrective actions and ensure incident reports are completed and submitted within the stipulated timeframe.
3. Collaborate with the Unit Manager to collect and evaluate clinical and administrative data and participate in hospital-wide surveys and accreditation activities, including MSQH, JCI and IMS, to support continuous quality improvement.
4. Participate in and contribute to the Baby-Friendly Hospital Initiative (BFHI) certification programme, with particular emphasis on promoting exclusive breastfeeding.
5. Comply with the Occupational Safety and Health Act and Regulations 1994, including the following responsibilities:

• Take reasonable care of personal safety and the safety of others at work.
• Cooperate with the employer in fulfilling occupational safety and health responsibilities.
• Wear and use protective equipment and clothing provided by the employer.
• Comply with occupational safety and health instructions and measures.
• Adhere to patient safety goals and relevant recommendations by the World Alliance for Patient Safety.
• Respect and uphold patients' and families' rights.
• Comply with Standard People Practice (SPP).
• Actively participate in 5S activities.

JOB REQUIREMENTS

1. Education

• Registered with the Nursing Board of Malaysia and possess a valid licence to practise as a Registered Nurse.
• Possess a Post Basic qualification in a relevant nursing field.

2. Knowledge and Experience

• Registered Nurse with at least three years of clinical experience, preferably with exposure to different clinical areas.

3. Skills and Competencies

• Possess relevant certifications in Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), Medical Trauma Life Support (MTLS), Paediatric Advanced Life Support (PALS) and Neonatal Resuscitation Programme (NRP), according to the respective clinical specialities.
• Proficient in written and spoken English and Bahasa Malaysia.
• Demonstrate caring, honesty, responsibility and good teamwork.
• Computer literate, particularly in Microsoft Office applications.

4. Personal Attributes

• Possess good leadership, interpersonal and communication skills.
• Demonstrate critical thinking, negotiation and problem-solving abilities.
• Willing to work according to scheduled hours, including shifts, weekends and public holidays, and be available when called upon during emergencies.
• Demonstrate passion and commitment to patient-centred care and continuous quality improvement.
• Possess high integrity, patience and strong attention to detail.