GENERAL DESCRIPTION

Accountable forproviding 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

ORGANIZATION AND MANAGEMENT

• Adherence to nursing care vision, mission, goals andobjectives, aligns with the scope of nursing services, and performs shift duties as assigned by the Unit Manager to ensurehigh qualitycarerendered

• Notifies the unit manager of any changes in the situation that couldimpactthe standards of care.

• 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.

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

• Identifyingand collaborating with doctors and team members to manage life-threatening conditions and effectivelycommunicatingwith relevant professionals to ensureoptimalpatient care.

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

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

• Obtains and handovers a report of patient progress, ensuring alldoctor'sorders are followed before changing or over taking shifts and notifying any incidents or problemsencountered

• Visit patients in the unit with teammembers to assess conditions, re-plan nursing care, anddeterminenursing priorities based on patient needs and staff availability.

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

• Providing emotional support andaccompanyingdoctors while doing rounds, as well asassistingin procedures as needed.

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

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

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

• 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.

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

• Inspect and document the supply of sterile packs to ensure the integrity of the packaging andmaintainan adequate supply of unit stock from CSSS.

HUMAN RESOURCE AND DEVELOPMENT

• Accountable for personal and professional growth keeps up to date with professional change bymaintainingmandatory learning hours.

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

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

• 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 achievethe clinicalattachmentobjectives

• Collaborates with the unit manager to evaluate staff performance, provide constructive feedback, andoptimizestaff, supply, and serviceutilizationfor efficient resource allocation and coordination with consultants for effective bed management.

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

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

POLICIES AND PROCEDURES

• Participates in the review and revision of nursing policies, procedures, and work instructions,providingvaluable insights, promoting best practices foroptimalpatient care, and continuously improving the process.

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

• Checks daily and audits resuscitation trolley periodically as scheduled.

• Promotes infection prevention and control by ensuring staff follow protocols, implementing surveillance activities, anddemonstratingcommitment through personal involvement.

• Maintain confidentiality of patient’s personal and medical history

FACILITIES AND EQUIPMENT

• Operates andmaintainsspecialized equipment in aunit, guidingnew staffon the use of it andmaintainingaccuraterecords.

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

• Notify biomedical personnel of faulty equipment andassistinmaintaininginstruments and equipment through proper cleaning, handling, disinfection, and usage.

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

SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

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

• Conduct thorough investigations, root causeanalyses,appropriate responseactions, andtimelycompletion of incident reports within the stipulatedtimeframe

• Collaborate with unit manager to collect and evaluate clinical and administrative data,participatein hospital-wide surveys like MSQH, JCI,IMSand etc.for continuous quality improvement efforts.

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

• Adhere to the Occupational Safety and Health Act and Regulations1994, 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 skillsarerequired

• Proficient in writing and conversing in English and BahasaMalaysia.

• Microsoft office literacy

Personal attributes

• Haveinterpersonal and communication skills.

• Critical thinking and problem-solving skills

• Caring, honest, and responsible workers

• Willingness to work on schedule hours,shiftand weekends, publicholidays and anytime called during an emergency

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

• High integrity,patienceand high attention todetails