Job Description

ORGANIZATION AND MANAGEMENT

1. Understands and carries out the nursing care in line with Vision and Mission Statements, Goals and Objectives that suit the scope of the Nursing Services.

2. Works shift duties or as assigned by Unit Manager according to Unit’s Operational Hours.

3. Informs Unit Manager when change occurs in circumstances which affect standards of care.

4. Receives and handover report of patient, knows the case in detail:

• Progress of the patient.
• Ensures all doctors’ orders are carried out before shift change and on taking over case.
• Any incident or problems encountered.

5. Visits every patient in the unit together with the team members on taking over of duties to:

• Assess condition of patient, compare with report.
• Re-plan nursing care according to assessment or evaluation
• Determines nursing priorities and plans patient care according to patient’s needs and staff availability

6. Provides individualized holistic care to patients using the Nursing Process approach with proper nursing documentation in patients’ files and that it is contemporaneous.

7. Reports all abnormal findings and progress of patients to the relevant doctors / consultants.

8. Conducts regular nursing rounds on all patients in the ward to ascertain for other additional needs; talk to patient/family members as an integral part of providing emotional support.

9. Follows doctors / consultants ward round and assists them in doing procedures when required. Carries out orders of doctors / consultants pertaining to care of patients and delegates to other team members according to their assignments. 10. Liaises and discusses with the relevant doctors / consultants with regards to care of patients in the unit / ward.

11. Establishes and develops effective communication with all disciplines, patients and relatives, to achieve optimal patient’ satisfaction.

12. Attends and participates in unit meetings, dialogue sessions and hospital’s activities.

13. Participates in the health education of patients and their families in the ward.

14. Assists the Unit Manager in the administration of the unit / wards when assigned as shift nurse in charge.

15. Acts on behalf of the Unit Manager in setting standards and expectations in the quality of care.

16. Carries out duties and responsibilities of the Unit Manager in her absence as directed. Ensure charges of equipment/consumable items into patient’s charges accordingly and checked for completeness.

17. Responsible for checking and documenting supply of sterile packs from CSSS and weekly checking for integrity of packaging.

18. Maintains and documents adequate supply of unit stock Carries out assignments scheduled by Unit Manager and provide feedback.

HUMAN RESOURCE AND DEVELOPMENT

1. Takes personal responsibility for own professional development and keeps up to date with professional change and growth by maintaining mandatory learning hours.

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

3. Involves in the supervision of the lower categories of staff:

• Assistant nurses, Midwives, Care Assistant
• Student nurses who are posted to the unit for their clinical experience and assist them to achieve their objectives of that clinical attachment.
• Assists the Unit Manager in appraising the job performance of the lower categories of unit staff by giving accurate feedback with no malice or prejudice.
• Participates in the development and maintenance of the nursing process when providing patient care as well as nursing documentation

4. Supports and assists the Unit Manager in effective and efficient utilization of staff, supplies and services.

POLICIES AND PROCEDURE

• Contributes suggestions in periodic revision and upgrading of Nursing Policies and Procedures and relevant work instructions.
• Checks DDA drugs with the off-going Nurse In-charge of the previous shift when in-charge of the present shift.
• Participates in the care, custody, and administration of medications in accordance with Hospital Policies and Procedures.
• Checks daily and audits resuscitation trolley periodically as scheduled.
• Ensure all staff complies with Prevention and Control of Infection including implementation of surveillance activity in the unit and evidence of involvement.
• Maintain confidentiality of patient’s personal and medical history.

FACILITIES AND EQUIPMENS

1. Assist the qualified staff in the following:

• Oversees the storage and condition of biomedical equipment within the unit, inspecting it regularly to ensure it meets the PPM schedule, reports any faulty equipment, and is ready for use.
• Overseeing the linen and medical supply store by ensuring adequate stock and linen supply according to par level, monitoring stock movement and tallying after charging, coordinating monthly internal stock counts, and maintaining accurate records of equipment, medical supplies, consumable items, and laboratory items for specimen collections.

2. Participate in doing a stock count with the finance team quarterly.

SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

1. Operates / maintains specialized equipment assigned to the unit and provides assistance / guidance to new staff in their use.

2. Assists the Unit Manager in keeping accurate records of equipment, medical supplies and drugs in the unit / ward.

3. Checks that all equipment in the unit are functioning well and service according to PPM schedule.

4. Report to Bio Medical personnel if any faulty and takes necessary action accordingly.

5. Assists in maintenance of instruments and equipment by proper cleaning, handling, disinfect and utilizing as directed Fully receptive and supportive in the activities that contribute towards continuous improvement of nursing service e.g., Quality Assurance, Infection Control and Fire and Safety Program.

6. Conduct investigation and root cause analysis in any incident in the services, takes appropriate action and ensure completion of incident reports within stipulated time frame.

7. Carries out duties as an employee as stipulated in Occupational Safety and Health Act and Regulations 1994: -

• To take reasonable care at work for the safety of yourself and other persons.
• To co-operate with your employer or any other person in the discharge of any duty.
• To wear or use any protective equipment or clothing provided by the employer.
• To comply with any instruction or measure on occupational safety and health.

8. Ensures compliance of Patient Safety Goals as safety improvement measures recommended by World Alliance for Patient Safety.

9. Ensures the policies on Patient and Family’s Rights are always addressed Complies with the Baby Friendly Hospital Initiative Breastfeeding Policy, and protect, promote, and support Baby Friendly Hospital activities. Participates in 5S activities and comply with the specified requirements Ensures all staff always adheres to Standard People Practice (SPP)

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 PALS

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.