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- Utilizes the nursing process and physical assessment skills while providing direct patient care
- Adopts a caring approach and responsible for the direct patient care by adhering to Standard Operational Procedures, Work Instructions and Policies
- Maintains patient’s privacy and confidentiality of information and records at all times.
- Provides hands-on care to patients according to plan of care/policies and procedure and standard of care:
- Performs physical care and treatment activities safely and in a cost-effective manner
- Makes nursing rounds according to patient needs
- Administers medication and manages intravenous lines as per policy,
- Observes and monitors patients’ conditions, maintains records and communicates patient care needs to doctors as necessary
- Execute doctor’s orders for all assigned patients, safely and properly administer medications and treatments
- Recognizes and documents patient’s response to plan of care and nursing interventions
- Assesses the quality and effectiveness of nursing care as an ongoing process and takes appropriate action
- Provide:
- Education and counselling to patients and families according to their level of understanding
- Instant medical care in emergencies
- Monitors patient’s condition and assessing their needs to provide the best possible care and advice
- Performs routine procedures (blood pressure measurements, administering injections, etc.) and fill in patient’s charts
- Observes and interprets patient’s symptoms and communicating them to doctors
- Develops, documents and updates a nursing plan of care involving patient/family and members of the team
- Follow doctors/consultant’s ward/unit round and assist them in performing procedure
COMMUNICATION:
- Collaborates with doctors and nurses to devise individualized care plans for patients
- Communicates and confers with team members throughout shift to ensure optimal care. Foster an environment where communication is encouraged and welcome
- Communicates with doctors and documents patient status/condition changes or a deviation from baseline
- Ensure all doctors’ orders are carried out before shift change
- Receives report from Registered Nurses from previous shift; delivers report to Registered Nurses coming on duty for next shift
- Maintain effective communication which include public relationship skill and interact with other healthcare professional to provide best multidisciplinary care to patients
LEADERSHIP/DELEGATION:
- Understands and carries out the nursing care in line with Vision and Mission Statements, Goals and Objectives that suit the scope of the Nursing Service
- Demonstrate ability to delegate, articulate patient care needs and expectations to team members
- Supervise team members providing direct patient care
- Participate in new employee orientation of new nurses as assigned, seeking out learning opportunities for orientees, serves as role model for new employees
- Participates in ward and interdisciplinary team meetings, reads minutes of meeting and initials those along with communication books/in-services/policies and procedures
- Identifies and intervenes in any unsafe practices that may pose a threat to patient, caregiver or other individuals
- Provides leadership in the unit through appropriate patient assignment and ongoing prioritization of patient need, acuity, and clinical expertise of the team member
- Assist the Unit Manager in administration of the unit when assigned as shift nurse in charge.
- Carries out duties and responsibilities of the Unit Manager in her absence as directed
PROFESSIONAL DEVELOPMENT
- Take personal responsibility for own professional development and keeps up-to-date with professional change and growth by maintaining mandatory learning hours
- Participate in the teaching program of the unit/ward and orientation of the new members of staff to the department routine
- Attends and complete mandatory education
- Attends in-service training programs, including but not limited to infection control, patient safety, quality improvement, Safety Data Sheet and OSH standards
- Expands knowledge and capabilities by attending education workshops, conferences, etc.
- Participate in performance improvement activities
- Involves in the supervision of the other categories of staff
- Patient Care Assistants
FACILITIES AND EQUIPMENT
- Operates/maintains specialized equipment assigned to the unit and provides assistance/guidance to new staff in their use
- Assist the UM in keeping accurate records of equipment, medical supplies and drugs in the unit
- Maintain and documents adequate supply of unit stock
- Ensure that:
- All equipment in the unit is functioning well and service according to scheduled maintenance plan
- Faulty equipment is removed from point of use immediately and report to Biomedical personnel and appropriate remedial action has been taken accordingly
- Instrument and equipment are maintained by proper handling, cleaning, disinfection and utilized as directed
PATIENT SAFETY/WORK PRACTICES/QUALITY IMPROVEMENT ACTIVITIES
- Responsible for abiding to safety and health work practices
- Complies with organization-wide and department specific policies and procedures, safety and health standards, rules and regulations
- To wear/use personal protective equipment or clothing when appropriate
- Identifies, documents and reports to the Unit Manager, CNO or COO
- Any unsafe patient and other occurrences which do not meet standards of care
- Any current or potential unsafe/unhealthy practices and conditions
- Reports all accidents, near misses, injuries, work-related illnesses, special occurrences, and other emergencies that the employee is involved in immediately to the appropriate supervisor
- Reports malfunctioning equipment/supplies to Unit Manager and remove from point of use as per policy
- Maintains personal appearance and personal hygiene as stated in per HSB policy (Dress Code), and applicable department policy while on duty. Maintain these standards when serving in any capacity while representing HSB
- Inspects the facilities and act to maintain excellent hygiene and safety (decontaminating equipment, sanitizing surfaces, preparing beds, etc.)
- Fully receptive, supportive and participate in the activities that contribute towards continuous improvement of patient care, e.g., Quality Assurance, Infection Control, Malaysian Patient Safety Goals, Fire and Safety Program, etc.
- Carries out assignments scheduled by Unit Manager and provides feedback
- Complies with the Baby Friendly Hospital Initiative Breastfeeding Policy, fully support and promote Baby Friendly Hospital activities
WORK SCHEDULE COMPLIANCE
- Recognizes that employment is offered based on compliance with work schedule, which are the responsibility of the employee to follow
- Maintains attendance standards by complying with Human Resource Policy
- Demonstrates punctuality by being ready and available for work at start of assigned shift and in accordance with departmental policy
- Works scheduled hours in accordance with departmental lunch/break time
- To ensure the overall activities are carried out professionally, ethically and in a timely manner
- To perform other duties or activities as assigned by Superior and/or Management as and when required
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