SENIOR STATE REGISTERED NURSE, MEDICAL WARD

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

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

5.     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.

6.     Conducts nursing rounds on patients, providing emotional support and accompanying doctors while doing rounds, as well as assisting in procedures as needed.

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

8.     Actively participates in the health education, dialogue sessions, and hospital activities.

9.     Provide clear, compassionate, and culturally sensitive communication with patients, ensuring their understanding of their condition, treatment options, and care plan comprehensively.

10.  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.

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

12.  Inspect and document the supply of sterile packs to ensure the integrity of the packaging and maintain an adequate supply of unit stock from central sterile supply services.

HUMAN RESOURCE AND DEVELOPMENT

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

• Executes continuous professional development through annual competency evaluations and privileges every 3 years, and is proficient in performing calculations, chemoport needle insertion and removal, 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:

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

• 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.

• 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, providing valuable insights, promoting best practices for optimal patient care, and continuously improving the process.

• Inspect the Psychotropic drugs with the previous shift'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, and demonstrating commitment through personal involvement.

• Maintain confidentiality of patient’s personal and medical history

FACILITIES AND EQUIPMENTS

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

• Collaborate with the unit manager to maintain equipment, medical supplies, consumable items, and drugs, ensuring proper functioning, service according to the planned preventive maintenance (PPM) schedule, and adequate stock and linen supply.

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

• 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, and participate in hospital-wide surveys like MSQH, JCI, IMS, etc. for continuous quality improvement efforts.

4.   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, and 5S activities.

JOB REQUIREMENTS

Education:

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

Knowledge and Experiences:

·       Registered Nurse with at least 5 years of clinical experience and diversity in clinical experience and teaching.

Skills & Competencies:

·       Possess certifications in BLS 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

·       Willingness to work on scheduled hours, shifts and weekends, public holidays, and any time called during an emergency.

·       Passionate and committed to patient-centered care and continuous quality improvement.

·       High integrity, patience, and attention to detail.

·       Be a positive and effective team player or team leader.