STATE REGISTERED NURSE, NURSING & OPERATION THEATRE

Provide professional, safe, and high-quality nursing care to patients undergoing eye surgery in accordance with the organization’s vision, mission, policies, and procedures. Perform duties assigned by the Head of Branch, Head of Service, Nurse Manager, or Nursing Supervisor based on operational needs and workload. Report any incidents or changes that may affect patient care, and take responsibility for continuous learning, professional development, and competency maintenance. Perform any other duties as required by the management.

ORGANIZATION AND MANAGEMENT  

• Responsible for carrying out high standard professional, quality and safe nursing care for patients undergoing eye surgery. 

• Proactive to facilitate the smooth running of OT. 

• Undertakes the role and function of the Scrub nurse and Circulator during peri-operative phase. 

• Receive and check patient pre-operatively and verify the correct patient, identity operative site and valid consent form. 

• Provide pre-operation and post-operation education to patients and next of kin / relatives. 

• Prepare Operation Theatre (OT), equipment, instruments, surgical sets, consumables and if needed specialized personnel for surgical procedures.  

• Liaise and discusses with primary Ophthalmologists including specific items needed for surgery.  

• Assemble consumables and surgical OT sets for daily procedures and ensures all required items are available for surgeries. 

• Ensure all equipment in OT are available and functioning including inventory checking. 

• Ensure adequate consumable stocks / sterile items are adequate and available for use in OT. 

• Communicate with other nursing team/ / Senior Specialist Nurse at other eye Branches if additional equipment, instruments, surgical sets, consumables needed for patient’s surgery. 

• Arranges to prepare patients to arrive at OT according to the scheduled time. 

• Receives and greets patient, checks patient with staff from outpatient clinic in accordance with checklist (consent completed and pre – operation preparation). 

• Notes for any abnormalities refer to the surgeon and anesthetist if necessary. 

• Escorts patient into Operating Rooms and always ensure patient’s safety. 

• Perform aseptic surgical handwashing, gowning, gloving. 

• Assists with draping patient. 

• Circulate and scrub for surgical procedures including passes instruments in a professional manner including maintaining sterile techniques. 

• Participates in performing “Time-out” with the team before commencing the surgery. Maintain concise and complete documentation of operative records which is inclusive of Time Out, Correct patient identification, Correct Site, Correct Surgery and Correct Lens. 

• Comply with safety protocols in OT, including effective communication using SBAR, the safe management of high-alert medications, the reduction of healthcare-associated infections, and fall prevention.  

• Reviews patient’s information and notes and report abnormal findings and patient progress to relevant Doctors / Consultants.  

• Ensure that all items used for the patients inclusive of medications, surgical supplies are duly recorded and charged. 

• Enters all cases in the Operation Theatre Record Book and hours utilized. 

• Check Doctor’s orders after surgery to ensure post – operation treatment care is recorded and carried out. 

• Responsible for the collection of surgical specimens, ensure correct labelling, documentation and follow – up with laboratory reports including inform doctor. 

• Ensure patient safety in OT by taking measures against accidents / incidents. 

• Discards all the used linen, clinical waste, general waste into the designated bins and bags. 

• Maintains cleanliness of OT and equipment, ready for use for the next surgery. 

• Carries out post-op observation's vital signs and document. Report abnormal findings and patient progress to relevant Doctors / Consultants. 

• Assists in maintenance of instruments and equipment by proper cleaning, disinfection, handling, disinfecting and utilizing as directed. 

• Checks to ensure that instruments are in good condition, function and sets are complete upon assemble. 

• Rejects instruments that are not clean properly. 

• Packs and labels instruments for sterilization.  

• Maintains cleanliness of the sterile store and shelves 

• Checks and records of Temperature and Relative Humidity of the sterile store as per schedule. Reports to superior if any abnormality. 

• Maintains the integrity of sterile sets/items in storage. 

• Follow the “First-In First-Out” system in issuing the sterile instruments and sets. 

• Perform inventory of instruments. 

• Monitor consumables and medications according to par level. 

• Perform Monthly stock take. 

• Report monthly census and any related reports to the Nurse Manager. 

• Report to the Head of Branch or Head of Service HOS / Nurse Manager / Nursing Supervisor any incidents or reportable situations.
  

  HUMAN RESOURCE AND DEVELOPMENT 

• Submit leave application in advance according to the number of days as stated in the employee handbook, to the Head of Branch or Head of Service HOS for approval. 

• Participates in teaching program and contributes to the orientation of new staff, Junior nurses and student nurses.  

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

• Adheres to ethical standards and displaying honesty and reliability in their work. 

• Demonstrates respect to senior staff in the organization. 

• Always adhere to Standard People Practice (SPP) and guide the staff, especially lower categories and non-clinical.
   

POLICIES AND PROCEDURES 

• Adhere to the policies and procedures and demonstrate evidence of compliance.   

• Assist to Perform random / regular audits on adherence and compliance to policies and procedures of the quality and safety systems.  

• Adhering to aseptic techniques of scrubbing, gowning, and gloving and infection Control procedures. 

• Maintain confidentiality of patient’s personal and medical records 

  FACILITIES AND EQUIPMENT

• Check that all equipment is functioning well and service according to the PPM schedule and report to Maintenance Officer cum Bio-Medical personnel / Procurement staff if any faulty and take necessary action accordingly. 

• Inform Head of Branch or Head of Service HOS repair / service report

• Provide and update the PPM data of all equipment regularly. 

• Perform and guide new staff on the use of new equipment.  

• Cleans the autoclave chambers and records in the autoclave cleaning book.

• Conducts test of autoclave machine efficiency by doing the Chemical test, biological test, and Leak test before running the autoclave machine. 

  SAFETY AND QUALITY IMPROVEMENT ACTIVITIES  

• Adhere, support and comply in the activities that contribute towards continuous improvement of nursing service e.g., Patient Safety Goals, Patient and Family’s Rights, Quality Assurance, Infection Control, Fire and Safety Program, and Occupational Safety and Health Act and Regulations 1994.

• Comply with the practice of administering medication according to 7Rights in in accordance with Policies and Procedures.

• Never leave the operating room, unless there is another un scrubbed person in OT.

• Disposes sharps and used items safely into the appropriate container according to policy to avoid sharp injury.

• Check and document of emergency trolley and medical gas (e.g. portable oxygen supply) according to Policy and Procedure.

• Check and document Controlled Drugs (DDA drugs) twice daily (in-going and out-going) according to Policy and Procedure.   

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

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

• Post Basic qualification in a related field (depends on the services availability at KPJ Eyecare specialist Centre).

• Diploma / Bachelor of Nursing.