Perioperative Registered Nurse – OT & Recovery

Responsible for rendering professional nursing care to patients within an assigned unit of the Centre. Such nursing care is an integral part of the individualized holistic patient care plan as directed by the medical staff according to the Policies and Procedures of the Centre and in keeping with the generally accepted principles, policies and procedures of the Nursing Services.

ORGANIZATION AND MANAGEMENT

• 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.
• Works shift duties or as assigned by Operation Manager according to Unit’s Operational Hours.
• Informs Operation Manager when change occurs in circumstances which affect standards of care.
• Receives and hands over report of patient, knows the case in detail: Progress of the patient, ensures all doctors’ orders are carried out on taking over case, any incident or problems encountered.
• Provides individualized holistic care to patients using the Nursing Process approach with proper nursing documentation in patients’ files and that it is contemporaneous.
• Reports all abnormal findings and progress of patients to the relevant doctors/consultants.
• Carries out orders of doctors/consultants pertaining to care of patients and delegates to other team members according to their assignments.
• Liaises and discusses with the relevant doctors/consultants regarding care of patients in the unit.
• Establishes and develops effective communication with all disciplines, patients and relatives, to achieve optimal patient satisfaction.
• Attends and participates in unit meetings, dialogue sessions and Centre’s activities.
• Participates in the health education of patients and their families in the unit.
• Assists the Operation Manager in the administration of the unit.
• Acts on behalf of the Operation Manager in setting standards and expectations in the quality of care.
• Ensures charges of equipment/consumable items in top patient’s charges accordingly and checked for completeness.
• Responsible for checking and documenting supply of sterile packs from CSSS and weekly checking for integrity of packaging.
• Maintains and documents adequate supply of unit stock.
• Carries out assignments scheduled by Operation Manager and provides feedback.

HUMAN RESOURCE AND MANAGEMENT

• Takes personal responsibility for own professional development and keeps up to date with professional change and growth by maintaining mandatory learning hours.
• Participates in the teaching program of the unit and orientation of new members of staff to the unit routine.
• Involves in the supervision of the lower categories of staff: Assistant nurses, Midwives, Care Assistants, Student nurses who are posted to the unit for their clinical experience and assist them to achieve the objectives of that clinical attachment.
• Assists the Operation 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.
• Supports and assists the Operation 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.
• Participates in the care, custody and administration of medications in accordance with the Centre’s Policies and Procedures.
• Checks daily and audits resuscitation trolley periodically as scheduled.
• Ensures all staff complies with Prevention and Control of Infection including implementation of surveillance activity in the unit and evidence of involvement.
• Maintains confidentiality of patient’s personal and medical history.

FACILITIES AND EQUIPMENT

• Operates/maintains specialized equipment assigned to the unit and provides assistance/guidance to new staff in their use.
• Assists the Operation Manager in keeping accurate records of equipment, medical supplies and drugs in the unit.
• Checks that all equipment in the unit is functioning well and serviced according to PPM schedule.
• Reports to Bio Medical personnel if any faulty and takes necessary action accordingly.
• Assists in maintenance of instruments and equipment by proper cleaning, handling, disinfecting and utilizing as directed.

SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

• 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.
• Conducts investigation and root cause analysis in any incident in the services, takes appropriate action and ensures completion of incident reports within stipulated time frame.
• Carries out duties as an employee as stipulated in Occupational Safety and Health Act and Regulations 1994.
• Ensures compliance of patient safety goals as safety improvement measures recommended by World Alliance for Patient Safety.
• Ensures the policies on Patient and Family’s Rights are addressed at all times.
• Participates in 5S activities and complies with the specified requirements.
• Ensures all staff adhere to Standard People Practice (SPP) at all times.

ADDITIONAL DUTIES AND RESPONSIBILITIES IN THE SPECIFIC AREA

Perioperative Nurse in general

• Assists the Operation Manager in overseeing the smooth running of OT and CSSS daily.
• Checks that damp dusting has been done and gas supply in the anaesthetic machine cylinder.
• Prepares trolleys and standing by items to be used.
• Arranges with other units to prepare patients to arrive into OT according to the scheduled time.
• Receives and greets patient, checks patient in accordance to the checklist.
• Notes for any abnormalities, refers to the surgeon and anaesthetist if necessary.
• Escorts patient into the Operating Rooms and ensures patient’s safety at all times.
• Enters particulars of all cases in the Operation Theatre Record Book.
• Ensures proper care and handling of all specimens after each case – properly labelled and recorded before they are sent to the laboratory or pathology department.
• If in doubt, always asks and confirms with the surgeon.

Anaesthesia Nurse

• Supervises and prepares anaesthesia equipment before anaesthesia and surgery.
• Maintains sterility of equipment and working environment.
• Performs daily routine tasks, counter checks GA machine and ventilator, adequate monitoring equipment and accessories in the GA trolley.
• Reviews patient’s information: age and weight, surgical procedure to be performed, type of anesthesia, allergic and other sensitive reactions, site marking at surgical site as needed.
• Notes any potential anaesthetic risks, hazards and complications.
• Prepares and obtains the necessary drugs and accounts for the Dangerous and Psychotropic drugs used in the OT.
• Remains with the patient prior to and during the induction of anesthesia.
• Assists the anesthetist in monitoring the patient throughout the surgical procedure.
• Maintains anaesthesia records with complete accurate and legible documentation.
• Observes safety measures in positioning the patient, paying particular attention to patient’s limitations.
• Passes over the patient with relevant information to the Recovery Unit.
• Maintains the cleanliness of the room, anaesthesia equipment and always ready for the use of next session.

Scrub Nurse

• Prepares the operation room for operations.
• Assists in cleaning the Operation Rooms in the morning.
• Prepares and counter checks trolley, ensures all required items are available for the case.
• Discusses with Surgeon the approach of surgery and any special preference.
• Verifies the correct patient identity, operative site and side and valid consent form.
• Conducts swabs, instruments, and sutures counts with circulating nurse prior to operation.
• Maintains sterile technique.
• Communicates with surgeon after each counting.
• Disposes sharp and used items safely into the appropriate container according to hospital policy.
• Documents the necessary information on the swab count form.

Circulating Nurse

• Prepares the operating room for the appropriate surgical procedures according to the operation list.
• Checks and records the temperature and humidity of the Operation Room daily.
• Prepares equipment for its designed purpose; lotion, packs, sutures for standby.
• Recognizes safety policies, procedures and adheres to them by practicing a “Time out” procedure.
• Records in the operating Swab Count Procedure chart.
• Helps to position patient safely.
• Maintains cleanliness of the room and equipment, ready for use for the next surgery.

Recovery Nurse

• Receives patient and report from Operation Room, carries out post-anaesthesia care.
• Checks and records vital signs on Recovery Chart/GA chart.
• Informs day ward staff to fetch patient when patient is ready for discharge from the Recovery Room.
• Ensures the recording of documentation is complete and accurate.
• Maintains general cleanliness of the room and always ready for next patient.

Coordinator Nurse

• Assists the Operation Manager in overseeing the smooth running of OT and CSSS daily by allocation of the staff assignment.
• Arranging and ensuring the vendor set required for surgery are available.
• Liaises with Anaesthetist for emergency cases.
• Records all monitoring parameters such as cancellation, postpone, any departure of best practice and quality objective data.

JOB REQUIREMENT

• Education: Diploma/Certificate in Nursing.
• Registered with Nursing Board of Malaysia with a valid license to practice as a Registered Nurse.
• Able to write and communicate fluently in Bahasa Malaysia and English language.

Skills & Competencies

• Good communication, counseling and interpersonal skills.
• Able to guide nursing staff, student nurse and non-nursing staff.
• Ability to improve knowledge and skill in teaching and supervision in the clinical areas.

Personal attributes

• Possess the attitude to make patient care the primary concern, treating every patient compassionately.
• Strive to provide high quality nursing care; maintain patient’s dignity, privacy, autonomy and confidentiality.
• Prepared to work as a team member in the best possible manner.