PURPOSE OF THE ROLE

At MBHS, a registered nurse works within a multidisciplinary team to provide high quality nursing care to all patients/clients who visit the clinic. They are often the first point of clinical contact for patients using MBHS services and assist in carrying out health histories, nursing assessments and procedures. All RNs work shifts and often rotate between triage/outpatient, inpatient, occupational health department, operating theatre and emergency services.

All MBHS registered nurses must provide patient-centred, compassionate, competent and quality care. All qualified nurses must adhere to the General Nursing Council of Zambia’s Code of Conduct as well as the MBHS Code of Conduct and must practice safe, ethical and evidence based nursing care at all times as dictated by the MBHS Healthcare Standards.

KEY ACCOUNTABILITIES

• Ensure that standard operating policies and procedures are followed with regard to nursing care that is in keeping with the Zambian nursing scope of practice and MBHS standards of care.
• Provide nursing care that is respectful, ethical, compassionate, competent, caring and professional at all times.
• Demonstrate an ability to work competently in triage, outpatient, in-patient, emergency services and any other areas assigned.
• Ensure that individual nursing knowledge and practice is up-to-date in order to perform required duties effectively.
• Must be accessible at all times when rostered and be available for shift work. 
• Maintain patient dignity and confidentiality at all times. Make ethical decisions related to consent and confidentiality. Any breach in patient confidentiality will result in disciplinary action.

KEY RESPONSIBILITIES

• Maintain a hygienic and safe work environment in accordance with the MBHS Healthcare Standards and all associated policies and procedures.
• Triage all patients that visit MBHS for urgent care and prioritise patients based on MBHS triage protocol.
• Perform physical examinations like blood pressure, pulse, temperature, blood smear testing, weight checks and health histories for all new patients.
• Maintain proper and legible nursing documentation and charting, in keeping with best practice guidelines and MBHS Healthcare Standards.
• Maintain effective written and oral handover procedures of patients to other clinicians and during shift change.
• Maintain routine patient observations/checks, as ordered by the medical doctor or unit leader.
• Develop nursing diagnosis following a health history or physical examination. Clearly document findings and inform the attending doctor. Create nursing care plans to assess patient care needs and continued progress based on nursing diagnosis and within scope of practice.
• Participate in the morning ward rounds or weekly grand rounds.
• Assist the medical doctors during clinical procedures, as requested.
• Escalate any change in patient health status, especially mental status, abnormal test results, deterioration in patient health or abnormal diagnostic results, medical doctors and appropriate clinicians.
• Monitor for any changes in the patient’s risk assessment.
• Discuss treatment with medical doctors and pharmacists in critical cases.
• Attend medical/clinical rounds, clinic meetings and mandatory in-house training, as required.
• Check and administer medications and injections, and observe for any adverse reactions or side effects. Document all findings and notify the medical doctor as required. Proper medication checks are always performed (right patient, right dose, right time, right route, expiry date, allergies, right medication and right documentation etc.) prior to administration.
• Review medication history and current orders. Ensure any change in medication is properly recorded in the patient’s medication chart and inform pharmacy accordingly.
• Check the medication stock on a regular basis to maintain correct inventory levels, and place orders when required.
• Check medical/clinical equipment as instructed and present documented reports to the Unit Leader where equipment needs to be repaired or replaced.
• Administer medications (oral, IV, injections, DDA’s), wound care, other personalised interventions (setting up IV medication, blood transfusion etc.) as ordered by the medical doctor.
• Respond quickly to emergencies. Involve the medical doctor or doctor on-call immediately if there are any urgent or emergency patient cases.
• Nursing assessment, examination and routine patient vital signs observations are clearly documented according to the clinic’s standard operating procedure.
• Ensure that all completed patient documentation is securely entered into the patients’ medical file; this includes, but is not limited to, consent forms, care plans, nursing/consultation notes, fluid balance sheets, discharge summary, risk assessments, medication chart, laboratory results etc.
• Plan patient discharge from hospital and liaise with GPs, pharmacists etc. Document all discharge interventions in the patient’s medical file.
• Ensure that all clinical rooms are clean and safe before and after any procedure.
• Follow patient isolation policies and standards at all times.
• Offer support and counselling to patients and their following a death or major diagnosis like cancer, surgical procedure etc.
• Support and/or mentor junior nurses as directed by the Unit Leader.
• Promote good health through patient education and document this in the patients’ medical file.
• Continually demonstrate adherence to the Infection Control Policy, especially maintaining proper hand washing technique. Use and maintain correct personal protective equipment (PPE) such as eye protection, gown and gloves where appropriate.
• Comply with all national legal regulations.
• Carry out any other duties assigned by the Unit Leader, Matron or Clinic Manager within the nursing scope of practice.

REQUIRED TECHNICAL SKILLS, TRAINING & EXPERIENCE

• Diploma in Registered Nursing or country equivalent.
• Current NMCZ Practising Licence
• Attention to detail
• Highly computer literate.
• 2 years experience as a registered nurse.
• Diploma in Critical Care/Trauma/Pediatric Nursing is added advantage.

Internal Job Code