Nurses play a crucial role when it comes to patient safety
Nurses play a crucial role when it comes to patient safety.

We are not only the largest group among the five healthcare professions in Malaysia (120,000 nurses and counting), but also the profession that is most in close contact with patients.

The International Council of Nurses (ICN) in 2002 had clearly stated that “promotion of a safe environment” is one of the key roles of nursing.

Therefore, nurses have an obligation to promote patient safety in every aspect of care.

This could be made possible by adopting two strategies.

The first is to include nurses with a degree as part of the staff in the provision of direct patient care.

Globally, a degree nurse is a first-line nurse, and that is a fact.

The inclusion of degree nurses will enable the nursing service to implement a patient-centred care (PCC) framework to replace the task-oriented service.

PCC involves four activities:

Assessment of the patient’s psychosocial and cognitive needs through the nursing process (i.e. assessment, diagnosis, planning, implementation and evaluation)

Incorporating nursing orders (i.e. directives for specific nursing interventions initiated by the registered nurse) through discharge planning to help shorten the patient’s length of stay

Providing health education to empower the patient about their current health problems, and

Providing continuity of care in the home, where indicated.

The second strategy is to include or enforce the practice of measuring quality care using outcome indicators, which are adverse events that are preventable.

Examples of these according to the Health Ministry are patient falls, medication errors, and pregnancy and childbirth- related incidents.

Further examples according to the ICN (2012) are urinary tract infections, skin pressure ulcers, hospital-acquired pneumonia or other infections, deep vein thrombosis or pulmonary embolism, wound infections, stroke, cardiac arrest or shock, and sepsis.

The inclusion of degree nurses will enable the nursing service to measure quality care.

Nurses not only form the largest group among the five healthcare professions (i.e. doctors, dentists, pharmacists, allied health and nurses), but are also the professionals who come in the regular, closest contact with patients.

Nursing safety standards

As an investment in reducing patient harm that could lead to significant savings and better patient outcomes, six nursing safety standards are proposed:

Adoption of “5 Moments of Hand Hygiene”

This model of hygiene introduced by the World Health Organization (WHO) in 2009 is aimed at preventing healthcare- associated infection (HAI) by emphasising the decontamination of hands:

Before touching a patient

Before clean/aseptic procedures

After body fluid exposure/risk

After touching a patient; and

After touching a patient’s surroundings.

In nursing, “hands decontamination”, as has been practised for decades, consists of cleaning the hands (using soap and water, or alcohol rub) from the elbows to fingertips without exception.

An all-RN nursing service delivery system

Registered Nurses (RNs) are diploma and degree nurses who possess a licence to practise nursing.

They are registered with a nursing board or council after passing a licensure examination.

Globally, this examination focuses on patient safety issues that require critical thinking, problem-solving and decision- making questions or approaches.

To ensure patient safety, no one without a license, and therefore, not registered with a nursing board or council, should be allowed to practise nursing.

An inclusive degree and diploma nursing service

An inclusive degree and diploma nursing service will ensure patient safety through the adoption of the following staffing principles:

Use of degree nurses with specialised training for areas requiring collaborative and independent decision-making, e.g. critical care services, delivery suites, burn centres, home care and school health programmes

Use of both degree and diploma nurses in areas that can tolerate “mixed” staffing, with or without specialisation, such as general adult hospital services and paediatric services, and

Use of diploma nurses in non-patient care areas, including outpatient departments and centralised sterile supply units.

Specialisation

Globally, nursing service necessitates advanced nursing education at every level, focusing on clinical specialisations corresponding to the relevant specialised areas in medicine that require heavy nursing input.

These include critical care, emergency care, midwifery, mental health/psychiatry, oncology, paediatrics, community health, primary healthcare and health systems management, as well as the various other medical and surgical specialities.

Our aim should be to make every nurse a specialist nurse, whether their base is a diploma or degree.

Failure to do so will deprive the healthcare system of the specialised care that every patient in Malaysia deserves.

One specialisation that every nurse should definitely have is midwifery, as nurses have to serve in maternity hospitals, obstetrics and gynaecology wards or delivery suites, and primary healthcare clinics.

Failure to meet this critical need would likely contribute to obstetric-related incidents, which are one of the top eight incidents leading to severe outcomes or deaths.

In Malaysia, the sole provider of nursing education from diploma to PhD, including specialisation programmes, is the Higher Education Ministry.

Good English skills as an entry requirement into nursing

While the emphasis has always been on pure science subjects (i.e. credits in biology and chemistry) for both diploma and degree nursing programmes, the same emphasis must be made on good English language skills.

This is as all text books (and online information) in medicine and nursing, doctors’ notes related to patients’ diagnosis and treatment regimes, and all prescriptions and lab results, which must be read/deciphered by nurses and nursing students are in English.

All patient care rounds, which must be attended by nurses and nursing students, are also generally conducted in English.

And certainly, no mistakes should be made that could compromise patient safety – e.g. in giving medication or providing information to patients – due to a nurse’s poor understanding of English.

All nursing lecturers should also set the standard by being exemplary in the use of English themselves.

In countries like Canada and the United States (where I studied graduate and postgraduate nursing), one mandatory entry requirement into nursing (and medicine) is English Literature.

This is because English Literature puts heavy emphasis on the use of English to understand the content.

As part of the Humanities, English Literature also puts heavy emphasis on soft skills, which require critical thinking involving intelligence quotient (IQ), emotional intelligence (EI) and spiritual intelligence (SI).

Indeed, English Literature should be a must-have entry requirement into nursing.

Effective teaching of the Humanities

“Caring behaviours” remain the cornerstone of patient safety.

In nursing, the teaching of the Humanities, which caters for caring behaviours, is fundamental in producing nurses who are critical thinkers and who have compassion, altruistic behaviours and soft skills – all important in meeting patient safety and quality care goals.

For nursing programmes, subjects relating to the Humanities include the history of nursing, codes of ethics, key performance indicators, communication and soft skills, nursing theories, PCC, and leadership.

Actions needed

Improving the quality of our nursing care requires drastic measures.

These need to begin with the adoption of a PCC framework (to replace the task-oriented service), which necessitates the adoption of all-RN and inclusive degree-diploma nursing service.

The implementation of PCC will become an investment in reducing patient harm, which can lead to significant savings and better patient outcomes.

To further enable the Malaysian Nursing Service to be on par with global requirements, the Health director-general, as the chairman of the Nursing Board Malaysia, should push for the Nursing Act 2019 (sent to the director-general on Dec 16, 2019) to be sent to Parliament for approval to replace the current 1950 Nurses Act.

The Nursing Act 2019 will invoke patient safety initiatives befitting the nursing service needs of the 21st century.

Nik Safiah Nik Ismail is a retired nurse academician and former Universiti Kebangsaan Malaysia Department of Nursing adjunct professor. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only, and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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As healthcare professionals who have extensive interaction with patients, nurses are a crucial element in creating a safe environment for patient care.