NURSING GUIDELINE

VERSION 1.0

NURSING DIVISION
MINISTRY OF HEALTH MALAYSIA
 GLOSARY
TERM DESCRIPTION

MOH Ministry of Health Malaysia

APC Annual practicing certificate

CNE Continuous nursing education

CPD Continuing Professional Development

State Matron Matron in charge of the State

Chef Matron Matron in charge of the hospital

Health Matron Matron in charge of the health clinics

Nursing A nurse who is responsible for managing staff,
Supervisor overseeing patient care and ensuring adherence to
established policies and procedures. Nursing Supervisor
is in charge of assigning staff and monitoring their
activities, and helping to recruit and train nurses newly
recruited.

Nursing care “Nursing” is the profession of performing the function of

a nurse while “care” refers to provision of welfare and
protection to children, the elderly in need, the sick and
other vulnerable people. Nursing care is an important
component of nursing practice.

Nursing Practice The range of roles, functions, responsibilities, and

activities which registered nurses been educate and are
authorize to perform.

Nursing Procedure Standard procedure practiced by nurses to achieve high

level of patient care which refer to activity such as
wound dressing, serving medication, giving intravenous
therapy, etc.
 INTRODUCTION
This Nursing Guideline is the first edition designed as a guid for all nurses in
fulfilling their tour of duties. This Nursing Guideline includes components that
need to be complied in order to maintain the professionalism of being a nurses
working in the Ministry of Health Malaysia.

Nursing is viewed as a noble profession. Patients come to seek treatment in

the belief that nurses will provide the service with the best care for their ailment.
Thus, it is our ethical and professional responsibility to ensure that this trust on
the nursing profession is upheld at all times.

APPLICATION
The Nursing Guideline applies to all registered nurses practiced in Ministry of
Health Malaysia.
 12 ITEMS
1 DRESS CODE
2 ANNUAL PRACTICING CERTIFICATE (APC)
3 MENTORING PROGRAMME
4 CONTINOUS PROFESSIONAL DEVELOPMENT
5 NURSING ROUND
6 SCHEDULING DUTY
7 ESCORTING
8 ABSENTEEISM
9 FORGERY OF MEDICAL CERTIFICATE
10 NEWS AND MEDIA RELEASED ON PATIENT’S INFORMATION
11 DISCIPLINARY ACTION
12 OTHERS
 1.0 DRESS CODE
OBJECTIVE To comply with appropriate
professional style of dress for the
delivery of professional nursing
services
NURSING Full compliance
STANDARD a. Uniform
b. Name tag
c. Nursing badge
d. All materials and patterns shall
comply with current MOH
guideline
 1.3.1 UNIFORM
• Wear Complete uniform
• Change or cover uniform when
I. Off duty
II. In public area unless on duty
• Appropriate attire according to function
 1.3.2 DISPOSAL OF UNIFORM
• Must destroyed if no longer wearable
• Ways of disposed
I. throwing the uniform into domestic waste
after all identifying marks which can the
nursing profession been removed completely
II. cutting or ripping to avoid reuse
• Any identifying marks reflecting nursing
profession such as logo, stripes and buttons
must be cut off
 1.3.3 FOOTWEARS
• Standard shoes as per specification
determined by Malaysia Nursing Board
• Socks
I. Female- skin colour
II. Male- black coloured
 1.3.4 HAIR AND NAILS
• Hair – well kept/ groomed and neat
• Short hair kept above the collar level
• Long hair – only for female nurses.
• Should be tied using black and dark blue band/
ribbon
• Shades of black or dark brown hair dye colour are
allowed
• Male nurses – can maintain beard and
moustache and well kept, 1-1.5 cm long
• Keep nails shot and non coloured
• All artificial nails are prohibited
 1.3.5 JEWELRIES
• Allow plain ring while on duty
• Shall remove the ring when performing any
nursing procedures
• Shall not wear bangles, bracelets , short
length chains and chokers
• Allow a pair of small earing
• Plain brooch for scarves
• No unnecessary piercing
• 1.3.6 TATTOOS- Not allowed within sight

• 1.3.7 HENNA- Allow for grooms only

• 1.3.8 COSMETICS
I. Shall apply in a presentable manner
II. Allow to wear natural colour contact lens
III. Artificial eyelashes are not allowed

• 1.3.9 INDENTIFICATION TAGS AND BADGES

I. - Right side. Visible all the times
2.0 ANNUAL PRACTICING CERTIFICATE
(APC)
OBJECTIVE To ensure that every nurse holds a
valid Annual practising Certificate
(APC)
NURSING Shall obtain APC by 1ST January of
STANDARD every practicing year
 2.3 STATEMENT
• Nursing supervisor to monitor every practising
nurse holds a valid licence
• Nursing supervisor to seek assistance from
Malaysian Nursing Board of no APC by 30 Sept
• Acquire sufficient CPD points
 3.0 MENTORING PROGRAMME
OBJECTIVE To train nurses who are posted to a
new field to be competent in delivering
safe, effective and quality nursing care
NURSING Newly posted nurses shall undergo
STANDARD mentor mentee program which has
been established by nursing Division,
Ministry of Health Malaysia in order to
facilitate professionalism and
competency among nurses while
delivering holistic, effective and
standard nursing care
 3.3 STATEMENT
• JKN committee to monitor the establishment of
mentoring policy and mentoring program
• Health facilities – a committee formed by Nursing
supervisor to
- Organise and monitor program achievement for 1
year and issue the certificate
- Submit mentoring program achievement to state
matron every 3 months
- If failed, extension of 6 months mentoring
program
 4.0 CONTINUING PROFESSIONAL
DEVELOPMENT
OBJECTIVE To enhance the knowledge and
competency of nurses in current nursing
practice
NURSING A continuous nursing education program
STANDARD for nurses to enhance knowledge, skill
and competencies in meeting ever
changing technological environment
alongside numerous challenges in
nursing practice. CPD points are also
used in he application of APC for nurses
 4.3 STATEMENT
• Nursing supervisor to ensure CPD
achievements
• Nursing Unit to analyse and plan nursing
education and trainings
• Nurses to attend formal
courses/conferences/seminars/workshops/
CME
 5.0 NURSING ROUND
OBJECTIVE To ensure holistic care though
implementation of purposeful and
timely nursing round
NURSING Planned nursing care rendered in safe
STANDARD and holistic manner
 5.3.1 NURSING CLINICAL ROUNDS
• Done on regular basis for every shift
• Nurses involve in doctors and nursing
supervisor rounds
• Assessment and findings must be recorded,
inform immediately any irregularities
• All medical and nursing care plans to be
carried out
 6.0 SCHEDULING DUTY
OBJECTIVE To provide sufficient manpower in
delivering effective patient care
through a continuity of nursing
services for 24 hour per day
without interruption
NURSING Nursing fraternity shall maintain
STANDARD undistributed nursing services by
proportioning an intermingle of
junior and senior nurses on duty
 6.3.1 DUTY ROSTER
• All nurses to abide by duty roster
• Schedule of work depends on staffing
requirement and workload
• Nurses on duty who take a short break shall hand
over responsibilities to another nurse during the
break
• Public holidays to nurses on rotational basis,
availability and ward condition

• 6.3.2 ON CALL DUTY – must be on

 6.3.3 DEPLOYMENT
• Deployment documented
• Nursing supervisor can deploy and monitor a
nurse from a discipline to another within her
area due to shortage
• Deployment can be within same facility and
same district
 7.0 ESCORTING
OBJECTIVE To provide and maintain
appropriate safe care during
patient’s transportation
NURSING Safe transportation to all patients
STANDARD within facilities and inter-facilities
 7.3.1 STATEMENT
• The nurse who escorts
I. Know clinical information of patients to pass
to receiving personal/referral hospital
personnel
II. Monitor and record patient’s condition
III. Provide family members with information on
transfers
IV. Make arrangement for logistics and prepare
appropriate functional equiment
 8.0 ABSENTEEISM
OBJECTIVE To provide sufficient manpower in
delivering effective patient care
through a continuity of nursing
services for 24 hour per day
without interruption
NURSING Maintaining sufficient number of
STANDARD nurses to ensure continuation of
nursing services
 8.3 STATEMENT
• Frequent absenteeism due to illness shall be
referred to respective enquiry committee
• Nursing supervisor to monitor and record
attendance/medical leave
• Nursing supervisor may deploy nurses from
other wards due to staffing crisis
• Disciplinary action against nurse absent
without valid leave/permission/reason
9.0 FORGERY OF MEDICAL CERTIFICATE
OBJECTIVE To ensure nursing supervisor is
competent in managing forgery of
Medical certificate among nurses
as it is one of his/ her duty to
ensure integrity among nurses.
NURSING To ensure nurses do not commit
STANDARD forgery of medical certificate
 9.3 STATEMENT
• Nurses who have attempted to forge will be
referred to nursing supervisor
• Nursing supervisor to monitor and record
nurses behaviours and nurses on medical
leave
• Disciplinary action shall be taken against
nurses found guilty
• Nursing supervisor to receive written report of
forgery and submit to higher management
10.0 NEWS AND MEDIA RELEASED ON
PATIENT’S INFORMATION
OBJECTIVE To protect the confidentiality of
patient’s information
NURSING Nurses shall not disclose patient’s
STANDARD information to anyone through any
mode of communications except to
other health care professionals who
contribute care to the patient.
Information shall be maintained
confidential at all times
 10.3 STATEMENT
• No release of patient’s information directly or
indirectly
• Disciplinary action for disclosing
 11.0 DISCIPLINARY ACTION
OBJECTIVE To oversee all nurses to render safe, quality and
effective training practices
NURSING All nurses shall comply with
STANDARD I. Nurses Act 1950 (ACT 14)
II. Midwives Act 1966 (ACT 436)
III. Nurses Registration Regulations 1985 (P.U.( A)
494/1985)
IV. Midwives Regulation 1990 (P.U.( A) 181/1966)
V. Code of Professional Conduct and Practice of
Midwives
VI. Other related Acts, Regulation, rules and guidelines

• Nursing supervisor informs Chief Matron misconducts

happened
• Chief matron informs State Matron
• State Matron takes remedial action and notifies
Nursing Division
• Director of Nursing Division notify the Malaysian
Nursing Board
 12.0 OTHER
• 12.1 Participating in Singing and Beauty
Contest or any other Entertainment
Competition/Event
I. Allowed without violating Peraturan
Peraturan Pegawai Awam (Kelakuan &
Tatatertib)
II. Require permission from HOD before
participating
 12.0 OTHER
• 12.2 Cleanliness Practices
I. Hollistic hygiene for patient safety
II. 5 moments of hand hygiene by WHO
a. before patient contact
b. Before aseptic task
c. After bodily fluid exposure
d. After patient contact
e. After contact with patient surrondings
 12.0 OTHER
• 12.3 Adhere to the rules and guidelines set by
MOH and rules applicable to civil servants

• 12.4 Adhere to National Principle of Malaysia

5 principles of Rukun Negara
1. Kepercayaan kepada Tuhan
2. Kesetiaan kepada Raja dan Negara
3. Keluhuran Perlembagaan
4. Kedaulatan Undang Undang
5. Kesopanan dan Kesusilaan