Tuesday, April 27, 2010

Organisational professionalism

I posted a comment in Bone Collector's blog entry on professionalism. Thought it's worth posting here for reference.


Hi Bone Collector,

It's so strange reading your slow and steady grooming into your ICU role.

Over here in sunny Singapore, I have the opposite problem. I am less than 1 year into the nursing profession but there are times when I'm the 2nd in-line in "seniority" by job title [Edit insert: and/or years-of-nursing-experience, on that shift]. Officially, my ward is an acute paediatric ward, but we get dumped with all kinds of patients (as another ward's staff puts it, "Might as well call your ward the General Ward."). The management's refrain is "you are trained as a general nurse, you should be able to handle all these cases". But hey, who is responsible if/when a HDU case collapse at my ward when we are not staffed to handle such acuity levels? [Edit insert: Nor do we have the resources within the ward for the variety of adult patients we receive. The ward has only a limited amount of basic adult items e.g. the adult emergency trolley.]

I'm not joking. I have been lucky so far. Twice on my shift, we had severely ill cases arriving at my ward, thanks to the A&E doctor's mis-diagnosis.

My ass was saved once by the consultant arriving early and immediately recognising the severity of the case. We did emergency interventions at the ward, and sent the patient to ICU for further stablization, before the case was transferred to another hospital. The patient died soon after at the other hospital. [Edit: Note this 10-Feb-2010 case was admitted as "Febrile Fit", subsequently diagnosed by the consultant as status epilepticus, and came up in the 25-Feb-2010 local news as "5 year-old boy dies of H1N1"].

[Online news extracted from TODAY]
Five-year-old boy dies of H1N1 flu
By Zul Othman, TODAY | Posted: 25 February 2010 2115 hrs

SINGAPORE : A five-year-old boy has become the latest - and one of the youngest - person to die from the Influenza A (H1N1) virus here.

He was said to have caught the virus from his uncle, and was admitted to KK Women's and Children's Hospital (KKH).

The boy was in critical condition over the Lunar New Year holidays. It was not clear when he died, as KKH was unable to provide details at press time. It is also not known if his uncle has recovered.

The death is possibly the first since the Ministry of Health (MOH) downgraded its H1N1 flu alert status from yellow to green on February 12.

Before this, the youngest reported H1N1 victim in Singapore was a two-year-old boy, who died in November last year.

MOH stopped reporting H1N1 fatalities after the virus was treated as part of the seasonal flu strains circulating in the community. As of September, the number of H1N1 deaths stood at 18.

According to the latest figures from MOH, the prevalence of H1N1 among patients with influenza-like illness was 28 per cent.

Overall, there are no signs of a significant rise in influenza activity in Singapore, according to the ministry. Last week, a daily average of 2,799 patients sought treatment at polyclinics for acute respiratory infections (ARIs), compared with 2,421 the week before.

The weekly number of polyclinic attendances for ARIs has also largely been below the epidemic level since early August last year.

But the official advice for those who have yet to get immunised is to get their jabs. As of early January, more than half a million vaccines remain uncommitted. - TODAY/ms

Another time recently, my senior staff nurse [Edit: SSN Y] happened to recognised the patient's Cheyne-Stroke breathing during IV cannulation and insisted that the consultant (a different doctor from the above) re-assign the "Acute Asthma" patient to ICU. We were informed that the patient deteriorated at ICU and needed to be intubated. He was subsequently transferred to another hospital.

My colleagues were not so lucky with incidents happening at their shift. As a result, each staff who has cared for the patient throughout his/her stay has to write a report of their assessment and care of the patient during their duty shifts. Those who were unlucky enough to be on-duty when the incident happened have to face management's (IMHO, "investigate and blame") process.
[Edit: E.g. SN L and SSN R who were hit with the 21-25 Feb-2010 "Febrile fit ?UTI" case that became lymphadenitis as diagnosed by the principal consultant (who is a very experienced paeds cardiac specialist). After being transferred to another hospital, the patient was re-diagnosed as "Atypical Kawasaki"* at the other hospital. According to the principal consultant's sources, even with the revised diagnosis, the new hospital had difficulty pinning down the actual diagnosis and were treating "blindly". Luckily for SN L and SSN R, the consultant also sided the nurses wrt the difficulty of caring for that case. Note *: Paeds cardiac specialists are especially familiar with Kawasaki disease due to its potential death from severe coronary/heart aneurysms.]

That's why I am eager to leave. I don't wish to put my nursing license at unreasonable risks. We are already fully stretched [Edit: more like overloaded] now. Yet, we will be taking more patients with the same staffing when the new patient rooms are opened for use.

Monday, April 26, 2010

19 weeks to go

I was going to reply to Bone Collector's previous comment and then I realised that I had a long rant on my hands instead. So, here goes.

[Note: I wonder if this "pick-a-victim" strategy is part of the negative reaction by colleagues (which my ex-nursing lecturer warned me about) to news that I was migrating. See comments section in the link on how/why that news leaked out.]


It's hard to imagine it's a week since that fateful busy-like-hell end-of-shift on 18-April-2010 evening where suddenly my ward had a serious of continuous admissions.

We had only 4 staff on-duty on a "quiet Sunday afternoon" (per the ward manager's expectations). SN J was in-charge overall, I and SEN L were taking teams (i.e. responsible for medications and passing report). Senior HCA K was running back-and-forth as our shared HCA. After 7pm, I had 2 new admissions. 7pm-8:30pm was our typical evening medication rounds and taping report time, so you can imagine I had to juggle the admission and interventions for the 2 new cases. Due to higher priority of interventions that needed to be done, I did not complete the 2nd new case's admission notes as ordered by SN J, who was sitting pretty at the counter.

Things got worse from 8:30pm onwards. I had another series of 4 new admissions. HCA K was upset that she had so much work to do. Both SEN L (with 9 patients, 1 discharged in late evening and 1 new admission to attend to) and I ( with 5 existing patients, 1 discharged at 5+pm, and 6 new admissions) were too busy on our medication/report rounds to assist her. I showed the new patients to their rooms, briefed them on the call-bell and returned to my rounds. I assisted the consultants with some of the IV cannulations and interventions, but had to interrupt medication interventions for the new patients to pass verbal report to the night staff. It was already around 9:20pm. While passing verbal report to the night staff, the HCA came shouting at me in an accusing tone that my patients (including new ones) were waiting for their IV drips and medications. Well, I cannot predict in advance which of the existing patients would suddenly have a temperature (after I was done with their evening medication rounds), can I?

Night staff took over. SN RO (recently promoted to Senior SN) was the most senior staff on-duty, together with SEN MY (because the usual night staff had a sudden family condolence to attend to) and night HCA L. SSN RO was her usual abrasive self. She complained that we are so messy that all the samples taken were not labelled and that we had not admitted the all the patients yet (well, some came at 9pm, the official start of her duty). It's not our fault that the samples were not labelled simply because the A&E staff and the porters in their rush to end their shift quickly, simply dumped the patients to my ward without first bringing them to Admissions Office. At least we did the tough work of IV cannulations and obtaining most of the required samples and clipped them to the respective case-notes (as per the ward's usual practice). The night staff sashayed into the obviously busy ward, but refused to come out to assist until all the reports were passed, by which time it was 9:45pm. As a result I stayed 1 hour passed my duty hours and left around 1030pm, even though I had a double shift (morning and afternoon) the next day.

The next morning, the ward manager was somewhat muted in her response to my 5 minutes late arrival, saying that she heard that we had a busy evening. I did not mention anything as I did not wish to complain. In the afternoon when both SN J and HCA K were on-duty, the ward manager gave all the morning and afternoon staff a earful about how messy we were, how we even made a mistake, how the new staff just aren't fast and good enough. Then SN J and HCA K both verbalised their share of complains, indirectly aimed at me. Then the ward manager cut me off before I could have my say. I was pissed off.

HCA K did not mention a single thing about me helping her with the serving meals to more than half the ward earlier that evening when I had the time. Instead she focused on that she had no help with the arranging the beds and water jugs for the flood of admissions and that she was harassed by parents asking for medications that night. No help? I was the one who showed the patients to their rooms for most of the new cases and settle them down because I knew she was busy with a series of new admissions. I even helped her with the dinner orders for 2 of the new admissions. Compared to the night HCAs who would help the night staff with admission interviews, HCA K is not as supportive of the staff, albeit it was a busy time for her. Hey, she was busy with the new admissions, so was I with the same new admissions. As for the medications, it when she saw and knew that that I was busy passing verbal report when she came to me about medications the night before (see above).

Similarly, SN J implied that I was MIA after 2 IV cannulations were done (in fact there were 3 that I was involved), such that she had to prepare and assist the doctor with a T&S. SN J did not count the 1 more IV cannulation (where I prepared everything and went out to get SN J's assistance when the consultant was ready) where the consultant was unassisted because SN J was ignored my request for assistance, continued discharging a patient and insisted that I assist her to check the discharge medications and that I answered the incoming phone call! Hello? Where is her sense of priority as the in-charge?

Finally, the pieces that took the cake.
  1. When the ward manager lectured us, she said that we need to be better at teamwork. In addition, the new staff are just not good and fast enough. That the new staff still are unable to prioritise our work [Note: What a big joke when one think of SN J's behaviour above.]. Previously her ex-staff could manage a much heavier patient load without issues. Perhaps she was talking about senior SN S who left and re-joined the hospital. Hey, she did not re-join the ward despite there being vacancy. Why? My thoughts then were, if the old staff are that good, please fire us newbies and pay your old staff to clean up the shit for you instead.
  2. In addition, the ward manager lectured that we were so messy, with "samples all over the place". Well, I don't know how the samples were all over the place when the ones I took were packed nicely into ziploc bags and clipped to the case notes as per ward standard for unlabelled samples.
  3. Finally, that we even make mistakes on top of not being fast enough. I didn't know what she was talking about although it was evident from her body language that it was directed at me. Only that evening, when SSN RO was on-duty again, that she told me "nicely" (after having backstabbed me) that I had put up the next pint of the IV drip on the wrong rate (half of the required rate) because I interpreted the order wrongly in my rush. Hello? It was almost 1030pm, when the IV pump beeped due to the completion of the previous pint, the night HCA could not get SSN RO time to replace the drip because she was busy with the new admissions. Thus, I offered to help, despite it being way past my official hours. Yes, I made a mistake in the drip rate [I reduced it to 1/2 the original rate 2 pints too early], but was it necessary to make such a big complaint to the ward manager over the plain IV D/Saline drip? She could have told me that very next morning when she handled the patients over, but nope, not a word from her until the next night (after the morning backstab). I just wanted to do the best for our patients' interest by offering to help, but 好心沒好報 (i.e. "kindness does not beget kindness in-return"). I should have just left SSN RO with her patient's IV pump beeping away.

On the 19-April afternoon, SN J was again in-charge and HCA K was again my runner. The other team had SN RB, another newbie SN, taking team. SN J pushed an A&E takeover form and insisted that I signed it. But after her backstabing antics, I signed it but told her off in her face, "Why is it always I have to sign it? Anything going wrong, I have to bear the rap, isn't it?"

Another 2 new admissions came in. Again SN J just pushed the admission interview forms to me (while sitting pretty at the nurses station again), insisting that I complete them stat (when the hospital policy allows 4 hours for the completion of the paperwork, and that interventions for the patients should take priority). Having completed the 1st admission interview form and in the midst of interventions for both new patients, I told her off, "I will complete the admission form for this patient later, this is not so urgent. I have more important things to do."

Later that day, I was in the treatment room assisting a consultant Dr I.C. with IV cannulation for one of the new cases. Thereafter, the consultant ordered stat interventions for this pre-term infant with respiratory problems and history of severe asthma. As I was returning the patient to her cot, I heard HCA K was shouting angrily down the corridor to SN J that she had 2 patients' NOKs asking for medication [Note: One of them had low-grade temperature, and the other was waiting for IV antibiotics]. Thus, I told SN J, "I was in the treatment room assisting Dr I.C. with this baby with severe respiratory problem, you saw it, and you know it. If anyone is going to complain, you know where I was."

Later, I heard HCA K grumbling to SN J as I walked passed. Both HCA K and SN J are from the same ethnic group, although HCA K is local and SN J is a foreigner [click here for my impression of HCA K with respect to racism/ethnicity]. I told her off. "K, I have had enough of back-stabbing here. I am not a back-stabber, so I am telling you in your face. I could hear you shouting down the corridor that I did not give medications to the patients. You are an experienced staff*, I was handling an infant with severe respiratory problem. You should know better than to expect me to drop the baby and attend to the other patients." [Note*: HCA K had been working in the hospital for 40+ years. SN J was with a restructured hospital for around 5 years and then joined my ward for around 3 years. HCA K would have known that the new case was an infant with respiratory problem as she had to prepare the cot for her admission.]

HCA K defended herself, "I am not shouting, I was just telling SN J that I couldn't find you and there are 2 patients who are waiting for their medications."

Hello? Speaking in a loud voice that one can be heard from a distance of more than 15metres away is not shouting? Plus, that annoyed/blaming tone of the loud voice? I told her, "I was in room xxx, and I could hear and see you were shouting from outside room yyy." And I left it at that.


Recently, it was found that the admission assessment notes was not done at all for one of the patients admitted on the chaotic night of 18-April-2010. The night staff SSN RO claimed to have taken-over and cleaned-up all our mess, but she did not complete the admission interview either. Neither did she passed over in the morning report that it was not done. Nor did any of the subsequent staff noticed that it was not completed, even during discharge (which was done on the last page of the same said admission assessment form). Someone (probably the admin staff) found the uncompleted form while checking through the discharged case notes and left it in-full display for all to see in the treatment room's notice board and then moved it to the nurses' room for continued display. I am going to leave it at that. I will not clean up after a back-stabber has claimed credit for doing something which she has not done.


Anyway, in short, I am pissed off with 3 of the staff (1 night and 2 day staff) for backstabbing me, and relationships are still not back to normal, even I though still do my tasks as per normal.
  • E.g. Yesterday, 25-April-2010, HCA K took the temperature more than 1.5 hour late for 1 of the patients and charted it under the 6pm slot. The child was afebrile until that point. This time around, HCA K did not bother to inform me of the febrile case, which I might have missed if not for my decision to check the patients for another round before I knock-off since I had some time. What did the ward manager say about teamwork and how good her old experienced staff are?
  • E.g. Today, 26-April-2010, SN J had taken over my patients from me, as I was in the morning shift and she was in the afternoon shift. At around 3:30pm, a patient's mother came out to complain of rashes on her son's buttocks due to acidity from the diarrhea. I had changed out of my uniform and was sitting at the nurses' counter to complete my paperwork. The mother knew that my shift was over, but recognised me and requested for help, since no one else was at the nurses' counter. I took down her request and passed to SN J. However, she tried to push it back to me, "What time did this happen?". I told her, "The child BOx3 watery stool this morning and the mother just...". Then she cut me off, "You handle it. I am busy now. Or you get SSN Y to handle it." Anyway, I passed the matter to SSN Y and left it as that.
One consolation. SSN Y, SSN R and SEN M were quite kind to me for the past week. They had experienced such shit before too.

My other consolation: 19 more weeks to go.

Monday, April 19, 2010

Target board on my back

I am angry, very angry. I feel like I'm wearing a target board on my back; getting "stabbed" left, right and centre. I am so angry that I don't even want to talk about it.

My consolation? My countdown -- 17 20 weeks to my last day at work. My mind is set already and the appropriate letters are just waiting to be printed, signed and submitted.


[Correction on 22-Apr-2010]

It should be 17 weeks, not 20 weeks as previously stated.

Monday, April 05, 2010

Good Friday and Excellent Easter

I had not been feeling well on the Thursday, the eve of Good Friday. Thanks to help and support from my colleagues (especially SEN M, SN O, SN L and SSN R), I survived my double shift on Thursday.

On the morning of Good Friday, the ward manager cancelled my afternoon shift due to low patient census. I was glad to take a break.

Saturday and Easter Sunday were happy working days. Thanks to the Good Friday and Easter festive season, the patient census remained low. Each team had a load of 4-7 patients. It puts the staff in a good mood, and resulting in a cordial working environment where staff were supporting each other. From the customers' perspective, they get better treatment and service.

It leads me to think, the first and major factor towards improving nurses' professional image would be to improve the staff-patient ratio.


p.s. This is my 100th blog entry. A milestone on my internet journal journey.