Made it through June, yeah!

Today is the 19th day of taking team for me. Made it through June, yeah!

Took the team with the rooms near the nursing station today. Started with 5 patients, of which 2 discharged by mid morning or early afternoon. Then 2 new cases arrived after noon, so the final total was still 5. Managed to complete the blank pharmacy billings and medications to-do list right after report passing.

2 SN (L and I), 1 HCA M and 1 SEN IV as runners (SEN IV on my team), the ward manager (NO) was in-charge. The admin staff M was also on-duty. The morning started off rather well. My patients were all in stable conditions. Served medications on-time, assisted 3 doctors on their rounds, discharged 2 patients, completed ward billings, answered call-bells, answered phone calls to the ward, reviewed case notes, documented events into nursing notes, and completed my flowcharts for the 3 remaining patients all by 1240pm. I even had time to assist the runners with meal ordering and entering, replacing missing patient information boards in the patient's room and preparing a room for new admissions.

Just as I was starting to tape my team's report around 1pm, there were suddenly 3 new cases of which 2 were for my team. From then the confusion started with the numerous admission related tasks to be done, diagnostic tests, referrals and medications to follow-up. SN L was busy with the new case on her team and could not help. Even with assistance from SEN IV and admin staff M, I did not finish with the items related to the new cases and had to pass report orally for the afternoon staff to follow-up. Luckily, my preceptor was on-duty in the afternoon and she reassured me that she will take-over and complete the outstanding tasks. I am really grateful to have her support.

2 challenges faced today.

1. NO's ideal expectations vs reality. This morning there was a doctor who came while the SNs and EN were busy with the morning routine. Given that we were busy, the doctor told us to continue with our work and that he didn't need any assistance. The admin staff offered our assistance again and the considerate doctor declined. SEN IV and I carried on with our work. The NO saw and insisted that we drop our work and assist the doctor instead. I grabbed the case notes and we (SEN IV and I) rushed after the doctor who was already at the patient's doorway at the end of the corridor. Then the NO came after us and lamented that we should be leading the doctor, not running after the doctor. I passed the case notes to SEN IV for her to assist the doctor. I was preparing an IV antibiotics that was due, so choosing to assist the doctor may result in a delay in medication that would provide fuel for another lament.

2. Simultaneous admissions of new cases during critical ward-busy time. There were 2 new admissions to my team, both arriving around 1pm. Confusion started with the arrival of the 1st child. Because the child vomited on the journey to the ward, the NO instructed SEN IV to bath the child immediately as per the mother's request. I completed the on-admission nursing assessment, administered the initial nebulization, prepared the oral medications and the diagnostic test forms for the case. The mother requested to delay the oral medications as the child was sleeping. SEN IV took the child's vital signs and applied Elma cream and while the admin staff called for the diagnostics staff to arrange for CXR. Even after the diagnostics staff returned the child from the CXR, the mother had not registered the child for admission, and thus the child's case labels were not available. By then the child was awake and I administered the 1st dose of PO medications. Since the consulting paediatrician was coming for a review of the case, I decided that there was no need to call the RMO (extra charges) for the blood tests and IV cannulation ordered. By then, the 2nd child arrived and I showed them to their room. I was looking at the specialist clinic's notes on the 2nd case and preparing the diagnostic test forms, when the 1st child's paediatrician came. Without even finding out why, she commented, "why so slow" that the child's IV cannulation was not done yet. Anyway, the NO and I assisted her with the IV cannulation and set-up the drip which she only ordered on-the-spot. Then the mother decided to upgrade to the deluxe room and HCA M and I moved their items to the new room because SEN IV was busy. This resulted in a delay in attending to the 2nd new patient. Seeing that I would not be able to complete this admission and the outstanding nebulization due for a current patient, I tasked SEN IV to do the initial nursing assessments. I quickly started the nebulization for the current patient, and returned to the 2nd new case to administer oral medications and started the nebulization. Then diagnostics staff came to collect the 2nd new patient while the nebulization was in progress. The NO instructed that we interrupt the nebullization to let the child go for CXR 1st. I hesitated, the IMR record of the nebulization timing would have to reflect this non-standard interruption. Fortunately the NO changed her mind and said to finish the nebulization first. Thereafter, I went to pass oral report for my team to the afternoon staff.

Had time for tea, but did not have time for lunch or toilet break. I was actually somewhat hungry, but did not feel like eating at the staff room after a stressful early afternoon. In the end, I took my packaged lunch home and ate only around 4pm. Emoticon for the day :-|

p.s. I was surprised to see SN L sitting at the bus-stop when I knock-off half an hour after my official shift time. I went over to chat with her, to ask her why she was still there despite having left earlier. It turned out that she was so tired that she fell asleep while waiting for the bus and would have continued if I had not approached her. My experience is similar. I often fall asleep on the bus journey home even though it is a short trip of less than 15 minutes.

Relaxing day

Took the team with the rooms near the nursing station today. Started with 4 patients, of which 1 discharged by late afternoon. Managed to prepare the medications to-do list before taking report.

2 SN (L and I), 1 HCA M as runner and my preceptor as in-charge. There were a total of 11 patients at the start of the shift. Today was a breeze. Had time to check through the pharmacy billings by the morning staff, update the ward billings along the way, serve medications on-time, answer call-bells, answer phone calls to the ward, review case notes, document events into nursing notes, assisted with an IV cannulation, top-up supplies in the treatment room and medication trolleys, help to serve dinner, and monitor some vital signs. I off-ed some hourly monitoring as soon as possible to cut down the sole runner's workload. By 8:40pm, I completed the flow charts and taped my team's report. While the night shift staff were taking report, a new case came and I handled the admission assessment.

At one time, my preceptor, SN L and I chatted at the treatment room as we made custom splints for infant use. Then a doctor arrived to review his patient. Although the doctor's patient was under my team's care, I did not move as I did not recognise him. Thus SN L stepped forward to assist the doctor instead. One of my areas for improvement is to recognise the regular consulting doctors.

Had time for tea, toilet and dinner break. HCA M shared some snacks from Australia as she had visitors arriving from there. SN L, HCA M and I are on-duty together again tomorrow morning. The ward manager will be in-charge. SN L and HCA M are genuinely helpful and supportive. Glad to be working with them. I am also thankful for the support and supervision from my preceptor.

Period blues

Took the team with the rooms near the nursing station today. Started with 6 patients, of which 3 discharged mid-to-late morning. Went in earlier to prepare the blank pharmacy billings and the medications to-do list.

SSN R and I were taking teams. HCA K was the only runner today for the whole ward of 13 patients, including 1 elderly adult lady. SSN Y (my preceptor) was in-charge. Before the shift started, I thought today would be a breeze, given that the 6 patients were rather stable and 1 was confirmed for discharge, and I did not have any medication pending supply urgently. Early in the shift there was a delayed medication in the morning. More about it below. Then accompanied a doctor on his patient review. Then in view of the confirmed and KIV discharges, I started entering the pharmacy billings forms and ward billings. The breakfast trolley arrived while I was updating the billings and preparing a morning dose of IV antibiotics for a neonate, and HCA K was busy taking the 6am round of vital signs monitoring (which was normally done by the night staff). For some reasons, SSN R instructed me loudly to serve the breakfast 1st, then my preceptor SSN Y heard and and repeated the same instructions. I didn't feel good about it. I was planning to serve breakfast once the antibiotics was ready. However it seems that the SSNs did not understand so, even given my usual initiative on such matters. After the rush to serve breakfast, I forgot about the interrupted antibiotics preparation and attended to other matters instead. Then my preceptor reminded me to get it done stat. I quickly completed the IV antibiotics and continued with preparing PO medications for the neonate. While I was doing that, another doctor arrived to review another child and I had to attend to her. The doctor decided to discharge the other child, so I started with the discharge paperwork. However, I was interrupted to attend to call bells, phone calls, and medications due. With interruptions upon interruptions, I missed out the housekeepers' request for the air-con man to clean a vacated isolated room's air-con, despite their repeated requests. I don't feel good about it. In the end, the discharges were completed by my preceptor. By late morning, I was exhausted and wondering if I would even have a toilet break, as I suspect my period had arrived. Managed to give all the other medications on time, completed the pharmacy billings and ward billings, the flow charts and taped my team's report before the end of the shift. However, in my attempt to append to my team's report, I accidentally cleared my earlier report and thus had to pass report orally instead.

------------------------------

There was 1 medication due in the early morning postponed from the night shift staff because the child was sleeping and the grandmother wanted to wait for the child to wake up. It took several attempts spread over 3+ hours to complete that dose. When I first checked on the child at 730am, he was still sleeping. When the child awoke, the grandmother insisted on adding the medications into 200 ml of milk which child completed only half. Then the grandmother insisted on waiting until after the child had his breakfast porridge before feeding the child the remaining medication. However, the doctor came in for review and the grandmother noted to her about the incomplete medication. The doctor probably wasn't pleased, because my preceptor instructed me to top-up for the shortfall stat, by PO neat. In an attempt to coax the child to drink, the grandmother fed the child with fair amount of water immediately prior to the PO neat medication. While struggling against his medication, the child vomited a fair amount of fluids and undigested porridge together with the PO neat medication. Thus we had to wait another 30 minutes to an hour for the child to digest before a next attempt. Thereafter, I warmed up the remaining 100 ml of milk because grandmother wanted to feed the medication-in-milk instead, but the child refused to drink. At my next attempt, the physiotherapist was about to suction the child for mucus for diagnostic tests. I helped with the suctioning which was quick and, of course, the child struggled. Then the grandmother warned the child angrily that if he refused to swallow the medication, he will have to undergo further suctioning. Finally the child co-operated and swallowed his PO neat medications. By then it was almost 11am.

Lessons learnt: Always advise care-givers to give medication before food, not after food, unless otherwise indicated. In addition, medications should be taken with minimal fluids, to reduce changes of regurgitation by child.

------------------------------

Did not have a tea break. Finally after 12 noon, I took a quick toilet break to wear a sanitary napkin for my period. My panty was already stained but fortunately not my uniform. Thankfully, a housekeeper offered to pack lunch for me around 12 noon and around 1pm I had a chance for lunch (which was also interrupted). At the end of the day, I felt exhausted and blue. I put it down to a combination of having high expectations of the day which fell through, not enough sleep due to the PM to AM shift switch, and the arrival of my period. I have 2 weeks to go before the new nurses orientation and training. Am counting down to it.

p.s. A major challenge of an SN is the numerous interruptions-upon-interruptions to her work. At some hospitals where there are more supporting staff (admin staff, ENs and HCAs), the SN on medication-round wears a vest indicating that she is not to be interrupted. This and other work processes to structure an SN's time are not implemented in my hospital. This is probably due to limited staffing and the customer service expectations (from consulting doctors, their patients, and the patients' visitors) of a small private hospital. Given the hierarchical staff structure of the wards, being an experienced staff in the ward also helps to manage the interruptions.

Pay day!

Took the team with the rooms near the nursing station this afternoon. Started with 7 patients, including 1 new case admitted in the early afternoon pending the doctor's review during report passing. After 2 discharges in the mid/late-afternoon, left with 5 patients. Went in earlier to review the pharmacy billings and prepare the medication to-do list.

There were 2 SN (L on double-shift and I), SEN IV as runner (for both team 1 and 2) and SSN R as in-charge. The ward manager was on-call, and was physically in her office until evening. During report passing, the blank IMR for the new case was taken by the reviewing doctor to write her prescriptions. In addition, another doctor arrived and took the IMRs for his 3 cases. Thus during report passing, I had only 3 of the 7 IMRs for reference and felt a little confused. Right after report passing, there was 1 IV cannulation and other follow-up actions for the new case, 2 discharges, and 2 cases of fever spike all happening together on my team. Luckily my colleagues helped. SEN IV autonomously managed the neonate fever case with cold compress and tepid sponging as there was no antipyretic prescribed due to its age. SSN R helped me with the paperwork for the discharges and discharged 1 case, while I followed up the new case. Even SN L offered help. Parents of the new case wanted to stay overnight but their son is above our cut-off age, and thus an overnight companion is not allowed in a shared room without medical justifications. More about this later. 1 delay to the early afternoon medication as the IMR was stuck with the doctor doing his reviews. Fortunately by mid-afternoon the confusion settled down. Managed to follow-up the rest of the medications on time, explained the for-home medications to the parents of a discharged patient, updated events in the nursing notes, added items to the pharmacy billings, and entered the ward billings into the system. As the runner was busy when the dinner trolley arrived, I served dinner for the ward. Near the end of my shift, I completed my flow charts and taped my team's report.

------------------------------

The new case was a 13 year-old boy turning 14 this year. His mother was fussing about him in the early afternoon while he seems to be sleeping away. When she was told of the hospital policy initially by my morning colleague, she requested for a single room so that she could be a paying overnight-companion for her son. However, a single room was not available at that time. When I took over and advised her that a suite was available, the mother insisted on speaking to the supervisor about making an exception for her request to stay overnight with her son (i.e. without additional charges in the shared room) instead of considering the suite. Later, even when a single room was available, the mother still did not want the room but wanted us to make an exception for her, claiming that her son was too young to be left alone. Yet, she left her son alone in the mid-afternoon. After she left, her son was actually more awake and alert, spending his time watching TV. In the evening, both parents returned. When I asked the father if he still wanted the single room, his 1st concern was whether his son coped with being alone that afternoon. I replied the parents that their son seems fine and was watching TV. Then the father decided that neither parents need to stay to accompany the son that night.

------------------------------

Did not have tea or toilet break, but had time for dinner. Nevertheless felt rather contented at the end of my shift. Was also very happy to receive my payslip today. It reminds me that I have survived here for almost 1 month. It would not be possible without the help and support of my colleagues.

p.s. SSN R, who has her own teenaged son, commented that the mother of the new case pampered her son too much. She felt that at 13-turning-14, a teen should be more independent, otherwise the boy would not survive NS (national service conscription). I agree. My mother molly coddled one of my brothers. My brother never mentioned it, but my sister heard from other sources that he did not fit during NS. Now even as an adult in his 30's, he still lives like a dependent child with my parents.

Runner

Today I am the runner for both teams 1 and 2. Started with 12 patients. There were 2 new admissions, 1 arrived early afternoon, the other late afternoon. Added to that, 1 case transferred-in early afternoon and was discharged by mid-afternoon. Of these, there were 2 elderly "risk for fall" adult females (in 4-bedded), and 2 adult males in a double room. Of the paediatric cases, there were 5 isolation cases, of which 2 required gowns, gloves, and mask.

Limited staffing today. Only 3 SN (L, O, and I) and my preceptor in-charge. Thus I was the only runner (literally) for the whole ward of about 14-15 patients. Managed to serve tea and dinner, complete the outstanding meal orders, monitor the 4-hourly vital signs, chart and sum the intake-output, monitor some patients hourly (off 1 case that was no longer critical), enter a couple of ward billings and attend to some call bells. Had to spend a lot of time assisting a risk for fall case to toilet, urine collection and body sponging. In the end, SN L and O had to cover some of the hourly monitoring entries, call bells, etc.

Glad that the day is done. Fortunately I managed to have tea, dinner and even 1 toilet break (towards the end of the shift). I am so physically exhausted. Luckily I turned down the request to do double-shift tomorrow. I need the extra sleep-in tomorrow morning to recover from today's busy shift.

p.s. The housekeepers mentioned today that they like having me around, because I would still be cheerful when the ward goes crazy-busy.