Controlling behaviour

In response to StorytellERdoc's blog entry titled "Who am I treating?".

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We get such controlling behaviour rather regularly in Singapore. Unfortunately, management and the work culture (it's a private hospital) tends to bow down to patients/NOKs who raise hell, so it becomes a recurring pattern on their future admissions.

I am in the Paediatrics, so parents have an "excuse" to provide information regardless of the child's age. Some parents seem to think that their treatment demands should be met, although our professional assessment of patient may indicate otherwise. It can be an annoying situation. [Edit: Come to think of it, even the consultant doctors face such demands. Although they face it less frequently than the nurses, IMHO, due to parents having more respect for a doctor's assessment.] Then again, IMHO such controlling behaviour often extends beyond just treatment demands (e.g. demand to jump queue for private room).

E.g. Recently there is a case that should rightfully belong to High Dependency Unit (HDU) but is nursed at acute ward levels. Ostensibly it was for the hospital's compassionate image in catering to the parents' budget issue. However, it results in overloading the ward nurses with HDU work in a busy acute ward short on trained staff.

The child was admitted because of infection from a previous ventricular shunt inserted at an overseas hospital. The mother was obsessed with the patient's temperature, because she wanted to keep the child afebrile to have a ventricular shunt inserted sooner and to prevent seizure. The child was still suffering from on-and-off low grade fever, and we followed our nursing protocols.

One day the temperature spiked from afebrile to 38.2 degC (100.8 degF) in-between an hourly temperature monitoring. The patient's mother was verbally nagging and blaming the nursing staff non-stop (especially me since I was in-charge of his medications that shift) for not monitoring him more frequently (on-demand) and not giving him the anti-pyretic while he was afebrile. She was demanding that I give paracetamol STAT via NGT, while I was preparing the patient's STAT IV Albumin drip order at his bedside. [Edit: I told the mother that I will feed the NGT paracetamol after I had set up the very important Albumin treatment. Nevertheless, she went on threatening and complaining of poor nursing care.] I finally told her, "I am handling a very important treatment for your child, please can you give me a few moments of peace to ensure that this goes correctly?"

The mother screamed "You cannot talk to me like this!" and repeated her broken record of why because of our treatment that her son is now having "high" fever. [Note: her son came in due to an infected shunt inserted overseas and had been febrile on-and-off since admission.]

The mother never paused for a moment to let me focus on her son's more important STAT Albumin treatment. I hit my tolerance limit. [Edit: I reiterated to the mother that I will feed the NGT paracetamol after I had set up the very important Albumin treatment.] I told her firmly that we have our protocols for managing a patient's fever, especially in preparation for operation, we don't want to mask any underlying infection and we were handling her child as per protocol. She disregarded my explanation and still raised her voice and continued to blame us. Finally, I told her that if she is not happy she could lodge a complaint. That I was there to help her child get well, if it were for her, I won't care either way. I continued with my work while her husband spoke to her in their language (presumably telling her to tone down), and then she continue running her broken record at a lower volume.

When the patient's consultant PHK came, we informed him of the incident details after he reviewed the patient. Fortunately for me, this consultant was fair to nurses. He returned to the patient's bed and told the mother that we the nursing staff are competent in our work and had been doing her family a huge favour in cost savings by treating her child at the ward. She had been privileged to received such good nursing care at lower cost (and free doctor's consultations). However if she insists on demanding interventions her way, he will re-assign the patient to HDU and she will have to foot the full bill.

That lecture bought us some peace for a while. I was glad the consultant was the one who dealt with the parents. Sadly, I am not confident that my hospital management would have been so supportive of its nursing staff.

Time to change tune

I have had sore throat and cough for more than a month. It's the longest that I've been coughing persistently since childhood [when I coughed over 3+ months, and I suspect, resulting in asthma]. Over the past 5 weeks and 6 trips to my hospital's A&E, my diagnosis has changed from:

1. URTI, to
2. URTI with Eye Infection, to
3. ?Sinusitis, to
4. Rhinitis [after Sinus-XR ruled out sinusitis], to
5. Acute Bronchitis, to
6. Acute Bronchitis with Asthma.

After 3 rounds of antibiotics [Augmentin, Ciprofloxacin, Zinnat], switching between cough suppressant and expectorant, loads of mucolytic and lozenges, some painkillers and Sofradex eyedrops, I am still having chesty phlegmy cough on-and-off, resulting in persistent sore throat and an attack of bronchospasm (on my 1st night-duty, self-diagnosed based on pain radiating from right sternum to the right middle lobe of lung). Yet, over the 5 weeks, I have been given only 1 + 2 + 2 = total 5 days of sick leave. Knowing the hospital's HR policy and culture, the resident doctors are reluctant to give any more than 2 days of MC each time. I wonder how it can be cost effective for the hospital not to give staff a week's sick leave to fully recover from illness. I know I'm not the only one returning back to work just as my health improved slightly, only to get worse. SSN Y also only got 2 days MC and returned to work with a hoarse throat. Similarly for my ward manager.

Given the hospital's severe shortage of nursing staff [and now even the resident doctors], the message I get from its actual operations is that staff's health can take a back seat to reaping in the profits, regardless of whatever management or its policies state. In fact, down the line of hierarchy, someone somewhere would re-interpret the policies to suit their vested interests.

E.g. There was a recent incident where we had an physically+verbally abusive 7 year-old girl with brain tumour and her equally verbally abusive mother. Despite what the DON said to me about taking staff abuse (physical or verbal) seriously, my ward manager's response [my guess is to keep her own image that she runs her ship well] combined with the other staff unwillingness to report the abuse they suffered [despite widespread complaints amongst staff and, I heard, even on Facebook over this patient], resulted in me being the only person to log an incident report. You can guess where the blame goes to from there.

I decided that it's time to change my tune. As people who meditate would attest to, the mind is like a magnet which draws into one's life whatever one focuses one's energy/attention on.

E.g. The ward manager was returning from a long annual leave and had a double shift on her 1st day back to work. Given my non-optimal health condition and the ward's chaos [yes, it's still chaotic after 1.5 months since the new rooms opened], I hoped that I would not have to work with the ward manager in-charge on her 1st day back [IMHO, my ward manager has a Type-A personality.]. Just before the end of my 2 days MC, SSN Y called asking me to be the only SN in-charge of 3 days of night shift, because several of my (S)SN colleagues are on sick leave as well. Thus, I got what I wanted, since the ward manager is not on night-duty. [In fact, 5 of 8 day-shift SN/SSNs have taken sick leave since the new rooms were opened.]

I am spending more of my time-off researching about my future home, enjoying my small collections of various stuff [which I would have to pack for shipment], planning my finances for relocation, reflecting on and getting tickled by simple serendipity in life.

• E.g. There was a day when I got ~666 and 088 in my queue number at 2 different service counters.
• E.g. At an ATM queue standing behind a lady (probably grandmother) of a toddler (approximately 1 year old). The toddler dropped the brochure that she was holding and I picked it up for her. She repeated, I picked it up again, but putting it on her stroller beyond her reach this time. I stood observing the girl, she is so beautiful. As they were about to leave, the toddler turned around and sent me a flying kiss. Her grandmother remarked, "You are so lucky, she doesn't do it to just anyone, not even for me!"
• E.g. Looking a my list of diagnosis above also brings a chuckle.

Yes, I am sick of ranting. Time to change my tune for now, until I get sick of being chirpy, ha ha.

URTI

I am down with URTI again (upper respiratory track infection).

My ward had H1N1 and H3N2 flu cases for the past week. I wore a surgical mask at work most of the time for the past 2 weeks. Mainly out of fear of sneezing, coughing or dripping fluids from my running nose in front of the patients and spreading my pathogens to them. Afterall, the surgical mask does not provide adequate protection to the wearer from airborne pathogens. No one in my ward wears the N95 mask since the H1N1 flu was downgraded in severity. The only exception that I have seen recently was a respiratory specialist consultant while attending to her adult patient at my ward. [Note: Doctor JY also happened to be my attending consultant for my pneumonia episode.]

Back to my symptoms. Had been having running and congested nose on-and-off for the pass 2 weeks. Appetite is less, but still Fair. However, from Thursday onwards, the symptoms took a turn for the worse. I had an acute sharp pain at my chest where I had a history of minor atelectasis. Onset of cough which became more chesty over the days. Mucus and phelgm turned yellowish and of mucoid consistency which is worse in the morning. [Note: Not uncommon, given my history of asthma.] Thankfully, SpO2 is within normal range. Significant drop in appetite. I only manage to take 1/2 share of 1 main meal each day. Thus, I supplement my intake with snacks, juices, electrolyte drinks and nutritional supplements.

Finally, this morning, my sleep was interrupted at 3+am due to nasal congestion and a painful, itchy and scratchy swollen larynx (i.e. sore throat). The throat was so bad that I could barely take some fluids for breakfast. I couldn't get back to sleep, so I did my laundry and other chores instead. Then around 7am, my tired out body finally rested for 3 hours. I woke up to run some errands before I went to my hospital's A&E.

My hospital's HR is more willing to accept MCs (medical certificate for excuse from duty) from its Medical Officers. Up to 3 days of MCs from GPs (general practitioners) are accepted by HR. Thereafter staff are required to consult with the hospital's A&E MOs for an extension of MC.

Although the A&E was not particularly crowded (maybe around 20 patients), the combination of my low-severity and my arrival at 1+pm led to a long waiting time. According to the agency nurse at triage, the A&E staff held-up the cases from 1pm onwards until the agency nurse started her shift at 2pm. Thus, my hospital visit took 3+hours. I requested for Doctor Y, one of the Medical Officers on-duty, since he is somewhat familiar with my medical history. [Note: He happened to be the attending MO when I had pneumonia, and was also my pre-Employment check-up doctor.] Besides auscultation and the visual throat assessment, his check with the otoscope reviewed that my ears are also partially blocked by mucus. He asked how many days of MC I needed. Ha ha, typical of the service-oriented doctors in the private sector! Anyway, I requested for 1 day of rest for tomorrow, since it's my day-off today. If needs be, I could always return to the A&E for a review.

My ward manager had mentioned previously that, due to an increase in staff MCs for respiratory infections during the past months, the DON had requested the admin staff of every ward to report all respiratory MCs directly to her. Guess I'm on the list now! The increase in respiratory cases amongst staff does not surprise me given that ADON G discouraged staff to wear masks at work, other than for Isolation cases. She claims that the it muffles the enunciation and blocks-off the lower facial visual communication. Now her direct report, the DON, has to personally track staff's respiratory MCs. What a farce!

I wore an N95 mask from my entry into the A&E until I returned home. I was offered a surgical mask at the A&E entrance, but I wore my own N95 saved from a previous training session instead.

Yes, I know that the N95 and other masks are supposed to be single-use only. But to save costs for the hospital, the Infection Control Officer instructed us to save the "clean" N95 masks for a future use.

On my way home, few people noticed that I was wearing a mask. And even if they did, they turned their gaze away quickly. Most are absorbed in their own worlds. I wondered what makes Singaporeans, myself included, reluctant to wear masks in public whenever they have coughs/colds? A lack of awareness on the purpose and usage of a mask perhaps?

E.g. While I was at the A&E Isolation Room, a family -- consisting of grandma, mom, daughter and son -- arrived after me. They were there because the boy was coughing for a week without improvement after several visits to their GP (general practitioner). Initially all 4 of them wore surgical masks. When I informed the grandma that she was wearing the surgical mask upside-down, she cheerily disregarded the information saying that she's not the one who is sick. Subsequently, while waiting to collect the medication in the general A&E area, all of them took off their surgical masks. The grandma even chased her coughing grandson out of the Isolation Room to join his sister and mother in the general A&E area. Sigh! Infection control failed.

New rooms opened

The inevitable has arrived. The new rooms at my ward were opened 2 days ago. There was a demand for single rooms and an upsurge in admissions. Thus the management gave the go-ahead to open the new rooms for use.

It was a whirlwind morning -- a mayhem of room transfers, discharges and admissions. I lost count of the actual numbers, but I think it was 7, 6, and 5 respectively for the ward, of which majority affected my side of the ward. Lucky for me, I was the runner, SN L was the staff nurse handling medications for the team. The other team's runner Senior HCA M and the admin staff assisted with some of the room transfers. Also fortunately, SN O was the other team leader (i.e. SN in-charge of medications) and SSN Y was the overall in-charge, thus everyone remained professional (but brisk) even though we were flooded by the workload.

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The patients and families who got the new rooms were initially very happy. The new rooms had Disney cartoon wall murals, brand new furnishing and were better equipped. However, it became apparent by early afternoon that the toilets' plumbing were choked.

The admin staff confided in us at the staff room, "Apparently all the new rooms on the other floors also have the same problem. That's why the [note: plumbing dept] staff is under tremendous stress to fix it."

I asked, "Are we the first to open the new rooms?"

She replied, "No, we are the last."

I asked further, "So all the other floors had choked toilets when they were opened, and management is aware that the problem is not fixed [yet]?"

She nodded.

I asked rhetorically, "Why then did management approve of opening our [floor's] new rooms when they know that it will cause more problems? Now, if we need to find rooms to temporary 'park' the patients while the problem get fixed, we cannot, because the hospital is full!"

The admin staff gave an exasperated smile.

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Near the end of my shift, the admin staff informed me that I had "lots of double shift next week" due to a shortage of staff. [Note: SEN L is officially transferred to another department and SN RB was scheduled to clear her annual leave next week.] I simply told the admin staff that I will not accept any double shift assignment because the stress of taking the additional workload [note: 14 patients per SN] is not worth the additional shift allowance.

The admin staff said worriedly, "Then we will have to call in agency nurses."

I replied, "So be it. Management have to be aware of our staffing shortage. If we continue to pick up the slack [Note: i.e. cover the shortage of staff by doing double shifts], management will simply assume that we have enough staffing and refuse to hire more as [i.e. which] is the situation now."

Apparently, SN L, SN RB and I were the last few trained staff still willing to do some double shifts. All the other trained staff [Note: ENs and SNs] vehemently refused to take on any additional workload.

Organisational professionalism

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

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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"].

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[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

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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.