Just do what you can

Have been pretty quiet and lazy on the electronic communications front since returning from my trip. Finally got around to sending out my year-end greetings today. Thank goodness for the internet's fast delivery times ;-)

Been busy with the usual post trip unpacking, home cleaning and gifts sorting. At JC's ROM reception, we missed TSC's presence for he is the sensibility counterbalance to MC's and my sense. LK looked under the weather. MC explained that LK is still adjusting to her self-employed life without external time regulations.

Thereafter it was back to work, with some busy days, some not-so-busy days and a Christmas party to lighten up the mood. Still it was some adjustment after my rest-and-relax break of a week.

Recently I met my nursing buddy CL while on the bus to work. Her ward was closed and the ward's staff deployed to the other maternity wards during this period. Her ward manager is a kind leader and the staff had a strong affinity to their own ward. Each maternity ward has a different organization of its supplies (even though its the same specialization), which required adjustment on the part of the temporary deployed staff. Thus, CL said that her colleagues did not like to be deployed to the other wards. Anyway, to cheer her up I told her of my new attitude to manage work stress, "Just do what you can."

On the morning of 19-Dec-2009, SEN L was my runner. Seeing that she was somewhat down at this festive season, I invited her to join me for a Chinese movie since I had a pair of free tickets from my credit card points. After the movie, we continued with shopping and a long chat [Edit: Yay, fruitful shopping! I spent about SG$100 on several items that I really love and L spent about $70+ in the sales]. I have always felt that L was too astute to be just an EN. Turns out that she was lured to be trained overseas in Singapore as a nurse, just before she was about to attempt China's university entrance examinations. To cut the long story short [click here, here and here], she is likely to be stuck as an EN if she stays in Singapore. She shared that she has siblings in Japan and Canada [IMHO, real first world countries], but she has not decided if she would join either of them. From her past sharing, she seemed keener on Japan than Canada. Since I have a collection of Japanese textbooks and dictionaries mostly lying idle [Edit: From 15-20 years ago when I learnt Japanese], I will be giving them to her. May it spur her to do something for her own future.

As for me, I have been tasked by my ward manager on several items, mostly to assist with documentation of procedures [Edit: For the forever impending JCI, ha ha!] and managing the treatment room. From my personal interests, I would like to share some IT skills with my colleagues while I am still around. Especially with the older or foreign-trained staff who did not have the benefit of IT exposure. That is the culture I inherited from my IT background, "One always try to pass on one's skills before leaving". I also plan to suggest some changes to the billing system so as to facilitate our nursing billings and to minimize the items used but were not billed.

On a personal front, I would like to meditate more consistently, as it helps to smoothen out my workday. In addition, I am planning to re-learn French again since Canada is officially bilingual. Meanwhile, I'm still awaiting for the approval from CRNBC to attempt the CRNE (Canadian Registered Nurses Examinations). Once that goes ahead, I will have a full plate studying for the examinations. If I have any time leftover, I would like to squeeze in some Yoga exercises... which I have neglected for years!

Looks like a busy and fruitful year ahead! May you have a good time too! For those interested in Chinese astrology, here's your forecast for the coming year of the Golden (Metal) Tiger.

Multi-facet thing

I am at the Budget Terminal waiting for the boarding gate to open. Perhaps it's the "getting away from it all" of vacation. For the past few days, I am hearing and seeing things from multiple angles.

Example 1: Yesterday ward manager mentioned how good LKY is. My usual response would be to go "Bah!", even if only internally. However, I was more circumspect and noted that her comment was valid from her own personal experience. [Note: My ward manager is an ex-Malaysian Chinese, converted to Singaporean citizenship.]

Example 2: Had my confirmation review with my ward manager today. IMHO, she is a much better leader than ADON G, who is currently her boss. I learnt about how my ward manager was transferred to be ADON for 6 weeks years ago. She came back to the ward to settle the chaos that ensured after her departure. Then I thought, "Well, at least this organization is not that hopeless. They did spot the leadership talent in my ward manager, just that circumstances were such that she stayed as the ward manager."

Another thing I noticed is that if I go on a vacation mode and am not conscious with my budget, I "spend money like water". I have not boarded the flight yet, but I have already spent almost $20 at the airport! There are just too many attractive material things available for sale. Ironically, I am going on a spa, detox and meditative break. Ha ha :-D

6 months old

I'm 6 months old at work, surprise surprise! Had pretty good times for yesterday and today. The ward manager was back from her annual leave yesterday.

Yesterday was a lull day. The ward manager even had time to share with us about traditional chinese medicine in the afternoon. SN J was in-charge, SN L and I were team leaders, SEN MY and SEN M were runners for each team respectively. I started with 3 patients (all relatively stable) and a booking for a ICU-return-to-ward case. 2 patients were discharged that evening, SN J helped me to label the medications for one of them as our pharmacy was already closed. SN L took the heavier team at the back with around 8 patients. I offered to help her, but her patients were also relatively stable and thus she didn't need much help except when she was taping the handover report.

Today SSN Y was in-charge, and there were 4 SNs (SN O, SN L, SN RB and me) + 1 HCA K. The assignment was SN O + HCA K for the heavier team and SN L + me (as runner) for the lighter team. SN RB as the extra runner between the 2 teams. Thanks to SN RB helping me out with the parameters and I/O charting, I could do ad-hoc jobs (e.g. collection of medication stock, collection of blood for transfusion, emptying Jackson-Pratt drain, HGT test, assist in clearance of an abscess, etc). SSN Y went through and signed my on-the-job training form as it is already due. I even had time to take photos of our ward's Christmas decorations. :-)

There were several admissions late in the evening, just before report handover. Nevertheless, I hope that the next 3 days will be peaceful for me too, because I am counting down to my vacation.

Students on work exposure

Our hospital is hosting some GCE 'A' levels students (i.e. 16-18 year olds) for work exposure this week. Some were from the junior colleges and some from the Integrated Programme.

3 students came by my ward around 2pm this afternoon, expecting someone to show them around. The sad truth is there is the nursing staff here are already stretched with their own duties. Unlike some hospitals, there is no Clinical Instructor at the ward with the time to show them around. I asked if they could come back another day or time, but it seems that they had a specific time-slot scheduled (2-5pm today) to be at my ward.

At 3+pm, I finished the outstanding work from my morning duties. The 3 students were still standing in front of the nursing station awaiting instructions, and looking lost as to what to do. Finally, I checked with my preceptor SSN Y who was the afternoon in-charge and offered to show them briefly around. I showed them our facilities, equipment, some paperwork and processes, the staff, etc.

One male student asked the typical questions raised to a paediatric nurse, "Is the job stressful? Is it very stressful to hear the children crying all the time?"

I joked, "Wow, like job interview questions like that".

Then I continued, "It depends on individuals. For me, I have taught at a childcare centre before, and I don't find the crying stressful. Of course, if you find it stressful, you can choose another specialization. During our nursing training, we are exposed to different wards, so you'd have an idea what you prefer. Some prefer to handle children while others prefer to talk to the elderly. Nowadays, the HR departments for nursing are quite open, and they will consider their employees' preferences when assigning the ward. For example, my male classmates prefer A&E, they were assigned there and are enjoying themselves."

He said, "Yes, where the action is."

"Yes, and minimal report passing", I added.

"Yes, minimal report passing" he reflected with a wide grin and we laughed.

Getting to the point, I told them, "Nursing is not just caring for the patients, but we also handle other administrative work. E.g. Room assignments, for which we may have to deal with irate parents awaiting for the limited number of single-bedded rooms. The stress also come in when you have several patients that need your attention simultaneously. E.g. If one patient's oxygen level suddenly drops, another needs attention on the IV, etc. That's why team work is important. We cannot survive without teamwork here." (Actually the example I cited happened earlier that afternoon, just before the students arrive. Ha ha!)

At one point during the briefing, my afternoon colleague HCA M distributed payslips to the 2 afternoon SNs and I at the nursing counter. We all had a big smiles on getting our payslips. I joked to the students, "Yay! The happiest time of the month."

We were done at 4:10pm and I signed their orientation forms. I told them cheerfully that they could have an early-off. They then looked at each other, uncertain as to what to do. It occurred to me that these are hardworking and keen-to-learn students, where ideas of leaving early or “吃蛇” or ponteng in Singlish (pronounced as "pond-ten") are remote concepts. They lingered for a while more until some students assigned to the other wards joined them.

After they left, a consultant, who observed part of my briefing, teased, "Don't make it sound so easy to them. It's not that easy."

I replied, "They are young, only 16 or 17. Must give them hope, mah!"

My preceptor chipped in, "These are the bright kids, future doctors whom we may have to work with."

We laughed.

Crying ladies

We had 2 staff who cried while on-duty today.

Firstly it was the admin staff M who cried upon arrival. She was disappointed with her son's PSLE (Primary School Leaving Examinations) results. PSLE being a major examination for typically 12 year-old children in Singapore. SSN R who was in-charge spent some time counselling her. At the end of her shift, the admin staff shared with me about her concerns.

At around 1pm, I walked into the staff room and saw SSN R pacifying SEN M who was crying. I left the room immediately as I did not wish to interfere. I have no idea what SEN M was crying about. Thereafter, SSN R gave permission for SEN M to leave work earlier at the end-of the shift.

SSN R has a fierce look and voice when she doesn't smile, but she is motherly at heart. As a nurse groomed on the old-style nursing training (i.e. School of Nursing), she has a tendency to whine about the new nurses by comparing with the past. However, after one incident when I confronted her for bad-mouthing about me behind my back, she has been supportive since.

As the in-charge, SSN R was willing to give some flexibility to staff depending on situation. After today, my respect for her increased. It is not easy dealing with a busy ward, overbooking by Admissions resulting in unhappy parents, and yet have to handle 2 staff with personal crisis.

NBM, NPU

Sometime last week, I met SN JM on my way to work.

SN JM is the best "informal" nursing preceptor I had throughout my student training. When we first met, she was an EN. From what I heard, she is a foreign-trained nurse who was downgraded locally to become a HCA, and was then promoted to EN, SEN and finally an SN after passing the SN qualification tests at Nanyang Polytechnic. Although SN JM came from the same country as SEN M, they have very different attitudes towards students and new staff. Unlike SEN M, SEN JM treats all new-comers well and was willing to share the secrets of the trade.

I asked how SN JM how she was. She replied, "So busy until NBM and NPU."

Note: For those not in Singapore nursing; NBM = Nil By Mouth (i.e. do not eat/drink), NPU = No Pass Urine. Please note that the acronyms may mean different things in other countries' nursing documentation. E.g. In B.C., Canada, NBM = No Bowel Movement (i.e. no stool), NPO = Nil Per Oral (i.e. do not eat/drink).

We laughed at how that would be a serious problem for our patients, but we nurses have to bear with such physical conditions. Then we talked about how the hospital was bursting at its seams for that few weeks. SN JM had this joke to share.

"One day we had a patient that just passed away and his family was gathered around the body, dealing with the loss. Admissions already had another patient waiting for the bed!"

More on my talk with ADON

Bone Collector's comment drew me to recall what I learnt from my "talk" with ADON G. That is, ADON G is not a leader whom I want to model after.

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ADON G came to my ward one morning telling me that she wanted to see me after my morning duty was done. She mentioned that she may not be at her office, so to call her first, but she needed to talk to me at her office that day.

I was tired out after working 7 consecutive days (I happened to have 12 consecutive work-days this fortnight, including 2 double-shift days). In addition, after my AM-shift work was completed at 3pm, I had to wait for the ADON to be available after 4pm.

ADON G, "Do you know what I want to talk to you about?" (It seems to me that ADON G has the habit of asking people what she wanted to talk about instead of going straight to the point.)

I replied honestly, "You asked me to see you, but I do not know what the matter is regarding."

It turns out that due to a "medication error" incident report, ADON G "puts it nicely" that she is merely speaking to me over the matter because it's her role as the ADON in-charge. Then ADON G started lecturing me over my medication error. My ward manager had already spoken to me about the incident some days ago, for which I am genuinely sorry and learnt from.

Actually the medication error is another story. While I was passing my shift report verbally to the afternoon staff, a post-op patient on my team was received by my preceptor who then rushed off to a meeting. The patient complained of severe pain and had low SpO₂. Ward manager took over from my preceptor, reviewed that patient, instructed the newbie SN RB to collect the painkillers stat from pharmacy, and then told me to give O₂ and the painkillers stat. Then she also went off for the same meeting. (A few days later, the admin staff told me that she saw the ward manager instructing me as such, and that she can be my witness). Anyway, I checked the case notes and misinterpreted the doctor's notes that 1 of the 2 PR (per rectal) painkillers were given in OT. I noted that my preceptor wrote in the IMR "given in OT" for both painkillers, so I thought she wrote wrongly in her rush to attend her meeting. Then I gave the other PR painkiller to the pt and made the serious mistake of canceling out my preceptor's "given in OT" note for that PR painkiller and initialled against my cancellation. SEN M who took over from my shift, kicked a big fuss over the matter.

ADON G's tone of voice was sharp and demanding. She did not at any point ask for my side of the story. Then she demanded that I DO NOT MAKE ANOTHER MISTAKE again. At that point, I got fed-up and told her, "If that's the case, then there's nothing to talk about". I got up and stepped out of her room.

ADON G raised her voice, "You are very rude, you know. How can you walk out just like that when I'm talking to you?"

At last, some non-bullshit words from her. I stepped back into her room and told her, "I am only human. As a human speaking to another human, I cannot promise you that I will not commit another mistake."

ADON G went hysterical, "I am your ADON, how can you raise your voice and speak to me like that."

I would have laughed in-her-face if not for the gravity of the situation and my tiredness. ADON G's miniscule world of nursing may be larger than my whole world of nursing for now, but IMHO her exposure to good leadership seems rather limited. Only lousy leaders demand to be respected based solely on their position. The true-blue leaders that I've worked for/with do not need to rely on their position to be respected. Their very presence and reputation for effectiveness earn them their staff's respect. In addition, my "ang-moh cultured" ex-bosses value candid feedback from their staff, it doesn't matter if they agree with the staff's view or otherwise.

Anyway, sad to say, I was very stressed by the whole event, so I broke-down. I told ADON G that people talk when we (new staff) check on the case notes to verify seniors' instructions. I am not the only one who experience it.

Yes, the nursing culture here is that if a senior instructs you to do something, you're supposed to just blindly obey stat. Not withstanding that ward nursing is not A&E or ICU where the urgency of interventions is critical. If you check the case notes or with another staff, they feel insulted and then they gossip about your "lack of trust" behind your back. E.g. The staff gossiped about SEN MY's "lack of trust" in my presence, but sadly none of them had the guts to tell SEN MY face-to-face about their displeasure.

I told ADON G that as a new staff I am struggling to survive. I don't even know how long I would last in the hospital, but I am definitely leaving after my bond. (I didn't want to tell her the reality that I could pay up my bond and quit stat if I wanted).

ADON G then said to me that it's like that in nursing, all newbies struggle and that I'm too sensitive to others' comments. When I told her that it does not have to like that, at least not in my previous industry. She said to me, "Of course it's different. You only deal with machines in IT." At that point, it struck me that I was talking to someone who knows zilch about software consultancy.

I asked then, "If nurses need to improve their communication, how about we have communication courses for all nurses, not just on SBAR, but to recognize the different personality types and the different communication styles?" [Edit: E.g. MBTI and DISC]

ADON G wrote it off immediately, "It is not possible to send all staff on training courses. That's why all the senior managers, we are working very hard on template formats for standard conversations. I believe that you may know about it too. Your Sister L contributed to it".

Note 1: Yes, my ward manager had asked me to research and write up a word document for self-introduction to patients. She was very pleased with my work.

Note 2: I don't know if ADON G was missing my point about inter-staff communication/rapport intentionally or the concept simply flew over her head. I asked about possibility of training staff on inter-personal communications because such training makes attendees more aware and appreciative of different communication styles. I was willing to share from my past exposures at such courses with my fellow colleagues. It struck me, "No point throwing pearls to swine."

I let ADON G launch into her stories of how tough it was for her during her early days as a new SN at a neural ward, how mean the doctors were, how lucky I was that the consultants for my ward are mostly reasonable compared to the consultants of the other wards under her care, and so on.

IMHO, it's the same-old "we survived the system so it cannot be bad, the toughness weeds out the weak" attitude of old nurses in Singapore.

Then she said that I was lucky that my ward manager Sister L, is a good and very experienced manager. I thought, "Sister L is not perfect, but she stands tall where it matters. At least ADON and I can agree on one thing, ha ha!"

ADON G went on to rebuke me for not raising my issues to her. She claimed that since she took over my ward from another ADON earlier this year, she has been taking care of our interests. "You staff are just like SSN L, just throw your frustrations at us and resign. It's not fair to me. I don't even know of your issues."

I thought, "Huh? Why am I being linked to SSN L's immediate resignation?". Anyway, I replied honestly, "When I have issues, I speak to Sister L (my ward manager) and I trust her to solve my issues. I am trying to follow the line-of-hierarchy."

ADON G then chastised others (like SSN L who quitted) and me for having a negative attitude. Blah, blah, blah.

To reassure ADON G, I told her honestly, "The best part of my job is my patients."

Then ADON G said, "Then you have the passion for nursing. Why do you let others kill off your passion?" (Okay, some truth to her statement, but of course she doesn't know that my exit plan is not out of nursing but out of nursing in Singapore.)

That started her off again about her nursing experience. E.g. How they saved a patient's life, how the patient was so grateful that he converted his religion, blah blah blah.

I also took the chance to "drive" ADON G into action about a case where an unhappy patient complained about his missing asthma MDIs (metered dose inhalers).

[Addendum 27-Feb-2010: After the patient was discharged, the housekeeper found the missing MDIs sitting on the window ledge, hidden by the window curtains next to the care-giver's chair. It turns out that the patient rested on the chair and placed the MDIs there but forgot about them. Thus, it proves that all the staff are innocent. It also proves that the patient was not trying to cheat the hospital of giving him free medication, as suggested by ADON G during her personal lecture to me].

It was evening twilight when we finished. I would give her a 4.5 out of 5 for effort, but only 1 of 5 for effectiveness. It was supposedly a pep-talk for me, but frankly I went off thinking that I do not want to work for this boss nor the organization for long.

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A fool never learns from anyone's experience,

A regular person learns from his own experience,
Only the wise learns from others' experience.

- Adapted from H.G. Wells' quote -

Sian!

ADON G lectured me for 2 hours, starting with a medication error made by me (for which my ward manager has already spoken to me about). One Singlish word: sian!

Bureaucrat in-the-making

I am so physically tired today after a PM shift, followed by a double shift (AM and PM), followed by an AM shift for these 3 consecutive days. An EN from the day shift has been re-deployed temporary to cover the night staff shortfall due to a staff resignation. As the ward staffing is very tight, some day staff has to do double shifts to cover the shortfall.

There was an elderly post-op patient with a surgical wound and some broken blisters on his right leg. As he was impatient to recover quickly, he tends to over-exert himself during the physiotherapy. His surgical Tegaderm with pad had haemoserous stains daily and his broken blisters weep fairly-to-badly. I had to change dressing twice for him yesterday (am and evening). While planning for CM (coming morning) discharge yesterday evening, his daughter asked if we could provide him with 10 sets of dressing items (dressing kits, various Tegaderm, gloves, Normal Saline in 20ml tubes, etc). They were happy to pay the hospital mark-up for the items in-exchange for the convenience.

In the past, I would be happy to get such a request. It brings profit for the company with minimal work involved. However, the ward stock was low and not enough to meet their request. I wasn't sure if the in-charge the next morning would be willing to put in the special order on their behalf. Thus, I advised them that I would prepare 1 set for their discharge and gave them a list of items to be purchased from any pharmacy instead.

This morning, another daughter of the patient spoke directly to the in-charge to ask for 10 sets of dressing items for home, using the list which I wrote for them the previous night. Fortunately SSN R (the morning SSN, not the permanent-night one that quit) was willing to call the store to put in this special order together with topping up of ward stock. When the store items came, I re-packed the items for this patient into a box for home and SSN R instructed SEN M to bill the items.

After work, I reflected on the matter and it occurred to me that I was behaving like a bureaucrat. To reduce my own workload and to avoid piling work to my colleagues, I had put the patient's wishes in a secondary position. I am not proud of this incipient change in my work attitude.

Resigned with immediate effect

One of the permanent-night senior SN (SSN L) resigned with immediate effect today. From what she had shared with me previously, it is probably an accumulation of frustrations. The last straw that broke the camel's back happened yesterday. Here's the gist of what I heard, although I have yet to hear anything from the horse's mouth.

Yesterday (Monday 16-Nov-2009) morning, SSN L's long-time night partner SSN R called up the ward about her MC (medical certificate for sick leave) for several days. However, the admin staff did not manage to find anyone to cover SSN R's absence. Finally it was escalated to ADON G, but somehow there still wasn't any staff replacement. Thus it was 1 SSN and 1 HCA covering the entire ward of acute patients for that night.

Well, yesterday was my day-off. At around 17:40hrs, I received a call from my ward's admin staff requesting me to cover SSN R's night shift. As I already had a dinner appointment, I turned down the request. According to the admin staff, she has tried asking all the other day-staff but could not find anyone. Thus, she had no choice but to call me, her last resort, at that late hour. She demanded to know why I could not come for the night duty. When I persisted that I could not change my dinner appointment as my friend would be flying back to Hong Kong, she then said she has no choice but to inform the ADON G.

It reminds me of the work culture in Singapore. People expects singles to sacrifice their private lives for work emergencies, without considering singles also have their social roles and responsibilities to attend to. I have made this mistake before of agreeing easily to “犧牲小我，完成大我。” ["sacrifice personal interests for the interests of the greater group"], pissing not just a handful of my friends/significant-others/family-members as a result. Such a habit does not buy one any goodwill at work either because after a while colleagues/supervisors take it for granted that the usual sacrificial lamb should do it. Thus, I am not about to fall into this rut again.

Branded

Had dinner with my friend JN today. He is based in Hong Kong, but back in Singapore for a short trip.

We first met at an online renovations forum about 3 years ago. We have chatted online occasionally and met face-to-face several times since. I would describe him as a good catch, being a decent down-to-earth guy who is straight forward. The typical goody Singaporean guy. The WYSIWYG¹ type of person. However, it is unlikely between us, although we did joke about it before.

Why? I suspect it's because I am not a WYSIWYG type of gal, I am more like an onion or even a chameleon.

For example, over dinner today, JN shared that at his father's funeral, a friend of his mother tried to get him to court her daughter. He then said that the potential-target came from "Rxx" school and went overseas for her education, returning with foreign-accented English.

His emphasis on "Rxx" raised my eyebrows. I remarked that I was also from the same school and asked if he had a problem with people from the school. [Note: Yes, Rxx was (and still is) a "branded" school. During my days, they admitted students from all social classes who happened to do well at their primary school-leaving examinations (PSLE).]

Then he went on to say that, well, the lady was from the "gifted" scheme (Gifted Education Programme). I smiled, the gifted scheme was started one batch after mine.

I recalled that the Ministry of Education did trial-run of their gifted scheme selection test at my school when I was in Secondary 1. I remembered then that many of my classmates (used to scoring As in primary school) panicked after the test because they could not finish the test. This reaction even though we had been told that it was just for information collection and would not affect our academic grades in any manner. Some of my classmates even went around complaining that they could not finish the test and asking everybody if they managed to finish. Apparently, many didn't finish the test and joined-in complaining. I kept very quiet and just gave non-committal "hmm" replies when asked. I had managed to finish the test and had time to check some of the answers, although not all.

It was only later in life (after some years of working) that I finally got my IQ tested. I told JN that it happens to be "on the upper end of the range²".

JN said, "Well, you don't seem like that to me."

"Maybe I'm good at hiding", I smiled. Years of socializing has made me keenly aware of the reverse prejudices against the gifted/genius. Thus my standard policy is not to tell unless I feel that the person knows me well enough not box me in on the basis of a simple number.

JN also harped on the potential target's foreign accented English. Thus, I shared, "Well, I did not always speak Singlish. In fact, I made a conscious effort to learn Singlish some years ago during my second job, in an effort to fit in with my colleagues".

I also shared that being academically smart does not necessary help one in life. I personally know those who struggle in life (myself included) even though we went through the "branded" school. JN jokingly remarked that we both live in the same kind of small public apartments. [Note: I thought to myself, "Ha ha, the typical Singaporean measure of success!"].

I shared an example of an academically smart, deep-thinking, and pious Christian friend who has yet to get over her divorce that happened suddenly years ago. IMHO, the Christian teaching that "the man is the head of the household" is a handicap to her recovery because the sudden divorce resulted in my friend losing her "head of the household".

JN conceded that the religion may not be the problem, but the behaviours of its followers. For example, although he is Christian, he does not fancy the "keeping up with the Joneses" behaviour of churchgoers. [Note: Okay, he did not actually use that "Joneses" phrase, but he meant that.] I agree with him, it's the people not the religion that's the problem. Then we went on to chat about the divorces amongst our friends and how they are coping, LGBT rights (I support it but JN considers them weird) and other stuff.

Like I said, JN is a WYSIWYG type of guy. Fortunately, he didn't take my contrary comments to heart... I think. After dinner, we went to shop for some toiletries which he said is cheaper in Singapore than Hong Kong. Thereafter, we parted ways. I am not sure when we will meet again, although he promised to buy a down feather jacket on my behalf since it'll be on Hong Kong's winter-clearance sale next year.

Note 1: WYSIWYG = What you see is what you get

Note 2: My standard replies to questions asking for my IQ are:

• "It is probably somewhere above average." for those who don't know me well enough; OR
• "It is somewhere above average." for the few whom I cannot bluff because they know from working closely with me that I'm smart.

Mean girls

I posted a comment on Bone Collector's blog entry about mean girls and boys.

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Hi Bone Collector,

Thanks! Agree with your views.

I was previously from another industry which was male-dominated. From there, I learnt/practise that guiding newbies do not have to involve bullying.

I suspect nursing culture involves a lot of bitching because it is female dominated. Since females are socialised into not expressing aggression openly, passive-aggression is the socially accepted alternative.

Of course, I'm no saint either, sometimes I loosen my tongue inappropriately even though I try to refrain from it. I also try to ignore the minor transgressions. However, if I deem the matter serious enough, I will (and did) confront the person involved.

IMHO, nurses in Singapore don't seem to be trained or promoted on the ability to mentor others. Many went through the same bitchy environment when they first joined nursing at a young and impressionable age. Years down the road when they become senior, they accept that it is the way to train newbies. [My impression from their conversations is that] They think that, afterall, they survived and the "weak" were weeded out by the process.

Add to that, amongst the experienced foreign nurses who downgraded from RN to EN when they come to Singapore, some have an axe to grind. Usually those new to nursing suffer at their hands. Don't know whether to be relieved or disappointed over the fact that I'm not the only victim, ha ha.

As for a green-eyed experienced foreign-trained senior EN at my ward, I feedback my unpleasant experience to the ward manager when she interviewed me over an incident involving us. I put it plainly that while I accept she has a right to whatever her feelings are, in my opinion, by hitting out at new RNs [Edit: click here, here and here for examples], her frustrations are misdirected. I also made commendations to the ward manager of those staff (including foreign ones) who demonstrate professional attitudes consistently. I am not sure how things will go from here, so I am just keeping my fingers crossed.

Generally, given the pathetic nature of nursing culture in Singapore, I honestly do not think we are anywhere near gaining professional respect from the public since we would not even cover each other's asses properly. We don't have a functional union to speak of in Singapore. I doubt we will have one anytime soon, given the political culture in Singapore.

Halloween Dinner

Went for dinner on the 31-October with my bunch of psychic friends.

Since it was Halloween, MC was in lighted devil's horns. LK was supposed to be in devil's horns too, but she forgot to bring hers along. I was dressed in black with a matching witch's hat. I even carried my handbag that had a cat on its front panel. When we met, I remarked to MC that my life is so boring that I needed to dress-up for some excitement. JC was so impressed that he asked if it was my regular clothes or I had bought them just for Halloween. Actually, other than the witch's hat, which cost SG$3.95 from the supermarket, everything else was put together from my existing wardrobe.

Both the guys JC and TSC had updates on their love-life to share. It was fun watching MC, the devil, grilling TSC, the goody-guy, with questions to coax out details of his love-life.

Over dinner, we learnt that when it comes to love, both MC and I are the straight-forward "yes or no" type. The other 3 tend towards the "test-test water" type.

My first sick day on MC

Recently, I had my first sick day from work, on MC (medical certificate). My low work morale may have affected my health.

Have been sniffing since last Saturday after a paediatric GE patient coughed into my face. I was without a mask then as I was preparing to return the child back to her parents after IV cannulation. Maybe the child had more than just GE.

Anyway, I got worse on Monday night when my nose was running so much that it was simultaneously blocked. Obviously, I couldn't sleep. I was beginning to get worried given my pneumonia experience [click here and here].

Thought I could get better after getting some sunshine while running errands that morning. Finally, I gave up around 12 noon and consulted a GP near my home. Thereafter I called the admin staff about my emergency MC (see below). Luckily, I did so because I was knocked-out for the whole afternoon in my bed, despite the non-drowsy prescription.

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When I called the admin staff at 12+ pm, she told me that it was a super busy day at the ward with lots of adult patients spilled-over. None of morning staff have had time for any break. She tugged at my emotional heartstrings saying that they needed SN's to take team, and asked if I could still get to work. After she confirmed that I had an actual medical certificate from a GP, she said that she will inform the ward manager.

Staff image audit

Recently, due to an internal audit of staff appearance, my ward manager and ADON G suddenly decided that female staff's pony tail should not touch the uniform's collar. If it does, it must be bun-up. Their logic was that long pony tails may accidentally brush against the patients, resulting in patients' complaints.

My pony tail barely touched the collar and was too short to swing around when I tilt my head. In fact, were you to brush against it accidentally, you'd have to be standing next to me physcially, touching not just my pony tail but my body as well. However, that afternoon, the ward manager singled me out because those with longer pony tails or hair weren't around for her to criticize.

• SN J quickly left the treatment room when the NO started talking about staff image.
• I think SEN L was not on duty that day.
• SEN IV was successfully nagged by the NO to bun-up her pony tail.
• SN O whose long bob hair touches her collar. I was later told by the admin staff that SN O had long hair years ago but cut it to a bob too as a result of an earlier image audit years ago.

For some reason (perhaps it's due to a double-shift and then 2 consecutive busy AM shifts), I felt pissed-off by nursing management expending so much energy on a minor image issue when they have bigger issues, e.g. staff recruitment and retention, yet to be solved.

Anyway, I decided to just shut-up the nonsense by heading to the hairdresser right after work. Thankfully the hairdresser did a good job of cutting my hair into a super-short bob. The next day, the NO was impressed by my new hair-do, but I made sure from my body language that she knew that I was not pleased.

As it turns out, even today, there are other staff still with long hair or pony tails touching or beyond the collar but they miraculously escaped the NO and the ADON's attention. This so-called problem is even more common in the other wards. This is a reflection of the management's policy implementation. Lack of consistency.

Understaffed!

My hospital had a town hall today. The hospital's further expansion plans were shown. I took the opportunity to ask if there was any plans to increase the staff strength, especially the nursing staff, given the increase in number of rooms.

The DON did not look happy about receiving the question. Her reply was that we will increase nursing staff strength only if there is an increase in occupancy. At the moment, the average occupancy rate is around 60-70%. Thus, there was no need to increase the staff strength. She added that on an adhoc basis, bank staff and agency nurses could be called in.

Of course I did not mention it, but IMHO that is a management wool-over-staff's eye. My hospital had a policy that adhoc staff can only be called-in if planned one shift in advance. Consider the common scenario where a shift started with staff to cater only to 50% occupancy. This happens when staff are told to take their public holiday leave because the ward census is low. Then the occupancy jumps to 90-100% due to a sudden surge in admission and/or acuity [see here on HDU intents]. Due to hospital policy and the urgency of the matter, one cannot suddenly call for bank or agency staff. Given the poor levels of inter-ward collaboration, existing staff on-duty are unlikely to be transferred from a more lax ward to the busy ward. What, then, is the impact on the quality of nursing care? What of the risks that nurses are exposing our license to?

As it is, based on my calculations, each SSN and SN at my ward can only take 7 days-off per year for MC, training and other leave (excluding annual leave). The calculations assume that new SNs are equivalent to experienced SNs in skills, e.g. newbies like myself and SN RB. Otherwise we would need SNs to work double-shift or ENs to act as SNs to cover the staff shortfall [Note: which often happens currently]. Given that the expansion represent 12.5% increase in my ward's maximum capacity (and we currently often take patients overflowed from the other wards), the DON's reply instructed me clearly to leave this hospital ASAP!

5 months old

Last week was alright, a mix of busy and not-so-busy days. I do not know if my "honeymoon" period is over, but I find myself getting cynical about my current workplace as I passed my 5-months milestone.

Today SSN Y was in-charge, on double shift this afternoon. SEN M is back from her maternity. Before the shift started, I saw her making a big show of missing her "mother" (SSN Y) and giving her big hugs at the nurses counter. For some unknown reason, at the start of the handover report, SSN Y (the mutual preceptor for both myself and SN RB) remarked snidely in front of the whole afternoon team, "Know everything already, very clever already ah, new SN".

To which SEN M rejoined, "How? More and more new SN". [Note: Bear in mind SEN M was the one who complained in my face about feeling unhappy whenever they see fresh new SNs joining the ward, taking higher pay and yet are less skillful than them. And SSN Y was the one who told me about how SNs petitioned against ENs recruitment years ago.]

For some reason, the team assignment was not done for this afternoon's shift. SN J, although more experienced than me, opted to take the team with the much lighter patient load. While SSN Y sounded surprised over it, she did not mention anything.

New staff SN RB was assigned to be runner for SN J, and (IMHO) was bullied around without guidance from her preceptor SSN Y or her team leader SN J.

• E.g. A specialist came to review her patient under SN J's care. SN RB had just taken the parameters for that patient. As I was busy with a urgent issue with my patient, I passed SN RB the case notes for the patient and instructed her to follow the specialist on her review first. I quickly popped into the staff room where I found SN J sitting around doing nothing in particular. I informed her that a specialist is here to review her patient and SN RB was with the specialist then. Her response? "SN RB is with the doctor? Then ok." No attempt to move from her seat.
• E.g. SSN Y passed SN RB the DDA order book and told her to collect DDA drugs from the pharmacy, but gave no further instructions. SN RB turned to me for help because she was new to this hospital and has never collected DDA drugs before. I approached SSN Y for the DDA key to get the DDA stock booklet which is required together with the DDA order book for collection of the DDA drugs. I wonder if SSN Y accidentally forgot about the DDA stock booklet or she was testing our knowledge as new SNs.

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Some thoughts about SN J and the nursing culture in my ward.

New staff RB told me that she almost made a medication error the day before (on Monday) because SN J, who was in-charge, suddenly assigned her to take the team of patients far from the nursing counter. This team is usually the heavier team in terms of workload. When SN RB needed someone to countercheck the new prescription, there was no one available.

This brings to mind another time when experienced SN SB from the adjoining ward confided in me with a similar complaint about SN J. In SN SB's case, SN J was supposed to be responsible for the back team and someone else was supposed to be in-charge. For some unknown reason, SN J assumed the role of in-charge after the handover report and instructed SN SB to take the back team. This was fine until SN J ordered SN SB around for runner's tasks for much of the shift instead of allowing her to focus on her role as the staff nurse taking team. SN SB does not know this but according to SSN R, SN J had complained about SN SB's black face over her "runner's job". When I probed SSN R about it, I realised that SN J did not mention that she had actually assigned SN SB to take over the back team from her.

I don't understand why the typical on-the-job training in this hospital is to assign new SNs to be PCAs and ENs and throw them into RN roles on an adhoc emergency basis. IMHO, this has 2 effects.

1. Experienced staff (from SSN to SEN to senior PCAs) complain about new RNs being not up to standard.
2. Experienced ENs and PCAs climb over the heads of new SNs, ordering them around. It is one thing to for RNs to understand the scope of their "juniors' work", it is another thing to perpetuate a bullying culture in the name of learning humility.

From what I heard about restructured hospitals, the SN, EN and PCA roles are well-defined. New RNs are guided by in-house clinical instructors (CIs who are experienced registered nurses) and eased into their work-role by gradually increasing the number of patients they care for. [See also here for 27-Oct thoughts about new RN training roadmap.]

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SEN M was assigned to be my runner today. PCA M was supposed to assist between the 2 teams, but spent more time at the back assisting my patients. She even offered to assist me with nebulization (i.e. holding the nebulizer mask for an infant patient) so that I can attend to a more urgent matter. Which made me wonder what SEN M did today, besides swapping perineum for one of the patients. At about 8pm, SEN M decided to tape my team's report on my behalf. Frankly, I don't feel comfortable with that, thanks to my past experience with her. But I didn't have a choice because she was unwilling to help me with a post-op case that arrived at 7:50pm and I had the evening medications to be dispensed. Thus, I gave her some face by openly thanking her for her help. Let's see what that gets me...

I actually had time for tea break but did not want to go into the staff room which seemed perpetually occupied by 2 or more of the following staff, SSN Y, SEN M, and SN J today. Thus I skipped tea. Same happened around dinner time. Thereafter, my post-op case came and I was busy.

I stayed a while to help the night staff with an IV cannulation and left at 10:30pm. I like this pair of permanent-night staff SSN L and SSN R. They are both very skilled and willing to teach. While they do check and question one's work, they do not kick a big hoo-hah over the mistakes made. They often advise on the corrective/preventive steps to take. A few months ago, SSN R ever asked if I would consider taking over her permanent night shift as she is considering changing to day-shift. I did not consider the idea at that time because of the long night-shift hours (10 hours) and night-shift runs on skeletal staff. Today, I seriously think that it might be help me to avoid the day-shift politics and the problem of enough staff but the diffusion of responsibility phenomenon (social psychology theory).

p.s. Ironically, the “吃蛇” [skiving] staff are often cited by the ward manager and the SSNs as being efficient when they want to criticize the performance of new staff. SN M from the adjoining ward, EN IV and myself have experienced such criticisms before.

Place-mark entry: End-Oct, early-Nov 2009

Quite few events happened recently at the end of October, early November 2009. Just putting a placemark entry because my thoughts on the events have not settled yet.

• 24-Oct: There was a staff image audit. The end result was I cut my hair but I felt pissed-off and demotivated nevertheless.
• 25-Oct: Attended a cousin's wedding dinner on my maternal side of the family. Family event always gets my mind buzzing. I recognize that it is partly due to my own prejudices. Took the chance during dinner to inform my siblings and 2 brothers-in-law about my intent to emigrate, they took it quite ok. I also told my aunt (who is a nurse herself) and an uncle. They are the 2 youngest siblings of my mother (both less than 20 years older than me) and have been generally open to new ideas. My aunt surprisingly did not take it too well. More later when my thoughts and feelings have settled.

  [Addendum on 9-Mar-2011: My aunt did not ask anything about my migration nor express any concern for my welfare. Her questions were all focused on who would care for my family members, in particular my parents and my younger brother, with my departure. See my comment dated March 9, 2011 12:53 AM on StorytellERdoc's blog entry.]

• 27-Oct: Blood taken by my night colleague SN R for nursing staff's regular health check. It reminded me that I really want to be certified for venepuncture procedure and but my request to attend the course in September-2009 (not long after my nurses' orientation) was turned down. My coursemate PL at a restructured hospital just got her certification. Luckily, my NO has put it as a course for me to attend next year, but she had omitted the LSCN training for me. It occurred to me that there is no roadmap for training new RN's in my hospital.
• 31-Oct: Halloween dinner gathering with friends.
• 2-Nov: Met up with my course-mates JS and PL. It soon became apparent that JS's fear of losing her acute nursing skills after being in a community hospital for a prolonged time has some basis. PL being in a restructured hospital has the most structured training and exposure. I am somewhere in between, but I'm feeling lost too.
• 3-Nov: Received my confirmation of permanent residency (COPR). Yeah!
• 3-Nov: My first sick day from work, on MC (medical certificate).
• 4-Nov: My hospital had a town hall today. The hospital's further expansion plans were shown. Instead of being motivated, I went away deciding to leave this hospital ASAP.
• 4-Nov: Back to work, despite still sniffing and occasional coughing. I wore a surgical mask at work, but I wonder what the patients think when they heard me sniffing and coughing. Had a :-| day.

Anyway, much thoughts and feelings still as yet unsettled.

Taxi! Get me to work

It's a sign of my declining morale at work. I have taken a taxi to work 4 times in the last 3 weeks. Mainly because I was dragging my feet in heading for work.

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[Addendum on Wed 04-Nov-2009]

Took taxi to work again on 31st October, thus giving a total of 5 times in October.

It's only the beginning of November and I already took taxi to work once in November. That is, today Wed 4th November.

Flash mob. Wish I was there!

Someone posted Flash Mob at Raffles Place 23.10.09 online. Wish I was there!



Quite honestly I cannot imagine my current colleagues taking part in a flash mob. They were rather non-sporting participants in a Michael Jackson imitation dancing contest during a company cruise. That is, to describe in Singlish, they "kenna arrowed" and then they "bay-lek bay-lek".

Suddenly, I miss my ex-colleagues from my previous career in the CBD (Central Business District, including Raffles Place). I can imagine us joining in the Flash Mob if we were there. Unfortunately, most have left Singapore, either back to their homeland or for better shores.

Unbearable pivot of not-here, not-there

I don't feel so good about work recently. The following e-mail to my friend provides a summary of my thoughts.

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Hi [edited],

I just spoke with the [edited] High Commission officer this afternoon of Tuesday 20-Oct. She informed me that she has received my passport but not my medical check-up package. As she wanted to process my application quickly, she enquired about the date of my medical check-up. After we hung up, I called the doctor's clinic and they told me that the High Commission's Immigration Section has already received and signed for the package on the Friday 9th October. Unfortunately I was unable to call back the [edited] High Commission officer to inform her of the update from the doctor's clinic. I'm keeping my fingers crossed that my medical check-up package is sitting in someone's in-tray and would be found and processed accordingly.

I have read further on the [edited: overseas location] requirements to be an RN. It seems like it may not be so straight forward. [Edited: snipped off details of the process.] Still I am so looking forward to move over.

Air my grievances a bit here. Recent days at work were somewhat frustrating.

• My ward manager wants to create High Dependency Unit in our ward. However we are understaffed at RN levels. Thus when HDU cases come in, the priority of getting their treatment done often results in compromised/delayed treatment to the regular acute patients. Of course, nobody wants to highlight this problem because no one wishes to face investigation into his/her nursing care.
• Another issue is the unclear boundaries of EN roles in my ward. One of the SEN told me directly that the SENs (especially those who are foreign RN-trained but downgraded to EN in Singapore) feel unhappy whenever they see fresh graduate RNs joining the ward, taking higher pay and yet are less skillful than them. In addition, the hospital is now putting emphasis on developing the RNs, and thus, the SENs feel neglected as second class employees. As a result of some unpleasant past experience (before my time), the SEN told me not to expect them to perform beyond HCA-level work for me or any new RNs when they are assigned to our teams. They are only willing provide EN/RN assistance to Senior RNs or the ward manager. While I appreciate the candidness of that SEN, I feel that she is misplacing the focus of her problem. Taking out her frustrations on the new RNs will not improve her future.
• Coincidentally, my preceptor chatted with me on a related topic one day before the SEN complained to me. My preceptor is a Senior RN who had been in the ward for 20+ years. She told me that previously there were only RNs and HCAs. Before the ENs joined the ward, the RNs petitioned against their recruitment. The reason was that the RNs did not want an EN level with an unclear scope of duty. In the end, ENs were still recruited to the ward.
• The ward staff also had some issues with a specialist doctor recently. According to my ward manager (NO), that specialist is trying to control the ward nurses by making us look and feel bad, so that he has someone to push the blame to if his fussy patients lodge a complaint. My NO also said that part of the problem is that nurses do not have a union and when incidents occur, they tend to back-stab each other instead of supporting each other. The solution was to have a strong nurses' union, which unfortunately does not exist in Singapore. [Edit: In fact, Singapore's workers' union is a joke, but that's another story.] My reply was, "it will change", to which the other experienced nurses (including my NO and my preceptor) gave cynical smiles. Actually, in my mind my thoughts were, "It will change. At least for me, it will.

" Of course, my ward manager does not know that I have migration plans.None of the above is really my problem, of course, but it makes my work less pleasant as a new RN. For now, the only thing that keeps me cheerful at work is when each child gets well and runs around happily.

Oops, sorry for my long-winded venting. Hope things are good with you. Will keep you posted of any further news.

Best Regards

Ma-ma scolded auntie this morning

I chatted with a 2 year old boy while giving him his last dose of IV antibiotics before his discharge this morning. I happened to enter the room at a bad time, when the mother was scolding the maid fiercely over something. The mother quickly paused from lecturing the maid, as I informed her about the last dose of antibiotics. While fixing up the syringe driver, I asked the boy about his morning activities to check on his intake and output. An extract of the conversation went as follow.

"What did you eat for breakfast?"

"Pancakes, and xxx, and yyy."

[And we went down the list of breakfast items.]

"So did you like the pancakes?"

Boy smiles, "Yes, mmm."

"And, what did you do after eating the pancakes?"

The boy's face changed from happy to upset. He blurted, "Then ma-ma scolded auntie."

An awkward silence. The mother was embarrassed. The maid stood away, looking anxious. I quickly switched the topic to the syringe driver, "Hmm, ok. You see this, it is to push the medicine slowly into your body..."

Later, the mother informed me that they had lost the TV remote control. It was last seen on the sofa bed early this morning. The mother verbalized that the maid said that the remote was gone after another nurse entered the room early this morning. As I needed to attend to another patient, I assured her that we will find it later. We may get the housekeeper's help for it. Then the mother thought of pushing out the sofa bed and searching the floor behind the bed. Just as she started to push one side of the sofa bed out, she saw the remote. It had slipped between the folding joint of the sofa bed and landed into the supporting base of the bed.

IMHO, a missing TV remote is too small a matter to be scolding the maid harshly over. I wonder if the boy had not blurted out the remark, would the mother realize the example she is setting for her child? Good parenting is no easy feat indeed.

Lucky for this ma-ma, the boy showed empathy even at his tender age of 2+. Such snippets of children's innocence and sincerity makes working at paediatrics a blessing.

Stupid

We had a 12 year-old girl with a proliferated appendix who went for an emergency appendicectomy on Monday. She had be on Nil-By-Mouth since post-op. In addition, she had an NGT (nasogastro tube), IDC (indwelling catheter), 2 IV drips (one Dextrose Saline for fluid intake and one Normal Saline with KCl for ml-by-ml replacement of NGT freeflow drainage+aspirate), a syringe pumping Morphine and 8 hourly IV antibiotics.

Today while assisting my colleague to change her hospital gown, I accidentally touched her NGT and she remarked audibly, "Stupid!"

I kept my cool and ignored her remark. Labelling the very people whom she depends on to get well as stupid? She doesn't realize the irony of her remark. Besides, unless her IQ prevails over 99% of the population, calling me stupid would mean she's even more so. Of course, she doesn't realize that too, ha ha!

Anyway, I shared about her remark with some of the afternoon staff when they came for work. Apparently this child has been rude to the other staff members yesterday too.

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After interacting with many children at work, I am beginning to understand why my ward manager often cite poor parenting as the cause of lack of social grace. I would reckon that 90% of the children we get are well-behaved considering their illness. The remaining 10% often have caregivers/parents that fall into the following categories.

• Parents/grandparents who treat the maids with poor social graces and the children copy likewise,
• Parents who assume that their maids will discipline their children without delegating to them the authority to do so,
• Parents who show strong favouritism towards one child over another, and
• Overly protective parents/grandparents.

While we cannot blame our parents for our behaviour as adults, I am persuaded that the foundation is laid during our formative childhood years. It would take much conscientious awareness on our part for change to occur. Sometimes though, serendipity plays a part.

New staff

I was taking team for the patients away from the nursing station today. SEN L was my runner today. We started with 9 patients under us, followed by 1 discharge, and 3 new admissions.

The adjoining ward wasn't open, thus SSN F and SN M were around. SN M was taking team for the patients near the nursing station. SSN F helped around for both teams. SN RB, a new employee freshly graduated from my local nursing school, was assigned to learn from me today. Although I had to spend some time showing SN RB some of the stuff, she had been a great help to me this morning. Add to that SSN F stepped-up to help me for stuff like NG aspirate, IV flushing, and patient's admission where SEN L wasn't willing. Even SN M covered me on a doctor's round while I was taping my handover report and HCA M, who was SN M's runner this morning, assisted to answer call bells. I am really lucky to have their help. Yet, despite the luxury of all the support I got, somehow we were still very busy this morning on my side.

Rumours are that the staff from the adjoining ward will be returned to their original wards when the adjoining ward closes permanently. I will miss them. Despite their laments to me about my ward, they have been personally supportive of me at work and voluntarily help me when they see that I'm busy.

SEN L was grouchy as usual. Her attitude is beginning to affect the quality of her work. I noticed a quite few temperature taken where the patients' temperature is recorded as 36.0 degrees Centigrade. Since she is a locally trained EN, I expect that she knows that this is not an acceptable temperature for children who are not warming up post-OT. I will observe her further before deciding on what is to be done to address the issue. I need to assess if this is a once in a blue moon event, or she does this slip-shot standards only when assisting me, or if it becomes a trend for her.

Topless sunbathing beds

I was assigned to take care of the ward's assets listing. On the recent asset audit day, finance lady NL and I searched high and low for 2 missing beds, but failed.

Today the ward manager NO and the admin staff M went around the hospital hunting for the 2 missing beds. It turned out that they were sitting outside the repairmen's workshop. NO described them thus.

"How can the beds be lying in the open air, under the rain and the sun? Gathering rust? Moreover the beds are without mattresses. It's like the beds are sunbathing topless!"

"If you say that to the xxx [repairmen's dept] people, they will tell you that they [the beds] are ang moh sunbathers [i.e. Caucasians who sunbathe topless].", I replied jokingly.

Good times, bad times, and fitting in

The ward census was not high since last Sunday. As a result the adjoining ward was closed, and their staff deployed either to my ward or other wards. In addition, my ward was opened for admission of adult patients.

Generally my past few days were pleasant other than this afternoon's FON mother and an FON adult female patient discharged 2 days ago. In a way, I am fitting into the ward.

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However, the same cannot be said of the staff from the adjoining ward who were deployed to join my ward. For example, SN SB told me her grouses yesterday morning at several brief intervals.

Sometime mid-morning, ADON G came to our ward. As several of the staff were at the staff room, ADON G saw SN SB at the ward area and asked her, "You know about the incident, right?"

The night staff had passed to us several issues, the most important of which was that a patient's uncle had complained of a water jug with an odd smell. SN SB replied, "Yes, you mean room XYZ who complained of the water jug with a smell?"

The ADON looked surprised and raised her voice asking aloud why no one told her about that incident.

SSN Y was in-charge that morning. According to SN SB, SSN Y was upset that SN SB leaked the cat out of the bag. SN SB was upset by the ADON's and SSN Y's reactions, especially since her information to the ADON was unintentional. Thus she shared her grouses with me. She told me that she plans to leave the hospital soon.

Then later at around 130pm, SN SB asked if I had taken lunch. I told her that I did not pack lunch from the staff canteen today because I intend to eat only after work. SN SB told me that she has not packed her lunch yet. I was surprised. I told her that our ward's housekeepers went around offering to pack lunch for us, which is the ward's norm. It could be that the housekeeper missed out SN SB because they were not familiar with her. SN SB then told me that she felt excluded because the other nurses knew that she was around and yet did not inform her about the arrangement nor did they tell the housekeeper to ask her. That added to her grouses.

I feel sad that SN SB didn't feel like she fitted into the ward and plans to leave the hospital. She is an experienced staff nurse and a wonderful teaching SN when I was a student nurse at her original assigned ward. She was subsequently transferred to the adjoining ward and now "kicked" (to use her own words) into my ward.

Another thought I had was that many of the nurse mangers and my ADON G need leadership training. Their common habit is to raise ruckus whenever they hear of any incident, instead of keeping calm and gathering the facts. Their behaviour may get one much attention and, hopefully, fast response. However, such a habit of making mountain out of every incident, regardless of it being a Mount Everest issue or a molehill, encourages staff to be on the defensive and thus impeding and/or defeating the problem solving process. In this regard, my NO is an excellent example to follow. Sadly, as I understand from my ex-nursing lecturer who previously worked in the hospital's sister organization, leadership training is sorely lacking at my hospital.

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After our shift ended yesterday afternoon, I sensed that SEN L was waiting around to speak to me confidentially. Finally after the other staff had left the staff room, SEN L asked me if I was interested in joining her at some events. It turns out that she joined an MLM company as she was interested in their beauty courses. At one point, SEN L said, “人此職的原因只有兩個，對工做沒興趣或者沒有前途。“ [Employees resign from their jobs over 2 reasons. Either not interested in their job, or there is no future in the job.]

I understood where SEN L was coming from. The school for registered nursing turning down her application for training to be an RN has had a big impact on her hopes. However, as I've mentioned to her on another occasion before, her nursing future is not limited to being trained and practising in Singapore. Thus I responded teasingly, “前途是自己創造的嗎！” [The future is in one's hands.]

To which she replied, “不只是“前途”。我講的還有“錢途”。” [Not "future", but "monetary rewards". Note: Both are homophones in Chinese Mandarin.]

I understand what SEN L was talking about. Nursing pay in Singapore is not high (click here and search for "nurse"). Even at managerial levels of NO, one can only expect around SGD4-5K/month gross pay. The highest paid are those trained and practising in highly specialized areas like OT and CCU nursing where SGD 7K-9K is a possibility after many years of experience, with overtime thrown-in. This is miserable compared to the pay of other "professional" fields where specialized training is a pre-requisite. There isn't a single nursing-based job listed on Singapore's top 100 best-paying jobs across all industries in 2009. Thus, nursing while labelled as a noble job, is not seen as a rewarding job by the Singapore society in general.

To quote one patient's grandfather words to me yesterday morning with regards to nursing, “這種工做，吃力又不挑好。” [This type of job, takes so much effort and yet is unrewarding.]

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Nursing is like that. With good times, bad times, problems with fitting-in, (hopefully) eventually fitting-in, handling one's ups and downs at work, and ultimately ownership of one's own work behaviour and career expectations.

Nursing is making me racist

Just so pissed off with another FON mother early this afternoon.

Her child was admitted last night at 10+pm for vomiting. Her child regurgitated 3 times after feeds yesterday, each time a small amount of undigested feeds. However, the mother insisted that the child was vomiting and insisted that the night staff charted it as vomiting. Since the mother insisted that the child vomited, the doctor's order is to stop feeds and rest the GIT. The night staff had a difficult time with this mother and noted to us in the handover report.

This morning, only her maid was around when the specialist reviewed her child at 9+, almost 10am. Both parents were not around for the child. The mother called around 1020am and asked for updates about her child. Since I was the staff nurse taking care of her child, the admin staff passed me the phone. I informed her of doctor's instructions that her child can start feeding and other updates. She requested that we provide her child the milk and bottles since they did not bring any on admission. I explained that we could only provide 1 milk bottle and the complimentary milk powder if we have stock. She agreed. We happened to have the milk powder, so I brought 1 tin and a milk bottle into the room. I informed the maid that she could make milk for the child using the hot and cold water provided in the room. The maid nodded her head. I further stepped into the room several times during my shift. Each time the child was still sleeping.

The mother came around 1+pm. First thing she did was to ring the call bell and kick a fuss to my colleague HCA M asking why her child was not fed this morning. As my colleague HCA M informed me, I went into the room to clarify the matter.

"Are you the child's mother?"

"Yes, I am. Why nobody told my maid that my child could be fed this morning?"

"Remember? You called this morning. I was the staff nurse who spoke with you and I explained to you that your child could take milk? I provided the milk and a bottle as you've requested..." [Note: I was interrupted by the mother.]

The mother widened her eyes and raised her voice, "Yes, it's only logical that if the milk and bottle are provided, that the child can drink. But, my maid is from the village. These village people wouldn't know anything."

"When I brought in the milk and bottle, I informed your maid that she could make the milk for the baby. I even pointed to the water flasks and explained that she could use the water for making milk. She nodded her head to indicate that she understood. If she claims that no one told her that your child could take milk, then I'm sorry, I have nothing to say."

"The doctor didn't tell my maid that the child could drink."

"Normally the doctor will explain to the parents if they are around." [Note: Both parents were not around that morning. This particular doctor prefers to do his rounds alone, so there was no witness on whether the doctor did explain to the maid or otherwise.]

Now switching to next line of tackle, mother said "Well you're nurses right? Why no one checked if my child has taken any milk since then? You know, my child has gone hungry since 1030pm last night. How can you let a child go hungry for so long?"

"I came into the room several times this morning. Each time your child was sleeping..."

Mother interrupted again, "Well the maid may not know that she has to feed the child once the child wakes up. Why didn't anyone check if my child has been fed? It's not just about my child. In any hospital, you would have to ensure that the child is fed, right?"

"I came into the room several times this morning. Your child has been sleeping the whole morning." [Note: In fact, the child was still sleeping at the time we were speaking. Anyone knows of a hungry child that sleeps soundly?]

The mother ran out of line-of-attack and changed topic to how much to feed her child. I replied accordingly.

I moved on to serve other patients. At around 230pm, HCA M informed me that the mother complained to her that no one informed her maid that the child could be fed and as a result the child was not fed in the morning. This after I have already explained to her? I was pissed. SSN R who was in-charge this morning asked me what happened, I updated her and SN J who was in-charge in the afternoon. SN L heard my update. She had dealt with the parents yesterday. She informed me that the father has arrived and he is more reasonable. Then I went into the room and spoke to the mother again. As noted by SN L, the child's father was also present by then.

"My colleague told me that you complained to her that no one informed your maid that the child could be fed. I already explained to you what happened this morning, right?"

Mother now switched to getting-sympathy mode, "Well, I am not feeling well myself. I feel like vomiting. I am very worried about my child. All she had was this. What's this? Does this have glucose?" Mother holding the IV drip bag, trying to read what was administered to her child.

"Yes, it's a combination of glucose and salt solution. Your child probably didn't feel hungry because she has the drip. You don't need to worry about her hydration. Anything else that you would like to clarify?" [This is me asking with a fake smile because I was really pissed off by the mother's attitude by then.]

"No, I don't have any further questions now. I am really feeling not well..." and she went on complaining about her condition.

Since she had mentioned that she was nauseous, I gave her some plastic bags for puking.

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This is the second mother from the same ethnic group to raise ruckus unreasonably recently. Add to that an FON adult female patient of the same ethnic group earlier this week. The adult patient was incidentally under the care of SN J's team and of the same ethnicity as SN J, but she ignored the call bells of her "difficult patient" on the morning of her discharge.

As much as I'd like to be nice and treat everyone fairly, it seems to me that those of this ethnic group think that being polite makes one a small fry to be trampled upon. Well, thank goodness my colleague HCA M who is from the same ethnic group behaves differently from the lot.

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[Postscript on Sunday 11th Oct, 2009]

While taking report this morning, SN J informed that during the afternoon shift on Saturday 10th Oct, she noticed the mother sleeping on an adult bed in their 2-bedded room. Since SN J was in-charge, she went into the room and informed the mother that she cannot sleep on the bed as it was meant for another patient to be warded subsequently. The mother then verbalized to SN J that a staff nurse told her that she can sleep on the adult bed and had arranged some staff to give her that bed. SN J was surprised by the matter and thus reported it this morning.

It turns out that the mother is twisting her words again. When she told me that she was feeling nauseous, she asked if I could give her some medication for it. I explained to her that our hospital policy is that we cannot dispense medication without a doctor's order. I recommended that she visit our A&E dept for a consultation. Then if our A&E doctor assesses that she needs to be warded, we can arrange for her to be assigned to the same room on the bed next to her child since he is in a 2-bedded room. The mother then verbalized with a slight mocking tone that she planned to go KKH (the restructured hospital for treating women and children). Subsequently, the runners needed a cot bed for a new admission, so they swapped out the cot-bed next to her child and replaced it with an adult bed. At no point did any staff offered her a patient's bed for free!

I was glad that SN J brought the matter up. It showed the mother's behavioural pattern clearly.

Migration medical check-up done

Just completed my medical check-up for migration today. According to my friend who has already received the confirmation of her PR, it will take 3 weeks for the confirmation of PR to arrive if all goes well. I'm keeping my fingers crossed!

While reviewing my medical notes, the doctor joked that perhaps I'd marry a white man there. He's not the only one to joke about it. Even my former nursing lecturer teased me about that too. My only reply, "It's hard to say."

Given that I do not have a preference for any particular ethnic group and I'm heading to a place where half its population are a visible minority, the probability is around 50% statistically speaking. That is, IF I found someone whom I wish to marry and vice versa. It's a BIG "IF".

Census W curve

Yesterday the ward was full during the morning shift. The ward manager (NO) was in-charge, admin staff was on-duty, I and SN O took the teams near and far from the nursing stations respectively, with SEN S and SEN MY as our respective runners. Thanks to the converted single rooms and 1 adult patient in a double room, I had 8 patients. Unfortunately for SN O, her side was full-house, and even had new admissions taking over the rooms vacated by the discharged cases. This is similar to my previous experience here and here. It was crazy busy for SN O yesterday. As she puts it, "NO as in-charge, SEN MY as runner, I wouldn't want to work with this type of lousy combination next time". At the end of our shift, there were still new paediatric patients awaiting for rooms, so the sister-on-duty spoke with the adult patient and arranged for her to be transferred to another ward. Thereafter, a few of the paediatric patients awaiting for rooms could be transferred over.

There were many discharges yesterday evening and this morning. SSN Y was in-charge, I and SN O took the teams near and far from the nursing stations respectively, and only 1 runner HCA K. When I arrived for duty this afternoon, the total census was 10 patients. My side started with 5 patients. Near the start of the shift, one patient was transferred to SN O's side because of their request for a single room. Towards the end of my shift, there was a new admission on my side. Thus, for most of today, I had only 4 patients, all in stable conditions. SN O started with 5 patients, had 1 transfer case from me, 1 new admissions mid-afternoon, 1 discharge and then near the end of the shift another case transferred from another ward. Thus total census at the end of our shift today was 12. I had time for tea, dinner and even chat with my preceptor SSN Y.

According to my preceptor that's the way the census is for paediatric ward. It can swing suddenly between busy and relaxing and vice-versa. Such an extreme W shaped curve. Hmm, it reminds me of the stock market :-P

4 months old

Had a series of busy mornings and double shift this week, with extra work due to various audits -- documentation, ISO, assets. Today was another busy morning for me at the ward. I started with 6 patients and had 2 new admissions this morning.

On duty this morning were the ward manager (NO), the admin staff, I and SN J -- taking teams near and far from the nursing stations respectively, HCA K and SEN MY for our respective runners. I arrived just-in-time to take report as I was overslept. NO briefed us during report handover due to the ISO audit to be done today. She wanted us to follow-up with various document and equipment checks.

There was a constant flow of admissions since yesterday evening, of which 2 admissions were assigned to my side of the ward. Majority were GE related cases. It was Children's Day yesterday, so it made me wonder what the children ate during the celebrations on the eve of Children's Day that may have caused their GE. Both team had many IV medications this morning -- probably correlated to our GE incidences -- and we did not have enough syringe drivers to go around between 10+am to 11+am.

Just after the shift handover report, there was an IV cannula that leaked. HCA K and I tried to save the IV cannula site but it couldn't work. Immediately thereafter, a new admission arrived for my team. I admitted and orientated the patient and her parents, assist the specialist who came to diagnose the patient's illness, follow-up with RMO for IV cannulation, IV drip and blood investigations. All that work took about 1.5 hours of my morning. Add to that following specialists on their rounds. By the time these were somewhat settled, it was already just past 10am. Unfortunately, many of the new medications (including IV medications) since yesterday night were not supplied and were not available from the ward stock either. Thus, I had to quickly put in my pharmacy requests. Thankfully, the night staff managed to give the morning doses of the TDS oral medications, and there wasn't any febrile cases, so I did not have to rush for the morning TDS medications, except for nebulization. Then I did one round of medications. Before I could administer the IV medications for those that were available, SN J came to borrow 1 of my 2 syringe drivers as her cases were slightly overdue. The rest of the morning was various medication follow-up when available or due, interruptions from both the NO and the admin staff to correct various documents and workplace items before the ISO audit. I was pretty stressed and hungry by 12+ noon, as I have not had any break. In addition, I was still pending several overdue IV medications due to a combination of medication and/or syringe driver unavailability. Then another new case arrived for my team. The admin staff instructed me to admit this new patient. I was already over-my-head with overdue medication and IV, so I told her to get the NO to admit instead. The NO helped. Seeing that I still looked stressed at 1+pm, the NO came over and instructed me to take a break, saying, "工作永遠做不完得。” ["Work will never be finished."]

Then I took a break and ate the bread that I brought from home. After my break, I did my mid-day round of medication and continued with my outstanding IV medications. While I was taping my handover report, I was interrupted for the pre-ISO audit briefing by the NO to all staff. Thereafter I continued to tape my report while the afternoon staff were listening to the other team's tape. Unfortunately I could not pass report for the second new case which I have not seen, and who went down with the case-notes for ultrasound investigations. Actually, I should thank the NO, the admin staff and my runner HCA K for handling this new case for me.

Thus I am 4 months old but I still struggled through today despite my side of the ward not being at full capacity. In the end, I only left work at 4pm after completing my documentation, pharmacy forms and ward billings. I am so tired!

Discharged At Own Risk

I had my first case of discharged at own risk today. The patient came in for vomiting for investigation sometime after 12 noon. Upon arrival at the ward, the admin staff showed her to the room. Then the in-charge and admin staff quickly arranged for the AXR to be done stat. HCA K sent the patient down for the AXR. As I was busy with my medication rounds, I did not note the exact time of patient's arrival at the ward and return from AXR.

At 1:10pm, the specialist reviewed the patient at the ward, wrote up the IMR and left. Around 1:20pm, I reviewed the IMR and noted the specialist's orders. Domperidone suppository was ordered. As the ward admission interview was not done yet, I did a quick check with the mother on the child's condition. She was carrying the child and walking up-and-down the corridor and talking on her mobile. The mother replied quickly that the child had vomited once before admission, but not since. Then she looked somewhat unhappy to be interrupted and went back to her phone conversation. Seeing that the mother was busy and not wanting to be interrupted on her phone, I explained to the mother that we will not give the child the suppository yet. That was my mistake in my judgement.

Around 2:20pm, the child vomited. The mother called the specialist to complain that we had not done any intervention for her child since her arrival 2 hours ago. At 2:30pm, the specialist called up and instructed me to give the supp Domper stat, which I did immediately. As the shift handover report was in progress in the treatment room, SSN Y who was in-charge in that afternoon instructed that I only call the MO to follow-up with the IV cannulation after the shift handover report was done. When the shift handover report was done around 2:40pm, SSN Y arranged for the IV cannulation to be done by the MO. Meanwhile, the afternoon staff interviewed the patient for ward admission.

At 3pm, before the MO arrived for IV cannulation, the mother came to the nurses' station and demanded to be discharged. I called the specialist for his agreement on the matter, the medication for discharge and his fees. Meanwhile I had a hard time searching for the AOR form, so SSN Y helped me. Although we received the X-ray report via fax, we had not received the X-ray film yet. The admin staff called X-ray department to ask for their delivery of the X-ray film, but their porter was overloaded too. It was around 3:30pm when we received the patient's admissions record (with the patient's ID stickers) from the admissions department. It turned out that the mother only registered her child's hospital admission at around 1:30pm.

We quickly did the billings and documentation labelling for this patient. While we were doing so, the specialist came round for a second visit. SSN Y, as the in-charge, accompanied the specialist for his round. The specialist returned and signed the required IMR and billing papers. Then SSN Y sent the afternoon runner SEN MY down with the relevant documents for the pharmacy and the billing office. According to the specialist, the mother is herself a staff nurse at a restructured hospital. She is also a friend of our ward staff SN J, who was not on-duty today. This is really strange to me, because as an SN herself, she should know the workings of a ward and the priorities of investigations/interventions.

It was almost 3:50pm. The NO returned from her meeting and the admin staff updated her of the AOR discharge. The NO said that from the way the patient's mother was on the phone almost all the time since arrival at the ward, the NO suspected that her claims of a 2 hour delay in intervention was not the main reason for her AOR discharge request. Anyway, the NO went to talk the mother for service recovery. According to the NO, the patient's mother was about to start complaining when her husband signalled for her not to. They even rejected removal of Emla cream from the child's hands. When the NO returned, she instructed me to remove the Emla cream which I did, stopping them as they exit along the ward's corridor to do so.

In the end, the NO reviewed the case with me. She instructed me that in future, for new admissions, always give the medication first to avoid such claims of no interventions done. Fortunately, my colleagues had sent the child for AXR which was completed with report, in-time for their discharge. Thus the mother's claim of "no intervention done" does not hold water. Later, SSN Y advised me that if I was too busy to handle admissions in future, I should seek the NO's help. Lessons learnt.