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.