Practising the
rofession P
The Choice Institution for Great Nursing
Contents Message
05
Dr Tony Tan Keng Yam, President of the Republic of Singapore
Pre-nursing A path less chosen Band of brothers
06
Dr Pauline Tan, Chief Nursing OfďŹ cer, Ministry of Health
Culture of care - Choosing TTSH
07
Madam Kay Kuok, Chairman, National Healthcare Group
08
Professor Philip Choo Wei Jin, Chief Executive OfďŹ cer, Tan Tock Seng Hospital
09
- Male nurses
Mr Yong Keng Kwang, Director of Nursing, Tan Tock Seng Hospital
18
Nursing newbie Dive into history Entering the environment
22 26
Nursing life Firm friends Go, have fun! Holistic pursuit of happi-nurse - Life outside TTSH
Interwoven yet individual - Nursing Manpower
Just superstitions Keeping the night vigil
2
10 14
30 34 38 42 46 50
56 60 64
Likeness in diversity
- Letters from the patients
76
98
Making marks overseas None left behind - Continuing and community care
Nursing development 68 72
When you watch over me
Of reaching for the stars Passage pavers - Specialisations: Nurse Clinicians
Quest for advancement - Specialisations: Advanced Practice Nurses
80
Rallying the troops
84
Standing on strong shoulders
88
Through trials and tests
90 94
Ushering the information age
- Ward management
Nursing leadership X-uberant and X-ceptional
102
Choice institution Yet we overcame - Remembering SARS
Zest for the road ahead
106 110
Others Milestones Acknowledgements
114 118
- Nurse Educators
- Nursing research
Value-added qualities - Nursing quality
3
“
I am of certain convinced that the greatest heroes are those who do their duty in the daily grind of domestic affairs whilst the world whirls as a maddening dreidel. - Florence Nightingale
Message ursing is an honourable profession. Besides the many tasks that our nurses perform to tend
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to patients, our nurses also provide care by listening to, encouraging and reassuring them.
In attending to patients, our nurses put themselves at the risk of contracting diseases themselves. Nursing is a calling that demands selflessness and devotion. Tan Tock Seng Hospital has a long tradition in nursing excellence and is a pioneer in many areas, including tuberculosis and neurosurgical nursing. Despite the ever-evolving challenges in the healthcare sector, the nurses at Tan Tock Seng Hospital have stayed true to the founder’s legacy and are passionately committed to care for the sick and the infirm in line with the hospital’s core values of compassion and care. I am heartened to note that the nurses are committed to meeting international benchmarks in key nursing outcomes and I encourage them to continue in their commitment towards excellence in healthcare delivery. This publication produced by Tan Tock Seng Hospital offers a glimpse to the lives and experiences of our nurses and shares their everyday trials and triumphs. Our nurses are our daily unsung heroes and they deserve our unwavering support and appreciation for their contributions to our community and our nation. I wish all nurses a Happy Nurses’ Day!
Dr Tony Tan Keng Yam President of the Republic of Singapore
5
Message ursing is a noble profession that combines art and science. The art of nursing is anchored on
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humanistic values framed by the profession’s ethical code of conduct. The science of nursing is
constantly informed by new knowledge and evidence-based nursing practice. The perfect blend of both allows nurses to discover boundless opportunities and “moments of truth” to touch humanity and to give meaning to what they do. Nurses connect with the cadre of dedicated healthcare colleagues and, to a larger extent, the community in the course of their work. They untiringly work with these individuals to improve lives, strengthen our social fabric and make our healthcare delivery system better and safer. Over the years, nurses have also influenced policies to recommend the right level, right provider and right approach to deliver nursing care to improve quality, access and cost for our system. Although nurses are very much on the frontline, they rarely shout about what they do, even though they are the lifeline that keeps our healthcare system ticking. This book is a firm demonstration of the nurses of Tan Tock Seng Hospital who stand committed to their mission to give their best to serve, care and heal. It affirms their resolve to excel, grow new capabilities and maximise the collective wisdom of every nurse to make each patient experience a truly special and marvellous one. I congratulate you on the publication of this book. It will add to the heritage of our local nursing annals and will serve as a reference book for new generations of nurses who need to know about the past in order to strengthen the present and to build a better tomorrow for the profession. I am confident that nursing in Tan Tock Seng Hospital will continue to set new benchmarks as a leader in the nursing arena, both in patient management and nursing innovation.
Pauline Tan (Dr) RN, FAAN Chief Nursing Officer, Office of the Director of Medical Services, Ministry of Health 6
urses, while caring for their patients in the course of their healing journey, have formed many
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synergistic partnerships with other healthcare professionals and built many strong bonds with
their healthcare partners over the years. Such relationships are key today with Singapore’s rapidly ageing population and the higher incidence of chronic diseases. Patients now need longer term and more personalised complex care. As we shift our focus to more team-based and patient-centric care, our doctors, nurses and allied health professionals will not only have to work more closely with one another but also beyond the hospital walls – in the primary and step-down care sectors with community partners. Nurses are the conduits and the partnerships they have built will form the foundations for better patient care, where every profession plays a valued and integral role, complementing one another in their different specialties. This commemorative book on nursing – a first for Tan Tock Seng Hospital – will show, among other things, how nurses have continuously diversified into different areas and specialised roles, as well as evolved with their healthcare partners, to create a community of care for our patients today and in the future. My warmest congratulations to our nurses on this first undertaking in documenting their changing roles and responsibilities. I wish them all the very best.
Madam Kay Kuok Chairman, National Healthcare Group 7
Message W
ith 9 per cent of the population above 65 today and these numbers expected to triple by the year 2030, Singapore faces an increasing challenge in meeting the healthcare needs of our
ageing population. As life expectancy prolongs, so too will the cases of multiple chronic diseases. These demands will critically shape the future nursing landscape. To cope with this, we need to ensure that Singapore has an ample number of quality, dedicated nurses, rather than just meeting the numbers. Healing is more conducive in a nurturing environment. Nurses are a cornerstone of Tan Tock Seng Hospital and we are committed to making sure that this institution is a great place for our nurses to work and learn in. This commemorative book celebrates the contributions of our nurses, who have helped mould Tan Tock Seng Hospital into the world-class healthcare institution it is today. It also gives us a greater insight into how nursing in Tan Tock Seng Hospital has evolved over the years, with technology, education, research, dedication and compassion spurring nursing to greater heights. Let Tan Tock Seng Hospital continue to be an environment for nurses to grow and fulfill their greatest potential. I wish all of you a very happy Nurses' Day!
Professor Philip Choo Wei Jin Chief Executive OfďŹ cer, Tan Tock Seng Hospital 8
urses form the backbone of the healthcare industry. Evidenced since the days of Florence Nightingale,
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nursing was especially poignant in Singapore during the SARS epidemic in 2003. The ensuing decade
witnessed the transformation of nursing culture into one that is open, inquisitive and daring. The language of nur sing today has thus evolved with it. Peppered with improvement managements, breakthrough research, forefront innovations and higher value-added patient care interventions, the Tan Tock Seng Hospital nurse is one in tune to the latest events surrounding him or her. We envision building Tan Tock Seng Hospital as a choice institution for patients, fellow nurses and healthcare partners due to great nursing work and culture. This first-ever book on nursing at Tan Tock Seng Hospital provides a window into the psyches of our nurses. By focusing on the stories of our everyday nurses, it chronicles their aspiration, insights and hopes, through the rhythms and colours of the dynamic nursing environment. Its simple, yet keen narratives aim not to laud the achievements of the administration but acknowledge the work of our nurses. The tributes belong to the nurse, be it the one with the early start or the one who has journeyed a thousand miles. It begins with the young school leavers’ first decision to choose nursing, follows the nurses as they made Tan Tock Seng Hospital “The Choice Institution for Great Nursing” and traces the memories back to the veterans in a full circle. Together with the present and the past, the last chapter opens to the new vista ahead for all our nurses. This book dedicated to nurses is “from nurses, about nurses, for nurses”. We hope you enjoy this memento served to you with a big heart.
Mr Yong Keng Kwang Director of Nursing, Tan Tock Seng Hospital 9
A
A path p less chosen
Why choose nursing when there are so many other varied choices? In a career path fraught with challenges, nurses relate their stories and how the difficulties are outweighed by far richer rewards An avid soccer player, Staff Nurse Muhammad An-Nur Bin Abdul Rahman (11C) became a nurse through Ngee Ann Polytechnic’s nursing course.
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o you want to be a nurse. Isn’t it a dirty job? Won’t you have to face long hours on your feet with demanding patients? What about having to cope with death and suffering and all that emotional baggage?
Aren’t you afraid of getting infected? Senior Assistant Nurse Anna Goh (10D) battled family objections to join nursing.
All valid questions, among others, that may be swirling around you, as you contemplate your choice. Why did those who chose nursing do it? For some, it was due to a traumatic, eye-opening moment. Nurse Manager Eugene Lam, who left his pre-university course to pursue a Nanyang Polytechnic nursing diploma after he witnessed a road accident, said, “I was struck by how I felt – I was standing right there, but I could do nothing to help the injured person.” Family also plays an important role in the decision-making process. Staff Nurse Muhammad An-Nur Bin Abdul Rahman and his younger brother Muhammad Hafiz chose to stick together and become nurses together, joining Ngee Ann Polytechnic’s nursing course. However, battling family objections to choose nursing made Senior Assistant Nurse Anna Goh, an ITE graduate, and Unit Nurse Manager
Witnessing a car accident spurred Nurse Manager Eugene Lam (Emergency Department) to leave his pre-university course and pursue a Nanyang Polytechnic nursing diploma.
Laura Ho more resolved about their career choice. At a crossroad between teaching and nursing after her A levels, Chia Gerk Sin chose to do a nursing degree as what she called a “practical choice” in National University of Singapore, as she knew she would enjoy a more hands-on vocation which directly applied what she had learnt in school. A senior staff nurse now, she said compassion and a desire to make a difference are essentials. For Nurse Manager Tan Tit Chai, his decision was made at a time when fear was rampant. It was in 2003 and the alarm over SARS was just starting to spread. He volunteered for what was a dreaded job – screening temperatures. He realised then that “society needs people who dare to step forward in times of crisis”. It made him re-evaluate his then ten-year career as an accountant,
Opting for a mid-career switch from accounting to nursing was Nurse Manager Tan Tit Chai (Nursing Service), who was involved in a hospital wide ward renovation project.
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eventually choosing to forge a new path in nursing. His advice for nursing hopefuls: “When you find meaning in what you’re doing – the comfort that
“
I always tell my nurses that we have miracle hands. If we choose to have sincerity in our hearts when we touch others, they would feel that difference, that therapeutic touch. – Laura Ho Unit Nurse Manager (Level 5)
you’ve offered to patients and their families – it pays you back manifold.” Sharing the same view on nursing’s benefits, Gerk Sin added: “If I could start all over again, I would still choose nursing because it has broadened my perspective on life and how to live more fully.” New nurses who come under Laura are always asked the reason they became nurses. “About 80 per cent tell me their mothers wanted them to do it,” she said. With a sigh, she would ask them to come up with a better answer. The veteran nurse of 18 years pointed to her hands and said: “I always tell my nurses that we have miracle hands. If we choose to have sincerity in our hearts when we touch others, they would feel that difference, that therapeutic touch.” Still uncertain? Well, the decision lies – in your hands.
Senior Staff Nurse Chia Gerk Sin (Palliative Care Services) chose a nursing degree as she knew she would enjoy a more hands-on vocation.
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B
Band of brothers Far from being the career choice of only women, nursing for men is on the rise. And male nurses bring more to their role in caring for patients than just strength of arm
Nurse Clinician Maran S/O Pakkirisami (TTSH Rehabilitation Centre) values the unique role and ability of each nurse — be it male or female — in contributing to the team effort.
eing a thorn among the roses is a familiar feeling for Rehab Nurse
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Clinician Maran S/O Pakkirisami. “Although the numbers are rising, we still don’t have many guys entering nursing, so we’re usually
surrounded by ladies,” he said. “But it’s not all about gender. Equally important are each person’s unique role and ability to contribute well to the team effort.” With changing times, the perception of nursing for men seems to have progressed. For Nurse Manager Laley Bin Senawi, who joined Tan Tock Seng Hospital in 1988, the resistance then was from his recruiter. “In my batch of 1985, there were only 14 male nurses out of an intake of over 200. I still remember during the interview, the recruitment officer took one look at me and asked, ‘Are you sure you want to be a nurse? You look too manly’.” Others, such as Assistant Nurse Muhammad Safiee Bin Abu Bakar who started work in TTSH in 2008, met with resistance from their family initially. Despite having an aunt, an uncle and a cousin who are nurses in the family, Safiee’s father preferred his sporty son to opt for a career in soccer, rather than nursing, which he thought of as a “soft kind of job”.
Initially met with familial resistance on his decision to become a nurse, Assistant Nurse Muhammad Safiee Bin Abu Bakar (STAR Team) eventually won his father over with his confidence and knowledge when dealing with sick family members.
However, it was seeing Safiee’s confidence and knowledge when dealing with sick family members that eventually won his father over. More recently, some such as Staff Nurse Nigel Chua, who joined TTSH in 2011, said it was family support that nudged him in the direction of nursing, even when he could not decide on a course for his studies. Answering the call of duty can sometimes literally mean life on the edge for these male nurses. Laley recalled: “My patient, who was in an altered mental state, had climbed out of the window and was standing on the parapet ledge. I climbed out after him and grabbed him, saving him from jumping off.” Subsequently, through the entire treatment process, the patient treated him like a brother. Although, due to his mental state during the attempted suicide, the patient could not recognise Laley, he later said something which moves Laley to this day. “He said, ‘There’s a guy
Family support nudged Staff Nurse Nigel Chua (7C) in the direction of nursing, who uses his talents in balloon sculpting to bring joy to patients.
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who saved my life and he looks like you’.”
At times, sitting with a patient for three hours while she cries, at times having to endure punches or kicks by violently struggling patients, male nurses — as do all nurses — follow the duties of being the patient’s advocate. Pushing aside downsides such as disparaging remarks by family members or patients, Maran summed up what keeps him going: “It is the disease which makes a patient behave the way he does. It’s not the patient’s fault.”
“
I still remember during the interview, the recruitment officer took one look at me and asked, ‘Are you sure you want to be a nurse? You look too manly’. – Laley Bin Senawi Nurse Manager (5D)
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C
Culture of care
Nurses love working here for its nurturing environment, at hierarchy and kampung spirit
For Senior Staff Nurse Evonne Oh (7D), the kampung spirit and ďŹ rm bonds with her colleagues are what keep her rooted in TTSH.
Senior Staff Nurse Anni Dionne Liew (Nursing Service) felt there was a plan charted for her in TTSH. With the support of the hospital, she recently completed her Bachelor of Science in Nursing (Minor in Healthcare Management) at the University of Pennsylvania.
A
pivotal decision in a taxi brought Anni Dionne Liew to TTSH’s doors five years ago. While looking for hospitals to work temporarily at before entering university, a chance encounter with then Senior
Nurse Educator Pua Lay Hoon led her to a meeting with Mr Yong Keng Kwang, now Director of Nursing and his predecessor, Madam Kwek Puay Ee. She was struck by how they seemed to genuinely care for how her interests could be furthered, rather than simply fitting her in to meet the organisation’s needs. She felt it was a place where she would learn the most and there was a plan charted for her. But as she had planned earlier to sign an employment contract at another hospital, she got in a cab after the meeting to head there. While in the cab, she realised that if TTSH ticked all the boxes, there was no need to go elsewhere. “That was when I made my decision and told the surprised cabbie uncle to turn back – to TTSH.”
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While the path to TTSH for most might not have been as dramatic as Dionne's, many said that it was TTSH’s culture that made them choose it in the first place and made them stay. Calling it kampung spirit, where everyone looks out for one another, Dionne, now a Senior Staff Nurse, added: “Where else can you find a workplace where everyone is so sincere?” TTSH’s flat hierarchy is another feature regularly brought up. “It’s the flattened hierarchy, where your manager is your friend – one who will encourage you along the way,” said Senior Staff Nurse Cheng Hong. When she first came to TTSH from China through an international profession exchange programme in 2004, Cheng Hong did not have much choice in the hospital she went to. After two years of training and four years as a staff member, she “could do things blindfolded”. As she did not
“
At TTSH, I feel safe at work. We have established safe practices and a constant emphasis on patient safety. In protecting the safety and interests of
want to be complacent, she left to join a private hospital. However, after
our patients, in essence,
a stint that lasted slightly more than a year, she returned to TTSH. Her
we as nurses are being
time away taught her to “think a lot more about the consequences of each action”. “At TTSH, I feel safe at work. We have established safe practices and a constant emphasis on patient safety. In protecting the safety and interests of
protected. – Cheng Hong Senior Staff Nurse (3A)
our patients, in essence, we as nurses are being protected.” For example, there are clear policies regulating what nurses can do on a verbal order. “There are rules are in place like documentation, to prevent any mistakes from occurring as a result of mishearing, such as giving patients the wrong medication dosage or something that they may be allergic to,” Cheng Hong says. As for Senior Staff Nurse Evonne Oh (7D), she chose TTSH seven years ago for its convenient location to get to from her Woodlands home. Even though other nearer alternatives have since sprung up, it is the kampung spirit and firm bonds with her colleagues that keep her firmly rooted here. “Once, just before my shift ended, a patient collapsed,” she related. “My colleagues dropped their work and rushed to help me, so I could do other duties like calling up the patient’s relatives.” At the end of her shift, she could go home with the peace of mind that they had her back.
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D
Dive into history Take a detour down memory lane and trace nursing moments captured in time from the past to the present day
50s
Staff of Middleton Hospital, which was set up as an isolation camp for infectious diseases and later became the CDC, made part of TTSH in 1985. Staff nurses are those with black belts (right-hand, second row from back). In the centre of the seated row (second row from front) of doctors and staff is Madam Louise Chew (in dark uniform with white collar), Middleton Hospital’s ďŹ rst Singaporean Matron from 1956-1969.
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50s CDC: A lesson on
reading X-rays for Tuberculosis department
nurses in 1959 .
ened wly op the ne process at f o s g workin dering ing the d up the laun observ e p w s e h h C ic h Louise 1957 w Madam ndry in Matron al steam lau nic mecha n Hospital. to Middle
50s
60s
Wheelin g a pati ent (wearing a nursin on the way to th g veil on e recrea extreme tion hall (building right) w atching in the b d e on. ackgrou tree-lin between nd, righ a g n d lo t), with e a lk ll a o w tr a nursin s y e ly th re u g ofďŹ ce as is d le e a y r d jo n n a e s s e e z rs e u re n b t a y e tr lm a e B th . s 3 a 1 nd ew avenu wards 12 a n Pavilio
60s
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80s
70s
Nursing staff ce lebratin shoulde g the firs re t birthda and nav paulets on the yw y blue fo w r staff n hite uniform th ith a child who urses. en used is in an iron lun to deno g. te assis tant nurs Note the burg undy es (third nurse fr om left)
t for ontingen nurses’ c a n the o in e g c in la h d – marc e taking p u d ro ra p a p n y o ati Da National ion and n ir profess es for the Doing the ecentralised venu ed one of th Mo Kio. y at Ang actual da
80s Graduating class of 1988 reciting the Nurses’ Pledge, blue shoulder capes differentiate staff nurses from the burgundy ones of assistant nurses.
ce p as bled u Neuroscien s dou d rd n a a w ic . bacute Orthopaed le patients a d ese su st - th rd 1 house science fem a p e euro of tim cases. Wa rridor E rd 3, N the co ards for A& nd Wa g a l n a lo ic A rg ation w as Su observ , Ward 2 w ts n e ti pa
70s
e ith som ether w rses tog eir caps that u n b a ge, reh ipe. s on th rd signa d stripe ts had one str hab wa ent nurses ha en re d e tu s th f e d o n in front 986. Stu . Year o Posing olleagues in 1 ey were in, eg c th r ty a u e y -d off the ed with coincid
80s
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70s Rehab nurses using spinal lifting technique to keep the body alligned.
80s
Atten ding a the p briefin ur g on nursin maint e white ca ps ain its g on by shape which we process r e re pa their s a n d instak views and t deno h t aff n e pe ted n ursing urse owne eking lace ingly starc acuity in 1 he 988. N rs. As t office otice seen rim that w d, ironed rs. e a here, one s re proudly nd tended tripe on th hand-stitc to e nav h y epa ed ulet
2000s At th the Istana at then President Nathan’s (front row, centre) invitation for Nurses’ Day 2001. Next to the President is Madam Rosie Pereira, Director of Nursing from 1998 to 2001, and at the extreme night is then CEO Dr Lim Suet Wun. Mad Nurses pictured are attired in the uniform that was adopted after the peach uniform at the end of 1999. Nursing officers Nur wore a skirt and blouse; staff nurses had blue piping along the V-neckline while assistant nurses had burgundy piping. wor
, ground d (fore t nurse. te a e s n e e nurs enior assista 92. Th s s in 19 ng her as a e u g a ti lle ard co paulet deno w h it e w oment rgundy ing a m e on her bu Catch ip tr s as a right) h
90s
2000s
90s
1993: Nurses here wear the peach uniform that TTSH adopted when it became a restructured hospital in 1992. In the centre, wearing the blouse and skirt uniform sporting a white bow of a Higher Nursing Officer (HNO) is Madam Ho Shin Hiong who became Director of Nursing from 1990 to 1995.The nurse in a white-collared uniform is an assistant nurse, while the rest are staff nurses.
2013: TB as a ba CU nurses w it c left) is kdrop. Attired h their herita ge a nursin in the c g offic and a urrent building work er blu u p burgun e horizontal who is flanke niform with o lace, the Tu be rc stripe (f d dy prin ts. or male by staff nurs hid prints, th rculosis Con es in b trol Un e nurse nurses lue it (T , right) in with an orchid prints blue uniform BCU), assista (f (fifth fr o r female nt nurs om nurs e (seco nd from es, left) left) wit h
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E
Entering the environment Take a visual tour of the hospital – its departments in the main building as well as outlying specialist centres
TTSH Rehabilitation Centre: A "rehab" patient enjoys her daily therapy session using a Wii video game console to improve coordination.
26
Nurses of 11D are passing central report using “Wonderboard�, a communication tool which they can creatively customise their nursing information.
Central Sterile Supply Department and Theatre Sterile Supply Unit (CSSD/TSSU): Nurses (in green cap) supervise and train the healthcare assistants in this department to ensure surgical sets are safe for use on patients. This service is provided for National Healthcare Group Polyclinics, as well as National University Health System.
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Buffer Stepdown Unit: This unit, which houses patients awaiting transfers to community hospitals or nursing homes, has its own patch of greenery to allow patients to participate in outdoor activities, such as gardening, while interacting with one another.
Travellers’ Health & Vaccination clinic: Besides travelling vaccinations and health assessments, this clinic also provides travel-related education, such as precautions to take when going to countries with high risks of dysentery or malaria.
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Invasive Cardiac Laboratory: A nurse sets up an intravenous drip and assists in procedures such as cardiac biopsies or coronary angioplasties.
Equipment storage room in Endoscopy Centre: One of the ďŹ rst lessons nurses in this centre learn is not to bend the delicate and costly endoscope as the fragile ďŹ breoptic wires may be damaged and the internal image compromised. Here, a nurse expertly handles and prepares the endoscope for use.
Subacute Ward 8: Integral to nursing, case presentations like this are opportunities to learn about complicated or rare patient events from the shared experiences of colleagues, to tap on expert opinions or to brainstorm solutions to a knotty issue.
Renal Unit: Ensuring that each step of haemodialysis is performed correctly to protect patient safety, a nurse carries out the procedure in the unit where patients undergoing it are solely dependent on the procedure to keep them alive.
TTSH Multi-Purpose Hall: On certain Fridays of the month, nurses are allowed to leave their shift half an hour earlier for Fabulous Fridays, which has team-bonding activities that promote healthy living. Here, nurses are doing upper body strength exercises conducted by physiotherapists. 29
F 30
Firm friends Having inspirational, vivacious, supportive non-nursing colleagues makes work such a joy. Here, we show our appreciation for them
“W
hen I first met this petite Vietnamese lady in 2004, she spoke little English and seemed
jittery. Over the years, it was such a delight to see her confidence grow and an irrepressible joy lights her face as she eagerly picked up skills and demonstrated such a commitment and dedication to her patients’ care. She is someone who, when given a task - no matter how small - would see it through to the best of her abilities. It was so inspiring to see how she strived to improve her language skills and has now become one of our official Vietnamese and Cambodian translators for patients.” – Senior Assistant Nurse Shanmuga Priya D/O Nadaraj, on Healthcare Assistant Lam Thuc Yen (both from 13A)
From left: Punam Devi and Lam Thuc Yen.
he is known for being funny and mischievous. Yet when it comes to
“S
work, she is very systematic, efficient and organised and all the nurses like to be nurse-in-charge when she is on that shift. Devi is someone
with a heart of gold. When she learnt that our previous healthcare assistant who had been with us for many years was hospitalised for an amputation above the knee, she found out which ward the amah was admitted to and visited her often, bringing food and drinks to encourage her to regain her health and intake. And when the healthcare assistant was stable enough to be transferred out of the ICU, Devi ensured that she came to our ward so that we could "jaga", or watch over, her and that she would be surrounded by familiar faces and encouragement for her rehabilitation.” – Senior Staff Nurse Grace Tan, on Senior Patient Service Associate Punam Devi D/O Ramgura Singh (8C)
“D
r Wu is well
“O
k n ow n fo r his kindness
and ap p r o a c h a b i l i t y,
ver the more than 10 y e a r s
I’ve worked with Frankel,
always patiently going
he’s always told me how
out of his way to help.
he appreciates the good
Ever willing to listen to
job that we nurses do in
nurse’s requests, even
caring for the patients.
when off-duty, you won’t hear him raising his voice at staff or nurses.” – Nurse Clinician Lim Meow Gek (Subacute Ward 8), on Dr Wu Huei Yaw
So, whenever he can Frankel Ng (centre) flanked by Chef Calvin Tan (left) and Chef Leo (right).
help, he really goes out of
the way to do so. For example, he is always more than generous with food quantity for ward catering or departmental orders and provides ‘mountains’ of fruits on every Nurses’ Day, much to the delight of our nurses.” – Unit Nurse Manager Mariam Bibi Piperdy (Level 10), on Frankel Ng, Assistant Manager of Support Services (F&B)
“W
ithout Pang Hung’s
dedicated training and
“A
sk around the hospital and you’ll find that Dr Tham’s name always pops up
when it comes to people who support
help, we wouldn’t have
nurses. She firmly believes in nursing
been able to star t the
education and will give her time to
‘Let’s Walk’ rehabilitation
conduct clinical lectures or guide
programme that brought
nursing officers when they are unsure of
benefits like reduced length of hospital stays
clinical skills or knowledge. She is truly
for patients. He was a keen partner when I first
a remarkable person who has no airs
mooted the idea of nurses participating in patient
about her, taking it as a matter of course
rehabilitation and diligently planned and conducted
to greet each staff by name and thank
a comprehensive training programme for our nurses
her nurses sincerely when she finishes
twice a week, over eight weeks. Now, our nurses
procedures or before she leaves work
are so excited to be able to do daily light physical
each day.”
therapy to help patients towards faster recoveries.”
– Senior Staff Nurse Nyo Nyo Win, on Associate Professor Tham Kum Ying (both from Emergency Department)
– Assistant Director of Nursing K Patmawali, on Principal Physiotherapist Lim Pang Hung
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Here, we recognise some of the colourful nurses who have made an impact on those around them and the nursing practice
“A
s a nurse with decades of experience, Sister Low may come across as the fierce matron when you first meet her.
But it only takes a moment to see that she is simply straightforward. She doesn’t sugar-coat the truth but tells what you need to hear in order to learn and grow. Her pragmatism is tempered with a naturally positive outlook on life that always leaves you feeling more assured, hopeful and clear-headed after chatting with her for advice.
ur ses have to juggle being ef fective communicators,
Her strictness belies a heart of tenderness for
empathising with patients and being flexible with plans
her charges to stretch themselves to reach bigger
for the efficient functioning of the ward while working
dreams. On one of the overseas charity outreach trips
we ll in te a m of do c to r s, a llie d he alth pe r s onnel and othe r he alth
for underprivileged children she organised, she inspired
workers. Staff Nurse Maria embodies these qualities while adding her
me about the unlimited areas that our hands as nurses
own quirky personality to the mix. With just the right sense of humour
can reach, and to never lose sight of that open-hearted
to loosen up grouchy patients or crack colleagues up on a gloomy day,
gentleness for the people we touch. For me, she not
she is fun-loving yet ver y competent at her work. With her colour ful
only role models the heart and professionalism of
presence, it really livens the ward and makes the working environment
nursing, but also exemplifies positive character traits
so much more enjoyable.”
like cultivating a close-knit family too.”
– Medical Officer Dr Mucheli Sharavan Sadasiv (Infectious Diseases Department), on Staff Nurse Maria Teresa Cruz Yunzal (CDC Ward 71)
– St af f Nur se Koh Yu Han ( 9A ) , on Nur se Manager Low Peck Sian
“N
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“A
s our ward sister, Sister Rozana represents the best of both worlds – she’s a fun, effervescent team captain
who always energises her staff, but at the same time, she’s an effective leader who is not afraid to make tough decisions for the good of the team. Sensitive and fair, she will tell her charges after disciplining them that they now start on a clean slate.” – Senior Physiotherapist Jayachandran Balachandran on Senior Nurse Manager Rozana Bte Arshad (6B)
From left: Johar Bin Salim, Rozana Bte Arshad and Mah Yoke.
heerful, responsible and committed, Johar is well-liked by patients
“C
under his care. I often see how he attends to patients with a warm smile and makes them feel comfortable by speaking in language
familiar to them. Other than his mother tongue, Malay, he has a surprising fluency in Chinese dialects and Tamil too and often breaks into a repertoire of Chinese, Indian and Malay songs to delight his patients with. It’s heartening to see them, especially elderly patients, light up when they hear his songs. We regularly receive positive comments and praise from staff, patients and their relatives about what a great attitude he has and how personable Johar is.” – Nurse Clinician Ismail Bin Mohamed, on Senior Assistant Nurse Johar Bin Salim (both from 11A) ung ho and with exceptional resilience, Mah Yoke never gives up on
ister Ho is someone who will not
“S
leave her staff to struggle on their own. If there’s any way that she
“G
challenges. Instead she is one of the most innovative people I know, always thinking of new ways to tackle a problem or improve work
processes. Whenever she is stressed, she uses jokes or funny stories about her
can help, she will step in to do so. At times when
globe-trotting travels to relax and it rubs off in the positive attitude of her staff. It’s
I wish that I could split myself into a few persons
all these qualities that make me look up to her as a role model. To me and our staff,
to get things done all at once, she truly makes me
she is a mother and sister - all rolled into one. Who else but a loving family member
feel like she understands what I’m going through
would be so willing to lend a listening ear anytime you feel down? I remember a
and calmly helps sort things out to ease my load.
time when I faced what I thought were insurmountable challenges and wanted to
It is testament to her wonderful personality that
give up. She spurred me to go on, saying "Never, never give up. You. Are. Capable."
everyone loves working with her.”
It was such an emphatic boost to me that it’s kept me going since.”
– Staff Nurse Vithya D/O A Asogan, on Nurse Manager Ho Sook Han (both from 5A)
– Patient Service Associate Supervisor Kalsom Shariff, on Senior Staff Nurse Mah Yoke (Clinic B2B)
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Arrr matey! In their 2012 year-end party, nurses from Level 11 went all out to channel the Pirates Of The Caribbean vibe in their swashbucklers and plumed hats.
Go, have fun! Share in the many moments of fun, laughter and celebrations that nurses enjoy
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Displaying their talents, nurses as cast and crew sang, danced and performed to rousing applause at the Nanyang Polytechnic Auditorium for TTSH’s first largescale musical "So You Want To Be A Nurse?" in 2012. Front row from left: Wendy Goh, Sui Sui and Maybelline Caneda. Elderly couple from left: Kim Min Hwa and Muhammad Afif. Centre row from left: Priscilla Fu, Farhana, Eric Koh, Faith Hwang, Mynelle R. Salas, Angielou P. Tinasas and Taufiq Mohd Othman. Back row from left: Ezekiel Kok and Harnesh Kaur. Not in picture: Staff Nurse Eliel Tan.
A crowd favourite with the hospital staff, the ED Band has performed at D&Ds and Founder's Day celebrations. Lead singer and guitarist, Staff Nurse Deney B. Buenconsejo, is seen here rocking his heart out at the Art of Healing event.
Ward 10B’s nurses ringing in 2013 in their rest lounge with food, fun and friends.
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Nurses were delighted when celebrities such as Fann Wong made appearances as a show of support to nurses after the SARS outbreak for Nurses' Day 2003.
Former Director of Nursing Madam Kwek Puay Ee (second from right, in red) and current Director of Nursing Mr Yong Keng Kwang (centre in green) display the vitality of their leadership on Nurses' Day 2006.
36
As part of the celebrations for Nurses' Day 2010, nurses have a fun day out at the Singapore Flyer.
Members of Nurses Inc, a welfare group for nurses, throw a party to celebrate TTSH Nursing's rebranding in 2008. Nurses Inc has since integrated under Shared Governance in 2012.
Ward parties, such as this Christmas barbecue for Ward 13A, draw colleagues closer.
Colourful costumes and get-up-and-go lively beats encourage the nursing crowd to let their hair down and have fun at the Nurses' Day 2010 celebrations.
Teams at the all-nursing Dodgeball competition in 2012 put on their "game faces" going with themed costumes.
DJs from radio station 938Live surprised the nurse clinicians with a spontaneous party and lunch after picking Nurse Clinician Jane Chee and Josephine Anthony’s entry to its surprise ofďŹ ce visit contest in 2010. 37
Holistic pursuit of happi-nurse From sporting activities to volunteering – nurses share about their pursuits in their free time
38
O
utside of work, Vivien Lee (3B) gets her adrenaline kicks from the competitiveness of dragon boating. Being out in the elements and enjoying the sun and sea while churning the waves with a
team of like-minded comrades add to the thrill. Her sun-kissed skin gives away her love of the outdoors as the nurse clinician from Ward 3B related enthusiastically: “Rowing is an excellent cardiovascular workout and it tones my muscles, plus teamwork is a breeze because our team spirit is fantastic.” A pioneer member of the dragon boat group which was started in 2003 by NHG headquarters staff, she found out about it when she met other NHG institution staff at various events. Together with a group of TTSH staff, mostly nurses, she started attending the weekly practices near Kallang Water Sports Centre every Sunday at 4pm. Besides training in the sea, they also mix it up with work outs on land with runs, circuit and weight training. The team subscribes to the motto of “work hard, play hard”. While training is tough and battle scars like blisters on sore behinds are accepted as part and parcel of their sport, they keep the atmosphere fun “with lots of laughter in the boat”. They also frequently head out for dinner after practice and make it a point to celebrate birthdays together. In all that fostering of a tight-knit, co-ordinated team, Cupid has struck up a few matches, leading to two couples walking down the aisle.
Nurse Clinician Vivien Lee (3B, second from left), a pioneer member of the dragon boat group that was started by NHG headquarters staff in 2003, said the team subscribes to the motto of “work hard, play hard”.
Besides indulging in hobbies, other nurses choose to use their free time volunteering for various causes. When a colleague of Staff Nurse Felicia Tang (6B) told her that relief organisation World Harvest Foundation was recruiting medical volunteers for a food and medical relief mission to northern Africa, she leapt at the chance and promptly emailed the organiser of the Singapore team. “Coincidentally, I had been thinking of going for a medical mission overseas but these are usually rare, so when this opportunity came, I was really keen to go,” she explained. She used her annual leave to participate in the 10-day mission trip in
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August 2012, where she spent two days in Kenya and eight in a base camp outside the city. She recalled the sight that welcomed them as their plane, together with land supplies on trucks, arrived: “People rushed forward to receive us and we were surrounded. It was quite overwhelming.” Leaving Kenya on a 12-hour ride, they ogled at wild giraffes and antelopes while bumping along roads, their vehicles blowing up clouds of dust, finally arriving at their destination: close to the border with Somalia. “The Singapore team – four nurses, including myself, and a doctor – and the Malaysia team – three doctors, a dentist and two other food relief volunteers – set up our medical camp. The United States team of three was mainly in charge of the food relief distribution, while the Africans were cooks, safari truck drivers and medical volunteers from the city in Kenya. It was all these amazing team members and the tight friendships we struck up over the mission’s duration that were my most precious memories from the trip.” At the base camp’s medical tent, Felicia and her medical relief team On her 10-day mission trip to Kenya and beyond in August 2012, Staff Nurse Felicia Tang (6B) was deeply touched by the hospitality and warmth of the African villagers she aided.
of Malaysians and Singaporeans prepared and dispensed medication like deworming tablets and did simple wound dressing for patients. “We were deeply touched by the hospitality and warmth of the people we aided. They were so keen to share their culture and practices with us, such as their rhythmic dances and singing, and plied us with their delicacies like dik dik – an animal resembling the mouse-deer – which was spit-roasted over an open fire. It tasted like mutton and was delicious.” She shared: “I’ll never forget the moonlit showers we took in stalls made with scrap metal sheets propped together, scooping paddles full of murky water, or lying on the hard uneven tent ground before sleep took me, listening to the myriad clicks, calls and chirruping resonating in the African wilderness at night. The experiences were such a world away from my familiar comfort zone. It was such an amazing time because I felt so privileged that our simple acts of service for the African villagers were received with such sincere gratitude.” Clinical Nurse Educator Wang Xiao Na, a regular volunteer for
40
various activities including assisting at a free clinic, making home visits and recycling medical supplies, agreed that small efforts can make a big impact. When she sees how thankful the recipients are for the home visits, medical supplies such as adult diapers and water thickener, she feels that she gains far more than she has given. “We look for ways to make ourselves happy. This may be a cliché, but really, we won’t find it in material things. Through volunteering with the less privileged, I’ve learnt how fortunate I really am and I want to give back with what little I have,” said Xiao Na. She started volunteering in 2004 as a student nurse when her senior took her for a volunteering experience and has not looked back since. Now, she helps coordinate volunteer doctors and nurses for a free clinic in Redhill. The clinic provides free medical, dental and TCM services for low-income patients, including foreign workers, as well as home visits, which includes providing consultation, medication and physiotherapy for low-income home-bound patients. Both services are under the Buddhist Compassion Relief Tzu Chi Foundation (Singapore). She also collects and sorts recyclable medical supplies to use in the free clinic, home visits or for training purposes. Despite Xiao Na’s volunteering activities which occupy two Sundays and a Saturday monthly, she still finds time to spend with her loved ones. “Since the recycling or free clinics take up only half a day, I have one and a half days left of the weekend and plan it so I can spend time with my family or friends then,” she said, smiling. An avid proponent of volunteering, she encourages her colleagues to join her in their free time. “Nurses just have that innate kindness and willingness to help. But because of tight work schedules or physical strain, to volunteer on their rest days can be tough. When they sacrifice a part of
“
Through volunteering with the less privileged, I’ve learnt how fortunate I really am and I want to give back with what little I have.
this to help others, I try to ensure that they are not overtaxed and keep the team spirit strong by working closely together. The people we reach out to may not be able to afford paying for medical services. So we see the
– Wang Xiao Na Clinical Nurse Instructor (Level 10)
fruits of our labour in reaching out to such people. That is what keeps our passion for our noble job burning.”
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Interwoven yet individual Flexible manpower policies which consider individual needs offer staff more options. Nurses share how they are reaping the benefits
Wilma Krishnan (Day Surgery Centre) was given the opportunity to upgrade to take on expanded role of the Principal Assistant Nurse.
42
43
B
eing able to return to work part-time after a year’s absence after she became a first-time mom was a great help to Clinical Instructor Charmaine Ting. “Coming back to work preserved my sanity because
I felt like my brain cells were becoming dull,” she said. She started a year of no-pay leave in August 2011 after her son’s birth and returned to TTSH in 2012 on a part-time basis. Her hours were decided after a discussion with her supportive supervisor, whose advice about taking no-pay leave first and then exploring other options at a later stage proved invaluable. The flexible work arrangement fit her needs as her husband travelled for work a fair bit and she had to be available for her family. “Of course, certain days are more physically or mentally challenging,” she added, “but I think as a nurse, we learn to be very adaptable. People are always amazed by how much
With the support of her supervisor, Clinical Instructor Charmaine Ting (Education and Practice) was able to return to work part-time after a year of no-pay leave following the birth of her son, Ethan.
I can accomplish even though I’m a part-timer.” School of Nursing graduate and Day Surgery nurse Wilma Krishnan had reached the highest rung of career advancement as senior assistant nurse after 24 years in nursing. Then, in a national initiative to upscale nurses, nurses like her who were not able to go beyond a certain level because of their educational constraints were given the opportunity to upgrade to take on expanded role of the Principal Assistant Nurse (PAN). This is the apex of career progression for an Enrolled Nurse. In June 2008, Wilma was the part of the second batch of graduates to complete the pre-requisite three-month advanced certificate course. Promoted to PAN in July 2009, Wilma enthusiastically related how she was empowered to take on more job functions. Her responsibilities expanded to include tasks which were traditionally done by a Staff Nurse. The flexibility to redesign jobs also helped Rachael Koh to find her niche in nursing. She was exploring the possibility of a post with more regular hours which would also allow her to develop her interest in geriatric nursing. The role of Geriatric Nurse Co-ordinator (GNC) was created to cater to the needs of the frail and elderly patients, which were becoming more complex. Working as a staff nurse on rotating shift at that time, she was looking for a change and approached her ward sister as well as Nirmala Bte Karmaroon, Deputy Director of Nursing, who was in-charge of manpower, for a chat on her
44
options. The GNC role was offered to Rachael, a position that appropriately matched her interest in geriatric care. Of her new position, Rachael explained: “There was no specialised role before to handle the complex discharge cases which may take more time, such as explaining homecare for elderly patients to their families or dealing with their queries on the patients’ social or functional needs. So my job now is to be there to see them through each step of the way.” Sister Nirmala shared: “We value each staff and consider their needs as individuals. We also want to retain expertise within the clinical environment. In the past, there were fewer options but, now, with positions like Rachael’s, there are more diversified work schedule choices available.” Rachael added: “My heart has always been for the elderly. In my new role, I can engage my patients in a more in-depth way, where I follow through with their families and home environment. That’s where I receive my biggest fulfilment. And I also continue gaining clinical experience, which is a big plus.”
“
My heart has always been for the elderly. In my new role, I can engage my patients in a more in-depth way, where I follow through with their family and home environment. – Rachael Koh Geriatric Nurse Co-ordinator
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Just superstitions? Despite professing to be men and women of science, nurses do encounter incidents which cannot be explained with logic
“I
f there are frequent mishaps in the ward or if you feel that evil may be trailing you, it’s best to bathe or wash yourself in water immersed with a special seven-flower blend. If once is not good enough, bathe seven times in it.”
– Senior Staff Nurse Sanipah Bte Yusoff (11B)
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47
“W
e’re surrounded by greenery in the CDC grounds. But there were
two big trees along the pavement and a third near Ward 76 which formed a triangle which we tried to avoid. We had heard a lot of stories about how large tree branches would fall on nurses just as they walk within this triangle. One nurse even had a snake fall on her while walking there. The worst incident happened to a security guard. One night,
ost nurses and doctors know this common superstition:
while patrolling on his bicycle, he heard a
Never eat a bao before, during or even after your shift –
voice calling his name just as he went past
because then you will bao patients. In Mandarin, bao
the two large trees. Getting off his bike, he
refers to a bun but also means to wrap or cover. It is also our lingo for
walked within the triangle of trees to see who
handling patients who pass away on our watch. So don’t ever eat bao. If
was calling him. Suddenly, out of thin air, he
you do, don't tell anyone.”
felt a hard slap on his face. His colleague
– Staff Nurse Tan Yi Ling (5D)
told us that he could still see the clear hand-
“M
shape d outline on his che ek whe n they exchanged shifts the next morning.”
“T
here is a special view from bed 27 a n d 28 i n Wa r d 71. O ve r the years, patients have told
me they see a white figure on the tree just outside. They describe that it flies from tree to tree and rests hanging upside down and they would often be kept awake by the loud rustling in the trees. Just three weeks ago, a patient asked me when I was doing my
“T
he number ‘3’ has special significance for nurses because
morning rounds, ‘Are there monkeys in the
we think that death or unfortunate situations like sudden
trees here? All night, I heard things moving
collapses usually occur in threes. So, when one takes place,
among the trees’.”
we anticipate that the second and third will follow in succession within the same day. This chart shows three deaths recorded in one night.” – Nurse Clinician Salina Bte Mohd Yacob (10A) 48
– Senior Assistant Nurse S.V. Jayalakshmi, who has been in TTSH for 36 years and is currently in CDC Ward 71, where she has been for 14 years
t the ICU, we usually have about
“A
eight nurses on night duty. One early morning in 1997, all eight
of us separately saw something that we would never forget. It was around 5am and we were seated in our individual cubicles when, one by one, we saw what we later described as a severed head hovering outside the building windows. It appeared to be the head of a man and it floated slowly past the windows of one cubicle to the next and was witnessed by each of us in turn. We all kept mum about it until much later in the morning, when someone c a u ti o u s l y r a i s e d a q u e s ti o n. W h e n we discussed it, we realised that we had all seen the same inexplicable thing that morning.”
“A
t the now defunct Ward 55 in the old building, where I used to work, patients seemed to be
drawn to the windows for some unexplained reason and many tried to climb out of the windows of this high floor. Once, in 1988, I caught sight of just a person’s fingers gripping hold of the window sill from the outside and dashed over just in time to see that it was a female patient dangling from the window. I quickly called for an amah’s help.
“D
ifferent depar tments have their own ways to keep new admissions at bay during their shift. Some general wards place empty beds that are facing the door at an angle so
that they are not facing it directly. Those in ICU are told that placing a pair
Together, we were able to pull the patient
of scissors on empty beds works. I used to scoff at it until I found that it
back to safety. When I gently talked to her
really does work. Now, I always keep a pair of scissors handy to ‘cut away’
later, she appeared confused and said that
any possibility of more patients being admitted. In CDC, the broom that
she was on her way to the toilet and didn’t
is placed at the main entrance to each ward serves a multi-purpose – to
know what happened.”
‘sweep away’ any new admissions and keep away unfortunate events, such
– Unit Nurse Manager Mariam Bibi Piperdy, who has been in TTSH for 40 years and is currently in Neuroscience Level 10
as patients acting up or collapsing.” – Senior Staff Nurse Inderjit Kaur D/O Dhian Singh (6C) and Staff Nurse Alicia Chua Wee Peng (6B) 49
21:15
22:00
Night shift nurses take over from the previous shift. With three rotating shifts, Geriatric Monitoring Unit (GMU): located in Ward 7B, the GMU is the only where Bright good handover is essential for care continuity.
Light Therapy is used to regulate sleep-wake routine of dementia patients. It encourages them to stay up during the evening hours, then sleep better throughout the night.
Keeping the night vigil As part and parcel of nursing life, the night shift charts both meditative moments of routine quiet as well as sudden bursts of adrenaline when emergencies occur 50
23:15
23:28
Monitoring telemetry: Nurses observe the telemetry monitor 24/7, and
Paperwork: The still night hours are the best time to catch up with the
alert doctors to proximal atrial ďŹ brillations (PAF). Ward 10B.
numerous documentations that needs to be done.
00:14 Admission: A new patient, who required assisted ventilator support, admitted into Medical ICU (6B) from the Emergency Department. Nurses from different bed locations coming together to effect a smooth transfer.
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00:17
00:39
Constant watching: whether it is day or night, ensuring the right patient for
On a break: Quiet chatter and the low buzz of the telly reign in the break
the right procedure never stops. Be it via PDA or oral veriďŹ cation.
room as nurses take their break to have dinner, rest and relax with colleagues.
02:45 Standby mode: A nurse from Recovery Ward 83 taking a check on her patient before moving on to those who require more attention.
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01:05 Helping out: A nurse from the STAR (Specialised Transfer and Acuity Response) team taking a blood sample. STAR team nurses are also deployed as oaters to the area with critical shortfall for the shift.
03:04
02:20 Quality control: Performing a quality control test on the Glucometer, a night shift nurse from Subacute Ward 8 seeing to one of her nightly duties usually done around 2am.
03:20
Nurse Manager Cheong Yoke Ling has been with TTSH since 1960 and is
Brief respite: A nurse from the Emergency Department taking a break in
on permanent night shift which is quite a feat. Here she skillfully handles a
front of an Incredible Hulk sculpture built by the department staff.
restless patient with the junior staff.
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04:00 Summing up: The night shift report is the chance to sum up and review the day’s events, outstanding concerns, and to remind follow up to action plans to the morning’s team of doctors and nurses, as the nurse from CDC Ward 75, a tuberculosis ward, is doing.
06:44 Kicking into action: In the fast-paced Emergency Department, paramedics (in dark blue) admit a new patient onto the resuscitation table while nurses deftly handle the situation.
07:05 Final checks: As the morning light peeks through the window, a night shift nurse (extreme right) completes morning assessments while morning shift nurses check on state of condition and details such as IV lines in readiness for the handover report.
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05:59 Essential checks: Having ďŹ nished turning and completing suctioning for her patient, the gowned nurse from Surgical High Dependency Unit (6C) rechecks the alarm settings on the monitor to ensure that everything is in order, repeating this routine two- to four-hourly throughout the night.
08:09
08:19
Signing off: At their lockers, rehab nurses chatting as they prepare to
Well-earned rest: Smiles all around as night shift nurses, changed into their
change out of their scrubs at the end of their night shift.
own clothes, head home after a night’s work.
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L
Likeness in diversity
Even though our nurses come from diverse backgrounds and different countries, they make the effort to understand where one another is coming from
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Foreign nurses from different parts of the globe in their national costumes. From left: Staff Nurse Joel Yap Eng Joo (6B), Staff Nurse Thiri Lwin Maw (10A), Staff Nurse Mya Su San (6B), Assitant Nurse Gaco Rosseanne Jade Capitan (7C), Staff Nurse Shen Lijin (Recovery Ward 85), Senior Staff Nurse Sindhu Thayyil Philip (10C), Staff Nurse Tan Nianche (6B), Assistant Nurse Bolis Viva Mungcal (9A), Staff Nurse Moe Moe Thwe (7C), Staff Nurse Nyo Mi Hlaing (8D), Assistant Nurse Jaya Paul Jaya Mabel (9C), Staff Nurse Zune Pwint Phwe Phwe (Recovery Ward 82), Staff Nurse Kim Min Hwa (9C), Staff Nurse Chong Seow Li (6B), Staff Nurse Lee Wan Lih (6B), Assistant Nurse Agnat John (6B), Staff Nurse Thwe Ni Oo (Recovery Ward 86), Senior Assistant Nurse Maung Kyaw Min Soe (10A).
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enior nurse Manager Geeta Pattath Raghavan makes it a point
S
to chat with new nurses joining her ICU and sharing her own experiences. “I tell them I know what it’s like to come in for the first
time and be shocked by all equipment or emergency action that they see in the ICU. But I remind them not to lose heart. I was new to Singapore, new to TTSH and had no clue about the ICU practices here, so I observed carefully and heeded my ward sister’s advice that in the fast changing pace of the ICU, you have to work as a team. We had people from different countries, including Australia, Malaysia and India, but we learnt to blend together,” says the 18-year ICU veteran who joined 1995 with a nursing degree from Kerala, India, accompanying her husband on his work posting here. When Hongyun came to TTSH in 2002 on a professional exchange programme from Sichuan, China, she was surprised by the duties that nurses here performed. “I saw them doing basic care like cleaning and changing patients. In China, that’s the responsibility of the patient’s family members who stay by their beds as caregivers, while nurses do the more technical tasks like inserting catheters or drawing blood. I was initially resistant to carrying out such basic care. But in Singapore’s different social environment, family members may not be able to do the same. I recognised then that in coming to a Singapore hospital to work, I not only met the stringent criteria set out, but also have the privilege of being chosen for my abilities and dedication to contribute. Although it takes a mindset change, I realised that picking up the practices and standard of care here was vital. When patients thanked me sincerely after I helped them, I appreciated how important our duties, such as basic care, are in caring for our patients,” she said. Sometimes, it was not understanding or not being understood that was the most challenging aspects of a new environment. Assistant Nurse Ehimwenma Rachel Akhigbe was very disheartened by how her colleagues could not understand her when she spoke. She often had to go over to where they were to show them what she meant. The gap in communication frustrated the Nigerian mother of three who came to Singapore with her husband when he was transferred here for work in 2000. “At the end of the day, I would go home and cry like a baby,” recalled the former high school teacher who underwent a two-year nursing course to make the career switch. Ward Sister Letchimi, learning from her colleagues about this rift, stepped in to help Rachel establish rapport with her colleagues. “Sister
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From left: Assistant Nurse Ehimwenma Rachel Akhigbe (Subacute Ward 9), Advanced Practice Nurse (Intern) Tan Hongyun (Geriatric), Assistant Nurse Maria Karen Guevarra (Invasive Cardiac Laboratory), Senior Nurse Manager Geeta Pattath Raghavan (6A) and Staff Nurse Ma Yin Yin Chit (Subacute Ward 8).
Letchimi was a big support to me,” says Rachel. “She helped to ‘translate’ what I was saying to my colleagues, making it light-hearted. Over time, I spoke slower and they learnt to understand me better.” She also credited Sister Letchimi with giving her good advice on handling people. “She said, ‘See what you can do to involve them. If you stay apart from them, they will definitely not understand you. If you involve them, you are together all the time, then they will surely understand you’. That really helped me. It was in this ward that I learnt to adapt to Singaporean customs and its lingo. Even though I miss my previous Ward 8C where we learnt to be sisters together, I’m enjoying my time in my current Subacute Ward 9.” Homesickness is another challenge that many living in a new country experience. Being in Singapore was the first time being abroad for Maria Karen Guevarra, who hailed from Angeles City in the Philippines. Gathering with colleagues for meals, barbecues and even badminton tournaments helped. She also remembered how her nurse educator checked on her periodically during
“
We had people from different countries, including Australia, Malaysia and India, but we learnt to blend together. – Geeta Pattath Raghavan Senior Nurse Manager (6A)
her first year. “I didn’t feel abandoned and left to drown,” she said. Hongyun remembered fondly her first taste of lontong during a training session and outings to places like Botanic Gardens, which were part of then Nurse Educator Lee Leng Noey’s efforts to integrate newbies into Singapore. As for concerns on career development prospects, Sister Geeta said there are plenty of opportunities available. Starting in 1995 as Staff Nurse, she became a Nurse Clinician in 2003 after a supportive push from then Nurse Manager Neo Chee Hoon. “She told me she had faith in me and encouraged me to apply for the post.” In 2012, she was promoted to Senior Nurse Manager. Staff Nurse Ma Yin Yin Chit, who is from Myanmar, related how she expressed an interest in learning more about behavioural difficulties in the elderly and was sent for such training courses. Currently an Advanced Practice Nurse intern, Hongyun said that it was the strong educational backing and emotional support that she is grateful for in TTSH. “Back in China, if you’re deemed inadequate, you’re left behind. But here in the hospital, there are so many people who have encouraged and supported me. Sister Laura and the late Sister Norina Bte Bukari singled me out for the Nanyang Polytechnic advanced diploma. Geriatrician Dr Chong Mei Sian and APN Jasmine Kang were the ones who told me that although the Masters in Nursing (Clinical) course was tough, I could accomplish it.”
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M 60
In 2004, just days after the devastating Indian Ocean tsunami, a relief mission team by the National Healthcare Group and Singhealth set off to Trincomalee, Sri Lanka, to provide medical relief. (Photo courtesy of Leslie Tan, Singapore Red Cross volunteer)
Makin marks Making oversea overseas Whether it is in extending help beyon beyond Singapore’s shores or growing ties with overseas counterparts, connecti connections abroad bring mutual benefits
A
bout a week after the tsunami that devastated 14 countries – hitting Indonesia, India, Thailand and Sri Lanka the hardest – struck on Boxing Day in 2004, Senior Nurse Manager Christopher Soh was on
his way to Trincomalee, Sri Lanka, to provide medical relief using skills from his emergency department background. Even though he was newly married, having tied the knot just a month earlier, it took him only a day to deliberate over his decision. He did not hesitate as male nurses were needed for a relief mission by the National Healthcare Group and Singhealth, under the banner of Ministry of Health and the Red Cross. “My wife who is also a nurse at TTSH saw the terrible effects of the disaster on the news. Despite the dangers of further aftershocks and Trincomalee’s political instability, we both agreed that this was an opportunity to help people in genuine desperate need. With my emergency experience, I was trained for and familiar with this, and I felt I could make a critical difference by going,” he said. In the 11 days he had before deployment, he and the team of about 20 – made up of nurses, doctors, pharmacists, community care and operations staff from hospitals including TTSH and NUH, nursing homes and the Singapore Red Cross – took nine days to organise and conduct a needs-andrisk assessment. Once they arrived, it took another three days of travelling from capital Colombo to the seaport of Trincomalee, which was under the Tamil Tigers’ control. What he saw when he arrived were the effects of the incredible power of
The relief mission team members saw an average of 200 patients daily. In their off-duty time, they reviewed their efforts or visited other affected sites. (Photo courtesy of Leslie Tan, Singapore Red Cross volunteer)
nature. “It was a truly desolated landscape. What were once entire villages with buildings and homes were reduced to a surreal painting of broken metal foundations sticking up here and there from the muddy earth. Like what we all saw on news channels later, huge marine vessels looked eerily out of place, marooned far inland among the debris.” There was massive displacement of the Trincomalee population and most were housed in quickly set-up refugee camps, living with donated tents and rations. “We had expected to have contact with dead bodies and severely injured casualties, but they had already been tended to by NGOs and relief teams arriving before us.” Sanitation and waste disposal were limited in the camps, so the team
TTSH nurses from different disciplines, ranks and age groups visited Thailand's Songklanagarind Hospital and Siriraj Hospital in February 2012 on an overseas training trip.
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visited different camps each day with a mobile treatment centre to meet as many needs as they could. The team members saw an average of 200 patients daily, mostly for non-critical illnesses like diarrhoea or coughs, with a few having airway difficulties and wound sepsis. In their off-duty time, they reviewed their efforts or visited other affected sites. Christopher’s most memorable experience was encountering a group of bubbly children playing next to an almost completely destroyed school building. After chatting for a bit, they repeatedly asked the team for study materials and stationery supplies, so that they could resume their studies. “It was heart-wrenching, the earnestness in their eyes. But we had hardly anything to offer them in the way of those items, since we only had medical supplies. We gave them the few pens and notepads that we had. “That made me realise that, while medical efforts to aid victims physically were important, support and recovery for rebuilding lives should equally not be overlooked.” Christopher continued: “As medical volunteers, we always think that During a study trip, Nurse Manager Tan Tit Chai (Nursing Service) gamely tried on the "Madonna jacket" which was specially designed for fathers. The aim was to allow husbands to be aware of challenges faced by their breastfeeding wives.
we’re there to help the people in need, but from this experience, I gained so much from the exposure as well. It taught me that, just like the way we care for our patients so well in TTSH, a holistic approach is needed for disaster relief missions to ensure that each person’s needs are fully met.” An important feature in a hospital’s connections abroad is its ties with partner hospitals and other medical institutions for training and educational exchanges. For Senior Staff Nurse Tang Choy Fung (9D), what stood out during her overseas hospital training in Thailand last year was the genuine warmth that the staff exuded to visitors and patients alike. She said: “With the warm, hospitable nature of Thai culture, the hospitals there have a practice at the start of each shift where the ward’s nursing officers greet each patient personally. That warmth continued as they attended to them throughout the day. We saw patients responding to it kindly in return.” The team, comprising a fair mix of nurses representing different disciplines, ranks and age groups, visited Songklanagarind Hospital in Hatyai
In January 2013, the roles were exchanged when TTSH hosted a group of 14 nurse leaders from four Thailand institutions, under the initiation of Her Royal Highness Princess Maha Chakri Sirindhorn (left).
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and Siriraj Hospital in Bangkok over 2½ days in February 2012. The goals of the trip was to observe the key process improvements using lean principles, hear and see their transformation highlights and adoption of
the lean culture and to establish network amongst Thai fellow colleagues and exchange experiences in lean culture and projects or initiatives in different cultures. We also wanted to expand our understanding on the principles of lean management in an Asian healthcare organisation. Amidst the packed schedule of walk-abouts and sharing sessions, Siriraj Hospital’s emphasis on innovation impressed the trainees. Staff members there were encouraged to turn their innovative ideas into reality with actual prototypes, which were then showcased and even sold in its innovation shop as well as on its website (www.creativesiriraj.com). These useful innovations included padded seat restrainers and gel-filled pressure-relieving mats. The Thai hospitals’ “No Shame, No Blame” approach in handling staff was another practice that the participants noted as a useful approach to adopt in TTSH. About the impact the Thai hospitals’ training had on her, Nurse Manager Salbiah Bte Atan (8C) shared: “I was inspired by how passionate and committed our nursing counterparts are from both hospitals. Like us, they too have limited manpower and financial resources, and high patient loads, but theirs is on a more acute level. ”
“
It taught me that, just like the way we care for our patients so well in TTSH, a holistic approach is needed for disaster relief missions to ensure that each person’s full needs are really being met. – Christopher Soh Senior Nurse Manager (Emergency Department)
“Yet despite this, they demonstrate great pride and a sense of ownership in their work, and took the initiative to bring an atmosphere of joyfulness to their workplace while improving quality care for the lives that they touch. This reminds me to constantly seek to improve in my pledge as a nurse – to bring comfort and care.” Following this training trip to Thailand, the roles were exchanged when TTSH hosted a group of 14 nurse leaders from four institutions in Thailand for two weeks in January 2013. Supported by Temasek Foundation (TF), the TFTTSH Nursing Specialist Programme in Occupational Health & Safety Training was initiated by Her Royal Highness Princess Maha Chakri Sirindhorn, who chose TTSH for its ties from the previous training trip. It aimed to enhance the knowledge and experience of these nurse leaders in preventive technology and innovations, such as safe handling of patients. It comprised senior nurse leaders from Mahidol University Faculty of Nursing, the Thai Red Cross College of Nursing, King Chulalongkorn Memorial Hospital and Siriraj Hospital. They had field attachments in TTSH wards and found the hands-on experience, such as the use of innovative transfer aids for safe transfers, invaluable.
Christopher Soh (extreme right from first row) and the medical team in Trinconmalee, Sri Lanka. (Photo courtesy of Singapore Red Cross) 63
N
None left behind The three arms of the Department of Continuing and Community Care (CCC) go beyond the hospital to care for patients in their homes, senior activity centres and nursing homes
Post Acute Care at Home (PACH) Provides homecare follow-up for patients with complex needs after hospital discharge On their visits to patients' homes with doctors, PACH nurses evaluate their patients’ well-being, including a physical assessment and review of their mental status and social concerns. PACH’s primary focus is to render treatment at patients’ homes where they feel more comfortable and familiar. This is to prevent unnecessary hospital readmission. They also enlist therapists such as physiotherapists, occupational and
speech therapists and advise on home safety modification. Nurses sometimes extend help beyond medical aid. This could involve
th iti issue i h h i Th first fi t ti S i Staff St ff Nurse N T the sensitive off home hygiene. The time Senior Tan Yen Peng saw a bedbug, she did not know what it was. “I saw a small dark insect crawling into the patient’s diaper.” She found out it was a bedbug and roped in a medical social worker and the town council to have the home fumigated.
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Senior Staff Nurse Joey Yeo (PACH) views PACH as a more personal form of care as patients know the nurses by name and nurses are able to create a special rapport with each patient and their caregiver.
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What is special about what PACH does? Senior Staff Nurse Joey Yeo explained: “I get to see patients in their home situation. So I can see the real reason they don’t take their medication. It’s also a more personal form of care: they know us by name and we’re able to create a special rapport with each patient and their caregiver.”
Community Health Engagement Programme (CHEP) Conducts an active-ageing programme in senior activity centres In a one -year comprehensive programme of fered to senior s called Stepping Out Into Active Life, the CHEP team runs twice-weekly exercise classes and conducts health and safet y assessments. It also does quarterly individual evaluations to track the seniors’ progress. In addition, interactive health education classes are held. Stepping Out’s main aims are fall prevention and promoting balanced active lifestyles. Home visits are scheduled for high-risk participants, such as those A happy exchange of farewells between Staff Nurse Sherlyn Lee Zhi Ling (PACH, far right) and her patient.
with high fall risk, to assess their home environment. “Some patients take their medication once a day instead of the prescribed thrice, thinking they can stretch out the supply,” said Senior Staff Nurse Mohammed Nizam Bin Urip. “We educate them on such issues.” Over time, bonds are forged, with participants asking after missing nurses or fellow participants and celebrating one another’s birthdays.
Project CARE Trains nursing home staff and facilitates Advance Care Planning discussions with patients, their families and nursing home staff on end-of-life care issues This pilot project initiated in 2009 aimed to raise nursing home staff’s capabilities and reduce unnecessary hospital readmissions. Project CARE Senior Staff Nurse Mohammed Nizam Bin Urip (second from right) and Nurse Clinician Rohana Bte Basri (far left) hail from the CHEP team, which runs twice-weekly exercise classes and conducts health and safety assessments for seniors.
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nurses conduct 12 tutorial sessions with the seven nursing homes they collaborate with. They are also on call 24/7 to support the nursing home nurses with intravenous cannulation and administration of intravenous
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We walk with the patient’s family to the end to assure them that their relative’s wishes will be honoured. – Amutha D/O Muvigasin Staff Nurse (Project Care)
medication, as these nurses are not trained to do these procedures. Advanced Care Planning is also offered to nursing home residents. Through this, the Project CARE team, made up of doctors, nurses and medical social workers, facilitate discussions with the residents, their families and nursing home staff on how they would like to be cared for when they fall sick in the future. Issues dealt with include whether they would like to receive treatment in the nursing home or hospital. Loved ones would then be able to carry out their wishes in the event that their conditions deteriorate and they are no longer communicative. Once discussions are completed, the residents will be recruited under Project CARE. Project CARE will co-manage them in the nursing home when they become unwell. “We walk with the resident’s family to the end to assure them that their relative’s wishes will be honoured,” says Staff Nurse Amutha D/O Muvigasin.
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O
Of reaching for the stars Support from family,
friends, colleagues and
supervisors plays a large part in
helping nurses go back to school to
upgrade themselves
From left: Staff Nurse Her Zhiyuan (Recovery Ward 85), Nurse Educator Dinah Djong (Education and Practice), Nurse Manager Maheas D/O Thanmugam (5C) and Senior Assistant Nurse M. Kowsula Kaur Patel Utkar (Clinic 5A) embarked on further education with the support of TTSH and their families.
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D
r Margaret Soon did not plan in advance for each of the academic courses leading to her PhD. She certainly did not anticipate becoming the Assistant Director of Nursing when she first
graduated from the School of Nursing in 1993. It was the feeling of being handicapped by her lack of knowledge in her work that led her to consider furthering her studies. Her hard work has paid off — she became Tan Tock Seng Hospital’s first Doctorate of Nursing holder when she completed her PhD in 2012. For others, the decision to pursue further education came at a later stage. For Assistant Nurse M. Kowsula Kaur Patel Utkar, to say that hitting the books after a gap of 22 years was a struggle would be an understatement. She had two O-level passes when she started as a nurse in 1989. Then marriage and other family commitments, such as looking after her father who had a stroke, kept her from pursuing further studies. She was finally able to take a three-month bridging course when her daughter was 18 and son was nine. She admitted facing tough times learning the basics during the course. But having crossed that hurdle, she shared excitedly about her next step: entering Nanyang Polytechnic at the same time as her daughter, who is doing chemical and pharmaceutical engineering, to do her nursing diploma. Many who took up the challenge of further education said it was the loving support from spouses and family which made it possible. “When the scholarship for my doctorate came through in 2008, my supportive husband resigned from his position as an engineering director and even went to a restaurant to learn how to cook. It took a leap of faith with my family moving to the United States for my four-year doctorate with my husband looking after all of us, but I believed that God would bring us through – and He has indeed.” said Margaret, whose daughter was four and son was newborn at that time. She related how the hectic routine of clocking research hours in the hospital and attending group discussions left her with little time with her kids and three to four hours’ sleep nightly. Nurse Manager Maheas D/O Thanmugam recalled how she handled the time when, in the midst of her exam period, her father suffered his third
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Assistant Director of Nursing Service Dr Margaret Soon, seen here with her family, became TTSH’s first Doctorate of Nursing holder when she completed her PhD in 2012.
stroke and was admitted to TTSH. “I remember going to his ward after work each day with my textbooks, so I could revise while he was resting. It was very draining but it helped when my brother who saw this strain told me not to worry and to concentrate on my exams.” Maheas, who did a bridging course after re-taking her O levels at 30, went on to obtain a slew of sterling results: a merit award for her diploma, an achievement award for her advanced diploma and a pass with distinction in her nursing degree. Encouragement and backing from colleagues and supervisors were also crucial for those going back to school. “Nurse clinicians from my ward readily
“
The bridging course really opened my eyes. I viewed my polytechnic
offered resources and nursing contacts who could provide more in-depth
diploma as a doorway
details necessary for my course projects,” related Staff Nurse Her Zhiyuan.
which opened to a lot
Kowsula, who used to fail every Maths and Science exam in school, went on to ace all her bridging course subjects. She shared: “I was so grateful to my NO’s for granting me leave to prepare for my exams. When my results came out, I was so excited. I attained all As.” With all these educational advancement opportunities made possible
more possibilities for me than before. – Maheas D/O Thanmugam Nurse Manager (5C)
through the hospital’s sponsorship, Maheas, one of the many recipients, is thankful. “I am so glad that we have an organisation that is so enthusiastic in sending us to upgrade ourselves.” As others like her who have chosen to upgrade their knowledge can attest, the benefits outweigh the challenges. Zhiyuan, recipient of the NUH Achievement Award for his outstanding results in his Advanced Diploma in Nursing (Orthopaedics), said: “For me, the true aim of the course was to learn more about my specialty and also interact with others; the award was a bonus.” Dinah Djong, a nurse educator with a post-graduate diploma in higher education, said further studies not only enhanced her role as an educator, but on a personal level, she grew more patient from learning to work with others in group projects. Maheas agreed that opportunities abound. “The bridging course really opened my eyes. I viewed my polytechnic diploma as a doorway which opened to a lot more possibilities for me than before.”
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Nurse Clinician Lam Chin Chin (Diabetes Care) educating a caregiver on insulin and its administration.
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P
Passage pavers Starting a specialist clinic is not easy, but these nurse clinicians took the initiative to learn how to educate patients and manage staff
hen specialist clinics first started, patients were hesitant about
W
having to pay for counselling conducted by nurses. “It was about $7, but more than the amount, I think people were surprised that
the time we nurses spent educating patients on issues was something that was even chargeable. Some would ask us, ‘How come I have to pay for you to talk to me?’,” said Senior Nurse Clinician Philomena Anthony. “But now, people see the value of the work we do and we seldom get any protests. In fact, some patients even thank us for explaining things.” Most of the nurse clinicians who run specialist clinics were initially roped in as part-timers. Rising patient numbers and the increasing need for patient education and counselling led to the clinics’ expansion and the part-timers converted to full-timers, rising from the most junior positions to being the nursing officers in charge. Senior Nurse Clinician Heng Lee Choo, who runs the Urology Clinic, recalled: “When I came on as staff, I was the most junior and took orders from above. But then, as the team grew to meet the demands and my seniors left, suddenly I was now the senior in charge. I was taken aback at the jump it took to learn to manage people.” Today, the NCs helm clinics in specialisations such as diabetes, infection
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Nurse Clinician Loo Yen Leng (Fall Care) testing the four limbs power to assess the patient's strength as part of evaluating patient's walking ability.
Nurse Clinician Karen Chng (Continence/Urology). Easy does it. These delicate percutaneous nephrostomy tubes drain urine into the urostomy bags which are changed regularly to prevent skin breakdown.
control, urology and even sub-specialties like dementia, within geriatric care’s speciality, with staff strength ranging from four to eight. Coming to the specialisations without extensive experience, they faced steep learning curves. They had to take the initiative to research on the Internet, read medical tomes, attend attachment courses and conferences and even sit in with doctors during consultation to pick up as much knowledge as possible. Sister Philomena remembered going through the process of setting up nursing assessment protocols in her clinic for new patients in discussion with doctors, as there were no precedents to follow. There was also the move to a multi-disciplinary approach – involving podiatrists, nutritionists, dietitians and other medical experts coming together – to manage the needs of a patient, unlike in the past, where patients were often referred to other departments to handle the various issues arising from their ailments. Although the NCs were thrown into the deep end, they could tap on a valuable resource – others who were in the same boat – for ideas and shared experiences. “We had a peer support group of nurse clinicians sharing knowledge and helping one another. The more established clinics were available to advise those starting up,” said Philomena.
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Correct mask fit is one of key component to staff protection against infective airborne organisms. Nurse Clinician Toh Cheng Yen (Infection Control Unit) demonstating N95 Particulate Respirator Training and Fit Test for employees.
This advice ranged from help on clinical practices and documentation to managing manpower issues. Sometimes, the more experienced NCs simply provided a supportive shoulder to lean on. Together, they helped one another as they grappled with the newness of managing staff. Sister Heng shared with a laughing: “I remember when I first started to manage people, I would regularly run to the diabetes clinic, which was one of the earlier ones set up in 1994, for help. It was such a relief to have someone who had experienced what I was going through, to whom I could vent.” For Senior Nurse Clinician Ng Poh Leng, a mindset change was necessary. Instead of a top-down approach, which the nurses had been used to as juniors, there was a more equal footing and open communication between nursing officers and their staff. As each clinic developed, they encountered memorable milestones. Infection Control unit’s Senior Nurse Clinician Poh Bee Fong remembered
The best results for a four-layer bandaging over lower limbs afflicted with vascular conditions comes from specially skilled hands. Here, Senior Staff Nurse Tina Lai (Stoma and Wound Care) intensely focused on getting it right.
how the clinic’s consultative role in coming up with policies came to climactic head during the 2003 SARS outbreak. They had to scramble to work out safety protocols, produce training videos overnight and quickly set up an inter-department task force involving housekeeping and facilities to make rapid preparations like converting rooms to house quarantine features. The clinic was able to apply the valuable lessons learnt then to handle the H1N1 swine flu pandemic in 2009. Asked about rewards, Sister Heng cited how patients were grateful for her experience and the comfort it brought. “After I did a catheterisation procedure for a patient, he said, ‘Missy, you do very good, no pain at all’.” Looking back on the journey it took to get here, Sister Poh Leng
“
Now, it’s much more fulfilling because, with practice and experience, I’ve learnt what to
shared about the satisfaction she gets from her job. “When I first started,
explain and how to do
I would nervously rattle off a whole list of instructions in 15 minutes to my
so in a way that patients
patients. At the end of that, you could see in their blank faces that they took in very little. “Now, it’s much more fulfilling because, with practice and experience, I’ve learnt what to explain and how to do so in a way that patients can understand and benefit from. Now, they get it. It’s so rewarding to see that, after I’ve
can understand and benefit from. – Ng Poh Leng Senior Nurse Clinician (Diabetes Care)
talked to them, their faces just light up.”
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Q
Quest for advancement Advanced Practice Nurses bridge the gap between doctors and nurses
T
TSH welcomed its ďŹ rst group of Advanced Practice Nurses (APNs) in 2004. Since then, driven by the desire to enhance their clinical knowledge in order to improve bedside patient care and safety,
nurses such as Geraldine Ng, Serene Tan and Jennifer Wong are among a group of APNs who had completed the 24-month Masters in Nursing (MN) programme at the National University of Singapore and are on the Clinical Nursing track. Geraldine, an APN intern in General Medicine, shared her journey
towards obtaining her APN licensure. Since graduating in 2012, she has been undergoing her internship under the mentorship of her medical consultant in General Medicine. The gruelling one-year internship requires
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her to complete 12 case studies and clock over 1,000 clinical hours of bedside patient clinical practice. While the MN programme equipped
Advanced Practice Nurse (Intern) Geraldine Ng (General Medicine) conducts an informal discussion with nursing students.
her with advanced clinical knowledge and skills for patient management, the internship would provide opportunities for her to hone her skills in areas such as critical analysis and clinical decision-making skills. These experiences would enable her to do guide the nurses. “For example, if the patient takes a turn for the worse and becomes drowsy, nurses monitor parameters and conscious level closely and await further instructions from the medical team. As an APN, I can guide them while intervening quickly by initiating investigations and treatment while waiting for the doctor,� she said. 77
Serene, who obtained her APN licensure in 2011 and currently cares for neurosurgical patients, affirmed that she was better able to understand and appreciate the process of diagnosing patients after her training. She cited the example of how high or low sodium in a patient could be due to many causes. She was able conduct the appropriate physical assessment and histor y taking, interpret and associate the physical signs and symptoms to the laborator y results and physical examination, and initiate early intervention. She passionately shared her clinical expertise by conducting regular clinical nursing rounds to improve bedside nursing care and patient safety. As an APN, besides other duties, Serene made it a point to teach nurses and students how to look for signs of dehydration, be attentive to slight changes in body temperature and take note of elevated blood pressure, which they might miss when they were busy with other duties. She added: “As they perform their routine work, they would be on the lookout for these signs. A step down the the road to recovery for a patient depends on the nurses’ attention to details, as well as the APN’s ability to catch signs early and take the necessary steps. Even though they may seem like small tasks, they make a huge difference.” These details handled by APNs have positive impact on the management of a patient’s condition. With their unique education and training, the APNs possess the best of both worlds and bridge the gap between nurses and doctors. APN Jennifer Wong from the Heart Failure Service said her role placed her in a unique position: “As nurses ourselves, we understand where our nursing colleagues are coming from and they feel more comfortable coming to us with questions. At the same time, because we work so closely with doctors, we can see from their perspective too.” She is able to clear the air between the two when misunderstandings arise and “educate both ways”, she said. She shared how hear t failure patients of ten have a long list of medication with many that may potentially lower their blood pressure. Often, nurses are hesitant to give the medication to a patient whose
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Advanced Practice Nurse Serene Tan (Neurosurgery) demonstrating a physical examination of a patient.
“
As nurses ourselves, we understand where our nursing colleagues are coming from and they feel more comfortable coming to us with questions. At the same time, because we work so closely with doctors, we can see from their
blood pressure was already low. Nurses may find it difficult to approach and a sk the doc tor s about it, while doc tor s may wonde r why the nurses do not give the medication as prescribed. Jennifer finds herself explaining the rationale to both sides to clear misunderstandings.
perspective too. – Jennifer Wong Advanced Practice Nurse (Cardiology)
“As APNs, we have our fair share of being misunderstood by our colleagues, peers and even patients,” she said. Serene added: “Despite our close collaboration with the medical team, we are still nurses, we are not doctors or physician’s assistants.” She went on to share that the APN track is far from being glamorous; rather, it involves long hours of study, hard work and perseverance. Jennifer concluded: “At the end of the day, what keeps us going is our passion to improve our patients’ clinical care.”
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R Rallying the troops Ward sisters are the stalwarts of the team – they are
supervisors, conďŹ dantes, protectors and motivators, all rolled into one
Unit Nurse Manager Tay Meow Hoon manages the Intensive Care Unit and High Dependency Unit. Supervisors from ICUs on Levels 3 and 6 preparing for latest updates from their lead nurse.
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A great way to bond with staff. Nurse Manager Yeoh Kim Choo at the beach with nurses (12C).
A
t the height of the SARS epidemic in 2003, when the fear of infection was a very real concern and colleagues were falling sick, then Nurse Manager Tay Meow Hoon stepped out from the sanctuary of her
office and went personally to the wards to rally the nurses. “As a manager, I didn’t need to go into the wards as often as my staff to tend to the patients, but I made it a point to, so that my staff knew that whatever they were going through, I was in it with them,” said the current Unit Nurse Manager of the ICU. In the same vein, Nurse Manager Sulimah Bte Sarmin (Emergency Department) was on permanent night shift during the taxing SARS period and made the opportunity to talk one-on-one with her staff so that they could have someone to share with or vent to about the day’s trials during the quieter wee hours. Besides being a good listener, a ward sister also needs to be a protector of not just her patients, but also the nurses working with her. Nurse Manager Sulimah Bte Sarmin (Emergency Department) who was on permanent night shift during the SARS period avail herself to staff to have someone to share with or vent to about the day’s trials during the quieter wee hours.
Nurse Clinician Akhterun Nisha Bte Idris recalled a harrowing incident about 10 years ago in which a HIV-positive patient, who was also a drug abuser, holed up in the toilet and threatened to inject anyone who tried to enter with a syringe filled with his infected blood.
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Her number one concern at that moment was for the nurses in her charge. She said: “I knew that they were concerned that the patient could self-harm, but I said that there was no point in being a hero and that we should wait for help to arrive. My first thought was for the safety of my staff.” It was the right call, as the police later arrived to take charge of the situation and no one was harmed. The care, concern and camaraderie shown towards one another in the nursing team are crucial, and no one knows this better than Nurse Manager Yeoh Kim Choo (12C). Standing with her hands on her hips, she cuts the stereotypical image of an authoritative, no-nonsense matron nurse. But spend just a moment with her and that image quickly disappears as she wins you over with her quick talking, can-do attitude and warm sincerity. Sister Yeoh, who won the Director of Nursing Award’s Best Supervisor Award in 2012, makes time to bond with her team over chatter in the
Nurse Clinician Akhterun Nisha Bte Idris demonstrating how she did night shifts in CDC 1 with her trusty umbrella which could prevent head injuries from falling fruits, and could also be doubled as a cane to ward off snakes.
tearoom. The nurses know that they can count on their ward-in-charge, be it to be a listening ear when they face personal problems or to provide unwavering support in moments of crisis, such as when they had to run the ward at half the necessary staff strength for months in 2007 due to an unusually large number of staff going on maternity leave or falling sick, with mostly freshly graduated staff remaining. The team spirit in her ward, 12C – which interestingly has one of the lowest attrition rate in TTSH – is so strong that, if faced with a staff member who cuts corners to get work done, a quiet word is all that is needed to set things right. Sister Yeoh said: “I tend to bring my staff in to talk things over first, rather than be ready to ‘shoot’ them. I will tell them that we have to be held accountable for whatever things we do.” Fostering a culture of where the doors of communication are always open means that the nurses know there is a strong support system for them,
“
My team knows that if anything happens to them, I’ll be the first one beside them. – Yeoh Kim Choo Nurse Manager (12C)
both personally and professionally. Sister Yeoh added: “My team knows that if anything happens to them, I’ll be the first one beside them.”
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S Standing on strong shoulders Nurse educators are not only passionate about
imparting skills and inspiring their charges, they also lend a listening ear to those in need
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F
or as far back as she cauld remember, Hnin Nwe Oo had always played the role of a teacher. She recalled playing school as a child, where she would lay out papers neatly in a row on a staircase, like notes for her pupils.
Senior Clinical Nurse Educator Kala Narayanasamy (Education and Practice, second from left) kept her lessons fun, upgraded her knowledge by taking a two-year Masters in Clinical education course and constantly evolved her classes to make sure her students take to her lessons.
“Maybe even then, I was visualising myself in the lecture theatre — played out on tiers of that staircase — speaking to my students,” she said, chuckling at the memory. What led her to become a nurse educator was the enjoyment she derived from being able to share her knowledge with others, she said. Inspiring a new generation of nurses, the same way she was, makes her a passionate teacher. In a way, she is standing on the strong shoulders of those who came before her.
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Sister Kala Narayanasamy, who has been a nursing officer running a ward for 10 years, ha s a we a lth of te ac hing ex p e r ie n c e w hile supervising her staff. So it was not a big leap when then Unit Nurse Manager Zing Mee Seng, who has since left TTSH, suggested she take on a clinical nurse educator role in 2002. Coming from a family with five siblings, of whom two are nurses and the other three are teachers, she noticed that after her job task switch, she began to relate to and see more similarities with her teaching siblings. “We’d exchange stories about how important it is to keep your students interested in what they’re learning. I found that if you teach the same stuff over and over again, even you would be bored of it, not to mention the students.”
Basic Cardiac Life Support (BCLS) Instructors conducting competency assessments.
So she kept her lessons fun, upgraded her knowledge by taking a two-year Masters in Clinical education course and constantly evolved her classes to keep abreast of improvements and current issues to make sure her students took to her lessons. Being kept on her toes, having ready contingencies and going with the punches when things do not go according to plan are what thrills her about her current position as a Senior Clinical Nurse Educator. “When you’re in the ward by the patient’s bedside, what you learn in theory – that you follow steps A to C – doesn’t always happen that way in reality. That’s when it gets exciting. And that really puts my skills to work as the students experience first-hand real-life situations and observe how I handle them. ” She recalled an incident where she defused a tense situation. Distraught family members were holding back the admission process of an elderly patient. Most of the young nurses, wary about dealing with the intimidating-looking group, were unsure what to do.
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Sizing up the situation, she quickly went for ward to show her concern for the patient by touching his hand and assuring his family members that their father would be well taken care of here. Suitably assured, they willingly went with her suggestion of leaving him in their care while they went for a meal and that they would return to find him comfortably settled in. “My students saw how everyone was visibly rela xed by what I did. I told them the most important thing to do when we first see patients is to make a connection to let them know that we’re there to care for them. It could simply be a touch on the hands. When family members, who are already under emotional distress with their kin ill, see this, they feel more assured as they know their loved ones are being looked after,” she said. But it is not always about imparting wisdom. Nurse educators also motivate and provide them a safe space to share about work or private struggles. Deputy Director of Nursing Pua Lay Hoon explained: “It’s very common for new nurses to find it hard to cope under the pressure of their own expectations. Sometimes, it’s not a knowledge deficit that stands in the way. It’s that they are so stressed that they need someone to encourage and affirm them in their abilities. And that’s what we are there for. The nurses don’t feel any threats in confiding their struggles with us because nurse educators are usually their first contact person as a new nurse in TTSH.” Hnin’s students, who clearly appreciate their teacher’s efforts, said they
“
I tell my students that I have sat where they now sit and I constantly think of ways to tailor
were “blown away by how well-planned the lessons were”. Not only did they
my teaching to suit
take away knowledge of nursing, they also found the whole process fun.
each student’s learning
Hnin said: “I tell my students that I have sat where they now sit and I
strengths.
constantly think of ways to tailor my teaching to suit each student’s learning strengths. I want to be there for them, to show them the ropes or support them through the ups and downs of their nursing life.”
– Hnin Nwe Oo Nurse Educator
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T
Through trials and tests The Nursing Research Department yields important breakthroughs and earns accolades for TTSH
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or a department newly set up in 2007, the Nursing Research team has garnered quite a few notable achievements. These include several national research grants – MOH Small Innovation Grant in 2009;
Nursing Research Grant in 2009 and 2010; Healthcare Quality Improvement and Innovation Fund in 2011. The team has also won Bronze and Silver placings in Singapore Nursing Award at Singapore Health and Biomedical Congress for two consecutive years. One of the breakthroughs was the Decision Algorithm to check feeding tube placement. Incorrect placement in the lungs can lead to dire consequences and even death. Prior to the Decision Algorithm, the most definitive way was using chest radiography. However, frequent exposure to radiography is harmful and a financial burden on patients. The most common bedside method of the acid-base indicator strip has its limitations to confirm placement. The Decision Algorithm the team came up with “overcame some of the limits in the acid-base indicator strip by directing nurses to systematically examine more factors to rule out the likelihood of a non-gastric placement before deciding whether chest radiography is necessary”, explained Nurse Researcher Isabel Ng. With nurses performing all necessary verification at the bedside using the Decision Algorithm, it led to another
From left: Nurse Researcher Isabel Ng, Executive Assistant Crystal Sim, Senior Staff Nurse Grace Tan and Senior Staff Nurse Stephanie Tai.
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breakthrough by empowering nurses to order chest radiography on a doctor’s behalf.
These achievements would not be possible without a pioneer trailblazer. The trailblazer is Chan Ee Yuee, who is now pursuing her PhD at University of Sydney. As a Senior Nurse Researcher, she and others in her team had envisioned a Clinical Decision Support System for managing chronic wounds. Now this dream is realised with a new electronic system which the nurses can know the recommended wound product and care for different wound types based on scientific basis after entering the wound characteristics. “Collaborative feedback from ward nurses made the Decision Support system possible. In addition, the nurses can mark the wound location on the electronic chart. Nurses soon would be able to view the exact wound pictures from the system and monitor healing trajectory without overexposing the wounds,” shared Nurse Manager Betty Khong, who is currently handling the project. Said Deputy Director of Nursing Lee Leng Noey, who heads the Nursing Research Department: “It was really revolutionary when we decided to invest in an Nurse Researcher role, which we never had before. This role required a trailblazer who could dream big, yet concretise the ambitious wish lists to meet organisation needs. Thus, we roped in Ee Yuee who had accumulated in-depth
Senior Nurse Researcher Chan Ee Yuee is the trailblazer of the Research team “who can dream big dreams, yet concretise these ambitious wishlists to meet present and upcoming needs”.
clinical experience in Intensive Care and was passionate about pursuing research as her next career. We gave her opportunity to pursue a Masters in Health Research Methodology. The first few years were tough but our results have paid off.” One such result was seen in Nursing Research's first major clinical trial, spearheaded by Ee Yuee, in collaboration with the Orthopaedic Department. The study aimed to improve pain management for patients undergoing knee replacement surgery. Other firsts were the development of the Decision Algorithm and electronic wound care system, which are expected to make TTSH renowned in international standing. The perseverance and hard work endured in the research process had gradually brought big rewards for the nursing profession in TTSH. Isabel elaborated: “The medical field now appreciates the value of the work we do to improve patients’ outcomes in ways that may not necessarily come from drug
“
The new knowledge generated through research ensures that the nursing care we give to patients remains relevant and safe.
trials. Our department’s vision is to engage more nurses interested in translating research into practice. There are so many things to discover each day if we challenge our current practices and mindset continually. The new knowledge generated ensures that the nursing care we give to patients remains relevant and safe.”
– Isabel Ng Nurse Researcher 89
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The RFID tag is used to track patients' locations, monitors patients' temperature and keep electronic records of patients' vital signs.
Ushering the information age Cutting-edge IT applications help nurses save time and effort as well as cut down on errors
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Benefiting from IT Radio Frequency Identification (RFID) technology and SmartSense Vital Sign Monitoring System What it is: A system using Radio Frequency Identification (RFID) technology to track a patient’s location as well as body temperature. s ,OCATION TRACKING 2&)$ FACILITATES PATIENT LOCATION TRACKING AT THE INPATIENT wards and reduced time taken to locate patients out of the wards. It promotes
better coordination of patient flow, better manages utilization of limited resources and provides real time status of ward capacity to the Emergency Department (ED), Bed Management Unit (BMU) and wards. s 4EMPERATURE MONITORING 4HE 2&)$ CONSTANTLY MONITORS PATIENT S BODY temperature and wirelessly upload the readings to electronic clinical chart. It also keeps a permanent electronic record of vital signs like blood pressure, pulse and respiration, which are entered manually to the system. Benefits: Principal Assistant Nurse Mageswary D/O Thambirajah said: “The RFID tag reduces my workload as a patient’s temperature is automatically captured every half an hour and I can view it from any computer, instead of having to spend time walking around looking for that one clinical chart. Trends in a patient’s vitals and sudden changes are indicated, making them easier to spot. I especially appreciate that the new system is user-friendly. What a far cry from the old days of disinfecting fragile glass thermometers in ‘printol’ solution (a common disinfectant then) and drying them before use.”
Intellivue Clinical Information Portfolio (ICIP) What it is: A comprehensive patient-data management system, which compiles their parameters, assessment and notes from doctors, nurses and Allied Health Service (AHS) staff in one place for easy referring and sharing. It was previously known as Carevue. The system is used in intensive care units.
Principal Assistant Nurse Mageswary D/O Thambirajah scanning the patient’s wrist tag using glucometer to ensure the blood glucose test is done for the right patient.
Benefits: Staff Nurse Wendy Goh Geok Chin said: “With ICIP, the records are much neater and clearer, especially when it comes to reading changes from the doctors or reports by fellow colleagues. By eliminating illegible handwriting, it also prevents errors. There are preloaded words and sentences in the system that saved us a lot of time when we are entering our reports. Doctors, nurses and AHS staff can now easily share a holistic view of a patient’s treatment and collaborate towards a common goal. I definitely prefer these electronic records over paper documentation.”
Closed Loop Medication Management System (CLMMS) What it is: An electronic system for the processes of medication prescribing, reviewing, dispensing and administration to ensure that the correct medication is served to the right patient at the right time. It consists of three components: s %LECTRONIC )NPATIENT -EDICATION 2ECORD AND )NPATIENT -EDICATION Adminstration Record (eIMR-iMAR) – e-records for medication prescription,
With CLMMS, Senior Staff Nurse Alyssa Chua (13B) finds it easier to understand the orders. This, in turn, reduces the risk of committing medication errors.
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medication review and administration purposes. s %LECTRONIC -EDICATION !DMINISTRATION 2ECORD 3YSTEM %-!23 n -EDICATION administration system used by nurses to administer medications. Paired with a PDA to scan the barcodes of medication and patient's identification on the wrist band, it ensures that the right patient is given the right drug at the right time, and even indicates any allergies or contraindicative medication. s /MNICELL !UTOMATED $ISPENSING #ABINET !$# n ! SECURED SYSTEM FOR efficiently managing, storing and dispensing medications. The guiding lights guide the user to the desired location in the cabinet to remove the correct medications. Other safety features include bin-locked compartments and controlled access such as thumbprint verification. The system also facilitates medication inventory process and triggers resupply of medications to the Staff Nurse Wendy Goh (3B) can now easily share a holistic view of the patient’s treatment from a collaborative standpoint among doctors, nurses and AHS staff with ICIP.
specific Omnicell cabinet. Benefits: Senior Staff Nurse Alyssa Chua Xing-En described its advantages for both patients and nurses. “We used to strain our eyes to read medication orders with tiny or scrawling handwriting but with CLMMS, it is far easier to understand the orders and has greatly reduced the risk of committing medication errors such as misreading orders. Not only that, the standardised medication serving process minimises interruptions and helps to prevent medication error. All these greatly increase patient safety. Now, medication orders can be viewed by multiple users from any computer station. With Omnicell, I don’t have to waste time and effort searching for medication. It improves workflow and patient care by ensuring supplies are readily available. CLMMS not only enhances patient safety, it also reduces waste steps and save time. This allows us to spend more time on direct patient care.”
When nursing meets technology Informatics Nurse Manager Chen Li finds her job exciting with its scope that includes testing new IT products and systems whenever a new project starts and developing new software applications for them. For example, she gets to test out applications for administering medication on the latest iPad mini. The nurse manager is proudest of her contribution to the Medical Device Interface (MDI) Solution – a system which auto uploads and documents vital signs readings to an electronic clinical chart. She said: "Not only did it eliminates transcription errors and thereby improves 92
patient safety, we were also able to cut down the average time spent on vital signs documentation per patient by half, from 3 min 11 sec to just 1 min 40 sec." Soft-spoken and methodical, her sentences consisted of technical jargon, such as “dropped connectivity” and “seamless integration of applications”. Yet just as easily, she switched to plain speak, such as when she has to present new systems or conduct software training. “In nursing care, nurses come to me when faced with difficult and complex cases. Now, just like caring for patients, I manage their queries, and guide them to find answers to resolve the ‘bugs’ that they encounter,” she said. However, she was quick to point out that, although an IT nurse provides technical support at times, the difference between an IT nurse and technical support staff is in the former’s main duty. Nursing informatics combines nursing knowledge with computer and information science to create resources, software applications and devices which optimize the gathering, storage and retrieval of information in nursing practice. This supports nurses and other healthcare
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Nurses come to me when they’re facing difficulties like system workflow issues and just like caring for patients, I handle their queries, ask them questions to troubleshoot the errors and guide them through till the ‘bugs’ are gone.
providers in their decision-making and other work processes and often lightens their load by intelligently automating what were more labour-intensive tasks.
– Chen Li Nurse Manager (Informatics)
Besides providing nursing input to develop new information systems and technologies, she also evaluates these systems to ensure that they do indeed help nurses provide efficient and effective nursing care. The challenges she face in her job includes having to continually update her knowledge to keep up with rapid technological changes and high user expectations of the IT systems used. “I think we want IT systems to always work perfectly to meet all our expectations and needs. However, for any IT system to achieve this and have good outcomes at the same time is tough. Nonetheless our department is constantly striving to attain this.” About her role, she added: “I see my role as a link that ties all the different protocols of nursing practice together with technological advances to improve patient care management and make work for my nursing colleagues safer, more efficient and easier.” Different protocols of nursing practice together with technological advances that improves patient care management and makes work for my nursing colleagues safer, more efficient and easier.” 93
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Value-added qualities The Quality team chat candid candidly about how ving for improvements tha striving that add value to rsing is a team effort nursing
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elmed by Assistant Director Hoi Shu Yin ( SY ) , the Qualit y department comprises Nurse Manager Betty Khong (B), Nurse Manager Candice Leong (C), Senior Staff Nurse Anni Dionne Liew
(D), Nurse Manager Tan Tit Chai (TC) and Nurse Manager Tan Tzuu Ling (TL) are proponents of achieving qualities such as a safer and happier workplace and a happier for nursing practice. They share about what they do.
Tell us about some of the projects you’ve been involved in. B: For me, planning the hospital’s first-ever nursing election was both thrilling and nerve-wrecking. First thing to tick off my long to-do list: kick-starting the election campaign for the governance councils (GCs) through the Nurses One stOp Gateway (NOOG) website, which was fast approaching. Next, a jumble of things to think about, including budget and logistics. All these items had to be top-notch and well thought through, otherwise they wouldn’t meet Quality’s standards. The most nail-biting par t was when I had to provide the voting results within half an hour of the election ending, scrambling to generate them while ensuring that the data was reliable and accurate. I think that
Nurse Manager Betty Khong
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summed up the whole Quality process for me, where we often go through
repeated rounds of planning and thinking, checking and verifying, all while time’s not on our side, yet giving our all to maintain our reputation of being fast, good, accurate and reliable. TC: That’s true. But other than faster, better, cheaper and safer, we’ve also included: easier, nicer, kinder and happier – because our main work is with and for people: our patients and colleagues TL: Yes, one example of this is in post-fall huddles for patient falls resulting in level 3 injury or incidents that require further investigations. Shu Yin initiated them last year and, as a team, we’ve been working on visiting wards and conducting these huddles. By doing this, we aim to create awareness of the incident immediately and promote effective teamwork, where teams are empowered to offer solutions based on what had actually happened. Ultimately, we want to encourage staff to have the willingness to report all safety events and near misses without fear of retribution, but with an understanding of accountability.
Assistant Director of Nursing Hoi Shu Yin
SY: (nodding) It’s really important to address the issue, yet prevent it from looking like we are pinning blame. So, my team members and I do it by gathering the staff involved in the primary nursing care team, including nurses, and their managers in a private space to talk about three things. The first and usually overlooked question is: How are you coping? After an unfortunate event, such as a fall where a patient sustained injuries, staff may feel emotionally distressed and blame or question themselves, such as “Why me?”, “What did I do wrong?”, “Maybe I should have done it this way instead?”, “What is going to happen to me?” and “What will my supervisor or the management think of me?”. A simple question such as “How are you coping?” offers them the avenue to discuss their fears and concerns and allows us to encourage and let them know we support them at this tenuous time. Then, we ask the nurses to talk about what happened and try to identify some key issues together.
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Finally, we end with a discussion on what we have learnt from the event and what we can do together to hopefully prevent a future occurrence. As Tzuu Ling has shared, there is an emphasis on team effort. I’ve found these huddles to be one of the most rewarding initiatives. After every session, I often leave with a heavy heart. It saddens me to see that nurses who have already tried so hard to give their best care to patients suffering as second victims. Yet, at the same time, each session with the nurses gives me a greater resolve to continue to do what I am doing – identifying system issues and working to improve the system – and I deeply hope that the nurses will have the courage to move on.
What do you enjoy about your job? TC: That it allows me to keep trying, failing and trying yet again. I truly appreciate the bandwidth that my bosses have given me to come up with better solutions. Nothing beats the feeling of finally hitting on a good idea and being able to help people out of sticky situations through my projects Nurse Manager Tan Tit Chai
or processes. Sometimes, when colleagues tell me that they, too, agree that something is not quite right in a situation, but are equally baffled about the solution, I feel like I’m no longer the only person standing there scratching my head. Or when they say, “I really like what you’re trying to achieve”, I feel so understood and validated. C: Yes, I agree with Tit Chai. Having great bosses goes a long way. Despite being even busier now as the recently promoted Assistant Director, Shu Yin never fails to ensure that all of us as her team members are doing all right. She usually has small chats with us as we start the day together to gauge whether we need help or support in any way.
Occupational hazards? SY: (gesturing at her watch) The work often does not stop when it’s time to go home. Many times, the Quality mind does not rest till a solution is thought through and this often extends to time at home and late into the night. As there are no easy solutions to the complex problems we face these days, I often have to take certain risks and make the decisions necessary to move us forward. When our decisions Nurse Manager Candice Leong
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give us problems, we learn from them to become better and move on.
Name some challenges that you face. SY: It’s not unusual for us in Quality to feel discouraged or uncertain, as the work involves much problem-solving and working with different people. It also requires us to pluck up our courage as we face senior doctors or directors in our quest for creating solutions to Quality-related problems. Much is at stake, as we carefully craft our proposals to articulate our interests. Often, with counter-proposals, we are handed the challenging task of creating win-win solutions that provide value without adding on to our colleagues’ workload. D: Since my area of focus – shared governance – is a relatively new concept to most, to fully engage the ground in decision making at the hospital level will require some momentum, although we are seeing many encouraging signs. It will also take time after setting up GCs to build up their capability to run independently. TL: Another challenge is in enabling others to understand the urgency to change. Other factors that enable change to take place could be
Senior Staff Nurse Anni Dionne Liew
leaders at the forefront championing it, a system change or staff being empowered. We need to move towards a healthcare system that treats errors not as personal failures but as opportunities to improve the system and prevent harm.
What’s Quality to you? SY: At first glance, we tend to think of Quality as managing standards and ensuring clinical governance. But when we delve deeper, we realise that the work itself involves understanding human interaction and behaviour, as well as recognising an individual’s learning, motivation and resilience. Our Quality executives in the team are learning that execution of plans alone does not necessarily bring about Quality. Instead, we need to have a deep desire to understand how our minds work within our complex environment and the determination to bring out the best in our people to achieve this moving target called Quality.
Nurse Manager Tan Tzuu Ling
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When you watch over me Patients and their family pen heartfelt letters to th the nurses, saying they are thankful for the little things done for them
Dear nurses of the
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TTSH rehab centre, It’s been 7½ year s since I was an inpatient at the re hab ward, but I st time there vividly. ill remember my 4hen I Ìrst came in, I had suffered a spinal cord in Fury from the necG dow from a fall and was n. I was totally de paralysed pendent on the nur ses. It was very ch to this, especially be allenCinC ad FustinC ing ex-military and used to calling the shots. I had to get instead, even to dr others to help me inG water or answer my handphone. 4ha t made it Fust that was the genuine w bit easier to cope arm smiles that th e nurses had for each of us patients ness, while tending , despite their busy to our every need. M y fa mily of six siblin gs, friends an d ex-colleagues re almost-one year I gularly ca me to vi spent there. But fa sit over the cin g the four walls For me, the longest for months on en hours to endure w d wasn’ t easy. ere at night. The nurses, however, se internal antennae that’s sensitive to emed to have an their patients and took particular care me during the night to come and talk to , keeping me compa ny to while the lon g hours away. There were also th e times when nurse s would make it a heard that you had point to come to m a fever last night, e and say, “I but I’m so happy to hear that your feve r has gone down
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HEOPAJEJC PK I as such an in A =O & OD=NA@ expressible c spoke to my h om for t. Then e a r t – a b ou t s being understo h e g a ve m e a hu g which words ever co od and that I uld. wasn’t standin g alone – fa r better than "RAJ PDKQCD ! AOIKJ@ D=O J KS >AAJ PN=JO IA PATP IAOO BANNA@ PK DEO ? =CAO PK ÌJ@ K QNNAJP ! S= QP DKS DA EO = N@ /=?DAH OPEHH J@ AJ?KQN=CA =NA =HS=UO S OA J @O AH?KIA@ SEPD IA ,QN REOEP S=NI DQCO = O > =?G J@ CAJQEJA EJ well-being. I MQENEAO =BPAN am sincerely KQN thank ful for w hat the nurse done – from s and staff h bearing with h ave is struggles a t the beginnin KJ DEO FKQNJA U PKS=N@O NA? g to cheering KRANU him This is Desmo
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Nursing leaders. Front row from left: Wee Fong Chi, Wong Mui Peng, Lim Siew Geok, Leong Yoke Yin, Kwek Puay Ee, Goh Lee Lee and K Patmawali. Centre from left: Chia Yeow Peng, Yong Keng Kwang and Pua Lay Hoon. Back row from left: Lee Leng Noey, Jamie Lim, Hoi Shu Yin, Shirley Tay, Margaret Soon, Nirmala Bte Karmaroon, Zee Ie Chuen and Tham Chui Min.
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X-uberant and X-ceptional Youthful leaders chart new paths for the profession through innovation, while helming the ship as champion of the staff
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hen Madam Kwe Kwek Puay Ee took on the role of Director of Nursing Service (DN) in 2001, 2 she saw her position as being a “transitional leader”. She says says: “I wanted to break the mould in which being a
Director of Nursing meant that th you stayed there till your retirement.” Right from the start, she sh had an uphill climb. As the youngest Director of Nursing Service ever appointed appo in Tan Tock Seng Hospital at 39 – with her last position as a Geriatric ward nursing officer – she had to prove her worth while bridging a gap that she saw in the lack of communication between the management and staff. “I held forums with all levels of staff including health assistants and ward clerks. I knew that I could not reach out to every single staff, so my aim was to touch every supervisor – 250 in all. I’d regularly meet up with them, group by group per floor or area,” she said. As she leaned forward, sharing with an enthusiastic sparkle in her eyes, it is easy to see how the self-confessed emotive speaker captured the hearts and minds of her staff. “During the SARS period in 2003, my staff saw me going through thick and thin with them and that sealed our relationship. I also realised how important youthful leadership was. At 41 then, I had the energy needed to deal with the crisis situation,” she said.
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T he cu r re nt D ire c to r of N u r sing, Ke ng Kwang, added : “Usually, once you become Director of Nursing, you can stay in the position for quite a number of years until you retire. But it was Puay Ee’s initiative to step aside to refresh and renew leadership.” Madam Kwek star ted to choose a nextge ne ration le ade r to take he r place at the beginning of her ninth year in her position. Referring to the fact that the vocation consists mostly women, she said : “Picking a woman would have be e n e a sie r, but I chose Ke ng Kwang based on his ability.” In 2011, after a 10year tenure, she “stepped aside”, passing the baton to Keng Kwang, then 40. With a degree in nursing from the University of Manchester, Keng Kwang, whose sole employer Unit Nurse Managers. First row from left: Ramasamy Letchimi, Lee Mui Whung, Julien Tan and Kunjuraman Suvaseni. Middle row from left: Senifah Radi, Mariam Bibi Piperdy, Kalaichelvi D/O G Govindaraju and Laura Ho. Back row from left: Magdalene Lim, Tay Meow Hoon and Quek Lee Kheng.
has been TTSH, joined in May 1996 as Senior Staff Nurse. He spent roughly eight months each at the medical, surgical and Neuro-ICU wards. Then, in 1998, he accepted an offer to take the full-time administrative route, assuming a project management role in nursing quality, and climbed from Senior Staff Nurse to Deputy Director over the next 13 years. It is clear as you speak to him that statistics, processes and analysis are among Keng Kwang’s strengths. Yet, as he carefully weighs his thoughts before giving his answers in calm, measured tones, his demeanour belies a quick intellect, gentle humbleness and warm care; the last especially so on the topic of his staff. A need he wanted to address when he assumed the director role was how, as students, nurses are trained to provide patient-oriented care, but when they enter hospitals and other institutions, red tape and administrative processes detract nurses from their core work – to provide care. “You speak to any nurse and you’ll find that they are willing to blur the boundaries to improve patient care. My aim is to remove such non-value-added work, so that the true work of
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nursing can be realised and more visible”. Creating the Ward of the Future, which included redesigning ward cubicles to cut down unnecessary legwork, such as in stocking or searching for supplies, by 50 per cent is one of the inroads to this, together with innovations like the Omnicell, an automated stock-tracking system for medication. He also places a priority on engaging with staff through new media on a blog he writes and staff tête-à-tête sessions. Of their diverse styles, Madam Kwek said: “It’s the combination of two different skills that brought us to where we are today.” This winning combination led to what they both call their “best breakthrough” – a 2004 study whose findings, when presented to the Permanent Secretary in 2006, resulted in the first five-year manpower funding in nursing. Badly needed manpower numbers were finally increased, as did staff satisfaction in nurses being recognised for their work. It was the culmination of the work that Keng Kwang, then in Nursing Quality, and his team did in replicating a 1989 MOH manpower study to produce up-to-date findings; and Madam Kwek, then the Director of Nursing, in knocking on the right doors to reach the decision makers. “I always tell my nurse supervisors, ‘The young ones (nurses) are the innovators and we the senior ones are the stabilisers,” said Madam Kwek. It is an apt analogy for their current roles with Keng Kwang at the helm and Madam Kwek, who is now Executive Secretary in the Singapore Nursing Board, continuing to contribute to TTSH in mentoring nurse leaders. They may be a study in contrasts, but they share one heart in being their nurses’ champion of causes, cheerleader and chief. Summing this up in his main goal as a leader, Keng Kwang said: “My job is to find the right
“
The young ones (nurses) are the innovators and we the senior ones are the stabilisers. – Kwek Puay Ee Former Director of Nursing
match for their training and interests, so that every nurse’s potential can be unleashed and their passion for the profession fulfilled.”
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From left: Associate Professor Leo Yee Sin, Dr. Balaji Sadasivan, then Minister of State in the Ministry of Health, Dr Lim Suet Wun, then Chief Executive Officer of TTSH and Professor Philip Choo, current Chief Executive Officer of TTSH, in one of their regular SARS discussions.
Yet we overcame The SARS epidemic may have broken b out 10 years ago, but its impact on how nurses work lingers ling to this day
“T
he unity and comradeship in leadership were some of the key factors that helped us overcome SARS. From the hospital management to nursing leadership, we all knew what our
individual roles were and worked as one towards our common purpose. I think that single-mindedness was pivotal because it translated all the way down to the ground staff, who mirrored what they saw and felt in their leaders. It was what kept us all going, knowing we were brothers- and sisters-inarms together in this battle. Topmost in our minds was how to provide a safe environment and to protect the safety of our nurses and healthcare workers before they were put on the frontline. ” – Dr Lim Suet Wun, former CEO, TTSH
“S
ARS was an invisible enemy that we didn’t know enough about. We were fighting against time and the worst part was
Ten years on – the smiles on their faces depict triumphs. Clinical Instructor and SARS survivor Ashirdahwani Bte Asmawi (centre) with her family and Prime Minister Lee Hsien Loong at a recent SARS memorial event at the NUS Cultural Centre.
seeing your colleagues getting sick, while you could only
standby helplessly.” – Senior Nurse Manager Harbhajan Singh
“W
hen the SARS epidemic first broke, we realised that lines of communication to disseminate information quickly were
very important. They would maintain the ground staff’s trust of the organisation and let them know how it was dealing the situation. We gave them information as we found things out, rather than them hearing it through other sources like news outlets. The CEO would hold regular townhall meetings with the latest status updates. As and when breaking news occurred, we would also have unit or ward meetings to inform the ground staff. I attribute our success in containing the spread to how nurses and staff pitched in to open and close wards. It was truly amazing to see how quickly they adapted to their changing environments to work well as a team together.” – Unit Nurse Manager Lee Mui Whung (Level 13)
Staff of Ward 91 at the completed container wards. After only two weeks of construction, 40 isolation beds were created in record time at CDC Ward 1.
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Singapore General Hospital (SGH) nurses with Madam Kwek Puay Ee, then TTSH’s Director of Nursing (middle in floral blouse), at an appreciation tea party for the SGH team.
“I
t was ver y moving to se e how selfless and commit te d my colleagues were in rising to the challenge at a time of crisis and unifying towards a common goal. We have taken away many
lessons from the experience and have risen to be stronger than before. It fills me with a positive belief that, should there be more bumps and challenges ahead, our resilient spirit will prevail again.” – Director of Nursing Yong Keng Kwang
“T
en years on, the continuing impact of SARS is the state of emergency preparedness. In the ICUs, equipment such as powered air purifying respirators (PAPR) are charged daily and all nurses undergo annual
recertification in PAPR use. The outbreak has further strengthened our fortitude to be ready for ‘out-of-routine’ duties as a quick response to crises. For example, when the H1N1 outbreak was announced, nurses immediately shifted mental gears. They started to make necessary preparations, such as the ICU nurses gearing up CDC 2 ICU to open four beds there.” – Nurse Manager Abdul Wahab Bin Hassan (6B)
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t the CDC where I was admitted, I was isolated
“A
immediately and it was really emotionally difficult fighting the disease on my own. The nurses’ sincerity
during such a frightening time deeply impressed and touched me. It was what later motivated me to enrol into the National University of Singapore nursing degree programme. My mother is also currently working in the healthcare industry. She wanted to give back to the profession that had such a profound impact on her, to touch the lives of others and to be a source of strength for her patients’ families.” – Staff Nurse Daphne Lim, who was 14 when both she and her mother caught SARS
“A
s I traced my life’s milestones in the years after SARS, I count my blessings. From being ‘Single And Really Sexy’, I moved on to being ‘Steadily
and Accountably Raising off-Springs’. I have four beautiful children – two boys and two girls. I constantly emphasise the
Nurses handing over reports of patients to the next shift during a shift handover.
importance of caring for patients as if they were our loved ones to my students. I was blessed with the first-hand experience of being nursed back to health by my own colleagues when I was sick. The genuine care and support really helped me through those difficult times. Now’ I can empathise with the patients and really understand the importance of emotional support for better recovery.” – Clinical Instructor Ashirdahwani Bte Asmawi, a SARS survivor
“I
n this millennium, where new emerging infectious diseases such as H7N9, the Middle East Respirator y Syndrome and many more are growing threats, as frontline staff, nurses have to be
constantly prepared to face the challenge of a pandemic outbreak. Nurses can draw on the knowledge and experience gained in the management of SARS and H1N1 to handle these unknown viruses. Even then, it remains critical for nurses to adhere to infection control practices while remaining vigilant in their day-to-day activities. A disciplined and proactive approach is still the best safeguard against any new outbreak.” – Senior Nurse Clinican Poh Bee Fong (Infection Control)
A nurse in the ICU isolation room communicates with her colleague outside the room so as to minimise cross infections.
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Members of the four Governance Councils and the Pathway Committee gather together for their ďŹ rst Pathway Fiesta in May 2013.
Zest for the road ahead Veteran nurses pass the torch to the next generation as the hospital looks forward to exciting developments in the profession
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I
magine a crowd of spectators on filled stands watching a relay race. The first runner of a team completes his lap and passes his
baton into the backward stretching hands of the next runner. For a few moments, the first runner continues to run alongside the second, cheering his compatriot on as he picks up speed. In the midst of encouraging whoops, the second runner finds his momentum and springs off to overtake his competitors. The transition of leadership from one generation of nurses to the next is akin to a relay race. It is a tough race where many eyes are looking up to the team to deliver. Therefore, the passing of the torch must be planned and coordinated with the predecessors bequeathing their accumulated wisdom and skills to the next generation so that the successors can take flight to greater heights. The hand-holding by the predecessors will be
Staff Nurse Chong Chai Min (right) was so inspired by her mum, Senior Assistant Nurse Yeo Keng Mui that she followed in her footsteps and joined nursing.
for a moment and then it is for the next generation to lead others in a whole new world. “One thing I would like the succeeding generations to know is that discipline and mastery, coupled with compassion, will drive the motivation to serve and care from our hearts for the many long miles,” shared Wong Mui Peng, Deputy Director of Nursing. Former TTSH Director of Nursing and current Executive Secretary of Singapore Nursing Board, Madam Kwek Puay Ee, who has 34 years of nursing experience, said: “We often associate volunteerism as giving of your time and talents through missions to whole-heartedly help the needy or the sick. Well, nursing in a sense is volunteerism with pay. Every day, we are rewarded financially to use our skills to tangibly help people when they are most in need and it comes with the satisfaction knowing that our work brings care and comfort in the lives we touch.” As one of the pioneers, Nurse Manager Chio Cheng Kay, 71, who has more than 50 years nursing experience, had this to say, “Coming from the
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older generation of nurses, it is stirring to see how the profession is being brought to a higher level. Nurses are now called upon to use clinical reasoning, critical analysis and evidence-based nursing to improve the level of patient care.” Nurse Manager Leong Wai Lin, 69, added, “Now, nurses are empowered to connect the parameters that they take with thinking through and participating in decisive action for patients’ treatment. What an invigorating leap from my time! I can’t wait to see the bigger dreams and greater milestones that our next generation will think up and see come true in their future.” Also looking forward to the energising road ahead, based on her experience of more than 20 years, is OT anaesthesia nurse Senior Assistant Nurse Yeo Keng Mui, whose example illustrated another legacy of caring. Her daughter, OT Staff Nurse Chong Chai Min, was so inspired by her mum that she followed in her footsteps and joined nursing. O n the horizon for T TSH nur sing are a Senior Nurse Manager Harbhajan Singh hopes the new generation to remember the importance of human touch for patients while improving their IT skills.
number of exciting developments. First, embarking on the prestigious American Nurses Credentialing Centre Pathway To Excellence programme, which honours nursing excellence and leadership through positively transforming practice environments and creating a healthy workplace for nurses. A development under the Pathway To Excellence programme that is currently being rolled out is Shared Governance (SG), which is a platform for shared decision-making between frontline nurses and nursing leaders on organisational-wide practices and workplace issues. Through SG, nurses are encouraged to make ground-up initiatives – as opposed to changes traditionally made from the top down – to play an active role in
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suggesting and implementing improvements that affect their practices and work environments. Cutting-edge technology is continually harnessed as automation takes over some of the manual routine work that nurses do. In the near future, automated remote monitoring through devices which wirelessly record vital signs, video motion detection for fall sur veillance and automatic detection of abnormal ECGs in telemetry monitoring will help enhance nurse productivity at the bedside. As the longest serving nurse in TTSH with 54 years under his belt, Senior Nurse Manager Harbhajan Singh, 72, had seen how technology has benefited the profession. But what he hoped to pass on to the next generation is this: “Technology has aided nursing tremendously – from easing the burden of manual tasks to giving us an edge over the illnesses
As part of a newer generation, Senior Staff Nurse Jasmine Tay (9C) adopts motto of “love and caring can cure”.
that we stand with our patients to battle. But we will always be mindful that, at its core, nursing is about ministering the human touch.” As part of a newer generation receiving the baton, Senior Staff Nurse Jasmine Tay (9C), who has close to six years’ nursing experience, agreed hear tily: “My grandma once told me that caring alone may sometimes be good enough to cure someone or make him feel better. When I asked my patients what they thought of this, they agreed that medicine alone did not help them. It was the human touch and the care that they received that did. There’s no other path I’d rather be on than nursing and I’m excited about being part of and adding to a heritage of care that will make a mark for nursing’s future.” Looking back on nursing’s journey in TTSH’s 169-year history, it is clear that the nurses has witnessed ground-breaking firsts and overcome great challenges. Now, as they looks forward into the future, Director of Nursing Yong Keng Kwang shares his vision of bright possibilities: “In our profession, we’ve been given the noble task of cushioning the suffering of our patients while celebrating their joys and that will remain indispensable to the nursing practice. Thanks to the foundation set by our predecessors, we have a wealth of wisdom to build on. This will ensure that TTSH remains the Choice Institution for Great Nursing and that the passion for care is caught and passed on to the many generations to come.”
“
Thanks to the foundation set by our predecessors, we have a wealth of wisdom to build on. This will ensure that TTSH remains the Choice Institution for Great Nursing and that the passion for care is caught and passed on to the many generations to come. – Yong Keng Kwang Director of Nursing
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Milestones 1956
1999
First nurse-led Clinical Practice Improvement Programme (CPIP): Reduction of Falls.
Early nursing innovation and development of the cholera bunk bed.
Start of life in a brand new hospital. Merging of centralised and theatre sterile processing services (CSSD/TSSU) for wards/departments and operating theatres.
Management of Urinary Incontinence CPG Launch.
Maheas D/O Thanmugham, Bessie Lioh and Navaletchumi are among the first batch of Enrolled nurses to attend the bridging programme leading to upgrade in Diploma in Nursing.
L7 CPIP on “Reducing Inappropriate Use of Diapers” awarded the Most Outstanding Project at MOH Quality Conference.
1972 Neurosurgical Operating Theatre Suite (OTS) set up by Staff Nurse Chai Teong Neo.
1973 Singapore's first department of Rehabilitation Medicine is set up for treatment of stroke and other neurological disorder, spinal cord and head injuries, arthritis and other orthopedic conditions.
1975 General Surgery OTS set up by Staff Nurse Wong Wai Cheng.
1981 The Neuro Assessment Chart introduced in Ward 43 Intensive Care Unit (ICU) of the former TTSH. It was incorporated into the Neurosurgical ICU Carevue system in 1994.
1989 TTSH opens Singapore's first Geriatric Unit.
1995 Nursing training and education became a fullfledged unit under the purview the Department of Nursing Administration.
1997 First local Emergency Department (ED) to protocolise Tab Panadol prescription for pain and fever at Triage - result of a study by a second batch of Advanced Diploma in Nursing (Emergency) students.
1998 First use of protocolised lower limb X-ray orders by ED RNs to facilitate early treatment and management. 114
First local ED to protocolise administration of IM Ketorolac by RNs. Telemetry monitorings in general wards was started in Level 8. Urodynamic studies procedures were started at Rehabilitation Centre.
2001 Non-invasive Ventilation Unit (NIVU) first started at Level 7. Moved in 2002 to its permanent place in Ward 8A. First Nursing Resource Utilisation and Process Improvement (RUPI) Committee. Since 2001, RUPI has been initiating, reviewing and designing quality and process improvements until they were integrated with Shared Governance in 2012.
2002 Clinical Nurse Educator position formalised for first four nurses to enhance support clinical supervision and teaching. Peripheral Intravenous Catheter Clinical Practice Guidelines (CPG) Launch. Prevention of Pressue Ulcers CPG Launch.
2003 Nursing Officer Hamidah Ismail who caught the Severe Acute Respiratory Syndrome (SARS) virus while on duty passed away. The Hamidah Award established in her name is awarded to nursing students with outstanding performance.
2004 A protocol-based initiative that uses the Post Anaesthesia Discharge (PAD) score to empower Registered Nurses to discharge patients from the Day Surgery Ward. CPIP: Reducing ventilator associated pneumonia rate in MICU. Multi-disciplinary effort among clinicians, nurses and respiratory therapists to reduce 50% ventilator-associated pneumonia for intubated patients. Measures included the use of MDI instead of nebuliasers, elevation of bed to 30 degrees and use of ventilator bundle guidelibes.
2005 TTSH achieved first Joint Commission International accreditation. Nursing embarked on major review of practices and processes in preparation for accreditation. Prevention of Falls CPG Launch. A knowledge survey of fall prevention measures found that existing fall risk assessment tool over identified high fall risk patients. A study to compare different validated fall risk assessment tools followed in June to December 2006. The current WheFra (Western HEalth Fall Risk Assessment tool) fall risk assessment was adapted and introduced in 2007. Nurses Inc was formed. It supported nurses’ welfare, gathered feedback and helped facilitate new nurses into their respective roles. In 2011, Nurses Inc formed an Executive Committee which creatively revamped dialogue sessions and organised sport competitions to energise the nurses.
2006 April. STAR (Specialised Transfer and Acuity Response) team services commenced. The service was extended to Invasive Cardiac Laboratory (ICL) in August and Chaperone service was started in November of the same year. First Nursing Continuous Quality Improvement (CQI) Day. First nurse-led Multidisciplinary Committee: Hospital Falls Committee. Ward 7C CPIP Project “To Elimination of Fall Incidences in the Night” was the recipient of the Most Outstanding Project on TTSH Quality Day. This led to change in staffing norms of night shift for better patient supervison to reduce falls. Ward 12B. Continuous Quality Improvement (CQI), Replacement of “sponge hand elevator with Brook’s sling” in orthopedic wards. The cost saving sling also reduces the risk of cross-contamination from shared use. With a cost saving of $3,013.19, it was the Champion at TTSH Nursing CQI Day 2007. Since then, the Brook’s sling has been in use in all Orthopedics settings. First two Clinical Instructors: Joanna Lee and Mary Leong Jan Mui. Ward 11C. First use of 4L (conventional 2L) urine bag for continuous bladder washout for post-transurethral resection of prostate. It improved BWO management for all post-TURP care.
2007 Use of radio frequency identification (RFID) to track CSSD/TSSU instruments. A project with A*Star to increase efficiency and effectiveness, reduce time and effort in inventory management and enable hospitals to provide higher and safer quality of care for patients. March 1. Day Surgery Ward RNs are authorised
to dispense “take home medications”. This post-operative one-stop service frees patients and families from queues to collect medications at the Pharmacy. October. Research. Alcohol handrubbing and chlorhexidine handwashing protocols for routine hospital practice: A randomised clinical trial of protocol efficacy and time effectiveness. A collaborative project with Infection Control physicians. Outcome: Alcohol handrubbing covering all hand surfaces is the most time-effective protocol for routine patient care activities in busy general wards. November. Electronic Meals Ordering System (EMOS) was implemented. The online meal ordering system eliminated the onerous manual system. The kitchen receives the orders directly and meal amendments becomes a fuss-free process. 2007 to 2009. Healthcare Quality Improvement Fund (HQIF). Teamwork and Communication via SBAR/Appropriate Assertion and Integrated Resuscitation Drill – a prelude to rapid response. Led by Dr Tan Hui Ling and in collaboration with Nursing. Post-operative Vital Signs Monitoring in Surgical Wards. The results of the study explored the possibility of reducing existing post-operative vital signs monitoring during the initial first 24 hours. Low height beds introduced in Geriatric settings in Wards 7C and 7D and have reduced the number of falls. The beds were adopted by other Geriatric wards and Rehabilitation Centre.
in Medical Intensive Care Unit with Active Surveillance Cultures and Chlorhexidine Wipes”. Study outcome: Active surveillance and decolonisation with chlorhexidine wipes resulted in a significant reduction in MRSA infection rates in MICU. Second runner up in poster competition at the 7th Annual Healthcare Quality Improvement Conference October 2010. December. SmartSense Vital Signs monitoring system. Led by Mr Yong Keng Kwang, it uses radio frequency identification (RFID) to monitor body temperatures and track patients’ locations. December. First patient seen at home by Post Acute Care at Home (PACH) nurses. Quality Improvement: To minimise pressure ulcer formation related to aplication of BiPAP mask and straps. Nurses implemented strict two-hourly release of bipap masks as tolerated, strict application of mapilex dressings amd application of cotton bandage to release pressure of straps on the ears. This saw a decrease in 40% of BiPAP related pressure ulcer formatiion in 6 montsh. In 2010, a follow up on this project was the procurement of total full face BiPAP masks. Evidence-based Practice: Translating Evidence Into Oral Care Practices: Oral Hygiene for Functionally Dependent and Cognitively Impaired Patients. Outcome: Ensured that the oral hygiene practices are in alignment with MOH CPG and based on the latest available evidence.
2008
Research: Nurses’ Nasogastric tube feeding practices: A Survey. This led to reinforcing correct practices in NGT feeding.
April. Buffer Stepdown Unit (BSU) Ward 79 for non-acute patients waiting for nursing homes or shelter home placement was set up. This was followed by Wards 77 and 78.
Intellivue Clinical Information Portfolio (ICIP) implemented in the ICUs/HDs provided shared views of care plans among 2008 last fact healthcare professionals.
November 2008 to September 2009. Research. HQIF. “Reduction of Methicillin Resistant Staphylococcus Aureus Infections
2009 “Let’s Walk” Programme implemented in 115
Rehabilitation ward. This daily walking training programme led by nurses helps to enhance the patients’ mobility. The project was reported in The New Paper and Lianhe Wanbao on August 2012 and September 2012 respectively.
v(WoF) project.
the PACH nurse.
CLMMS, eIMR, EMARS, Omnicell ADC were implemented to reduce medication readings and prescription errors, minimise interuption during medication servings.
December. Implementation of X-ray order on doctors’ behalf to confirm NGT placement. It won a Silver placing for Singapore Nursing Award at the 2012 Singapore Healthcare Biomedical Congress.
August. First Community Health screening of elders for Falls by Community Health Engagement Programme (CHEP) nurses.
January. First flu vaccination given by a PACH nurse in a patient’s home.
September. First batch of nursing home residents screening by Project CARE at St Theresa Home.
March. For the first time in the history of a nursing home, a Project CARE nurse nursed a resident in the nursing home on a syringe pump for end-of-life symptom control.
September. First in-house comprehensive nursing leadership programme “Nurse Leader Management Preparation Programme” to prepare nurses as leaders.
April. First collaboration between Home Nursing Foundation and TTSH on Integrated Home Care Programme.
October. First visit to a participant's home by a CHEP nurse to review the medication management in CHEP Stepping Out Programme. Ward 7A collaborated with Food & Beverages department in a “6S” project: “Auto Top Up for Rations”. It was eventually implemented across the hospital. 7C/7D CPIP project “To improve accessibility to acute beds in the ACE unit” was awarded the most outstanding project in TTSH Quality Day. It was also the finalist in the MOH 9th Health Quality Improvement Poster Competition. June 2009 to March 2011. HQIF. Reducing inappropriate catheter-associated urinary tract infections through use of UTI bundles in identifying patient populations. Five-point catheter care and algorithm for nurse-led catheter removal was implemented. Quality Improvement: “Patma Stopper” was implemented to achieve zero falls from commode in the Rehabilitation ward. The innovation was adopted across inpatients. Research. Comparing the effectiveness of Glycerine Magnesium Sulphate paste, Hirudoid Cream and Warm compress in Treatment of Post Infusion Phlebitis. It led to a hospital-wide change practice in monitoring the post-cannula site for further complications without active topical treatment with Glycerine Magnesium Sulphate (was eventually removed from the market) or Hirudoid.
2010 First nurse-led LEAN Ward of the Future
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May 1. Enrolled Nurses from STAR team were empowered to perform cannulation and venepuncture after office hours. July 2010 to February 2011. CPIP: To measure post void residual urine within one hour of voiding for incontinent patient. This was followed by the implementation of enuresis alarms across inpatient wards in July 2011. August. Use of simulation in nursing and interprofessional training commenced. Quality Improvement: Outstanding award for Flu Vaccination Project that increased uptake of annual Influenza Vaccintation among HIV patients from 27% to 80%. TTSH Best Quality Improvement Project Competition held in conjunction with TTSH Quality Day 2010. External Cooling Methods for Treatment of Fever in Adults: a Systematic Review. Published in Joanna Briggs Institute. Quality Improvement: Pressure Ulcer Care Bundle Launch. Research: Use of Barley Drink on Urinary Tract Infection prevention.
2011 January. First nurse-led Advance Care Planning (ACP) done in a nursing home. June. Decision Algorithm for Nasogastric Tube (NGT) Placement checking - A pilot. It won a Bronze placing for Singapore Nursing Award at the 2011 Singapore Healthcare Biomedical Congress. December. First nurse-led Advance Care Planning (ACP) in the home of the patient by
“Comprehensive Vaccination Program” (CVP) a Healthcare Quality Improvement Fund (HQIF) project based on the 2010 project. It seeks to provide comprehensive nurse-led vaccination services such as vaccination against Influenza, Pneumococcal, Hepatitis A and B infections for eligible HIV Patients. Research: Predicting the Terminally Ill: Validating the prognostic tool. Research: Postoperative pain following hospital discharge after knee replacement surgery: A patient survey. The study aims to determine patients’ pain experience and potential barriers to effective pain relief after discharge. The results suggested that more could be done by the hospital to ensure optimal use of pain medication and nonpharmacological strategies to improve patients’ quality of life and satisfaction.
2012 January. E-Wound for digital documentation of wounds was implemented. January. Peritoneal Dialysis (PD) nurses were trained in scrub and circulating roles to assist Renal clinicians in the operating theatre. February. Medical Device Interface (MDI) was implemented to streamline vital signs documentation process and to reduce humanassociated entry and transcription errors. February. A study trip to Bangkok Siriraj Hospital by 24 nurses. February. Works start on the first two of 24 subsidised wards to be renovated under the “Wards of the Future” Project. In addition to creating better working and healing environment in the wards, the project aims to better patients’ experience by increasing nurse presence at the bedside and improving nursing processes through infrastructural changes. April. Improved staffing norms for better nurse: patient ratio. May. Nursing orders and treatments ordered by nurses on CCOE/Aurora.
June. Five-day work week started for better work life balance for nurses on shift. August. Shared Governance was formed, seeing our first nursing election to form the Governance Councils. August. Glucosemeter with IT connectivity was implemented to allow better user management and traceability is linked to data management system which can populate into electronic charts. October. TTSH’s first Nursing Musical “So You Want To Be A Nurse” raised $34,000 for TTSH Community Charity Fund. November. Certified as approved training center to conduct ITE skills certificate in healthcare (INPATIENT) by ITE. December. Research: Pre-Operative Fasting Experience among Elective patients. Ward 10B saw the first Enrolled Nurses trained in Paroxysmal Atrial Fibrillation (PAF) monitoring. Research: Validation of decision algorithm to verify nasogastric tube (NGT) placement. Factors such as pH trend and the use of proton-pump inhibitors are part of NGT placement assessment. Acute exacerbation of asthma is a common condition managed at Emergency Departments (EDs) globally. Patients seen at the ED with poor asthma control were directed to the new Fast-Tracked-Clinic (FTC) to stabilize and optimize asthma control. A CPIP conducted later further reduced default rate appointments to FTC from the current 50% to less than 10%.
2013 January. Inaugural collaboration with Temasek Foundation on Occupation Health and Safety Training for Thai Nurse Leaders. March. Enrolled Nurses trained as BCLS and AED Instructors. March. Pre-professional Education Office set up to support clinical education for preregistration healthcare providers which include nursing trainees. April. E-Wound Computer Decision Support System (CDSS). First Hospital in Asia to Introduce e-Wound CDSS. The Intelligent Platform improves nurses’ wound care management, reducing wound deterioration and
complications for patients. A groundbreaking initiative by Nursing Service and Wound Care Nurse Clinicians, the new system empowers nurses with the knowledge to handle more complex wounds and standardise their assessment and management of wound care practices, providing a new paradigm of wound management practice in Asia.
October 2011 Serene Tan Leong Hwee, Neurosurgery
May. 116 staff resources from Jurong Health Services deployed to support our surge situation due to dengue, MERS-CoV and H7N9.
March 2012 Audrey Wong Yoke Poh, Psychiatry
July. TTSH’s first nursing commemorative book “Practising the Profession: The Choice Intuition for Great Nursing” was published and given to TTSH nurses to commemorate Nurses’ Day. An Initiative to detect deterioration in condition: Early Warning Sign (Aggregated Warning Score, AWAS). Research: Review of routine-replacement of peripheral intravenous cannula every 48-72 hours: Are nurses optimising the cannula use?
Directors of Nursing, TTSH 1970-1975 1975-1977 1977-1979 1979-1984 1984-1987 1987-1990 1990-1995 1995-1996 1996-1997 1997-1998 1998-2001 2001-2011 2011-present
Lousie Chew Tan Yew Hiang Seah Geok Cheng Loo Pai Cheng Yeo Soo Har Kang Gek Inn Ho Shen Hiong Sim Teck Meh Dianne Campbell Anne Irani Rosie Pereira Kwek Puay Ee Yong Keng Kwang
First specialties with Advanced Practice Nurses October 2006 Jamie Lim Chuen, Cardiology February 2008 Kamilah bte Shekh Jabin, Neurology April 2010 Jasmine Kang, Geriatric June 2010 Quek Poh Seo, Respiratory Care
October 2011 Tan Soak Buay, Orthopaedics October 2011 Jiang Yan, Coronary Care Unit November 2011 Jennifer Wong Chee Mei, Heart Failure
April 2013 Choo Li Ming Elaine, Renal
First specialties with Nurse Clinicians 1981 Lily Lang, Infection Control 1993 Lai Yee Khim, Diabetes Care 1993 Ann Yin, Stroke Nurse 1994 Mary Choo Geok Kim, Dementia Care 1994 Pong Lee Yeng, Rheumatology, Allergy and Immuniology 1995 Chen Mui Lee, Rehabilitation Centre 1995 Tay Ai Choo, Stoma & Wound care 1995 Eliada Yap, Palliative Care 1996 Jamilah Che’Mat, Acute Pain service 1996 Chia Hwee Huang, Continence/Urology 1996 Tang Chwee Ying, Clinical Immunology/ Allergy 1998 Patmavathy Chellaiyya, Breast care 1998 Lathy Prabhakaran, Respiratory care 1999 Hee Yik Lan Melina, Cardiac Rehabilitation 1999 Lim Beng Hee, Fall Care 1999 Jeff Thayalamurugan Naidu, Infectious Disease 2000 Rohana Bashri, Geriatric Assessment 2000 Jamilah Che’Mat, Spine and Chronic Pain Service 2008 Lee Kong leng Christopher, Orthopaedics, Casting and Traction 2009 Wong Toh Luan, Oncology 2012 Sun Tao, Home Ventiliation and Respiratory Support Services
September 2010 Ang Ching Ching, Palliative Care 117
Acknowledgements We would like to extend our heartfelt appreciation to the following people and organisations for their generous support to make this book a success:
3Caps Consulting Anonymous donor Context Architects Pte Ltd Dr Lim Suet Wun Globalwide International Pte Ltd Hospimek Pte Ltd
Sponsors
ISS Facility Services Private limited King's Dental Surgery (Kovan) Pte Ltd Kwek Puay Ee Laerdal Singapore Pte Ltd Lee Leng Noey MJ2L Fund Poh Bee Fong Prema and friends Tan Tit Chai / Susiwaty Luhur Total Jet Services Pte Ltd TTSH Department of Rehabilitation Medicine TTSH Emergency Department UE Managed Solutions Singapore Yeqi Pte Ltd
118
Nursing editorial team
The nursing editorial team worked hard for the birth of this long awaited "baby"!
01 Deputy Director of Nursing Lee Leng Noey
09 Senior Staff Nurse Candy Koh
02 Senior Staff Nurse James Ang Wei Kiat
10 Senior Staff Nurse Mohd Hiedayyat
03 Nurse Clinician Prema Harrison
11 Staff Nurse Ginny Lim Jing Mei
04 Senior Nurse Manager Rozana Arshad
12 Nurse Researcher Isabel Ng
05 Nurse Manager Tan Tit Chai
13 Nurse Clinician Quek Hwee Chen
06 Staff Nurse Samuel Ho
14 Nurse Clinician Josephine Anthony
07 Senior Staff Nurse Benita Bangar
15 Staff Nurse Jeremy Teo
08 Senior Staff Nurse Joey Yeo Jia Yang 119
Practising the Profession: The Choice Institution for Great Nursing Published by
Focus Publishing team
Tan Tock Seng Hospital
Publishing Consultant: Seow Choke Meng Editor: Sng Shu Min
Produced by
Writer: Sharon Sim
Focus Publishing Limited
Photographers: Lee Tiah Khee, Seyu Tzyy Wei, Jonathan Yeap
(A subsidiary of Singapore Press Holdings)
Creative Director: Kenz Chew Designer: Li Mandy
Printer
Project Managers: Lam Zhi Xin, Lee Whei Ting
KHL Printing Co. Pte Ltd TTSH in-house photographer Henry Lim Seng Tiong
Special thanks to Singapore Red Cross for contributing photos to the publication.
ISBN
978-981-07-6987-1
First published on July 2013
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the Publisher.