18 minute read
LIVE WELL Taking Urban Farming to Greater Heights
TAKING URBAN FARMING TO GREATER HEIGHTS
KTPH and YCH are well known for their lush landscaping — not only on their grounds, but on rooftops, too. Beyond growing pretty plants, a team of gardening volunteers is setting its sights on turning the rooftop plots into an even more productive farm.
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The gardening volunteers (in blue) together with Yishun Health CEO Prof Chua Hong Choon and COO Ms Yen Tan during a visit to the rooftop farm
Volunteers have long been the lifeblood of Yishun Health’s rooftop farms, which grow a wide variety of fruits and vegetables, including some jumbo-sized, award-winning pumpkins and gourds. Working on a roster, they spend several hours every week to plant, weed and tend to the vegetable beds and fruit trees.
According to Simon Chan and Rosalind Tan, members of Yishun Health’s landscaping team, there have been ambitions to ramp up the output of the gardens for a while now. And since 2019, a plucky group of eight volunteers has been taking on that challenge, moving the small vegetable farming operation into the fast lane to better prepare for the future. Venturing into hydroponics, they began to research, experiment and build their own vertical urban farming system from scratch.
FROM HOBBY GARDENERS TO HYDROPONICS FARMERS
Among them are ex-Singapore Airlines colleagues, M Radhakrishnan (Krish), 69; A Jaiakumar (Jaia), 70; and Gomez Steven John (Steven), 52.
While the three of them have had a lifelong passion for gardening and plants, it has been an uphill task to learn about this new form of farming. From building the tiered system
Volunteer Krish explaining how the hydroponics system works
and finding the best configuration to installing the piping system and calibrating the amount of nutrients, water and sunlight, the team put in many hours of experimentation. “It has been difficult,” admits Krish. “But Steven and Jaia worked for many hours to perfect the system.”
At the start, the team would buy seedlings from external vendors, which would be ‘planted’ into their hydroponics system, where they would come to maturity. However, this was an expensive route. At about $0.90 per seedling, a crop of 144 plantings used to cost them almost $130. To cut costs, they learnt how to germinate seeds, then transplanted the seedlings into their hydroponics system. The challenge was in ensuring a conducive growing environment for the small and fragile young sprouts. “It was not easy because, on a rooftop garden, temperatures tend to fluctuate and be quite extreme,” explains Krish.
After about six months of trial and error with different growing mediums and seeds, they succeeded in transplanting their seedlings into the system and harvested their first crop of chye sim and kai lan in January 2021. This milestone was no mean feat. By germinating their own crop from seeds, they enjoyed significant savings — one pack of seeds costs just $3, and is enough to grow multiple harvests. Their vegetables have also passed the test, literally. “We sent samples of our first crop to the hospital lab for testing to ensure they are safe and meet nutritional standards,” Krish shares with pride.
Seeing through a harvest brings them a great sense of achievement. For Christopher A Nathan (Chris), 71, who joined the project in October 2020, it is an impressive feat to witness, and he has enjoyed participating in two harvests so far. An old school friend of Jaia and Krish, he has enjoyed learning about this new form of farming. “This is very different from the kind of gardening I grew up with,” he describes, recalling his youth in Malaysia, where he picked up tips from his avid-gardener father. “I am so fascinated with what has been done at KTPH — from soilbased gardens and aquaponics to the hydroponics system.”
Since then, despite disruptions caused by COVID-19 restrictions, the team has completed five harvesting cycles and collected a total of about 30kg of vegetables. In fact, they have used their time well, taking up courses in the interim and making plans for an even bigger comeback. Tapping into their SkillsFuture credits, Krish, Jaia and Steven have taken courses on soil management, pest control, and urban farming hydroponics. “The courses have helped us level up,” assures Jaia.
EMBRACING TECHNOLOGY TO SCALE UP
Their hands-on experience coupled with on-the-ground work have seen
them develop an effective system. Apart from chye sim and kai lan, they have also grown nai bai and xiao bai cai; Bayam spinach is next in line. Each batch of vegetables now takes about a month to grow from seed to harvest. “The next goal is to improve our setup and increase our yield,” Jaia says.
And this is where their newest and youngest member comes in. Twentyyear-old M Devnavin (Dev), a family friend of Krish, has brought young blood, new ideas and technical knowhow to the team’s endeavours. Since joining in November 2020, Dev has taken the initiative to explore ways to modernise and automate the hydroponics system. By integrating more technology into the project, he hopes to raise the output and quality of the crop, as well as reduce the amount of manpower needed to monitor the plants. “I am looking at things like taking the temperature of the water, checking water levels, and ensuring nutrients are at the right concentration levels,” he explains.
In fact, Dev even has plans to rope in university mates who are pursuing studies in engineering and programming so that they can explore ways to improve operations. Installing sensors and integrating them with mobile apps will go a long way to help increase productivity, he points out. “The goal is to reduce the manpower needed for monitoring so that we can focus on other areas, such as harvesting and germination.” It also lays the foundation for future automation, such as the automatic topping up of nutrients or water, especially when scaling up. There is so much potential, Dev states. “Vertical farming provides higher yield per unit area, and hydroponic farming reduces the need for pesticides, making for more sustainable and healthy operations.”
Together, this multi-generational team effort has taken a community gardening project into something more. Hours of labour under the hot sun have seeded the ground for turning a rooftop garden into a farm-to-table operation. “When we first started tinkering with the idea in 2019, we were all greenhorns,” recalls Simon. “But our volunteers have done very well in developing a workable hydroponics system.” Says Rosalind, “It is my hope that we can expand our operations on the rooftop so we can intensify the farm and increase output. The dream is to grow enough to supplement our kitchens and share the fruits of our labour with all our patients.”
Water, nutrient pH levels and temperature are regularly checked and adjusted to optimise growth
A CARE CULTURE OF DIGNITY & PERSONHOOD
A/Prof Philip Yap (in apron, gloves and purple scrubs) leading a team to assist a geriatric patient
FRAILTY, DIGNIFIED CARE & LEAVING WELL
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Aligning with our efforts to be an age-friendly hospital, Yishun Health staff are being trained in a methodology to foster greater connectedness between healthcare providers and patients. This relationship-based approach improves the patient experience, harnesses innate potential in patients, raises care outcomes, and instils more dignity and compassion into care delivery — particularly for vulnerable and dependent persons.
At 80-over-years old, diagnosed with dementia, and having experienced repeated falls, Aunty Doreen was too afraid to even stand on her own. This fear was causing her to decline physically during her stay at KTPH, as she was mostly confined to her wheelchair and bed. Both her family and the staff saw little hope of her walking again. However, gentle persuasion, active listening, masterly techniques, and positive reinforcement soon helped her to overcome her fears. To the delight of her care team — and Aunty Doreen herself — she gained the confidence to take a walk.
For Jessie Tan, Senior Nurse Clinician, experiencing this first-hand was mindset-changing. As a nurse with 30 years of experience — 25 of them in geriatrics — it was greatly validating for her to see how a shift in communication and techniques could make such a big difference in handling patients who were previously considered ‘challenging’, having ‘limited rehabilitation potential’, and ‘beyond hope’. “As an Advanced Practice Nurse in Geriatric Medicine, I believe that the care of elderly persons — particularly persons with dementia — needed to be changed,” she shares. “I’m truly happy to find a solution to change the way we care for these patients!”
Aunty Doreen was not the only patient who responded well to a shift in care and communication. Using a special care methodology called Humanitude, one patient with advanced dementia — who would scream intermittently due to agitation and confusion — was soothed from distress into sleep and calmness.
According to Mdm Yiap Pok Ling, Deputy Director, Nursing, it was first introduced to a small number of clinicians, nurses and Yishun Health leaders. Witnessing the profound impact on patient care during a pilot training session in 2019, the Yishun Health leadership team mooted the idea, and began to progressively roll out training of this technique to staff. Since the 2019 pilot, two more runs have taken place, the last of which took place in November 2021. In all, some 200 staff have taken part; among them were 16 doctors, 154 nurses, and 34 physiotherapists, occupational therapists and speech therapists. The goal is to train 500 staff, with greater participation from doctors and allied health professionals.
IMPROVING OUTCOMES FOR COGNITIVELY FRAIL PATIENTS
A/Prof Philip Yap, Senior Consultant, Geriatric Medicine, who was also a participant in the pilot run, sees this methodology as an important way to improve care for vulnerable and
dependent older patients in an acute setting.
He points out that a significant proportion of older patients in hospitals are frail, both physically and cognitively. Every day, there are approximately 300 patients in KTPH who suffer from dementia and/or delirium, and they make up 40–50% of those aged 78 years or older.
“These patients fit poorly into the hospital environment, are prone to hospitalisation-associated disability, and leave the hospital with marked functional decline, and in poorer physical, cognitive, psychological and functional states than at admission,” he shares. While the acute-care setting is effective in treating a patient for a problem such as pneumonia or a urinary infection, patients may deteriorate in other ways during a prolonged stay in hospital. “They tend to cooperate poorly, and spiral downwards very quickly in terms of overall wellbeing,” A/Prof Yap points out.
Compared with other patients who are independent, mobile and able to carry out activities of daily living, this group of patients — due to their physical and/or cognitive deficits — may not even understand the reasons for them being in the hospital. They are also unable to communicate their needs well.
Say, for instance, a patient with dementia needs to use the toilet, but cannot understand why he is not allowed to get out of bed on his own. Instead, he has to use a diaper, which he has not done so since he was a child. Or take someone who wishes to get up for a stretch or a walk, but has to be confined to the bed, where he becomes increasingly bored, frustrated and even agitated.
“Naturally, if patients do not understand the reasons for care, they will begin to regard the caregivers and environment as hostile, especially if their freedom is thwarted,” elaborates Dr Rachel Cheong, Consultant, Geriatric Medicine. “They will become upset, and it can result in very trying situations both for them and their care team.” This may lead to patients acting up and being perceived as ‘difficult’.
Eventually, physical restraints and other restrictions may have to be applied, thus exacerbating the problem. “Once you restrain people, it takes away trust, leads to depersonalisation, and engenders animosity. And this compromises our care delivery,” she adds.
And as more cognitively frail patients with high needs are being admitted into the wards, it becomes more crucial that healthcare providers look for ways to care better for this group of vulnerable patients.
Mdm Yiap Pok Ling Deputy Director, Nursing, KTPH
SHIFTING FROM PROCESS ORIENTATION TO PERSONAL CONNECTIONS
This is where Humanitude training comes in. It seeks to shift the caredelivery paradigm from one that is task-oriented to building care that is relationship-based and enabling. It emphasises sensory communication, where caregivers make use of gaze, speech, touch and verticality (an upright position) when interacting with patients. The idea is that these four relational behaviours are natural to us, and is what we learn from birth in the way we socialise as we build human relationships.
Dr Tay Poh Peng, Associate Consultant, Geriatric Medicine, explains, “These elements are often missing in the lives of older people with frailty and dementia, as they are usually left to languish in beds or chairs with little human contact. But through employing these techniques, we can enhance care for patients whom many see as lost or beyond restorative care. Humanitude gives hope!”
Importantly, this approach dovetails with Yishun Health’s Cognition 6th Vital Sign initiative, which is aimed at improving care for vulnerable seniors in the hospital.
FRAILTY, DIGNIFIED CARE & LEAVING WELL
PART 2 OF 3
Staff at a Humanitude training session (above), and putting into practice what they have learnt during a hands-on session in the ward (left)
It comprises care standards and a care protocol for frail older patients with cognitive impairment of dementia and/or delirium. At its core, it seeks to nurture a work culture that shifts priorities from being taskfocused to being more person-based.
“We adapted the Institute for Healthcare Improvement’s (IHI) four criteria to deploy an age-friendly health system suited to the needs of our population. This has informed the 6 Vitals of Care,” says A/Prof Yap.
This has meant extending IHI’s 4 Ms — What Matters, Medication, Mentation, and Mobility — to include addressing Malnutrition (including dehydration), and Multi-morbidity (co-existing chronic conditions).
Based on these standards, the team developed a care assessment tool, encapsulated in the acronym ‘KNOW our VIPS NEEDS BEST’: l KNOW: Know patients as persons, and learn about their biographies, likes and dislikes, values and love language. l VIPS: Each patient is Valued and cared for as a unique Individual. Care must adopt the Perspective of the patient, and Social psychology allows us to tailor care to the needs of the patient. l NEEDS: Operationalise personcentred care in more concrete terms. It includes making the hospital experience close to what is Normal in the daily routine of the patient; Enabling and Empowering patient with greater agency and Dignity despite being hospitalised; and attending to older patients at a Slower pace. l BEST: Sets out the key medical and nursing needs of patients that warrant close attention to prevent and manage confusion.
TIME WORTH TAKING
According to A/Prof Yap, Humanitude “gives us the tools” to effectively achieve the 6 Vitals of Care. “And it can be extended to all areas of care, even for palliative care, where the goal is to secure good quality of life with good quality of care,” he adds.
The main challenge, however, is putting it into practice.
Mdm Yiap notes that the traditional approach of nursing care in the acute setting has always been very processdriven. “We work based on routines and sequences,” she says. But when it comes to patients with delirium or dementia, flexibility and patience are needed. “We have to slow down to
THE HUMANITUDE MODEL OF CARE
Humanitude is a care methodology developed by Yves Gineste and Rosete Marescotti in 1979 to care for vulnerable dependent persons, including those with dementia. It uses a multi-modal communication approach to enhance the connection and care between caregivers and patients.
Among the key techniques is to take time to know patients, their routines, and what is known as ‘relational kin’ — something about a person that helps to establish rapport quickly. It also uses gentle persuasion, elaboration, appropriate touch, and other tools to improve receptivity to care.
Pre-preliminaries KEY APPROACHES Preliminaries
Knock Await response & enter patient’s space peacefully Face-to-face interaction
Greet by preferred name
SENSORY CIRCLE
Promoting positive connection through relational pillars
Gaze
• Horizontal • Axial • Sustained • Near
Touch
• Professional • Progressive • Permanent • Sweeping
Speech
• Frequent • Melodic • Soft/Low • Positive Introduce yourself and why you are here
Verticality
• At least 20 mins/day
connect and communicate better with more elaboration, and adapt to place the needs of the patient over tasks.”
For example, she shares that when giving sponge baths, nurses are taught to start with the face because the sequence is typically to start with the cleanest part of the body before moving on to the rest of the body. “But the face is a very personal part of the body,” she points out. “It can be seen as intrusive to start there.” Under the new methodology, caregivers are taught to begin with the hands, arms and legs instead as a way to help patients get used to the idea of a sponge bath.
Another example is making the effort to explain the care process and giving patients time to absorb the action. During a training session in September 2021, participants encountered a patient who refused care. He became confused and combative. By taking a little time to understand the source of his reactions, they found that he needed more time to process what was happening. What worked was the auto-feedback technique, which involved announcing and describing each step and allowing him time to process it. By explaining every step, it gave him more reassurance and security about what was going to happen. This was complemented by positive reinforcement so that he felt good about the care he was receiving. This reduced his anxiety, as he was more aware of what the next step in care would be and how it benefited him. In the end, he was mollified into friendliness with his nursing team, even offering them some of his breakfast.
But while it may take more time,
A/Prof Philip Yap Senior Consultant, Geriatric Medicine, KTPH
FRAILTY, DIGNIFIED CARE & LEAVING WELL
PART 2 OF 3
especially at the outset, Mdm Yiap and A/Prof Yap both believe it is time worth taking. “With high patient loads and time pressures, it can be challenging to take the time to know the patient well, but it can lead to better outcomes, and patients don’t resist,” assures Mdm Yiap. “When you undergo the practical training sessions, it is very convincing. You really start to see the impact of the approaches.” A/Prof Yap emphasises the crucial need for a mindset change. He is hoping to grow greater awareness and intensify training so that a more conducive environment can be developed for this approach. “While lack of time is often cited as a reason for not being able to commit to relationship-centred care, in actuality, this approach is able to lower the incidence of challenging behaviours, build better rapport, and increase cooperation, which ultimately
REINVIGORATING CARE
Giang Thuy Anh, Occupational Therapist, Rehabilitation Services, and her research team, under the mentorship of A/Prof Philip Yap, are conducting a study to evaluate the effectiveness of Humanitude on patients and healthcare staff.
In her research, she has found that the approach not only improved patient outcomes in terms of improved function, engagement and decreased agitation, it also boosted the job satisfaction of staff. They reported decreased burnout, increased empathy, and improved attitude towards people with dementia. saves time on reactive interventions,” he advises. He emphasises that research has repeatedly shown that Humanitude actually saves time compared to conventional care because patients do not fight or resist attempts to provide care.
Just as importantly, this approach to care also improves staff satisfaction and reduces turnover. “With its focus on people and relationships, it sparks the desire to care beyond merely completing tasks, and rekindles the joy and meaning of working as a healthcare professional,” adds A/Prof Yap. He hopes that, with the roll-out to more staff, KTPH can help set new standards of effective and agefriendly hospital care for older people in Singapore. “By recognising patients’ individual needs and innate potential, independence is enabled and dignity maintained, care is improved and the patient’s experience is elevated.”
The training also reinforced participants’ passion for the work. “Humanitude has been very empowering and spiritually uplifting. It’s the kind of care I would want for myself,” states Ummu Kharr Unais, Senior Staff Nurse, Ward D48. For Tha Zin Aung, Nurse Educator, Nursing Administration, it is the recognition of dignity and personhood in care. She says, “The four pillars of Humanitude are essential; all human beings — especially the vulnerable and sick — deserve to receive them.”
The team has witnessed very encouraging patient transformations since using Humanitude care approaches. A disengaged patient who had to be bed-bound with restraints started sitting up and eventually walked with assistance; she also started expressing concern for another patient, even holding that patient’s hand to provide comfort. Another patient in a similar state was going to be placed in a nursing home, but turned around and came off his nasogastric tube, ambulating with support, and was eventually discharged!
