The invited speaker for this webinar was Ms Hanijah Abdul Hamid, Deputy Director of Nursing Education & Research as well as Staff & Talent Development at Changi General Hospital. She is also the Deputy Chair for Singhealth College of Clinical Nursing (CCN) and the Deputy Director Group Nursing (Education). During the first part of the webinar, Ms Hanijah shared with us the impact Covid-19 had on our hospitals and healthcare professionals, as well as the challenges faced with regard to clinical attachments.
The webinar also featured two other guest speakers, Mr Eng Kok Wee and Ms Shahira Abdul Qadir. Mr Eng is a Staff Nurse and ALCNS NUS alumnus, while Ms Shahira is a Senior Clinical Instructor and Student Engager. During the webinar, Mr Eng shared with us his experience of graduating amidst the pandemic, while Ms Shahira enlightened us on the challenges in the internal nursing structure as well as the measures put in place to support students during the pandemic.
During this webinar, our speakers also addressed many of our questions. The following are the questions that our speakers have answered with their respective responses!
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Ms Hanijah Abdul Hamid
Question 1: How do you keep your interest in nursing?
Answer: Because I chose to be a nurse - I was not asked to become one. Starting from the time when I chose to be a nurse, I have travelled a long journey in nursing. I had my challenges and I guess that’s the reason why I put up the quote there as well (“She was unstoppable. Not because she did not have failures or doubts, but because she continued on despite them.” - Beau Taplin). It’s not that I did not have any challenges, but because I just continued to do what I wanted to do because this was my passion.
I will summarise my interest in nursing with just one story that I have to share with all of you. During my junior days when I was not a very competent nurse then, I had an elderly patient who was in my ward. And what happens is that during Chinese New Year, many of our patients would go home the day before Chinese New Year for reunion dinner. What typically happens is that they go on a home leave. All the patients who have been allowed home leave would still have cannulas in them, but we would close it up with a dressing and tell the patient and their family members what to do and we then proceed to send our patients home. And for those who can’t (go home), we would spend some time with them. Sometimes, it depends on your luck. If you work in a surgical or medical ward, the population differs. We will typically have three-quarters of empty beds, so we only have one-quarter of patients and we would love to work during the eve of Chinese New Year because it would be so nice to work compared to a typical busy day that we have.
What happened was that I had an elderly patient. She kept coming to us to ask if her family was coming to fetch her home because it was the day for reunion dinner. She kept coming to check with us ever since two days before Chinese New Year eve, and I was actually the nurse in charge of her. I kept calling the family and telling them that she had been asking to return home during the day and asked if they were going to come so that I could ask the doctor to sign the documents. There wasn’t a very affirmative answer so it was hard for me. The patient came to me on the day itself (Chinese New Year eve) and asked me if her son was coming to fetch her and I said to her, “You go and wait, Aunty. Maybe he might come later.” Then, my senior told me that I shouldn’t have said that because the patient would look forward to her son coming, and she would be very upset if her son did not come. So, I went back to the patient and told her that I would try to call her son one more time to check whether her son was going to come. She was kind of sad but she said okay and just kept quiet. She didn’t say anything much. I went to make the call and we waited and waited. It was around 7 o’clock in the evening and nobody came. So what I did was that I bought my dinner but I went to her table because I felt very uncomfortable, and I realised that she did not take her dinner. I asked her if she would like me to warm up her dinner for her and she just kept quiet. I went to warm up her dinner and I just sat there. At that time, it was quite quiet so we could actually spend some time with the patients. So I sat next to her and had my dinner with her. She didn’t eat so I scooped the food up and tried to feed her. As she was opening up her mouth to eat her food, there were tears that were trickling down her eyes. I felt sorry for her so I told her not to cry and passed her a tissue. And then I said “Aunty, you keep me company okay? Because I also don’t have a reunion dinner so let’s eat together.” So we had that meal.
After about a week, she recovered and it was time for her to go home. And when she was about to go home that day, I was somewhere busy and she refused to leave the ward until she met me. So my colleagues came to look for me and told me about it, and I went to her after finishing up what I had been doing. I said “bye-bye” to her and told her that I was very happy that she was going home. And what she did was that she sneakily took out an angpao and put it into my uniform pocket. She did it in front of everyone, including my ward Sister. Then I took the angpao out and opened it up, there was $10 inside. I said thank you to her but told her that I could not accept it and returned the money to her. Then the aunty took the money back, just to put the money back into my pocket and gave me a long lecture on why I cannot return the angpao back to her. I looked at my preceptor so she came and said, “Okay, Hanijah you just take the money and we will buy some chocolates to distribute.” And before the patient left, she let go of her son’s hand and she came back to hold onto mine. She didn’t say anything and just looked at me with tears in her eyes. Then she smiled and left.
That’s one of the stories that has kept me in nursing all this while. I still remember what she looks like, what she said, and I remember how she made me feel. I’m sure many of you have experienced these sorts of things and I guess that’s why we just continued on with nursing.
Question 2: How to stay positive (such as in the event of meeting violent patients)?
Answer: Well, I had one encounter with a female renal patient where she used vulgarities. I was with a group of new nurses and I went in. We wanted to do her bed bath and she started to hurl vulgarities at me. My students were shocked because they couldn’t believe that a lady who looked so gentle had so many vulgarities coming out from her. I myself couldn’t believe it because I don’t use vulgarities. But I said, “Nevermind” and went on as usual. I told my students that it’s okay and that she was not well. At one point when we were changing her, she grabbed my pocket and pulled it really hard. And because she pulled it so hard, my pocket ripped and things from my pocket started to spill out. My students got frightened because she was pulling and tearing my uniform while I was still continuing to do what I was doing. After I was done, I stepped out, pulled open the curtains and her son was there. And the next minute, she became an “angel” and was very nice to her son. Then her son looked at me and said “I’m really really sorry. I did not know my mum could use all these vulgarities.” He too was very shocked because she was such an “angel” to him but was tough with us.
Then I brought my students out and one of my students was crying because she couldn’t bear the vulgarities that she was hearing. And she looked at me and asked me “Ms Hanijah, how can you be so numb?” Then I told her that it’s not about being numb and I took the opportunity to teach the whole group of them the physiology of patients with chronic renal disease. So I went through the whole process of what happens with them, the irregularities, and I also asked them some questions. As we were going through the renal disease process, they realised that she was not herself - she was doing it purely because of her comorbidities. The reason why she was not herself was because of her diagnosis, nothing to do with her using vulgarities at me.
Many of you are asking me how I deal with violent patients. If you go back and reflect, many of these patients are violent because they are not well, and it is usually due to the disease process itself. So if you see the patient as behaving in such a manner because of their disease process, then it’s easier to understand what they are going through and provide the care that we had promised to do so, in a competent manner. But if you are going to be upset with that physical expression of the emotions they are showing, and when we start to get emotional, then I guess that’s where you will find it hard to cope with such patients.
So I guess that’s how I have done it, and I think that’s how many of my fantastic nurses out there are doing it. We just associate it with their disease process. Sometimes, it’s not their disease, but due to psychosocial reasons. Perhaps they do not have family members or maybe they have other forms of addictions. And the addictions come because their social background creates such a situation for them. So if you focus on all those things rather than on their violence or the abuses that you are getting, then of course it is easier to provide nursing care.
I would like to reiterate that it is about nursing care. But if they go beyond that, then we need to know when to call for help. We don’t have to stand there and get abused if it is not necessary. I think you should know what to do when it is not. There have been times where we handled such situations and I think it is up to seniors like myself to step in when such situations happen to our junior nurses. I had one situation where a very young nurse was sexually abused by one patient and that patient was close to 80 years old. He was also the perfect “angel” to his family but he abused one of our junior nurses so we stepped in. We informed his family that their father was behaving in such a manner and the family was pretty upset with us. But we told them very clearly that if their father was going to behave in this manner, it would be good for them to speak to him and tell him that he is not supposed to do this to our nurse anymore. If he continued to do this, then what I would do is to make sure to get all my nurses who are 50 years old and above to handle their father. And I stood and said this in front of that patient, “Dear uncle, you are going to get nurses who are people my age to attend to you. And I am going to see how you are going to sexually abuse us.”
So typically it is how we step in and manage the situation. And that means that you need to speak up. If things are not going right, we need to go up to our leaders, tell them that things are going wrong, and seek help appropriately.
Question 3: How do you manage your fears whilst nursing a patient?
Answer: I think this question posed is referring to being a nurse in this pandemic. However, as I mentioned, it’s not about the diagnosis of patients with Covid-19, but about us pushing on during this pandemic. Other ways to manage your fears is to seek help from people that you’re comfortable speaking to and the right help will come along the way. But that doesn’t mean that we give up our profession. One patient is not worth giving up the profession for the many we can actually serve. So that’s the ideology behind it when I say that.
Question 4: How did Covid-19 affect you?
Answer: It has affected me just like it did for everyone. I think the first thing that comes to my mind is my worry that I won’t be around for my children. Whatever it is, I’m still a mother, so that is what worries me most even up till today when I go to work. Then again, what I’ve told my children (which they understand because they have seen me work all this while) is that I will not stop going to work just because there is a risk with all this happening. They did ask me if I can work from home, then I asked them “How can I work from home for this job?” *laughs* When my son asked “Was SARS this tiring?”, I told him that it was less tiring. He also asked if I had received anything back then, which I more or less recalled to be a heroes badge from the President. He then continued to ask if I would receive something else as well this time, to which I replied that it did not matter to me personally, whether or not we have a badge, medal or plaque to show; I think it’s beyond all that.
One of the significant reasons that made me stay on, is this incident with one student whose parents were hesitant for her to return home after her posting when Covid-19 first struck our shores (when it was not Dorscon Orange yet). In fact, initially, there were a couple of students who had such experiences as well. Back to the story, I had actually received a call from the student’s lecturer who informed me of the situation, and I asked the lecturer to give my number to the student first as I was on-call at that point in time. When the student called me, she was crying quite badly and it was in the evening. She was still waiting at the void deck of her house, unsure of how to go home because her parents had asked her to connect them to senior staff from the hospital. I asked her if she had her meal yet, and if she would like to come back to the hospital to have a meal together first. I also told her to pass my number to her parents, and they called me shortly after. I then assured them and gave relevant information pertaining to the situation. Thereafter, they were a little more reassured, but told me that if anything were to happen, they would hold me responsible. I said “Okay, please allow your daughter to return home. If not, I would have to either bring her back to my house, or search for a room in the hospital for her to stay.” Eventually, they consented and we moved on from it.
Of course, this was one of the few cases we saw in the initial phase. Nowadays, it does not really happen anymore, probably due to more public education being done and because things have moved on. At that juncture, I was a little affected, being a mother myself. I must say, we need more leaders who can handle things confidently and calmly as well, to address parents’ anxiety with regards to their children exposing themselves to risks in the hospitals during postings.
Question 5: How challenging was it to adapt to the hospital policies and will it continue after the pandemic?
Answer: I guess because we have always been used to circulars and policies, where we start the shift listening to things that are happening in the hospital during the roll call. A roll call happens every shift and you’ve got to listen to it. The previous shift tells you what is happening, then you go on to check the patients. The patients could also have a lot of things to take note of - one day they could be good, and the next day they could be bad. So, this sort of uncertainty sort of settled in with us as we went along in the nursing profession. Honestly, the policy changes and stuff like that doesn't affect me to a certain extent. I’d just accommodate them as they come along, while understanding the rationale behind them. And now what we need to do is to explain the rationale of what we need to do and why we need to change or follow the policies accordingly.
Perhaps for students and more junior staff, it is definitely taxing. That’s because one day you hear something and the next day you hear another, so I guess the challenge would be having to accept and accommodate what is coming forward and understand the rationale behind, while not getting upset at what one hears. Of course, we still do get upset, but it’ll help if we have a good support system around us. That is why I always encourage having good friends. I would say find your own kind, and befriend those you feel relaxed with and can talk to. You need that sort of social network around you. When unpleasant things happen, they can become your strength that would help you to move on.
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Mr Eng Kok Wee
Question 1: How is the current pandemic clinical attachments for students different from the past?
Answer: When I was a student, we were encouraged to assist the entire team. That includes attending to call bells from patients who were in other cubicles. However, students are currently expected to stay in their assigned cubicles in order to minimize any cross-infection. Personally, I see this as a great opportunity for students to practice holistic nursing, which would require a student to have an in-depth understanding of their assigned patients. Another difference would be the shift away from group teaching to individualised coaching. This would mean that clinical instructors are able to provide prompt feedback when necessary. I feel this is a good prelude to the probation period that new nurses have to go through eventually. Such one-on-one debriefing sessions also provide students with ample opportunities to seek clarification with their clinical instructors, which is good for the development of clinical proficiency and critical thinking.
Question 2: How can we prepare as a new graduate nurse for the pandemic both mentally and physically?
Answer: Current infection control practices require us to minimally don the N95 masks in in-patient clinical settings. Prolonged use of N95 masks can get very stuffy at times, but I think for the new nurses, it is important to pace yourself appropriately and to understand your limits well. You should have a strong grasp of the clinical competencies, and brush up on those that you're not too confident in. You should also spend some time navigating through the transition from being a student to being a staff nurse; do not rush through your probation. Of course, do make sure you're getting sufficient rest and staying active.
Question 3: What has helped you to keep your passion alive as a new nurse?
Answer: I feel the motivation for being a nurse varies among individuals. It is essential for new nurses to have something to ground themselves on. It can be an innate desire to help patients recover, a loved one, or it can also be a fond memory. It is most important that new nurses identify their sources of motivation and not lose sight of them, especially when things get overwhelming. For me, what helped was the support I received from my family and friends, as well as from my supervisors and colleagues. My colleagues and supervisors were very encouraging. They gave me guidance on how to improve when they noticed the areas I was weak in. They made me feel that I was not alone during this transition that I had to go through. All I needed to do was to reach out for their help.
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Ms Shahira Abdul Qadir
Question 1: What are the challenges in the internal nursing structure or how procedures are carried out?
Answer: With the current Covid-19 pandemic, great importance has to be placed on strict infection control measures to prevent or minimise the spread of the virus. With that, in the clinical setting, the movement of staff between wards has been minimised. Work processes continue, with added measures for infection control e.g. donning of the N95 mask at all times when in the clinical setting and full Personal Protective Equipment (PPE) when engaging in aerosol-generating procedures.
Question 2: What are the measures taken to support students during this pandemic?
Answer: On the first day of clinical attachment, students will have to undergo a mandatory orientation programme via Zoom. During the briefing, details on infection control measures in the hospital, expectations, and support given during attachment are shared. Students also view videos on proper hand hygiene and donning and doffing of PPE. The advisory for nursing students during Dorscon Orange was reinforced, such as compliance to safe distancing, keeping of masks during meal breaks, staggering meal times, staying in assigned cubicles and the consequences of non-compliance to these measures. In the clinical setting, just like the staff, students are also required to don the N95 mask to protect themselves. Visual prompts are also present in the clinical setting to remind students and staff to practise the 5 Moments of Hand Hygiene strictly. Compliance is being monitored by the Clinical Instructors in their wards and by periodical assessments by Infection Control Nurses and Auditors.
Our students have also been provided with Sanyrene spray and Duoderm Thin in the wards to help them manage the possible pressure injuries sustained with the prolonged use of the masks. Some of them are also allowed to resize their masks for more comfort when the previous measures mentioned do not reduce the pressure. Besides the support received in the clinical setting, our department of Nursing Education has initiated a task force to provide support for students. We are called the NUS Engagers, and I am an Engager too! The NUS Engagers provide support to students with regards to non-clinical issues and are basically open to chatting with students who require support. Engagement sessions via Zoom are planned every 2 weeks and we also have alternate week training sessions for non-clinical topics such as team bonding and communication. Previous NUS students have shared that they have benefitted from the sessions and were comforted to know that they have an avenue to seek help or clarification when required. As an Engager, I too enjoy dialogues with the students. They are open to sharing their experiences, points of view on clinical scenarios and contribute to how we can move forward efficiently and positively in any given situation.
Question 3: Could you share some challenges students face coming for clinical attachments during the pandemic?
Answer: Our nursing students have been very adaptable and resilient. They have been adhering to the rapid changes in the Covid-19 advisories with the help of their Clinical Instructors. However previously, students have also shared their challenges such as the limited eating spaces allocated for the staff during their breaks, and it has been brought to our attention. It has propelled us to expand the eating venues and seats. Pre-pandemic, students are assigned to a team during their shift, which consists of 2 cubicles consisting of about 12 to 15 patients. Hence, they had more exposure to the patients’ clinical conditions and clinical skills they could practise. With the current pandemic advisory, students are only assigned to 1 cubicle which has about 6 to 8 patients during their shift, and they are not allowed to cross cubicles for at least 4 weeks of their clinical postings. As Clinical Instructors, we were initially concerned about the reduced exposure students may have to their clinical skills, if they were to be confined to 1 cubicle. However, during the NUS Engagement sessions, students have positively shared that being in 1 cubicle enabled them to focus on a smaller number of patients, allowing them to follow through with the patients’ plan of care and progress more efficiently, thus providing holistic care for their assigned patients. Other students who had less opportunity for skills that were not so common in their cubicles shared that their Clinical Instructors had provided simulations and discussions on their skills and disease process, hence benefitting the students.
Question 4: How do you keep your passion alive and keep the students motivated?
Answer: As cliché as it sounds, students are the ones who keep us going as Clinical Instructors. Seeing them brave through the clinical attachments despite the real fear of the pandemic, their enthusiastic spirit of curiosity and motivation to learn and better themselves, keep us Clinical Instructors very driven. The Clinical Instructors and ward staff have been very open to sharing their experiences and journeys with the students, which has at many times contributed to uplifting our students’ morale. If we do encounter students who feel demotivated and demoralised, we are happy to support their growth. Our Clinical Instructors in the clinical setting have been very supportive toward the students, alongside the support from their Clinical Facilitators. This has allowed students to see the pandemic in a better light. Students have also greatly benefitted from the NUS Engagers who are just a phone call away.
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Challenges faced with regards to students’ postings:
Some challenges faced in the context of students’ clinical attachments included the disruptions happening in our healthcare institutions. The suspension of clinical attachments was also a result of Dorscon Orange.
Initially, the healthcare sector had less understanding of Covid-19 and its management. Internal changes had to be done with great urgency, as providing simulations for graduating nursing students were not as fruitful as real-life clinical interactions and experiences. The dilemma of depriving students of learning how to cope during a pandemic surfaced, should hospitals remain status quo without accommodating students to safely return for clinical attachments. It could also cause additional issues such as lack of knowledge and competency, should another pandemic arise in the future.
MOH, nurse clinicians and student leaders were involved in the planning of crisis management to allow clinical attachments to resume. The unwavering efforts eventually succeeded, by placing every possible safety measure in clinical settings. The positive mindsets, resilience and flexibility of the healthcare sector kept education excellence going.
Measures include:
Students familiarising themselves with terms such as SASH (which means swab and stay home)
To understand legal requirements for acute respiratory symptoms that patients present with
Learning about active cluster alerts and their management in the hospital
Clearly understand required guidelines such as PPE for general wards, isolation wards and Accident & Emergency areas
Transferring of suspected or confirmed Covid-19 cases
Mandatory mask wearing for patients to prevent patient-to-patient and staff-to-patient transmissions
Screening tests and indications of the different sticker labels used
Visitation policies
Additionally, different swab operations were done whenever necessary, both in dormitories and in hospitals. Online resources are also available for people to refer to and deepen their knowledge of the situation.
To wrap it up, strategy planning, clear leadership and governance, and the ability to continuously make changes to ever-changing situations are important in the healthcare setting. Other significant factors include the adaptability and clarity of different duties of healthcare professionals. Not to mention infection control, which prevents unwanted growth of clusters. The compliance of visitors to measures in place greatly helps as well.
Ms Hanijah ended the webinar with the following quote:
Being a Nurse isn’t about grades, it is about being who we are.
No book can teach you how to cry with a patient.
No class can teach you how to tell their family that their parents have died or are dying.
No professor can teach you how to find dignity in giving someone a bed bath.
A Nurse is not about the pills or charting.
It’s about being able to love people when they are at their weakest moments.
- Anonymous
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