Improving Support for Nurses
Sir, nurses are there for us in good times and bad times and I have seen first-hand the lifesaving work that nurses do for us.
There were there with me when my first child Ella was born, celebrating with us as we welcomed Ella into our lives. There were there with me when I said goodbye to my dad. I remember the nurse crying together with us as they processed the terminal discharge so we could fulfill my dad’s wish of passing on at home.
Part of me was surprised that the nurse was crying. I thought they would be used to seeing patients come and go. But the nurses truly cared for daddy. He could not have been better cared for and I am very grateful for the nurses at SGH who made his final days more comfortable.
And nurses were there with me when we welcomed my twins Katie and Poppy into the world almost exactly six years ago. Actually, tomorrow, it is their birthday. It was both a happy and extremely worrying time as Katie and Poppy were born premature and spent 10 weeks at the Neonatal ICU (NICU) and High Dependency Ward at SGH. Doctors and nurses there saved their lives.
As I shared in my Adjournment Motion in 2017, “it was surreal sitting at the NICU, doing kangaroo care with my baby, singing to her while watching the mayhem in NICU. Watching the staff handle a never-ending arrival of pre-term babies and a never-ending chorus of alarm bells as babies stop breathing. The staff members handle each situation so professionally, so meticulously and with so much tender loving care.”
I do not think we can thank nurses enough for the work they do for all of us.
Sir, in this year’s Budget Statement, Deputy Prime Minister shared, “through our collective effort, we have found our way through this pandemic.”
One group of workers who played an outsized role in helping Singapore find its way through the pandemic is our healthcare workers. I sincerely thank all of our healthcare workers – our nurses, doctors, therapists, pharmacists, TCM physicians, allied healthcare professionals and many, many more.
Today, I will focus my speech on nurses who form the largest proportion of our healthcare workforce. The reality is that, as most Singaporeans are celebrating the move to DORSCON Green, nurses would not have the chance to celebrate. Their workloads are heavy, their shifts are long and they get little time to rest. So many nurses have shared with me that nurses are resigning en masse. Attrition rates have gone up and I know the Government is aware of this problem.
I am glad that the Ministry of Health (MOH) has been reviewing the salaries and allowances of nurses and also announced a 2022 Nurse Special Payment package. These increases in pay are welcomed but do not go far enough.
Emily, a nurse, told me, “There is not enough trained people to handle the cases. Everyone is exhausted from the lack of staff, resignation rates. I have recently been attached to a few different hospitals and I see the same issue everywhere. Patient’s safety is compromised and nurses are just burnt out. We are thankful that the Government has been increasing our pay and giving us special payments. But what I really, really want is more quality time with my family. Better shifts, better working hours.”
I spoke with nurses across multiple dialogues last year and this year and collected their ideas in a public survey of 173 nurses.
Based on these consultations, I will raise three recommendations today: first, protect rest time for nurses between shifts; second, protect rest time for nurses during shifts; and third, provide more ancillary support staff for nurses.
My first recommendation is that we ensure that nurses have protected rest time between shifts. The first problem is that nurses often stay on average one to two hours after every shift to ensure that their work is complete. Working overtime is not uncommon. But for nurses on shift work with irregular hours, working overtime means that they lose precious hours of rest between shifts.
The second problem is that nurses often do a morning shift (AM) which starts at 8 am immediately after doing an afternoon shift (PM) the day before which ended at about 10 pm.
Some do this on consecutive days, so PM, AM, PM, AM and they call this the PAPA shift. They often get home at midnight, sleep for a short while before they wake up to prepare for the AM shift, which again starts at 8 am. Some nurses have shared with me that they work such punishing shifts almost every week or every other week.
One nurse shared with me, “As I am typing this message now, I am in the train, on my way back home. Will be doing morning shift tomorrow and that would mean about five hours of rest for me before my day starts again.”
Constantly working overtime and four, five hours of sleep – how can that be enough sleep? We already know insufficient rest is dangerous.
That is why we have regulations in other industries setting basic requirements to manage fatigue. For example, we require flight crew members to get an equivalent amount of rest when they work 10 to 16 hours. If they work any longer, they must get at least 24 hours of rest. Can our nurses get the same level of protection as our air stewardess and stewards?
Many studies have been done on the importance of fatigue management in healthcare. A 2019 meta-study on fatigue in healthcare found that it increases error rates, slows reaction times, increases likelihood of accidents and injuries, and reduces motivation.
This is not just about nurse well-being but also about patient-safety. Our nurses have to make life and death decisions on every shift.
The Government cannot just leave this to the hospitals to manage and decide on their own. Fatigue affects the well-being of nurses and the health outcomes of patients. Will the Government look into regulations to address nurses’ fatigue instead of leaving again these matters to hospitals to decide on their own?
This will also not be new for the Government. The Government has introduced regulations for the airline industry. The Ministry of Manpower (MOM)’s Workplace Safety and Health Council also has guidelines on fatigue management.
My second point is on protected rest time for nurses during their shifts. While they usually have a one-hour rest of rest time, many nurses have shared with me that they simply do not have enough manpower to rest for a full hour. So, they do not enough rest between shifts and even during shifts.
One nurse shared with me, “It is not uncommon for nurses to not have enough time to have toilet breaks because of the amount of things that come to us during the shift.”
Of the nurses I surveyed, 90% shared that it is common for them to have to continue working during their rest break. They shared that they have to do so because of patient needs and administrative work.
Emily, the nurse, shared with me a day of work for nurses in her ward, “one junior takes care of and showers 16 patients. At the same time, we have to make sure they get their breakfast and lunch, while checking their vital signs twice per shift or according to their doctors’ orders. We have to make sure every intake or output – drains, urine, motions – of every single patient is charted and diapers are changed.”
She continues, “The nurse in charge will have to serve the medication. It is very common for patients to have more than 10 medications, be it IV, oral, pre-meals and post-meals. There are different timings for patients. We have to follow doctors’ rounds, carry out orders, and make sure that the physiotherapist, occupational therapist, speech therapist and medical social worker have seen our patients. We have to do dressings and help the junior out.”
At the end she said, “we hope we get to finish our report before the next shift comes so that we get to go home on time.”
I was exhausted just from reading that.
MOH has shared that it is working closely with public healthcare institutions to shore up recruitment, for both local and foreign staff. However, time is needed to recruit and train nurses. Meanwhile, our nurses are on the brink of burn-out.
Concurrent with recruitment efforts for nurses, will the Ministry work with hospitals to ensure that the rest time of nurses during their shifts are protected? I understand that current realities of nursing means that there has to be some flexibility around rest times. But we must mandate some level of protection of rest.
Sir, I understand that the lack of adequate rest for nurses that I have raised is rooted in a lack of manpower which MOH is already looking into.
Of the nurses surveyed, nearly 80% felt that they were not able to focus on clinical care because of administrative duties that were much heavier than necessary. MOH is already looking into recruiting healthcare ancillary staff for non-clinical duties. But beyond non-clinical administrative duties, patients and next-of-kin also demand customer service from nurses. Seventy-seven percent of nurses surveyed felt that they cannot focus on clinical work because too much time is spent on providing customer service to patients.
One nurse commented that patients and families “want us to clean their surroundings for them, want us to heat up their food and water and even collect their food delivery orders.”
Another nurse said, “Sometimes patients and relatives will tend to request for nurses to do unreasonable things like washing their underwear, buying food for them, fixing their spoiled charger/handphone. Even as simple as changing the channel of the TV, they will ask nurses to do it for them. Sometimes, patients and relatives treat nurses as their personal helper.”
I understand that patients who are unwell and next-of-kin who are stressed understandably look to nurses for support. But the kind of customer service demanded by some patients and next-of-kin is a misuse of invaluable time and expertise of nurses who are already overworked. Yes, we can do a public education campaign on this, but nurses need us to do much more to help them.
Nurses shared with me that they appreciated the 900 Singapore Airlines cabin crew who were redeployed as Care Ambassadors during the height of COVID-19. These Care Ambassadors worked with nurses and doctors on non-clinical nursing tasks. More than 70% of nurses shared that the Care Ambassadors were helpful or very helpful in allowing them to focus on clinical care for patients.
A nurse said, “The Care Ambassador helped to offload some of the non-nursing work and allowed nurses to be more focused on caring for sick patients who need more attention. The Care Ambassador was able to spend time talking to patients, allay their anxiety and make them feel supported.”
MOH has recognised that Care Ambassadors’ service and communication instincts helped to alleviate the manpower tightness in healthcare institutions during the pandemic, allowing again nurses to focus on more complex clinical and care-related work.
Khoo Teck Puat Hospital (KTPH) has been working with SIA to train KTPH’s new Patient Care Officers, a new role inspired by the Care Ambassadors. I hope MOH will consider studying and expanding KTPH’s Patient Care Officers programme to other public hospitals. This will relieve the workload of nurses, enable them to deliver better patient care and ultimately reduce the attrition rate.
Finally, as we hire more support staff, the current one nurse to four to five patient ratio must be enforced. Many nurses were upset when we shared in this House that “The typical nurse-to-bed ratio for general wards in public acute hospitals is one nurse for every four or five beds.” The reality on the ground is far, far from this typical ratio that MOH shared.
Nurses stressed to me that we should also ensure that the hiring of more ancillary healthcare workers or even Patient Care Officers should not affect the nurse-to-patient ratios. They need more nurses, not less.
Sir, let me conclude. It is good news that MOH has acknowledged the manpower needs in the nursing industry and is working on recruitment.
However, concurrent with shoring up recruitment, let us retain those already in the profession. To retain nurses, we of course have to ensure that salaries are competitive. But we must also go beyond the monetary.
The need for more rest is the recurring cry for help that I hear from nurses. Can we help our nurses have more rest by mandating protected rest time between shifts, providing strong protections for rest time during shifts, and hiring more support staff, including ancillary care staff and Patient Care Officers?
Nurses care for us and those who are dear to us. But the burden of that care is now too heavy for them. As one shared, “Our health and our relationship with our families are compromised. We are taking care of people when we can’t even take good care of ourselves and our family.”
I have been struck by how many nurses I talked to spoke of their love for the profession and their desire to serve, even as they talked about how exhausted they are.
Another nurse told me, “We are called back for overtime when staff is down, when we don’t go to work because we are tired, the management counts the number of times and mentions it in our appraisal for not being a team player and marks us down for it. These are just sad realities. We end up feeling burnt out and essentially hating the very job that we started loving. People leave because they see no end to this dark tunnel.”
I hope MOH can provide nurses with some light at the end of this dark tunnel and look into the three recommendations I have raised on their behalf.
Sir, during the pandemic, we clapped for our nurses as part of the Clap for #SGUnited campaign, to show appreciation for those on the front lines of the fight against the pandemic. As we transition out of the pandemic, the workload of nurses has not eased and they continue to be on the frontline when it comes to our health. There are there for us in good times and bad times and we need to be there for them now, to protect them and help them when they need us the most.