SINGAPORE: “Aiyo,” he mutters, squirming in his chair. “Come out already.”
Panic flashing in his eyes, Mr K lets loose a string of Singlish, Hokkien and Malay exclamations. They are mostly inaudible over the tacky beats of a ‘90s Vengaboys hit playing in the background, but one word catches the room’s attention: “Berak”, or poop.
I follow the staff nurse over. As she helps up the nonagenarian, a mound of fecal matter slides down his pants and plops neatly onto the spotless vinyl floor.
The smell hits like a brick and I wince on reflex. Barely two hours into my stint as an assistant nurse at Tan Tock Seng Hospital’s (TTSH) Geriatric Monitoring Unit (GMU), and it is already a morning to remember.
There were more firsts to come over the next 48 hours, as I tiptoed around the nurses on shift, trying hard to be useful but failing miserably at the simplest things like putting on a disposable apron.
I was most nervous about causing discomfort to the GMU patients - who are typically admitted to the usual TTSH wards first, before being referred to the specialised five-bed unit to treat delirium caused by underlying medical conditions.
With its patients all above 85, the restraint-free ward - built in 2010 - is elder-friendly: The walls are decked with a traditional Chinese calendar and photos of a younger Singapore; the exit is a concealed door painted like a bookcase to prevent patients from wandering off; and bright light therapy is utilised at dusk to keep them awake so they sleep better later at night.
Along with the likes of Khoo Teck Puat Hospital’s Care for the Acute Mentally Infirm Elder Unit and the National University Hospital's (NUH) Silver Unit, the GMU points to the increasing attention being paid to Singapore’s rapidly ageing population.
Official figures place the proportion of citizens aged 65 and older at 14.4 per cent this year, up from 13.7 in 2016 and 9.4 in 2007. A UN report this week projected that by 2050, nearly half of Singapore’s population will be at least 65 years old.
To tackle the demands of a greying populace, the Health Ministry (MOH) estimates 30,000 more healthcare workers will be needed by 2020. And nurses form the bulk of these - there were 40,561 of them as of 2016, compared to the next largest group of 12,967 doctors.
Yet according to the Manpower Ministry, over the last two years, nursing has held the dubious honour of having the most vacancies unfilled for at least six months - a statistic which may suggest the profession remains somewhat shunned by Singaporeans.
One of the first things I learn at the GMU is the difference between hyper- and hypoactive delirium. The former condition - characterised by restlessness, agitation and at times, aggression - afflicts Mr K, although he has been on the mend.
On the other hand his neighbour across the room, Pakcik Y, is a classic hypoactive case: Withdrawn, inactive and perennially drowsy. The staff nurse tells me he often refuses to eat, and needs plenty of encouragement to do so.
I discover this for myself. Armed with a pathetic grasp of Malay, I attempt to entice him to the mouthwatering delights of a blended greenish mush - but not before plenty of gentle nudging and coaxing to stop him from dozing off in between each gulp from a tiny plastic teaspoon.
Each meal takes him a gruelling 45 minutes or so to complete, but this is routine for the nurses. The same for diaper-changing - but helping the staff nurse remove Pakcik’s soiled nappy, and wiping up after him, was an especially grim moment for me, driving home the infant-like helplessness of the patient, and his utter reliance on being cared for.
Such duties have also unfortunately led to longstanding stereotypes of nursing as being made up of mindless, mundane tasks and the mere following of doctor’s orders, said Esther Chew, 24, a geography graduate who worked for a year before successfully applying for an MOH master’s scholarship in nursing.
“I knew (nurses) have to undertake to a certain extent, dirty work like cleaning people’s backsides, blood and vomit. It did definitely affect me a little prior to making my decision,” she admitted.
These “mundane tasks”, said TTSH’s chief nurse Yong Keng Kwang, are in fact essential to helping patients maintain bodily functions and dignity when they are weakest.
“More importantly, it empowers the nurse with the knowledge to independently assess daily care plans for a patient to regain full functions or adapt optimally to a disability,” he explained.
“These tasks, while seemingly 'mundane', are much appreciated by the patient in his most vulnerable moments, and often facilitate the formation of a trusting and meaningful bond between the nurse, the patient, and family.”
“NO LONGER HANDMAIDENS"
Chew added: “There’s a lot more work that goes on in the nursing profession than what we see on the surface. They have more autonomy than we tend to think. They do almost everything.
“If the wrong medicine or dosage is prescribed, nurses have to be aware and inform the doctor. They are first to notice behavioural changes as they spend the longest time with the patients. Most importantly, nurses are the main advocates for patients - they are the ones who have to speak up for the patient’s rights and welfare.
“Nurses can specialise in different areas such as gerontology and mental health and help advance the healthcare and medical sector in their own way - not any less significant than other healthcare professions.”
Hence a concerted push by authorities to show that nurses are “no longer handmaidens to doctors”, as described by one TTSH staff during an orientation session ahead of my time at the GMU.
“MOH has taken a serious effort to raise the perception of nursing,” said Dr Manav Saxena of global consultancy Oliver Wyman’s Asia Pacific health and life sciences division.
“In the 2020 Manpower Plan, it specially profiled the role of nurses and put in plans to attract more to the profession. There have been media advertisements as well, which sent very strong messages. Also, MOH is giving out scholarships and developing career paths for the nurses.”
Public sector nursing salaries have also increased by up to 10 per cent. Professor Emily Ang, head of the National University of Singapore’s (NUS) Alice Lee Centre for Nursing Studies, pointed out that graduates from the programme start with median monthly salaries of at least S$3,400, higher than the S$3,360 median salary for most other degree-holders.
While higher salaries do “send a message”, a pivotal shift in public perception takes time, said Dr Saxena.
“As the public sees more nurses in a decision-making role in the care process in hospitals and nursing homes, the perception will definitely change.”
“YOU DON’T BE STUPID"
Outside of the GMU there are other aged patients also suffering from delirium and other behavioural issues - and that’s where TTSH’s Geriatric Resource Nurse (GRN), Ong Poh Poh, comes in. I tail her for a few hours as she walks the wards engaging these elderly. It is an eye-opener.
There is the patient alternating between smiling sweetly and screaming her lungs out to be taken home; the one who gave Ong two bloodied scratches on her arm and neck for waking her from a nap; and an outwardly mild-mannered lady placed in restraints for continually pulling out her tube feeding apparatus.
I attempt to interact with the latter, asking basic questions - but perhaps due to my poor Hokkien or unfamiliar face, she quickly turns furious, shouting in dialect: “You don’t be stupid. I don’t have to stay here, I have a big house…”
For Ong - who appears capable of conversing in every language and patois known to Singaporeans - this is just another day at the office, having spent the last three years as a GRN out of her decade-long nursing career.
“Everyone will get old one day,” said Ong, 32. “Geriatric care is a fulfilling job and provides me satisfaction when taking care of the elderly.”
“When you’re able to understand an elderly person’s needs, and participate in improving their care especially during their last few years of life, you will find the beauty of geriatric care.”
That there are over 200 GRNs at TTSH is no surprise, given its proximity to mature estates like Ang Mo Kio and the resulting size of its elderly population: one in two patients are above 65, one in three above 75 and one in five above 85.
Mr Yong said about 10 per cent of TTSH’s resource nurses are trained in advanced geriatric practice. The hospital is aiming for 75 per cent of its workforce to undergo additional training over the next five years, whether at polytechnics or through in-house programmes.
“Currently, at TTSH, our numbers generally can meet the demands for nursing care,” he observed. “But we anticipate that as demands grow with the ageing population, we will certainly need more healthcare workers - especially nurses.”
MORE ABOUT SKILLS THAN DEMAND-SUPPLY
Most other hospitals are also identifying nurses from all specialties to do diplomas in gerontology, said Associate Professor Reshma Merchant, head of NUH’s geriatric medicine division.
“They then come back and become geriatric console nurses, decentralised in most non-geriatric wards and responsible for training the rest of the staff,” she explained.
When it comes to nursing our ageing population, it is less a supply-demand issue than about the training and skillsets required, Prof Merchant added.
“Besides the cure or treatment, they also need a lot of care and comfort so that they can recover faster and not suffer from hazards of hospitalisation - for example confusion and functional decline.”
“We need to upskill our nurses, and hire more basic care assistants to help. We need to re-engineer the current role of nurses and empower them to do assessments, plan discharges and enable seniors to transit smoothly out of hospital.”
Said Dr Saxena: “Today nurses are doing much more, especially in geriatric care. Elderly, because of their fragile health and multiple conditions, need special care, especially as a minor health issue can escalate and become critical.”
“The senior nurse managers or the Advanced Practice Nurses are effectively coordinating and managing (this) care... If you visit a nursing home, you will see that effectively all care is managed by the nurses, who are also the decision-makers on a daily basis.”
“DO SOMETHING MEANINGFUL”
Well-accustomed to excretory episodes like Mr K’s, the staff nurse at the GMU goes about cleaning him up like clockwork, and has him back on his bed resting in no time.
But she is also keenly aware of his acute distress and embarrassment. As he lies there, murmuring about being a burden, hands clasped together praying for no more of such mishaps, the nurse leans in to whisper words of comfort, and later helps him plug in headphones playing a selection of his favourite Hokkien songs.
In a few hours, Mr K returns to his usual chatty, jovial self while doing his favourite activity - colouring.
Later the thin, elfin man is a bundle of laughs when I accompany him in some light exercises using resistance bands and dumbbells - and even pulls off a deadpan joke about performing 1,000 repetitions the day before.
During my orientation at TTSH there were also a handful of junior college students who had voluntarily signed up for a nursing internship at TTSH during the school holidays. All said they wanted to do something meaningful. Undoubtedly, there was value in the manner in which the GMU nurses attended to Mr K.
Could their interest be a sign of changing attitudes amongst the young? According to MOH, intake into local nursing training programmes grew by 20 per cent between 2014 and 2016, with this year’s expected to spike by another four per cent.
Prof Ang of NUS said the school’s nursing programme saw 2,200 applications in 2017, up from 1,730 in 2015. In response, it has upped intake to 235 from 155 in 2016, with a view to accepting a 300-strong batch within the next few years.
The Singapore Institute of Technology (SIT) also recorded a 27 per cent increase in applicants from last year.
PROS OVER CONS
Said Chew, the 24-year-old who made the career leap to nursing: “I’m happiest when I interact with patients directly and regularly. I feel a deep sense of motivation whenever I can bring joy to the patients through activities. Seeing their smiles after spending time with them brings great warmth to me.
“I wanted to work in a role where I can help look out for them, and care for them in their time of deepest needs.”
But she admitted: “Prior to switching to nursing, I heard that nurses tend to be overworked, underpaid and under-appreciated; that it was going to be physically and emotionally demanding.”
My experience from a mere two days attests to this. By the end of the first, I was already drained: Aching from having to bend over and stand nearly all day, and rather absurdly, feeling the effects of compassion fatigue. Just a day of trying to be perpetually nice, friendly and helpful towards the patients had worn me out.
So it was with some measure of dread that I stepped back inside the GMU for my second shift - and was promptly tasked to help a nurse with showering Mr K.
When we ask if the water temperature is okay, he is politely unfussy; when the nurse informs me I’ve put too much soap on his legs, he tells me not to worry about it - and strikes up a conversation instead.
“Are you married? Do you want to win the lottery? Can I wash my dentures?”
It was all very random, but knowing he must have picked up on the slight awkwardness in my body language, and was trying to help defuse it, in appreciation of what we were trying to do for him - that made me all the more grateful.
And in that moment I caught a fleeting glimpse of the intrinsically rewarding, satisfying nature of nursing.
As Chew said: “I believe the positives outweigh the negative aspects of the profession. The knowledge that you’ll be ultimately serving, adding value to a patient’s life and making a difference - I hope - to their lives is invaluable.”