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PERSPECTIVE: “It is really chaotic, because at the moment we have to stretch our resources, and we don’t have a lot of space.”

Such is the situation described by a junior nurse working in the Emergency Department (ED) of a hospital in Singapore amidst an unprecedented surge in the daily number of Covid-19 cases, which reached a record high of 26,032 on Feb. 22.

The Ministry of Health (MOH) repeated its call for members of the public to refrain from flooding the hospital ED for non-emergency conditions.

MOH also made an urgent call on Feb. 20, for more manpower to support the ramp-up of Covid-19 operations as the number of cases rose.

On Mar. 4, MOH announced that they will postpone the streamlining of Safe Management Measures (SMMs), "in solidarity with the healthcare workers" as they are still under significant pressure.

John* (not his real name), is one of many healthcare workers on the ground dealing with exhaustion and immense pressure. He shared his experience and explained what he hopes others could try to understand about their situation.

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A typical workday

“For me, when I wake up, I need to plan my work, and mentally prepare myself," said John, who has been working in the ED for two years now, speaking of how demotivating the job has become.

John shared that he's found himself having to steel himself for the busy day ahead, as part of his daily routine.

Generally, nurses get assigned to one of three nine-hour shifts – morning, afternoon, or night. This ensures that hospitals are staffed round the clock while staff get adequate time to rest.

But John says nurses are being asked to work overtime more often, as there is a manpower shortage.

It’s also been harder to take breaks, as there is so much to do:

“Before Covid-19, we’d usually go for a break around mid-morning. But now, we separate our usual one-hour break into [two breaks of] 30 mins each. We try to go as early as possible, as after that, you won’t have time to go for a break. The cases will keep coming in.”

Not feeling equipped

John shared that he's seen patients wait in the ED for a bed in the pandemic ward – a ward for those who are Covid-19 positive – for up to three days.

The ED can easily get clogged up, with nowhere to send the constant influx of patients arriving in ambulances or walking in.

“At the moment it’s really really bad, it’s crazy lah basically. I think to be honest, we’re not equipped.”

These days, John says he sees more elderly people coming in, including patients who are over 80.

And while hospitals in Singapore also had to respond to a surge last year, the majority of patients coming in then were in their 40s or 50s, and were more stable.

The increase in elderly patients — who typically have medical complications requiring greater care — has stretched resources.

The ED has had to open extra beds and ration portable oxygen tanks across multiple zones.

In addition, as the turnover rate has been slower, John noted that even in the ED, they’ve run out of trolleys for patients to lie down on.

He added that while it was understandable that the older patients were coming in, there were also a lot of other individuals who were visiting the ED simply because they wanted a PCR test.

John has seen many patients who come in with very mild symptoms of Covid-19, who just wanted to be "extra careful" as they viewed PCR tests to be more accurate than the ART. This continues to happen even now.

“It is really chaotic, because at the moment we have to stretch our resources, and we don’t have a lot of space. So sometimes, one nurse has to take on 14 patients, even 18. Ya, it’s bad, because imagine a small space [the holding area in the ED], then you have to squeeze in 18 patients, aiyah it’s quite tiring lah.”

Impatient customers and verbal abuse

Often, nurses like John have to deal with aggrieved patients, who don’t understand the longer waiting times, and may not see all that the nurses are doing.

Some would complain about the hospital food, or about having to fast for longer than usual while waiting for their test results. More often than not, these interactions escalate to verbal abuse:

“They’ll shout and say ‘I pay so you must take care of me.’ Then, you need to calm them down and help them understand that the doctors are overstretched too, and so might take a longer time to get back.

Because we are patient-facing, we have to do this, and it’s an additional task on top of all that we are already handling.

Sometimes, I can empathise, but also it’s not fair. Like, I’m also tired, please see from my point of view.”

John shared: “After that, we still have to care for them, because that is our job. I can’t say that I no longer want to take care of the patient. My colleague might take over the patient lah, but yea, I still have other tasks to do. We are seeing so many patients, we can’t be selective of them.”

Breaking point

John says his “never-ending” workload and insufficient rest has culminated in serious emotional and physical exhaustion.

With the manpower crunch and a surge in the number of cases, John shares that he has been abruptly asked to come back during his days off, making it hard to spend time with family and friends.

Nurses who had just ended their morning shift could be asked to return to work just a few hours later, for the night shift.

He shares: “We can say no, but we know how bad the situation on the ground is. So it’s also hard for us to say no. Because we know our own people are suffering, so we want to help as much as we can. So [usually] we will go down.”

The few times that John had to say no, he struggled with feelings of guilt, despite having declined in order to attend to family matters.

“Like, the whole day we keep thinking about it lor, like alamak. It’s a guilty feeling lah.”

The resignation of senior healthcare workers

In the midst of the day-to-day struggle, the industry is also seeing an unprecedented wave of resignations.

At the start of the year, about 15-20 nurses resigned from the ED alone; a substantial loss as the majority of those who left were experienced staff.

A number were foreign healthcare workers, who wanted to go back to their families, while some were simply burnt out and needed rest.

As a result, John shares that there are now more juniors than seniors on the ground, which further creates pressure on the remaining staff.

Junior staff who come in during this period have to juggle between learning how the healthcare industry works, seeing a lot of patients everyday, and the handling of a constant incoming stream of tasks.

Some overwhelmed juniors end up leaving as well.

“So imagine if the number keeps going down, this means that we need more help from outside, and people from other departments will get deployed. It’s a good thing that [the Singapore Armed Forces (SAF)] is being deployed down here to help," says John.

John himself has not thought of leaving just yet:

"I mean, there’s a reason why I studied for [my nursing qualification]. So if I never help, what’s the point of me studying for it right? But no hate to the people who left, and I can't speak for everyone, because they too, have personal reasons to have left."

That being said, he is currently serving a bond, though he says he wouldn't have left if that were not the case.

John says that the feeling of seeing his colleagues leave is bittersweet. On one hand, he is happy that they are returning to their families overseas, but on the other, it’s “one man lesser” for the team.

He says: “I think the main problem is that we have more patients, but not enough healthcare workers.”

Feeling unappreciated and left behind

The lack of manpower adds fuel to fire on a general sentiment that has been raised by many other healthcare workers – of feeling underappreciated and “left behind”.

Last month, a Singapore healthcare worker created a comic strip illustrating her hope that the public would not forget medical staff as Covid-19 measures loosened, while others penned open letters to the authorities, calling attention to the plight of nurses in hospitals.

John agreed:

“I understand that they [the Government] want to get everything back on track, but when you experience firsthand [the situation] on the ground, it’s totally different.”

John admitted he’s even asked himself whether it’s worth being “foregone”, in exchange for greater normalcy in society, and the economy.

“Because I think at this point in time, we should be taken care of too. They say that despite the surge in numbers we’re holding out. But we’re not.”

Despite the Government's efforts to urge the public to refrain from visiting EDs unnecessarily, John noted that many people still come in for the wrong reasons.

Some also insist on staying despite having been cleared by hospital staff to go home, and again, turn verbally abusive when asked to leave.

This makes healthcare workers like John feel unheard and alone in their struggles, in a pandemic that has stretched on far longer than any other.

He says: “SARS was more deadly, but it was for a short period of time. Covid-19 has been going on for the third year now.”

Appeal for support

John is calling for more support on the ground, and greater empathy.

John opined that increasing pay at this point might not be enough to retain staff.

“Increasing pay will help to a certain extent but when one handles too much pressure and workload, trust me: If they give up, they give up. They won’t think about money.”

John shared that what healthcare workers need instead is more manpower and rest, to ease the burden.

He put forth a suggestion to make it mandatory that all those who had studied nursing, doctors and the allied health profession to come back and “help out” as a temporary solution.

These individuals could return as volunteers, or in paid contract positions. John acknowledged that the suggestion was draconian, but stressed that it'd only be temporary.

John also suggested for more proactive measures to look after the mental health of all healthcare workers.

“They do come up with measures, but it’s more like, 'Okay if you feel mentally tired, or you need help you can seek this hotline.' I feel like more of what they should do is to send professionals in to reach out to us, to really check how we are coping mentally.

That would help us a lot, because at this point in time, nobody is gonna go down specially to see [a mental health professional].”

John also had a simple message for members of the public:

“I’d ask the public to please empathise with us. Sometimes we tend to do things slower, but it is because of the number of patients we have to take care of.

Please don’t be verbally abusive. We’re also human... so when you scold us like that, it creates self doubt lah. My colleague cries, which is so unnecessary because she’s already doing what she can."

As for those who are able to recover at home, John had the following message: "You don’t have to go to hospitals and clog up the lines."

"That’s what we need from the public at this point in time.”

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Top image via Mothership