What nurses have learnt after three years of Covid-19

It took more than two years for deputy director of nursing Patricia Yong and her intensive care unit (ICU) nurses to finally regain their footing after the Covid-19 pandemic upended their workflows and worsened the manpower strain in healthcare.

“Experience is always a teacher. You learn to be cleverer after a while and have prevention strategies. At this stage, we would be in a better starting point if another pandemic happens,” said Ms Yong, 58, who oversees several hundred ICU nurses and other areas at Singapore General Hospital (SGH).

The SGH ICU nursing team learnt to perfect three Cs – clarity, communication and collaboration – across departments to ensure that the hospital’s most sick are well taken care of despite many uncertainties.

Over the months, they have had more clarity about how the virus behaves and they grew used to fast-changing health protocols.

Ms Yong is one of many senior nurses who on Dec 29 were named recipients of special national awards for outstanding contributions to Singapore’s fight against Covid-19.

Spanning nine award categories, the names of about 9,500 recipients – including pilots, scientists, general practitioners and school principals – were released at the end of December.

Ms Yong will receive the Covid-19 Public Administration Medal (Bronze).

Two new awards, the Covid-19 Resilience Medal and the Covid-19 Resilience Certificate, will be given to about 800 teams and 99,000 people who were directly involved in the fight against the virus. Their names will be announced later.

The most stressful and trying period at the ICUs was during the peak of the deadly Delta wave in late 2021, when the infected patients were more ill and stayed longer in intensive care, said Ms Yong.

Nurses had to deliver a higher level of care and keep a closer eye on critically ill patients who were hooked up to mechanical ventilators. Some of them were on the life-supporting extracorporeal membrane oxygenation (Ecmo) machine, a resource-intensive treatment that takes over the function of the lungs.

But during the Omicron waves, most of the seriously ill patients did not need ventilators as the variant and its strains were less severe. Patients responded well to non-invasive oxygen therapy using high-flow nasal cannulas and by lying on their bellies so they could breathe better.

Now, the ICUs are almost back to a comfortable level, with fewer Covid-19-related hospitalisations and ICU cases. The number of Covid-19-related hospitalisations remains below 100, and the number of infected patients in intensive care is in the single digits as at Jan 4.

But at the National University Hospital’s Emergency Medicine Department, Ms Uma Chandra Segara, 46, assistant director of nursing, and her nurses are gearing up for busy days ahead.

While a packed emergency department (ED) is not surprising to healthcare staff, the virus has exacerbated the problem. Every infection wave has led to a flood of patients in the EDs and longer waiting times for admission.

During the recent wave caused by the XBB sub-variant of Omicron in late 2022, some patients had to wait for up to 30 hours to get a bed, said Ms Uma.

“Every time when Covid-19 restrictions are lifted, I would say that the emergency department’s work has not changed since the Covid-19 (pandemic) began.

“Schools have just reopened and Chinese New Year is coming. We are bracing ourselves for any surge. But we are quite prepared to manage a next wave,” she said.

With the population getting older, she is seeing more seniors in their 90s and even 100s being rushed to the hospital. They tend to have more complications and will have to be hospitalised for a longer time, making it tricky to free up more beds in the wards.

When patients with non-urgent conditions come to a packed ED, nurses have to sometimes spend more than 10 minutes persuading them to go to a nearby clinic instead, Ms Uma added.

With the bed crunch, inpatient care now begins in the EDs. Ms Uma is no longer surprised when she sees the same patient from her previous shift. Inpatient doctors would visit the emergency medicine department to start patients on treatment.

Ms Uma, who has been in the nursing profession for more than 26 years, is one of more than 7,200 who will receive the Commendation Medal (Covid-19).

She oversees about 180 nurses in the Emergency Medicine Department and leads the Covid-19 vaccination efforts for staff and patients, among other duties.

The pandemic has worsened the shortage of nurses here and in the rest of the world.

In 2021, the number of nurses in Singapore’s public hospitals who resigned reached a five-year high, with 7.4 per cent of local nurses and 14.8 per cent of foreign nurses leaving their jobs.

Travel restrictions during the pandemic also meant that foreign nurses were separated, often for years, from their loved ones.

Video calls were the only way for Malaysian Ng Sook Ting, 37, to check in on her mother, who lives in Kuala Lumpur and suffers from ailments such as diabetes and hypertension.

“My family was worried about me as a front-liner, and at the same time, I was worried about them,” said the senior staff nurse at Khoo Teck Puat Hospital’s acute and emergency care department.

Even when borders reopened in 2022, nurses had to take turns to return home, recalled Ms Ng, who will also receive the Commendation Medal.

Once the borders opened up, Ms Yong said a couple of Singaporean nurses emigrated. Some foreign nurses returned to their home towns or sought employment elsewhere, said Ms Uma and Ms Yong.

The manpower strain was felt the most when nurses also came down with Covid-19 during the infection waves.

Foreign nurses make up almost 30 per cent of Singapore’s registered nurses, and about 40 per cent of enrolled nurses.

Typically, each nurse at the NUH emergency medicine department would care for six to eight patients. There are between 30 and 35 nurses during every shift. But there were times when each nurse had to attend to 15 to 20 patients when the ED was overwhelmed, said Ms Uma.

Support care staff were recently hired to help with duties such as monitoring the vital signs of patients so that nurses can focus on new patients or tend to the severely ill ones.

Singapore expects to employ about 4,000 more nurses by the end of 2023 to boost the nursing workforce.

Ms Chen Jing, a senior nurse manager at the National Centre for Infectious Diseases, said that for nurses, dealing with the pandemic felt like a “never-ending battle”.

Keeping nurses in their jobs will require, among other things, redesigning their roles to allow them to focus on delivering care, said the 40-year-old, who has 18 years of nursing experience and will receive the Public Administration Medal (Bronze).

On top of that, the pressures of being in healthcare require one to develop strategies to build mental resilience, she added.

For Ms Chen, this includes taking on community work whenever she can, such as by distributing necessities to the needy during the Chinese New Year period.

“It makes me feel like I’m contributing to society (in other ways), not only by caring for the sick.”