EDGAR TAN

“Sometimes you are the only person with them in their dying moments.”

I am a registered nurse specializing in aged care.

I was always interested in nursing and all things medical, so straight after high school I went to do a nursing course at the Institute of Technical Education of Singapore. Coming from an Asian background where nursing as a career can be frowned upon, especially for males, I was lucky to have a pretty supportive family.

I did a two-year certificate to become an enrolled nurse. Thereafter, I did around four months work in a public hospital before it was time for me to do the mandatory two year military service.

For some reason, even though I was a nurse, I wasn’t assigned a medical role. After initial 3 months basic military training, I was made a catering supervisor. But I actually really loved being in the kitchen and learning how to cook, so I wasn’t too upset about it!

As I worked office hours in the army, I was free to do extra work after-hours, so I did nursing agency work in the evenings and weekends. I got sent to various hospitals and homes to do jobs or cover shifts. So that allowed me to earn extra income and keep up with my nursing skills during the two years of national service.

After national service, I got a job as an anaesthesia nurse in a private hospital for about a year.

I assisted the anaesthetist with patient sedation, maintaining sleep and making sure everything went smoothly in theatre. Afterwards I helped patients with awakening and recovery.

A few of my friends went to study in Australia, and I heard good things about it. I decided I would come here to study and upgrade myself to become a registered nurse, and then return to Singapore.

I moved to Melbourne to go to La Trobe University.

I had to do the full course again, as I only got a few credits for previous study. It took three years, during which I lived on campus for 9 months. The reason I went to La Trobe, was that it had a very strong marketing presence in Singapore. Back home, if you tell people you are a La Trobe graduate, it’s more recognised.

But here in Australia, it’s different, as I discovered once I graduated: as long as you have a degree, and more importantly, your registration – you will get a job.

At the end of my studies, I decided not to return to Singapore.

After doing placements and working in Australia, I found that the environment and conditions for nurses are much better in Australia. Patients respect you, and don’t treat you like a servant or a maid.

Patients, and their families, are more willing to help with small things, like getting a glass of water, and respect the work that you are doing for them. In Singapore, you tend to get a lot of abuse from the relatives, who have very little respect for nurses.

So I decided to stay a few years, and I liked it.

I ended up applying for residency, and after a couple of years my application was accepted and now I have my PR.

After graduation, I didn’t have any big preference of where I wanted to be. I sent out a lot of resumes, but I was also doing agency work, being sent to do shifts at all the different hospitals and nursing homes.

And that’s how I found out about a permanent night nurse position going at one of these homes.

I spoke to the manager about it, and she encouraged me to apply.

I was dubious at first. Working nightshift in a 60-beded home, you are the only person in charge. If anything happens, there is no one to consult with – the buck stops with you. That’s the challenge of night shift.

But I decided that I’ve had enough experience as an enrolled nurse to take on the challenge. So I applied and got the job.

I started working 6 nights a fortnight, eventually going up to 8 nights a fortnight within my three years there. Night shifts are generally 9-10 hours, so they are a bit longer than day shifts.

The night shift role is quite varied. You are in-charge of security of the premises, the residents, and the carers working with you. You are also in charge of roster maintenance and ensuring there is enough staff on for the dayshift: so if anyone calls in sick at night or in the morning, you need to fill their shift.

It’s vital to maintain the carer-patient ratios, as working with staff down is very difficult. So that’s the HR aspect.

Then there’s the paperwork. Because the majority of residents are asleep, you don’t do a lot of assessments and clinical work, so you pick up administration work left over from the day shift. Finish up any uncompleted paperwork, tie up loose bits and pieces.

From the patient care aspect, if any residents are unwell, you need to assess them, treat and monitor them. You need to make sure everyone is getting their sleep. If a resident is not asleep, you need to investigate why they are up. Is it pain or insomnia they need treatment or help with?

Or is it an emotional problem: are they anxious or missing their family?

Then you have the occasional wanderers, trying to move around the residence. You need to make sure they are safe, and using their walker if they need to, to avoid falls.

Because I work at night and most residents are asleep, I didn’t get to build a bond with them as quickly as a day shift nurse might. I reckon it was after a year working there, that I actually managed to start building rapport with some of them – mostly the night owls, and the early birds.

However, I did build a close relationship with my night shift team.

In a 60 bed facility, you might have 3 carers and one nurse per night shift. So you grow to rely on each other. As the head nurse, I relied on my carers to be my eyes and ears around the facility and residents, reporting to me if anything was wrong.

I enjoyed the close-knit relationship I had with my team. We used to bring in food and have dinners together, sometimes even breakfasts after the shifts.

After 3 years, my ex-manager, who had moved to a bigger facility, told me of a night shift position available there and invited me to apply again.

I decided to go for it, figuring there would be better career progression opportunities within a bigger organization.

I applied, went through the interview process and was accepted. I’ve been here around 6 months now and am really enjoying it. The job is similar, but the facility is bigger –  I am currently looking after 90 residents. I work five nights a fortnight here doing the night manager role.

The company I work for also owns another aged care facility that specializes in psychiatry. So they have residents with mental illnesses, such as dementia, bi-polar or just aggressive patients. I have also started doing a couple of night shifts a fortnight there.

This role can be quite challenging. When it’s quiet, it’s OK, the same as my other night shift work. But unfortunately, often you have conflicts and behavioural situations where residents can get aggressive, attack each other or staff without provocation.

I, together with my carers, need to de-escalate these situations.

The first step is generally to separate them, try to talk to them and calm them down. We try to distract them with conversation, redirect them to another activity they might enjoy. Sometimes we even bribe them with treats, like ice cream!

Sometimes though, the residents are either too confused, or worked up and they don’t comprehend. So the next step is to medicate them to calm them down.

Occasionally we even have to call the police to report assaults and attacks.

I like both my jobs, they both have their challenges. In psychiatry, it can get very busy, and most of the work is behavioural – I don’t do so much clinical work here.

But of course, there’s clinical work involved in both places. People can have seizures, attacks, feel unwell. Falls are a very common occurrence: residents slip or misbalance while walking, or they roll out of bed while asleep.

When something happens, you need to assess the patient; are they bleeding, injured or suffering from a condition? You need to apply first aid or treatment, possibly get an after-hours doctor to attend, or even send them to emergency hospital.

I enjoy getting to know the residents, enjoy aged care work.

However, part and parcel of life is dying. Sometimes I feel really sad, especially if it’s someone I got to know really well and became emotionally attached to. Sometimes they are all alone by themselves, and you are the only person with them in their dying moments.

That happens pretty often. In these cases especially, being a good nurse really makes an impact to the residents in your care. You get to provide their last comfort, hold their hand as they pass, alleviate their fear or sadness.

Other times residents slip away in the night, between your rounds.

The hardest part is calling the family to deliver the news. That is always hard and heartbreaking.

Whether you try to save and resuscitate the resident, or let them pass away, is controlled by their Advanced Care Directive. This is a very important document that any patient, admitted to any medical facility, should have. In a hospital setting, it states what to do, if a procedure, even the simplest one, goes wrong.

To what extend do you want to be treated? Do you want to be revived and stay alive, but have a poor quality of life? Or do you want to be let go, and at what point?

In a nursing home, as each patient enters the system, the Advanced Care Directive is created.If the patient is of sound mind, they give the instructions. If not, it’s up to the next of kin.

Sometimes, you have a resident who is in their nineties, with multiple conditions and poor quality of life. It may be better for them to pass away peacefully, rather than go through the pain and stress of resuscitation and further treatments. But many times, families are heartbroken, and they hold on to their mum or dad, and they try to insist on resuscitation against the directive.

As an aged care nurse, you sometimes find yourself in a difficult position of trying to advocate for the patient, trying to console the family and make them see that their loved one has had a good long life, but maybe now they are tired and would like to go.

But then the patients themselves hold on, often waiting for a visit from their son or daughter.

This happens all the time. Once they get the long-awaited visit, they pass away. I remember a lady whose son was working overseas. As she deteriorated, all her family came to visit her, but she kept hanging on until the son returned. Once she saw him, she passed on.

For those patients who wish to be kept alive, we do everything possible: we will perform CPR, rush them to the hospital – regardless of what their quality of life might be afterwards – it’s not up to you to decide.

But for those who request to just be let go, you might administer first aid, or some antibiotics, but if they continue to deteriorate, you must let them go.

So as an aged care nurse, you must face and do a lot of end of life care, and you need to know how to make a person as comfortable in their passing as possible.

Most of the time, this is done through pain management, morphine. But also through making sure they are physically comfortable, re-positioning them, ensuring they are clean, wetting and cleaning their mouths, changing incontinence aids.

Occasionally you bring people back from the dead.

You might have a really sick resident, and you might think that’s it, they won’t last more than a day or two. So you provide your best care, give them antibiotics, make them really comfortable and offer emotional support. And then next thing you know, they spring back to life! When that happens, that’s truly a joyous feeling and you feel hugely satisfied and rewarded by your work.

For me, one of the most rewarding things is being thanked by the residents and their families, who remember you and tell you they appreciate the work you do. That’s a big driver for me.

I am glad I chose a nursing path.

My only regret is not studying better in school and so not getting in to do the full registration course from the start – that would have saved some time re-qualifying in Australia.

Possibly in the future, I would move into doing day shifts, working as a clinical coordinator to coordinate resident care, or even a facility manager. But I am happy where I am now, I like aged care and definitely want to stay in it.

Some people find nursing homes to have a depressing atmospheres, but compared to Asia, Australian nursing homes are way ahead.

Here, you have single rooms, or sometimes double rooms. In Asia, in public system, you often have up to eight residents per room, which is not ideal.

Nursing in aged care can be heavy work. Some patients are immobile, you need to do a lot of lifting and hoisting, do every life tasks for them. There’s a lot of incontinence, so you work a lot with poop. I’m not a huge fan of it, but that’s a fact of nursing, and you have to take the good with the bad.

Yes, it can be a depressing atmosphere, however there is also a community spirit in any home, and as a nurse, it’s up to you to bolster it, make sure it’s strong by building bonds with the residents and your team, and making sure the residents have the high quality and respectful care that they deserve at the end of their lives.