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Why some healthcare workers in Singapore’s hospitals have quit — and others soldier on

*Names have been changed. 

SINGAPORE: It was early 2021. Lisa*, then a senior staff nurse at a public hospital in Singapore, received news that her father had contracted COVID-19 in Malaysia amid the Delta wave.

She would have gone home straight away, but her nurse manager’s response to her leave request shocked her.

“She told me that with the manpower shortage, I shouldn’t be so selfish and (should consider) my other colleagues,” said the Malaysian in her 30s who had worked here for 12 years at that point.

The hospital relented only when she said she would quit. She considers herself “very lucky” that she was granted a month’s no-pay leave: Eventually, her father’s condition deteriorated, and he needed intensive care.

“The saddest part about being in healthcare is when you spend so much time taking care of patients and their families, but you end up neglecting your own,” she said.

CNA Insider could not get the hospital to verify her account without identifying her. But she said it was the last straw in a series of events that had “drained” her. She realised that the long shift hours and lack of rest was taking a physical and mental toll.

She left the hospital last August but is still in public healthcare: At a polyclinic, where she works more regular hours. She is only the tip of the iceberg.

In November, the Ministry of Health (MOH) released statistics showing that about 1,500 healthcare workers resigned in the first half of last year, compared with 2,000 annually before the pandemic.

Last month, Senior Minister of State (Health) Koh Poh Koon elaborated on these numbers in Parliament: In 2019, the overall attrition in the healthcare workforce was 9.6 per cent. It dipped to 6.8 per cent in 2020, but then the two-year average attrition reached 9.8 per cent last year.

Two of the public healthcare clusters approached by CNA Insider did not share their attrition rate. The third, the National Healthcare Group (NHG), said last year’s rate was “higher than pre-COVID periods (2018 and 2019)” but “manageable”.

WHAT’S HAPPENING ON THE GROUND

But even as the Omicron wave wanes, healthcare workers CNA Insider spoke to say manpower shortage remains a concern.

More than 20 nurses, doctors and allied healthcare workers were interviewed and spoke on condition of anonymity, as they were not authorised to speak to the media.

About half of them had left their jobs in public and private acute hospitals or have tendered their resignation.

When James*, a mid-career nurse in a public hospital, tendered his resignation in January, he realised that at least five colleagues from his renal ward had done the same that month. Another nurse from the ward, whom CNA Insider spoke to, corroborated this.

The departures this year were “more pronounced” than last year, he felt. “(With) the third year of the pandemic, I guess most of them had enough. There was uncertainty over when their next break would come.”

A speech therapist in another public hospital said she has not seen this number of resignations in her 10 years there: This year alone, seven people in her department left, though not all owing to burnout or stress, she noted.

“Usually, about three, maximum four, people leave in a year,” she said.

Senior pharmacist Dean*, who has been in a public hospital setting for four years, said that in his section of about 150 staff, the resignations are most notable among pharmacy technicians. They number more than pharmacists and assist with pharmacy operations such as dispensing of medication and inventory-related matters.

About 30 to 40 per cent of them, mostly foreigners, left between the end of last year and early this year during the height of the Omicron wave, when the impact of departures was most acute, he said. Pharmacists like himself had to fill the gaps.

“Pre-COVID, if people left, (the hospital) would just hire people from overseas to replace them, so nobody really felt the pain. But with COVID and the borders closed, it wasn’t so easy to plug the holes,” he added.

For David*, a nurse in the emergency department with 10 years’ experience, the fact that experienced workers are quitting is a deeper concern than the numbers alone.

His colleague, Yvette*, agreed. “The need to retrain new nurses — which takes time — will increase the burden on the experienced ones, which gives these remaining experienced nurses even more of a push factor for leaving, like a vicious circle,” said the emergency doctor.

The mental health of healthcare workers has recently been a topic of concern across different platforms, from social media posts to authored studies.

In late February, an Instagram post from @thehonesthealthcareworker on how nurses were “not coping well” did the rounds. It said that the healthcare system was on a “slow road to collapse”, that working conditions have “worsened significantly” with no increase in practical support and that many workers were leaving.

The nurse-patient ratio has also increased “from 1:6 to 1:12 or more”, wrote the author, who later told CNA Insider he saw this happening in his hospital — although this could not be verified officially.

A study published in the same month by the Saw Swee Hock School of Public Health, Tan Tock Seng Hospital and the National Centre for Infectious Diseases highlighted the burnout brought on by overwork, emotional exhaustion and inability to take adequate leave as a “morale breaker” among healthcare workers.

There may also be pull factors at work, particularly among foreign nurses who may be attracted to other countries. According to MOH figures in Dr Koh’s parliamentary speech, last year’s attrition rate among foreign nurses was 14.8 per cent, double the 7.4 per cent among local nurses.

As the Omicron wave wanes and Singapore regains a semblance of normality, is there respite in sight to stem the flow, particularly for healthcare workers in acute hospitals? It may not be a given.

“It was never only about the pandemic,” said Tina*, a former senior staff nurse in her 30s who left her post in a renal ward at a public hospital. “This pandemic only brought more attention to healthcare workers and the issues we face at work.”

Related:

Healthcare workers describe struggles as patients flood emergency rooms amid Omicron wave

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WHAT THEY’RE LEAVING FOR

Sunlight. That was the first thing that came to mind for Lisa when asked what marks her polyclinic job out from her previous one in an acute stroke unit.

“You’re always in the building throughout the day. You don’t get to see the little, simple things that tell you it’s going to be a good day,” she said, tears welling in her eyes at the memories.

She also worked night shifts (9pm to 8am). For every three of these shifts, she used to get a “sleeping day” to readjust her body clock, on top of her regular days off. But this was removed even before COVID-19.

“You didn’t get to rest and recharge before your next shift starts,” she said.

She often worked overtime. As a senior staff nurse, she oversaw 12 to 14 patients and had to manage complaints. She was also a clinical instructor mentoring nursing students.

Today, she often leaves work at 5.30pm. Her mood is “much better”, and she is “energised” for the day, she said.

If this trend for nurses going to nursing agencies continues, there is cause for concern, said Associate Professor Jeremy Lim of the National University of Singapore’s Saw Swee Hock School of Public Health.

“Staffing becomes more difficult and expensive, which cascades into higher costs for patients and, potentially, safety issues due to staff turnover and unfamiliarity,” he said.

Higher pay outside public hospitals was a strong pull factor for some. Farez*, a staff nurse who left a general ward last August for a private dialysis clinic, said he is earning more while the workload is less.

“(People who quit) don’t feel like they were paid for the amount that they worked,” he said.

Occupational therapist Ryan*, who left public healthcare last month after six and a half years of service, was offered a 20 per cent pay increase in the private sector. He was also told he would be “chased home at 5.45pm”.

“I now see about 10 patients a day. I get to spend quality time with them. I’m able to relate better, understand their needs more thoroughly and assist them throughout the recovery process so much more,” he added.

Before he made the switch, his daily case numbers during the pandemic had risen to about “19 to 20”, as there were more elderly patients whose physical function “fell quite a bit” after they contracted COVID-19.  

There are others who have quit just to rest. One of them is Tina, who has eight years’ experience. She said her patients’ growing demands, especially during the pandemic, had drained her.

For example, when visits were not allowed, her ward provided video calls as an “extra service” — which, in turn, patients “demanded”. “If we were busy, you had to wait a while. But there’d be people … shouting at us just to get the video-call phone to call their family,” she said.

She also felt recognition for nurses was lacking. Pandemic notwithstanding, Tina said she had patients asking her, “Do you even earn S$2,000 a month? You’re just a missy. You’re just wiping buttocks. Why do you need a degree for that?”

WHY THE REST ARE STAYING

Despite the overall challenges, many healthcare workers have soldiered on — together.

In her two and a half years in the oncology department of a public hospital, staff nurse Kelly* has had her share of bad days, but what has kept her going is her colleagues.

“That motivates me to come to work every time, knowing that I’m well supported by others working on a shift with me, regardless of the situation and demands of the day,” she said.

Sometimes they help to answer call bells from her patients on her behalf or start medications that doctors have ordered for her patients.

When manpower is lacking, especially with nurses coming down with COVID-19, her supervisors step out of their offices and work with them on the ground — helping with dressings and even feeding or showering the patients, she added.

This is a view echoed by Alex*, a medical officer in the emergency department of another public hospital.

“Sometimes when I’m unable to (fill in) a certain form or talk to a patient’s family, my nurses will say, ‘Don’t worry, I’ll help you.’ Or sometimes when nurses are busy and can’t check (patients’) blood pressure, I’ll tell them, ‘Don’t worry … I’ll do it,’” he said.

“Everybody is in one team helping to solve the problem … It’s a far nicer feeling than feeling isolated … facing all this shit yourself.”

WHAT’S BEING DONE

In response to CNA Insider’s queries about the attrition rate, manpower shortage and nurse-patient ratio, the MOH pointed to Dr Koh’s parliamentary speech last month.

The three public healthcare clusters, meanwhile, outlined efforts on the ground to retain staff and ensure their well-being.

The NHG said it aims to help staff achieve higher job satisfaction by automating manual tasks and empowering them to make decisions when redesigning roles. It added that it has stepped up efforts to monitor the well-being of staff, including their psychological health.

Staff at SingHealth have access to experienced medical social workers, counsellors and psychologists, coordinated by the SingHealth Staff Care Centre, “whenever they may feel distressed or simply want someone to talk to”, highlighted group chief human resource officer Esther Tan.

The cluster also has about 500 peer supporters who are “trained to extend emotional support to their fellow colleagues in times of need”.

The National University Health System (NUHS) has rolled out meetings in certain specialities whereby senior and junior staff can have “frank discussions about their emotions and feelings of vulnerability” in the clinical environment.

On the issue of leave, the NHG said staffing needs are managed through “advance planning and staggered rostering of leave”.

“This ensures that staff are able to go on leave by turns to rest and recharge or to return to their home country,” said Olivia Tay, its group chief human resource officer.

SingHealth, meanwhile, said the prevailing guidelines on overseas leave applications are largely “no different” from usual leave applications.

“As the Omicron situation in Singapore eases further, more staff will be able to resume some pattern of time away from work to rest and recharge, and for our foreign staff, the opportunity to return home to spend time with their families,” said Ms Tan.

As for recruitment, the NUHS is stepping up efforts locally and internationally, to “combat exhaustion”, and has introduced flexitime opportunities and part-time nursing schemes “where appropriate”.

Returning staff are also valued, said its group chief human resource officer, Priscilla Teo.

For example, some locum nurses who worked at its Community Care Facilities have joined the cluster full-time. There is also an “alternative workforce” comprising basic care assistants and student nurses who support its nurses in patient care.

At SingHealth, while recruitment efforts are in place, the cluster devotes “much more attention” to staff development, especially with the “insatiable global demand” for healthcare manpower.

Related:

'I haven't seen the daylight in ages': Pressure on healthcare workers as COVID-19 cases spike

LIGHT AT THE END OF THE TUNNEL?

Now with the Omicron wave waning, some healthcare workers said their working conditions have improved.

Janine*, a senior staff nurse in her 30s, told CNA Insider earlier this month that morale in her department, an intensive care unit, was “rather low”. But since then, things have started to look up — the lifting of restrictions has helped “in a big way”.

Some of her colleagues have taken leave and even travelled, including foreign colleagues off to see their families. “We have sufficient manpower now, so that means … no one’s getting a call back on their days off,” she said.

She had also been hoping that training opportunities would resume — in particular, courses to help her specialise in trauma. And she got her wish: Training sessions that were on hold for months have recently resumed.

In senior pharmacist Dean’s case, while the COVID-19 workload is decreasing, there is little respite. Manpower has yet to be replaced, and patient cases and projects that were postponed over the past two years are coming back “fast and furious”.

Since January, he has been able to take up to two consecutive days off. Anything longer than that, he said, is subject to balloting. And overseas travel requires approval from his head of department.

Still, he remains hopeful and looks forward to a time when the manpower issues can be resolved.

As for doctors, those CNA Insider spoke to welcomed the recent news about a national wellness committee for junior doctors, which will review and recommend changes to existing healthcare practices and guidelines to improve the well-being of junior doctors.

Singapore Medical Council guidelines stipulate that junior doctors may work up to 80 hours a week. But surveys showed that 20 per cent of them exceeded this stipulation, possibly owing to “the nature of clinical work in certain departments or exigencies of service”, Dr Koh said last month.

Now that the ministry is involved, Terry*, a medical officer in the general medicine department of a public hospital, is “hopeful that the committee will make a difference”.

“But with regard to whether (the recommendations) will be adopted and whether they’ll be enforced properly … only time will tell,” he said.

He listed two things that would help significantly: Mandated rest days that are strictly enforced and a “nationwide effort to move away from 30-hour calls”. This refers to doctors having to stay through the night at the hospital after their shift and continue the next working day.

ONCE BITTEN, TWICE SHY

Those who have left acute hospitals, however, said it is unlikely that they will return. “It’s a fulfilling job, but the amount of recognition doesn’t reciprocate the amount of hard work,” said Tina.

With plans in the pipeline to start a family, Lisa, too, is unwilling to endure irregular hours and shift work once again. “The hours aren’t friendly to working mothers,” she said, adding that as her husband is also a nurse, it would mean days when they barely see each other.

Farez is another who is contented where he is, at the private dialysis clinic.

“I might go back only if the hospital has a better staff to patient ratio and more protection for nurses,” he said, highlighting multiple occasions of “verbal abuse” from patients as one of the triggers for his departure. Some allied healthcare workers CNA Insider spoke to echoed this view.

Indeed, the NUHS said that besides the workload and working hours, a “significant part of staff burnout” is due to abuse, in person and online, and that it has “increased measures to mitigate risks”, without elaborating on these protective measures.

Related:

Hurting the hands that heal: Cases of abuse, harassment of public healthcare workers on the rise

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One way to take this forward, suggested Assoc Prof Lim, is to “very publicly punish” the people who abuse healthcare professionals.

“Yes, you’re under emotional stress,” he said. “But so are the nurses, and so are the doctors. I think people can take a lot more when they feel that their bosses have their backs.”

Another way to improve matters is to raise wages, he added. “We agree that nursing, physiotherapy and so on create a lot of societal value — then society should be prepared to pay.”

Last year, the MOH announced a salary increase of up to 14 per cent for nurses in the public healthcare sector, phased over two years. For allied health professionals, pharmacists and administrative and ancillary staff, the increase was 3 to 7 per cent of their monthly base salaries last year.

What is important, stressed Assoc Prof Lim, is that nurses’ salaries be benchmarked to their peers in other essential public services.

“For new recruits to any profession, it’s not what you’re paid relative to three or five years ago if you’d been (in that profession),” he said. “It’s the opportunity cost: If I wasn’t in nursing, would I be a teacher?

“Is a nurse with 10 years’ experience similar to a police officer with 10 years’ experience? A Singapore Armed Forces officer? That’s the sort of equilibration we should be looking at.

“And if the pay goes up, respect goes up.”

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