In a first among hospitals in Singapore, Enrolled Nurses at Singapore General Hospital (SGH) can now look forward to expanded roles in Operating Theatres (OTs). They are being trained to assist in selected functions, such as the retraction of tissue in breast surgeries, holding the camera scope during minimally invasive surgeries, and assisting in the changing of burns wound dressings and superficial skin grafting procedures in the Burns Operating Theatre.

Ms Regina Png is a Principal Enrolled Nurse at SGH. For the past 17 years, her key responsibilities as an Enrolled Nurse have been largely administrative in nature, including reception duties, preoperative and circulating nurse duties in the OT.

Seven years ago, Ms Png was offered the opportunity to upskill and take on some clinical care duties. She started off by helping to hold the camera scope for minimally invasive surgeries, such as laparoscopic hepatobiliary (HPB) procedures – a task that used to be performed by the Medical Officers (MOs) on the team as it required steady hands and an understanding of the peritoneal cavity.

After undergoing a six-month training period that included both lectures by Clinical Instructors and on-the-job training with the senior OT nurses and surgeons themselves, Ms Png was ready.

Her first time holding the scope was a nerve-wrecking and memorable experience. "I was so nervous, but I was reassured by the close support and guidance from the Surgeon and OT Nurse."

Ms Png has since gained plenty of experience, and has become well-skilled at holding the scope at the perfect height and location. "The surgeons now ask me if I would be the one rostered to hold the camera for them at the surgery the next day. This was really a boost of confidence for me, knowing that they valued my help and that I was contributing directly to patient care as part of the surgery team," she said.

Bridging the Gaps in the Operating Theatre

The possibility of expanded roles for the Enrolled Nurses started off as conversations between Deputy Director of Nursing Goh Meh Meh with some surgeons about the manpower difficulties they were facing in the OTs.

Identifying the Enrolled Nurses as an untapped pool of trained nursing staff to simultaneously meet manpower needs in the OT while creating sustainable efficiencies in the workforce, Ms Goh and the surgeons got down to work to make this happen.

One of the surgeons who was instrumental in bringing the plan to fruition is Dr Veronique Tan, Head and Senior Consultant of Breast Surgery in SGH. "Our nursing leadership in SGH Major Operating Theatre (MOT) developed systematic structured training and accreditation, and made changes in rostering to empower our Enrolled Nurses to take on the expanded roles," explained Dr Veronique.  

Senior Nurse Manager Oo Cheng Sim added, "Our Enrolled Nurses have really gone over and beyond meeting manpower needs in the OT, especially during COVID-19 in 2020 when the doctors were deployed to the dormitories, and we faced shortages in the breast surgery teams to carry out breast surgeries."

Dr Veronique agreed. "It was really remarkable in the way we came together during a time of need, and found a possible solution to rethink team and work models to increase capacity. The role expansion initiative was shaped with so many willing hands and hearts, and with open minds."

Today, more than 18 Enrolled Nurses are benefitting from the expanded roles, and their contributions have supported the surgical doctors in providing more timely and optimal patient care.

Workforce Development Enabled by Thorough Training and a Culture Receptive to Change

Coming up with these expanded roles for the Enrolled Nurses was one thing, but gaining the trust of everyone on the OT teams was another. After all, the teams in the OTs were very used to functioning in set roles that stretched generations back.

Fortunately, it was not too difficult to get everyone onboard with the change. And this, Ms Goh pointed out, had a lot to do with the surgeons themselves, who played an immeasurable role in setting the tone right.

 "The surgeons were extra nice to the Enrolled Nurses, which really helped to put the nurses more at ease. These actions also signalled to the rest of the team, from the ground staff to the other nurses to the doctors, to be welcoming."

Clinical Instructor Marhaini Bte Mohd Zain also emphasised the importance of training, receiving ongoing support while on-the-job, and competency assessments as crucial elements in ensuring that the Enrolled Nurses had gained the skills they needed to perform the new tasks well. This was also instrumental in gaining the trust of everyone on the team.

"Our Enrolled Nurses are already trained to perform basic nursing duties, so we are not starting from zero. We could focus on training them specifically in OT skills such as instrumentation, scrubbing in, gowning, gloving, and surgery safety," Ms Marhaini said.

She added, "What we really wanted for our Enrolled Nurses was to receive training by the experts themselves. For example, being able to hear from the Breast Surgeons or observing the Burns OT Senior Staff Nurses (SSN) change the patients' dressings, helped them learn how to perform these tasks efficiently and accurately."

Empowering Staff to Work at Top-of-License to Future-proof Workforce

With fewer Enrolled Nurses entering the workforce every year, SingHealth has its sights set on equipping its Enrolled Nurses to work at the very top of their licence in other potential surgical assistant roles.

The benefits are multi-fold, explained Ms Oo. "They feel a great sense of satisfaction from being able to contribute to the team. Many of them aspire to become Registered Nurses in the future, and having these expanded areas of work prepares them for that."

Enrolled Nurse Nur Sarah Indah Binte Nasir, who will be embarking on her Diploma in Nursing next year, wholeheartedly agreed. It is her dream to become a transplant nurse someday, and to her, every bit of clinical experience gained in the OT counts.

"Taking on the expanded role of assisting with breast tissue retraction in the OT is an achievement for me and makes me feel like I'm one step closer to realising my goal," she shared. "There is also that sense of satisfaction of contributing directly to the team's efforts."

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