Guest Editorial
SARS and the effect on nurse education in Singapore
Philip Docking
Lecturer, School of Health Science, Nanyang Polytechnic, Singapore
PP: 005 - 008
Article Text
Singapore is usually a transit centre. Many visitors come here each year but most are passing through, rerouting to another destination. Singapore has a population of around 3 million, plus 1.5 million expatriate and migrant workers. Many people know of Singapore, but it has recently hit the world headlines because of the SARS (severe acute respiratory syndrome) outbreak in Asia in the second quarter of 2003.
How has the SARS outbreak affected us in Singapore?
There has been a major impact on the whole of Singapore, especially the economy, tourism and health. From a nurse education perspective the impact has been great. There was a lot of uncertainty in the early days of SARS; however, once the mode of spread was established the government quickly put control measures in place. Many practices have been changed to afford better protection to those working in the front line. Parents were concerned that their children (our students) were being exposed to patients who were potentially infected by SARS. The Ministry of Education (MOE) decided on measures that would have the least disruption of teaching in higher education. Primary and secondary schools were closed for a short period to reduce the likelihood of spread. Large group teaching was stopped as a way of reducing the likelihood of mass transmission.
What did we do?
Within any crisis it is important to provide some sort of normality and the need for crisis management is clearly established in educational literature (Embry 1997; Bender and McLaughlin 1997). Senior management met on a daily basis and different ideas were brought out almost daily as a result. This was a time of uncertainty and change. Staff were required to attend weekly updates. In a time of crisis organisations can experience a 'crisis or loss of legitimacy' if they are not seen to act appropriately (Suchman 1995; Seeger 1986). What was appropriate? We were being pulled in a number of different directions at any one time. Concerned parents were calling the Polytechnic about the situation. Students also had some concerns and the Polytechnic was trying to ensure the educational process was only minimally interrupted. The press also became involved when a student went on air to voice concerns over the handling of the students' welfare.
Nanyang Polytechnic is the sole provider of education programs for Registered Nurses, Occupational Therapists, Physiotherapists and Radiographers in Singapore. A number of factors were considered before a decision was made, together with hospital managers, to withdraw all students, initially from the SARS receiving hospital; but very soon extended to ALL clinical placements. The coordinator of the SARS designated receiving hospital received daily bulletins which often meant that wards were being closed to admissions because of suspected SARS cases and to students for their own safety. Consequently students were reassigned to a different clinical placement. However, other wards were slowly being forced beyond their capacity with the number of students allocated to them. Additionally staff from all areas of the hospital were being deployed to the newly opened wards for SARS suspected patients. This meant that supervision for nursing students was diminished which could lead to errors being made. Consequently, the decision was made to remove year one students from clinical practice.
The year two and three students still remained in the clinical area. Keeping the remaining students informed and reassuring them as much as we could was essential for their welfare; parental concerns were high on the agenda. Fortunately few students reported sick. However, maintaining contact with the students who had reported sick was very important to ensure that they saw a doctor and they had not been in contacts with any suspected patients. As a precaution a few students were sent to the Communicable Diseases Centre (CDC) for follow-up. Fortunately most were discharged following tests. Two students were warded overnight then discharged the following day.
The main concern of the year two and three students was the need to make-up clinical hours. Within our nursing curriculum there is the stated minimum number of hours required to register as a practitioner with the relevant board. The shortfall between required hours and the actual practice hours has to be made up. Students were coming to the end of the year and it was anticipated that make up would be done in their holiday time. The year three students were particularly concerned as they would be graduating this July and as a consequence would not have time to make up hours.
The week following the removal of year one students from the SARS receiving hospital, the decision was taken to withdraw all students from this hospital. Some students were interviewed by the media about being in the hospital shortly after this and how the Polytechnic had supported them. Subsequently, senior management of the Polytechnic decided that no hours make up would be required for students removed from the clinical setting. Whether these decisions were appropriate remains to be seen. This was a war against SARS and a first for Singapore.
Our students were no longer allowed to visit the clinical areas. The resources, in particular the workforce, were needed by the hospitals to look after the patients. This meant that the clinical supervision of our students, particularly year 1 students, could be compromised. The added risk of contact with infected and potentially infected patients was also addressed by this measure. This also has had a massive impact on the teaching curricula. Additionally, as practice based professions, issues related to clinical practice had to be addressed.
The restriction on teaching group size spurred the generation of e-learning strategies. These increased from a minimum of 10% to 30% of teaching delivery platforms. Self directed learning (SDL) also increased. The number of lectures delivered had to be increased to accommodate all students getting the same information. We were approaching the run-up to exams; the question papers had already been set and printed. Some questions in the paper would ask about issues not covered yet by the teaching team. The tutorials carried on as normal but tended to be more intense as students required constant reassurance. We, as lecturers, had to ensure that students received sufficient information so as not to be disadvantaged by the changes imposed upon us. Students received lecture notes through the photocopy shops. They were also told to stay away from the Polytechnic if they had a fever or felt unwell.
Clinical education
How were we to give our students a touch of reality without the risk? This applied to 180 students who were unable to complete any clinical practice and required an end of year assessment.
Simulation was suggested as a possible alternative in the short term during the SARS threat. All we had to do was to make it happen. The lecturers managing this group of students met to discuss how we were going to turn an idea into a realistic option and from this, came the case scenarios which were used to depict the patients. Drawing on previous experience with a simulation affectionately called 'Ethel Skinner', case notes were prepared for 4 patients, to contain the pre and post-operative history. Students had 3 weeks to spend on the case and were assessed at the end of each week.
Examinations
Another role emerged for nursing lecturers on the campus of the Polytechnic. One of the measures to be put into place for controlling the spread of SARS was the taking of temperatures of all staff and students. We were coming up to examination time and this meant that all students would need their temperature taken before they could enter the examination venue (Fig. 1). Lecturers from the School of Health Science (SHS) were seen as the logical choice to take temperatures because of our experience. Consequently, lecturers from the other schools supervised our exams. Teams of lecturers from SHS were allocated to one of eight temperature taking stations (Fig. 2). These stations were staffed 2-4 times a day from 1.5 hours before the examination start time to 30 minutes after, to allow time for late comers. Before any one examination, between 200-500 students had their temperature measured at each station. Staff responsible for taking temperatures wore a N95 mask, disposable gown and gloves as a precaution.
When students first had their temperature checked they were given a thermoscan (tympanic) cover and asked to bring it with them for each subsequent examination. This assisted in saving scarce resources. Most students did comply. Those students who did not bring their thermoscan had their temperatures checked orally. The mean time for each student was about 20 seconds.
An acceptable temperature was <37.6°C tympanic or <37.2°C orally. Students whose reading was >37.9°C (tympanic) were given a red card and those in between 37.9°C and 37.6°C (tympanic) were given a yellow card, for identification. All these students were rested and rechecked after 15-20 minutes. Those still registering a temperature above 37.9°C tympanic or 37.6°C orally were sent home and advised to see a doctor. Students who fell in the middle were allowed to sit for the examination but in a separate venue, which had been previously reserved for the purpose. Before going home, students given a red card were asked to fill in a SARS health declaration form consisting of travel history and possible contacts with SARS suspected patients. These students would sit for their examination at a later date.
Despite the disruptions brought about by SARS and the extra precautions put in place, the examinations went smoothly with a student performance similar to previous years. The students themselves were quite happy about the extra precautions being taken even though it meant they had to arrive early for the exam. There were still a few, who arrived just after the exam had started. They still had to have their temperature taken. This has gone remarkably smoothly with only a few students being sent home.
Evaluation
Despite the disruptions brought about by SARS and the extra precautions put in place, the examinations went smoothly with a similar percentage of students doing well and not so well compared to other years. The students were very positive about the simulation and threw themselves into it. We had to ensure that the acting did not deflect from the objectives, and that the assessment was on the performance of the skills.
Although the incidence of SARS has diminished, this crisis has given us the opportunity to explore different ways of doing things which we normally do not think twice about. Therefore, good ideas and innovation have arisen as a result of this crisis. Nanyang Polytechnic has invested a lot of money, time and staff time to ensure that our campus remains free from SARS. All visitors have their temperature taken when they come onto campus. Staff monitor their own temperature before they come to work then a.m. and p.m. while at work. Students now pass by thermal imaging cameras whenever they come onto campus. Other measures are underway for the start of the July 2003 semester.
References
Bender WN & McLaughlin PJ. (1997) Weapons violence in schools: Strategies for teachers confronting violence and hostage situations. Intervention in School and Clinic 32(4), 211-216.
Embry DD. (1997) Does your school have a peaceful environment? Using an audit to create a climate for change and resiliency. Intervention in School and Clinic 32(4), 217-222.
Seeger MW. (1986) The Challenger tragedy and search for legitimacy. Central States Journal 37, 147-157.
Suchman MC. (1995) Managing legitimacy: Strategic and Institutional Approaches, Academy of Management Review 20, 571-610.
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