Ethical /moral points of view:

I really enjoy teaching in Singapore the array of different cultures and ethical / moral points of view always make me reflect on life and consider another point of view: Ethics and morality are often interchanged…. Some people confuse ethics and think that it is ethical standards or a code of ethics even religion, which it is not…there is a subtle difference between ethics and morals….. Ethics is how society views social structure where as morals are a personal characteristic which often includes a religious flavor…. However generally people use the terms to mean one and the same…. Let’s face it morals are influenced by our religious, spiritual, cultural, scientific or learned experiences. Ethics goes one step further than morality in the sense that we have ethical theories (Utilitarian & Deontology)and principles, such as autonomy, beneficence, non-malefence, justice and veracity. Peter Singer states “Ethics has no necessary connection with any particular religion, nor with religion in general."


Interestingly I believe as we get older we generally change our point of view…. I think with maturity comes an understanding and wisdom and letting go of idealism. I think back to the days when I was a nursing student at 18… young and idealistic; I wanted to save the world from its self… I was given this knowledge as a student nurse and it was fantastic…. This particular day I was working in a rehabilitation ward looking after an elderly man recovering from major surgery, taking his blood pressure…and suddenly there was no blood pressure… I looked at the man and yes he was grey, pale, he had just passed away as I was talking to him….my first instinct was to resuscitate him…..so I did… when the team arrived someone read his chart and said….”he’s not for resus so maybe we shouldn't be doing this” I looked up and continued for a few more minutes then stopped. The man had died. The matron who was a nun asked me to see her in the office….. I had no idea what I had done wrong…. She asked me why did you resuscitate the patient. I am embarrassed now by my answer…. But I said… “God has given me the knowledge to resuscitate this man if he wants him to die he will die anyway”. The nun just looked and me and said nothing…..As I look back I can see I thought I knew best…. Ask me what I would do today…. I would respect the patients request not to be resuscitated…. I am not saying all young people are like this but I do think as we get older our morals, values and ethical views change due to our life experiences…. That is just part of life and getting older……

As a health practitioner I maintain that you have to have a good sense of “self” in order to care for your clients. That is understanding your own moral and ethical grounding, this sense of self awareness allows you to understand why you react in the way you do and allows you to step back and not be judgmental in the care you are providing to the client. I must say I did not become self aware until I was in my 30’s.


As we know there is no right or wrong when it comes to discussing ethics; however when you focus on the hard issues such as capital punishment, abortion, organ transplant, euthanasia, genetic testing, and allocation of health resources the students came up with some pretty black and white answers, they are rather pragmatic about the whole issue. Singapore’s Medical Council is currently reviewing its code of ethics to keep in line with the advancing technological age (biotechnology) and the demand for organ transplants and genetic issues. This is an attempt to hold the health profession more accountable for decisions made within these areas.

Recently President Obama called on Americans to “expand our moral imaginations, to listen to each other more carefully, to sharpen our instincts for empathy, and remind ourselves of all the ways our hopes and dreams are bound together”. This was an attempt to defuse the abortion debate in America which often reverts to violence due to such opposing views. But the reality is we all worlds apart in finding solutions – everyone has their own idea about polices and justice. Often our moral imaginations are so divergent that never the twain shall meet.

When I asked the students how valuable do they consider human life within today’s society? Everyone said it is valued, and yes it is wrong to kill another human being; except if they have killed another person…..(Singapore has the death penalty) I then asked what about drug traffickers? They haven’t directly killed anyone. Again most agreed that yes they deserved to die because they contribute to someone else’s death or changed circumstances; even though they are really only the carrier or victim because the real culprit is rich and to clever to be caught….this was food for thought. So in essence the wrong person is being killed: In order to question the rules of society I then asked what about the woman who is stoned for committing adultery….(not in Singapore). In this instance the person that is being killed is the woman; the man did not get the same punishment. This did generate some discussion and most agreed that this was wrong……however most agreed with the philosophy that if some takes a life theirs should be taken.

Abortion always creates a debate…. No one can agree on this topic, I wonder if the world will ever reach a consensus on this; Pro Choice v Pro Life; with a multi-cultural, multi-religious class it was an interesting discussion at least there was a discussion and an expression of opinions however the divide still remains; does life begin at conception? Or when the fetus moves @ 16 weeks or when the fetus can live independently from its mother? Is abortion under 12 weeks acceptable? What about late term abortion for abnormality or not? All these questions need to be explored by the people and policy makers in a peaceful and respectful way.

The ethical debate will continue on many subjects, should the alcoholic or drug addict have a liver transplant, the smoker have a triple bypass, what if a prisoner for murder needs a kidney transplant.....Should the pregnant woman who is a drug/alcoholic be in prision?(as they do in America), I hope this never happens in
Australia, the list is endless... what is the individuals responsibility towards health care....rich v poor.... if you can't help yourself in improving your health care.... should the government support your treatment....? we are spending billions of dollars on health care.... what is the solution? the debate about health care resources continues.

Nursing in Tanzania:

The airport:

It is hard to know where to start with this blog... as there is so much to tell, therefore I think there will be several blogs relating to Tanzania; The main focus of the trip was to take 20 nursing students from five different universities to experience nursing in Tanzania. My first impressions were biased with a preconception of what things would be like, having already lived in Africa, however some things still were confronting and the total lack of resources, water, infra-structure (in rural areas) and medication still came as a surprise:


The process through customs, immigration is the usual for any African airport, slow, hot and humid, confusion as to which forms to fill out, eventually we all got through.... the main currency for Tanzania is shillings..... 1000.00 approx for each $1.00.... we changed some currency and got some local sim cards for our phones, we were met at the airport which was fantastic.... we were all bundled into cars and buses, with our luggage perched preciously at the back of the bus. Our hotel was about 35 mins from the airport, the first thing that struck me was the amount of cars on the road.... it did not take long to realise that they all drive like lunatics.... it was equal to Egypt which I thought have the worst driving in the world. There were hundreds of people milling around, over crowed buses and many street markets......


Health care in Tanzania is dependent on social status and level of income is the most predominant social determinant of health for people. This means access to clean water, sufficient food and reasonable health care. Health care access is further compromised due to issues of geographical location and distance to services as well as lack of resources and technology. It was interesting to note that everyone has access to mobile phones even when electricity was not available.


Our Hotel:

We arrived at our hotel ...... pleasant, clean, small, friendly staff.... the first thing I noticed was there was no bar fridge.... now I know what you are thinking....no not for alcohol... I wanted a cold drink of water.... alas this was to be one of my biggest complaints.... a must in a hot humid country....the availability of cold water and tea and coffee making facility.... minor things really, just shows how spoilt I am. Every day began at 0530... the bus collected us at 0645 to get us to both hospitals..... we would split into two groups, two supervisors and 10 students in each hospital: one to a private hospital and a government hospital.... then the following week we would swap. Mine was the government hospital first.... this was a baptism by fire.... it was a culture shock for all, I was a acutely aware of how the students would be coping, sights, smells, queue’s of people, sad hollow eyes watching our every move....we stood out like beacons in our stark white uniforms; at times I felt like the fish in the fish bowl..... Intruding into the lives of people I could not really make a huge difference to....We would attend the hospital handover, all given in English we would then go to our allocated wards.


I had to focus on the task at hand..... once orientated to the ward we would begin to assess the situation and decide how to move forward.... each ward had a notice board which listed the 10 most common disease and drugs used, together with the tasks for the day: There was no surprise to find No 1 condition in the medical ward was HIV (there are medications and treatments for HIV which was good to see), I learned about the finger test for HIV.... great idea quick and efficient, next condition was Malaria, hypertension, anaemia and diabetes: each ward (medical & surgical male and female) consisted of approx 30 beds, sparse furniture, a single sheet on the beds and some ceiling fans, however the wards were stifling hot.........patients bought in their own food and water; sometimes it was hard to know where to start.... so often I would get students to take vital signs, as this was something I knew they could do well and would start the two way conversation... however our Swahili consisted of “Jambo” – Hello, or “ Hujambo” – how do you do, “Jina langu ni......Pauline – my name is....


The nurses work very hard and are short staffed, often 1 RN to a ward, a couple of student nurses and nurse assistants; doctors milling around, completing ward rounds, barking orders, nursing assistants scurrying around to get tasks completed. There was often only one oxygen cylinder and the ethical decision would be who needed it the most... and sometimes someone would come urgently from another ward requiring the oxygen cylinder ..... what do you do?


The sister's desk:

The drug cupboard was sparse, patients are ordered medications and it is a pay as you get service.....the students coped remarkably well.... all equipment used for patients are paid for by the patient, such as IV cannula’s, drips, catheters, tests etc, everything we take for granted here.... it really makes you appreciate the excellent health care service we have.


We witnessed some interesting procedures and dressings, at times did some teaching as well as sharing experiences and ideas.... it was an interesting journey: documentation, nursing notes, filing cabinets, policies were all nonexistent in the literal sense.... there were two cardboard boxes... marked “discharge notes” a stark reminder of where we were....... Pain seemed second nature to patients....as well as lack of dignity and privacy due to overcrowding and lack of resources..... the hard working underpaid nursing staff and health workers, were not well respected......they do the best they can in these harsh conditions, always with a resolve that things would get better. Also acutely aware of how the situation must look to us the ‘foreign nurses’ apologising for the bad conditions and stating they just do not have enough staff or resources to treat all these patients.


I was amazed at how long people wait to see a doctor or nurse; they have walked for hours and sit patiently in the sun until they are seen, with not a word of complaint.... just happy to be seeing someone and getting some treatments. Our challenge was often to think of cheaper effective ways of treatments, dressings etc choices of medications were limited to bare essentials.......families assisted with patient care, feeding and bathing.......traditional medicines were popular and the stigma of HIV was an issue: I was surprised to see that bowel obstruction was very common – top 10 surgical conditions were: Intestinal obstruction, peptic ulcer, pyomyocties (infection of the muscle), hernia, haemorrhoid, hydrocele, osteomylitis, burns, diabetic wounds, and motor vehicle accidents (no surprise there with the driving we witnessed).

The nursing system is three tiered; enrolled nurses (2yrs training nurse/midwife), registered nurse/midwife (degree course 3yrs), diploma registered nurse/midwife (3yrs or 1yr after EN course): nursing assistant (2yrs – can go on and do diploma RN 3yrs); a diploma RN/M can go on and complete the degree course 3yrs – equal to 6yrs: Their scope of practice is wide and varied........the medical system is equally complicated: from medical assistants to degree MD’s. The graduation I attended had only 10 degree RN/M’s, 20 diploma RN/M’s and 40 Doctors graduating....... nursing is not considered a prestigious career, parents try to discourage their daughters from doing nursing if they are going to do a degree.......nursing assistants and diploma nurses usually complete form 1V (equivalent to year 10).


discharge notes:

The question I ask is how do we make a difference? Some of the students who travelled will travel again, they have all be touched by the experience, maybe two or three will go back to Africa and help make a difference; I think you need to stay in one area for a two – six month placement and introduce structures for change; working alongside our fellow nurses exchanging ideas and promoting change: providing mentorship, support for the new students, therefore providing for the future..... Fundraising for essential equipment (gloves, alcohol gel, fob watches, thermometers etc); now that this will be an ongoing project I am hopeful that we will be able to make a difference in some small way:


On our last day we met four first year nursing students, all straight from school, they were so young, full of enthusiasm, our students took them under their wing and taught them vital signs, it was delightful to see, gave them some text books, our equipment, stethoscopes, thermometers etc... and we wished them well. I have promised to keep in touch with one student and provide some mentorship from a distance. If I am to return I will ensure to follow her up.........This has been an incredible journey for me and I will be forever touched by the courage of the patients I have met and for some of the brave nurses I worked with....... I am eternally humbled from the experience.......I have met some fantastic students who are know RN’s and also have made special friends with the other supervisors from our trip........partners in crime.......next blog..... Midwifery!


Good luck to all my students (now RN's)as well as the new students starting....life is a continuous journey which we are all learning.....

RCNA offering freebee to student nurses.......

On reflection............It came to my attention when teaching the undergraduate nurses that the RCNA was offering free membership to student nurses.....now I pride myself on being pro-active and passing this enthusiasm onto the students... I thought what a great incentive for the students to have free membership to a professional body that offers them support, information, collegiality and professional support.... so I thought i would engage the students on a discussion about professional bodies and their usefulness and ask how many of the students had taken up the RCNA's offer of free membership.... to my surprise...not one of the 31 students had picked up on this fabulous offer.... this was a shock to me...when I asked them why...one said she didn't know what the RCNA had to offer her , 2 others said it was for a limited time and the rest just were not interested.... is this a sign of the times? or a societal problem... do our students get everything to easy...? or am I making a mountain out of a mole hill.... I don't think so. I think that this is apathy starting as a student....yes I know students have a lot of work...but so does everyone... or maybe it is that they really do not appreciate the benefits of belonging to a professional body... or is this the problem with nursing... how many doctors do you think would never consider belonging to their professional body? I wonder if they have this problem?
It begs the question, do nurses and student nurses really believe in the profession of 'nursing' and its professional body? what do you do to increase membership to professional bodies?

Teaching Nursing Ethics & Law – Singapore

It is great when you are passionate about your job/work because you give it 110% and it is so satisfying. I consider myself so fortunate to be able to go to Singapore every year to teach post-graduate nursing students an ethical and law unit. However in doing so I appreciate the enormous cultural diversity that Singapore has to offer and learn something new about myself, each trip. This year I was particularly tired and needed some time to recharge my battery. I know that seems a contradiction of terms, 12 hours of intensive teaching and time to recharge.... well it is about spending time doing what you love and doing what you want to do.... without fear or recrimination...... not having to please anyone except yourself.....it’s about finding a balance.


Strangely as a mother, you are always a mother you are never considered ‘anything else’ as you have roles and responsibilities within society. I find when I go away...... I can be ‘whoever I want’ time for ‘me’ without having to be anyone else. Don’t get me wrong.... I am enormously proud of being a wife, mother, nanna, and miss my family immensely when I am away, but miss being able to express me as ‘me’. I think that men get the better deal..... Because even if they are a father, it does not change how they are viewed within society.....they seem to be considered the superior sex and why because they are a man.....They seem to be able to do whatever, and it does not matter if they are a father or not.... they are just ‘men’. I am sure as hell going to come back as a ‘man’ in my next life.


I love the life style of Singapore.... it’s a vibrant clean city, with a low crime rate, taxis are like getting into a freezer and the people are polite. The choice of shopping is enormous and the shopping hours are extended late into the night.... as opposed to Perth’s draconian shopping hours & choices.


Singapore is a mix of an old colonial world (The Raffles Hotel for a Singapore Sling at extortionate prices but it has to be done, of course not a Singapore fling) and a modern city with a great MRT (underground rail system)...... the contrast is staggering at times and it’s such a romantic city, I can imagine a clandestine liaison happening, something straight out of a Barbara Cartland book... Singapore at Christmas time is beautiful..... Ian and I spent a pre Christmas here a few years ago... and this time it was even more beautiful... the city is lit up like a Christmas tree.


There are many, many temples, of which this trip I only visited one the ‘Buddha Tooth Relic’ Temple...... it has to be one of my favourite temples....spending time quietly sitting, watching, reflecting and admiring the exquisite beauty.
China Town is another favourite, with its bargains, massages and outdoor eating....


The Intercontinental Hotel is sheer indulgence..the staff are excellent... one more mix of old and new world Singapore...... having room service, is just sheer luxury..... And I love it.... Breakfast in the Olive Tree Restaurant with Mr Wong cooking your eggs just how you want them..... Watching business people wheeling and dealing over meals.... it really is a different world. I have to say the only thing I really dislike is the Humidity...... I don’t know why I put make up and blow dry my hair in the mornings because as soon as I step outside it’s like my internal body temperature turns on a tap and I am dripping wet...... not a good look.


My favourite shopping centre has to be Takashimaya and the Kinokuniya bookshop.... I also found the Harrods store in basement 2 of the Takashimaya Fantastic..... Ian will be disappointed..... Major purchases this trip....... pearls magnificent pearls...... couple of books both work and pleasure....kids silk dressing gowns. and a couple of electronic gadgets..... Not much really.


I get great satisfaction from teaching.... however the proof will be in the pudding when the assignments are ready for marking. Most of the students are enthusiastic, try very hard, and they work hard, I do admire the fact that they work full time and then come in for their classes after work or on the weekend for the lectures. I had a good uptake of students considering it is not compulsory for them to attend. It is challenging teaching professional issues, (ethics) in Singapore; there are several issues to be mindful of... namely different values and morals. Also fundamentally the attitude is ‘doctor knows best’ and nursing is viewed as a subservient role..... My aim is to empower the nurses to be evidenced based and not to be afraid to stand up for what they believe is right, to advocate for the patient together with empowering patients and not be paternalistic in their care. I managed to also visit a couple of hospitals this trip.... watch for the next blog....

Soooo busy marking papers! no time for blogging!

I am so busy marking papers I can not see the forest for the trees. I am dreaming case studies, law and ethics. Marking is fun when your students are getting it right - however marking is so much harder when they get it wrong, there has got to be a better way of testing knowledge. The biggest issue I am facing is incorrect referencing, paraphrasing or incorrect paraphrasing and PLAGIARISM, role on next semester when I will use a computer system that detects plagiarism for you. I am sure that will make both the students life and mine easier. I found this great site that helps you understand referencing, paraphrasing and plagiarism - have a look and pass it on to others who may be interested it is called The Owl at Purdue:
Must go, marking calls, the joys of lecturing/teaching.....................