Daryl Lim, LL.B (Singapore)
Abstract A new national action plan is needed to articulate the direction of healthcare in the new millennium and ameliorate the nursing shortage. Without a proper understanding of how labour statistics relate to deeply entrenched barriers, current short term solutions will only serve to sabotage future efforts. In order to raise nursing professionalism, three changes are suggested. First, there is a need to replace top down management with participatory management. This must be done through a redefinition of the nurses’ role at the ward level through specialisation and autonomous decision making. Second, changes should be made at the policy making level by realising the full leadership potential of nurses at the very top of the hierarchy as well as fairer representation at the Board level. Third, it must be done through developing better clinical practice and creating conducive environment for nurses to continue their nursing education. Key words : nursing professionalism, specialization, autonomous decision making, leadership, representation
Introduction Singapore falls amongst the ranks of developed countries faced with a shortage of nurses. Nurses, who form the largest proportion of healthcare workers in these countries, are shrinking against a rapidly increasing demand for more sophisticated and prolonged healthcare services as their affluent populations live ever longer (Steinbrook 2002). Studies indicate that the fewer the nurses, the greater the likelihood of adverse patient outcomes (Needleman et al 2002). With a rapidly greying population accompanied by a rise in the prevalence of complicated long term illness, it is critical that the Singapore healthcare system has an adequate pool of appropriately prepared nurses as its bulwark. Thus far, the government has focused primarily on increasing the existing pool of workers by economic policies. While these measures go some way to alleviating a health care crisis in the short term, studies and the experiences from other jurisdictions have conclusively shown a self-sustaining nursing workforce can only come about first through a thorough re-examination of the profession itself, and subsequently through a reexamination of how it relates to the healthcare industry. This was recognized to some extent by the Ministry of Health (MOH) when it set up a Nursing Task Force in 1997 to review the role of nursing in Singapore (Premarani 1999). The Task Force Report (the Report) made three main recommendations. This paper begins by examining recent policies aimed at ameliorating the shortage through quantitative means. It then examines evidence suggested by studies advocating a qualitative, rather than quantitative approach to the problem. Next, the principles underlying the Report’s three recommendations will be developed with a view of tackling the qualitative barriers to nursing. It is suggested that a re-definition of “nursing” is what is needed to stem the labour haemorrhage. This will in turn revitalise the market competitiveness of this noble profession. The author would be the first to admit that issues raised within the narrow confines of this paper cannot receive the thorough analysis they deserve. There is a dearth of local research in this area, and what little writing is available is painfully brief and often fragmented. Most of the information was sourced from the Singapore
Nursing Journal (SNJ) and its predecessor, the Professional Nurse (TPN). Where possible, informational gaps were filled by visits to the institutions or direct correspondence with the key office bearers in MOH and elsewhere. Residual gaps were simply filled with informed deduction. Nonetheless, it is hoped that these etchings will prove useful to those interested in further work.
Money and Manpower: Inappropriate Infusion? The developed world is facing one of its greatest health crises in recent memory. According to Dr. M. Kingma (2002), consultant to the International Council of Nurses (ICN), most hospitals in the United States (US) face position vacancies of 10-15%. Enrolment rates have declined by 13.6% from 1995 to 1999. If allowed to continue, this trend will result in a 29% shortfall in supply of nurses by 2020 (Manino). Similarly, experts in Canada, Switzerland and the United Kingdom (UK) project massive nursing shortfalls of up to 50% based on dwindling recruitment figures and high turnover rates (Kingma 2002). In Singapore, a report in 2000 noted that over the next 4 years, 3,000 additional nurses would be needed. The 500 nurses per year recruited at that time would lead to a shortage of 2000 nurses by 2003 (Hahn 2000). In response, the Singapore government has focused its efforts in two areas, both economic. Its first strategy was to increase wages. Nurse salaries across the board were revised upwards by 13% in 2000 at the cost of $33m (MOH 2000). In addition, allowances were also increased to provide incentives for nurses to perform more demanding, round the clock duties (MOH 2000). Intriguingly, the same report noted an increase in doctor’s salaries by a significantly higher 22%. This raises difficult issues on the perceived value of different classes of healthcare worker which seem to permeate every level of later discussions. However well-intentioned, the thrust of these monetary incentives were sadly off target. A local study conducted after the wage increase observed that an overwhelming 86.3% of nurses were still dissatisfied with their salaries (Tan 2004) . This move shadowed a failed attempt to solve the same problem in 1982 through general pay increases and night duty allowances in steadfast belief that “these material inducements are necessary to fill the shortage of nurses” (Wan Hussin Zoohri 1982).
A parallel study by Willian Mercer Inc in the US found that nurses leaving the profession were significantly more dissatisfied with their narrow responsibilities, career prospects and workload than with their wages (Kingma 2002). That is not to discount the importance of financial incentives. In fact, there is no question about the need for pegging nursing salaries at competitive levels as is currently done with other professions. However, financial incentives must be explicitly linked to varied education and practice competencies nurses bring to patient care. To compete as an attractive professional destination, nursing institutions must recognize and reward these differences by defining nurses’ roles, and by utilizing and compensating nurses according to their different education levels and competencies (Singapore Legal Service). The government’s second strategy was to increase the worker pool. At the entry level, MOH ordered an increase in the number of student nurses. Nanyang Polytechnic (NYP) had to increase its student intake from 450 in 1997 to 850 in 2003. The intake at Institute of Technical Education (ITE) more than doubled from 136 in 2000 to 360 in 2004. Prima facie, it appears that there will be sufficient students graduating locally to meet demand. However, a recent article noted that the drop out rate was as high as 10-15% (Lim 2002). Further, there are a significant number of graduates who opted out after a few years of practice. This can be deduced from official statistics. From 1980 to 1990, the proportion of non-practising nurses remained relatively constant, increasing only marginally from 14.0% to 14.4% (see annex). However, following the transfer from the registered nurse (RN) course to NYP and ITE in the 1990s, this figure shot up to 21.1% in 2002 (see Annex). This should not be surprising. With increased interaction with peers from various disciplines, nursing students are more aware of non-nursing job opportunities, especially in the service industry where interpersonal skills developed during ward training would be highly prized. If the graduates of these nursing programmes are not being meaningfully integrated and retained, they would naturally seek to work elsewhere. This correlation, while inconclusive, ferrets out issues worthy of closer examination. More controversially, there is a drive to recruit foreign nurses en masse. While a minority are given scholarships
for the diploma course at NYP with the six year bonds, a majority are qualified nurses engaged on biannual contracts. (Ang 1997). The proportion of foreign nurses doubled from 9% in 1995 to 18% in 1998 (See Annex). In 2002, the figure bloated again to 20.8% (see Annex). In the private sector, figures are as high as 28% (Lee 2004). Justifying the surge, the government explained that if the healthcare industry did not get skilled workers, it will not be able to grow to meet demand (Goh 2004). The figures look set to rise with the newly announced Spass s cheme raising the foreign worker cap to 35% (Goh 2004). Despite the official rhetoric expressing reluctance at the massive injection of foreign workers, there is every financial incentive for healthcare institutes to prefer foreign nurses to local ones. Foreign nurses usually originate from poorer neighbouring countries and are more willing to do a broad range of tasks, including many which their more educated and pampered Singaporean counterparts would consider menial. Rather than employing expensive and “picky” local nurses, it would simply be more cost effective to opt for acceding foreign workers. In fact, statistics show a curious correlation to the number of local nurses not in active practice and the number of foreign nurses. In 1997, there were 2,300 foreign workers or 15.6% of the nursing population. In 2000, this figure rose to 3,156 or 19%, corresponding to a rise in the number of non-active nurses to 3,518 or 21.2% (see Annex). This suggests that the foreign nurses did not come to supplement the local nursing force; they came to fill the empty ranks of deserters. If those local nurses can be re-recruited, Singapore could have a healthy and sustainable workforce. Further, the number of foreign nurses should be capped well below 10%, so that hospitals will not simply take the simpler and cheaper option to meet short term needs at the expense of long term sustainability. It cannot be denied that the government has identified this problem, and even attempted to woo the deserters through a “Return-to-Nursing” scheme. However, the success of this scheme speaks for itself: a grand total of 15 nurses were re-trained under this initiative in 2000 (MOH 2000). A more recent government initiative was to recruit midcareer workers retrenched during the recent recession through an accelerated diploma programme (Lee2004). While this doubtlessly has much merit in bringing mature
workers with the benefit of experience from the various sectors into nursing, the trickle of 100 trainees fro 2004 are hardly significant to replace the outflow (ST 2004). It is important to remember that healthcare independence gives a measure of sovereignty that is no less critical than areas such as defence or foreign affairs. Foreign nurses in Singapore possess skills highly sought after worldwide. How different is relying so heavily on this group of people who do not have a stake in Singapore’s future from peddling other security sensitive jobs on the open market? If anything, depending so heavily on foreigners tethered here only by flimsy twoyear contracts appears an even foolhardier choice . Concerns have also arisen within the nursing community that foreign nurses bring cultural peculiarities that may create conflict. While small numbers lead to constructive cultural cross-fertilization, the large proportion of 20% may seem more like an unwelcome insurgence into local hospital culture (See Annex). With new foreign nurses being flushed through the hospitals every two years, it is difficult to see how they can both adapt and be competent in general nursing skills, much less specialist skills that are increasingly required for nurses here. More than 20 years ago, the Health Minister then had warned against precisely such an approach: “At the upper end the demand is for an increasing number of highly skilled nurses to be members of specialist teams. The acquisition of extra skills through advanced training provided in hospitals will enable our nurses to keep in step with sophisticated developments in the clinical fields. But the rapid turnover of nurses does not permit the training of adequate numbers to meet this increasing demand” (Howe 1982). Reliance on foreign labour is at best a temporary tourniquet to the nursing shortage. However, it is equally clear that the current dependence on foreigners to sustain the local healthcare system will plague us for several years to come. This is not peculiar to Singapore. The UK reported a 27-fold increase in foreign workers over the last decade (Lee 2004). Organisations representing doctors, nurses and patients in the UK have uniformly expressed that “without them, the healthcare system would be in chaos” (Lee 2004). Locals can and must be attracted back into the workforce. The government’s attempts at infusing local blood have fared poorly, not because their targets have been off.
The retrenched, the deserters and the students all are fully viable sources. Yet there seems something taht almost inexplicably repels them from entering and building a career in it. In 1982, the Minister of Health admitted “the shortage or nurses is not a problem that can be solved by simply recruiting and training more nurses. We must study the cause of that shortage” ( Howe 1982). Pay increase and foreign recruitment are often for short term improvement only. It is pertinent that nursing explores other long-term strategies. It is not possible to isolate single factors or solutions. Rather... it is critical to include the systematic issues in education, health delivery systems and the work environment. Further, the impact of legislation, regulation and technological advances must also be considered. Failure to consider the relationships among these aspects limits the full appreciation of the nursing workforce shortage complexity (Singapore Legal Service). The cause of that shortage does not lie in a single factor, but interconnected strands deterring those without and driving out those within. While it is difficult to find an end point in the quest to end the nursing shortage, it is possible to start at points that would most likely lead to that result. A study by the sociology department at the National University of Singapore (the NUS study) (Ayre 1994) as well as a more recent one done by MOH (Tan et al.2002) both came to a two important conclusions. Firstly, the development of nursing professionalism is hindered by nurses themselves, the organisations they work for and broader social and healthcare policies. Secondly, that this in turn contributes toward harsh working conditions, a high turnover rate and an unfavourable public perception of nursing. Against this backdrop, we turn next to the report’s recommendations for a thorough re-examination of the nursing profession in Singapore.
Demystifying The Nursing Haemorrhage The report made three recommendations: firstly, for RN to be cultivated into “lead agents” of healthcare, and the enrolled nurses (EN) trained to play a complementary role; secondly, that the Singapore Nursing Board (SNB) be transformed into a statutory board and given greater autonomy to regulate professional standards in Singapore. This change included changes in its composition to reflect more diverse views.
Thirdly, that the training for ENs to be transferred from the School of Nursing (SON) to ITE. This would mirror an earlier move fro RNs to diploma courses at NYP and create an integrated system for educational programme. Three corresponding principles may be deduced. First, nurses must be individually empowered through a redefinition and enlargement of the scope of nursing competence. Secondly, nurses must be collectively empowered through a representative authority, and through it, influence the nursing policies in particular and healthcare policies in general. Thirdly, that mainstreaming nursing education with other disciplines is critical in enhancing its competitiveness.
To the public, nursing is a vocation rather than a profession (Friss 1994). It is the manifestation of a mother’s care in the hospital setting. Disillusioned by the unattractive nursing career structure with little prospect for promotion, many quickly leave, contributing to the high turnover rate ( Tan et al. 2002). Nurses’ responsibilities should increase in tandem with their preparation and training and leave the less specialised areas to the health auxiliaries. Their desire to care for patients should not be reduced to basic care. On the other hand, while there is much merit in developing the nursing competencies, the effectiveness of such policies should be closely monitored.
A) A Re-definition of “Nursing”: More than a Calling
1. Expanding the Nursing Role
For too long, nurses have been relegated to the role of the physician’s handmaiden. In addition, sexual stereotyping by the community and internalization of their noble but lowly status by the nurses themselves has led to perpetuation of the status quo. Established in the Crimean War, nursing acquired a high profile in the Civil War and came of age during World War I. It has been suggested that these military roots explain why nursing has a tendency to concentrate on completing tasks and following rules rather than developing a egalitarian partnership with doctors (Friss 1994). Further, nursing is a heterogeneous profession. Florence Nightingale, an upper class woman, established a rigorous hospital-based training program that concentrated on building character. The heterogeneity of the nursing workforce was perpetuated as many young women from lower-income families who did not want to teach chose nursing rather than domestic work to support themselves, while women from upper class families were attracted to nursing because it allowed them to lead an independent life. With abundant career opportunities for the modern woman, nursing no longer holds the allure it did for her forebearers. Instead, the model of female servitude that has persisted to this day within the healthcare system is an ominous deterrent to potential nurses. The NUS study shows that nurses in recent years still feel trapped in their roles as the doctor’s handmaiden (Tan et al. 2002). Notably, 75.9% of nurses polled perceived nurses as incapable of independent decision making (Tan 2004).
Nurses work in ways defined for them by traditionally dominant groups within the health system (Clare 1993). Often, nursing is regarded as subservient to medical care and playing a relatively unimportant role. Unfortunately, many nurses opt to perpetuate these norms, impeding their own professional development often at the expense of the interests of their patients. In the US, nurses are under a duty to follow doctor’s orders whatever the local or national standard. If a physician instructs a nurse to perform a certain action and the nurse fails to do it, resulting damages will be charged to the nurse’s negligence. The corollary is true. In Moore v. Carrington (Ga 1980), an emergency department physician and nurse failed to resuscitate a child. The hospital could not be held liable for the fault of the physician because he was an independent contractor and not an employee. Neither could the nurse or the hospital be held liable because she had done as the physician had instructed. Consequently, only the doctor could be held liable in line with the doctrine of responeat superior. This obligation thus becomes the nurse’s shield when the nurse performs as instructed with a negative outcome.However, it also becomes her crutch, perpetuating the role of nurses as a handmaiden. More importantly, it encourages irresponsible obedience even when the nurse might know better than the doctor. There is another disadvantage of treating nurses as vocational employees rather than independent professionals. It makes both nurse and hospital more susceptible to litigation. This is because it is easier and more tempting for potential plaintiffs to use the nurse as
a conduit to inpute a vicarious relationship, adding the hospital with its deep pockets as a defendant. (ICN 1999). Increasingly, states in the US have made it illegal to fire nurses who oppose to comply with conduct she reasonably believes to be illegal. This protects a nurse who opposes the reasonably believed illegality of malpractice, and encourages nurses who suspect or know that the physician has failed to treat the patient to remedy the problem (Gic 2001). The precise position here is unclear. A survey of local cases, legislation and health reports reveal that no official position has been taken. However, it would be unsurprising that the doctrine of responeat superior flourishes in local soil, with its strong culture of nurse endorsed medical paternalism. In a bid to develop nursing autonomy, the Report recommended introducing nurse clinicians as an alternative path for nursing career advancement to nurse educators and nurse administrators (Premarani 1999). Specialty nursing practice has emerged as a result of both rapid changes in the health care system and the efforts of professional nursing organizations. This lead to a restructuring of the profession to make it more challenging by encouraging the growth of specialists, case managers and trainers in 2000. A study in the US concluded that nurse practitioners, the equivalent of nurse clinicians, render care that is equivalent to the quality of care offered by physician. With regard to prescriptive practice, it reported "no difference between nurse practitioners and physicians in the "adequacy" of their prescribing practices" (Safriet 1992). Furthermore, nurses in an advanced practice role not only provide equivalent health care, but their services have been identified as cost-effective. (McGrath 1990). Access to the nurse practitioner has reduced health care spending because they offer equivalent physician services at a lower cost (Safriet 1992). For example, estimates indicate that 50% to 90 % of the services provided by physicians could be rendered by primary care nurse practitioners at significantly lower cost. In 1992, the State of New Jersey amended legislation which defines advanced nursing practice and expands the tasks which may be performed by a certified nurse practitioner or clinical nurse specialist to include prescriptive authority within this broadened scope of practice (New Jersey Nurse Practice Act).
It is submitted that the US counter-initiative toward recognizing nurse autonomy are worth a lcloser look. There is much to be said fro developing specialisation by nurses in various expertise. This not only makes their skills more valuable to healthcare institutions (Tan et al. 2002), it serves the interests of professional development as well as reducing health care expenditure. If this is right, then legislation should also reflect the expanded nursing role. This calls for an examine what “nursing” means in the local context. “Nursing” is defined by section 26(2) of the Nurses and Midwives Act (NMA) (Cap 209): "act of nursing" means an act of nursing in — (a) the observation, care and counsel of the ill, injured or infirm; (b) the maintenance of health or prevention of illness of others; or (c) the supervision or teaching of nursing, the proper carrying out of which requires skill and knowledge acquired by undergoing an accredited course of nursing or an equivalent course. During Parliamentary debates over the Act, section 26(2) was criticised as being “nebulously broad” (Chiang 1999). Indeed it is so. Duties found in subsections (a) and (b) in their plain meaning do not vary significantly from what is expected of any parent. This must be read in the context of section 17 of the Medical Registration Act (MRA). Section 17 defines the practice of medicine broadly and exclusively reserve the performance of medical tasks to physicians (MRA Cap 171). As the scope of nursing practice expanded to include tasks that were previously exclusive to the medical profession, the restrictions placed on nursing by the combined effects of section 26(2) of the NMA and section 17 of the MRA becomes increasingly untenable. Accordingly, the scope of nursing duties found in section 26(2) should be expanded to include the core duties covered by case managers and clinicians. This may routinely include the competencies to give diagnosis and prescriptions. As one commentator noted, there can be little doubt that most nurses, with adequate preparation, would be more than capable of undertaking a wide range of clinical skills more commonly associated with doctors, such as venepuncture, treating common ailments and prescribing medication. However, if nursing is to advance and patients are to receive the highest possible standards of nursing care, nurse experts must become experts in nursing,
and not tasks that doctors no longer want to do for themselves and yet do not wish to fully relinquish (see Annex). It is worth mentioning that courts should be slow to find a single standard of care for negligence in interpreting this section. With increasing specialisation and diversification of roles, the nurse today is no longer a generic profession. For example, a nurse anaesthetist would be expected to fulfil higher standards that a general registered nurse would not. Therefore, a more sensitive approach should be taken toward determining liability. In the US, the American Nurses Association has produced guidelines suggesting appropriate standards of care that courts will rely on to determine how a reasonably prudent nurse should act (Premarani 1999). Nurses who bear greater duties should also be prepared for a correspondingly enlarged sphere of liability. Unless nurses are prepared for this, it will be difficult to justify greater autonomy and professional status they desire.
2. Balancing Specialisation with Wholistic Care: Nurse Clinicians and Case Managers If nursing practice is to be expanded, then a principled balance must also be found. With an increasing number of medical specialists in Singapore, many patients are being treated symptomatically. Specialised nurse clinicians may aggravate the situation. The increase in nurse clinicians within a static labour pool comes at the cost of reduced occupational mobility, leading to care being fragmented amongst various specialities. Patients therefore get pushed from one station to another, often without any concern for their affective needs. Nursing care becomes mechanistic with the high degree of specialisation, offering the clinician little satisfaction in seeing the patient through his course of treatment. Case management provides a solution to this. It allows health care to be co-ordinated across a continuum (Tan 1997). Case managers co-ordinate the personal delivery service by developing care plans for patients through collaboration with other healthcare staff. This increases opportunities for autonomy as well was professional recognition, as these nurses work more closely with both doctor and patient. Doctors can be a liability when there is a disjunction between his official authority and his actual knowledge. Often, nurses know more about the case than the doctors in charge, and are better collaborating
with other healthcare providers (Clare 1993). A synergistic relationship between manager and clinician would allow the creation of strategically planned specialised care, and will become increasingly critical in light of a worrisome local development. Singapore is the fastest aging country in Asia. By 2030, one in five will be above 60 years old, compared to one in ten presently. As more people suffer from chronic illnesses needing help to manage their diseases there will be a greater need for case managers and nurse clinicians to collaborate in developing community nursing skills (See Annex). To date there are only 120 case managers and few nurse clinicians (Lee 2004). Many more generic nurses need to be groomed to take on more of these professionally demanding roles. However, local nurses themselves are an aging group. Current demographics paint a deceiving picture. In 1997, prior to the mass foreign recruitment exercise, the number of nurses below 30 were 2,877. In 2002, this figure rose to 4,298, while the number of non-practising nurses continued to rise from 2,227 to 4,031 in the same period However, of the foreign nurses, only 5.6% were over 50 years of age, in comparison with 23.5% of locals (Tan 2003). Once more, the spectre of foreign dependence arises. Singaporeans are increasingly leaning upon a pillar of foreign nurses, rooted here only by their short term financial interests. Since many of them are below 30, they are likely to be single, and therefore geographically mobile. Aging European nations already offer far more lucrative deals, both in terms of remuneration and working conditions. Yet, why have we have not seen an exodus? Many foreign nurses come from China and South-east Asia. Except for Filipinos, many often struggle with simple English, lack proper professional training and culturally uncomfortable with making a quantum leap into what is literally, a new world for them (Tan 2003). Singapore is therefore attractive as a transit point. Nothing more. Nothing less. One solution would be to intensify efforts to groom local nurses to be case managers and nurse clinicians, leaving generic nursing to the large number of foreign nurses on short term contracts. This will allow proper training of local stakeholders in the healthcare system without compromising on generic healthcare, since manpower and expertise will remain unchanged.
This will also allow the large number of foreigners to continue to filter through our healthcare system every few years without compromising the quality of healthcare.
B . R e p r e s e n ta t i o n : Vo i c e s U n h e a r d The NUS study reveals that the limited ability of nurses to influence policies that affect them stands as a key barrier to professional development (Tan et al. 2002). Two institutions dominate the nursing scene in Singapore: the first is SNB, whose task is to accredit all courses providing qualifications in nursing and midwifery and maintain professional standards. The second, is the Singapore Nurses Association (SNA), the only nongovernmental body representing nurses in Singapore. Because of their key roles in nursing interests, it is vital that both co-exist in a dynamic relationship. Policies at the top should be made with a fair representation of different nursing interests from different sectors of the profession. As these policies trickle down the various hospitals and nursing schools, feedback and fresh proposals should be fed back up for consideration. This will create a virtuous cycle of good governance. Following the Report’s recommendation, SNB became a statutory board in 2000 under the Nurses and Midwives Act. This was to give it greater flexibility to respond swiftly and effectively to changing healthcare and societal needs as well as the needs of the profession. Unfortunately, this new entity carried a relic of the past: a doctor was Chairman again. This is not a trite observation. Indeed, the issue dominated much of the Parliamentary debates when the Bill was presented by the Health Minister. Members rose consecutively to speak out against this wholly inappropriate appointment of a doctor as head of a nursing board. It was noted that in Australia, New Zealand, the UK and US all have nurses as Chairman. A similar practice here would be “logical and in line with practice in other professional bodies” (Neo 1999). This echoed an earlier observation by the former President of SNA: “Changes recommended include the composition of the SNB. It should not be chaired by a doctor. Whether SMC would allow a nurse to chair. Statutory regulation should be parallel to other professions” (Kong 1993). Brushing aside this recommendation, the Minister stated that there were “great advantages in having the
Director of Medical Services (DMS) as Chairman” (Lim 1999). It was most regretful that he failed to give any reasons to substantiate this broad assertion. However, he wisely conceded that it was possible that the future Chairman could be anyone “who would lead the Board effectively”. With all due respect, this is unsatisfactory. There is tremendous iconic significance in the office of Chairman in an organisation like SNB. It is the body regulating nursing practices and to a large extent, nursing policy, since SNB is conjoined to its sister Nursing Policy Unit at MOH at their heads, with the Chief Nursing Officer holding the post of Registrar in SNB and DMS as its Chairman. This is more than a simple choice of hairdos. If nursing is to break free of the manacles of physician servitude, it must happen at the top. Nurses must not only be given the opportunity to steer the course of their profession, they must be manifestly seen to do so. As another Member pointed out, entrusting this important post back to a nurse, “would indicate the Ministry’s faith and confidence in the leadership capabilities of the nursing profession” (Lee 1999). As the de jure head of nursing in Singapore, perhaps the Chief Nursing Officer (CNO) would be the most appropriate officer bearer for the job. The second matter relates to the composition of the Board itself. Section 3(2) of the NMA provides that the Board shall consist of the following members: (a) the Director of Medical Services; (b)the Director-General of Education or his representative; (DGE) (c) the Chief Nursing Officer; (d) 14 other members to be appointed by the Minister, of whom at least — (i) 9 shall be registered or enrolled nurses with at least 5 years’ experience in the practice of nursing; and (ii) 2 shall be registered midwives with at least 5 years’ experience in the practice of midwifery. As a preliminary point, the current composition of the Board is as follows:- (see Annex). * 3 from MOH * 3 from Ministry of Education (MOE) * 5 from SingHealth * 4 from National Healthcare Group (NHG) * 1 from SNA * 1 from the Private Sector.
Two observations may be made. Firstly, section 3(2) provides for three ex-officio posts, and 14 individually determined ones. During the Parliamentary Debates, the Minister was questioned more than once why the SNA President was not given an ex-officio seat (Neo, Chiang 1999). It was argued that “the Association is the only professional body that can clearly articulate the interests and concerns of the profession as well as challenges faced by patients... it is the most legitimate vehicle to process policy and professional matters relating to medical management. The lack of a provision for the President to be present would be a lost opportunity for the governing Body in getting the relevant feedback from practitioners in the field” (Chiang 1999). The Member also queried why private nurses were not proportionately represented (Neo 1999). In 2002, 9690 nurses and midwives were from the public sector, while 4313 were from the private sector. This meant that instead of the one seat given, the Act should provide for four ex-officio seats from the private sector, as representative of their numbers. Another Member agreed with this, adding that the Board could help to “develop a common understanding in matters relating to wages, service standards and other matters relevant to setting standard nursing practices” (Neo 1999). In response to these recommendations, the Minister merely asserted that : “We have decided to go for a general approach (that does not define who should be in the Board) ... to allow the Board’s composition to toggle representation from the different private and public sectors and areas of practice.... although we want fair representation, this is not a trade union committee which must have representation from every group to make sure their interests are taken care of”. With respect, whatever the Minister might have meant by his analogy with a trade union, this assertion is misguided. There is clear evidence both within the Act as well as through actual appointments within the current discretion, of a manifest intention to provide for the interests of distinct groups to be represented. Firstly, the section provides ex-officio positions for CNO, DMS and DGE. This clearly underscores the Ministry’s recognition of the importance the presence and participation of key office bearers in the health and education ministries. However, it goes further than that.
The Board positions of Chairman and Registrar have been held by those in the positions of DMS and CNO for so long that they have become ex-officio in themselves. Secondly, sub-section (d) expressly requires representation of at least two registered midwives. This harks back to the time when midwifery was a distinct profession from nursing (MOH 1997). Although midwives are still represented as a separate statistical class, following its integration into nursing as a form of specialist training, “pure” midwives are disappearing, and in 2002, formed a mere 2.2% of the labour pool. (SNB 2002). There is every reason for enrolled nurses, who form a far more significant 21.2% to be statutorily represented (See Annex). In any case, it is clear that Parliament did intend that the interests of nurses and midwivesbe represented on the Board as distinct classes. Thirdly, despite the “general approach” the Minister advocated, he obviously took pains to ensure representation by a proportionate number from the two public healthcare groups, the education institutions, the private sector and more recently, SNA. If by “trade union”, the Minister meant an organisation that brings together the representative voices of the profession, then he has done exactly that, albeit through his own discretion, rather than through legislative direction. Therefore, the pertinent question is really not whether there should be ex officio representation, since despite the Minister’s blunt denial, there already is. It should be whether or not, and how, the ex officio seats should be allocated. Expressly providing for a fair representation on highest regulatory authority is a crucial element to bring nursing toward full professional status. Every class within the profession should and must have a corresponding voice in order for them to feel like they have a stake in both the decision making process, as well as its outcomes. That this is the wishes of nurses is without doubt: we must have leaders who are able to contribute in the decision making of policies that have an impact on health care service delivery and care management (see Annex). The World Health Organisation noted that nursing practice and education are governed by legislation that is often archaic and determined by those outside the profession, leading to insensitive policies that are detrimental to nursing development (WHO 1982). The policy reason for regulating nursing practice is to protect public health, safety and welfare.
SNB develops and maintains standards for nursing practice which reflect the minimum requirements necessary to assure that the public is provided with safe and competent health care. It is difficult to see any reason how anything less than fair representation would satisfactorily achieve its policy mandate. This would include ex officio seats for private and public healthcare groups, SNA, and even, as one Member boldly suggested, even the foreign workers (Neo 1999).
C. Education: Beyond Degrees Traditionally, nurse training in Singapore was hospital based under an apprenticeship scheme. Following the Report, education for both enrolled and registered nurses have been placed within the mainstream education system. The mainstreaming allows streamlined upgrading similar to those found in engineering and business studies (Premarani 1999). Further, government scholarships are awarded to “A” level science graduates for nursing degrees in the UK since 1988. Local undergraduate and post graduate programmes are have already been planned at NUS (ST 2004). Commentators have lauded these developments as more graduates enter the healthcare profession with tertiary qualifications, the pressure on their clinical seniors to re-train increases. This creates a virtuous cycle for advancing professional nursing (Barnett and Birks 1998). Higher education gives nurses better clinical and academic knowledge. This raises awareness of barriers to developing nursing professionally as well as the opportunities to overcome them. The development of nursing education at the university helps prepare nursing to deal with political issues. Higher education creates nurses that are more inclined toward critical reasoning and inquiry. They can then better deal with the social and political forces that result in institutionalised hegemony that hinders the professionalism of nursing (Ho 1997). However, this glosses over a critical issue: while continuing nursing education has been encouraged officially, in reality relatively few nurses actually do so. The acute shortage of nursing labour inhibits health institutes from funding courses done on the employer’s time. Nurses are expected to put service before their own educational needs, while at the same time are expected to pursue higher education at their own time and expense (Ho 1997).
In contrast, there are massive efforts to promote nursing through a series of well planned legislative initiatives in the US. In fact, state legislatures introduced over 100 bills in 2002 aimed at increasing the number of students who graduate from nursing programs (ANA 2002). Florida's Nursing Shortage Solution Act authorizes loan repayment up to $4000 per year for up to four years to select graduates of accredited or approved nursing programs who show proof of continued employment in designated facilities within the state (West 2002). Kentucky created the Nursing Workforce Foundation to provide funding and award grants to nursing education programs and nursing employers for student recruitment and for training registered nurses or licensed practical nurses (Banks-Balwin 2002). The Foundation will award nursing scholarships and loan repayment programs for registered nurses enrolled in a state program designed to lead to a master's degree or higher in nursing (Id. 314.462). The Nurse Investment Act 2002 is the latest effort, aimed to provide federal money to help pay for nursing training and forgive education loans for trainees who agree to work in areas with acute shortages (Nurse Reinvestment Act 2002). In addition, it directs student funds to be established for the purposes of augmenting the nursing faculty. These initiatives indicate that US legislators are acutely aware of the seriousness of the problem. In order to bolster the local nursing educational infrastructure, there is a need to fund student scholarships for all levels of nursing education. Nursing studies should be marketed as an attractive option for those desiring the financial independence their 19th century predecessors gained from joining the profession. Further, with the establishment of nursing at the Bachelor and Masters level in Singapore, the government should work with SNA and SNB to establish suitable faculty grants to attract the top nursing professors as they have consistently done with other disciplines.
IV. Conclusion A new national action plan is needed to articulate the direction of healthcare in the new millennium and ameliorate the nursing shortage. Without a proper understanding of how labour statistics relate to these deeply entrenched barriers, current short term solutions will only serve to sabotage future efforts.
In order to raise nursing professionalism, there is a need to replace top down management with participatory management. This must be done through a redefinition of the nurses’ role at the ward level through specialisation and autonomous decision making. It must be done at the policy making level by realising the full leadership potential of nurses at the very top of the hierarchy as well as representation at the Board level. It must be done through developing better clinical practice and creating conducive environment for nurses to continue their nursing education.
Ultimately, any effective long term measures must have two results. Firstly, it needs to stop the bleeding of local nurses into non-nursing jobs as well as being recruited overseas. Secondly, it needs to attract talented and visionary people into the nursing profession in order to transform it from within. Today, the nursing revolution has begun. During the recent SARS outbreak, the sacrifice and dedication of nurses was brought into the limelight (Tan 2002). This catalysed a change in the public’s perception, with many contributing toward significant nursing initiatives like the Courage Fund. Further, it was recently announced that nurses would be included in interview team to choose potential doctors (Davie 2004). However, whether these truly mark the beginning of long overdue initiatives remains to be seen.
ANNEX Source: State of Health Report 1997- 2002
NURSES (RNS AND ENS) AND MIDWIVES BY ACTIVITY STATUS Year Public Private Not in ActivePractice Total
1980
1990
2001
2000
No. 5,357 1,801
% 64.4 21.6
No. 6,150 2,610
% 60.1 25.5
No. 8,927 4,166
% 53.7 25.1
No. 9,297 4,224
% 53.4 24.3
1,166 8,324
14.0 100.0
1,478 10,238
14.4 100.0
3,518 16,611
21.2 100.0
3,877 17,398
22.3 100.0
CITIZENSHIP OF NURSES (RNS AND ENS) AND MIDWIVES IN SINGAPORE Year
1997
No. 11,938 Singaporean / PR Private 467 Not in ActivePractice 2,300 14,705 Total
2000
% 81.2 3.2 15.6 100.0
No. 13,070 385 3,156 16,611
2002 % 78.7 2.3 19.0 100.0
No. 13,915 365 3,754 18,034
% 77.2 2.0 20.8 100.0
COMPOSITION OF THE SNB AS REFLECTED IN THE SNB 2002 REPORT MOH Position
Title / Name
Representing as
Chairman
Prof Tan Chorh Chuan
Director of Medical Services
Registrar
Ms Ang Beng Choo
Chief Nursing Officer
Member
Dr Ling Sing Ling
Headquarters
MOE Position
Title / Name
Representing as
Ex-officio Member
Mrs Long Chooi Fong
Representative of DG Education
Member
Mrs Theresa Cheong
Lecturer, School of Health Sciences, NYP
Member
Ms Gwee Mui Boon
Course Manager, ITE
SingHealth Position
Title / Name
Representing as
Member
A/P Terry Kaan
Director, SingHealth
Member
Ms Gwee Pek Hoon
Director of Nursing, SingHealth Polyclinics
Member
Ms Mary Fong
Senior Nurse Manager, KKH
Member
Ms Lee Yen Yen
ADN, CGH
Member
Mdm Tan Lay Geok
Assistant Nursing Director, SGH
NHG Position
Title / Name
Representing as
Member
Dr Lim Suet Wun
CEO, NHG
Member
Ms Siti Zubaidah Mordiffi
ADN, NUH
Member
Mdm Yeo Kim Luang
DN, IMH
Member
Ms Ann Yin
Nurse Manager, TTSH
SNA Position Member
Title / Name Mrs Jeanne Lim
Representing as Vice-President, SNA
Private Hospitals Position Member
Title / Name Ms Nellie Tang
Representing as General Manager, Mount Elizabeth Hospital
* This paper was written while the author was a final year student at NUS Law School as part of his course in Biomedical Law and Ethics. The author wishes to express special thanks to the following persons whose assistance, encouragement and insights made this paper possible: Prof. Tan Chorh Chuan, then Director of Medical Services; Ms. Ang Beng Choo, Chief Nursing Officer and Ms Chen Yee Chui, Nursing Officer; all of the Ministry of Health; Ms Tan Wee King, President of Singapore Nurses Association, and not least, Associate Professor Terry Kaan of the Faculty of Law, National University of Singapore. The author stresses that the views expressed may not neccessarily be those of any person or organisation mentioned above. Facts are true to the author’s knowlege as of April 2004. Finally, all errors and ommissions remain the author ’s alone.
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