In the first of a two-part series on the future of nursing in Singapore, experts discuss how to ensure the country has enough nurses to deal with an ageing population.
The clock is ticking for Singapore’s healthcare sector to ensure it has enough staff to cope with the country’s ageing population. In less than 10 years, Singapore could join more than 30 countries in becoming a “super-aged” nation, where 20 per cent of the population is 65 years of age or older.
An older population will place more demands on its healthcare sector. The Health Ministry has said it expects that 9,000 additional staff will be needed to support its public healthcare and elderly care settings in the next three years. Half of those positions will be nursing, therapy and administrative jobs.
However, filling the nursing vacancies could be a challenge: According to annual labour statistics by the Manpower Ministry, nursing remains unpopular among Singaporeans. Among PMETs, vacancies for registered nurses that were unfilled for at least six months sat at the top of the table in 2015 and 2016, although there was a slight decrease in unfilled vacancies last year.
This could mean that Singapore needs to cast its net more widely overseas to fill the gaps.
One expert Channel NewsAsia spoke with said it is unrealistic to assume Singapore’s demand for additional nurses will be filled by locals alone. Dr Jeremy Lim, head of Asia Pacific's health and life sciences sector at consulting firm Oliver Wyman, said that at this stage, Singapore needs to be “ethnicity and nationality agnostic”.
Singapore's population is ageing so rapidly that in less than ten years, it would become a "super-aged" nation, where one in five is 65 years of age or older. (File Photo: Xabryna Kek)
Dr Lim said Singapore is ageing so rapidly that “it is untenable to consider standard or incremental solutions”. Questions have been raised about the proportion of foreign nurses in polyclinics and public hospitals and Dr Lim said this is to some extent irrelevant as the need to fill vacancies is pressing.
“On this point on the ratio of foreign to local nurses, I think it really does not matter,” Dr Lim said. “This is a false metric that we should not pay too much attention to, but it should lead us to ask more fundamental questions around why locals are not interested in nursing. Why are we unable to get numbers because nursing is a very important profession to Singapore.”
Even as the search is underway to find more nurses, progress has already been made. In the five years since it set up the National Nursing Taskforce, the Government’s focus on developing and strengthening the sector has reaped slow, but steady, results. During the Committee of Supply debate in March this year, Senior Minister of State for Health Dr Amy Khor said after five years of seeing a decrease in the number of nursing graduates, the ministry has had a breakthrough.
“MOH has attracted more students to join nursing programmes in ITE, polytechnics and National University of Singapore from 1,500 in 2012 to over 1,800 in 2016,” said Dr Khor. “Overall, our intake for nursing has increased by 20 per cent.”
Other initiatives to strengthen the 34,000-strong sector include targeting mid-career professionals to join the sector. The ministry said it has admitted more than 400 Singaporeans from other industries into its healthcare conversion programmes since 2009. Starting this year, it also enhanced the programme, through providing higher training subsidies and more on-the-job training support.
It has also turned its attention to local non-practising nurses. In a bid to encourage them to return to work, the Government enhanced a scheme that would provide nurses with salaries during the three-month refresher course they need to attend, as well as a retention bonus if they joined the community care sector.
It has also made it more attractive for nurses who studied in approved overseas universities to come back and serve in public healthcare institutions.
TRANSFORMING THE SECTOR THROUGH JOB REDESIGN
To make nursing more attractive, higher salaries are being offered: As part of the recommendations by the National Nursing Taskforce in 2014, the ministry announced that nurses in the public healthcare would see an increase in wages by up to 10 per cent, as well as a new annual bonus. While this may pull more people into the sector, attempts are also being made to create greater efficiencies through technology. Government Parliament Committee Chair for Health Dr Chia Shi Lu said although the Government has highlighted 9,000 vacancies, job redesign could mean two to three positions could be handled by one person.
New hospitals like the Sengkang General and Community Hospitals, due to open in late 2018, will offer tele-rehabilitation and video conferencing services. Technological support could also mean allied health professionals like physiotherapists can monitor several patients at the same time, said Dr Chia.
The Sengkang hospitals will offer tele-rehabilitation services when it opens, and Dr Chia said it's one example of achieving job efficiencies through technology. (Image: Sengkang Health)
“For example, with a patient learning to walk in the old days, you would have a physiotherapy assistant standing next to a patient saying ‘OK, take your foot forward, and do this’ and you’d have to watch them. Nowadays, they have harnesses which are attached to overhead devices - it’s like a circuit that allows them to walk around with a harness.
“The patient walks but he feels that he’s protected because of the harness system and the harness also gives feedback. A lot of things we are already trying out and this can reduce the manpower requirements and be more effective at the same time,” Dr Chia said.
Older hospitals are also redesigning jobs to allow healthcare workers to focus on more important parts of care. The National University Health System (NUHS) introduced Basic Care Assistants at the National University Hospital. MOH said these assistants help nurses with activities such as sponging, bathing and feeding after receiving a month of training in the ward.
NUH said there are currently 18 certified assistants, with 13 more undergoing training.
Mr Yeo Eng Huat is one of 18 Basic Care Assistants at NUH. His duties include taking patients' blood pressure and temperature, and allows nurses to focus on more complex treatment and care of patients. (Photo: NUH)
Ms Joanna Lau, an assistant nurse clinician at NUH, said this allows nurses like her to focus on more complex treatment and care. “Some of these care activities include the nurse-led rounds during the regular physician and multidisciplinary ward rounds, providing and monitoring patients on active treatment, and discharge plans,” she said.
Job redesign through the use of technology could also result in the minimising of shift work and overnight duties, said Dr Lim. “It’s not just money but it is redesigning the job to minimise the less pleasant but necessary parts of this job,” he said.
“I think here, the Health Ministry is already doing a lot in the use of technology and what (Health) Minister Gan Kim Yong calls ‘from the hospital to the community’. The more that in-patients are discharged in a timely fashion, the more they can be cared for by their loved ones in familiar settings, perhaps with remote monitoring. This means fewer night shift nurses will be needed and nursing as a profession will become more attractive.”
RETAINING NURSES IN A TIME OF GLOBAL HEALTHCARE SHORTAGE
Even as Singapore makes nursing a more attractive job and creates greater efficiencies, it faces global competition to retain those who are working in the sector, as well as challenges in ensuring it is a lifelong career. According to a report by the World Health Organization (WHO), there will a global shortage of almost 13 million healthcare workers by 2035. It said that 40 per cent of nurses in developed countries would leave the sector by 2023, due to a demanding job and low pay.
“The reality is that many young health workers receive too few incentives to stay in the profession,” the report said.
Dr Lim and Dr Chia agreed that attrition is an issue that needs to be addressed.
“We are actually training enough,” Dr Chia said. “The problem is we can’t retain our staff - at least in the public sector it is a problem. A lot of healthcare workers may suffer from burnout, especially those in more intensive jobs. So that’s why we have to look at retention - how to make the job easier, through flexi-time and work-life balance. Otherwise it’s just like opening a tap but the sink hole is just open and it flows out.”
While MOH said the attrition rate among nurses in the public sector decreased from 8 per cent in 2014 to 6.5 per cent in 2016, Dr Lim said more needs to be done.
“Every developed country in the world will be competing for ever scarcer nursing resources. So the competition is global and it will get tougher,” he said.
“We will have to compete on essentially three major fronts. One is pay, if working as a nurse here in Singapore is attractive relative to working in other countries. Secondly, what is the general quality of life here in Singapore and the third factor is if nurses see a long-term future for them here in Singapore.”
Dr Lim said the last point is especially important when attracting and retaining foreign nurses who have been working in Singapore for many years. He cited countries like Australia and the UK, where nurses there are “reasonably confident” that they will be offered permanent residency or citizenship after working for a number of years. That is not the case in Singapore, said Dr Lim.
“I think that if nursing gets more attractive as a profession, the reliance on foreign nurses will undoubtedly fall,” he said. But Dr Lim said Singapore has also had a long tradition of successfully bringing in nurses, and with a global demand, it needs to consider all possible avenues to attract and retain nurses from overseas.
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