Expansion Of The Nurses Roles In Singapore

There is no such thing as Advanced Practice Nurse (APN) in Singapore 10 years ago. However, Singapore started to expand the nurse’s role recently due to ever-changing of medical developments and technology, as well as the increase healthcare cost and waiting time within the healthcare industry due to ageing population. It posed a challenge to the healthcare models in Singapore to compete with other countries.

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“A multidisciplinary team approach and the recognition of nursing expertise through clinical career paths are also important”. (Chiarella & McInnes, 2008).

It is wise that Ministry has expanded the role of nurses with Masters Degrees. It can uphold nursing profession with advanced skills. The implementation of APNs can be an advantage to Singapore’s healthcare services.

Critically analyze the development of role of APN in Singapore

“An Advanced Practice Nurse (APN) is an umbrella term given to a Registered Nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for extended practice” (Ministry of Health, 2007).

“The American Nurses Association defines an advanced practice nurse as a registered nurse with advanced specialized clinical knowledge and skills for providing health care” (Yarbro, Wujcik & Gobel, 2011, p.1846).

Rajasoorya (2002) observed that the role of APN in Singapore is formed with reference of APNs’ practices from United State while United Kingdom, Australia and New Zealand took the similar approaches.

The ability to make decision by having advanced knowledge with leadership skills, proactive in self-upgrade and actively participating with patients care management are essential qualities for an APN to have.

Kjervik and Brous (2010) stated that APNs have increased in autonomy and authority over decision over patients care management compared to regular nurses’ roles.

It crossed the boundaries of the traditional nurses’ roles.

APNs are able to order a list of medications and investigations such X-rays if it is necessary for patient’s treatment. They are able to provide health assessment to patient where regular nurses doesn’t have the full knowledge to perform.

Kjervik and Brous (2010) agreed that APNs shifted and expanded their roles towards collaboration with medical personnel and specialist as well as providing primary and preventive care to patients, families and the communities.

APNs are not like regular nurses who provide direct clinical care of the patients, but also discuss with the doctors and suggest alternative treatments that may benefit patients in terms of health and cost. In addition, APNs also collaborate with families on the abilities on managing patients’ illness so as to minimize the chance of readmission to the hospital. APNs also actively participle in research and health teaching to the communities to improve Singaporeans’ well-being so as to reduce the chance of developing chronic disease.

The history of APNs

Let us look at the history of APNs and examine how it can make an impact Singapore’s healthcare system.

Arthur (2007) noted that Singapore nurses were limited by the highest qualification of being a Diploma holder without local career path to obtain higher qualification until recently, National University of Singapore (NUS) commenced the first Master in Nursing in Advanced Practice Nurse in 2003.

Sheer and Wong (2008) noted that Singapore’s first batch of graduated APNs started in 2004 and Singapore established a registry for APNs in 2006.

Schober (2010) agrees that the student who is selected by the employer or hospital can be fully funded by Singapore Ministry of Health during the course of studying period in National University of Singapore as well as to fulfill a period of bond after graduation after undergoing a period of 1 year of internship in order to registered with Singapore Nursing Board (SNB) as APN.

“Grounded in practicum experiences and guided by health care theory, policy, and research, graduates possess the knowledge and competencies to assume the advanced leadership roles required in future health care systems” (Aduddell & Dorman, 2010).

The need of having APNs:
It is important to understand why Singapore needs to have APNs. We will look into the reasons why the need of APN is important. I will covered in 4 terms. Completive, Aging population, providing better care and integrated healthcare,

Chia et al. (2007) labeled Singapore; including Hong Kong, Taiwan and South Korea; as “Four Tigers of Asia” – countries with a strong competitive advantage by having highly educated and skilled workforce.

To be able to compete with countries like Hong Kong in field of healthcare industries, Singapore have to upgrade healthcare workers.

According to International Business Publications (2009), one of the economic development board’s plans of Singapore is to develop into world-class medical hub for medical research, education and advanced care in specialized fields and healthcare services.

“With the pace at which health care is changing, we as nursing health care providers need to provide quality evidenced based health care, which is affordable to our patients” (Bettin, 2010).

Patients over the world would choose a higher standard of care if needed or affordable to. With the help of technology and the skills that APNs have, it will bring in a positive effect on Singapore’s healthcare industries, be it reputation or economically. Hence it is important to increase the skills and education of the nurses to attract the riches and the needy who in need of healthcare services, and most ultimately to save more lives by treating or preventing diseases. The introduction and increasing of APNs in Singapore represents a significant milestone in terms of nursing career path and expertise. It also contributes Singapore to form a world-class medical hub.

Ageing population

MCYS (2006) reported that the baby boomers reaches 65 years old in 2012.

According to Kannusamy (2006), the need of providing better healthcare service and the nurses to upgrade their skills in the clinical arena is necessary to manage Singapore’s ageing population and chronic illness such as diabetes and heart disease and therefore, the role of Advanced Practice Nurse is formed.

As people ages, people tends to fall sick or develop chronic illness, hence more people are dependent on healthcare services. >>>>

Advanced skills to provide better care

According to Schober (2010), Singapore provided the title APN is to retain highly skilled and potential nurses as well as to equip them with advanced skills and knowledge which can fill the gaps in the provision of healthcare services.

With the skills and knowledge that APNs learnt in university, they are able to render specialized care to a patient where staff nurses are incompetent to perform these skills.

Example : Wound nurse APN

APNs plays an important roles as it acts as a bridge between nurses and doctors, as well as other healthcare professionals and services.

“Advanced practice nurses are taking their place in the forefront of the rapidly changing health care system, developing a myriad of roles in organizations that aim to provide cost-effective, quality care.” (Jansen & Stauffacher, 2010, p.3)

By putting APNs into more discipline to practice, it relates to the vision of Singapore’s healthcare delivery.

“In Singapore, interest is growing in the advanced practice role for both acute and primary care settings, in an effort to improve patient outcomes with the least cost” (Kannusamy, 2006).

Intergated care of community and hospital (health services) – APN roles is to collaborate

“The vision for transforming healthcare delivery in Singapore is to develop integrated Regional Health Services (RHS) to pro­vide healthcare from prevention to palliation” (Saxena, 2009).

It means its aim is to try to collaborate from short term to long term care individual.

It shown the urge Singapore needs to procedure more APN to increase the professional level of nurses in Singapore. This will not only increase the standard of nursing in Singapore but also recognized internationally.

Sheer and Wong (2008) know that there are plans for Singapore to increase the number of APNs to two hundreds and also to include them into different fields like acute care, community care, mental health care and medical-surgical care. According to Tan Tock Seng Hospital, Ministry of Health’s vision is to develop 200 APNs by 2014.

A discussion of the influence on nursing in Singapore
Postive influence – Great professional satifcation.

“There is evidence that collaboration among advanced practice nurses and physician colleagues improves the quality and cost of health outcomes and can lead to professional satisfaction” (Maylone, Ranieri, Griffin, McNulty, & Fitzpatrick, 2011).

“Relationships with other health care professionals are crucial because many advanced practice nursing roles involve a significant element of collaboration” (Kannusamy, 2006).

Expansion of roles in singapore

Postive influence – the needs of APNs.

According to Ministry of Health (2007) in Singapore, the scope of practice as an APN includes diagnose, treat and management of illness; health education to the public; initiate and implement changes in health care services according to demands; provides education to nursing staffs and healthcare professionals and conduct nursing research.

This role is registered and protected by the Singapore Nurse Board – The Nurses and Midwives Act.

By giving APN authority to practice

The contemporary nurses’ role in relation to the issue
Negative – shortage of staff

Lim, Bogossian and Ahern (2010) agreed that Singapore have much shortage of nurses in the workforce compared to Western countries and hence will contribute to increase workload.

According to Health Manpower Statistics (2009), it indicated that there is an increase of about 12% of Registered Nurses between 2007 to 2009 in Singapore.

Singapore plays an active role by having Ngee Ann Polytechnic (2007) introduced Nursing Course in 2005, in addition to Nanyang Polytechnic, where students graduate as a registered nurse 3 years later upon completed of the course. This may explains on the increment of Registered Nurses in Singapore.

“Changes in the health-care system, shortage of staff and increasing workload may also be affecting stress levels of nurses trying to adapt to increasingly higher levels of responsibility” (Lim, Bogossian & Ahern, 2010).

This will affect how well an APN will perform after graduation.

Singapore may need to think twice about the number of APNs to be increase. By increasing APN will only make shortage of Registered Nurses workforce even worst. If the solution is to upgrade enrolled nurses to registered nurses, who will take on the enrolled nurse roles? Singapore needs to increase the number of intake of nurses from schools.

Negative – Scope confusion

Rajasoorya (2002) stated that in U.S., most often APNs may found themselves closely take up the role of the doctors as increase of APNs caused an expand of their practice nature.

Doctor may fear and concerned about loss of power over nurses.

“APNs should be viewed not simply as doctor substitutes but as part of a new approach to address the changing nature of illness care” (Kane, 2009).

“APNs are not necessarily the same as doctors of nursing practice” (Kane, 2009).

“APNs are being trained for a number of different tasks. Some are specialists; some are generalists” (Kane, 2009).

Getting lack of support and collaboration from the doctors or surgeons for managing a group of patients, APNs may found themselves difficulties to fulfill their roles.

Singapore need to consider by having clear and define roles between APNs, doctors, nurse clinician specialists to prevent overlapping and confusion of individual roles.

“Practice guided by the concepts of a conceptual model of nursing is more appropriate for advanced practice nursing than practice guided by a medical model” (Ruel & Motyka, 2009).

“Conceptual models are the foundation of advanced practice nursing and enhance nursing practice at all levels” (Ruel & Motyka, 2009).

“The use of conceptual models promotes professionalism which includes autonomous nursing practice, knowledge, and service” (Ruel & Motyka, 2009).

The current and/or potential impact of the issue on the health care system.
Conclusion – focus cost effective, professional increase, integrated healthcare service, aging population.

Lim, Bogossian and Ahern (2010) emphasized Singapore healthcare system focus on affordability for Singaporean on healthcare service by restructuring hospitals and the challenges Singapore needs to overcome like rising in healthcare cost and increasing public healthcare services’ expectation.

“Advanced Practice Nurses (APNs) are taking their place in the forefront of the rapidly changing health care system, developing a myriad of roles in organizations that aim to provide cost-effective, quality care” (Jansen & Stauffacher, 2010).

“Advanced Practice Nurses (APNs) are taking their place in the forefront of the rapidly changing health care system, developing a myriad of roles in organizations that aim to provide cost-effective, quality care”

Jansen & Stauffacher (2010) said that in a rapidly chaning health care system, APNs take in roles to provide cost-effective, quality care to patient in a myriad roles in organization.

By having APN in polyclinic for consultation for disease such as diabetes, it not only lowers down healthcare cost and also decreases waiting time for doctor consultation.

Lacking of nurse workforce in Singapore to accommodate the aging populations’ healthcare needs, Singapore needs to continuously train more nurses not only to maintain the standard of nursing practice but to increase the standard and advanced their skills so as to cope with healthcare demands.

Expansion of APNs workforce and practice to improve integrated patient care with heightened levels of safety and quality, and responsive to patient’s requirements both in hospital and in community.

“The implementation of APN roles is having a transformative effect on the healthcare systems of Singapore” (Schober, 2010).

“witnessing a pride in the anticipated increased status for nursing associated with academic education and advanced nursing roles while at the same time watching some of the unanticipated struggles that occur with such a significant change” (Schober, 2010).

“APN interns, as they mature in their role, are working in close partnership with physicians and are assuming responsibility for tasks that had been performed traditionally by doctors” (Kannusamy, 2006).

Conclusion end line.

“The APN scope of practice will continue to evolve to match the changing needs of the healthcare system” (Wong, 2009).

“With the changes to and complexity within the health care system, advanced practice nurses need academic preparation in advanced care management of populations and leadership competencies” (Aduddell & Dorman, 2010).

Politics of nursing practice (Community at large, CLUTURE OF INDIVIDUALS, GROUPS, government regulation.)

Power of nursing as APN (more control and directions.)


Singapore government – SNB, MOH, ministry of environment, MOM, SHS

Different perspectives on health care and health
Image of nurses

Nurse view as cleaning, maid, slave. As APN show different initiative.

Legal issue re: APN, practicing outside nursing scope.

Different perspectives on health care and health

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