Health Minister Ong Ye Kung has announced a slew of initiatives and efforts to recruit more in the past year, in addition to granting permanent residency status to about 700 nurses each year from 2018 to 2022.
“Foreign healthcare workers are an integral part of our healthcare system, and for those who become valued members of our healthcare community and demonstrate commitment to Singapore, we have been and are prepared to grant them PR status,” he said in Parliament last July.
More recently, on Feb 20, Mr Ong unveiled Angel – or Award for Nurses’ Grace, Excellence and Loyalty – a retention scheme benefiting about 29,000 nurses with bonuses of up to $100,000 each spread over 20 years.
Expanding our nursing pool is undoubtedly necessary, given Singapore’s ageing population and escalating healthcare demands.
Singapore has ramped up nursing numbers quickly – the Ministry of Health announced 5,600 nurses accepted offers to work in the public healthcare system in 2023. This is an impressive number, considering the public sector had about 23,720 registered nurses as at 2022.
The critical questions then are how quickly, how safely, and in what number new nurses, especially those from abroad, can be safely absorbed into the health system.
The answers can help set limiting rates on nursing recruitment as we cannot compromise patient care in the pursuit of “spreadsheet ambitions”.
Determining the pace of absorption is a delicate balancing act, requiring real-time calibration to ensure both immediate needs and long-term sustainability are addressed.
Tough to hit the ground running
Foreign nurses, and health professionals more generally, can’t be expected to “hit the ground running”.
Nursing demands emotional intelligence, critical thinking and technical skills, necessitating a robust support system for newcomers. For foreign nurses, beyond clinical training, training requires cultural orientation to help them adjust to Singapore’s healthcare environment, healthcare expectations and societal norms.
The role of nursing can vary greatly across countries. In the Philippines and India, both source countries for Singapore’s foreign nurses, it is common for patients’ family members to remain at the bedside and actively contribute to fulfilling the patients’ fundamental needs, including providing hygiene care and assisting with feeding.
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Here, however, nurses are tasked with providing comprehensive care, encompassing all aspects of patient support, from medical to basic daily needs.
Little wonder that foreign nurses intending to leave the profession say they find nursing in Singapore challenging, according to a recent local study on current and former nurses conducted in Alexandra Hospital.
These professionals must navigate not only the complexities arising from cultural and linguistic differences but also adapt to the distinct expectations and responsibilities accompanying the practice of nursing in Singapore.
Furthermore, new foreign nurses are typically younger and may be living abroad away from their families for the first time, which can be a major stressor in itself.
A high-touch onboarding process
Public healthcare institutions in Singapore have been mindful of these challenges and implemented strategies to integrate new nurses. Every new nurse undergoes an onboarding process lasting three months, which includes in-house courses, and a probation period of at least six months.
Through this period, new nurses are paired with experienced preceptors, ensuring a one-to-one mentor-to-nurse ratio, to provide personalised, on-the-job mentorship. This adds to the already heavy load of the experienced nurses and nursing leaders have to watch for burnout and stress in their existing staff too.
Recognising the unique acculturation challenges faced by foreign nurses, some public health institutions offer additional support. Expanded programmes deepen their understanding of the local culture and dialects, thereby facilitating a smoother transition into the Singapore healthcare environment.
Fostering a supportive and inclusive work environment that values diversity and the contributions of all staff members is also essential. For foreign nurses, creating a sense of belonging and community, a necessary partial substitute for the family, is vital for their integration and retention.
The public healthcare clusters have formal initiatives intended to achieve these goals. For example, the National University Health System (NUHS) staff go through the Arbinger Institute’s “The Outward Mindset” workshop designed to promote empathy for colleagues and mutual support while SingHealth has a funded acculturation programme that gives nurses a chance to bond and interact.
These are useful but will be ineffective if patients and their families do not play their part.
In 2023, the Ministry of Health reported that “almost one in three healthcare workers in Singapore witnessed or experienced abuse at least once a week”. This is frankly deeply embarrassing and reflects poorly on us as a society. We can and have to do better.
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Retaining nurses
We need to recognise that monetary incentives, while important, are not the sole factor in retaining nurses. Nurses motivated by a sense of purpose exhibit increased productivity and a lower propensity to leave their positions.
Author Daniel Pink of the best-selling Drive: The Surprising Truth About What Motivates Us describes motivation as being driven by autonomy, mastery, and purpose. This concept resonates particularly with the younger generation of nurses, who aspire towards a broader range of experiences and opportunities for career progression.
Consequently, the healthcare system must commit to nurturing the professional growth of nurses by providing avenues for ongoing education, specialisation, and advancement within the profession.
The introduction of Advanced Practice Nurses (APNs) can help. It represents a significant step up in professional development and specialisation in nursing.
APNs are registered nurses with a minimum master’s degree qualification in nursing, who are legally able to diagnose and manage patients’ treatment plans, prescribe medications, and perform procedures within their scope of practice.
Singapore has a national target of 700 APNs with prescribing authority and career paths for other nurses keen on specialist practice, administrative leadership, education or research.
Regardless of whether a nurse aims to become an APN, a manager, a clinician, or a researcher, it is crucial for the health system to diversify and enrich the experience of nursing as a profession and to loudly celebrate them.
By implementing such measures, the healthcare system can significantly improve job satisfaction and foster loyalty among nurses.
This, in turn, would lead to lower turnover rates and contribute to the development of a more stable and seasoned workforce. A 2023 review of 345 research papers from European Union and non-EU countries explored the main factors influencing job retention among nurses and physicians. One was career development.
A 2021 review of nine studies across five countries – Britain, Jordan, Greece, Australia and the Netherlands – found nurses’ participation in continual professional development increases their motivation and commitment to work, which leads to higher retention and better work performance.
Measure outcomes of hiring more nurses
The challenge of integrating and retaining new nurses is not a trivial one, especially when 60 per cent are foreign.
Hopefully, more Singaporeans will see nursing as a viable career.
Attracting the requisite numbers and putting in place retention schemes are necessary but insufficient to ensure better patient outcomes.
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With more nurses hired in 2023, we should measure the success of recruitment and retention efforts together with metrics of patient safety and clinical quality.
The Ministry of Health should take the lead here, to collate and report the outcomes. Metrics such as medication errors, patient falls, hospital-acquired infections and critical incident reporting could serve as vital indicators for policymakers and institutional leaders to gauge the appropriate pace of nurse absorption.
Former Singapore president Halimah Yacob once said: “Save one life, and you’re a hero. Save a hundred lives, and you must be a nurse.”
This statement is not merely a tribute to nursing but should be seen also as a call to action.
Nursing’s success in recruitment, safe onboarding and retention benefits Singapore immeasurably. Let’s all play our part.
Associate Professor Jeremy Lim is with the NUS Saw Swee Hock School of Public Health. Dr Brigitte Woo is a research fellow at the Alice Lee Centre for Nursing Studies, NUS Yong Loo Lin School of Medicine.
