Nurse-to-patient Ratio and Efforts to Reduce Nurses' Administrative Workload

My answer will also address written Question No 36 from today's Order paper, oral Question Nos 20 and 21 and written Question No 53 raised by Mr Louis Ng from the Order Paper on 1 August.

Thank you, Mr Ng, for your concern over our nursing workforce. I believe it is also not too late to wish all nurses in Singapore, Happy Nurses' Day. [Applause.]

Over the last five years, there has been a slight overall increase in the attrition rates for local nurses. The attrition of local public sector nurses increased from 6% in 2017, to 6.3% in 2018 and 7% in 2019, then dropped to 5.4% in 2020, before increasing to 7.4% in 2021. For foreign public sector nurses, international competition has been more intense and attrition rate has increased more significantly, from 8.2% in 2017, to 9.1% in 2018 and 9.4% in 2019, then dropped to 7% in 2020, before increasing to 14.8% in 2021.

The typical nurse-to-bed ratio for general wards in the public acute hospitals is one nurse for every four or five beds. The typical nurse-to-patient ratio in the Intensive Care Unit (ICU) in the public acute hospitals is one nurse for each ICU patient and could be higher, such as two nurses for more complex ICU cases. This has not changed significantly over the past five years.

Mr Ng has asked for salary comparison between private and public hospital nurses. We are reluctant to provide this so openly, as we know that both sectors compete for manpower. We also do not have data for the private sector.

I will, however, share a few data points. Staff Nurses (SNs) and Senior Staff Nurses (SSNs) form the largest proportion of our nursing workforce. The median annual salaries for SNs ranged from $42,800 to $53,700 in 2017, and rose to $46,300 to $58,500 in 2021, while that for SSNs ranged from $65,000 to $79,700 in 2017, increasing to $71,200 to $87,600 in 2021. In general, it takes an average four to six years for a fresh graduate to move up to SSN. Hence, an SN in 2017 may be drawing the annual salary in the SSN range by 2021.

The key issue is to retain the services of nurses. Our strategy to stabilise the nursing workforce covers several key aspects. These include reviewing the scope of work that nurses are doing to enable them to spend more time on direct patient care. Equally important is to ensure that remunerations are competitive, locally and also internationally.

On reviewing the scope of work, our public healthcare institutions adopt a multi-prong approach to reduce the administrative workload for nurses and enable nurses to focus on patient care. This includes streamlining care processes and deploying dedicated administrative and support care staff to assist nurses.

Over time, we have also introduced innovations in automation, technology, robotics and AI-enabled technology to assist nurses and healthcare staff, to ease the load of non-clinical and administrative tasks. An example of such technology is the Nursing Software Suite, introduced by Singapore Health Services (SHS) in their hospitals to enable patients to self-help, such as enabling them to check their results, medications, schedules for tests and indicating their requests to the care team.

Other than reviewing the job scope and administrative workload, as our population ages, there will continue to be growing demands on healthcare manpower. I also urge families and caregivers to be a partner in the care journey of your loved ones, as working together with us will help alleviate the workload faced by our healthcare staff.

Mr Louis Ng also asked if the National Wellness Committee for Junior Doctors (NWC-JD) could broaden its scope of work to include the working hours and conditions of nurses. We would like to explain that the NWC-JD was formed to specifically address issues related to junior doctors. These need to be tackled differently in the case of junior doctors because of their regular rotations across the public healthcare system, compared to other staff groups who are employed directly by the respective public healthcare clusters.

MOH and the public healthcare clusters have always been concerned about the well-being of nurses and other staff groups. For example, we had formed an internal cross-cluster Staff Well-being Committee in 2019 for clusters to share best practices with one another and provide feedback to MOH on enhancements to improve well-being across all categories of staff. One example of its recommendations was for MOH to look deeper into the issues of abuse and harassment of healthcare workers. Hence, we announced earlier in March 2022 the formation of a Tripartite Workgroup to address this nationally.

Clusters have also enhanced their support measures for staff. For example, Chief Wellness Officers have been appointed by clusters to oversee and develop system changes to improve the well-being of all healthcare staff. Counselling services, peer-support networks and staff support assistance plans have also been put in place to support staff.

The rest day provisions and work hour limits for public healthcare workers are stipulated in the Employment Act or set out in the public healthcare clusters' employment contracts, as previously explained to Mr Louis Ng in Parliament, in March. While the Ministry does not impose a minimum number of rest hours, duty rosters for nurses are planned in advance to ensure staff have adequate rest between shifts.

Even as we prioritise the well-being of our nurses, we appreciate the reality of their work, which is to deliver timely and quality patient care. The Ministry is working to ensure there are sufficient nurses on the ground. In fact, the registered stock of nurses over the past few years has remained stable, with a slight increase from around 42,800 at end 2019, to 43,000 at end 2021. Local nursing intakes have also increased from around 1,500 in 2014 to around 2,100 in 2021, to ensure that there is a stable inflow of nursing manpower into our healthcare system.

We understand the importance of recognising nurses' contributions and the Ministry has worked on reviewing their salaries and allowances. Over the last five years, the annual salaries of local nurses in public healthcare institutions – which comprises base salary, allowances and bonuses – have increased.

With the easing of COVID-19, public healthcare institutions have been allowing nurses to take time off work to rest and recover. This includes allowing foreign staff to return home to spend time with their loved ones, after a long period of time away from them in 2020 and 2021, when many borders were closed and travel restrictions were in effect. We know from clusters' data that leave is being approved and allowed.

MOH remains committed to provide support to the public healthcare clusters in our efforts to ensure that there is sufficient manpower on the ground, and look after the well-being of our nurses, as they continue to face pressures from COVID-19 surge waves and an ageing population.

Madam, I thank the Senior Parliamentary Secretary for the reply. But I have three clarifications.

One, the Senior Parliamentary Secretary mentioned that the nurses should have adequate rest. But I am just wondering whether MOH can clarify what "adequate" means. I think a lot of nurses are sharing that they sometimes end their shift at 9.00 pm or 10.00 pm, and then they are back at work at 7.00 am, and that is insufficient rest for many of them.

Two, can I ask whether MOH has an ideal nurse-to-patient ratio and what are we doing to work towards that ideal ratio, both in the general wards and the ICUs as well?

Lastly, for the ancillary care staff, I asked for their median salary as well, but I understand we cannot provide. Still, I think they do help in reducing the nurses' workload. So, if I could ask the Senior Parliamentary Secretary what is MOH doing in terms of increasing the salary of the ancillary care staff, their career progression, as well as increasing the hiring of these staff members.

I thank the Member for the question. Let me address the first one, in relation to rest hours. There are many different arrangements within the public healthcare institutions in the different clusters on how they actually manage the rest hours amongst the healthcare workers. So, in some clusters, it is about ensuring that they typically work on rotating shifts and they are rostered such that they have adequate rest time within shifts. Guidance has also been given, so that they are given rest time for their breaks. Duty rosters are planned in advance and there are guidelines, so that they are not working consecutively beyond a certain number of days so that they get the rest they needed. Within the working space, they are also given dedicated hall rooms, staggered break times so that they can have sufficient rest.

The reality on the ground is that there are many challenges and these nurses work very hard. There are realities of their workplaces that require them to go beyond their call of duty. We really appreciate that and we know that it has been challenging for the nurses and all the healthcare workers.

So, the key thing is making sure that there is a sufficient number on the ground and that is something that we are continually looking at. The attrition rate is a reflection of this. The numbers that we are looking at in respect of the local nurses are actually stabilising. Our key issue and problems are that we are losing the foreign nurses.

The second question is related to the ideal nurse-to-patient ratio. This is a function of the type of wards and the work that they do, because it is a function of the care that is needed for the patient. And, as you know, they are all tiered in terms of what specific care needs to be given. So, this is a function of those two. And that is a priority because patient care is important. So, in a lot of the settings, what we are trying to do is also ensuring that they have sufficient time to dedicate to patient care.

What are the other pieces of work that they need to do? For administrative work, we are looking at various ways on how we can manage some of this work, so that there is sufficient time and they are able to dedicate their time to the work in relation to patient care.

In relation to the Member's concern and queries with regard to salaries, and also that of the other workers, the healthcare workers, I think this is something that we are constantly looking at because we know how valuable they are in our community. We are concerned about the pandemic still being around and also the fact that we have an ageing population. So, this is something we are constantly looking at, at making this sector a favourable one, something that is attractive, so that we can have people go into the sector and relieve the manpower on the ground.

But the reality is, as I have mentioned earlier, we are doing everything. It is a multi-pronged approach. The issue that we are seeing right now is the fact that we are losing foreign nurses due to the pandemic. Now that the borders are open, they can go back. They are also being attracted by prospects overseas. So, there is international competition and we are losing all these workers. That means that we are losing the numbers on the ground here, locally.

So, while salaries and working conditions are important and we are constantly looking at how we can improve these, we should not jump to the conclusion that they are always the root of the manpower problems.

MOH remains committed to trying to look at this issue holistically and adopt a multi-pronged approach in improving the situation on the ground.

Just a quick last point. I do agree that we have a lot of guidelines in place. But I think it is very difficult to follow at this point because, as the Senior Parliamentary Secretary mentioned, a lot of the foreign nurses are leaving and that really puts the stress now on the local nurses.

So, we can rely on their passion, they are very passionate about it, but I think they are really urging for some protection, especially of their rest time. Again, I ask whether MOH can, at least, make sure that the guidelines on adequate rest for nurses are being adhered to at this point.

I thank the Member again for his question. Indeed, I understand the concerns and I mentioned earlier that there was an internal committee that was set up, the Staff Well-being Committee. And amongst some of the issues raised is clearly the issue of giving sufficient rest to the nurses. And this is something that they are looking at. There have been a few recommendations. The implementation of these different recommendations is being rolled out and we do hope to see that these recommendations and proposals are impacting the workflow and, hopefully, they will improve outcomes.

On the other hand, there are also other things that we hope to see, because I also mentioned earlier about how family members, there is a certain expectation of what nurses are expected to do in hospitals and this also does not help in terms of adding to their workload. The culture may be different elsewhere, and we may want to educate and look into this matter.

There is also a task force that is looking to address issues of abuse, which also impacts the work conditions of the staff and the nurses. These are also all things that we are currently looking at. So, give us some time to roll out some of the recommendations that have been put up. Hopefully, through all these efforts that we are putting up, there is improvement and we will constantly review this to see how it has impacted the ground.