Our guest speaker for the first of the three-part webinar is Mr Yong Keng Kwang, Chief Nurse of Tan Tock Seng Hospital and vice president of Singapore Nurses' Association.
As a young nursing leader, Mr Yong’s vision is to bridge the gaps in the advancement of nursing in Singapore, especially in raising the profile of nurses in healthcare institutions and the application of modern technology.
During this webinar, Mr Yong answered a myriad of thought-provoking and honest questions from the floor. Mr Yong highlighted several key points with passion making the session remarkably honest and inspiring for our young nurses! The following are the questions that Mr yong answered with his respective responses and a summary of the answers to each question!
Question: Mr Yong, what are your thoughts on some key healthcare challenges we currently face in Singapore and possibly in the near future?
Answer: Mr Yong identified four key healthcare challenges he found to be of significance in Singapore and they are as follows:
1. The healthcare demand is expected to increase over time, in parallel to the increasing elderly population.
2. A double whammy scenario due to the mismatch between supply of nurses required to meet the increasing healthcare demands. Mr Yong highlighted that the significance of dealing with this double whammy scenario cannot be underplayed.
3. The need for continuous learning in spite of limited time set aside for skill advancement and learning amidst working concurrently serves as another challenge. Mr Yong stated that one way to mitigate it would be through expanding our capabilities or optimising our competencies as nurses. Hence, we must recognise the importance of having strong learning agility as students and not have any expectation of being provided protected time to learn all the time.
4. Another challenge that may arise is the inability to find meaning in the face of adversity as many may perceive this profession negatively. Conversely, finding meaning enables one to practice at the “top end of the license” as Mr Yong puts it, otherwise one may succumb to a burnout.
In a nutshell, Mr Yong mentioned that “these are the challenges that are more associated with the healthcare system. But it is going to directly impact nursing if we are not well prepared for it”. Therefore, the significance of being aware of the breadth of challenges in the healthcare system and being well-equipped to face them is critical for us as novice nurses.
Question: Mr Yong, are there any challenges that are more/most relevant to the nursing profession?
Answer: While Mr Yong did mention that all the challenges he had mentioned are relevant, he felt that competency would be a challenge that is most relevant to the nursing profession.
Over time, as care becomes more complex and possibly cause considerable strain on available manpower resources, healthcare professionals will need to be equipped with an increasing number of competencies to be able to deliver the necessary integrated holistic care for the patients. Mr Yong believes that equipping oneself with the necessary competencies is more of a “mindset issue rather than preparing a framework or system”. He mentioned that he sees this role “to be played a lot by nurses, either in inpatient outpatient or community setting” signifying the importance of this challenge to nursing, given that nurses are likely to be the first touchpoint of the patients.
Mr Yong believes that equipping oneself with the necessary competencies is more of a “mindset issue rather than preparing a framework or system”.
However, Mr Yong also mentioned that personally, he is worried about whether we can adopt that mindset of a nurse needing to be transdisciplinary, as people may not have the resilience or motivation. However, it is notable that while competency is a key challenge faced by nurses, there are bigger factors at play that contribute to becoming a competent nurse.
Nevertheless, the main takeaway of this point for students is about whether or not we are prepared to expand our scope so as to add value to the nursing care rendered to patients.
Question: How do we as student nurses cope with burnout in Nursing?
Answer: Mr Yong addressed this question from a system/management perspective. He mentioned a disclaimer before going into details, that, albeit the various methods to handle burnouts in nursing, it may not necessarily be the “perfect” solution as burnouts can be perceived to be an individualised issue. Mr Yong highlighted two measures he considers to be of importance, and they are as follows:
1. The first measure is: Finding meaning in work.
Mr Yong said “If you are really motivated by the work that you are doing, you may not even realise that you are working very hard because it just continues to drive you on. Meaningfulness is a source of energy”. Generally, most people may require some form of affirmation either in the form of reciprocation or appreciation to prevent one from losing meaning in the job they do. Reciprocation stems from patients, peers and supervisors appreciating the effort you put into the work you do. Hence, Mr Yong believes that meaning can be derived either from the work that you do or via reciprocation.
2. The second measure, which requires more effort on one’s part, would be personal resilience.
Mr Yong believes that despite the fact that “you may not feel like your work is reciprocated but you need to continue to engage with those who really appreciate your work”. In the Asian culture we live in, nurses will most likely encounter patients who complain or criticise more than those who explicitly expressed their appreciation. This may eventually take a toll on one’s energy and motivation, especially when people do not speak up about incidents that negatively affect them. Hence, nurses are generally advised to look out for their peers and recognise the signs so as to seek support or affirmation. That being said, burnout cannot be solved by a top-down approach and people need to constantly look out for one another.
. Question: Do you have any experiences of burnouts in your career?
Answer: Mr Yong generally said that while he does not recall experiencing a burnout, he does remember times when he asked himself what he could have done better.
However, he overcomes these thoughts by reframing his outlook and pursuing tasks that can distract him. His way of coping would be to spend time after work focusing on projects dedicated to improving nursing as a system or to engage himself with a supportive social circle. This gives him energy to find meaning in his job on his tough days. He would also remind himself of the people who appreciate nurses and peers who want to do better for patients. This drives him to constantly find meaning for himself as well as nursing practice as a whole. He mentioned that these are merely some ways that had sustained him all these years along with his faith and positivism.
Question: It is common to relate not having burnout to having a good work life balance. Hence, given that there are burnouts in the nursing profession, is it related to having a poor work life balance? How can the leaders ensure that nurses in Singapore can achieve this?
Answer: Mr Yong believes that this question may be interpreted and answered differently by individuals based on their respective opinions. Mr Yong's opinion on this issue is that “Burnouts are something that can be contextualised and individualised. I would say that work life balance is primarily a mindset of what you define work as and what you define life as”.
Therefore, burnouts are usually associated with whether or not one still finds meaning in his work, as when “your work becomes a drag,” people may generally become frustrated and distressed. The positive correlation between poor work-life balance and burnouts occur when people’s lives are solely defined by work hence integrating work and life together without a clear division. However, we should acknowledge that some others may not want their work to define their life and tend to look for a different life outside their profession.
“Burnouts are something that can be contextualised and individualised. I would say that work life balance is primarily a mindset of what you define work as and what you define life as”.
To accommodate such preferences, some institutions have introduced flexi shifts and a 5-day work week, making it more possible for nurses to titrate a good balance between work and life commitments/pursuits.
Question: What are the common political issues in the hospitals that we should be aware of so as to avoid any distractions, so as to serve a higher calling as a nurse?
Answer: The student who posed this question narrowed the question with a specific example, questioning if budget together with the patient’s background and status will compromise the nursing care provided to the patient.
Mr Yong stated that most times in public health, “money wouldn’t or shouldn’t really affect the way to you care for the patient”, allowing the nurse to prioritise the patient’s well-being as much as possible. While there are certain times when money may affect patient’s care options e.g. use of non-standard drugs vs standard (with government subsidies) drugs, they largely do not have an adverse impact on how health care professionals deliver care.
Mr Yong also continued to say in a matter of professional opinion, in his years in Singapore’s public healthcare system, he has not seen anybody being deprived of care because of budget issues.
Question: Are there any challenges retaining the workforce of nurses and getting people into the nursing workforce?
Answer: Mr Yong firstly laid the foundation that there will certainly be an entry criteria in recruiting young nurses, as in every other profession, as “nursing wants to make sure that the people that apply for this program, have the necessary qualifications, and their ability to master the concept and the skills that are required”. Therefore, while nursing is generally lacking sufficient manpower, and appreciates people applying into this field, it is necessary to screen for the right applicants via a system of assessment, academic qualifications and/or interviews, to understand the prospective applicant’s attitude and aptitude for this career. This is to minimise the attrition rate within the profession, after realising a mismatch between the expectation of their aspirations and the reality. Nonetheless, Mr Yong believes that there is always room for refinement of the recruitment criteria.
“Nursing wants to make sure that the people that apply for this program, have the necessary qualifications, and their ability to master the concept and the skills that are required”.
Additionally, he commented on the reduced entry criteria in terms of academic qualifications, reflecting the system’s decision to recognise people’s aptitude and experience working in the healthcare sector as an important factor, rather than being fixated on academic qualifications so as to identify individuals who may be exceptional in caring for patients. Hence Nursing has started to look into alternative pathways to help individuals move up the career ladder to become licensed practitioners.
Question: Regardless of the institution, be it NUS or Polytechnics or ITE, there is usually a very low cut off point to enter into nursing courses. This gives a wrong impression to the public which is that ‘it is easy to be a nurse’ when we all know that it isn’t. So, is there anything we can do about it?
Answer: Mr Yong mentioned that this situation weighs heavily on calibration along the spectrum between having no criteria versus having a very tight criteria. When the criteria are tightened to provide the “quality”, nursing may lose quantity. Thus, herein lies the pressing question: “Do we tighten the criteria so much that we trade off on numbers, or do we loosen the criteria so much that we trade off on quality?”
Due to the rising demand, nursing cannot lose out on numbers by focusing merely on quality. Over time, hopefully, nursing can have more confidence in calibrating the screening criteria. Currently, nursing has in place programs that aim to build confidence in those with less-desirable academic qualifications and requiring more support and guidance. Mr Yong elaborated further that if “you have the right attitude, I think we will have the right programs in place to groom you and to give you room to grow. Hence, we have to take a leap of faith to let people in, regardless of their academic qualifications.”
He highlighted that the screening criteria is not merely based on academic qualifications but rather emphasizes on choosing the“right people”. He highlighted that “we (nursing) are very cognizant on this issue and we are regularly calibrating or titrating.”
Question: Do you have any tips for those who want to join public health? In the sense of how they can go into the policy level or do nursing stuff at a much bigger scale?
Answer: Mr Yong mentioned that for every hospital system, there are various career paths available for nurses. For students interested in policy making, he advises entering the management pathway.
Given its large number, nursing is the only one among most other healthcare professions that is more structured. Unlike other allied health professions and Medicine, nursing has full time administrators, however, the tight selection criteria limit the number of available slots.
Mr. Yong's suggestion for an individual who wants to specialise in administration or public policy, would be for him or her to come up with proposals so as to discuss if there are opportunities for progression and to highlight one’s interest in that career pathway.
Additionally, given the large quantity of nurses, whilst administrators put out a radar to detect any promising individuals who show aptitude, it may not be possible to identify all these individuals with capabilities and hence, one can express a particular interest in this field by going forth with a proposal typically targeted to improve and/or advance the profession.
Question: You have been speaking about nursing autonomy in Singapore and you know that APN was introduced only 10 years ago in an attempt to improve our autonomy as nurses. As we move into contemporary nursing, I believe a lot of us would not be surprised that nursing autonomy has increased over the years, but as to how fast nursing will progress is still uncertain. What are your thoughts on this?
Answer: Mr Yong agreed with the statement above and mentioned that nursing autonomy will inevitably increase given the increasing burden of chronic diseases. Hence, given that nurses have more touch points than other healthcare professionals, he feels that “It's not a matter of whether it will come but a matter of when it will come.”
The trend from studies across other regions suggest that generally areas with the more rapid development to nursing autonomy correlates to areas where access to medical services and doctors are sub-optimal. In Singapore, given the high accessibility and availability of medical services, the presence of a doctor to make the primary decisions naturally renders less of the nurse’s involvement in the decision-making process.
“It's not a matter of whether it will come but a matter of when it will come.”
However, he believes there are high levels of safety factored into the decision-making process when nurses are given the autonomy to make decisions, as they consider all factors in seeking to ensure smooth coordination of care. Given that nurses are the first responders and have multiple touchpoints on the continuity of care, they have to be ready to be accountable to make first line decisions. He believes in the next 5 years, we will see more developments and it would not just stay with APNs but will move beyond the APNs to include Nurse Clinicians and Nursing Officers to make/initiate key clinical decisions.
Question: Regarding younger nurses rotating once they graduate, do you think it will benefit them if they were to be rotated as SNs in different departments for the first two years? This will actually help them find what they are interested in and might also retain them in nursing for a longer time, don’t you think?
Answer: Mr Yong laughed and mentioned that this question is commonly posed by new graduates during his tenure as a Chief Nurse. Mr Yong explained that his mindset changed over time as initially, he was hesitant to change the system given that the rotation of new nurses every six months or one year may affect the hospital’s system due to its heavy logistical demands. Furthermore, nurses may not be able to consolidate their skills as the nurses will have to acquire and apply new skills constantly, hence while covering breath in terms of their skill set, the depth and competency of the level may be potentially compromised.
However, he shared that his opinion changed after COVID-19, when the system required nurses to move rapidly from one clinical area to another, and may affect the quality of care rendered to patients. This is because, when patients present with multiple comorbidities, the specialized skills and mental model that the nurse has acquired may not be applicable to help the patient. as she/he would have been too accustomed to a particular speciality. Hence, it would be ideal to rethink the system’s decision regarding rotation, as it may benefit nurses by making them more resilient through wider exposure and not limit them to a silo mentality.
Nonetheless, the logistical coordination for a system-wide rotation would still need careful consideration and mitigation before it can be implemented.
Question: Do you think that a greater focus on clinical training or on job training would benefit student nurses or better prepare them in a greater corporation in the clinical into the current curriculum?
Answer: Mr Yong mentioned that he takes on a “biased perspective” on this, as he strongly believes that preparation in school in terms of nursing concepts which will help to build and strengthen the foundation and identity of nursing. Given that nurses are the major touchpoints in healthcare, it would be ideal to achieve a proper titration between theoretical concepts and clinical placements.
Mr Yong addressed that two key points to be observed if clinical placements were to be increased would be that there has to be a balance such that one does not lose his or her nursing core concepts and that the increased clinical placement has to be converted to effective learning hours.
Mr. Yong highlights that more clinical hours may not necessarily translate into quality in the form of a positive learning curve Hence, without productive clinical hours, it renders the increased hours in the hospital less impactful thereby compromising quality of clinical placements. Mr Yong would suggest focusing on the quality of clinicals before calibrating the quantity required.
Question: Looking at the signs up, there are a significant number of ITE students. So, this question is for them. When we are talking about development of nursing, discussion revolves around staff nurses. Enrolled nurses (ENs) are valuable to clinicals as we often find them in most of the nursing care, practical wise. In terms of continuing education, how do hospitals ensure better career progression for them? Are there any effective developments in the EN role?
Answer: One of the fundamental principles that Mr Yong mentioned is acknowledging that an increasing number of ENs yearn for development. Hence, more progression opportunities are made available, making it easier for ENs to become Registered Nurses.
Previously, a certain academic qualification was required for an EN to register for a bridging programme to become a RN. That has since changed to only requiring a certain level of experience and recommendation from their superiors.
For those who find gratification and satisfaction being an EN, there are an increasing number of progression pathways to value-add to their job e.g. working beyond task-based jobs (e.g. turning/parameter). With further training, they can be assigned cases that cover documentation and doing basic care plans under the supervision of RNs, so as to increase their accountability to the patient. We have also looked at enhancing their career progression, expanding their job scopes and giving them autonomy to give medicine.
These enhancements seek to empower ENs and ensure that they have a purposeful career.
Question: It is on the point about empowering nurses and it is centered around the issue of caring for transgender patient. How do you feel about that, considered that you are a gender minority, because in the past, it would be rare to see a male nurse. There must be some restrictions to delivering nursing care. Would you like to share more about it?
Answer: Mr Yong started off by highlighting that he finds this question intriguing. Firstly, there are several social issues at play here which are not easy to overcome. In Singapore, the cohorted cubicles and toilets further exacerbates the social problems associated with this question.
For such cases, Mr Yong urges us as nurses to always remain person centric. It would be appropriate to have a respectful conversation with this person and make some accommodations to make him or her more comfortable.
The core of nursing is to build a relationship with the patients so as to deliver person-centric care, and not patient-centric care. Nurses have a greater opportunity to build stronger relationships with the patient, and hence they should be the ones to champion person-centric care.
The core of nursing is to build a relationship with the patients so as to deliver person-centric care, and not patient-centric care.
Question: How do you feel that the education system is fairing with respect to evolving to match up to equip nursing students today with the competencies required of a contemporary RN? Is there a need for further change?
Answer: Mr Yong first underlined some statistics saying, “More than 75% will pass their probation within 6 months and that’s a good demonstration that new nurses have a good foundation from their respective education system.” He then drew a comparison to other countries and explained how Singapore has a robust education system that equips nurses well in caring for patients and this can be further illustrated by how nursing students are able to cope effectively with stress during their probation period. In order to supplement the learning opportunities for students during their clinical attachments and for schools to track how well graduates fare in the hospitals, schools engage people who practice in the hospitals to comment on the curriculum, thereby making the genuine efforts by the system commendable in ensuring students do well. However, there is certainly room for improvement.
Thus, Mr Yong emphasizes that greater titration between the school and clinical placements on a system level is something that is being discussed on a regular basis with strong conviction to continuously improve, where appropriate.
Mr Yong truly broadened our knowledge and inspired the many young nurses present during the webinar by sharing his valuable insights, perspectives and advice on the healthcare challenges faced by nurses. Mr Yong’s experiences and achievements are a true testament to his successes thus far in Nursing and we hope that the webinar inspires nursing students who tuned in to shape the future of nursing, as the next generation of transformational leaders.
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