NUR 3114: Leadership & Management Module E-lectures & Tutorials

Week 1 Materials:
1. Watch the video "Singapore's healthcare system" (must know)
2. Watch the video "How much does the Singapore Government spend on
Healthcare?" (must know)
3. Read the article "Healthcare made affordable with 3Ms" (must know)

Week 1: E-lecture

About MOH:

Vision Mission Values

Championing a healthy
nation with our people.
To live well, live long & with
peace of mind.
Promote good health and The following signifies the
reduce illness core values that the
Ensure access to good and Ministry embodies through
affordable healthcare our staff: DEPICT
Pursue medical excellence Dedication
Excellence
Professionalism
Integrity
Care & Compassion
Teamwork

Singapore’s Healthcare System:

System Overview:
1. Mandate, mission & vision
2. Historic healthcare roots
3. Factors that influenced system development
4. Major stakeholders

1. Mandate, mission & vision

a. mandate/philosophy: MOH believes ensuring quality & affordable basic
medical services for all
b. mission: 3 strategies
i. promote good health & reduce illness – public education on lifestyle
ii. ensure access to good & affordable healthcare – good clinical
outcomes & professional standards
iii. pursue medical excellence
c. vision: championing healthy nation with our people, live well, live long & with
peace of mind – values (above)
2. Historic healthcare roots
a. SG used to be country of poor incomes & poor health outcomes
b. gained independence in 1965, faced housing shortages & high rates of
unemployment
 c. PAP provided political stability for SG & contributed to many successes of the
country
d. early initiatives were put in place to improve housing, clean water etc
e. 2011 – increased concern that families were experiencing bankruptcy when
trying to pay for elderly care – govt doubled MOH spending & subsidies, for
home care, day care & rehab – middle income financial relief
3. 4 factors influencing system development
a. movement towards outpatient services after Independence in 1965
b. sending doctors abroad to train in specialties – Healthcare Manpower
Development Program – cornerstone of current system
c. 1983 National Health Plan, which reconstructed public hospital system &
introduced Medisave - merging with financial disciplines
d. release of White Paper – “Affordable Healthcare” in 1990s
4. Major Stakeholders:
a. Patients – compulsory Medisave for paying own expenses (can only pay $400
cap per day in Medisave)
b. Government – percentage of income contribute to CPF
c. Healthcare providers
d. Hospitals administrators & governing bodies – regulation of public & private
sectors
e. Health insurance

A. Analysis of healthcare system

1. SG’s healthcare system is a mixture of both public & private sectors & would fit
under an etatist social health insurance system according to Bohm et al
2. Healthcare funding Structure
a. spends <4% of GDP (vs Canada at 11.2&)
b. consists of 3M – Medisave, Medishield & Medifund (in order)
c. Eldershield addition
d. Private insurers also help fund healthcare system
e. Medisave: national insurance for SGporeans savings for future healthcare
needs
f. 7-9% of monthly income
g. Medishield: Complementary to Medisave – insurance: settle part of
outpatient service for serious illness & prolonged hospital stays
i. medishield yearly premiums – increased cost per age
h. Medifund: endowment fund – last resort for inadequate Medisave &
Medishield funding
i. elderly priority
ii. Medifund added when healthcare budget is in surplus (1.3B in 2010)
iii. Medifund-approved institutions give approval to medifund applicants
i. Eldershield: affordable insurance for severe illness or disability to those who
need basic financial protection, ran by private insurers (3 insurers);
automatically covered at 40.
j. Private insurance: 5 insurers – cover inpatient, outpatient medical expenses,
surgical costs, critical illness, disability & LT care
i. other 2 plans: PMIS – private med insurance scheme & non-PMIS
3. Regulatory Bodies – 3 main regulators
a. 1st: MOH – oversees provisions & regulations of healthcare services
i. promotes health ed
ii. prevent & control diseases
iii. allocating resources
iv. monitoring accessibility & quality of healthcare services
v. administering licenses for healthcare facilities – institutions need to
adhere to laws & regulations
vi. create legislative acts under MOH
b. Health Science Authority – works under MOH, has 3 main functions
i. national regulation for health products
ii. creates blood supply for hospitals throughout nation through
operation of national blood bank
iii. represents expertise in forensic medicine, forensic science &
analytical chemistry testing capabilities
c. Monitory Authority of Singapore – SG Central Bank
i. regulates financial assistance aspect of insurance sector
ii. administers Insurance Act
iii. regulates insurer’s activities – including registration & licensing
requirements
d. HCP regulatory bodies
i. SMC – SG Medical Council
ii. SDC – SG Dental Council
iii. SNB – SG Nursing Board
iv. SPC – SG Pharma Council
v. TCM PB – TCM Practitioners’ Board
vi. O&OB – Optometrist & Opticians Board
vii. AHPC – Allied Health Professional Council
4. Organization of Health Services & delivery
a. supplies its citizens with primary, hospital, long-term & integrated care
services
b. 80% - provided via private practitioners
c. 20% - delivered publicly
d. hospitals – 80% public, 20% private; ward tiers: A, B1, B2+, B2 & C

e. Medical Clinics – med treatment, upstream programs & education – 80%

private, 20% publicly funded
f. Healthcare clusters – to provide more holistic & integrated care
i. 6 to 3 systems
 B. Health Status of Nation
a. Healthcare concerns: aging population, management of chronic diseases &
communicable disease control
b. Ageing pop: 2030 – 20% >65 y.o.; increased life expectancy & declining BR
i. thus, shift from episodic care to long-term care
ii. treatment of chronic disease
iii. community disease prevention
c. Management of Chronic Diseases: prevalent illnesses – Asthma, COPD, Dm,
HTN, HLD & Stroke
i. increasingly greater population of DM & obese population – 2010 SG
population, 11% are DM – increased by 3% between 2004 & 2010
d. Communicable diseases: 2003 SARS, 2008 Chikungunya, influenza outbreaks
& dengue fever – vector control
e. Internationally – SG meet healthcare needs with low healthcare spending
i. life expectancy good: Women – 84 y.o., Men – 79 y.o.
ii. infant mortality: 2 deaths per 100 live births annually, lowest rates
WW
iii. childhood diseases: National Childhood Immunization Programme &
increased in diphteria, tetanus, polio & congenital rubella
iv. adult mortality rate: 60/1000 adults annually & significantly lower
than in ASEAN
v. Evaluation done by patient satisfaction surveys & Government
responsiveness to citizen concerns (responding to elderly needs)
C. Barriers to service provision
a. aging population – affordability & accessibility
i. service delivery – engaging different ministries: finance, transport etc,
integrating facilities to all neighbourhood (daycares, nursing homes),
allowing for continuum of care recipient following discharge
ii. Linking acute care & community services supported by primary care
providers & community organizations
b. manpower challenges
i. current shortage of nurses & specialists
ii. lead to overseas recruitment
iii. makes it difficult to initiate change in the healthcare
D. Conclusion
a. SG ranks 6th in world in healthcare outcomes
b. spends less on healthcare than any other high-income country
c. providing exceptional healthcare services to entire population through a
variety of delivery methods

SG’s expenditure on healthcare:

1. Total 2013 – SGD$6.5B on healthcare

a. portion spent on hospital (mostly), polyclinic & CHAS, aged care, medisave top-ups
& health promotion/research
b. benefits:
 i. Health Assist – go to CHAS approved clinic; hence bill is subsidized,
inpatient bill subsidy, homecare subsidy, integrated health screening programme
(free) & subsidized consultation
ii. only SGporeans & PRs eligible for subsidies; non-PRs unsubsidized except
for ER services. Proportion of subsidy depends on ward type.
iii. Special Outpatient Clinics: A/B1 pts pay full, B2/C pay subsidized
iv. no cash deposit required during stay unless expected hospital bill exceeds
Medisave withdrawal limits/ Medisave balances. Er do not require deposit

Week 2 Materials:
1. Watch the e-lecture videos: Impact of healthcare policies on hospital operation (part 1
& 2) (must know)
2. Watch the YouTube video (from the weblink) of Minister for Health Gan Kim Yong (talk
on 7 March 2018) (must know)
3. Read the article "the future of Singapore Healthcare" by Prof Benjamin Ong - Ref: Ong,B.
(2016). The future of Singapore healthcare, Medicine, 20, 20-23. (must know)

Week 2: The ‘3 Beyonds’ and Impact of Healthcare Policies on Hospital Operations

A. Pre-Reading Article: The future of SG Healthcare by Prof Benj Ong

Community Hospital were opened last year. By 2020, there will be an additional 6,600
places in community care, home care, and palliative care sectors. Marine Parade Polyclinic
has just been expanded and further plans for the primary care sector are in the pipeline to
2020 as part of our initiatives to strengthen community care.
On manpower, the residency programme was started in 2010 in part to introduce training
structure, reliability and efficiency in specialist training. There are now more doctors
entering specialty and Family Medicine training. The number of medical students
in our three medical schools has also increased over the years. Nonetheless, the training of
healthcare professionals takes years and more so for specialists, who may require more
than a decade to train. This makes it inherently challenging to calibrate the training pipeline
and constantly maintain an appropriate number of healthcare workers in the system.
Occasionally, we have needed healthcare professionals from overseas to augment our
teams.

The Ministry has been taking steps to further improve the quality of healthcare delivery. To
ensure that we do not sacrifice quality for quantity, the Ministry is reviewing the training of
our healthcare professionals, taking into consideration the current practice and learning
environment. For local specialist training specifically, residency has provided a framework to
anchor our training even though there are areas that need improvement. The first batch
of residents has just completed training. We will continue to monitor and improve the
system. For healthcare professionals from abroad, the professional boards and councils
have put in place supervisory frameworks to ensure that they can practice safely and
competently here.

The Ministry has also been implementing the recommendations of the Nursing Taskforce
since 2012 to strengthen the development of the nursing profession in the areas of Career
progression, Autonomy, Recognition and Education. Some of these initiatives include
providing bridging courses for our Enrolled Nurses to become Registered Nurses and the
nurturing of more Advanced Practice Nurses.

The third focus of Healthcare 2020 is affordability. Apart from the Community Health Assist
Scheme (CHAS) and the Pioneer Generation Package, MOH launched the MediShield Life in
November last year. MediShield Life provides better protection and higher payouts, so that
patients pay less Medisave/cash for large hospital bills; it covers all Singapore Citizens and
Permanent Residents, including the very old and those who have pre-existing conditions;
and it is protection for life.

Beyond Healthcare 2020 -Ensuring Effective Sustainability

However, to truly prepare ourselves for the change in the healthcare needs, we have to put
the patients back at the centre of healthcare delivery and better appreciate how they
journey through their stages of health and illness, and across different care settings.
Optimising these care journeys requires us to develop a system perspective and not,
myopically, a single care setting focus. We will have to go upstream to focus on resource
utilisation, disease prevention, and home and community care. All these have to be done in
a sustainable way, bearing in mind the constraints on resources we will increasingly face in
the future. These are encapsulated in the Beyond Healthcare 2020 plan as
"from hospital to community", "from quality to value" and "from
healthcare to health".

From Hospital to Community

The transition from a traditional hospital-centric model to a broader community-based one
will require building stronger links between tertiary institutions and the primary,
intermediate, long-term and home care sectors, to better deliver care to Singaporeans.
Much has been said about the Regional Health Systems (RHS). Each RHS will have oversight
of the acute hospital, community hospitals, nursing homes, polyclinics and home care
providers under its purview, ensuring that patient flow is seamless and care is coordinated.
This can be done in many ways, one of which is integrated care pathways. Private primary
care providers like the GPs should also come under this framework for the benefit of their
patients.

Primary care is the foundation of any healthcare system. We are strengthening its place in
our healthcare system as the first and continuous line of care. Our goal is to realise the
vision of "One Singaporean, One Family Doctor". Our Family Physicians and general
practitioners, and not the specialists, should be the first point of contact for most
Singaporeans, both the ill and well.

Healthcare Manpower
As we reshape our health delivery system, we will have to re-look the whole care process
ecosystem and reduce duplicative and unproductive clinic visits and tasks as well as tests.
However, there is also a need to modify the way we train our healthcare workforce. First,
we need to re-balance the tide of sub-specialisation and bring back generalist skills to
reduce care fragmentation. Too many times, we hear of patients with multiple specialist
appointments in different places, a long shopping list of medications that seems to grow
with every appointment, and no one doctor to take overall responsibility. A diabetic patient
with stable cardiac and neurological complications does not need to be separately seen by
the endocrinologist, cardiologist and neurologist. Siloed, episodic models of care will
become increasingly unsustainable as life expectancy becomes longer and more
Singaporeans live with multiple chronic conditions. This is where generalist disciplines such
as Internal Medicine, Family Medicine and Geriatric Medicine come in. Doctors in these
areas are overall in-charge and coordinate the care for patients with multiple co-
morbidities. Unfortunately, these are not as popular among doctors as we would like them
to be.

To further strengthen primary care, MOH has introduced training subsidies to encourage
our primary care colleagues to undergo postgraduate training in Family Medicine for
continued upskilling. As the prevalence of chronic diseases and complexity of cases increase,
with more people having multiple co-morbidities, the MBBS alone may become insufficient
for independent professional practice. These efforts will take time but I hope with this, the
public can slowly appreciate the professional value-add that Family Physicians can bring to
their care.

This generalist approach applies not only to doctors but also

the nurses and pharmacists. As we train more Advance Practice Nurses (APNs) who can
specialise in areas such as critical care and psychiatry, all nurses should still be able to
provide good basic nursing care. Similarly for the pharmacists, though the numbers are
much smaller than the APNs, specialist pharmacists should still be able to, if I may quote
from the Department of Pharmacy's website, "tackle challenging human health problems"
and maintain "clinical acumen and scientific mastery that translate to applications in clinical
practice, pharmaceutical research and service".

Here, I should make a special mention about our medical social workers (MSWs). You are an
integral and important part of the healthcare team and I say this from personal experience.
Singapore may be affluent but changing family structures possibly mean more elderly living
alone and with their co-morbidities. This is where our MSWs will become more important.
You bridge patient care across sectors and it is not just from the acute hospitals to step
down care but also within the community. As we mourn the passing of Mr S. R. Nathan, take
pride in the achievements he has accomplished, academically and professionally, in the area
of medical social work and build on it, exemplify it.

Demand for healthcare will continue to grow with an ageing population and the supply of
local manpower will shrink due to falling birth cohort sizes. As such, innovation and
productivity must increase to take on the challenge ahead. Productivity and efficiency
efforts by healthcare workers are for a noble purpose, as they enable us to serve patients
and residents better. Each of us can lead in this effort, by reviewing workflow and
eliminating waste, deploying equipment and technology that extend manpower, expanding
our skills with training to meet changing care needs and empowering patients, caregivers,
volunteers to support the care delivery. At the systems level, we are reviewing policies and
regulations and are prepared to change if they no longer serve their intended purpose. We
are also designing for efficiency and automation upfront when planning new healthcare
facilities. There have been many good ideas that have been implemented and we must
continue to strive to create ways to do more with less manpower.

From Quality to Value

I mentioned ensuring sustainability in the face of re-modelling our healthcare delivery. With
so many new drugs and medical devices coming out of the market, what is the most
appropriate for our patients and that is sustainable for the healthcare system? The Ministry
has recently set up the Agency for Care Effectiveness to (1) guide the proper use of such
treatments and technology, and (2) encourage providers to manage costs while providing
quality care. (low cost but high quality)

From Healthcare to Health

While I have been expounding on what we are doing to provide care for the ill, we need to
remove the causes of ill-health early and reduce the progression of long-term chronic
diseases. This is a challenging task for it not only involves our colleagues in the Health
Promotion Board, everybody from outside the healthcare sector must be engaged. A
mindset change, to move away from the current lifestyle, must be embraced.
The World Health Organization recently announced that the global number of adults living
with diabetes is over 400 million in 2014. Of these 400 million, 400,000 are in Singapore.
The Minister for Health has therefore recently declared War on Diabetes. You are certainly
aware of the many risk factors and complications related to this one single condition.
Tackling diabetes will have collateral benefits on the prevention and management of other
chronic conditions such as diseases of the heart, nerves, and kidneys. However, rather than
a campaign against one specific disease, may I urge you to see this as an anchor upon which
the entire healthcare sector - health promotion, primary care, acute care and rehabilitation
need to come together to reduce the rate of increase in diabetes, and support and
empower patients with diabetes to manage their condition well. This is going to require the
sustained efforts of everyone here.

Expect the Unexpected - Infectious Diseases

Singapore is a global travel hub, with about 60 million travellers
passing through Changi Airport last year. Some of these travellers may bring with them
communicable diseases. SARS was brought
into Singapore through air travel. Zika may also have come in
from the region in the same manner. We are preparing for the
importation of MERS. Thailand, Malaysia and the Philippines have
already experienced imported MERS cases. A single imported case can result in a huge
outbreak and national crisis as we saw in South Korea last year. We also have to contend
with endemic diseases such as tuberculosis, HIV and dengue. The principle is simple:
prevent or stop outbreaks through early detection and disruption
of the chain of transmission. Even as we strengthen our national
surveillance systems, the Zika outbreak has illustrated to us the
importance of vigilant healthcare workers - to pick up the unusual. Early detection of SARS,
chikungunya and Zika was all effected
through such vigilance. If we are able to detect an outbreak early, we would have a better
chance of minimising its impact.
Your Role
I have highlighted the main areas which we have identified as high priority for Ministry
development, such as primary care, intermediate and long-term care and public health. I
also covered infectious
diseases and the response that needs epidemiologists, infectious
diseases physicians and public health experts. I encourage you to
consider careers in these sectors in future. Not only will you be
moving Singapore healthcare forward, you will also find yourselves genuinely fulfilled as you
touch the lives of everyday Singaporeans.

We will need skilled healthcare professions to lead the charge in

the community. Patient care will be more complex and challenging. It is therefore even
more important that you see yourselves as part of one public healthcare system. The
relationships that you build in school now will allow you to have a shared goal and
camaraderie. More importantly, the relationship you build with your patients will enrich
your professional lives ahead.

Conclusion
All systems must evolve and adapt to changes. Changes
present opportunities for us to grab. I very much hope you
will all embrace this time of change and lend your talent to the
healthcare system to ensure Better Health, Better Care and a
Better Life for all Singaporeans.

B. Video: 3 Key shifts in SG’s Health System by Minister for Health Gan Kim Yong

Singaporeans living longer, longer life expectancy, highest in the world, 72 y.o. males, 75
females. Aging population – growing chronic population ¾ >65y.o, DM, HLD & HTN. Want to
live well. Need to adopt healthy lifestyle. good healthcare system: affordable & accessible.
healthcare progress 2020 – accessibility & affordability improvement. Next few year – add
healthcare facilities – woodlands health campus 2022, down south outram community
hospital and national cancer center outram revamp, east – Sengkang hospital & CGH
medical center and west – NUH oral health & central integrated hub & national infection
centre. More community hospital beds & nursing homes. Home based & center-based
places. Workforce growth by 26%. Increased subsidies and outpatient clinics, CHAs – blue &
orange care. 2015 – medishield life introduced for inpatient care. Future ready workforce
for transformation of healthcare. Grow & upskill manpower. Innovate for healthcare
delivery for effective, efficient better health outcomes. Pioneer polyclinics – patient cared
for by regular primary care team for better continuity of care – initiatives for improved
quality of care. Higher NHE increase – 10.9B 2010 to 18.9B 2015. 4.6% GDP, lower than
most countries, rise over time as population ages. Govt expenditure on health grew by
120% over same period – affordability of healthcare (share of out of pocket expenses from
40 to 30%). Pioneer Generation package, Medishield life & extended use of Medisave – 8/10
hospital bills <$100. Cannot increase higher subsidies – require higher subsidies which borne
by SGporeans in higher tax & premiums.

3 Beyonds – roadmap to sustainable system beyond 2020 healthcare.

Accessibility: Beyond hospital to community. Total spending in primary & intermediate care
by 4 times. Reflect priority to anchor care firmly in community. Invest social & healthcare
services closer to serve people better – silver generation office & expansion network for
seniors on SG cares. Better accessibility to homes: 6 new polyclinics will be built by 2020.
Add another 6-8 polyclinics by 2030. Partner with GPs for subsidy via CHAS.

Affordability: Benchmark fee as reference for doctors to set fees and for patients to know
options. Guide for cost-effective drugs & treatment by ACE. Healthcare productivity fund to
improve healthcare initiatives. Co-payment integral feature in integrated shield plans and
Medicare life for healthcare sustainability. Emphasize for healthcare responsibilities &
prudent decisions & service providers to make cost-effective expenses. Full-riders
encourage buffet syndrome as 0 cost incurred for patients. Undermines co-payment
principle and dilutes necessity to choose appropriate care. Will incur rising healthcare cost.
Issued new requirements for integrated health care insurance – require co-payment
features. Encourage responsible behavior by patients & healthcare providers. Policies
remain evaluated through co-payment. Medifund will remain as safety fund.

Countability: Best way to beat rising cost – is to stay healthy, beyond healthcare to health.
Challenge against diabetes. Create supportive environment for healthy life. 3 shifts in multi-
year effort. Completely reorganized public healthcare system into 3 clusters. To create
synergy & better care for patients. Create seamless care between primary & community
care. New national integrated supply change goes beyond procurement office by Singhealth.
pool resources of 3 cultures to achieve EOS – for synergy, capabilities & innovate supply
chains. Mitigate cost increases & better conveniences. Advances in medical science,
increasing digitalization & connectivity provides better opportunities for healthcare. MOH
office of healthcare transformation (MOHT) – LT ideas scaled up for system level
transformation – tested at health empowering Alexandra campus. Master planning of NUH’s
KR campus for future healthcare needs, developments – 2013 NUH medical center, oral
health 2020, master plan study – plan ahead & reimagine KR & main NUH building can
rejuvenated for current & future models of care.

Choose to live healthily for vibrant, good quality of life and sustainability. Active community
by taking ownership of individual health will create ripple effect to many more. Bring better
health and better care for all SGporean lives.

C. E-lecture: Impact of Healthcare Policies on Hosp Operations

1. identify healthcare trends in the local setting; (golden years – insight into SG Aging
population)
a. Elderly activities: collecting cardboards, hunched back, chilling at void decks,
collecting trash, wheelchair bound, aging as a couple, looked after by a domestic
worker, aging as a construction worker & florist.
b. 2015: 1.5 elderly, 1/6 2020, ¼ 2030

c. aging population impact healthcare services

i. increased demand on healthcare services requiring expanded capacity
ii. changes in how we deliver healthcare
1. increase in chronic diseases
2. increase care within community
iii. increase in healthcare costs
1. greater demand leads to increased costs
d. Health Minister Gan Kim Yong – Challenges of Aging Population 2012 video
i. 2030: >65y.o. tripled – increased demand on healthcare services hence
expand capacity to meet needs
ii. shift in healthcare – focus on acute care episodes of diseases, to chronic
diseases: change model of care respectively with delivery in the
community for elderly convenience
 iii. cost changes – due to demand increase resulting in cost increase
iv. healthcare landscape evolve globally – each country have subjective
problems but have common grounds to improve healthcare by sharing
experiences, knowledge & challenges through world health summit –
academics, researchers, scientists & HCP thorugh different perspectives
and collaborate to innovate solutions. A platform for stakeholders to
network and create solutions.
e. Healthcare strategies
i. Ensure access to good & affordable healthcare
ii. Promote good health & reduce illness
iii. Pursue medical excellence
iv. Keep programs relevant
v. Integrated care
f. Reorganize of healthcare system into 3 integrated clusters
i. Regional Health System – Network of healthcare providers across care
continuum offering integrated, well-coordinated patient-centric services
to regional population. Means to organise healthcare providers to deliver
patient centred care through integration of services & processes.
ii. 6 to 3 – Central, Eastern & Western – new integrated cluster will have
fuller range of facilities, capabilities, services & networks for better
deployment of resources
iii. new clusters will also be able to draw from the combined strengths &
talents of their two original clusters for wider & deeper range of
professional developmental opportunities & broader platform for cross
learning
g. Building a healthy nation video
i. affordable & accessible healthcare – healthcare financing
1. govt subsidies
2. 3Ms – medisave, medishield (voluntary savings) & medifund
(endowment fund – safety fund)
3. integrated care – public & private acute, intermediate & long-term
care centres & hospitals: from discharge going to day care, nursing
homes, community hospital and home nursing. Outpatient
polyclinics and clinics. Eventually one physician for every
individual.
4. The White Paper on affordable healthcare sets out the
Government’s philosophy and approach to controlling health care
costs in order to keep basic health care affordable for all
Singaporeans
5. The Government has guaranteed Singaporeans access to
affordable basic medical services.
6. A large part of the basic care will be provided under the Public
Healthcare System in restructured hospitals.
7. Five fundamental objectives:
a. To nurture a healthy nation
b. To promote personal responsibility for one’s health
 c. To provide good and affordable basic medical services to
all Singaporeans
d. To improve service and raise efficiency
e. To keep health care costs down
ii. promoting good health & reducing illness – new complex conditions &
greater demand on manpower
1. prevention with healthy workforce
2. biomedical research through specialist centres – translational &
clinical research, supporting clinical trials 7 working with
international partners
a. biopolis – biomed research hub to spur medical discoveries
– responsive & responsive system for safety & quality
iii. keep healthcare relevant
1. medical education & training
a. YLL - MBBS, DUKE-NUS – physician scientist

2. discuss the impact of healthcare policies on hospital operations; and

3. discuss the role of nursing and the key challenges for nurses.

Tutorial:

Discussion:

1) How do you feel about Singapore’s healthcare system and financial model (from last
week e-lecture)? Review quiz questions and content from week 1

2) What is the ‘3 Beyonds” and how would it impact on nursing practice?

Beyond Hospital to community, beyond healthcare to health & beyond quality to value.

3) What hospital’s policy that you have experienced with during your posting?

Case Scenario Questions:

New policy – patients that stabilize after 2 weeks, to be transferred to step down care in
community hospitals for rehab. This eases bed crunch.

1) If you were Nurse Yuki, how would you explain to Linda’s husband regarding Linda’s
husband regarding his concerns?
a. To provide psychosocial support for wellbeing and communication
b. Acknowledge concerns
c. Inform the rationale for shift from acute to community hospitals – no longer require
staying in acute setting
d. Provide support groups available for caregivers
e. Inform him of the updated treatments costs and associated financial resources
f. Inform him that the wife is going through therapy that will facilitate her to recover, hence
she will not be helpless
g. Recommend hiring of caregiver
h. prioritize which intervention to execute according to your own time management

2) How would you relate the key shifts of healthcare system that was addressed by Minister
for Health Gan Kim Yong on 7 March 2018 (from attached video) to this case?

3 Beyond
Beyond Hospital to Community Community hospital:
o more stable, priority for rehab
o comm hosp has better resources &
environment for rehab
o tap on community resources

Beyond Healthcare to Health Encourage independence to take charge of

her own health through OT & PT
o Reduce risk of future accidents as she
has greater awareness to her own
capability
o promote prevention – Linda’s husband
& Linda
Beyond Qualtiy to value o better delegation of resources to
ensure sustainbability in healthcare
system because reduces bed crunch
o patient can enjoy lower hospital bills
during rehab in comm hospital –
instead of in the acute hospital
o patient can enjoy the most appropriate
patient care that he needs

3) What are the relevant community services that Linda and husband can tap on?
Relevant community services:
I.AIC
o ACTION – Aged Care Transition Project –
o Day care centres/rehab centres
o caregiver support/training
o Home Nursing
o Community Nursing & Polyclinic
II. MSW
o Finance: CHAS, Merdeka, Pioneer Generation & 3Ms, senior’s inability
o Emotional/Pych needs – counselling
o Education
o Volunteer services
 o Community refunds
III. Education
o Caregiver training grant
o Interim Disability Astitute

4) Regarding the new care model and shifting the focus from acute care to the three
beyonds, what are the nurses’ roles that would change, and what are the changes?

Beyond hospital to community

o shift towards community nursing
o 5 new community hospitals: Woodlands, Yishun
o Expanded Renci
o Community Nursing Posts – Singhealth
o Nursing Homes –
o primary care networks
o more specialization
o geriartric, palliative
o require more comptency

Beyond healthcare to health:

o nurses involve in health promotion: prevent, promote, manage & empower
o nurses led diabetic clinics
o initiate care plans – advice
o empower – giving education
o promote activity yet be involved
o promote active aging & healthy living
o advocate for patients to make better choices

Beyond quality to value:

o May cause care fragmentation due to too many specialists – thus APNs can be
referred to for most cases
o better advocates for drug alternatives – cost effective
o low cost but high quality

5) How does the new care model relate to the health concerns (e.g. ageing population,
chronic diseases management, communicable disease control) in Singapore?
o Aging population
o prevent chronic condition from health check-up/ accessible & convenient
o free-up hospital beds – acute cases
o community care for rehab
o home visits for frequent flyers
o chronic disease management
o home nursing foundation, support groups, upskilling of health care workers
 home visits for dressing change, medication
o Communicable diseases:
 early detection
  ACE – agency for care effectiveness: research treatments that give
better value for money
 DOT therapy – for people in Tb; quarantined for 2 weeks, however
after that, they have to take medication in polyclinics under nurse
supervision
 clinic/hospital
 endemic – dengue alert in high risk places
 clinic/hospital screen for MERS

Week 3 Materials:
1. Watch the e-lectures (part 1, part 2, and part 3) and the hospital organizational structure
video. (must know)
2. Read Chapter 7, 12 & 13 in Marquis, B.L. & Huston, C.J. (2017). Leadership Roles and
Management Functions in Nursing: Theory and Application (9th ed.). Philadelphia:
LWW (nice to know)
3. Read the vision, mission, and values from the MOH weblink (must know)

Week 3: Organizational structure, culture & values

 describe how organizational structure facilitates or impedes communication;

 describe the role of organizational environment and culture;
 define power and describe it at different levels; and
 discuss and be aware of the cultural work environment in healthcare delivery system
in Singapore

Hospital Organizational Structure:

organizational structure: levels of management within hospital
 levels – allow efficient management of hosp dept
 structure – exhibit the chain of command

organizational structure varies between hospitals.

 large hospitals – more complex
 smaller hospitals – have simpler organizational structures

grouping of hosp depts within structure:

 promotes efficiency
 grouped according to duty categories – similarities

common categorical grouping:

 admin services
1. biz people running hospital
2. oversee budgeting & finance
3. establish hospital policies & procedures
4. perform public relation duties
 informational services: document & process information
 1. admission, billing, medical records, computer information systems, health
education & human resources
 therapeutic services: provides treatment to patients
1. PT – improve large muscle mobility
2. OT – regain fine motor skills
3. ST – identify, evaluate, treat speech/language disorders
4. RT
5. Psychiatric
6. MSW
7. Pharma
8. DT
9. Sports Med
10. Nurs
 diagnostic services: determine the cause of illness or injury
1. medical lab
2. medical imaging
3. emergency med – emergency med & treatment
 support services: provides support for entire hospital
1. central supply – orders, receives, equipment etc
2. biomed tech
3. housekeeping & maintenance

Pyramid: demonstrates symbolic organizational structure of hospital

Week 3 Tutorial:

Types of Power:
 Reward, coercive referent, expert, information & self-power
Organizational Culture:
 safety
 no blame
 honest
 nurse-friendly

Organizational Values:
 teamwork, professionalism, caring & integrity

1) What do you think about the working relationship between RN Ann and Nurse Manager?
Transformational: focus on the sincerity of the action
Transactional: focus on the outcome to gain a greater reward

Can be assumed that Ann and the manager has a formal and hierarchical relationship, with
an interplay of dominance, authoritative, submissive and fearful. Thus it becomes
impersonal and transactional. This is a result of poor communication, as Ms Ann did not
express her lack of competence to cope with the workload: increased patients and
supervisory nursing students.

2) What do you think about the ward culture and teamwork of this ward?
Culture affects Teamwork

Culture Teamwork
Hierarchical: Lack of teamwork:
Fear – do not dare to speak up Other nurses did not help to respond to the
call bell – only care of their own cubicle
No one came back to help

Non-nurse friendly: No communication skills between nurses

High workload which will affect the reputation of the
NM did the bare minimum whole ward

Weak mentorship:
Students probably did not get much
guidance
Students likely did not want to disturb the
RN – did not verify order

Self-centred:
Not my patient, not my problem hence no
one came back to help

Patient Safety Culture:

Nothing to prevent medication error

Requires gradual implementation of own

initiative and action, but once become
nurse manager, can implement certain
competencies.

3) What do you think about RN Ann and what power does she have?

Ann not exercising her legitimate power since her role as an SN(I), to negotiate about her
workload and suggest to the Nurse Manager to take up some workload so that it becomes a
safer workplace.
Ann can exercise her charismatic power to negotiate and persuade the colleagues and NM
to ease her workload especially since the NM’s proficiency is affected.
Ann could have use the expert power, the knowledge to now that her incompetence to look
after 8 patients and a student nurse.
Ann could use reward power, talk to her 8-12 patients before the start of the shift to
cooperate with her throughout the shift. Build understanding and treat with biscuits.
However, use sparingly as people may expect the reward all the time and will be the only
motivation to cooperate.

4) If you were RN Ann, how would you do differently to prevent all the undesirable events
above?
 assess own ability – can I supervise the students alone without compromising care
 plan her day
 be honest & open up about her concerns
 brief the students before the shift on patients’ condition: NBM, fall risk, etc and
assessing students’ capabilities
 share responsibilities of extra load – supervise the students (teamwork); possibly the
NM can give her walkie-talkie patients (can walk & talk)
 ask the NM where it is possible to request for manpower from another ward

5) If you were the Nurse Manager, what would you do differently to prevent all the
undesirable events above?
 ask staff from other ward
 NM take case/help out/supervise
 in future, have someone to standby for each shift – give OT allowance
 NM should elicit concerns from the SNs, be more in touch with the staff on the
background
 approach it from a reward & charismatic power

Staff to take MC workflow:

 reward the staff that get called back during their off
 on-call nurses – pay the nurse

Objective:
1. Prevent the problem
2. Manage better
Week 4 Materials:
1. Watch the e-lectures: Management and motivation (Part 1 & Part 2) (must know)
2. Read Chapter 2 & 18 in Marquis, B.L. & Huston, C.J. (2017). Leadership Roles and
Management Functions in Nursing: Theory and Application (9th ed.). Philadelphia:
LWW (nice to know)
3. Read the article “Hospital nurse work motivation” (nice to know)

Week 4: Management & Motivation

Learning Objectives:
1. define components of management;
2. identify the management process and roles;
3. correlate management theories & theoretical contributions;
4. define motivation and discuss theories of motivation; and
5. identify strategies to enhance motivation at workplace.

1) What is your motivation to become a nurse?

 helping people
 changes over time with patients’ condition and nurses’ knowledge

2) What did demotivate you as a nursing student during your clinical postings?
 unfriendly staff
 no support group especially in a high conflict environment
 unable to help the patients
 environment does not exhibit valuing you

3) What do you think about the article “Hospital nurse and motivation”?
 intrinsic & extrinsic motivation
 bedside nurses are greatly intrinsically motivated
 managers are greatly extrinsic motivated
 outcomes were not specified hence could not measure the association between intrinsic &
extrinsic motivation
 over time nurses become less intrinsically motivated by providing occasional professional
training & have the recognition for their years of service thus making them feel valued –
increasing their motivation to work longer

Class quiz:
I. One of the main focuses of the human relation management is:
 Participation in decision making.

Behaviour of people might change with the proliferation of technology – dictating the nature
of interaction, may result in different management theory formed.
Scientific Management Human Relation Management

Productivity Employees’ satisfaction/empowerment

Supervising, directing, training to fit the job Participation in decision making

Using incentive Providing training to improve work
Example: Magnet hospital
 Magnet status: recognition program for for recognizing nursing excellence
 especially for bachelor’s graduate – there is greater patient safety

Chapter 2: Management
Chapter 18: Motivation

II. Management functions: planning, directing, organizing & controlling not educating

III. Salary is part of hygiene factors not in motivating factors of the Herzberg’s 2 Factor
theory.

Case scenario: Senior Nurse Clinician Raja in MICU role play on motivation

Raja is a senior nurse clinician who has been working at the medical intensive care unit
(MICU) for 8 years. Lately, she is assigned to lead a quality improvement project to improve the
handover process in MICU (on the top of her routine work such as taking care of patients and
training new nursing staff). She has to work with 4 nurses in the team and she feels that she is the
only one who is working actively in this project. When she presents the proposal to the team, she
gets very bad comments and has to make a major revision on the proposal. Raja also gets complain
from a patient who was very upset with her care. Raja is married and her husband is very busy
working at a cold storage as a manager. So, she is the main person to take care of her three young
kids. Today, Raja comes to the Nurse Manager’s office and she tells the Nurse Manager that she
doesn’t want to work here anymore.

Utilizing the different content & process theories:

Each group has 10 minutes to talk to Nurse Raja and each group will apply different motivation
strategy/theory when talking to Nurse Raja

Use theory to guide you and use theory to explain the action:

Theories applied through Human Relation Management – to retain experienced and well-trained
staff.
Need to approach from the employee as a person.

Maslow’s hierarchy of needs:

Theory Application
physiological needs ensure their physical needs such as sleep is
given
safety

social

Mc Gregor’s Theory Y:
Empowering for better self-direction especially through tender loving care
 Component Application
Ambitious Compliments:
 supermom
 SNC – recognized she is very
experienced

Self-motivated
Enjoy work
Greater productivity as freedom given to
employees
Accept responsibilities or work outcomes

Expectancy theory:
Motivation builds on effort translating to results.
Component Application
Expectancy Assess Raja’s expectancy
Instrumentality Support and reinforce that effort she put in is
adequate
Valency Manager will talk to the project members,
reduced effort, lightening of burden.

Frederick Herzberg’s 2 factor motivation-hygiene:

Hygiene Factors Motivating factors
Salary – can provide opportunity to support Recognition & Achievement – has been 8 years
children with domestic worker of experience and part of many projects
Security Growth & Development – challenges to equip
Status her with more skills
Work condition Advancement – to a greater role as SNC (I)
Interpersonal relations Responsibility

Reinforcement theory:
Relationship between operant behaviour & associated consequences.
Positive reinforcement Negative Reinforcement
Intervention through this: Not to use this at all for relationship and
Appraise - praise reputation
Recognition - Punishment – giving negative review
Shaping – recommend to solve the problem Extinction
Week 4: Face to face lecture - Patient safety & Risk management
Mr Wong Kok Cheong – ADON CGH

I. Areas for systems changes:

 continuous quality improvement
 risk assessment & management
 process redesign: review the current standards of procedure
o e.g. requiring a witness column for pre-operative consent – hence CGH removed it as
nurses can only observe the transaction between doctor and patient however it is not
within their expertise to evaluate the quality of informed consent taken
 innovation & technology
o acute shortage of manpower – insufficient nurses and to look after the patients
o leverage on innovation & technology
 e.g. app for nurses who cannot speak dialect
 AI – to monitor patients better
 engagement of nurses
o engage mind & heart to make a difference for the nurses

II. Mission
1. how to ensure patient safety under our care
2. how to ensure nurses are aware of risks
3. how to equip nurses

Patient Safety:
III. How risky in healthcare
1. People dying in healthcare in the US is 98,000 annually.

2. Example of patient harm

a. medication error/treatment error
b. patient suicide despite around the clock care
c. surgery on wrong patient/body part regardless of magnitude of operation – time-
out required
d. hemolytic transfusion reaction involving the administration of incompatible blood or
blood products – double-check for nurses
e. infection related death or permanent disability – HH required
f. death resulting from a preventable fall – elderly unaware of their limitations of
unsteady fall

3. Examples of SG cases:
a. Drug blunder at KKH, Nov 12 2009
i. two cancer patients given more chemotherapy drugs than they were
supposed to get
ii. supposedly the slow pump released over 3 days finished over 3 hours,
similarly another patient slow release over 5 hours instead of 5 days
 iii. CADD-Legacy 1 (over 24 hours – slow release) & CADD-Legacy PLUS (over 1
hour – fast release); very similar so the setters used the wrong pump
iv. hence antidote bought from abroad
v. human error can cause big issues
b. NUH liable for causing Donor’s death
i. woman donate organ to the husband
ii. woman died – due to inner arterial bleeding
iii. poor post-operative monitoring
c. IVF Mix-up
i. used the wrong sperm to the egg
ii. the skin colour and blood group does not match
iii. reputational hazard – Thompson Medical
IV. Medical errors
1. error is defined as the failure of a planned action to be completed as intended (error of
execution) or the use of wrong plan to achieve an aim (error of planning)

V. Types of common healthcare risks

 diagnosis
 prevention
VI. Most common root causes of medical errors:
 communication problems
 inadequate information flow
 human errors
 patient-related issues
 organizational transfer of knowledge/training
 staffing patterns/workflow
 technical failures
 inadequate policies & procedures

VII. Root cause of sentinel events

VIII. Swiss Cheese Model by James Reason

 errors can occur at every stage of healthcare service – each piece of cheese are defenses,
barriers & safeguards system defenses
 however, if the cheese aligned, it will allow harm to pass through the system
o e.g. anaphylactic shock induced in patient due to their allergy
 patient’s allergy history is not obtained
 doctor prescribing drug to check for drug allergy
 pharmacist fails to check patient allergy status
 nurses administering patient a drug to which she/he is allergic
 patient goes through cardiac arrest and dies
o investigation and improvement analyses all the holes
o robust & effective risk management system will find the holes in the processes
which contribute to the medical errors
IX. What contributes to the risks of medical error
 all humans make errors
 most of medicine is complex & uncertain: variations in healthcare increasing
 most errors result from defective system – inadequate training, long hours,
ampoules that look the same, lacks of checks
 healthcare has not tried to make itself safe

X. Nurses are always at the sharp end

 the nurses are always at the sharp end when a clinical error occurs
 if risk management system only focuses on the nurse, they will not make the system safe
 this also arises with second victim – the unintentional error maker will become the victim
o E.g. Kimberly Hiatt Case – Seattle children hospital, 24 years of experience
o error, gave 10000 dosage of overdose medication: calcium
o hospital shift the blame on the hospital – sanctioned her
o nurse got a 4-year probation every time she has to administer medication
 o she decided to commit suicide after running out of coping mechanisms
o hence she became the second victim
o hence to evaluate the way organizations look at error

XI. Evolution of safety culture

 Past: blame culture: live in fear – sweep errors under the carpet; no reports, hospitals belief
they are a safe hospital
 Shift to No Blame culture: to encourage people to report error.
 Today: Just culture
o no in the extreme of blame culture or no blame culture but in the middle
 Accountability of our behavioral choices:
Human error At-Risk behaviour Reckless behaviour

Product of our current design Unintentional risk-taking Intentional Risk-taking

Manage through changes: Manage through:
 processes  remove incentives for Mange through:
 procedures at-risk behaviours  remedial action
 training  creating incentives for  disciplinary action
 design healthy behaviours
 environment  increasing situational
awareness – initiatives

Console Coach Punish

Risk Management in healthcare

 how to identify risk in healthcare
 interventions in place to curb risks
o quality improvement project to reduce risk

I. Risk
1. General definition: chance or likelihood that an undesirable event or effect will occur
2. Management risk: Risk is anything that may affect the achievement of an organization’s
objectives
3. Healthcare context: risk management in health care considers patient safety, quality
assurance & patients’ rights.

II. Types of risk – enterprise level

Patient safety – medical error Service delivery or operational Stakeholder satisfaction/
risk risk Public perception risk
Staff health & safety risk People/ HR Risk Legal/ Regulatory compliance
risk
Financial Risk Information/ Knowledge Risk Governance/organizational
risk
Reputational Risk – social Strategic/Policy risk
media
Technology risk

Privacy risk
 Security risk
III. Rationale for Risk Management
1. The alternative to risk management is crisis management: much more expensive, time
consuming & embarrassing
a. preventing rather than solving
2. Risk management means more than preparing for the worst, also taking advantages of
opportunities to improve services or lower costs
3. Risk should be controlled before harm could occur

IV. Quality Improvement & Patient Safety – QPS

 standard QPS.11: ongoing program of risk mana

V. Healthcare risk management

 A good comprehensive system/process will have the components: identified, classified,
evaluated & controlled risks
 Steps to risk management: Risk identification > Risk analysis > Risk mitigation/control > Risk
monitoring/review

Risk identification
Identify potential risk factors from incident/process reviews

I. root cause analysis (RCA)

 retrospective review of past incidences
 est root cause of problems & solutions to minimize risk of reoccurrence
 chronology of events
 focus on systems & processes
II. Healthcare Failure Mode & Effective Analysis (HFMEA)
 proactive look at the steps of the process – esp high risks
 flowchart the process & predict where risks or failure exists & redesign process to
eliminate those risks
time-consuming however extensive to reduce errors

Risk analysis
Analyze to determine risk levels:
 Events, patterns & frequencies of events & system defects that contribute to the
occurrence
 Traits of patients susceptible to high risk events are developed
 Environmental elements contribute to high risks are categorized

I. Utilizing incidence reports to analyze common risks

II. Patient complaints
 message – the risks highlighted
 identify areas that can be improved
 highlights communication problems
III. Determining risks priority – risk matrix
 Risk priority number = likelihood of occurrence of harm X severity of harm
 5 likelihood x 5 Consequences
  Risk identification register: document the area of risks identified

Risk mitigation/
control
Formulate intervention strategies
 solicit suggestions & observation from a variety of sources (within the system)
 utilize these to formulate alternative approaches to mitigate identified risks
 engage end-users from the beginning in planning strategies and action plans

Risk avoidance/removal
 remove risk by doing things differently where it is feasible to do so
o E.G. removal conc KCL from all patient areas – many times they are not
diluted

Risk reduction/control
 development & implementation of policies, standards, procedures & physical
changes to reduce the risks of adverse events: performing time-out

Transfer the risk

 shifting responsibility or burden for loss to another party through legislation,
contract, insurance or other means – third party vendor for housekeeping
service (someone of the expertise to do it – creating specialties)

Risk acceptance
 tolerate the risk: nothing can be done at a reasonable cost to mitigate it or the
likelihood and impact of risk occurring are at an acceptable level
o e.g. employment of foreign healthcare staff

Common strats:
1. reduce reliance on memory – (visual aids, checklists)
2. improve information access/flow – (use of IT)
3. error-proof processes – (forcing function to change human behaviours)
4. standardize tasks (protocols & guidelines)
a. ensure two departments do not do the same work, ensure smooth
workflow
5. reduce the number of hand-offs (integrated care & pointing of care testing)
a. message diluted from one person to another
Implementation:
 1. action plan
2. processes & outcome measures
3. complete baseline measures
4. commitment to action plan

Risk monitoring/
review
1. Communicate high alert risks
2. Analysis & assess incident report
3. Yearly review of risks regulator to evaluate impact

Example:
Background: porters do not know the patients’ information
Incidents related to transfer of patients for out-of-ward procedures

Labelled as high risk

 Intervention: providing a checklist for the portering

VI. For nurses

 effective communication
o be well informed of patient’s treatment plan
o communicate timely with doctors & other healthcare team members
o do not advice beyond your scope
 good documentation
o patient’s medical records
 must be accurate, complete, meaningful
 serve as a conduit of communication
 play a role of witness: chronology of events
 must not assign blame to colleagues
 should record patient’s remarks verbatim
 especially if a case is brought to court
  crisis management
o when an adverse event happens to patient:
 ensure patient is not being harmed further
 present vital information as evidence
 document evidence of actions taken
 report through appropriate channels

VII. Nurses can build safety culture

 reporting incidents
 help to identify & assess risks
 provide additional information on risks if possible
 practicing risk management in day to day operations in your own area
Week 5 Materials:
1. Watch the e-lectures: Leadership theories & styles (Part 1, 2, & 3) (must know)
2. Read Chapter 2 & 3 in Marquis, B.L. & Huston, C.J. (2017). Leadership Roles and
Management Functions in Nursing: Theory and Application (9th ed.). Philadelphia:
LWW (nice to know)
3. Optional reading: Read the article “Prepare nurse leaders for 2020”. Ref: Huston, C.
(2008). Prepare nurse leaders for 2020. Journal of Nursing Management, 19(8), 905-
911. (nice to know)

Week 5: Leadership theories & styles

At the end of this session, the students should be able to;

1. describe leadership theories and styles;
2. be aware of their own leadership styles; and
3. discuss leadership skills that are required in healthcare delivery system.

Reading:
Chapter 2 & 3 in Marquis, B.L. & Huston, C.J. (2017). Leadership Roles and Management
Functions in Nursing: Theory and Application (9th ed.). Philadelphia: LWW

Summary of key points

Coping effectively with change Global perspective or mindset

A working knowledge of technology Expert decision-making skills

Prioritizing quality & safety Being politically astute

Collaboratively & team building skills Balancing authenticity & performance

expectations
 Being true to your own values & act
accordingly
 Balance between organizational
expectations and your principles
(achievement)
o balancing – practicality of own
and organizational
expectations
o healthcare affordability –
affordable to certain groups
only thus to compromise by
expanding the budget
E-lecture:

Leadership theories & styles Part 1

Leadership types
Coercive Pacesetting Authoritative Affiliative Democratic Coaching Visionary

Well-developed leadership style:

 pace setter
 coaching

Coercive Coercive leaders demand immediate obedience. In a single

phrase, this style is ‘Do what I tell you’. These leaders show
initiative, self-control, and drive to succeed. There is, of
course, a time and a place for such leadership: a battlefield is
the classic example, but any crisis will need clear, calm,
commanding leadership. This style does not, however,
encourage anyone else to take the initiative, and often has a
negative effect on how people feel.

Pacesetting Pace-setting leaders expect excellence and self-direction,

and can be summed up as ‘Do as I do, now’. The Pace-setter
very much leads by example, but this type of leadership only
works with a highly-competent and well-motivated team. It
can only be sustained for a while without team members
flagging. Like the Coercive leader, Pace-setters also show
drive to succeed and initiative, but instead of self-control,
these are coupled with conscientiousness.

Authoritative

Affiliative An affiliative leader values and creates emotional bonds and

harmony, believing that ‘People come first’. Such leaders
demonstrate empathy, and strong communication skills, and
are very good at building relationships. This style is most
useful when a team has been through a difficult experience,
and needs to heal rifts, or develop motivation. It is not a very
 goal-oriented style, so anyone using it will need to make sure
others understand that the goal is team harmony, and not
specific tasks. It is probably obvious from this that it cannot
be used on its own for any length of time if you need to ‘get
the job done’.

Democratic The democratic leader builds consensus through

participation, constantly asking ‘What do you think?’, and
showing high levels of collaboration, team leadership and
strong communication skills. This style of leadership works
well in developing ownership for a project, but it can make for
slow progress towards goals, until a certain amount of
momentum has built up. Anyone wishing to use this style will
need to make sure that senior managers are signed up to the
process, and understand that it may take time to develop the
consensus.

Coaching A coaching leader will develop people, allowing them to try

different approaches in an open way. The phrase that sums
up this style is ‘Try it’, and this leader shows high levels of
empathy, self-awareness and skills in developing others. A
coaching style is especially useful when an organisation
values long-term staff development.

Visionary Authoritative leaders move people towards a vision, so are

often described as ‘Visionary’. This style is probably best
summed up as ‘Come with me’. It is the most useful style
when a new vision or clear direction is needed, and is most
strongly positive. Authoritative leaders are high in self-
confidence and empathy, acting as a change catalyst by
drawing people into the vision and engaging them with the
future.
Tutorial Week 5:

At the end of this session, the students should be able to;

1. describe leadership theories and leadership styles;
2. be aware of their/your own leadership styles; and
3. discuss leadership skills that are required in healthcare delivery system.
4. Be able to apply management theories (exam)

Theories
Know definition from e-lecture Details in textbook

As a framework As an explanation

LKY Servant leadership – prioritize needs

SMRT CEO

Case scenario: NM Tanya - leadership and management skills

Ms Tanya is the Nurse Manager (NM) of a medical ward.
Recently, there is a 15-year-old Indian boy, Jason Revi, was admitted with newly diagnosed
with Diabetes Mellitus (DM) Type 1.
Jason is a delightful, very polite, and easy-going patient. However, his family has been
visiting him in increasing numbers, and bringing him food that he should not have.
The nursing staff has come to Tanya on two occasions and complained about the family’s
noncompliance with visiting hours and bringing unauthorized food.

Tanya has listen to those complaints quietly and was taken by surprise, because the unit
has tried to develop a culturally sensitive nursing care plan for patients with special cultural
needs. inappropriate: nurse do not understand the culture and poor communication
skills – emphasize on quality of care

Yesterday, two of family members visited NM Tanya and complained about the hospital
visitor policies and two staff nurses who were rude to them.
NM Tanya spent time talking to the family, and when they left, they seemed agreeable and
understanding.

Last night, one of the staff nurses told the family that according to the hospital policy, only
two members could stay with the patient, and if the other family member did not leave, she
would call hospital security.
This morning, the boy’s mother and father have asked that they will take Jason home, if this
matter is not resolved even though the patient’s diabetes is still not controlled.
Questions:
1) How can Tanya keep this situation from deteriorating further?
Application of knowledge
Planning: goals Staffing Controlling
 safety of the patients  debriefing of staff after  evaluation after talking
 keep hospitalization what happened with family & nurses
 diabetes management  specific training:  monitor & ask family
– food restriction cultural diversity & members feedbacks
 patient & family communication skills  rollcalls for handovers
understanding of the 
situation
 customize care plan
 family education

Organizing Directing
 speak to the family  using theory Y
members  TLC staff & motivate
 speak to the colleague them further
 ask nurse to  speak to family
accompany & members about future
apologize again care plans
 plan to move forward
from here

2) What leadership styles would be applied in this situation? Why?

 coercive & autocratic

With SN NM Tanya to Family

Transactional:
 mention how this will affect performance
rating & future promotion - rewarding
 against code of conduct
Transformational:
 foster nurse to be more sensitive
 when a similar problem arrives, she will
be able to understand from others’
perspective: NM, Family, etc.
Shared leadership:
 shared goal & responsibility: both want
to control Joseph’s DM
 NM & Family: need to understand
cultural boundaries & family needs to
understand ward’s boundaries

Ev: Transactional use reward &

transformational do not use reward to
influence people to follow

Main: Connective Leadership

 connects & empowers them towards common goal
 ability to think long-term & act short term, connect present & future

3) How would you divide the management functions and leadership roles in this
situation? Linking Question 1 & 2
 management functions: the actions required
 leadership theories: the method of execution
 linking management fx & leadership theories

Management functions leadership

 planning  trait
 controlling  behaviour
 organizing  situational & contingency
 contemporary
For nurse:
 directing
 staffing – training

Management functions Leadership theories

Staffing
 Send nurses for culture sensitivity
workshop
 Improve communication
 Nurses can assess the
knowledge gaps of the family
Connective
 Connect staff
 Remind nurses and patient family of
the shared goal (patient’s recovery
and discharge)
Shared
 Nurse can inform the family
regarding the hospital policy→
everyone on the same page/ idea

Directing Transformational
 Communicate expectations to  Work with the nurses to identify
nurses needed change (culture sensitivity
 Performance appraisals to review and communication), creating a
work vision to guide the change through
 Communicate expectations to family
inspiration, and executing the
members
change in tandem with committed
members of a group.

Charismatic: when talking to both the family

and nurses
 Display persuasiveness/ strong
conviction
 When explaining to family
members rationale of not
bringing in outside food/
following the hospital visiting
hour policy
 Explain to nurses to be
understanding of patient’s
culture

Autocratic (for nurses but not patients)

 Patient right to accept/refuse treatment
– not recommended
 Can utilize for nurses to follow the rules
o nurse may get upset and
leave the job
4) How will you develop your leadership skills to make you be more effective leader?
 strategies to improve your leadership skills
 need to foster different leadership skills according to the situations

5) Can you be just a leader/ manager? Why or why not?

 managers assigned official position however leaders are able to gain influence
 hence a leader manager is a better option as it provides a direction & motivation for the
team and also equip the team with skills to better improve the productivity and efficiency.
 manager is an official appointment however a leader is not appointed. manager requires
leadership, nonetheless.

Week 6 Materials:
1. Watch the e-lecture video: Change and innovation (must know)
2. Read Chapter 8 in Marquis, B.L. & Huston, C.J. (2017). Leadership Roles and
Management Functions in Nursing: Theory and Application (9th ed.). Philadelphia:
LWW (nice to know)
3. Read the article "Diffusion of Innovation Theory" (nice to know)

Week 6 Seminar: Topic: Health Information Technology By Mr Wong Kok Cheong

(GCH) (must know)

Week 6 Tutorial:

At the end of this session, the students should be able to;

1. define and identify change in healthcare delivery system in Singapore;
 3 beyonds – acute to chronic, merging clusters
 inter-professional team oriented & patient centric healthcare

2. identify forces of change within a healthcare organization;

3. discuss classic change theories and their relevance to nursing;

4. identify and discuss strategies for change

5. describe Kotter’s eight steps to initiating change in an organization

Required reading/activity before tutorial session:

1. Watch the e-lecture video: Change and innovation
2. Read Chapter 8 in Marquis, B.L. & Huston, C.J. (2017). Leadership Roles and
Management Functions in Nursing: Theory and Application (9th ed.). Philadelphia:
LWW
3. Read the news and watch the short video clip from the weblink (news from the
Straits Times-23 July 2015): Hospitals turn to cutting edge robots and technology for
healthcare assistance. This will be discussed in the tutorial session.
Opening questions
1) What do you want to change in the organization that you had been posted to
during the/your clinical placement?

2) Do you think other people/staff would agree or accept the proposed change?

Case-based learning
Activity
 Students will be working as a group (6-7 students per group, total of 6 groups)
 Each group will be assigned to answer the question, and present their answers to the
class
 Each group has 10 minutes for group discussion, and 10 minutes to present their
answers
 The other groups can ask questions/give comment to the group that are presenting
 Debriefing will be at the end of the discussion

Case scenario: Cutting–edge technology for healthcare assistance

Watch the news from the Straits Times (the link below)

https://www.straitstimes.com/singapore/health/hospitals-turn-to-cutting-edge-
robots-and-technology-for-healthcare-assistance (2.22 mins)

According to the news, discuss and answer the questions below.

1) If you are an RN who is working in a general ward, and one day, your nurse
manager tells you that they will use the robots (as shown in the news) for patient
care, please list reactions that you would have with rationales?

Roger’s Diffusion of Innovation Theory for explanation (as does not trigger the reaction/ or
not a guide) – different aspect of the theory
Reactions Group Roger’s Diffusion of Action
Innovation Theory
Fear Laggard Conservative, Leave
Anger Traditional & reject organization
changes

Apprehension Late majority Follows majority as Different timings

skeptical of change of change
Early majority Require evidence for
change
Excited Early adopters Requires minimal
direction to embrace
change

Acceptance Innovators Proactive & Earliest to

Adventurous change
2) As an RN, how would you adapt yourself to the change?
What strategies will you use to adapt to the change?

Demands for adaptation & Strategies

Empirical rational:

Rational
 change is inevitable
 deal with situation with open mind and set aside negative feelings
o overcome the fear by highlighting the benefit
Empirical
 nurses’ efficiency in providing patient care
 communication discussion on using technology: its benefits outweigh the costs
o cost: inconvenience arising from lack of knowledge to use tech, deters
change
o solution: technology troubleshooting knowledge –providing solution

Normative-Reeducative
 assumption: people are active participants
 reeducative: establishing relationship with her peers

Power-coercive NA

3) As a Nurse Manager, what are the barriers and challenges that you would face?

Strategies to communication barriers

Individual
Natural human fear of unknown
Cognitive dissonance
Failure to recognize need for change
Employees fear they lack competence to
change
Organizational
Failure at previous change creates an aura
and folklore about dangers associated to
change
Structural inertia creates natural barriers

4) If you are a Nurse Manager of this unit, how will you apply a change theory to
this situation (choose one change theory)?

Roger’s DOI Theory:

Knowledge Assessment of the ward (sensing)

First exposure to innovation
Inform ward about robots – provide
materials

Persuasion Encourage staff to find out more about the

robots and their usage

Decision Weigh pros & cons of innovation

 Facilitate feedback session & decide
whether they prefer to use it

Implementation Pilot: Have a ward to implement first

Put innovation into practice – thus to
introduce in stages
Determine usefulness at this stage:
evaluate effectiveness & efficiency
NM to troubleshoot & observe usage

Confirmation Interpersonal:
1. conduct staff evaluation
2. reaffirm choice to confirm usage
Intrapersonal:
1. implement withdrawal protocol

5) As a manager, how would you deal with resistance of using the new
technology/robot? What theory, would you apply to this situation?

Kolter’s 8 Stages:
1. Establish a sense of urgency:
a. highlight evidence for change to your manpower
2. Creating a guiding coalition: focus group - find the innovators & early adopters
3. Develop a vision & Strategy:
a. competitive edge – adaptive
b. technological advancements
c. reduce errors
4. Communicate the changed vision: advertise benefits of robots and results in ward
setting
5. Empower employees:
a. training to staff, overcoming fear of unknown and improve competency
b. feedback channels: communicate fears
6. Generate short-term: reinforced perceive benefits – benefits of tech; reduced
workload
7. Consolidate gains: Address feedback
8. Anchor new approaches: (sustainable since consider the continuity)
a. tell story of success
b. align new employees with changed vision (ensure they are not the new
resistance)

Evaluation:
Kotter’s and Roger’s DOI both serves as guide for strategies/implementation for change,
however the usability depends on the context and its usability (rationale for innovation – in
the case of Kotter’s). Sustainability is the determined by the leader who execute the
implementation: ensure confirmation (just support) by the DOI theory and anchor new
approaches (institutionalize protocols)

Agent of change: the facilitator, in charge of the driving force.