Nursing Attrition and Shortage

There has been many reports about the shortage of nurses in Singapore and the increasing attrition rates we have seen lately. Parliamentary questions have been asked and answered. It was reported in The Straits Times (2 Aug 22, Resignation rates of nurses in public hospitals at a five-year high in 2021) that between 2017 to 2020, the attrition rates for local nurses hovered between 5% to 7% and in 2021, the attrition rate rose to 7.4%.

What is more distressing is that attrition rate for foreign nurses rose to a whopping 14.8% in 2021, double than that of local rate. If this keeps up, we can theoretically turnover our total foreign nurse workforce completely in 7 years and the local nursing workforce completely in 14 years.

Another way to look at it is that a local nurse will on the average stay in local nursing for 14 years and a foreign nurse will stay with us in nursing for 7 years. That is not too encouraging. Nursing is a calling and it’s different from say being an air stewardess. Singapore Airlines wants to keep its inflight crew young and fresh and not everyone can be promoted to be an inflight supervisor or leading stewardess. So an average period of employment of say 7 years may be pretty good for an airline.

Nursing, on the other hand, has other imperatives and contexts to consider. For one, it takes at least three years to train a person before one becomes a state-registered nurse (SRN) (i.e. staff nurse). It takes a few more years before a SRN becomes really proficient in what she is supposed to do, and even longer if he or she specialises in certain areas by getting an advanced diploma, e.g. ICU nurse, scrub nurse etc. This is about the time he or she becomes a senior staff nurse (after 4 to 6 years of being an SRN) and her contributions to the organisation and patient care rise significantly beyond that of a “junior”, fresh out-of-school SRN.

Therefore, we really want a nurse to work for at least 20 to 25 years or longer if possible so that the healthcare system can derive maximal benefit from their experience, expertise and productivity. But clearly it is not happening. But I guess if the average local stays for 14 years, it’s still a pretty decent period of time. Many marriages don’t even last that long nowadays. In any case, if a nurse leaves the public sector for the private sector and still works as a nurse, then it is not a complete loss as he or she still contributes to the healthcare system. But we don’t have the data on this and let’s defer comment on this until we have more information.

The situation with foreign nurses looks much more dire if the attrition rate stays at >14%. It is nice to think that if we recruit and retain more local nurses than our dependence on foreign nurses will decline. But with <40,000 births a year on this island and a rapidly ageing population, Singapore needs more foreign nurses now and going forward. Period. It takes time for a foreign nurse to adapt and settle in our working and living environment. Some say this period is anywhere from 3 to 5 years. When the foreign nurse is finally settled in and up to speed, they leave after a year or two. This is a lament that is often heard amongst nursing administrators and doctors.

And then there is the acuity of the current problem. Previously, we could try to recruit nurses at a steady pace when demand and supply were stable. But with the pandemic, we do not have the luxury of time and stability in demand and supply. We need to keep each and every nurse we have today, even as we try to recruit more from overseas or train more locals to be nurses. The analogy is that we have to stop the source of bleeding while we transfuse the patient. No point transfusing when the patient continues to haemorrhage profusely. The haemoglobin ain’t gonna rise.

It is great to see nurses in the public sector getting 1.7 to 2.1 months of retention payment this year. But will this stop or decisively slow the bleeding? Only time will tell. But this hobbit suspects this may not be enough. Typically, a worker looks at compensation and benefits as well as prospects when deciding to stay with a job or an employer. Anecdotal evidence from foreign nurses here suggests that remuneration is not the main reason why they leave for other lands. Basically, the Anglophone world is recruiting nurses aggressively and they know that any nurse that is licensed by SNB (Singapore Nursing Board) is of a high quality and so they are being actively targeted by these English-speaking countries. In other words, Singapore has become the on-the-job training ground of these Asian-origin foreign nurses so that they can eventually work in other countries such as USA, UK, Australia, New Zealand and Canada.

This has been so for many years. I remember there was, outside a public hospital where I worked at, a public bus-stop (a mere few metres from the edge of the hospital compound) which had a large advertisement with the words “Join US Nursing” boldly displayed. Apparently, there was nothing the hospital could do because the bus-stop was located in a public area and whoever owned the bus-stop took the advertising money already.

But what has changed in the last 12 to 18 months is that their recruitment efforts have intensified and their offers have improved. And the 24 months of border closure has deepened the pain of separation from family members and the loneliness of living alone in Singapore.

Most of the countries mentioned above offer benefits that cannot be recompensed by more money: – e.g. the ability to bring your family members along and for these family members to enjoy subsidised healthcare and education. So while the money to be made in Singapore is not less than elsewhere (especially given our low tax rates), the peace and happiness that comes with living with your spouse and children cannot be matched by mere dollars and cents. These are employment policies that affect all employers of nurses, both public and private and they cannot be adequately addressed by employers themselves. There needs to be a national relook at how Singapore remains a competitive if not attractive country for foreign nurses to work and live in.

The policy quagmire that detractors may come up with is to ask why should special arrangements or dispensation be given to nurses and not to other skilled workers that Singapore also needs, e.g. IT support staff, construction supervisors and foremen, skilled hospitality workers etc. And then somehow the whole thing gets stuck from here onwards and every mind trying to solve the problem enters a state of deep freeze.

The hard truth is nobody outside of Singapore cares if you have parity in treatment between different skilled workers working in different sectors. We just have to be nimble and competitive so that we get what we need, be they nurses, IT support staff or plumbers. Adopting a one-size fit all approach (no accompanying family members for S-pass holders, regardless of sector) just means we lose experienced nurses to places that are more competitive and compelling.  

Another possible solution is to raise foreign nurses salary to the point that they qualify for employment passes instead of S-passes, so that they can bring in family members as well. But that would mean raising salaries across the board for all nurses, both local and foreign. This hobbit thinks this may be workable but someone better do the math and see if we can afford it.

In other words, there are no easy choices. Singapore has always survived on the belief that nobody owes us a living and we must remain competitive. Well, nobody owes us  foreign nurses either, especially experienced ones. We either do what needs to be done or we don’t get what we want or need. The cheese has moved with the pandemic. What is our response?

Let us now return to the problem of attrition rates for local nurses. The attrition rates may seem less ominous than for foreign nurses, but the problems may be even more deep-seated and cannot be changed by quick and purposeful policy adjustments.  

This hobbit is reminded of a story he heard long ago that happened in Middle-earth in the previous millennium. This tale was told to this hobbit by a dwarven assistant director who happened to be there when the incident happened. The great Non-Temporary Secretary of the Sickness Ministry of the Kingdom of Crimson Speck summoned all his senior staff to sit at the Grand Boardroom Table. This was in the days when The Sickness Ministry was so small that even a deputy or assistant director can somehow find a seat at this Great Table.

The Non-Temporary Secretary asked all who were seated at the table, “Do you have daughters”? Quite a few answered in the affirmative. He then followed up and asked “If I gave you a binary choice; to choose between being a teacher or a nurse, what would you want your daughter(s) to be?” (This was in the last Millennium, when people were less politically correct and more gender-specific)

Sadly, all the wise and august elves, men, dwarves, halflings seated at the Table indicated they would want their daughters to be teachers. Not one said “Nurse”. The Non-Temporary Secretary looked at the ceiling of the Great Boardroom and sighed. He concluded, “If that is the belief of all of us in this room, then how can we even convince others to let their daughters be nurses so that our present nursing shortage in the Sickness Ministry can be addressed”?

Well, the above fictional story may have come from mythological Middle-earth in the last Millennium, but it underscores the point that a society’s worldview may have to be addressed before nursing can be commonly considered to be an attractive career option by young adults and their families.