Driver 3: An expectation that APNs would add value to the provision

services, relieving the doctors’ workload and improving timeliness or accessibility to healthcare services. Where there is lack of constancy among health care providers, as in the context where medical officers and residents rotate constantly, participants suggested that APNs could provide continuity in care. When seen as physician substitutes APNs were perceived to offer the possibility to free up physicians to manage complex cases and conduct clinical research. However, a concern was voiced that if APNs were seen as physician substitutes that they might be relegated to a position that was not the original intent of the role or they might be taken advantage of simply to better the lot of physicians. Even though participants indicated this driver provided impetus for the APN role the benefits described in this subsection appeared to emerge following participant exposure to APNs. It was not clear how dominant this driver was in the initial exploratory discussions. Based on study findings, the potential for APNs to close some of the gaps in care was identified as a separate driver from the possibility of their just simply adding value to healthcare services. The next subsection examines how APNs were viewed as adding value to the healthcare system in terms of cost effectiveness and enhancing the quality of care.

6.3.3 Driver 3: An expectation that APNs would add value to the provision of healthcare

Whereas filling gaps in the provision of healthcare services was identified as a driver for APN roles findings revealed a notable discrete perspective that referred to APNs as a ‘value add’ to healthcare. Adding value to healthcare was identified as:

 Contributions to cost effective care or a cost savings (e.g. value for money spent)

 Enhancement of quality clinical care (e.g. better understanding of care options with improved education and communication for patients)

Key physician participants indicated that their perception of added value with inclusion of the APN role rested on a country-based platform benchmarked against a view of what was regarded as world-class care. This view suggested that APNs, as one option in the

healthcare workforce, were perceived to have the potential to play a part in cost effective services while also contributing to improved quality with their comprehensive approach or holistic care. The benefit of the APN was seen as integrating increased knowledge and skills with their familiarity and sensitivity to patient populations. In describing a strategic approach for cost effective healthcare services key participants emphasised that these arrangements should include nursing. A nursing leader illustrated the implication of utilizing APNs in delivering cost effective care with the following quote:

‘Our current Minister of Health believed APNs would be able to do a lot of things that a doctor used to do but should pass on to the APN because as the Minister of Health his interest is in containing healthcare costs and providing care efficiently. If you talk about economics of healthcare this would definitely provide better value for money in terms of healthcare delivery at all levels…the ministry will support

whatever it takes as long as it is in the interest of advancing healthcare and done in the most cost effective manner’ [Participant 3NL]

Findings indicated that contributing to cost effective healthcare was mentioned consistently as a driver for APN roles; however, there was no concrete evidence as to how the cost savings would actually occur. In addition, there was no clear evidence found in the literature

that inclusion of APNs is a cost effective approach for provision of healthcare services. Enhancement of the quality of healthcare in Singapore with the inclusion of APNs was

recognised by most participants as an incentive for developing this new nursing role. Attributes of fundamental nursing principles were thought to add value to comprehensive healthcare services. Findings suggested that APNs at the advanced level of nursing would add to quality of care with the combination of a nursing foundation plus advanced

knowledge and skills. A nursing leader commented on expectations from the Minister of Health in reference to improved quality of care:

‘The Minister of Health expects to provide a world-class healthcare system. The minister himself sets the direction and tone. Nursing needs to position themselves to be a vital player in helping to transform Singapore as a world class health care

centre … by looking at patients from a holistic perspective and incorporating the caring element to enhance the value of care that we have been imbued with’ [Participant 3NL]

The preceding quote implies that APNs could contribute to quality comprehensive

healthcare due to characteristics attributed to the nursing profession such as attention paid to increased clarity of communication and education of healthcare issues. Most participants provided the perspective that the APN with strong fundamentals of nursing plus skills and knowledge that overlap with medicine could contribute significantly to improved healthcare services with this new concept of providing care. A high-ranking physician referred to this potential value in the following quote:

‘ It is a huge value added where I see that a well-trained, motivated advanced practice nurse can add so much value just because there are so many things that need to be done … I think the nursing profession is one profession that can do so much more … if we provide the profession with a framework followed by all the necessary regulatory and legislative policies to allow this maximum potential to be effective then I think everyone will benefit. Patients will benefit. The profession would benefit and the country would benefit. Healthcare in general will greatly benefit’ [Participant 14ML]

Repeatedly the view emerged that nurses promote comprehensive care and approach patients as individuals thus participants provided the perspective that the APN would add this value to care. One participant with a nursing and medical background illustrated this perspective with the following quote:

‘My view of the APN is that they are nurses who would be caring for patients more holistically … you need to equip them with a lot more power and training so that they could think through the process and suggest things. You want someone who would be caring for the patient … [and] actually knows what they are doing rather than just caring for the patient and following orders. The nurse has a very personal view of patients as individuals. So having the … advanced knowledge would improve the care the nurse gives to the patient’ [Participant 6NEd]

An academic for the APN programme reiterated the timeliness of the APN option for nursing with this quote:

‘This is an opportunity for nurses…they will carve a niche…they may be clinically competent doing what the doctors are doing but ultimately they are adding value to what the doctors are doing. Not replacing them.’[Participant 5NEd]

The topics of cost effective and quality healthcare were consistently mentioned as values APNs could add to the Singaporean healthcare system. Although aspects of this driver were agreed to by most participants, findings suggested that some of the ‘value add’ referred to could possibly be done in general by well positioned nurses. In addition, no participant clearly specified what ‘value add’ really meant in practical terms of integrating these nurses into the healthcare workforce. Findings associated with Driver 3 demonstrated support and encouragement for APN roles as a cost effective option to enhance quality of healthcare. However, sentiments expressed by participants appeared somewhat vague and seemed to lead to speculation as to what an APN might do without specific definition as to the economic implications or value added to healthcare services. Key nursing and physician participants referred to a value add

dimension when referring to the impetus for APN roles but Driver 3 was not mentioned

universally by all participants. In summary, this section of the chapter has provided an account of the main drivers that

influenced APN development in Singapore. The primary driver for APN roles was the intent to retain proficient clinical nurses in the healthcare system along with a hope that this would also contribute to professional advancement and improved status for nursing. The

introduction of APN roles to fill gaps in healthcare services and as an option for cost effective quality healthcare services added further impetus for APN development. There was no evidence that there was a clearly identified need for the APN role in Singapore; on the contrary, three participants provided the view that there was no acknowledged need for APN clinical services at the outset of the initiative. Nevertheless, once consensus was reached to move forward and key decision makers supported the scheme, momentum for the APN initiative proceeded to policy development. The next section examines the development of policy as it relates to the significance of pivotal decisions and decision makers, the utilisation of decision-making networks for information exchange and linkages among key stakeholders that led to the unveiling of the APN scheme.

6.4 Policy development: Networks of communication, processes of information