Skill mix and model of care
A team comprising a RN/EN/HCA mix, a RN/EN mix, or a RN/
HCA mix typically provides nursing care in Singapore’s inpatient
wards. Similar staff mix models have been described in USA and
Canada, with the addition of an all-RN model (McGillis Hall
1997; Unruh 2003). Regardless of team composition, the RN
serves as the team leader and delegates assignments to his or her
team members according to their competencies, qualifications
and scope of permitted practice within the hospital.
The Singapore Ministry of Health has established staffing
norms for nurse-to-patient ratios and staff mix according to the
type of unit (B.C. Ang, personal communication, 14 November
2005). These norms were derived with input from a timed-task/
activity study, a method for estimating staffing based on the type
and frequency of nursing interventions required by patients.
Although the study was conducted more than a decade ago, the
Nursing Branch of Ministry of Health conducts periodic reviews
to ensure they are still valid given changes in population demographics
and health needs. The hospitals use these norms to
determine their nursing requirements for each unit taking into
account other factors such as bed capacity and average occupancy
rate. Unlike USA and Canada, computerized workload
measurement systems are not used in Singapore’s public hospitals
to make decisions on day-to-day nursing requirements.
Rather, ward nurse managers make such decisions based upon
their clinical judgement, local knowledge of the ward and
patients’ needs.
The staff mix in a typical medical-surgical unit in a Singapore
acute care hospital is 60% RNs, with the remaining proportion
comprising ENs and/or HCAs. In contrast, the intensive care
units have a higher RN population. Furthermore, there is an additional
requirement that the staff mix includes specialty-trained
RNs in order to maintain a minimum level of expertise in the unit
at all times. This minimum requirement differs by specialty, for
instance an intensive care unit will require critical care trained
RNs to form at least 50% of its staff mix on any given shift. However,
there has not yet been any empirical work in Singapore to
determine if these proportions are the most appropriate and costeffective
to achieve and maintain maximum effectiveness of care
and produce the best outcomes.