There are 36,995 registered nurses in Singapore in 2022[1], of which 1% are Advanced Practice Nurses (APN).[2] Twenty years since the introduction of the Master of Nursing programme in 2003, how much progress has the APN profession made, and what can future nurses aspiring to become APNs expect?
Did you know—APN is a protected professional title regulated by Singapore Nursing Board (SNB) in Singapore? To become an APN, one must complete the Master of Nursing programme at Alice Lee Centre for Nursing Studies (NUS Nursing), National University of Singapore Yong Loo Lin School of Medicine. This is the only programme that provides APN education in Singapore. To gain a better understanding of the programme and its transformation over the years, NUrSing caught up with Ms Tan Soh Chin. Ms Tan played a pivotal role in shaping and advocating for the programme during her tenure as the Chief Nursing Officer, Ministry of Health, from 2015 to 2020.
2003 – Birth of the Programme
When the Master of Nursing first began in 2003, the programme duration was 2 years, full-time, followed by a 1-year internship at hospitals. Four clinical tracks, namely medical/surgical, acute care, mental health and community, were available for specialisation. To graduate, APN interns had to fulfil a certain number of required clinical hours and pass an exit formal assessment panel interview conducted by SNB. The interview conducted by clinical domain experts appointed by the Singapore Nursing Board (SNB) would assess and decide if the nurses were ready to be accredited.
Ms Tan shared, “The Master of Nursing programme is designed for nurses who are ready to embrace the Clinical Nursing track and perform at an advanced level. Naturally, it is intense—and rightly so. Because upon completing the programme, they would have acquired clinical knowledge and skills that enable them to work independently and collaboratively with doctors.
The rigour also meant that only nurses who have at least 5 years of continuous clinical practice as Registered Nurses (RN) are eligible for the programme. “Becoming an APN involves taking on more responsibilities—which can be stressful—so we need our APNs to be committed and well-trained. That is also why it is important for nurses deciding to go for the programme to have full support from their family and sponsoring organisation,” Ms Tan said.
2016 – Introduction of a More Structured APN Assessment Framework
The Master of Nursing programme ran largely unchanged from 2003 to 2014. “Around this time, we asked ourselves if there was a better way to assess the competency of our APNs— and how we could make the internship experience for our nurses more structured. The answer is ‘Yes’. With that, we reviewed and decided to do away with the exit assessment panel, and restructured the internship programme,” Ms Tan said.
In lieu of the exit assessment panel, nurses would sit for an Objective Structured Clinical Examination (OSCE)—a simulation of a real clinical environment with a standardised patient who presents with different clinical problems—at the end of their internship. Notably, medical students go through a similar format examination.
At the same time, the OSCE was incorporated into the Master of Nursing curriculum—and all students must pass the OSCE to graduate. In addition, the Enhanced APN Internship Programme was introduced to minimise disparity between internship programmes offered by different institutions. During the 1-year internship, students’ progress and performance would be tracked and recorded. Additionally, they would receive feedback on areas for improvement from physician supervisors and APN preceptors throughout the Enhanced APN Internship, to ensure readiness for the final OSCE for accreditation.
Ms Tan said, “The Enhanced Internship Programme provided a more structured and harmonised approach for the APN internship. Each internship starts with a formative phase to hone nurses’ skills, progresses to a summative phase where they are prepped for assessment, before ending with the OSCE at the end of the internship.”
Ms Tan continued, “There was a strong case for making these changes. But different stakeholders were involved, so it was necessary to get their buy-in. Particularly, support from NUS Nursing and healthcare institutions where APNs were practising was important—because they are the ones putting through the changes. With proactive engagement and support from policymakers and SNB, the Master of Nursing programme eventually entered into a new phase.”
2020 marked the beginning of a transformative period—which saw the implementation of 2 significant changes to the Master of Nursing programme. Ms Tan recalled, “It was evident that we had to change what we were doing—fast—if we wanted to keep up with changes in our nation’s changing demographics and healthcare needs.”
Ms Tan said, “That’s when we decided to make a significant change—reducing the length of the programme from 24 months to 18 months. This was challenging because we had to make sure that we were not compromising any learning outcomes with the shorter programme duration. By focusing on core skills training, we managed to do that.
Just as things stabilised, the Integrated APN Internship Programme was introduced in August 2021, replacing the Enhanced Internship Programme. Under the Integrated APN Internship Programme, the final OSCE was replaced by a summative portfolio assessment where the Committee of APN Competence (CAC) would review the nurses’ journeys to assess their readiness for accreditation. Ms Tan shared, “This change was welcomed by the nurses because, rather than depending on passing the OSCE to get accredited, they would now be assessed based on their workplace performance over the 1-year internship—which is fairer and more relevant to their clinical development.”
However, that was not the only change brought forth by the Integrated APN Internship Programme. “From the beginning, APNs always had the option to specialise in medical/surgical, acute care, mental health or community tracks. But increasingly, there was a need for APNs to be able to see patients in a more holistic manner. This meant that APNs’ training had to be more broad-based—with a greater focus on building their medical/surgical skills,” Ms Tan said.
The Integrated APN Internship Programme requires all APN aspirants to undergo medical/surgical training instead of choosing from 4 specialisations. “It was an unpopular decision—but it was the correct thing to do. Having broad-based skills means that APNs can be deployed to various specialties, and they can choose to specialise subsequently if they prefer. More importantly, regardless of their work settings, their skills provide a strong foundation for them to administer comprehensive care for patients—for example, a mental health patient could also have chronic conditions such as diabetes, hypertension or high cholesterol.”
A huge departure from the original programme, the team encountered pushback from both healthcare institution leaders and APNs who were previously practising in acute care, mental health and community tracks. Fortunately, there were also strong proponents among practising APNs and support from NUS Nursing, SNB and the policymakers.
2024 and Beyond – The Living Curriculum
The Master of Nursing programme crossed its 20th anniversary milestone in November 2023. Looking back at the changes, Ms Tan said, “Changes are never easy. But we shouldn’t shy away from making them—because our ultimate aim is to build a stronger healthcare system that is adaptive and ready to cater to the population’s needs. That should guide us in our decision to do the best for the programme and Nursing.”
As Singapore’s healthcare landscape continues to evolve, there is a growing demand for registered nurses to step up to become APNs—and APNs to wear bigger hats by taking on bigger roles. For one, Singapore is looking to increase the number of APNs who are licensed to prescribe medication to 700—more than the total number of practising APNs today.
Ms Tan explained, “APNs are well-trained and versatile. Can you imagine the value they can add to the whole healthcare system if we have more APNs? Clinically competent, APNs can be the first point of contact to assess whether a patient needs escalation at the General Practitioner’s clinic or emergency department. The potential of that is patients get prompt and safe care. But before that can happen, we need to first stabilise the Nursing workforce in Singapore.”
“Only then would NUS Nursing’s efforts in keeping the curriculum up-to-date and aligned to the ground’s needs truly pay off,” she added.
