INTRODUCTION
With the globe population is ageing, chronic disease had become an important issue in the world. On the early 20th century, infectious disease is the main causes of mortality in the world, resulting in an average expectancy of 47 years (Metha & Quagliarello, 2010). However, with the prevention and management of infectious diseases such as vaccination, health measures and aseptic techniques, the average life expectancy increased to 76-80 years in most developing countries (Metha & Quagliarello, 2010). It is also estimated that 70 million people will be more than 65 years old in the year 2030. Today, with the increasing of life expectancy throughout the world, people are living longer than before. This means that the older adults and longevity will be increased, resulting having higher risk of getting chronic diseases in the older age (Grady, 2011). Statistics have shows that 9 out of 10 older adults will have chronic disease with at least 43% having at least 3 multiple conditions such as hypertension, blood lipid abnormalities and any other chronic medical condition (Ng, 2009). With this epidemiologic transition shifting of the mortality causes from infectious disease to chronic diseases, this leads to enormous challenges to the society. Hence, there is a need to address the significant impacts caused by the increase in ageing population such as healthcare services delivery and planning. In addition, there is also a need to address the ways to minimise the chronic diseases’ burden that had on the elderly and their family as chronic diseases do not bring about discomfort in the elderly people’s physical being but also it will burden the family members or even these elderly people’s financial problems. These ensures older adults are able to manage their life properly even with multiple chronic disease, in order to receive a better quality of life (Szczepura, 2011). In the following parts of the essay, definition and causes of the chronic diseases will be explained followed by the discussion of ageing population that influenced nursing and the contemporary nurses’ role in relation to ageing population in Singapore. Besides these, this essay will also touched on the current and potential impact on the causes of ageing population in the health care systems, different perspectives in health care and health, and politics of nursing practices. In an article by Forbes & While 2009, stated that ” chronic disease are illnesses, that are prolonged, do not resolve spontaneously, and are rarely cured completely.” This means that once an older adult have chronic diseases such as heart disease, diabetes, cancer and stroke, the chances of recovery are slow and cure are minimal. According to Singh (2008) stated that the globalization, urbanisation and population ageing are the top causes of chronic disease in World Health Organisation (WHO). These are divided into common modifiable risk factors such as unhealthy diet, physical inactivity and tobacco use, and non-modifiable risk factors such as age and heredity (Singh, 2008). With the modifiable and non-modifiable risk factors, it leads to immediate risk factors such as raised blood pressure, raised blood, abnormal lipids and obesity and ultimately having chronic diseases (Hyman & Roizen, 2009 & Singh, 2008). As such, chronic disease often leads to complication such as pain, functional limitations, bringing the frequent of admission to the hospital for long term management and all these belongs to lifelong medical condition that required continuous supportive care over years (Grady, 2011, Hyman & Roizen, 2009). In Singapore, population ageing is rapid and unprecedented. The ageing in Singapore’s population was mainly due to the decline of fertility rate beginning in 1970s (Chan, n. d.). Currently, a total of 7% were aged 65 years and above, and by year 2030, this will increase to 19% (Chan, n. d.). Out of these statistics, ageing population are heading with chronic diseases and complications (Phillips & Bartlett, 1995) and according to Martin et al, 2010, mentioned that in worldwide aged 65years and above, had already contacted with chronic diseases. From these statistics, there is a need to resolve issues that foresee, to provide quality care to a larger number of populations. To provide quality care to larger number of populations in Singapore, Singapore are facing issues such as economics, social policy, setting up restructure hospitals or residential home, and provide more healthcare services education in prevention and management. To overcome the economics and social policy of aging population in Singapore, a national policy on ageing and contribution to central provident fund (CPF) system were introduced to Singaporean. Schemes such as medisave, medishield, and eldershield were introduce in 1984 and 2002 respectively to reduced the burden of individual and family (Teo, Chan, & Straughan, 2002). These schemes were introduced to provide coverage for high health care costs to those who can’t afford, causing from ageing population and chronic diseases that were predicted by the government in Singapore in the year 2030 (Teo, Chan & Straughan, 2002). According to Flesner (2004), high care costs are expected to rise when the elderly ages in most societies. It was predicted that one elderly have to be supported by 9. 8 working people (Teo, Chan & Straughan, 2002, Chan, n. d.). Therefore, Singapore government are concerned with the population to understand the economic implication of ageing, and the importance to ensure financial plan with the elderly through retirement savings or extension of employment years went smoothly (Rice & Fineman, 2004, Ng, 2009). This will help in the financial management for population especially elderly with chronic diseases in later years. Having said that, Teo, Chan & Straughan (2002) mentioned that these will become an issue on retirement savings for Singapore when elderly are not working during the young age, or working as self-employment where no contribution to Central Provident Fund (CPF). As the same time, social policy includes the need for appropriate restructure hospitals, residential homes and integrated care for aging population with chronic diseases were also implemented in Singapore and other developing countries such as Europe, Japan and New Zealand (Lim, 1998 & Flesner, 2004). These helped in providing shelter and medical care areas for them to rest, as well as integrated care to manage their chronic disease with their families or caregivers with the help by a team of professionals. As these are important and essential to implement, Singapore may face the social policy’s issue as places are limited to set up restructured hospitals and residential homes. Besides the economics and social policy are being taken in the consideration, education campaigns such as chronic disease management program, active ageing and national disease control plans were introduced to help in focusing early detection, prevention to focus on their diseases and promotes the highest possible of wellbeing in old age (Ng, 2009 & Chan, n. d.). These aids in the management of preventing chronic diseases, managing the diseases, at the same time to improve the level of care of chronic diseases for ageing population in Singapore (Lim, 1998). The above issues create challenges for the nurses in Singapore. The combined impact of growing and ageing population, setting up restructured hospitals, polyclinics and nursing homes require a strong driver for healthcare demand in order to meet the expectations and standards of care to the population in Singapore (MOH, 2012). Szczepura (2011) mentioned that the benefits of high input nurse practitioners are expected not only in Singapore but also in developing countries such as USA and Australia, to order to provide direct care to the older adults. In order to meet the demands of the increase patients’ care, demands and expectations, the dynamics of nursing work will be higher than before and had to be changed (Fawcett & Moreno, 2007). As these increases more workload to the nurses, there will be higher chance of turnover rate and low retention of nurses (Habermann & Stagge, 2010). Other causes of shortage might also due to the increase of ageing workforce of nurses. Therefore, there will be issues on the shortage of experiences nurses working to nurse the ageing population in the later years. Hence, Singapore will also be expected to face shortages of nurses to meet the supply and demands in later years (Johnstone, & Kanitsaki, 2009). To overcome the shortage, more training and development were formed for the nurses to build up on their knowledge. At the same time, rewards and benefits were formed to attract employment of nurses from overseas. Beside Singapore, countries such as United States and Australia create solutions to workforce such as introducing of new roles, provide opportunities for them to learn and upgrade, in order to overcome the shortage of nurses and increase their retention rates (Mckenna, 2013 & Halcomb et al, 2007). The increased of opportunities will enhanced them to ready to work competently in the future (Fawcett & Moreno, 2007). New roles such as educator, clinician, case manager and advanced nurse practitioner are roles that can further expand their existing roles and extension of the existing scope of professional in nursing practices (Hunter & Walsh, 1999, Randall, Diginon & Mills, 2011). These expansions of roles allow nurses to empower themselves, and giving more autonomy to help to manage care to the ageing population (Randall, Dignon & Mills, 2011). However, different roles have its different scope of care and acts differently. For example, the role of educator and clinician help to guide the nurses to take care of elderly, improve on nurses’ skill level and the complexity of the tasks in the hospital, restructured hospitals or residential homes. Case manager helps in transition of care through coordination from acute hospital to step-down care. As for the advance nurse practitioner, they help to review the elderly and reduce the stress on the shortage of medical practitioners in the hospitals or polyclinics, working more consistently with patients with chronic condition who require constant support and monitoring of their condition’s progress (Parker, Walker & hegarty, 2010). However, Mckenna (2013) mentioned that these expansions of roles maybe potentially overlap other professionals’ job scope, leading to role conflict and role confusion. Besides caring the ageing population in the restructured hospital or nursing homes, it is also important for nurses to have fundamental role in promoting the health using educational aids or campaigns and social welfare to the older people. It is important for the older people to empower themselves to meet their own needs and lifestyles in order to have healthy ageing (Fawcett & Moreno, 2007). These are important for the nurses to be an advocate, helping in shaping the future rather than merely react to the present situation (Wilkes, Butler, Trammell & Faulk, 2005). In order to fulfil their advocacy role effectively, nurses need to have sufficient knowledge pertinent to the chronic disease prevention and management through training or development, and to be confident about the advice and health promotion they are providing to the population. This is to ensure that nurses are ready to provide sufficient information to the population as nowadays elderly are more knowledgeable and educated (Johnstone & Kanitsaki, 2009, Davies, 2011). With these above mentioned, there will be impacts on the current and future of the healthcare systems in Singapore. Singapore is an independent country which has diverse community of Chinese, Malay, Indian and Caucasian after the year 1965 (Lim, 1998). The prevailing wisdom of Singapore cut off its obstacles and survived to become one of the Asia’s most prosperous nations. Health care has always been placed high priority in Singapore and it is important to build a health care system that is not separated or fragmented (Lim, 1998). In Singapore’s health care system, it begins with building a healthy population through preventive of diseases and promoting a healthy lifestyle (MOH, 2012). Singaporeans will not be withholding any medical services due to financial constrains and are benefit from good, affordable basic healthcare services through public hospitals and clinics. However, cost might be became one of the issue for Singapore to ensure that ageing population are able to pay their medical bills. Healthcare system are categorised into different categories for the population such as primary healthcare, hospital care, intermediate and long term care, and integrated care (MOH, 2012 & Lim, 1998). All these services provide a link from one another to reach the optimise goals for the population especially ageing population. Primary health care services are provided to the population by the general practitioners and nurses. They are the first point of contact with patients and then referred to hospital care for further investigation and treatment if required. After the treatment in the hospital care, there is intermediate and long term care such as residential and community-based healthcare services that caters to the long-term care needs of Singaporeans. This service includes such as community hospitals, inpatient hospices, nursing homes especially for ageing population that have chronic diseases. With that the Agency of Integrated Care (AIC) was also set up to smooth the transition of patients from one care setting to another (Lim, 1998 & MOH, 2012). Thus, Singapore is facing a public healthcare system that is growing increasingly more complex. The environment, the expectation and demands are factors all add up to the complexity, causing the impact to the healthcare system. The environment required a change that includes setting more ageing-friendly facilities such as mobility and wheelchair friendly areas, neighbourhood primary healthcare services, hospitals and long-term care services. In fact, to address these issues, Jurong healthcare community hospital and other neighbourhood hospitals are opening soon in Singapore to see the welfare of the ageing population. Thus, increases the manpower to place these areas became the current issue for Singapore. For these, more healthcare professionals were employed from overseas to overcome the shortage, causing a dependency of foreigners and over populated (Habermann & Stagge, 2010). Also, as more foreigners are working, ageing population will be mainly taking care by them, thus causing communication barriers. Therefore, more Singaporeans nowadays are being trained to become healthcare professionals so that by year 2030, there will be more professionals in Singapore are Singaporeans. However, it may become as a potential issue when the periods of training are shorter than ideal period of time to develop appropriate programs (Kespichayawattana & Jitapunkul, 2009). Thus, government need to prepare for the future impacts in that might foresee in healthcare systems. Besides setting up more care services and trained more professionals, the needs and essential for elderly to remain healthy, functional and place elderly with dignity within a closely knit community are required. In order to achieve these aims, promoting active ageing, healthy lifestyles and good aged care are essential and important. These will keep the population to keep the body to be active and healthy, better accessibility, affordability and enjoy quality of golden years towards ageing (MOH, 2012). With all the prevention and management towards ageing population, nurses also need to integrate complementary and alternative therapies from a holistic perspective rather than from the limitations of a traditional western medical model (Barbara, 1997). Robinson (2009) defined complementary and alternative therapies as ” a diversity of therapeutic practices and alternatives healthcare approaches that fall outside the boundaries of conventional allopathic medicine.” In fact, over world-wide, the use of complementary and alternatives therapies continue to be increase especially those with chronic diseases (Robinson, 2009). There are a total of seven types of categories in complementary and alternative therapies. They are the mind or body interventions such as mediation or dance, bioelectromagnetics application in medicine which involves wound healing or electroacupuncture, alternative systems of healing such as homeopathic medicines or naturopathic medicine, manual healing methods such as massage or qiqong, pharmacological and biologic treatment such as immunoaugmentative therapy, diet and nutrition in the prevention of chronic disease such as vitamins and study of various food group , and herbal medicine from China, Europe (Barbara, 1997). These are the alternatives that can enhance caring and healing at personal levels to head towards a better wholeness lifelong journey for the ageing population. The politics of nursing practice also plays a part in the recent years. Nursing practices are dynamics and the scope of practices for many professionals such as nurses may change as a response to greater demand to an ageing population. It was also influenced by many requirements such as economics, societal, and political pressures set by the regulatory framework such as Singapore Nursing Board, Singapore Nursing Association, Ministry of Health, Ministry of Manpower and Singapore health services for the professional nursing practices. These allow nurses to understand themselves and how it can articulate their profession such as their images and knowledge on the health care delivery. Thus, patient care will be improved and promote professionalism when there are competency standards in the regulatory framework. However, due to the standard regulations, it may affect and hinder nurses’ autonomy in our practices at times. CONCLUSION: Ageing population is in the increasing trend that are concerned to anywhere in the world. As age increases, there are also risks in chronic diseases. Therefore, the foresee issues and impacts are significant to address as it shifted the dynamics of the healthcare system and ultimately affect nurses’ roles and practices in Singapore. Being as a nurse, nurses’ roles do not only perform their primary role of caring for patients while these patients are hospitalised. Nurses need to go further to equip themselves with healthcare knowledge and resources, to educate the elderly and their families, and also to promote healthy ageing through healthy lifestyles and campaigns. With that, potential impacts such as shortage of experienced nurses, ageing workforce and high turnover rate will bring further changes in healthcare. As such, Singapore will view these impacts as significance issues. Hence, training are provided to nurses currently to overcome the foresee circumstances. Singapore are concerned and are prepared to face the future challenges that might have on the ageing population with chronic diseases, as healthcare is being viewed as the top agenda in Singapore.
