In the article "Developing professional nursing in Singapore: a case for change,' the author highlights the challenges facing the nursing profession, particularly nursing shortage, and their causes. The author explained that the shortage is chiefly occasioned by the definition of nurses" role within the healthcare system. Firstly, the widely held perception that nursing is women's job and an extension of maternal role to hospital setting have made many women seek other career opportunities. Secondly, the unequal power and work relationship between the physicians and nurses has helped fuel high turnover rates being witnessed in the profession. Historically, nurses have been seen as doctors' personal maids or female servants. Because of this, they have dictated what nurses should or should not do. In such cases, nurses are deemed inferior to the doctors and incapable of making independent decisions. Moreover, the society's failure to appreciate the role of nurses as well as little prospects for promotion are also to blame for the nursing deficit. To help attract more people to the nursing profession and curb nursing shortage, the author proposed an expansion of nurses' roles within the medical field (Lim, 2005, 34-39).
Since the time of the publication of this article, the government has made concerted efforts to redefine the position of nurses within the health care field. In 2012, the government set up the National Nursing Taskforce (NNT) aimed at strengthening the nursing profession. NNT has put in place mechanisms to promote nurses' autonomy. First, NNT has expanded the clinical accountability and enhanced nurses' independence in decision making. Nurses can now make protocol-based diagnoses and order treatment, unlike in the past when they had to take instructions from physicians. The Singaporean Ministry of Health (MOH) is also moving towards giving senior nurses the power to prescribe medicines to patients in stable conditions. Moreover, NNT has provided nurses opportunity to upgrade their careers, developed pathways for their promotions, and expanded their leadership roles. Lastly, nurses have been awarded salary increments and educational opportunities (Moh.gov.sg, 2017).
Progress made on meeting Lim's recommendation
Lim (2005, 34) recommended three changes that need to be effected in the health care system if the nursing shortage is to be reversed in Singapore. First, the author suggested that there is a need to incorporate nurses in health care management (participatory management). The author stated that the role of nurses needs to be redefined at the ward level through the promotion of independent decision making and also through specialization and participatory management is to be realized. Third, the author underscored the need for nurses to take up full leadership position at the top hierarchy and Board level. Lastly, Lim (2005, 34) emphasized the need to enhance nurses' clinical practice and the creation of a conducive environment for nurses to pursue further education.
Singapore has made substantial progress towards meeting Lim's recommendation. For instance, the MOH provides degree training opportunities for nurses to enable them to take leadership positions. The MOH has also created a new position, Assistant Nurse Clinician, to allow nurses to take up leadership roles and supervisory and guidance roles in care delivery. Additionally, the MOH has rolled out sponsorships further studies (clinical, degree, and masters studies). Lastly, NNT has enhanced nurses' clinical accountability and their autonomy in decision making (Moh.gov.sg, 2017).
Ethical Dilemma: Euthanasia
A woman named Agnes had lung cancer. She showed some level of success in managing her illness two years after being diagnosed with this type of cancer. When the illness entered its third year, Agnes suffered a major setback all the medications meant to relieve the symptoms of the disease were no longer working. The treatments were proving ineffective. During her final weeks, she was fatigued, had lost more than half of her body weight, sweated all night, could not stop itching, her abdomen swelled, lost appetite, had frequent constipation, vomited all day long, and experienced untold, chest, and stomach pain. This was the final stage of lung cancer.
Even though she was hospitalized for a short duration, Agnes opted to spend her last days at home, where his husband assumed the responsibilities of nursing her and providing her with basic needs as she lay in bed. After realizing that she only had few months left to live, Agnes foresaw her life ending horribly and consequently stored lethal drugs to end her life. Even after being administered with painkillers, she continued to suffer. When her suffering became unbearable, she decided to end her life at home. However, at this time, she was too weak to take the lethal medications meant to end her life. She asked her husband for assistance in bringing her life to an end. However, her husband refused. She turned to friends and family members, but all of them denied her request. She was eventually taken to hospital for further treatment.
When the family saw that her conditioning was worsening with each passing day, Agnes was transferred to hospital. Upon arrival at the hospital, the patient was terminally ill and could not walk or talk. She had very poor prognosis and had less than one month to live. Diagnostic results showed that the patient was at the fourth stage of lung cancer: the tumor had grown very large and invaded both lungs and other organs surrounding the lungs. The patient showed blood clotting complications and also suffered from emphysema. Based on these diagnostic results, I did not see the need to keep the patient alive any longer. The cost of keeping the patient alive for one month would have run into thousands of dollars, which the family could not afford to raise. After assessing her condition with other medical professionals, we decided to involve the family members in discussing the possibility of carrying out euthanasia. In this case, voluntary euthanasia was impossible because the patient was not in a position to give informed consent. We explained to the family members the need for euthanasia' deteriorating patient's health, the high cost of sustaining the patients' life or high cost of medical care expenses, the poor prognosis of the patient, and health complications associated with the disease. At initial stages of the discussion, there was rejection from some of the family members because of religious and moral reasons. But after a lengthy discussion on the pros and cons of keeping the patient alive for only one month, all the family members agreed.
Singapore is experiencing a health crisis emanating from diabetes. Diabetes is currently the second leading cause of mortality and morbidity in the country. Data from the National Health Survey carried out in 2010 show that 11.3% of citizens were victims of diabetes, with a third of them unaware of their status (Webcache.googleusercontent.com, 2017). It is projected that the number of diabetic cases will continue rising. By 2050, 1 million people will be living with this condition (Webcache.googleusercontent.com, 2017). If poorly managed, diabetes can cause devastating life-long complications which can adversely affect a person's health and quality of life. These complications include cardiovascular diseases, stroke, lower limb amputations, blindness, and kidney failure (Deshpande, Harris-Hayes and Schootman, 2008, 1254). Additionally, such complications negatively impact the lives of the victim's family members tasked with taking care of them.
The current treatment approaches for diabetes are ineffective because they cannot fully reverse the condition. This begs the question: Are there any hopes, in the near future, of finding a cure or medication capable of reversing this condition? I believe the answer to this question is a YES.' I believe that the cure for this condition lies in regenerative medicine. Regenerative medicine is the next frontier in healthcare because of its potential to replace and regrow damaged tissues and organs, unlike the current treatment approaches which focus mainly on the treatment of the symptoms. In regenerating a diseased tissue or organ, cells capable of regrowing and restoring tissue and organ function are delivered to the affected body parts. This can be done using cell-based therapy or through growth factors.
In diabetes, a disease that leads to hyperglycemia due to insulin deficiency, cellular therapies can help prevent complications arising from the disease. It is worth noting that current treatment approaches are not effective against diabetes. Drugs have also been found to elevate the risk of hypoglycemia (McGinnis et al., 2013, 70). For instance, intensive blood sugar regulation through the use of insulin or sulphonylureas have been reported to lead to a substantial decrease in the risk of microvascular complications, but has no effect on macrovascular disease, in individuals who have type 2 diabetes. Examples of macrovascular complications associated with diabetes include stroke, peripheral arterial disease, and coronary artery disease. These complications arise because of the ineffectiveness of the current treatment approaches to prevent and control hyperglycemia (Fowler, M. 2008, 77). Because current medications cannot adequately deliver glucose to body tissues, they do not offer any protection against harmful effects of hyperglycemia on body tissues (UK Prospective Diabetes Study (UKPDS) Group, 1998, 837) and hence there is a need to explore alternative treatment methods of regenerative medicine.
Insulin promoter factor 1 (pdx-1) and pancreas transcription factor 1(PTF1-a) can regenerate islet cells (Grande and Aparicio, 2014, 170). In addition to iPDX-1, a developmental study has shown that PTF1-a is expressed in most parts of the pancreatic tissues. PTF1-a is a transcription factor needed for the development of the pancreas. The pancreatic cells can also arise from neurogenin-3 expressing precursor cells (Desgraz and Herrera, 2009, 3567). Because of the regenerative capacity of these cells, there is a high likelihood that pancreatic duct cells can undergo both de-differentiation and re-differentiation forming new types of cells, such as islet cells (Zhou et al., 2008, 627). The likelihood of regrowing islet cells through regenerative medicine will eliminate the need for ineffective medicine in the treatment of diabetes. Moreover, the ability to generate islet-like cells from murine pancreas have been reported to be highly effective in controlling hyperglycemia when in diabetic mice (Zhou et al., 2008, 627). Because of high efficacy of regenerative medicine in the treatment of diabetes, these medicines are key to reducing the current diabetes prevalence in Singapore.
Desgraz, R. and Herrera, P.L., 2009. Pancreatic neurogenin 3-expressing cells are unipotent islet precursors. Development, 136(21), pp.3567-3574.
Deshpande, A., Harris-Hayes, M. and Schootman, M. (2008). Epidemiology of Diabetes and Diabetes-Related Complications. Physical Therapy, 88(11), pp.1254-1264.
Fowler, M. (2008). Microvascular and Macrovascular Complications of Diabetes. Clinical Diabetes, 26(2), pp.77-82.
Grande, E. and Aparicio, L.A. eds., 2014. Stem Cells in Cancer: Should We Believe Or Not?. Springer.
Lim, D. (2005). Developing professional nursing in Singapore: A case for change. Singapore Nursing Journal, 32(1), pp.34-47.
McGinnis, J.M., Stuckhardt, L., Saunders, R. and Smith, M. eds., 2013. Best care at lower cost: the path to continuously learning health care in America. National Academies Press.
Moh.gov.sg. (2017). CARE for Nurses - NNT Recommendations | Ministry of Health. [online] Available at: https://www.moh.gov.sg/content/moh_web/home/pressRoom/highlights/2014/NNT-recommendations.html [Accessed 13 Apr. 2017].
Webcache.googleusercontent.com. (2017). State of Health. [online] Available at: https://webcache.googleusercontent.com/search?q=cache:2MO7f3LP0ncJ:https://www.moh.gov.sg/content/dam/moh_web/Publications/Reports/2013/Report%2520of%2520the%2520Director%2520of%2520Medical%2520Services.pdf+&cd=2&hl=en&ct=clnk&client=firefox-b-ab [Accessed 13 Apr. 2017].
Zhou, Q., Brown, J., Kanarek, A., Rajagopal, J. and Melton, D.A., 2008. In vivo reprogramming of adult pancreatic exocrine cells to YUV-cells. nature, 455(7213), pp.627-632.
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