Posted: March 24th, 2023

Critical Success Factors

Clinical Incidents Sharing Programme for Nurses in a Singapore Nursing Home: Critical Success Factors

  1. Introduction

Singapore faces the challenge of providing care to the elderly population. By 2023, the country had 19% of individuals aged 65 years and above (Low, 2017). Demographic changes have created the burden of care, including the emergence of dual-income, reduction in extended families, and growth in age-associated degenerative diseases. Inadequately resourced families face difficulties in providing care and support to the aged at home. Moreover, frailty, functional dependence, and the risk of falls worsen the situation for loved ones (Low, 2017). Consequently, many families prefer taking their elderly members to nursing homes to receive critical and medical support in their older age or during illness. However, clinical errors continue to threaten quality health provision. Some of the common clinical errors that health practitioners commit include, mistaking identities of patients and wrong medication administration. Clinical errors are financially strenuous to health providers. Errors and substandard services not only damage the image of the health organizations but also increase the healthcare providers’ expenses in the rectification of the committed errors (Mosadeghrad, 2012). Therefore, many healthcare organizations have initiated different programs that would minimize errors and ensure that patients receive quality healthcare services. The American Nurses Credentialing Centre (ANCC) has recommended the introduction of peer review nursing program as a measure of monitoring and nurturing quality services by nurses (Kelly, McHugh, & Aiken, 2012). One of the programs that are gaining popularity in health care is sharing of experiences between the peers. The Clinical Incident Sharing Session Programme (CISSP) is a planned program Kwong Wai Shiu Nursing Home (KWSNH)  that uses established standards to assess the quality of clinical care. Such professional assessment intends to determine the weaknesses and strengths of the practices and to recommend the appropriate policies that can be used to address the gaps discovered (Roberts & Cronin, 2017). The development of the program also aims to improve the quality of services in the facilities by minimising and eliminate medical errors that would have been costly to nursing homes.

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  1. History

The ageing population has always posed a unique challenge for the healthcare system in Singapore. The country has witnessed major changes in its demographics, including dual-income and reduction in the role of extended families. Other changes include an increase in age-related degenerative disorders because of longer lives (Wong, Yap, & Pang, 2014). Nursing homes have become increasingly relevant in Singapore to care for this population and provide families with critical support in caring for the dependent members. However, their acceptance in the country took time because they were regarded as last resort decisions by both professionals and patients. Besides, such programmes were considered with stereotypical views such as being “physically unattractive, often smelly, and populated with people who are frail and often demented” (Sitoh, 2003, p. 57). However, such opinions have changed with time, and nursing homes have become important in the healthcare system.

Nursing homes, as alternative organisations providing aged care at home, developed in the United States in the 1930s, and later, in other countries around the world. The last three decades have witnessed gradual changes in Singapore regarding the care of the elderly. The original model involved retired nurses who welcomed the ill and elderly in their homes for caregiving purposes. In Singapore, community-based charitable agencies provided the initial model of the services. They were sheltered accommodations that cared for the destitute and homeless aged immigrants. For instance, in 1935, St Theresa’s Home founded the Little Sisters of the Poor to provide services to such people, including food, shelter, and clothing (Wong, Yap, & Pang, 2014). In 1965, Teresa Hsu was a social worker who established one of the pioneering nursing homes known as the Aged Sick at Jalan Payoh Lai. During the 1970s, the country had only a limited number of Homes for the Aged. Recent statistics indicate that the nation has more than 6,400 nursing home beds (Sitoh, 2003). According to the Ministry of Health (MOH), 8,300 such health care workers provided eldercare in the country as of March 2017 (Tang, 2019). The changes have also enhanced nursing home care in Singapore.

The nursing home system in Singapore has improved tremendously. Voluntary welfare organisations (VWOs) operate around 75% of the nursing homes, while the private sector runs the remaining proportion (Sitoh, 2003). Besides the growth in the nursing home beds, a change in the focus of residential care for the elderly has also transformed. For example, in the 1970s, the nursing home facilities cared for aged destitute by providing basic accommodation and care. Gradually, nursing home facilities took over the care for the elderly, focusing on medical and intensive support. Furthermore, the current nursing homes are motivated to provide a broader range of services for residential aged, creating “nodal points” within every community. The facilities should offer a wide range of eldercare services, including home nursing for the sick, home help/support, and residential care. The changes are aligned with the healthcare goal in the country to provide a seamless continuum of care to the aged Singaporeans.

The Singapore government has invested more resources to improve nursing care. For example, in 2014, the MOH enacted the long-term care plan to improve the services offered to the elderly in the country. The plan is future-oriented, aiming at improving the old-age support ratio to 2.1 by 2030. It will decrease the need for caregiving by members of the family to allow them to contribute to the economy. The care process will focus on institutionalised care (Chin & Phua, 2016). Later, in 2015, the government created the enhanced nursing home standards to provide better quality aged care (Chin & Phua, 2016). The health plan focused on the affordability, accessibility, and quality of support provided to the elderly. The government is committed to the achievement of the these objectives to reduce the burden of caring for the elderly.

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  1. Challenges

Healthcare providers are expected to provide quality care, devoid of medical errors. However, the challenge continues to affect their work, particularly in various aspects, such as during the medication administration process. The increase in the number of patients and the elderly population in the country also has made the management to raise major concerns in the facility. The management is aiming at developing a supportive and open culture that would help in improving the safety of the patients in the facility. Some of the concerns raised are; lack of a special committee set aside to integrate frontline people, lack of special techniques to collect, analyse and interpret the data of various clinical incidences, and lack of a special platform that can be used to establish and share the findings and discussion on the most effective and feasible practices that can be employed to improve the safety of patients in the facility (Bowen-Brady et al, 2019).

According to O’Brien and Arthur (2007), although the nursing sector of the country is made up of a considerable good number of ENs and RNs, the number of nurses who can critically analyse a clinical incidence is very small. Most of the nurses in the country have basic training in healthcare matters and therefore only a few can approach such situations from a critical perspective and produce a positive outcome out of the situation. In addition, there has been limited discussions about various critical thinking skills that the nurses need while working in home settings. These skills can be very useful because the nurses must function independently in some of the situations while attending the patients in the home settings.






  1. Development of the CISSP

5.1 Rationale of the CISSP

KWSNH is regarded as one of the most substantial single-site nursing homes found in Singapore. It has 624 beds, but it is undergoing expansion to accommodate more than 1100 beds in the next two years. The increase in the residential burden in the nursing home requires significant changes in practice to improve quality through effective services, such as minimising clinical errors. The required transformation is motivated by the concerns raised by the senior management of the nursing home.  The concern are : (i) the facility requires an open and supportive culture based on general agreement among the caregivers that continued organisational learning is critical for quality outcomes and prevention of adverse effects (Abstoss et al., 2011).  (ii) the facility requires a committee to spearhead the integration of the programme into practice through proper gathering, analysis, and evaluation of data regarding clinical incidents for timely reporting and remediation. (iii) a platform is necessary to establish and share research findings regarding the types of feasible and effective interventions for safe patient outcomes (Bowen-Brady et al., 2019).  However the existing reporting system (single loop system) – explain brieflty what is single loop system has not been effective in improving the quality of services offered, medical care and not addressing management’s three concerns. With a single loop system, its limits the nurses on the number of actions they can take following a critical incident. Often, the root causes, implementation actions were not being shared or disseminated to the ground nurses. Thus the nursing home developed the CISSP. A couple of nursing administtator got together and initated the development of the CISSP.

 (Table 1)

  Sharing Analysis Discussion (how to deal with situation better) Summary/lesson learnt
Activity/ task Sharing the real-life incidents, what had happened Break down the event. Sequenced.



Brainstorming among all nurses divided into two groups, given time for discussion and proposed solutions The NM (facilitator) will summaries the case and conclude the learning point via:


– skills


* the Nm will then tidy the slides and circulate the roll call slides to all

Tools SBAR format from which an assessment will carry out using situation, background, assessment, and recommendation to communicate information to the management. The root cause analysis will be carried out to support the SBAR report considering the factors directly contributing to effective work practices. It assists the healthcare practitioner to recognize, quantify, and implement the changes to the nursing profession. This encourages the nursing staff to commit towards improving patient’s care to perform their duties more efficiently.



Sample Logic Model- as shown below (develop one based on the information above . As for the outcome of the logic model, do not need to have short and long term goal.

(sample Logic Model)


5.2 CISSP Frameworks

The CISSP implemented in KWSNH is based on a framework introduced by the American Nurses Association (ANA) using the Nursing Magnet Model (Upenieks & Abelew, 2006). The model had an application manual directing peer-reviews that concentrated on five components: (i) transformational leadership, (ii) knowledge enhancement, innovation and improvement, (iii) professional practice, (iv) structural empowerment, and (v) quality results (Grant, Colello, Riehle, & Dende, 2010). Since the model became international practice, KWSNH nursing administrators developed it to meet the needs of the organization aiming to improve ongoing learning on collaborative efforts in reporting critical incidents to minimise clinical errors and improve the quality of care.

The program uses various algorithms that help to determine the quality of services and medical care in a facility by use of the established standards. The program also identifies the gaps in the healthcare system by evaluating its strengths and weaknesses and coming up with the most relevant and appropriate policies and strategies that can be employed (Roberts and Cronin, 2017). In general, the CISSP  process includes the following components: sharing, analysing, discussing, and summarising.

Followed by the implementation of the CISSP, CISSP with a double loop system (Explain brieflty what is double loop system)  is an extension of a single loop. In addition to all the stages in the single loop system, the double loop has been developed to accommodate more steps such as a phrase involving a nurse clinician. Furthermore, the programme is also designed to categorise the incident and ensure that a solution is established to prevent a recurrence of the same. The double loop system also ensures that all the stakeholder in a health facility is included in coming up with a measure to enhance safety and the quality of medical care in the facility.

The enhancement from single loop system to double loop system (figure 2)


  1. Critical Success Factors

6.1 Culture of Learning

6.1.1 Culture of Training of nurses/competency

The improvement of quality using the system requires sufficient training for nursing care service providers. Kwong Wai Shiu Nursing Home has already adopted critical training for nurses to improve their service delivery tendencies and improve the quality and safety of the care they offer to the nursing home residents. In 2018, the facility’s training department embarked on a project, “Thinking Nurse” to promote critical thinking skills among nurses. The programme focussed on empowering nurses to develop a continuous learning mindset, which is at the core of the CISSP. The initiative ensured successful development of confidence and skills development in decision-making and critical thinking. It created a team of nurses ready to take relevant actions using their critical thinking skills and clinical judgment for the benefit of their patients. Therefore, training and skills development are among the required critical success factors for the integration of the CISSP into nursing home care.

The CISSP supports the training of providers working in nursing home care. Mahajan (2010) suggests that incident reporting systems are educational tools for nurses, which are beneficial for ongoing quality improvement. Critical skills and expertise are critical in the implementation process because they motivate nurses to develop an ongoing learning culture. It eliminates constraints evident in continuous learning, such as time and resources, because it includes the training component as part of its regular use. The programme enables nurses to continually improve their skills and proficiency in providing care to patients in a safe environment. Learning becomes an important part of their care delivery practice. The sharing sessions enable nurses to identify limitations in their abilities and competencies in providing patient care, creating the room for improvement. The less-experienced caregivers have the opportunity to continue improving their learning in the workplace under the guidance of expert nurses. The programme closes the knowledge gap through ongoing knowledge development.

Professional competence is at the core of effective service delivery in healthcare settings. The improvement of nursing care to the patient in the institution will be achievable if the care providers develop the necessary capabilities to meet the increasing demands. Additional needs include a growing number of residents and the complexity of medical conditions experienced by elderly patients. Besides, the organisation requires trusted medical staff with the competence of health care delivery due to the delicate nature of the recipients of their services (Shieh, Wu, & Huang, 2010). Providers should have excellent communication skills, problem-solving abilities, adequate assessment abilities, and other professional qualifications that ensure their suitability in working in nursing homes. Hence, training on problem-solving and communication skills is necessary to promote positive interactions between trusted medical staff and patients. Overall, training and competency is a critical success factor for quality improvement through CISSP.

6.1.2 Improved nurses’ knowledge and Quality of Care (QoC)

The improvement of the quality of care through the knowledge of nurses is beneficial to the nursing home through the use of the CISSP. Through the programme, they have the opportunity to improve their experience for better patient outcomes. The system is based on collaborative learning and sharing sessions that provide the opportunity for quality enhancement (Lincke-Salecker, 2004). It provides the much-needed opportunity for the nurses to use their theoretical knowledge in practice. The programme will help them to improve their critical thinking and clinical judgement capabilities while working with patients with diverse needs. It will also support them to change their attitudes and behaviours towards the most vulnerable aged residents receiving care in the nursing home (Vincent, Neale, & Woloshynowych, 2001). The system will enable nurses to learn about the new and emerging challenges affecting the elderly to continue improving their care delivery practices. Healthcare providers have the opportunity to use acquired evidence-based strategies to determine the patient’s needs and create appropriate interventions in an error-free environment.

6.1.3 Continuous learning

The continuous learning is at the core of the implementation and use of CISSP in a nursing home in Singapore. Stavropoulou, Doherty, and Tosey (2015) stated that the programme supports ongoing learning in the healthcare setting. The programme supports learning and provides critical information on the way and why patients can experience harm in a medical institution, such as a nursing home. The success of the project emanates from concerted efforts by nurses to continue learning and improving care (Mahajan, 2010). The system that ensures patient safety allows nurses, providing care to nursing home residents, to access critical information and reporting systems that improve their daily learning process. They achieve the creation of a safety culture in the institution that meets various needs, such as prevention of medical errors in the care delivery process. A learning culture is an enabler of the critical change and effective implementation of CISSP at the nursing home.

6.2 Culture of collaboration

6.2.1 information Sharing and Communication

Collaboration through information sharing capabilities and communication are also critical factors for the successful implementation of the programme. The effectiveness of the CISSP emanates from the potential for the nursing home to capitalise on the ability to collect and share information seamlessly (Kash, Spaulding, Johnson, & Gamm, 2014). Nurses should have the competence to retrieve and use data to support clinical decisions. The capability enables the reporting of critical incidents to minimize medical errors in the nursing home. Information sharing includes elements of accountability and transparency in the facility, especially because of the advanced needs of aged patients. In such environments, patients might be unable to communicate their challenges relating to the type of care they receive. Thus, nurses should be accountable and transparent in communicating their services to patients and their families.

6.2.1 Promoting transparency

The effective implementation of the programme promotes transparency among nurses providing care at the facility. The system creates a platform for nurses to share information and interact freely with their peers and management. Hence, the administration shares insights about the creation and implementation of the initiative to ensure proper application. Nurses are the primary information creators in any healthcare facility (Potgieter, 2012). Consequently, their input is critical in the design and integration of the plan into the nursing home facility. Therefore, success depends on the extent to which the management includes them in the necessary conversations regarding the adoption of the new process. The programme encourages critical transparency and accountability in the organisation to achieve the quality and safety improvement objectives. It also enables the management and nurses to effectively manage emerging conflicts in the facility (Norushe, Van Rooyen, & Strumpher, 2004). Therefore, it encourages the creation of a healthcare environment that supports team-work and transparency in patient care.

  • Outcome and Evidenced Based practice        

6.3.1. Translation of Evidence into Practice

The programme supports the translation of evidence into practice by care providers working in the Singapore nursing homes. O’Brien and Arthur (2007) support the need for the programme because of the limitation in using available evidence in practice in the country. Although nurses have the necessary training in various aspects of care, they lack the necessary knowledge to critically approach incidences and achieve positive outcomes in their care processes. Thus, the system is necessary to instill critical thinking skills while providing care to patients in nursing homes in the country. Besides, it helps to meet the demands for nursing services among nurses working independently in the nursing home settings. It will help them to use the available skills to improve the quality of care, such as through timely identification of clinical errors and implementation of remediation strategies to achieve positive practice and patient outcomes. Generally, the programme is appropriate to create a culture of timely and effective translation of evidence into practice.


6.3.2 Building a safe culture

The programme supports the development of a culture of safety in the nursing home. The main goal of the programme is to ensure effective incident sharing and rectification of limitations in the process to prevent adverse outcomes, such as clinical errors. Consequently, the programme promotes cohesiveness and team-work in the provision of care to the residents. The management achieves the objective by creating an enabling environment for the deployment. Regardless of the argument that such programme implementation is still underway in Singapore, proper adoption into the nursing home practice will enable nurses to work in a safe environment and create an enabling culture to achieve patient safety objectives (Stavropoulou, Doherty, & Tosey, 2015). The programme also enables proper collaborative efforts among nurses to improve patient and practice outcomes. Vertical and horizontal collaboration within the expanding organisation is critical to creating an error-free environment as the nursing home receives additional patients. The sessions update them about emerging knowledge and medical information relating to the care of elderly patients. It also improves information sharing, communication, and interpersonal relations between care providers. Consequently, nurses become better at solving clinical problems affecting their patients.

A safe culture should place high emphasis on the safety values, attitudes, and beliefs. These aspects should be shared by the majority of employees within the company. The leadership should enhance conducive environment that supports the new programme and achieves the quality improvement objectives (Kash, Spaulding, Johnson, & Gamm, 2014). The management at Kwong Wai Shiu Nursing Home should build a safe culture by enhancing close relationships with the residents. The organisation should include close working relationships between the nurses and their leaders. The management will have a reduced burden when integrating the system in a working environment that has a positive culture and values. Therefore, safety culture should be embraced by the senior management for it to be successful.

  1. Conclusion

The CISSP plays a critical role in eradicating the prejudiced and stereotypical view of a nursing home in the country. Sitoh (2003) noted the history of a negative perception of nursing homes among professionals and patients in Singapore. Such views are addressed effectively when systems are in place in nursing homes to improve the care of elderly persons in the country. The programme achieves the objective by enhancing the image of nursing homes and caregivers among the public. It helps to eliminate the negative images presented in the media of aged residents experiencing mistreatment in the country’s nursing homes. Generally, CISSP creates a new and improved perception of long-term care, which motivates families and the elderly to seek their services. The programme enhances care-giving through ongoing training to develop competent nurses.  Although many types of changes can achieve quality improvement in nursing homes, a model based on adequate research evidence and tested framework, such as the CISSP, is one of the most effective approaches. The proposed programme is implemented in Kwong Wai Shiu Nursing Home. The programme ensures improved reporting and communication of incidences to minimise errors and improve the quality of care in the healthcare organisation. Nurses can apply critical thinking and clinical judgment in making decisions affecting the elderly patients receiving care in the facility. They can collaborate with peers, leaders, and families to implement evidence-based interventions. The programme will improve affordability, accessibility, and quality objectives within the aging care area of health care services in Singapore. Since such programmes are limited in the country, an extensive evaluation of efficacy and impact is necessary after implementation in the nursing home.

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