PROFESSIONAL

Community nursing services

during the COVID‑19 pandemic:
the Singapore experience
Xu Yi, Nursa’adah Binte Jamil, Irene Tan Cheng Gaik, Lim Su Fee
Xu Yi, Senior Nurse Clinician, Community Nurse
Nursa’adah Binte Jamil, Senior Staff Nurse, Community Nurse
Irene Tan Cheng Gaik, Nurse Clinician, Community Nurse
Lim Su Fee, Deputy Director of Nursing, Advanced Practice Nurse, all at the Department of RHS-Community Nursing,
Population Health and Integrated Care Office, Singapore General Hospital, Singapore

xu.yi@sgh.com.sg

T he Chinese authorities alerted the World Health

Organization (WHO) on the first case of
coronavirus disease (COVID-19) on 31 December
2019 (WHO, 2020a). Singapore reported its first confirmed
COVID-19 case on 23 January 2020 (Ministry of Health
Singapore’s experience with the 2003 SARS outbreak
aided the government to take swift precautions, such as strong
epidemiological surveillance, contact-tracing capacity and a
strict hospital and home quarantine regimen for potentially
infected patients (Heijmans, 2020).
(MOH), 2020a).The COVID-19 outbreak was subsequently In April 2020, the Singapore government was prompt to
declared a pandemic on 11 March 2020 (WHO, 2020b). take unprecedented measures termed the ‘circuit breaker’
As of 7 July 2020, the number of cases were approaching (CB), where stricter measures were implemented to contain
11.5 million worldwide (WHO, 2020c). In Singapore as the spread of COVID-19 (Government of Singapore, 2020a).
of 7 July 2020, there have been 45 140 COVID-19 cases, The enhanced safe-distance measures during the CB period
including 4112 (9.1%) active cases and 26 reported deaths from 7 April 2020 to 1 June 2020 have resulted in community
(MOH, 2020b). services, such as home personal care and centre-based care
services, being scaled back and limited to serve only residents
with inadequate family support and intensive care needs.
The COVID-19 situation has aggravated the social
ABSTRACT
vulnerability of older adults.The lack of social interaction and
Community nurses in Singapore support vulnerable older persons with
physical activity could have a negative impact on the mental
chronic health condition(s). In the situation of scaled-down community
and physical health of vulnerable older populations (Narici
health and social services during the COVID-19 outbreak, the community
et al, 2020). Older persons with chronic health conditions
nursing team adopted measures for pandemic preparedness. This
were affected not only by the scaled-down community
report is to share the Singapore General Hospital community nursing
services, but also by the disruption of acute-care services in
experience, preparation and transforming efforts during the pandemic.
institutions. These included early discharges from hospital
Team segregation, active screening and triage before visits and other
to home, rescheduling non-urgent elective procedures/
precautionary measures were executed to minimise the risk of exposure
outpatient appointments and redeployment of staff.
to COVID-19. There was a shift from face-to-face to teleconsultation to
During the CB period, the withdrawal of routine face-to-
meet the requirement of safe social-distancing. Community nursing teams
face (FTF) care by other services, closure of most ambulatory
continued to play an active role in supporting older persons during the
care and the stay-at-home directive have all added significant
pandemic, despite the challenges. Moving to the lockdown phase (‘circuit
pressure on the health management and care coordination in
breaker’), teleconsultation, virtual meetings and integrated partnerships
community settings. This paper reports the experiences and
were essential to ensure healthcare accessibility and continuity of care.
transforming efforts of the community nursing services of
The experience gleaned was valuable to advance future community nursing
the Singapore General Hospital (SGH) during the pandemic.
services in the evolving healthcare landscape. Structured teleconsultation
© 2020 MA Healthcare Ltd

and technology advancement are useful to complement the service.

Background
KEY WORDS
w Community nursing  w COVID-19 pandemic  w Teleconsultation 
Demographic of Singapore
As of June 2019, the population of Singapore was 5.7 million
w Chronic disease w Older persons
(3.5 million citizens). Some 78.6% of the population lives

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 PROFESSIONAL

in government-owned apartments, also known as Housing

AdobeStock/Qualit Design
Development Board (HDB) flats (Department of Statistics
Singapore, 2020b). From 2000 to 2017, the proportion of Health and
three-generation households among all resident households geriatric assessment
decreased from 10.5% to 8.7%; the proportion of older persons
aged 65 years and above living alone increased from 19.3% to
32.0% (Ministry of Social and Family Development, 2019).
The life expectancy was 81.4 years for males and 85.7
years for females in 2019 (Department of Statistics Singapore,
Care referral Health coaching
2020a). The citizen population aged 65 years and above is for disease
forecasted to reach 21% by 2025, compared with 16% in and coordination
prevention
2019 (National Population and Talent Division, 2019). The
proportion of older adults with three or more chronic diseases
nearly doubled from 2009 to 2017 (Choo, 2019).

Singapore General Hospital

community nursing Chronic disease
Support and education
Community nurses in Singapore play a similar role to district monitoring and
for medication
nurses in the UK. They focus on promotion of health and education for
self-management
self-management
wellness, prevention of illness and the care of people with
differing abilities, the ill and those needing palliative care.The
philosophy of care is characterised by person-centredness,
Figure 1. Scope of community nursing services at Singapore General
client and family empowerment and continuity of care
Hospital (SGH and SingHealth, 2019b)
(MOH, 2019).
The home- and centre-based community nursing services
were traditionally provided by voluntary welfare organisations of mental/cognitive wellbeing, health literacy and health-
or private agencies, which were more procedure-based. seeking behaviour as well as a complex social background.
In 2017, the MOH announced strategic directions for a Rapport building with patients and their families, as well
sustainable healthcare system beyond 2020 (MOH, 2018). In as close-knit community partnerships, are essential to
October 2017, community nursing pilots were implemented overcome these.
across the three integrated clusters (Lau, 2017; MOH, 2020c). The community nursing prog ramme enrolled
Singapore General Hospital is the first and largest tertiary 4038 residents with 7998 home visits and 8525 community
hospital in Singapore and a member of the SingHealth cluster nurse post consults from April 2019 to March 2020. The
of healthcare institutions (SGH and SingHealth, 2019a). nurse-to-resident ratio was 1:150. The team actively led
Funded by the MOH, the SGH community nursing and participated in community outreach events, such as
pilot was officially launched on 28 February 2018 with community health posts, health talks and a falls prevention
the establishment of the first community nurse post. programme with the support of government and community
Geographically based community nursing is envisaged agencies, as well as volunteers.
as a key anchor for population health management and is Besides routine services, the community nursing team also
expected to respond to a portfolio of patients across the five conducts quality improvement projects to encourage self-
SingHealth Southeast Communities of Care (CoC). care among older persons, which proved to be beneficial
The services include (i) early interventions for pre-frail older during the pandemic. One of the projects targeted older
persons, (ii) chronic disease management for patients whose persons diagnosed with chronic diseases who did not receive
conditions are not well-controlled, (iii) care for frail patients influenza vaccination within a year. The project successfully
in the immediate post-discharge period and (iv) palliative care achieved an 86% increase in vaccine uptake through a tiered
for those at the end of life (Xu and Lim, 2019). Community approach over 6 months, involving health talks, individual
nurses collaborate with other home care nursing agencies coaching and standardised referral processes. Other projects
outside of acute hospitals in the community care settings for focused on improving older persons coping with their
patients requiring long-term support of nursing procedures, medical conditions, such as developing a wall decal with
for example, wound care and medication management. important contacts of next of kin, health and social service
The community nursing team is led by an advanced providers and appointments; and educating residents from
practice nurse. Each team comprises a team leader who is a senior activity centres on self-monitoring of blood pressure.
© 2020 MA Healthcare Ltd

nurse clinician and four to seven senior staff nurses.They are

included in 27 community nurse posts in the neighbourhood. Pandemic preparedness
The scope of services provided at the posts or patients’ homes
is illustrated in Figure 1.They play a critical role in health and Staff wellbeing and team readiness
social care service integration. The complexity in managing The COVID-19 situation presents a public health threat that
patients’ health conditions is often associated with a lack may carry on for a long time. On 20 March 2020, the MOH

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PROFESSIONAL

of Singapore announced stricter safe-distancing measures to The team was further segregated into teamlets based on
reduce the risk of further local transmission of COVID- community nursing post locations. Physical contact across
19, especially for vulnerable segments of the population teamlets was minimised. The distance reduced the risk of
(MOH, 2020d). Community nurses continued to provide cross-infection between staff, meaning they not only kept
services with added precautions. Notices were displayed at themselves safe but also prevented the risk of possible spread
community nursing posts, and triage stations were set up to within the team.
screen for fever and/or respiratory symptoms and travel and 3. Workload distribution: the community nurses’
contact history before nursing consults. Community nurses workloads were reduced due to the suspension of walk-in
reviewed their existing workload to prepare for home visits consults and individual/group activities at the community
and teleconsultations. Team leaders facilitated the handover nursing posts. The workforce of each teamlet was also kept
of cases in preparation of staff deployment and reassigning at a minimum to meet the daily workload of essential home
of the caseload. visits and teleconsultation.
4. Triage of patients via teleconsultations and electronic
Survey on staff readiness for COVID-19 medical records (EMR) to determine the need for visits:
An online platform was created to assess the team’s readiness risk assessments were undertaken through telephone calls
to tackle the COVID-19 outbreak and seek suggestions to and EMR review before visiting patients. This was to
overcome the challenges in view of the emerging situation ascertain the need for essential home visits and any potential
and influx of information on the spread of COVID-19. exposure to COVID-19. The screening questions included
The survey helped the senior management team to quickly ones about respiratory symptoms and body temperature,
evaluate the frontline community nurses’ responses to the overall health status, contact history to COVID-19 for
pandemic as well as adjust the preparation work needed.The patients and persons in the same household, sufficient
survey showed that approximately 90% of the community stock of medications and the availability of caregiver or
nurses were confident in handling the outbreak situation. family support. EMR reviews aimed at identifying hospital
The nurses were assured that the MOH and hospital admissions/emergency department (ED) visits, whether
were implementing stringent measures to allay healthcare a COVID-19 test had been performed, risk of falls and
workers’ fear of contracting COVID-19 infection. In treatment adherence, to determine the need for a home
addition, senior community nurses who had experienced visit. The community nurses also liaised with other service
the severe acute respiratory syndrome (SARS) pandemic in providers for additional support during the CB period, such
2003 provided tremendous psychological support to their as transport to appointments, meal delivery, medication
younger colleagues in alleviating their fears in dealing with delivery and home personal care.
patients during the pandemic.The following measures were Patients with symptoms of fever or respiratory tract
suggested as some of the strategies to manage the evolving infections and close contact with COVID-19 cases were
COVID-19 situation: (1) alleviate public fear of contracting referred to the nearby Public Health Preparedness Clinic
the infection from healthcare workers through education, (PHPC) or ED with appropriate coordination. Testing for
(2) coordinate community services to support frail residents COVID-19 could be performed at public hospitals and
and (3) perform home visits for essential needs that cannot selected PHPC (Government Technology Agency, 2020).
be delivered remotely. 5. Observed FTF visits of limited duration without
compromising care delivered: the bulk of the essential
Revised workflow with assessments was performed through telephonic and EMR
precautionary measures reviews. Essential home visits were conducted when (i)
Moving into the CB phase, community nurses continued patients were uncontactable or unable to comprehend
to play a critical role, implementing novel adaptations of instructions through the telephone, (ii) adequate symptom
FTF consults towards telephonic and video consultations. control could not be achieved through teleconsultation, (iii)
The services at community nursing posts were ceased, but physical examination or nursing procedure was required;
support through home visits was permitted for essential or iv) the patient was at risk of abuse/self-harm or causing
services with strict adherence to precautionary measures. harm to others. The visit was limited to 30 minutes.
The community nurses adopted various precautionary 6. Risk-based approach for personal protective equipment
measures, which included the following: (PPE) use: to protect the safety of community nurses, the
1. Staff surveillance: hospital staff surveillance was MOH provided guiding principles for PPE use following
conducted through temperature monitoring (twice a day), the risk-based approach. The SGH also regularly updated
contact tracing and any visits to areas with possible clusters. the PPE guidelines in the context of the COVID-19 Disease
All hospital health workers including community nurses Outbreak Response System Condition (DORSCON)
© 2020 MA Healthcare Ltd

were tested only if they met the clinical case definitions alert according to the setting, personnel and type of
for COVID-19. If anyone was not feeling well, they activity. All community nurses attended N95 mask-fitting
were advised not to turn up for duty and seek medical sessions and refresher training on the use of powered
attention immediately. air-purifying respirators.
2. Team segregation: the community nursing team of Community nurses would ensure the appropriate PPE
each CoC prepared a standby workforce for deployment. was available and put on before performing any services

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PROFESSIONAL

or making a home visit for residents with/without any distancing. Care escalation was warranted for a few senior
household member(s) living within the same premises on residents during home visits due to health deterioration.
Stay Home Notice (SHN) and Home Quarantine Order The community outpatient parenteral antibiotics therapy
(HQO). A 14-day SHN applies to anyone who enters or (CoPAT) service continued during the pandemic. The
returns to Singapore from abroad. The HQO differs from CoPAT service provided frail patients with limited mobility
the SHN as it has legal ramifications, with a severe penalty with an alternative to inpatient hospitalisation when they
for non-compliance. It is issued to quarantine or isolate an required prolonged intravenous antibiotics (Xu et al, 2019).
individual who is suspected to be a carrier of COVID-19 Several older people had their medical consultations
or a contact of a confirmed COVID-19 case (Government postponed. Some were reluctant to visit specialist clinics
of Singapore, 2020b; 2020c). for appointments, and some did not top up their chronic
7. Virtual meeting: leveraging on digital technology, disease medications due to fear of contracting COVID-
virtual meetings with teamlets and community agencies 19. Community nurses remained accessible to ensure care
were organised for case discussions and care coordination. continuity and constant supply of medication through the
medication delivery services to patients’ residences. They
Delivering community nursing assisted older persons in medication self-management
services during pandemic through health coaching, medication consolidation and
short-term medication packing at home.
Teleconsultation Moving towards the post-CB phase, the clinical outcomes
During the pandemic, teleconsultation has come to light of teleconsultation and home visits will be evaluated.
as a feasible solution for the precaution and prevention of Nevertheless, it was reassuring to note that none of the
COVID-19 (Portnoy et al, 2020). It has the potential to patients visited by SGH community nurses during the
provide timely information with reassurance and confidence pandemic tested positive for COVID-19.
that help is a phone call away. It increases communication
with healthcare providers while fulfilling the requirements Virtual outreach
of social distancing. For older persons with stable health Community outreach and screening activities were suspended
conditions, community nurses provided teleconsultation to during the CB period. A virtual ‘live’ outreach programme
assess their general wellbeing, health and self-monitoring for older individuals was conducted by community partners.
measures, for example, for blood pressure. The ongoing Community nurses were invited to deliver health talks on
monitoring was essential for targeted interventions and falls prevention in Mandarin and a local dialect. It was well-
care escalation when the medical conditions were not well- received by the audience. They commented that the facts
controlled and/or when the patient had had a recent change and tips of falls prevention were helpful for them at home.
in medication.
During teleconsultation, community nurses needed to be Practising beyond the community
well-versed with the patient’s chronic condition to perform COVID-19 patients were admitted to appropriate tiered
detailed assessment through questioning of the patient facilities, such as hospitals, community care facilities (CCFs)
and/or caregivers on baseline conditions, disease-specific and community recovery facilities (CRFs), for medical
symptoms and presence of red flags. However, this proved care and support. Patients were transferred between these
challenging to conduct with older persons who have hearing facilities according to their needs and discharged when they
impairment. Moreover, the social, physical, environmental were well and no longer infectious (MOH, 2020e).
and non-verbal cues of older persons are critical aspects Nurses, including one-third of the community nursing
of health assessment and management. Therefore, workforce, were deployed to clinical areas to cope with
teleconsultation via phone or video might not adequately surges in the SGH ED and isolation wards over 3–5 months.
replace FTF consults when an older person is unable to Some community nurses were subsequently deployed to join
describe their conditions due to language barriers, mental/ the CCF and mobile medical teams (MMT) at workers’
cognitive impairment or lack of self-monitoring devices. dormitories and swab isolation and facilities (SIF) to look
after the medical needs of migrant workers in Singapore.
Home visits with essential needs Building on their experience working in the community,
Social and fitness activities organised by government the community nurses adjusted swiftly to their new roles
agencies for older persons have been suspended since 11 at a different ‘community’. As part of MMTs, community
March 2020. Older people may experience social isolation nurses worked with doctors, pharmacists and administrative
due to lack of meaningful activity engagement and less staff to triage, assist with or perform COVID-19 specimen
face time with others (Yip, 2020). Community nurses also collection and other procedures, as well as provide education
© 2020 MA Healthcare Ltd

observed that some older persons’ health deteriorated, to migrant workers on self-care (for physical and mental
probably due to social isolation and deconditioning. For wellbeing and use of monitoring devices, for example,
those who were not contactable, screening was done at the pulse oximeters). In addition, community nurses assisted
door during a ‘surprise’ visit to ensure wellbeing and safety. medical teams to manage migrant workers diagnosed with
It was important to balance the need for close monitoring chronic diseases and conduct health coaching on treatment
by social and healthcare providers with the need for social adherence and lifestyle modification.

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Conclusion
The experience gained from the COVID-19 pandemic KEY POINTS
preparation and service delivery was helpful to guide future The lack of social interaction and physical activity during the COVID‑19
w
community nursing practice in the ever-changing healthcare pandemic could lead to mental and physical health decline among
landscape. Keeping the community nursing service accessible vulnerable older populations
during the pandemic was essential for vulnerable older During the Singapore ‘circuit breaker’ period, the withdrawal of routine
w
persons through timely interventions. It is anticipated that face-to-face (FTF) care by other services, closure of most ambulatory care
structured teleconsultation will complement community services and ‘Stay at Home’ directives have all added significant pressure
nursing services with technological advancements and to the health management and care coordination in community
further improve the clinical outcomes of older persons in Community nurses play a key role in health and social care services
w
the community. Equipping community nurses with a broad integration. Their efforts in empowering older persons on self-care proved
skillset was also fundamental in times where staff deployment to be beneficial during the pandemic
to various healthcare and community settings was necessary
Community nurses moved smoothly from FTF consults towards
w
to cope with the pandemic surge. BJCN
teleconsultations and kept their services accessible during the pandemic.
Accepted for publication: July 2020

Conflicts of interest: none CPD REFLECTIVE QUESTIONS

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