Enhancing care in nursing homes: Qualitative insights from the ENHANCE programme

Dear Editor,

Empower Nursing Homes And improve staNdards of CarE (ENHANCE) was a pilot programme introduced by Sengkang General Hospital to address the challenges faced by Singapore’s ageing population. With nearly 1 in 4 Singaporeans projected to be aged 65 years and above by 2030, the demand for effective long-term care solutions is increasingly urgent.¹ The ageing population is a global phenomenon that results in increased healthcare expenditure.² ENHANCE seeks to improve nursing home care and reduce preventable hospital admissions through collaboration with an acute hospital.³ The initiative aligns with the World Health Organization’s Integrated Care for Older People guidelines, focusing on preventive care and tailored interventions to improve elderly care in community settings.⁴

The ENHANCE programme incorporates several key interventions, including the National Early Warning Signs (NEWS) tool, teleconsultations with hospital physicians and the establishment of clinical care pathways. These components empower nursing home staff to manage residents’ acute health issues more effectively, thereby reducing emergency department visits and hospital admissions.

Qualitative in-depth interviews were conducted with 26 staff members from 2 nursing homes in the northeast of Singapore that piloted the ENHANCE programme. Using semi-structured interviews (Supplementary material), we sought to understand the practical implementation, challenges faced and perceived benefits among nursing home staff. Interviews were transcribed and thematically analysed with NVivo 14.0 (Lumivero, CO, US).

The study revealed several important insights into the programme’s impact and factors influencing its success. Table 1 summarises the themes and subthemes which emerged from the study. Nursing staff generally demonstrated a good understanding of the collaboration’s purpose and workflow. The ability to consult hospital physicians via teleconsultation provided a valuable support system. This real-time access to expert advice was particularly appreciated, enabling staff to manage complex cases effectively within the nursing home setting. The reassurance and confidence gained from this support empowered staff to make informed decisions, thus allowing them to continue managing patients without the immediate need for hospital transfers. This not only bolstered the competence of the staff but also helped prevent overburdening of the nursing home system by identifying patients who truly required hospital intervention.⁵ Despite this positive feedback, there were varying perceptions about the optimal use of the collaboration. Some staff members expressed uncertainty regarding when and how to fully utilise the available resources. Clearer guidelines and more comprehensive training are needed to ensure that all staff members can confidently leverage the collaboration most effectively.

Table 1. Themes and subthemes that emerged from the interviews.

One of the major strengths of the ENHANCE initiative was its focus on improving staff skills and knowledge. Training sessions provided nursing home staff with practical experience in using the NEWS tool, an established and validated method for assessing patient acuity and guiding escalation of care. This training was complemented by simulated scenarios allowing staff to practice and refine their skills. The user-friendly nature of the interventions, including teleconsultation and the NEWS assessment, was highlighted as a significant advantage. The collaboration also improved efficiency; by streamlining processes and providing direct access to hospital physicians, the programme helped save time and resources, allowing nursing home staff to manage acute situations more effectively. This efficiency is crucial in a setting where staff often juggle multiple responsibilities and face high workloads.

However, the study identified several challenges impacting the implementation of the ENHANCE initiative. Resource limitations within nursing homes were significant issues, with many facilities facing constraints related to access to diagnostic tools, medications and other essential resources. These limitations hindered the staff’s ability to manage residents effectively and contributed to higher rates of hospital transfers.⁶ Additionally, a lack of staff also exacerbated these issues, limiting nursing homes’ ability to fully utilise the tools and interventions provided by the programme.

Institutional policies and protocols sometimes restricted staff capabilities, leading to underutilisation of new skills and resources. Decisions regarding transferring residents to hospitals were sometimes influenced by next-of-kin preferences, complicating care pathway implementation and undermining the programme’s objectives.⁷ This highlights the importance of clear family involvement protocols and decision-making frameworks that foster trust between families and nursing staff, to facilitate discussions with family members.⁸ This is particularly important in Asia, where family-centred care is emphasised, ensuring that family preferences and values are integrated into the care process.

Concerns were also raised about the ability of the NEWS tool to capture all relevant aspects of a resident’s condition. While NEWS is a valuable tool, some staff felt it did not fully address the complexities of managing residents with multiple health issues. The additional paperwork required by the programme also added to the existing workload and could detract from direct patient care.

Despite these challenges, several factors contributed to the success of the ENHANCE initiative. Internal support, including having a designated contact point within the nursing homes, was crucial for overseeing the project and providing necessary assistance. Competent nursing staff, who are familiar with residents’ baseline conditions, were better equipped to assess clinical status and decide on appropriate escalation of care. The intrinsic motivation of nursing staff to improve care quality was also a driving factor, aligning with the programme’s goals and contributing to its success.⁹

To enhance the effectiveness of the ENHANCE programme, key recommendations include ongoing training and specialised geriatric education for nursing staff to keep them updated on best practices and improve their ability to manage acutely ill residents.^2,10 Expanding the nursing workforce is also essential to balance workloads and maximise the use of ENHANCE interventions. On a policy level, improving resource allocation for nursing homes, providing government support for telemedicine and integrating geriatric care into community health settings are crucial steps. These measures aim to improve care quality, facilitate access to specialists, reduce preventable hospital transfers and promote ageing in place.

The ENHANCE initiative highlights the benefits of integrating acute care services with nursing home care, offering a model potentially replicable in other regional countries facing rapidly ageing population. Addressing resource limitations and refining workflows are essential for further success. By expanding emergency care beyond traditional hospital settings, ENHANCE aims to improve care delivery as Singapore’s elderly population continues to grow.

Supplementary material

Qualitative evaluation of project ENHANCE

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