NURSES AND MIDWIVES BILL

Order for Second Reading read. 2.15 pm

The Minister for Health (Mr Lim Hng Kiang): Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

This Bill seeks to provide for the registration and enrolment of nurses, the registration of midwives and for matters connected therewith, and to repeal the Nurses and Midwives Act (Chapter 209 of the 1985 Revised Edition). It will enhance the regulatory role of the Singapore Nursing Board to allow it to discharge its functions more effectively and to ensure higher professional standards of conduct and practice.

There have been major changes in the last 25 years in the training of nurses, the practice of nursing and the types of nursing services in Singapore. To maintain a high standard of nursing, there is a need to update the Nurses and Midwives Act. Let me briefly describe some of the major changes.

Traditionally, nurse training in Singapore was hospital-based under an apprenticeship scheme. The Singapore Nursing Board's role then was to set the training curriculum and to conduct the examinations. Today, the training of nurses and midwives is part of the mainstream educational system with registered nurses and midwives trained in the Nanyang Polytechnic. The enrolled nurses will soon be trained in the Institute of Technical Education. The Nursing Board's role will therefore have to be changed accordingly to ensure that nursing standards are maintained and that nurses have the skills to meet the changing healthcare needs in Singapore.

Over the years, the role of nurses has evolved in tandem with the advances in medical science and technology. Many nurses today are highly skilled, with more than a quarter possessing advanced qualifications in various clinical specialties. As at December 1998, 42 nurses are already designated as "nurse specialists" in their hospitals. Hence, there is a need to guide the development of advanced nursing practice and to ensure the proper use of the title "nurse specialist".

Despite the gradual increase in the number of nurses in Singapore, it is still not sufficient to meet the needs of our expanding healthcare service. To protect public safety, measures are needed to prevent persons making use of the situation to indulge in unqualified nursing practice or to employ unqualified persons as nurses. My Ministry aims to prevent such occurrences by empowering the regulatory role of the Nursing Board.

Provisions in the Nurses and Midwives Bill

Let me now highlight the major new provisions that are being introduced in this Bill.

Constitution of the Nursing Board

The present Nursing Board consists of 17 members, of whom six are ex-officio members and another 11 are appointed by the Minister for Health. The size of the Board is about right. However, to widen the representation and to change some of the titles and terms that have become obsolete with time, clause 3 establishes a Nursing Board with three ex-officio members and 14 appointed members. The ex-officio members are the Director of Medical Services, the Chief Nursing Officer and the Director-General of Education or his representative. Of the 14 appointed members, 11 must be nurses and the remaining three need not be nurses.

Clauses 6 and 12 allow the Minister to appoint the Chairman and the Registrar of the Board. Clause 4 provides for the removal of an appointed member from office if the member, for example, is found guilty of infamous conduct or is absent without leave from three consecutive meetings of the Board or its committees. This is similar to the provisions in the Medical Registration Act (MRA) and the Legal Profession Act.

Functions of the Nursing Board

Let me now turn to the functions of the Nursing Board. In devolving the training of nurses to educational institutions, the existing functions of the Nursing Board to determine and provide for the training and examination of student nurses are no longer relevant. Hence, these functions are deleted. Additional functions are included in clause 8 to enhance the role of the Nursing Board in:

(a) accreditation of formal nursing courses;

(b) regulation of training and continuing education for nurses and midwives; and

(c) regulation of the scope of nursing practice.

This is to ensure that nurses continue to receive appropriate training, keep abreast of advances and developments, and provide safe and competent nursing care to patients.

Registration of nurses and midwives

Sir, let me now move on to matters concerning registration. Currently, a nurse who has stopped working for more than 10 years is required to successfully complete a retraining and competency assessment programme before the nurse could be registered or enrolled to practise again. This is to ensure that the nurses and midwives are updated in practice. Clause 15 allows the Nursing Board to provisionally register or enrol such nurses to undergo the retraining and competency assessment programme.

Another new provision in the Bill is the issuance of Practising Certificates. This is to enable nurses to show proof of current registration, including the type of conditions imposed on registration whenever required. With the issuance of practising certificates, the existing provisions for removal of name if the nurse fails to pay the annual fee or has ceased practice will be deleted.

The Bill also provides for a person who is refused registration by the Board to appeal to the Minister.

Register of Nurse Specialists

With the advancement of medical science, there is a corresponding move towards specialisation in clinical nursing practice. It is necessary to monitor the development of advanced nursing practice and accredit "nurse specialists". Part 5 provides for the formation of a nurse specialist register and the issuance of nurse specialist certificates.

Cancellation of registration or enrolment

The existing Act allows the Nursing Board to cancel the registration or enrolment of nurses who, for example, have been found guilty of professional misconduct or are deceased. In addition, the Bill provides clauses to allow the Nursing Board to cancel the registration or enrolment of nurses who failed to comply with the conditions as stated in their registration or who failed to renew their practising certificates for a continuous period of time.

The Bill also contains provisions for the Nursing Board to restrict the practice of a nurse whose fitness to practise is impaired due to health problems. Appeal

The existing Act only allows for a nurse who is aggrieved by the Board's decision to de-register her to appeal to the High Court. Clause 21 will allow for a person who is aggrieved by the Board's decision to impose any of the prescribed disciplinary penalties to appeal to the courts.

Restoration of name

Clause 23 provides for a nurse whose registration or enrolment has been cancelled by the Nursing Board, to only apply for restoration of name onto the register or roll after a minimum period of three years.

Disciplinary procedures

Presently, the Board is required to consider complaint letters and decide whether they should be further investigated. This is cumbersome as it slows down the investigation of complaints. The Bill will provide for the formation of Complaints Committees that will investigate into complaints and report the findings and recommendations to the Board instead.

New Offences

I had mentioned earlier about preventing persons from indulging in unqualified practices and the employment of unqualified persons as nurses. In order to maintain nursing standards and to protect public interest, such unqualified practices will be considered as offences. However, as the intent is not to penalise innocent acts, exceptions are made for persons such as doctors, other healthcare professionals, persons rendering emergency help or home carers who render nursing care.

The present penalty for each offence under the Act is a fine not exceeding $1,000, except for failure to surrender the registration certificate, where the fine is a sum not exceeding $500. The Bill increases the present penalties from $500 to $1,000 and from $1,000 to $10,000. Consequential and other minor amendments

The Bill also proposes consequential changes as a result of the amendments I have earlier described, other minor amendments to delete obsolete terminology and to update the existing provisions.

Mr Speaker, Sir, the nursing profession has undergone significant changes over the years. The role of nurses has grown in scope and complexity with the advancement of medical science and technology. As the standards of any profession are dependent upon the quality of its practitioners, the profession must ensure that nurses are properly trained and highly competent, and that their professional development is promoted.

This Bill will help to achieve these objectives by empowering the Nursing Board to safeguard both the high standards of nursing practice and the interests of our patients and the public.

My Ministry has actively sought the views and support of the Singapore Nursing Board, the Singapore Nurses Association, and the senior nurses from all hospitals and institutions during the preparation of the Bill. They have made some suggestions on the operational procedures which my Ministry will take into consideration when preparing the Regulations.

Sir, I beg to move.

Question proposed.

Dr Lily Neo (Kreta Ayer-Tanglin): Mr Speaker, Sir, I stand to support the Nurses and Midwives Bill. This new Bill is much more comprehensive in comparison to the old revised Nurses and Midwives Act of 1985. This new Bill will more aptly address the new and changing trends in many areas of the nursing field. Sir, I would like, however, to raise a few of my concerns in this Bill.

Clause 3 provides for the establishment of the Singapore Nursing Board as a body corporate and constitution of the Board.

Clause 3(2)(a), (b) and (c) spells out the members of the Singapore Nursing Board. Sir, I feel that here we should include as a member the President of the Singapore Nurses Association. It is more appropriate to have the representative of the voices of the nursing profession to be in the Board. This will give weightage to the Singapore Nursing Associations, to recognise them and to acknowledge their contribution.

Clause 3(2)(d) specifies that 14 members are to be appointed by the Minister. Under this action, I have three points to make.

(1) I feel that we should have a provision for the recommendations from the Chief Nursing Officer, public and private health care institutions and the Singapore Nurses Association.

(2) The Nurses Registration Board in New South Wales has 13 members, most of whom are nurses but three are lay persons, out of which one is a lawyer nominated by the Minister and two are nominated by the Minister as representatives of consumers. Sir, the benefit of having people outside the profession is that it allows a wider spectrum of views, perspectives and objectivity. I think this is a good idea and should be considered by the Government.

(3) There is no specification on the number of members from the public and private sectors. In the past, the majority of the members are from the public sector. As there are about 30% of nurses or about 3,827 nurses in the private sector, it would be reasonable that this clause caters for at least four members from the private sector.

Clause 6(1) provides for the appointment of the Chairman of the Board and it states that the Minister shall appoint one of the members as the Chairman of the Board. In my opinion, the Minister should appoint a registered nurse as the Chairman of the Board. In the past, this has not been the case with the Singapore Nursing Board, as the Directors of Medical Services have been the Chairmen. The appointment of a registered nurse as Chairman in the Nursing Board is adopted in countries like Australia, New Zealand, England and America. This is logical and would be in line with practice in the other professional bodies.

Clause 17 deals with the general provisions for registration and enrolment. Clause 17(5)(b) states that the Board may refuse registration or enrolment where the applicant is, in its opinion, not of good reputation and character. This subclause is too brief and open to subjective opinions, as there is no relevant yardstick. A test of relevancy should be applied, as for instance, "not of good reputation and character which renders him unfit to be practising as a nurse or midwife." Sir, in this area we may find some useful provisions from the equivalent Australian Nurses Act 1991.

Now, the Australian Act defines "professional misconduct" and "unsatisfactory professional misconduct" as being two instances where there can be a cancellation. For the purposes of the Act, professional misconduct, in relation to an accredited nurse, means unsatisfactory professional misconduct of a sufficiently serious nature to justify the removal of the nurse's name from the Register. For the purposes of the Act, unsatisfactory professional conduct includes any of the following:-

(i) any conduct that demonstrates a lack of adequate knowledge, experience, skill, judgement or care by the nurse in the practice of nursing;

(ii) the nurse contravening (whether by act or omission) a provision of this Act or the regulations;

(iii) the nurse's failure to comply with an order or condition of registration;

(iv) any other improper or unethical conduct relating to the practice of nursing.

It is noteworthy that the aforementioned grounds are all relevant and the words "conduct relevant to the practice of nursing" are significant. This qualification, Mr Speaker, Sir, is strikingly absent from our aforesaid Bill.

Under clause 17(6)(a), the Board needs to consider the reasons why the registration or enrolment in another country has been cancelled or suspended. This may be due to mere technicalities as, for example, when the applicant had failed to pay the prescribed fee on time or when the applicant was no longer practising in that country. The provision in its current form does not impose such an obligation on the Board.

Under clause 17(7), the Board should not only inform an applicant by written notice of such refusal pursuant to the section, it should also furnish its reasons for the applicant to lodge a meaningful appeal to the Minister. Sir, the rules of natural justice also suggest that there should be a procedure whereby an applicant can appear before the Board to submit his case, prior to the final avenue of appeal to the Minister. Since this affects livelihood, it is not unreasonable that an applicant be given more than a chance.

Clause 22 deals with conviction final and conclusive. Under this clause, it appears to mean that anyone convicted of a criminal offence cannot be registered or enrolled, or whose registration or enrolment will necessarily be cancelled. There is no definition in this Bill of "criminal offence". Taken broadly, it simply applies to all offences (and this extends beyond the Penal Code) which lead to conviction. Sir, the offence, which a person is convicted of, may not be relevant in determining whether he or she is fit to be a nurse or midwife.

Clause 23 concerns application for re-registration or re-enrolment. In clause 23(3), the restriction on re-application seems harsh, as three years is a considerably long period since this concerns a person's livelihood.

Clauses 28 and 29 deal with the appointment of unqualified persons to practise nursing or midwifery and with the nurse's agents. Here, under clause 28(5)(b), clause 29(3)(b) and clause 29(4)(b), the words "due diligence" connote a higher level of care than "reasonable diligence". Sir, is it then sufficient if the nurse or midwife produces a copy of a current practising certificate and a prospective employer accepts this? This would be deemed a reasonable effort on the part of the employer, but to show "due diligence" would infer that he should investigate further, like seeking confirmation from the Board as to its authenticity.

Clause 32 is about nurse specialists, etc. Clause 32(2)(a) (b) and (c) deal with registration of nurse specialists and the issue of nurse specialist certificates. Here, there is a vague definition on the type of specialist's qualifications. I am of the opinion, Sir, that there should be specifications like holding a Masters degree or equivalent qualification, in a specialised branch of nursing, and a minimum of five years of experience in that branch of nursing.

Under clause 32(4)(e) and (4)(f), there should be a statutory recourse, same as in clauses 17, 18 and 19 as in the case of nurses and midwives, instead of leaving these to the discretion of the Board to make regulations.

Clause 39 provides for the appointment of a legal assessor and a medical assessor. Here, Mr Speaker, Sir, whilst the role of the legal assessor is broadly defined, there is nothing mentioned about the role of the medical assessor. There is also no mention made about the requirements of a medical assessor as in the case of a legal assessor who needs to be an advocate and solicitor of at least 10 years' standing. In order for a legal assessor to make a meaningful contribution, his role should not be restricted to questions of law. Indeed, there is very little question of law involved in determining the requirements of the approval, cancellation and suspension process, and it deals a lot with the facts and arguments of facts to which contributions from a suitable legal assessor with an appropriate background will undoubtedly be immense. For instance, questions of whether the conduct or negligence of an applicant or a nurse or midwife would render him unfit to be registered or enrolled.

Sir, I support the Nurses and Midwives Bill.

Mdm Claire Chiang See Ngoh (Nominated Member): Sir, the initiative to introduce new provisions relating to the establishment of the Singapore Nursing Board, practising certificates and the registration of nurse specialists is a timely move. As we adopt a "step-down" strategy of health care delivery from hospitals to the community, the need for clear regulations for managing good practices becomes critical. We need community nursing skills that focus beyond the epidemiological factors of illness and address the many life aspects of the persons who are ill. We also need nurses specialists for patients with special needs like cancer and mental illnesses. In the light of this expanding scope and expectations of the nursing role due to changing demographic trends and the diversity of demands arising from more educated patients, I am in full support of this Bill. Furthermore, I would urge the Board to immediately conceptualise a Nursing 21 national action plan to articulate the visions, goals and guidelines of nursing for the new millennium. To me, nurses form a significant resource that we must develop.

The Bill, however, is silent on a number of issues which I feel could minimise the effectiveness of the Board in servicing the needs of the community. Allow me to highlight a few.

On membership of the Board, in Part II, clause 3, I would like also to echo Dr Neo's call for the President of the Singapore Nurses Association (SNA) to be a committee member. The Association is the only professional body consisting of 3,000 nurses who could clearly articulate the interests and concerns of the profession as well as challenges faced by patients. It is also the most legitimate vehicle to process policy and professional matters relating to medical management. The lack of such a provision for the President to be present and to present the views of the professional body is, in my regard, a lost opportunity for the governing Board in getting the relevant feedback from the practitioners in the field.

What is the percentage of representation of nurses from the private sector on the Board? Should it be consistent with the 30% of nurses in private sector currently, meaning appointing at least three members out of 14 members in the committee? What about the 21% of foreign nurses in our total corps of 15,000 nurses? Should their interests be represented in this Board by a nominated Permanent Resident nurse? If their inclusion is not deemed necessary at a formal level, I hope the committees formed subsequently, as indicated in clause 10, will have representations from the private sector.

Apart from meeting the condition of fair representation, by adopting a more inclusive membership policy, the Board helps to draw together the professional groups from the private and public sectors to a common understanding in matters relating to salary, competence, service standards, among others, in order to regulate nursing practices, benchmark service standards and avoid excessive disparities and inequities between nursing groups. Ultimately, it is in the interest of the public that we uphold the dignity and morale of the nursing community.

Does the Minister, to again emphasise and stress Dr Neo's point earlier, see the appropriateness of appointing a highly qualified registered nurse as the Chairman, or at least assuming the position of a Co-Chair? The argument for this is plain enough that he or she being in the nursing profession for years, will have the competence to assess the needs of the sector. Part II, clause 6(1) is silent on this matter, whereas previously, the Director of Medical Services always assumed the position of the President. I noted yesterday that in the Info-communications Development Authority of Singapore Bill, a provision was made in clause 31 that the Minister may appoint a Deputy Chairman. Can such a provision be also included in this Bill, if the idea of a Co-Chair is not acceptable?

On the mechanism of appointment, can the Minister clarify what are the criteria for selection and will he accept nominations from the SNA, for example? I mean, can a mechanism be set up whereby professionals nominate their candidates for Board governance to ensure that at least one or two are admitted to articulate nursing needs in different medical settings? Could the Bill be specific in delineating the number of formal representations from different nursing sectors among the 14 committee members?

This brings me to the definition of "nurse" and "nurses specialists". In Part IV, clause 26, the Act defines "qualified nurse" as a registered or enrolled nurse who holds a valid practising certificate authorising him to practise nursing. From what I observe, the word "nursing" is sometimes nebulously broad, referring to someone who has a certified and approved degree usually dressed in white uniform, in contrast to another who is para-professional who executes the nursing functions without having a degree or being in white uniform. The nurses in private clinics are one such example, as I was told. It is hence expedient, and I fully support the Ministry for its timely initiative in streamlining the definition in order to avoid abuses and mis-application.

However, in view of our aging demographic trends and the low number of nurses in training facing a high challenge in attrition rate over the years, the nursing profession will need a wider network of support from non-certified assistants to deliver home nursing services. Especially in community nursing, the definition of who is and who is not a "nurse" can sometimes be inexact. During the Budget debate this March, I called for the development of a network of para-professionals under the supervision of certified senior nurses through the Singapore Nurses Association. My call arises from the practical concern of an increasing need for taking care of the old. Although we can count on home carers, who would primarily be daughters and daughters-in-law, this may not be a sustainable solution. One reason is that women want to work outside the home, and the second reason is that they are not trained in the task of nursing.

The kind of nursing services older persons need fall into a continuum from one end demanding very specialised care from "nurses specialists" to those at the middle level who simply need routine health care assistants to attend to bed sores, for example, and those on the other, who only want "nursing aides" to carry out basic physiotherapy routines to upkeep their body capabilities. When no accidents and death occur, the difficult task of "naming" escapes us. When a disaster does occur, how is the person who does not call himself or herself a nurse but carries out nursing tasks which result in maiming or killing the patient, judged or sentenced?

Given a broadening in the scope of nursing aides at both community and hospital care, it may be useful that the Singapore Nursing Board establishes guidelines on a registration and accreditation scheme to identify, recognise and regulate a broad range of nursing roles and practices. Could the Bill include a section on Advisory Guidelines on registration of health care assistants other than "qualified nurses"? Do we need to sort out these terms like "para-nurses", "home nursing assistants", "nursing aides"? The other common term is health care worker or assistant. In view of these concerns which I gathered from the nursing community, I urge the Minister to review once again Part IV on "Offences", specially clauses 26 to 28.

On the matter of accreditation as spelt out in clause 14, can the Minister clarify if correspondence courses obtained by already certified nurses from an allegedly good university which our Government also sends nurses to are recognised by the Ministry? I heard from the Singapore Nurses Association that the recognition was not given. Can we review and broaden the system of accreditation to include a larger number of approved institutions abroad and at home, and accept modes of learning from long distance correspondence course to part-time basis? The community already facing limited nursing power could thus benefit from continuing nursing support at the same time being managed by higher level competence learnt in the process. In the spirit of pursuit towards a knowledge-based economy and in promoting lifelong learning, I urge the Board in future deliberations on accreditation to cast a wider net to capture the motivations and skills of many individuals who due to personal and unique circumstances learn and upgrade in diverse ways.

One last point. In a recent address at a press conference reported in the papers on 19th November, Minister Lim Hng Kiang said that he would like to see family doctors adopt a lifelong training attitude and upgrade their skills by continuing medical education through a Masters or post-graduate diploma course. I am totally in support of his visionary call. I urge the Minister to also seriously consider continuing education within a specified number of hours to be mandatory in the nursing and midwife profession in order to uphold quality delivery services by attuning the practitioners to fast changing information and technology in the medical and nursing sciences. Due to the increasing diversity of nursing work, the development of new sophisticated concepts of care, and the nature of professional practice which increasingly demands the acceptance of responsibility and accountability, the role of nurses and midwives has expanded considerably. In response, the pressure for higher qualifications will be inevitable.

I recommend that such a mandatory training provision be made under clause 44 to prescribe a certain number of hours per year for mandatory training. This initiative would develop a new confidence within the nurses and midwives community. I would also urge policy consideration being given by the Board on matters relating to remuneration and recognition packages attached to training depth and specialisation to ensure work and pay equity.

I hope this piece of legislation will extend, not limit the practice of nurses; that it serves as a platform for policy formulations that enable nurses in fulfilling their potential in policy making and decision making at all healthcare levels.

Mr Lim Hng Kiang: Mr Speaker, Sir, I would like to thank both Dr Lily Neo and Mdm Claire Chiang for their support and their very comprehensive comments on the Bill. Let me take their comments on the various clauses in turn.

First, on clause 3 on the composition of the Singapore Nursing Board. There are two approaches that we can go by defining the composition. One is a general approach as we have done, and the other is to define in specifics who should or who should not be a member of the Board. We have decided to go for a general approach. But I can assure Members that in nominating or appointing the members of the Board, we will consider a wide representation of views. For example, the President of the Singapore Nurses Association may not be defined as a member of the Board in the Bill, but traditionally that person has been appointed as a Board member. So it is a question of whether you want to define it or leave it in the appointment process to make sure that there is this wide representation of views and the people who are appointed come from both the public sector as well as the private sector and from the different fields of nursing, whether they are nursing midwives or psychiatric nurses, so that it is broad enough to make sure that the Board can discharge its duties effectively, ie, to set the standards and to regulate the registration and enrolment of nurses.

Similar comment on the Chairman of the Board. I agree that there are some pros and cons in defining whether the Chairman should be a registered nurse and that is the reason why we have made it broader. Previously, the Director of Medical Services has traditionally been the Chairman of the Singapore Nursing Board. Personally, I do see great advantages in having the Director of Medical Services as Chairman of the Singapore Nursing Board as opposed to insisting that the Chairman must be a registered nurse. But in this Bill, we have broadened the scope and therefore it is entirely possible that the future Chairman can be a registered nurse or he can continue to be the Director of Medical Services or indeed any other person who can lead the Board effectively.

Let me also clarify that the function of the Board is essentially to regulate the registration and enrolment of nurses. So we are not setting up the Board as a representative to look out for the salaries, conditions, practices, etc. So we want to appoint people who have the qualifications to regulate the registration and enrolment and the practice of nursing. Therefore, although we want fair representation, this is not a trade union committee which must have representatives from every group to make sure their interests are taken care of.

Let me next deal with clause 17 where Dr Lily Neo commented about the definition of what is good reputation or good conduct. This provision is a fairly standard provision in all the professional Acts, whether it is the legal profession, engineers, etc. There is always this clause which says persons must be of good reputation and character. I think we do have a fairly good understanding of what that means. In the case of the nursing profession, in fact, this is outlined in the Code of Ethics and Professional Conduct which is issued by the Singapore Nursing Board in March this year. And the definition which Dr Lily Neo pointed out is very much included in this code. So I think basically we are talking about the same thing.

Secondly, Dr Lily Neo also asked whether in not registering a nurse because of overseas regulatory practices, would we make an effort to find out the reason why an equivalent overseas regulatory body did not register the same nurse. I think this is the current practice. If the Singapore Nursing Board decides not to register somebody because that somebody did not receive registration overseas, we would find out the reasons. In not registering the nurse, we would also give the reasons to the applicant why her registration is not approved.

It is not possible to outline all these in specific details in the Bill. The Bill is intended to set out the general provisions and the details would be in the subsidiary regulations. Members can be assured that the best practices will be maintained.

Clause 22 deals with the term that the conviction is final and conclusive. Let me clarify that this is to be seen in conjunction with clause 19. We have this clause 22 which says that any conviction for a criminal offence is final and conclusive. If somebody is convicted by the courts, we will take that as a starting point and treat that as final and conclusive. But then the Board itself, when deciding whether the application is to be registered, will take this conviction and consider whether the nurse is fit to be registered as a nurse. So the criminal offence is just taken to be final and conclusive and then starting from that point, we will assess whether that offence has any relevance to the registration of the nurse. The final criterion really is whether the nurse is fit to be registered.

Clause 23 is regarding the three-year de-registration period. This is to make a distinction between suspension and de-registration. The Bill provides for a range of penalties. If the offences are not so severe, then of course the Board can impose a period of suspension and the maximum period of suspension is two years. And therefore anything more severe than that which requires de-registration must obviously be above two years. So the minimum period for de-registration is stipulated as three years.

Dr Lily Neo also questioned whether the term "due diligence" requires a higher level of care than reasonable diligence. My understanding is that both have similar connotations and, that is, that somebody must take proper and due care in making sure that whoever is practising as a nurse or who purports to practise as a nurse is duly qualified.

Let me now turn to the whole issue of nursing specialist. I agree with both Members' comments that with advances in medical technology, there will be a greater role for nursing specialist within our system. The provision in the Bill provides for the setting up of a nurse specialist register. We intend that the details of that register to be set out in subsidiary regulations and not put in the main Act itself. Because it is still in its early stages. We have to decide how we want to set out the criteria for determining the different categories of nursing specialists, whether they require Masters degree or years of practice or different post-graduate qualifications. All this will be stipulated in the subsidiary regulations.

The next area which is critical and very important is the whole idea of registration and how to prevent people who do not have the qualifications from practising as nurses. I agree with Mdm Claire Chiang that, with an ageing population, we need a wider range of health care and nursing care people to look after the different levels of care. What this Bill intends to do is only to set out the criteria for registering and enrolling nurses. So this Bill does not cover the other areas of health care personnel, such as care givers, health care assistants, etc. The Bill is strictly defined to cater for the registration of nurses. In the Bill itself, the definition of who constitutes or who will qualify as a nurse is clearly spelt out. For the other para-professionals who are involved in caring for the elderly, we will have to deal with that separately.

Finally, on the topic of continuing education and upgrading, I agree with the sentiments that nurses should keep up with what is going on in their profession. It is our intention to make the avenues for continuing education and upgrading as accessible and easily available as possible, so as to encourage all our nurses to continue to upgrade. We will assess whether this needs to be mandatory in due course, in the same way as the Singapore Medical Council is putting in place a mechanism for continuing medical education. We will do the same for the Nursing Board, and whether to make it mandatory, we will cross the bridge in due course.

A final comment on correspondence courses. Although I am in favour of everybody upgrading, in the field of nursing where really a lot of the skills are hands-on, I would have some reservations in liberally accrediting correspondence courses. I think correspondence courses make sense for nurses who want to upgrade themselves in terms of care management and nursing administration. But for purposes of being a clinical specialist, I would have some reservations on correspondence courses. But we will review the whole scheme of where and how our nurses ought to be trained and putting the details of the accreditation to the Specialists Register.

Dr Lily Neo: I would like to thank the Minister for his vision that best practices will be maintained in the implementation provisions of this Bill. May I ask the Minister whether he will appoint several lay persons to be in the Singapore Nursing Board so as to allow broader views, perspectives and objectivity?

Mr Lim Hng Kiang: My apologies. The Bill does provide for three members of the Board to be non-nurses and it is our intention that that three persons will represent the lay public.

Mdm Claire Chiang See Ngoh: I would like to inform the Minister that the President of the Singapore Nurses Association has not been admitted to the Board for the last five years and therefore, I would like him to look into this matter. The second point is whether he will please comment on the request for a Deputy Chair being a certified nurse if he thinks the Director of Medical Services should assume the position of Chairman.

Dr Jennifer Lee (Nominated Member): If I may just add my voice to Dr Neo's and Ms Chiang's in the matter of the Chairperson for the Nursing Board. We have talked a lot about promoting nursing as a career and engendering pride in the profession and if, in fact, the Ministry would consider a registered nurse as Chair of the Board, it would be such a clear and much appreciated indication of the Ministry's faith and confidence in the leadership capabilities of the nursing profession.

Mr Lim Hng Kiang: I do not want to belabour the point. Basically, the main criteria for appointment to the Singapore Nursing Board must be the qualifications of the person himself rather than who he or she represents. But as I said, in making sure that the composition of the Board represents a wide section of the nursing profession, we will, of course, draw members from the public and private sectors, the Singapore Nursing Association, different types of nursing profession, etc, and we will send the right signals to the nursing profession that the Board would represent and be the appropriate Board which is competent enough to regulate them.

On the specifics, the President of the Singapore Nursing Association was a member from 1993-1996. She is not a member in this current Board, but we will consider the qualifications of the President on its own merits. For Deputy Chairman, that is another flexibility which the Minister has. If the Minister thinks that there is a need for the appointment of a Deputy Chairman to increase the effectiveness of the Board, I am sure that the present Minister and future Ministers will take that into consideration.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. - [Mr Lim Hng Kiang].

Bill considered in Committee; reported without amendment; read a Third time and passed.

Mr Speaker: Order. I suspend the Sitting and will take the Chair again at 3.30 pm.

Sitting accordingly suspended at 3.06 pm until 3.30 pm. Sitting resumed at 3.30 pm