Chief Human Resources Officer Singapore / Southeast Asia

Decisions about nurses that cost us something

Colleagues in three countries: 17,400; Aravelle Health Group, June 2026, including 7,900 nurses
Annual group staff costs: S$1.04bn; 2025; separate from the S$41m HR operating budget
Nurse turnover at our Johor Bahru hospital: 31% to 16%; 2022 compared with 2025, after the cross-border pathway

Decisions & consequences

Turning the Johor–Singapore nurse flow into a priced internal pathway

In 2022 our Johor Bahru hospital lost 31% of its registered nurses. Of about 150 who left, 61 took jobs in Singapore, and 23 of those joined our own Singapore hospitals through ordinary external hiring. A Singapore staff nurse earns roughly three times what the same nurse earns in Johor, measured in ringgit, and many commute across the causeway daily. Johor's vacancy rate reached 22% and the hospital closed 40 of its 310 beds. Our two hospitals, thirty kilometres apart, were competing for the same people, and one was winning by default.

The stakes were Johor's viability as a 310-bed hospital and the group's credibility with Malaysian nurses, who saw us recruiting them out of our own wards. Johor's chief executive, Kumaresan Pillai, asked for a two-year freeze on internal moves. Clement Yeo, who ran our Singapore hospitals, opposed any restriction, arguing that other Singapore employers would simply recruit the nurses instead. Both were partly right. Our group chief financial officer, Terence Wee, questioned the cost of new allowances.

I proposed a third course from January 2023. Johor nurses with two years' service could apply for Singapore posts through an internal pathway, up to sixty moves a year. The receiving Singapore hospital paid S$14,000 per move into Johor's training budget, the nurse kept their seniority, and anyone who moved could return to Johor within three years at the same or a higher grade. Johor introduced an allowance of RM 600 a month for intensive care, theatre and emergency nurses and funded post-basic courses. We gave up the Singapore hospitals' freedom to hire Johor nurses at will and about RM 2.9 million a year in allowances.

By the end of 2025, Johor's nurse turnover was 16% and its vacancy rate 8%, and 34 of the 40 closed beds had reopened. One hundred and fifty-one nurses moved through the pathway; 27 returned, 19 of them as senior nurses or educators. Agency nurse spending in Singapore fell by S$5.8 million a year.

What I would do differently: I set the annual limit by grade rather than specialty, and Johor's intensive care vacancy rose to 30% in mid-2023 before we corrected it. I also explained the transfer charge poorly. Several nurses felt they had been priced like equipment; I should have shown them that the money trained their replacements.

Integrating Wiralaksa Hospitals without exporting the Singapore ward

In September 2023 Aravelle completed the acquisition of Wiralaksa Hospitals, five hospitals in Jakarta, Surabaya, Bandung and Medan with 4,900 employees, 1,380 nurses and 410 employed doctors. About 900 specialists held practice privileges there, and most also practised at other hospitals. The integration plan prepared before completion proposed Singapore or Malaysian nursing directors in each hospital, Aravelle's grade structure within six months and a request that specialists commit most of their sessions to us.

The stakes were the people the deal depended on. Wiralaksa's value lay in its referral relationships and its nursing leaders, and Indonesian staff were watching for signs that Singapore had bought them to impose its habits. Our integration director, Marcus Lowe, and our group chief medical officer, Benedict Lau, wanted experienced Aravelle leaders in charge of clinical standards from the first day. The founder, Gunawan Wiralaksa, whose earn-out depended on two years' earnings, wanted nothing to change.

I argued for keeping all five Indonesian heads of nursing, seconding 22 Indonesian nurse managers to our Singapore and Malaysian hospitals for ten weeks each, mapping grades over eighteen months with pay protection, and asking specialists for nothing beyond our credentialing standards. Our group chief executive accepted the proposal after Benedict Lau agreed to a joint clinical standards review with the Indonesian heads of nursing. We gave up speed: S$9.4 million of savings planned for 2024 slipped, and two hospitals' accreditation surveys moved back a year.

At twenty-four months, 41 of 44 nursing leaders remained. Nurse turnover across the five hospitals fell from 19% to 13%, and specialists holding privileges rose from about 900 to 970. Incident reports per thousand patient days rose from 1.1 to 2.6, which our clinical governance committee read, as I did, as a sign that staff now trusted the reporting system. By the end of 2025, S$7.6 million of the savings had been realised.

What I would do differently: I ran the secondment programme in English, which favoured managers who already spoke it. It should have run in Bahasa Indonesia, with Singapore managers learning alongside. I also published the grade map four months too late. In early 2024 a rumour of pay cuts reached Surabaya, and 58 people resigned before we could show them the map that protected their pay.

Paying the whole cost of recruiting foreign-trained nurses

In 2019 our Singapore hospitals recruited about 280 foreign-trained nurses a year from the Philippines, India and Myanmar through thirteen agencies. A survey of new arrivals that year found that 71% had paid fees to someone in the recruitment chain, the median equal to about four months of their Singapore salary, and that some were repaying loans. First-year attrition among these nurses was 26%, and 88% completed supervised practice at the first attempt. Their contracts carried a penalty for leaving within three years.

The stakes were supply and decency together. Nurses arriving in debt were more likely to take extra shifts elsewhere, to struggle through supervised practice and to leave at the first chance. I proposed that Aravelle pay every recruitment cost, reduce our agencies to those willing to charge candidates nothing and accept audits, collect fee declarations directly from candidates in their own language, fund a twelve-week paid adaptation period and drop the early-exit penalty. Terence Wee estimated the extra cost at S$5,200 a hire, about S$1.5 million a year. Our nursing directors feared that four agencies could not supply enough nurses during the pandemic. Two agencies withdrew rather than accept the terms.

We accepted a slower pipeline. In 2021 we hired 205 foreign-trained nurses against a plan of 290, and ran more overtime and agency cover than we wanted. Our chief executive for Singapore and Malaysia backed the change after I showed that the cost per nurse still employed after three years would probably fall.

By 2023 first-year attrition was 11%, first-attempt completion of supervised practice 95% and renewal at the end of the first contract 79%, up from 52%. The cost per foreign-trained nurse still with us after three years fell by about 18%.

What I would do differently: I assumed that paying our agencies' fees removed the fees. In 2022 exit interviews showed that nine nurses had paid a local recruiter in their home province who passed them to one of our agencies. We repaid them S$41,000 in total and began annual source-country audits. I should have audited the whole chain from the first year rather than trusting declarations made in Singapore.

Taking first-year nurses off the night roster

In 2021 first-year nurse turnover in our Singapore hospitals reached 29%. I commissioned an analysis of eighteen months of medical and surgical ward rosters. Nurses in their first year worked 38% of night shifts on those wards; nurses with more than ten years' experience worked 9%. Nobody had decided this. Roster preferences were granted by seniority, and experienced nurses with families had earned the right to decline nights. The result was that the least experienced nurses carried the hours with the least supervision.

The stakes were patient safety at night and the loss of nurses we had spent a year training. I proposed rules from April 2022: no more than three night shifts a month for nurses in their first six months, no first-year nurse as nurse in charge at night, and an increase in the night allowance for senior staff nurses and above from S$45 to S$110 a shift, so that taking nights became a paid choice rather than a junior's duty. Self-rostering software would apply the rules, with exemptions for caring responsibilities or health reasons.

Ward managers opposed the loss of flexibility. A letter signed by 140 senior nurses argued that we were taking away a privilege they had earned. Terence Wee put the cost at S$4.6 million a year. Norhayati Jamaluddin, our group chief nursing officer, supported the aim but wanted a year-long phase-in; we compromised on six months. We gave up the goodwill of some experienced nurses: 31 left in 2022 and cited the change.

By 2024 first-year turnover was 15%. Overtime hours fell by 19%, and the share of night shifts worked by nurses with more than ten years' experience rose to 24%. Medication errors at night fell, although other changes in the same period mean I would not attribute that to rostering alone. We extended the rules to our Malaysian hospitals in 2024.

What I would do differently: I sent every exemption through a committee, which took six weeks to hear 212 appeals while nurses waited. Exemptions for carers and for nurses with known health conditions should have been agreed individually with ward managers before the rules started. Some of the 31 who left were people we could have kept.

Discuss a leadership challenge