Is The Nursing Profession in Good Health - Penang Monthly

4/22/2016
Isthenursingprofessioningoodhealth?|PenangMonthly
Cover Story
January, 2016
Is the nursing
profession in
good health?
By Julia Tan
Nursing is an art; and if it is

to be made an art, it requires
as exclusive a devotion, as
hard a preparation, as any
painter's or sculptor's work...
- Florence Nightingale
In February, an Air Asia advertisement caused an uproar among the nursing community and for good reason.
The advertisement, which read You want your momma, because you are in the hospital with lousy nurses,
was termed offensive by the president of the Malaysian Medical Association, Dr N. K. S. Tharmaseelan, as it
belittled the nursing profession[1].
A petition put up on change.org calling for the advertisement to be withdrawn drew more than 1,000 signatures.
Among the signatories was Teh, 58, who had devoted most of her life caring for the health and comfort of
others. It was disgusting, says the retired nurse, who specialised in neonatal intensive care, about the
advertisement. It had absolutely no relevance. It was demoralising to be regarded as such.
The outrage died down over time, but it has brought to attention the publics perception of the nursing industry.
Like in many other industries, the nursing profession has not been spared the effects of Malaysias well-known
brain drain. Indeed, in spite of nursing vacancies, many local nurses still find themselves unemployed. This
raises questions about our nursing graduates and why so many are disappearing overseas.
http://penangmonthly.com/isthenursingprofessioningoodhealth/
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Image credits: AUCMS
Nursing education: then and now

Nursing in Malaysia began in 1800 under the British East India Company, when hospitals for the sick were
established in the Straits colonies, i.e. Penang and Singapore. Nursing duties were performed by Catholic nuns
and, later, by nurses from England. Education-wise, on-the-job training was carried out, while lectures in
theory and practice were given by English matrons or assistant matrons, sisters and doctors at the hospital
level. Students sat for their own state examination, and standards varied from one state to another. Upon
completion of training, they were promoted to staff nurses and later, if considered suitable, to senior staff
nurses[2].
From that state of affairs, we now take a quick leap into modern times. In 1950, the Nurses Act was enacted. A
Nursing Board was established with the power to control the training and registration of nurses, whose tasks
included developing the curriculum for basic nurse training. In the past, a nurses principal role was to provide
care and comfort to sick clients, but changes in the field have expanded the professional nursing role to
include increased emphasis on health promotion and illness prevention, as well as concern for the client as a
whole[3].
Present-day registered nurses (RNs) are generally required to have at least a diploma or a degree from either a
public or private college (three years for a diploma and four for a degree). The curriculum is divided between
45% to 55% theory and 45% to 55% practical knowledge, and consists of three core sciences: Health Sciences
(10%-20%), Behavioural Sciences (10%-20%) and Nursing Sciences (60%-80%). The core competence of
nursing is considered to be critical thinking and the intelligent application of knowledge to practice. This is to
say that todays nurses do not just manage illness; they are also required to manage the health of the
community and the environment in order to enhance the quality of life[4].
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Todays nurses do not just manage illness; they also have to deal with the latest technologies
involved.
The 21st century has also seen the establishment of postgraduate programmes in clinical nursing at various
public institutions, such as Universiti Malaya, UiTM and Universiti Kebangsaan Malaysia (UKM). The emphasis
on postgraduate education in nursing has been on the clinical aspect to enable graduates to use the content
and experience to teach at bachelor degree level or to manage an acute care institution. On top of that, medical
advancement has had a significant impact on nursing education and practice the role of nurses constantly
changes in response to the growth of biomedical knowledge, changes in health services and the evolution of
professional relationships between nurses, doctors and other healthcare professionals[5].
Nurses have the opportunity to practice in a variety of settings in many different roles, but hospitals remain the
primary worksite for RNs. Approximately two-thirds of nurses worldwide work in hospitals, and of these, 90%
are employed as staff nurses. Hospital nursing has always been physically and mentally gruelling, and
contemporary nurses must cope with patients who require more complicated care than ever before. For
example, new complex illnesses, such as HIV/AIDS, have emerged over the last few decades, and nurses also
have to deal with the latest technologies involved. On top of that, hospital nurses work either an eight or 12hour shift, and this scheduling must be maintained irrespective of the nurse-topatient ratio. The hospital must
simply be staffed at all times[6].
Thus, nurse education teaches strategies to deal with long hours and to balance work and private life
especially to student nurses who are just starting out. Preparation is crucial. Even before they enter nursing
and up till they are finished with their studies, we have to tell them the reality, says Lim Gek Mui, principal of
Adventist College of Nursing & Health Sciences (ACNHS) in Penang. Its the mindset that you should have.
Some nurses are on shift duty, some work office hours and some are teachers who have to bring their work
back home. So I tell my students this: when you orientate yourself, plan and set your mindset correctly, you can
achieve a balance.
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Lim Gek Mui.
Brain drain
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Malaysia faces a chronic brain drain problem, and naturally nurses are also among the many who choose to
practice overseas, citing low remuneration as one of the main reasons for leaving. About 10%-20% of
Malaysia's 84,000 nurses are estimated to be working overseas, with the majority working in Saudi Arabia
which chooses Malaysian nurses because of the high quality of their education[7]. According to Lim, the agent
recruiting nurses to work abroad will look at certain credentials, i.e. the nursing college and the hospital where
the nurse has worked before, and they are very reluctant to take on fresh graduates.
Furthermore, in Saudi Arabia, the nursing profession is still frowned upon by families because of customs and
traditions, and as many as one in three Saudis reject nursing as a profession for women[8]. As such, where
there is a vacuum, there will be those who will fill it. The pay is a very lucrative draw: Malaysian nurses working
in Saudi hospitals can earn at least RM10,000 per month, entirely tax-free. On top of that, they do not need to
spend much on living expenses, as the hospital subsidises them. Teh, who was one of the pioneers who
travelled to work in Saudi Arabia back in 1980, admitted that although money was a factor, the main draw for
her generation was the sense of adventure and the lure of the unknown. And she actually found life there to be
quite enjoyable. We shared an apartment with colleagues of our own nationalities, and wed look forward to
the holidays, says Teh, listing down the places shed been. Egypt, Holland, France, England and Switzerland,
among others. Theres that chance to travel.
Another factor that leads many nurses to go abroad is the chance to gain working experience. Its a good
place to earn skills, says Teh, who underwent nursing training in the UK back in the 1970s. In addition to the
experience, a change in working environment is also appreciated. Many staff nurses do not stay long in any one
hospital, perhaps due to a greater array of job opportunities to choose from, many of which pay better and offer
more flexible schedules than the eight or 12-hour shifts that hospital work requires[9].
The professional nursing role includes increased emphasis on health promotion and illness
prevention, as well as concern for the client as a whole.
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When asked about retention strategies, Lim reveals that better pay and positions are offered to nurses who
return. I personally think that if the institution would allow them to keep their old jobs after lets say two or
three years, these nurses would come back. Theres that fear of a lack of vacancies, and even if theres a
vacancy, it might be for a lower position and very often the nurse would have to start again from the beginning.
Thats the risk that theyre taking, whereas for the nurses who stay on, theres a career path that they can
follow. On top of that, research has shown that effective leadership can help retain nurses[10].
With the need for nurses overseas, Malaysia has become an exporting country of nurses. However, contracts
have been signed with Albania, Bangladesh, India, Indonesia, Myanmar, Pakistan and the Philippines to
mitigate this problem, and from September 2007, a total of 813 foreign nurses have been working in private
hospitals in Malaysia, making up about 40% of all their nursing staff [11]. Since foreign nurses are only allowed
to work in private institutions, their proportion in the private sector is rather large, but overall they only make
up two per cent of the total nursing community[12]. The Ministry of Health (MoH) actually has a quota for the
amount of foreign nurses that we can hire based on the size of our hospital, reveals Lim. Even with that quota
filled, we do still face a shortage of staff.
Malaysian nurses working in Saudi hospitals can earn at least RM10,000 per month, entirely tax-free. On
top of that, they do not need to spend much on living expenses, as the hospital subsidises them.
Glut in nursing graduates

So why is it then that so many nurses are jobless?
In 2012, as many as 8,000 graduates from nursing colleges were hard-pressed to find employment[13], and the
number might have been as high as 30,000 in 2013[14]. One would think that with the departure of nurses to
Saudi Arabia and elsewhere, these graduates would not face difficulties in getting posted. But the reality is a
different matter.
There were 61 private institutions which were given the green light by the Higher Education Ministry to conduct
nursing courses in 2012, with more than 37,500 nursing undergraduates registered in these private
institutions[15]. Back in 2010, as many as 7,665 nursing graduates from private institutions sat for the Nursing
Board Examination, and out of this number, 70.1% passed the examination compared to the passing rate of
98.4% in Malaysian Health Ministry colleges. On top of that, 42.7% managed to acquire jobs at hospitals and
clinics[16].
It is easy to see why the government is encouraging more Malaysians to take up nursing. The World Health
Organization (WHO) stipulates that the recommended nurse-to-population ratio for a country such as Malaysia
is 1:200. As of 2012, we are still lagging behind with a ratio of 1:345[17], which means we are short of 150,000
nurses or so[18].
And to understand the situation, one needs to take a broader perspective. As many as 40% of graduates from
various disciplines in Malaysia are jobless[19], and this is due to a number of reasons, such as high
expectations, lack of skills and experience, and inability to communicate efficiently[20]. If applied to nursing,
these can be translated in the following way: graduate nurses may have the wrong mindset and lack certain
criteria, such as proficiency in English and aggressiveness in looking for jobs.
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The World Health Organization (WHO) stipulates that the recommended nurse-to-population ratio
for a country such as Malaysia is 1:200. Currently, it stands at 1:345.
Theres stiff competition to get hired, especially for graduates who are privately funded, says Lim, who admits
that it is not just hospitals abroad who are more inclined towards hiring nurses who already have the
experience, but private local hospitals as well. In our college, I can safely say that 90% of our students are
receiving scholarships, says Lim, which means that these students will be bound to the hospital for the next
five years. The other 10% are privately sponsored students, and these usually want to return to their
hometowns to serve. But Lim stresses on the advantages of the scholarship deal: We do not offer loans, but
for sponsored students, they will already have a job when they graduate.
On the other hand the location of the job opportunity also plays a part sometimes, its the graduates who are
unwilling to relocate. For example, in Sabah and Sarawak, there arent as many private hospitals as on the
peninsula, and some graduates arent willing to leave their families behind. But at the end of the day, it is still
the preparedness of the graduates to accept the posting they get. The bottom line is their mindsets. They
should understand that they might have to relocate for the job," says Lim.
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Image credits: ACNHS
A temporary situation
According to the president of the Malaysian Nurses Association, Dame Ramziah Ahmad, the surplus of nurses
is expected to be only temporary following measures taken by the government[21]. The Malaysian government
is trying to rectify the situation by spending RM150mil to appoint 6,800 more nurses[22], while the number of
applicants for nursing courses has dropped after a minimum requirement of five credits, instead of three, in
Sijil Pelajaran Malaysia was imposed. In addition, the Nursing Board of Malaysia has a student-to-teacher ratio
quota to control the number of student intakes.
Private colleges are also starting their own initiatives to address the situation. According to the assistant
deputy head of nursing at Allianze University College of Medical Sciences (AUCMS), Nor Hayati Hamzah, the
universitys faculty has organised a pilot apprentice project for its nursing alumni with the aim of preparing new
graduates for the working environment at private hospitals. And to improve its students communicative
abilities, nursing students at AUCMS are introduced to community service activities organised by the institute.
Last year, we participated in more than 23 activities. It is a compulsory activity during weekends, and the aim
of this involvement is to give exposure to our students to the community and to improve their interpersonal
skills, says Nor Hayati.
In addition, Nor Hayati says that the reported glut which was highlighted by the media has had the indirect
effect of scaring off future candidates, when in reality students from AUCMS have actually been actively
employed. The total number of graduate nurses to this date is 328, and by the end of this year, another 68
would have graduated, says Nor Hayati. Out of the total graduates, almost 100 of them have been employed
by the MoH, while many are employed by Gleneagles Medical Centre, dialysis centres all over Malaysia and
other private hospitals in the northern region.
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Nor Hayati also defends the nurses training, stating that during clinical training, government hospitals have
given the faculty full support. The students have specific posting objectives and a log book to complete at the
end of each posting, she says. The clinical instructor will ensure that the students have achieved their clinical
objectives before they start the next semester. The AUCMS nursing faculty has been given a five-year
accreditation, and therefore we need to maintain our standards.
Indispensable role in society

Nursing is not just a science it is also an art. Nurses are taught to deliver care with compassion and respect
for a clients dignity and individuality[24]. They sacrifice their time and sometimes, in the case of military
nurses, their lives for the sake of others. They are prevalent in all aspects of our lives, and one must have a
great amount of intrinsic patience and altruism to pursue the nursing profession.
As Penang strives to be the hub for medical tourism, highlighting our medical facilities, technology and
expertise, lets not forget our nurses, for it is they who are the hidden hands that make lives more comfortable.
They are the lymph nodes in medical establishments. No one can do without nurses, that much is for certain.
[1]http://english.astroawani.com/news/show/airasia-called-to-apologise-and-remove-lousy-nursead30841
[2]www.mohe.gov.my/portal/images/penerbitan/JPT/Pengurusan_Pembangunan_Akademik/BukuBuku_Kajian_Hala_Tuju/Development_of_Nursing_Education_in_Malaysia_Towards_the_Year_2020. pdf
[3]Ibid.
[4]Ibid.
[5]Ibid.
[6]Ibid.
[7]http://news.asiaone.com/News/ AsiaOne+News/Malaysia/Story/ A1Story20120304-331457.html
[8]www.arabnews.com/news/521966
[9]www.mohe.gov.my/portal/images/penerbitan/ JPT/Pengurusan_Pembangunan_Akademik/ BukuBuku_Kajian_Hala_Tuju/Development_of_ Nursing_Education_in_Malaysia_Towards_the_ Year_2020.pdf
[10]Ibid.
[11]Matsuno, A., (2009), Nurse migration: The Asian perspective. ILO/EU Asian Programme on the
Governance of Labour Migration. Technical Note, Retrieved from www.ilo.org/ wcmsp5/groups/public/--asia/---ro-bangkok/ documents/publication/wcms_160629.pdf
[12]www.doiserbia.nb.rs/img/doi/0350- 7599/2011/0350-75991102053I.pdf
[13]www.thestar.com.my/News/ Nation/2012/10/08/About-8000-graduatesfrom- nursing-colleges-arejobless/
[14]www.fz.com/content/budget-2014-doctorslaud- brave-political-move-cut-sugar-subsidy
[15]www.themalaysianinsider.com/sideviews/ article/thousands-of-private-college-nursinggrads- joblessjeyakumar-devaraj
[16]www.jil.go.jp/profile/documents/Durrishah_ Idrus.pdf
[17]www.moh.gov.my/images/gallery/publications/ final%20buku%20petunjuk%202013.pdf
[18]www.theborneopost.com/2011/12/01/staffshortage- makes-nursing-jobs-harder/
[19]www.thestar.com.my/News/ Community/2013/07/27/Close-to-halfof- Malaysian-graduates-eitherjobless-oremployed- in-mismatched-fields/
[20]http://english.astroawani.com/news/ show/3-main-reasons-graduates-stillunemployed- 11109
[21]www.thestar.com.my/News/Nation/2012/02/06/ Surplus-of-nurses-temporary-says-group/
[22]www.nst.com.my/latest/font-color-red-2014- budget-font-highlights-1.384893
[23]www.mohe.gov.my/portal/images/penerbitan/ JPT/Pengurusan_Pembangunan_Akademik/ BukuBuku_Kajian_Hala_Tuju/Development_of_ Nursing_Education_in_Malaysia_Towards_the_ Year_2020.pdf
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4/22/2016

Nursing is an art; and if it is

Image credits: AUCMS

Nursing education: then and now

Lim Gek Mui.

Glut in nursing graduates

Image credits: ACNHS

Indispensable role in society

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TPPA The Winners and the Losers

Education Ever the political victim

One heck of a hill

The Ringgit And Sen Of Festivals

Is Penangs tourism on the right track?

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