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Isthenursingprofessioningoodhealth?|PenangMonthly

CoverStory

January,2016

Is the nursing
profession in
good health?
ByJuliaTan

Nursingisanartandifitisto
bemadeanart,itrequiresas
exclusiveadevotion,asharda
preparation,asanypainter'sor
sculptor'swork...Florence
Nightingale

InFebruary,anAirAsiaadvertisementcausedanuproaramongthenursingcommunityandforgoodreason.The
advertisement,whichreadYouwantyourmomma,becauseyouareinthehospitalwithlousynurses,wastermed
offensivebythepresidentoftheMalaysianMedicalAssociation,DrN.K.S.Tharmaseelan,asitbelittledthenursing
profession[1].
Apetitionputuponchange.orgcallingfortheadvertisementtobewithdrawndrewmorethan1,000signatures.
AmongthesignatorieswasTeh,58,whohaddevotedmostofherlifecaringforthehealthandcomfortofothers.It
wasdisgusting,saystheretirednurse,whospecialisedinneonatalintensivecare,abouttheadvertisement.Ithad
absolutelynorelevance.Itwasdemoralisingtoberegardedassuch.
Theoutragedieddownovertime,butithasbroughttoattentionthepublicsperceptionofthenursingindustry.Like
inmanyotherindustries,thenursingprofessionhasnotbeensparedtheeffectsofMalaysiaswellknownbraindrain.
Indeed,inspiteofnursingvacancies,manylocalnursesstillfindthemselvesunemployed.Thisraisesquestions
aboutournursinggraduatesandwhysomanyaredisappearingoverseas.

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Imagecredits:AUCMS

Nursing education: then and now

NursinginMalaysiabeganin1800undertheBritishEastIndiaCompany,whenhospitalsforthesickwere
establishedintheStraitscolonies,i.e.PenangandSingapore.NursingdutieswereperformedbyCatholicnunsand,
later,bynursesfromEngland.Educationwise,onthejobtrainingwascarriedout,whilelecturesintheoryand
practiceweregivenbyEnglishmatronsorassistantmatrons,sistersanddoctorsatthehospitallevel.Studentssatfor
theirownstateexamination,andstandardsvariedfromonestatetoanother.Uponcompletionoftraining,theywere
promotedtostaffnursesandlater,ifconsideredsuitable,toseniorstaffnurses[2].
Fromthatstateofaffairs,wenowtakeaquickleapintomoderntimes.In1950,theNursesActwasenacted.A
NursingBoardwasestablishedwiththepowertocontrolthetrainingandregistrationofnurses,whosetasksincluded
developingthecurriculumforbasicnursetraining.Inthepast,anursesprincipalrolewastoprovidecareand
comforttosickclients,butchangesinthefieldhaveexpandedtheprofessionalnursingroletoincludeincreased
emphasisonhealthpromotionandillnessprevention,aswellasconcernfortheclientasawhole[3].
Presentdayregisterednurses(RNs)aregenerallyrequiredtohaveatleastadiplomaoradegreefromeithera
publicorprivatecollege(threeyearsforadiplomaandfourforadegree).Thecurriculumisdividedbetween45%to
55%theoryand45%to55%practicalknowledge,andconsistsofthreecoresciences:HealthSciences(10%20%),
BehaviouralSciences(10%20%)andNursingSciences(60%80%).Thecorecompetenceofnursingisconsidered
tobecriticalthinkingandtheintelligentapplicationofknowledgetopractice.Thisistosaythattodaysnursesdonot
justmanageillnesstheyarealsorequiredtomanagethehealthofthecommunityandtheenvironmentinorderto
enhancethequalityoflife[4].

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Todaysnursesdonotjustmanageillnesstheyalsohavetodealwiththelatesttechnologiesinvolved.

The21stcenturyhasalsoseentheestablishmentofpostgraduateprogrammesinclinicalnursingatvariouspublic
institutions,suchasUniversitiMalaya,UiTMandUniversitiKebangsaanMalaysia(UKM).Theemphasison
postgraduateeducationinnursinghasbeenontheclinicalaspecttoenablegraduatestousethecontentand
experiencetoteachatbachelordegreelevelortomanageanacutecareinstitution.Ontopofthat,medical
advancementhashadasignificantimpactonnursingeducationandpracticetheroleofnursesconstantlychanges
inresponsetothegrowthofbiomedicalknowledge,changesinhealthservicesandtheevolutionofprofessional
relationshipsbetweennurses,doctorsandotherhealthcareprofessionals[5].
Nurseshavetheopportunitytopracticeinavarietyofsettingsinmanydifferentroles,buthospitalsremainthe
primaryworksiteforRNs.Approximatelytwothirdsofnursesworldwideworkinhospitals,andofthese,90%are
employedasstaffnurses.Hospitalnursinghasalwaysbeenphysicallyandmentallygruelling,andcontemporary
nursesmustcopewithpatientswhorequiremorecomplicatedcarethaneverbefore.Forexample,newcomplex
illnesses,suchasHIV/AIDS,haveemergedoverthelastfewdecades,andnursesalsohavetodealwiththelatest
technologiesinvolved.Ontopofthat,hospitalnursesworkeitheraneightor12hourshift,andthisschedulingmust
bemaintainedirrespectiveofthenursetopatientratio.Thehospitalmustsimplybestaffedatalltimes[6].
Thus,nurseeducationteachesstrategiestodealwithlonghoursandtobalanceworkandprivatelifeespeciallyto
studentnurseswhoarejuststartingout.Preparationiscrucial.Evenbeforetheyenternursinganduptilltheyare
finishedwiththeirstudies,wehavetotellthemthereality,saysLimGekMui,principalofAdventistCollegeof
Nursing&HealthSciences(ACNHS)inPenang.Itsthemindsetthatyoushouldhave.Somenursesareonshift
duty,someworkofficehoursandsomeareteacherswhohavetobringtheirworkbackhome.SoItellmystudents
this:whenyouorientateyourself,planandsetyourmindsetcorrectly,youcanachieveabalance.

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LimGekMui.

Brain drain
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Malaysiafacesachronicbraindrainproblem,andnaturallynursesarealsoamongthemanywhochoosetopractice
overseas,citinglowremunerationasoneofthemainreasonsforleaving.About10%20%ofMalaysia's84,000
nursesareestimatedtobeworkingoverseas,withthemajorityworkinginSaudiArabiawhichchoosesMalaysian
nursesbecauseofthehighqualityoftheireducation[7].AccordingtoLim,theagentrecruitingnursestoworkabroad
willlookatcertaincredentials,i.e.thenursingcollegeandthehospitalwherethenursehasworkedbefore,andthey
areveryreluctanttotakeonfreshgraduates.
Furthermore,inSaudiArabia,thenursingprofessionisstillfrowneduponbyfamiliesbecauseofcustomsand
traditions,andasmanyasoneinthreeSaudisrejectnursingasaprofessionforwomen[8].Assuch,wherethereisa
vacuum,therewillbethosewhowillfillit.Thepayisaverylucrativedraw:MalaysiannursesworkinginSaudi
hospitalscanearnatleastRM10,000permonth,entirelytaxfree.Ontopofthat,theydonotneedtospendmuchon
livingexpenses,asthehospitalsubsidisesthem.Teh,whowasoneofthepioneerswhotravelledtoworkinSaudi
Arabiabackin1980,admittedthatalthoughmoneywasafactor,themaindrawforhergenerationwasthesenseof
adventureandthelureoftheunknown.Andsheactuallyfoundlifetheretobequiteenjoyable.Wesharedan
apartmentwithcolleaguesofourownnationalities,andwedlookforwardtotheholidays,saysTeh,listingdownthe
placesshedbeen.Egypt,Holland,France,EnglandandSwitzerland,amongothers.Theresthatchancetotravel.
Anotherfactorthatleadsmanynursestogoabroadisthechancetogainworkingexperience.Itsagoodplaceto
earnskills,saysTeh,whounderwentnursingtrainingintheUKbackinthe1970s.Inadditiontotheexperience,a
changeinworkingenvironmentisalsoappreciated.Manystaffnursesdonotstaylonginanyonehospital,perhaps
duetoagreaterarrayofjobopportunitiestochoosefrom,manyofwhichpaybetterandoffermoreflexible
schedulesthantheeightor12hourshiftsthathospitalworkrequires[9].

Theprofessionalnursingroleincludesincreasedemphasisonhealthpromotionandillnessprevention,
aswellasconcernfortheclientasawhole.

Whenaskedaboutretentionstrategies,Limrevealsthatbetterpayandpositionsareofferedtonurseswhoreturn.I
personallythinkthatiftheinstitutionwouldallowthemtokeeptheiroldjobsafterletssaytwoorthreeyears,these
nurseswouldcomeback.Theresthatfearofalackofvacancies,andeveniftheresavacancy,itmightbefora
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lowerpositionandveryoftenthenursewouldhavetostartagainfromthebeginning.Thatstheriskthattheyre
taking,whereasforthenurseswhostayon,theresacareerpaththattheycanfollow.Ontopofthat,researchhas
shownthateffectiveleadershipcanhelpretainnurses[10].
Withtheneedfornursesoverseas,Malaysiahasbecomeanexportingcountryofnurses.However,contractshave
beensignedwithAlbania,Bangladesh,India,Indonesia,Myanmar,PakistanandthePhilippinestomitigatethis
problem,andfromSeptember2007,atotalof813foreignnurseshavebeenworkinginprivatehospitalsinMalaysia,
makingupabout40%ofalltheirnursingstaff[11].Sinceforeignnursesareonlyallowedtoworkinprivate
institutions,theirproportionintheprivatesectorisratherlarge,butoveralltheyonlymakeuptwopercentofthetotal
nursingcommunity[12].TheMinistryofHealth(MoH)actuallyhasaquotafortheamountofforeignnursesthatwe
canhirebasedonthesizeofourhospital,revealsLim.Evenwiththatquotafilled,wedostillfaceashortageof
staff.
MalaysiannursesworkinginSaudihospitalscanearnatleastRM10,000permonth,entirelytaxfree.Ontop
ofthat,theydonotneedtospendmuchonlivingexpenses,asthehospitalsubsidisesthem.

Glut in nursing graduates

Sowhyisitthenthatsomanynursesarejobless?
In2012,asmanyas8,000graduatesfromnursingcollegeswerehardpressedtofindemployment[13],andthe
numbermighthavebeenashighas30,000in2013[14].OnewouldthinkthatwiththedepartureofnursestoSaudi
Arabiaandelsewhere,thesegraduateswouldnotfacedifficultiesingettingposted.Buttherealityisadifferent
matter.
Therewere61privateinstitutionswhichweregiventhegreenlightbytheHigherEducationMinistrytoconduct
nursingcoursesin2012,withmorethan37,500nursingundergraduatesregisteredintheseprivateinstitutions[15].
Backin2010,asmanyas7,665nursinggraduatesfromprivateinstitutionssatfortheNursingBoardExamination,
andoutofthisnumber,70.1%passedtheexaminationcomparedtothepassingrateof98.4%inMalaysianHealth
Ministrycolleges.Ontopofthat,42.7%managedtoacquirejobsathospitalsandclinics[16].
ItiseasytoseewhythegovernmentisencouragingmoreMalaysianstotakeupnursing.TheWorldHealth
Organization(WHO)stipulatesthattherecommendednursetopopulationratioforacountrysuchasMalaysiais
1:200.Asof2012,wearestilllaggingbehindwitharatioof1:345[17],whichmeansweareshortof150,000nurses
orso[18].
Andtounderstandthesituation,oneneedstotakeabroaderperspective.Asmanyas40%ofgraduatesfrom
variousdisciplinesinMalaysiaarejobless[19],andthisisduetoanumberofreasons,suchashighexpectations,
lackofskillsandexperience,andinabilitytocommunicateefficiently[20].Ifappliedtonursing,thesecanbetranslated
inthefollowingway:graduatenursesmayhavethewrongmindsetandlackcertaincriteria,suchasproficiencyin
Englishandaggressivenessinlookingforjobs.

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TheWorldHealthOrganization(WHO)stipulatesthattherecommendednursetopopulationratiofora
countrysuchasMalaysiais1:200.Currently,itstandsat1:345.

Theresstiffcompetitiontogethired,especiallyforgraduateswhoareprivatelyfunded,saysLim,whoadmitsthatit
isnotjusthospitalsabroadwhoaremoreinclinedtowardshiringnurseswhoalreadyhavetheexperience,butprivate
localhospitalsaswell.Inourcollege,Icansafelysaythat90%ofourstudentsarereceivingscholarships,saysLim,
whichmeansthatthesestudentswillbeboundtothehospitalforthenextfiveyears.Theother10%areprivately
sponsoredstudents,andtheseusuallywanttoreturntotheirhometownstoserve.ButLimstressesonthe
advantagesofthescholarshipdeal:Wedonotofferloans,butforsponsoredstudents,theywillalreadyhaveajob
whentheygraduate.
Ontheotherhandthelocationofthejobopportunityalsoplaysapartsometimes,itsthegraduateswhoare
unwillingtorelocate.Forexample,inSabahandSarawak,therearentasmanyprivatehospitalsasonthepeninsula,
andsomegraduatesarentwillingtoleavetheirfamiliesbehind.Butattheendoftheday,itisstillthepreparedness
ofthegraduatestoacceptthepostingtheyget.Thebottomlineistheirmindsets.Theyshouldunderstandthatthey
mighthavetorelocateforthejob,"saysLim.

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Imagecredits:ACNHS

A temporary situation
AccordingtothepresidentoftheMalaysianNursesAssociation,DameRamziahAhmad,thesurplusofnursesis
expectedtobeonlytemporaryfollowingmeasurestakenbythegovernment[21].TheMalaysiangovernmentistrying
torectifythesituationbyspendingRM150miltoappoint6,800morenurses[22],whilethenumberofapplicantsfor
nursingcourseshasdroppedafteraminimumrequirementoffivecredits,insteadofthree,inSijilPelajaranMalaysia
wasimposed.Inaddition,theNursingBoardofMalaysiahasastudenttoteacherratioquotatocontrolthenumber
ofstudentintakes.
Privatecollegesarealsostartingtheirowninitiativestoaddressthesituation.Accordingtotheassistantdeputyhead
ofnursingatAllianzeUniversityCollegeofMedicalSciences(AUCMS),NorHayatiHamzah,theuniversitysfaculty
hasorganisedapilotapprenticeprojectforitsnursingalumniwiththeaimofpreparingnewgraduatesfortheworking
environmentatprivatehospitals.Andtoimproveitsstudentscommunicativeabilities,nursingstudentsatAUCMSare
introducedtocommunityserviceactivitiesorganisedbytheinstitute.Lastyear,weparticipatedinmorethan23
activities.Itisacompulsoryactivityduringweekends,andtheaimofthisinvolvementistogiveexposuretoour
studentstothecommunityandtoimprovetheirinterpersonalskills,saysNorHayati.
Inaddition,NorHayatisaysthatthereportedglutwhichwashighlightedbythemediahashadtheindirecteffectof
scaringofffuturecandidates,wheninrealitystudentsfromAUCMShaveactuallybeenactivelyemployed.Thetotal
numberofgraduatenursestothisdateis328,andbytheendofthisyear,another68wouldhavegraduated,says
NorHayati.Outofthetotalgraduates,almost100ofthemhavebeenemployedbytheMoH,whilemanyare
employedbyGleneaglesMedicalCentre,dialysiscentresalloverMalaysiaandotherprivatehospitalsinthenorthern
region.
NorHayatialsodefendsthenursestraining,statingthatduringclinicaltraining,governmenthospitalshavegiventhe
facultyfullsupport.Thestudentshavespecificpostingobjectivesandalogbooktocompleteattheendofeach
posting,shesays.Theclinicalinstructorwillensurethatthestudentshaveachievedtheirclinicalobjectivesbefore
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theystartthenextsemester.TheAUCMSnursingfacultyhasbeengivenafiveyearaccreditation,andthereforewe
needtomaintainourstandards.

Indispensable role in society

Nursingisnotjustascienceitisalsoanart.Nursesaretaughttodelivercarewithcompassionandrespectfora
clientsdignityandindividuality[24].Theysacrificetheirtimeandsometimes,inthecaseofmilitarynurses,theirlives
forthesakeofothers.Theyareprevalentinallaspectsofourlives,andonemusthaveagreatamountofintrinsic
patienceandaltruismtopursuethenursingprofession.
AsPenangstrivestobethehubformedicaltourism,highlightingourmedicalfacilities,technologyandexpertise,lets
notforgetournurses,foritistheywhoarethehiddenhandsthatmakelivesmorecomfortable.Theyarethelymph
nodesinmedicalestablishments.Noonecandowithoutnurses,thatmuchisforcertain.
[1]http://english.astroawani.com/news/show/airasiacalledtoapologiseandremovelousynursead30841
[2]www.mohe.gov.my/portal/images/penerbitan/JPT/Pengurusan_Pembangunan_Akademik/Buku
Buku_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/A1Story20120304331457.html
[8]www.arabnews.com/news/521966
[9]www.mohe.gov.my/portal/images/penerbitan/JPT/Pengurusan_Pembangunan_Akademik/Buku
Buku_Kajian_Hala_Tuju/Development_of_Nursing_Education_in_Malaysia_Towards_the_Year_2020.pdf
[10]Ibid.
[11]Matsuno,A.,(2009),Nursemigration:TheAsianperspective.ILO/EUAsianProgrammeonthe
GovernanceofLabourMigration.TechnicalNote,Retrievedfromwww.ilo.org/wcmsp5/groups/public/asia/
robangkok/documents/publication/wcms_160629.pdf
[12]www.doiserbia.nb.rs/img/doi/03507599/2011/035075991102053I.pdf
[13]www.thestar.com.my/News/Nation/2012/10/08/About8000graduatesfromnursingcollegesarejobless/
[14]www.fz.com/content/budget2014doctorslaudbravepoliticalmovecutsugarsubsidy
[15]www.themalaysianinsider.com/sideviews/article/thousandsofprivatecollegenursinggradsjobless
jeyakumardevaraj
[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/staffshortagemakesnursingjobsharder/
[19]www.thestar.com.my/News/Community/2013/07/27/ClosetohalfofMalaysiangraduateseitherjobless
oremployedinmismatchedfields/
[20]http://english.astroawani.com/news/show/3mainreasonsgraduatesstillunemployed11109
[21]www.thestar.com.my/News/Nation/2012/02/06/Surplusofnursestemporarysaysgroup/
[22]www.nst.com.my/latest/fontcolorred2014budgetfonthighlights1.384893
[23]www.mohe.gov.my/portal/images/penerbitan/JPT/Pengurusan_Pembangunan_Akademik/Buku
Buku_Kajian_Hala_Tuju/Development_of_Nursing_Education_in_Malaysia_Towards_the_Year_2020.pdf
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