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Review Article

A critical review of the nursing shortage

in Malaysia inr_784 32..39

T. Barnett1 RN, BAppSc(AdvNsg), MEd, PhD, FRCNA, FRSA,

P. Namasivayam2 RN, BN, MSc(NsG) &
D.A.A. Narudin3 RN, BScNursing(Hons)
1 Associate Professor, School of Nursing and Midwifery, 2 PhD Candidate, Monash University, Victoria, Australia, 3 Deputy
Dean, Fakulty of Nursing and Allied Health Sciences, Selangor International Islamic University College, Bandar Seri Putra,
Bangi Selangor, Malaysia

BARNETT T., NAMASIVAYAM P. & NARUDIN D.A.A. (2010) A critical review of the nursing shortage in
Malaysia. International Nursing Review 57, 32–39

Objective: This paper describes and critically reviews steps taken to address the nursing workforce shortage in
Background: To address the shortage and to build health care capacity, Malaysia has more than doubled its
nursing workforce over the past decade, primarily through an increase in the domestic supply of new
Methods: Government reports, policy documents and ministerial statements were sourced from the Ministry
of Health Malaysia website and reviewed and analysed in the context of the scholarly literature published
about the health care workforce in Malaysia and more generally about the global nursing shortage.
Results: An escalation in student numbers and the unprecedented number of new graduates entering the
workforce has been associated with other impacts that have been responded to symptomatically rather than
through workplace reform. Whilst growing the domestic supply of nurses is a critical key strategy to address
workforce shortages, steps should also be taken to address structural and other problems of the workplace to
support both new graduates and the retention of more experienced staff.
Conclusion: Nursing shortages should not be tackled by increasing the supply of new graduates alone. The
creation of a safe and supportive work environment is important to the long-term success of current measures
taken to grow the workforce and retain nurses within the Malaysian health care system.

Keywords: Malaysia, Nurses, Occupational Health, Work Environment, Workforce Shortages

Introduction (Buchan & Calman 2004; Simoens et al. 2005). The shortage has
Few countries or nations are untouched by what has been been influenced by conditions on both the supply and demand
described as the ‘crisis in nursing’, a critical shortage of profes- sides of the labour market equation.
sional nurses to deliver care, largely in the acute health care sector A reduced supply of nurses, especially new graduates, has been
attributed to a variety of factors including a reduced number of
student nurses within the system. This may be associated with a
Correspondence address: Tony Barnett, School of Nursing and Midwifery, Monash lack of funding for places, low demand from school graduates
University, Churchill, Vic. 3842, Australia; Tel: 613-990-26636; Fax:
(who may regard nursing as a less attractive career choice),
613-990-26527; E-mail: tony.barnett@med.monash.edu.au.
attrition or poor course progression, as well as the closure or

© 2010 The Authors. Journal compilation © 2010 International Council of Nurses 32

Nursing shortage in Malaysia 33

rationalization of schools of nursing. In many countries, there is bases using full and truncated keywords such as: nursing, nurses,
also a net loss through migration (Cowin & Jacobsson 2003; workforce AND Malaysia with no limit on year of publication.
Kingma 2007; Simoens et al. 2005). Very few papers were located. As a consequence, this paper draws
The demand for nurses has increased due to ‘ageing popula- upon literature that reports on the experiences of shortages in
tions, increased consumer activism and rapid evolution of other countries to critically review responses to the shortage in
medical technologies’ (Simoens et al. 2005, p. 4) as well as popu- Malaysia within a more global context. Whilst a lack of empirical
lation growth and the associated burden of disease. This demand literature on the topic of nurse shortages is a major limitation
has been exacerbated by the aging of the workforce (resulting in to this review, the information sourced has been informed by
more nurses retiring or seeking part-time work); less than experience. Collectively, the authors have had many decades
optimal separation rates from the industry; globalization of the of experience with nursing, nurse education, research and
labour market; and an increased propensity for nurses to seek administration in Malaysia. One of the authors was privileged to
alternative (though often health-related) careers. Low job satis- serve as Chief Matron of the country. These experiences and
faction, associated with a poorer quality of working life, can discussion of these experiences between the authors have pro-
impact on both the current and future workforce (Blegen 1993; vided some balance to the weight of local (Malaysian) literature
Duffield et al. 2007). Less satisfied nurses are more likely to exit obtained primarily from government sources.
or reduce the number of hours they work and those who are
thinking of entering the workforce are dissuaded from making a The nursing workforce in Malaysia
long-term commitment to the profession as other employment Located in South East Asia, Malaysia is a rapidly developing
options promise greater levels of satisfaction, remuneration and country with a population of 27 million (Department of Statis-
benefits. tics Malaysia 2008). It has an ageing population with the propor-
The nursing shortage is prevalent amongst many Asia-Pacific tion of the population aged 65 years and over expected to double
countries (Buchan & Calman 2004; Lee et al. 2007). For example, by the year 2030. Life expectancy at birth is similar to that
in China, whilst the number of nurses is reported to have reported by many developed countries (>70 years for both males
increased from 3300 in 1949 to 139 000 in 2006, the nurse to and females). The government allocates approximately 7% of the
population ratio is less than that of medical doctors and there national budget to health (Ministry of Health Malaysia 2007)
remains a significant shortage (Liu 2007). In Australia, it was and is challenged by changing patterns of communicable and
estimated that in 2006 there was a shortage of around 3000 non-communicable diseases as well as workforce shortages,
nurses or 1.6% of the total registered nurse workforce (Preston especially in nursing (Ministry of Health Malaysia 2008).
2006) though efforts to increase the number of university places In Malaysia, nurses comprise 2–3% of the female workforce
for nursing have been frustrated by the barriers and constraints and a large proportion of the health care workforce. Approxi-
associated with clinical placements, an essential requirement for mately two-thirds of nurses work in the government (public)
any course leading to registration as a nurse (Barnett et al. 2008). sector where they are encouraged to work full-time and are gen-
Singapore has maintained its nurse to population ratio at erally required to retire upon reaching the age of 55 or 56. Due to
around 1:220 over the 2003/5 period through an increase in the historical and cultural reasons, very few nurses are male though
recruitment of overseas trained nurses from countries such as small numbers have been taught nursing skills and prepared as
China, the Philippines, India and Malaysia. In 2005, the number ‘medical assistants’ (Ministry of Health Malaysia 2007, 2008).
of new registrants who were trained overseas was twice that of Nurses are prepared in colleges or universities by undertaking
local Singaporeans (Singapore Nursing Board 2006). In common a 3-year diploma level qualification, though 4-year degree
with many other developed countries, this reflects a sustained courses are being introduced. Graduates are often bonded to the
demand for nurses and midwives against a backdrop of insuffi- Ministry of Health or a private hospital for a period of time
cient local supply (Tan 2003). In response to this situation and following their initial preparation in recognition of the employ-
to bolster local supply, Singapore has recently increased the er’s contribution to the cost of their education. Entry to a
numbers of students taken into nursing courses and also nursing course is usually restricted to high school graduates. For
expanded the number of institutions conducting courses. the diploma, entry level is most commonly the Sijil Pelajaran
To describe and analyse the nursing shortage in Malaysia, Malaysia (SPM, equivalent to ‘O-levels’ i.e. successful completion
government documents and press releases from the Ministry of of the penultimate year of secondary schooling) and entry to the
Health Malaysia were sourced from official websites and searched degree, the Sijil Tinggi Pelajaran Malaysia (STPM equivalent to
for any reference to nurses or nursing over the period 2000 to ‘A-levels’ i.e. successful completion of the final year of secondary
2007. A search was also conducted using CINAHL and other data schooling). Community Health Nurses (Jururawat Desa) are pre-

© 2010 The Authors. Journal compilation © 2010 International Council of Nurses

34 T. Barnett et al.

Table 1 Total number of nurses and nurse/population ratios in Malaysia re-structuring the workforce and substituting other types of
(1996–2006)* workers in place of nurses. Initiatives may also be taken to
improve the working environment and support retention (Jasper
Year Total no. of nurses Nurse : 2007). A number of these measures are listed in Table 2; some of
(Jururawat Desa) population which have been implemented in Malaysia.

1996 20 056 1:1055

1997 24 545 1:883
1998 23 672 1:937 Increase supply
1999 27 236 1:834 The Malaysian authorities have increased the number of public
2000 31 129 1:747 and private institutions providing nursing courses and have also
2001 33 295 1:715 increased the total number of students (Cruez 2006). That these
2002 35 280 1:695
2003 36 784 1:681 places have been filled, suggests a continued demand for nursing
2004 40 220 1:636 although some school graduates see nursing as an opportunity to
2005 44 120 (15 618) 1:592 leave home at a younger age than would otherwise be the case,
2006 47 642 (16 667) 1:559
and the more recent availability of student loans though the
national higher education fund (the Perbadanan Tabung Pendidi-
*Source: Ministry of Health, Malaysia (2007). kan Tinggi Negara). As schools and colleges compete for the same
pool of school graduates, some concern has been expressed that
entry standards may fall. This could further challenge teaching
pared separately and work in areas such as child health and staff and clinicians to provide the support required to enable the
family planning clinics and in rural areas where they provide maximum number of students to progress through their course
home visits and also service the less advantaged. in minimum time and to enter the workforce as safe and com-
Table 1 shows that there was an increase in the number of petent nurses. The introduction of degree courses to replace the
nurses from 20 056 in 1996 to 47 642 in 2006 with a subsequent diploma level qualification, with entry set at the higher STPM,
improvement in the nurse to population ratio from 1:1055 to may address this concern as experience from other countries
1:559 (Ministry of Health Malaysia 2007). This increase has been suggests that such a change has little detrimental impact on
a significant achievement though the country still faces a critical overall course demand (Heath 2002).
shortage. It has been estimated that a total of 174 000 nurses will A greater number of new graduates entering the workforce has
be required by the year 2020 to reach a targeted 1:200 nurse resulted in changes to the skill mix of many hospitals. Patient
population ratio, in line with similar ratios in some neighbour- care areas are now more likely to be staffed by younger nurses
ing countries (Chua 2004; Cruez 2006). The increase has been with less experience. A new generation of graduates will also have
achieved primarily by escalating the domestic supply of new different attitudes toward patients and those in authority than
graduates. A dramatic expansion in the number of schools and their predecessors. This has been identified as a factor contrib-
colleges of nursing, nursing students and subsequent increase in uting to the recent, widespread public and political criticism
the proportion of new graduates within the workforce has been levelled at nurses; their poor attitudes toward patients and
associated with a number of workplace challenges. In this paper, decline in the standard of care they provide (Chua 2006a). In
it is argued that unless sufficient and systematic attention is paid response to such criticism, the introduction of symptomatic pro-
to address these, such a rapid expansion will pose a threat to the grammes, such as the ‘7S soft skill’ behaviour change pilot by the
long-term stability of the workforce and impact on the quality of Ministry of Health Malaysia (Table 3), have tended to place
care delivered. responsibility on nurses themselves rather than the structural,
social and political determinants of care such as staffing short-
Responses to nurse shortages ages, working conditions, the lack of support provided to new
A range of measures may be taken to combat workforce short- staff or fully appreciate the generational changes that have
ages. These are generally directed to either increasing supply, occurred in the workplace (Stuenkel & Cohen 2005). An over
reducing demand and/or improving the retention of nurses emphasis on soft or ‘be nice’ skills, which focus upon the inter-
(Cowin & Jacobsson 2003). For example, supply may be personal workplace behaviours of nurses, also draws attention
increased by encouraging more school-graduates to enter the away from those more professional, technical and therapeutic
profession or by the active recruitment of nurses from other skills of the nurse that should be valued more highly and that
countries (Kingma 2007). Demand may be reduced by contribute to improvements in health outcomes.

© 2010 The Authors. Journal compilation © 2010 International Council of Nurses

Nursing shortage in Malaysia 35

Table 2 Response options to nurse workforce shortages

Option Measure

Increase supply • Increase the number of nursing schools and entrants to pre-registration courses.
• Improve the public image of nurses, promote positive professional self-image (to help attract a larger number of quality applicants
to courses).
• Reduce attrition associated with training.
• Encourage re-entry of RNs who have left the workforce (e.g. by maintaining or improving benefits and entitlements).
• Increase in-migration (and reduce out-migration).
Reduce demand • Change staffing mix (reduce reliance on RNs).
• Re-configure role, relationships and work function of the RN.
Improve retention • Better match graduate attributes with future workforce needs (modify or enhance curricula and training provided in preparatory
(reduce workforce courses). Address challenges associated with the theory-practice gap.
separation rates) • Improve the mentorship and support provided to new graduates and experienced clinicians.
• Improve rewards, benefits and working conditions including workloads and staffing levels.
• Increase worker’s control over work (improve professional autonomy and equivalence by reducing hierarchical control and
dominance of the workplace by powerful others).
• Create the conditions for greater flexibility and participation in the workforce (to allow part-time work and better support re-entry
to the workforce).
• Formalize succession planning at all levels.
• Improve the clinical career structure and career mobility
• Extend ‘compulsory’ retirement age
• Reduce occupational hazards (e.g. workplace violence and abuse, back and needlestick injuries), provide adequate compensation
for accidents and injury, improve Occupational Health and Safety (OH&S) generally.

RN, registered nurse.

Table 3 The ‘7S’ system to help improve nursing’s public image* competence and achievement of professionhood, takes time and
resources – a requirement not always acknowledged by health
Term in Bahasa Malaysia Meaning workforce planners and policymakers. The risk of not providing
(translation) such support can be an escalation of workforce retention prob-
lems, low staff morale, stress and burnout; all of which may
Senyum (smile) To remember to smile adversely affect care delivery and patient outcomes. In recogni-
Salam (greeting) To greet or welcome in a friendly way tion of this, some steps have been taken to roll-out a mentorship
Segara (prompt/urgent/ To act promptly or quickly, to be responsive
without delay)
scheme for new graduates in Malaysia (Chua 2006a; Materia
Sensitif (sensitive) To be sensitive to the needs of patients and Medica Malaysiana 2006) though to date neither formal graduate
families nurse programmes nor professional supervision programmes
Sopan (polite/respectful/ To be polite and respectful during interactions (Hyrkas et al. 2006; White & Winstanley 2006) that could draw
courteous) upon the country’s stock of retired nurses have been widely
Sentuh (touch) Use of personal touch/approach (within
cultural context)
Segak (smart looking/ To maintain a professional (smart) appearance The nursing workforce has become globalized (Kingma 2007).
elegant/chic) Increasingly, employers (and governments through immigration
policy) recruit nurses internationally – further contributing to
*Source: Tee (2006). the shortage of nurses in those countries they target for recruit-
ment, including Malaysia (Chua 2004). Comparatively low
wages, the high standard of education provided, with its focus on
The regular, large influx of new graduates has placed an addi- clinical practice and English language competency, has made the
tional workload on more experienced nurses to whom the out-migration of Malaysian registered nurses (RNs), especially
primary responsibility falls to guide novices into the professional to English-speaking countries such as the UK, the USA and
role. This mentoring process, important to the development of Australia, very attractive. Islam, the national religion of Malaysia

© 2010 The Authors. Journal compilation © 2010 International Council of Nurses

36 T. Barnett et al.

also attunes many nurses to employment opportunities in the nance level, nursing, which used to be under the jurisdiction of
Middle East and other predominantly Muslim areas where less the Medical Practice Division of the Health Ministry, is now a
adjustment is required to fit in with local customs and mores. separate division with more autonomy and, arguably, greater
Short-term employment contracts in such countries have been influence on policy development (Materia Medica Malaysiana
particularly attractive to nurses who have been required to retire 2006).
from the government (public) hospital sector and have sought to Whilst such initiatives have been welcomed, there is urgent
enhance their quality of life in later years by spending time need not only to increase the level of support and mentorship
earning significantly more income overseas. provided to the influx of new graduates, but also to reduce the
In addition to increasing the supply of nurses, other options to occupational hazards associated with nursing work, for example,
address workforce shortages are to reduce demand and to violence (Jackson et al. 2002), needlestick and back injuries
improve retention or plug the ‘leaky bucket’. (Kong & Chor 2007) as well as stress. As found elsewhere, these
hazards have become the ‘new’ epidemics of the profession
Reduce demand (Peterson & Mayhew 2005) and also exacerbate the nursing
The health workforce crisis has prompted suggestions for the shortage in Malaysia. A failure to address these workplace con-
introduction of a new type of health care worker as a more cerns is likely to increase the risk of new graduate burnout and
cost-effective way to deliver patient care than the current skill contribute to workforce attrition.
mix with its relatively high reliance on RNs (Duckett 2004).
Commentators have suggested that the health care professions The work environment in Malaysia
should review the boundaries that tend to restrict practices and With the implementation of the Occupational Safety and Health
constrain health care innovation and reform (Nay & Pearson Act 1994, and measures taken by national agencies such as the
2001). Critical to this argument has been political recognition Department of Occupational Safety and Health and the National
that nursing care is a significant item of expenditure and that an Institute of Occupational Safety and Health, the prevalence of
ageing population is likely to escalate these costs (Productivity reported workplace accidents in Malaysia has fallen from 21.4
Commission 2005). With an elderly population that is expected per 1000 workers in 1993 to 6.7 in 2004 (Che Man & Musri
to more than double in size over the next two decades, Malaysia 2005). Under-reporting of work-related accidents and occupa-
has favoured an expansion in the nursing workforce rather than tional illnesses however remains a major problem (Lee 2005). It
to actively pursue other solutions that would diminish the pres- has been suggested that this lack of notification could be due to:
ence and influence of the RN (Chua 2006b). the inability to diagnose occupational disease or to make the link
between work and disease; ignorance of notification require-
Improve retention ments; the absence of established procedures; fear that notifica-
Shortages can be addressed by improving worker retention and tion may affect contractual agreements between the employee
by minimizing preventable losses (Jasper 2007). One way is to and the employer (Rampal 2000); and because workplace psy-
better prepare students for the reality of nursing practice and chosocial and musculoskeletal problems or injuries can be
reduce the theory-practice gap associated with many systems of regarded as less important in many work settings (Sadhra et al.
nurse education throughout the world (Bryant 2005). A strategy 2001). These findings also apply to the variety of clinical envi-
implemented by the authorities in Malaysia has been to prescribe ronments in which nurses work; and whilst little is known about
the minimum amount of clinical experience a student is required the impact many workplace hazards have on nurses, it is highly
to undertake as part of their course, and in this way, enhance probable that back, needlestick (sharps) and other injuries are
their capabilities and better shape their expectations of nursing also under-reported at a national level.
work on graduation (Ministry of Higher Education Malaysia
2008). Back injuries
It has been reported that the career prospects for nurses in Nursing can expose workers to high physical loads and there is
Malaysia have improved and a range of measures have been taken growing evidence to suggest that few nurses survive their
to support professionalization (Tee 2006). Staged opportunities working life without sustaining an injury of some description
have been introduced for nurses to upgrade their qualifications (Smith et al. 2004). A significant proportion of these injuries are
and to provide rewards for this achievement. Within the govern- to the spine or its related structures; back injuries incurred or
ment sector, moves have also been taken to improve the range of associated with positioning, moving or lifting patients as part of
financial benefits available to nurses and to bring these more in patient transfers and the routine delivery of nursing care (Retsas
line with those found in private sector employment. At a gover- & Pinikahana 2000). Peterson (2003) claims that there is a posi-

© 2010 The Authors. Journal compilation © 2010 International Council of Nurses

Nursing shortage in Malaysia 37

tive association between stress and musculoskeletal injuries, will contribute to a less hazardous and less stressful working
including those of the back. Although anecdotally common, environment. With appropriate leadership, these initiatives may
there is little empirical data available on the incidence of back also help to change the culture of health care organizations such
pain among nurses in Malaysia and further studies are needed to that workers are encouraged to identify and report workplace
assess the prevalence and long-term impact of these injuries hazards and accidents (Duffield et al. 2007).
(Jabar 2005; Malaysian NGO Shadow Report 2005).
Manual handling principles and techniques are an important Conclusion
component of the nursing curriculum though, as experienced In order to address the nursing shortage and also to build health
elsewhere, the consistent application of such techniques (such as care capacity, Malaysia has taken a strategic decision to increase
the use of slide sheets and lifting devices) is not widespread in the the number of students undertaking nursing courses and thereby
hospital sector. A range of strategies to prevent workplace back increase the supply of new graduates. Increasing domestic supply
injury could be implemented more extensively in Malaysia has been favoured over other strategies such as boosting
(Wong 2007). Elsewhere, these measures have included: worker in-migration of nursing labour and is widely regarded as the
education, workplace modification, the use of lifting teams, exer- single most sustainable and responsible solution to grow the
cise programmes, and the development, implementation and nursing workforce.
monitoring of manual handling policies (Mitchell et al. 2008; Such unprecedented expansion has placed a strain on more
Vieira et al. 2006). Such measures may be embraced within a experienced clinical nurses and nurse educators. Whilst a
broader ‘no lift’ policy that aims to eliminate or minimize number of reforms and support measures have been put in place
manual handling and create a culture that supports these for nurses, some initiatives such as the ‘7 S soft skill’ programme
changes by management (Passfield et al. 2003). can serve to devalue the professional contributions that nurses
make to health care. We have argued that more fundamental
Needlestick/sharp injuries measures should be taken to improve the working environment
Needlestick injury is a common occupational hazard among of RNs and to better support new graduates in their transition to
health care workers and can result in the spread of bloodborne the professional role.
diseases such as Hepatitis and HIV. In Malaysia, whilst workplace Measures to improve the work environment should be effec-
accidents and injuries may have fallen overall, for the period tive and visible. In this way, both old and new staff will be less
2000 to 2006, the number of needlestick injuries reported by likely to leave (Tzeng 2002). These could include more realistic
health care workers increased by 50% from 498 to 746 (Chua workload determinations that focus on the professional patient
2007). As with back injuries, it is likely that these figures repre- care responsibilities of the RN and better reward both educa-
sent only the tip of the iceberg. Whilst national reporting guide- tional and experiential achievements. Additional strategies
lines have been developed and widely distributed to health care should also be implemented to reduce the risk of injury. These
agencies (Occupational Health Unit Ministry of Health Malaysia may include regular, systematic workplace risk assessments and
2002, 2005), nurses and other health industry workers can dem- more effective implementation of policies, procedures to mini-
onstrate a reluctance to report such injuries due to ignorance or mize manual handling and other potentially injurious activities.
fear of reprisal (Lee & Noor Hashim 2005). Staff education and The introduction of more flexible employment options such as
support as well as more widespread use of needle-free devices are part-time work, family friendly practices and extending the
important injury prevention strategies (Vaughn et al. 2004). retirement age for nurses employed in the public sector may also
These could be implemented more widely in clinical areas in encourage greater levels of participation in the workforce and
Malaysia (Mohamad & Ismail 2003), though unless critical staff- enhance succession planning. Improvements to the conditions of
ing shortages are addressed, the pressures of work will encourage work that encourage both new graduates and more experienced
staff to take procedural shortcuts, abandon more time- clinicians to continue their service to the industry measures may
consuming safe practices and escalate the risk of injury. help to plug the ‘leaky bucket’ and create the conditions in which
The implementation of back, needlestick and other injury the full benefits of an increased domestic supply of nurses may be
prevention policies, as well as having a direct effect on nurses, realized and enjoyed well into the future.
will also impact on other dimensions of the work environment.
A strong predictor of workplace stress is a climate in which Author contributions
workers perceive that management have a negative view of All listed authors were involved in study conception/design; data
employees (Peterson 2003). The introduction of workplace poli- collection/analysis; drafting of manuscript; critical revisions for
cies, training and support, as well as the necessary equipment, important intellectual content.

© 2010 The Authors. Journal compilation © 2010 International Council of Nurses

38 T. Barnett et al.

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