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
Malaysia.
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
graduates.
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
Few countries or nations are untouched by what has been
described as the ‘crisis in nursing’, a critical shortage of profes-
sional nurses to deliver care, largely in the acute health care sector
Correspondence address: Tony Barnett, School of Nursing and Midwifery, Monash
University, Churchill, Vic. 3842, Australia; Tel: 613-990-26636; Fax:
613-990-26527; E-mail: tony.barnett@med.monash.edu.au.
(Buchan & Calman 2004; Simoens et al. 2005). The shortage has
been influenced by conditions on both the supply and demand
sides of the labour market equation.
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
lack of funding for places, low demand from school graduates
(who may regard nursing as a less attractive career choice),
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
rationalization of schools of nursing. In many countries, there is
also a net loss through migration (Cowin & Jacobsson 2003;
Kingma 2007; Simoens et al. 2005).
The demand for nurses has increased due to ‘ageing popula-
tions, increased consumer activism and rapid evolution of
medical technologies’ (Simoens et al. 2005, p. 4) as well as popu-
lation growth and the associated burden of disease. This demand
has been exacerbated by the aging of the workforce (resulting in
more nurses retiring or seeking part-time work); less than
optimal separation rates from the industry; globalization of the
labour market; and an increased propensity for nurses to seek
alternative (though often health-related) careers. Low job satis-
faction, associated with a poorer quality of working life, can
impact on both the current and future workforce (Blegen 1993;
Duffield et al. 2007). Less satisfied nurses are more likely to exit
or reduce the number of hours they work and those who are
thinking of entering the workforce are dissuaded from making a
long-term commitment to the profession as other employment
options promise greater levels of satisfaction, remuneration and
benefits.
The nursing shortage is prevalent amongst many Asia-Pacific
countries (Buchan & Calman 2004; Lee et al. 2007). For example,
in China, whilst the number of nurses is reported to have
increased from 3300 in 1949 to 139 000 in 2006, the nurse to
population ratio is less than that of medical doctors and there
remains a significant shortage (Liu 2007). In Australia, it was
estimated that in 2006 there was a shortage of around 3000
nurses or 1.6% of the total registered nurse workforce (Preston
2006) though efforts to increase the number of university places
for nursing have been frustrated by the barriers and constraints
associated with clinical placements, an essential requirement for
any course leading to registration as a nurse (Barnett et al. 2008).
Singapore has maintained its nurse to population ratio at
around 1:220 over the 2003/5 period through an increase in the
recruitment of overseas trained nurses from countries such as
China, the Philippines, India and Malaysia. In 2005, the number
of new registrants who were trained overseas was twice that of
local Singaporeans (Singapore Nursing Board 2006). In common
with many other developed countries, this reflects a sustained
demand for nurses and midwives against a backdrop of insuffi-
cient local supply (Tan 2003). In response to this situation and
to bolster local supply, Singapore has recently increased the
numbers of students taken into nursing courses and also
expanded the number of institutions conducting courses.
To describe and analyse the nursing shortage in Malaysia,
government documents and press releases from the Ministry of
Health Malaysia were sourced from official websites and searched
for any reference to nurses or nursing over the period 2000 to
2007. A search was also conducted using CINAHL and other data
© 2010 The Authors. Journal compilation © 2010 International Council of Nurses
33
bases using full and truncated keywords such as: nursing, nurses,
workforce AND Malaysia with no limit on year of publication.
Very few papers were located. As a consequence, this paper draws
upon literature that reports on the experiences of shortages in
other countries to critically review responses to the shortage in
Malaysia within a more global context. Whilst a lack of empirical
literature on the topic of nurse shortages is a major limitation
to this review, the information sourced has been informed by
experience. Collectively, the authors have had many decades
of experience with nursing, nurse education, research and
administration in Malaysia. One of the authors was privileged to
serve as Chief Matron of the country. These experiences and
discussion of these experiences between the authors have pro-
vided some balance to the weight of local (Malaysian) literature
obtained primarily from government sources.
The nursing workforce in Malaysia
Located in South East Asia, Malaysia is a rapidly developing
country with a population of 27 million (Department of Statis-
tics Malaysia 2008). It has an ageing population with the propor-
tion of the population aged 65 years and over expected to double
by the year 2030. Life expectancy at birth is similar to that
reported by many developed countries (>70 years for both males
and females). The government allocates approximately 7% of the
national budget to health (Ministry of Health Malaysia 2007)
and is challenged by changing patterns of communicable and
non-communicable diseases as well as workforce shortages,
especially in nursing (Ministry of Health Malaysia 2008).
In Malaysia, nurses comprise 2–3% of the female workforce
and a large proportion of the health care workforce. Approxi-
mately two-thirds of nurses work in the government (public)
sector where they are encouraged to work full-time and are gen-
erally required to retire upon reaching the age of 55 or 56. Due to
historical and cultural reasons, very few nurses are male though
small numbers have been taught nursing skills and prepared as
‘medical assistants’ (Ministry of Health Malaysia 2007, 2008).
Nurses are prepared in colleges or universities by undertaking
a 3-year diploma level qualification, though 4-year degree
courses are being introduced. Graduates are often bonded to the
Ministry of Health or a private hospital for a period of time
following their initial preparation in recognition of the employ-
er’s contribution to the cost of their education. Entry to a
nursing course is usually restricted to high school graduates. For
the diploma, entry level is most commonly the Sijil Pelajaran
Malaysia (SPM, equivalent to ‘O-levels’ i.e. successful completion
of the penultimate year of secondary schooling) and entry to the
degree, the Sijil Tinggi Pelajaran Malaysia (STPM equivalent to
‘A-levels’ i.e. successful completion of the final year of secondary
schooling). Community Health Nurses (Jururawat Desa) are pre-
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
1998 23 672
1999 27 236
2000 31 129
2001 33 295
2002 35 280
2003 36 784
2004 40 220
2005 44 120 (15 618)
2006 47 642 (16 667)
*Source: Ministry of Health, Malaysia (2007).
pared separately and work in areas such as child health and
family planning clinics and in rural areas where they provide
home visits and also service the less advantaged.
Table 1 shows that there was an increase in the number of
nurses from 20 056 in 1996 to 47 642 in 2006 with a subsequent
improvement in the nurse to population ratio from 1:1055 to
1:559 (Ministry of Health Malaysia 2007). This increase has been
a significant achievement though the country still faces a critical
shortage. It has been estimated that a total of 174 000 nurses will
be required by the year 2020 to reach a targeted 1:200 nurse
population ratio, in line with similar ratios in some neighbour-
ing countries (Chua 2004; Cruez 2006). The increase has been
achieved primarily by escalating the domestic supply of new
graduates. A dramatic expansion in the number of schools and
colleges of nursing, nursing students and subsequent increase in
the proportion of new graduates within the workforce has been
associated with a number of workplace challenges. In this paper,
it is argued that unless sufficient and systematic attention is paid
to address these, such a rapid expansion will pose a threat to the
long-term stability of the workforce and impact on the quality of
care delivered.
Responses to nurse shortages
A range of measures may be taken to combat workforce short-
ages. These are generally directed to either increasing supply,
reducing demand and/or improving the retention of nurses
(Cowin & Jacobsson 2003). For example, supply may be
increased by encouraging more school-graduates to enter the
profession or by the active recruitment of nurses from other
countries (Kingma 2007). Demand may be reduced by
1:883
1:937 Increase supply
1:834 The Malaysian authorities have increased the number of public
1:747 and private institutions providing nursing courses and have also
1:715 increased the total number of students (Cruez 2006). That these
1:695
1:681 places have been filled, suggests a continued demand for nursing
1:636 although some school graduates see nursing as an opportunity to
1:592 leave home at a younger age than would otherwise be the case,
1:559
and the more recent availability of student loans though the
national higher education fund (the Perbadanan Tabung Pendidi-
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
staff and clinicians to provide the support required to enable the
maximum number of students to progress through their course
in minimum time and to enter the workforce as safe and com-
petent nurses. The introduction of degree courses to replace the
diploma level qualification, with entry set at the higher STPM,
may address this concern as experience from other countries
suggests that such a change has little detrimental impact on
overall course demand (Heath 2002).
A greater number of new graduates entering the workforce has
resulted in changes to the skill mix of many hospitals. Patient
care areas are now more likely to be staffed by younger nurses
with less experience. A new generation of graduates will also have
different attitudes toward patients and those in authority than
their predecessors. This has been identified as a factor contrib-
uting to the recent, widespread public and political criticism
levelled at nurses; their poor attitudes toward patients and
decline in the standard of care they provide (Chua 2006a). In
response to such criticism, the introduction of symptomatic pro-
grammes, such as the ‘7S soft skill’ behaviour change pilot by the
Ministry of Health Malaysia (Table 3), have tended to place
responsibility on nurses themselves rather than the structural,
social and political determinants of care such as staffing short-
ages, working conditions, the lack of support provided to new
staff or fully appreciate the generational changes that have
occurred in the workplace (Stuenkel & Cohen 2005). An over
emphasis on soft or ‘be nice’ skills, which focus upon the inter-
personal workplace behaviours of nurses, also draws attention
away from those more professional, technical and therapeutic
skills of the nurse that should be valued more highly and that
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
adopted.
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
Middle East and other predominantly Muslim areas where less
adjustment is required to fit in with local customs and mores.
Short-term employment contracts in such countries have been
particularly attractive to nurses who have been required to retire
from the government (public) hospital sector and have sought to
enhance their quality of life in later years by spending time
earning significantly more income overseas.
In addition to increasing the supply of nurses, other options to
address workforce shortages are to reduce demand and to
improve retention or plug the ‘leaky bucket’.
Reduce demand
The health workforce crisis has prompted suggestions for the
introduction of a new type of health care worker as a more
cost-effective way to deliver patient care than the current skill
mix with its relatively high reliance on RNs (Duckett 2004).
Commentators have suggested that the health care professions
should review the boundaries that tend to restrict practices and
constrain health care innovation and reform (Nay & Pearson
2001). Critical to this argument has been political recognition
that nursing care is a significant item of expenditure and that an
ageing population is likely to escalate these costs (Productivity
Commission 2005). With an elderly population that is expected
to more than double in size over the next two decades, Malaysia
has favoured an expansion in the nursing workforce rather than
to actively pursue other solutions that would diminish the pres-
ence and influence of the RN (Chua 2006b).
Improve retention
Shortages can be addressed by improving worker retention and
by minimizing preventable losses (Jasper 2007). One way is to
better prepare students for the reality of nursing practice and
reduce the theory-practice gap associated with many systems of
nurse education throughout the world (Bryant 2005). A strategy
implemented by the authorities in Malaysia has been to prescribe
the minimum amount of clinical experience a student is required
to undertake as part of their course, and in this way, enhance
their capabilities and better shape their expectations of nursing
work on graduation (Ministry of Higher Education Malaysia
2008).
It has been reported that the career prospects for nurses in
Malaysia have improved and a range of measures have been taken
to support professionalization (Tee 2006). Staged opportunities
have been introduced for nurses to upgrade their qualifications
and to provide rewards for this achievement. Within the govern-
ment sector, moves have also been taken to improve the range of
financial benefits available to nurses and to bring these more in
line with those found in private sector employment. At a gover-
© 2010 The Authors. Journal compilation © 2010 International Council of Nurses
nance level, nursing, which used to be under the jurisdiction of
the Medical Practice Division of the Health Ministry, is now a
separate division with more autonomy and, arguably, greater
influence on policy development (Materia Medica Malaysiana
2006).
Whilst such initiatives have been welcomed, there is urgent
need not only to increase the level of support and mentorship
provided to the influx of new graduates, but also to reduce the
occupational hazards associated with nursing work, for example,
violence (Jackson et al. 2002), needlestick and back injuries
(Kong & Chor 2007) as well as stress. As found elsewhere, these
hazards have become the ‘new’ epidemics of the profession
(Peterson & Mayhew 2005) and also exacerbate the nursing
shortage in Malaysia. A failure to address these workplace con-
cerns is likely to increase the risk of new graduate burnout and
contribute to workforce attrition.
The work environment in Malaysia
With the implementation of the Occupational Safety and Health
Act 1994, and measures taken by national agencies such as the
Department of Occupational Safety and Health and the National
Institute of Occupational Safety and Health, the prevalence of
reported workplace accidents in Malaysia has fallen from 21.4
per 1000 workers in 1993 to 6.7 in 2004 (Che Man & Musri
2005). Under-reporting of work-related accidents and occupa-
tional illnesses however remains a major problem (Lee 2005). It
has been suggested that this lack of notification could be due to:
the inability to diagnose occupational disease or to make the link
between work and disease; ignorance of notification require-
ments; the absence of established procedures; fear that notifica-
tion may affect contractual agreements between the employee
and the employer (Rampal 2000); and because workplace psy-
chosocial and musculoskeletal problems or injuries can be
regarded as less important in many work settings (Sadhra et al.
2001). These findings also apply to the variety of clinical envi-
ronments in which nurses work; and whilst little is known about
the impact many workplace hazards have on nurses, it is highly
probable that back, needlestick (sharps) and other injuries are
also under-reported at a national level.
Back injuries
Nursing can expose workers to high physical loads and there is
growing evidence to suggest that few nurses survive their
working life without sustaining an injury of some description
(Smith et al. 2004). A significant proportion of these injuries are
to the spine or its related structures; back injuries incurred or
associated with positioning, moving or lifting patients as part of
patient transfers and the routine delivery of nursing care (Retsas
& Pinikahana 2000). Peterson (2003) claims that there is a posi-
Nursing shortage in Malaysia
tive association between stress and musculoskeletal injuries,
including those of the back. Although anecdotally common,
there is little empirical data available on the incidence of back
pain among nurses in Malaysia and further studies are needed to
assess the prevalence and long-term impact of these injuries
(Jabar 2005; Malaysian NGO Shadow Report 2005).
Manual handling principles and techniques are an important
component of the nursing curriculum though, as experienced
elsewhere, the consistent application of such techniques (such as
the use of slide sheets and lifting devices) is not widespread in the
hospital sector. A range of strategies to prevent workplace back
injury could be implemented more extensively in Malaysia
(Wong 2007). Elsewhere, these measures have included: worker
education, workplace modification, the use of lifting teams, exer-
cise programmes, and the development, implementation and
monitoring of manual handling policies (Mitchell et al. 2008;
Vieira et al. 2006). Such measures may be embraced within a
broader ‘no lift’ policy that aims to eliminate or minimize
manual handling and create a culture that supports these
changes by management (Passfield et al. 2003).
Needlestick/sharp injuries
Needlestick injury is a common occupational hazard among
health care workers and can result in the spread of bloodborne
diseases such as Hepatitis and HIV. In Malaysia, whilst workplace
accidents and injuries may have fallen overall, for the period
2000 to 2006, the number of needlestick injuries reported by
health care workers increased by 50% from 498 to 746 (Chua
2007). As with back injuries, it is likely that these figures repre-
sent only the tip of the iceberg. Whilst national reporting guide-
lines have been developed and widely distributed to health care
agencies (Occupational Health Unit Ministry of Health Malaysia
2002, 2005), nurses and other health industry workers can dem-
onstrate a reluctance to report such injuries due to ignorance or
fear of reprisal (Lee & Noor Hashim 2005). Staff education and
support as well as more widespread use of needle-free devices are
important injury prevention strategies (Vaughn et al. 2004).
These could be implemented more widely in clinical areas in
Malaysia (Mohamad & Ismail 2003), though unless critical staff-
ing shortages are addressed, the pressures of work will encourage
staff to take procedural shortcuts, abandon more time-
consuming safe practices and escalate the risk of injury.
The implementation of back, needlestick and other injury
prevention policies, as well as having a direct effect on nurses,
will also impact on other dimensions of the work environment.
A strong predictor of workplace stress is a climate in which
workers perceive that management have a negative view of
employees (Peterson 2003). The introduction of workplace poli-
cies, training and support, as well as the necessary equipment,
© 2010 The Authors. Journal compilation © 2010 International Council of Nurses
37
will contribute to a less hazardous and less stressful working
environment. With appropriate leadership, these initiatives may
also help to change the culture of health care organizations such
that workers are encouraged to identify and report workplace
hazards and accidents (Duffield et al. 2007).
Conclusion
In order to address the nursing shortage and also to build health
care capacity, Malaysia has taken a strategic decision to increase
the number of students undertaking nursing courses and thereby
increase the supply of new graduates. Increasing domestic supply
has been favoured over other strategies such as boosting
in-migration of nursing labour and is widely regarded as the
single most sustainable and responsible solution to grow the
nursing workforce.
Such unprecedented expansion has placed a strain on more
experienced clinical nurses and nurse educators. Whilst a
number of reforms and support measures have been put in place
for nurses, some initiatives such as the ‘7 S soft skill’ programme
can serve to devalue the professional contributions that nurses
make to health care. We have argued that more fundamental
measures should be taken to improve the working environment
of RNs and to better support new graduates in their transition to
the professional role.
Measures to improve the work environment should be effec-
tive and visible. In this way, both old and new staff will be less
likely to leave (Tzeng 2002). These could include more realistic
workload determinations that focus on the professional patient
care responsibilities of the RN and better reward both educa-
tional and experiential achievements. Additional strategies
should also be implemented to reduce the risk of injury. These
may include regular, systematic workplace risk assessments and
more effective implementation of policies, procedures to mini-
mize manual handling and other potentially injurious activities.
The introduction of more flexible employment options such as
part-time work, family friendly practices and extending the
retirement age for nurses employed in the public sector may also
encourage greater levels of participation in the workforce and
enhance succession planning. Improvements to the conditions of
work that encourage both new graduates and more experienced
clinicians to continue their service to the industry measures may
help to plug the ‘leaky bucket’ and create the conditions in which
the full benefits of an increased domestic supply of nurses may be
realized and enjoyed well into the future.
Author contributions
All listed authors were involved in study conception/design; data
collection/analysis; drafting of manuscript; critical revisions for
important intellectual content.
38 T. Barnett et al.
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