An appendix on nurses

The provision of cheap and high quality healthcare has catapulted the Malaysian healthcare system into the top global echelon. In 2014,’s annual Global Retirement Index ranked Malaysia as the third best and most affordable country for healthcare globally. Malaysia’s healthcare scored 95 out of a possible 100 points for the following criteria:

  • cost of care
  • quality
  • number of people per doctor
  • number of hospital beds per 1,000 people
  • percentage of population with access to safe water
  • infant mortality rate
  • life expectancy
  • public health as a percentage of GDP

Malaysia has long been recognised as world class destination for healthcare. However, the past four years have seen the industry expand at a faster rate compared to during the years in the middle of the last decade. Figure 1 shows that between 2007 and 2008, the number of healthcare travellers to Malaysia increased by an annual average of 3.78%. Between 2010 and 2013 though, the number increased by 23.9% per annum.

Does Malaysia have the medical personnel to accommodate this medical tourism boom? This month we’ll take a look at the human resource element of the medical industry, with a particular focus on the nursing profession. We examine whether our hospitals are staffed to the optimal amount with nurses before considering the effect on patients.

The World Health Organization (WHO) stipulates that the recommended nurse-to-population ratio for a country such as Malaysia is 1:200.

Table 1: Total population, number of nurses and nurse-to-population ratio

Source: Health facts 2006-2013, Ministry of Health Malaysia ( section.Section_3549ea8f-c0a81049-874bd300-302e756b).
Source: Health facts 2006-2013, Ministry of Health Malaysia ( section.Section_3549ea8f-c0a81049-874bd300-302e756b).

Figure 1: Number of healthcare travellers to Malaysia, 2007-2013

Source: Malaysian Healthcare Travel Council.
Source: Malaysian Healthcare Travel Council.

Figure 2: Nurse-to-population ratio, 2006-2020 [1]


Malaysia’s healthcare sector is still far away from achieving the recommended nurse-to-population ratio. In 2012, the nurse-to-population ratio was reported as 1:345 by the Ministry of Health. While this figure is an improvement from previous years – the nurse-to-population ratio has been steadily decreasing since 2006 – there is still a shortfall of approximately 146,570 nurses needed to achieve that ratio.

Fortunately, the growth rate of the number of nurses far exceeds the population growth rate. Between 2006 and 2012, the number of nurses expanded by 10.12% annually, while the population growth rate was 1.6% on an annual basis. If the population growth rate and the nursing staff growth rate remain unchanged over the next few years, then the target nurse to population ratio can be achieved by 2019.

Table 2: Number of doctors, nurses and nurse-to-doctor ratio

Source: Health facts 2006-2013, Ministry of Health Malaysia ( section.Section_3549ea8f-c0a81049-874bd300-302e756b).
Source: Health facts 2006-2013, Ministry of Health Malaysia ( section.Section_3549ea8f-c0a81049-874bd300-302e756b).

The shortage in nurses also does not help doctors. WHO recommends that each doctor should have a minimum of 2.5 nurses assisting him/her at all times, but in Malaysia, this ratio has hovered at around 1:2.10 for the past seven years.

Recognising that there is an acute shortage, the government has classified nursing as a critical field and allowed the formation of many new nursing colleges. Currently, there are four types of nursing colleges in Malaysia.

Table 3: Type and number of nursing colleges in Malaysia


Table 4: Survey of English proficiency among nurses


A recent study by Universiti Teknologi Mara (UiTM) found that private colleges alone produce about 1,200 trained nurses for whom there are only 1,000 to 1,500 nursing jobs in the private sector. Government hospitals usually hire public university graduates while private hospitals employ their own nurse trainees. As a result, there exists a large pool of nurses who are unemployed. According to the president of the Malaysian Medical Association, Dr N. K. S. Tharmaseelan, the number of unemployed nurses stands close to 15,000 [2]. Human Resource Minister Datuk Seri Dr. S. Subramaniam has also said, “This phenomenon is because of the low quality of nurses, including poor language proficiency and nursing skills and training” [3].

The same study by UiTM conducted a survey of unemployed nurses in three private nursing colleges. All the respondents had undergone formal nurse training and, at the minimum, each had a diploma in nursing to show for it. The survey was interested in determining unemployed nurses’ English proficiency. None of the survey respondents were confident enough to indicate that they had an excellent command of English. Seventy-five per cent also said that they had average writing skills while the same percentage indicated that they had poor English speaking skills.

The lack of English proficiency coupled with a high nurseto- population ratio is likely to have taken a toll on standards within the profession.

Figure 5: Contributing factors to medication error among nurses in Hospital Sik, Kedah


The Faculty of Health Sciences in UiTM conducted a survey on the “contributing factors to medication error” in Hospital Sik in Kedah. The results in Figure 5 show that 95.8% of all respondents indicated that the heavy workload contributed to the error – a direct result of a shortage of nurses on staff. The same percentage also indicated that they could not understand the doctor’s orders, possibly due to a lack of English proficiency. Worryingly enough, 66% of respondents said they made the error because of “Personal Neglect” while 45.8% of respondents were completely unfamiliar with the medication they were administering.

The nursing shortage also results in a heavier workload for each nurse currently employed in the healthcare industry. This is a precursor to job stress and burnout which have also been linked to lower job satisfaction. To determine whether the heavy workload was indeed affecting job satisfaction among nurses, a survey was conducted in a private hospital in Perlis. The respondents were asked to state their satisfaction with their supervisor, job variety, co-workers, HR policies, time given per task and overall satisfaction. Their responses were rated on a scale of one to five, where one = strongly disagree and five = strongly agree.

Table 5: Job satisfaction survey among nurses in Perlis

Source: journal/Vol3No1/Article_10.pdf
Source: journal/Vol3No1/Article_10.pdf

Based on the mean response, we can say that the nurse population is moderately satisfied with the elements of their work. Furthermore, there is also little intention to leave among those surveyed. Nevertheless, the fact that the mean responses hovered around 3.3 could be an indication that the proportion of those satisfied was only slightly more than those who were dissatisfied. Even though the mean response here shows that the majority are satisfied, we note that there is still a large proportion of nurses who are dissatisfied.


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