KUALA LUMPUR, Dec 28 – Emergency rooms in private hospitals in Malaysia have hit capacity due to insufficient beds in wards caused by a dire shortage of nurses, compounding the crisis of overcrowded emergency departments in public hospitals.
The Association of Private Hospitals Malaysia (APHM) said patients in private hospitals now wait up to six to eight hours or longer for ward admission. The congestion in the emergency room (ER), or emergency and trauma department (ED), of private hospitals is occurring in most major cities this year, including the Klang Valley, Penang, Melaka, and Johor Baru.
APHM president Dr Kuljit Singh explained that private hospitals have the infrastructure, but the Private Healthcare Facilities and Services Act (PHFSA) 1998 — which only applies to private facilities — prohibits private hospitals from opening up beds unless there are sufficient nurses to staff these beds.
“Imagine, there are days when we are not able to send patients to any other private hospital because all are full,” Dr Kuljit told CodeBlue yesterday.
In 2019, patients in private hospitals typically waited only an hour for a bed, though there might be isolated cases of long waits for ward admission during pre-pandemic days, he added. Patient loads in private hospitals also increased this year compared to 2019.
Health Minister Dr Zaliha Mustafa said in a statement Monday that the Ministry of Health (MOH) would hold stakeholder engagement sessions with emergency departments, APHM, and doctors’ group Malaysian Medical Association (MMA) to come up with long-term solutions for ED overcrowding across government hospitals nationwide, following CodeBlue’s series of reports on severely congested emergency rooms in the public sector.
“We cannot help them this time around as private hospitals are full and the waiting period to get a bed is six to eight hours or more. ERs are full in private hospitals. These are patients who can afford private health care!” Dr Kuljit told CodeBlue in response.
CodeBlue reported last December 12 that critically ill patients, including those on ventilator support, are stranded for up to six days in the emergency department of Raja Permaisuri Bainun Hospital (HRPB) — an MOH tertiary hospital in Ipoh that serves the entire state of Perak — due to insufficient beds and staff, including doctors and nurses.
Doctors have highlighted similar days’ long waits in the EDs of university hospitals for ward admission, such as Hospital Canselor Tuanku Muhriz UKM (HCTM) and Universiti Malaya Medical Centre (UMMC).
Even military hospitals are not spared from the nursing shortage. The Auditor-General’s 2021 report (Series 1) found that less than half of beds in three military hospitals from the national audit were filled from 2018 to 2021 because of a shortage of health care workers, particularly nurses.
This means that anyone wishing to seek treatment for medical emergencies in Malaysia may be forced to wait either days in public hospitals, whether in MOH or university hospitals, or more than eight hours in private hospitals for ward admission. The ER or ED is meant to serve as a stabilisation and resuscitation unit, where patients in critical condition are rushed in, stabilised, and rushed out to be immediately admitted into their respective inpatient wards.
In a previous statement, APHM said private hospitals in the country are currently suffering an unprecedented shortage of nurses that it believes is also happening in public hospitals. APHM has urged MOH to immediately liberalise the nursing labour market and bring in foreign nurses amid an acute shortage.
“There are measures that can be put in place to monitor quality and safety of the patients,” Dr Kuljit told CodeBlue yesterday. “We cannot just state the obvious but with no solutions. Patients suffer.”
In Johor, the shortage of nurses is estimated to be between 15,000 and 18,000, following an exodus to Singapore, where some nurses are paid as much as specialist doctors here.
Lincoln University College pro-chancellor Prof Dr Bibi Florina Abdullah told news station BFM last December 14 in an interview that some nurses are paid “three times” higher in Singapore, bringing home as much as RM20,000 per month in basic salary, not inclusive of paid shifts, house allowance, and other perks.
Dr Bibi Florina is also formerly a registrar at the Malaysian Nursing Board and the first director of nursing at the MOH.
“They are remunerated very well and to match their remuneration is far from possible,” Dr Kuljit said in the same BFM interview with Dr Bibi Florina. “[People tell us] so many things, ‘Oh you know, just pay them a little bit more’, but they get far more and definitely, economically, in Malaysia we will not be able to match that.”
Hiring Foreign Nurses
On the positive side, the demand for Malaysian nurses reflects the country’s high nursing quality standards, Dr Kuljit said. “We are very proud of that. Our nurses are very good.”
“They are easily snapped up in the Middle East, even with our southern neighbour (Singapore), they can very easily get jobs there,” he added.
However, this forces local hospitals to consider hiring foreign nurses from countries such as the Philippines or the Indian subcontinent, as an immediate solution to their staffing woes.
“Some nurses in other parts of the world are probably happier to be in Malaysia with what we actually pay compared to what they’re getting in their own country, and maybe for reasons best known to them.
“But putting all the other factors in, Malaysia is probably a better option for them, maybe socially and a lot of other factors. I think Malaysia has always been a favourite ground for a lot of nursing staff and I personally used to speak to them and they actually enjoy working here – our working environment is probably better,” Dr Kuljit said.
Foreign nurses were previously allowed to work in private hospitals nearly a decade ago, Dr Kuljit said. Private hospitals had an accreditation system in place to ensure that nurses were up to par in their certification and qualifications.
“Our local nursing and nursing heads will actually go through their work and we doctors who work with them, we found they were actually extremely good and they were very motivated to work with us in Malaysia. Many doctors actually miss them when they are with us in private hospitals,” Dr Kuljit said.
Application For Foreign Nurses
Dr Bibi Florina said the procedures for private hospitals to hire foreign nurses involve vetting by the Malaysian Nursing Board.
“When private hospitals sort of apply for foreign nurses, they have to show us the evidence that they’ve actually exhausted all avenues – three times advertising in the newspaper and there are no takers and things like that – and they need this specialty for their programme.
“So, they will write to us and then, of course, if let’s say, they want to take from India, they will have to send all the certificates, transcripts and all that and we will have a look.
“The nursing board is the one who will look into whether this nurse is qualified or not. Once the board is satisfied, they will be sent to the private sector and we will give them an observation period of three months and [the private hospitals will then] give a report to the nursing board to say that they (the nurses) are competent and they can continue.
“So that’s how it was, and I think it hasn’t changed,” Dr Bibi Florina said.
Commenting on the hiring process for foreign nurses, Dr Kuljit said it was a “very rigid process” similar to bringing in any expatriate to work in the country.
“That takes a long time and sometimes, in that process, these potential nurses which we have identified from overseas, they give up and they go to another country,” Dr Kuljit said.
“And to me, this is going to be a short-gap measure because I think we will get some sort of footing in solving this problem as we go along – increasing the production of nurses, but right now, there is a gap that we need to fill up.”
According to the Nursing Board Meeting’s employment criteria for foreign trained nurses in Malaysia, which were enforced from October 15, 2018, foreign trained nurses practising in clinical areas must possess post-basic qualification and provide certification from the training institution from their country of origin.
APHM, however, said that this clause is not applicable in international settings because nursing qualifications are not aligned across the globe.
“Exemption to be given for applicants from countries where post-basic is not a recognised training certification. Allowance for nurses with more than three years’ experience in specialised areas to be considered,” Dr Kuljit told CodeBlue, in recommending immediate measures from the government to resolve the nursing shortage crisis.
“The requirement for running three advertisements to look for local talent before sourcing for overseas applicants is obsolete and hence must be abolished. Immediate sourcing and recruitment will be tied up in this red tape. There is an established shortage of nurses in the country and every newspaper has run several articles highlighting the matter.”
Nursing Graduates And The Ideal Ratio
Dr Bibi Florina said the ideal nurse-patient ratio depends on the level of care, ranging from intensive care to regular wards.
“In the ICU, it is 1:1 or 1:2. If you can afford it, it’s 1:1. In the labour room, for example, 1:1. In the surgical ward, maybe 1:3 or 1:4. This is the norm I’m talking about. Of course, you can see nurses running around at 1:10 or 1:20 in certain hospitals because they don’t have enough manpower. For some nurses, because there isn’t enough manpower, they are doing double shifts and that’s why they have stress and things like that.
“Looking after the patient is not just physical, it is mental, physical, and even spiritual. I mean, especially those oncology patients, you’ve got to hold their hands. How do you break news which is very sad?” Dr Bibi Florina said.
At Lincoln University College, Dr Bibi Florina said they produce about 50 nurses each year. “And we are supposed to supply to the private sector.”
There are over 25 private nursing schools, with more than 200 private hospitals in the country. Some private hospitals have their own training schools to train future staff but for others, they rely on nursing schools such as the one at Lincoln University College for supply.
Dr Bibi Florina attributed the low production of private nursing students to higher education requirements and insufficient student loans provided by the National Higher Education Fund Corporation (PTPTN).
“In the Nurses Act 1950, it says SPM. Then we came up with requirements like you must have five credits. So when you have five credits [requirement], including maths and science, some of the girls cannot reach that target for maths and science.
“So there’s a drastic drop in the number of nurses going to the training, especially in the private sector. Now when you say five credits, some of them don’t even want to come in, they go for other programmes. They have five credits so they can go for programmes like business, hospitality, like, I don’t know, IT, something like that.
“Now we feel it because suddenly, I can only give you 10 when it was like hundreds to 200 (graduates from the nursing programme),” Dr Bibi Florina said.
“Okay fine, if that is the policy, it is already gazetted by the government, but I feel that we should have some flexibility. So if you come in with only a pass in maths and science, we can give you one year and within one year, you sit for that single paper and if you get credit, you can come in so that means it’s a conditional offer letter to you.
“And it doesn’t really matter (if they get credit or not) because at the end of the year, if you fail to get the credit, you can always end up as a caregiver and caregivers in this country, minimum RM3,000, maximum RM6,000 monthly salary, so they can be employed anywhere.
“So meaning, you give a chance for them to get jobs, especially for rural students. They find it so difficult to have this one (five credits),” Dr Bibi Florina added.
A reduction in student loans also makes private nursing programmes unaffordable for some students from lower income households.
“We also have problems with PTPTN. It has gone down so much that, say, I’m offering RM45,000 for the nursing programme and the PTPTN loan is RM37,000, for example, so you have to meet the gaps.
“Normally, we at Lincoln, we will just follow [PTPTN] and put it at RM37,000 to make it easier for them. You need to do that because where are they going to get the money for training?” Dr Bibi Florina said.