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Hospital Authority’s efforts to retain nurses fail to stem exodus

Reporters: Ian Cheng and Vivian Ng

Dozens of patients were resting in a big hospital ward. One of them wanted to get out of bed to go to the toilet, so he pushed a red button beside his bed to call for a nurse. Help did not come. After a long wait, the patient pulled himself out of bed. He fell onto the floor.

Incidents like the one above happen all the time, according to an experienced nurse in a public hospital who spoke to Varsity on the condition of anonymity.

Nurses in public hospitals work one of three eight-hour shifts, the morning, afternoon or night shift. That may not sound very long, but each shift is gruelling. They often do not get breaks and even if they do have breaks, they are too busy to take them.

On a typical shift, a nurse might start their day distributing medication, then take patients’ blood pressures and pulse rates. They may feed their patients, change dressings and even help with bathing. They have to listen to advice from doctors and act on their instructions immediately. Getting anything wrong could lead to grave consequences.

The hectic day ends only for another to begin. Sometimes a night shift may be followed by an afternoon shift, so the body does not have time to adjust to the different rhythms and sleep patterns.

The overworked nurses in Hong Kong’s public hospitals are a symptom of staff shortages. There are about 40,000 nurses registered or enrolled under the Nursing Council of Hong Kong (HKNC) but below 80 per cent of them are currently working as nurses. In July last year, the Hospital Authority (HA) said it was still short of 1,000 nurses, despite an expensive recruitment drive.

Susan, not her real name, is a registered nurse in a public hospital. She says the nurse-to-patient ratio at her hospital is around 1:13 during the day but can rise up to 1:40 or even more during the night. The international standard is 1:4 to 1:6.

She says nurses who work on medical wards are so busy that they do not even have time to go to the washroom during the night shift. They dare not drink too much water.

Susan finds the demands of her work very stressful. She finds it hard to fall asleep after work and often spends time trying to remember if there was anything she forgot to do on duty.

The pressure does not just come from the work itself, but also from patients’ families.

Susan cites the case of a patient whose relative claimed to be a policeman. The man suspected the nurses of stealing from the patient and wanted to search them. The nurses felt they could not just ignore the accusations.

“When you retorted, he would say your attitude was bad,” says Susan, adding that it is useless for nurses to argue with patients’ irrational family members.

Wong Kam-man, a nursing officer working in a public hospital in Kowloon, says it is also common for nurses to be sworn at by family members of patients. Although such verbal violence upsets her, she feels helpless to do anything.

“There is no reason why I have to be scolded by you when I go to work,” says Wong. “You can just speak if you have something to say.”

Wong recounted an incident where a colleague was attacked by a visitor who dashed into the ward during non-visiting hours. Wong says the nurse was scared to go to work after the incident and had to seek medical help for psychological trauma afterwards.

Private hospitals offer an attractive alternative to such a tough working environment.

Susan says her peers in private hospitals have a smaller workload because the hospitals admit a smaller range of cases. Also, private patients often hire their own private nurses as well.

Apart from the lighter workload, there is a big difference in salaries between the public and private sectors. For instance, the starting salary for nurses at the private Hong Kong Sanatorium and Hospital is $32,000 plus a $2,000 allowance. They also enjoy year-end double or triple pay. The starting salary plus allowance for nurses working in the public sector is only $24,000.

Unsurprisingly, this has led to an exodus of nurses from public hospitals. Some leave for higher pay and a better working environment in the private sector while others have gone back to schools to teach nursing. Others have left the profession altogether.

According to the HA, the staff turnover rate of registered nurses in the public sector more than doubled from 2.4 per cent in 2005 to 5.3 per cent in 2010, the highest in five years. Among those who left, those with more than 10 years’ experience accounted for the largest proportion.

To alleviate the problem, the government allocated $200 million to training and recruitment in the medical sector for three years starting from 2012 in its 2011-12 Policy Address. Parts of it are earmarked to provide more opportunities for specialty training and promotion in the hope of retaining experienced nurses.

Eric Chan Lu-shek, the principal nursing officer of the HA, says the number of specialty training classes offered each year has nearly doubled.

The HA has also given nurses more promotion opportunities. For example, there are now more advanced practice nurses and nurse consultants and 50 nurses were promoted to nurse specialists in the year 2011-12.

But nurses are critical of the move. Kwan Chi-man, a nursing officer at the Queen Elizabeth Hospital, says the HA’s policy is ineffective in preventing nurses from leaving.

He points out that the nurses who have taken the specialty training courses are not necessarily promoted afterwards. “Taking the training course is only an entrance ticket, it can’t be cashed in for an immediate benefit,” he says. Kwan says there are just too many experienced nurses waiting for promotion.

Another registered nurse, Mary, not her real name, thinks the HA’s measures do not address the root cause of the problem. Mary left the hospital ward to work as a community nurse a couple of years ago due to the harsh working environment and duty-shift system.

She acknowledges the government has spent money on raising the number of advanced practice nurses. However, she points out this has not increased staff numbers on the wards.

“There were 10 nurses on the ward originally. There may just still be 10 nurses [after the promotion]. It is simply that one of them has changed his or her post,” she says.

As she sees it, the only way to tackle the work burden and stem the exodus is to increase the number of nurses on the wards.

The government has tried to cope with the increasing need for nurses. In 2008, it reopened nursing schools, which closed in 2000, to train both enrolled and registered nurses.

The schools were closed because the HA said it lacked the resources to run them at the time and the government wanted to upgrade the quality of teaching by offering nursing degrees at the universities.

After the reopening, 2,400 nursing students will graduate each year after 2014 from both the nursing degree programmes at four universities and from the nursing schools.

However, the number of nurses may still be insufficient to satisfy the community’s needs, especially as the population ages, health care services expand and disease patterns change constantly.

Also, the government’s attempt to fill the gaps left by experienced nurses with fresh graduates may not be an effective solution to the shortage problem.

Many seniors have complained that junior nurses are too inexperienced to handle working on their own and require a lot of help from the experienced nurses. This has added more pressure on top of their heavy workload.

Nursing Officer Wong Kam-man has also noticed that some university nursing graduates are not keen on working in the hospitals after graduation. Some may focus on conducting research or work in other industries instead. “They just want to get a degree,” Wong says.

Winnie Chan, a second-year nursing student at the Chinese University of Hong Kong (CUHK), appears to confirm this. She says more than 20 students transfer to other disciplines each year in her school.

“I think those who have transferred never wanted to be nurses, even when they entered [the school], they came just because they wish to transfer,” says Chan. “Entering nursing is not that difficult, and it’s easy to transfer in the CUHK.”

To Diana Lee Tze-fan, the director of the Nethersole School of Nursing at the CUHK, a long-term and coordinated manpower planning strategy is more important than the government’s current measures to tackle the shortage. The planning should take into account the changing patterns of chronic diseases and the need for community health care services in an aging society.

“What [we have from the government] now is a knee-jerk reaction,” says Lee. “There is an outcry in the hospitals now. This knee-jerk and short-term vision can’t really help.”

Apart from the lack of a coordinated manpower plan from the government, there is another side of the problem that is often overlooked. Some nurses think their profession is not respected in Hong Kong and this is another factor driving them to leave the field.

Chow Ting-kwan, a registered nurse working in the North District Hospital, says Hong Kong people usually regard doctors as professionals, but not nurses. Unlike the nurses in some other countries, those in Hong Kong cannot prescribe medicines to patients and give doctors their opinions on treatment. They have to listen to doctors’ orders.

“A nurse [in Hong Kong] is just a handyman or an assistant,” says Chow. “People don’t respect nurses like people in the foreign countries do.”

Nurse Mary seems to agree with Chow. She says a patient’s family member once accused her of not “serving” the patient well. She feels this showed a lack of respect. “I’m not here to ‘serve’ the patient,” says Mary. “But to ‘take care of’ the patient’s basic needs only!”

Mary says when a patient recovers, they usually think the doctors are great. They always thank the doctors first and may take for granted the efforts made by nurses during their treatment.

Mary sighs: “Nurses are always the forgotten ones. Doctors take the leading role but we are just foils at the back.”

Hong Kong Nurses’ Hierarchy

1. Enrolled nurses
Nurses who completed a nursing training programme which lasts for two years in a recognised training school and have enrolled with the HKNC.

2. Registered nurses
Nurses who completed a three-year nursing training in a recognised training school and have registered under the HKNC.

3. Advanced practice nurses
After working for several years, nurses can take a postgraduate course in advanced nursing practice in order to apply for the position of advanced practice nurse.

4. Nurse consultants
Nurses possessing a master’s degree in a clinical specialty. They should have achieved clinical excellence in a clinical specialty and a high level of professional standing.

(Sources: HKNC and Association of Hong Kong Nursing Staff)