Director of CUHK’s Nethersole School of Nursing shares her take on manpower and maximising the role of nurses in Hong Kong

MIMS Hayes Chu

In June 2017, the government released its long-awaited Strategic Review on Healthcare Manpower Planning & Professional Development report. According to the report’s best guestimate, there will be a shortage of 1,669 general nurses by year 2030.

However, the report has quickly come under fire since its release. Despite the projected shortfall, critics from the nursing sector commented the number is still largely underestimated.

In this exclusive interview, Professor Sek-Ying Chair, Director of the Chinese University of Hong Kong (CUHK)’s Nethersole School of Nursing, sits down with us for an in-depth discussion pertaining to this topic. As the Director of the No. 1 School of Nursing in Hong Kong (according to QS World University Rankings 2016 & 2017), Chair shares with us her views on the manpower issue—and her insights into alternatives to maximise the role of nurses in the city.

Three reasons why a manpower forecast based upon the existing service level, model and data is less convincing

The forecast of manpower on nursing—including general, mental and midwifery—is based upon the much-disputed assumption of “the existing service level and model will remain unchanged throughout the projection period and no new services will be provided”. Chair summarises for us the three reasons explaining why such assumption is less convincing.

Firstly, the current nurse-to-patient ratio is unable to meet the needs in reality. The number is far below international standards.

“Nowadays, many critically ill patients with complex conditions are admitted to hospitals. For those who are less critical or just require simple treatment, they can be handled with ambulatory care settings,” elaborates Chair. “Even so, the current average nurse-to-in-patient ratio in acute hospital unit is 1:10, which is far below the international standard of 1:4-5. During peak seasons, such as the winter surge period of influenza, the hospital occupancy may even reach 120% to 140%,” she adds.

In view of the complexity of the cases today, the severe nurse shortage is posing a huge challenge, particularly in upholding safety and quality of nursing care.

The second reason is the misleading count of the number of nurses in the report. Chair points out the number may “underestimate the actual needs to fill up the manpower gap”.

“Registered nurses (RNs) and enrolled nurses (ENs) should not be lumped together (in counting) because of the difference in their qualifications, capacities and functions,” clarifies Chair.

RNs refer to those who have completed a 5-year bachelor’s nursing programme provided by local higher education institutions, or a 3-year nursing programme provided by hospital-based nursing schools; whereas ENs refer to those who have completed a 2-year nursing programme in the hospital or higher education institution setting. According to Chair, RNs and ENs serve in different capacities and they function in a relatively distinctive way.

Students learning patient management and life support skills in a high-fidelity simulated ward environment.

“Generally speaking, ENs can only fulfil partially the complete professional role of RNs because of their educational preparation as well as their specialty training and related experience,” explains Chair.

In addition, the existing healthcare environment where nursing workforce is predominantly used for hospital-based care contributes to the final reason—why such manpower forecast is a concern.

Chair opines that the report should be interpreted cautiously. “With the shift of caring model, the report may have underestimated the nursing manpower needs in preventive and rehabilitative care settings,” she shares.

“Overall, a comprehensive approach should be taken in planning and forecasting nursing manpower. We have to be attentive to not only acute care, but also preventive and rehabilitative care; not only hospital setting, but also ambulatory and community settings. Reasonable nurse-to-patient and nurse-to-population ratios should be set with reference to the international standards,” advises Chair.

Reforming the Licensing Examination as a pre-requisite to increasing its frequency

To address the understaffed issue, the manpower report recommends increasing the frequency of the Licensing Examination—to increase the non-locally trained nurses. Chair, however, looks at this issue from a different perspective.

“We need more quality nurses to serve our patients and the entire population of Hong Kong. Although the Licensing Examination is certainly one of the better ways to attract international nursing talents from overseas such as Australia and Canada, the passing rate of the Licensing Examination is exceptionally low,” echoes Chair.

“I have come across a case when even a Registered Nurse Practitioner, who had practised for a few years in the United States, actually failed the examination. As I know, many overseas nurse graduates failed the examination—not because of their professional inadequacy, rather due to their unfamiliarity with the relatively out-dated examination format and content,” laments Chair.

Therefore, a reform of the Licensing Examination appears to be imperative to curb this impediment. “We need to revisit and revise the examination format and content to make sure the examination keeps pace with time—and appropriate for assessing nurses’ professional knowledge and competencies.”

The authorities may then consider whether they increase the frequency of the Licensing Examination after the reform. Chair suggests that a detailed and careful examination of the resources—including manpower resources—is also required to increase the frequency of the examination.

Two pieces of advice for nurses to overcome stress at work

While it takes time for the government to carefully revisit the manpower report and formulate long-term strategies, Chair understands nurses are now working under immense stress.

“Not just for the nursing field, due to technological advancement in the society where we now have higher standard and easier access to information—people in all kinds of industries are becoming more stressed, in comparison to our past generations,” laments Chair. “The manpower shortage and growing complexity of diseases further fuel the issue,” she adds.

Chair emphasises that teamwork plays an indispensible role under such circumstances. “It’s less stressful for nurses to overcome challenges if they can build rapport and work in a happy and healthy environment,” she explains. “Instead of drawing borders to nurses who need help, things may become easier if nurses could help out and give more support to each other,” advises Chair.

Skill laboratory setting similar to ward environment.

Another advice for nurses is to convey a clear message to patients and their family members to avoid any misunderstandings.

“Nurses are busy. Sometimes, we are used to communicating with the patients and their family members in a very fast paced manner. We assume they understand; but they might not have received (understood) what we wanted to convey,” elaborates Chair. “We take much more time and effort to resolve a complaint or miscommunication, in the end. This eventually brings us more stress in return. Therefore, we should avoid such cases right at the beginning.”

Though the work schedule is hectic, Chair stresses the importance of communication with patients and their family members. “When we approach the patients, try to explain to them why we are here, and what we are planning to do for them. Do not use any technical jargons. Elaborate more if the patients are confused, ensure they fully understand the situation,” expresses Chair.

Ultimately, this would help foster a harmonic and healthy relationship among nurses, patients and their family members.

Maximising the role of nurses

In optimising the use of nursing talents for the provision of healthcare services, Chair comments that the levels and roles of nurses should be differentiated according to their qualifications, experience and specialty skills, so as to achieve the best health outcomes in a cost effective way.

“Readmission to hospital, which costs around HKD4,830 per day, could be minimised with the expansion of nurse-led clinics and community services, which costs only approximately HKD535 per day,” Chair raises an example which was indicated in a press release jointly issued by the Hong Kong Academy of Nursing and the schools of nursing of the Chinese University of Hong Kong, the Hong Kong Polytechnic University and the University of Hong Kong.

With an ageing population and the increasing prevalence of chronic illnesses, healthcare reform is inevitable in a government subsidised healthcare system, like Hong Kong.

Over the years, nurse-led clinics operated by clinical nurse specialists or advanced practice nurses have continued to expand and have demonstrated satisfactory patient outcomes. Nurses in these clinics either practise independently; or undertake supervised adjustment of medications; or initiate treatment according to protocols for timely patient care.

Besides, there are nurse consultants who are expected to function comparatively to nurse practitioners in western countries. In view of the increasing demand for primary and hospital care services coupled with doctor shortage in Hong Kong, Chair suggests that nurse consultants could be further empowered to fill this gap.

To achieve this goal, Chair points out that the city needs more quality nurses to take up high level nursing roles to meet the complex healthcare needs and to support the healthcare reform in Hong Kong.

She also highlights the need for the government to increase UGC-funded nursing student quota to admit more high calibre students to become future nurse leaders—who shall become capable of taking up new and extended roles of nurses.

With the increasing healthcare needs and the expanding roles of nurses, future nursing manpower planning should take into account the provision of services in different care settings from a comprehensive perspective—with the projection of demand for nurses to meet both short-term and long-term healthcare needs of the community, as a whole.

Contributing to the nursing and healthcare development

According to the QS World University Rankings 2017 for the subject of Nursing, the Nethersole School of Nursing ranks No.1 in Hong Kong, No. 3 in Asia, and No. 27 in the world.

The Clinical Learning & Simulation Centre is equipped with Advanced Patient Simulation Systems, allowing the design of tailor-made case scenarios to support students’ clinical learning.

In the past 25 years, the school has nurtured more than 5,000 competent and caring nurses to serve in the community. Each year, they receive over 6,000 applications for about 200 places, and has remained the largest UGC-funded nursing programme with impressive admission GPA.

“I am glad that our efforts and achievements have been locally and internationally recognised,” expresses Chair gratefully. “As the leading nursing institution in Hong Kong, our school will continue to excel in nursing education and research—as we foster more capable nurse leaders and professionals—to promote nursing and healthcare quality in the city.”

The school is also the first nursing institution to admit students via the highly competitive Hong Kong PhD Fellowship Scheme. Till date, they have admitted six PhD nursing students via this scheme, which is the most among local UGC-funded universities.

Apart from academic achievements, the school has also conducted a lot of quality research to inform best nursing practices, and knowledge transfer research projects to empower the public for self-management and health enhancement.

Simulation training to care patient with complex health

When being asked about what contributes to the success of the school, Chair highlights the importance of partnership with the original Nethersole School of Nursing—which was established under the Alice Ho Miu Ling Nethersole Hospital in 1893 as the first hospital-based nurses training school in Hong Kong.

Apart from regular workshops organised by the Nethersole Hospital—which enable students to know more about the history of the nursing profession in the city—Chair mentions that it shares the same motto with CUHK in nursing education: to nurture students who can provide compassionate care to the sick.

“Skills are easily acquired, but it takes much more time and efforts to nurture the students so that they can take good care of the patients with love and empathy,” emphasises Chair. “We also encourage them to reflect on their civic responsibilities. Apart from patients in the hospital, shouldn’t care also be given to the needy in the society?” quips Chair, with a smile. MIMS