Nurses in Malaysia

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. Narudin 3 RN, BScNursing(Hons) 1 Associate Professor, School of Nursing and Midwifery, 2 PhD Candi Candidate, date, Monash Unive University rsity,, Victoria Victoria,, Australi Australia, a, 3 Deputy Dean, Fakulty Fakulty of Nursing and Allied Health Sciences, Selangor Selangor International International Islamic Unive University rsity College, Bandar 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 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 Keywords Occupational Health, Work Work Environment, Workforce Workforce Shortages

Introduction Few countrie countriess or nati nations ons are unt untouc ouched hed by what has been described describ ed as the ‘crisis ‘crisis in nursi nursing’ ng’, a critical shortage of profes profes-siona si onall nu nurs rses es to de deli live verr ca care re,, lar large gely ly in theacut theacutee he heal alth th ca care re se sect ctor or

Correspondence address: Tony Barnett, School of Nursing and Midwifery, Monash University,, Churchill, Vic. 3842, Australia; Tel: 613-990-26636; Fax: University 613-990-26527;; E- mail: [email protected]. 613-990-26527

© 2010 The Authors. Journal compilation © 2010 International Council of Nurses

(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 supply of nurse nurses, s, especi especially ally new graduates, graduates, has been attributed attribut ed to a variety of factor factorss 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 (wh o may regard nursing nursing as a les lesss attr attract active ive career career cho choice ice), ), attrition or poor course progression, as well as the closure or

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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 populations, tio ns, incr increas eased ed con consum sumer er acti activis vism m and rapi rapid d evo evoluti lution on of medical technologies’ (Simoens et al. 2005, p. 4) 4) as well as population growth and the associated associated burden of disease. This demand has been exacerbated by the aging of the workforce (resulting in moree nur mor nurses ses ret retirin iringg or see seeking king part-time part-time wo work); rk); less than optimal separation separation rates from the industry; globaliz globalization ation of the labour market; and an increased propensity for nurses to seek alternative (though often health-related) careers. Low job satisfaction, associated with a poorer quality of working life, can impact on both the current and future workforce workforce (Blegen 1993; 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 long-t erm 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 countri es (Buchan (Buchan & Calman 2004; 2004; Lee et al. 2007 2007). ). For example, example, in Ch China ina,, wh whil ilst st the nu numb mber er of nu nurs rses es is re repo porte rted d to ha have ve 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 nursess or 1.6% of the total registered nurse workforce nurse workforce (Preston (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 increa increase se 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). 2006). In common with many other developed countries, this reflects a sustained demand for nurses and midwi midwives ves against a backdr backdrop op of insuffi insuffi-cient local supply (Tan 2003). In response to this situation and to bol bolste sterr loc local al sup supply ply,, Sin Singap gapore ore has rec recent ently ly inc increa reased sed the numbe nu mbers rs of st stud udent entss tak taken en in into to nu nurs rsing ing co cour urse sess and als also o expanded the number of institutions conducting courses. To describ describee and analyse the nursi nursing ng shortage in Malaysia,

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bases using full and truncated keywords such 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. experie nce. Collectively Collectively,, the authors have had many decades of exp experie erience nce with nur nursin sing, g, nur nurse se edu educati cation, on, res resear earch ch 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 provided 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 Statistics Malaysia 2008). 2008). It has an ageing population with the proportion 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-com noncommun munica icable ble dis diseas eases es as wel welll as wor workfo kforce rce sho shortag rtages, es, 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. Approximately two-thirds of nurses work in the government (public) sector where they are encouraged to work full-time and are generally required to retire upon reaching the age of 55 or 56. Due to historical histo rical and cultu cultural ral 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-y 3-year ear dip diploma loma lev level el qua qualific lificati ation, on, tho though ugh 4-y 4-year ear degr degree ee 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 employer’ss con er’ contrib tributi ution on to the cost of the their ir edu educat cation ion.. Ent Entry ry to a nursing course is usually restricted to high school graduates. For the diploma, entry level is most commonly the Sijil Pelajaran Malaysia (SPM equiv equivalent alent to ‘O-l ‘O-levels evels’’ i.e. succ successfu essfull completion completion





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T. Ba Barn rnet ettt et al al..

Table 1 Total number of nurses and nurse/population ratios in Malaysia (1996–2006)** (1996–2006) Year

Total no. of nurses (Jururawat Desa)

Nurse : population

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

20 056 24 545 23 672 27 236 31 129 33 295 35 280 36 784 40 220 44 120 (15 618) 47 642 (16 667)

1:1055 1:883 1:937 1:834 1:747 1:715 1:695 1:681 1:636 1:592 1:559

*Source:: Ministry of Health, Malaysia (2007). *Source

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. 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). 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 popula tion ratio, in line with simila similarr ratios in some neighbourneighbouring 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 graduat graduates es within the workfo workforce rce 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 shortages. These are generally directed to either increasing supply, reduci red ucing ng dem demand and and and/or /or imp improv roving ing the ret retent ention ion of nur nurses ses

re-structuring the workfo re-structuring workforce rce and subst substitutin itutingg other types of worker wor kerss in pla place ce of nur nurses ses.. Ini Initia tiativ tives es may also be tak taken en to improve the working environment and support retention (Jasper 2007). A number of these measures are listed in Table Table 2; some of which have been implemented in Malaysia.

Increase supply The Malaysian Malaysian authori authorities ties have increased the number of publi publicc and private institutions providing nursing courses and have also increased the total number of students (Cruez 2006). That these places have been filled, suggests a continued demand for nursing although some school graduates see nursing as an opportunity to leave home at a younger age than would otherwise be the case, and the more recent availability of student loans though the nationa nati onall high higher er edu educati cation on fun fund d (th (thee Perbadanan Tabung Pendidikan Tinggi Negara Negara). ). As schools and colleges 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 competent 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 les lesss exp experie erience nce.. A new gen generat eration ion of grad graduat uates es will als also o hav havee different attitudes toward patients and those in authority than their predecessors. This has been identified as a factor contributing to the recent, widespread public and political criticism levell lev elled ed at nur nurses ses;; thei theirr poor att attitu itudes des to towar ward d pati patients ents and decline in the standard of care they provide (Chua 2006a). In response to such such criticism, the introduction of symptomatic programmes, such such as the ‘7S soft skill’ behavi behaviour our change pilot by the Minist Min istry ry of He Health alth Mal Malays aysia ia (T (Tabl ablee 3), 3), hav havee ten tended ded to pla place ce responsibility on nurses themselves rather than the structural, social and political determinants of care such as staffing shortages, working conditions, the lack of support provided to new staff sta ff or ful fully ly app apprec reciat iatee the gen generat eration ional al cha change ngess tha thatt hav havee occurred in the workplace (Stuenkel & Cohen 2005). An over emphasis emphas is on soft or ‘be nice nice’’ skills, which focus upon the inter-






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Table 2 Respons Responsee options to nurse workforce shortages Option

Measure

Increa Inc rease se suppl supplyy

• Increas Increasee the the num number ber of nursi nursing ng scho schools ols and entr entrants ants to pre pre-reg -registra istration tion cou courses rses.. • Improv Improvee the public image of nurses, promote promote positive professional professional self-image (to help attract a larger number of quality applicants to courses) courses).. • Reduce attrition attrition associated with training. training. • Encourag Encouragee re-entry of RNs who have left the workfor workforce ce (e.g. by maintaining or improving benefits and entitlements). • Increa Increase se in-migration (and reduce out-migration). out-migration). • Change Change staf staffing fing mix (red (reduce uce reli relianc ancee on RNs) RNs).. • Re-con Re-configure figure role, relationships relationships and work function of the RN. • Better match graduate attributes with future workforce workforce needs (modify or enhanc enhancee curricula and training provided in preparatory courses).. Address challenges associated with the theory-practice gap. courses) • Improv Improvee the mentorship and support provided to new graduates and experienced clinicians. clinicians. • Improv Improvee rewards, benefits benefits and working conditions including workloads and staffing levels. • Increa Increase se worker’s control over work (improve professional professional autonomy and equivalence by reducing hierarchical hierarchical control and dominance of the workplace by powerful others). • Create the conditions conditions for greater flexibility and participation in the workforce workforce (to allow part-time work and better support re-entry to the workfor workforce). ce). • Formalize succession succession planning planning at all levels. • Improv Improvee the clinical career structure and career mobility mobility • Extend ‘compulso ‘compulsory’ ry’ retirement age • Reduce occupational occupational hazards (e.g. workplace violence and abuse, back and needlestick injuries), provide adequate compensation compensation for accidents and injury, improve Occupational Health and Safety (OH&S) generally.

Reduce Redu ce dema demand nd Improve retention (reduce workforce separation rates)

RN, registered nurse.

Table 3 The ‘7S’ system to help help improve improve nursing’s nursing’s public image* image* Term in Bahasa Malaysia (translation)

Meaning

Senyum (smile) Salam (g (gre reet etin ing) g) Segara (prompt/urgent/ without delay) Sensitif (s (sen ensi siti tive ve))

To remember to smi le le To gr gree eett or we welc lcom omee in a fr frie iend ndly ly wa way y To act promptly or quickly, to be responsive

Sopan (polite/respectful/ courteous) Sentuh (t (tou ouch ch)) Segak (smart looking/ elegant/chic)

*Source: Tee (2006).

To be se sens nsit itiv ivee to th thee ne need edss of pa pati tien ents ts an and d families To be polite and respectful during interactions Use of pe pers rson onal al to touc uch/ h/ap appr proa oach ch (w (wit ithi hin n cultural conte context) xt) To maintain a profession professional al (smart) appearance

competence and achievement of professionhood, takes time and resources – a requirement not always acknowledged by health workforce planners and policymakers. The risk of not providing such support can be an escalation of workfo workforce rce retention retention problems, low staff morale, stress and burnout; all of which may adversely adve rsely affect care delivery and patient outcomes. outcomes. In recogn recogniition of this, some steps have been taken to roll-out a mentorship scheme for new graduates in Malaysia (Chua 2006a; Materia Medica Med ica Mal Malays aysiana iana 200 2006) 6) thou though gh to dat datee neit neither her form formal al grad graduat uatee nurse programmes nor profe professiona ssionall supervis supervision ion programm programmes es (Hyrkass et al. 2006; White & Win (Hyrka Winstanley stanley 2006) that could draw upon the country’s stock of retired nurses have been widely adopted. The nursing workforce has become globalized (Kingma 2007). Increasingly, employers (and governments through immigration policy) recruit nurses internationally – further contributing to the shortage of nurse nursess in those countries countries they target for recrui recruittment,, inc ment includ luding ing Mal Malays aysia ia (Ch (Chua ua 200 2004). 4). Com Compara parativ tively ely low wages the high standard standard of educat education ion provided, provided, with its focus on





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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 enhanc enh ancee thei theirr qua quality lity of life in lat later er yea years rs by spending spending tim timee earning significantly more income overseas. In addition to increasing the supply of nurses, other options to addres add resss wor workfo kforce rce shortages shortages are to red reduc ucee dem demand and 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 presence and influence of the RN (Chua 2006b).

Improve retention Shortages can be addres Shortages addressed sed by impro improving ving 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 education throughout the world (Bryant 2005 2005). ). A strategy implemented by the authorities in Malaysia has been to prescribe the mini minimum mum amou amount nt of cli clinic nical al exp experie erience nce a stu student dent is req requir uired ed 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 Malays Mal aysia ia hav havee imp improv roved ed and a rang rangee of mea measur sures es hav havee bee been n tak taken en to support professionalization (Tee 2006). Staged opportunities have been introduced for nurses to upgrade their qualifications qualifications

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, violenc viol encee (Ja (Jacks ckson on et al. 200 2002), 2), need needles lestick tick and bac back k inju injuries ries (Kong & Chor 2007) as well as stress. As found elsewhere, these hazard haz ardss hav havee bec become ome the ‘new’ epidemic epidemicss of the pro profes fessio sion n (Pete (P eterso rson n & Ma Mayhe yhew w 200 2005) 5) and als also o exa exacer cerbat batee the nur nursin singg shortage in Malaysia. A failure to address these workplace concerns 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). 2005 ). Und Under-re er-reporting porting of work-r work-related elated accidents and occup occupaational 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 requirements; the absence of established procedures; fear that notification may affect contractual agreements between the employee and the employer (Rampal 2000); and because workplace psychosoc cho social ial and mus muscul culosk oskele eletal tal pro proble blems ms or inju injuries ries can be regarded as less important in many work settings (Sadhra et al. 2001). These findings also apply to the variety of clinical environments 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 grow gr owin ingg evi evide denc ncee to su sugg gges estt tha thatt fe few w nu nurs rses es su survi rvive ve th thei eirr working life without sustaining an injury of some description (Smith et al. 2004). A significant proportion proportion of these injuries injuries are






tive association association betwe between en stres stresss and muscu musculosk loskeletal eletal injuries, includ inc luding ing thos thosee of the bac back. k. Alth Althoug ough h anec anecdot dotall allyy com common, mon, 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 thee us th usee of sl slid idee sh sheet eetss an and d li lift ftingdevic ingdevices es)) is no nott wid wides espr prea ead d in th thee hospital hospit al sector. A range of strateg strategies ies to preve prevent nt workplace back injury inju ry cou could ld be imp implem lement ented ed mor moree ext extens ensiv ively ely in Mal Malays aysia ia (Wong 2007). Elsewhere, these measures have included: worker education, educat ion, workp workplace lace modification, modification, the use of lifting teams, teams, exe exerrcise programmes, and the develo development, pment, implementation implementation and monitoring of manual handling policies (Mitchell et al. 2008; Vieira et al. 2006). Such measures may be embraced within a broader bro ader ‘no lift lift’’ pol policy icy tha thatt aims to eli elimina minate te or min minimiz imizee manu ma nual al han handl dlin ingg and cr crea eate te a cu cult ltur uree th that at su supp pport ortss th thes esee changes by management (Passfield et al. 2003). Needlestick/sharp injuries Needlestick/sharp 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. 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 represent only the tip of the iceberg. Whilst national reporting guidelines have been developed and widely distributed distributed to health care agencies (Occupational Health Unit Ministry of Health Malaysia 2002, 2005), nurses and other health industry workers can demonstrate a reluctance to report such injuries due to ignorance or fear of reprisa reprisall (Lee & Noor Hashim 2005). 2005). Staff education and support as well as more widespread use of needle-free devices are important injury prev prevention ention strateg strategies ies (V (Vaughn aughn et al. 2004 2004). ). These could be implemented more widely in clinical areas in Malaysia (Mohamad & Ismail 2003), though unless critical staffing shortages are addressed, the pressures of work will encourage encourage staf st afff to ta take ke pr proc ocedu edural ral sh short ortcu cuts ts,, ab aban ando don n mo more re ti time me-consuming consu ming safe practices and escalate the risk of injury injury.. The impl impleme ementat ntation ion of bac back, k, need needles lestick tick and oth other er inj injury ury prevention policies, as well as having a direct effect on nurses, will also impact on other dimensions dimensions of the work environment. environment.

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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 be been en fa favo vour ured ed ov over er oth other er st strat rategi egies es su such ch as bo boos osti ting ng 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 experie exp erience nced d cli clinic nical al nur nurses ses and nur nurse se edu educat cators ors.. Whi Whilst lst 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 Meas ures to impro improve ve the work environment environment should be effective and visible. In this way, both old and new staff will be less likely to leave (Tzeng 2002). These could include more realistic workload worklo ad determ determination inationss that focus on the profes professional sional patient care responsibilities of the RN and better reward both educational tion al and exp experie erientia ntiall ach achiev ieveme ements nts.. Add Additi itional onal stra strategi tegies es should also be implemented to reduce the risk of injury. These may include regular, systematic workplace risk assessments and more effective implementation implementation of policie policies, s, procedures procedures to minimize manual handling and other potentially injurious activities. The introduction introduction of more flexible employment employment options such as part-tim part -timee wo work, rk, fami family ly frie friendly ndly prac practic tices es and ext extend ending ing 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 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’ bucket’ and create the conditions conditions in which the ful fulll bene benefits fits of an inc increa reased sed dom domest estic ic sup supply ply of nur nurses ses may be realized realiz ed and enjoy enjoyed ed well into the futur future. e.







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