Historically, Macao, a Special Administrative Region (SAR) in the People’s Republic of China, has been troubled by a shortage of nurses. This shortage became especially severe during the period immediately after the handover of Macao from Portugal to the People’s Republic of China in 1999. A fast-growing population, an aging population, the risk of epidemics, and competition for personnel with other industries have all contributed to this shortage. In recent years, Macao has implemented the following successful strategies to address the shortage: increased school enrollments, benefits, and professional development, along with the development of a clinical specialist program, a transition program for new graduates, and training for more certified nursing assistants. Strong government support and collaboration among all stakeholders have also served to enhance the nursing work force. In this article, the authors describe the nursing shortage in Macao SAR, discuss factors contributing to the shortage, and present strategies used to manage the shortage. They conclude by emphasizing the importance of increasing salary and professional status and providing transition programs for new graduates.
Keywords: nursing workforce, nursing shortage, Macao, nursing shortage solutions, government support, stakeholder collaboration
Macao Special Administrative Region (Macao SAR) was a Portuguese colony from 1887 to 1999. Since the transfer of sovereignty from Portugal to the People’s Republic of China, Macao SAR has operated under China’s policy of “one country, two systems.” This means that although Macao SAR is part of China, it still has a high degree of autonomy and its government policies and health care systems are different from those of mainland China.
...Macao faced a challenge in managing its health care workforce. The rapid growth of the population, along with other factors resulted in a significant shortage of nurses...Around the time of the sovereignty transfer, Macao faced a challenge in managing its health care workforce. The rapid growth of the population, along with other factors resulted in a significant shortage of nurses in the workforce. This shortage affected the quality of health care interventions, treatment outcomes, and even patient safety (Beadnell 2006; Leong, 2011; McDermid, Peters, Jackson, & Daly, 2012).
The causes of nursing shortages worldwide are attributed primarily to aging populations, increasing patient acuity, an explosion of knowledge and technology, and the ever-expanding role of nurses (Wolff, Pesut, & Regan, 2010). In Macao SAR, the lack of training resources, including limitations in budgets, faculty, and facilities have also contributed to the nursing workforce shortage (Solano & Rafferty, 2007). Macao SAR has recently developed various measures to address these factors and to strengthen recruitment and retention of staff nurses and nursing students.
Rosseter (2011) noted the benefits of the following measures for increasing a national supply of nurses: increased government and organizational grants for nursing schools to enlarge student numbers; improved benefits for nurses; creation of healthy work environments; and opportunities for personal development. However, the success and limitation of each of these methods are country or region specific. In this article, we describe the nursing shortage in Macao SAR, discuss factors contributing to the shortage, and present strategies used to manage the shortage in Macao SAR, with the goal of contributing to the understanding of the global nursing shortage problem. We conclude by emphasizing the importance of increasing salary and professional status and providing transition programs for new graduates.
...the top priority for the World Health Organization in 2006-2015 is to increase human resources in the area of health development. Although nurses are the largest component of health care professionals in Macao SAR, currently there are only 1,536 registered nurses in the region with a nurse-to-resident ratio 2.74:1,000 (Statistics and Census Service, 2011). This is a higher ratio than that of most other areas in China, which have an average ratio of 1.4:1,000 (National Bureau of Statistics in China, 2010). However, it is a lower ratio than that of other highly developed Asian regions, such as Hong Kong and Singapore, which both have a nurse-to-resident ratio of approximately 4:1,000 or above (Leong, 2011). Furthermore, as mentioned in the 55th World Health Assembly, the top priority for the World Health Organization in 2006-2015 is to increase human resources in the area of health development (World Health Organization, 2006), and this would certainly be applicable to Macao SAR. The government of Macao SAR has planned to increase the ratio of nurse-to-resident to 3.5 - 4: 1,000 by 2020 (Leong, 2011). With an estimated population of 829,000 people by the year 2020 (Statistics and Census Service, 2009), the total number of nurses will need to be increased by 50.1% within the next several years to achieve this goal.
A variety of factors contribute to the nursing shortage in Macao SAR. These factors, described below, include a fast-growing and aging population, competition for manpower from other industries, and epidemics that increase the demands of the nursing workforce.
Fast Growing Total and Aging Population
Since Macao SAR ceased being a Portuguese colony and became part of China in 1999, the total population of Macao SAR has increased by 28.9%, from 435,000 to 561,000. The major factor contributing to this increase is the immigration of Chinese people from mainland China, Hong Kong citizens, and overseas foreigners coming to work here. Additionally, the life expectancy of Macao SAR residents has risen dramatically from 77.6 in 2000 to 82.5 (male 79.5, female 85.4) in 2011. The proportion of the population over the age of 65 has now reached 8.32% (Statistics and Census Service, 2011).
Aging is a risk factor for chronic disorders, such as arthritis, diabetes, and cardiovascular diseases (Shi, Liu, Zhang, Lu, & Quan, 2008). Wolff, Starfield and Anderson (2002) reported that 82% of the elderly had one or more chronic conditions. The prevalence of chronic conditions between those 65 to 69 years of age and those who were 85 years of age or older were 74% and 88%, respectively. Moreover, Mion (2003) explained that chronic conditions can cause disability, and this disability may be exacerbated in those elderly having multiple chronic conditions. Consequently, the older population utilizes a large proportion of the health care services.
These factors have led to a high demand for practicing nurses in various health care sectors, including hospitals, community health centers, nursing homes, and senior centers (Kovner, Mezey, & Harrington, 2002; Mion, 2003). A study by Van (2010) estimated that, due to the aging population, 20% more nurses will be required in Macao by 2020, thus creating an even more severe nursing shortage.
Competing for Manpower with Other Industries
Since 2000, the per capita gross domestic product (GDP) of Macao SAR has increased by 160%, from 14,631 to 38,026 Macao patacas (1 U.S. dollar = 8 Macao patacas). This is mainly due to the expansion of the gambling and tourism industries, which account for 13.5% and 12.1% of Macao’s labor workforce, respectively (Statistics and Census Service, 2012a). These two leading industries may have absorbed a significant proportion of the potential nursing workforce, thus increasing the turnover rate of practicing nurses and also limiting the number of nursing school enrollments. Local universities have shared with us that they are seeing an increase in the number of high school graduates who prefer to enroll in the majors of business, accounting, administration, or convention exhibition, and a decrease in those seeking enrollment in nursing programs (Cheong, personal communication, October 21, 2012).
Unpredictable Epidemics Increasing the Demands of the Nursing Workforce
Macao SAR is reputed to be one of the most densely populated regions in the world with 1,935 people/km2. This is contributing to a high risk of epidemic outbursts, such as SARS, H1N1, and H1N5 bird flu, and seasonal flu. Macao SAR is also one of the most popular tourist destinations in the world. In 2011, there were 28 million tourists in MACAO SAR with an estimated yearly rate of increase of 12% (Statistics and Census Service, 2012b). These tourists increase not only the demands placed on the nursing workforce in treating those with highly contagious infections, but also the demands for providing preventive measures, such as vaccination and health care education seminars in community health centres, schools, customhouses, private clinics, and casinos. According to the government regulations, each casino must now set up a clinic to offer emergency health services, counseling, and health promotion education to the gamblers and staff. Plans for opening an increasing number of casinos will increase the demand for more nurses accordingly.
The following paragraphs will describe the primary strategies Macao SAR has used to address their nursing shortage. These strategies include improvements in benefits and professional status, expanding nursing school enrollments, training clinical specialists, providing transition programs for new graduates, and reducing nursing assistant workloads.
Improving Nurses’ Benefits and Professional Status
To tackle the nursing shortage, nurse representatives...have strongly lobbied the Macao SAR government to improve nursing benefits. To tackle the nursing shortage, nurse representatives including hospital nurse administrators, clinical managers, school directors, frontline nurses, and leaders of various nursing associations, such as Macao Sino-Portuguese Nursing Association, Macao Nurse Association, and Macao Nursing Staff Association, have strongly lobbied the Macao SAR government to improve nursing benefits. All of the above associations are professional, non-governmental organizations and are organized by nurses in Macao. These associations have conducted special seminars in order to discuss nursing-related issues with nurses and other professionals. Nurse representatives from the three associations listed above have also talked directly with Senators and/or the Chief Executive of Macao SAR.
In 2009, the Macao SAR government issued a new career policy placing nurses in one of six hierarchical categories, including junior nurse, senior nurse, clinical nurse specialist, senior clinical nurse specialist, chief nurse, and nurse supervisor. Table 1 exhibits the professional categorization scheme of nurses in the government hospitals. [view Table 1 pdf ] This policy has resulted in an across-the-board increase in nurses’ salaries from 33% to 42%. In Macao SAR, the government has financial control over the health care system and pays the nurses who are working in the government hospitals. For example, the baseline salary for an entry-level nurse (level I junior nurse) was increased from about 20,000 Macao patacas to about 28,000 Macao patacas (1 U.S. dollar = 8 Macao patacas) per month (Macao Government Printing Bureau, 2009). This increase has improved the status of nursing professionals, enhanced morale in the work place, and motivated nurses to seek further education. Since 2009, the actual turnover rate of staff nurses has remarkably decreased (Ma, personal communication, April 23, 2012), and more nurses without baccalaureate degrees have tried to enroll in the ‘Supplementary Program of Bachelor of Science in Nursing.’ The proportion of baccalaureate-prepared nurses has increased from 57.4% in 2006 (Liu, Yin, Ma, Lo, & Zeng, 2009) to 69.1% in 2011 (Cheong & Zhu, personal communication, April 23, 2012).
Expanding Nursing School Enrollments
Since 2008, the Macao SAR government has dramatically increased funding for nursing training, focusing on the undergraduate level and seeking to improve teaching facilities and increase faculty members.Since 2008, the Macao SAR government has dramatically increased funding for nursing training, focusing on the undergraduate level and seeking to improve teaching facilities and increase faculty members. Currently, Macao SAR has two nursing schools. One is a public school fully funded by the government, and the other one is a private school supported by the Kiang Wu Charitable Association. Both schools offer baccalaureate degrees in nursing sciences. The annual enrollment has increased by 50%, from a total number of 60 - 70 freshmen to about 130 freshmen since 2008 (personal communication from two nursing schools in Macao SAR). The government has also set up a special scholarship plan to attract highly qualified students and help them gain acceptance in domestic or overseas nursing schools. This plan has already enabled 204 students to enter the nursing programs since 2008 (Ng, personal communication, May 7, 2012). The first group of these students will enter professional practice in 2012.
Training Clinical Specialists
A lack of career development opportunities can affect nurses’ attitudes and desire to learn in a way that may eventually decrease the quality of patient care outcomes (Leong, 2011). In 2006, the Macao government health bureau, hospitals, and nursing education institutes worked together to introduce various types of clinical specialist postgraduate diploma (PGD) programs. These two-year, part-time programs include specific theoretical studies, projects, and a six- month clinical placement that includes four weeks of overseas experience. These programs are fully funded by the Macao SAR government, which provides free tuition and six-month clinical placement with full salary. During the six months of clinical placement, each student has a four-week overseas learning experience with partial financial support that includes transportation and accommodation costs. This four-week overseas experience is usually arranged in Hong Kong or Taiwan.
Informal feedback from graduates and current students indicates that these programs have encouraged them to remain in the nursing profession because they are now more satisfied with their advanced career skills and opportunities. By the end of 2012, 110 clinical registered nurses will have already graduated from these programs; most of them are now practicing as nurse specialists in various clinical specialty areas in Macao SAR. Informal feedback from graduates and current students indicates that these programs have encouraged them to remain in the nursing profession because they are now more satisfied with their advanced career skills and opportunities.
Providing a Transition Program for New Nursing Graduates
...the Macao SAR health bureau and nursing institutes now provide a six-month training program that includes use of simulation models to smooth transition from the student role to the staff nurse role.Nursing is one of the most stressful professions (Hamaideh & Ammouri, 2011; Rella, Winwood, & Lushington, 2008), particularly for new graduates. The stress is due to several factors: lack of experience with a fast-paced, work environment; difficulties in applying what students have learned; difficulties in handling patients’ complaints concerning the appropriateness of treatment; and dealing with death and dying patients (French, Lenton, Walters, & Eyles, 2000). As a consequence, some new graduates leave the profession every year. The Student Affairs Office at Macao Polytechnic Institute has shared with us that about 5-7% of the new graduates leave the profession early (Lei, personal communication, April, 23, 2012). Therefore, the Macao SAR health bureau and nursing institutes now provide a six-month training program that includes use of simulation models to smooth transition from the student role to the staff nurse role. The program is funded by the Macao SAR government and conducted in the local hospitals, while nursing schools support the development of the training curriculum. Each graduate participant receives 15,000 Macao dollars (about 1,880 U.S. dollars) allowance monthly. A description of this training is provided in Table 2. The trainers include clinical nurse supervisors, head nurses, physicians, hospital managers, nutritionists, and senior laboratory technicians. Evaluation of the effectiveness of this transition program in the retention of new graduates is currently in progress.
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Reducing the Workload by Training Nursing Assistants
Excessive workload of nurses not only reduces quality of patient care (Al-Kandari & Thomas, 2008; Hegney, Plank, & Parker, 2003), but also adversely affects nurses by threatening their physical safety, lowering job satisfaction, causing burnout, and increasing turnover rate (Clark, Sloane, & Aiken, 2002). One of the effective strategies for reducing nurses’ workload is utilizing support personnel to assist nurses in patient care (Hogan & Playle, 2000). In Macao SAR, more than 90% of hospital beds are constantly occupied, leading to a substantial workload for health care professionals, including nurses (Macao News, 2011).
In order to use support personnel, the hospitals and nursing institutes (schools), since 2008, have continuously offered a Certified Nursing Assistant (CNA) training program to members of the public who are interested in working with nurses in the hospitals or other health care sectors. It is a fully funded program by the Macao SAR government. The program consists of two levels, basic and advanced, with each requiring 120 hours of classroom and 240 hours of on-the-job training for the programs. Upon successful completion of the basic program, the graduate is authorized, as a Certified Nursing Assistant, to perform certain tasks under the supervision of a registered nurse. These tasks include general ward restocking; tidiness and cleanliness; and assisting patients with meals and personal hygiene. Advanced CNAs can perform more highly skilled tasks, such as conveying specimens and mouth care. Presently, about 252 out of 280 trained CNAs are practicing, which has greatly alleviated the workload of registered nurses.
Macao SAR has identified the need for all stakeholders to work together to implement, as soon as possible, effective strategies to reduce nursing shortages.In summary, the nursing shortage is a global issue. Though small in both population and geographic territory, Macao SAR faces the same nursing shortage problem as do other countries or regions. Macao SAR has identified the need for all stakeholders to work together to implement, as soon as possible, effective strategies to reduce nursing shortages. Specific strategies that have contributed to Macao SAR’s success in alleviating the shortage include improving nurses’ benefits and professional status, expanding nursing school enrollments, training clinical specialists, providing a transition program for new nursing graduates, and reducing the workload by training nursing assistants. We have noted that enhancing salary and promoting personal development can effectively increase nurses’ morale and intentions to stay in nursing. Additionally, providing transitional programs for new graduates for reducing their stress and facilitating their adaptations to nursing practice is also an effective way to keep them in the nursing profession.
Ming Liu, PhD, RN
Dr. Liu is a Professor and Dean of the School of Health Sciences, Macao Polytechnic Institute, Macao SAR. She received her MSN degree and PhD from Chiang Mai University in Thailand. Dr. Liu is experienced in both academia and clinical practice. She has conducted research in clinical nursing and nursing education, and has published numerous articles in professional journals.
Bernice Lam, MSc, RN
Ms. Lam is a Lecturer and Coordinator of the Post Graduate Diploma in Specialty Nursing program in the School of Health Sciences, Macao Polytechnic Institute, Macao SAR. She received her MSc degree in education from Macao Inter-Universities Institute and currently is a PhD candidate at Macao Saint Joseph University. Ms. Lam’s nursing career has included nursing education, community health nursing, and nursing management. Her research focuses on Advanced Practice Nursing education and nursing management.
Pedro Fong, PhD, MRPharmS, MRSC
Dr. Pedro Fong is a Lecturer of the School of Health Sciences, Macao Polytechnic Institute, Macao SAR. He received his Master of Pharmacy degree and a PhD from the University of Manchester, United Kingdom. He is a member of the Royal Pharmaceutical Society and the Royal Society of Chemistry of Great Britain. His research is focused on healthcare professional education and computer-aided drug design.
Hao Bin Yuan, PhD, RN
Dr. Hao Bin Yuan is an associate professor at Macao Polytechnic Institute. She graduated with a Doctor of Philosophy (PhD) in Nursing from Chiang Mai University in Thailand. Dr. Yuan has been an accredited trainer for the Joanna Briggs Institute Comprehensive Systematic Review since 2007. Her professional experiences include both nursing education and research, with a focus on evidence-based nursing practice and education. She has published numerous research papers in international and Chinese professional journals.
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