Development of Nursing Education in Malaysia Towards the Year 2020

Department of Higher Education
Ministry of Higher Education Malaysia

University Publication Centre (UPENA)
Universiti Teknologi MARA l SHAH ALAM l 2010

© Ministry of Higher Education Malaysia 2010

All rights reserved. No part of this publication may be reproduced or transmitted in
any form or by any means, electronic or mechanical, including photocopy, recording,
or any information storage and retrieval system, without permission in writing
from Department of Higher Education, Ministry of Higher Education Malaysia.
e-mail: [email protected]

Perpustakaan Negara Malaysia Cataloguing-in-Publication Data

Development of Nursing Education in Malaysia-towards the year 2010
References: p. 55
ISBN 978-967-363-172-8
1. Nursing--Malaysia. 2. Nursing--Practice--Malaysia.
610.73

Cover design : Mohd Nor Firdaus Mohd Isa
Typesetting : Ahmad Basrah Mohd Yasap
Typeface : Helvetica/Times
Typesize : 11/12

Printed in Malaysia by :

Contents

Preface vii

CHAPTER 1 INTRODUCTION 1

CHAPTER 2 HISTORICAL DEVELOPMENT OF NURSING IN MALAYSIA 3
7
Summary
9
CHAPTER 3 THE STATUS OF NURSING IN MALAYSIA 9
9
Nursing Education 11
13
Basic Requirement of Nursing Education 18
21
The Diploma Programme 22
22
The Degree Programme 22
25
Graduate Education 29
32
Other Educational Programmes
39
Nursing Practice 39
39
Nursing Practice Defined 40
40
Scope of Nursing Practice 41
42
Realities about Nursing in Malaysia 44
45
Nursing Research 46
47
Nursing Autonomy



CHAPTER 4 VISION 2020 FOR NURSING

Addressing Nursing Needs and Issues

Agenda One

Agenda Two

Agenda Three

Agenda Four

Agenda Five

Agenda Six

Agenda Seven

Agenda Eight

Agenda Nine

Agenda Ten 48
48
Agenda Eleven 49

Proposed Plan of Action 53

CHAPTER 5 CONCLUSION 55

References

vi

Preface

I would like to congratulate the Department of Higher Education, Ministry of Higher
Education Malaysia, for initiating this project.

The focus of this report is on the increasing complexity of preparing nurses in Malaysia
and our preparations toward the year 2020. In the past decades, new and innovative
pathways have emerged to prepare nurses for future healthcare challenges in a consumer-
driven and competitive environment. Therefore, we take those responsibilities seriously to
prepare our nurses to meet the challenges ahead.

It is our intention for the higher learning institutions which offer the Bachelor of
Nursing programme, to initiate subjects and courses that can help to enhance professional
development, prepare for a broader scope of practice, provide a better understanding of the
cultural, political, economic and social issues that affect patients and care delivery.

Hence, this report is intended as a guide to improve the existing nursing curriculum at
tertiary level, in order to prepare future nurses for the challenges that await them.

On behalf of the committee, I thank the Ministry of Higher Education Malaysia as
an academic leader for allowing nursing education to grow. From this point, this field of
study could be developed further, churning the aspects of research, human relationship and
community building as a way of demonstrating tangible outcomes to the society.

ASSOCIATE PROF. DR. HAMIDAH HASSAN
Chairman,
Nursing Education Task Force
Ministry of Higher Education Malaysia



Chapter 1

Introduction

Nursing in Malaysia earns its heritage from the British. While British nursing has
evolved with time, the old British system is still with us. In nursing service, for example,
we continue to use such nomenclatures as matrons, sisters and tutors and yet have not
gained much in terms of autonomy and empowerment. Nursing practice is task oriented
based almost entirely on doctors’ orders. Leadership remains subservient to the medical
profession either because it provides stability, or because nursing does not know how to
get out of it. For example, the Nursing Board of Malaysia is chaired by a medical doctor
for the last 60 years. Presumably, Malaysia remains the only country in the world that has
a board headed by a medical doctor. In Britain, all of these have changed. There are no
more matrons and sisters. They have a Nursing Council (The UK Nursing Council) which
has control over nursing practice and the Head of the Council is a nurse. Thailand Nursing
Board (chaired by a doctor) had changed to a Nursing Council in 1986 and has a nurse as
its chairperson. South Africa has changed its board to a council in 2005, also headed by a
nurse.

In nursing education, the emphasis remains on teacher-centred and didactic in
approach in most colleges, despite changes in the educational scene in other disciplines,
both locally and abroad. For some, students are given allowance to study nursing and
positions are secured upon graduation. Licensure exam remains paper-and-pencil in nature
despite the rapid advances in computer and communication technology. Nursing database
at the Ministry of Health is almost nonexistent. Relationship between nursing service and
nursing education remains distant in most institutions, and has yet to be established by
either Ministry of Higher Education or Ministry of Health. Currently, Malaysia has two
systems of nursing education, one under the Ministry of Higher Education (approximately
75%) which are subjected to the Malaysian Qualifications Framework (MQF) standards
and criteria, and the other under the Ministry of Health which is not subjected to the MQF
standards and criteria.

Altogether, there are 98 public and private institutions offering diploma and degree
in nursing programmes: 17 in the Ministry of Health, 10 public universities, 70 private
colleges/universities and 1 in the Ministry of Defence. Out of the 98 institutions, 88 of
them offer diploma programmes. Diploma graduates dominate almost the entire nursing

Nursing Education in Malaysia

service, placing nursing in the sub profesional group within the government structure.
Without planning for a better future, this scenario will remain in nursing till 2020, if not
forever.

While the Nurses Act 1950 remains in control of the nursing practice through its
Regulatory Procedures including Annual Practicing Certificate (APC), nursing activities
otherwise remain quite separate, in that:
1. The Ministry of Health has a Nursing Division headed by a Director of Nursing, who

reports directly to the Director General of Health. The division is responsible for
nursing service activities within the Ministry of Health. Being the largest nursing
organization within the healthcare system, its leadership is crucial to the development
of nursing service for the whole country. Indeed, the status of nursing in Malaysia
today is a reflection of the Ministry of Health nursing leadership.
2. Private hospitals as well as university hospitals adopt their own systems of governance
and the nursing service headed by Directors of Nursing function within these
systems.
3. Nursing education remains as separate entities within all institutions. In the Ministry
of Health, nursing education is within the purview of the Training Division, whereas
Ministry of Health, headed by a nonhealth personnel.
In the education sector, nursing education is placed in universities or private colleges
or university colleges, Ministry of Higher Education, as a faculty or as a part of a faculty
of medicine or health science.
For certain, nursing in Malaysia has many challenging needs. The analysis of these
needs would result in nursing having numerous opportunities for further development and
improvement.

Chapter 2

Historical Development
of Nursing in Malaysia

The history of nursing in Malaysia began from the year 1800, with the formation of the
East India Company when hospitals for the sick were established in Penang and Singapore.
Nursing of the sick was carried out by catholic nuns and later by English nurses from
England.

At this time, every state in Malaysia established and organized its own “on-the-job
training” for nurses. Lectures in theory and practice were given by the English matrons
or assistant matrons, sisters and doctors at the hospital level. They sat for their own
state examination and the standards varied from one state to another. Upon completion
of training, they were promoted to Staff Nurses and later, if considered suitable, would
become Senior Staff Nurses.

The emphasis of nursing practice then was on patient care in hospital which was
mainly on the curative aspects.

In 1923, legislation for the control of the Practice of Midwifery and the training of
midwives were established. This was followed by the establishment of the Midwives Act
and the development of the Midwifery Board, which regulated the practice of midwifery
requiring the registration of all nurse midwives in the country in 1966.

In 1950, the Nurses Act was enacted which provided for the establishment of the
Nursing Board, with the power to control the training and registration of nurses in the
practice of nursing. This included the power to control the development of the curriculum
for Basic Nurse Training, regulation for the conduct of final examination, issuing of
Nurse Training Certificate and the Regulation to control the practice of nursing through
registration, issuing of Nurse Registration Certificate and Registration Badge.

In 1969, the Nurses Act 1950 was extended to Sarawak and in 1978 to Sabah. In
1985, the Nurses Registration Regulation had been revised to include the implementation
of the Annual Practicing Certificate. The Nurses Act 1950 remains in use today.

Nursing Education in Malaysia

1959 marked the beginning of the development of health services throughout the
country. Health services became mainly the responsibility of the central government with
delegation of service delivery through state and district health administrations.


Within this period, the maternal and child health services came to the forefront as an
essential part of the National Rural Health Development programme.

In response to this development, Public Health Nurse programme was started in
Penang using the British Society for Health Programme curriculum. By early 1960s this
programme was rightly placed in the Public Health Institute, Kuala Lumpur.

The early 1970s saw the integration of Family Planning Service and School Health
Programme into the healthcare system. By 1978, there was a relatively well developed
public sector health service consisting of rural health network with urban-based district
hospitals (150-400 beds), general hospitals (500-2000 beds), general outpatient department
care, inpatient care and specialist services which served as referral centres.

Nursing education in Malaysia progressed in tandem with the development of the
country’s health services. Before the enactment of the Nurses Act (1950), three regional
schools of nursing were established: School of Nursing, Hospital Johor Baru (1946), School
of Nursing, Hospital Pulau Pinang (1947) and School of Nursing, Hospital Kuala Lumpur
(1948). All the three schools were headed by English tutors. At this time, education of
nurses was based on “on-the-job training” approach where lectures were given by the
matrons or assistant matrons, sisters and doctors.

In 1952, the training became more formalized using a curriculum based on the
General Nursing Council (GNC) of the United Kingdom. The block system curriculum
was adopted comprising 20% theory and 80% practice for the duration of three years and
four months. The ultimate aim of the training at this point in time was to obtain reciprocity
with hospitals in England and Wales, to enable Malaysian nurses to continue their studies
in countries abroad that have reciprocity with England and Wales. During this period,
many nurses were sent for nurse tutor courses (including midwifery tutor course) in Great
Britain, Australia and New Zealand (Nursing Board of Malaysia).

The first private school of nursing was the Tun Tan Cheng Lock School of Nursing,
established in 1967 at the Assunta Hospital, Petaling Jaya. In 1968, the University Hospital
School of Nursing Kuala Lumpur was set up. Both schools were subjected to the 1950
Nurses Act regulations and procedures.

Up until 1992, the graduates of nursing programmes, on passing the Final Nursing
Board Examination, received a Certificate in General Nursing. By late 1992, the certificate
curriculum was upgraded with more theoretical input (up to 50%), to become a diploma
curriculum.

2/ Historical Development Nursing in Malaysia

While the Ministry of Health remained the biggest producer of diploma graduates
at this time, the number of private institutions began to multiply. Currently, there are 70
private colleges, 17 Ministry of Health colleges and three public universities that produce
approximately 12,000 diploma graduates annually. To date, the Ministry of Health colleges
remain the major institutions to conduct postbasic courses in clinical nursing.

Year 1993 marked the beginning of tertiary education for nursing. The first university
programme started in 1993 at the University of Malaya, admitting diploma graduates to
prepare them to become nurse educators and nurse administrators. It was a three-year
programme awarding a Bachelor of Nursing Science (BNSc) with honours. In 2003,
the Quality Assurance Division, Department of Higher Education, Ministry of Higher
Education through a high level committee including a member of the Nursing Board of
Malaysia, developed guidelines in curriculum design for a four-year Bachelor of Nursing
(Honours). Currently, at least eight universities are conducting the four-year curriculum,
six in the public sector – Universiti Malaysia Sarawak (UNIMAS), Universiti Kebangsaan
Malaysia (UKM), Univertsiti Sains Malaysia (USM), Universiti Putra Malaysia (UPM),
International Islamic University Malaysia (IIUM), Universiti Teknology MARA (UiTM)
and two in the private sector (International Medical University (IMU) and University
College Sedaya International (UCSI).

With the introduction of the four-year degree programme, the three-year degree
programme of the University of Malaya ceased to exist.

The proposed curriculum is comprehensive yet balanced proportionately between
three major sciences: Basic Medical Sciences, Core Nursing Sciences, Humanities and
Social Sciences. The entry requirements include pure sciences at Sijil Tinggi Pelajaran
Malaysia (STPM) or matriculation level, Mathematics and Bahasa Malaysia at Sijil
Pelajaran Malaysia (SPM) level and Malaysian University English Test (MUET).

These standards and criteria mark the beginning of a true upgrading of nursing
education in Malaysia. The entry requirements have placed nursing at par with other
profesional programmes such as Medicine, Dentistry, Pharmacy or Engineering where the
pure science subjects become the main criteria for admission. The current scenario in
Faculty of Medicine where both nursing and medical students coexist and where sharing of
resources is inevitable, the outcome is not only competitive but also synergistic in nature.

The 21st century also mark the beginning of the establishment of postgraduate
programmes in clinical nursing at various public institutions, namely University of Malaya,
UiTM and UKM. The emphasis on postgraduate education in nursing must be clinical to
enable the graduates to use the content and experience as experts in order to teach at the
bachelor’s degree level or to manage an acute care institution.

Nursing Education in Malaysia

This clinical postgraduate nursing education is seen as another positive milestone for
nursing. Being a practice profession, nursing must be practiced by nurses at all levels.
(The 3 public universities offer Masters of Nursing degrees in: Critical care and Women’s
Health (UiTM); Clinical Specialty (UM); Midwifery, Mental Health, Community Health
and Orthopedics and Traumatology (UKM).

Several private institutions of higher learning, namely MAHSA University College
and Open Universiti Malaysia (OUM) offer nursing-related courses at Masters level.

While nursing education has made an impression in the Malaysian education system,
its nursing service, however, remains static. In hospitals, across the board, the nursing
method used had always been the functional method (evolved from World War II, to
overcome nursing shortage). The method is based on identified functions such as, an
injection nurse, a dressing or medication nurse and so on. Although it is economical, it
could lead to fragmented care and the possibility of overlooking priority patient needs, for
example, patients’ need for counseling, health education, passive exercises, extra fluids,
etc, which are outside of their functional responsibilities, may be missed.

In general, of the four fundamental responsibilities identified within the International
Council of Nurses (ICN) Code of Ethics, only aspects of “restoration of health” and
“alleviation of suffering” might have been covered if only unconsciously; the other two
aspects: “Health promotion” and “Illness prevention” hardly receive much attention, if any,
within hospital nursing.

On the whole, nurses working in the community, in particular Public Health Nurses
are able to cover the four aspects (if only unconsciously) within the scope of maternal and
child health.

The latest development in nursing records the following events:

1. At the end of 2008, there were about 70,000 nurses registered with the Nursing
Board. The nurse-patient ratio was 1:375 where the target by 2015 should be at 1:200
to meet the standards set by Worldf Health Organisation (WHO). There were 17
public colleges of nursing, 10 public universities and 54 private colleges. Together,
they produced 6,000 diploma graduates (2,500 from Ministry of Health and 3,500
from private colleges) (New Sunday Times, 9 November 2008). Six months later
in 2009, the number of private colleges has increased to 70, ie. 16 more in a matter
of months. The number of graduates produced has been doubled (12,162 including
community nurses who are not registered nurses). Currently, there are 109 private
and public institutions offering nursing programmes and among them, 88 offer
diploma programme. By December 2009, there were 83,302 nurses in the country
(New Sunday Times, 26th June, 2010).

2/ Historical Development Nursing in Malaysia

For many years now, the production of nurses has become a competitive venture
among businessmen. The nursing shortage is being seen as a numbers game. To win
the game, with its current rules, the more the nurses they can produce, the closer they
will be to winning the game. The fastest way is to take in as many students as the
colleges can possibly take. As crudely put by Ford (2009), nurses are “being pumped
into the healthcare system as water might be pumped into the fire”. The question is,
will these numbers put out the fire, that is, fix the shortage?. Temporarily, maybe.
More importantly, will these numbers add to the improvement of healthcare, or the
caring that nurses have been entrusted by society to provide.

In response to all of these, the Minister of Higher Education in April 2010 stated
that “the mushrooming of private nursing colleges will soon be a thing of the past.
Applications to set up new institutions will not be accepted from July”. He continued
to say that institutions of higher learning should concentrate more on degree courses
(The STAR, 27th April 2010).

Around the same time in April 2010, the Minister of Health stated that “Medical
services in Malaysia are heading for major improvement with better services,
particularly at the clinical wards, as more graduate nurses are roped in to serve at
these facilities”. According to him, public universities currently are producing 415
graduates yearly and 1,760 graduates by private universities (The SUN, April 2010).

2. In June 2010 (New Sunday Times, 26th June 2010) the Minister of Health announced
“a temporary freeze of nursing courses by July 1 … to cap the number of diploma
courses offered by private and public institutions”. Accordingly, the Minister stated:

“The Cabinet has agreed that a moratorium be placed on new nursing courses and
institutions. This is to make sure the current institutions place importance on the
quality of the courses and the performance of students”.

The Minister further affirmed that the next aim was to focus on degree nurses because
“We want to improve the quality of nurses in the country”. But what the Minister is not
aware of is that some graduates of public universities, with the exception of JPA scholars,
are not hired by government hospitals. These graduates are now looking at other avenues
including the private sector and foreign countries. Currently, UIA, UNIMAS and UKM
graduates are employed by Prince Court Medical Centre Kuala Lumpur and hospitals
in Singapore. A private organization in Singapore is now seeking to hire degree holder
Malaysian nurses to serve Singapore hospitals.

Nursing Education in Malaysia

Summary
It is safe to say that evolvement of nursing in Malaysia, as a whole, is slow and lethargic
despite rapid and sophisticated changes in the world of medicine, education and technology.
We cannot blame the British, because British nursing has evolved with the rest of the world.
It would take extraordinary leadership qualities to move Malaysian nursing in tandem with
the development experienced by other professions. Nursing in Malaysia lacks leaders with
vision, courage and maturity to plan, organize and initiate change. For as long as the entry
into nursing service remains at the diploma level, leadership will evolve from these diploma
graduates, and the outcome of changes made will remain at diploma thinking level. The
constant presence of poor input produce weak output, because ultimately, the process will
be affected by the constant presence of the weak output within the same system. Nurses in
leadership positions arising from such a system may not be ready enough to make profound,
sustainable change in nursing culture.

Chapter 3

The Status of Nursing
in Malaysia

Four major areas are seen as affecting the status of nursing in Malaysia: nursing education,
nursing practice, nursing research and nursing autonomy.

Nursing Education

Basic Requirements of Nursing Education

To become a nurse, requires a significant amount of formal education. Globally, it is
agreed that nursing education is important to practice and that education needs to respond
to changes in healthcare created by scientific and technological advances. It is also agreed
that the core competency of nursing is critical thinking and application of knowledge into
practice. Nurses are responsible for making accurate and appropriate clinical decisions and
that clinical decision making separates profesional nurses from technical nurses. It is the
professional nurse, for example, who takes immediate action when a patient’s condition
worsens, who decides if a patient is having complications that call for notification of a
physician (or other healthcare provider), or who decides a teaching plan needs revision,
etc. Clinical decision making is seen as “judgment that includes critical and reflective
thinking and action and application of scientific and practical logic” (Benner, 1984).

Critical thinking, in itself, requires not only cognitive skills, but also a person’s habit
of asking questions, to remain well-informed, to be honest in facing biasness and to always
be willing to reconsider and think clearly about issues. There are core critical thinking
skills that, when applied to nursing, show the complex nature of clinical decision making.
The core critical thinking skills include: interpretation, analysis, inferences, evaluation,
explanation and self-regulation. Being able to apply all of these skills takes practice and a
sound knowledge base. By this definition, critical thinking can only be effectively done by a
profesional nurse. In the US, the American Nurses’Association defines professional nurses
as those who graduate from a four-year degree programme (Potter and Perry, 2009).

Nursing Education in Malaysia

To be classified as a profession, the first criterion is for nursing to have an extended
education for its members as well as a basic liberal foundation. In 2003, the QualityAssurance
Division, Department of Higher Education, Ministry of Higher Education, through a high
level committee comprising nursing members of public and private universities, Nursing
Board of Malaysia and National Accreditation Board (LAN) developed guidelines in
curriculum design for a four-year Bachelor of Nursing (Honours). To provide the so-needed
liberal foundation, the proposed curriculum design is comprehensive yet proportionately
balanced between three major sciences (Medical, Nursing and Social):

Basic Medical Sciences (15-20%)

Core Nursing Sciences (55-65%) of which 45-50% must be practicum

Humanities & Social Sciences (15-25%)

Scientific (Research) Methods (4-7%)

Electives (2-7%)

The entry requirements for the Bachelor of Nursing include Sijil Tinggi Pelajaran
Malaysia (STPM) or Matriculation or equivalent with minimum pass in Biology and
Chemistry, or Biology and Physics OR a recognized Diploma in Nursing with transfer of
credits to the appropriate level of four-year programme AND credits in Mathematics and
Bahasa Malaysia at Sijil Pelajaran Malaysia (SPM) level AND MUET Band 3 or 4.

These standards and criteria including those of the MQF mark the beginning of a true
upgrading of nursing education in Malaysia. The entry requirements have placed nursing at
par with other profesional programs such as Medicine, Dentistry, Pharmacy or Engineering
where the pure science subjects (and Mathematics) become the major criteria for admission.
The current scenario in the Faculty of Medicine of several universities where both nursing
and medical students exist and where sharing of resources and interprofessional training
approaches are inevitable, the outcomes are not only competitive but also synergistic in
nature.

The role of pure sciences (biology, chemistry and physics) and mathematics in nursing
is unquestionable. Nurses are confronted with literacy, scientific and numeracy issues at
every facet of their professional life, for example, in the implementation of nursing process,
patient education, medication administration, nutritional requirements, statistical analysis
and all kinds of measurement. This holds true for both degree and diploma programmes.

Thousands of SPM students graduate with pure science and maths every year. They
are privileged to choose to enter nursing (diploma) or matriculation and STPM programmes.
Matriculation and STPM programmes are the best competitors diploma programme in
nursing could ever have, just as Bachelor of Nursing with medicine, dentistry or pharmacy.
Such “competition” is good for nursing.

10

3/ The Status of Nursing in Malaysia

In Malaysia, there are two education preparations for registered nurses-diploma and
bachelor of nursing. In addition, there are graduate nurse education, continuing and in-
service education for practicing nurses.

The Diploma Programme

With the exception of Universiti Kebangsaan Malaysia (UKM), Universiti Malaysia
Sabah (UMS) and Kolej Kejururawatan Universiti Hospital, UM whose curriculum are
uniquely theirs, all other colleges that conduct diploma programmes follow the requirements
stipulated by the Nursing Board of Malaysia. The Nursing Board curriculum design for the
three-year diploma programme comprises the following:

1. Total credits of 90-115 in three years based on the old credit system ie, 14-16 hours
of teacher workload per week;

2. Curriculum components consisting of three core sciences: Health Sciences (10-20%);
Behavioral Sciences (10-20%); and Nursing Sciences (60-80%). There must at least
be 45-55% theory and 45-55% practical.

3. Teaching-learning approaches: lectures, tutorials, practical.

4. Student assessment: Continuous assessment (30-40%) and summative (60-70%) in
the form of exams.

The curriculum must have three outcomes: It must meet the registration requirements;
application of knowledge, skills and attitudes; and production of safe and competent nurses.
Up to 2010, the entry requirements into the programme have been: pass in SPM with three
credits including one science subject and pass in BM and Mathematics (the requirements
from 2010 are A pass in SPM or equivalent with five credits) .

According to the local study, “Basic Nursing Competencies for Recent Diploma
Graduates” conducted by the Nursing Education Task Force, Ministry of Higher Education,
in 2009/2010, some 47% of the diploma graduate respondents (N=814), did not have
science in their entry qualification, therefore, did not meet the minimum Nursing Board
requirement. Of these, more than 14% had technical vocational and “others” qualifications.
“Others” could mean non-SPM graduates.

The same study findings showed that the graduates from diploma programmes
without affiliate hospitals had difficulty getting clinical experience during their training to
the point that their clinical experience could last only three to five days per posting. Many
of these graduates further claimed that they would often arrive late for clinical posting
because of poor transportation system and/or the result of staying too far from the clinical
hospital (source: Basic Nursing Competencies for Recent Diploma Graduates”, Nursing
Task Force, MOHE, 2009/2010).

11

Nursing Education in Malaysia

With the exception of UKM graduates who are bound to Hospital Universiti
Kebangsaan Malaysia (HUKM) for at least five years up on graduation, other diploma
graduates are furnishing the current market nationally and internationally. Irrespective of
quality, they make a very attractive commodity. The impact in terms of “critical thinking,
problem solving and decision making” has not been apparent as a group – individually
perhaps, but this is rare and far between.

It is said that the product is as good as who makes them but on the other hand, the
product can only be as good as the input that is brought into the system. For more than 25
years, the entry requirements into the diploma programme have not changed. The same can
be said of the curriculum and its implementation. As far as nursing service is concerned,
this is the critical mass and the impact of patient outcomes is mostly generated by these
graduates. Further, the impact of the 12,000 diploma graduates produced per year has led
to the belief that for as long as the current situation continues to exist, nursing will remain
in the “support service” category and nurses will remain in the sub-professional group
within the government service.

If education is truly “an investment in human capital” then, the paradigm shift must
occur. The changing educational scenario is everywhere and nursing should and must be
a part of this scenario.

The UK experience where newly qualified nurses entering the profesion without the
necessary standard of skills most notably in numeracy and literacy and which has become
a growing problem for the National Health Service (NHS) is a lesson to be learned. This
statement sparked the issuance of a circular stating that by the time a student has qualified,
it expects to demonstrate the literacy and numeracy skills “essential for care delivery”.

In December 2008, NHS London had started introducing a quality control scheme,
a system called Quality Assurance, which rates the performance of all London healthcare
colleges and universities supplying staff to the NHS against key performance indicators
(KPI). Institutions would be issued a “traffic light” rating of red, amber or green. Those
with a red rating could have their contract terminated or reduced (the first rating was made
in April 2009).

The move was to ensure that the profesion recruits “The best candidates into nursing”.
It has been acknowledged that “The standard of pre-registration training-was not up to
scratch”. To this end, the National Committee had ratified proposals to make nursing “an
all-graduate profesion” across the UK by 2015. (Ford, 2009).

In the US, there are two levels of nurses: technical and profesional. The technical
nurse is to be prepared in a two year associate degree programme at universities or colleges
and the profesional nurse is to be prepared in a four year degree programme. The American
Nurses’Association in 1985, proposed that the profesional nurse with a degree be licensed

12

3/ The Status of Nursing in Malaysia

under the legal title Registered Nurse (RN) and the technical nurse with an associate degree
be licensed under the legal title Associate Nurse (AN). These changes must be legislated
so that such changes would have major implications on diploma nurses. According to
“Timelines for Transition” (1987), the US is expected to practice nursing by all degree
nurses by 2010. However, an expert stated that “what is best for nursing may not coincide
with what is best for society at large. Financially, to have all BN-RN staffing in the US
(whose needs range from three to four million nurses) may not be possible. Currently US
has degree nurses, associate degree and diploma nurses (Kozier, Erb and Blais, 1992).

In Canada, the entry requirement into professional nursing practice by 2000 was the
Bachelor of Nursing. The issue of titling and licensure remains unresolved (Kozier, Erb
and Blais, 1992).

The Future of the Diploma Programme – Learning from the US experience, it is
foreseeable that the Diploma programme will continue to be conducted. It is also foreseeable
that diploma graduates will be required to service less priority areas which are areas that
can tolerate a staff mix of degree and diploma nurses with or without specialization. Such
areas include adult general care and paediatric services. In addition, all non-patient care
areas must be adequately staffed by registered nurses prepared at minimum the diploma
level. Such areas include specialist Centre Services, Operating Rooms, Centralized Sterile
Supply Unit, and the like.

Nursing’s plan must include the notion that by 2012, all universities must cease to
prepare diploma graduates and that only recognized colleges with affiliate hospitals will
continue to prepare diploma nurses. The number of graduates must be determined based
on future service requirements. It is expected that the number required would be much
reduced and that by 2020, the number will be less than the degree nurses.

The Degree Programme

Any programme higher than diploma must give a significant impact to the profession
and to the employers. The Department of Public Services (JPA) is expecting a degree
nurse to function in the clinical setting, not just teaching and managing. This expectation
is not out of context because a degree nurse is a first line nurse. He/she is a skillful nurse,
someone who is able to assess what patients need and plan for the care with the full
knowledge of all other aspects (such as psychological and social components) and to do it
in a compassionate and caring way. It is the ability of the nurse to be a critical thinker, to
work well in a team and to think on his/her feet that makes a difference. Indeed, a degree
nurse is expected to serve in all priority areas of patient care which require collaborative
and independent decision making. These areas include all critical care services (ICU,
CCU, PICU, NICU, Burn Centre, Emergency Room, Trauma Centre and Delivery Suites);
extended programmes requiring independent decision making such as Home Care Services,
Day Care Surgery, Infection Control and all Community Health Programmes.

13

Nursing Education in Malaysia

These are areas (with exception of Infection Control Programme) that “admit” and
“discharge” patients, where needs must be assessed, problems identified and whose care
must be planned, implemented and evaluated collaboratively or independently. The degree
of patient contact may affect the quality of care. Generally, the principle to go by is that the
more remote/isolated/rural the service, the more critical is the requirement for independent
decision making, the higher is the need for degree holder nurses.

The foreseeable future might see the transformation of the services currently given by
Jururawat Desa to one of “group practice” by degree and diploma nurses. This is saying
in other words that the Jururawat Desa position may become extinct, at least by 2020 if
not sooner.

About 40-50 years ago in the US and perhaps 10 years ago in Australia, a degree is
an upgrading of the diploma, hence served as a promotional criterion. Now in Malaysia,
nursing is in a privileged position to NOT BE in the same situation. It could now have
first level nurses with degrees right from the start, hence, all universities are encouraged to
take in STPM/Matriculation students. This is an opportunity nursing has been waiting for,
ie. to have STPM/Matriculation as entry qualifications into nursing. It is so much easier
to mould STPM/Matriculation students into critical thinkers than to convert the diploma
holders into something different from what they used to be for years. Nursing’s future plan
must include the positioning of degree nurses at the bedside.

To position degree nurses in the clinical setting (or at the bedside), there must exist a
clinical structure (similar to medicine) where nurses can rise both in pay and power while
remaining in the clinical setting providing direct or indirect care to patients and families.
This clinical ladder will provide a new horizon for the nursing profession where nurses
do not have to change direction, either toward teaching or management, in order to gain
profesional recognition.

The Bachelor of Nursing degree is to become the most basic qualification for all
promotional posts in nursing (Figure 1).

By year 2020, the nursing profession may see the merging of nursing service and
nursing education in the same organization, and the structure may be represented like so
(Figure 2).

14

SPM 5 cr Diploma In Bachelor of SPM,
In Pure Science, Nursing Nursing Matriculation or

Maths, BM, Staff of Equivalent in
BI. etc Nurse Pure Science

Clinical Nurse Masters Postgraduate Nurse
Specialist Degree Cert/Diploma Educator
in Nursing In Diploma
in Nursing Programme

Advanced Practice Nurse Head Nurse
Nurse in Single or Manager r Lecturer
Group Practice or Director of r Associate
Nursing
in Employment (Hospital/Ministry) Professor
r Professor
Doctoral
Degree or PhD

in Nursing

Figure 1: Career Development in Nursing

DIRECTOR OF NURSING
(Associate Professor/Professor)

(DNP) Professor/Associate Nurse (DNP) Clinical Nurse (DNP)
Professor/Sr. Lecturer Manager Consultant

Lecturer Head Clinical Nurse
Nurse (MN) Specialist (MN)

Staff Nurse (BN) Staff Nurse (BN) Staff Nurse (BN)

*(BN = Bachelor of Nursing: MN = Master of Nursing: DNP = Doctorate in Nursing Practice)

Figure 2: The Merging of Nursing Service and Nursing Education

Nursing Education in Malaysia

Overall, nursing’s focus should be on issues related to:

1. Entry requirements
2. Curriculum content and implementation
3. Student assessment
4. Teaching qualification

Entry requirements
Nursing needs pure science and mathematics irrespective of Cumulative Grade Point

Average (CGPA). Based on experience, a 2.00 CGPA student (or equivalent to SPM)
with pure science and mathematics is better than high CGPA without. Nursing needs this
category of students to develop the “critical thinking” aspects of nursing.

In 2010, the Department of Higher Education, Ministry of Higher Education Official
announced that the entry requirements for diploma programme is SPM, five credits
without specifying details. Tun Tan Cheng Lock College of Nursing was the first college
to respond to the requirements specifying them to include credits in Bahasa Malaysia,
English, Mathematics and Science (Learning Curve, New Sunday Times 19th September
2010). UKM was the first University to implement in 1996, a five-credit requirements to
include Biology, Chemistry/Physics, Bahasa Malaysia and Mathematics. The five-credit
requirement was strongly opposed by a number of private organizations, reflecting the
organizations’ lack of understanding about nursing as a profession.

Curriculum content and implementation
The CORE CURRICULUM should focus on “critical thinking and the intelligent

application of knowledge” to practice and holistic care. The curriculum content must
include appropriate proportion of medical and nursing sciences, liberal arts, research and
electives. Implementation process must include “good” habits of the mind (critical thinking
and problem solving) and the heart (compassion, caring, integrity) and that the two must be
so organized that the “Body, Mind and Soul” (physical, mental and spiritual) be integrated.
The application of Nursing Process Model and Problem-based Learning (PBL) are highly
indicated.

Student assessment
Students should be assessed in clinical knowledge, clinical competence and clinical

performance.

Clinical klnowledge can be assessed through objective and subjective written
examinations whereas clinical competence can be assessed through “clinical” examinations.
Students are assessed in their clinical effectiveness through giving of direct care to one
patient/client using technical procedures and nursing process.

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3/ The Status of Nursing in Malaysia

Clinical performance can be assessed through continuous assessment methods.
Students are assessed in clinical performance including daily habits/behaviours in a complex
practice environment. This encompasses a number of patients/clients in the wards or
homes, management of patients during emergency, relationships with colleagues, patients
and families. Skills assessed include management, communication, team capabilities,
leadership, efficiency and effectiveness as seen from nursing care outcomes.

No matter how and when assessment is carried out, it must be clinical-based: to be
authentic, the students must have direct access to a regular clinical setting where continued
learning can occur. Assessment in both clinical competence and clinical performance
require that students and teachers are in constant contact with each other and with patients
and their families. This would mean that to achieve validity as well as to ensure reliability
in the assessment methods, a college or university must be attached to or an affiliate of a
specialist hospital (250 beds and above as specified by Higher Education Department).
Failure to achieve this, authenticity of clinical assessment can be questioned.

Teacher qualification
Preparation of teachers must be consistent with the curriculum content and approach.

MQA advocates the use of content experts for each course/subject or content area. In
other words, there must be content experts in the medical sciences (anatomy, physiology,
biochemistry, microbiology, pharmacology, nutrition, medicine, surgery, orthopedics
etc); nursing sciences (medical-surgical, pediatrics, obstetrics and gynecology, mental
health, community health, critical care, oncology, gerontology, etc); humanities and social
sciences (communication, sociology, psychology, management, IT, etc); scientific/research
methodology, nursing process, etc); and so on. Authenticity of the programme depends on
the availability of these experts.

It is saying in short that while teaching process is indispensable, the effective process
must not be without indepth knowledge of the content. Medical lecturers survive without
the structured teaching process because they have excellent in depth knowledge of the
subject.

Nursing needs to review its priorities. The current situations where new graduates
of the bachelor of nursing programme are directly employed as teachers; where matrons
and sisters from service organizations occupy such positions as deans, deputy deans and
lecturers; where nurse teachers are allowed to teach medical sciences and social sciences,
research and statistics without the expertise of the subject content, etc – are no longer
acceptable.

To teach in a diploma programme, the nurse teacher needs a clinical degree (a Bachelor
of Nursing) and a probable specialized area of nursing. Teaching skills qualification must
be obtained outside of this degree. Similarly, to teach in a degree programe, the lecturer
must have at least a masters degree in the clinical area of the course to be taught. It simply

17

Nursing Education in Malaysia

means that to teach mental health nursing, the lecturer must have in-depth knowledge and
extensive experience in mental health. The same could be said of every other clinical
specialty. It is saying in otherwords that a lecturer with a Bachelor of Nursing and a Masters
degree in education (for example) is not qualified to teach mental health nursing, unless
she/he has indepth knowledge and extensive experience in the specialty (in this case, mental
health) to be taught. It means that whilst it is ideal to be skillful in the teaching process
(Masters degree in education), it cannot compensate for the lack of teaching content.

Graduate Education

The minimum requirement for graduate education is the Bachelor of Nursing degree.
Nurses can pursue graduate education leading to:

1. Postgraduate certificate and postgraduate diploma in nursing
2. Masters degree in nursing
3. Doctoral degree in nursing or related fields
4. Continuing and In-Service Education

Postgraduate certificate and postgraduate diploma in nursing
Based on the assumption that not all nurses want to pursue Masters qualification or

that some may not meet the entry requirements into the Masters programme, postgraduate
certificate or diploma courses would offer the best alternative. The future holds that, to be
a Head Nurse in a specific clinical setting or to teach in a diploma programme, the nurse
must be specialized in that area of management or academic content (see Figure 1).

All universities with hospitals or affiliate hospitals are encouraged to establish
postgraduate programmes. Currently, only UKM (since 2000) has such a programme,
namely postgraduate diploma in Nursing (Midwifery) and soon to be expanded to include
Oncology Nursing, Mental Health Nursing, Infection Prevention and Control and Patient
Care Management.

The principle to go by is that all postgraduate certificate programmes will offer six
month (24 week semester) courses worth 20 credits and these may include: Renal Nursing,
Neonatal Care Nursing, Emergency Care, Intensive Care Nursing, Coronary Care Nursing,
Spinal Nursing, etc; and that all postgraduate diploma programmes will offer one-year
(two semesters) courses worth a minimum of 30 credits and these may include: Midwifery,
Mental Health Nursing, Community Health Nursing, Infection Prevention and Control,
Patient Care Management (general wards, OR, Day Care, Home Care, etc), Oncology
Nursing, etc.

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3/ The Status of Nursing in Malaysia

Masters degree in nursing
A nurse who meets the criteria for entry into a Masters programme should do so after

gaining some experience as a Staff Nurse. Further, those who have desires to become
lecturers or nurse managers or clinical nurse specialists must pursue a Masters degree in
clinical nursing.

All universities are encouraged to establish Masters programmes in clinical courses
such as critical care, midwifery, mental health, community health, paediatrics, oncology
and so on, to enable nurses to become nurse experts which will allow them to teach, to
manage clinical programs, to conduct research, or to be entrepreneurs.

The clinical nurse specialist position is a good example, whereby its very “name”
(nomenclature), she is a specialist, therefore an expert. She has a Masters degree in a
clinical specialty and strong knowledge and skills in teaching and research. She is the
expert nurse in a particular setting who is responsible for the total care of patients within
her specialty. She is accountable for accurate nursing assessment, problem identification,
planning of care and in particular evaluation of care as a basis for effecting change in
the nursing care of the patients. She is responsible for developing the “critical pathways”
(designed along with the case mix system) and for their effective implementation.

The clinical nurse specialist will provide leadership in bedside nursing which involves
direct care with its ethical and medico-legal issues, patient education, discharge plan,
counseling of patients and quality assurance. She is the “referral centre” for all nurses in
the unit and the consultant for medical specialists and for Nurse Manager and Director of
Nursing. She is also responsible for providing leadership in the conduct of team research as
a basis for providing evidence-based care. Lastly, she will provide leadership in planning
and conducting educational programmes for the Unit.

For certain, a nurse with a Bachelor of Nursing with a postbasic course (as
currently practiced) cannot be a clinical nurse specialist. She would lack the maturity
and intellectual capacity to collaborate with medical specialists, to conduct research and
to initiate educational programmes for nurses. Only nurses with a Master’s degree in a
clinical specialty and sufficient research input and education and management technology
can do this.


In this context, all universities are encouraged to include in the Masters programmes,
core courses in research (statistics and research methodology), education and management,
besides the clinical specialty, so that upon graduation, they can use the specialty knowledge
and skills to teach, manage a facility and conduct research or simply be a clinical nurse
specialist. In the same token, universities are also encouraged to employ only those with
expert knowledge and skills in a specialty as lecturers. For example, a Masters degree in
Nursing (Critical Care) to teach critical care nursing, in order to perpetuate a culture of a
clinical ladder as an integral part of nursing.

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Nursing Education in Malaysia

Doctoral degree in nursing or related fields
The need for nurses with doctoral degrees is increasing. Expanding clinical roles,

continuing demand for well-educated nursing faculty and new areas of nursing specialties,
and the need to conduct research in nursing, are some of the reasons for increasing the
number of doctorate nurses. The Department of Higher Education has clearly stipulated
that by 2020, there should be 30-50% PhD holders in a nursing faculty (QA Division, JPT
2003).

In nursing, there are two ways in which nurses can gain a doctoral degree: one is
through profesional doctoral programmes eg. Doctor of Nursing Science (DNS) or Doctor
of Nursing Practice (DNP). The programme prepares graduates to apply research findings
to clinical nursing. The other doctoral programme emphasizes more basic research and
theory and award the research-oriented Doctor of Philosophy (PhD) in Nursing. The
programme prepares graduates with nursing background to apply research findings to, for
example, education or management (two areas most chosen by nurses). On the basis that
these graduates (PhD in education or management) are not truly “experts” in education or
management, the American Association of Colleges of Nursing recommended the Doctor
of Nursing Practice (DNP) as the terminal practice degree and required preparation for all
advanced practice nurses in the US by 2015 (Potter & Perry, 2009).

Lessons to be learned by Malaysia in this context are:

(a) The Master of Nursing must be in clinical nursing specialty; and

(b) Doctoral curricullum (by 2015 or sooner) must be in clinical practice to earn
a doctoral degree, “Doctor of Nursing Practice” (DNP). By this time, there
should be sufficient PhD holders to supervise doctoral students to do clinical
research in nursing.

Continuing and in-service education
Nursing is a knowledge-based profession, and technological expertise and clinical

decision making are qualities that the consumers demand and expect. Continuing education
programmes are one way to help nurses remain current in nursing skills, knowledge and
theory. Nurses are compelled to do this if only to renew their Annual Practicing Certificate
(APC).

Continuing education involves formal, organized educational programmes offered
by universities, hospitals (of the Ministry of Health and private institutions), profesional
organizations and healthcare institutions.

For more than 25 years, the Ministry of Health has offered excellent post basic courses
ranging from six months to one year, in all aspects of clinical nursing. The respective
certificates have been widely accepted by universities as part of entry requirements into

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3/ The Status of Nursing in Malaysia

the degree programme or meeting conditions for clinical requirements in the academic
setting.

Some universities also offer post-graduate certificate and diploma as part of continuing
education for degree holders.

There is now a need to synchronize the efforts of the Ministry of Health and Ministry
of Higher Education, to avoid duplication and redundancy.

In-service education programmes are training programmes provided by a healthcare
agency or institution, designed to increase the knowledge, skills and competencies of
nurses and other healthcare profesionals employed by the institution.

In Malaysia, continuing and in-service education programmes are well planned and
extremely well received by nurses.

Other Educational Programmes

The Nursing Board of Malaysia, in 2007, had produced “Guidelines on Standard and
Criteria for Approval of Nursing Programmes” and one of the programmes mentioned was
the “Post Registration (Degree)”.

The Post Registration Degree programme, known also as a “TOP-UP” programme
worth 80 credits, admits diploma graduates for two years full-time. At least five institutions
of higher learning are known to conduct or will conduct this degree programme within two
years part-time (instead of full-time). These institutions are: Open University Malaysia
(OUM), MAHSA University College, Masterskill University College, International
University College of Nursing (IUCN) and SEGI University College.

For all intentions and purposes, the product of this programme must be clinically
competent, i.e, At the 3rd level (competent level) of the Benner: From Novice to Expert
Nursing Standard, and proficient in the use of the Nursing Process Model. The graduates
must also be skillful in critical thinking, problem solving and the research process.

A formal study needs to be conducted on the graduates of these programmes to find
out the proficiency level in critical thinking and problem solving, the application of the
Nursing Process Model and Research process. The question arises whether two-year part
time degree programmes should be allowed to be conducted by any institution.

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Nursing Education in Malaysia

Nursing Practice

Nursing Practice Defined

Nursing is an art and a science. Nurses are taught to deliver care artistically with
compassion, caring and a respect for client’s dignity and individuality. In addition, nursing
practice incorporates social values, profesional autonomy, a sense of commitment and
community and a code of practice. As a science, nursing is based on a body of knowledge
comprising social and behavioral sciences, biological and physiological sciences and
nursing theories. The integration of the science and the art of nursing into practice will
result in the quality of care which is expected to be at the level of excellence.

The latest definition of nursing is given by Wilson (2003), which can be applied in
any locality. Nursing is defined as

The protection, promotion and optimization of health and abilities, prevention of
illness and injury, alleviation of suffering through the diagnosis and treatment of
human response, and advocacy in the care of individuals, families, communities
and populations.

Globally, nursing has a mandate to provide health care for clients at different points in
the health-illness continuum. The ICN Code of Ethics states clearly that nurses have four
fundamental responsibilities: to promote health, to prevent illness, to restore health and to
alleviate suffering, and that the need for nursing is universal (ICN, 2005).

The client is the centre of nursing practice. The client includes the individual,
family and/or community. Clients have a wide variety of healthcare needs, experiences,
vulnerabilities and expectations, making nursing both challenging and rewarding.

Scope of Nursing Practice

Scope of nursing practice are:

1. Legal implications
2. Nurses roles and responsibilities
3. Basic requirements to practice nursing
4. Additional requirements to practice nursing
5. Practice settings

Legal implications
In Malaysia, the Nurses Act 1950 regulates the scope of nursing practice and

protects public health, safety and welfare. The protection includes shielding the public
from unqualified and unsafe nurses. In this context, the act defines that all Registered

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3/ The Status of Nursing in Malaysia

Nurse candidates must pass the licensure examination conducted by the Nursing Board
of Malaysia, regardless of educational preparation. The licensure examination provides a
standardized minimum knowledge base for nurses. After passing the initial examination,
nurses have to maintain an Annual Practicing Certificate (APC) through ongoing continuing
education and clinical or administrative practice for a minimum fee paid by their respective
employers.

Nurses’ roles and responsibilities
In the past, a nurse’s principal role was to provide care and comfort to ill clients.

However, changes in nursing have expanded the profesional nursing role to include increased
emphasis on health promotion and illness prevention, as well as concern for the client as
a whole. Currently, in the 21st Century, the emphasis is not just about managing illness it
is also about managing health of the community and the environment. The emphasis is on
wellness as well as the health of population and the environment in order to enhance the
quality of life.

Nursing has to respond to these multiple changes and challenges. Firstly, demographic
changes influence the population’s health and healthcare. Other aspects include rural to
urban shift; increase life span; higher incidence of chronic, long-term illness; and increased
incidence of cancers, alcoholism, drug addiction, HIV/AIDS, etc – all will affect nursing
practice, nursing education and nursing standards.

Accordingly, the role of nurses will change drastically. They have to be multiskilled
and versatile caregivers; be a client advocate where they need to protect clients’ legal rights,
to provide additional information to help clients make decisions and to be culturally and
religion sensitive at all times; be good in client teaching and health education; be excellent
communicators to promote nurse-client relationship to meet the need of individuals, families
and communities; and last but not least be a good manager of care activities to establish an
environment for collaborative care to provide quality care and good client outcomes.

Basic requirements to practice nursing
Nursing is a knowledge-based profession. The core competence of nursing is

critical thinking and the intelligent application of knowledge to practice. These are basic
requirements because:

(a) Nurses use critical thinking to collect and interpret information and make sound
judgement that contribute to good decisions, and that in many instances, these
decisions involve the patients’ well-being, even their survival;

(b) Everyday nurses are expected to link, synthesize and coordinate the work output
of multidisciplinary team comprising doctors and other healthcare professionals.
To this end, nurses are expected to possess the knowledge and skills to perform
as coordinators of care;

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Nursing Education in Malaysia

(c) Nurses are expected to provide holistic and comprehensive care involving the
use of a scientific approach using six systematic steps: assessment of health
needs, making nursing diagnosis, formulation of patient outcomes, planning of
care, implementation of the care plan, and evaluation of care. Nurses must be
concerned with the whole person under the full range of patient’s needs which
may include health teaching, discharge planning, extending care to the home,
etc.

(Nik Safiah, 2010)

Additional requirements to practice nursing
Medical advancement/specialization has a significant effect on nursing education and

practice. The role of nurses constantly changes in response to the growth of biomedical
knowledge, changes in patterns of demands for health services and the evolution of
profesional relationships among nurses, doctors and other healthcare professionals.

While there is a need for nursing to adopt multiskill approach and for nurses to be
versatile, at the same time, there is a need to keep abreast with medicine, for example,
with trends in cardiology, oncology, transplant, burns and plastic surgery, the various
aspects of nephrology and renal care, etc. Nurses, like doctors, need to extend their roles
in specialized fields because specialization ensures a continuing commitment to practice
that demands expert knowledge and skills. Nurses’ role as experts must include direct and
continuous care of sick patients as well as health promotion for individuals who are well.

Practice settings
Nurses have an opportunity to practice in a variety of settings in many roles. But,

hospitals have remained the primary worksite for Registered Nurses (RN). Approximately,
two-thirds of nurse population in the world work in hospitals and of these 90% are employed
as Staff Nurses (McNeese & Donna 2003).

Hospital nursing has always been physically and mentally gruelling and contemporary
nurses must cope with patients who are sicker and who require more complicated care than
ever before. From time immemorial, hospital nurses work either an eight hour or a 12-
hour shift and this scheduling must be maintained irrespective of nurse-patient ratio. This
24 hour scheduling in rotation is the only option for nursing and for all hospital nurses,
without exception.

It is also common knowledge today that hospital nursing, for majority of nurses, is
done only to gain experience and some do not often stay long in anyone hospital. Reasons
could be that nurses today have a greater array of job opportunities to choose from, many of
which pay better and offer more flexible schedules than the eight hour or 12 hour shifts that
hospital work requires. Research has shown that effective leadership can help retain nurses
at the bedside. Promoting the right individuals into leadership and managerial positions

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3/ The Status of Nursing in Malaysia

would pose a real challenge to nursing. Another reason could be that there is no clinical
ladder for promotion. Currently, career advancement is available only in management or
teaching.

Realities about Nursing in Malaysia

The scope of nursing practice, as described earlier must ideally be met in order to
provide quality care. However, a number of realities need to be accepted as being relevant
to Malaysia which could provide both challenges and opportunities for change. They are:

1. Almost all staff nurses working in hospitals and the community are diploma holders.

2. The trend in Malaysia is toward a population of newly graduated degree nurses
occupying promotional positions without practicing nursing.

3. Changes that are taking place in nursing practice do so because they are inevitable i.e,
they have to change because the time has come for nurses to change. Nursing hardly
plans for such change.

4. Standards for Nursing Practice, although not available on the Internet (as are Nursing’s
vision, mission and goals), have been written but highly probable that they are not
being enforced.

5. Quality Improvement Initiatives ie activities carried out by nursing organizations to
evaluate and improve the quality of client care services provided to all clients might
have been done only through ISO initiatives.

6. Key Performance Indicators (KPI) for nursing has not been finalized by the Ministry
of Health.

7. Evidence-based Practice (EBP) in Malaysia is not on nursing’s agenda.

Almost all staff nurses working in hospitals and the community
are diploma holders

The standard of education between colleges that prepare diploma graduates varies
based on entry requirements, curriculum content, delivery and evaluation system. It is
every new diploma graduate’s wish that what they have learned can be used during their
working life. The extent to which this can be realized is highly dependent upon quality
of candidates taken into nursing, and the quality of teachers who can adopt teaching
approaches which must go beyond that of merely learning of facts to that of application,
analysis, synthesis and evaluation. It is generally accepted that diploma nurses are task
oriented, obedient and passive, the result of, may be, low entry requirement and teacher
centred, didactic approach in education.

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Nursing Education in Malaysia

A local study (Basic Nursing Competencies for New Graduates of Diploma
Programmes, Nursing Task Force, MOHE, 2009/2010) showed clearly that there was no
evidence of the Nursing Process being applied in the diploma students’ clinical training,
nor was there evidence of the use of nursing process as a tool of care in any of the study
hospitals. Clearly, it can be stated that the core of nursing, namely, critical thinking and
the intelligent application of knowledge to practice, specifically in the use of Nursing
Process Model, is currently not relevant to nursing practice in Malaysian hospitals (Refer
to Appendix 1).

The trend in Malaysia is toward a population of newly
graduated degree nurses occupying promotional positions
without practicing nursing

The level of education in nursing is changing. University degree holders enter the
scene to hold higher positions on merit, displacing seniority. It has been reported that in
certain hospitals, degree holders are placed in special locations such as in Matron’s Office
without having to wear uniforms, promoted to sisters or clinical nurse specialists or some
other positions created for them. Notably, in the field of teaching, nursing colleges of the
Ministry of Health and private institutions employ fresh degree graduates as nurse tutors/
lecturers to teach nursing. These positions had been previously held exclusively by senior
diploma graduates especially trained to become nurse tutors. Clearly, experience has been
displaced by level of education. While having teachers with a degree in nursing to teach in
diploma programmes is a good thing, a nurse who has never practiced nursing, would only
be teaching theory without the context.

This attitude must change, that is, the perception that degree holders are not meant
to be bedside nurses. The fact of the matter is that nurses with degrees should rightfully
be at the bedside because they possess the core competence of nursing which is critical
thinking and the intelligent application of knowledge to practice. The four-year Bachelor
of Nursing programme would enable the graduates to effectively apply the nursing process
as a tool in nursing practice, to work as coordinators of care, to use best evidence to make
decisions and most importantly to work collaboratively with doctors and independently as
profesional nurses. They need this experience for at least three years (based on a six month
rotation for each clinical setting), before they are allowed to teach in schools. Within these
three years they must equip themselves with specialized knowledge and skills in the area
they are going to teach as well as with education technology.

The challenge is for the management to make the best use of each personnel to achieve
quality nursing practice.

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3/ The Status of Nursing in Malaysia

Changes that are taking place in nursing practice do so
because they are inevitable i.e, they have to change because
the time has come for nurses to change. Nursing hardly
plans for such change

Consumers of healthcare are more informed than ever before and with the Internet,
consumers have access to more health care and treatment information. Nursing is pivotal
in the provision of relevant information, not only because they are the frontline healthcare
providers, but also because nurses constitute the largest number of healthcare professionals.
Yet, health information and health teaching or counseling on, for example, drug therapy,
nutritional needs, exercise regime or even about disease process are not given to patients
and families.

Nursing roles continue to expand broadening the focus of nursing care in such
areas as mental health, reproductive health, health tourism, wellness management, cancer
survival nursing, disaster management, healthcare financing, etc, yet nursing does not plan
to meet these challenges. Financial management, for example, is hardly (if ever) in nursing
practice agenda. It is as if nursing care is not costly. A small example, is the wearing of
gloves. The ward aids wear gloves to make beds, to sweep the floor and to push trolleys.
Nurses wear gloves to test urine, to bandage an arm or to sponge patients. While wearing
of gloves may be acceptable at most times, nurses need to be aware of the cost of gloves,
unsterile and sterile. In general, nurses are not “taught” to think about cost. This situation
needs to change. Nursing practice needs a vision statement and a plan to meet the vision
which must include cost effective nursing care.

Currently, in the Internet, the only vision and mission available are related to the
Nursing Board of Malaysia but not to nursing practice and nursing service.

Standards for nursing practice although not available on
the Internet (as are nursing’s vision, mission and goals),
have been written but highly probable that they are not
being enforced

Globally, standards for clinical nursing practice focus directly on standards of care
which constitute the Nursing Process Model. The Model outlines six important steps:
Assessment, Nursing Diagnosis, Outcome Identification, Planning, Implementation and
Evaluation.

As mentioned earlier, the Study on Basic Nursing Competencies for New Graduates
of Diploma Programme (2009/2010) stated clearly that there was no evidence of the nursing
process being applied as part of nursing practice in all study hospitals.

Standards for profesional performance such as “quality of care”, “Education”,
“Ethics”, “Research”, etc. may have been spelt out, but the extent to which these standards
have been enforced and therefore evaluated must be ascertained. For certain, quality of

27

Nursing Education in Malaysia

care has not been assessed, or research has not been carried out. Aspects on “resource
utilization” as they relate to cost may not be included and even if they are, they may have
not been enforced, because all along “nursing care costs” are not on nursing’s agenda.

Quality improvement initiatives i.e, activities carried out by
nursing organizations to evaluate and improve the quality
of client care services provided to all clients might have
been done only through ISO initiatives

The evaluation of nursing care is a professional responsibility. Evaluation that
focuses on a single clients’/patient’s plan of care enables a nurse to know the effectiveness
of interventions and whether expected outcomes are met. Since Nursing Process Model is
not enforced in all hospitals, hence, it can safely be concluded that outcomes management
(clinical outcomes of clients as a result of prescribed treatment) is not carried out.

At the institutional level, evaluation involves QI (Quality Improvement) activities
that focus on the delivery of care provided by the nursing division of that institution. Since,
outcomes management programme does not exist at unit levels (through nursing process
model), it can safely be concluded that outcomes management (to measure effectiveness
of interventions, standards of care, and whether delivery of care is necessary), is also not
done.

National initiatives however, have been known to exist which include: client
safety; reduction of unnecessary healthcare costs, identification and use of best
practices and health risk appraisal.

The purpose of QI (and performance improvement) is not to identify problems after
the fact, but to identify opportunities prospectively to improve the quality of care. A well
organized QI programme focuses on processes of care that significantly contribute to
outcomes (Potter and Perry, 2009). QI is also concerned with exceeding the standard
of care, examining ways to be more efficient, improving client satisfaction, etc. – all of
which must be based on Nursing Process Model. Since the Model is not used in Malaysian
hospitals, it can be safely concluded that QI is not part of nursing’s agenda.

Key Performance Indicators (KPI) for nursing has not been
finalized by the ministry of health

Attempts are now being made to come up with KPI for nursing. The Nursing
Task Force, Ministry of Higher Education however, has identified four basic nursing
competencies for new graduates and for those entering nursing service. The four basic
competencies are internationally recognized and they are: Critical thinking and problem
solving, knowledge-based practice, clinical competence and accountability and ethics. The
first two competencies, i.e, critical thinking and problem solving and knowledge-based
practice are directly related to Nursing Process Model. Since the model is not included in
the practice, from the higher education perspective, KPI for nursing have not been met.

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3/ The Status of Nursing in Malaysia

Evidence-based Practice (EBP) in Malaysia is not
on nursing’s agenda

EBP is a problem solving approach to clinical practice that uses the best available
evidence along with nurses’ expertise and client preferences and values in making decisions
about care, requiring nurses to actively pursue the best scientific evidence (Potter & Perry,
2009). Evidence from research studies and the opinions of experts provide a basis for
making evidence-based changes in nursing care.

Since practicing nurses in Malaysia do not carry out research, they still need to develop
critical thinking skills to determine whether research evidence is relevant and appropriate
for their patients. In this context, Malaysian hospitals need expert nurses eg. Clinical
Nurse Specialist, prepared at Masters’ level, to pursue EBP as well as conduct at minimum
outcomes research and intervention research. Currently, this is not available.

Nursing Research

In Malaysia, nursing research is taught to undergraduate students in all the four-year
Bachelor of Nursing programmes. How well it is taught and to what extent the teaching is
effective in producing “research-oriented” graduates depend to a large extent, on the ability
of the lecturers and the attitude of the institution. For example, in public universities, the
students’ research proposals would have to go through the Faculty’s Ethics Committee, and
on acceptance the committee would even provide financial assistance for data collection
and analysis. In addition, a few universities practice the interprofessional approach where
both nursing and medical students are being supervised in research by either nursing or
medical lecturers. This healthy attitude will promote more positive research culture among
doctors and nurses. Such a scenario, however, is more of an exception rather than the
rule.

The rule is that, in Malaysia, nursing research is not carried out. The research
culture is yet to be developed. As mentioned, diploma graduates dominate the clinical and
community setting, and since research is not part of the diploma curriculum, it would be
difficult to enforce or even introduce research culture without appropriate leadership in
research. Hence, for research culture to flourish, at minimum, the clinical setting must be
dominated by degree graduates and leadership provided by a clinical nurse specialist (a
nurse with Masters in clinical nursing).

Historically in nursing, research is not new. It began 140 years ago by Florence
Nightingale. In the US, research became a high priority in the 1950s and 1960s with
the development of graduate programmes and the growing number of nurses with
masters’ degrees and doctorates. During this period, the first research journal, NURSING
RESEARCH, was published. Studies conducted during the two decades focused on topics
such as nursing education, standards for nursing practice, nurses’ characteristics, staffing
patterns and quality of care.

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Nursing Education in Malaysia

Research activities in the US advanced extensively during the 1970s and 1980s. The
major focus was on the conduct of clinical research to improve nursing practice. Several
research journals were initiated, numerous research conferences were held and in 1985
the National Centre for Nursing Research (NCNR) was created. NCNR was to support
the conduct of basic and clinical nursing research and dissemination of findings. Under
the direction of an expert (Ada Sue Hinshaw, PhD. RN), the NCNR in 1993, became
the National Institute of Nursing Research (NINR). The change in title increased the
recognition of nursing in the US as a research discipline and expanded the funding for
nursing research.

In the ‘80s and ‘90s, outcomes research emerged as an important methodology for
documenting the effectiveness of healthcare services. The Agency for Health Care Policy
and Research (AHCPR) was established in 1989 to facilitate the conduct of outcomes
research.

For the 21st century, the vision for nursing in the US is the development of a scientific
knowledge base that enables nurses to implement an evidence-based practice (EBP). NINR
is now seeking expanded funding for nursing research and is encouraging a variety of
methodologies: quantitative, qualitative, outcome research and intervention research – to
be used to generate essential knowledge for nursing practice (Burns & Grove, 2001).

Lessons to be learned from the US experience of nursing research are:

1. To ensure an effective research enterprise in nursing, the discipline must:

(a) Create a research culture;

(b) Provide quality educational programmes (baccalaureate, masters, doctoral and
postdoctoral)

(c) Develop a sound research infrastructure; and

(d) Obtain sufficient funding for essential research

2. On the basis that research is a process and is similar in some ways to other processes,
it is useful to include early in nursing education a strong background in problem
solving and nursing process. A comparison of the problem-solving process, nursing
process and research process will show similarities and differences in these processes
which would provide a basis for understanding the research process. The problem-
based learning (PBL) approach is one good example of a problem-solving process
that provides a lot of similarities to research process.

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3/ The Status of Nursing in Malaysia

In short, nursing education should include as early as possible in the curriculum, the
application of NURSING PROCESS and PROBLEM-SOLVING PROCESS such as
PBL approach, as a basis for better understanding of the research process.

3. Nursing research incorporates both quantitative and qualitative research and two new
methodologies: outcomes research and intervention research.

(a) Quantitative research (objective, systematic process of using numerical data
to obtain information) and qualitative research (subjective approach used to
describe life experiences to give them meaning and values) compliment each
other, because they generate different kinds of knowledge and are useful in
nursing practice. Combined (triangulation), the two methods will ensure the
most comprehensive approach taken to solve a research problem.

(b) Outcomes research (end-results of care or a measure of the change in health
status of the patient) should be encouraged or made a necessity, because healthcare
is costly and nursing should be held responsible for answering questions about
the quality and effectiveness of nursing care and the patient outcomes related to
nursing service. Outcomes research can influence:

i. Patient health status;
ii. Delivery of practitioners service
iii. Use of limited resources
iv. Development of public policy
v. Purchaser demand

(c) Intervention research (investigation of effectiveness of a nursing intervention
in achieving the desired outcomes in a natural setting) provides a methodology
for determining how, when and for whom an intervention works. The goal is
to generate sound scientific knowledge for nursing actions that can be used by
nurses to provide evidence-based nursing care.

To make nursing research a reality, nursing needs nurses who are qualified to undertake
research. In Malaysia, there are about 10 nurses with Ph.D qualification and 30-40 more
are registered in PhD programmes locally and abroad. In addition, there are about 200 or
more masters’ prepared nurses. Together as a group, research activities could be activated.
There is a need for a mechanism to facilitate research activities, even if it is centralized,
to make nursing part of the research community, and in the process, facilitates nursing
autonomy.

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Nursing Education in Malaysia

Nursing Autonomy

Someone describes nursing as “powerless, apolitical and disorganized, swept along with
change, able only to react and not to control” (Anonymous as cited by Stephan G. Wright,
1989). In so many dimensions, the description fits nursing in Malaysia like a glove.

Worldwide, nursing is considered a profession because it has the following
characteristics:

1. It requires an extended education for its members as well as a basic liberal
foundation;

2. It has a theoretical body of knowledge leading to defined skills, abilities and norms;

3. It provides a specific service;

4. Members have autonomy in decision making and practice; and

5. It has a code of ethics for practice. (Potter & Perry, 2009).


At a glance, nursing in Malaysia seems to have met all the five characteristics. But,
how does one explain the fact that the Government of Malaysia has classified nursing as
a sub-profession, where almost 98.8% of its members receive a starting salary of U29,
and where the majority retire at below U36/37, far below the professional group salary of
U41.

Nursing as a profession has been classified as a support service within the government
service structure and nurses, as a group, have been referred to as a sub-profesional group,
no matter how well-paid or well qualified some of them are. In reality, while nurses in
many countries in the world enjoy the professional status, nursing in Malaysia must fulfill
a number of conditions before its members can enjoy the same status. Notably, Malaysian
nurses as a group and Malaysian nursing as an organization does not have autonomy in
decision making and practice (the fourth characteristic). This is because of three major
reasons:

1. To be autonomous, the group must have effective governance, which is the
establishment and maintenance of social, political and economic arrangements
by which practitioners control their practice, their self-discipline, their working
conditions and their professional affairs.

2. Autonomy is an essential element of profesional nursing. There are independent
nursing interventions that nurses must initiate without medical orders.

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3/ The Status of Nursing in Malaysia

3. Nursing must be seen by the public as active in politics, professional and financial
issues affecting healthcare and the nursing profession. Professional organizations,
for example, the Malaysian Nurses Association, Nursing Students Associations or
even Nursing Alumni Associations can be strong lobbyists in professional practice
issues which help promote professionalism.

To be autonomous, the group must have effective governance,
which is the establishment and maintenance of social, political
and economic arrangements by which practitioners control
their practice, their self-discipline, their working conditions
and their professional affairs

In Malaysia, the governance that controls nursing practice, discipline of members,
their working conditions and their professional affairs, is the Nursing Board of Malaysia.
The Nursing Board is “positioned” in the Ministry of Health and is structured based on
the system of “ex-officio” as members. Membership is predominantly led by medical
practitioners, the chairman being the Director General of Health. The Head of Nursing at
the Ministry of Health serves as the Registrar and another a Secretary. More critical, the
board serves exclusively the interests of the Ministry of Health, irrespective of the scope of
nursing beyond this ministry.

A profession is autonomous if it regulates itself and sets standards for its members. To
be autonomous, a professional group must (a) be granted legal authority to define the scope
of its practice; (b) describe its particular functions and roles; and (c) determine its goals and
responsibilities and delivery of its service. The amount of autonomy a profesional group
possesses depends on its effectiveness at governance.

To gain this status, the Nursing Board must be an independent body that serves the
interest of the nursing profession and legal aspects of nursing practice. The chairman of
the board must rightfully be a nurse who is highly qualified and with exceptional leadership
qualities. Its members must be equally qualified in all areas of nursing practice, education
and management. This independent board must be concerned with the quality of its services
which constitutes the heart of its responsibility to the public. Through this board, nursing
must control its practice in order to guarantee the quality of its services to the public.
The more expertise required to perform the service, the greater society’s dependence upon
those who carry this out, the more powerful the profession.

This simply means that the effectiveness at governance to ensure the quality of practice
will determine the amount of autonomy nursing profesion will possess. The achievement
rests heavily on firstly, the quality of leadership and expertise of the members of the board,
and secondly, on the ratio of professional nurses (degree prepared nurses) to technical
nurses (diploma prepared nurses) to provide nursing services. The higher the ratio of

33

Nursing Education in Malaysia

professional nurses to technical nurses to perform the service, the greater the society’s
needs for nursing service, the greater the power it gets to control its services, the more
autonomous is the profession. Malaysian Nursing is denied of all these.

Autonomy is an essential element of professional nursing.
There are independent nursing interventions that nurses
must initiate without medical orders

Nursing is not simply a collection of specific skills and nurses are not simply persons
to perform specific tasks. The level of care must be demonstrated by the critical thinking
model known as the NURSING PROCESS: assessment, diagnosis, outcomes identification
and planning, implementation and evaluation (ANA, 2004). The nursing process is the
foundation of clinical decision making and includes all significant actions taken by nurses
in providing care to clients, outside of doctor’s orders.

In Malaysia, the use of nursing process is not part of nursing standards. Nursing is
practiced, for most part, to the extent that doctors’ orders are met. Diploma graduates are
only expected to “implement” the care orders and since, currently, nurses are not expected
to perform health assessment, make nursing diagnosis and plan for the care, the orders in
question would have to come only from doctors. For nursing to be autonomous most of
the nursing care activities must come from nursing orders. Doctors’ orders should only
be part of these activities. To enable a nurse to come up with “nursing orders”, there
must exist a “nursing diagnosis” which requires that the nurse functions at minimum at
analysis, synthesis and evaluation level. Medical doctors function at this level all the time
because they have extensive and in-depth knowledge of the sciences to help them in critical
thinking and problem solving. Hence, it is fair to say that for nurses to be in the same
circumstances, the educational programme must provide extensive in-dept knowledge of
the sciences to enable them to think critically and to solve problems effectively, which only
degree programmes can provide.

Nursing must be seen by the public as active in politics,
professional and financial issues affecting healthcare
and the nursing profession. Professional organizations,
for example, the Malaysian Nurses Association, Nursing
Students Associations or even Nursing Alumni Associations
can be strong lobbyists in professional practice issues
which help promote professionalism


In Malaysia, the Malaysian Nurses Association (MNA) exists only to perform certain
activities for its members. It appears to have a lot of constraints in words and deeds and a
far-cry from being a lobbyist. For example, it could have involved itself in the issues of five
day week for nurses, higher entry requirements into nursing, or the issues of mushrooming

34

3/ The Status of Nursing in Malaysia

of private colleges or issues of nursing shortage, and so on. In general, MNA appears to
mainly exist to support Ministry of Health’s agenda.

To be of benefits to nursing as a profession, the establishment of another professional
body is seen as a positive step in helping to bring about awareness to the public about
nursing’s active role in politics, profesional and financial issues affecting nursing.

It is safe to conclude that nursing in Malaysia, while fulfilling other characteristics of
a profession, lacks the autonomy that is required by all professions to control its practice.

In conclusion, Nursing in Malaysia has several challenging needs which must be
addressed. These include:

1. Nursing Education

(a) Having all nursing education programmes under one umbrella, that of the
Ministry of Higher Education based on the principle that all programmes must
be accredited using MQF standards and criteria.

(b) Having a mechanism to ensure that the entry requirements into basic nursing
programmes at diploma and baccalaureate levels be specified to include pure
science subjects and mathematics as a basis for ensuring a strong background in
critical thinking and problem solving.

(c) Employing teachers of nursing who are content experts and experienced in
relevant clinical specialties as well as ensuring that each nonnursing subject be
taught only by content experts at respective levels of nursing education.

(d) The inclusion of one of the conditions for reviewing of Annual Practicing
Certificate (APC) for nurse teachers as participating actively in the practice of
nursing in the clinical setting, as a basis for ensuring that what is taught to
students is current and relevant; and that the APC should be the concern of the
individual nurse not the employer as a basis for achieving autonomy.

(e) Achieving the 30-50% target of PhD/Doctorate in Nursing holders in public and
private universities by 2020 as expected by the Ministry of Higher Education.

(f) The participation of only institutions of higher learning with hospitals or
affiliate hospitals in the conduct of Diploma in Nursing, Bachelor of Nursing
and Masters of Nursing degree. Accordingly, by 2020 only nurse teachers
with clinical degrees (Bachelor’s degree with postgraduate clinical diploma/
certificate, Masters in Clinical Nursing, and doctorate in clinical practice) should
be allowed to teach nursing.

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Nursing Education in Malaysia

(g) A plan to reorganize the conduct of diploma of nursing programme by the
Ministry of Higher Education in the following manner:

i. By 2012, the entry requirements must be a pass in SPM with five credits
in Biology, Chemistry or Physics, Mathematics, Bahasa Malaysia and
Bahasa Inggeris;

ii. By 2012, all universities should cease to conduct diploma in nursing
programme;

iii. By 2015, only colleges of nursing with hospitals or affiliate hospitals
should be allowed to conduct diploma in nursing programme;

iv. By 2020, graduates of diploma in nursing should only be 40% of the total
Registered Nurse graduates in the country;

v. The criteria for teachers teaching in the diploma programme are: a
Bachelor of Nursing, a postbasic/postgraduate certificate or diploma in a
clinical specialty, satisfactory clinical experience of two to three years and
teaching process/technology qualification.

(h) A plan to reorganize the conduct of professional nursing programmes –
undergraduate and postgraduate studies – by the Ministry of Higher Education,
in the following manner:

i. Major emphasis on all programmes must be in clinical specialty to ensure
in-depth content and expertise in the practice of nursing to meet consumer
needs; the need to participate in the growth of Malaysia economy through
health tourism, foreign investments such as the presence of John Hopkins
University; shift in paradigm with special focus on mental health,
reproductive health, financial management, cancer survival nursing,
research building capacity; the compulsory integration of Nursing
Process Model, PBL (Problem-based Learning) approach in teaching and
practice;

ii. Student population must include foreign students, increase in male students
and an increase in the participation of multiracial group (as opposed to
almost 99% Malay and female gender in diploma programmes);

iii. The product of the programmes should be prepared to participate/be
involved in business ventures as entrepreneurs in healthcare, homecare,
women’s health issues and practitioners in individual or group practice;

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3/ The Status of Nursing in Malaysia

iv. Nursing programmes should be conducted within its own faculty that is,
Faculty of Nursing.

2. Nursing Practice

The inclusion into nursing practice, the Nursing Process Model as a basis for building
a strong background in critical thinking and problem solving in its effort to provide the
highest quality care, better understanding of the research process and for achieving nursing
autonomy.

(h) The composition of the nursing profession in Malaysia be shared between
Registered Nurses of two levels: Level 1 with Bachelor of Nursing to be known
as Profesional Nurses and Level 2 with Diploma in Nursing to be known as
Diploma Nurses. The roles of both levels will differ in both the functions as
well as responsibilities.

(i) The degree-diploma nurse ratio by 2020 be at least 60:40 to ensure (a) the
provision of the highest quality of profesional care to clients through the
implementation of the Nursing Process Model, (b) Maximum possibility
of being classified into the profesional status within the government service
structure; and (c) the achievement of nursing autonomy through the provision
of care based on nursing orders (over and above doctors’ orders), throughout the
system.

(j) Nurses’ extended role to be regarded as part of routine profesional nursing
activities, in the care setting and these include providing information to clients,
patient/health education, counseling, discharge planning and follow-up care,
and participating in research. Accordingly, they must be prepared to assume
such roles.

(k) Standards for clinical nursing practice which focus directly on standards of care,
must constitute the Nursing Process Model, which outlines six important steps:
Health assessment, nursing diagnosis, outcomes identification, planning of care,
implementation of care plan and evaluation of care.

(l) Standards for profesional performance which focus on quality of care, education,
ethics, areas of accountability, research, resource utilization etc. must be spelt
out, enforced and evaluated.

(m) Quality improvement (QI) initiatives must be carried out through outcomes
management at two levels: (a) at a single client’s plan of care level which looks
at the effectiveness of interventions and whether expected outcomes are met;

37

Nursing Education in Malaysia

and (b) at institutional level which looks at the delivery of care (standards
for profesional performance) provided by the nursing division of respective
institution.

(n) The need to identify key performance indicators (KPI) for nursing, as a profession.
Globally, at least four basic nursing competencies have been identified as being
indicators for quality nursing care performance. These four indicators: critical
thinking and problem solving, knowledge-based practice, clinical competence
and accountability and ethics have been the focus of a recent study conducted
locally by Nursing Education Task Force, Ministry of Higher Education, the
result of which revealed many challenging issues.

3. Nursing Research

(o) The development of an effective research enterprise in nursing to support
evidence-based practice initiatives which can be made possible only through
the preparation of nurses who are highly qualified to undertake research.

(p) The need to place evidence-based practice (EBP) on nursings’ agenda, and
accordingly, the need to conduct at least two kinds of research: outcomes
research and intervention research to support EBP.

4. Nursing Autonomy

(q) Having its members classified as a profesional group within the government
service structure, at par with other profesional groups (eg. In medicine, dentistry,
pharmacy) instead of the current “support” group status.

(r) Being in possession of the autonomy to control its own practice through an
independent Nursing Board/Council headed by a nurse.

(s) The establishment of an independent professional Body, capable of lifting
nursing profession to a level where nursing could be seen by the public as active
in politics, professional and financial issues affecting healthcare and the nursing
profession.

38

Chapter 4

Vision 2020 for Nursing

Addressing Nursing Needs and Issues

Vision 2020 for nursing regarded as ‘Nursing’s Agenda for the Future’ is a collection of
nursing needs and issues, some of which are very basic requiring serious efforts and firm
commitments from the government and relevant nursing organizations.

Agenda One

By 2020, nursing in Malaysia will be classified as a professional service and its
providers as professional staff within the government service structure, replacing the
current support service classification and support staff status.

Strategies
1. Mechanisms are in place within the Ministry of Higher Education and Ministry

of Health to ensure that by 2020, at least 60% of the nurse population constitute
professional nurses, i.e, nurses who are holders of the Bachelor of Nursing and are on
a degree starting salary;

2. Nursing organizations at various levels to include in their current planning and
implementation strategies the use of professional nurses in the provision of direct
patient care in most acute care facilities and in the community including the rural
setting; and

3. The Bachelor of Nursing degree is to become the most basic qualification for all
promotional posts in nursing. The soon-to-be established Malaysian Academy of
Nursing will produce a working paper to justify career development strategies in
nursing as reflected in Figure 1 and Figure 2.

Nursing Education in Malaysia

Agenda Two

By 2020, the nursing profession will have the autonomy in decision making and
practice through an effective governance that enables members to control their practice,
their self-discipline, their working conditions and their professional affairs.

Strategies
1. Nursing organizations at various levels of the healthcare system to ensure that nursing

care provided to clients (individuals, families and the community) is based on the
critical thinking model known as the Nursing Process Model. The model specifies
that nurses perform nursing assessment, derive nursing diagnosis, identify client
outcomes, plan for the care, implement and evaluate the plan of care. This process is
the foundation for clinical decision making and includes all significant actions taken
by nurses in providing care to clients, outside of doctors’ orders;

2. A mechanism is established through which nursing could be seen by the public as
active in politics, professional and financial issues affecting health care and nursing
profession.

The mechanism to be established is the setting up of THE MALAYSIAN ACADEMY
OF NURSING, an independent professional institution devoted to advancing the
art and science of nursing by promoting and maintaining the highest professional
standards of nursing education, thereby providing the highest quality of patient care
for the people of Malaysia. It is expected to establish in 2011; and

3. The Malaysian Academy of Nursing with the support of the Ministry of Higher
Education to advocate the notion that nursing practice should be controlled by the
Nursing Board or Nursing Council which is independent of the Ministry of Health. The
Board/Council must be headed by a nurse with highly qualified nursing membership.
The major concern of the board/council must be on the quality of nursing services
which constitutes the heart of its responsibility to the public.

Agenda Three

In support of Agenda 1 and Agenda 2 as well as for the advancement of nursing
education in Malaysia, by 2015 a one-system nursing education must be in place implying
that all nursing programmes conducted by the Ministry of Health be placed under the
umbrella of the Ministry of Higher Education.

Strategies
1. The Malaysian Qualifications Agency (MQA) to advocate the conduct of accreditation

initiatives on all current Ministry of Health nursing education programmes using the

40

4/ Vision 2020 for Nursing

Malaysian Qualifications Framework (MQF) standards and criteria. This will include
the top-up degree programme advocated by the Nursing Board of Malaysia; OR

2. The Ministry of Health to plan for the placement of all its nursing education programmes
to be under the umbrella of the Ministry of Higher Education either completely or as
private entities, while remaining within the Ministry of Health; AND/OR

3. Building partnership with universities, thus necessitating making changes to suit the
need of university standards.

4. The Malaysian Academy of Nursing will monitor the progress of the development of
one-system nursing education that should take place by 2015 through a mechanism
that would support MQA and Ministry of Health initiatives.

Agenda Four

In support of Agenda 1 and Agenda 2 as well as for the advancement of nursing
practice standards, the inclusion of the Nursing Process Model into nursing practice by
2015, as a basis for building a strong background in critical thinking and problem solving
in its effort to provide the highest quality care to clients. The Nursing Process Model
provides the following standards of nursing practice:

1. Assessment
The registered nurse collects comprehensive data pertinent to the patient’s health or

the situation.

2. Diagnosis
The registered nurse analyses the assessment data to determine nursing diagnosis and

issues.

3. Outcomes identification
The registered nurse identifies expected outcomes for a plan, individualized to the

patient or the situation.

4. Planning
The registered nurse develops a plan that prescribes strategies and alternatives to

attain expected outcomes.

5. Implementation
The registered nurse implements the identified plan.

6. Evaluation
The registered nurse evaluates progress toward attainment of outcomes.

(Adopted from ANA, 2004)
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Nursing Education in Malaysia

Strategies
1. The Nursing Division of all healthcare organizations, in particular the Ministry of

Health Nursing Division, to enforce standards for clinical nursing practice to constitute
the Nursing Process Model which outlines six important steps in its standard of care
to clients.

2. The Ministry of Higher Education to enforce a mechanism that compels:

(a) The Nursing Process Model be taught, assessed and applied in clinical practice
sessions at all basic and graduate nursing programmes;

(b) The entry requirements into basic nursing education programmes at diploma and
degree levels be specified to include pure science subjects (biology, chemistry/
physics) and mathematics to enable graduates to have the nursing literacy and
numeracy skills so needed in the provision of quality service.

(c) Teachers of nursing are well versed and qualified to teach and practice the
Nursing Process Model.

(d) The Malaysian Academy of Nursing to participate in the implementation process
of the Nursing Process Model by providing leadership and capacity building.

(e) By 2016, all employers of new nursing graduates have a right to expect the
graduates to possess at minimum four basic nursing competencies, to be
referred to as ‘Key Performance Indicators (KPI) for New Graduates’. The four
nursing competencies are: critical thinking and problem solving, knowledge-
based practice, clinical competence and accountability and ethical practice, all
of which are included in the Nursing Process Model.

Agenda Five

By 2020, the degree to diploma nurse population ratio be at least 60% : 40% to
ensure:

1. The provision of the highest quality of professional care to clients through the
implementation of the Nursing Process Model;

2. Maximum possibility of achieving the profesional status classification within the
government service structure; and

3. Maximum possibility of achieving nursing autonomy through the provisioin of care
based on nursing orders (over and above doctors’ orders) throughout the system.

42