Employees morale and psychological needs are some of the most discussed topics within most organizations recently. Employees are the important assets for any organization, as they are the main reason behind the success or failure of a company. Therefore when company faces high employee turnover rates, one might need to consider and investigate the root of the cause to prohibit the situation to worsen, as no company should ever underestimate the power of employees.
Decades ago, many dream of working for the Hong Kong Government, people even labeled it as “Metal Bowl” to portray the job security and the superb working hours it can offer. As the transition of British colonies to The People’s Republic of China in 1997, the government has implemented many policies, which caused interference to such “Metal Bowl”.
Hong Kong Hospital Authority (HA) is a governance statutory body, for which are responsible for managing Hong Kong’s public hospitals. The body employs around 59,000 people; close to 50% is professional medical staff (doctors and nurses), where nurses summed up the total of the 25,000 plus medical professionals. The Hospital Authority Report 2010-2011 shows that the number of outpatient attendances is over 10,000,000, in the mean time year 2011 is the year where HA encountered the highest nurses turnover rates in decades. Even though, shortages of nurses or other professional medical staff is one common dilemma among many countries (Appendix 1). However, as Hong Kong is a small city with a relatively low population compare to other countries, such high turnover has revealed the underlie problems of HA and the reasons behind it all.
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The HA sets out a clear core values for their staff to follow (Appendix 2), they emphasis immensely on the importance of PEOPLE, however the high turnover rate might reflects the problematic issues of the group. In recent years, the professional medical staff’s turnover is reaching to its maximum heights (Appendix 3), HA understands the urgency of the problems and how it can truly affect their image as well as their service level to the general public, and therefore they have been launching different kind of programs in hopes to disentangle the problems. However the effectiveness of those programs might require some period to demonstrate a positive result.
In this study, we will critically analyze the main issues of HA in causing the high turnover of a targeted group of medical professional – Nurses, and critically evaluate their current solution as well as to propose suggestion for enhancement.
There are 5 main issues which have constructed the results of the high turnover rate for HA. Each issue is as problematic as the other, with the continue neglect of these problems, it will not only causes damage to HA but to the Hong Kong society as a whole.
Retaining nurses has been one of the major challenges of HA. In terms of pay, private hospitals provide a more competitive salary than HA does. The starting salary of a registered nurse (RN) that works for private hospital is more than $30,000 per month, which is equivalent to Point 20 of HA pay scale. On a contrary, if she works for HA, she only gets $23,000, which is 5 points lower than the offer of private hospital. Besides, the maximum salary of the same position also varies and private hospital are able to provide a more attractive financial reward to the right candidate including double pay and higher amount of cash allowance.
Since HA has little room to raise its pay level, providing intrinsic value to work at public hospital is of the utmost importance in relation to nurse retention. Therefore, adopting total reward strategy would be the most effective way to reduce the turnover rate of nurses. It focuses not only on tangible reward; it also emphasizes non-direct financial benefits, training and development opportunities and working environment (Jennifer Paterson, 2011).
2.1.1 Direct Financial Benefits
It is difficult for HA to review its pay scale and match its pay with the “market price”, since there are numerous restrictions and it would affect not just the nurse, but all the staff that work for HA. Beyond adjusting the pay scale, there are other measures that could be adopted to improve the overall competitiveness of their pay. HA provides monthly cash allowance besides basic salary, but no matter how well the staff perform, they do not get any incentive for their effort. Introduction of merit pay would enhance the competence of the remuneration package, moreover, it could also act as the motivator for nurse to improve their overall performance (Raymond J. Stone, 2011, p. 469-70), and in return, it helps HA shape the desired behavior of staff. More importantly, it gives credit to nurses for their performance.
2.1.2 Training and Development Opportunities
Comparing with private hospital, the patients handled by HA hospital are versatile and cases are much more complicated. This is the major reason for newly graduated nurse to join HA according to our interviewee, Catherine, who is an experienced RN from Orthopaedics & Traumatology of United Christian Hospital(UCH). Thus, introducing mentorship and comprehensive on-the-job training would further raise the value of working at public hospital beyond the monetary motivation because more clinical experience could be earned. The significant issue followed is how HA can retain experienced nurses. In the light of equipping junior staff with clinical experience, HA could also invite competent nurses with certain years of experience to join professional specialty training, or even providing training allowances for them to study Master of Nursing or Overseas, these measures allow senior staff to develop professional specialty skills and pave the way for future career development. It elevates the competitiveness and creates value for staff. The benefits to both staff and HA could not be expressed simply in terms of money.
2.1.2 Working Environment
Working environment improvement is one of the intrinsic-value-added aspects under the total reward strategy. Compared with public hospital, private hospital provides a less pressure working environment and nurses could be evaluated according to performance. However, HA fails to eliminate unfairness, since different person doing the same job entitles to different pay, which is caused by differences between the old and new HR practices of HA. Fair treatment to all staff is one of the pre-requisites in creating a friendly and rewarding workplace. On a contrary, unjust treatment would depreciate the morale of the team. Thus, HA has to be careful in setting up HR policy framework in the future to avoid unfairness and ensure every HR practice is justice in order to maintain the morale and employee satisfaction.
2.1.3 Introduction of Total Reward Statement
With regard to the nurse retention issue of public hospital, adoption of total reward strategy could be the solution in terms of remuneration packages. In order to stay competitive in the talent retention battle against private hospital, both tangible and intangible values for nursing staff must be raised. Even though different approaches have been proposed, perception of these measures differs and varies among staff. To make sure employees understand the total value of the benefits package, total reward statements (TRS) could be introduced. It is a tool to demonstrate the actual monetary value of their benefits besides pay, the value of the entitled medical benefits, training opportunities etc. would be shown(Hannah Brenton, 2012) Therefore, before nurses turn to private hospital, they could have a second thought by looking at the total value of the package instead of focusing only on the amount of basic salary and double pay offered by private hospital which could only generate no dissatisfaction, but not satisfaction according to Herzberg’s two-factor theory (Raymond J. Stone, 2011, p. 427).
High pressure in job is one of the major problems causing high turnover rate of nurses in public hospital, the reasons are listed as follows:
2.2.1 Aging population in Hong Kong
The problem of aging population in Hong Kong is worsening due to a longer life expectancy. According to Government statistics, the expectation of life at birth was increased by 5.3 years to 80.5 for males and 6 years to 86.7 for females from 1991 to 2011.1 It will bring enormous pressure to local medical system in terms of medical treatment and rehabilitation services. The Association of Hong Kong Nursing Staff conducted a survey about HA Human Resources in Nursing in 2012, the result showed that bed occupancy rate in Medicine / Geriatric was 104% which was the highest among specialist departments.2 In addition, it should be noted that respondents from Medicine / Geriatric felt high pressure at 8.1 in providing patient care services which was slightly lower than Emergency Medicine (A&E) at 8.9.3
2.2.2 Work overload in Emergency Medicine (A&E)
Frontline staff in A&E Departments feels fatigue, frustration and stressful because of high nurses-to-patients ratio comparing to international standard4, however, this problem is getting worse since increasing numbers of doubly non-permanent resident pregnant women giving birth in Hong Kong in recent years. The most suffering unit is the A&E of North District Hospital according to a TV program of Hong Kong Connection (é-é˜é›†) broadcasted on 8 July 2012.5 Its frontline staff when encountering dangerous cases of pregnant mainland women give birth, however, they could not seek for assistance from Obstetrics & Gynaecology and Paediatrics since the hospital lacks these units. Consequently, they had to transfer the women to Prince of Wales Hospital, the nearest one with Obstetrics & Gynaecology for special treatment. Although a “zero quota” policy will be implemented in private hospitals next year6, the influx of pregnant mainland women to A&E of public hospitals still non-stops. Furthermore, the problem has already been extended to Paediatrics and Neonatal Intensive Care Units (NICU).7 Therefore, frontline staff is experiencing extremely high pressure at 8.9 as shown in the survey.3
2.2.3 Pressure from medical incidents
Starting from Oct 2007, all public hospital clusters are required to report serious medical incidents to HA Head Office within 24 hours. Then HA will disclose such information to enhance its transparency and responsiveness.8 It was reported from Risk Alert, a periodic newsletter of HA, the number of serious medical incidents increased by 33 % from 33 in Q4 2009 – Q3 2010 to 44 in Q4 2010 – Q3 2011.9 With increasing numbers of incidents, medical staff inevitably faces “excessive attention” from media, criticism from publics and complaints from patients’ families. According to Catherine, a Register Nurse from Orthopaedics & Traumatology of United Christian Hospital, nurses were instructed to be customer-oriented when dealing with difficult patients and apologize to them even nurses were right.
“Happy Staff” is one of the HA’s vision.10 To ensure staff feel happy, fairness and motivated, it is recommended that HA should review its current HR planning policy to ensure sufficient human resources supply in short-run and long-run. For short-term planning, HA can recruit temporary oversea professionals to alleviate the pressure in Geriatric, A&E, Obstetrics & Gynaecology and Paediatrics to tackle the problems of aging population and work overload. For long-term, HA can hire consultants to provide HR viewpoints on medical services expansion and corporate strategic planning. Besides, the rocketing number of serious medical incidents has led to a decline in trust from community and patients, nurses will be difficult to satisfy their needs of self-esteem in Maslow’s needs hierarchy theory, i.e. lacking respect from others.11 To promote the positive image of nurses, we suggest HA producing TV dramas and/or movies to arouse public’s concern on nurses’ work-life imbalance and enormous pressure. Finally, a secretive and anonymous feedback and complaints channel should be established for nurses to freely express their feelings, opinions and suggestions. For example, drop boxes should be placed in corridors in each department so that management can alert to the problems and find ways to solve them at soonest possible.
2.3 The demoralization of nursing staff
In April 2011, thousands of on duty nurses from public hospitals participated in a three-day “silent” protest, wearing stickers showing a tired and angry face, to express their dissatisfaction towards HA (Serinah Ho, 2011). The Association of Hong Kong Nursing Staff (AHKNS) also conducted a survey on HA nursing staff’s job satisfaction level and job happiness level in 2011 and 2012, in which more than 3500 and 2150 returns were received respectively. The surveys’ results (see figure 1) indicated that, the nursing staff in HA were unsatisfied with their job and unhappy under the existing working condition. These failures acted as a signal alerting the HA’s management that the nurses morale was low. To identify the causes of the low morale in workplace is the fundamental principle before tackling the issue. The causes across HA can be rooted to external and internal factors. The external factors are the impacts from the society, including patients and their relatives’ expectations, the concerns from the public and the culture of the society. The internal factors included the seniors’ management skills, mentors’ expectations and peer influences.
2.3.1 External Factors
Nowadays, patients and their relatives have high expectations on the public health professionals. Most of them are well educated and knowledgeable. They can easily gain access to the references of various diseases, and have free consultation on deferent treatment from newspaper, magazine, bloggers and the internet. They have much knowledge on the disease, before any healthcare professionals approached them. A lot of nursing staff at the front line were criticized by the patients and their relatives in a rude manner. Moreover, nursing professionals in HA are providing the Holistic Health Care which is the highest standard of quality in nursing field up to today. Their main duty is to provide 24 hours professional bedside nursing care to patients. However, some patients or their relatives vent their anger to nurse when they lost their temper. Oriental Daily reported on 10 April 2012; “a nurse was attacked by a drunken man while stopping him yelling at A&E department in Queen Elisabeth Hospital.” The other factor is about the concerns from public and common value in the society. The public focus on the right to know in Hong Kong. In this connection, the reporters are busy on finding the news or searching for the valuable information related to public sectors in order to getting more reader and increasing their market share on selling newspaper. According to the database from Wisers Information Limited, more than 3000 news related to HA have been published from over 20 newspapers in 2012 (until the end of September). 1/3 of the news was delivered from the negative perspective. It is agreed that monitoring the government and the public sectors’ programme is one of the most important responsibility of the media. Honestly speaking, the morale of the nurses had dropped sharply after reading these articles with very harsh wordings. They are discouraged to serve the public from the bottom of their hearts.
2.3.2 Internal Factors
In a much customer-oriented society today, hospital services had also became more customer focused. “When receiving the complaints, the senior would always make an apology immediately, before doing any investigation on the cases. In fact, it might not be our fault.” Catherine, our interviewee said. Nurses are unhappy that they were not receiving sufficient support from their seniors. As a nurse with more than 10 years’ experience, Catherine is responsible for performing the daily bedside care in the orthopedics ward in UCH. Same as other experienced nurses in HA; she is responsible for training up the new staff as well. Recently, more than 35 % of the manpower in UCH orthopedics ward were fresh-graduate nurses. The HA management had developed a preceptorship programme for the newly graduated degree / HD nurses, which included clinical rotation to at least in 2 clinical settings in the first 2 years of the contract period. This programme helped the freshman to consolidate their learning and to integrate into the clinical settings. On the other hand, they are required to rotate to other wards after having familiarized with the ward settings. “It is difficult to train up a fresh graduate nurse. Some of them are so arrogant, and always stick on the theories which might not be applicable to every situation. It is discouraging to train the new staff, and then having to say goodbye to them as they rotate to other wards, and this have to happen repeatedly.” Catherine said helplessly. Moreover, there was even a higher intensity of dissatisfaction when they compare the workload and salary with their peers in private hospitals. Workloads in public hospitals were generally much higher than that from private hospitals, but the salary was in the opposite way.
2.3.3 Tackle the issues
From the Herzberg’s Motivation-Hygiene Theory (Raymond J. Stone, 2011, p. 427-8), employee satisfaction level can be influenced by 2 set of factors. The first set call hygiene factors which including salary, enumeration benefit, job security and work conditions. This set of factors can only lead the short-run success in the organization. For the long run success, the positive personal growth, recognition and achievement of the motivated factors are needed. These are factors leading the employees to satisfaction. To increase the satisfaction level in HA, it is suggested to work on the motivated factors. Per the above internal factors have been mentioned, some freshmen care more about the working location than the services’ needs. They even let behind the golden rule in nursing profession – the patients’ needs should come first. In this connection, they do think twice before stepping in to the nursing career. It is proposed conducting education talks to the secondary students in order to promote the nursing professional standard. In addition, students could also have a better understanding on the nursing field. Moreover, to increase the sense of belonging is greatly needed. It has been suggested to recruit second-year nursing students as Temporary Undergraduate Nurse Students (TUNS) to work and gain experience in HA. From existing practices, the nursing students were invited to submit the TUNS application in their final year. If HA recruited the students at an earlier stage, they would be more familiar with the ward setting by the time they graduate. At the same time, they could gain clinical experiences, and develop the sense of belonging as they work with HA nurses. The senior nurses can train up a freshman much easier when they are well equipped. This is a win-win situation, as both nurses morale could be raised. Moreover, it is advised to give recognition to staff, including verbal appreciations, records of appreciation in appraisals, and recommend them to attend the international convention. Job enrichment is another alternative to motivate the nursing profession as they develop towards more senior level. For senior nurses who had at least 10-15 years of experience, they would need a more challenging work environment to further develop their skills. One option would be to let these senior nurses handle primary level of consultation with the patients, or multi-task oriented patient care. These duties are part of the simple duties that doctors are handling. In this way they could gain more job satisfaction through job enrichment, and could also relieve doctors’ workload, and thus reduce the waiting time of the patients. Last but not least, the backup from HA management and senior’s support to the front-line nursing professional are also important. The key message of “YOU ARE NOT ALONE” should be delivered to all staff. The more respect given to staff, the more job satisfaction could be gained.
2.4 Work-life imbalance
The high turnover of nurses in Hospital Authority could be induced by inability in achieving work-life balance, which is a balance between work and lifestyle. This study focuses on the impact of overtime work, shift duty and geographic mismatch to work-life balance.
Some nurses, especially those who work for operation rooms, are facing serious overtime work. In Queen Mary Hospital, the surgery workload is increased with the aim to shorten the waiting time for receiving surgeries. These nurses thus normally have to work overtime for 4 to 8 hours per day. In an incident in 2009, almost half of these nurses applied sick leave on the same day to show their dissatisfaction (Appendix a). Despite the time-off policy, nurses find it difficult to take time-off and even annual leaves due to serious lack of manpower and heavy workload. They are in average unable to take annual leaves for 10 to 17 days (Appendix b).
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Regarding the working schedule, nurses have to work 8-hour shift on morning, afternoon and night. According to a survey conducted by the Association of Hong Kong Nursing Staff in 2011, nurses have to work on a night shift every 5 days. Due to a lack of manpower, nurses are sometimes requested to work for two shifts on the same day or even work for two continuous shifts. The unstable working schedules would affect their health and the quality of professional services. A survey conducted by the Centre for Suicide Research and Prevention in 2012 shows that during 2003 to 2010, an average of 9.46 out of 100,000 nurses has committed suicide, which indicates a 20% higher suicide rate than the general employed population (Appendix c). The director of the center believes that this is stemmed from the on shift nature of nurses which has affected their social lives and mental health (Appendix d).
When nurses are arranged to work in hospitals which are remote from their living areas, geographic mismatch arises. Throughout these years, the Association of Hong Kong Nursing Staff has received abundant cases from nurses who have encountered this mismatch. Despite the fact that newly appointed nurses are invited to indicate their preference of cluster to work for, there is no guarantee on which cluster and hospital are finally assigned. In an extreme case, a nurse who lives in New Territories and indicates her preference to work for the New Territories East Cluster and Kowloon West Cluster is finally being assigned to work in the Hong Kong East Cluster (Appendix e). Some nurse incumbents also encounter this mismatch after home relocation. Switching to another cluster would not be easy as departments are not willing to release their nurses with the fear of adding pressure to their own tight manpower. Thus, the long travelling time has frustrated nurses especially those who play parenting roles in families.
All the above has induced negative impact on work-life balance. Both physical and mental health of nurses is deteriorated through overtime work and on shift duties. Without normal working schedules, nurses are relatively difficult to have normal lifestyle to socialize with friends and families. Geographic mismatch may further lead to work-family mismatch when time conflict and negative emotion are brought into families by fatigued nurses. With reference to the Maslow’s Hierarchy of Needs, the third level of need is regarded as love and belonging. Nurses may feel comparatively hard to satisfy this level of need in terms of family, friendship and connection, as a consequence high turnover is observed.
In the case of Catherine, she does not suffer seriously from these situations. She shared that overtime work is not usual and serious in her department and it is totally voluntary. In fact, her supervisor encourages colleagues to leave on time. Catherine also works on shift for morning, afternoon and night. The working schedule is based on the time sheet and she is not required to work for two shifts within a day. Moreover, working in United Christian Hospital is her first choice of hospital. According to her understanding, the Hospital Authority would take into account each nurse’s preferred cluster in arranging manpower over various clusters. In general, she could maintain a work-life balance and it seems that support from supervisor and the Hospital Authority and the busyness of each department are critical factors.
To minimize work-life imbalance and satisfy the third level of Maslow’s Hierarchy of Needs, one may learn from the supervisor of Catherine, which is to become a supportive supervisor. Serious overtime work should be discouraged to avoid adding pressures to nurses. While on one side the nurse association has successfully strived for an increase of 41 to 48% on the continuous night shift allowance since 2011 (Appendix f), on another side more efforts could be exerted in scheduling the duty roster. The supervisor should take into consideration each nurse’s preference of particular shifts, maintain equitable treatment, ensure a much stable shifts and avoid arranging two shifts per day. In tackling geographic mismatch, the Hospital Authority has introduced a scheme in 2009 to match nurses’ preferred clusters and exchange nurses between clusters (Appendix g). Almost 500 nurses have successfully switched clusters in that year. However, one drawback is that nurses may not be able to switch to the same department in different clusters, which may lead to lack of relevant knowledge and experience. In order to maximize effectiveness, priority should be given to nurses whose preferences of cluster and departments working at match each other. In the meantime, the Hospital Authority may consider initiating other supporting measures such as providing shuttle bus services during the starting and ending time of each shift to nurses who work outside their living areas and reinforcing child care service to staff.
2.5 Manpower shortage
Manpower shortage has resulted in a gradual growth of turnover rate amid nurses and remains a chronic problem for the public hospitals. The problem of undersupply of nurses emerged in 1999 when Hospital Authority(HA) announced to cease intake of students to its nursing schools and the mission of training nurses was then rested on the local universities. The number of nursing gradates dropped drastically from 1391 in 2001-2002 to 336 in 2004-2005, with an estimated shortfall of approximate 500 nursing graduates per annum in the following ten years. Although in 2008 HA re-opened the nursing school on which expectation was put to partially relieve the tensed manpower supply in public hospitals, a consecutive rise in turnover rate created uncertainties. 1,044 nurses left HA in 2011and they constituted 5.4 % of the population.
The acute shortage of nurses piled pressure on nurses’ working hours and work intensity. According to a recent survey conducted by the Association of Hong Kong Nursing Staff, each of the HA nurses has to serve 10 to 11 patients on average. Nurses-to-patients ratio for senior nurses and those on night shift can even reach 30 and 21 respectively in contrast to the global standard of 4 to 6. The shortage problem also incurred a series of counteraction, for instance, 16 nurses from Queen Mary’s Hospital lodged complaint with the hospital against excessive overtime working by taking sick leave together in 2009, and thousands of nurses wore stickers showing tired and angry faces to echo a three-day protest initiated by the Association of Hong Kong Nursing Staff.
Nurses under prolonged working period and substantial stress sustain mental, emotional and physical exhaustion. When the problem becomes intolerable, they select to quit and switch to the private hospitals in which the working condition and remuneration are more desirable. Continued departure of nurses subsequently aggravates the problem of adverse working condition and a vicious cycle is eventually formed.
Government has planned to expand the public medical services and implement public healthcare reform. In this context, nurturing nursing graduates and retaining existing staff becomes HA’s prioritized objectives to ensure sufficient supply of nurses for quality public medical services. The shortage can be resolved in a variety of ways including:
Strategic planning. Shortage of nursing graduate is associated with absence of strategic planning in training of nurses. The blueprint of public medical services should comprise a long-term training assessment that considers both internal and external factors, such as demographic change, technology advancement, immigration policy, internal re-structuring and private hospitals development. With a more strategic training assessment, HA can make a precious prediction on the training needs to address the manpower requirement in different specialties and ensure adequate investment in training.
Contingent employment. Since complete training of a nurse generally takes number of years, recruiting temporary and part-time nurses can satisfy the imminent needs. They can also serve as an inventory to facilitate flexible manpower deployment.
Cure from abroad. The manpower sources can be broadened by overseas recruitment of nurses and healthcare workers to minimize the risk brought by fluctuating local supply. To assure the qualification hold by overseas candidates is in compliance with local requirement, HA can provide some bridging courses or programmes.
Outsourcing. Public-private partnership is a common mode of management and operation in many public services. Instead of full-scale privatization, HA can consider subcontracting some specialist out-patient services the with private hospitals in which the resources and facilities are in greater abundance so that the understaffed public hospitals can free up more manpower for the core operations and abate the existing pressure.
There are many causes behind the current high turnover rate in medical professionals, however the 5 main issues discussed above had identified the underlie roots for such consequence. Monetary incentive might satisfy the financial needs for employees, however there is more than financial satisfaction for one individual, as job satisfaction is a more complicated subject than one can imagine. “Employee satisfaction is essential to the success of any business. A high rate of employee contentedness is directly related to a lower turnover rate. Thus, keeping employees’ satisfied with their careers should be a major priority for all employers.” (Kristen Gregory, 2011) Employers must truly understand the all-round needs of their employees; identify the true reason behind the problem, so to act on it without further delay. HA must find better solutions than believing financial rewards is the resolution to such turnover predicament. The continuation use of erroneous approach in solving the current condition, the Hong Kong public medical service might derail to a further low point. Employees are the reason on the excellent reputation of Hong Kong public medical service in the past decades, therefore with that in mind, HA’s priority is to understand the thoughts of their people and in order to tailor made the best possible solutions to untie every knot they might have encountered.
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