Unemployment among Graduate Nurses in Malaysia : A Case Study

Linguistic and cultural communication skills are essential for nurses as they are at the fore front in public and private hospitals, physicians’ offices, clinics and other outpatient care facilities. Indeed nurses provide the human touch for patients seeking medical advice at a particular medical centre before consulting a physician. Recently, the Ministry of Higher Education has released statistics on unemployment among nurses about 8000 nursing graduates have not secured jobs. As such, a study was carried out to examine the reason for such a serious situation in Malaysia when other parts of the world are in dire need of nurses. A quantitative methodology was adopted to determine the reason for unemployment among nurses as well as to find ways to relocate these unemployed nurses to parts of the world where their service is needed. This study draws several conclusions about the unemployed nurses and ways to enhance their communication and English language skills to make them more ‘marketable’ as well as be able to execute their duties effectively at workplace. The results indicate a need for a special English language course-design for theses trained nurses.


Introduction
In Malaysia there are many private and public nursing colleges.Statistics show that private colleges alone produce about 1,200 trained nurses though there are only 1000 to 1500 nursing jobs in private sector each year.This makes Malaysia, apart from the Philippines, as one of the countries in Asia to export nurses to countries like Saudi Arabia, Middle East, Australia and New Zealand.The government hospitals mostly hire public university graduates while private hospitals employ their own nurse trainees, for example Pantai Medical Centre has its own nursing college which serves as a feed centre to the hospital.Other private hospitals prefer to hire graduates from public universities since these graduates are perceived to have the necessary academic qualification and skills which are important for the prevailing job environment (Latisha, 2010).As the production surplus the demand, this results in many fresh graduate nurses being jobless.
Unemployed nurses are facing the burden of repaying study loans, which will affect both loaners and their parents who have sent their children for further studies in the hope that they will have a secure future (Qualifying exam, 2013).As English is still the main language used in the medical field, graduate nurses are required to sit for qualifying examination with the Malaysian Nursing Board (MNB) before they could register and practise nursing.Public Health Assistant Minister Dr. Jerip Susil said that poor proficiency in English among graduates could be another factor contributing to their unemployment (Qualifying exam, 2013).He stressed that graduate nurses must enhance their command of English to carry out their duties as well as to perform in interviews.

Importance of Communication and Linguistics Skills for Nurses
Potential pain-reducing implications and increasing recovery rates is greater when patients are provided with additional information about their diagnosis, prognosis, care and treatment (Dougherty & Lister, 2007).Nurses can facilitate successful and therapeutic patient contact through questioning, listening, summarising, reflecting and paraphrasing information received from patients (Harrison & Hart, 2006;Northouse, 2004).Thus it is essential for nurses to have good communication skills to expedite their employability.Nurses use communication skills on a daily basis to gather information, reassure, facilitate patient expression, views and opinions; encourage critical thinking, and promote continuity in patient care (Berry, 2007;Murray et al., 2006;Bury, 2005;Bayne et al., 2002).Therefore, they must have the critical thinking skills as well interpersonal skills that are necessary to recognise and manage emerging patient problems and life-threatening conditions.
Trainee nurses who learned new vocabulary found them to be of great help in the learning of new medical jargons (Arumugam & Kaur, 2011;Health Care, 2007).This study also reported that 75% of these trainee nurses preferred to use skill-oriented strategies to comprehend their peers and superiors' use of medical genre.This would help them to comprehend their counterparts and to get the message across in a most effective and concise way (Health Care, 2007).The ability to listen to and understand information and ideas presented verbally (assist physician during exams).88

Oral Expression
The ability to communicate information and ideas verbally so others will understand (explain treatment procedures to patients).

Speech Clarity
The ability to speak clearly so others can understand (answer telephone calls).78 Adapted from Arumugam & Kaur (2011) In 2009, JobStreet.comconducted an English Language Assessment (ELA) test where Singaporeans scored the highest, followed by Filipinos.Malaysians scored the lowest in this test due to the poor command of English among them.In October 2011, JobStreet.com'ssurvey involving 571 human resource practitioners revealed that fresh graduates' unrealistic demand for high salary and employment benefits mainly contributed to them being unemployed (Fresh Graduates' Unrealistic …).Meanwhile, in a survey conducted by Ranjit (2008), it was discovered that Malaysian graduates lacked soft skills such as planning, organising, problem-solving, decision-making, leadership, creativity, critical thinking, conceptual and networking skills, the generic skills which are most sought-after by employers.These results leave us to question the Malaysian graduate nurses' ability and efficiency in carrying out their duties.

Statement of Problem
Currently a lot of nursing colleges are mushrooming in Malaysia.Statistics show that private colleges are generating about 1,200 trained nurses annually whereas there are only 1000 to 1500 jobs available.This proves that these colleges enrol too many students, more than the demand which contributes to unemployment further.
As most government hospitals have their feeder colleges, they are unable to employ graduates from the private nursing colleges.Besides, most private hospitals prefer to hire nursing graduates from the public universities as these nurses are perceived to have the necessary academic qualifications and employability skills which are significant in the current job environment (Latisha, 2010).
Unemployment among nurses in Malaysia is becoming increasingly serious as graduates have become too selective.Some experienced nurses think that fresh graduates have trouble finding work because of their selective attitude.It was also expressed that employers place importance on work experience and even some nurses with work experience are unemployed (Bhat, 2012).Lakshmanan (2008) on the other hand states that, selective employers are also one of the reasons why graduates are unemployed.These employers often place work experience as a prerequisite the position.Clavreul (2013) perceived that the senior nurses' extension of retirement to one major reason for unemployment among nurses.Besides that, Hutchinson Vickers, Wilkes and Jackson (2010) felt that the issues of adequate support for experienced nursing staff assisting and recapturing new staff is crucial.Based on the statistics provided by the Ministry of Higher Education on unemployment among local graduates, of the 100,000 students who graduated last year, 24 percent are still unemployed.In the medical field alone, 8000 nursing graduates have not secured jobs; the statistics also indicates that the majority of those unemployed were first degree holders.
Datuk Seri Dr. S. Subramaniam, Minister of Human Resource then felt, this phenomenon was due to the low quality of nurses, their lack of nursing skills and training (New Strait Times, 2013).In order to address this problem of unemployment among nurses in Malaysia, the government should cooperate with health ministries from the overseas such as Canada, United States, England, and Australia as there are job opportunities in this area.

Research Questions
The following are the research questions: 1) What are the factors that contribute to the problem of unemployment among nursing graduates in Malaysia?
2) What are the skills required of the graduate nurses by potential employers?

Method
The methodology adopted in this study was quantitative.A set of questionnaire was adopted from Arumugam and Kaur (2011) to elicit information from sample population of 60 unemployed medical nurses from three private nursing colleges in Malaysia.The questionnaire was divided into three sections: demographic profile and academic qualification, knowledge of language pertaining to their occupation and their perception of the need for an English course.To obtain in-depth information, five unemployed nurses, two instructors and an administrator at a private nursing college in Malaysia were interviewed.

Demographic Findings
An analysis of the demography of the respondents showed that 51% of the nurses were in the age category of 21-23 years while 49% were between 24-28 years old.All of them had undergone formal nurse training in healthcare facilities.All of them admitted that the medium of instruction in college was English.They did not attend any other courses or training while waiting to be employed.The demographic profile also showed that most of the unemployed nurses held a diploma and did not have any work experience.

Challenges Faced in Securing Employment
A total of 65% of the respondents felt that they did not have adequate skills and unable to promote themselves during interviews respectively.Meanwhile 30% lamented that there was no proper channel to obtain information on job availability.15% of respondents shared that there were far too many nursing colleges churning out too many nurses which did not match the demand for nurses in the country.A surprising 55% of those who had completed their nursing course did not believe that they possessed the necessary skill and confidence to apply for jobs outside the country.Meanwhile, 30% disclosed that they turned down jobs that offered salary which did not commensurate with their service and qualification.Though the number of unemployment seemed to be high among graduate nurses, 85% of the respondents admitted they had not enrolled at any employment agencies to secure a job.It is crucial for nurses and medical assistants to have good communication, critical thinking, and technical skills in order to be employed (Dougherty & Lister, 2007;Waldvogel, 2007;Waldvogel, 2005).Employers preferred nurses who possessed soft skills such as competency in the English language, general communication skills and sound medical knowledge.65% of the respondents felt that the main hindrance was their weak grasp of the English language while 25% blamed it on their lack of communication skills.However, only 10% felt that there was too much of competition from public university graduates.

Importance of Language Competency
In terms of English language proficiency, surprisingly 75% of the respondents mentioned that they were not fluent English language speakers though they were fairly good writers.This perhaps could be one of the reasons for their failure in securing an employment.30% perceived to be good while none rated themselves as excellent in communicating in English language.The majority, 82% informed that they were taught in the English language in college but seldom used this language in daily communication.This is another factor that contributes to their lack of confidence in communicating in English.A total of 78% felt that they needed to upgrade their English language to communicate effectively during interviews while another 70% were confident that with good English proficiency they could even be employed abroad.68% felt that good communication skills would assist them to secure a job either in Malaysia or overseas.However, only 6% felt that they could survive with only a good command of the Malay language.They acknowledged that though in college they learned all subjects in the English medium, their use of the language was limited to completing assignments and examinations only.All the respondents agreed English language was vital to their career especially the spoken skill.They need to be competent in English communication skill to provide quality service, as it is a norm for the nurses to interact personally with the patients from all walks of life.This is supported by Health Care report (2007) which stresses that nurses need be adequately competent in English to accomplish the needs of patients and demands of doctors dealing with healthcare facilities.English language is important in my career 100 0 0 I do not need good speaking skill in English to get a job 0 0 100 In the structured interview, one of the respondents (unemployed nurse) said that she preferred more English classes to brush up her spoken skills as well as her general English language because this will enable her to manage everyday situations especially in dealing with patients.All the nurses (100%) admitted that the nursing colleges should emphasise on English language and communication skills as it is at the core of a nurse's duty to render service to humans.Besides, this will also enable them to perform confidently at interviews.One respondent felt that local nursing graduates were facing a great challenge due to influx of foreign nurses in the country.Nurses from developing countries like India, Bangladesh, Pakistan and Middle East countries were willing to be employed at a lower salary as the high currency conversion rate worked in their favour making their earnings really attractive.
One of the instructors in the medical college explained on the importance of communication skills for nurses.She said, 'Some graduate nurses have knowledge of theory but they lack practical communication skills and interpersonal skills.These graduates should also remember that they need to learn a lot of practical skills before they demand for a high salary.'She also advised them not be too selective while securing a job.This reason was also advocated by Shyam Lakshmanan (2008).
Another instructor shared the need for English language skills for nursing students to be marketable at workplace.She stressed it was crucial for nurses to be proficient in English language in order to understand doctors' instructions especially during ward rounds.
"Most of the medical jargons are still in English and the nurses are required to explain them to the patients.Besides, doctors too give their prescription in English and nurses need to read and understand that clearly before they send their patients to pharmacy to collect their medication…" She added, 'Though the trainee nurses undergo training for three years in the English language, some of them are still unable to communicate in English.This is one of the main reasons for their unemployment.' An administrator revealed that nursing syllabus and curriculum were accredited by the Ministry of Health in Malaysia and the instructors were qualified and experienced.So it was the student nurses who had to take the initiative to improve themselves and to equip with various skills in order to be more marketable.He said that it was a must for all student nurses to go the extra mile to equip themselves with better communication and language skills in English.He added, 'There are ample of job opportunities for nurses, be it in Malaysia or abroad.It is up to the students (nurses) to make themselves more enterprise by enhancing their skills and demonstrating their ability at interviews.Even some private hospitals request the CV (Curricular Vitae) of our students before they graduate.If their results are good and they perform well in the interviews, the hospitals employ them even before they graduate.' This reveals that the main cause of unemployment among fresh nurse graduates may not be the lack of demand for nurses but their incompetence in terms of limited language and communication skills.The researchers also noted that the respondents had a weak grasp of the English language and were unable to response in English during interviews.

Conclusion
Despite the limitations of this study which surveyed only 60 unemployed nurses from three private nursing colleges in Malaysia, several preliminary remarks could be made.It was clear from the study that communication skills and English language competency are vital for nurses to secure a job as well as to function well in their profession.The syllabus and curriculum designers at nursing colleges especially private ones, need to take into account the provision of training for communication enhancement as this would help make graduate nurses more marketable.They should consider a longer clinical internship for nursing students to give them more hands on experience which in turn will help to elevate their level of confidence in handling duties at hospitals later.
Incompetence in language skills pose a great deal of obstacle for these unemployed nurses.Hence, an appropriate course design inclusive of language classes to develop communicative skills will be valuable.This perhaps could change these graduate nurses' attitude and enhance their eagerness to be more competent, which will be a springboard towards a more marketable nurse.It is hoped that the findings of this research will create awareness among college administrators, syllabus designers and student nurses that English is undeniably the medium of communication in healthcare services.As such, it is of utmost importance that prominence is given towards improving the English language and communicative competence in designing nursing courses.

Recommendations
The Higher Learning Institutions and Nursing Education should come up with job related English courses for student nurses.Therefore, the relevant course should include the use and the usage of the language that is job specific as advocated by Hull (2004).Since English is essential in the medical field, the course designers should consider items related to tasks that nurses need to accomplish.
Hospitals need to device ways to enable new nurses gain support and guidance from their experienced counterparts.This would guide and facilitate young nurses to transfer their "bookish' knowledge to real life practice.
Nurses need to have good communication skills by equipping themselves with good language and communication skills.Exposure to English speaking environment is an important element in grooming and preparing the trainee nurses.The policy makers and the higher learning institutions should work together in designing nursing syllabuses (Pratt & Brookfield, 2002).

Table 1 .
English language knowledge required in workplace situations for nurses

Table 2 .
Showing the challenges of unemployed nurses

Table 3 .
Showing respondents' ability in English language

Table 4 .
Importance of English language skills