How Hong Kong hospital overcrowding takes its toll on nurses, mentally and physically
Nurses in the city’s public hospitals are at high risk of stress and mental health problems because of their workload, but many don’t seek help for fear of appearing weak
It’s no secret that nurses in Hong Kong’s often overcrowded public hospitals are prone to stress - from having to care for ever more patients and working long hours, including frequent night shifts. Surveys have repeatedly drawn attention to the problem.
A 2015 study of 850 nurses showed they are three times as likely as the general population to suffer stress, anxiety or depression. A 2012 report by the Centre for Suicide Research and Prevention at the University of Hong Kong found that nurses had the highest suicide rate (9.46 per 100,000 people) among professions including police (9.39) and teachers (7.35). In a 2014 survey, more than 1,600 nurses rated their stress levels at 8.2 out of 10 points, and job satisfaction at 3.9 out of 10.
Yet who is there to nurse the nurses? And how can a nurse worried about their mental health be persuaded to get help?
“Police officers might need counselling after they fire their guns … but people expect nurses to take care of themselves,” says a nurse who’s worked in public hospitals for more than a decade. “This image plays an important role, so no one is going to take the first step. We don’t want to seem weak, because then how are we going to take care of patients?” adds the nurse, who requested anonymity but who cares for mental health patients.
Although the Hospital Authority provides counselling, nurses are often afraid of people finding out about their mental health issues, particularly because they are medical professionals.
The mental health nurse says she has heard of new nurses cutting themselves to relieve stress.
Ming (not his real name), a third-year student nurse, saw first-hand the pressure on the system when he worked on a general nursing ward recently. With hospitals operating at up to 120 per cent capacity during the winter flu surge, he was struck by how crowded wards were.
“One ward might [normally] fit 30 beds, but they have so many patients that there would be 40 beds or more. That means you don’t have a lot of space; you have to turn sideways and stand on tiptoe to walk between the beds.”
One of Ming’s classmates said every possible space was taken up with beds. To look after patients, he and fellow students had to work non-stop throughout their shifts.
“I don’t even have time for a toilet break or a sip of water,” he says.
Teris Cheung Cheuk-chi, co-author of the 2015 study of nurses’ risk of suffering mental health problems, said: “Mental and physical problems play off each other, so the problem is just going to snowball if it is not addressed.”
Calling it an “urgent problem”, she said: “This could just be the tip of the iceberg.”
Cheung, a clinical associate at the Polytechnic University school of nursing, speaks from experience. Formerly a nurse herself, she says nurses are under stress from having to care for a rising number of patients; from long working hours (44 hours a week in Hong Kong versus 37.5 hours a week in Britain); and the lack of a permanent night nurse system which means each nurse must work at least one night-shift per week – something which affects their sleeping habits and limits their social life.
The Association of Hong Kong Nursing Staff has called for government hospitals to be given more staff and funding.
Responding to Hospital Authority figures released on March 5 which showed that all but one of the 16 public hospitals struggled with more than 100 per cent occupancy over the winter,the association published an open letter to Chief Executive Leung Chun-ying urging more resources to lighten its members’ workload.
If nurses have too many patients to look after, patient care suffers. A 2014 study published in leading medical journal The Lancet found that for every extra patient added to a nurse’s workload, the chance of a patient dying within 30 days of being admitted to a hospital went up by 7 per cent. It was based on data from 300 hospitals in England, Finland, Norway, and six other European countries.
The 2014 survey by the Association of Hong Kong Nursing Staff of more than 1,600 of its members found each nurse was caring for 11 or 12 patients, and most reported having to cope with staff shortagesup to 81 per cent of the time.
The mental health nurse says the demands of some patients’ families can be a source of stress. “Relatives ask nurses for information, which is normal; but sometimes they interrogate you,” she says. “When we already have such a large workload but have to spend all this time explaining, or the relatives question you again and again in a rather unfriendly manner, this creates stress.
“They expect the primary nurse to know everything about a patient, more than they do. The patient might be 40 or 50 years old, yet [relatives]expect us to know what happened to him or her 40 years ago, and then get very angry if we don’t.”
The growing amount of paperwork nurses have to file also means they have less time for patients, she says. It is a way for the Hospital Authority to track and document patients’ treatment, but some forms they have to fill in seek similar information found on others and are redundant.
Because of such administrative work she gets less than 15 minutes to talk to each patient when she would like about 45 minutes to get to know them better.
“We’ve talked about simplifying the procedures, but if managers don’t do anything, there’s no point [raising the issue again], so we just keep it to ourselves.”
Joseph Lee Kok-long, the legislator representing the health services functional constituency, says nurses have raised the issue of stress and overwork for years to little avail.
The problem lies with government plans to expand hospital services and add beds without hiring more staff, which means already overstretched staff have more patients to care for, he says.
Lee, who is head of nursing and health studies at the Open University of Hong Kong as well as chairman of the nursing staff association, argues that the government should manage people’s expectations of public hospitals.
“If you keep expanding the hardware and adding beds, the government is escalating public expectations. You may have all the hardware in place, but you don’t have the people to manage patients. This creates more conflict and [puts] stress on frontline [staff].”
Lee says Hong Kong enjoyed excellent public health care in the decadeup to 2000 because the system was well funded and adequately staffed. In recent years, however, resources allocated to public health services had been inadequate but the government still encouraged the public to believe that the quality of hospital care hasn’t suffered.
“If you have the money, then you can get better treatment [at private facilities]; if you don’t have the money, the government can provide the essentials,” Lee says. “This is what’s happening, but the government doesn’t dare say that. That’s why people keep expecting the public health care system to be good.”
Sophia Chan Siu-chee, undersecretary for food and health, disputes Lee’s assessment. Instead, she points to a Bloomberg analysis from 2015 which rated Hong Kong health care system the world’s most efficient based on three weighted factors: life expectancy, health-care costs per capita, and costs as a percentage of gross domestic product. Chan says the government and Hospital Authority are fully aware of staffing issues and are doing their best to address the problems, such as by paying staff more if they can work extra hours during the winter surge.
The Hospital Authority was also recently allocated HK$570 million to hire retired nurses and doctors to help boost manpower, she adds.
Addressing Lee’s concerns about resources, Chan points to this year’s policy address, which earmarked HK$200 billion for a 10-year plan to redevelop and expand government hospitals.
“That is unheard of… the budget is [drawn up] year by year usually,” Chan says. “Because we see long-term population ageing coming, the government has [made] this long-term commitment about redeveloping hospitals.”
Looking ahead to the next legislative session this year, Chan says the bureau plans to introduce legislation to better regulate private health-care providers, and to set up a voluntary health insurance scheme. The goal of both laws is to encourage the people who can afford it to use private health providers, which reduces the burden on the public health care system so the government nurses won’t be constantly swamped with work.
Lee agrees that a key to reducing stress among nurses is to alleviate the heavy workload they currently face in the public health system, but he is not as upbeat as Chan in assessing the government’s track record in recent years.
“The administration is just paying lip service to health care,” he says.