Shortage of nurses in Hong Kong: the challenges ahead

Abstract

Purpose

The aging of a population poses significant challenges to healthcare, housing, social security and elderly care services. Active aging is promoted by the Hong Kong government but is compromised by a shortage of nurses, doctors and professional aides. This study aims to review the history of nursing education in Hong Kong, evaluate Hong Kong's nursing manpower policy with a macro–micro analysis based on sociological imagination and provide sound recommendations.

Design/methodology/approach

This article analyzes the nursing shortage in Hong Kong. A comprehensive literature review was conducted, concerning the Hong Kong healthcare workforce and covering relevant government reports, consultation papers and articles from academic journals from 1943 to the present.

Findings

The nursing shortage in Hong Kong can be understood from both absolute and relative terms. The total number of practicing nurses and fresh graduates registering through the four aforementioned pathways increased from 17,034 in 1996 to 61,295 in 2020 (growth rate of 74.4%), but it is predicted that there will be a shortage of 455, 1,383 and 1,669 nurses in 2020, 2025 and 2030, respectively. Moreover, Hong Kong had 8.2 nurses per 1,000 people in 2020. Although this rate exceeds those of China, South Korea and Singapore, it lags behind those of the USA and Australia as well as the international recommendation of nine nurses per 1,000 people. The nurse shortage has been further aggravated by an interaction between macro factors, including aging population, a lack of coherent and long-term nursing manpower policy (an analysis is based on a health policy triangle), numerous obstacles imposed on nurses from abroad and micro factors emanating from an interplay of push–pull factors among nurses.

Practical implications

The proportion of the Hong Kong population aged 65 years or older was 18% in 2019. The availability of healthcare workers is essential for attaining optimal health outcomes for older adults. The high turnover rate of nurses in public hospitals negatively affects the provision of timely high-quality medical services in the dual-track medical system. Therefore, workforce projections should be made every three years. Such policy should rely primarily on local nurses trained both by University Grant Committee-funded institutions and by self-financed tertiary institutions. Foreign nurses should be a supplementary resource. The budget allocated to the public healthcare sector should be increased to improve remuneration, provide abundant training opportunities and improve working environment to retain nurses in public hospitals.

Originality/value

Given that deep-seated problems surrounding the quantity and quality of nurses, the avenues for pursuing nursing degree education and the turnover rate of nurses in public hospitals remain unsolved, it is imperative to investigate how to alleviate the healthcare workforce shortage in Hong Kong.

Citation

Lam, G. (2023), "Shortage of nurses in Hong Kong: the challenges ahead", Asian Education and Development Studies, Vol. 12 No. 1, pp. 89-102. https://doi.org/10.1108/AEDS-08-2021-0179

Introduction

Nursing shortage is a global phenomenon. The World Health Organization (2021) predicted that there will be nine million nursing and midwives' shortages worldwide by 2030. Hong Kong is no exception. Nursing shortages are defined as lower than the minimum number of nurses per head of population required to achieve population health targets by the World Health Organization (World Health Organization, 2016). The nursing shortage is commonly caused by aging population, tough working environment, low recognition of nurses, unattractive renumeration package and a lack of career development (Drennan and Ross, 2019). To alleviate nursing shortage, some countries, such as the USA, increase the supply of locally trained nurses (Drennan and Ross, 2019), while some core countries, including Britain and Australia, recruit foreign-born nurses from the peripheral countries, such as the Philippines and India (Braw, 2021). This brain drain, however, perpetuates global stratification in the healthcare system because the sending countries are susceptible to a loss of nurses in the medical sector (Braw, 2021). Given that an inverse relation between nursing workforce and unfavorable outcomes is found as predicted by the production theory (Newbold, 2008), this paper addressed the following questions: does Hong Kong share the same causes of nursing shortage as the other regions, and what can be done to alleviate nursing shortages in Hong Kong?

History of nursing education in Hong Kong

Nursing education in Hong Kong dates back to 1893, when a three-year nurse training program, based on the British apprenticeship model, started at Alice Ho Memorial Hospital (Poon, 1983). Hong Kong adopted both the apprenticeship model and monitoring mechanism used in the UK. Under this model, nursing students were paid to provide services to the hospital in exchange for training in hospital wards and supplementary classroom lectures (King, 1987). The monitoring mechanism is operated under the Nurses Registration Ordinance (first as a statutory registration and then a regulation in 1931 and 1958, respectively) and the Nursing Board of Hong Kong (formed in 1958 and renamed the Nursing Council of Hong Kong in 1999), a statutory body that ensures the quality of nursing through a registration system and official recognition of nurse training courses (Nursing Council of Hong Kong, 2010a).

Hong Kong continued to follow the British apprenticeship model when adding the category of auxiliary nurses in response to the nurse shortage in 1960 (Stratton, 1973). Because auxiliary nurses focused more narrowly on practical training (Poon, 1983), their professional status was inferior to that of registered nurses (Chan and Wong, 1999). Auxiliary training was later replaced by a two-year hospital-based enrolled nurse program provided by nursing schools.

Another acute nurse shortage occurred in 1980, when the economy was generally thriving. Low salaries, tough hospital-based training, night shifts, demanding workload, stressful and challenging work environments and limited career progression discouraged potential nurses from working the field (Chan et al., 2013a). The career paled in comparison to the others in the flourishing economy. The vocational training provided by nursing schools often placed the educational needs of nursing students in conflict with the needs of the employees of the Hong Kong Hospital Authority (Chan and Wong, 1999). Because the students were subjected to intense schedules in public hospitals, their guidance and supervision were compromised (College of Nursing Hong Kong, 1992). Therefore, in 1989, the Nursing Board of Hong Kong proposed offering a small number of university nursing degree programs (Nursing Board of Hong Kong, 1989).

Lagging behind countries such as the USA by a century [1] (Scheckel, 2009), in 1990, Hong Kong approved four-year nursing degree programs at three publicly funded universities: The University of Hong Kong, The Chinese University of Hong Kong and The Hong Kong Polytechnic University. The four-year model was later lengthened to a five-year model in accordance with the academic structure proposed by the Education and Manpower Bureau in 2005.

Although the total number of first-year university degree positions in Hong Kong increased from 40 in 1990 to 180 in 1998 (Ming Pao Newspaper, 1995), 20 nursing schools were closed in 2000 because of a government budget deficit (Hong Kong Economics Journal, 2019). However, those schools had reopened by 2008 in response to nursing shortages in the aftermath of the severe acute respiratory syndrome (SARS) epidemic (Hong Kong Economics Journal, 2019).

The government hence responded to the ongoing nursing shortage by subsidizing nursing programs at self-financed tertiary institutions, such as the Open University of Hong Kong, Tung Wah College and Caritas Institute of Higher Education, in 2005, 2012 and 2015, respectively (Food and Health Bureau, 2017). In its 2015/2016 budget, the government announced that it would spend HK$960m to subsidize full-time, locally accredited, undergraduate degree programs at privately funded tertiary institutions for 1,000 students (The 2015–16 Budget, 2015), resulting in the launch of the Study Subsidy Scheme for Designated Professions/Sectors (SSSDP). Approximately 420 nursing students were expected to receive a subsidy of HK$70,000 per year to attend one of two self-financing tertiary institutions, the Open University of Hong Kong or Tung Wah College, in the 2015/2016 year. The SSSDP nursing program increased to 480 students in three self-financing institutions in 2016 (Food and Health Bureau, 2017), which has been regularized since 2018/2019.

Evaluation of nursing shortage in Hong Kong

The total number of practicing nurses and fresh graduates increased from 17,034 in 1996 to 61,295 in 2020 (growth rate of 74.4%), but it is predicted that there will be a shortage of 1,383 and 1,669 nurses in 2025 and 2030, respectively (Food and Health Bureau, 2017). This projection was a result of the 2012 establishment of a steering committee to conduct a strategic review of the healthcare workforce in Hong Kong; in 2016, the University of Hong Kong was commissioned by the steering committee to produce healthcare workforce projections. The computer model projection took into account future demand regarding demographic changes and other relevant factors, including externalities and policy interventions, whereas future supply was derived from nursing registrants from both local programs and their counterparts holding non-local qualifications and the retirement pattern by taking 2015 as the base year (Food and Health Bureau, 2017).

Of particular importance is whether the supply of nurses can keep pace with the healthcare needs of Hong Kong. A typical measure to reflect the public's healthcare needs, adopted by the World Bank and Organization for Economic Co-operation and Development (OECD), is the number of nurses per 1,000 people. The international standard adopted by the OECD is nine nurses per 1,000 people (Hong Kong Economic Journal, 2019). Figure 1 shows that, although the number of nurses per 1,000 people gradually rose from 5.9 in 1999 to 8.2 nurses in 2020, between 1999 and 2020, it always fell short of the international standard.

However, the number of nurses per 1,000 people does not present a complete picture. Comparison with the situation in other developed countries can provide context. As shown in Figure 2, the number of nurses per 1,000 people in Hong Kong was higher than those in other Asian countries, such as China, Singapore and Korea, between 1999 and 2019. However, the number was lower than those in the USA, Australia and the UK (which provided the model upon which Hong Kong's nursing apprenticeship model and monitoring mechanism were based) by between five and 11 nurses per 1,000 people.

Another link between the supply of nurses and the aging population is vividly demonstrated in Figure 3. It shows a decrease in the number of nurses per 1,000 people aged 65 and older from 54.9 in 1999 to 44.7 in 2020. The corresponding number hovered around 40 from 2005 onward. Thus, we inferred that it was the compound effect of the decrease of nurses coupled with a significant increase in the proportion of elderly people aged 65 and older from 10.7% in 1999 to 18.3% in 2020.

The shortage of nurses is further demonstrated by the staggeringly low nurse–patient ratios in public hospitals. In an examination of 2,812 nurses working under the Hospital Authority, the Association of Hong Kong Nursing Staff found that the nurse–patient ratios in public hospitals in 2013 were 1:11, 1:12 and 1:24 in the morning, afternoon and night shifts, respectively, which fell short of the international standard of 1:4 to 1:6 (The Government of the Hong Kong Special Administrative Region, 2018).

Causes of nursing shortage

The aforesaid nursing shortage can be understood in light of a sociological imagination in terms of an interaction between macro and micro factors (Mills, 1959). Sociological imagination is a theoretical framework studying the interaction of history (i.e. macro factors) and biography (i.e. individual factors) by linking personal troubles to public issues. Macro factors pertain to population structure, a lack of nursing manpower policy and difficulty of recruiting foreign nurses whereas micro factor refers to an interplay of push–pull factors of nurses.

Macro level: population structure

Figure 4 presents that the growth rate of nurses between 2005 and 2020 exceeded that of population but was just comparable to that of population aged 65 or above. The growth rate of nurses even lagged behind that of the population aged 65 or above from 2016 to 2017, which aligns with growing aging population shown in Figure 3.

Macro level: a lack of long-term nursing manpower policy

The aforesaid nursing shortage can be understood in light of a health policy triangle in terms of an interaction between content, the actors (i.e. the individuals, organizations and nation state that make and implement policy), processes (i.e. how policies are initiated, developed, negotiated, communicated, implemented and evaluated) and context (i.e. the political, social and economic environment in which actors work) (Walt and Gilson, 1994). Health policy triangle was first proposed by Walt and Gibson in 1994 as a useful way to organize different factors that might affect policy. This triangle was mainly applied in health settings, including health human resources, services and systems, communicable and non-communicable diseases, physical and mental health, and antenatal and postnatal care (O'Brien et al., 2020). Although this triangle was criticized as simple and descriptive in nature, the triangle can be used either retrospectively or prospectively, and it is generalized to many health-related policies (O'Brien et al., 2020). While this triangle was predominantly applied to national settings in low- or middle-income countries and pitched at national or international levels, an attempt to apply at a local or regional level in high-income regions is encouraged (O'Brien et al., 2020). Hence, the current paper attempts to retrospectively evaluate the nursing manpower policy in Hong Kong between 2000 and 2008 at a local level with the health policy triangle in relative to the other analytical frameworks.

Content

The supply of nurses comes from two major sources, including locally trained nurses (94%) and foreign nurses (6%). In Hong Kong, all local nursing candidates must either complete a two-year pre-enrolment nursing program from a gazetted training school accredited by the Nursing Council of Hong Kong to enroll as nurses or complete a pre-registration nursing program [2] not less than three years from an accredited gazetted school to become registered nurses. Nurses can register in four ways: (1) enroll in any higher diploma, bachelor or postgraduate program offered by any one of the three publicly funded universities (The University of Hong Kong, The Chinese University of Hong Kong and The Hong Kong Polytechnic University) or the three self-financed tertiary institutes (The Open University of Hong Kong, Caritas Institute of Higher Education and Tung Wah College); (2) enroll in the fully subsidized Higher Diploma in Nursing run by the Hospital Authority; (3) complete the Enrolled Nurses (General) Training Program in nursing schools run by public hospitals; or (4) obtain a Higher Diploma in Nursing from nursing schools run by private hospitals (The Nursing Council of Hong Kong, 2010b).

Actor (Hong Kong Special Administrative region government) and context (an economic and epidemic context)

The current predicament is wholly attributed to the blunders committed by the government in terms of the sudden shutdown of 20 nursing schools run by the Hospital Authority from 2000 to 2007 because of a government budget deficit (Hong Kong Economics Journal, 2019). The total number of practicing nurses and fresh graduates registering through the four aforementioned pathways increased from 17,034 in 1996 to 61,295 in 2020 (growth rate of 74.4%), with some fluctuation between 2000 and 2005 attributed to the abrupt closure of nursing schools in 2000. Figure 5 shows that the considerable growth rate decreases to 12.5% in 2004 and 6% in 2005 in the aftermath of the nursing school closures. Concerned with further decreases in the growth rate to 2.7% in 2006 and 1.4% in 2007, in 2006, the government announced the planned reopening of nursing schools in response to nursing shortages in the aftermath of the SARS epidemic (Hong Kong Economics Journal, 2019). Those schools were finally reopened in 2008, contributing to a gradual increase in the growth rate from 1.3% in 2008 to 3.5% in 2010.

Process

Even though the decision was justified on the grounds of (1) the backlog of nurses exemplified by a net increase of 29,712 nurses in 2000 and (2) the advantages of training nurses in universities relative to training them in nursing schools (Lee, 2011), it would be hard to assume that relying solely on the nursing graduates from three universities, with an annual average of 501 graduates between 2004 and 2007 shown in Figure 6, could satisfy the healthcare needs of the elderly population several decades in the future.

The decision also conflicted with the evidence from the Census and Statistics Department's 30-year population projection using a component method in 2000 (the first year of the closure of nursing schools), 2002, 2004 and 2007 (across the period of the closure of nursing schools). The 30-year population projection made in 2000 clearly projected an increase of the elderly population aged 65 and older from 15% in 2019 to 20% in 2029 (Census and Statistics Department, 2000). The projections made in 2002 and 2004 projected that the proportion of elderly people aged 65 and older would reach a peak of 25% in 2028 and 2031, respectively (Table 1). The 30-year population projections, however, were futile in shaping manpower policy as the government still reached its short-sighted and one-sided decision to close the nursing schools. It was difficult to envision that they could suddenly reopen the nursing schools in the near future to cope with the growing medical demand, as the years-long gap could not be easily overcome. Specifically, the programs for registered nurses and enrolled nurses take at least three and two years, respectively.

The dismissal of the population projections demonstrated a lack of central coordination across government departments and bureaux. A lack of coordination even extends across the universities and nursing schools in which they all work separately to train nurses without knowing the exact demand for and supply of nurses (Chan and Wong, 1999; Moy, 2008). No projection of the demand for nurses in terms of a nurse–patient ratio existed at the time.

The lack of a long-term and comprehensive nursing manpower policy is further compromised by reluctance toward the full development of university nursing education. The shutdown of nursing schools could actually be viewed positively as a turning point toward that full development. The development of university nursing education is an international and irreversible trend that equips students with leadership skills, critical thinking, autonomy and creativity, as well as clinical skills on both theoretical and practical grounds (Kelly and Joel, 2002). An empirical study from nine European countries indicated that having a 10% increase in nurses holding degrees correlated with a 7% decrease in the mortality rate of patients (Aiken et al., 2014). Advocates for nursing degree education support the thoughts of Florence Nightingale and the Nightingale schools, i.e. they aim to equip nursing students with comprehensive knowledge covering anatomy and physiology, surgery, chemistry, nutrition, sanitation and professionalism, regardless of hospital control (Stewart, 1943). Unfortunately, there was only a negligible increase of nursing graduates from the three publicly funded universities from 450 in 2000 to 517 in 2007 (Figure 6) constrained by unchanged University Grants Committee (UGC) funding devoted to the healthcare courses in the past decade (The Government of the Hong Kong Special Administrative Region, 2016b). The HKSAR government then immediately reopened the nursing schools to mitigate the shortage of nurses, but without a noticeable expansion of university nursing education (Figure 6) (Hong Kong Economics Journal, 2019).

Macro factors: the difficulties of recruiting the overseas nurses

One may wonder whether the admission of overseas nurses could replenish the supply of nurses. However, foreign nurses cannot utilize their overseas nursing qualifications for a local registration. Nursing graduates from overseas hospital-based nursing schools or three-year pre-registration nursing programs at universities, colleges and polytechnics must possess a certificate granted by one of the certifying bodies approved by the Nursing Council of Hong Kong. Additionally, they must pass the Licensing Examination for Registration (one written test and two practical tests) to become registered nurses in Hong Kong. In 2021, the low passing rates for enrolled nurses on the exam were 48.9 and 30% respectively for the written and practical categories; for registered nurses, the numbers were 15.1 and 70.6%, respectively (The Nursing Council of Hong Kong, 2021). Overseas candidates are sometimes required by the Nursing Council of Hong Kong to take additional training The Nursing Council of Hong Kong (2010c). A vast difference between Hong Kong and foreign countries is the required hours of practicum experience. Nursing students need 1,400 h of practicum experience in Hong Kong, whereas their overseas counterparts need fewer hours, such as 800 h in Australia. Unsurprisingly, therefore, overseas nurses only accounted for a negligible 6% of the registered nurses in Hong Kong in 2010 (Cagape, 2010). Hong Kong stands in a sharp contrast to the UK (21.9%), Australia (35.3%) and OECD countries (16%), which recruit foreign-born nurses to alleviate nursing shortage (Braw, 2021).

Micro level: push–pull factors

Moreover, nurse shortages in public hospitals are exacerbated by a rate of nurses leaving public hospitals for private ones, as demonstrated by an increase of turnover rate of nurses in public hospitals from 2.1% in 2005, 4.7% in 2009, 5.4% in 2017 to 6.1% in 2018 (Chan, 2012; Cheng and Cheung, 2019; Department of Health, 2010). Nursing shortages in public hospital are aggravated under the dual-track medical system, referring to a public sector with highly subsidized (95%) services provided by the Hospital Authority and Department of Health, complemented by a private sector offering flexible and timely services to those who can afford them (Food and Health Bureau, 2008). Public hospitals tend to be responsible for secondary and tertiary care, whereas private hospitals are the main providers of primary care (Food and Health Bureau, 2010); 90% of inpatient services are provided by public hospitals, and 70% of outpatient services are provided by private hospitals (Chung and Marmot, 2020; Food and Health Bureau, 2017).

The Hospital Authority then provided HK$200m to compensate for the exodus of nurses from public to private hospitals, new training opportunities and additional allowances to recruit 1,600 nurses in 2011 and 2012 (Lee, 2011). However, this measure failed to fully compensate for the nursing shortage (Chan et al., 2013b).

According to global trends, the personal reasons given for such nursing turnover are related to working conditions, job satisfaction and family. Similarly, in Hong Kong, an interplay of push and pull factors and demographic variables compelled nurses to switch from public to private hospitals. Although the attractive remuneration packages and superior career prospects in the private hospitals are pull factors, unfair remuneration policies on the public side must also be examined. A semi-structured interview with 12 nurses who moved from public to private hospitals indicated two major push factors: the implementation of an increment freeze policy [3] on nurses employed by the Hospital Authority on or after June 15, 2002 (The Government of the Hong Kong Special Administrative Region, 2016a), and an overwhelming workload driven by insufficient nursing supply in public hospitals, arising from the government's futile efforts to adopt effective strategies for maintaining a balanced workforce (Chan et al., 2013b).

Another push–pull interplay can be revealed by the migration intention of nurses. It found that 53.8% of nurses intended to migrate to foreign countries in an examination of 684 nurses by the Association of Hong Kong Nursing Staff in 2020. Worse still, 57.5 and 14.2% of nurses with five years of working experience or above plan to migrate and process migration application, respectively (Association of Hong Kong Nursing Staff, 2020). While social and political environment in Hong Kong, unfavorable working conditions, a lack of promotion, an unattractive remuneration represent the push factors, an expected improvement of working environment and a better educational system for their children overseas can be understood as the pull factors. It will be affected by global nursing shortage because the nurses are not required to take the additional examination for practicing in some countries, such as Australia.

Conclusion

The nursing manpower policy can be summarized as a creation of approximately 3,000 nurse training positions each year (755 funded by the UGC and 2,200 provided by the Hospital Authority, private hospitals and the SSSDP-funded nursing degree positions; Food and Health Bureau, 2017). Although it is a sincere attempt to cope with the nursing shortage, the situation remains dire because it not only faces the internal demand arising from the aging population but also is affected by the brain drain globally. A lack of coherent manpower policy, the difficulty of recruiting foreign trained nurses and a push–pull factor interplay can be disentangled as the major unique causes of nursing shortage in the aforesaid analysis of macro–micro factors. Specifically, the adoption of a health policy triangle unraveled a lack of long-term nursing manpower policy in terms of how government suddenly closed the nursing schools in 2000 in response to economic and epidemic context without taking into population projection consideration and failed to take this opportune time to expand the nursing degree education.

A forward-looking and comprehensive workforce policy for nursing, addressing both the quantity and quality of nurses, is an imminent goal for the government. Such a long-term manpower policy should avoid oversimplified linear thinking but rather treating as policy bundles, referring to the interrelatedness and continuity across different components (Drennan and Ross, 2019). The first policy bundle includes accurate projections of the supply and demand for nurses based on the 30-year population projections made once every three years (Food and Health Bureau, 2017). Data-driven population projections lend credence to another policy bundle of attracting local workers to training as a foundation to be supplemented by certified and qualified workers trained abroad via an established mechanism (the licensing examination was proposed by the Steering Committee to be arranged once to twice per year; Food and Health Bureau, 2017). Nurses from abroad still face numerous difficulties in registering with the Nursing Board of Hong Kong, and insights can be learned from the other countries about relaxing those constraints.

The government should continue providing SSSDP positions by stimulating self-financing tertiary institutions to help in alleviating the nursing shortage; however, increasing university-based nursing degree education through the number of UGC-funded training positions is still crucial (Food and Health Bureau, 2017).

A 2021 collaboration among three nursing schools (Caritas Medical Centre, Queen Elizabeth Hospital and Tung Mun Hospital) operated by the Hospital Authority and the self-financing tertiary institution, the Caritas Institute of Higher Education (Ming Pao Newspaper, 2021a) indicates the governments dedication to nursing degree education. The new program is characterized by a change from the previous three-year diploma in nursing at Hong Kong Qualifications Framework (QF) [4] Level 4 to the current four-year professional diploma in nursing at QF Level 5. The graduates cannot only work as registered nurses after graduation but also take an additional year to study a Bachelor of Health Science (Nursing) degree at the Caritas Institute of Higher Education.

Increasing the supply of nurses and pursuing a shift toward university-based nursing education are essential elements of the nursing workforce policy, but they alone cannot reduce the high turnover rate of nurses in public hospitals and brain drain across the globe arising from the pull–push interplay. The compounding effect of the budget allocation to the public medical sector must be considered. Contrary to a socialist medical model advocated by Dr. Yeoh Eng-kiong (ex-director of the temporary Hospital Authority and ex-chairman of the Hospital Authority) in the 1990s (Chong, 2019), Hong Kong currently has a hybrid capitalist–socialist model (Lai, 2021). Constrained by the nature of this medical model, the total healthcare expenditure increased from 3.6% of the gross domestic product (GDP) in 1989 to 6.8% in 2019, less than doubling; this rate lags behind those in other high-income economies, such as South Korea (8%), Japan (11.1%), Australia (9.3%) and the UK (10.3%; Food and Health Bureau, 2018). While postponing retirement age to 65 and proposing a new career advancement of Vice Associate Nurse Consultant represent the very initial attempt to alleviate the nursing shortage (Ming Pao Newspaper, 2021b), the budget allocated to the public medical sector should be increased to provide attractive remuneration packages and abundant training opportunities to enhance nurses' intellectual capital, improve working environment and lessen patient–nurse ratio to retain healthcare professionals actively working in that sector.

Figures

Figure 1

Number of nurses per 1,000 population in Hong Kong 1999–2020 (Census and Statistics Department, 2021; Department of Health, 1996; Department of Health, 2004; Department of Health, 2006; The Nursing Council of Hong Kong, 2021)

Figure 2

International comparison of number of nurses per 1,000 population, 1999–2019 (OECD, 2021)

Figure 3

Number of nurses per 1,000 population aged 65 or above in Hong Kong, 1999–2020 (Census and Statistics Department, 2021; Department of Health, 1996; Department of Health, 2004; Department of Health, 2006; The Nursing Council of Hong Kong, 2021)

Figure 4

The growth rate of nurses, overall population and population aged 65 or above, 2005–2020

Figure 5

The growth rate of nurses in Hong Kong, 2000–2020

Figure 6

Number of degree places of UGC-funded nursing programs, 2004–2018

Table 1

Projected proportion of elderly aged 65 or above

Base year			Projected proportion of elderly aged 65 or above
	2004	2009	2014	2019	2024	2029
1999 (benchmark)	12%	12%	13%	15%	17%	20%

	2006	2011	2016	2021	2026	2031
2001 (benchmark)	12%	13%	15%	18%	22%	25%

	2008	2013	2018	2023	2028	2033
2003 (benchmark)	13%	14%	17%	20%	25%	28%

	2011	2016	2021	2026	2031	2036
2006 (benchmark)	13%	16%	19%	23%	26%	28%

Source(s): Census and Statistics Department (2000, 2002, 2004, 2007)

Notes

1. The first university nursing degree program, introduced at the University of Minnesota in 1909, more closely resembled diploma programs. The first bona fide nursing degree program was introduced at the Teachers College of Columbia University in 1917 (Scheckel, 2009).

2. Preregistration nursing programs are (1) full-time five-year degree programs, (2) full-time three-year hospital-based diploma programs, (3) three-year part-time conversion programs from enrolled nurses to become registered nurse or (4) full-time three-year master's programs for students with a degree in a field other than nursing.

3. The increment freeze policy refers to the rule that nurses and allied health professionals employed by the Hospital Authority on or after June 15, 2002, are not entitled to an annual increment within the first two years following their promotion.

4. The Hong Kong Qualifications Framework (HKQF) is a seven-level hierarchy launched in 2008 covering qualifications in the academic, vocational and professional sectors. The Award Titles Scheme was introduced to regulate the use of titles for qualifications under the HKQF in which QF Level 4 covers associate degrees and higher diplomas and Level 5 covers bachelor degrees, professional diplomas and advanced diplomas (Qualifications Framework Secretariat, 2018).