“The society identifies that any girl in a white uniform, whether qualified or unqualified, be addressed as a nurse. This gap between self-image and public image has caused a painful anxiety about the status and has made nurses aware of the injustice of it,” laments Capt Valsa Thomas, Nursing Director, Dr LH Hiranandani Hospital, Mumbai.
Echoing similar concerns Beena P Mathew, Nursing Superintendent, BGS Global Hospitals, Bangalore says, “A nurse’s job deals with life and death, which is most stressful and accountable but it has been least appreciated.”
It is quite disheartening to acknowledge the pathetic situations some nurses find themselves in. Nurses are underpaid, compelled to do bonded labour, forced to work in adverse environment, with no job security. They are sometimes physically and mentally harmed and work in difficult shifts with less time off duty. These are some of the issues that mar the dignified and humane profession started by Florence Nightingale.
“Nurses today are paid lesser salary than a clerk at the billing counter, keeping in mind the skill and the degree of expertise with which she has to function, which is not justifiable. Long working hours, shifting duties, long commuting hours, family pressure, unreasonable expectation of patients/ relatives from nurses etc are also disheartening factors faced by our nurses,” adds Captain Thomas.
Adding to this Captain Usha Banerjee, Director of Nursing, Apollo Hospitals says, “In India, this profession is slowly gaining importance as it plays a pivotal role in clinical outcomes. But it’s also important to build pride and honour in order to ensure that the best resources are retained and contribute to the Indian healthcare industry. Pay, power, recognition, empowerment and ideal working conditions are the points of discussion today.”
Nurses in India
Almost all hospitals, whether they are in public or the private sector face the challenge of attracting and retaining their nursing staff. According to Dileep Kumar, President, Indian Nursing Council, the nurse to population/patient ratio in India is low compared to other countries. The ratio was 1:110 in India and 1:100 in Europe. Many states in India face shortage of nurses and midwifes. Most states have no system for re-registration of nurses. About 13.28 lakh nurses and 6.18 lakh Auxiliary Nursing and Midwifery (ANMs) have been registered with various State Nursing Registering Councils. Only 40 per cent of the registered nurses are active because there is no system of live registration in India. In India, the nurses to doctor ratio is almost 1.5:1 while it is 3:1 in developed countries. Most nurses in service hold a diploma and some hold a bachelor’s degree in nursing and midwifery. There are no specialist nurses in clinical practice.
Twenty years back, nursing was seen as a lucrative profession, mainly dominated by the females. In contrast, today not many youngsters opt for the nursing profession. “The reason for not accepting nursing as a job-oriented profession by the youngsters are existing job insecurity, low pay and lack of conducive work environment in the healthcare set-up,” explains Lt Col TG Chandrika, Nursing Coordinator, Kerala Institute of Medical Sciences (KIMS), Kerala.
Shortage
There are many nursing colleges in India, both in the government as well as the private sector producing a sizable number of nurses every year. According to an official record, presently there are 2205 nursing schools, 1387 B.Sc. (Nursing) colleges and 414 M.Sc. (Nursing) colleges with a capacity of 88202, 68858 and 8000 students respectively functioning in the country. But, a sizeable chunk of the pass outs from these institutions go to the Western and Middle Eastern countries. The government has said that the Health Ministry is making concerted efforts to augment nursing personnel in the country.
“We are setting up 269 new ANM and General Nursing and Midwifery (GNM) Schools, particularly in the remote and underserved districts of the country at a cost of Rs 2030 crores. This will significantly add to our training capacity and will result in an additional 22000 nurses being trained annually,” said Union Health Minister Ghulam Nabi Azad in a recent press release.
Another area of concern shared by the senior nursing staff is that newly trained nurses may not be industry ready and are bulldozed by the challenges faced on the job. “There has been mushrooming of nursing colleges across the country to tide over the issue of staff shortage. But the quality of nursing education that have been catered in these educational institutes need to be questioned. The nurses coming for practice in hospitals lack the skill as many of them have not got hands on training in hospitals. They have to be mentored into the clinical skills which cause a whole lot of stress as they are not able to complete their assigned task within their eight hours shift that they are in the clinical area,” says Captain Thomas.
Migration
Nurses are in high demand in developed countries such as the US and the UK, and recruitment of foreign nurses have become an attractive option as a quick fix to the ever growing national nursing shortages for these countries. Indian nurses are trained in English and are good workers. According to a report, 20 per cent of current Indian nursing school graduates go abroad.
“Every year a good number of nurses pass out as graduates and post graduates, however, a majority of them find their way to other countries, not only for better pay and perks but also for their professional growth,” explains Lt Col Chandrika.
A survey conducted at the AIIMS of 448 nurse practitioners, nurse educators and nurse administrators to a questionnaire administered to them in December 2004-January 2005 revealed that nurses working in the government sector seemed to be more worried about being unable to adjust to working conditions abroad, and therefore less keen to migrate. The fact that they enjoy better pay scales, a more relaxed work atmosphere and more facilities may have also played a part here.
Apart from economic factors, dissatisfaction with working conditions and unhappiness with prevalent social attitudes towards nurses were identified as being of crucial importance for the international migration of Indian nurses. It was found that nurses working in the private sector and from some linguistic and religious groups were particularly prone to migration.
Safety
Work-place induced injuries and illness are occupational health hazards for a nurse. The safety of nurses from such injuries and illnesses are not only important for them but also for the patients they serve. Nurses experience significant physical and psychological demands while working. Coupled with this, the organisation’s pressure to multitask and establish quick turnaround time for patient care (early discharge, higher patient loads) are some of the problems that nurses face everyday.
Individual nurses are overloaded with a number of tasks they perform. Both cognitive overload by engaging in multitasking and perceptional overload due to mechanical devices, illegible handwriting, long working hours, and patient demands lead to high incidence of unintentional errors, resulting in demotivating consequences.
This has led the nurses to join various organisations to unite and fight against such events. Trained Nurses Association of India (TNAI) is one such organisation which seeks to uphold, in every way, the dignity and honour of the nursing profession; promote a sense of esprit de corps among all nurses; and enable members to take counsel together on matters related to their profession.
On the occasion of the 73rd Biennial Conference of TNAI, Prof (Sr) Gilbert, President – TNAI in her presidential address said, “Safeguarding the nursing personnel at work place, be it mental or physical harassment of any form, TNAI’s council, governing board has taken serious cognizance of the improper policies, rules etc. of the hospital and institution e.g. keeping the bond, confiscating the original certificates, disparity in the pay structure, long working hours and so on.”
“TNAI has presented these issues to the court by hiring a legal advisor (as per the resolution adopted in TNAI Council in November 2011). To fight for our rights and privileges we have to first understand our rights and privileges, make ourselves aware of these ‘rights’. Then only we can face these challenges through collective bargaining mode,” she added.
“At TNAI headquarters we have one committee that deals with the grievances of nurses. Everyone needs to understand that safety of our caregivers is vital to our clients-receivers of our care,” she further added.
Most of the institutions and hospitals, are supposed to have grievance cell/ committee where these issues can be tackled amicably in one to one meeting with the management/administrators of the concerned institution/hospital. However, the willingness of the institutes to address such matters is lacking in reality. Nurses will be able to overcome the challenges and enhance the quality of clinical nursing practice only if the management, administration focus on the betterment of nurses.
“Healthcare is a changing field with constant new developments and industry is witnessing a shortage of nurses as a growing crisis situation. It is crucial that the healthcare segment focuses on the skill training recognition and retention of this critical resource. Continuing education and skill training is very important as it equips the nurses to handle these changes better,” sums up Capt Banerjee.