Neglected Concerns of Nurses and Their Unheard Voices;
A Blind Spot in our Health System
Priya Baby1, Manju Dhandapani2,
L Gopichandran3
1Lecturer,
College of Nursing, NIMHANS, Bangalore.
2Lecturer,
National Institute of Nursing Education, PGIMER, Chandigarh.
3Associate
Professor, College of Nursing, AIIMS, New Delhi.
ABSTRACT:
The current scenario of nursing in India forces us to
introspect if the nurses are equipped enough to bring out their best
contribution towards the health of our country and if their voices are well
heard in the healthcare system. Despite being highly skilled professionals,
nurses are neither facilitated nor rewarded enough to sustain their motivation
and inputs. To understand the struggles faced by nurses in India, we reviewed
literature that addresses Indian nurses’ concerns and brainstormed about the
major challenges that nurses encounter with key nursing personnel from nursing
education, clinical services and administration from selected hospitals of
India. The major challenges that negatively affect the contribution of nurses
are shortage of nurses, poor working conditions and career opportunity,
ineffective leadership roles, poor educational quality, low salary and state
neglect. The COVID-19 pandemic has proven the vast contribution and sacrifice
of nurses. The competency of nurses has gone up with specialization, and
advanced nursing degrees. Enhancing nurses’ involvement in collaborative
healthcare research would be a hallmark in improving the quality patient care.
To efficiently utilize the contribution of the nurses in healthcare system, the
society and state have to recognize the potentials and vulnerabilities of
nurses, appreciate their strengths and reciprocate responsibilities to their
neglected concerns.
KEYWORDS:
concerns of nurses, health system.
INTRODUCTION:
Professional nurses in India have the largest share in the
health workforce of the country. They contribute at every level of the complex
organizational structure of health delivery. It is estimated to have over 3.07
million registered nurses in India1. However, nursing has many times
failed to get its deserved attention in our health system2. The
international nursing models promote reliable and stable workforces by
optimizing investment in nursing3 when the same in our country is
mostly remaining status quo.
As we look forward to the nursing profession’s
contribution towards the better health of our country, we need to introspect if
the nurses are equipped enough to bring out their best and if their voices are
well heard in the healthcare system. The objective of this article is to
discuss the challenges faced by nursing community as perceived by nurses
working in various roles. We brainstormed about the concerns that nursing
personnel in various positions including nursing education, nursing
administration and clinical services have, regarding the challenges faced by
nurses from three major national institutes of the country. The article
discusses these concerns in the light of the reviewed literature.
2020- The Year of Nurse Midwife:
For the first time, WHO is observing 2020 as a year of
nurses and midwives with an intention- ‘to put nurses and midwives at the
center of global and national health policy, and to celebrate what nurses and
midwives do to improve health and health care in their communities and across
the world’4. WHO has asked the countries across the world to
invest in nurses as a part of their contribution towards universal health coverage.
Another effort is ‘The Nursing Now Campaign,’ a global
campaign to improve health by raising the status and profile of nursing,
launched in 2018 in our country in collaboration with the International Council
of Nurses (ICN) and World Health
Organization (WHO)5. One of the major areas of its focus is to
ensure that nurses and midwives have a more prominent voice in health policy-
making and to encourage greater investment in the nursing workforce. Such
efforts from international bodies are to propound nursing to the spotlight and
to bring it to the agenda of governments globally. These are needed to enable
the next generation of nurses to play bigger and stronger roles in
multidisciplinary teams. India, as a country, needs to introspect into how the
nurses are acknowledged and recognized here when they are making a massive
impact in the global picture. Indian nurses also need to reflect on the
ambitious efforts to be civically engaged in work and make direct positive
changes.
Status and Profile of Nursing in India:
Nursing leaders of our country have constantly lamented
the poor/inadequate attention given to this profession by the state and the
public6. Early nursing leadership has acknowledged this public
miscomprehension and had vexed questions on making the voice of nurses heard7.
To enhance job engagement and productivity, the nurses must be intrinsically
motivated and positively reinforced. Unlike, the situation in India is
different, with nurses having to brave multiple challenges in their
professional front. There are multiple reasons which have hindered nursing from
getting a suitable position or power, both in health hierarchy and in the
social structure. The social stigma that prevailed in the early years and the
lack of perceived autonomy of nurses in contributing to direct patient outcomes
are some of those. Female dominion also made the nurses to be recognized as
passive workers rather than being assertive professionals. Nurses are not
showcased in the healthcare platform amidst their vast contribution. Very
commonly, nurses themselves also do not make conscious efforts to make their
contributions visible. Another key shortcoming of nursing in India is that
nurses here are largely unorganized and lack tactical advocacy strategy involving
key stakeholders8. The compromised
position of nurses in the social and health hierarchy negatively affects the
contribution possible by them to the health system9. Some of the
major concerns raised by nurses include:
Shortage of nurses:
The shortage of nurses hinders scaling up the health services
and often limits their contribution. Despite being one of the countries that
train the highest number of nurses, we lack almost 2.4 million nurses to meet
our requirements10. One of the main reasons for the critical nurse
shortage is our country's inability to retain nurses with good pay and working
condition. India is reported to export the largest number of nurses and
healthcare professionals to other countries. Migration is facilitated by an
attractive salary, career opportunity and better working conditions in other
countries. The Filipino experience of losing nurses to migration, leading to an
acute crisis of workforce shortage 2, is a lesson to learn from for
India.
The ethical principles of fairness and justice are denied
for the entire nursing community in this regard. Not only for nurses, but the
ethical principles of distributive and social justice are denied for the health
care consumers at large when the nursing workforce is understaffed. The moral
obligations that the health care systems have to their consumers is undoubtedly
denied and breeched due to the shortage of nurses.
Poor working conditions and career opportunity:
The working condition of nurses in many hospitals across
the country is not up to the standard recommendations6. Poor
resources and inefficient resource allocation at workplaces make them victims
of occupational hazards and lead to poor work engagement. Nurses in India are
not facilitated with an adequate
career opportunity in promotion, in-service education or staff development
programs. Exploitative working conditions comparable to bonded labor exist in
the private sector9. Strong political commitment is required to
improve the working conditions of nurses as per the recommendations. The nurses
and nurse educators in different sectors are stagnated due to the absence of
cadre structure and promotion.
Ineffective leadership roles:
The status hierarchy implicitly present in the health
system places nurses at a lower position, posing constraints to their
leadership roles. Several nursing leadership positions at the district and
state levels in the public sector have been abjured in the recent times11.
The compromised social position of nurses and mal- distributed power in the
health system has created an imbalance of attention given to nursing leaders8.
The female dominant gender identity given to nursing in the sociocultural
context has also been a reason not to deploy an adequate number of trained and
qualified nurse leaders in clinical and public health domains.
Poor educational quality:
There has been a disproportionate increase in the number
of non-governmental nursing colleges across the country over the past few
decades. The training provided in some
of these institutions tends to be of poor quality and may
not meet statutory bodies' standards. Rigorous training is mandatory for the
nursing students to take over a highly responsible and accountable job as
nurses when they enter the job as novices.
Low salary:
Inadequate salaries and insufficient recognition of
services has always caused nursing to be looked down upon12. For a
long time, nurses are being exploited by private hospitals by paying very low
wages to them13. Sadly, the origin of this can be traced to the very
beginning of establishing nursing in India. In the early years, the native
Indians who joined religious nuns in nursing jobs considered it a charity. Thus
nursing mostly became a humanitarian vocation rather than a paid labor14.
This is very much reflected in the usual clichés like ‘angels in white’
interchangeably used for nurses. The ‘nobility’ and ‘service- mindedness of
nurses, were major grounds on which most private hospitals denied a decent
salary for them. As the qualification of nurses is often not known to the
clients, the private hospitals mostly ran the show with trainees whom they
could pay in peanuts. In an attempt to make more profit, they reduced the
nurse’s salary14.
On the contrary, to retain good doctors, they pay handsome
salaries and build the hospital infrastructure by investing huge amounts of
money14. The scapegoats here are the nurses, who are largely an
unorganized workforce in the private sector. However, the parsimoniousness of
private hospitals is usually not questioned by the state.
The underpaid status of nurses working in the private
sector becomes all the more annoying when one congruently discusses the
contribution of migrated Indian nurses to our economy. The large numbers of
Indian nurses who have migrated to various parts of the globe in search of
greener pastures have irrevocably contributed to our country's growth. They made
sure a constant inflow of not only money but assured a hailing country of a
well-bred generation. They sacrificed the young years of their lives away from
families in hostile working environments, with the hopes and dreams of gaining
a better future and it was mainly an economic opportunity15,16.
Indian economy is a sure benefactor of their sacrifice.
State neglect:
The major factor which has caused nursing to lose its
importance is state neglect. The social mandate of nursing is largely
determined by public policies. A paradox exists between the power of the
profession and the promise made by the policymakers. Governance approaches are
not scaled to support the nursing profession. The claims that nurses make about
nursing being a profession is bleakly reflected in terms of the recognition it
gets. Despite nurses constituting 38% of the entire workforce of the country17,
their voices are often unheard, even in policymaking.
There have been longstanding fights that the Nursing
community had to do for establishing its place and power. It is often found
difficult to bring the problems faced by the community to the administrative
gaze. An example of this is the decade-long legal battle fought by the
professional association of nurses in India, i.e., the Trained Nurses
Association of India (TNAI) to bring into the legal eye the nurses' grievances
working in the private sector. The judgment made by the honorable Supreme court
of India in January 2016 reads, ‘Nurses who are working in private hospitals
and nursing homes are not being treated fairly in the matter of their service
conditions and pay18’. A committee constituted in compliance
with the Supreme Court judgment has recommended that the salary of nurses
working in hospitals with more than 200 beds should be on par with the salary
given to nurses working in Government hospitals of the state and any case, it
should not be less than 20000 Rupees per month. It also states that the working
conditions including working hours, leaves, medical facilities, transportation
facilities and accommodation given to nurses in the private sector, should be
on par with the nurses working in state /UT hospitals. The committee also
endorsed the states to take steps for formulating legislation/guidelines for
the implementation of the recommendations19.
It is sad to notice that the state governments have not
taken adequate measures to ensure that the recommendations are instituted19.
Except for a few states like Kerala, Mizoram, Goa, and Maharashtra, there were
no major changes from the previous situation. Uproars of nurses have made some
unrest in the private health industry, but they are still at the mercy of the
private lobby hospitals. The minimum salary for nurses decided by the states is
yet to be implemented by many private hospitals. Despite protests staged in
many states by the nurses working in private sector hospitals, deaf ears have been
turned to it14,20. The news about nurses protesting was multiple
that it ceased to agitate society’s conscience or evoke any feeling in the
general public.
There is a very poor budgetary allocation for health in
our country. The poor resources at work and lack of staff
empowerment/development programs are major factors that increase the stress and
adversely affect the work engagement of nurses. It can be a leading factor for
poor outcome and reduced visibility of the contribution of nurses. Hard physical
and emotional work, poor social recognition, and inadequate incentives
demotivate many young professionals from taking up the profession.
Media ignorance:
The nurses are portrayed as physician’s handmaid,
assistant, unskilled or as angels in various media documentaries and movies.
Similar to the angels being invisible and fictional characters, the needs of
nurse angels also go invisible. Media, many times, fail to showcase the worth
of a nurse. This has misshaped the public perception of nurses and has played a
large role in undermining nurses and has depicted it as an unattractive career.
The Impact of COVID:
COVID 19 has become a ripe area of opportunity that has
demonstrated the importance of nursing in our health care system. The
contribution and dedication of the nurses have become more visible to society
during these desperate times. Nurses have been appreciated for being the
frontline warriors in fighting the virus.
In several places, nurses take up their duty to serve despite the
non-availability of adequate PPE. When nurses are abiding by the ‘social
contract’ that they have made by entering into the profession, the society and
state also have a ‘reciprocal contract’ that they need to abide by. Not
dismissing the importance of senior doctors and administrators, it is often
nurses and resident doctors who do the courageous act of caring and curing
these patients21. Neglecting this infantry of nurses is not only
ethically sound but also rationally illogical.
Altruism is a true value that governs nursing practice.
But there is a clear conflict between the profession’s demands and societal
expectations. In the present times, nurses have to combat not only COVID, but
the societal neglect, unappreciation, and violence22. The grueling shift duties amidst the class
struggle of being treated unimportantly test the loyalty of the nurses. In a
situation where the previously advocated minimum salary is not paid for nurses,
the current pandemic situation has warranted salary cuts23,24 which
leave the nurses in no way able to face the crisis. The safety, health and
priorities of nurses are the bedrock of our health system more than any time before.
The COVID 19 pandemic has proven the contribution and
sacrifice of our nurses among frontline health workers. Nurses’ contribution
during this pandemic extends to the generation of evidence and policies for
COVID-19 care as well25. This potential of the nursing community was
recognized by the WHO during the Ebola outbreak and it has recommended placing
nursing at the center of its long-range workforce recommendations26.
COVID 19 teaches us new models of governance and investment in the Nursing
community.
Nurses for improving the health system of our
country:
Nursing is an important discipline that contributes immensely
to the care of patients, families and communities. It has a broad scientific
base of practice and an expanding body of vast knowledge. Empowerment of this
profession can vitally empower the healthcare system of our country.
Utilizing the services of specialized nurses in key areas
of health delivery enhances the outcome. With specialization and advanced
nursing degrees, the competency of nurses has gone up. Nurse practitioners and
specialized nurses are an asset to the healthcare system and can take over many
tasks done by the physician in different care levels. Such ‘task shifts’ are
essential for easing the burden on health system27. The creation of
job opportunities for specialized nurses in the public and private health
sector will aid in expanding and extending the professional boundaries of the nurses.
Clear roles, adequate training, and most of all adequate
incentives can ensure that nurses can replace doctors in primary care28.
When 70 -80% of the primary care can be provided by nurses, investing in this
community is far better even from in economic view point29. Several
countries have demonstrated how a capable workforce of nursing can strengthen
primary health care and support the achievement of health system goals.
Involving nurse leaders in decision making at
organizational and national levels is important to ensure that their share of
voice is heard in the health system8. Policy reforms are necessary
to facilitate nurse leadership. The national and state nursing councils needs
to be better powered with political clout to influence decisions related to
nursing. The need is not just to create a few nurse leader positions high up in
the hierarchy but also to have a culture of distributed leadership. Distributed
leadership focuses on leadership shifts from individual leaders to the entire
system thereby facilitating leadership culture in organizations30
and subsequently strengthening every nurse's voice. Although the ‘esprit de
corps’ among Indian nurses is higher than before, nurses need to be more
unified, organized and utilize their collective bargaining power to advocate
for themselves and make their voices heard.
Enhancing nurses’ involvement in collaborative healthcare
research would be a hallmark in improving the evidence-based nursing practices
for quality patient care and to improve the visibility of nurses’ contribution31.
Utilization of the best pieces of evidence in patient care enhances recovery,
prevent complications, reduce hospital stay and prevent delay in transfer of
care. The contribution of nurses to direct patient outcomes should be made more
perceptible to the community through research. Nurses should scale up to these
and use their acquired skills in making palpable changes in practice.
These concerns of the nurses raise ethical questions.
Nurses are entitled to impartial and just working conditions. There should be
fairness in terms of distribution of funding, educational quality, wages, wage
increment, resource allocation etc. in comparison to all other healthcare
providers.
CONCLUSION:
Nurses in India are under-recognized. But the worth of
these professionals in India, if tapped well, can be phenomenal in improving
the health system of our country. The central mission of the profession being
service to humankind; the state and society at large have their moral
obligations to this community. Despite the intimidation that many of them face and
the apathy shown to them, they continue to be the health system's backbone.
Nurses should be given more satisfying jobs within the country to retain them
here. To efficiently utilize the contribution of the nurses in healthcare
system, the society and state have to recognize the potentials and
vulnerabilities of nurses, appreciate their strengths and reciprocate
responsibilities to this largely unheard community. The unheard voices of their
bare necessities should not be a blind spot suspending the growth of the
country’s healthcare system. They are the unsung heroes of our health polity.
The literal meaning of nurse is to nurture. But is it not the responsibility of
the state and society to nurture them right back?
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Received on 19.06.2021 Modified
on 03.07.2021
Accepted on 12.07.2021 ©A&V Publications All right reserved
Asian J. Nursing
Education and Research. 2021; 11(4):594-598.
DOI:
10.52711/2349-2996.2021.00138