The skewed policies, over the years, have festered into stagnant designations, limited recruitments, arbitrary deputations, lack of motivation to advance career, and importantly, lack of respect, said the nursing community.

Three months ago, Subi was caught in a crossfire between two political parties in Somalia, where he is working as a nurse. Beyond the life within the hospital and the four walls of his accommodation, he has no social life considering the political tension. Security personnel escort him and his colleagues from India to run errands. However, even amid the threat of armed robbers, kidnappers and no stable political system, two factors keep Subi, a native from Kannur in Kerala, from leaving his job in Somalia. “A good salary and respect,” said Subi. “More than salary, it’s the value Somalia gives Indian nurses. We don’t get that in India,” he said.

Dayananda was a first rank holder in the entrance exam for a government job in a state cancer institute in Karnataka. With a PhD in nursing, he requested a lecturer post. However, the Karnataka government selected Dayanand as a staff nurse. Today, he is working in the United Kingdom as a registered nurse, but with a completely different definition of the role. “Unlike India, where doctors give nurses orders, nurses can be independent practitioners in the UK. Under the National Health System (NHS), a majority of the patient care services are managed by nurses, who can decide the treatment and consult with doctors too,” he said.

Subi and Dayananda are classic examples of migration to foreign countries for greener pastures and a better life. On the flip side, however, these stories often idealise migration to a degree that eclipses the actual reasons driving Indian nurses out of their own home country.

Sample this: Delhi-based Liladhar Ramchandani has been in the nursing profession since 1995. K Sakthivel from Tamil Nadu has been serving as a nurse for the past 23 years. Gangadhar has 23 years of experience as a nurse in the Karnataka government sector, with 14 years of teaching experience. All three have been holding the post of a Staff Nurse — the entry-level position — in the government sector, doing the same set of duties (and more), without any promotion, for over two decades.

Since health is a state matter, the recruitment rules vary from state to state and the Union government. However, promotion is set within three to five years or even 10 years.

Homilies about nurses being the pillar of the healthcare sector are plenty. However, when #KhabarLive spoke to nurses and nursing associations in at least six states, their resentment against the existing rules and regulations was writ large. The skewed policies, over the years, have festered into stagnant designation, limited recruitments, contractual hiring, the arbitrary deputation of nursing faculty, lack of motivation to advance career, and most importantly, lack of respect.

“In India, nursing as a profession gets caught in the hierarchy, where doctors are considered superior to nurses,” noted Anant Bhan, a researcher in the field of global health, health policy and bioethics.

“How often are nurses seen on media panels to discuss health? How many nurses are seen at the top management of health institutions or organisations? It is only during COVID-19 that our profession was discussed,” said Nagaraju Swamy, a nurse at the Rajiv Gandhi Institute of Chest Diseases in Karnataka.

Nagaraju completed his Masters in Psychiatric Nursing, which is recognised by the Indian Nursing Council (INC), the regulatory body under the Indian government for nursing and nursing education. “In reality, however, the Karnataka government does not recognise my qualification, primarily because nursing, as a profession, is still confined to the general perception of hygiene and care of a patient. As far as a hospital is concerned, that is enough,” he alleged.

“There are policies, protocols, training calendar, performance matrix for nurses; all exist, but not in reality,” said Antonia Pushparaj, the principal assessor at National Accreditation Board for Hospitals and Healthcare Providers (NABH). After serving as a nurse for 27 years, Antonia left the organised sector of a hospital. “I embraced nursing as a service. However, during the decision-making process, somebody makes and executes decisions for nurses. There is no freedom and autonomy, which hinders nurses from realising their self-worth,” she said.

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Nursing profession: Expectations vs Reality

Nurses constitute the largest population in the health workforce in any country. Providing emotional support to patients, feeding and bathing them, changing bedpans and urinals, and making their beds remain the foundational duties of nurses. Gradually, science was integrated into their daily practices, elevating their role from patient care providers to healthcare providers. Today, they perform core medical duties, administer medicines and prepare diet plans, among other tasks.

“As a medical student, I learnt my first injection from a nurse. In fact, most doctors begin their training with a nurse, as they can give a better prognosis of patients,” said Dr Namratha, a resident doctor in Karnataka.

However, the apathy toward the profession was pronounced in some of the recent band-aid measures announced by the state governments because of the COVID-19 pandemic.

The Maharashtra government, in July 2021, announced a three-month course to train 20,000 youth in nursing and paramedical care. On June 16, the Delhi government said it will train 5,000 people for the role of Community Nursing Assistant within two weeks. Their duties would include paramedical care, collect samples and administer injections, among other tasks. These are some of the tasks that nursing students painstakingly learn over a course of three to four years.

“No person can do the job of a nurse with a 10-day training,” stressed Pappa Henry, a staff nurse at the Kottayam Medical College Hospital in Kerala.

A typical day for a nurse in a ward of 29 beds, for example, would look something like this: If 20 beds are occupied, three nurses, along with an Auxiliary Nurse Midwife (ANM), would divide the patient cases according to seniority. One nurse would handle up to five to six patients. They start with rounds, study the medical condition of each patient, send samples and collect reports of clinical investigations, take the patient for a diagnostic procedure (if prescribed), consult with the doctor and start the treatment, write the case sheet or nurse’s note recording the patient’s medical history. They also supervise cleaning, plumbing and electric work in the ward.

With too many patients and tasks packed into one day, patients often complain nurses do not attend or respond to them on time. According to the nursing community, governments do not address the unhealthy mismatch between the number of nurses and the daily patient load.

Understaffing that remains a crisis

Ever since the regulations for the nursing sector were officially laid down in the Indian Nursing Council Act, 1947, numerous expert committees were set up from time to time, to review the profession, identify the problems and formulate policies. One of the key issues — as identified by the Shetty Committee 1954 and High Power Committee on nursing and nursing profession (1987-1989) — was the shortage of nurses, which remains so, even today.

According to the State of World’s Nursing 2020 report by the World Health Organisation (WHO), India was among countries with the largest shortages of nurses (in numerical terms) in 2018.
In March 2020, the Union Health Ministry said that India’s nurse-patient ratio is 1.7 nurses per 1,000 population, while the optimum ratio is 2.5 nurses for 1,000 patients, as recommended by the WHO. This implies that about 4.81 lakh nurses are needed to meet the recommended standard.

Why are governments, however, not filling these gaps? “There is no timely recruitment and filling of existing posts in the government sector. Population-wise, we are short on nurses, but from the perspective of posts, we have excess nurses,” said Professor Roy K George, the national president of Trained Nurses Association of India (TNAI), which is a member of the Indian Nursing Council.

Fewer recruitments, excess workload

Three top posts for the Nursing Section in the Ministry of Health and Family Welfare, including the highest post of nursing advisor to the government of India, have been lying vacant for the last five years. The only post in the Ministry that is operative now is the Assistant Director General (Nursing).

While the posts of Staff Nurse are filled by recruitment exams, the other hierarchical positions are promotional posts across the state and Union-government-run hospitals.

In most cases, recruitment exams are either delayed or sporadic. The delay in conducting recruitment exams left the Maharashtra government, for example, scrambling during the COVID-19 pandemic. While it announced the recruitment exam to fill about 1,500 vacancies in February 2019, it was conducted only two years later. It had to request the Kerala government to depute nurses and doctors to meet the shortage amid the rising number of COVID-19 patients in May 2020.

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According to the nursing fraternity, fewer or no recruitments or promotions not only belittle their experience but burden them with work of the higher posts, for the same pay. “One of the key reasons behind fewer recruitments is contractual hiring. Nurses are appointed on contract, for a period of three or 11 months. These contracts are often not renewed, and are given to another candidate,” said Jibin TC, state president (Maharashtra) of United Nurses Association (UNA).
As stop-gap measures, nurses alleged, state governments hire unskilled persons on a contract or hire trained professionals for a limited period, just to meet the immediate demand.
In Tamil Nadu, government hospital nurses have been protesting since 2017, seeking to regularise their services. In 2015, the state government had recruited a batch of 14,000 nurses through the Medical Services Recruitment Board (MRB) on a two-year contract through an examination, promising to regularise their services. The state government, according to reports, has regularised only 2,000 nurses so far. Besides, the 2014 policy of the National Health Mission (NHM) follows a 2:1 ratio, under which, one nurse will be moved into a permanent post with higher pay, while two will continue the contract job.

However, a nurse on contract handles the same set of duties as a permanent staff nurse, albeit a lower pay of Rs 7,700. In 2017, after protests, this was raised to Rs 14,000 (consolidated pay) with a fixed annual increment of Rs 500.

The uncertain promotions

S Valarmathi, General Secretary of Tamil Nadu Government Nurses Association, was recently promoted as the Nursing Superintendent in Thanjavur Government Hospital after 27 years of service as a staff nurse. “However, many nurses in Tamil Nadu, who finished their training in 1989, got posted only in 1999. They were without a job for 10 years because the state government didn’t conduct the recruitment exams, thus diminishing their chances for a promotion,” she said.

The effects of skewed recruitment policies reverberate through nursing colleges, too. Most governments hire nurses who have completed their Masters and PhD as nursing faculty on a deputation basis or contract. However, there are no fixed rules and regulations in hiring nursing faculty, the effects of which impacted nurses like Gangadhar from Karnataka.

After completing his Masters from Bangalore Medical College and Research Institute, Gangadhar was deputed as a faculty member. In 2013, he was deputed to the Karnataka government’s Rajiv Gandhi University of Health Sciences as the Vice-Principal, and then as the Principal in 2020.

However, the tenure lasted only for six months, he said. “Two nurses who had more clinical experience than me were deputed as the Principal and VP. I, who had more experience in teaching, was demoted as teaching faculty,” he alleged.

Today, he works three days of clinical duty as a staff nurse and three days of teaching in the college as nursing faculty.

“Government hospitals do not have adequate staff or facilities to take care of patients, who are then referred to private hospitals. So, delayed recruitments or contractual hiring is indirectly favouring the private sector,” alleged Jibin.

A majority of the nurses in India work in private hospitals, which shoulder the lion’s share of the country’s healthcare needs. However, nurses in the private sector, too, have a fair share of difficulties. While the Supreme Court directed state governments to ensure a minimum salary of Rs 20,000 for nurses in private hospitals (with less than 50 beds), this is yet to be implemented in many places, nurses alleged.

The gender policy

Article 16 of the Constitution guarantees equality of opportunity in matters of public employment.This constitutional provision, however, is conspicuously violated in the nursing profession, where the majority of the vacancies are reserved for women.

In 2019, the Central Institute Body (CIB) of All India Institute of Medical Sciences (AIIMS), under the Union government, issued a new recruitment policy that reserved 80% of vacancies for the post of Staff Nurse (or Nursing Officer) for women.

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The West Bengal and Maharashtra governments, too, have a similar policy of 90:10 female to male nurses. What’s more, male students cannot enrol for BSc Nursing courses in AIIMS, PGIMER (Post Graduate Institute of Medical Education and Research) and a few other central institutions.

Such gender-based reservation policy only appropriates the stereotyping of the profession as a women-specific service, said nurses. AIIMS justified the reservation on the premise of ‘patient care and comfort.’ However, the profession, in its true sense, involves administering clinical services in the health sector, not the hospitality sector.

“The entry of male nurses engendered unionisation of nurses,” argued Jibin. Many female nurses were overburdened by the daily chores at hospitals and then houses, often leaving them with little time or inspiration to venture out to establish their rights.

“When unions like AIIMS Union came to the fore, it empowered nurses to come together, which the medical fraternity saw as a threat. Such reservation policies are a way to reduce male nurses in the system,” he alleged.

Gender reservation policies also impact the LGBTQIA+ community. Being a transgender person, Rakshika Raj could not register with the Tamil Nadu Nurses and Midwives Council (TNNMC), due to which, she could neither take the recruitment exam nor get employed as a nurse. She managed to get an interim order from the Madras High Court, allowing her to register as a transgender nurse. The 25-year-old is now serving as a COVID-19 staff nurse (on a contract basis) at the Chengalpattu government hospital, even as she awaits a permanent solution by an amendment in the INC Act.

“The law should be changed at the central level. From admission to registration and employment, no nurse should face difficulty because of their gender,” Rakshika told #KhabarLive.

Better laws for better work

In November 2020, the Union Health Ministry issued the draft National Nursing and Midwifery Commission Bill, 2020, to replace the 1947 Act. “The Indian National Council Act, 1947, only focuses on nursing education and gives no teeth to nurses, which puts the profession in an infant stage even today,” noted Roy, who is also the principal of Baby Memorial College of Nursing in Kozhikode, Kerala. The proposed Bill is comprehensive, and nurses hope will catalyse some much-needed changes. Overall, however, it does little to promote and strengthen the profession in the country, the fraternity said.

Six issues in particular warrant more discussion, noted advocate Nishtha Chawla, who is the legal advisor to Delhi Nurses Federation — “Centralisation of power at the Union government level; no decision-making power; weak in setting standards and scope of nursing; no regulation on the number of educational institutions and nursing professionals; lack of attention to administrative and service aspects; and restrictive nature of grievance redressal system.” The  NNMC Bill 2020 provides for the constitution of regulatory bodies at the national and state levels, which can keep a check on the pay patterns and the educational system.

The government has been pushing desultory recommendations to burnish the nursing training and profession (example: here and here). However, all nurses whom  #KhabarLive spoke to, had certain policies that they would want the governments to implement, including encouraging research, having refresher/bridge courses, a nursing directorate or ministry.

“Introduce a ranking system instead of creating new posts. For example, after service of five years, a Nursing Officer will get Senior Nursing Officer rank, and bring other trained nurses on board. This will help nurses divide the daily tasks effectively and avoid being pinned to an entry-level position,” suggested Fameer CK, General Secretary, AIIMS Nurses Union.

“Beyond laws, there should be mechanisms to address how professions interact with each other and ensure there is respectful engagement and teamwork. These must be implemented at an institutional level,” said Anant.

“The consequences of bad policies would be a deterioration for the health system. Many will be discouraged to take up the profession, as the current health policies are organised around doctors. Children of doctors get into the profession, but not nurses,” pointed out Roy.

However, nurses are not settling for the way the state of affairs has been for years, said Roy. “Things are better because nurses are coming out strongly against the long neglect, but we have a long way to go.” #KhabarLive #hydnews