International Nurses’ Day: Some Pride, More Plights

May 11, 2013

by Maya John


Tomorrow (May 12) as International Nurses’ Day is celebrated worldwide, it is important that we introspect on a crucial fact about nursing, which is that it is one of the most devalued socially necessary labour performed by an extremely skilled workforce. While some hospitals, nursing schools, etc. commemorate this important day, for many who are aware of the highly exploited condition of nurses, these celebrations represent sheer tokenism. Organized by managements of private hospitals, the health ministry of local governments, as well as of the central government, most of such festivities/programmes are occasions where managements and governments conceal their day to day exploitation of nurses behind feel-good-about-what-you-do-kind of speeches and advertisements. Indeed, even today, the majority of nursing personnel have had to simply report for duty like any other working day, and have consequently had no time to attend or call for public meetings to discuss their issues and concerns on the occasion of Nurses’ Day.

In our larger society, nursing is regarded as a service that somewhere represents an extension of the ‘natural’, ‘feminine’ ‘duties’ of women, namely, caring and nurturing. Another popular perception of nursing staff is their alleged inattentive and impatient handling of patients. Ironically, concealed behind each of these images is a disconcerting reality about how our economy and state policies have reduced women’s skilled work into an underpaid and undervalued service, and have also created stressful work conditions which nurture poor performance in patient care.

It is a appalling yet true that in a metropolitan city like Delhi, nursing personnel of private hospitals, nursing homes and those working on contract in government hospitals receive in hand an average of only seven to ten thousand rupees per month. In other cities like Chennai, most private hospitals pay their nurses three to four thousand rupees in hand. It is no better in private hospitals located in highly expensive cities like Bombay where nurses are forced to bear with high costs of living on a meagre salary of fifteen thousand rupees a month. Of course, if this is the condition of salaries in metropolitans, one can imagine how much nurses in smaller cities receive in the name of a salary. Quite obviously, their remuneration is shockingly low.

Salaries of nurses do go up, but only marginally after completion of one or more years of service. In private hospitals where the majority of nursing personnel are absorbed, the difference between the starting salary of a new recruit and an experienced nurse is not very significant. However, despite the negligible salary hikes that come with years of service, managements of private hospitals are more prone to replace experienced nursing staff with new recruits – a practice allows hospitals to keep their wage costs low. Indeed, the noticeable pattern of constant movement of nurses between private hospitals and between cities is not always attributable to the tendency of nurses to move to ‘greener’ pastures. Instead, discriminatory policies of hospital managements, such as preference for new staff recruitment and non-absorption of nurses after strikes, contribute equally if not more to the constant migration of nurses between hospitals and cities. In addition to this, administrative policies like stringent rules for salary hikes, the denial of promotions, lack of sufficient leave, etc. in, both, private and government hospitals that employ nurses on contract, have compelled nurses to constantly shift jobs. Of course, the search for less exploitative terms of employment is almost never ending. Even when nurses migrate abroad and seemingly earn more, most of them fall prey to placement agencies which exploit them financially.

However, the problem is not just that the majority of nurses in India are underpaid but that the majority of them are overworked. Nurses in India work under nurse to patient ratios of 1:20 and even 1:40 in most hospitals, whereas the prescribed norm of the World Health Organization, Indian Nursing Council, etc. is a 1:6 ratio in general wards. In special wards, the prescribed norm of nurse to patient ratio is 1:4, and in critical wards it is 1:1. On the ground, however, we see nurses struggling to look after such critical patients because of skewed nurse to patient ratios in these wards. Unfortunately, this problem of inhuman workloads, or basically, the tendency to make one nurse perform the work of three, is characteristic not just of private hospitals, but also of government hospitals. One would expect government (permanently employed) nurses to enjoy better work conditions, but the truth is that insufficient nurse recruitment has left existing nursing staff overburdened. The ‘impatient attitude’ which most nurses are accused of is really a misconception, and is something which is directly attributable to the unethical workloads imposed on the majority of nurses in our country. Indeed, it is only if we expect nurses to be reincarnations of the many-armed goddess, Durga that we can even begin to legitimize assumptions about ‘poor performance’ by nurses and their supposedly inattentive and hurried approach to patient care. Moreover, such skewed nurse to patient ratios deny both, doctors and nurses, a work atmosphere that is conducive. Such work ratios contribute to a stressful relationship between doctors and nurses, which leads to the devaluation of work performed by nurses. In reality, the low pay scales and exploitative workloads of nurses nurture the misconceived notion that nurses are subordinate to doctors and that nursing is the lesser of the medical professions, whereas nursing personnel are actually colleagues with different yet complementary services in the patients’ care.

Problems exist not only for practicing nurses but also for students aspiring to be nurses, as well as for teaching staff in nursing colleges. Teaching faculty, for example, enjoy very few job incentives, in terms of promotions, salary hikes, etc. Most of the time a nurse educator enters as a clinical instructor or sister tutor and retires as a sister tutor! Despite the fact that their teaching load is almost the same as that of college teachers, nursing tutors’ salaries are not equivalent to the University Grants Commission‘s pay scales for teaching faculties under other university programs. For students the lack of affordable government-funded nursing colleges is a huge obstacle because it forces them to enroll in expensive private nursing colleges which charge four to seven lakh rupees in fees for a four year nursing degree. Some nursing students are even deceived by private institutes which fail to gain recognition from the Indian Nursing Council. These students end up losing the value of a four year long education, and of course, the money they invested.

Burdened by bank loans, nurses graduating from such private colleges are forced to take up jobs immediately. With the lack of employment opportunities in government hospitals, as well as growing contractualization of jobs in government hospitals, more than 60,000 nurses annually end up working in the private sector. A large number of nurses migrate to big cities like Delhi, Mumbai, etc. which are the main centres for healthcare. Needless to say, this trend is part of a vicious cycle of wage depression. With an entire crop of new nurses entering the labour market at low wages, the tendency for wages to remain low across board is very high in this profession. Furthermore, nurses who are absorbed in the private sector are tied down to such workplaces for anywhere between one to three years under the cruel bond system – a system which compels them to surrender their original certificates (including their registration certificate) to the hospital management. Under the bond system nurses have to pay huge sums of money, even more than they actually earn, to free themselves from the job contract. These sums have even touched figures like thirty thousand rupees and more. Although a recent court verdict against the bond system exists, there is no state regulation of whether private hospitals are following or violating the order.

Of course, at first all these concerns may seem mere professional ones. However, each of these concerns, like the overworking of nursing personnel, poor remuneration, contractualization of jobs, lack of government hospitals and government nursing colleges, are intrinsically connected the state’s skewed, anti-people health policies. After all, nurses attend to people – they facilitate the recovery process of the sick, the hurt and the aged, and it through their skilled work that an essential responsibility of the community is actualized. If their work conditions and their lives are compromised then so is patient care. A state that fails to provide greater educational facilities for healthcare workers and does not create more jobs and conducive work conditions for nursing personnel is not serious about providing better and more affordable healthcare to the majority. The shortage of government-funded nursing colleges, for example, represent the lack of commitment towards creating more and better trained nurses to cater to society’s growing healthcare needs. Likewise, the paucity of permanent employment for nurses in government hospitals is indicative of not just the lack of sufficient government hospitals that can absorb existing nurses in the field, but also of how the state grudgingly provides an essential service like healthcare by covering up the costs of subsidized healthcare through steady contractualization of nursing jobs in government hospitals. Similarly, the violation of stipulated nurse to patient ratios across hospitals shows that rather than creating more jobs for nurses, the state would rather play with human lives by placing patients in the hands of overworked nursing staff, as well as by exposing overburdened nursing staff to professional hazards brought on by fatigue.

Ultimately, the current challenges faced by nurses, nursing students, as well as other healthcare workers are nothing but the product of sustained neo-liberal state policies which have fuelled unhealthy developments like privatization of the health sector, and hence, neglect of public healthcare. The question is how long can successive governments adamantly ignore the issues of public health and of the nursing community? The recent strikes in different cities that have emerged from within contractual nursing staff indicate the genuineness and widespread nature of the discontent. Expectedly, most of these strikes have exposed the nexus between government authorities, the local police and hospital managements. Thus, it is not just that the state ignores the voice of the nursing community, but that it actively participates in breaking nurses’ strikes, and is consciously preventing nurses from forming their organizations. Indeed, the anti-labour conduct of the district administration and police during many recent strikes has well exposed this connivance. Time and time again during nurses’ strikes, the district administration turns a blind eye to managements’ unfair practices like cutting the electricity supply and placing jammers in their nursing accommodations. In other instances, the local police have blankly refused to file FIRs against local goons brought in to intimidate striking nurses. Nevertheless, the biggest nexus between the government authorities and private hospital managements is reflected in the simple fact that many MPs and MLAs own shares and/or are present on these hospitals’ board of directors.

In such a context, certain common demands emerging from the nursing community are very crucial as they expose the compromised nature of state policies, as well as unite nurses across different states and hospitals. The demand for a wage board, the right to organize, regulated work hours, removal of contractualization, provision of compulsory conveyance for nursing personnel by employers, and more government hospitals and nursing colleges are some of the common demands which will help build better coordinated and combined struggles across hospitals. It is precisely by raising such common demands that the nursing community can also unite with the larger labour movement which seeks to fight the onslaught of neo-liberal state policies. In reality, if the shortage of nursing personnel in India is combined with a well organized movement on common demands, the untapped potential of nurses’ striking power can be realized. May be this International Nurses’ Day, the untapped potential can be given a new lease of life through concerted efforts to mobilize nurses more effectively and across government–private sector divide.

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