12th May as International Nurses’ Day is celebrated worldwide. However, this Nurses’ Day is marred by the harrowing accounts and mounting discontent of nursing cadre battling with the apathetic attitude of the Central and State governments during the Covid-19-cum-lockdown situation. The situation ushered in by the Covid-19 pandemic has clearly revealed, yet again, the highly unsafe and insecure work conditions that the majority of nurses find themselves in. In recent weeks we have watched the condition of nurses and other frontline healthcare workers worsen in the present crisis, particularly with governments neglecting their just demands for Personal Protection (PPE) kits and provision of other proper safety measures in hospitals. Incidents of how nurses have been exposed to round-the-clock shifts to make up for the shortfall in the number of healthcare staff are open secrets.
It is then important to use the occasion to introspect on a crucial fact about nursing; namely, that it is one of the most undervalued socially necessary labour performed by an extremely skilled workforce. While several hospitals, nursing colleges, etc. commemorate this important day, nurses continue to work in highly oppressive conditions; making these celebrations tokenistic at best.
In our larger society, a popular perception of nursing staff is their alleged inattentive and impatient handling of patients. Ironically, concealed behind each of these stereotypes is a disconcerting reality about how our economy and state policies have reduced women’s skilled work into an underpaid, undervalued service, and have also created stressful work conditions which consciously breed poor performance in patient care. In this way, the ‘impatient attitude’ which nurses are accused of is directly attributable to the unethical workloads imposed on the majority of nurses in our country. 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, nurses struggle with much higher number of critical patients. Currently, with the rising pressure brought on by the pandemic, governments have failed to hire more healthcare staff like nurses to attend to the general healthcare needs of the public, and have instead drastically scaled down OPD services in public hospitals. Such measures have created huge health hazards for the millions of labouring poor who heavily depend on public hospitals.
It is appalling yet true that in our big cities, nursing personnel of private hospitals, nursing homes and those working on contract in government hospitals receive in hand paltry sums as salaries. Apart from the basic salary of seven to ten thousand rupees, a large component of their salaries is simply incentivized. Consequently, nurses in the private sector and those working on contract in public hospitals are indirectly compelled to put in longer hours to earn higher salaries in their respective institutions. Of course, with such dismal conditions in metropolitan cities, one can imagine how little nurses earn in smaller cities. It is precisely the non-remunerative nature of their salaries that facilitates a high job turnover among private sector nurses. 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. However, 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. Even when nurses migrate abroad and seemingly earn more, most of them fall prey to placement agencies which exploit them financially.
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! For nursing students, the lack of affordable government-funded nursing colleges is a huge obstacle. Many are compelled to enroll in expensive private nursing colleges, for which they often take loans. Repaying loans is often an uphill task, given the low remuneration of nurses in private hospitals and in contractual positions in public hospitals. Unfortunately, some nursing students are even deceived by private educational institutes which fail to gain recognition from the Indian Nursing Council or State Nursing Councils. 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 limited 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. The pressure to pick up work in the private sector is all the more, given the recent stipulations of Central government that candidates fulfilling the General Nurse Midwifery (GNM) course must show at least one year’s job experience to be even considered ‘eligible’ for government employment. Needless to say, the regular entry of job-hungry nurses into the healthcare labour market of big cities 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.
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 public hospitals and government-funded 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 subsidized educational facilities for nurse aspirants, and does not create more jobs and conducive work conditions for nurses is not serious about providing better and more affordable healthcare to the majority. To elucidate, the paucity of permanent employment for nurses in public hospitals is indicative of the lack of such hospitals that can absorb existing nurses in the field, as well as the grudging manner in which governments provide an essential service like healthcare by covering the costs of subsidized healthcare through steady contractualization of nursing jobs. 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.
The question is how long can current governments adamantly ignore the issues of public health and of the nursing community? In recent years the strikes in different cities that have emerged from within contractual nursing staff and private sector nurses indicate the genuineness and widespread nature of the discontent. 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. Time and time again during nurses’ strikes, the district administration and labour department officials turn a blind eye to managements’ unfair practices like cutting the electricity supply of nursing accommodations, placing jammers in nursing accommodation, sacking local nurse activists, etc. 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 the basic demand of greater pay parity with public sector nurses continues to be shelved despite recommendations of noted committees constituted in recent years following Supreme Court directives. The delay in implementation is closely linked to the sheer might of the private hospital owners’ lobby, and also to the fact that some MPs and MLAs own shares in such ventures or are present on the board of directors of private hospitals.
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 challenges posed by the Covid-19 scenario require that immediate attention be paid to the needs and interests of nurses who are in the frontlines providing their services. In this light, the provision of adequate safety measures for nurses on duty, a pandemic allowance for them and other frontline workers, granting of leaves to pregnant or breast-feeding female nurses, and recruitment of more nurses by public hospitals and recalling of retired medical staff are crucial.
Moreover, the demands for provision of government-funded nursing colleges; more public hospitals; enhanced nursing positions and permanent employment; constitution of a wage board; the right to organize, regulated work hours, removal of contractualization; among others, are the common demands which will facilitate combined struggles across hospitals. There is also a significant synergy of these demands with the public healthcare needs of the common masses. Further, it is precisely by raising such common demands that the nursing community can unite with the larger labour movement which seeks to fight the onslaught of successive governments’ budgetary cuts in healthcare etc.
Maya John teaches in Delhi University and has been associated with the Left movement for the past two decades. She assists the nurses platform called United Nurses of India (UNI)
(Written on the occasion of International Nurses’ Day, 12 May 2020)
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