Migrating Nightingales: Tackling Nurse Brain Drain
By Dr. Sweta Jalan
India has become a breeding ground for nurse exporters. This has resulted in a domestic shortage of nurses and is consequently having a detrimental effect on our healthcare system. Dr. Sweta Jalan digs deeper into a worrisome trend
Last year, BBC’s Why Indian nurses want to return to Iraq? told the story of Sonia and Sindhu, two Kerala-native nurses who were working in Iraq and returned to India, luckily just a day before the militant group ISIS began over-running northern and central Iraqi towns and cities. Sindhu worked as a nurse in Delhi where she earned a monthly salary of INR 11, 000 rupees; in Nasiriya, her salary was INR 85, 000. This had helped her to clear the loan she had taken to pay the recruitment agency, but returning home had got her very worried about paying back her education loan “because of the salaries nurses are paid in India.” Sonia is prepared to wait "until the problem is sorted out in Iraq. I want to work there because I like working there." Sindhu and Sonia represent millions of Indian nurses who are compelled to migrate abroad because of low pay, bleak professional prospects, and lack of a conducive work environment and infrastructure facilities in their home country.
A Lancet study shows the number of new Indian nurse registrants in the UK grew from 30 in 1998 to 3,551 in 2005. Indians constitute the second largest group of visa seekers as nurses in the US. With the rise in geriatric population, non-communicable and communicable diseases, demand for nurses is increasing ever more, both in developed and developing nations. The International Council of Nurses reports that the majority of nations experience ‘shortage, maldistribution and misutilisation of nurses.’ “While developed nations fill their vacancies by enticing nurses from other countries, developing countries are unable to compete with better pay, better professional development and the lure of excitement offered elsewhere,” stated WHO-bulletin titled Wanted: 2.4 million nurses, and that's just in India. The shortage is felt more acutely in developing nations; it drains the country of desperately needed skilled personnel, which in turn increases the workload, resulting in harrowing working conditions and push nurses to leave for greener pastures.
Nurses are paid only a pittance in India and this is the chief reason for nurse migration. Most nursing professionals in India take an educational loan and their meager salaries make it near impossible for them to pay back the loan. “Majority of the nurses are in debt when they complete their studies. Once they start working, they have to pay at least monthly installments of 5000/- rupees. With the marginal salaries hospitals pay them they are not able to pay the debt not even in 10 years of work . Often, hospitals who charge good amount as fee for the nursing education are exactly the one who is not willing to pay a standard pay to nurses. There is a massive difference in the salary for nurses in India compared to other foreign countries. Even countries like Bangladesh, Maldives pay more to nurses than Indian hospitals. Bangladesh pays around INR 30000 INR, Maldives INR 45000 while our country pays only at an average of INR 7000. Further, the yearly increment is also major concern; Most of the hospitals pay only INR 250 - 500 as increment per which is very less compared to other professionals.” says Anu Jacob Simon, National Treasurer, Indian Nurses Association.
All around the world, nurses are underrated and underpaid, in comparison to the doctors “At the time of second pay commission (1966), the basic pay of senior resident doctor at entry level was INR 110 against the basic pay of staff nurse at entry level, as INR 150. The corresponding pay band and grade pay of resident doctor now (as per 6th Pay Commission) is INR 15600/-+6600/- whereas the pay scale of staff nurse starts at INR 9300/- +4600/-. This re-placement grade of resident doctors is substantial higher than that of the nurses. In fact the pay of senior resident doctor (INR 15600/-+ 6600/-) is equal to the scale of the Nursing Superintendent which is the 4th level promotion of staff nurse if at all she gets it,” reports Memorandum to The Seventh Central Pay Commission on behalf of The Nurses of India, published by Trained Nurses Association of India (TNAI) in July 2014. In this elaborate memorandum, the organization is pushing the Government to increase the minimum wages for nurses.
“Doctors are paid almost 4 to 6 times that of nurses in India but I guess in other countries also doctors are paid more but not more than double the salary of nurses,” says Simon. In Australia, while a doctor entering the profession is paid $30-32 an hour, a nurse too gets about $28-30. Lesley Bell, Nurse Consultant on Socio-Economic Welfare, International Council of Nurses, says that though it depends on the country and its health care system, in general, the difference between nurse and doctor salary is markedly skewed. Citing an example, she says that in Canada on a fee for service compensation model average a little more than $225,000. But, again, there is a range, from psychiatrists, the specialists who bill the least ($232,000 gross; $186,000 net), to ophthalmologists, who bill the most ($676,000 gross; $418,000 net). The average pay for a Canadian Registered Nurse (RN) is C$31.48 per hour (C$34,180 - C$80,758 yearly).
Adverse Working Conditions
Job satisfaction ranks quite low in nursing globally; in India, the unfavourable working conditions have a lot to do with it. High nurse to patient ratios, long working hours, reduced time with patients due to overburdened administration, shortages of qualified professionals together with inadequate compensation, contribute to discontent with the workplace. TNAI and Indian Nursing Council report that Indian hospitals have an abysmally high patient-nurse ratio which often ranges from 1: 20 to 1:60; stipulated norms states 1:5 in general wards, 1: 3 in special wards and 1:1 in critical units. In addition, India has approximately one nurse and one nurse-midwife per allopathic doctor, while in most countries nurses and midwives outnumber doctors.
The nurse-patient ratio should be 1:3 for medical colleges and 1:5 for district hospitals. There should be one nursing superintendent against 200 beds, one deputy nursing superintendent against 300 beds, seven departmental nursing supervisors/ nursing sisters against 1000 beds, one staff nurse for wards against three to nine patients and 30 percent leave reserve. Other norms of INC include one nurse against 100 people in out-patient departments like blood bank, X-ray and diabetic clinic, one nurse for intensive care unit (ICU) against one to three patients and eight nurses for specialized departments and clinic such as OT, labour room against 200 patients.
The high patient-nurse ratio makes the work back-breaking; often nurses are commanded to work extra hours, without any over-time benefits. They often work at odd hours, during natural and manmade disasters, public holidays and even in the absence of Government transportation. However, the concept of pick-and-drop facilities, resting quarters and changing is largely non-existent. Many private hospitals impound nurse educational certificates at the time of appointment to force them into contractual agreement and restrict their professional mobility. While hospital authorities take utmost care to improve work environment for doctors, nurses are provided with minimum facilities. Let’s compare the situation in India with Australia, a popular destination for nurses to migrate to. The Western Australian Government provides plenty of options to achieve a reasonable balance between work and personal life. Hospitals offer flexible shift options. Some employers also offer “family friendly” shifts such as 9am–2pm, 6pm–11pm or 5pm–1am. Work is offered on a full-time, part-time or casual basis. Nurse working full-time receive five weeks annual leave and ten public holidays that can be used at other times. It is no wonder that nurse prefer to work in Australia.
Paucity of Training
While the single and most pervasive cause of migration in many developing countries is economic, nurses also move in search of improved learning and practice opportunities. Bell believes that being able to access continuing education and professional development opportunities is an important pull factor for many nurses to migrate, along with the opportunity to learn and work with different cultures, and find fulltime work. Unlike many other services, nursing demands from the worker a great range of skills and people management expertise. However in India, they rarely have the avenues to spruce up their skills. In Australia, the Department of Health funds many initiatives to support the training of nurses to ensure their skills are current and up to date. Hospitals encourage nurses to study further as well as sponsor certain education programs. In addition, the Government offers Continuing Education Allowance and mandates that nurses do a minimum number of continuing professional development hours directly relevant to the nurse or midwife’s context of practice.
Bleak Career Prospects
In addition, in the West, there are way better prospects for nurses. There are more than 30 specialty nursing specialty courses abroad. “Graduate nurses can pursue courses in anesthesia and critical care to become nurse-anesthetists and critical care nurses respectively, and these nurses are paid as much as general physicians. There, nurse practioners have the right to take certain clinical decisions; in India, nurses are expected to merely carry out the administration of doctor’s orders,'' says Ankush Gupta, Corporate Head- HR, Sterling Group of Hospitals, Ahmadabad. According to TNAI, in India, staff nurses are eligible for promotion only after five years of service.
In developed countries, nurses have a lot more professional independence. “Nurses are involved in decision making process about treatment protocols, physical infrastructure, resource planning and training. Nurses in the States have even become CEOs of hospitals. Here, nurse administrator or specialty nurses is the maximum extent of their promotion,” adds Gupta. Sometimes, even after completing 20-30 years of service, they get no promotion and many of them retire as staff nurses.
A Thankless Job
There exists a disturbing hierarchy in healthcare. Doctors are treated as second gods whereas nurses are treated as nobodies. Doctors cannot function without a nurse, nor can a hospital. Similar to doctors, nurses study a tough curriculum, work at odd hours in hospitals and play an important role in patient care, yet in society they is a massive contrast with regard to respect the two professionals draw. Nurses working in India are not respected while those in abroad are admired and this knowledge is one of the reasons for nurses to migrate. “Most of the hospitals consider the nurses as inferior and exploit them in offering fewer wages and more duty hours than other workers,” says Simon. They are often victims of verbal and physical abuse, from doctors, patients and administrator and have a low social status. They have minimum facilities and there no protocols in place for employers to ensure nurses’ occupational health and safety.
Stringent Migration Norms?
There are potential benefits of migration, including learning opportunities and the rewards of multicultural practice. International nurse migrants have long been recognized as faithful senders of remittances and important contributors to their national economies. “These funds lessen the burden on health systems by improving access to food, housing, and education – all three significant social determinants of health. Importantly, remittances play a significant role in reducing the level and severity of poverty and contribute to the economic development in many low and middle income countries,” explains Bell. However, and unfortunately, remittance is not always invested back into our healthcare system and negatively affects our healthcare quality; it is the smartest of the lot who have a better shot at working abroad. So should India make migration laws for nurses more stringent? Bell believes that nurses in all countries have the right to migrate as a function of choice, regardless of their motivation. Simon says that though this is an urgent need, making migration laws stricter will discourage students from pursuing nursing. Probably because some nurses pursue this career only to work abroad and improve their quality of life. In the study Transcending Boundaries: Indian Nurses in Internal andInternational Migration, Sreelekha Nair writes “during middle of the 1980s and in the wake of the Keralite, mass emigration to the countries of the Persian Gulf that nurses started occupying a pivotal role in the phenomenon of family migration, starting with their spouse. The face of nurse migration changed after that. More and more of them began living with their husbands and in the case of those who had sufficient income and a job for their spouse in the same city, children were brought to stay with them.” Hence, stringent migration laws in an encroachment on human freedom and may in fact aggravate the situation.
Time for a System Makeover
“Migration is a symptom of dysfunctional health systems and condemns the practice of recruiting nurses to countries where authorities have not engaged in human resources planning or addressed problems which cause nurses to leave the profession and discourage them from returning,” says Bell. Hence, it is important for the government to address the issues that made nurses leave their home countries. A number of measures can be taken to stem the exodus of healthcare professional from developing countries, says Bell. “Firstly, they can establish Nursing Councils who regulate the profession by establishing standards for education and practice. In addition, Governments need to address the same issues listed above- remuneration, safe working conditions, housing, uniforms, transportation (e.g. bicycles so the nurse can get to the workplace without having to walk miles), and career advancement opportunities,” she suggests. Simon lists five measures that the Government can take to plug our nurse brain drain; the government should bring some sustainable measures to reduce the burden of the educational loans on the nurses; mandating rural internship where the Government pays a fixed stipend of at least rupees INR 25000 will win-win situation for both Government and nurses; bodies like NABH, MoH, etc. should come up with statutory measures, in the form of new laws and ensuring implementation of existing ones, with regard to maximum patient-nurse ratio, minimum salaries and better yearly increments; increasing the number of Government nursing educational institutions under their hospitals will reduce the financial burden of the students. Gupta too believes that quality training is key to retention. “Government should make efforts to increase nursing colleges in a private partnership model and offer more super-specialty courses.”
Hospitals administration, staff and physical infrastructure can contribute tremendously to improve nurses’ job satisfaction and hence encourage them to stay back. Promoting work-family balance, regularizing pay packs, career development and training programs and involving them in decision-making process can make an immense difference. Every staff contributes to the functioning of hospital and retention of all staffs is the responsibility of the human resource department, emphasizes Gupta. “For nurses, hospitals should allot and sponsor regular training to enhance their skills. They should encourage further education by offering scholarships for Masters in Hospital Administration, part-time executive programs and nurse specialty education. Knowledge and competency brings respect to any profession. Nursing being a physically-demanding job, HR should conduct innovative stress-buster programs and yoga classes. Incentives does not always have to be in the form of cash,” he adds. One of the most significant factors in retention is the relationship between the nurse and her immediate supervisor, says Bell, adding, “This is especially true for new graduates who need support and mentorship. Ensuring that there is a nursing supervisor with good leadership skills present in the clinical area and available to her staff, rather than in management meetings, is a key factor. Retention strategies should include listening and responding to the needs of nurses, addressing workload issues, ongoing continuing education, flexible work schedules and showing respect and recognition publically for the valuable work nurses do. Repatriating nurses who have gained new knowledge and skills enables them to pass on their learnings when they return home resulting in better patient outcomes and care.”
It’s time to acknowledge the valuable services that nurses offer; it is also a wake-up call to make amends as per their demands and lure them back home, or else there is no hope for India’s healthcare