workers' rights

Why nurses go unheard in India – even when they strike

India has more than 16 lakh nurses. But their complaints seem to be ignored repeatedly.

The indefinite strike by nurses that began on September 2 was short lived. The strike was called off after just two days following a meeting between the All India Government Nurses' Federation and health ministry officials at which the nurses were assured that their demands will be sent to the finance ministry by September 12.

However, the Delhi government had already invoked the Essential Services Management Act on Friday classifying the strike as illegal. It detained more than 20,000 nurses. Even though ESMA was declared only at 1.30 pm, nursing association leaders were arrested at 10.30 am that day. Two association leaders were even sent to Tihar Jail. Media reports focused on state health services affected by the nurses’ strike but not on the nurses demands.

The All India Government Nursing Federation has presented their demands to the government many times before. Their basic demand is for a better entry-level pay-scale, which they say has been due for correction since the Fifth Pay Commission in 1996. The nurses contend that while doctors have been given a salary hike of more than 14% in the Seventh Pay Commission, nurses have continued to be ignored.

Substandard working conditions

Most of India’s nurses work in private hospitals, which are largely unregulated and do not follow the norm of having nurse-patient ratios of one to every four. Nurses work nine- to 14-hour days, often doing double shifts. Their starting salaries are between Rs 3,000 and Rs 15,000. Many nurses are required to sign contractual bonds with their employers withholding their educational certificates as guarantee.

In the public sector, nurses are paid better than in private hospitals. But even here, nurse patient ratio are a far cry from the 1:4 norm. Nurses get promotions based on their management abilities and the number of years of experience they have. However, higher authority positions are occupied by physicians, with a nurse being restricted to one promotion in the course of her career. Many retire as staff nurses due to a lack of the higher positions and few opportunities for continuing education. Daily duties are also difficult with most hospitals not providing proper spaces for nurses to change or rest.

A World Health Report of 2006 reveals that 70% of the doctors are male and 70% nurses are female. In India, more than 90% of the nurses are women. In the rigid healthcare hierarchy, nurses are not considered independent professionals but are dominated by physicians and hospital managements.

Most health authorities, physicians and politicians acknowledge that nurses are the backbone of both health system and hospital but when nurses demand autonomy and legal recognition or even basic facilities like changing rooms, toilets and conducive work environments, they go unheard.

Protesting nurses are often punished, as has been reported many times. In December 2009, staff nurses of the Batra Hospital in New Delhi went on strike demanding basic facilities and minimum basic salary of between Rs 10,000 and Rs 15,000. They succeeded in getting the salary hike but those nurses at the forefront were fired on disciplinary grounds. In the public sector, nurses protesting working conditions are sometimes sent to difficult locations or may be refused leave.

A new dimension to nurses’ exploitation by the state is through contractual systems and recruitment outsourcing. The National Rural Health Mission recruits nurses on contractual basis with salaries from Rs 5,000 to Rs 11,000 but without offering any other conveniences. Even if they work for the same hospital, nurses with the same qualification and job description are paid differently depending on whether they are permanent and contract workers. These differences are in the range of Rs 15,000 to Rs 30,000.

India had more than 16 lakh nurses, according to a survey in December 2008. But their complaints seem to be ignored repeatedly. First, the government only set up nursing institutions in 2002, even though these were proposed in all five-year plans and other policy documents. Even here, a majority of nursing colleges were run by the private sector.

Few of states like West Bengal, Gujarat and Odisha have created a nursing director post but these are occupied by doctors. In Karnataka, which also has a nursing director position occupied by a doctor, the state government is merging nursing and paramedical boards.

Nursing movements

In the late 1970s and early 1980s, there were strong agitations by government nurses, who formed associations and unions. They made basic demands regarding uniforms and residence facilities. These associations were concentrated in the northern region and included the Delhi Nurses Union, the Maharashtra Government Nurses Federation, the Rajakiya Nurses Sangh in Uttar Pradesh , the Nursing Research Society of India and the All India Government Nurses Federation. Many of these are still active.

As nursing services have been commercialised over the past two decades, thousands of nursing institutes emerged between 2002 and 2005, especially in the southern states. Many young nurses formed associations such as the Indian Professional Nurses Association, Delhi Private Nurses Association, and the United Nurses Association to demand better working conditions. In May 2015, there was attempt to unite all nursing associations of India.

It's a difficult task. After all, a physician-dominated health system with men in the majority will not allow the advancement of professionals groups that have more women. However, healthcare needs teamwork: each member has to contribute, coordinate and cooperate for better outcomes. Uniting nurses and improving their conditions is essential to build a healthy nation.

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When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

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Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.