Nurses put the care in health care, more so during the pandemic

Nurse Anju Rawat, 41, went above and beyond the call of duty during the pandemic. Even her pregnancy did not stop her from caring for Covid-19 patients at the All India Institute of Medical Sciences, Delhi. She was five months pregnant when she tested positive this May. She, too, now is a patient at AIIMS.

Rawat’s infection was acute and she was put on ventilator support. “The baby was born prematurely and died. The doctor said it was a boy,” says Rawat’s husband Lekh Raj Singh, a software developer with a mobile company in Noida.

Rawat suffered a cardiac arrest on the 14th day of hospitalisation, two days after she was taken off ventilator support. She also suffered hypoxic brain injury (lack of oxygen supply to brain). “Doctors are giving a poor prognosis,” says Singh.

Every Indian nurse has a story to tell—a story of struggle, hardships and commitment. They are the backbone of our health care system and yet they are paid a pittance. A visit to a Covid ward makes one wonder what keeps these nurses going in the face of deaths and the fear of contracting the virus.

Perhaps, Vibin Chandy has an answer. “If dreams die, life is a broken-winged bird that cannot fly,” he quotes from the Langston Hughes poem Dreams. Chandy, 35, is a nursing officer at the Government Medical College, Kottayam, Kerala.

His world turned upside down in 2018, while he was heading home from work. “That day, I was delayed, as I had to attend to a patient whose condition was critical,” recalls Chandy, who worked in the major operation theatre (MOT) then. He pauses and apologises for talking a lot. His social skills, however, have helped him build a quick rapport with patients.

Chandy sounds cold and clinical as he talks about the worst day of his life. “I was riding at 50km/hr on a highway. It was an accident-prone area,” he says. While trying to avoid hitting a truck that seemed to have lost control, he fell from his bike. “The truck ran over my leg. I lay on the road for half an hour, with people thronging around me to take my pictures,” he says.

He was saved by a doctor couple who rushed him to a hospital. “I had a head injury, and my bones and nerves had been crushed badly. My left hand was fractured. I bled profusely and my haemoglobin level had dropped below 5.0g/dL (normal range is 13.8g/dL-17.2g/dL),” he says.

Chandy was shifted to the Kottayam Medical College. His left leg was amputated below the knee. Losing the limb was extremely distressing, and his parents were shattered. He was discharged after two months. A charitable trust donated a wheelchair. Later, his parents got him an artificial leg from Germany, and Chandy slowly got his life back on track.

A postgraduate in nursing, Chandy is still passionate about his work. “I used to work mostly in casualty, the cathlab and MOT before. It was challenging, but immensely fulfilling,” says Chandy. “I cared for a patient with schizophrenia—Rajesh—in 2012. He came to meet me when I was bedridden after the accident.”

Chandy, who works in the outpatient department, talks to me while climbing the stairs, and tells me that he avoids taking the elevator. It is like he never lost a leg at all. Chandy is now a motivational speaker and has taken to writing, too.

Chandy’s accident came soon after he cleared the civil services preliminary exam. “Civil service remains an unfulfilled dream. I could not pursue it because of my head injury, and now I have crossed the age limit of 32 years,” he says. Not one to give up, he is planning to do a PhD in nursing.

But not everyone can afford to be optimistic. The last two years have been particularly hard for nurses. Sini Ullas, 33, who works at San Joe Hospital, Perumbavoor, Kerala, is struggling to raise her two kids alone. She got infected while on duty in the Covid-19 ward. Her husband and in-laws caught the infection and died.

The nursing cadre has been the mainstay of Covid care in India, says Dr H.M. Prasanna, president, Private Hospitals and Nursing Homes Association, Karnataka. During peak pandemic, he says many a time doctors in government hospitals would not visit the wards even once a day. “They would just give advice over the phone. The nurses would carry out those orders. They saved many lives,” says Prasanna, an orthopaedic surgeon and managing director of Pristine Hospital, Bengaluru.

And, how did we show our gratitude to our nurses? By banging pots and pans from our balconies, and then pushing them into oblivion.

S.M. Anas, a nursing officer at Government Medical College, Thiruvananthapuram, is stretched beyond limit. “Since the pandemic began, there have been 22 to 28 patients in our ICUs at any time. There are just two nurses for these patients, most of whom are seriously or critically ill. This results in patients not receiving quality nursing care,” says Anas. The ideal nurse to patient ratio in an ICU is 1:4.

Dr Roy K. George, president of the Trained Nurses Association of India, points out that India has only 1.7 nurses per 1,000 people, which is less than the WHO recommended minimum of three nurses. Currently, there are only 10 lakh working nurses in India, according to the Indian Nursing Council’s live registry.

Despite that shortage, nurses are working tirelessly to provide the best possible care. Take, for instance, Sapna Gurung, 24, from Meghalaya. She is like any other young woman her age, spending her free time bingeing on Netflix or gorging on panipuris. Once inside the Covid ICU of Hiranandani Hospital, Navi Mumbai, she becomes the quintessential Indian nurse—empathetic, dedicated, passionate and hardworking.

Gurung recalls tending to a young patient who was in the ICU for a month. After her condition improved, she was shifted to the non-Covid ward. “She would still remember us,” says Gurung. “Once she left a message for me saying, ‘Please come and meet me.’ But because of my schedule, I could not meet her. After a few days, her condition deteriorated and she died. I still feel guilty about the incident.” Deaths leave her devastated, and sometimes she seeks comfort among her colleagues. But when the pandemic peaked in Mumbai, Gurung did not even have time to grieve.

There is no doubt that nurses work under tremendous pressure, especially those who work in Covid wards. Indian nurses typically work 48 hours a week. They do not get time to eat or drink, and sometimes get dehydrated. At Aster CMI Hospital, Bengaluru, nurses now have a four-day work week, at 12 hours a day. Wearing a PPE kit for 12 hours is painful, says Biji George, chief nursing officer at Aster CMI.

For some, the workday begins in the wee hours. Havovi Fouzdar, general manager (nursing) at Kokilaben Dhirubhai Ambani Hospital, Mumbai, works an early morning shift. “By 6am, the staff briefing begins, during which we review the distribution of staff responsibilities and balancing the nurse-to-patient ratio,” she says. “The majority of each day is spent dealing with emergencies, troubleshooting, crisis management and daily meetings.” Her day is made when a critical patient recovers and is discharged.

Crazy shifts and long working hours have taken a heavy toll on the health of India’s nurses. Anas says that around 95 per cent of nurses in their late 40s or early 50s suffer from joint problems and varicose veins due to prolonged standing. Cases of anxiety and hypertension are also common. A recent study on ‘the impact of shift work on excessive day-time sleepiness among health care professionals and its association with medical incidents’ shows that they experience a wide range of problems, from sleep disorders to poor concentration, leading to workplace errors like drug administration mistakes and needle stick injuries.

As head of nursing at Apollo Spectra Hospitals, Koramangala, Bengaluru, Shashikanthraddy Patil is on his toes all the time.

His responsibilities include preparing the duty rota on daily/weekly basis according to the patient load and requirements; documentation and supervision of high-risk medications like insulin or chemotherapy; monitoring drug availability, expiry dates and consumption; coordination between outpatient and inpatient department, and also between nursing and other departments of the hospital. “Nurses do not regularly get weekends off,” he says. “We do not get to party. We do not get to celebrate festivals, because everyone cannot take a day off on festivals. One has to make a lot of sacrifices.”

Ashwini M., 32, a senior staff nurse at HCG Cancer Hospital, Bengaluru, stayed alone for more than a month after a colleague tested positive for Covid-19. She sent her family to their hometown. “Staying away from my family was a challenge, that too with a young daughter,” she recalls.

Unsurprisingly, many Indian nurses secretly harbour the dream of moving abroad. More than 40,000 Indian nurses migrate abroad every year. In India, nurses have always been an ignored lot, says Shiji Joji, 36, from Kerala. She now works in a long-term care home in Canada. The work environment for nurses in Canada is much better, she says. “Doctors ask nurses for their assessments. Nurses here have a more important role to play in diagnosis and treatment, than just accompanying doctors on rounds,” she adds.

Joji now earns Rs2,392 per hour. The highest pay she received in India was Rs5,000 per month. “That was in 2008. As a nurse, my responsibilities included making beds, housekeeping and oral care of patients, besides checking their vitals and giving them medications on time,” she recalls.

While working in a leading cardiac hospital in Bengaluru, she earned Rs3,000 per month. And, she had to sign a bond, breaking which would have meant coughing up Rs75,000.

But now the minimum wage has been fixed, says Prasanna. “The salary for a fresher starts from Rs9,000,” he says. “All registered bodies have to pay above that.” However, George says, “Nurses in some of the lower-rung hospitals in Uttar Pradesh are paid just Rs5,000 per month. And, they work 12-hour shifts six days a week.”

The remuneration varies from region to region. It depends on the paying capacity of patients, explains Prasanna. Some regions like north India and Maharashtra are high paying, whereas salaries for nurses in south India are lower by at least 30 per cent. Also, nurses in bigger, chain hospitals get paid more than those in standalone hospitals and nursing homes. Top hospitals in Delhi pay nurses about Rs25,000, says George.

The Central government and insurance companies are also responsible for the lower pay, says Prasanna. “The Ayushman Bharat scheme is an atrocity on health care,” he says. “The rates are so low. Some hospitals are forced to take those schemes just to fill up their beds. In the end, what you are earning is peanuts…. Insurance companies have come up with various schemes, putting a cap on ward charges. The hospital itself is earning less, so we cannot pay our doctors and nurses more.”

Since the onset of the pandemic, 128 nurses have died of Covid-19, says George. Patil says these nurses should be accorded the same kind of respect and compensation that martyrs get.

Nurses working in private homes deal with a different set of challenges. Portea has over 2,500 nurses on its rolls, besides consultant nurses. While most families treat nurses with respect, there are a few who are not polite to them, says Dr Vishal Sehgal, president, medical services, Portea.

Before a nurse is sent to a patient’s home, Portea’s nursing manager tells the family what the nurse can and will not do. “Even after this we come across a few cases where the nurses are asked to cut vegetables, serve food for the family, and do cleaning and dusting,” says Sehgal. “Not all families provide the nurses with access to a television or interact with them socially. If our nurses are not comfortable, we move them out.” Also, unlike in a hospital setting, the nurses are on their own at home and have to perform their duties in front of family members, which adds to their stress.

The pandemic has taken a toll on the mental health of India’s nurses in more ways than one. Dr Sailaxmi Gandhi, professor and head of department of nursing at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, has a training programme that helps nurses deal with stressors at the workplace and build resilience. The programme, funded by WHO-India, unfolded over three phases.

The first phase involved a situational analysis using Google survey to understand the stress faced by nurses in different parts of the country. Although most of these nurses had previous experience in disaster management and psychological training, most of them felt stressed and tired while taking care of Covid-19 patients. “They were sad at times and less motivated occasionally,” says Gandhi, who holds a PhD in nursing. “Their fear of infecting family members was quite high.”

In the second phase, an online meeting was held with nursing leaders and nurses taking care of Covid-19 patients. In the third phase, a Trainer of Trainers programme was developed. “The sessions dealt with managing emotions and handling stressors, self-care and handling interpersonal relations and seeking support,” says Gandhi. The programme trained 2,000 nurses.

Also, Covid-19 threw up challenges never faced before. “Nurses also had to learn on a week-to-week basis about new treatment modalities. It was a tremendous challenge,” says Dr Dhirja Sharma, an anaesthesiologist who works as nursing head at Pan Max, New Delhi. For Sharma, the transition from an anaesthesiologist to a nursing head has been life-changing and immensely fulfilling.

Nursing superintendents and tutors have a key role to play in helping nurses keep up with emerging technologies and therapies. “The therapies, treatment modalities and medications have improved over the years,” says Sharma. “It is imperative that nurses keep up with new developments in their field.”

But nursing colleges are yet to keep up with the times, it seems. “In the last two decades, we have seen huge technological advancements, not just in the medical field, but also in technologies available for patients,” says Sharma. “In our hospital, the patient records are digitised. Even the medication administration is completely digitised. This is a technology that is not taught in traditional nursing colleges. So the nurses have to upgrade and train themselves.”

It is very important that organisations put in some resources to fill this gap, says Sharma. Max Healthcare has a dedicated department that takes care of nursing quality, and education and continual training. Different technologies and digitisation processes are taught to the nurses before they start work.

“With changing times, it is not just the clinical knowledge of a nurse that is important. How to transform or deliver that knowledge to the patients’ bedside and the different technologies that are used also matter a lot,” says Sharma. “For instance, a nurse must get used to the different monitors and devices that are being used.”

Crisis and challenges, however, have made some like Ashwini R. stronger. She works in a cancer hospital, and deals with deaths on a daily basis. Over the years, she has learnt to manage her emotions. A trained classical and folk dancer, she dances away her stress.

Her patients have been her greatest teachers. One of her patients was a four-year-old boy with leukaemia. “He faced death bravely,” recalls Ashwini. “He was ready for any procedure. He would ask his parents to step out when we had to insert a IV cannula, saying that his parents would not be able to bear the pain of watching it.” He made his mother promise that she would not cry over his death. She kept her promise when the boy died five months ago.

That was one of Ashwini’s greatest learnings: fortitude in the face of death.