On January 27, 2021, the nation-wide vaccination programme began with a senior staff nurse of Kurmitola General Hospital, Runu Veronica Costa. Even though this manifestation of respect is highly admirable, it remains to be said that the nursing profession in the country is far from being duly recognised.
Bangladesh is one of the very few countries in the world where doctors outnumber nurses. According to the World Health Organisation (WHO) guidelines, the ideal ratio of doctors to nurses is 1:4; that is to say, there should be four nurses against each doctor in a country to provide healthcare services expediently. But there is one doctor for only 0.74 nurses, or in other words, the number of doctors is almost 1.41 times greater than the number of nurses (excluding the 9,608 dental surgeons and 4,396 midwives). There are only 66,958 registered nurses in Bangladesh and 46 per cent of them work in the government sector. A majority of them work in metropolitan areas. While there are 5.8 nurses for every 10,000 people in the country's urban areas, there are only 0.8 nurses for the same number of people in rural areas.
It is quite evident that we do not have adequate number of nurses in this country. But to understand why the number is so low, we have to delve deep into our history, culture and social fabric. A recent research article titled "A Policy Analysis Regarding Education, Career, and Governance of the Nurses in Bangladesh: A Qualitative Exploration" published in the Journal of Policy, Politics and Nursing Practice reflected on these issues.
The research investigated the history of nursing as a profession in Bangladesh, the cultural, professional, and public-policy obstacles, and some instances of progress in recent times. The most significant events for nursing in pre-independence era Bangladesh were establishing the Nursing Services Act for Armed Forces in 1952 and the College of Nursing in 1970-- the latter opened up the possibility for a four-year-long diploma course on nursing. After the Liberation War, a two-year-long post-basic nursing course was initiated in 1977. In the same year, a B.Sc. course was also introduced as a higher degree in nursing. It was regrettably shut down a few years later due to the protest of nurses who had completed diploma courses. Other instances of progress in this sector in post-independence Bangladesh are establishing the Directorate of Nursing Services, College of Nursing, Nursing Training Institute, and forming rules for recruiting nurses in government hospitals.
The Nursing Council Ordinance was drafted in 1983, which helped create a regulatory framework for nursing education. After being shut down in 1980, the B.Sc. course was reintroduced, first in the private sector in 2006 and in the government sector in 2008. In 2011, nurses were elevated as second-class government employees. 2016 was an important year for nurses in Bangladesh. In that year, midwifery was added to nursing, and Bangladesh Nursing Council was renamed Bangladesh Nursing and Midwifery Council (BNMC). Additionally, the Directorate of Nursing Services was elevated to Directorate General of Nursing and Midwifery.
Nurses, like doctors, are seen as an indispensable part of clinical management in developed countries, whereas nurses are not even allowed to write prescriptions in ours. It is unimaginable for even an experienced nurse to conduct a medical procedure without oversight from a doctor.
Unfortunately, nursing has been traditionally frowned upon by the two major religions of our country: Islam and Hinduism. Due to the tradition of the Hijab, it is considered not permissible for Muslim women to touch and nurse male patients and remain on night-long shifts. On the other hand, due to Hinduism viewing bodily fluids as unholy, nursing was reserved for women belonging to the lowest castes.
Only women from the bottom of the society took up nursing as a profession since the colonial period. As a result, it was viewed as a profession that only suits unprivileged section of the society. This mindset was not only present among the general populace but also among educated people. A high ranking official from the nursing sector remarked, "You will see, when the media reports on the health sector, they always focus on the absence of physicians, lack of amenities, unavailability of essential drugs, and lack of cleanliness, and so on. They just forget about the existence of another indispensable service provider, the nurses. As a result, they remain invisible both in the policy discussions and the public recognition." Another health-reporter said, "A politician would take more pride in claiming that he has a medical college in his constituency than having a nursing school."
As a result, even though there is a vast demand for nurses, there is no urge from society to meet it. As a substantial portion of the population does not have any interest in this field, private investors also refrain from opening new nursing educational institutes as it would not be financially profitable.
There are many who question the educational qualification and quality of service in the nursing industry. Many of them are part of the general populace, while others are doctors or officials in the healthcare sector. A high-ranking official from the DGNM refuted these allegations saying, "You have to consider the immense workload nurses have to undertake every day. At times, they have to work round the clock. Is it possible for a person to serve patients tirelessly while holding a smile for that long?"
But amidst all these challenges, some recent developments have come as a ray of hope for this sector. We mentioned elevating the profession to a second class government service, forming a separate directorate general, and reintroducing the B.Sc. course. Additionally, introducing a government allowance for nurses, encouraging more nursing institutes through the private sector, and creating new posts are noteworthy.
However, this progress can be a cause of worry for some people. We have seen the displeasure of many nurses in the past when the B.Sc. course was first introduced. There was also scepticism when the government nurses were elevated to class-two from class-three status. Nurses appointed by the DNS (currently DGNM) became worried about their position over the appointment of nurses by the Public Service Commission (PSC). Allegedly, nurses became suspicious again when the decision of attaching nursing schools with the new medical colleges was made. Many nurses assumed that the freedom of the teachers of the nursing institutes would be threatened by the authority of the principals and professors of the medical colleges. The sudden resurgence of midwifery and the creation of many government jobs for midwives were also viewed with suspicion.
But amidst all these limitations, it is undeniable that the nursing profession has come a long and arduous way in our country. I am proposing three definitive proposals to develop this sector :
Firstly, the quality of nursing education has to be improved, and more students should be encouraged to enroll. There should be a clear and effective policy on where and on what basis a nursing school should be established. An increase in budget is also necessary. We have to keep in mind that nursing has to evolve from a conventional clinical-management profession to an evidence-based, leadership-oriented responsive profession. Taking into account the Lancet Commission guideline for healthcare professionals created in 2010, inter-professional education may be considered to be incorporated.
Secondly, policymakers and health decision-makers should realise that the nursing profession's problems are complex, multidimensional, and socially embedded. It is not the sole responsibility of the health sector to increase the social status of nurses. It demands a long-term inter-sectoral socio-cultural intervention. Different stakeholders, such as the media, other health professionals, public health experts, social scientists, and educationists should be engaged in the process.
Thirdly, as new initiatives can fail due to a strong sense of uncertainty from the nursing community, policy decisions and guidelines regarding this sector have to earn nurses' trust before they can be implemented. Their opinions must be prioritised in such scenarios. Both their number and their service quality have to be upgraded to meet world-class standards. They should not be only passive helpers to the doctors; their educational qualifications have to be raised to a level where they can be active caregivers, as they are in the rest of the world.
Dr Taufique Joarder is the Executive Director of Public Health Foundation, Bangladesh.