"Colleagues at the hospital think I am a prostitute"

June 4, 2006 -- Today the Inter Press Service News Agency (IPS) posted a generally strong, balanced piece by Ashfaq Yusufzai about the distressing state of nursing in Pakistan. The headline is: "Pakistan: Nurses Get Little Training or Respect." Relying on an impressive variety of sources, the article paints a grim portrait of a profession confronting a severe shortage, an abysmal lack of training, poor working conditions, and a public image as a group of disposable female sex objects. The piece also includes anecdotes of sexual assaults of nurses leading to no action by authorities. Though the piece might have further developed some points, we commend Ashfaq Yusufzai and IPS for highlighting these important issues in a powerful way.

The piece begins by noting that Pakistan's health care system is "hamstrung by an acute shortage" of nurses resulting from poor training and "an extremely difficult work environment." It reports that a 2005 survey found Pakistan had only 46,331 nurses for its 150 million people--which is roughly one nurse for every 3,000 people, far short of the 1:100 ratio in many developed nations. Unlike many comparable nursing shortage stories, this one relies on a wide variety of human sources. These include nursing association leaders, a bedside nurse, a nursing school "principal," a nursing student, various physicians and government officials; the only additional sources we might suggest are patients. The story these health professionals tell is not a happy one.

The article focuses closely on poor training as a key cause of the nursing crisis. It quotes Pakistan Nurses Association (PNA) vice-president Parveen Rais as saying that the great majority of nurses join the profession "because their parents cannot afford to send them to university." University students pay a monthly fee, but students at nursing schools receive a monthly stipend, so "poor parents" enroll their "daughters." Not surprisingly, the piece reports that PNA "chief" Nazi Abdur Rehman says that more than 100 Pakistani nursing schools "have neither syllabus nor proper teaching staff." She notes that senior nurses serve as tutors, and some teachers are hired by the day, with their salaries deducted from the student stipends. The piece reports that the "principal" of the largest undergraduate nursing school in Peshawar, Shamshad Begum, said enrollment fell 10% this year.

The piece cites several "[c]oncerned doctors" for the idea that poor training is undermining nursing and patient care. It notes that such physicians have repeatedly appealed to the government to improve nurses' education and salaries. Dr. Omar Ayub Khan, president of the Pakistan Medical Association, says that "[a]n outdated curriculum and poor quality teaching have lessened the importance of nurses in Pakistan." Dr. Muzaffar Tareen, who teaches at a Peshawar hospital, says that "[w]e acutely miss the presence of trained nurses--it's a matter of patients' care." Surgeon Zahid Aman, who teaches at another Peshawar hospital, reportedly states that half the nurses at his hospital cannot insert intravenous tubes. Similarly, Khan asserts that most of the nurses' duties "are performed by the doctors themselves." Khan also claims that the Pakistan Nursing Council (in the reporter's words) "should be revising the training courses," but that it has "done nothing." The piece includes no response by the Council or any nurse to these latter points.

The piece does include some response from government officials. Pakistan Health Secretary Abdus Samad says that the nursing syllabus will be revised. Inayatullah Khan, Health Minister of the North West Frontier Province, "insists" the government has a plan to improve nurses' skills and status, pointing to plans to increase the student stipends, and to promote 2,000 staff nurses "to the posts of charge nurses." Dr. Jalilur Rehman, director-general of the nation's Health Services, notes that 67 nurses have been sent to the U.K. for postgraduate training. Rehman also says that 13,000 nurses have recently been appointed as "lady health visitors" (LHVs). The LHVs "provide primary health care at the village level and are often the only qualified persons available to handle health concerns." The piece suggests that LHVs focus on maternal and child health programs. The piece does not explain if the "lady" health visitor program is named for the nurses or their patients; if the former, we wonder if male nurses are ineligible.

The story also places a commendable emphasis on the role that nursing's poor image and the resulting social prejudice play in this dismal state of affairs. The story states bluntly: "As a mainly female profession, nursing ranks lower in status than medicine." This appears to be an understatement. The PNA reportedly wants better working conditions, but the only specific cited is protection from sexual harassment. PNA press secretary Hameeda Bano says that "[t[he majority of patients and their relatives regard us as sex symbols," noting that 13 nurses were sexually assaulted in 2005, and that one of them was stabbed in the back because she refused to spend the night with a student. The piece also quotes Nausheed Alam, a student at the College of Nursing at Khyber Teaching Hospital, who says nurses need "training facilities and respect." Alam tells a story in which an appendectomy patient--whose excruciating pain she had just relieved with a painkiller--tried to force her onto his bed. She fled and complained to her registrar, but nothing was done. Alam says she knows of a student nurse who left the profession after an emergency ward physician raped her, and nothing was done.

The piece also states that "[s]ocial prejudice" hurts nurses' marriage prospects: "Educated men with jobs do not want to marry nurses, who either remain single or find uneducated men who live off their salaries." Gul Meena, whom the piece describes as a "nurse," says that (in the piece's words) "not even paramedics are prepared to marry her." She explains: "Colleagues at the hospital think I am a prostitute." The piece then adds that Meena is "condemning herself for her situation," though it's not clear what that refers to.

In response to these concerns, the piece notes that Dr. Khan of the PMA has urged the government to launch a media campaign to "sensitize people about nursing." Dr. Rehman, the Health Services director, says that the "lady health visitors" have been (in the piece's words) "trained by behavioural experts to tackle social prejudices against nurses." It would have been good to hear more about these potentially useful ideas.

On the whole, the piece does a good job of describing some basic elements of a nursing crisis with a fair degree of balance. It cites a variety of nurses, though it might have included some nursing response to the PMA's Dr. Khan's claims about physicians performing nurses' duties and the alleged inaction of the Nursing Council. The piece suggests that the lack of respect for nurses is an important part of the problem, though it might have explicitly noted that a likely reason for the failure to allocate resources to nursing was that too many decision-makers themselves have no respect for nursing. Along these lines, it might have been helpful to make clearer some of the things that nurses do (or can do with adequate training) to save lives and improve outcomes. To its credit, the piece does mention the ability to start IV's, but this is just one of thousands of demanding clinical judgments and actions that skilled nurses use to keep their patients alive and on the road to better health.

The piece might also have done more with the profession's continuing gender disparity, and the regressive assumptions that seem to underlie much of the way nurses are treated, most obviously in the accounts of sexual harassment and nurses' poor marriage prospects. The piece does not mention the reports in May that some Pakistani government officials were reportedly considering barring female nurses from caring for male patients, because of the level of sexual harassment. As we noted, such a rule might help some nurses avoid harassment in the hospital, but would also seem to ignore the roots of the problem, limit the nurses' own professional care, and place an extraordinary burden on male nurses (and their patients). The IPS piece also does not discuss how many Pakistani nurses are male, or whether it might be wise to stop associating the profession with the female gender, for instance by not including words like "lady" in nurses' job titles.

Of course, we admit that "lady" is a step up from "prostitute."

See the article "PAKISTAN: Nurses Get Little Training or Respect" (with registration) that appeared on the IPS website on June 4, 2006.