Letter from a Pakistani Nursing Student: Barriers to Family Planning in Pakistan

Letter from a Pakistani Nursing Student: Barriers to Family Planning in Pakistan

Once again, DailyNurse is publishing a series of blog posts on nursing issues in the developing world by MScN nursing students at the Karachi, Pakistan campus of the Aga Khan School of Nursing and Midwifery.

These articles were written as part of a class assignment that involved composing and submitting short research articles for publication in a recommended nursing blog or journal. The object: to help them hone their English language communication skills as future nurse leaders in Pakistan’s healthcare system. As their instructor put it, one of the goals of the exercise is to encourage nursing students to become “Change Agents” in healthcare settings and the world. DailyNurse thanks the instructor and all of the Change Agents who submitted articles. We hope you will find the selected posts informative and thought-provoking.


Encouraging the use of family planning and birth control is crucial. Birth control allows women to make independent and appropriate decisions leading to women’s empowerment and also has immediate positive effects on health.

A number of Pakistani women face serious health consequences both for the mother and the unborn child as a result of their frequent pregnancies. The prevalence of unplanned pregnancies and precarious abortions, which are major contributors to maternal deaths, may decline with the increased use of contraceptives (UNFPA, 2013). Pakistan has the sixth highest population in the world — and cultural and religious influence is so high that talking about family planning is a strange and difficult thing.

According to available research, Pakistani spouses are less likely than other couples to use contraceptives. Here are a few of the most challenging barriers:

Lack of knowledge: One of the key obstacles to taking on contraceptive methods is the absence of information about health problems that are brought about by the continuation of pregnancies. Another barrier to couples using family planning techniques is the lack of knowledge about contraceptive options or misunderstandings about them (Khan et al., 2015).

Lack of motivation: A lack of drive is another obstacle to utilizing contraception among Pakistani couples. It has several influencing factors. Firstly, the idea of more males is a huge source of delight in Pakistan which enhances a family’s status in the society (WCP, 2016). Because of this, families, especially mothers-in-law, put pressure on the newlywed couples to have many male descendants accordingly. Furthermore, religious convictions (like the notion that God’s will govern potency) affect Pakistani couples’ decision to use birth control practices. Lastly, worries regarding its side effects may result in negative views regarding the usage of methods such as birth control pills and IUDs (WCP, 2016), for instance, using contraceptives would damage a woman’s uterus (Agha, 2010).

Lack of agency: The absence of support and consent from in-laws is another barrier to using such methods which affect women more than men particularly (Agha, 2010). Approval from the husband and mother-in-law is also a crucial factor in deciding whether to initiate contraceptive use (Khan et al., 2015; WCP, 2016). Accordingly, females are unable to make decisions regarding their reproductive habits. Even though women may have varying opinions regarding the usage of contraceptives (Khan et al., 2015), in Pakistani society most females think their husbands should make the decision (Agha, 2010).

Lack of Communication: Communication is another significant barrier between couples in using contraceptive means (Kiani, 2003), most probably as a result of societal and religious stigmas related to the subject. In some circumstances, shyness between a couple creates confusion when they do not want another child. If they fail to discuss their feelings, the influence of in-laws can in effect push them to have children (WCP, 2016).

Inadequate availability of resources: Moreover, the use of contemporary birth control techniques are also hindered in places where there are no such clinics that provide family planning facilities (Sultan, Cleland & Ali, 2002). However, despite the presence of such centers, they are frequently underutilized as a result of the societal barriers to them (Sultan et al., 2002).

Ways to reduce barriers to family planning

  1. Increasing perception of health hazards of multiple pregnancies and knowledge about family planning options
  2. Address any concern about the use of contraceptives
  3. Address the issue of low motivation and disapproval of family planning
  4. Urging partners to talk about birth control
  5. Increasing the availability of contraceptives on the individual and community level

In conclusion, the societal hindrances to using contraceptives in Pakistan were discovered in this study. Lack of understanding and motivation, in-laws’ resistance, religious and cultural beliefs, availability issues, and lack of communication are a few societal obstacles that affect contraceptive use. Both males and females need to be made more aware of the use of current contraceptives to better understand and use them, and religious experts and community representatives must take part in identifying the social issues relating to family planning.

Amid Overdose Crisis, Harm Reduction Groups Face Local Opposition

Amid Overdose Crisis, Harm Reduction Groups Face Local Opposition

Casey Malish had just pulled into an intersection in the 2nd Ward when a woman with tattoos and pinkish hair unexpectedly hopped into the back seat of his gray Mazda. He handles outreach for the Houston Harm Reduction Alliance, a nonprofit that helps drug users like her stay alive.

The woman, Desiree Hess, had arranged to meet with him, but Malish, as usual, wasn’t sure what to expect on this recent afternoon. Hess told Malish to take her to near the Value Village thrift store before she explained why she was so frantic.

Earlier that day, around 2 a.m., Hess said, a woman — a “teeny-tiny little girl” — overdosed in the warehouse where Hess was hanging out. No one there could find naloxone, a medicine that reverses opioid overdoses, and the woman’s lips turned blue. Hess said she blew into the woman’s mouth, trying to keep her alive, while others covered her with ice. Finally, someone found some naloxone, often referred to by the brand name Narcan, and sprayed the medication into her nose. After the woman regained consciousness, Hess made a decision. Originally published in Kaiser Health News.

“I knew I had to call Casey,” the 39-year-old recalled, “to get more Narcan.”

Malish drives city streets handing out needles, naloxone, cotton balls, and condoms from the trunk of his sedan. But the Houston Harm Reduction Alliance, which tax records show operates on less than $50,000 annually, can afford to pay Malish only a couple of thousand dollars every now and again. His full-time job is as a research assistant at the University of Texas Health Science Center at Houston.

Malish — a 31-year-old who said he had a problem with alcohol and opioid pills and then heroin before giving them all up nearly 10 years ago — estimated he can reach only about 20 people like Hess a month. Meanwhile, drug overdoses killed 1,119 people in the city last year, according to the Houston Police Department.

President Joe Biden wants to expand harm reduction programs like the one Malish works for as part of a broader strategy to reduce drug overdose deaths, which surged to more than 107,000 nationwide in 2021. But the $30 million plan faces a complicated reality on the ground. In Houston, as in many parts of the country, harm reduction programs operate on the fringes of legality and with scant budgets. Often, advocates like Malish must navigate a maze of state and local laws, fierce local opposition, and hostile law enforcement.

Regina LaBelle, who served as acting director of the Office of National Drug Control Policy until November, credits the Biden White House with being the first presidential administration to openly embrace harm reduction to curb drug overdoses. She said that the $30 million, tucked into the $1.9 trillion American Rescue Plan Act, is still just a first step and that too many groups rely on an unstable patchwork of grants.

“You shouldn’t have to hold bake sales to get people the care that they need,” said LaBelle, who now directs an addiction policy program at Georgetown University.

Plus, the administration faces limits on what it can do when programs face blowback from state legislatures and local leaders. “What you don’t want to do is have the federal government coming in and imposing something on a recalcitrant state,” she said.

Both Republican- and Democratic-led states have legalized aspects of harm reduction, but many remain resistant.

By 2017, all states and Washington, D.C., had loosened access to naloxone, according to Temple University’s Center for Public Health Law Research. Yet, fentanyl test strips — which help people avoid the powerful synthetic opioid or take more precautions when using it — are illegal in about half of states. According to KFF, seven states don’t have a program that provides people with clean needles, which help prevent the spread of HIV and hepatitis C, as well as bacterial infections and embolisms that develop when overused, weak needles break off in a vein. And New York is the only city operating injection sites, where people can use drugs under supervision, although Rhode Island has legalized them and the Justice Department has signaled it may pave the way for more sites to open.

Texas is among the states that have been slow to embrace the interventions — and hasn’t expanded eligibility for Medicaid, so Texans with low incomes have limited access to recovery programs. During the 2021 legislative session, lawmakers scuttled a bill that would have rescinded criminal penalties for possessing drug paraphernalia, items such as clean syringes and fentanyl test strips.

That means the Houston Harm Reduction Alliance operates in a “legal gray area,” said Malish. Although it has tacit support from the Houston police and other local entities, the nonprofit could face trouble if it strayed into a neighboring city.

“Programs that facilitate addictions by providing the tools people need to continue using drugs are not helping our community,” Texas Sen. Ted Cruz, a Republican, wrote to KHN in an email. In February, Cruz criticized Biden’s grant program by saying it would fund “crack pipes for all” in a retweet of a story on a conservative website. Fact checkers debunked the story’s claim, but it continues to provide fodder to opponents of harm reduction practices in state and local governments, even in places where overdose deaths are quickly rising.

Louisiana allows local officials to decide whether to authorize syringe exchange programs, but only four of the state’s 64 parishes allow the services. “We know in the public health space how these programs save lives,” said Nell Wilson, project director for Louisiana’s Opioid Surveillance initiative. “But being a more conservative state, a lot of the problem is battling against wide-ranging misconceptions not based in fact.”

In Kentucky, local public health departments run harm reduction programs, said James Thacker, a program manager at the University of Kentucky’s harm reduction initiative. In some parts of the state, local law enforcement agencies support programs. In others, they enforce laws that consider fentanyl test strips illegal drug paraphernalia.

Harm reduction programs face backlash in progressive places, too, such as San Francisco, where some residents believe they foster drug use.

Still, state and local harm reduction groups say the Biden administration’s $30 million grant isn’t enough money to expand their programs to reach the number of people who need help.

“We were disappointed by that number,” said Cate Graziani, co-executive director of the Texas Harm Reduction Alliance, which sought the maximum $400,000 in funding but wasn’t among the two dozen organizations to receive grants. Her group planned to distribute the funds to local outposts such as the Houston Harm Reduction Alliance.

“These programs are still running on a shoestring,” said Leo Beletsky, a public health law expert at Northeastern University. “That is not how public health is supposed to be done.”

Advocates for harm reduction don’t believe such efforts alone will suddenly halt overdose deaths. Addiction is a complicated, chronic disease. And in 2021, overdose deaths jumped 15% from a year earlier, according to the Centers for Disease Control and Prevention. Today, illegal fentanyl and its analogs from Mexico and China have tainted the street supply of counterfeit pills, heroin, and even stimulants like cocaine and methamphetamine, causing both casual users and those with long-term addiction to overdose and die.

“No one thing is going to solve the overdose crisis, but this is going to save a lot of people’s lives,” Dr. Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health, said about harm reduction efforts.

Many of Malish’s clients talk about wanting to quit drugs. People who use syringe services programs are five times as likely to start treatment and three times as likely to stop using drugs, according to the CDC.

As Malish drove Hess past the Value Village to the abandoned strip mall where she usually lives, she said she plans to start methadone treatment for heroin addiction as soon as she can get an ID the city offers to people without housing.

“I’m so sick of seeing my friends die,” said Hess.

When she got out of Malish’s car, he loaded her arms with boxes of syringes, sterile water, injectable naloxone, tourniquets, and fentanyl test strips for her to share with others.

Hess then asked Malish if she could take two quarters she found in the seat cushions of his car to buy drinking water, before walking through the mall’s double doors.

Now and Always, Nurses Need to be Advocates for Health Equity

Now and Always, Nurses Need to be Advocates for Health Equity

Changes in the status of women’s reproductive health and protections have been at the forefront of new headlines in recent weeks. The leaked Supreme Court documents indicating that the justices are on the precipice of turning over 50 years worth of reproductive health precedent has a lot of people pausing to consider the implications of losing something they have largely taken for granted. Many women are recognizing that if Roe v. Wade is overturned, they will have less bodily autonomy than corpses often have in their home states.

Of course, for many women – particularly minority women in deeply conservative states – these rights were slipping away long before this. In many of these states, the number of reproductive health clinics is extremely limited and causes undue burdens on women trying to access them. Multiple studies on the topic have shown that minority women, especially those from poorer backgrounds, are the most likely to face difficulties accessing any sort of reproductive healthcare than their more affluent, white peers.

Regardless of where our personal beliefs related to abortion rights fall, we can all agree that women having better access to reproductive healthcare is a valuable endeavor. For many nurses out there, this means striving to break down barriers that limit healthcare access. It also means becoming an advocate for health equity. But how does one become an advocate within their own community?

Address Inequalities

Many of the inequalities that nurses see every day aren’t easy ones to just address and deal with. Rather, they are ingrained, pervasive community and cultural issues that will take years to fully unpack and start to address in a positive manner. However, there are things that nurses can do to help address some of the healthcare inequalities that minority women face regularly.

Perhaps one of the most powerful things nurses can do to help address health disparities is to recognize and empathize with the differences. Minority nurses with a background in minority communities are in the position to play a unique and powerful role here. Who better to build a bridge of understanding and trust than someone who already has an understanding of the social, cultural, and economic factors that may be influencing healthcare choices.

Nurses can also be the linchpin in making sure that healthcare facilities are working to adopt more inclusive practices both for employees and for patients. These can be things such as:

  • Immediately addressing any form of blatant discrimination.
  • Advocating for policies that promote human rights and equity.
  • Working with numerous professionals across disciplines to ensure patients are receiving holistic healthcare.
  • Encouraging medical trials that are inclusive and address the concerns of minorities.
  • Seeking out and promoting other professionals that are striving to address equity issues in their communities.

Encourage Screenings

When working directly with patients there are a few things that can be done to help decrease health disparities. Arguably the most important is building trust in the community, which most certainly will not happen overnight. Small steps to start can include things like doing preventative health education out in the community, finding strategies that can help with payment for medical services, and being available for health-related questions without requiring an appointment.

Unfortunately, minority women are typically at greater risk for developing a number of diseases. For instance, African American women are twice as likely to develop breast cancer. Likewise, African American women are more likely to develop high blood pressure earlier in life than white women. There are many factors that influence this, but ultimately detection is one of the best forms of prevention.

Women can benefit from regular health screenings, but many are reluctant to do so. Going to the doctor’s office is uncomfortable, time-consuming, and potentially expensive. Helping women, especially minority women, understand the value of preventative health screenings over the long term is a vital role that nurses can play. Promoting more screenings can be one straightforward way to catch and treat issues before they become life-altering health problems.

Soft Skills Matter

Minority women, particularly women of color, are more likely to face negative health outcomes than other groups. Ingrained inequalities and cultural perceptions of the healthcare system play a major role in this. As nurses work to address these health disparities it becomes apparent that not only is a deep knowledge of nursing and healthcare important, but so are the soft skills that help convey the message.

For example, soft skills such as empathy are critical to understanding and adequately responding to the difficulties that some patients are facing. Empathy can lead to better, more realistic health prescriptions and outcomes. Patients are also more inclined to trust and listen to someone that shows an understanding and compassion for the information they are providing about themselves and their health.

Communication is another important factor. Even the best messages can be lost if they are not delivered in an understandable and relatable way. Patients do not like to feel talked down to and many very deeply want to understand the healthcare system before they have to make major decisions within it. Clear communication about procedures, health factors, costs, and outcomes are also imperative for building trust and making patients feel comfortable about their health choices.

Healthcare inequalities are significant for some demographics of the population, particularly minority women seeking reproductive healthcare. Nurses can make a real difference in starting to address some of these disparities by becoming advocates for their patients. It involves building trust, showing empathy, and encouraging positive health choices. None of it is easy, but it can add up to make a powerful difference in local communities.

In the Wake of Uvalde, Trauma Surgeons Share Experience of Mass Shootings with Congress

In the Wake of Uvalde, Trauma Surgeons Share Experience of Mass Shootings with Congress

When Dr. Roy Guerrero, a pediatrician in Uvalde, Texas, testified before a U.S. House committee Wednesday about gun violence, he told lawmakers about the horror of seeing the bodies of two of the 19 children killed in the Robb Elementary massacre. They were so pulverized, he said, that they could be identified only by their clothing.

In recent years, the medical profession has developed techniques to help save more gunshot victims, such as evacuating patients rapidly. But trauma surgeons interviewed by KHN say that even those improvements can save only a fraction of patients when military-style rifles inflict the injury. Suffering gaping wounds, many victims die at the shooting scene and never make it to a hospital, they said. Those victims who do arrive at trauma centers appear to have more wounds than in years past, according to the surgeons. Originally published in Kaiser Health News.

But, the doctors added, the weapons used aren’t new. Instead, they said, the issue is that more of these especially deadly guns exist, and these weapons are being used more frequently in mass shootings and the day-to-day violence that plagues communities across the nation.

The doctors, frustrated by the carnage, are clamoring for broad measures to curb the rise in gun violence.

Weeks after the Uvalde school shooting, what steps the country will take to prevent another attack of this magnitude remain unclear. The House on Wednesday and Thursday passed measures aimed at reducing gun violence, but approval in the Senate seems uncertain at best.

Many physicians agree something substantial must be done. “One solution won’t solve this crisis,” said Dr. Ashley Hink of Charleston, South Carolina, who was working as a trauma surgery resident at the Medical University of South Carolina in 2015 when a white supremacist killed nine Black members of the Mother Emanuel African Methodist Episcopal Church. “If anyone wants to hang their hat on one solution, they’re clearly not informed enough about this problem.”

The weapons being fired in mass shootings — often defined as incidents in which at least four people are shot — aren’t just military-style rifles, such as the AR-15-style weapon used in Uvalde. Trauma surgeons said they are seeing a rise in the use of semiautomatic handguns, such as the one used during the Charleston church shooting. They can contain more ammunition than revolvers and fire more rapidly.

Overall gun violence has increased in recent years. In 2020, firearm injuries became the leading cause of death among children and adolescents. Gun-related homicides rose almost 35% in 2020, the Centers for Disease Control and Prevention reported in May. Most of those deaths are attributed to handguns.

study recently published by JAMA Network Open found that for every mass shooting death, about six other people were injured. Trauma surgeons interviewed by KHN said the number of wounds per patient appears to have increased.

“I feel we are seeing an increase in the intensity of violence over the past decade,” said Dr. Joseph Sakran, a trauma surgeon at Johns Hopkins Hospital in Baltimore. He cited the number of times a person is shot and said more gun victims are being shot at close range.

Survival rates in mass shootings depend on multiple factors, including the type of firearm used, the proximity of the shooter, and the number and location of the wounds, said Dr. Christopher Kang of Tacoma, Washington, who is president-elect of the American College of Emergency Physicians.

Several recent shootings have left few survivors.

The perpetrator of the Charleston massacre shot each of the nine people who were killed multiple times. Only one of those people was transported to the hospital, and, upon arrival, he had no pulse.

Last year, shootings at three Atlanta-area spas left eight dead — only one person who was shot survived.

The chaos at a mass shooting scene — and the presence of an “active” shooter — can add crucial delays to getting victims to a hospital, said Dr. John Armstrong, a professor of surgery at the University of South Florida. “With higher-energy weapons, one sees greater injury, greater tissue destruction, greater bleeding,” he added.

Dr. Sanjay Gupta, a neurosurgeon who is chief medical correspondent for CNN, wrote about the energy and force of gunshots from an AR-15-style rifle, the type also used in the recent mass shooting in Buffalo, New York. That energy is equal to dropping a watermelon onto cement, Gupta said, quoting Dr. Ernest Moore, director of surgical research at the Denver Health Medical Center.

Medical advances over the years, including lessons learned from the battlefields of Iraq and Afghanistan, have helped save the lives of shooting victims, said Armstrong, who trained U.S. Army surgical teams.

Those techniques, he said, include appropriate use of tourniquets, rapid evacuations of the wounded, and the use of “whole blood” to treat patients who need large amounts of all the components of blood, such as those who have lost a significant amount of blood. It’s used instead of blood that has been separated into plasma, platelets, and red blood cells.

Another effective strategy is to train bystanders to help shooting victims. A protocol called “Stop the Bleed” teaches people how to apply pressure to a wound, pack a wound to control bleeding, and apply a tourniquet. Stop the Bleed arose after the 2012 shooting at Sandy Hook Elementary School in Newtown, Connecticut, where 20 children and six adults were killed.

The CDC, which in the past two years has been able to conduct gun research after years of congressional prohibitions, has funded more than a dozen projects to address the problem of gun violence from a public health perspective. Those projects include studies on firearm injuries and the collection of data on those wounds from emergency rooms across the country.

For some doctors, gun violence has fueled political action. Dr. Annie Andrews, a pediatrician at the Medical University of South Carolina, is running as a Democrat for a seat in the U.S. House on a platform to prevent gun violence. After the school shooting in Uvalde, Andrews said, many women in her neighborhood reached out to ask, “What can be done about this? I’m worried about my kids.”

Dr. Ronald Stewart, chair of surgery at San Antonio-based University Health, told KHN that the people shot in Uvalde had wounds from “high energy, high velocity” rounds. Four of them — including three children — were taken to University Hospital, which offers high-level trauma care.

The hospital and Stewart had seen such carnage before. In 2017, the San Antonio hospital treated victims from the Sutherland Springs church shooting that left more than two dozen dead.

Two of the four Uvalde shooting victims have been discharged, University Health spokesperson Elizabeth Allen said, and the other two remained hospitalized as of Thursday.

It will take a bipartisan effort that doesn’t threaten Second Amendment rights to make meaningful change on what Stewart, a gun owner, called a “significant epidemic.” Stewart noted that public safety measures have curbed unintentional injuries in car crashes. For intentional violence, he said, progress hasn’t been made.

 

  • KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
NNU Urges Passage of S.4182 (Health Care Violence Prevention Bill) in Wake of Tulsa Shooting

NNU Urges Passage of S.4182 (Health Care Violence Prevention Bill) in Wake of Tulsa Shooting

National Nurses United has released a statement concerning the mass shootings that closed the month of May (as there have been so many mass shootings: NNU is addressing the one that left a surgeon, receptionist, and visitor dead in a Tulsa hospital).

Yet another tragic mass shooting demonstrates the importance of legislation currently in the U.S. Senate that would provide substantial safety protection for our nation’s health care workers, patients, and their families, noted National Nurses United.

S. 4182, the Workplace Violence Prevention for Health Care and Social Service Workers Act currently supported by 27 Senators, would mandate that the Occupational Safety and Health Administration (OSHA) create a federal standard requiring health care and social service employers to develop and implement a comprehensive workplace violence prevention plan. S. 4182 is a companion to H.R. 1195, which passed the House of Representatives in a strong bipartisan vote in April 2021.

This legislation is especially important given that health care and social service workers face extremely high rates of workplace violence, noted NNU.

“Tulsa’s terror on Wednesday should remind us all of both the accelerating incidents of violence in health care settings and the urgency of legislative action to safeguard our caregivers, other health care staff, and every patient or family member in those facilities,” said NNU President Jean Ross, RN.

Reports now confirm that the Tulsa gunman was a former patient who, according to The Washington Post, murdered two doctors, a receptionist, and another patient in an orthopedic clinic at the St. Francis Hospital Natalie Building. He was also reportedly armed with an AR-15-style weapon he bought on the same day as the attack, a reminder also of the need for a national ban on assault weapons, added Ross.

“If the caregivers who save our lives and who provide therapeutic healing when we are at our most vulnerable cannot be safe, we are all in danger,” said Ross. “Protecting public safety must be a top national priority. As the past few weeks have grimly proven, we have a horrifying national crisis of public safety, whether it is in our schools, supermarkets, houses of worship, or hospitals.”

“With S. 4182, there is legislation ready to be enacted to address a vital part of the national solution for this emergency,” Ross added. “We urge the Senate to act.”

S. 4182 was introduced in the Senate in May by Sen. Tammy Baldwin, D-Wis., at a press conference that also included Rep. Joe Courtney, D-Conn., chief sponsor of H.R. 1195, as well as NNU President Ross and representatives of the AFL-CIO, American Federation of Teachers, United Steelworkers, and American Federation of State, County and Municipal Employees.

“We need the Workplace Violence Prevention for Health Care and Social Service Workers Act to help protect us on the job, so we can continue to care for you, your loved ones, and our communities,” Ross said then. “We strongly urge the Senate to take up this bill with the urgency it deserves, pass it, and send it to the president’s desk for his signature.”

recent NNU national survey of more than 2,500 hospital nurses found that nearly half of RNs (48 percent) reported a small or significant increase in workplace violence, up from 30.6 percent in September 2021 and 21.9 percent in a March 2021 survey. This is a nearly 57 percent increase from September 2021 and a 119 percent increase from March 2021.

Between 2011 and 2016, as reported in the U.S. Bureau of Labor Statistics Census of Fatal Occupational Injuries, at least 58 hospital workers died as a result of violence in their workplaces. In 2016, the Government Accountability Office found that health care workers at inpatient facilities were five to 12 times more likely to experience nonfatal workplace violence than workers overall.

National Nurses United is the largest and fastest-growing union and professional association of registered nurses in the United States with more than 175,000 members nationwide.

Letter from Pakistan: The Nursing Profession is Still Fighting for Respect

Letter from Pakistan: The Nursing Profession is Still Fighting for Respect

In Pakistan, the pandemic did little to raise the profile or status of the nursing profession. However, it does seem to be inspiring a movement among nurses and even physicians to reform the conditions that are hampering the work of nurses and the well-being of patients.

Back in April 2020, in an editorial in Pakistan’s Daily Times, Dr. Ghulam Nabi Kazi wrote, “In practice, nursing remains a neglected and least preferred line of work, despite the noble duty performed towards the treatment and quick recovery of patients, post-operative management or specialized interventions. Ninety (90) percent of nurses are females working in a highly misogynist culture, [who are] liable to sexual harassment and treated sub-optimally. They are often encumbered with long working hours, low wages, and poor career or promotion prospects or perks in comparison with officers with similar qualifications in other cadres.” Events and occasional editorials in Pakistani media sing the praises of Florence Nightingale, but in practice, low pay and lack of respect are driving a “brain drain” exodus of dedicated nurses to move to Kuwait or venture even further to find better treatment and higher salaries.

In this letter, Faryal Ghafoor, a Pakistani nurse and an MScN student at Aga Khan University School of Nursing and Midwifery outlines the key issues and the solutions nurses are pursuing to modernize the profession in Pakistan.


Despite our rigorous education and training, in developing nations like Pakistan, the respect for the nursing profession is little higher than it was in the West before the advent of Florence Nightingale.

Because in Pakistan the role of nurses is poorly defined, the general public has many misconceptions about the norms and values of the profession. The public views a nurse as a sort of servitor who dispenses medication on the orders of a doctor. Other roles of nurses are altogether ignored, and in the public sector, our ability to act as caregivers is often rigidly constrained by outdated mores and traditional practices. As a result, nurses are often unable to utilize their education to provide counseling, engage in advocacy or collaboration and remain restricted to the administration of medication.

A waste of an educated labor force

Many traditional and ongoing practices cause nurses to be overwhelmed with responsibilities that reduce the time they have to care for patients. In addition to performing inventory on supplies and managing staff, a nurse on a unit assists not only CNAs but ward attendants, Aya, and sanitary workers. The unavailability of service structure and monotony of tasks reduces the time they have to treat patients and—adding insult to injury, a nurse working in a Public sector job often ends up retiring on the same scale on which s/he was first appointed.

The perception of nursing as a profession designed to serve actual health care providers may correlate with the gendered nature of the profession in Pakistan. We are seeing more male nurses entering the profession but there remains substantial resistance and misconceptions about male nurses are almost as troubling as those about female nurses.

The impact of the commercial nurse education industry

Another significant issue that needs to be addressed is the burgeoning number of private nurse education programs. Despite the labor, long hours, and low pay, limited employment opportunities in Pakistan make nursing a highly attractive career option and as a result, private investors are cashing in by building new nursing schools to meet the demand. Unfortunately, their primary concerns revolve around profit and the bottom line, and the quality of education often seems to be an afterthought.

This is high time to bring reforms in Nursing Profession. There is a need to construct a positive image of nurses, without deconstructing the traditional image, the progressive image of nurses, and the quality of their services.

How can we improve conditions and keep nurses in the country?

Following are a few suggestions to reform the role of nurses, increase respect for the profession in Pakistan, and improve the conditions that are driving talented nurses to seek employment in other countries:

  • There must be a clear job description for nurses. There must be different domains of ward administration to look after the affairs of inventory, supplies and staffing. Nurses should be dedicated to patient care.
  • Nurses should use social media platforms to convey their values and concerns. By speaking out, they will help the public better understand the roles of nurses and the nursing profession.
  • There must be accredited courses of therapeutic communication in nursing to familiarize and encourage student nurses to communicate with patients. Thus, the gap between patients and nurses can be eliminated.
  • There must be specific tools to evaluate the care provided by nurses to patients. Nursing is a unique discipline. So, there must be a separate and unique audit system to assess and evaluate Nursing skills.
  • There must be criteria to include ongoing training programsspeak in every Nursing institution to meet the learning demands of nurses and to keep them updated about advances in knowledge.
  • Government lawmakers need to formulate service structure policies for the upgrowth of the nursing profession.

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