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are altogether ignored, and in the public sector, our ability to act as caregivers is often rigidly constrained by outdated mores and traditional practices.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.
Letter from Pakistan – Brain Drain: The Exodus of Nurses to Wealthier Countries is Killing Us

Letter from Pakistan – Brain Drain: The Exodus of Nurses to Wealthier Countries is Killing Us

This is the first of several blog posts on nursing issues in the developing world contributed by MSc nursing students studying at the Karachi, Pakistan campus of the Aga Khan School of Nursing and Midwifery .

Their class assignment involved composing and submitting short research articles for publication in a recommended nursing blog or journal. The object: to help them hone their 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.

The health care systems in western and Gulf countries are well developed and established as compared to Pakistan and other developing countries. Developed countries have become magnets for qualified nurses and other healthcare personnel from developing countries—who are leaving their homes in growing numbers to seek higher pay and better working conditions in more prosperous nations.  The loss of trained, knowledgeable native healthcare workers is eroding the healthcare systems of these countries and endangers patient health outcomes. It is no coincidence that people in the United States on average live more than 10 years longer than people in Pakistan and other developing states. 

According to the Pakistan Economic Survey 2020-2021, Pakistan had a total of 116,659 registered nurses in 2020 for a population of about 200 million people (Pakistan Economic Survey, 2020-2021).  In the general wards of Pakistani hospitals, the current nurse-patient ratio is 1: 40, while the Pakistan Nursing Council recommends a nurse-patient ratio of 3:10 (Firdos, Asghar, & Ashraf, 2020). These facts and figures demonstrate the urgency of the issue of nursing shortages, and the danger they present to the public health.   

The first and most obvious effect of this brain drain is a severe reduction in the availability and quality of health care services in developing nations, particularly in rural regions and the public sector as a result of the cascade effect (Marchal & Kegels, 2003). The nursing shortage in the developing world cannot be arrested overnight, but can be mitigated by implementing the following provisions and measurers: 

  1. Identifying and eliminating factors that prompt healthcare workers to emigrate and seek positions in other countries  
  1. Providing incentives such as annual salary increments, educational expenditures for nurses’ children, free health care, retention allowances, scholarships for nurses’ higher education and professional growth, and housing allowances (Pang, Lansang, & Haines, 2002). 
  1. Providing a safe and conducive working environment for female nurses in Muslim countries as well as in developing countries, particularly in the public sector. 
  1. Mutual agreement is essential between countries to contain brain drain to a certain point, or they can negotiate to trade on a temporary basis if one country experiences a shortage of health care professionals. 
  1. World Health Organization (WHO) should intervene when inequity is observed and take initiative on ‘managed migration of health care professionals’ to avoid any health care crises. 
  1. Promoting a culture of awareness about the nursing profession to increase respect for nurses and make nursing a more attractive career choice. 
  1. Establishing worldwide ethical rules for the exodus of nurses and other healthcare professionals. 
Aga Khan School of Nursing and Midwifery, Karachi, Pakistan.
The Aga Khan School of Nursing and Midwifery, Karachi, Pakistan.

It is the right of each individual to have access to amenities of life such as shelter, good food, health, and education facilities. When affluent nations hire away our best-qualified nurses, patients in developing countries like Pakistan are deprived of native health care expertise and desperately needed care. As the world learned from the pandemic, when one country suffers a healthcare crisis, it places all countries at risk. The WHO needs to set guidelines to reduce the impact of this global injustice because draining the best talents from poor countries to serve the wealthier draws a deadly line of inequality.