Picture: Discarded PPE on a road. Credit: Alexas_Fotos, via Pixabay

The World Health Organization designated 2020 as Year of the Nurse and Midwife, to draw attention to these vital, and often under-recognised, frontline roles in healthcare services. Unfortunately, 2020 turned out to be more notable for another reason – the COVID-19 pandemic. In this blogpost, SATHI researchers Shweta Marathe and Deepali Yakkundi highlight findings from their recent research on problems faced by nurses in Maharashtra during the early stages of the pandemic. They argue that urgent change is needed in the conditions of work for nurses, as well as greater investment in healthcare resources and staffing.

A disaffected workforce

“Instead of spending funds on showering flower petals from an aircraft on various hospitals in Mumbai, the government should have ensured adequate provision of PPE equipment for its frontline workers. When health staff and patients are going through a crisis and are fighting back, such demonstrations have no practical meaning”.

This comment was made by a representative from a nurses’ federation in Maharashtra during our recent study on the challenges faced by nurses during the COVID-19 epidemic. The quote refers to an act of apparent thanksgiving by the Indian armed forces in May 2020, and the limitations of that gesture in the face of chaos and tragic loss that has played out in Indian healthcare since the beginning of the epidemic.

In the subsequent months, nurses went on strike in various parts of the country including Mumbai, Delhi, Pune, Patna and Kolkata. They were protesting over unfair and unsafe working conditions that risked undermining India’s response to COVID-19 and the longer-term sustainability of healthcare in the country.

Bearing the brunt

We wanted to know more about the challenges facing nurses as a result of the COVID-19 epidemic, to highlight the problems being faced by a group of workers who are simultaneously at the forefront of patient care, with significant clinical responsibility, but also who typically have much less voice and power than medical professionals. SATHI ran an online survey for nurses which attracted 367 responses from nurses in a range of locations, facilities and seniority, and we complemented this with in-depth interviews with five key representatives from nursing associations.

What we found was that nurses, as frontline healthcare workers who made possible the health system response to COVID-19, experienced an enormous social cost for their hard work. In both the public and private sectors there were commonly issues with shortage and poor quality of PPE, high workloads, and not receiving the daily salary top-ups (known as an allowance) they were entitled to for working on COVID-19 wards.

Precarious work

There were some differences between the public and private sectors. In the public sector, nurses were often completely overworked with abysmal nurse-to-patient ratios: one-third were regularly expected to care for 20 or more patients on their ward during a shift; some as many as 80. In some districts nurses have been hired on temporary contracts, often through recruitment agencies, and suffered badly from delayed payments and lacked the same opportunities to raise their voice due to agency employment status.

On the other hand, nurses in the private sector seem to remain devoid of quarantine facilities and lacked dedicated wards for nurses who became ill with COVID. They faced much more uncertainty and pressure regarding their employment conditions, with frequent threats of being fired or being forced to resign, as well as salary deductions. A representative from the United Nurses Association described one instance, reflective of the wider scenario, of how nurses who complained were dealt with by their hospital employer:

“management threatened them saying, they would not give the nurses experience certificates, they would not pay salaries and even sent male bouncers to the nurses’ hostel. This bullying is not just with this particular hospital but was observed in many other private hospitals.”

Action must be taken

While this study is based in Maharashtra, the problems it highlights seem to be ubiquitous to nursing pan-India, and the findings emphasise the need for a major range of measures at two levels. The first is providing adequate protection, facilities, employment and working conditions to enable these frontline workers to function in a humane and enabling environment. The second is tackling deeper health system issues such as significant improvement in resources and staffing of public health services. We must move beyond symbolic gestures and take immediate action to address these challenges. That would be a far greater tribute to nurses.

The research described in this blogpost is based on a study by SATHI, Pune, entitled: Rapid Assessment for Understanding Challenges Faced by Nurses During COVID-19 Epidemic in Maharashtra. The study was funded by The Fund for Global Human Rights and the authors thank all the respondents, United Nurses Association, Nurses Federation, and other related networks and contact persons for their help in the study, and Dr Swati Rane and Dr Abhay Shukla for their guidance and support. You can find a full version of the report (available in English and Marathi), and a shorter research brief, on SATHI’s website. Readers may also be interested in another article based on the findings of this SATHI study which contextualises the analysis in relation to the fundamental rights of workers to health and occupational safety: The Impact of COVID-19 on Fundamental Rights of Nurses.