Underpaid, burnt out and unappreciated! This summarises what the life of most nurses in India looks like. There are over three million registered nurses in India. It might sound like a lot. However, when compared to the country's 1.3 billion population and the growing number of diseases and people who need medical care, these figures are concerning.

The World Health Organisation's recommendation is three nurses for a population of 1000 people. The current figure in India is 1.7 per 1000 people. In 2021, a group of nursing and midwifery organisations came together to highlight this acute shortage of nurses through their campaign titled '#NurseMidwife4Change'. They claimed that India would need at least 4.3 million more nurses by 2024 to meet the WHO norms. This is despite the increase in the number of nursing registrations.

There's been a lot of talk around the fact that India needs more doctors. No doubt about that. But one must remember that nurses are the backbone of our healthcare system. Any kind of healthcare delivery, especially hospital-based healthcare delivery is centred around healthcare workers.

Dr Biju Sivam Pillai, a Delhi-based cardiothoracic and vascular surgeon said, "The common concept is that the keystone in healthcare is the doctor. But that is not true. They are tertiary or secondary caregivers because patients who seek such care are institutionalised, they need round-the-clock care. A doctor's job is primarily a consulting job, in the sense, he provides the diagnosis and treatment, but in the interim, the caregiver is the nurse. The nurse is almost like a surrogate family, except that he or she is trained to provide the care."

He added that our country needs to look at nurses as valuable resources. "Nursing is a long learning curve. If you branch off into specialties, the average time duration that a nurse requires to be a 'well-trained' ICU nurse, a cardiac, neuro surgery or oncology nurse is [trained] anywhere between eight to ten years. Highly rarefied fields of medicine need more domain knowledge and on-the-job experience to bring forth that kind of accuracy in management as well as marrying it with a certain kind of empathy.

“These [nurses] are rare resources. In fact, hospitals can very easily acquire doctors, you'll find the best talent if you pay well. But in case of nurses, neither are healthcare leaders, doctors, or owners of institutions looking at them as resources that are limited and need to be nurtured. The moment we start realising that it is a talent pool and it is something we don't want to lose, we start valuing it. If we value it, you are not reluctant to pay for the talent. There needs to be robust conversation that includes all stakeholders," he said.

India has been one of the largest exporters of nurses to the rest of the world and continues to be. Although, of course, there are now other countries like the Philippines that have taken the lead. "Indian nurses are some of the most sought after nurses in the world, in the Gulf, the U.S. And in the U.K. These are the products of high quality nursing colleges. For years, there has been a reputation of Indian nurses being of high quality. That's still going on," said Dr Sunil Chandy, Medical Director, ITC Healthcare.

There are three major reasons why nurses are choosing to go abroad. Indian nurses are paid a pittance for the amount of work they do. The basic salary in most hospitals, be it private or government hospitals is around Rs 15,000 to Rs 18,000. This is for almost an eight-hour work shift with hardly any offs and extremely challenging work conditions.

"All of us have limited career spans and all of us want to do something to the best of our ability and earn well while doing that, so necessarily nurses look at greener pastures," said Dr Biju.

Feba Paul, a 27-year-old nurse worked for nearly three years in a prominent private hospital in New Delhi. But she quit and moved to Ireland and works as a nurse there. She said, "The pay in India was very less. If I had to get paid more, I would have had to join a government hospital, which is again very difficult for general category nurses. So for nurses like me, the grass is obviously greener on the other side, why would we not choose something better when there is an opportunity? Here, in the U.K., I'm paid for every hour I work, if I stay an hour longer, I'll get paid for that as well. I've got a night allowance and a weekend allowance too."

Dr Chandy added that in most Indian communities, nursing is a way out of their misery. "If you look at the background of most nurses, they come from a relatively ‘low social strata’. For them, nursing is a lifeline. Usually it's the elder sibling who needs to support the rest of their family. Life is pretty stressful for them. Nursing for them is a source of earning. It is not to improve their skills or anything. They hope to go abroad and have a better life."

Kanchana, a professor at Apollo College of Nursing said about her students, “these students spend about Rs 2 lakh to complete the course, but they get paid only about Rs 15,000 a month when they enter the workforce. It is not viable."

Khalishwari, another staff nurse working in Chhattisgarh said she applied in at least 15 hospitals before she landed her current job, but the salary is way too less.

Dr Chandy added that there is an undeniable social difference between doctors and nurses, not just in India, but across the world. "The only way nurses can match a doctor's salary is if they get into academics because the teaching stream is guided by the university system. The problem is that the [wage] drop from what a doctor gets to what a nurse gets is not smooth. Some of them get appalling salaries.

“There are instances where helpers get paid more than them. So where is the incentive for them to work? The work is hard, long hours of strenuous work. There are so many unemployed people and they're told that if they don't want to work for that amount, they should get out and that there are more people in line. It's very competitive. Lots of these nurses are just waiting for a job and are willing to work for anything."

The other reason why nurses choose to leave India is because of the extremely poor working conditions here. Anyone who's been hospitalised in India, either in a private or government hospital knows how stressful a nurse's job is. There are never enough nurses around. They are always running around trying to cater to everyone's needs.

Sowmiya, a nurse who worked in a Bengaluru based hospital for close to five years resigned from her job and is now looking to go abroad. She said, "I was a staff nurse in the paediatric ICU. I've been looking to move to Ireland not just because of better pay, but also because the working hours are lesser, or you get paid extra for extra time.

“Even doctors don't do half the work we do. Mine is supposed to be a six hour shift, but we somehow end up staying much longer. If another department is busy, we can't just leave. We need to wait till others are free. Night shift is 12 hours, depending on how the situation is."

Based on her analysis, Sowmiya said that in Ireland, someone with her experience would probably get about Rs 1.5 lakh and working hours are just 37 hours a week. They would get night allowance, extra pay for extra hours and compensation if they work on public holidays.

“Prices are increasing, so why won't people move abroad when they have opportunities, especially when they give visas for the whole family after a few months?" she added. Even if she were to wait to get to a higher position, say that of a nursing supervisor, it would take about 15 years and even then the pay, according to current standards, would just be around Rs 50,000.

According to Sowmiya it's also about respect at the workplace. "Here in India, there's no credit for the work we do. Nurses have to coordinate with not just patients, but so many other departments, be it pharmacy, collection of blood samples from the lab, billing process, placing orders. We have many responsibilities apart from taking care of the patients. It gets frustrating.

“We are supposed to do everything related to the patient. If anything happens, the patients come and shout at us even if it is not us who dealt with it in the first place. We try to direct them to other departments, but they always come back to us. Especially in the NICU, parents of kids get very frustrated.

“We do whatever the doctors tell us, but parents get frustrated when, say, we prick the child a couple of times. They take it out on us. When the doctor comes, they are very polite, but when we tell them the same thing, they talk to us rudely."

Recalling an incident, she said, "We are disrespected by doctors too, not just by patients. Once my colleague called up a doctor for a doubt at midnight. The patient's health was deteriorating. He got angry and asked why she couldn't handle it herself. He shouted at her using abusive language. This was a resident doctor, someone who's still learning. I know it was a stressful situation, but it was stressful for us as well. Nurses are somehow not respected at all."

Speaking about the poor working conditions in her hospital, Feba Paul said, "I wanted a change, I wanted a work life balance, I wanted to have opportunities to upgrade myself. Most importantly I wanted to be respected for my profession and of course to earn better to provide for my family.

“Back in India, nurses sacrifice a lot, but are paid so little. I did extra duties, even nights, but never got paid for it. It's like work exploitation is so normalised that people don't realise they are being exploited.

"I was always emotionally and physically tired after work. When we wanted leave, we had to go through a long process, but it was hardly approved as per our wish because there was always a staff shortage.

“Apart from that, the hierarchy system was so overwhelming. I've seen administrators yelling at nurses for silly reasons in front of patients, which is unprofessional by all means and is one of the reasons why nursing profession is not respected in India. This profession is looked down upon by the majority in India."

She recalled how when she was in school and told her friend that she would become a nurse, her friend told her that her family would never let her do that as they looked at it as a lowly profession. Paul feels that somewhere, that statement was true. "In India, I never got the respect a nurse should get."

In the U.K. though, she feels she has a life. "Here they prioritise work-life balance. Even though it's a 12-hour duty, I only have to work three days a week, so I get enough rest. I can take time for my hobbies or even earn extra money if I want. Here I can give my leave request as I want and they approve it.

“Here they don't demand, they request for anything they need to change and if we say no it's a no, my choices are respected. I'm treated with respect by all. My hospital has a goal to have a no hierarchy system even in terms of uniforms, which by itself speaks of how much they care about its importance.

“My hospital provides me with opportunities and support to upgrade my profession. I'm happy because I feel it's rewarding to be here. My profession is not looked down upon. And I feel empowered being a nurse now because I'm respected by all."

When asked if there was anything that would convince her to come back to India, she said, "A total change in the system - A better pay for nurses, prioritise work-life balance by limiting work time and thereby putting a stop to work exploitation and more opportunities for professional upgradation."

Lekshmi, another nurse who moved to the U.K. said, "I worked in an N.I.C.U. in Pune for three years. In India, in the N.I.C.U, the nurse patient ratio was 1:3. Here, in the U.K, it is 1:1. Even in our theory lessons, we were taught that 1:1 is the appropriate ratio for an N.I.C.U.

“It was extremely difficult to handle three babies in an N.I.C.U. Most are preterm babies weighing just about 500 grams. They need complete attention round the clock. It's not easy to do that for three babies."

Another reason for the brain drain from India is the fact that other countries have really attractive opportunities. Apart from attractive salaries and better working conditions, many countries also provide visas for families and have made entry criteria easier. Especially post COVID, there is a huge demand for well-trained nurses across the globe and India is naturally one of the countries that has ample well-trained nurses, especially in states like Kerala.

Dr Biju, the Director of Cardiac Surgery at a tertiary care institution said he has had to really look deep and fight with the management to retain his nurses. He felt that the problem is that we don't value our nurses. "There's a talent bank of trained nurses. But we don't consider them as quantifiable resources, be it at the national level, state level or institutional level. We treat them as it suits us and they are left to fend for themselves and they 'are' fending for themselves.

“The moment COVID hit, other countries realised we need a huge amount of nursing care and since they do not have a lot of shortfall of economic need, they looked worldwide for well trained nurses and India seems to have a huge quantum of well trained nurses who are being paid low.

“So automatically, they have eased the entry barriers into these countries, be it into Ireland, U.K. or Canada, they have diluted entry barriers like English language requirements because they need to take nurses in. We have had significant attrition,” he said.

Dr Chandy said that there is a lowering of standards of practical bedside nursing skills. "That is due to the mushrooming of nursing colleges all over the country. In commercial clinics that also run nursing schools, the nursing students hardly get practical experience.

“They run courses for the sake of money. Admissions are racketeering, but they do not have experience of bedside care or structured learning. So they have degrees, but do not have the skills. They then try to go to a good institution to do a bridging course and then learn the skills. At the end of that one year, they get a certificate.

“There are lots and lots of colleges that do not meet the standards of the Nursing Council of India, and do not meet the quality that is expected of good patient care. These are mostly ones who work in private nursing homes and polyclinics. There are also fake colleges now, although I have no evidence of it. There are hundreds of colleges just running courses because it's a source of income.

"Clinical education is done mostly by private colleges which are usually owned by rich businessmen or politicians or such. There is no clarity about whether their standards or quality are good enough. So what happens is that children who go there get barely any experience in nursing and get a degree and try to join somewhere. But it is a job that requires hands-on experience, it is not a very easy job.

Dr Biju also felt that this lack of well-trained nurses is also because the qualified ones are moving abroad. "In any hospital that is accredited, there's a constant process of quality assessment. You look at the number of errors that are accumulating in patient care, medication errors, point of care errors, charting and documentation errors, we have seen a massive increase.

“Hospitals try to address these issues through internal educational programmes, but the challenges are that they don't have good nursing educators, or the moment the nurses get trained, they get hired abroad and move out. This is a stop gap arrangement and is not working well. Nurses as a community are well collaborated.

“Say a nurse goes to the U.K. and finds that everything is working well for her there, the first thing she does is she communicates the ease of entry and quality of life to her batch mates. Now everybody is aspirational. They know the process, so they start working towards it."

The Way Forward

In the Budget 2023, Finance Minister Nirmala Sitaraman announced 157 new nursing colleges. Will this help? Dr Biju said, "For a country that is as large as India, we are going to forever be short-staffed when it comes to healthcare. To actually assume that we can catch up with the need by focusing on quality alone won't work.

“So starting new nursing colleges is a step in the right direction because that will help create a new pool of healthcare workers that are required. But simultaneously, we should have conversations in political circles and society about making sure we have systems that allow these talents to be retained.

“We need campus placements for nurses. A lot of healthcare chains try to hire nurses right out of college. If there is a ranking system, if there is competition, people will become more aspirational. They will try to get into the best colleges knowing the pay scale for those graduates will be good."

Dr Chandy added that it has to be mandated by the state or centre or the nursing council that no nurse should get less than a particular amount. "Otherwise it would be a sheer exploitation of labour," he said.

Professor Kanchana felt that, "Hospitals need to depute nurses for higher education so that they will get better incentives. Hospitals abroad do that. If nurses want to work in CCU or ICU, the hospital sends them for short courses."

The experts also agreed that increasing the salary alone would not solve the problem, simply because there is no way the Indian healthcare system, which works on a subsidy system, can match the salaries given in the western world.

"Nobody is going to start paying someone who's been getting about Rs 40,000 here, Rs 2 lakhs a month all of a sudden, to retain them," said Dr Biju.

Instead, he believes that everyone has a career chart planned out and that if they get a role that allows them to progress and achieve goals which go with their own perception of who they are, then they are happy.

He said, "The issue with most nurses is that one, the salary is less, then the career seems to have flattened and they realise that they are not going anywhere. They are jumping from hospital to hospital and we are not creating a system of filial escalation in the profile of the job.

In the West, as nurses become senior, they are transitioned into administrative roles, so what happens is if a girl is a team leader, she knows that she will one day become a nursing supervisor. If there is a path in front of them, that will help.

“But in India, we run healthcare like the wild west. Anybody can do whatever they want to do, and if it works, great. We are hiring M.B.As into the healthcare system to be administrators. They have worked in other sectors. They have never been at the point of care, have never cared for patients in real time.

“These are being mass produced. They are not sensitised to the needs of a patient. But nurses know what patients go through and they are the right people to empower. We have to take them into nursing administration, maybe even hospital administration."

To drive home his point, he mentioned how his Principal nurse Sonia has been with him for 14 years despite better paying opportunities abroad. "Sonia's husband was in Nigeria and had a good remuneration, but he came back because Sonia didn't want to leave this hospital. He eventually left his Rs 2.5 lakh job and came back to something much lesser. These are cardiac nurses that get paid about Rs 1 lakh a month.

“Everyone who wants to become a nurse should understand that there are nurses who get paid that much staying in India and with their families. We need to talk about people who have excelled, and highlight their careers. That will give them hope."

There are only a handful of institutions in India that are trying to change the role of nursing, empower the nurses and add value to their profession, some of which are Christian Medical College (Vellore), Manipal Academy of Higher Education, St John's Medical College Hospital and National Institute of Mental Health and Neuro Sciences, Bengaluru.

Another example, Dr Biju said, is the Ramakrishna Mission Sevashram. "They have a model where they have nursing colleges and the nurses take care of all the points of care in the hospital, whether it is pharmacy, billing or any other department.

“These are young girls, but they are empowered to take care of everything. Although their pay scale is one third of what normal hospitals pay, it is still very difficult to get a nurse out of there, and into a hospital outside, because they are empowered, have a place to stay and their work environment is conducive to their happiness."

Swami Kalikrishnananda, the hospital administrator said, "We have about 160 nurses, it's a family atmosphere. Less protocols and less hierarchy, that keeps the bonding. All the staff here get a chance to improve their skills.

“In private hospitals, staff will not be allowed to do anything on their own. So the nurses here are more empowered, that's one of the reasons they tend to stay here. We have nursing supervisors who have been working as nurses for many years. These nurses are as good as any other corporate managers."

While the government is taking steps to fill up nursing positions and add more nursing colleges, there is also an urgent need to review current organisational and management structures. More investment needs to go into training and recognition. Experts also say that there is a need to include nurses in the decision-making process.