June 15, 2006

The state of most of the nursing schools provides an insight into the root causes of ‘medical blunders’ or lapses often reported in the media. With incomplete knowledge and poor professional training, these future nurses are not only open to abuse but can also endanger a patient's life, writes Faiza Ilyas

Dreams cost, especially when the will to materialise them is not supported by resources. The consequent frustration coupled with an unfair system makes the journey all the more painful. Very few succeed, as most fail to cross the barriers of poor quality education, dull conditions at the work-place, and last but not the least, bureaucratic wrangling.

Samina and her colleagues at the nursing school of Civil Hospital, Karachi (CHK), are among the countless in Pakistan who are pawns the state creates every year to be exploited, abused in society and to keep the rotten system rolling. Unaware of the consequences of being denied the right to good quality education, especially in a profession like nursing, these young girls don’t know that they would have to work a lot harder later in life to compete with their counterparts being trained in high standard institutions. Till that time, they are actually a threat to a patient’s life than a saviour, as their profession envisages them to be.

It is shocking that the first year students of this school, one of the oldest nursing schools in the metropolis, just three months after their induction, are required to do night duties in wards from 8pm to 8am, usually without any supervision of a senior staff nurse.

“We spend the whole night sitting on chairs alone, while the doctor sleeps in the other room after closing the door. They do not even let us use their toilets and we have to use the dirty ones for the patients, jointly shared by men and women, which is obviously very embarrassing. We are not paid for this ‘forced’ job but are punished if anything goes wrong. It is frightening to sit in the ward at night during electricity breakdowns as there are no chowkidars in many wards and attendants keep coming till late at night,” says a group of students at the nursing hostel.

This is not the end but the beginning of their problems. The school faces an acute shortage of teachers and first year students claim that they have been asked to contribute Rs300 for a subject teacher.

“There are only three teachers in the school as all the other teachers have gone for postgraduate training. Only three months are left for our exams and our studies started just this month. From 8am to 12 noon we attend classes, from 1 to 4pm we have to do morning ward duty, while the night duty is from 8pm to 8am,” a second year student says.

The students also complain that they have to pay from Rs900 to a little over Rs2,000 for admission in different years (no admission fee is supposed to be taken from female students in any of the nursing schools under the Sindh government). After deducting Rs500 as mess charges from their meagre Rs1,100 stipend, most of them only get Rs300 because more deductions are made on various counts. The girls from Punjab get no stipend at all.

“We perform duties in the emergency, gynae departments and labour rooms independently, but even then our stipend is deducted. Nobody questions the doctors who disappear for hours but we are taken to task for leaving the ward for even 15 minutes. Despite taking away Rs500 as mess charges from our stipend, the standard of food is bad and we have to eat daal every night,” they add.

These days there is no water in the nursing hostel and the students have to fetch water from a water tank inside the school premises. Also, their hostel is in a complete mess as sweepers rarely bother to do their job.

When the Chief Nursing Superintendent and Principal School of Nursing, CHK, Zaira Naqvi was contacted to give her point of view, she refused to talk saying that the medical superintendent had prohibited her from giving an interview. This attitude clearly proves that the school administration wants to hide facts from the media.

Though all the complaints by the students are of a serious nature and demand immediate looking into, two concerns raised by them are blatant violations of Pakistan Nursing Council’s (PNC) rules and regulations: first, the forced night duties and second the deduction of stipend as mess charges.

According to the PNC rules, there should be no night duty in the first year of general nursing training. However, in the second, third and fourth years, the students can work at night for only two months, and that too, under the supervision of a senior staff nurse/head nurse. The rule on stipends says that the stipend provided to each student will be according to the revised basic pay scale of a staff nurse, in addition to the prescribed mess and uniform allowance.

Going by this rule, the stipend of a student should be at least Rs3,500 as the basic salary of a staff nurse is Rs3,565, excluding the uniform allowance and mess charges. The stipend is different in different provinces. In Punjab, it is Rs3,500, the Jinnah Postgraduate Medical Centre (JPMC) under the federal government offers Rs2,700 to its students, in Quetta it is Rs3,750 and in Peshawar it is around Rs1,275. Abbasi Shaheed Hospital under the city district government Karachi, offers around Rs3,300 as stipend to nursing students.

Under the Sindh government, the nursing schools offer Rs1,525 to male and female students on regular seats. Those male students admitted on self-finance basis are not entitled to the stipend and have to pay Rs5,000 as admission fee and Rs500 as tuition fee per month. The students at the CHK school are perhaps the worst off where students receive a meagre amount of Rs600 or even less.

Another significant case is the Ayaz Samoon Nursing Institute belonging to the Lyari General Hospital, the second nursing school under the Sindh government in the city, which faces similar problems.

“We live in the same country, then why are the nursing students in Sindh discriminated against when it comes to stipends? Our colleagues at JPMC get a decent stipend, while our meagre amount is mercilessly cut down on trivial grounds. Girls come to Lyari from as far as Korangi, Mehmoodabad, Qayyumabad, Baldia Town, Ittehad Colony, Mohajir Camp, Orangi and Labour Colony and face a number of problems while commuting. The school management is indifferent to our troubles. It does not let girls enter the school if they are even five minutes late and thus their stipends are deducted. However, this year the students have not received their stipends since March,” they added.

The major problem which has put their careers in jeopardy is the acute shortage of teachers. “We have hardly been taught anything since last October when our exams ended. The three teachers we have are not competent enough, while there is no teacher for Pakistan Studies and Community Health.”

Also, security is a big issue at the school as part of the school’s boundary wall has fallen down and anybody can come in from that side. There is no equipment for practical demonstrations and unhygienic conditions prevail in the hostel and institution.

The female students complain that there is too much pressure on the trainees who tolerate abusive behaviour, perform every trivial job they are told to do, but have no voice to highlight their grievances.

The state of these nursing schools provides an insight into the root causes of ‘medical blunders’ or lapses often reported in the media. With half-baked knowledge and poor professional training, these future nurses are not only open to abuse but can also endanger a patient’s life. According to some senior nurses, the curriculum taught in schools has been revised many times and to an extent meets the international standards. What is lacking, however, is the guidance of a competent teaching staff and professional training. The practice of forcing new students to perform long ward duties without any knowledge of handling patients and understanding their medical problems, reflects poorly on their grooming, they add. These are some of the reasons why most nurses are rude to patients.

After a turbulent four years training, these students get a diploma and not a degree in general nursing. The next step is to get a job. The government hospitals, where nurses are desperately needed, can’t hire them because of a decades old on recruitment, so most of them end up in private hospitals and clinics.

“The nurses of the CHK school or any other school under the Sindh government won’t find jobs in hospitals under the provincial government as there is a ban on recruitment. There have been no fresh appointments in the CHK since 1992. This is ironic. The 1900-bed CHK visited by 2,500 to 3,000 OPD patients alone, has only 219 nurses. The nurse-to-patient ratio is as high as 1:50 and that is the reason why students are required to do night duties,” observes Nasreen Gill, President of Pakistan Nursing Association, Karachi.

Discussing the problems of nurses at the CHK, she says that the 219 nurses in the hospital have a huge workload. In addition, they have not been promoted to higher grades for a long time. Nurses inducted in grade 14 in 1979 are still working in the same grade. They have been promoted in Punjab after the government’s 2003 announcement, but here nurses are still struggling to go into a higher grade.

Their salaries, however, have been raised during the period. For instance, Rehana, whose starting salary as a staff nurse at CHK was Rs6,000, is now getting Rs13,000 after 11 years of experience. She does not receive any medical cover, though, and her salary is deducted if she fails to appear on a strike day. Her Medical Ward 2 faces chronic water shortage and the only toilet for nurses, paramedical staff along with 25 (male and female) patients is in a pathetic condition.

A grade five employee who wishes to remain anonymous, has been working as an aide nurse in the same ward for 16 years. He learnt his basic nursing skills at different hospitals and was employed at the CHK with a salary of Rs5,000. In his opinion people generally tend to ignore the role and contribution of aide nurses, which in government hospitals facing a shortage of nurses, increases all the more. Today, he gets nothing from the hospital management not even a uniform, except his Rs8,000 salary.

The situation in the Jinnah Post Graduate Medical Centre, run by the federal government, has improved especially as far as the number of nurses is concerned. Recently, the strength of their nursing staff was increased from 200 to 330 after the induction of 116 nurses and more are being interviewed.

“The major problem we have been facing at the JPMC is the shortage of nurses which would be solved with the induction of newly sanctioned number of staff. The JPMC is now in a better position to cope with any emergency situation. If the new recruitment had not happened, we would not have been able to cope in an organised way, as we did when the recent bomb blast took place,” says Rehana Afghani, CNS and Principal JPMC School of Nursing.

When the nurses at the JPMC accident and emergency department were asked to mention one major problem they faced, all unanimously singled out the rowdy behaviour of attendants who often delay on-time assistance to the patient.

What is happening in most private hospitals can be gauged from the example of a senior nurse working in an established private hospital who has been in the nursing profession for the last 26 years. According to her, nurses working in private set-ups, by and large, don’t get any service benefit, other than their salary, no matter how long they work. The nurses and the para-medical staff are at the mercy of the employer.

She does double-duty in the same hospital to earn Rs8,000. In her case, the management was kind enough to arrange the delivery of two of her grandchildren for free and admit her daughters to the hospital for a day.

The tale of nursing woes is long and after getting to know the ground realities one can say that until the government upgrades its institutions, especially the nursing schools in this case, no tangible change can occur. The acceptance of the longstanding demand of promotion of nurses in Sindh recently shows some willingness and interest on part of the government to address the nursing issues. This increases the responsiblity of the associations working for the welfare of nurses, which should also raise voice for improvement in the working and living conditions of nursing students.

 

A different outlook

Starting with a humble six-member faculty as the first academic unit of Aga Khan University in 1980, the Aga Khan School of Nursing (AKU-SON) has been transformed into a centre of excellence for nursing education in the country today, having a faculty of 64 members for its various programmes. Its role in the uplift of nursing education and status in Pakistan is critical as it has given empowerment to nurses by quality education and proved that nurses are as important as doctors. It has been a great inspiration for other public and private sector nursing institutions to upgrade their education and working conditions. The school is the first institution in Pakistan to introduce bachelors’ and masters’ degree programmes in nursing and has also established nursing programmes and collaborations in East Africa, Afghanistan and Syria. The AKU-SON’s experienced faculty provides conducive atmosphere for learning, programmes to support the under-privileged, assistance of international organisations to attract women to nursing from all over the country. So far, 2,088 nurses have been awarded undergraduate and post-graduate degrees. Of them, 234 students have graduated under the Track 1 programme, specially designed for the under-privileged. Fifty per cent of the nursing school students receive financial assistance from AKU-SON, which has also helped the federal and provincial governments in developing their nursing systems and strengthening the role of nurses and lady health visitors. “The most important impact of AKU-SON is that it has taken nursing from apprenticeship model to higher education. It is also working closely with the Higher Education Commission (HEC) for a national curriculum for nursing schools to be adopted from the AKU with minor amendments according to the country’s needs,” says Rozina Karmaliani, Director MScN programme. At the time of establishment, five diploma holders and one MSc director constituted the nursing faculty which now stands at 64 which includes only two RNs, 45 undergraduates, 30 masters and five PhDs. Four are in the process of completing their masters and one PhD programme. The programmes offered at the school include two baccalaureate programmes, a four-year Bachelors of Science in Nursing (BScN) leading to eligibility for licensure as a Registered Nurse; Post-RN BScN (a two-year programme designed to give experienced Registered Nurses an opportunity to acquire in-depth knowledge and skills needed to practice nursing care as clinically competent professional nurses; diploma in general nursing (a three-year programme). The Track 1 programme was developed in 1989 to help the under-privileged. Students who meet the basic entrance criteria for the RN diploma programme initially receive intensive course work in mathematics, English, basic sciences, and personal and professional development. Later, the successful candidates join the diploma programme. When asked to comment on the impression that most of the nurses after completing their education and acquiring a few years experience at AKU hospital, prefer to leave for abroad, Karmaliani says, “Retention of nurses has remained a major issue at the hospital. After two years experience, retention rate is as high as 25 per cent. If the education of a student is free then there is a job contract of three to five years, depending upon the investment. The student, upon graduating, pays the amount of investment in instalments once she starts her job. But, if the candidate has paid for the education the institution cannot impose any restriction. The institution suffers when our graduates leave after five to ten years.” The secure and enabling environment at AKU-SON has given its students huge confidence, which one can feel while talking to them. Most of them were inspired by the high level of education at the school and conducive working atmosphere at the hospital for them to opt for nursing as a career. They want to work in the AKU hospital because of better working conditions and future prospects. However, some students have other reasons for joining the institution. “Nursing is a neglected area in my town. I want to learn from here and go back to serve my people. Since the fall of the USSR, practically nothing has been done for the uplift of nursing in my town. I am thankful to AKU-SON for providing me with an opportunity to fulfill my dream,” says Hurayo Ilnarazova, a student of Track 1 programme, who has come from a Central Asian country. Commenting on the training and education at the school, the students said that nurses here are taught to make their own diagnosis side by side with the regular medical diagnosis, and for that they don’t need the physician’s permission. Since nurses spend more time with the patient and understand his psychological and emotional state, they have better knowledge of the patient’s condition. “Nurses are the advocates of patients and they should fight for their rights. Their responsibilities are manifold as they counsel, understand the physical, spiritual and emotional needs of the patient and help in his or her complete recovery. If a nurse suspects that there is something terribly wrong which could endanger the patient’s life, she has the right to challenge the physician’s decision and stop the procedure on the spot,” says Shahnaz Jillani, third year BScN student, generic programme. –– F.I.