It’s a great time to be a nurse, away from India

A year and a half later, she is a registered nurse in a senior living home in New Castle, earning five times more than she did in India. Most of all, her work is respected by her employers and those in her care.

“We are not angels, we are human beings. In India, nurses don’t get remuneration and dignity for their work. I have found that here," she told Mint in a phone conversation from New Castle. “I miss my family—I have left my child in India, but I know that by working here I can give her a good future with the money I’m earning," Ashwathy explains.

Earlier, nurses had to bear the burden of poor pay and working conditions in the country, but now they have the opportunity to pursue better prospects abroad. And thousands, like Ashwathy, are choosing to do just that. The exodus has left the country facing one of its worst shortages of nursing staff in recent years. Exhaustion from the pandemic, poor pay, and lucrative opportunities have pushed these experienced nursing professionals to make a beeline for developed countries.

Before the pandemic, roughly 50,000 qualified nurses from India used to migrate in search of better prospects each year. But that number has more than doubled since the covid outbreak, according to Roy K George, national president, The Trained Nurses Association of India (TNAI). “This exodus is happening because nurses in India are not treated well. Calling them angels but not recognising the demands of the profession is not helping either," George tells Mint.

The brain drain comes at a time when India’s tired healthcare system is transitioning from the covid-19 pandemic to refocus on other ailments. Policymakers need to address the systemic issues plaguing the profession as the lack of quality nursing staff has a direct impact on the quality of healthcare in the country.

India currently has over 3 million registered nurses and midwives. Though it leads the world in turning out thousands of nursing staff every year, that number is still not adequate considering the pressures on the country’s health system. India has 1.7 nurses per 1,000 people, whereas the World Health Organization norm is 3 per 1,000. The latest exodus could skew that ratio further, particularly since estimates indicate that by 2024, India will need at least 4.1 million additional nurses to cater to the growing demand of its ageing population.

In demand worldwide

Once stuck on the fringes of India’s healthcare system, trained nursing staff are making their presence (and absence) felt in most parts of the world. As many rich countries have been facing a shortage of nurses, they have turned to India to bridge this gap. Those who have been watching the trend say that Indian nurses have become something akin to IT professionals, who were in demand in the West a couple of decades ago.

In the UK, the National Health Service (NHS) has a shortage of nearly 40,000 nurses. The American nursing association estimates that 500,000 registered nurses will retire this year and that the country will need 1.1 million new nurses to fill the immediate gap.

The NHS has been on an aggressive recruitment spree, hiring thousands of nurses from India. It has been offering a slew of incentives, including paying for English language assessment tests, visa fees and air tickets for qualified nurses. Between April and September 2021, the UK registered 4,500 nurses from India.

The healthcare system in the West treats a nurse as a professional, at par with a general physician, unlike in India, where a nurse is seen as a patient attendant. “I get to make evidenced-based decisions and I am encouraged to make those decisions independently, and my decisions are backed by the general physicians," says Ashwathy.

The pandemic has been hard on healthcare workers across the world. Burnout, exhaustion, and increased health risks due to covid are a common thread across the healthcare community. In rich countries, some nursing staff have also been leaving the profession due to vaccine mandates. Most governments in the West have provided income support to their population, and due to this financial security, many nurses have chosen to retire early or quit the profession altogether. Consequently, demand for Indian nurses has gone up.

“Historically, most nurses have been moving to the Gulf region. But over the last five years that trend has changed and now the pandemic has opened new opportunities as our nurses are trained to handle the most difficult cases," says George. In the past, citing ethical grounds, Germany did not hire nurses from countries such as India, which face a nursing deficit. However, it has now changed that rule to address an internal shortage.

Health system under pressure

Shashi Bala Kalra, 48, a senior nurse at New Delhi’s RML Hospital, who has 35 years’ experience, said that high pressure, excessive work, low pay, and lack of gratitude even from patients has hit the morale of the nursing community. “Most nurses are the sole breadwinners of their families, and they have a poor work-life balance. Yet there are no rewards, monetary or otherwise, for their sacrifices," Kalra says.

There is also a feeling that senior doctors add to the stress of the nursing staff. On an operational basis, the nurses, 90% of whom are women, have to triage (the process of deciding how seriously ill or injured a person is, so that the most serious cases can be treated first), at times leaving other patients and their families feeling neglected. The result is added stress leading to high tempers in medical wards.

“Our profession is not something we can do sitting in an office. And there is no work from home for us either. If a patient is going into the ICU or undergoing an operation, we have to extend our work hours," Kalra explains.

Over the years, nursing unions have demanded adequate monetary compensation and dignity for the gruelling demands of the profession, but little has changed on the policy front. Most healthcare staff have to labour under poor working conditions, where even having a proper washroom seems like a luxury. Hospitals run by the central government and state governments offer better pay than private hospitals, but even so, the compensation is inadequate.

Pvt hospitals’ poor record

Several nurses and industry representatives that Mint spoke to said private hospitals are the worst offenders when it comes to the violation of rights of nursing staff. If the average salary in government hospitals for nursing staff is around ₹40,000, in private hospitals it is a mere ₹10,000.

The nurses here are made to work over 13 hours a day, and in some cases, there is no grievance mechanism in place to redress issues of workplace harassment, including sexual harassment. Private hospital lobby groups have also been stalling implementation of a Supreme Court of India order mandating that salaries of nursing and midwifery staff in private hospitals be at par with those in government hospitals.

In 2016, a health ministry directive to state governments noted that “the pay and working condition of nurses is pathetic and some steps are required to be taken to uplift the standard of working conditions". The recommendations advised state governments to mandate that private hospitals with less than 200 beds pay salaries at par with what nurses in state government hospitals would earn. In the case of private hospitals with more than 100 beds, it said the salary should be only 10% less than a state government hospital nurse’s salary. And the minimum salary in 20-bed hospitals should be ₹20,000, it added. The recommendations also said that nursing staff should have better working conditions, including paid leave, assigned working hours, medical facilities, transportation, and accommodation during night shifts.

“For a lot of older nurses, this is the last chance to earn a decent income in their lifetime. There are nurses who have lost family members due to covid. These people need to secure their future," says Saleena Shah, principal, Government College of Nursing, Thiruvananthapuram.

A nurse in her late 40s, who has two years of service left with a government hospital and did not want to be identified, said she is considering moving to the US where a new opportunity has opened up. This is because the US is specifically looking to hire experienced nurses, with at least 20 years of experience.

“The US is clearing its visa backlog for healthcare professionals such as nurses, so people in their 50s also are leaving. These are people who had applied for work visas in 2008 and were not getting calls for immigration," says George.

The shortage of nurses is also impacting the quality of nursing schools, which are struggling to find teaching staff. “India is able to boast of quality nurses because our syllabus is clinically oriented and has equipped those in the profession to provide quality care. But we need qualified teachers, too," says Shah.

Kerala, Maharashtra and Tamil Nadu are the top three states in producing nursing staff. But these states also face policy hiccups when it comes to new recruitments. In Kerala alone, 10,000 nurses graduate every year but the state health services need to create openings to ensure that these graduates find lucrative work options and do not leave, Shah says.

Policymaking challenge

Though India officially promotes the export of its nursing professionals, it may be staring at a scenario where a shortage of healthcare providers could bring down the quality of care.

At the height of the pandemic, the healthcare system even in the national capital collapsed due to a shortage of hospital beds and healthcare workers. A report by the International Council of Nurses (ICN) released this year says that in low-income countries, the low nurse-to-patient ratio and high nurse workload are linked to “in-hospital mortality, hospital-acquired infections, and medication errors among patients".

As India recovers from the covid pandemic and shifts its focus to other diseases, many of its healthcare professionals are suffering from exhaustion and burnout after enduring extreme challenges over the last two years. A survey of 120 nurses in emergency departments found that most of them experienced moderate to severe levels of burnout, emotional exhaustion, and depersonalisation, according to the ICN report.

“Most of us enter this profession with a sense of public duty. I have given 33 years of my life to this profession and my state but not everyone can, especially in the current working conditions," Shah explains. The unanimous call from nurses across the country is that their profession should be given the respect and dignity it deserves.

Nursing and midwifery staff, experts point out, need a pay hike and the ball is in the government’s court. Meanwhile, private hospitals have seen massive attrition in terms of nurses quitting to join government hospitals. Healthcare industry watchers say doing more to protect the rights of their staff, and implementing wage reforms could change that equation overnight.

The current shortage in India comes at a time when demand for nursing staff is at an all-time high in countries that are ready to pay at least ten times what a graduate nurse could earn here. Quite simply, it’s a great time to be an Indian nurse. Just not in India.