Although the government makes big claims on building hospitals and expanding health services, it is ignoring the need to hire nurses that form the backbone of hospitals.
Rita Lamsal |CIJ, Nepal
When a team of doctors visited the Surgical Intensive Care Unit of the Bir Hospital, in Kathmandu, for the morning round of check ups, nurses were busy with patient care. After realizing that sanitation work had not been completed till 10 am, a doctor said, “Sanitation work should be completed before the round.”
Rameela Joshi, in charge of nursing, responded: “A nurse has to take care of three patients. How can we complete it on time?”
On that day, the 18-seater surgical ward was occupied. There were six patients on the ventilator itself. As per the Minimum Service Standard of the Ministry of Health and Population, there should have been 12 nurses in the ward. But that morning, there were only eight nurses on duty. The standard mandates the provision of one nurse per patient on ventilator and one nurse per two patients not on a ventilator.
Surgical ICU of Bir Hospital.
“There is a shortage of nurses here. So if we are tending to one patient, another will have problems already,” Joshi told CIJ-Nepal.
According to Dr Ravi Ram Shrestha, Chief Consultant Anaesthesiologist, nurses should complete their work before 9.30 am if the doctors’ round is at 10 am. Shrestha said there is a risk of infections if a single nurse is looking after multiple nurses in the ICU.
The condition of the surgical and medical wards at Bir Hospitals is worse. According to Sangita Shrestha, the Chief Administrator of Nursing at the hospital, one nurse has to look after 40 patients in the surgical ward, and the scenario is the same in the medical ward. This is in stark contrast with the fact that, in a ward, a nurse can look after a maximum of six patients.
“How can we provide quality care if a nurse has to care for 40 patients simultaneously?” Shrestha said.
A nurse at Bir Hospital who did not want to be named confessed that she gave the wrong medicine to a patient when the patient flow was excessive. “Thankfully, it was not a big loss,” the nurse said. According to Shrestha, nurses need more time if they have to look after multiple patients simultaneously. The scarcity has often led to a misconception among patients and their caretakers that the nurses are careless.
Dr. Bhupendra Kumar Basnet, Chief of Bir Hospital, said many patients were not satisfied due to the lack of nurses. “There are 68 ICUs in the hospital, including HDUs. A total of 272 nurses are required in the ICU to cover the shifts and holidays. This means that all the nurses that have been employed through government seats are enough only for the ICUs,” he said.
Sangita Shrestha, Head of Nursing Administration, says 938 nurses are currently required for Bir Hospital, which has a capacity of 550 beds. However, only 400 nurses work currently as permanent, contractual, and monthly wage workers.
This hospital, which is running and expanding multi-speciality services, has 186 seats. However, it has only 134 nurses at the moment. According to Shrestha, 22 nurses that Bir Hospital employs have been assigned to other places. Another nine nurses are on study leave, and 11 are on unpaid leave. Apart from government seats, there are 124 seats for nurses under the National Academy of Medical Sciences.
More problems at Kanti Children’s Hospital
Kanti Children’s Hospital is the central government hospital for the referral of child patients. Roshni Laxmi Tuitui, Head of Nursing Administration, said relatives of patients complained about the irregularity in providing medicine. However, the ratio of patients to nurses is so low that they cannot provide better service even if they want, said Tuitui.
Kabita Thapa, a nurse at the hospital, says over 100 patients are admitted every 24 hours in the emergency ward. Kanti, meanwhile, has a capacity of 25 beds. Infants are mainly admitted within 1-30 days of birth. At the moment, only 15 nurses are providing care in the emergency ward. In the case of more patients, three patients are tended to in a bed in the emergency ward.
A nurse giving medicine to a sick child in the observation ward of Kanti Children’s Hospital.
“There are fewer patients in the morning, and four patients are kept in one bed by the evening. Everyone wants a single bed, and conflict arises between us,” Thapa said.
There are 25 beds in the observation ward of the hospital, where the patients are kept after emergency treatment. According to Narayani Sigdel, in charge of the ward, there is a need for more nurses in the observation ward.
If the guideline is to be followed, there should be a minimum of 600 nursing staff. At Kanti Children’s Hospital, which has 350 beds, including 52 ICU beds, there are 169 nurses under government seats, development committee, contract, and daily wage appointments. However, per the guidelines, there should be 600 nurses.
At Kanti, there are 97 nursing seats in total, among which 92 are from the government quota and four from ANM. However, only 66 are working, among whom there are 58 nurses and 8 ANMs. Other nurses have taken study or maternity leave. Some nurses are engaged in various other kinds of work. Similarly, 59 nursing seats are available under the development committee, including 3 ANMs.
According to the World Health Organization and Guidelines for Health Institutions Establishment, Operation and Upgrade Standards, and Minimum Service standards, Kanti Hospital, which has a capacity of 350 beds, has four times fewer human resources.
Dire situation t Maternity Hospital
The Paropakar Maternity and Women’s Hospital in Thapathali also reels under the scarcity of nursing staff. Althought the permitted number of beds in the hospital is 415, there are 479 beds in operation. Only 154 nurses work in the hospital, including permanent government appointments, development committee and contractual employment. According to the guideline, a hospital containing 400 beds needs 735 nurses at minimum.
There are 27 government seats in the hospital, among which 15 are occupied, leaving the rest 12 vacant. A total of 146 seats are under the development committee, 27 nurses are working, and 139 nurses are employed on a contractual basis. Due to the hospital’s lack of human resources, there is a problem caring for pregnant women, new mothers and their children.
Provincial and district hospitals out of Kathmandu valley also lack doctors and nurses. During the Covid-19 pandemic, more beds were added in the ICUs and HDUs, but no attention was paid to human capital.
Trishuli Hospital, which comes under Bagmati province, has seven nursing seats. Even though the hospital has hired 34 nurses from internal sources, they are significantly fewer when patients occupy the beds.
Dr. Dipendra Pandey, a medical superintendent, says the need for nurses is causing problems while providing service. “If we can generate nursing human capital through public service, we could improve health services. Temporary staffing is affecting the service,” Pandey said.
What is in the guideline?
According to the Guideline for Health Institution Establishment, Operation and Upgrade Standard, and Minimum Service Standards, a hospital’s general ward should have one nurse for four to six beds. Operative rooms should have one nurse for two beds; ICUs and CCUs with ventilators should have one nurse per bed; and labour beds of the maternity wards should have two nurses trained in skilled birth attendance (SBA) or midwives for each woman.
The Ministry of Health and Population has directed every government hospital to follow the guideline formed in 2018; however, the ministry is not concerned about adding the hospitals’ nursing seats.
“Nowadays, hospitals lack human resources as they do not follow the guidelines. And since we do not have enough nurses, there are fewer seats in all,” said Dr. Madan Upadhyaya.
According to the ministry’s guidelines, government hospitals all over Nepal require almost 22,155 nursing staff. But, there are only 10,585 seats available in total–less than half of the seats required. Among the 829 seats of nursing staff, 205 seats are vacant in the 13 government hospitals of the federal Ministry of Health and Population. These 13 hospitals consist of 3,574 beds, including ICUs and HDUs.
Government lacks data
The 10-year National Nursing and Midwife Free master plan prepared by the Nursing and Social Security Division under the Ministry of Health and Population also laments the lack of data on nursing resources.
The master plan highlights the failure to maintain the ratio of nursing resources in government and private hospitals, use the expertise of skilled resources, and expand the quality of service. According to Bala Rai, chief of the Nursing Section at the Division, there has been an attempt to build software in coordination with the Nepal Nursing Council to keep a record of nursing professionals working at government institutions.
After the government ordered the discontinuation of contractual employees, most of the hospitals running with the help of a contractual workforce have been under tremendous pressure.
Nursing Council does not have data either
As per the data made available by the Nepal Nursing Council, 72,550 nurses, 36,853 ANMs, 31 midwives, 645 specialists, and 848 tourist nurses have obtained a license in Nepal.
However, among them, only 23,417 nurses, and 407 ANMs have renewed their licenses. About 110,927 nurses are registered with Nepal Nursing Council. Binda Ghimire, Former Registrar of Nepal Nursing Council, says a single person has registered their names in ANM, registered nurse, and specialist, so the number is higher than stated.
According to the Nepal Nursing Council, almost 22,000 nurses have gone abroad with the council’s permission. Among the registered nurses, 8,000 are deceased now. Similarly, 4,000 nurses have resigned from their jobs, and some nurses have retired.
According to Roshani Laxmi Tuitui, former Director of the Nursing and Social Security Division and Head of Nursing of Kanti Children’s Hospital ,only 48,000 nursing human resources are active in the data. Among them, 15,000 are working for the government on permanent or contract bases. Similarly, 17,000-20,000 nurses are working at private hospitals and almost 5,000 are working in the educational sector. Almost 12,000 nurses are still unemployed.
According to the Minimum Service Standard of the Ministry of Health and Population, if nursing human resources are to be filled, government health services need 32,000 nurses. The nurses available in the country today cannot fulfill that need.
Demand higher than production
According to Yam Prasad Bhurtel, the Examination Controller of the Council for Technical Education and Vocational Training (CTEVT), before the Medical Education Commission was set up, 110 nursing colleges operated PCL nursing courses in Nepal. Every year 4,400 PCL nurses were produced from 40 seats each.
But the Medical Education Commission directed that there should be a hospital to conduct nursing classes. After the Act, only 24 colleges had permission to run nursing classes. Altogether, 1,360 students were admitted in these 34 colleges.
According to Bhurtel, 1,440 students are admitted in 36 colleges which have permission to teach PCL nursing.
The council’s data shows 48 medical and nursing colleges have permission to run the bachelor’s level in the nursing programme.
The council has determined 2,936 seats for BSc. Nursing, midwifery, BNS and BNS Community Nursing, BNS Adult Nursing, BNS Pediatric Nursing, and BNS Psychiatric Nursing for the year 2021/22.
But these seats are only partially occupied. According to the council, only 1,687 seats are occupied out of 2,936, leaving the remaining 1,249 seats vacant.
Why are these seats of nursing colleges vacant? The Vice-Chairperson of the Medical Education Commission, Dr. Shree Krishna Giri says, “Many students pass the entrance exam, but only a few are admitted. The seats are vacant because the students do not want to study nursing.”
The Medical Education Commission has provided a certificate from October 2, 2020, to the students studying nursing abroad. According to the Vice- Secretary of the council, Govinda Sharma, 160 students have taken the certificates for studying Bachelor’s in Nursing in one year since October 2, 2020.
Similarly, 43 students have taken the certificate from the council in one year for Master in Nursing. The council does not have the data of students who went before 2020. The council does not have the exact data of the nurses who came back to Nepal after completing their studies abroad.
The council has data on the nurses who own a license after completing their studies abroad.
According to the data of the Nepal Nursing Council, 5,200 nurses have obtained licenses after completing their BSc. Nursing from abroad from 2053BS to 2079BS. In this period, 2,340 have obtained licenses in PCL nursing.
According to the Department of Foreign Employment, which started keeping records in 2013, a total of 1,152 nurses have taken permission to work abroad until November 20, 2022. The number of those taking permission for foreign employment is increasing each year.
Mankumari Rai, President, Nepal Nursing Association
The situation is worse in private hospitals
The impact of the lack of nurses in hospitals is evident in the nurses as well as the patients. In many cases, there is a need for two nurses to become available to patients on a ventilator. The number of ventilators, ICUs and HDUs has increased in hospitals, but the number of nurses remains the same. There are fewer seats in government hospitals and even those seats are not fully occupied.
There are more problems in private hospitals. The private hospital nurses face more issues than the government hospital nurses. There are few nursing seats in private hospitals as well, and fewer nurses. The nurses have complained to the council about low wages, lack of compensation for night shifts, sickness and maternity leaves.
We have to hear the complaints of nurses about their behaviour. However, this problem is caused due to lack of nurses and more workload. The nurses do not even get their salaries on time.
How many are needed?
The Nursing and Social Security Division has prepared data under Minimum Service Standard about the nursing human resources required in the hospitals containing five beds at the local level to the hospitals containing 1,000 beds at the central level.
Four nurses in hospitals of five beds, seven nurses in hospitals of 10 beds, 12 nurses in hospitals of 15 beds, and 38 nurses in hospitals of 25 beds are required. However, only seven nurses work in the provincial hospitals, which have 50 beds.
Similarly, 224 nurses in the hospitals containing 100 beds, 449 nurses in the hospitals containing 200 beds, 594 nurses in hospitals containing 300 beds, 735 nurses in the hospitals containing 400 beds, 913 nurses in the hospitals containing 500 beds, 1,068 nurses in the hospitals containing 600 beds, 1,279 nurses in the hospitals containing 700 beds, 1,468 nurses in the hospitals containing 800 beds, 1,641 nurses in the hospitals containing 900 beds, 1,780 nurses in the hospitals containing 1000 beds are needed. This data is collected excluding the midwifery human resource.
