The Role Of Pakistani Nurses In Amidst Of COVID-19

The Role Of Pakistani Nurses In Amidst Of COVID-19

The profession of nursing encompasses the attribute of compassion, caring and strong ethical values. These personnel are always under a constant learning curve with high responsibility, accountability for insightful practice and demonstrate an outlook for inflexible and collaborated attitude. They are entitled to bear the burden and provide care for each individual of all ages, families, groups, and communities, sick, well and in all settings. In addition, they are responsible for healthcare promotion, prevention of infectious disease and attend to ill, disabled, and dying people.

In Pakistan, nursing is an integral part of the healthcare system. In 2009,  the government recognized the importance of nursing care and intended to improve it to raise quality standards. Such professions are of immense importance in developing countries as they are the ones involved in the complete treatment of the patient.

Healthcare Care Delivery In Pakistan

Developing countries such as Pakistan often faced a stringent concern for uplifting the healthcare system. Analyzing the financial circumstances of Pakistan, it has been reported that health expenditure per capita in Pakistan is approximate 750-800 (US $ 12-13). Out of the total expenditure, only 25% is contributed in the public sector whereas the remaining 75% is uncashed by the private service fee system. Thereby, portraying a minimum expenditure of only 0.6-1.19% of GDP out of a total of 3.4% allocated budget for the healthcare sector. Unfortunately, the amount spent is mostly for curative purposes mainly in secondary and tertiary care services.

Pakistan reported its first COVID case on February 26, 2020, in Karachi. It was astonishing, regardless of an overburdened healthcare system for 200 million population, these frontline warriors managed to save many lives and maintain the mortality rate at 2.0% per 100,000 population as informed by Johns Hopkins compared to Europe and the United States, which were comparatively lower (14.6% and 5.7% per 100,000 population, respectively).

However, Pakistan yet struggles to achieve quality health care standards despite setting several goals. According to the WHO standards, Currently, in Pakistan, the ratio of nurses to physicians is comparatively low and overburdening. Hence, the workers endure hardship in combating looming threats such as contagious diseases like COVID-19, polio, TB and hepatitis effectively.

Recently, it was reported that around 70 nurses from 440 healthcare workers across Pakistan were tested positive for Covid-19. This clearly denotes, nurses represent the largest part of the healthcare profession, who plays a pivotal role in a healthcare facility in prevention, infection control, isolation, incessant monitoring of patients. In this way, the professional exposure during comforting the patient's reserves to be high especially during COVID 19 summed up with limited resources and facilities in Pakistan.

The wave of COVID 19 was an eye opener for many authorities including in Pakistan. The failure to counteract the pandemic and rebellious attitude perceived from nurses was seen to be due to incompetency, shortage of staff, structural mismanagement, and gender insensitivity. According to the Pakistani Nursing Council, the ratio reported is 1:10, whereas the actual ratio is 1:20 at present. This type of false registration often misleads authorities in investing in nursing care and negatively impacts the quality of a nurse's life.

Moreover, in recent news, according to United Nations Development Program (UNDP), in Pakistan for every 10,000 patients, there are only 9.8 physicians, 5 nurses, and 6 hospital beds. Nevertheless, compared to high-income countries (11.0) and 1.0 in low-income countries,  is suggestive 0.7 rate of nurses per thousand people in Pakistan lies on the average scale and shows a sign of development. However, the prolonged course of the pandemic has triggered frustration, anxiety and depression among many nurses, which has led to deteriorating mental health and influenced the quality of patient care provided.

Challenges Nurses face in Pakistan

The pandemic 2019 revealed a new prospectus in healthcare alliances; apart from the doctors, the Pakistani nurses proved to be the first line of defense in the fight against COVID 19. However, they were the most vulnerable group during the pandemic in Pakistan. Globally, the nurses are considered as a figure of compassion for the patients. These individuals are responsible for assisting the patients from the emergency up to the recovery room, following the triage, supporting the families and commuting all sorts of help. During the critical situation, these nurses selflessly worked beyond their call of duty to combat the outbreak despite the high risk of the virus. However, this turmoil of the season not only created short term but long term impact on the social, physical and psychological of each individual.

The underdeveloped countries such as Pakistan produces several barriers for these frontline saviors, which led to the development of physical and psychological distress among the healthcare workers especially nurses. These nurses were burdened with high responsibility and duty towards the patients, which instigated fear, anxiety, depression, post-traumatic symptoms, moral distress, deteriorated their overall health and well-being.

Among all the nurses, the critical care nurses were often closely associated with these contagious patients, attending them in isolation in intense and complex care units wearing full protective gear for 8–10 hours per shift; in addition, to serving other infected, critical, and dying patients along with addressing to families concerns. Nonetheless, the violent behavior of families, health safety restrictions, lack of resources and inadequate understanding of new diseases burnout many nurses and added to the frustration, poor physical and mental well-being. Many nurses collapsed into severe depression due to prevention from reuniting with their families and communities due to the fear of spreading the virus, financial constraints with limited recognition and appreciation in the healthcare system.

In recent times, many front-line caretakers also faced difficulties in aligning themselves to the critical situation since it is a new disease.  Many healthcare sectors worldwide encouraged nurses to master new skills and educated them about SARS COV prevention and management. Nevertheless, the majority of underdeveloped cities faced difficulty in controlling the death toll. The reason sought is due to the placement of nurses based on their past experiences rather than proper education and training. The negligence to properly invest in nursing care education costed many underdeveloped countries during the pandemic

Over a period the nursing community has faced several socio-cultural challenges that have evolved their position and status. These boundaries have often trapped thousands of women who started as midwives and nurses assisting doctors and caring for the patients. For these nurses working together was like building a sisterhood; however, these under-trained professionals were unable to cope with the rural pandemic crisis.

Previous studies established that only a few of the 162 nursing schools in Pakistan have proper facility to train nurses with highly reputable faculty and well developed OPDs and ward for their skill development. The lack of interest by authorities at the federal and provincial levels and limited reserves were the main reasons undermined for untrained non registered nurses in various clinics. On the contrary, to attract financially unstable interested individuals in a particular field, few institutions offered nursing diploma, situated in rented buildings without any associated or attached hospitals.  Thus, these types of exploitation led to poor quality of healthcare servers along with raised levels of anxiety, fear and depression among the healthcare workers when they are met with challenges.

Currently, moral distress is one of the major challenges these critical care nurses are facing due to the huge inflow of infected patients laying on the death bed and severe complications. The pandemic mounted an array of dilemmas and ethical considerations among the nurses due to the complex form of the disease. In addition, to the struggle of treating the patients, these nurses also faced harassment and were a target of the violence by the general public in the Pakistani healthcare system. The main reason for this illiterate behavior was due to a lack of awareness, misguided cultural beliefs, the low reputation of nurses, no leadership and administrative support, and poverty. Moreover, unprofessional behavior and limited knowledge of the novice nurses added up to the number of unattended critical patients, which caused rage among many families and made them more vulnerable to moral and psychological distress.

Many authorities believe that the lacking and inferiors status of this profession is due to various penetrating stigmas such as negative portrayal, female nurse's interaction with males patients, gender bias, and social norms. These are the factors that led to a decrease in nurse to patient ratio with mere gender discrimination. Although many universities started programs encouraging the admission of all types of students; however, the number is less with the script of feminity and unequal distribution over the country. The stereotypical portrayal has compelled many including the physicians to consider females worthy of the profession who can provide emotional and physical labor to the patient and devalued the importance of the profession. These social and moral dilemmas along with unattractive salary packages are the main instigating factor for self-degradation and loss of self-belief, which affects the delivery of high-quality healthcare.

Mental health  impacts from overwork

Throughout COVID 19, people have observed the levels of unprecedented workload mounting on the shoulders of the nurses, especially in the intensive care units. Despite the risk, these nurses continued to serve while wearing a protective suit, face mask, goggles, and gloves, surrounded by thousands of coronavirus patients while holding a chart, taking blood pressure and assisting each patient without considering their health, fatigue and tiredness. These individuals risked and sacrificed comparatively more than others in terms of recuperation, support, care and service with limited considerations for their mental health and wellbeing. These known external stressors potentially be a triggering factor for depression and mental disturbance.

The evidence can be gained from the mental health services records, which claimed to have an increased number of patients in the preceding year after COVID. Many believe that the overflowing patients and intensity of the work along with the new process of treatment, care and application added stress for these nurses resulting in high levels of mental stress and health issues especially the nurses in rural areas.

At present, the news reported that the lack of proper protection resources such as PPE derived many nurses to protest. Despite the regular call from WHO to increase the number of available testing kits for health workers and the wider population for COVID-19 screening, many countries failed to provide the nurses with the optimum level of protection, which caused them to step back from their duties and remain safe with their families. On the contrary,  many people also accused these nurses to be a source of risk rather than a solution. These Pakistani nurses faced violence and were thrashed by the police during a protest in Pakistan.

However, the poor system to report the violence against the healthcare worker is disrupted in Pakistan along with other countries. Hence, the effectiveness of their raised voice was hindered. These stark incidents are only useful for media publicity stunts. It is disgraced that their need for specialized equipment like PPE, inadequate compensation and limited internet access during the COVID-19 pandemic were met with physical assaults. Moreover, the case was further worsened by a downplay by the federal and provincial government rather than prioritizing their request and their wages were furthered reduced to fill up COVID 19 government funds. Regardless, many nurses managed to adopt this new lifestyle and endure rapid deterioration to serve mankind and honor their profession.

The violence was not only endured at that time of protest but they were victimized in many government-owned facilities also. The poor facilities and lack of resources to treat their family members triggered frustration and anger among these perpetrators. In addition,  illiteracy, religious conservatism and superstition among the underdeveloped countries were also identified as a perpetuating factor that triggered the offenders to believe COVID 19 as a hoax to mint money. Thus,  the love for their family caused them to wreck the hospital and inflict harm on many healthcare workers

WHO’s Mr. Cometto expressed serious concerns regarding nurses being considered as the risk among many populations rather than a solution. He emphasized the need to reinforce adequate communication for the public and establish specific policies to protect the rights of the health care workers, especially in unprecedented times.

Reflection for solution

The pandemic 2019 exposed various lacking in the health care system growing in Pakistan. Irrespective of the doctor's credibility and selfless efforts in treating patients, the current situation showed utmost vulnerability at stake for the nurses. The nursing profession is recognized as a respectable profession around the world; however, the acknowledgment of their service is not enough. These healthcare alliances are the first being to be in contact with the patient and carry greater responsibility than any other healthcare workers. Therefore, creating adequate awareness, constant guidance and support are necessary to maintain their safety physically, socially, psychologically, and spiritual health and well-being.

Moreover, one of the reasons for poor quality healthcare service is overload work with unattractive salary package. The amount of effort invested by these nurses is unprejudiced; however,  low income and lack of proper grooming in terms of skills and experience constantly build negligence and frustration among these wellbeing leading to poor clinical outcomes. It is astonishing that people in rural areas often associate themselves with nurses and follow their instructions. Irrespective, the workplace attitude is also influenced by the organizational structure. Thus, keeping in mind the poor conditions of Pakistani hospitals, policies are required to be developed to secure their future and uplift their role in primary healthcare and welfare.

On the other hand, in many countries to support the healthcare system, countries fast-tracked their nurse's schooling to gain an increasing number of nurses registered in addition to rehiring their retired nurses. Hence, redeploying the nurses, adding to new specialties or in higher acuity areas with previous retired supporting staff demonstrated to have a positive impact on the mental health and well being of the nurses. Thus, it is recommended for Pakistan to take a similar action to increase the ratio of nurses to the patient. Moreover,  the hospitals should retain the experienced nurse after retirement in order to train the new nursing staff in adhering to a complex hospital environment and invest more in the healthcare sector for better-standardized quality service.

Furthermore, the government, health and nursing regulatory bodies, as well as the local health authorities of Pakistan, should evaluate the level of moral distress and anxiety the pandemic has triggered among these nurses in order to enhance their ability to provide high quality, safe and sensitive care. To avoid any future constraints the hospitals should remain at par with the standardized protocols by delivering appropriate supplies such as PPE, gloves and mask to the foremost frontline healthcare workers and continuously train and educate them in accordance with new information and technology. In addition, proper counseling session for these nurses are also necessary to encourage and support them for better mental health

Nonetheless, many people fear that the lack of emergency training and limited facility support is the main reason for the erroneous application in medical facilities, which proves to be dangerous for families and patients. However, regardless, the system proved to be weak in providing the optimum measures for healthcare, economic, and social protection, there still is an opportunity for the higher authorities to address these hidden matters and prepare a better response system for the future. Hence, it is essential to address the critical issues timely to minimizes the harm and enhance the quality of service provided for all in Pakistani healthcare.

Recommendations

To derive the Pakistani population towards a better and healthier future each nursing institute should address the concerns that derange the nursing care system and devise relevant policies and curriculum to groom them. This supporting system would instigate the determination and confidence against undermining challenges nurses faces in daily work life.

Moreover, the Punjab policy round-table initiated a task ti optimize the utilization of existing nursing workforce and decided to engage more people in nursing career with higher merits associated to increase the ratio of nurse to doctors. Thus, it is recommended to improve the nursing curriculum and prioritize their engagement in the service delivery. Considering the situation, shorter modules should be kept for certifications and specialization to increase the number of nurses in the country. In addition, an undergraduate program for midwifery and a cadre for public health nurses should be introduced.

In the era of the 21st century, nurses are the heart of a medical facility, supporting the transition of the patients through their healthcare journey. Throughout the patient's experience, the nurses are the foremost individuals present to cater to every need of these individuals. This profession is beyond respect, compassion and dedication served by each of these specialized professionals that are continuously addressing new rising concerns of the patient, technology alignment and attending different programs to understand ongoing critical health issues of the public.

The rise of COVID 19 has devastated many people across the globe leading to an upsurge in mental, social and psychological health. As reported by the World Health Organization, among 213 countries affected,  5,596,550 cases and 353,373 deaths were registered, respectively. Whereas according to the Government of Pakistan, to date, 85,264 positive cases and 1,770 deaths are reported in Pakistan. The turmoil of COVID 19 changed the viewpoint of many health-seeking behaviors and determinants of healthcare.

The writer is an educator at the private college of Nursing in Karachi, Pakistan. He found at ameetkumarnsn@gmail.com