Why injecting more nurses in public hospitals can lead to a decline in quality of care: Case study from Bangladesh
Background: The World Health Organisation monitors the ratio of nurse to population globally. In 2017 theNetherlands for example, reported employing 111,043 nurses per 100,000 population, Indonesia 20,583, India 21,071 and Rwanda 8,307. Bangladesh falls behind with 3,067 (ref). The tasks expected to be provided by nurses in public hospitals vary from country to country but usually include provision of basic personal hygiene, basic ‘nursing’ activities, following doctors’ orders and monitoring of the patient’s condition (Duffield et al 2008). The Bangladesh revised nursing curriculum and its predecessor reflect these expectations (Bangladesh Nursing and Midwifery Council, 2018).
Findings: However, a time and motion study conducted in 2004 in selected public hospitals calculated that nurses spent just 5.3% of their time on ‘direct nursing care’ (Hadley & Roques 2007). This reality was, however, contradicted by the rhetoric given by the same nurses during interview, thus indicating that nurses were aware of their roles and responsibilities. A follow-on study (Hadley et. al., 2007) was designed to identify the underlying factors to this time-use pattern. Its findings indicated that the ‘Western’ model of nursing, introduced in Bangladesh (then West Bengal, during the colonial period contradicted four fundamental social and cultural norms. Bangladeshi nurses are predominantly female. Cultural norms dictate that women should not travel outside the homestead unaccompanied by a delegated male (father, husband or other assigned male) and especially not during night hours. Women are not expected to touch or communicate with people outside the household nor touch bodily fluids (considered ‘dirty’). As a result of these conflicts with the prevailing expectations of women’s conduct, the study found comparisons linking the nursing profession to that of sex workers. Both occupations require contact with strangers, especially men, outside the secure environment of the homesteadand at night. Nurses in public hospitals, therefore, adapted their behaviour to construct a ‘homestead’ within the ward. The nurses’ station, where nurses spent most of their time on the ward, became the homestead substitute while the patients’ area represented the public space. The importance of ‘paperwork’ (53% time use) condoned the excessive amount of time spent at the nurses’ station; all the more interesting sinceall ‘paperwork’ was in English while nurses did not speak, read or write in English. Standard text was copied from the previous day’s entry and fromone patients file to another. Efforts were made by the nurses to maintain the status quo. Any nurse who attempted to disturb the well-established ward ‘norm’ and wanted to ‘nurse’ was strongly discouraged from doing so at risk of being ridiculed, physically assaulted or shamed. Meanwhilethe patients, their relatives, the cleaners or porters and doctors carried out the tasks normally expected of nurses.
Policy implications: The Western concept of nursing was introduced into Bangladesh without consideration of the prevailing norms pertaining to women’s behaviour. The authors concluded that injecting additional nurses into the wards of public hospitals in Bangladesh is unlikely to increase the quality of care. Conversely, posting more nurses on a ward are likely to deter any nurse who does want to ‘nurse’. The morenurses working on a ward the lesslikely nursing care would be provided to the patients. Should we be adapting societal norms into the Western model of hospitalcare or designing health care systems to adapt to the prevailing social norms
