Title : Nursing distress

 KR Dhanya grew up admiring Florence Nightingale, the founder of modern nursing. It was a dream come true when in 2007, she became a nurse after completing her graduation. But, now, Dhanya wonders if it was the right step.

The 30-year-old has been working as a nurse at a private hospital in Kannur, in northern Kerala, for nearly a decade. Her shift at the hospital lasts eight hours, most of which is spent standing or running around. There is little time for food. Till recently, the shifts were longer. But that is little solace for the meagre salary. Dhanya earns ?14,200 a month, including allowances.

The future doesn't look promising either. Dhanya married recently. Her husband works in a private firm, and the two want to have a child. But Dhanya is worried about the expenses.

“Maybe Nightingale showed the divinity of this noble profession. But we are a distressed lot in this God's Own Country, literally on a war path to get our eligible, minimum wages as fixed by the Supreme Court,” she says . Dhanya’s hopes soared in July when the month-long agitation under the banner of the United Nurses Association and the Indian Nurses Association made the Kerala Government intervene and ask hospitals to implement the Supreme Court order to pay nurses a minimum monthly salary of ?20,000.

Dhanya and over a lakh of her peers heaved a sigh of relief.

But three months on, private hospitals are yet to implement the revised pay scale. The four-member committee comprising secretaries of Health, Law, Labour and the Labour Commissioner submitted its report in the last week of August, recommending the need to implement the Supreme Court order. Now, the Kerala Government has to come out with a notification.

It's not going to be a smooth passage. The Association of Healthcare Providers (India), which represents the hospitals, has questioned the rationale of the hike (see The scare of a bigger wage bill).

According to hospital managements, they were not a signatory to the deal.

Also, they could not implement the new wage structure unless the Minimum Wages Advisory Board gives the green signal.

The promise

Dhanya grew up in Kannur listening to rags-to-riches stories of families whose women members had become nurses, got jobs overseas (mostly in West Asia) and sent back money. Small houses were replaced by villas, and lifestyles changed dramatically. It was a story that was common in Kerala, from where nurses had started venturing out from the 1970's.

Dhanya also hoped to do the same.

But the path is a difficult one. Every year, 11,000 new nurses pass out from 99 colleges in Kerala. While it is not very tough to get into these colleges, the courses can be expensive. While Dhanya's parents didn't have to give a donation, thanks to her good showing in high school, many have to shell out as much as ?1 lakh. A bachelor’s course in nursing can cost up to ?8 lakh. Many are forced to take an education loan in the hope of paying it back after they catch a plane to somewhere overseas. As it is clear, working in Kerala doesn't pay.

Vidya Ravi, a nurse from Kothamangalam in Ernakulam district, had similar plans when she took a loan of ?3.75 lakh to complete her nursing course from a local college. Her father had deserted the family, and her mother worked in several houses as a maid.

The first three years of her work life, Vidya was earning ?6,000 a month, half of which went to paying the EMI. A pay hike later, she shifted to a bigger hospital and her salary increased to ?12,000 a month.

Wedding and motherhood put a break on her career. "I want to start working now," says the 32-year-old who still has to pay back ?2.75 lakh of the loan. It was higher, but thanks to the State Government 's intervention in the form of a one-time settlement for defaulters, the outstanding loan amount has come down.

Most of these nurses take home about?8,000 a month, after deduction for provident fund, food and accommodation. The lucky few who manage to get employment in government hospitals are better off with a basic salary of ?28,900 a month.

Vidya hopes that work conditions will be better after the Government intervention to increase basic salary. Says her peer Dhanya: “Can you believe the annual increment of a full-time nurse in a private hospital is hardly ?100-150? Even the present monthly salary of ?12,000 was increased from ?8,800 in 2012, after a prolonged strike for better minimum wages."

Few dare to speak out for fear of losing their livelihood. Dhanya points out that many also keep quiet in the hope of greener pastures abroad after a three-year-term in a reputed hospital in Kerala, which helps to build their resume. Industry watchers say that 20,000 nurses from Kerala migrate overseas every year.

But the crisis in many of the countries in West Asia has made the region less attractive. Many Kerala nurses now prefer destinations such as Canada, New Zealand and some of the European countries. But there is a hitch again. The requirement to clear the IELTS exam, to get to these countries, adds to the financial burden of the nurses. The fee for the IELTS is about ?25,000.

The infrastructure

Given the circumstances, including the poor working condition in general and the burden of the loan EMI, the nurses agitation was waiting to happen, says KVA Iyer, a veteran trade union leader.

Kerala has 1,282 hospitals, ranging from those that have less than 50 beds, to super-speciality ones. Of the over one lakh nurses in the State, up to 10 per cent are male. But hospital managements, say industry watchers, prefer to employ women to seemingly reduce the risk of labour strife. But if the photos from the June protests are any sign, the hospitals might want think again.

The recent boom in the healthcare sector though hasn't helped nurses. EA Mohammed Shihab, General Secretary, Indian Nurses Association, points out the dismal nurse-patient ratio in hospitals to prove the point.

Those accredited by the NABH (part of the Centre's Quality Council of India) maintain a nurse-patient ratio of 1:4 in general wards and 1:1 in ICUs.

"However, in other majority private management hospitals, the ratio is 1:10 for general wards; and may extend to 40. But in government hospitals, the figure is a whopping 1:60," he says. "The demand-supply ratio is controlled by managements and there are even reports that some hospitals have stopped new recruitment in the wake of the strike," adds Shihab.

Though job prospects in the rest of the country has soared with hospitals mushrooming in cities and towns, that is little consolation for the nurses in Kerala.

Even their 'demand' in the State's marriage market seems to be eroding. There was a time when Kerala nurses were the preferred choice in matrimonial columns of regional newspapers. Marrying a nurse was seen as the most suitable gateway for jobless youths in Kerala to migrate.

"But the situation is totally different now,” says Shihab.