The care-giving profession - expectations and realities

In November 2024, I started working with a nursing college. Initially I did a quality improvement exercise, evaluating their community health program and auditing some of their lectures and practical classes in the college. Over the past four months I have gained a deeper understanding of the politics of the care-giving profession. In the 20 plus years of my career as a physician, I have had the opportunity to closely work with nurses. Over this long association I have developed a deep and enduring respect for the nursing profession because I have seen how the nurse holds the burden of running the entire hospital ward on her shoulders. It is her grounded and constant presence in the hospital that keeps the work running seamlessly. At the same time I have also seen and understood how she is always treated as a second-tier citizen within the hospital ecosystem. The doctor is venerated as the hero of the medical enterprise and the nurse is often placed in a supporting role. Given this power dynamics, I have also observed how the nursing cadre is highly regimented and hierarchical. They are required to follow this rigid hierarchy and protocol so that they can defend their own honour and navigate their work and life within the oppressive hospital environment. 

I vividly remember an encounter I had as a second year post graduate trainee. I was on hospital duty that day. Hospital duty involved attending to all the 110 beds which included general ward, pediatric ward, obstetric ward, labour ward and post operative ward. In addition I also had to attend to emergency calls in the casualty department. It was a particularly busy day with a 100% bed occupancy and a very busy casualty. I was running around all day from 7 AM and then all night and when it was time to hand over the duty at 8 AM the next morning, I was exhausted and hungry. At that time a young staff nurse kept coming to me demanding that I write the delivery notes on a labour I had assisted the previous night. I had forgotten to write the notes as the night was busy with multiple deliveries. She caught me in a particularly vulnerable moment and I shouted at her, "Sister, will you stop nagging me for the notes. I will not be able to write it now. Go and ask the intern." The nurse immediately broke down and started crying. She dropped everything on the table and ran to the nursing superintendent. She was immediately removed from the labour room posting and posted elsewhere. I handed over the duty and left to my room to freshen up. I came back to attend to the out patient clinic that morning, and around mid morning I got a call to the office of the head of the department. A complaint had been filed against me for harassment. I had to face an inquiry and I then gave a letter of apology to the nurse and they ensured that I also attended counselling for anger management in the department of psychiatry. I am narrating this episode to emphasise the good practices and policies in the institution where I worked. They had such mechanisms in place for nurses, that would defend their honour in the hospital environment and protect them from the abuse by doctors like me (I have changed a lot since then. I try my level best to avoid shouting at people). In most hospitals I have worked before this one and after, such mechanisms do not exist. Nurses are subject to oppression and treatment as second-class members of the medical treatment team. 

Last year I read a book on the politics of the nursing profession by Maya John and Christa Wichterich titled "Who cares? Care extraction and the struggles of Indian health workers" The book very poignantly captures the social reproduction phenomenon which refers to how the gendered caregiving role ascribed to women in the society is reproduced and reflected within the hospital environment. Just like how the home-maker is not valued for her care-giving role as a mother, wife, daughter or sister, the staff nurse in a hospital is not given due respect and value for her services to the patient. The society fails to see care-giving as a professional duty. They equate it to the care that is provided by the mother, wife, sister or daughter at home, often unpaid and often thankless. I was witness to a very interesting conversation yesterday during the governing council meeting of the nursing college. A few senior members were discussing their personal experiences with home-care nurses who were attending to their ailing loved ones. One senior member said, "The nurses are hired from this ABC hospital. They wear beautiful uniforms. Nothing else other than the uniform is good. I went to visit my brother in law who is ill. I asked the nurse to fetch me a glass of water. The nurse failed to budge. My brother in law then shared water from his flask for me to drink and said that the nurses won't fetch water for guests. Their duty is only to care for the patient. Everything else will be considered as domestic violence." The member was disgruntled by the quality of 'care giving' by the nurse. To this another senior member added, "Yes, the quality of home care nurses is appalling. They are all always on the mobile phone either watching YouTube videos or chatting with someone" Another member of the council who had recently been hospitalised and just discharged from the hospital shared her experience of nursing care that she received. "The nurses in XYZ hospital are excellent. They are not allowed to use their mobile phones during duty. But they are extremely caring. They are disciplined and well mannered" This conversation made me quite uncomfortable. I did not understand it immediately. But then as I was going back home from the meeting, I had time to reflect on this. This discussion that I witnessed was a perfect reflection of social reproduction. The 'care giver' is seen as the compassionate, benevolent, kind, self-effacing 'woman' who is 'disciplined' and 'obedient' with a 'smile on her face'. That is the nourishing role that the society ascribes on the 'ideal woman', the 'benevolent mother'. This society fails to see the normal ordinary woman next door, with her own household struggles, financial challenges, family responsibilities who has donned the uniform of a nurse and is standing there to deliver a professional service. These people appoint home-care nurses because they or younger members of their family do not have the time or patience to provide care to the sick and ailing in their homes. If they stop for a moment to think about what the home-care nurse must be going through, they wouldn't judge her for speaking on the mobile phone, or for refusing to fetch water for every visiting relative. Care givers have always been taken for granted. But there is no need for women in care-giving professions to tolerate being taken for granted anymore. 

During the process of carrying out the quality improvement audits in the nursing college I had an interesting observation. There was a lot of emphasis on discipline and decorum. The place did not look or sound like a college campus at all. It was totally quiet and orderly throughout the day. Even during tea breaks and lunch breaks the usual cacophony of youthful chitter chatter that is typical of any college was missing. I understood through discussions with students and teachers of the college that there was a high emphasis on discipline and code of conduct within the college campus. Mobile phones are banned inside the campus. Violation of codes of conduct would invite strict punitive action. I was wondering all along about this kind of enforced discipline bordering on oppression. But in the context of the discussion that I witnessed about the 'quality' of the home-care nurses yesterday, I can imagine how people who run such a college would enforce such strict discipline. Nursing colleges largely function as manufacturing units of obedient second-class labourers within the hospital ecosystem. Second-class labourers who will not dare to challenge the 'orders' given by the doctors, who will not dare to think of treatment decisions and plans and who would obediently carry out the 'orders' given by the doctors. At the end of my quality improvement audit, I gave a rather scathing review to the management and faculty of the institution requesting for liberal use of mobile phones in campus, relaxation of strict punitive action, and less emphasis on regimented life. I also advocated for an open and liberal thought within the campus and promotion of critical thinking and analytical reasoning among the students. This was not received well initially and there was denial and debate about these reviews and recommendations. I cannot blame the college fully. They are catering to an employer market that wants nurses who are obedient and do not think too much! I now have a small window of opportunity to interact with the nursing students in the college. Maybe I can try inciting some critical thought! One student at a time!