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The heart of a nurse: A glimpse into the profession in Maldives

On occasion of Nurses' Day, the hearts of local nurses which are filled with compassion and care for their patients are captured in this feature to illuminate their struggles and give a voice to the highly undervalued backbone of the healthcare professionals.

Aishath Shuba Solih
12 May 2024, MVT 11:22
Nurses employed at Hulhumale Hospital (HMH) standing in front of the Dr. N. D. Abdulla Abdul Hakeem Ophthalmology Centre located in Phase 1 of Hulhumale' City.
Aishath Shuba Solih
12 May 2024, MVT 11:22

The anniversary of the birth of Florence Nightingale – born in Italy on May 12 to British parents – was etched in history to commemorate the foundational philosopher of modern nursing.

One hundred and fourteen years later, the legacy of Florence, nicknamed ‘the Lady with the Lamp’, lives on within the thousands of professional nurses working day and night in hospitals to care for the sick today, much like the mother of nursing who walked among beds late into the night with a lamp for light, scanning the injuries of wounded soldiers during the brutal battles of the Crimean War.

Dubbed International Nurses Day (IND), May 12 now reveres the contributions of thousand of nurses world-wide in nurturing solid health care services for the population.

“The very first requirement (in a hospital) is that it should do (the sick) no harm,” said Florence Nightingale.

However, despite being termed critical pillars of the healthcare industry, challenges faced by nurses remain largely undermined amid the precedence conferred to provision of quality patient services.

2024 IND Theme: Our Nurses. Our Future. The economic power of care

In setting the theme for this year’s International Nurses Day, President of the International Council of Nurses, Dr Pamela Cipriano stated that financial crises have repeatedly enforced budgetary restrictions onto the healthcare sector, often at the expense of nursing services.

This statement not only cites the concerns of nurses world-wide but also iterates a fraction of the unease nestled within the nursing community in the rural city of Hulhumale', Maldives.

More often than not, misinformed civilians raise their objections over halted healthcare services with exposed hospital caregivers or reception clerks. Unnerved that basic equipment such as emergency drugs are quoted out of stock, confused civilians demand their right to continuous health care, oblivious to the practicalities that lead to this outcome.

As affirmed by a Ward Manager at Hulhumale' Hospital (HMH), Aminath Muslima, a significant portion of the hospital’s budget was cut down this year under a cost containment strategy, ultimately leading to a lack of human resources as well as uninterrupted streams of medicine import. This comes amid a time when the country’s economic finances are in prospective peril with local news media outlets reporting statements by the International Monetary Fund (IMF) signaling high risk of debt distress early February.

“When there are more costs, the basic needs of health sector are cut down. Staff cannot be offered the alleviations mandated in the regulations due to understaffing,” said Muslima, the Ward Manager of Medical, Pediatric and Surgical units at the HMH.

Patient outcomes is decisively linked to the satisfaction of nurses. Research conducted by the National Institute of Health (NIH) corroborates this and further suggests the pivotal role of nurses in retaining the quality of treatment and surveillance system of the hospital as the root cause of this association. While nurses are widely coined as the backbone of the healthcare industry, restricted access to stipulated eases and coercion mandating longer hours now habitual due to a lack of hands raises salient concerns over the contentment rates of nurses in the country.

A local nurse administering care to a patient admitted at the hospital.

Time constraints amid increased demand

Early in the year 2015, the second phase of Hulhumale' City was reclaimed and in 2021, the Hiya Flats were established. These flats now accommodate a general population of over 22,800 civilians according to surveys conducted by HDC in 2022 and with the increase of additional housing units such as the Vinares Towers and housing flats of State Owned Company (SOE), the total population of Phase 2 is substantially higher. With this rose a high stream of strenuous demand for the Hulhumale’ Hospital which remains the sole public healthcare facility established in both cities; Phase 1 and Phase 2.

However, despite the outpatient increase, the number of patient beds remained the same for 20 years with nothing done to cater to the drastic shift in demand. Workload for nurses are increasing as a result and the staff shortage has resulted in restless duty hours, with nurses working a minimum shift of 9-10 hours to cater to the demand.

While staffing guidelines for registered nurses mandates an eight hours routine shift, this stipulation is buried under remnants of articles prescribed with necessity.

Nursing is a profession that requires unrelenting determination in addition to an elementary trait to simply enjoy offering heart-felt care. It entails true compassion towards others and a devotion to provide a continual therapeutic presence. The profession is structured to nurture and heal but the question remains; are the wellbeing of nurses and their fundamental rights maintained in their drive to effectively manage patient care amid such pressing circumstances?

“The girls work nine to ten hours minimum without a proper break. The level of understaffing forces nurses to neglect their own health, their basic rights, to proceed their work. Some go without restroom breaks the entire shift. I myself finish a shift and only then does it hit; I wonder how I could have gone this long without a bathroom break,” said Muslima.

Posed a question on the root cause of undervaluation surrounding the profession, she highlighted this factor. Elaborating that constraints of time resulting in overwork contributes to diminished quality, she remarked that time is essential to generate satisfied customers.

The aforementioned study by NHC confirms that overburdened nurses lead to distraction, depleted motivation, along with the drive to execute the job carefully.

In order to sustain the nurse-patient ratio, nurses are required to make sacrifices, consequently unable to find a balance between their individualistic person and work. More often than not, their families are neglected and external support in retaining a thin balance remains relatively scarce. Muslima highlighted that most of the nurses employed at the facility are of child-rearing age, all entitled to maternal leaves of six months. However, a solution to replace the void left by a new mother is not feasible due to the staffing shortage and budget deductions which negates the possibility of expanding personnel.

Gratification of nurses as well as their own health must be considered in order to nurture a balanced environment for quality services, particularly with the weight held over patient fulfilment.

“When nurse‐to‐patient ratios are reasonable, coworkers can assist each other and nurses can avoid excessive overtime, thus fulfilling innate needs for competence. On the flip side, when staffing is insufficient, nurses are overburdened during each shift, under‐resourced to do their job, and may feel obligated to work extra shifts.” –Study on The Effects of Nursing Satisfaction and Turnover Cognitions on Patient Attitudes and Outcomes compiled by the National Institute of Health (NIH).

Hulhumale Hospital (HMH) located in Phase 1 of Hulhumale' City.

An overtime cap embroiled in conflict

The recently implemented pay framework for nurses (enforced on May 21, 2023) has instilled nearly as much concerns as it did gratitude. Questions on the feasibility of this framework are springing among nurses and civilians alike, mostly focused on a singular feature engraved in the structure.

Speaking on behalf of nurses under her management at the Hulhumale' Hospital, Ward Manager, Muslima stated that the framework in itself is valiantly structured. The fresh regulations followed defined new areas of specialization in recognition of a lack of nurses in these areas, which produced additional job posts and expanded career prospects. The new framework further observed a pay hike for nurses and the overall health sector, achieving pay harmonization sought by the government, albeit at an inexact sense. While the raise in remuneration proposed prominent improvements for managerial level nurses, regular duty nurses –although advantaged—were noticeably deprived in comparison to their senior counterparts.

Moreover, Muslima also underscored the vacant seats of multiple added positions due to financial and staffing constraints despite promotions and higher stipend being a fundamental need required for a fulfilled life. Special areas categorized in the framework are unimplemented til present such as the university taught specialization programs despite a completed course outline. She further emphasized the urgent need for the Maldives National University (MNU) to commence the promised courses, maintaining that this deprivation has induced countless bereaved promotions.

However, the most pressing concern encircling the recent pay framework is the well-intended overtime cap. Initially employed to presumably abolish the habitual overtime practice in the nursing profession, this stipulation argues that healthcare workers cannot exceed overtime past ten percent of their basic salary.

Nevertheless, nurses continue to be subjected to overtime beyond the scope specified in the framework and as a result of this clause, without compensation as well.

“The inadequate ratio of healthcare workers to patients necessitates healthcare personnel to exceed the 10 percent overtime threshold specified in the pay framework,” wrote Maldives Health Professionals Union (MHPU) in a post on social platform X.

This statement remains true for healthcare workers in the nursing profession. This conduct further breaches the Maldives Employment Act and also violates international agreements endorsed by the country.

“Nursing is not a job that can be finished on time, it is not like working in an office. This profession involves sick patients and saving their life. The overtime cap is not appropriate for this field. The administration needs to understand that the best service is given by a fulfilled nurse and demotivated nurses cannot offer the best quality of services,” said Muslima, Ward Manager at HMH.

She stated that while the framework consists of feasible alterations, the overtime cap is the only cause for severe dissatisfaction among employees in the profession.

“I don’t believe nurses are people who will stay longer just to collect some overtime.”

Muslima shared that the new framework has stipulated eleven days as holidays, which unduly stripped holiday benefits from any day that transcends this threshold, including weekends.

Moreover, addressing the recent conflict aroused due to restricted pay despite performance of work during the recent 10 days of Ramadan dubbed a holiday by the government, the Ward Manager revealed that the nurses were offered remittance solely surrounding attendance.

The singular drive to administer care: Is it gender specific?

Nurses are the advocates for patients. They are the closest companion and the observer constantly surveilling for prospective risks. They educate, supervise and monitor patients all while assisting in surgeries and collaborating with other teams in instances of urgency.

The majority of local nurses despite assigned to a single department are strung across all areas of care due to inadequate staffing. They further coordinate the treatment of allocated patients and offer home-based healthcare as well. Also active in roles of research and spreading awareness through verified information gathered from scientific studies and reports, nurses are also mandated to initiate activities to educate and advance the healthcare system. They ensure patient safety and shelters patients from critical and non-critical falls.

While all these roles require energy and strength, the harm of the archaic stereotype confining administration of care solely to females has come to light. A gender-balanced facility (or close to it) assists in creating a more stabilized landscape while further nurturing an environment better equipped to facilitate quality healthcare.

Addressing this gender stereotype, Muslima declared that manpower is essential in the field of nursing and attested that despite a near balanced male-female ratio of nursing overseas, the profession has not seen much male participation in Maldives.

“This field needs men as well. It may have been labeled as a female-centric profession due to the caretakers of the past also being women. Florence Nightingale [the founder of modern nursing] was also female. So there’s a heavy stigma surrounding this. There are about one or two boys in a batch. But energetic boys with strength in their bodies are very much needed. I encourage men to choose the nursing profession.”

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