COMMENT: Nurses and medical care —Dr Syed Mansoor Hussain

In Pakistan, nurses are very much the ‘invisible’ face of medicine. Unless we can empower nurses and the nursing profession, we will never be able to improve the quality of healthcare available to our patients

International Nurses Day was
celebrated on May 12. Unfortunately, in the largest hospital in Lahore no celebration or commemoration took place that I know of. Over the last year, much has been done about the rights of women in general and those in the workplace. Interestingly even today, nurses are probably the single largest group of female professionals in Pakistan and yet there has been no discussion about their rights and how they are treated.

There is much said and written about the quality of healthcare available to ordinary people and also about the state of our hospitals. Yet virtually no mention is ever made about the quality of nursing care that is available. Based on decades of experience in medicine, I can safely say that the quality of nursing care essentially determines the quality of general medical care.

In Pakistan, nurses are very much the ‘invisible’ face of medicine. Unless we can empower nurses and the nursing profession, we will never be able to improve the quality of healthcare available to our patients. Perhaps if we revisit the unfortunate case of little Imanae, we might find that the nurse on duty told the doctor that he was giving the wrong medicine and yet he insisted that the nurse give the child the injection he ordered. If the nurse was empowered to say no, things might have turned out differently.

I still remember vividly a time when I visited Pakistan trying to decide if I wanted to return to Pakistan to practice cardiac surgery. That was not to be. Nevertheless, of the places I visited the one that left a lasting impression on me was the Aga Khan Hospital in Karachi. The hospital was still being built, and the medical school still a distant dream. But the first thing being started was a nursing school. That perhaps is the real secret of the success of that institution.

Why are nurses so invisible? Well, for starters most of them are women and once upon a time most of them belonged to a minority community. Things have changed considerably and today most nurses are from the majority religious dispensation though many still come from relatively modest backgrounds. During the time I have worked in Pakistan, I must admit that the nurses working in our hospitals are definitely much better educated and trained than those that I worked with before leaving for the US.

Most people in Pakistan have no idea how important nursing care is. I still remember when a lifetime ago I started my house job in Mayo Hospital in Lahore; it was a nurse who taught me how to give an intravenous injection! And when I started my internship in the US, it was the nurses who taught me the basics about how medicine was practiced in the US. They were the ones who prevented me from doing anything stupid. Yes, I knew more medicine but they knew more about patient care.

Nurses have three very important roles. They are the primary providers of patient care, they are the intermediaries between doctors and patients, and they are the patient’s advocate. It is always the nurse that tells the doctor that the patient is not doing well. Most people think that nurses just give out medicines and check the patients’ ‘vital signs’. But the reality is much more complex.

The first thing we have to accept is that nurses are also healthcare professionals who have spent a minimum of four years in nursing school before they start their nursing careers. Also, many of them have accumulated years of experience, often in demanding specialties. For instance, in most intensive care units (ICUs) that I have worked in, the nurses have often been around for years while the junior staff, which includes most residents, come and go after a few months or perhaps a year. When I need to know how a patient is doing in a cardiac ICU, I first ask the nurse about the patient.

All this does not mean that nursing as a profession is doing well; better, but not well enough. Most nursing schools are still teaching outdated syllabi, there is no formal continuing education process available to them, and sadly they are still treated as second class members of the healthcare team. Changes will have to come from within the profession as well as from physicians and other healthcare providers.

The single most important thing must be an improvement in the quality of education they receive as well as the training imparted to them during nursing school. Also, continuing education programmes must be instituted in all major hospitals. Nurses must undergo advanced training before they are allowed to work in ICUs and operating rooms. For general nursing cadres, continuing medical education programmes should be instituted so they can keep up with newer techniques and advances in medical care.

Most of this educational activity will have to come from within the nursing profession. Physician educators can at best provide some advanced teaching but it is very difficult for the physicians to oversee basic education for the nurses working in their wards or operating rooms. Also, nurses are not just ‘lesser’ physicians but rather members of a distinct profession that encompasses a lot more than handing out pills and checking temperatures and blood pressures.

As far as physicians are concerned, they have to accept the idea that nurses are professional colleagues and deserve respect as such. They must realise that the diagnosis and treatment of disease is not the only thing. Somebody has to actually look after the patients and cater to their overall needs as well. And that is what the nurses do.

Patient care is a collaborative effort that is usually led by a physician but a physician alone cannot do everything necessary. A well trained and caring nurse is at times more important for a patient than even the best doctor.

Syed Mansoor Hussain has practised and taught medicine in the US. He can be reached at smhmbbs70@yahoo.com