“I am feeling very depressed because young people with no comorbidity are dying. So, in one night, five people expired and when I came back and was trying to sleep. I couldn’t sleep because I was just seeing their bodies. I was tensed. Now I am relaxed as cases are dropping. Earlier I wasn’t getting sleep, I was unable to sleep,” shared a nurse who worked in COVID-19 wards recently. This was not an isolated anecdote, but a common lament across the country this year.
India has been among the worst-affected countries during the COVID-19 pandemic, especially after the first wave. During the second week of June 2021, out of the 734 districts, 143 districts have a test positivity rate of over 10%, and the second wave peaked on May 8, 2021, to 391,232 cases.
The entire situation had overwhelmed the existing healthcare system.
As it is, our healthcare system has traditionally been limping due to infrastructure gaps and poor healthcare worker (HCW) to patient ratio. According to NITI Aayog’s SDG India Index Report (2020-2021), only eight states have achieved the target of 45 as set by WHO for the number of skilled healthcare professionals per 10,000 population. This poses serious concerns to the stressed health systems which have been further exacerbated by the demands of the COVID-19 pandemic. According to a few studies, the risk of HCW getting infected has increased 11 fold as compared to the general population. This increased risk is on account of strained contact conditions with a high level of exposure from COVID-19 infected patients, which could lead to deaths of HCW in worst-case scenarios. Front-line HCW are exposed to hazards which include exposure to the virus, long working hours, burnout, fatigue and psychological challenge with a potential negative impact on their health.
Such experiences lead to mental pressure on the HCW and their lived experience becomes a battle of life and death on daily basis. While there is ample discussion on the fatigue faced by the HCW the sole focus of this on nurses have been overshadowed.
The COVID-19 pandemic has thrown HCW especially the nurses into the deep by designating and deploying them as frontline workers; they need to attend and manage people who tested COVID-19 positive in the hospital setting. The nurses faced the challenge of providing proper nursing care to patients by knowing very well the high risks of getting infected themselves, and the fear of becoming diseases carriers to their home and family members. Meanwhile, the fear of sudden and untimely deaths drove patients and their family members into a state of panic, and this getting transmitted to, and cause undue stress to the HCW. No way poor nurses could meet their unrealistic expectations. On top of that, health systems were ill-prepared to respond to the need of the hour causing confusion, chaos and a less-than-optimal level of management. The National Human Rights Commission’s advisory on Right to Health in the context of COVID-19 dated September 28, 2020, mentioned humane working hours for Healthcare Workers, but against rising positive cases, it was difficult to achieve in reality. Even though the healthcare providers were working on the roster, their working hours were overwhelmingly strained inducing stress.
There are limited studies done to understand the experiences of nurses as caregivers directly attending to infected and critical COVID-19 patients. To name a few, Suryavsanshi et al (2020) in their study, ‘Mental health and quality of life among healthcare professionals during the COVID-19 pandemic in India’, found that work environment was associated with increased risk of depression and anxiety; another study on ‘Feeling the Early Impact of COVID-19 Pandemic: Mental Health of Nurses in India’ found that the odds of having depression, anxiety and stress were lower in nurses who have not been posted for the care of confirmed or suspected COVID-19 cases (Parel et al 2020); Parthasarathy et al (2021) in their ‘Mental health issues among health care workers during the COVID-19 pandemic – A study from India’ reported HCWs with anxiety disorder were more likely to be doctors/ nurses/hospital assistants, older, female, unmarried, without a leisure activity, who reported increased alcohol use and suicidal thoughts after pandemic onset and having a history of receiving mental health interventions.
In one of the discussions with the HCWs on their experiences during the pandemic, nurses highlighted: “Very different experience in COVID. During the first wave, we were disappointed because we were not provided with PPE kits, gloves, N-95 masks. This is the reality I am telling you that on paper it is shown that all health benefits are given but only we know how we have managed. Still very difficult times. Also, last year I had scars on my face and chest due to N95 masks.”
“To work in direct contact with contagious, infectious disease, PPE does make me feel secured to work freely. But it’s a challenge for you to make yourself comfortable and adapted to wear PPE for long hours without much disturbance to your work. The sweats, invisibility, pain, headache, body ache, exhaustion, the urgency to pass urine, thirst, hunger, dizziness.”
India does have a mental health policy that takes cognisance of mental health, not merely reducing it to a disorder, but believes it as an integral part of overall health endeavour. Pertinent psychosocial challenges being faced by the nurses are evident but what is required is psychological support to them which has to emerge at the workspace and extend to a personal level. It could be in the form of counselling, training and crisis support unit within each hospital. Furthermore, the hospital management should take cognisance of limited infrastructure adding to the stress of HCW and make provisions for addressing equipment shortages for their safety. The focus should be placed on improving the HCW to patient ratio to a reduced burden on nurses.
Nurses are the backbone of the Health care system round the clock. If they are not supported, the system cannot bear the weight, and it plunges.
The Author is Advisor, Health Transformation, Advisor – Digital Health and In-charge, North East States at the Public Health Foundation of India ( with inputs from Ravneet Kaur, Senior Research Assistant, PHFI)
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