How Inadequacies in the Nursing Field Deteriorate the Quality of Health Care in a Developing Nation
Shuvashish Das Bala1, Moustaq Karim Khan Rony1*,Priyanka Das Sharmi1, Ishraq Rahman1, Mst. Rina Parvin2, Tanzida Akther3
1College of Nursing, International University of Business Agriculture and Technology, Bangladesh
2Combined Military Hospital, Sylhet, Bangladesh
3 Department of Economics, Pabna college, Bangladesh
*Corresponding Author:Moustaq Karim Khan Rony Email: [email protected] ABSTRACT
The purpose of this article is to describe the factors responsible for the decline in the quality of care in the health sector of Bangladesh. A significant aspect of the health system is nursing. Service quality largely depends on the nurses. Over the past decades, nurses have faced a variety of parameters that are hampering the quality of service in the Bangladeshi health sector. Negative social attitudes, lack of developed organizational structures, insufficient leadership skills, lack of employees, and lack of appropriate nursing opportunities cause work dissatisfaction, and this job dissatisfaction has a negative effect on the quality of health care. The quality of care will be ensured by ensuring the rights, independence, and adequate facilities of nurses.
Keywords
Job Dissatisfaction, Health Sector, Quality of Service, Parameters, Bangladesh.
Introduction
Quality Nursing Care Scale (QNCS) is linked to organizational infrastructure. QNCS is necessary to identify nursing defects in the clinical setting (Liu et al., 2021). The implementation of QNCS requires an improved organizational infrastructure. The application of QNCS is rare in developing countries. Because of quality standards are there where nurses are satisfied with their work and the causes of nursing dissatisfaction are low and the quality of nursing care is at a standard level.
Nursing was first introduced into Bangladesh in 1947, decades before it became the independent country that it is today (Hadley & Roques, 2007a). Since then the sector has definitely evolved, although many of the advancements of more developed countries are yet to be incorporated into the systems. At the heart of the healthcare environment are nurses. Nursing is a self-explanatory profession, it is not a subservient profession, but it is proportional to the medical profession (Nightingale, 2010). The key and distinctive point of treatment in their community is nurses. The power in every health sector is nurses. In the war against an epidemic, nurses play a leading role.
The importance of world nursing is clearly illustrated in this COVID-19 epidemic situation (Gunawan, 2020a). Job satisfaction has a positive effect on the quality of care (Kwak et al., 2010). And patient satisfaction also depends on nurses' job satisfaction (Gunawan et al., 2020).
Also, nurses need to work independently and create an environment where nurses can share their opinions, participate in decision-making, and provide a unique work environment for providing high-quality care.
One of the key challenges faced by heath sector in Bangladesh is that there is a huge shortage of nurses. According to (Mahmood 2012), even in the last decade, Bangladesh had a deficit of about 140,000 nurses. Hence, Bangladesh was one of the countries with the worst nurse-doctor ratios.
This has a detrimental impact on the overall services provided by the country’s healthcare system. In this paper, we will look at what causes this staggering low number of nurses in the workforce by discussing the reasons for job dissatisfaction among the nurses.
The Parameters that cause work dissatisfaction for nurses in Bangladesh
Negative Views Toward Nurses
Nursing services in Bangladesh have been neglected forever (The Daily Star, 2020). In our nation, nursing is recognized as a second-class job. This low value and social identification prevent bright learners from joining this profession (Ahmed, 2019). In particular, as a nursing profession, women are seen negatively in social terms. The marital status of women nurses is lower than that of other girls in society. For any woman, night duty is deemed bad. Also, local leaders treat them (Hadley et al., 2007b). While nurses in this COVID-19 epidemic situation in Bangladesh are the front-line fighters, they are neglected (Mosharef, 2020). However, the Bangladesh government is creating some first-class posts for qualified nurses and new meritorious students are coming into the profession positively.
Organizational Uncertainty and Lack of Supervision Skills
The lack of organizational support leads to major effects of work instability for nurses. Some of the reasons for disappointment with the work of Bangladeshi nurses are also poor nursing supervising abilities and their non-cooperation (Bishwajit, M., et al., 2016). Our nursing supervisors in the clinical setting are unable to provide adequate support to nurses if they are adversely affected by physicians or even relatives of the patient (Akter et al., 2019). Several foreign-national partner hospitals in our country are providing quality care because the nurses there are trained by international nursing specialists.
Workload and Stress at Work
The lack of nurses in the clinical area creates an incredible workload (Chang et al., 2013). That creates dissatisfaction in the work of nurses. In addition to disrupting healthcare, there is a huge shortage of nurses in Bangladesh (Joarder et al., 2020). Excessive workloads reduce the satisfaction of the job. The reasons for job dissatisfaction are additional job stress. Work dissatisfaction due to work stress leads to bad mental activities that affect work control (Tatsuse
& Sekine, 2013). Also, Bangladeshi nurses face various causes of work stress due to a poor work environment (Das et al., 2019). Thus, along with nurse staffing, care environment resources must be developed to maintain quality of care. (Aiken et al., 2008)
Scale of Wage
A graduate nurse's average salary is 15,700 BDT per month. In Bangladesh, the salary of a nurse-
midwife ranges from 11,900 BDT (minimum wage) per month to 41,300 BDT (maximum wage) per month (Salary Explorer, 2021). Only a few international non-governmental organizations give more than forty thousand BDT a month. It is difficult to maintain their monthly living expenses for nurses who receive less than 30,000 BDT. The main reason for the dissatisfaction of nurses with their jobs is this low salary because of Salary satisfaction is the key to job satisfaction (Gunawan, 2020b).
Nurses' Defense During COVID-19
In this epidemic situation, Bangladeshi hospitals provided substandard and inadequate PPE for the nurses. Likewise, the mask provided as KN-95 was not original (Akter, 2020). Nurses are worried that when caring for patients with highly infectious diseases such as COVID-19, most hospitals are not in a position to have the requisite personal protective equipment (PPE). The nurses have cared for cough and fever patients without PPE. The hospital does not have any residential facilities for nurses who work with patients affected by Corona and there is an incentive for family members of affected nurses. The nurses’ claimed that the lack of adequate PPE is raising safety concerns for them, as the number of coronavirus-infected patients in the country is increasing every day. Hospital authorities refused to pay their PPE as nurses at private hospitals resigned. Nurses are getting lower priority in terms of security despite providing maximum services to the people. "It would be suicidal to serve people without any protection during this epidemic” (Prothom Alo, 2020). Thus, Bangladeshi nurses are disrespected by the authority’s day after day. These parameters make the nurse dissatisfied and also hinder the quality of care.
The relationship between job dissatisfaction and declining quality of care
Inpatient satisfaction is significantly and positively associated with the general job satisfaction of nurses (Tzeng & Ketefian, 2002). Work dissatisfaction can have a negative effect on the relationship between the patient and the care provider and affect the quality of treatment (Gillet et al., 2018). Because of low facilities, and a poor working environment, a high percentage of nurses in Bangladesh are dissatisfied with their jobs (Al-amin et al., 2019; Rony, 2021). Job dissatisfaction is the key reason to reduce the quality of care which results in a feeling of negative attitude when nurses dislike their work environment and are annoyed at work (Senek et al., 2020). Job dissatisfaction reluctant to provide mental health support to patients because they themselves experience emotional dissatisfaction (Extremera et al., 2020). Excessive workload impedes the good practice of standard operating procedures (SOP) and Infection prevention and control (IPC). (Reda et al., 2010) Because a nurse is allocated for a minimum of 46 patients in a Bangladeshi government hospital with insufficient hospital resources (Mohiuddin, 2020). In this situation, it is not possible to maintain good SOP and IPC practices result in declining the quality of care. This also disrupts therapeutic communication between Physician-nurses and nurse- patients, leading to misunderstandings between healthcare providers, patients, and patient groups that hinder the quality of care (Maame Kissiwaa Amoah et al., 2018). Excessive work stress and
administrative negligence Nurses feel dissatisfied with their work which increases the nurse's work stress which in turn reduces the patient's adequate mental health support and reduces the quality of care to prevent a good relationship with the patient.
Figure-1 The relationship between job dissatisfaction and declining quality of care. (developed by authors)
Some of the antecedents of nursing services that reduce the quality of care
Therapeutic communication: Therapeutic communication aims to advance a patient's physical and emotional well-being. It is important to ensure interaction and cooperation in treatment.
Strategies of therapeutic communication to provide patients with resources and care. Proper therapeutic communication of patients by healthcare staff can reduce hospital service risks that improve service delivery (Amoah et al., 2019). This improves patients ’interest in their treatment and speeds up their improvement along with health engagement and quality of care. However, work stress and poor work conditions prevent nurses from therapeutic communicating properly.
Mental Health Support: Supporting each patient's mental health is an important part of nursing services. Because when a new patient comes to the hospital or clinical environment, they are emotionally confused. Nurses in these situations should be given adequate time for emotional counselling. If healthcare workers provide mental health support to hospitalized patients, it helps the patient to develop mentally and be satisfied with the quality of service (Shield, 2003). This is why the lack of nurses in the clinical setting prevents nurses from giving appropriate mental support to patients.
Standard Operating Procedure: An outline of the interventions required to ensure the quality of nursing services is a standard operating procedure (SOP). Standard operating procedures (Forsberg et al., 2015) meet the standard of service in the clinical setting. In any clinical setting, an SOP is performed if there is a good working environment, adequate resources, and adequate staff. This prevents performing SOP as there is a huge shortage of nurses in Bangladesh.
Infection Prevention Control: Good practice infection prevention control (IPC) is a crucial part of nursing services. Good practice of infection prevention coincides with the standard of service in the clinical setting (Kaier et al., 2012). This leads to patient protection. Due to poor working environment and inappropriate approach to clinical setting, Bangladeshi hospitals have a huge chance of contracting the nosocomial infection. Also, aseptic techniques are difficult to maintain in work overload situations
Figure-2 Quality of care components. (developed by authors)
Recommendations for policy-change and future work
In order to fully understand the underlying issues of the health sector in respect to nurses, more systematic research needs to be carried out. The research needs to acknowledge all the factors including financial aspects, organization, provision, and governance of nurses. Research like that can provide us with a comprehensive understanding of which areas are actually at fault so that the solutions can be focused at that. Additionally, a policy reform from the government level would improve the situation. To be fair, several policies are already in place that promote well-being of nurses at the workplace. However, the problem lies at the execution of those policies and hence a rigid framework is required that ensures the proper implementation of the policies. However, other structural changes should still be brought about by the relevant ministries. As mentioned in the earlier sections of this paper, the pay scale of nurses is comparatively poorer. This may be improved by reforming the national wage scale for this profession. Furthermore, the stigma against nurses can be addressed by promoting the profession through a nationwide campaign. The campaign may highlight the benefits and the long-term career rewards of the profession. If the campaign is regulated from the government level with an emphasis on the reformed policies which will ensure higher job satisfaction for nurses, then surely a lot more people will be willing to take up nursing as a profession. This, in turn, will be able to increase the number of nurses in
the workforce.
Conclusion
Job comfort has a great influence on the quality of care. Because the quality of care in a health care setting combined with four components of quality of care. There is a link between job satisfaction and quality of care and job dissatisfaction which adversely affects the quality of care by interfering with quality indicators of care. The quality of service can be ensured by providing adequate opportunities to nurses in clinical management.
Source of Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors have no conflict of interest to declare.
Ethical Approval
There are no ethical or financial issues, conflicts of interest, or animal experiments related to this research.
Author Contribution
All authors contributed equally in all parts of this article.
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