The search for greener pastures is beneficial for progress: the mobility of workforce is one example. The healthcare sector like several other professions often has high staff turnover as employees like nurses seek better opportunities elsewhere. Hospitals in Kerala are no stranger to this phenomenon.

Numerous nurses working with hospitals in Kerala often find placements in new lands after working there for a couple of years. These new opportunities open up the doors to better pay, dignity, and living standards.

Such migration has left many hospitals back home in a quandary as they have to deal with inadequate nursing staff.  

Here's one such example: A patient awaiting surgery at a prominent private hospital in Kochi could not get a room. The hospital had enough vacant rooms, but could not allot one to him due to a shortage of nurses. This case best exemplifies how the migration of nurses affects hospitals in Kerala.

In several major private hospitals in Kerala, resignation letters and requests for experience certificates often outnumber job applications as more than 100 nurses quit every month. Nurses working in the private sector normally seek greener pastures after completing a year.

The Government General Hospital in Ernakulam recently held an interview to recruit nurses on a temporary basis. The hospital invited applications multiple times, and yet, the number of candidates who turned up was less than its requirement.

Earlier, private hospitals used to receive at least 100 applications for 10 vacancies of nurses. The situation has now changed. They receive merely seven to eight applications.

This paints the stark reality of the shortage of nurses the healthcare sector has been facing. To overcome the shortage, several hospitals are now employing other staff members to take care of tasks that do not need nursing proficiency!

"It is true that the private hospitals in the state are facing a shortage of nurses. We have demanded the government to approve new nursing colleges and add more seats in existing ones. However, the government has not taken any favourable steps," said Hussain Koya Thangal, President, Kerala Private Hospital Association.

Nursing courses, not jobs, sought-after

In fact, there is no dearth of qualified nursing professionals as thousands of local students opt for nursing courses within Kerala and other Indian states. More than 25,000 Keralites with fresh nursing degrees or diplomas from colleges and schools in Kerala and outside are joining the existing pool of qualified personnel every year.

Institutes in Kerala alone contribute 6,718 BSc Nursing graduates and 3,972 others with diplomas in General Nursing and Midwifery annually to the Indian health sector.

A majority of students in the hundreds of nursing colleges in Karnataka, Tamil Nadu, Andhra Pradesh, and other states, too, are from Kerala.

BSc Nursing has the largest demand in Kerala after the conventional arts and science graduation courses. Even those with high marks in Plus-Two have no guarantee that they will get admission to this course.

However, the case is different with MSc Nursing; very few pursue the course. In Kerala, 725 seats are available for MSc Nursing, but many nursing colleges are struggling to retain the course. For instance only three students joined MSc Nursing course in a college in central Kerala when it has 14 seats for it.

New trend: Study abroad

Nowadays, even students aspiring to join a nursing course, if given a choice or if they can pay, would pursue it abroad.

Kerala is witnessing a new trend as several students pursue nursing courses overseas since they have a better chance of landing a job after completing the course. Additionally, they need not waste time in getting registered in a foreign country after completing the course in Kerala. Though pursuing nursing in a foreign country is expensive, the students are not worried. They are confident of getting a job there.

Further, the difficulty in getting admission to BSc Nursing in Kerala also fuels the migration. NoRKA's 'Triple Win-Trainee' scheme, floated in association with the Government of Germany, helps students study and find employment in this European country.

"Pursuing a nursing course in the UK, Canada, Australia, New Zealand, and the US would help in getting registration there without other verifications. Since many countries are facing a shortage of nurses, they are open to teaching our students and providing them with jobs," said Denny Thomas Vattakunnel, Chairman and MD, Santa Monica Study Abroad.

Quit Kerala or quit India?

'Malayala Manorama' enquired with several Keralite nurses now based abroad about the factors that had led them to migrate. Their responses were almost similar.

They raised the low salaries in Kerala as the main reason. However, it is not the only one. There are many: Lack of dignity of labour, living standards, and so on.

Neethu Shibu of Ochira in Kollam district worked as a nurse on a contract basis at government-run public health centres for several years. She is now with the NHS Trust Hospital in the United Kingdom.

"A nurse appointed on a temporary basis in a government hospital in Kerala draws Rs 17,000 a month. The salary barely meets the daily commute and other expenses. The only solace is that we get an experience certificate. I have also worked in a private hospital for six months without pay," said Neethu sharing the dilemma of nurses forced to work without salary.

A large number of nurses are still working in the private sector in Kerala for a pittance. They are all seeking overseas employment opportunities.

Wanted: Respect and recognition

Another push factor for native nurses is the lack of respect and recognition. Neither the healthcare sector nor the general society grants them the recognition they deserve.

"Doctors and nurses go to work in their cars in foreign countries. In Kerala hospitals have earmarked specific parking spaces for doctors. Have you ever seen such exclusive spaces for nurses? Asked Renu Susan Thomas, State Treasurer, Trained Nurses Association of India.

Several countries utilise the services of nurse practitioners (also known as Advanced Registered Nurse Practitioner) to ensure better healthcare at the grassroots level. Kerala is not even considering the possibility of having such nurse practitioners.

Nurse practitioners are mid-level practitioners equipped to assess patient needs, recommend and interpret laboratory test results, diagnose disease, and prescribe medications and treatment protocols.

A recommendation to establish a Nursing Directorate in Kerala for policy planning and framing is in the cold storage after it ran into opposition. A fund of Rs 1 crore allotted for the purpose remains unutilised.

The issues nurses face in the private sector, too, are left unaddressed.

"A Nursing Directorate should be established to ensure that nurses get more consideration and to solve their issues. Though attempts were made to set up the directorate, opposition from several quarters stalled its progress. Nurses in the private sector are getting no consideration now," stated P Ushadevi, President, Kerala Nurses and Midwives Council.

Study bares known facts

The World Health Organisation and Health Systems Research India Initiative studied the overseas migration of Kerala nurses in 2022. Its major findings point to the pitiable state of affairs that force nurses to leave the State.

Less pay in hospitals, lack of recognition in society and lack of opportunities to gain advanced professional knowledge like Nurse Practitioners are factors that drive local nurses out of the country. Meanwhile, better living conditions in foreign countries, opportunity to relocate the family abroad, citizenship and option to settle down permanently in the US or European nations, free education for children, free medical care, and pension benefits available in a new land are attractions for migration.

The aforementioned study recommended a slew of measures like the following to improve the job prospects of nurses in Kerala.

• Introduce licence verifications like Objective Structured Clinical Examination (OSCE) as in Western countries.

• Introduce Communicative English in the curriculum from the beginning of the course, and encourage students to employ it in their daily lives.

• Provide an option to study German, Japanese, and Dutch languages as electives along with the course.

• Ensure the coordination of agencies recruiting nurses for foreign clients

• Initiate steps to prevent illegal recruitment by private agencies.

• Prepare data on nurses going abroad.

The conclusion

Equipping nurses in Kerala to tap the opportunities available in foreign countries is the need of the hour. Experts recommend the introduction of practical training and English proficiency courses in the existing curriculum. Simultaneously, nurses should be encouraged to take up employment in Kerala. Their service conditions should also be revised in tune with the times.

This is the fifth of the series on opportunities for nurses abroad. Read : Part 1 - Opportunities galore as Kerala nurses head to Europe

Part 2 - Numerous opportunities for nurses abroad but how to avoid pitfalls in recruitment!

Part 3 - Avail ODEPC, NORKA services for nursing opportunities abroad

Part 4 - Note these tips if you are planning a nursing career abroad

(The series concludes here)