Jan Swasthya Abhiyan – Mumbai, Clinical Nursing Research Society,Trained Nurses Association of India- Maharashtra State Branch, Association of Nursing Teachers Maharashtra, Municipal Nursing and Paramedical Staff Union- Mumbai, and United Nurses Association Maharashtra have written to Municipal Commissioner, Iqbal Singh Chahal, IAS about concerns with respect to frontline nurses and other health workers involved in the care and treatment of patients with COVID-19 disease.

Many hospitals in turn have become COVID-19 hotspots in the city. According to media reports about 1,500 frontline MCGM workers have contracted COVID-19 and 25 have succumbed to the virus so far.

We outline below some issues which need your immediate attention.

Testing & Treatment

The growing number of healthcare workers in the city infected by the coronavirus when on duty is deeply worrying. Despite this there are no dedicated facilities for healthcare workers who are at the frontline of the COVID response. We have received complaints of nurses having to wait long 6- 9 hours to get admitted in COVID hospitals with no access to even food or water making them feel neglected and unwanted. Most have to manage logistics on their own Since mid-May, we have been getting distress calls from COVID positive nurses admitted in COVID Care Centers. As per MCGM guidelines health care workers nurses cannot have their second swab test done. The orders re contrary to the ICMR COVID-19 testing protocol2 which  clearly states that “asymptomatic direct and high-risk contacts of a confirmed case are to be tested once between day 5 and day 10 of coming into contact.”

Quarantine

Some COVID Care Centers have poor and unhygienic facilities, shortage of housekeeping staff,poorly maintained washrooms, and no privacy. In some of these wards, men and women are reportedly being kept together . Staying in such poor conditions for 10-14 days is stressful and difficult for nurses recuperating from COVID19 and affects their morale. Nurses tell us “when the ordinary person gets COVID-19, nurses take care of them. When nurses get COVID-19, there is no one for us”. Many have left families including infants at home to carry out their duties and serve the community during this crisis. They are living in hostels that are often poorly maintained with no clean bed sheets or locker facilities, to keep their families safe from infection while carrying out their duties.In many cases nurses have ended up in crowded facilities which lack basic services like water,sanitation and medical facilities.

There have been reports that nurses are kept in the dark about their test results and are often told not to reveal to other staff members that they have tested positive. This adds to the fear, stigma and discrimination surrounding COVID-19 disease and must be discouraged. Denial of information regarding one’s care is also a violation of patients’ rights as outlined by the Ministry of Health and Family Welfare, Government of India. It is the duty of the treating physician and hospital to ensure that patients receive information regarding the nature of illness, provisional/confirmed diagnoses, and records and reports including investigation reports.

Work Environment

Nearly 200 nurses from Kerala have resigned from hospitals and left for their home state due to the fear of getting infected from COVID owing to continued issues they have been facing on duty . There are also reports of private hospitals cutting paid leaves and salaries of nurses in quarantine thereby indirectly penalizing them for getting infected with COVID 19 – somethingtotally out of their control.The government has also only been providing PPE kits and N-95 masks only to those who work with high-risk COVID-19 patients. However, in Mumbai non COVID hospitals also receive suspected cases. Few of these suspected cases later test COVID positive but by the time their results come, the staff nurses are already exposed to them (which has been driving the increase in numbers of health workers testing positive). The rest of the staff in non COVID-19 hospitals and wards have nothing to protect themselves with but surgical masks and cotton gowns

. This is bound to be ineffective: most COVID-19 patients are asymptomatic and the criteria for testing continues to be restrictive. We have received complaints from nurses working in non- COVID hospitals or wards that they do not receive full PPE kits and N-95 masks6 but are instead given HIV Kits or 3 ply masks as per Ministry of Health and Family Welfare guidelines for PPE use in non-COVID wards and hospitals. These guidelines set minimum standards to be followed and do not prevent states from developing their own norms taking into account their specific epidemiological contexts. Cities, like Mumbai that have a higher burden of disease must contextualise the PPE requirements according to their specific epidemiological situations so that healthcare workers are not exposed to unnecessary risk. With Mumbai seeing a rapid rise in the number of infections the distinction between COVID and non COVID health settings is getting increasingly blurred.

Further, instead of taking measures to support health workers by ensuring provision and

implementation of adequate safety measures, Government of Maharashtra as brought in the

Maharashtra Essential Services Management Act (MESMA) 2005, threatening to take action

against workers who do not cooperate . At a time when the health workforce is putting their health and lives at risk, an adversarial approach towards health workers is counter-productive to tackling the COVID pandemic and also extremely demoralizing.

Representation in decision making and leadership roles

Nurses represent 60 per cent of the healthcare force but are not represented in key decisionmaking bodies related to the pandemic. The previous Municipal Commissioner Mr. Pravin Pardeshi had agreed on the need to have a nursing task force to address issues related to capacity building, training, duty timings, leaves, days off, quarantine protocols, testing facilities, health insurance, and staying facilities being faced by nurses.The lack of nursing professionals in leadership and decision-making positions related to the COVID 19 response has led to the framing of protocols and guidelines that do not adequately foreground their issues and concerns. implementation of existing protocols and guidelines is also poor. Some hospitals are openly flouting protocols regarding healthy and safe work environment and there are no redressal mechanisms/ platforms for nurses to raise their legitimate concerns.. There is no consistency in the work schedule of nurses in different hospitals, with some hospitals requiring nurses to work 12 hours per shift, some 8 hours and some 6 hours.

Remuneration

The recruitment advertisement dated 14. 04. 2020 released by MCGM for Seven Hills Hospital (a COVID quarantine/ isolation centre, Andheri) classifies nurses under the category of paramedics. The remuneration for B. Sc. Nurses, as per the advertisement, is not commensurate with qualifications. B. Sc. Nurses and GNM diploma nurses have been treated at par and their salaries fixed at Rs. 30,000. B. Sc. Nurses are more qualified and should receive a higher remuneration.One of the significant barriers to recruitment would be the contractual nature of the appointment and that too for a limited duration. Contractual workers have limited negotiation powers, lower salary scales and uncertain work environments. The advertisement MCGM for Seven Hills Hospital also does not mention whether other basic requirements such as life insurance, health insurance, on-duty meals and stay facilities close by will be provided. This discriminatory and inequitable treatment of professionals taking on equal risk during a pandemic is unjust Discrimination against the nursing profession The advertisement also mentions that nurses who apply should have passed class 12th. We would like to bring to your notice that a high school certificate is a requirement for enrolling in any nursing programs. The nursing community finds the mention of this specific requirement only for nurses and not doctors, to be discriminatory and belittling.

The need to fill vacancies with regards to nursing administrators in large institutions.

There are many vacancies of nursing staff in hospitals, especially for senior positions like ‘Sister-incharge’, ‘Supervisor’ and ‘Matron.’ Every vacant post poses operational challenges for those on the frontline impacting patient safety and quality of care. For example, JJ Hospital has 2 posts of matrons lying vacant. Teaching hospitals like KEM and Nair with more than 2000 beds each need  strong nursing administrators. Currently most hospitals under MCGM and State Government have just one matron and that too in an officiating capacity. This limits the decision-making power of persons in authority. Key administrative posts in Mumbai and Maharashtra are lying vacant such as Superintendent, Nursing Services at both MCGM and and state government level and Assistant Director, Nursing Health Services and Registrar, Maharashtra Nursing Council at the state level. Leadership positions are critical for guiding the nursing workforce during a pandemic and must be filled at the earliest.

Need to acknowledge the role of different nursing professionals

The government does not seem to recognise and appreciate different qualifications and expertise among nursing professionals. The GNM course is a three-year full-time diploma program; a Basic B. Sc. Nursing is a four year full time program; a Post Basic B. Sc. Programme after GNM diploma is a two year programme; an M.Sc. Nursing is a post-graduate programme after B.Sc. Nursing; and a Ph.D in Nursing comes after an M.Sc. Nursing. Thus, nurses have different levels of expertise and training and hence differ in their professional capacity to treat and provide care to patients. Appointment for COVID-19 duty must be made keeping these differences in skills and capacity in mind to ensure safety of healthcare workers. It is unfortunate that GNM second year students were posted in the COVID-19 ward at Seven Hills Hospital, while the graduate and post-graduate nurses remained underutilised.

Staff members posted to COVID hospitals or wards must be adequately trained. The nursing

students who were posted at Seven Hills hospital were not adequately trained with respect to WHO standards. They only received six hours of training to manage COVID patients and use PPE.

Further, the students were made to function without any supervision. It is mandatory that student nurses must work under supervision of their faculty as they are not legally licensed or experienced to work independently. Nursing faculty are M.Sc. Nurses with more than 10 years of experience and a good source to manage the COVID facilities, which needs to be tapped by authorities.

Availability of qualified nurses in Maharashtra

We are also confused by the Maharashtra government’s decision to recruit medical personnel from Kerala to deal with the shortage of health care personnel including nurses in the state. In February 2018, the Directorate of Medical Education and Research, Government of Maharashtra had verified candidature of close to 2200 nurses (who successfully cleared the qualifying exam and got  on to the merit list) for staff nursing positions when it was attempting to fill up 528 positions that were lying vacant in different parts of the state. Of the 528 vacant positions that were advertised,401 posts were filled. Thus 1,800 nurses of the State who passed the qualifying examination would be available for recruitment at the earliest. The COVID-19 pandemic has exposed the fault lines

of the health care system in Maharashtra, Mumbai and the country at large. We need to revamp and strengthen the health care system of the city and state and one way to do so is reduce the shortage of healthcare providers, including nurses by filling vacant positions and augmenting nursing capacity within the state by using available human resources. We therefore urge the Government of Maharashtra and DMER to employ nurses from Maharashtra with adequate training as a long term – sustainable solution to the shortage of nurses in the state and city, instead of resorting to adhoc/temporary measures such as bringing in nurses from another state,

Our letter dated 05 April 2020 had various concerns. We are highlighting the ones that still

remain unaddressed:

● Adequate precautions for infection control and triaging are not being taken by hospitals,

putting every health worker’s safety at risk.

● Nurses are using public transport to commute between their homes and hospitals. Unless

adequately protected from infection, they could become carriers of coronavirus and

unknowingly spread it among the community.

● Adequately nutritious food is not being made available to the nurses who are working non

COVID areas in hospitals. Lack of nutritious food compromises immunity and puts the

nurses at risk of coronavirus.

● Nurses have been working in COVID-19 wards continuously without adequate rest and

opportunity to recuperate. This compromises their immunity, safety and health.

● Nursing leadership are not represented in decision making bodies constituted by the

Government. Thus, their issues and concerns are not being adequately foregrounded and

continue to remain largely unaddressed. There is not a single nurse in the state appointed

COVID-19 taskforce.

● Nurses who are bringing lapses in treatment and care to public notice are being victimized

by the hospital administrators. A nurse was suspended for speaking out against lack of

PPE in the Wadia Group of Hospitals.

Recommendations:

This is however, not the time to dwell on what could have been but on what should be going into the

future. If the city administration intends that its health workers come out of this pandemic with

even a modicum of faith in its government and local administration, the first step the State

Government/MCGM needs to take is to prioritize the safety of health workers.

PPE -Kits

1. Provide complete PPE kits for all health workers in non-COVID wards. While the MoHFW

has issued the minimum guidelines for provision and use of PPE in non-COVID wards,

there is a need to go beyond these guidelines considering the disease burden in Mumbai; the

fact that the majority of COVID positive cases are asymptomatic and the rising numbers

of infections among health care workers. MCGM has demonstrated that it can adapt

national guidelines to the local context in larger public interest. The testing criteria for

nurses as formulated by MCGM for example is different from ICMR guidelines on the

same. There MCGM and the State Government must not hesitate from instituting

measures in the larger interest of health care providers given the epidemiological profile of

the city.

Vacancies and Recruitment

2. The vacancies in nursing positions must be filled immediately, with permanent postings.

Preference to be given to the contract nursing staff who are already working in COVID19 wards. This will motivate more nurses to join the workforce.

3. 1,846 nursing positions lay vacant in Maharashtra as of April 2019 as per communication

received from DMER. Instead of hiring nurses from Kerala, the 1,800 nurses who have

cleared the DMER exam process and who are waiting to join work should be given

appointment letters and recruited for vacant permanent posts at the earliest.

4. Proper training for newly recruited nurses and doctors is necessary, for this will prepare

them to work with confidence and not in fear. Delay in recruitment/training has a direct

impact on patient care.

5. Immediate formation of a Nursing Task force with representation of nurses from

MCGM, State Government, Private hospitals, Nursing Associations, Unions and

Community.

COVID Care for Infected Health Workers

6. A live dashboard indicating the number of infected medical personnel and the number of available beds in each hospital treating COVID-19 patients must be set up.

7. MCGM must take responsibility to ensure every health worker who is a high-risk contact/has tested positive is quarantined/isolated at a hygienic facility equipped withbasic services such as water, food, sanitation and medical care.

8. Ensure adequate privacy, sanitation and medical facilities at quarantine centres. Quarantine period of 14 days must be maintained for all workers who are high risk contacts irrespectiveof the test result and a healthcare worker should only be brought back into work after he/she has tested negative COVID-19.

9. Set up separate COVID Care wards in hospitals and Dedicated COVID Health Centres (DCHC) for health workers with the best of facilities, meant for all health workers who test positive for COVID-19, irrespective of their symptomatic status. Many ESIS hospitalscan be utilized for treatment of HCWs.

10. Hospitals must ensure appropriate working hours with breaks and nutritious meals for all nursing staff.

11. Healthcare workers are naturally under great mental stress. The government should ensure access to mental health and counselling services for nurses. A helpline for nurses is a must.

12. The salaries of all health workers should be fully protected during the period of isolation/quarantine. In private hospitals salaries are paid half and leaves of quarantine are adjusted with earned leaves, this must be stopped.

Improvement in working environment of nurses

13. Clear standard operating procedures must be provided by MCGM for utilisation of different categories of student nurses. Further, guidelines and circulars should clearly mention which category of student nurses can be posted for COVID duty to avoid any confusion.

14. Allow workers to exercise their right to remove themselves from a work situation that they have reasonable justification to believe presents an imminent danger to their life or health.When a health worker exercises this right, they should be protected from any negative consequences.

15. Ensure accommodation for nurses close to the hospitals to minimize their need for travel and restrict the spread of infection. A minimum of 5 – 6 days advance notice must be given to nurses who are transferred from one hospital to another. Hospitals must provide them residential accommodation.

Grievance Redressal Cell

16. Hospitals should not be allowed to victimize nurses who are highlighting issues pertaining to their working conditions and safety.

17. Immediate formation of a nursing task force for handling of nurses’ issues.

18. A proper line of communication must be set for grievance redressal at the health facility level with the opportunity to scale up the matter with appropriate administrative authorities if there is a need. Mechanisms must be set up for time bound grievance redressal

19. Nursing leadership must be included in decision making bodies that have a clinical and public health mandate.

20. Lastly: for a long time, nurses in the State have been demanding a change in their designations from ‘staff nurse’ to ‘nursing officer’, as in Central Government Hospitals.

This does not need any extra funds and resolution of the long pending demand will be an acknowledgement of the critical role they play within the health system at all times and especially now during the COVID-19 crisis.

We must keep in mind that these measures are not only to ensure the safety of health workers but also to keep their morale high. The COVID pandemic has revealed the deeply fractured and inadequate public health system in the city of Mumbai. The pandemic is an opportunity for MCGM to institute systemic changes to strengthen the public health system, so as to serve people even beyond the pandemic.Improving health systems need a multidisciplinary approach with deliberations with experts from fields of public health, medicine (including nursing), hospital administration, epidemiologists,statisticians, researchers and communities. We hope that your administration will implement these recommendations so that our health workers stay healthy

1 Thomas, T. (2020, May 14). COVID-19: No help for Mumbai’s healthcare workers who test positive.

livemint.Retrieved from: https://www.livemint.com/news/india/COVID-19-no-help-fore-mumbai-shealthcare-workers-who-test-positive-11589424869214.html

2 PTI. (2020, 18 May). ICMR revises testing guidelines; asymptomatic, high risk to be tested between 5-10

days. The Print. Retrieved from: https://theprint.in/health/icmr-revises-testing-guidelines-asymptomatic-high-risk-tobe-tested-between-5-10-days/424449/

3 Thomas, T. (2020, May 14). COVID-19: No help…

4 Iyer, M. (2020, May 22). 200 ‘homesick’ Kerala nurses leave Mumbai, call hospitals insensitive. The Times of India. Retrieved from:

http://timesofindia.indiatimes.com/articleshow/75878118.cms?utm_source=contentofinterest&utm_medium=text&utm

_campaign=cppst

5 Ibid footnote 3

6 Lakhani, S. (2020, May 26). Nurse’s death: Colleagues say had to wear used PPEs. The Indian Express.

Retrieved from: https://indianexpress.com/article/cities/delhi/nurses-death-colleagues-say-had-to-wearused-ppes-6427321/lite/?__twitter_impression=true

7 Barnagarwala, T. (2020, May 23). Maharashtra: State govt warns healthcare staff with MESMA, nurses

say need more safeguards. The Indian Express. Retrieved from:

https://indianexpress.com/article/india/maharashtra-state-govt-warns-healthcare-staff-with-mesmanurses-say-need-more-safeguards-6423106/

8 Dhupkar, A. (2020, Apr 29). 6 staffers test positive at Wadia maternity hospital. Mumbai Mirror.

Retrieved from: https://mumbaimirror.indiatimes.com/coronaviru s/news/6-staffers-test-positive-atwadia-maternity-hospital/articleshow/75438473.cms

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