Approaches to Improving Nursing and Midwifery Services in Bangladesh: A Network Meeting

Nurses and midwives form a significant part of a country’s health care system. Their work contributes to people’s health and well-being, particularly for hospital patients. It also supports the families and communities of sick people. “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well and in all settings. It incorporates health promotion, illness prevention, and care for the ill, disabled and dying. Advocacy, promotion of safe environment, research, participation in shaping health policy and patient and health systems management, and education are also key nursing roles” [1]. Midwifery is skilled, knowledgeable, and compassionate care for childbearing women, newborn infants, and families across the continuum from pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life” [2]. Nurses and midwives require safe workplaces with appropriate facilities. They also need their workplace to recognize their rights. Indeed, the theme of International Nurses Day 2022 was investment in nursing and respect for their rights [3]. Investment may include preparing nurses and midwives with modern and adequate teaching and providing suitable learning facilities. Their rights may include suitable workloads, supportive workplaces, respectful wages, leave, transport, accommodation, treatment facilities, in-service training and education facilities, promotion opportunities, and participation in hospital/health care decision-making.

Modern scientific medical advancements have increased human life expectancy. Meanwhile, new communicable and non- communicable diseases continue to emerge. Both factors have increased the demands of nurses and midwives. Sustainable Development Goal 3 (SDG 3) is to ensure healthy lives and promote well-being for all at all ages [4]. Prioritizing nursing and midwifery services is an important element of achieving this goal. The present Bangladesh government has invested significantly to improve the nursing and midwifery sector. Notable investments include (1) upgrading nurse and midwife entry positions from 3rd to 2nd class; (2) upgrading the nursing and midwifery regulatory organization from Directorate of Nursing Services (DNS) to Directorate General of Nursing and Midwifery (DGNM); (3) deploying a substantial number of nurses and midwives in different health care settings, such as specialized hospitals, medical college hospitals, district and general hospitals, Upazila health complexes, and union-level healthcare facilities; (4) providing a variety of in-service training opportunities for nurses and midwives. However, to allow nurses and midwives to use their skills and education to their full potential, authorities need to improve support for their rights and develop the resources available to them. As the regulatory organization of nurses and midwives in Bangladesh, DGNM held a networking meeting in May 2022. This meeting aimed to collect approaches for improving nursing and midwifery services in Bangladesh.

The networking meeting was conducted in the DGNM’s auditorium. The 180 participants were nursing managers, including nursing superintendents, deputy nursing superintendents, divisional deputy directors, and district public health nurses working in different government hospitals and offices. They were divided into 8 groups according to division and workplace. They were then asked to discuss and record their findings about two issues: 1) the difficulties that nurses and midwives face in the workplace, (2) possible approaches to overcoming those difficulties. Next, they presented their findings via PowerPoint presentations. Finally, their presentation ideas, and particularly the proposed approaches, were collected, categorized, and documented.

The study found 29 approaches for improving nursing and midwifery services in Bangladesh. These approaches were categorized as follows: (1) personal (8 approaches), (2) patient care (3 approaches), (3) professional (2 approaches), (4) workplace (6 approaches), (5) administrative (6 approaches), (6) training (1 approach) and (7) financial (3 approaches) - see (Table 1).

Personal approaches: Nurses and midwives are trusted figures in health care settings. They are in a position to advise patients about healthy lifestyles. However, they may not follow a healthy lifestyle themselves [5]. They should be aware of their own health needs, take steps to prevent communicable and non-communicable diseases, and lead healthy lives. Patient care is the crux of nursing and midwifery care, and the key components of this care are love and respect for patients. Love and respect create interest and commitment toward integrated and patient-centered care [6]. Nurses and midwives should love their profession and respect the patients. Moreover, good relationships are key in patient-centered care, and good behavior is critical to developing good relationships. Therefore, nurses and midwives should behave well with patients and their relatives. A good nurse/midwife-to-patient relationship decreases the duration of a patient’s hospital stay, improves the quality of care they receive, and increases their satisfaction [7, 8]..

Time management impacts the quality of nursing and midwifery care and patient satisfaction. Time management is the cleverest, fittest, and maximally satisfying use of every second [9]. Inadequate time management undermines patient care and patient security [10]. Therefore, nurses and midwives in Bangladesh should provide care while deploying effective time management skills and engaging with time management systems [11]. English is the second language of nurses and midwives in Bangladesh. Although nursing and midwifery courses were and are taught in English, nurses and midwives have little opportunity or support for academic reading and writing in English at work. It is not particularly supported by the healthcare system or management and is only likely to occur if an individual employee chooses to do so. Academic reading in English is essential if nurses and midwives are to understand the current body of knowledge about nursing and midwifery care, including best practice, innovation, and research. It is also essential for writing and publishing nursing and midwifery research [12]. In the aspect of caregiving, nurses and midwives need to follow a role model. Florence Nightingale is the mother of modern nursing, wellknown as “the Lady with the Lamp”, and recognized as a healthcare reformer [13]. Therefore, nurses and midwives in Bangladesh should follow Florence Nightingale as a role model.

Patient care: Patients are the main focus of nursing and midwifery care. Most patients go to hospitals infrequently, usually only when they are seriously ill. Hospitals are therefore often unknown places for patients and may evoke anxiety, fear, insecurity, or discomfort. Effective hospital orientation may help patients to be familiar with the hospital environment and reduce such feelings. Patients often also need educating about their disease(s) [14]. Such health education should include information about how health services increase the likelihood of desired health outcomes and should be consistent with current professional knowledge [15].

Professional: Professional associations play an important role in sustaining and developing a profession. They create power structures, encourage the flow of ideas, and undertake the work required by a strong profession. They provide direction for patients and nurses and develop society’s trust in health care [16]. Members select their leaders at Upazila, district, division, and national levels through elections, which demonstrates their legality and increases acceptance of the leaders. This process makes associations’ activities valid, gives them a legal voice, and improves their professional image. These professional associations can work to provide nurses with better services and resources and can support their professional advancement throughout their careers [17]. In Bangladesh, nurses and midwives have professional associations. Although midwives’ professional association activities are significant, nurses’ professional association activities are less visible. Indeed, nurses sometimes have difficulty becoming members of these associations due to improper management. Nurses should be members of their professional associations and admission should be open and easy for all.

Workplace: A nurse’s or midwife’s workplace is usually a hospital or health care facility. A suitable hospital environment supports nurses and midwives to provide satisfactory care to patients. Hospital environments should be safe and clean for both caregivers and care-receivers and should have proper hospital waste management systems. Safe hospital waste management protects hospital workers, patients, patients’ relatives, and the hospital environment [18]. In Bangladesh, government hospital structures were not designed to manage the number of patients that now attend. They are often over-capacity and nurses and midwives find themselves overloaded with work. In addition, there is a significant shortage of support staff. These issues undermine hospital waste management systems. However, nurses and midwives in Bangladesh must still work to ensure proper hospital waste management.

Nursing and midwifery are growing professions in Bangladesh and the number of nurses and midwives deployed in hospitals is increasing. The official workload required of these roles is also increasing and they need greater support from office staff to complete this work. Nurses’ and midwives’ tasks are monitored by supervisors. Correct monitoring can ensure the quality of patient care, support independent decision-making, and protect patients and staff through reflection upon and analysis of clinical practice [19]. Thus, nurses’ and midwives’ tasks need to be regularly monitored, and authorities should deploy adequate numbers of nursing and midwifery supervisors. Documenting nursing and midwifery tasks is an important part of the care process. It provides evidence of care, encourages diligent care, acts as an essential communication tool, and may improve patient safety [20]. However, the documentation of care by nurses and midwives in Bangladesh is imperfect. They need to follow standard procedures for providing care, including correct documentation. Nursing supervisors and superintendents manage nurses and midwives. They prepare duty schedules, manage required leave, and select training participants. In addition, they need to cooperate and collaborate with hospital administration. To conduct their role effectively, they need a suitable workplace. Hospital nursing supervisors and superintendents need separate offices, preferably in an administrative block. However, this is rarely the case in Bangladesh, with most working in a single room. The participants also identified that official tasks required of them can be excessively time-consuming and difficult. They wanted such tasks to be easier and faster to complete.

Administrative: In this context, ‘administrative approaches’ refers to the actions of nursing and midwifery authorities. Today, it is often the case that both parents in a family work, and this is also true among nurses and midwives. In Bangladesh, most nurses and all midwives are female. These women are also usually the primary careers for any young children they have. Due to the irregular hours of hospital shift work (often involving day, evening, and night shifts), many are worried about the welfare of their young children. Such worries could be reduced by establishing child daycare centers in hospitals.

Promotion is a motivating factor in any profession. It increases employee status, provides new challenges, and usually increases wages. Most employees desire regular promotion opportunities. However, in Bangladesh, few nurses are promoted until they have completed more than 30 years of employment. As a result, some lose interest in nursing and become dissatisfied. Additionally, absent or delayed promotion undermines the nursing chain of command. Such issues may cause lower-quality patient care.

Nurses and midwives in Bangladesh should be rewarded with regular promotion opportunities based on their qualifications and job experience. In addition, the Departmental Promotion Committee (DPC) should use promotion to bring about desirable changes in the profession. This can be achieved by the government demonstrating willingness through guidance and legislation. It was mentioned earlier that the present government has upgraded nurses’ and midwives’ job statuses from 3rd class to 2nd class. However, the position of nursing supervisor (previously 2nd class) has not been similarly upgraded to 1st class. This has created a false perception of equivalency between the positions and undermined the authority of supervisory staff. Nurses are now reluctant to follow the instructions of supervisors because both roles bear the same rank. This undermines the smooth running of health providers and negatively impacts patient care. Nurses and midwives in Bangladesh also want to change certain job titles to reflect their new 2nd class statuses. In particular, they wish to change ‘senior staff nurse’ to ‘nursing officer’ and ‘midwife’ to ‘midwifery officer’.

Nursing is usually considered a female profession [21], although some men are employed in nursing roles. The proportion of male and female nurses varies from country to country and is often influenced by a country’s health policy. In Bangladesh, most nurses are female. Officially, 10% of nurses are male, but the real number is likely to be much lower. During disasters or emergencies, female nurses experience difficulties working [22] and male nurses are usually deployed to manage the situation. In addition, in most district- and Upazila-level hospitals, male nurses usually work in the emergency department. This is the busiest and most crowded place in the hospital, and women are often unwilling to work there. In addition, emergency departments are less secure and female nurses want to avoid there. In light of these contextual issues, the Bangladesh healthcare system needs more male nurses. Nurses increasingly work in different specialized departments and the demand for specialized nurses is increasing. To meet this demand, DGNM has provided various specialized training courses for nurses. To make optimal use of this specialized training, specialized nurses must be deployed in specialized healthcare settings.

Training: Training is an important component of nurses’ and midwives’ professional development. Training empowers nurses and midwives, improves their competency, leads to improved patient care, and helps hospitals meet their aims [23]. Nurses and midwives in Bangladesh have received a variety of professional training. However, the demand for training is increasing as the demand for specialized nurses increases. Specialized nursing training should be continued and expanded to meet current needs. In addition, nursing and midwifery leaders, managers and administrators need to be developed via specialized leadership training.

Financial: Finance is crucial to many aspects of nurses’ and midwives’ professional development. The demands placed upon nurses and midwives are increasing at local, national, and international levels, and increased financial support is required to help them meet these demands. Primarily, wages and salaries should reflect increased workloads and should reward nurses and midwives for high-quality performance. In addition, nurses in Bangladesh need to celebrate special events and days. Doing so can be expensive, and authorities should fund these celebrations. Thirdly, motivational activities for nurses and midwives contribute to improved morale and work performance and should be funded. Finally, evidence-based practice is in high demand because it improves clinical patient outcomes, increases the quality of healthcare, and reduces healthcare costs [24]. Such evidence-based practice requires nursing and midwifery research, so nurses and midwives require research funding.

The present study found seven types of approaches for developing nursing and midwifery in Bangladesh: (1) personal approaches, (2) patient care approaches, (3) professional approaches, (4) workplace approaches, (5) administrative approaches, (6) training approaches, and (7) financial approaches. These approaches should be adopted by nurses and midwives in Bangladesh and their related authorities to improve nursing and midwifery services in Bangladesh. Doing so will also help to improve the professional image of nurses and midwives in Bangladesh nationally and globally.

None.

No conflict of interest.

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