Nurses' working conditions have come under the spotlight in a recent report, with a Cairo seminar giving nurses a forum in which to air their views. Sarah Eissa investigates
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One of Shebin Al-Kom Teaching Hospital nurses on strike last month in the garden, resting with a banner with their demands on her legs
They are asked to be angels of mercy and have the difficult job of looking after sick patients. Sometimes, however, they are looked down upon by society, and it is far from an easy job being a nurse, especially with apparently ever- declining working conditions. With a current shortage of around 37,000 nurses, according to 2009 Ministry of Health statistics, things look bleak for the profession. Consecutive governments have neither managed to attract new entrants nor to improve the remuneration of those already in it.
Now, the working conditions of Egypt's nurses have drawn the attention of a group of NGOs, the New Woman Organisation, the Egyptian Centre for Economic and Social Rights, the Association of Health and Environmental Development, and the Children of the Earth Foundation, which recently held a seminar to discuss a report on the subject at the Press Syndicate in Cairo.
According to the report, nurses' bonuses in government hospitals are limited to between LE7 and LE20 every two months, while those working in the insured sector commonly receive meals instead of a shift allowance. The report also highlighted the fact that nurses come at the bottom of the health industry pecking order, far below doctors and administrators, and they rarely receive their allowances or payments on time.
Nurses have the right to medical check-ups in public hospitals, but only once or twice monthly. If they need more, they have to pay. Nurses in private hospitals often do not have health insurance. While the Nurses Syndicate will support members suffering from certain serious conditions, this is restricted to three years and a limited payment.
They are often also taken advantage of, according to the report. After finishing a shift, nurses may not sign off before their replacement arrives. Should she not arrive, the original nurse will be required to work an additional shift. Overtime payments are often restricted to senior nurses alone.
Nurses also have limited opportunities to make their voices heard. Following a one- month strike at the Shebin Al-Kom Teaching Hospital, nurses and x-ray technicians ended their strike after receiving promises that the situation would be reviewed. However, according to Sarah Abdel-Fattah, a nurse at the hospital, none of the promises have been kept. "They told us that an agreement was due to be signed by the ministries of health and finance and then we would receive our rights. However, nothing happened," she said.
According to Mohi Kamel, an x-ray technician, a presidential decree had stated that all workers in municipal hospitals were to receive a 75 per cent bonus, but this had not been applied. Even when nurses specifically demanded it, they were not listened to. "Technicians and nurses are the only people who get a 25 per cent bonus," he said, adding that all they were asking for was equitable treatment.
However, Osama Abdel-Azim, secretary- general for technical affairs at the General Organisation for Teaching Hospitals and Institutes, said that bonuses for nurses and technical workers had been increased to 35 per cent. The larger bonus could not be applied at teaching hospitals, he said, since these were government institutes and were not run by municipalities.
Talks had been held with the Ministry of Finance to increase bonuses to 75 per cent, but these had not got anywhere. "However, we make around 25 per cent of additional funds available from our own budget, so nurses' bonuses in teaching hospitals are nearer 50 per cent." Minister of Health Hatem El-Gabali has now raised nurses' bonuses to 125 per cent, as part of a government plan to raise the salary of workers in the healthcare sector, including nurses.
However, there have been dissenting voices from among hospital staff themselves. According to Arabi Abdel-Rehim, a senior x-ray technician who has been working in the field for 35 years, workers only receive a LE1.5 allowance for being exposed to radiation hazards, and they often do not have the proper shields to protect themselves.
Workers can be exposed to a large amount of radiation, as they work with around 120 patients daily. According to technician Talaat Fouad, additional equipment costing LE50 had not been made available as "there was no budget".
In response, Abdel-Azim said that technicians were housed in a separate, radiation-protected room when dealing with patients. Each technician is fitted with a device measuring the amount of radiation he or she has been exposed to. "If a technician is exposed to more than the limit, he is assigned to other tasks. We care about them more than they care about themselves," he said.
Abdel-Azim also said that nurses' bonuses should be linked to patient satisfaction. "Patient satisfaction often doesn't exceed 24 per cent for nurses and 74 per cent for doctors. We offer nurses training programmes, in order that they can enhance their skills and improve patient satisfaction. "Bonuses should be seen as a return for services rendered, and not as a right that everyone should have," he said.
However, nurses say that while patient satisfaction with their performance is often low, this is because of the poor working conditions they face.
Nurses at other hospitals who chose not to strike and commented on the situation anonymously said that the low number of nurses caused staff to become exhausted at the amount of work required of them and the difficulty of finding time to take a holiday.
One nurse, Rehab (not her real name), a nursing supervisor, had been accepted for a post abroad, but she had not been able to take up the job because of hospital restrictions. While her unit director had written a recommendation letter on her behalf, her line manager refused to sign it, according to Rehab because he did not want to give her her holiday entitlement.
Commenting on the case, Nabiha Mahmoud, assistant secretary-general of the council of the Nurses Syndicate, said that nurses were often not authorised to work abroad until they had completed 20 years of service. "We have complained about this situation, and we are looking for a compromise in cases such as that of Rehab," she said. Since there was already a shortage of nurses in Egypt, many hospitals are reluctant to authorise their staff to work abroad for fear that they will not be able to find replacements.
There are also further concerns. According to Rania (not her real name), a nurse in an intensive care unit for newborn children in a public teaching hospital, infection-control regulations require nurses to wear gloves when dealing with babies. But corners are often cut, and "if the head nurse orders 20 boxes of gloves a month, they will tell her that five are enough, which don't last for five days."
Maha Sabri from the Shebin Al-Kom Hospital said that this was a common story, and there were often not enough gloves available. Yet, if a nurse is observed treating a patient without wearing gloves, she can be sanctioned and money deducted from her salary. Sometimes, "we have to buy gloves at our own expense," she said.
For his part, Abdel-Azim replied that any nurse who does not observe proper infection- control requirements will face investigation. "We stress the importance of the regulations, but they ignore them, saying that God will decide." A whole department of the teaching hospitals is dedicated to the issue of infection- control, and this is taken very seriously, with the hospitals having a partnership agreement with a French hospital to ensure that international standards are followed.
In spite of all their efforts in taking care of sick patients, other nurses complained that workplace injuries were considered to be the responsibility of nurses. According to one nurse, her shoulder was injured as a result of moving heavy patients, "but this was still considered my responsibility." For Rania the only advantage a nurse has is the health insurance that goes with the job, though this, she says, can often not be worth as much as it should be. Some doctors working for the insurance administration do not do their jobs properly, and administrative issues can prevent nurses from receiving the treatment they are entitled to.
All these concerns were raised at the Cairo seminar, though there was little consensus about how they should be addressed. According to Amal Meselhi, a nurse from the Tanta governorate, the nurses' threat to strike and the support they had received in the media had meant that they had received some of their rights. However, they would have to go on insisting before they received the rest. Many nurses were reluctant to demand their rights, she said, and many of them feared the risk of sanctions.
According to Samia Abdel-Kader, chair of the Alexandria Nurses Syndicate, one problem was the way nurses were presented in the media. "Whenever a problem occurs, the doctors blame the nurses. If anything happens to a patient, it is the nurse that is blamed," she said.
Umm Rizk Mohamed, a nurse, said that there was an urgent need for better training of nurses. Nurses' retirement age should also be reduced to 55 from the current 65, she said. Mahmoud Salem, a nurse at Abul-Reesh Hospital, invited whoever had decided the retirement age to "try carrying heavy patients, turn them in their beds every two hours, and wash them once daily, and then see whether this is possible for someone who is 65 years old."
According to Sarah Ibrahim from the Shebin Al-Kom Hospital, nurses have few places to turn in demanding their rights, including the Nurses Syndicate. Nabiha Mahmoud of the Syndicate Council said that the syndicate had delayed its response to strikes, because "we are a new syndicate, though we are trying to protect nurses' rights. The syndicate's board members and chair were only elected three months ago. If the problem is a minor one, we invite head nurses to try to resolve it. If the problem is more major, we will always try to investigate it ourselves."
On the issue of strikes, there was division among those attending the meeting. Mahmoud criticised the Shebin Al-Kom strikers, saying that when the Ain Shams University Hospital nurses wanted to strike, a nurse from each department took their demands to the hospital director, who showed himself willing to listen to them. However, at Shebin Al-Kom the nurses' strike had meant the closure of departments and leaving patients unattended. This was unacceptable, she said.
Nurses from Shebin Al-Kom replied that only 125 of 700 nurses went on strike, meaning that most were still available to care for patients. Moreover, the hospital had also brought in nurses from other hospitals, paying them extra to work at Shebin Al-Kom during the strike.
Mahmoud vigorously defended the syndicate's actions and its programme of activities designed to benefit its members. A syndicate building was being built, and this would contain a training centre for the use of nurses. The syndicate's first priority was to increase nurses' standing, both financially and professionally. "We are demanding salary increases across the board, and we have legal officers who will defend nurses in professional disputes," she said.
Abdel-Azim excused the strikers, saying that they had legitimate grievances linked to low incomes. However, strikes in the medical context were always difficult, since they could place patients' lives at risk. In the case of the Shebin Al-Kom strike, he said, this possibility had been averted due to the use of additional nurses from other hospitals.
However, even though the strike at Shebin Al-Kom has now ended, it seems that nurses are still waiting for better remuneration and patients for better services.