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“Convince Your Patients and You Will Convince Society”: Career Decisions and Professional Identity Among Nurses in India:

“Convince Your Patients and You Will Convince Society”: Career Decisions and Professional... This article reports on the results of qualitative research to investigate the career plans of Indian nurses working in the southern Indian city of Bangalore. The globalized health care market in Bangalore has generated opportunities for an increasingly diversifying profession, many of whose members are keen to pursue global careers, work in specialized clinical settings, and pursue further education, and whose sense of professional identity is strongly influenced by these career choices. The research drew upon interviews with 56 nurses employed across six sites, including public and private health facilities. Decision-making related to the setting of nursing work and the negotiation of boundaries between medical “treatment” were of analytical interest in understanding career drivers and the professional identity of nurses working predominantly in the context of hospital care. Lateral trajectories were found to be important to the construction of a career in nursing— where the extent to which nurses could demonstrate competencies in clinical skill and knowledge and maintain professional control over the practice of nursing are key aspects in constructing a career. The renegotiation of nursing’s public image is at the heart of professionalizing strategies being adopted by nursing’s leaders and is also evident in the accounts presented by hospital nurses in their depictions of nursing practice and career plans. The findings suggest that greater attention to the professional project of nursing in India and the construction of nursing careers would benefit the development of more responsive human resource policies around the retention of nurses. Keywords nurses, careers, professional identify, India overseen by missionary nurses (Fitzgerald, 1997). Studies Introduction tracing the history of nursing in India frequently examine the Nurses are the largest group of health providers in most coun- cultural context that has given rise to the historically low tries and are vital to the efficient functioning of health ser- social position of Indian nurses through analyzing the effects vices. Nurse shortages have been reported in countries around of religion, caste, and class on notions of appropriate work the world, including India (Castro-Lopez, Guerra-Arias, for women (Abraham, 1996; Somjee, 1991). In particular, Buchan, Pozo-Martin, & Nove, 2017; Hawkes, Kolenko, concerns around providing physical care to the bodies of oth- Shockness, & Diwaker, 2009; Walton-Roberts et al., 2017). ers is tainted by traditional caste prejudices in South Asia, in Studies looking at the extent of shortages of health workers, which such forms of labor were seen as exclusively the pre- including nurses, have examined factors that contribute to serve of the lowest rungs of the Hindu caste system; thereby attrition in the health workforce, such as migration, geo- characterizing nursing as low status work. More recent soci- graphic and organizational maldistribution, employment con- ological studies have reexamined the social status of Indian ditions, poor governance, and weak health infrastructure nurses in light of migration opportunities (Nair, 2012; Nair & (Aluttis, Tewabech, & Frank, 2014; Buchan & Campbell, 2013; Goel et al., 2016; Ono, Lafortune, & Schoenstein, Union for International Cancer Control, Geneva, Switzerland 2013). The opinions expressed in this article are the author’s own and do not The emergence of Western nursing in India came about reflect the views of the Union for International Cancer Control (UICC). through the introduction of missionary medicine to the sub- Corresponding Author: continent along with the expansion of European trading Sonali E. Johnson, Union for International Cancer Control, Avenue routes. The bulk of the training of Indian nurses during the Giuseppe Motta 31-37, 1202 Geneva, Switzerland. colonial period, therefore, took place in mission hospitals Email address: sonali.johnson@gmail.com Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open Percot, 2011; Walton-Roberts, 2012), and the economic and The following article examines the construction of nurs- social opportunities that women gain from migration that ing careers in the Indian context and the main career drivers. have enabled them to break through traditional, patriarchal It highlights the key themes that emerged from the data boundaries (George, 2005). These studies argue that migra- analysis, including decision-making related to the setting of tion is transforming the image of nursing as a low status nursing work, the negotiation of boundaries between medi- “undesirable” occupation into that which can bring material cal “treatment” and nursing “care,” the institutional context benefits to nurses’ spouses and families through increased (public vs. private sector), and the choice of clinical spe- earnings overseas. Migration is therefore a “life strategy” for cialty. It also discusses the perceived benefits of seeking nurses and a means of vertical social mobility (Nair & Percot, employment abroad and the career profiles of prospective 2011; Percot, 2005). migrant nurses. Finally, the article highlights the importance Relatively few in-depth studies have been carried out on of the professionalizing strategies being promoted by repre- understandings of work and career from the perspectives of sentatives of national nursing bodies to achieve greater health workers themselves. Where career aspirations of social and economic rewards for Indian nurses as key play- Indian nurses have been examined, these have concentrated ers in a globalized health care market. on working conditions, pay, and employment opportunities that may “push” or “pull” Indian nurses into seeking over- Method seas employment (Alonso-Garbayo & Maben, 2009; Garner, Conroy, & Gerding Bader, 2015; Hawkes et al., 2009; Rao, Study Location Bhatnagar, & Berman, 2012). Given the visibility of migra- The study was undertaken in the city of Bengaluru (Bangalore) tion in Indian nursing and vice versa, whether or not to seek in the state of Karnataka, south India, that has a population of overseas employment serves as a useful entry point to exam- approximately 8.4 million people and is the third largest city ine broader decision-making processes for Indian nurses in the country (Government of India, 2011). Industries based related to work and career. The research, on which this article in Bangalore include aerospace and aviation, manufacturing, is based, used qualitative methods to explore, on one hand, biotechnology, and Information Technology. This has made how nurses understand and construct career pathways and on Bangalore an important internal labor destination for people the other, what these decisions tell us about conceptions of from different parts of the country, particularly the surround- professional identity in Indian nursing. Such research is ing states of Kerala, Tamil Nadu, and Andhra Pradesh. Due to timely in that there is increased discussion from a policy per- its range of medical and research facilities, including super spective on human resources for health in India, including specialty hospitals and biotechnology companies, Bangalore the shortage of nurses. In India, as in other settings, under- is also considered to be a key “medical hub” and a preferred standing the career motivations of nurses is important for location for a globalizing health workforce—particularly improving management and recruitment practices of this nurses (Johnson, Green, & Maben, 2014). essential health workforce. Like other metropolises in India, Bangalore has a mix As theories of careers have been developed in Western, of private- and government-run health facilities, as well as industrialized countries, exporting the term “career” to non- private and government nursing schools and colleges. The Western contexts requires some thought as to the universal size and profiles of hospitals in the city also vary widely suitability of this term. The concept of a “career” is typically and include corporate “high end” hospitals catering to used to describe the work experiences of an individual wealthy Indian and foreign clients, small private clinics throughout the course of his or her life (Arthur, Hall, & and nursing homes, faith-based “mission” hospitals, and Lawrence, 1989; Hall, 1976; Wilensky, 1961). Theories of government hospitals accessed mainly by middle and vocational choice and career development have transitioned lower income patients from Bangalore and surrounding from focusing on “organizational careers” where an indi- areas. Interviews were conducted across eight different vidual’s career path is located within a hierarchical manage- sites (private hospitals, government hospitals, a mission rial structure within an individual institution, industry, or hospital, and a privately operated outpatient clinic) so as to professional association to a more fluid conceptualization of reflect the diversity of health facilities in the city and to career encompassing the context in which careers are built include the perspectives of nurses working in different and nurtured. In particular, there has been greater emphasis settings. on the notion of a career as an evolving self project (Savickas, In this urban setting, nurses are able to actively engage 2002; Super, 1990). This framework allows for the exami- with the possibilities brought by globalization, particularly nation of an evolving work biography where a person through the construction of new “hi-tech” corporate hospi- imposes meaning on their vocational choices (Savickas, tals catering to the upper and middle class as well as foreign 2002, 2005) and as such is helpful to understanding the “medical tourists” to India, many of which have ties to hos- work decisions and career aspirations of a small sample of pitals and medical institutions in Western countries. Such nurses in India. Johnson 3 international networks thus foster another important feature differences in perceptions of work and career. Participants of globalization, that is, the possibility for “mobility” and the were recruited to the study after consultation with the hospi- prospects of a global nursing career. tal medical director and nursing superintendent to inform them of the study’s aims and methods, to request permission to interview onsite, and to ensure that recruitment procedures Design were appropriate and in line with hospital protocols. It is well recognized that qualitative research methods are best suited for studies that seek to explore the texture and Data Collection nuances of the social world in an in-depth manner (Green & Thorogood, 2014). As the study examined the ways in which The interviews typically lasted between 45 min and 1 hr. nurses construct a professional identity, an inductive, quali- Questions were open-ended and structured around a topic tative approach was viewed as the most appropriate means guide. The questions covered topics such as the decision to by which to elicit data on meanings and experiences identi- choose nursing, descriptions of daily work, relationships fied with membership in the nursing profession. In-depth with medical colleagues, future plans for work or study, pre- interviews with nurses were core sources of data where the ferred locations of employment, and international migration. purpose was to examine nurses’ presentation of their work- Although recording dialogues provides access to verbatim ing lives and conceptions of work and career. quotes, as recordings do not capture nonverbal communica- The author also attended a two-day state-level nursing tion they do not reproduce the interview setting in its entirety. conference, a workshop held at a nursing college and visited Therefore, to complement data from the interviews, notes a nursing hostel during the course of the research. In addi- were made on the interviews in the author’s field journal. tion, approximately 20 hr of observation were undertaken These included observations of the interview encounter, across the sites and included “shadowing” nurses on rounds impressions of the interview, as well as emerging lines of and observing events, conversations, and interactions. This enquiry. The interviews were predominantly carried out in enabled the examination of some aspects of nurse–patient English. A small number of interviews (four) were carried and nurse–doctor interaction and to get a feel of nursing life out in a mixture of Kannada and English by a research assis- outside a formal interview environment. Articles on Indian tant in the presence of the author. Four interviews were con- nurses in Indian newspapers were used as data on recent ducted with doctors. developments in nursing and to follow up current issues of The interview discussion was followed up with a few interest to the study, such as developments in nursing educa- “questionnaire” style questions to collect some demographic tion and trends in overseas migration. The research took information about the participants. This information was place over 9 months and included a preliminary site visit for important to understand more about the participants in the 2 months in April-May 2007, 6 months of field work between study and was also helpful in observing any differences or January and June 2008, and a visit from December 2009 to similarities across the accounts. Nurses were also asked January 2010 for follow-up. about the nursing qualifications that they currently held. Sampling Data Analysis Apart from state registration statistics, employment data of The main approach to data analysis drew upon the “grounded nurses at central and state level is not comprehensive. In theory” method. An appealing characteristic of grounded addition, limited information is available on human resources theory is its “funnel approach,” whereby the initial research and staffing in the private sector. It is therefore possible that questions and hypotheses are fairly broad and then progres- many nurses who are registered with the Karnataka Nursing sively defined according to information emerging from the Council (KNC) are not currently working or have emigrated. data. In the grounded theory tradition, data collection is Therefore, in the absence of a secondary data set from which guided by emerging theoretical categories in which research- to draw a random sample of nurses, a purposive convenience ers gather data to expand on or to eliminate preliminary ana- sampling approach was utilized. lytical leads (Charmaz, 1990, 2006; Glaser & Strauss, 1967). In-depth interviews were conducted with 56 nurses, One of the disadvantages of the grounded theory including 51 nurses working in hospital practice and two approach is that achieving saturation of categories can nursing superintendants and one member of staff in two pri- require a great amount of time. In the case of this research, vate nursing colleges. In addition, the author interviewed a it was not possible to undertake the theoretical sampling retired nurse and her daughter, also a nurse, who had left approach outlined by Glaser and Strauss (1967) where India to work overseas. Nurses were informed of the research sampling is determined purely by the emerging theory, as by the nursing matron and invited to participate. A wide age this would involve an indefinite length of time collecting range of participants was desired so as to capture the experi- data. The time lag between data collection, analysis, and ences of nurses of different ages, as well as any generational further collection of data through theoretical sampling 4 SAGE Open would have extended the time frame beyond what was fea- Findings sible for this research. However, preliminary analysis of each interview and each “round” of interviews at each Demographic Background research site did occur alongside data collection where The final sample was overwhelmingly female (49/56 nurses) themes and categories that emerged in early interviews and is indicative of the larger overall number of women in were noted and emerging hypotheses were tested and nursing in India. Seven male nurses participated in the study, refined in subsequent interviews. Each interview recording where five worked in private health facilities, one worked in was transcribed and read numerous times for familiarity. the central government–managed hospital, and one was a This was followed by line-by line open coding, where nursing principal. However, in India, as in other countries, these early codes were listed in a preliminary coding men are increasingly being trained as nurses. For example, in scheme along with properties and dimensions of the code. one college visited, male students accounted for almost 50% As the analysis of transcripts progressed, codes were of the student body. This suggests the increasing popularity of revised with properties added or deleted through constant nursing as a choice for boys—largely due to the prospects of comparison with cases across the data set. Cases were employment both in India and overseas. compared to one another according to site of work (public/ In terms of the age range of nurses interviewed, the private/clinical setting), as well as across age, religion, and youngest nurse was 22 years old and the oldest was 80 years type of degree. Narratives of male nurses were also com- old and retired. The nurses at both government hospitals pared with those of female nurses. were generally older than those interviewed in the private Relevant parts of the interview transcripts (interview sector. At the first government site, the nurses ranged from number and lines) were organized in a word document under 30 to 59 years and the second from 32 years to 57 years, a particular code. Through comparing codes and their prop- whereas in the first two private hospitals visited, most nurses erties to one another, the codes were developed into theo- were in their 20s. retical categories. Comparing the findings to other studies Out of the 56 nurses, 26 were Christians, 29 were Hindus, on Indian nurses was particularly helpful with regard to the and one was a Muslim. Although the study size is too small topic of migration. For example, in comparing the data set to as to provide a representative picture of the religious back- those of these studies, similarities and differences were ground of nurses in India, the large number of Hindus in the noted and followed up to investigate the perceived opportu- sample indicates that nursing is increasingly being taken up nity/costs of migration for different groups of nurses. by Hindus. The almost negligible presence of Muslims indi- Research memos were written to keep track of emerging cates that nursing was and still is not a popular choice among codes, hypotheses, and theoretical reflections. Memos writ- the Muslim community. When nurses were asked if they ten later on in the research process built on previous memos worked alongside Muslim nurses, their response was that and were organized around theoretical categories and emerg- this was “rare,” and that only a few of their colleagues were ing theory. In writing these memos, the author went back to Muslims. the original transcripts to reexamine the coding frame and to Out of the 29 Hindu nurses interviewed, most were from make necessary adjustments. Finally, through writing and historically disadvantaged Hindu castes, where six were rewriting memos and draft sections of the analysis, catego- from what the Indian Government classified at the time of ries began to unify around a central analytical theme, where the study as “scheduled castes” (SC), two were from the the data was “put back together” into a coherent whole “scheduled tribes” (ST), and 11 were from the category (Charmaz, 2006; Corbin & Strauss, 1990). “other backward castes” (OBCs). A further two were from the Naidu community, formerly classified as OBC, found in Ethical Considerations different states in the South. Five nurses were from “forward Ethics approval for the study was received from the ethics Hindu castes,” particularly Nairs (Kerala) and Lingayats committee of the London School of Hygiene and Tropical (Karnataka) and one nurse was from the Nagarathar caste Medicine. To ensure that participants understood and agreed (Tamil Nadu). Specific caste data were not obtained from to participate in the study, each nurse was given an informa- three of the Hindu nurses, although one indicated that she tion sheet to read and invited to ask any questions. After was from a high caste family. An important note with regard explaining that participation was voluntary and confidential, to caste is that the list of castes identified as OBC, ST, and the author asked whether she could proceed with the inter- SC is flexible and often updated with castes added or view and orally recorded permission from each participant. removed according to social, economic, and educational Participants were informed that they could end the interview indicators. They may also be classified as OBC or SC in one at any time and that all recordings and transcripts were being state and not in another. Historically, caste was intimately given an interview number so as not to identify individuals connected to the occupational hierarchy, with higher castes by name. Consequently, all names that are included in this having better access to higher status and higher income occu- article are pseudonyms. pations and assets than lower castes. Although caste does Johnson 5 have an important place in the study of Indian occupations, In expressing satisfaction with their choice of nursing there is evidence of a loosening of the caste–occupation rela- qualification, diploma nurses frequently highlighted a “glass tionship (Desai & Dubey, 2011). ceiling” associated with a GNM diploma. GNM nurses were Of the 56 nurses interviewed, 16 were from Kerala, 34 mainly limited to clinical settings unless they opted to under- were from Karnataka, four were from Tamil Nadu, one was take a 2 year “postbasic” nursing course to upgrade to the from Andhra Pradesh, and one was originally from Bihar, but equivalent of a BSc degree thereby opening up the possibil- whose parents had settled in Karnataka. Consequently, the ity of entering nursing education. GNM nurses also reported data set presented an overwhelming picture of nurses from finding it more difficult to obtain nursing management posts the south of India. It is difficult to ascertain the numbers of and therefore remain staff nurses for much of their careers. nurses from north India working in Karnataka as comprehen- A few of the nurses interviewed had worked for more than 20 sive employment data from the private sector is limited, but years as a staff nurse before being promoted to more senior that the sample consisted entirely of nurses from the southern “in-charge” positions. Although GNM nurses can receive states was not unexpected. Apart from the strong tradition of specialized “in-service training” in their hospitals, as was the nursing in the south of the country, the difference in language case in one of the sites, this is not a formal qualification as and culture between the south and the north of India may such but rather an internal requirement of the hospital. present a formidable barrier for Hindi and other northern lan- Nurses holding GNM diplomas therefore often expressed guage speakers. their desire to undertake the postbasic certificate course to All the Keralite nurses interviewed in the study were in convert their GNM qualification to a BSc. the private hospitals. In both the public hospitals, the sample Of the nurses interviewed, relatively few had climbed sig- consisted overwhelmingly of “local” Kannadiga (Kannada nificantly up the nursing hierarchy. Most promotions were speaking) nurses and a handful of nurses from Tamil Nadu. from staff nurse to an “in-charge” post, where nurses took on It was not possible to ascertain how many Keralite nurses administrative and/or managerial duties and supervised nursing are working in government hospitals in Karnataka. Although care in one or more wards. Nurse Matrons or Superintendents some nurses in the government hospitals mentioned that were not always drawn from among senior nurses within the they worked alongside a few nurses from Kerala, it appears internal hierarchy, but were frequently hired from other that comparatively few Keralites work in government facili- hospitals. ties in Karnataka, as employment is mainly reserved for Consequently, for most nurses, career pathways mainly “local” state nurses or those from other Indian states who involved a lateral succession of posts in different hospitals have settled permanently in Karnataka and thus satisfy the and teaching institutions, clinical settings, and for some, residency requirements for working as a state government stints abroad. Consequently, these lateral trajectories were employee. found to be important to the construction of a career in nurs- ing in the study setting for both female and male nurses. While the sample of male nurses in the interviews was too Educational Qualifications small to draw conclusions as to whether male nurses were The majority of nurses across the hospital sites held a able to secure senior positions more easily than their female Diploma in General Nursing and Midwifery (GNM). A peers, it did appear that male nurses leaned more toward smaller number of participants held BSc and MSc nursing careers in nursing management and education. Senior faculty degrees, some of whom had upgraded from a GNM Diploma in nursing colleges were frequently male, as were many of after undertaking a 2 year postcertificate baccalaureate the keynote speakers at nursing events attended during the course. The decision to undertake a BSc or GNM program course of the research. The relative ease of male nurses in was determined by a number of factors. Those commonly climbing the career hierarchy into senior management both mentioned by nurses at the hospital sites included the avail- in hospitals and in nursing education was raised by some ability of BSc programs at the time of entering nursing train- female nurses as an issue of “internal sexism” in nursing in ing, obtaining the required examination marks, having which male nurses become managers of predominantly undertaken a major in science subjects in the last years of female care provision. secondary school, and the cost of the course. The context and nature of nursing work was particularly A BSc nursing degree is a higher qualification than a important to conceptions of a satisfying work biography— GNM Diploma and is required for entry into MSc and doc- particularly the potential to undertake more clinical tasks and toral programs, as well as to join teaching faculty in nursing achieve higher levels of skill and autonomy in nursing prac- schools and colleges. Nurses interviewed in the nursing col- tice. Investigating the relationship between nursing and med- leges therefore held MSc and PhD qualifications. For the icine in the study setting was a means through which to BSc nurses, a degree course was purposely selected so as to generate information on nurses’ understandings of their role provide more flexibility in career opportunities, such as in patient care and the importance of this role to the develop- being able to follow a teaching path or to enter MSc and PhD ment of a strong professional identity in nursing and forging nursing programs. a meaningful career. 6 SAGE Open nurses’ “care” was described as a “24 hr activity” that involved Negotiating Professional Boundaries attending to patients’ various medical, psychological, and The analysis of power dynamics between health professions social needs during their stay at the hospital. Nursing care forms a key part of literature on interprofessional relation- was thus viewed as advancing a “holistic” approach in the ships within hospital settings and the construction and nego- management of patients as opposed to the “disease-oriented” tiation of professional boundaries (Allen & Hughes, 2002; approach of the medical profession. As Parvati, a nurse work- Liberati, 2017; Miers, 2010; Niezen & Mathijssen, 2014). ing in a central government hospital, explained, The way in which the occupational jurisdiction between medicine and nursing was depicted in the narratives, as well In medicine you are only treating the patient, but you are not as the extent to which nurses could “cross-over” from care close to the patient, the joys and sorrows you are not able to share properly with them. Of course, that kind of profession is into treatment, contest doctors’ opinions regarding the man- different from nursing. I think that nursing has got closer agement of patients and maintain professional control over attachment to the patient. the practice of nursing were found to be key aspects in con- structing a career. At the same time, while nurses were responsible for car- During the site visits, nurses were observed engaging in a rying out treatment instructions laid out by doctors, many variety of functions that related to their area of nursing spe- were able to conduct their own management of conditions cialty (e.g., cardiology, psychiatry, obstetrics) as well as to not seen as requiring immediate medical attention—such as the wards in which they were posted (e.g., delivery room, management of fever and administering analgesics for pain casualty, ICU, psychiatric ward). Consequently, nursing relief. Doctors intervened based upon the monitoring and duties ranged from the transfer and monitoring of a patient assessment of nurses, including nurses’ observations of following heart surgery, the antenatal care, and delivery of patients’ responses to treatment. Nurses’ observations were uncomplicated pregnancies managed by the nurses working also included in “nurses’ notes” that were handed over to in the maternity hospital to the counseling and recreational subsequent nursing shifts and frequently accessed by activities conducted by psychiatric nurses. doctors. The interview and observational data across the sites indi- The boundary between doctors’ “treatment” and nurses’ cated that medicine was largely responsible for major deci- “care” was frequently blurred in the daily routine of nurs- sions regarding a patient’s course of treatment. For example, ing practice. For example, boundary overlaps often occurred doctors decided which patients were to be admitted as in- in response to the urgency of “time” and the proximity of patients, the types of treatment required, and when patients the attending doctor to the patient. Many nurses reported could be discharged. Nurses worked alongside doctors in taking on medical tasks as required by the situation, such as functions such as assisting in emergency cases and surgery, administering IV antibiotics or inserting nasogastric tubes undertaking admissions and discharge procedures, giving when doctors were busy or unavailable, as well as perform- medicine, administering IVs, preparing patients for diagnos- ing emergency resuscitation while waiting for the doctor to tic procedures or surgery, checking fluids and electrolytes, arrive. This type of boundary crossing was seen as neces- monitoring vital signs, recording medical history, and updat- sary and unavoidable to respond to the needs of patients ing clinical charts. Ward sisters at the sites who were respon- who were assessed by nurses as requiring immediate sible for one or more wards instructed and supervised the attention. work of orderlies, cleaners, and housekeeping that assisted Evidence of different boundary settings between medi- nurses in carrying out activities related to feeding patients cine and nursing also emerged in the work histories of nurses. and maintaining cleanliness and hygiene. Nurses also pro- Some nurses complained that in former appointments, hospi- vided counseling support and health information to patients tal regulations meant that they were able to do limited clini- and their families. cal tasks and had to follow doctors’ orders even to undertake The interview narratives of nurses across the hospital set- routine nursing functions. For instance, Sister Deidre gave tings indicated a clear distinction between “medicine” and the following account of her experience when accompanying “nursing” and a subsequent distinction between the functions her husband for admission at a well-known private hospital of doctors and nurses with regard to patients. As has been in Bangalore: found in other contexts, nurses’ testimonies defined the boundary between medicine and nursing through highlighting See, for example, from my own personal experience I will tell you. a “treatment/care” divide (Bridges et al., 2013; Churchman & When my husband was admitted to Hospital X, to give a steam Doherty, 2010; Reeves, Nelson, & Zwarenstein, 2008). inhalation the nurse was asking for a doctor’s order. I told her Nurses frequently referred to providing “care” as the main “Excuse me. This is purely a nursing function. Why do you need a role difference between themselves and their medical col- doctor’s order for this?” The nurses who are working in the leagues. Doctors were seen more as “treatment providers” corporate set-up, they feel that they have to follow only doctors’ who came into contact with patients predominantly during orders. They will not do anything independently. Even to give a their rounds or when called for medical assistance, whereas steam bath, you don’t need a doctor’s order! Johnson 7 In some hospitals therefore, the setting of boundaries fol- hospital, recalled being able to get a lot of “practical experi- lows a more formal division of labor between medicine and ence” during his hospital training in a government hospital. nursing, where hospital management and staff adhere more However, he also described how the lack of facilities and strictly to professional and hospital regulations. In other hos- high patient load in government hospitals led him to feel that pitals, nurses reported being able to demonstrate greater he was unable to provide high standards of nursing care: autonomy over decision-making regarding patients than their It is because of the facilities that they provide. If you are a nurse, nursing colleagues working elsewhere. However, even you are bound to give the maximum care to the patient. But it is within contexts with more regulated boundaries between not only in your hands. It is also the facilities you have been medicine and nursing, nurses were not lacking in agency. provided in your position. If you want to carry out your duty, Three key features of the work environment across the hos- you need a lot of things. With bare hands you can’t do it, you pital settings were found to influence nurses’ ability to secure can’t do anything. So, when you don’t find anything to do for greater autonomy in nursing practice. These were the institu- your work, you’re helpless. That’s what happens in the tional context in which medical/nursing care is organized— government job. particularly the division of labor between government and private facilities, the clinical setting of nursing work, and the Although nurses praised the work environment of private strength of interpersonal relationships between nurses and hospitals with reference to the higher levels of hygiene, med- doctors. Although both institutional and clinical settings can ical care, and equipment, many felt that a career in the pri- be seen as structural conditions of the work context and in a vate sector was insecure and that there were fewer financial sense are less negotiable than interpersonal relationships, incentives. Most of the critique leveled at government hospi- these conditions were found to create an environment that tals was focused more on the work environment rather than facilitates the agency of nurses to cross the traditional bound- the employment benefits available to government nurses. In ary between medicine and nursing. this respect, the majority of nurses across the sites acknowl- edged that the biggest incentive to work in government hos- pitals was the “job security.” Rival Work Cultures: Private Versus Public Nursing In the government sector it is a very secure life. So that’s what I Across the interview set, common perceptions emerged that wanted. Because outside you will be football, you will be thrown were related to the choice of institutional setting within from this institution to that institution. (Parvati, 34 years, which to locate a nursing career. The often polarized views government hospital) of the benefits of a working life as “public sector nurse” or a “private sector nurse” were particularly striking with these Nursing in government facilities was seen as offering “life- institutional contexts being presented as “rival work time” security as nurses would be able to receive a state pen- cultures.” sion, health insurance as well as housing and other benefits. In In the narratives of private sector nurses, government hos- addition, for nurses across government and private sites, fur- pital nursing was characterized by lower levels of hygiene, ther education in nursing was seen as very important, being limited equipment, and a generally poor work environment. key to career progression and to ensuring a high standard of A career in government hospitals would result in less expo- nursing care. Nurses in the government sector were more able sure to modern medical and nursing techniques and equip- to pursue these opportunities as part of their professional ment than that found in the private sector: careers than private nurses as they are supported by govern- ment scholarships or bursaries that cover fees and related I am giving preference to private hospitals because hi-tech expenses. For nurses working in the private sector, as the costs technology is there. Government hospital means nothing will be of further study are not typically borne by private institutions, there. Nothing will be there. They will not provide proper further education has to be financed by nurses themselves. materials, proper medicines also. How can we manage with Some private sector nurses therefore highlighted that though those things? (Thomas, 24 years, private hospital) they would like to undertake a postbasic certificate to upgrade to a BSc qualification, they could not afford the time off or the The limited technology and equipment associated with costs of the program. Manjula, a 24-year-old GNM nurse government hospitals was not only seen as a disadvantage in working in a private teaching hospital, recounted, terms of gaining new knowledge, but could affect nurses’ “job satisfaction” through limiting their ability to provide In government training, scholarship is available, like they effective care to patients. A number of private nurses inter- provide stipend, it is government training. Since I was doing in viewed had undergone their training in government hospitals government training, I received a stipend, but now we do not and were therefore familiar with the environment and set-up receive, for government staff they can pursue further training of the public sector. For example, Santosh, a 25-year-old with salary for free . . . as we are in private, not in government, male staff nurse working in the operating theater of a private we have to pay money. 8 SAGE Open Consequently, while some private sector nurses demon- Forging a meaningful career in nursing also included strated no desire at all to construct a career in the public sec- working with greater professional autonomy. The ability to tor, for others, the perceived benefits of a career in the public conduct independent assessments of patients, undertake cer- sector through the incentives of better salaries, the potential tain medical tasks, and demonstrate higher levels of profes- for further study, and “life security” were a powerful motiva- sional responsibility was perceived by respondents to be tor to seeking employment in this institutional context. largely determined by the clinical setting of nursing work, thereby suggesting a hierarchy of desired settings in which to locate a nursing career. Here, general ward nursing was seen “Expert Knowledge” and the Clinical Setting of at the bottom of this hierarchy in both public and private Nursing Care work settings. Nursing work in this context was perceived as Nurses favored placements according to the level of clini- less “technical” and mainly involved essential nursing duties cal experience and “learning on the job” that they offered. such as bathing, administering medicine, providing meals, Respondents with GNM and BSc qualifications high- and overseeing the general comfort of patients. Consequently, lighted their desire to “specialize” rather than becoming a ward nursing duties were typically assigned to junior nursing “general nurse,” a term that was used to describe essential staff. adult nursing care. Although in one site (a private teaching Providing essential nursing care on the wards was per- hospital) nurses were routinely transferred to different ceived as the least attractive setting for a nursing career in clinical areas every few years, most respondents felt that that it was perceived as low-status work and often described acquiring specialized nursing skills through training and as “boring.” For example, one nurse described providing experience in one clinical area was more valuable than care on the general adult wards as involving little more than “split nursing duties”—a term used by some nurses to “administering a tablet.” Being assigned to ward duties was describe a mixture of ward and specialist nursing duties also considered to be less marketable in terms of securing such as working in the operation theater or ICU or moving employment in other hospitals both in India and abroad. between two or more clinical areas. Soraya, a 22-year-old Therefore, a higher premium was placed by nurses on spe- staff nurse who worked in one of the private hospitals, cialized skills that were considered to be in short supply and, explained, thus, “in demand” rather than routine nursing skills that could potentially be undertaken by auxiliary categories of health workers. Speciality working is better no? Than working in all other At the other end of the spectrum of professional responsi- combination, speciality means we will come to know better. If other, all, it means it will be come to be like a mixture. This bility was the status awarded to nurses working in critical thing, that thing, we will not come to know in detail. Speciality care. The interview narratives with doctors and nurses illus- means we can come to know regarding that case. We can handle trated that nurses working in the ICU were considered to be individually. If others, means the cases will be together like the most experienced and skilled nursing staff. For example, cardio, nephro, neuro, everything will be together. in discussing areas of nursing recruitment, the medical direc- tor and a visiting consultant in the cardiothoracic hospital This view was supported by the Nursing Superintendent of a explained that they put their “best nurses” in the ICU. The large multispeciality private hospital in Bangalore who reason for the high professional status awarded to critical encouraged her students to consider specialization in a clini- care nurses is the level of independent responsibility associ- cal area to avoid becoming what she termed as “a jack of all ated with providing care to critically ill patients. This trades and master of none.” The choice of speciality was included questioning physicians over drug prescriptions for often related to the perception of opportunities abroad, so patients. As one doctor noted, that speciality areas such as obstetrics and gynecology were not as popular as areas such as cardiology or psychiatric I had somebody pointing out to me that this drug might further nursing that were considered to be much more “in demand” diminish the white cell count in a patient whose white cell count overseas. was already diminished. I was so glad when they came up with The choice of nursing speciality also revealed the gen- that. dered pathways through nursing in India. For example, male nurses were directed toward specialities such as psychiatric, As nursing has historically been viewed as a low status emergency nursing, and orthopedic nursing which were seen occupation in India due to its association with “dirty work, as more “suitable” for men. Although male nurses also upgrading nursing skills through working in specialized set- undertake training in midwifery as part of both the GNM and tings or through further education also provides the opportu- BSc curriculum, none of the male nurses interviewed consid- nity to present a ‘skilled’” persona to the public. While nurses ered obstetrics and gynecology to be an appropriate career predominantly highlighted positive experiences with patients, path for male nurses due to cultural sensitivities around negative patient encounters were most often linked to behav- male–female interaction in India. ior reinforcing perceptions of nurses’ social inferiority largely Johnson 9 linked to the public perception of nursing work as “unskilled.” The interviews demonstrated that age and seniority acted For example, some nurses described being treated “like ser- upon the extent to which nurses were given more autonomy vants” while others complained that the low status given to in decision-making by doctors. Older and more senior nurses nursing work meant that patients deferred medical and treat- tended to exert a larger measure of professional control than ment related questions to doctors. younger nurses, and showed a greater ease of communica- tion with doctors. “Being at ease” with doctors also meant that they were more empowered to question a doctor’s The public is not giving that much value for a nurse. See, if we tell the patient “this is the problem, relax, the doctor will instructions or able to take over certain medical duties with- come and examine you. We are checking your vitals. out having to specifically request permission. Some younger Everything is normal, don’t worry.” Sometimes the patients nurses therefore felt quite disempowered in their relation- won’t listen to us. “Where is the doctor”? When a nurse ships with doctors compared with their “seniors” and felt comes to attend to them, they are not happy. “Call the doctor, unable to question doctors’ decisions regarding the care of let the doctor come.” (Shalini, 29 years, private outpatient their patients. clinic) Constructing International Nursing Careers The public image of nurses and nursing work was there- fore important to nurses in designing their career as well as For private nurses in particular, a key career decision was to strengthening the profession as a whole. Nurses were par- whether and when to seek out opportunities for nursing ticularly concerned about the possibility of knowledge “stag- abroad. Analysis of the interviews indicated that the decision nancy” where they would remain in predominantly to migrate is strongly rooted in the desire for increased earn- task-oriented roles with little opportunity for further learning ing power and knowledge. Most nurses complained that and skills development. nursing is not well paid in India and that this was a major incentive to work abroad. Private nurses were found to You know, in the medical field every four months, five months express higher levels of dissatisfaction with pay and job there is a new technology and people who are teaching us are not security than their government sector colleagues and were in touch with that. So, they are teaching something that has therefore more likely to express an interest in nursing passed already . . . For doctors . . . they keep upgrading because overseas. they constantly have to deal with the patients. But ours, it For those nurses interested in migrating, the economic becomes sometimes like a sort of mechanical job . . . you might rewards of a foreign salary were seen as key to buying a be highly intelligent, but if you are not in touch, you tend to house, providing support to families, and for female nurses forget. So, upgrading skills is really important . . . (Sarita, 37 in particular, to putting money aside for marriage as “dowry” years, government hospital) payments. Although both male and female nurses expressed an interest in migration, the possibility to seek overseas Being bypassed by developments in medicine and nurs- employment was found to have particular social benefits for ing and becoming “mechanical” introduces the risk of “de- women. For example, an overseas salary can enable nurses to skilling,” in which nursing functions could potentially be save for their marriage and in doing so, also presents them as downgraded by hospital management to “basic care” tasks more desirable marriage partners. and distributed to other hospital employees. Counteracting The study found notable differences in the profiles of pro- the threat of “de-skilling” through acquiring additional spective migrant nurses across the data set. Nurses who artic- skills emerged as a career driver for nurses as well as being ulated an interest in overseas migration were typically in of key importance to maintaining occupational closure for their 20s, working in private hospitals, unmarried, and came the profession of nursing itself. from Kerala. Five out of 16 nurses from Kerala were return Across the study sites, almost all nurses highlighted migrants and six nurses expressed an intention to seek work good working relationships with doctors as well as with abroad (n = 11). Of the five nurses who were reluctant to other health staff such as physiotherapists, dieticians, and seek work abroad, three felt that such a decision would only technicians. The majority of nurses interviewed described have been possible before marriage. The other two nurses positive working relationships between doctors and nurses, from Kerala explained that they had considered working some using the word “family” to describe interprofessional overseas, but decided to stay in India as their husbands were relations. The term “team” was used frequently by psychi- not supportive of the idea. atric nurses indicating the interdisciplinary nature of men- In their interviews, both male and female nurses from tal health care. For many nurses, years of experience Karnataka typically expressed less interest in migrating working in one area enabled them both to build up clinical abroad than their Keralite colleagues and preferred to stay in skills and medical knowledge as well good interpersonal India. Of the 34 nurses from Karnataka in the sample, 19 relationships with medical staff. This often led some nurses stated that they were not attracted to the idea of seeking nurs- to be labeled as “competent” by doctors and thus trusted to ing employment overseas. An additional nurse (59 years) take on a greater range of medical activities. 10 SAGE Open explained that she had previously explored the possibility of this, indicating that male nurses may also seek the approval working abroad but did not pursue these plans due to family and support of their families with regard to migration. reasons. She now felt that it was “too late” in her career as The interview narratives also demonstrated the impor- she was close to retirement. Other nurses from Karnataka tance of two types of networks in constructing a career in cited family reasons for their desire to stay in Bangalore, par- nursing—“social” and “professional.” “Social networks” ticularly the reluctance to leave parents and children behind include family, community, and nurse class mates and are and wanting to stay in India. However, eight nurses from mainly horizontal in that they function as a “news service” Karnataka did highlight an interest in working overseas and about available opportunities in nursing, including possible mentioned similar reasons to nurses from Kerala, particu- employment opportunities in Bangalore as well as working larly the desire to gain knowledge, skills, and expertise and overseas. As Santosh described, earning higher pay than in India (Johnson et al., 2014). Four It’s a lot of networks because as you know, basically, in this field nurses from Karnataka had already migrated abroad, of it’s like 95% Kerala people and it’s a lot of network between the which three were return migrants and one currently lives in staff, the students, and so, so many people from the same towns. the United Kingdom. There is a lot of networking, so somehow you come to know Nurses across the data set frequently described them- which hospital is having vacancies. Rather than coming to know selves as part of larger social groupings that included family from ads and all, it’s from the network itself. and community. Female nurses in the study often referred to their husbands, parents, and extended family members, Many of the younger respondents, in their 20s and early including their in-laws, when discussing decisions around 30s, described how they had submitted their applications to where to live and work. These findings reflect gender norms particular hospitals in Bangalore because their friends were in decision-making processes for women and girls in Indian working there. The desire to work alongside friends indi- society. For example, before marriage, a young woman’s cated that rather than being a site of “competitiveness,” family and kin networks are instrumental in making deci- social networks were cohesive and supportive of individual sions around key areas of life such as education, employ- careers. ment, and marriage. After marriage, decisions are frequently made in consultation with husbands and “in-laws.” For Actually my goal is to go abroad. Means Australia or US. example, Rita, a nurse working in a private outpatient clinic, Because my friends are working there. They are telling it is a stated how though she was keen to work abroad, her husband nice place, you come here, please come immediately. (Karthik, was not willing to leave Bangalore, “He told me very frankly 34 years, private outpatient clinic) ‘If you want to go, go! Forget about me.” Concerns about leaving children in the care of others were “Professional networks” included other nurses and medi- also frequently highlighted by female nurses as a barrier to cal professionals who work at the hospitals. These are mainly working abroad. Consequently, for many young nurses, vertical in that they assist nurses in learning about employ- migration was an experience to capitalize upon before mar- ment opportunities, writing reference letters, and providing riage and family life. This may symbolize a period in nurses’ recommendations for vacancy positions. Some nurses lives where there is more room for autonomous decision- described how some doctors, with whom they had good making. For example, in discussing whether she had consid- interpersonal relationships within one hospital and who had ered going abroad, Parvati stated, subsequently moved to other hospitals, also continued to keep them informed of vacancies. Nurses also reported being Yeah, that was before marriage obviously. But now after having frequently advised by doctors about potential career paths, my child, maybe even after my marriage also, I even thought such as choosing speciality areas within nursing or the poten- about going abroad. But after the delivery, then I just stopped tial for migrating abroad. Some nurses who described being thinking about going abroad. assisted by doctors highlighted how they also came from the same “community,” for example, from the same town or Although male nurses appeared to be less constrained by state. Consequently, the reach of community ties within pro- gender norms that act upon women’s ability to demonstrate fessional networks in hospitals and teaching institutions autonomous career decisions, male nurses also made key life appeared to be extensive and fundamental to career decisions in consultation with their families. For example, decision-making. young, unmarried male nurses looked to their parents for advice around their careers, many of whom had joined nurs- ing upon the recommendation of their parents. Out of the Collective Social Mobility and the Professional seven male nurses interviewed in this study, six had joined Project of Indian Nursing nursing following the encouragement of their parents. One Given the historical association between nursing and low sta- male nurse from Karnataka stated that he was not consider- tus work, professionalizing strategies promoted by nursing’s ing migrating overseas as his parents were not in favor of Johnson 11 leaders focused on constructing a positive public image of qualifications in some quarters and the critique, in others, nurses with the aim of achieving greater social and political that these trends are driving nurses further away from the legitimacy. Across the sites, the low public image of nurses in patient and have become a threat to occupational closure India was seen as a major threat to achieving both social and (Maben, Latter, & MacLeod Clark, 2007; Nelson, Gordon, & professional recognition for members of the nursing profes- McGillion, 2002). sion. The following anecdote relayed by a speaker at a state Diminished control over nursing knowledge was raised level nursing conference illustrates how the occupational title frequently as a challenge to professional status, where nurs- of “nurse” continues to denote a somewhat stigmatized ing education was described by many nurses as a “business” identity. that threatened to undermine public confidence. Since the early 1990s, there has been a large increase in the number of private nursing schools and colleges in Bangalore offering I was on a train and I was chatting with a man who then asked nursing courses. The development of private nursing facili- me for my visiting card. He looked at my card and asked “Are you from X (well known hospital in Bangalore)?” I said “Yes.” ties came about largely to meet the demand for nurses both He said “Are you a doctor? What is your specialty?” I said “I am domestically and abroad, particularly in countries such as the a PhD, I am a nurse.” “Oh (pause) a nurse” he said. He looked United States that were reporting a large shortfall in their like I had just pricked his balloon. nursing workforce. These education facilities have attracted nursing students from surrounding states particularly For nursing’s leadership, including the national Indian Kerala—where despite its strong historical roots in Indian Nursing Council (INC) and its state-level body, the Karnataka nursing has fewer available nursing spaces. The mushroom- Nursing Council (KNC), the low public image of nursing ing of private nursing educational institutions has become a presents nurses with an important collective threat to claims matter of concern for the INC and KNC particularly around for greater professional status. Professionalizing strategies the quality of instruction and insufficient facilities. This has put forward by nursing’s leaders therefore concentrated upon resulted in the tightening of controls and the closure of a improving the image of nurses in the hospital environment, number of institutions. where this was perceived to have a “knock on” effect on the Migration, on the other hand, was overwhelmingly perception of nurses in wider Indian society. As a key note depicted by nurses as an important social and economic speaker at the state nursing conference urged his fellow “asset” for the profession, providing clear “evidence” of the nurses “Convince your patients and you will convince soci- “competency” of the Indian nurse. The perception of nurse ety!” Student nurses were encouraged to speak in English to migration as a positive development for Indian nursing was their hospital colleagues and were discouraged from speak- also supported by the presence of a Bangalore-based recruit- ing in the vernacular which was seen to present a more ment agency throughout the state level nursing conference. “local” identity to patients and hospital staff rather than that The recruitment agency set up an information stand within of an assertive “global” nurse. In Bangalore, as in other large the main conference hall, and their representatives gave a Indian cities, the effects of globalization have underlined the presentation to the audience on opportunities for nurse importance of English as a common professional medium of migration particularly to the United States. In addition, while communication. senior nurse managers did highlight the logistical challenges Among some nurse leaders, there was dismay that the in providing nursing care due to high rates of staff turnover emerging generation of nursing students were rejecting bed- in some hospitals, as well as the difficulties in finding quali- side nursing in favor of a career in specialized clinical areas, fied MSc and PhD nursing staff to teach courses and super- in hospital administration, and through pursuing further edu- vise students, they were supportive of their staff members’ cation—areas that would further their career trajectories in a plans to apply for overseas positions, often giving them time competitive global health care market. For some nurses in off to attend interviews or sit the relevant examinations. the professional associations, the desire to move away from Furthermore, migration was viewed as a key means to bedside nursing was undermining the traditional role of improve the professional and social standing of nurses in nurses to provide holistic care to patients. For others, engag- India. In their testimonies, nurses frequently highlighted the ing in many of the essential care activities required in bed- low pay of nurses, stating that their pay levels reflected those side nursing was a waste of nursing “skill.” This group of “unskilled” workers rather than medical professionals. A promoted specialization as a form of professional prestige speaker at the nursing conference passionately told the audi- and highlighted the importance of developing advanced ence, “Let India be empty of nurses and then they will nursing knowledge and skills in specialty areas as a way to acknowledge us!”—a sentiment which suggests that at the modernize nursing practice and meet the expectations of 21st political level, migration functions as a rationale to press for century health care. In many ways, the debate within nursing changes in working conditions and salary levels in Indian in India echoes the debate within nursing in other contexts in hospitals. Consequently, as migration offers the potential for which a series of professional dilemmas are posed by the individual social and economic mobility for migrating nurses, preference for increased specialization and educational it is also a strategy to achieve collective social mobility. 12 SAGE Open behind nurse migration from India, such as dissatisfaction Discussion with employment conditions in Indian hospitals and percep- The confluence of local and global perspectives character- tions of better salaries abroad, the possibility of professional izes the professional project of nursing in contemporary development, and the potential to join family overseas India in which nurses are seeking to carve a new identity (Hawkes et al., 2009; Thomas, 2006; Walton-Roberts et al., both within the Indian medical system and in wider Indian 2017), this study of nurses working in Bangalore is one of society (Johnson et al., 2014). This research supports other the few that embeds the decision of whether or not to seek studies that describe the dual function of migration—both as overseas employment among other career decisions rou- an individual life strategy (Nair & Percot, 2011) and as a col- tinely faced by nurses in India during their working lives. lective bargaining tool for the nursing profession (Timmons, The landscape of global public health is continually shift- Evans, & Nair, 2016). As demonstrated by the interview ing, partly as a result of the social and economic changes data, the career paths of nurses into nursing education, brought about by globalization, as well political consider- advanced nursing practice in specialty areas, and the deci- ations. Since this study was carried out, there have been sion to migrate abroad has resulted in a profession that is important geopolitical events including “Brexit” and restric- increasingly diversifying. For nurses in Bangalore, global- tions on the recruitment of international workers to countries ization has introduced the potential for status renewal such as the United States that will affect the career plans of through the incorporation of new technologies into nursing health workers, including nurses, looking to work outside practice and the prospect of global employment. As reported their countries of origin. It is too early to anticipate what this by Walton-Roberts and colleagues (2017), rather than being may mean for the career trajectories of Indian nurses or for a “hidden” process, this research found that migration was enrolment into the nursing profession itself in India. discussed openly by Indian nurses. Moreover, the interna- However, as this study has illustrated, the decision to migrate tional recruitment of nurses is a profitable industry with tie- overseas for nursing employment is one aspect of the career ups between overseas and India hospitals in the training and trajectories of nurses in India. While not all nurses wish to recruitment of Indian nurses, where Bangalore has emerged migrate, globalization and international migration have as one of the three main recruitment hubs in India along with important implications for nurses’ professional identity as an Delhi and Kochi (Khadria, 2007). Consequently, migration occupational group. In addition, urban centers such as to Bangalore is one step along the migratory pathway for Bangalore that are characterized by fast-growing global many nurses from Kerala who are able to gain work experi- opportunities offer nurses the possibility to work in large ence in the city’s various private hospitals before applying hospital set-ups where they can enter speciality fields, move for positions abroad. For other nurses, Bangalore is a large, into nursing education, or gain exposure to new medical cosmopolitan city, and working in Bangalore may be viewed technologies, in addition to developing the skills required to as “equivalent” to moving abroad. These nurses, particularly seek a nursing position abroad. from rural Karnataka, explained that migrating to Bangalore The research findings show that the notion of a meaning- was itself considered an important transition and that their ful career has great resonance among Indian nurses and plays families would not be supportive of their desire to leave a far more important role in work-related decisions than has India. been attributed to-date in the literature. Nursing careers in Compared with nurses from Karnataka, the pronounced the study setting were not restricted to climbing the nursing interest in migration among Keralite nurses is well supported hierarchy, but involved a series of lateral work roles in differ- by the literature on nurse migration from India (Nair, 2012; ent clinical settings, institutional contexts, and overseas Nair & Percot, 2011; Walton-Roberts et al., 2017). This study placements. Careers were found to be flexible and agential, found that the decision to migrate is often “communal” and where career achievement was characterized by skills acqui- influenced by the existence of overseas community net- sition, learning, enjoyment of nursing work, and professional works, as well as family and spousal support. These features autonomy in addition to material rewards. Career stagnation were particularly evident in the narratives of nurses from was found to be a concern of nurses across the data set, where Kerala, many of whom had relatives and friends already this was characterized by the absence of opportunities for abroad (Johnson et al., 2014). The Keralite community has a additional knowledge and skills. Whereas policy-level dis- long history of international migration in nursing and thus courses around migration have focused on individual “push” the presence of an international network of friends and fam- and “pull” factors that encourage international nurse migra- ily acted as a strong incentive to pursue nursing work tion, these discourses could be expanded to include concerns overseas. around professional autonomy, career incentives, and profes- Where career aspirations of health workers have been sional status. examined in empirical research, overseas employment is fre- This research is also one of the few that has looked at the quently depicted as the career decision for health workers negotiation of professional boundaries between nursing and from low- and middle-income countries. While the findings medicine in India and the implications for professional iden- of this research do concur with studies examining the factors tity. While nurses accepted that medicine was the dominant Johnson 13 paradigm over treatment decisions, they resisted any attempt Aluttis, C., Tewabech, B., & Frank, M. W. (2014). The workforce for health in a globalized context–global shortages and inter- to bring nursing under the purview of medicine and asserted national migration. Global Health Action, 7(1), Article 23611. a distinctive identity. As has been found elsewhere, the treat- Arthur, M. B., Hall, D. T., & Lawrence, B. S. (1989). Generating ment/care divide is often more symbolic than functional in new directions in career theory: The case for a transdisciplinary that such boundary lines may shift or be unclear when pro- approach. In M. B. Arthur, D. T. Hall, & B. S. Lawrence viding health care to patients within a hospital setting (Allen, (Eds.), Handbook of career theory (pp. 7-25). Cambridge, UK: 2015; Miers, 2010; Niezen & Mathijssen, 2014). 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Reframing professional quences, and policy responses to the migration of health work- boundaries in healthcare: A systematic review of facilitators ers: Key findings from India. Human Resources for Health, and barriers to task reallocation from the domain of medicine 15(1), Article 28. doi:10.1186/s12960-017-0199-y to the nursing domain. Health Policy, 117, 151-169. Wilensky, H. L. (1961). Orderly careers and social participation: Ono, T., Lafortune, G., & Schoenstein, M. (2013). Health The impact of work history on social integration in the middle workforce planning in OECD countries: A review of mass. American Sociological Review, 26, 521-539. 26 projection models from 18 countries (OECD Health Working Papers No. 62). The Organisation for Economic Author Biography Co-operation and Development (OECD) Publishing. Sonali E. Johnson has a PhD and post-doctorate diploma in public doi:10.1787/5k44t787zcwb-en health and policy from the London School of Hygiene and Tropical Percot, M. (2005, March 16–20). Indian nurses in the Gulf: Two Medicine and an MSc in Gender and Development from the London generations of female migration. Sixth Mediterranean Social School of Economics and Political Science. Johnson has worked as and Political Research meeting, Robert Schuman Centre a technical officer and consultant for the World Health Organization for advanced studies at the European University Institute, on gender and women’s health, sexual and reproductive health and Montecatini Terme, Italy. gender and HIV/AIDS, as well as research ethics and knowledge Rao, K. D., Bhatnagar, A., & Berman, P. (2012). So many, yet few: translation. She is currently senior advocacy manager at the Union Human resources for health in India. Human Resources for for International Cancer Control (UICC). Health, 10, Article 19. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SAGE Open SAGE

“Convince Your Patients and You Will Convince Society”: Career Decisions and Professional Identity Among Nurses in India:

SAGE Open , Volume 8 (1): 1 – Mar 8, 2018

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Abstract

This article reports on the results of qualitative research to investigate the career plans of Indian nurses working in the southern Indian city of Bangalore. The globalized health care market in Bangalore has generated opportunities for an increasingly diversifying profession, many of whose members are keen to pursue global careers, work in specialized clinical settings, and pursue further education, and whose sense of professional identity is strongly influenced by these career choices. The research drew upon interviews with 56 nurses employed across six sites, including public and private health facilities. Decision-making related to the setting of nursing work and the negotiation of boundaries between medical “treatment” were of analytical interest in understanding career drivers and the professional identity of nurses working predominantly in the context of hospital care. Lateral trajectories were found to be important to the construction of a career in nursing— where the extent to which nurses could demonstrate competencies in clinical skill and knowledge and maintain professional control over the practice of nursing are key aspects in constructing a career. The renegotiation of nursing’s public image is at the heart of professionalizing strategies being adopted by nursing’s leaders and is also evident in the accounts presented by hospital nurses in their depictions of nursing practice and career plans. The findings suggest that greater attention to the professional project of nursing in India and the construction of nursing careers would benefit the development of more responsive human resource policies around the retention of nurses. Keywords nurses, careers, professional identify, India overseen by missionary nurses (Fitzgerald, 1997). Studies Introduction tracing the history of nursing in India frequently examine the Nurses are the largest group of health providers in most coun- cultural context that has given rise to the historically low tries and are vital to the efficient functioning of health ser- social position of Indian nurses through analyzing the effects vices. Nurse shortages have been reported in countries around of religion, caste, and class on notions of appropriate work the world, including India (Castro-Lopez, Guerra-Arias, for women (Abraham, 1996; Somjee, 1991). In particular, Buchan, Pozo-Martin, & Nove, 2017; Hawkes, Kolenko, concerns around providing physical care to the bodies of oth- Shockness, & Diwaker, 2009; Walton-Roberts et al., 2017). ers is tainted by traditional caste prejudices in South Asia, in Studies looking at the extent of shortages of health workers, which such forms of labor were seen as exclusively the pre- including nurses, have examined factors that contribute to serve of the lowest rungs of the Hindu caste system; thereby attrition in the health workforce, such as migration, geo- characterizing nursing as low status work. More recent soci- graphic and organizational maldistribution, employment con- ological studies have reexamined the social status of Indian ditions, poor governance, and weak health infrastructure nurses in light of migration opportunities (Nair, 2012; Nair & (Aluttis, Tewabech, & Frank, 2014; Buchan & Campbell, 2013; Goel et al., 2016; Ono, Lafortune, & Schoenstein, Union for International Cancer Control, Geneva, Switzerland 2013). The opinions expressed in this article are the author’s own and do not The emergence of Western nursing in India came about reflect the views of the Union for International Cancer Control (UICC). through the introduction of missionary medicine to the sub- Corresponding Author: continent along with the expansion of European trading Sonali E. Johnson, Union for International Cancer Control, Avenue routes. The bulk of the training of Indian nurses during the Giuseppe Motta 31-37, 1202 Geneva, Switzerland. colonial period, therefore, took place in mission hospitals Email address: sonali.johnson@gmail.com Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open Percot, 2011; Walton-Roberts, 2012), and the economic and The following article examines the construction of nurs- social opportunities that women gain from migration that ing careers in the Indian context and the main career drivers. have enabled them to break through traditional, patriarchal It highlights the key themes that emerged from the data boundaries (George, 2005). These studies argue that migra- analysis, including decision-making related to the setting of tion is transforming the image of nursing as a low status nursing work, the negotiation of boundaries between medi- “undesirable” occupation into that which can bring material cal “treatment” and nursing “care,” the institutional context benefits to nurses’ spouses and families through increased (public vs. private sector), and the choice of clinical spe- earnings overseas. Migration is therefore a “life strategy” for cialty. It also discusses the perceived benefits of seeking nurses and a means of vertical social mobility (Nair & Percot, employment abroad and the career profiles of prospective 2011; Percot, 2005). migrant nurses. Finally, the article highlights the importance Relatively few in-depth studies have been carried out on of the professionalizing strategies being promoted by repre- understandings of work and career from the perspectives of sentatives of national nursing bodies to achieve greater health workers themselves. Where career aspirations of social and economic rewards for Indian nurses as key play- Indian nurses have been examined, these have concentrated ers in a globalized health care market. on working conditions, pay, and employment opportunities that may “push” or “pull” Indian nurses into seeking over- Method seas employment (Alonso-Garbayo & Maben, 2009; Garner, Conroy, & Gerding Bader, 2015; Hawkes et al., 2009; Rao, Study Location Bhatnagar, & Berman, 2012). Given the visibility of migra- The study was undertaken in the city of Bengaluru (Bangalore) tion in Indian nursing and vice versa, whether or not to seek in the state of Karnataka, south India, that has a population of overseas employment serves as a useful entry point to exam- approximately 8.4 million people and is the third largest city ine broader decision-making processes for Indian nurses in the country (Government of India, 2011). Industries based related to work and career. The research, on which this article in Bangalore include aerospace and aviation, manufacturing, is based, used qualitative methods to explore, on one hand, biotechnology, and Information Technology. This has made how nurses understand and construct career pathways and on Bangalore an important internal labor destination for people the other, what these decisions tell us about conceptions of from different parts of the country, particularly the surround- professional identity in Indian nursing. Such research is ing states of Kerala, Tamil Nadu, and Andhra Pradesh. Due to timely in that there is increased discussion from a policy per- its range of medical and research facilities, including super spective on human resources for health in India, including specialty hospitals and biotechnology companies, Bangalore the shortage of nurses. In India, as in other settings, under- is also considered to be a key “medical hub” and a preferred standing the career motivations of nurses is important for location for a globalizing health workforce—particularly improving management and recruitment practices of this nurses (Johnson, Green, & Maben, 2014). essential health workforce. Like other metropolises in India, Bangalore has a mix As theories of careers have been developed in Western, of private- and government-run health facilities, as well as industrialized countries, exporting the term “career” to non- private and government nursing schools and colleges. The Western contexts requires some thought as to the universal size and profiles of hospitals in the city also vary widely suitability of this term. The concept of a “career” is typically and include corporate “high end” hospitals catering to used to describe the work experiences of an individual wealthy Indian and foreign clients, small private clinics throughout the course of his or her life (Arthur, Hall, & and nursing homes, faith-based “mission” hospitals, and Lawrence, 1989; Hall, 1976; Wilensky, 1961). Theories of government hospitals accessed mainly by middle and vocational choice and career development have transitioned lower income patients from Bangalore and surrounding from focusing on “organizational careers” where an indi- areas. Interviews were conducted across eight different vidual’s career path is located within a hierarchical manage- sites (private hospitals, government hospitals, a mission rial structure within an individual institution, industry, or hospital, and a privately operated outpatient clinic) so as to professional association to a more fluid conceptualization of reflect the diversity of health facilities in the city and to career encompassing the context in which careers are built include the perspectives of nurses working in different and nurtured. In particular, there has been greater emphasis settings. on the notion of a career as an evolving self project (Savickas, In this urban setting, nurses are able to actively engage 2002; Super, 1990). This framework allows for the exami- with the possibilities brought by globalization, particularly nation of an evolving work biography where a person through the construction of new “hi-tech” corporate hospi- imposes meaning on their vocational choices (Savickas, tals catering to the upper and middle class as well as foreign 2002, 2005) and as such is helpful to understanding the “medical tourists” to India, many of which have ties to hos- work decisions and career aspirations of a small sample of pitals and medical institutions in Western countries. Such nurses in India. Johnson 3 international networks thus foster another important feature differences in perceptions of work and career. Participants of globalization, that is, the possibility for “mobility” and the were recruited to the study after consultation with the hospi- prospects of a global nursing career. tal medical director and nursing superintendent to inform them of the study’s aims and methods, to request permission to interview onsite, and to ensure that recruitment procedures Design were appropriate and in line with hospital protocols. It is well recognized that qualitative research methods are best suited for studies that seek to explore the texture and Data Collection nuances of the social world in an in-depth manner (Green & Thorogood, 2014). As the study examined the ways in which The interviews typically lasted between 45 min and 1 hr. nurses construct a professional identity, an inductive, quali- Questions were open-ended and structured around a topic tative approach was viewed as the most appropriate means guide. The questions covered topics such as the decision to by which to elicit data on meanings and experiences identi- choose nursing, descriptions of daily work, relationships fied with membership in the nursing profession. In-depth with medical colleagues, future plans for work or study, pre- interviews with nurses were core sources of data where the ferred locations of employment, and international migration. purpose was to examine nurses’ presentation of their work- Although recording dialogues provides access to verbatim ing lives and conceptions of work and career. quotes, as recordings do not capture nonverbal communica- The author also attended a two-day state-level nursing tion they do not reproduce the interview setting in its entirety. conference, a workshop held at a nursing college and visited Therefore, to complement data from the interviews, notes a nursing hostel during the course of the research. In addi- were made on the interviews in the author’s field journal. tion, approximately 20 hr of observation were undertaken These included observations of the interview encounter, across the sites and included “shadowing” nurses on rounds impressions of the interview, as well as emerging lines of and observing events, conversations, and interactions. This enquiry. The interviews were predominantly carried out in enabled the examination of some aspects of nurse–patient English. A small number of interviews (four) were carried and nurse–doctor interaction and to get a feel of nursing life out in a mixture of Kannada and English by a research assis- outside a formal interview environment. Articles on Indian tant in the presence of the author. Four interviews were con- nurses in Indian newspapers were used as data on recent ducted with doctors. developments in nursing and to follow up current issues of The interview discussion was followed up with a few interest to the study, such as developments in nursing educa- “questionnaire” style questions to collect some demographic tion and trends in overseas migration. The research took information about the participants. This information was place over 9 months and included a preliminary site visit for important to understand more about the participants in the 2 months in April-May 2007, 6 months of field work between study and was also helpful in observing any differences or January and June 2008, and a visit from December 2009 to similarities across the accounts. Nurses were also asked January 2010 for follow-up. about the nursing qualifications that they currently held. Sampling Data Analysis Apart from state registration statistics, employment data of The main approach to data analysis drew upon the “grounded nurses at central and state level is not comprehensive. In theory” method. An appealing characteristic of grounded addition, limited information is available on human resources theory is its “funnel approach,” whereby the initial research and staffing in the private sector. It is therefore possible that questions and hypotheses are fairly broad and then progres- many nurses who are registered with the Karnataka Nursing sively defined according to information emerging from the Council (KNC) are not currently working or have emigrated. data. In the grounded theory tradition, data collection is Therefore, in the absence of a secondary data set from which guided by emerging theoretical categories in which research- to draw a random sample of nurses, a purposive convenience ers gather data to expand on or to eliminate preliminary ana- sampling approach was utilized. lytical leads (Charmaz, 1990, 2006; Glaser & Strauss, 1967). In-depth interviews were conducted with 56 nurses, One of the disadvantages of the grounded theory including 51 nurses working in hospital practice and two approach is that achieving saturation of categories can nursing superintendants and one member of staff in two pri- require a great amount of time. In the case of this research, vate nursing colleges. In addition, the author interviewed a it was not possible to undertake the theoretical sampling retired nurse and her daughter, also a nurse, who had left approach outlined by Glaser and Strauss (1967) where India to work overseas. Nurses were informed of the research sampling is determined purely by the emerging theory, as by the nursing matron and invited to participate. A wide age this would involve an indefinite length of time collecting range of participants was desired so as to capture the experi- data. The time lag between data collection, analysis, and ences of nurses of different ages, as well as any generational further collection of data through theoretical sampling 4 SAGE Open would have extended the time frame beyond what was fea- Findings sible for this research. However, preliminary analysis of each interview and each “round” of interviews at each Demographic Background research site did occur alongside data collection where The final sample was overwhelmingly female (49/56 nurses) themes and categories that emerged in early interviews and is indicative of the larger overall number of women in were noted and emerging hypotheses were tested and nursing in India. Seven male nurses participated in the study, refined in subsequent interviews. Each interview recording where five worked in private health facilities, one worked in was transcribed and read numerous times for familiarity. the central government–managed hospital, and one was a This was followed by line-by line open coding, where nursing principal. However, in India, as in other countries, these early codes were listed in a preliminary coding men are increasingly being trained as nurses. For example, in scheme along with properties and dimensions of the code. one college visited, male students accounted for almost 50% As the analysis of transcripts progressed, codes were of the student body. This suggests the increasing popularity of revised with properties added or deleted through constant nursing as a choice for boys—largely due to the prospects of comparison with cases across the data set. Cases were employment both in India and overseas. compared to one another according to site of work (public/ In terms of the age range of nurses interviewed, the private/clinical setting), as well as across age, religion, and youngest nurse was 22 years old and the oldest was 80 years type of degree. Narratives of male nurses were also com- old and retired. The nurses at both government hospitals pared with those of female nurses. were generally older than those interviewed in the private Relevant parts of the interview transcripts (interview sector. At the first government site, the nurses ranged from number and lines) were organized in a word document under 30 to 59 years and the second from 32 years to 57 years, a particular code. Through comparing codes and their prop- whereas in the first two private hospitals visited, most nurses erties to one another, the codes were developed into theo- were in their 20s. retical categories. Comparing the findings to other studies Out of the 56 nurses, 26 were Christians, 29 were Hindus, on Indian nurses was particularly helpful with regard to the and one was a Muslim. Although the study size is too small topic of migration. For example, in comparing the data set to as to provide a representative picture of the religious back- those of these studies, similarities and differences were ground of nurses in India, the large number of Hindus in the noted and followed up to investigate the perceived opportu- sample indicates that nursing is increasingly being taken up nity/costs of migration for different groups of nurses. by Hindus. The almost negligible presence of Muslims indi- Research memos were written to keep track of emerging cates that nursing was and still is not a popular choice among codes, hypotheses, and theoretical reflections. Memos writ- the Muslim community. When nurses were asked if they ten later on in the research process built on previous memos worked alongside Muslim nurses, their response was that and were organized around theoretical categories and emerg- this was “rare,” and that only a few of their colleagues were ing theory. In writing these memos, the author went back to Muslims. the original transcripts to reexamine the coding frame and to Out of the 29 Hindu nurses interviewed, most were from make necessary adjustments. Finally, through writing and historically disadvantaged Hindu castes, where six were rewriting memos and draft sections of the analysis, catego- from what the Indian Government classified at the time of ries began to unify around a central analytical theme, where the study as “scheduled castes” (SC), two were from the the data was “put back together” into a coherent whole “scheduled tribes” (ST), and 11 were from the category (Charmaz, 2006; Corbin & Strauss, 1990). “other backward castes” (OBCs). A further two were from the Naidu community, formerly classified as OBC, found in Ethical Considerations different states in the South. Five nurses were from “forward Ethics approval for the study was received from the ethics Hindu castes,” particularly Nairs (Kerala) and Lingayats committee of the London School of Hygiene and Tropical (Karnataka) and one nurse was from the Nagarathar caste Medicine. To ensure that participants understood and agreed (Tamil Nadu). Specific caste data were not obtained from to participate in the study, each nurse was given an informa- three of the Hindu nurses, although one indicated that she tion sheet to read and invited to ask any questions. After was from a high caste family. An important note with regard explaining that participation was voluntary and confidential, to caste is that the list of castes identified as OBC, ST, and the author asked whether she could proceed with the inter- SC is flexible and often updated with castes added or view and orally recorded permission from each participant. removed according to social, economic, and educational Participants were informed that they could end the interview indicators. They may also be classified as OBC or SC in one at any time and that all recordings and transcripts were being state and not in another. Historically, caste was intimately given an interview number so as not to identify individuals connected to the occupational hierarchy, with higher castes by name. Consequently, all names that are included in this having better access to higher status and higher income occu- article are pseudonyms. pations and assets than lower castes. Although caste does Johnson 5 have an important place in the study of Indian occupations, In expressing satisfaction with their choice of nursing there is evidence of a loosening of the caste–occupation rela- qualification, diploma nurses frequently highlighted a “glass tionship (Desai & Dubey, 2011). ceiling” associated with a GNM diploma. GNM nurses were Of the 56 nurses interviewed, 16 were from Kerala, 34 mainly limited to clinical settings unless they opted to under- were from Karnataka, four were from Tamil Nadu, one was take a 2 year “postbasic” nursing course to upgrade to the from Andhra Pradesh, and one was originally from Bihar, but equivalent of a BSc degree thereby opening up the possibil- whose parents had settled in Karnataka. Consequently, the ity of entering nursing education. GNM nurses also reported data set presented an overwhelming picture of nurses from finding it more difficult to obtain nursing management posts the south of India. It is difficult to ascertain the numbers of and therefore remain staff nurses for much of their careers. nurses from north India working in Karnataka as comprehen- A few of the nurses interviewed had worked for more than 20 sive employment data from the private sector is limited, but years as a staff nurse before being promoted to more senior that the sample consisted entirely of nurses from the southern “in-charge” positions. Although GNM nurses can receive states was not unexpected. Apart from the strong tradition of specialized “in-service training” in their hospitals, as was the nursing in the south of the country, the difference in language case in one of the sites, this is not a formal qualification as and culture between the south and the north of India may such but rather an internal requirement of the hospital. present a formidable barrier for Hindi and other northern lan- Nurses holding GNM diplomas therefore often expressed guage speakers. their desire to undertake the postbasic certificate course to All the Keralite nurses interviewed in the study were in convert their GNM qualification to a BSc. the private hospitals. In both the public hospitals, the sample Of the nurses interviewed, relatively few had climbed sig- consisted overwhelmingly of “local” Kannadiga (Kannada nificantly up the nursing hierarchy. Most promotions were speaking) nurses and a handful of nurses from Tamil Nadu. from staff nurse to an “in-charge” post, where nurses took on It was not possible to ascertain how many Keralite nurses administrative and/or managerial duties and supervised nursing are working in government hospitals in Karnataka. Although care in one or more wards. Nurse Matrons or Superintendents some nurses in the government hospitals mentioned that were not always drawn from among senior nurses within the they worked alongside a few nurses from Kerala, it appears internal hierarchy, but were frequently hired from other that comparatively few Keralites work in government facili- hospitals. ties in Karnataka, as employment is mainly reserved for Consequently, for most nurses, career pathways mainly “local” state nurses or those from other Indian states who involved a lateral succession of posts in different hospitals have settled permanently in Karnataka and thus satisfy the and teaching institutions, clinical settings, and for some, residency requirements for working as a state government stints abroad. Consequently, these lateral trajectories were employee. found to be important to the construction of a career in nurs- ing in the study setting for both female and male nurses. While the sample of male nurses in the interviews was too Educational Qualifications small to draw conclusions as to whether male nurses were The majority of nurses across the hospital sites held a able to secure senior positions more easily than their female Diploma in General Nursing and Midwifery (GNM). A peers, it did appear that male nurses leaned more toward smaller number of participants held BSc and MSc nursing careers in nursing management and education. Senior faculty degrees, some of whom had upgraded from a GNM Diploma in nursing colleges were frequently male, as were many of after undertaking a 2 year postcertificate baccalaureate the keynote speakers at nursing events attended during the course. The decision to undertake a BSc or GNM program course of the research. The relative ease of male nurses in was determined by a number of factors. Those commonly climbing the career hierarchy into senior management both mentioned by nurses at the hospital sites included the avail- in hospitals and in nursing education was raised by some ability of BSc programs at the time of entering nursing train- female nurses as an issue of “internal sexism” in nursing in ing, obtaining the required examination marks, having which male nurses become managers of predominantly undertaken a major in science subjects in the last years of female care provision. secondary school, and the cost of the course. The context and nature of nursing work was particularly A BSc nursing degree is a higher qualification than a important to conceptions of a satisfying work biography— GNM Diploma and is required for entry into MSc and doc- particularly the potential to undertake more clinical tasks and toral programs, as well as to join teaching faculty in nursing achieve higher levels of skill and autonomy in nursing prac- schools and colleges. Nurses interviewed in the nursing col- tice. Investigating the relationship between nursing and med- leges therefore held MSc and PhD qualifications. For the icine in the study setting was a means through which to BSc nurses, a degree course was purposely selected so as to generate information on nurses’ understandings of their role provide more flexibility in career opportunities, such as in patient care and the importance of this role to the develop- being able to follow a teaching path or to enter MSc and PhD ment of a strong professional identity in nursing and forging nursing programs. a meaningful career. 6 SAGE Open nurses’ “care” was described as a “24 hr activity” that involved Negotiating Professional Boundaries attending to patients’ various medical, psychological, and The analysis of power dynamics between health professions social needs during their stay at the hospital. Nursing care forms a key part of literature on interprofessional relation- was thus viewed as advancing a “holistic” approach in the ships within hospital settings and the construction and nego- management of patients as opposed to the “disease-oriented” tiation of professional boundaries (Allen & Hughes, 2002; approach of the medical profession. As Parvati, a nurse work- Liberati, 2017; Miers, 2010; Niezen & Mathijssen, 2014). ing in a central government hospital, explained, The way in which the occupational jurisdiction between medicine and nursing was depicted in the narratives, as well In medicine you are only treating the patient, but you are not as the extent to which nurses could “cross-over” from care close to the patient, the joys and sorrows you are not able to share properly with them. Of course, that kind of profession is into treatment, contest doctors’ opinions regarding the man- different from nursing. I think that nursing has got closer agement of patients and maintain professional control over attachment to the patient. the practice of nursing were found to be key aspects in con- structing a career. At the same time, while nurses were responsible for car- During the site visits, nurses were observed engaging in a rying out treatment instructions laid out by doctors, many variety of functions that related to their area of nursing spe- were able to conduct their own management of conditions cialty (e.g., cardiology, psychiatry, obstetrics) as well as to not seen as requiring immediate medical attention—such as the wards in which they were posted (e.g., delivery room, management of fever and administering analgesics for pain casualty, ICU, psychiatric ward). Consequently, nursing relief. Doctors intervened based upon the monitoring and duties ranged from the transfer and monitoring of a patient assessment of nurses, including nurses’ observations of following heart surgery, the antenatal care, and delivery of patients’ responses to treatment. Nurses’ observations were uncomplicated pregnancies managed by the nurses working also included in “nurses’ notes” that were handed over to in the maternity hospital to the counseling and recreational subsequent nursing shifts and frequently accessed by activities conducted by psychiatric nurses. doctors. The interview and observational data across the sites indi- The boundary between doctors’ “treatment” and nurses’ cated that medicine was largely responsible for major deci- “care” was frequently blurred in the daily routine of nurs- sions regarding a patient’s course of treatment. For example, ing practice. For example, boundary overlaps often occurred doctors decided which patients were to be admitted as in- in response to the urgency of “time” and the proximity of patients, the types of treatment required, and when patients the attending doctor to the patient. Many nurses reported could be discharged. Nurses worked alongside doctors in taking on medical tasks as required by the situation, such as functions such as assisting in emergency cases and surgery, administering IV antibiotics or inserting nasogastric tubes undertaking admissions and discharge procedures, giving when doctors were busy or unavailable, as well as perform- medicine, administering IVs, preparing patients for diagnos- ing emergency resuscitation while waiting for the doctor to tic procedures or surgery, checking fluids and electrolytes, arrive. This type of boundary crossing was seen as neces- monitoring vital signs, recording medical history, and updat- sary and unavoidable to respond to the needs of patients ing clinical charts. Ward sisters at the sites who were respon- who were assessed by nurses as requiring immediate sible for one or more wards instructed and supervised the attention. work of orderlies, cleaners, and housekeeping that assisted Evidence of different boundary settings between medi- nurses in carrying out activities related to feeding patients cine and nursing also emerged in the work histories of nurses. and maintaining cleanliness and hygiene. Nurses also pro- Some nurses complained that in former appointments, hospi- vided counseling support and health information to patients tal regulations meant that they were able to do limited clini- and their families. cal tasks and had to follow doctors’ orders even to undertake The interview narratives of nurses across the hospital set- routine nursing functions. For instance, Sister Deidre gave tings indicated a clear distinction between “medicine” and the following account of her experience when accompanying “nursing” and a subsequent distinction between the functions her husband for admission at a well-known private hospital of doctors and nurses with regard to patients. As has been in Bangalore: found in other contexts, nurses’ testimonies defined the boundary between medicine and nursing through highlighting See, for example, from my own personal experience I will tell you. a “treatment/care” divide (Bridges et al., 2013; Churchman & When my husband was admitted to Hospital X, to give a steam Doherty, 2010; Reeves, Nelson, & Zwarenstein, 2008). inhalation the nurse was asking for a doctor’s order. I told her Nurses frequently referred to providing “care” as the main “Excuse me. This is purely a nursing function. Why do you need a role difference between themselves and their medical col- doctor’s order for this?” The nurses who are working in the leagues. Doctors were seen more as “treatment providers” corporate set-up, they feel that they have to follow only doctors’ who came into contact with patients predominantly during orders. They will not do anything independently. Even to give a their rounds or when called for medical assistance, whereas steam bath, you don’t need a doctor’s order! Johnson 7 In some hospitals therefore, the setting of boundaries fol- hospital, recalled being able to get a lot of “practical experi- lows a more formal division of labor between medicine and ence” during his hospital training in a government hospital. nursing, where hospital management and staff adhere more However, he also described how the lack of facilities and strictly to professional and hospital regulations. In other hos- high patient load in government hospitals led him to feel that pitals, nurses reported being able to demonstrate greater he was unable to provide high standards of nursing care: autonomy over decision-making regarding patients than their It is because of the facilities that they provide. If you are a nurse, nursing colleagues working elsewhere. However, even you are bound to give the maximum care to the patient. But it is within contexts with more regulated boundaries between not only in your hands. It is also the facilities you have been medicine and nursing, nurses were not lacking in agency. provided in your position. If you want to carry out your duty, Three key features of the work environment across the hos- you need a lot of things. With bare hands you can’t do it, you pital settings were found to influence nurses’ ability to secure can’t do anything. So, when you don’t find anything to do for greater autonomy in nursing practice. These were the institu- your work, you’re helpless. That’s what happens in the tional context in which medical/nursing care is organized— government job. particularly the division of labor between government and private facilities, the clinical setting of nursing work, and the Although nurses praised the work environment of private strength of interpersonal relationships between nurses and hospitals with reference to the higher levels of hygiene, med- doctors. Although both institutional and clinical settings can ical care, and equipment, many felt that a career in the pri- be seen as structural conditions of the work context and in a vate sector was insecure and that there were fewer financial sense are less negotiable than interpersonal relationships, incentives. Most of the critique leveled at government hospi- these conditions were found to create an environment that tals was focused more on the work environment rather than facilitates the agency of nurses to cross the traditional bound- the employment benefits available to government nurses. In ary between medicine and nursing. this respect, the majority of nurses across the sites acknowl- edged that the biggest incentive to work in government hos- pitals was the “job security.” Rival Work Cultures: Private Versus Public Nursing In the government sector it is a very secure life. So that’s what I Across the interview set, common perceptions emerged that wanted. Because outside you will be football, you will be thrown were related to the choice of institutional setting within from this institution to that institution. (Parvati, 34 years, which to locate a nursing career. The often polarized views government hospital) of the benefits of a working life as “public sector nurse” or a “private sector nurse” were particularly striking with these Nursing in government facilities was seen as offering “life- institutional contexts being presented as “rival work time” security as nurses would be able to receive a state pen- cultures.” sion, health insurance as well as housing and other benefits. In In the narratives of private sector nurses, government hos- addition, for nurses across government and private sites, fur- pital nursing was characterized by lower levels of hygiene, ther education in nursing was seen as very important, being limited equipment, and a generally poor work environment. key to career progression and to ensuring a high standard of A career in government hospitals would result in less expo- nursing care. Nurses in the government sector were more able sure to modern medical and nursing techniques and equip- to pursue these opportunities as part of their professional ment than that found in the private sector: careers than private nurses as they are supported by govern- ment scholarships or bursaries that cover fees and related I am giving preference to private hospitals because hi-tech expenses. For nurses working in the private sector, as the costs technology is there. Government hospital means nothing will be of further study are not typically borne by private institutions, there. Nothing will be there. They will not provide proper further education has to be financed by nurses themselves. materials, proper medicines also. How can we manage with Some private sector nurses therefore highlighted that though those things? (Thomas, 24 years, private hospital) they would like to undertake a postbasic certificate to upgrade to a BSc qualification, they could not afford the time off or the The limited technology and equipment associated with costs of the program. Manjula, a 24-year-old GNM nurse government hospitals was not only seen as a disadvantage in working in a private teaching hospital, recounted, terms of gaining new knowledge, but could affect nurses’ “job satisfaction” through limiting their ability to provide In government training, scholarship is available, like they effective care to patients. A number of private nurses inter- provide stipend, it is government training. Since I was doing in viewed had undergone their training in government hospitals government training, I received a stipend, but now we do not and were therefore familiar with the environment and set-up receive, for government staff they can pursue further training of the public sector. For example, Santosh, a 25-year-old with salary for free . . . as we are in private, not in government, male staff nurse working in the operating theater of a private we have to pay money. 8 SAGE Open Consequently, while some private sector nurses demon- Forging a meaningful career in nursing also included strated no desire at all to construct a career in the public sec- working with greater professional autonomy. The ability to tor, for others, the perceived benefits of a career in the public conduct independent assessments of patients, undertake cer- sector through the incentives of better salaries, the potential tain medical tasks, and demonstrate higher levels of profes- for further study, and “life security” were a powerful motiva- sional responsibility was perceived by respondents to be tor to seeking employment in this institutional context. largely determined by the clinical setting of nursing work, thereby suggesting a hierarchy of desired settings in which to locate a nursing career. Here, general ward nursing was seen “Expert Knowledge” and the Clinical Setting of at the bottom of this hierarchy in both public and private Nursing Care work settings. Nursing work in this context was perceived as Nurses favored placements according to the level of clini- less “technical” and mainly involved essential nursing duties cal experience and “learning on the job” that they offered. such as bathing, administering medicine, providing meals, Respondents with GNM and BSc qualifications high- and overseeing the general comfort of patients. Consequently, lighted their desire to “specialize” rather than becoming a ward nursing duties were typically assigned to junior nursing “general nurse,” a term that was used to describe essential staff. adult nursing care. Although in one site (a private teaching Providing essential nursing care on the wards was per- hospital) nurses were routinely transferred to different ceived as the least attractive setting for a nursing career in clinical areas every few years, most respondents felt that that it was perceived as low-status work and often described acquiring specialized nursing skills through training and as “boring.” For example, one nurse described providing experience in one clinical area was more valuable than care on the general adult wards as involving little more than “split nursing duties”—a term used by some nurses to “administering a tablet.” Being assigned to ward duties was describe a mixture of ward and specialist nursing duties also considered to be less marketable in terms of securing such as working in the operation theater or ICU or moving employment in other hospitals both in India and abroad. between two or more clinical areas. Soraya, a 22-year-old Therefore, a higher premium was placed by nurses on spe- staff nurse who worked in one of the private hospitals, cialized skills that were considered to be in short supply and, explained, thus, “in demand” rather than routine nursing skills that could potentially be undertaken by auxiliary categories of health workers. Speciality working is better no? Than working in all other At the other end of the spectrum of professional responsi- combination, speciality means we will come to know better. If other, all, it means it will be come to be like a mixture. This bility was the status awarded to nurses working in critical thing, that thing, we will not come to know in detail. Speciality care. The interview narratives with doctors and nurses illus- means we can come to know regarding that case. We can handle trated that nurses working in the ICU were considered to be individually. If others, means the cases will be together like the most experienced and skilled nursing staff. For example, cardio, nephro, neuro, everything will be together. in discussing areas of nursing recruitment, the medical direc- tor and a visiting consultant in the cardiothoracic hospital This view was supported by the Nursing Superintendent of a explained that they put their “best nurses” in the ICU. The large multispeciality private hospital in Bangalore who reason for the high professional status awarded to critical encouraged her students to consider specialization in a clini- care nurses is the level of independent responsibility associ- cal area to avoid becoming what she termed as “a jack of all ated with providing care to critically ill patients. This trades and master of none.” The choice of speciality was included questioning physicians over drug prescriptions for often related to the perception of opportunities abroad, so patients. As one doctor noted, that speciality areas such as obstetrics and gynecology were not as popular as areas such as cardiology or psychiatric I had somebody pointing out to me that this drug might further nursing that were considered to be much more “in demand” diminish the white cell count in a patient whose white cell count overseas. was already diminished. I was so glad when they came up with The choice of nursing speciality also revealed the gen- that. dered pathways through nursing in India. For example, male nurses were directed toward specialities such as psychiatric, As nursing has historically been viewed as a low status emergency nursing, and orthopedic nursing which were seen occupation in India due to its association with “dirty work, as more “suitable” for men. Although male nurses also upgrading nursing skills through working in specialized set- undertake training in midwifery as part of both the GNM and tings or through further education also provides the opportu- BSc curriculum, none of the male nurses interviewed consid- nity to present a ‘skilled’” persona to the public. While nurses ered obstetrics and gynecology to be an appropriate career predominantly highlighted positive experiences with patients, path for male nurses due to cultural sensitivities around negative patient encounters were most often linked to behav- male–female interaction in India. ior reinforcing perceptions of nurses’ social inferiority largely Johnson 9 linked to the public perception of nursing work as “unskilled.” The interviews demonstrated that age and seniority acted For example, some nurses described being treated “like ser- upon the extent to which nurses were given more autonomy vants” while others complained that the low status given to in decision-making by doctors. Older and more senior nurses nursing work meant that patients deferred medical and treat- tended to exert a larger measure of professional control than ment related questions to doctors. younger nurses, and showed a greater ease of communica- tion with doctors. “Being at ease” with doctors also meant that they were more empowered to question a doctor’s The public is not giving that much value for a nurse. See, if we tell the patient “this is the problem, relax, the doctor will instructions or able to take over certain medical duties with- come and examine you. We are checking your vitals. out having to specifically request permission. Some younger Everything is normal, don’t worry.” Sometimes the patients nurses therefore felt quite disempowered in their relation- won’t listen to us. “Where is the doctor”? When a nurse ships with doctors compared with their “seniors” and felt comes to attend to them, they are not happy. “Call the doctor, unable to question doctors’ decisions regarding the care of let the doctor come.” (Shalini, 29 years, private outpatient their patients. clinic) Constructing International Nursing Careers The public image of nurses and nursing work was there- fore important to nurses in designing their career as well as For private nurses in particular, a key career decision was to strengthening the profession as a whole. Nurses were par- whether and when to seek out opportunities for nursing ticularly concerned about the possibility of knowledge “stag- abroad. Analysis of the interviews indicated that the decision nancy” where they would remain in predominantly to migrate is strongly rooted in the desire for increased earn- task-oriented roles with little opportunity for further learning ing power and knowledge. Most nurses complained that and skills development. nursing is not well paid in India and that this was a major incentive to work abroad. Private nurses were found to You know, in the medical field every four months, five months express higher levels of dissatisfaction with pay and job there is a new technology and people who are teaching us are not security than their government sector colleagues and were in touch with that. So, they are teaching something that has therefore more likely to express an interest in nursing passed already . . . For doctors . . . they keep upgrading because overseas. they constantly have to deal with the patients. But ours, it For those nurses interested in migrating, the economic becomes sometimes like a sort of mechanical job . . . you might rewards of a foreign salary were seen as key to buying a be highly intelligent, but if you are not in touch, you tend to house, providing support to families, and for female nurses forget. So, upgrading skills is really important . . . (Sarita, 37 in particular, to putting money aside for marriage as “dowry” years, government hospital) payments. Although both male and female nurses expressed an interest in migration, the possibility to seek overseas Being bypassed by developments in medicine and nurs- employment was found to have particular social benefits for ing and becoming “mechanical” introduces the risk of “de- women. For example, an overseas salary can enable nurses to skilling,” in which nursing functions could potentially be save for their marriage and in doing so, also presents them as downgraded by hospital management to “basic care” tasks more desirable marriage partners. and distributed to other hospital employees. Counteracting The study found notable differences in the profiles of pro- the threat of “de-skilling” through acquiring additional spective migrant nurses across the data set. Nurses who artic- skills emerged as a career driver for nurses as well as being ulated an interest in overseas migration were typically in of key importance to maintaining occupational closure for their 20s, working in private hospitals, unmarried, and came the profession of nursing itself. from Kerala. Five out of 16 nurses from Kerala were return Across the study sites, almost all nurses highlighted migrants and six nurses expressed an intention to seek work good working relationships with doctors as well as with abroad (n = 11). Of the five nurses who were reluctant to other health staff such as physiotherapists, dieticians, and seek work abroad, three felt that such a decision would only technicians. The majority of nurses interviewed described have been possible before marriage. The other two nurses positive working relationships between doctors and nurses, from Kerala explained that they had considered working some using the word “family” to describe interprofessional overseas, but decided to stay in India as their husbands were relations. The term “team” was used frequently by psychi- not supportive of the idea. atric nurses indicating the interdisciplinary nature of men- In their interviews, both male and female nurses from tal health care. For many nurses, years of experience Karnataka typically expressed less interest in migrating working in one area enabled them both to build up clinical abroad than their Keralite colleagues and preferred to stay in skills and medical knowledge as well good interpersonal India. Of the 34 nurses from Karnataka in the sample, 19 relationships with medical staff. This often led some nurses stated that they were not attracted to the idea of seeking nurs- to be labeled as “competent” by doctors and thus trusted to ing employment overseas. An additional nurse (59 years) take on a greater range of medical activities. 10 SAGE Open explained that she had previously explored the possibility of this, indicating that male nurses may also seek the approval working abroad but did not pursue these plans due to family and support of their families with regard to migration. reasons. She now felt that it was “too late” in her career as The interview narratives also demonstrated the impor- she was close to retirement. Other nurses from Karnataka tance of two types of networks in constructing a career in cited family reasons for their desire to stay in Bangalore, par- nursing—“social” and “professional.” “Social networks” ticularly the reluctance to leave parents and children behind include family, community, and nurse class mates and are and wanting to stay in India. However, eight nurses from mainly horizontal in that they function as a “news service” Karnataka did highlight an interest in working overseas and about available opportunities in nursing, including possible mentioned similar reasons to nurses from Kerala, particu- employment opportunities in Bangalore as well as working larly the desire to gain knowledge, skills, and expertise and overseas. As Santosh described, earning higher pay than in India (Johnson et al., 2014). Four It’s a lot of networks because as you know, basically, in this field nurses from Karnataka had already migrated abroad, of it’s like 95% Kerala people and it’s a lot of network between the which three were return migrants and one currently lives in staff, the students, and so, so many people from the same towns. the United Kingdom. There is a lot of networking, so somehow you come to know Nurses across the data set frequently described them- which hospital is having vacancies. Rather than coming to know selves as part of larger social groupings that included family from ads and all, it’s from the network itself. and community. Female nurses in the study often referred to their husbands, parents, and extended family members, Many of the younger respondents, in their 20s and early including their in-laws, when discussing decisions around 30s, described how they had submitted their applications to where to live and work. These findings reflect gender norms particular hospitals in Bangalore because their friends were in decision-making processes for women and girls in Indian working there. The desire to work alongside friends indi- society. For example, before marriage, a young woman’s cated that rather than being a site of “competitiveness,” family and kin networks are instrumental in making deci- social networks were cohesive and supportive of individual sions around key areas of life such as education, employ- careers. ment, and marriage. After marriage, decisions are frequently made in consultation with husbands and “in-laws.” For Actually my goal is to go abroad. Means Australia or US. example, Rita, a nurse working in a private outpatient clinic, Because my friends are working there. They are telling it is a stated how though she was keen to work abroad, her husband nice place, you come here, please come immediately. (Karthik, was not willing to leave Bangalore, “He told me very frankly 34 years, private outpatient clinic) ‘If you want to go, go! Forget about me.” Concerns about leaving children in the care of others were “Professional networks” included other nurses and medi- also frequently highlighted by female nurses as a barrier to cal professionals who work at the hospitals. These are mainly working abroad. Consequently, for many young nurses, vertical in that they assist nurses in learning about employ- migration was an experience to capitalize upon before mar- ment opportunities, writing reference letters, and providing riage and family life. This may symbolize a period in nurses’ recommendations for vacancy positions. Some nurses lives where there is more room for autonomous decision- described how some doctors, with whom they had good making. For example, in discussing whether she had consid- interpersonal relationships within one hospital and who had ered going abroad, Parvati stated, subsequently moved to other hospitals, also continued to keep them informed of vacancies. Nurses also reported being Yeah, that was before marriage obviously. But now after having frequently advised by doctors about potential career paths, my child, maybe even after my marriage also, I even thought such as choosing speciality areas within nursing or the poten- about going abroad. But after the delivery, then I just stopped tial for migrating abroad. Some nurses who described being thinking about going abroad. assisted by doctors highlighted how they also came from the same “community,” for example, from the same town or Although male nurses appeared to be less constrained by state. Consequently, the reach of community ties within pro- gender norms that act upon women’s ability to demonstrate fessional networks in hospitals and teaching institutions autonomous career decisions, male nurses also made key life appeared to be extensive and fundamental to career decisions in consultation with their families. For example, decision-making. young, unmarried male nurses looked to their parents for advice around their careers, many of whom had joined nurs- ing upon the recommendation of their parents. Out of the Collective Social Mobility and the Professional seven male nurses interviewed in this study, six had joined Project of Indian Nursing nursing following the encouragement of their parents. One Given the historical association between nursing and low sta- male nurse from Karnataka stated that he was not consider- tus work, professionalizing strategies promoted by nursing’s ing migrating overseas as his parents were not in favor of Johnson 11 leaders focused on constructing a positive public image of qualifications in some quarters and the critique, in others, nurses with the aim of achieving greater social and political that these trends are driving nurses further away from the legitimacy. Across the sites, the low public image of nurses in patient and have become a threat to occupational closure India was seen as a major threat to achieving both social and (Maben, Latter, & MacLeod Clark, 2007; Nelson, Gordon, & professional recognition for members of the nursing profes- McGillion, 2002). sion. The following anecdote relayed by a speaker at a state Diminished control over nursing knowledge was raised level nursing conference illustrates how the occupational title frequently as a challenge to professional status, where nurs- of “nurse” continues to denote a somewhat stigmatized ing education was described by many nurses as a “business” identity. that threatened to undermine public confidence. Since the early 1990s, there has been a large increase in the number of private nursing schools and colleges in Bangalore offering I was on a train and I was chatting with a man who then asked nursing courses. The development of private nursing facili- me for my visiting card. He looked at my card and asked “Are you from X (well known hospital in Bangalore)?” I said “Yes.” ties came about largely to meet the demand for nurses both He said “Are you a doctor? What is your specialty?” I said “I am domestically and abroad, particularly in countries such as the a PhD, I am a nurse.” “Oh (pause) a nurse” he said. He looked United States that were reporting a large shortfall in their like I had just pricked his balloon. nursing workforce. These education facilities have attracted nursing students from surrounding states particularly For nursing’s leadership, including the national Indian Kerala—where despite its strong historical roots in Indian Nursing Council (INC) and its state-level body, the Karnataka nursing has fewer available nursing spaces. The mushroom- Nursing Council (KNC), the low public image of nursing ing of private nursing educational institutions has become a presents nurses with an important collective threat to claims matter of concern for the INC and KNC particularly around for greater professional status. Professionalizing strategies the quality of instruction and insufficient facilities. This has put forward by nursing’s leaders therefore concentrated upon resulted in the tightening of controls and the closure of a improving the image of nurses in the hospital environment, number of institutions. where this was perceived to have a “knock on” effect on the Migration, on the other hand, was overwhelmingly perception of nurses in wider Indian society. As a key note depicted by nurses as an important social and economic speaker at the state nursing conference urged his fellow “asset” for the profession, providing clear “evidence” of the nurses “Convince your patients and you will convince soci- “competency” of the Indian nurse. The perception of nurse ety!” Student nurses were encouraged to speak in English to migration as a positive development for Indian nursing was their hospital colleagues and were discouraged from speak- also supported by the presence of a Bangalore-based recruit- ing in the vernacular which was seen to present a more ment agency throughout the state level nursing conference. “local” identity to patients and hospital staff rather than that The recruitment agency set up an information stand within of an assertive “global” nurse. In Bangalore, as in other large the main conference hall, and their representatives gave a Indian cities, the effects of globalization have underlined the presentation to the audience on opportunities for nurse importance of English as a common professional medium of migration particularly to the United States. In addition, while communication. senior nurse managers did highlight the logistical challenges Among some nurse leaders, there was dismay that the in providing nursing care due to high rates of staff turnover emerging generation of nursing students were rejecting bed- in some hospitals, as well as the difficulties in finding quali- side nursing in favor of a career in specialized clinical areas, fied MSc and PhD nursing staff to teach courses and super- in hospital administration, and through pursuing further edu- vise students, they were supportive of their staff members’ cation—areas that would further their career trajectories in a plans to apply for overseas positions, often giving them time competitive global health care market. For some nurses in off to attend interviews or sit the relevant examinations. the professional associations, the desire to move away from Furthermore, migration was viewed as a key means to bedside nursing was undermining the traditional role of improve the professional and social standing of nurses in nurses to provide holistic care to patients. For others, engag- India. In their testimonies, nurses frequently highlighted the ing in many of the essential care activities required in bed- low pay of nurses, stating that their pay levels reflected those side nursing was a waste of nursing “skill.” This group of “unskilled” workers rather than medical professionals. A promoted specialization as a form of professional prestige speaker at the nursing conference passionately told the audi- and highlighted the importance of developing advanced ence, “Let India be empty of nurses and then they will nursing knowledge and skills in specialty areas as a way to acknowledge us!”—a sentiment which suggests that at the modernize nursing practice and meet the expectations of 21st political level, migration functions as a rationale to press for century health care. In many ways, the debate within nursing changes in working conditions and salary levels in Indian in India echoes the debate within nursing in other contexts in hospitals. Consequently, as migration offers the potential for which a series of professional dilemmas are posed by the individual social and economic mobility for migrating nurses, preference for increased specialization and educational it is also a strategy to achieve collective social mobility. 12 SAGE Open behind nurse migration from India, such as dissatisfaction Discussion with employment conditions in Indian hospitals and percep- The confluence of local and global perspectives character- tions of better salaries abroad, the possibility of professional izes the professional project of nursing in contemporary development, and the potential to join family overseas India in which nurses are seeking to carve a new identity (Hawkes et al., 2009; Thomas, 2006; Walton-Roberts et al., both within the Indian medical system and in wider Indian 2017), this study of nurses working in Bangalore is one of society (Johnson et al., 2014). This research supports other the few that embeds the decision of whether or not to seek studies that describe the dual function of migration—both as overseas employment among other career decisions rou- an individual life strategy (Nair & Percot, 2011) and as a col- tinely faced by nurses in India during their working lives. lective bargaining tool for the nursing profession (Timmons, The landscape of global public health is continually shift- Evans, & Nair, 2016). As demonstrated by the interview ing, partly as a result of the social and economic changes data, the career paths of nurses into nursing education, brought about by globalization, as well political consider- advanced nursing practice in specialty areas, and the deci- ations. Since this study was carried out, there have been sion to migrate abroad has resulted in a profession that is important geopolitical events including “Brexit” and restric- increasingly diversifying. For nurses in Bangalore, global- tions on the recruitment of international workers to countries ization has introduced the potential for status renewal such as the United States that will affect the career plans of through the incorporation of new technologies into nursing health workers, including nurses, looking to work outside practice and the prospect of global employment. As reported their countries of origin. It is too early to anticipate what this by Walton-Roberts and colleagues (2017), rather than being may mean for the career trajectories of Indian nurses or for a “hidden” process, this research found that migration was enrolment into the nursing profession itself in India. discussed openly by Indian nurses. Moreover, the interna- However, as this study has illustrated, the decision to migrate tional recruitment of nurses is a profitable industry with tie- overseas for nursing employment is one aspect of the career ups between overseas and India hospitals in the training and trajectories of nurses in India. While not all nurses wish to recruitment of Indian nurses, where Bangalore has emerged migrate, globalization and international migration have as one of the three main recruitment hubs in India along with important implications for nurses’ professional identity as an Delhi and Kochi (Khadria, 2007). Consequently, migration occupational group. In addition, urban centers such as to Bangalore is one step along the migratory pathway for Bangalore that are characterized by fast-growing global many nurses from Kerala who are able to gain work experi- opportunities offer nurses the possibility to work in large ence in the city’s various private hospitals before applying hospital set-ups where they can enter speciality fields, move for positions abroad. For other nurses, Bangalore is a large, into nursing education, or gain exposure to new medical cosmopolitan city, and working in Bangalore may be viewed technologies, in addition to developing the skills required to as “equivalent” to moving abroad. These nurses, particularly seek a nursing position abroad. from rural Karnataka, explained that migrating to Bangalore The research findings show that the notion of a meaning- was itself considered an important transition and that their ful career has great resonance among Indian nurses and plays families would not be supportive of their desire to leave a far more important role in work-related decisions than has India. been attributed to-date in the literature. Nursing careers in Compared with nurses from Karnataka, the pronounced the study setting were not restricted to climbing the nursing interest in migration among Keralite nurses is well supported hierarchy, but involved a series of lateral work roles in differ- by the literature on nurse migration from India (Nair, 2012; ent clinical settings, institutional contexts, and overseas Nair & Percot, 2011; Walton-Roberts et al., 2017). This study placements. Careers were found to be flexible and agential, found that the decision to migrate is often “communal” and where career achievement was characterized by skills acqui- influenced by the existence of overseas community net- sition, learning, enjoyment of nursing work, and professional works, as well as family and spousal support. These features autonomy in addition to material rewards. Career stagnation were particularly evident in the narratives of nurses from was found to be a concern of nurses across the data set, where Kerala, many of whom had relatives and friends already this was characterized by the absence of opportunities for abroad (Johnson et al., 2014). The Keralite community has a additional knowledge and skills. Whereas policy-level dis- long history of international migration in nursing and thus courses around migration have focused on individual “push” the presence of an international network of friends and fam- and “pull” factors that encourage international nurse migra- ily acted as a strong incentive to pursue nursing work tion, these discourses could be expanded to include concerns overseas. around professional autonomy, career incentives, and profes- Where career aspirations of health workers have been sional status. examined in empirical research, overseas employment is fre- This research is also one of the few that has looked at the quently depicted as the career decision for health workers negotiation of professional boundaries between nursing and from low- and middle-income countries. While the findings medicine in India and the implications for professional iden- of this research do concur with studies examining the factors tity. 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Journal

SAGE OpenSAGE

Published: Mar 8, 2018

Keywords: nurses; careers; professional identify; India

References