A suitable job?: A qualitative study of becoming a nurse in the context of a globalizing profession in India

Abstract

Background

Research on Indian nurses has focused on their participation as global migrant workers for whom opportunities abroad act as an incentive for many to migrate overseas. However, little is known about the careers of Indian nurses, or the impact of a globalized health care market on nurses who remain and on the profession itself in India.

Objectives

To explore nurses’ accounts of entry into nursing in the context of the globalisation of the nursing profession in India, and the salience of ‘migration’ for nurses’ individual careers.

Design

Qualitative interview study (n = 56).

Settings and participants

The study drew on interviews with 56 nurses from six sites in Bangalore, India. These included two government hospitals, two private hospitals, a Christian mission hospital, a private outpatient clinic and two private nursing colleges. Participants were selected purposively to include nurses from Christian and Hindu backgrounds, a range of home States, ages and seniority and to deliberately over-recruit (rare) male nurses.

Methods

Interviews covered how and why nurses entered nursing, their training and career paths to date, plans for the future, their experiences of providing nursing care and attitudes towards migration. Data analysis drew on grounded theory methods.

Results

Nursing is traditionally seen as a viable career particularly for women from Christian communities in India, where it has created inter-generational ‘nurse families’. In a globalizing India, nursing is becoming a job ‘with prospects’ transcending traditional caste, class and gender boundaries. Almost all nurses interviewed who intended seeking overseas employment envisaged migration as a short term option to satisfy career objectives – increased knowledge, skills and economic rewards – that could result in long-term professional and social status gains ‘back home’ in India. For others, migration was not part of their career plan: yet the increases in status that migration possibilities had brought were crucial to framing nursing as a ‘suitable job’ for a growing number of entrants.

Conclusions

The possibility of migration has facilitated collective social mobility for Indian nurses. Migration possibilities were important not only for those who migrate, but for improving the status of nursing in general in India, making it a more attractive career option for a growing range of recruits.

Introduction

In 1998/9, there were 48 nursing colleges in the state of Karnataka, south India. By 2003/4 this number had risen to 145 (Government of Karnataka, 2006). This dramatic expansion of training capacity reflects the emergence of nurses as an important ‘export’ for India (Alonso-Garbayo and Maben, 2009, Dicicco-Bloom, 2004, George, 2005, Gill, 2011, Khadria, 2007, Thomas, 2006, Walton-Roberts, 2012, Woodbridge and Bland, 2010). As part of a globalizing health care workforce (Kingma, 2006), Indian nurses migrate to access higher pay structures abroad, increased possibilities for professional development, to join family overseas or to escape dissatisfaction with social attitudes towards nursing in India (Hawkes et al., 2009, Khadria, 2004, Thomas, 2006).

To date, however, discussions of the motivations for and implications of this expansion in nurse migration have been based largely on the experiences of migrant Indian nurses themselves (George, 2005, Thomas, 2006, Woodbridge and Bland, 2010) and on the impact of the ‘brain drain’ from low and middle income countries on health system performance (Chen et al., 2004, Gill, 2011, Organisation of Economic Co-operation and Development, 2010, Rao et al., 2012, World Health Organization, 2006). Few empirical studies address the views of nurses who remain in India. One exception is a recent study by Nair (2012), who surveyed and interviewed nurses from Kerala who were working in Delhi. Nair notes that despite international migration having raised the visibility of nursing, it remained a job with low social status.

The current status of nursing in India relates to the intersections of religion, caste and gender through India's colonial history (Abraham, 1996, Fitzgerald, 1997, Nair and Healey, 2006). Nursing, in its modern form, can be understood as arising from the colonial expansion of medical services and education in the second half of the 19th century, with the bulk of nursing education taking place in Christian missionary hospitals. The emergence of Western style nursing in India came to be incorporated into historical social divisions in which nursing became associated with the traditional caste based division of labour and specifically with low status work. In the Indian caste hierarchy, notions of ‘purity’ and ‘pollution’ within the body come to be signified through rituals and social practices that separate higher and lower castes in the public arena (Gupta, 1992).

With its association with menial work, nursing has traditionally been viewed as a ‘polluting’ occupation that presented a threat to the social identity of those from the upper Hindu castes, and thus an inappropriate choice of employment for them (Abraham, 1996, Somjee, 1991, Walton-Roberts, 2012). As the caste hierarchy was not so visible in Christianity, converts were less affected by fears of pollution and other caste constraints found in Hinduism (Abraham, 1996). However, the affiliation of low caste Hindus and Christian converts with nursing made those from higher Hindu castes reluctant to enter the profession, thus presenting a challenge to female medical missionaries working in India who sought to recruit Muslim and upper caste Indians to lift nursing's public image (Fitzgerald, 1997).

That nursing is predominantly gendered work has also been widely analyzed as one important element in the relative status of nursing and its attractiveness as a career to those of high social status (Davies, 1995, Ehrenreich and English, 1973, Gamarnikow, 1978). Little of this work has drawn on settings such as India, but as nursing's modern origins lie in Western systems introduced during the colonial period, and nursing continues to be a female dominated profession, these feminist analyses resonate with the Indian setting. However, in India, changing opportunities for women are reflected in a loosening of the significance of caste stratification, particularly in urban settings such as Bangalore, where cosmopolitan mixed populations diminish (to some extent) the salience of pollution rules (Beteille, 1992). New jobs in IT and the service industry are outside the boundaries of traditional work-caste arrangements and, through providing competitive salaries, Westernized work place culture and opportunities to travel for young men and women, are part of social liberalization trends that are beginning to transform previously held attitudes towards caste and gender (D’Mello and Sahay, 2007). As Chauhan (2007), Beteille (1992) and other social commentators on India argue, caste has become one signifier among many, with class and income becoming important markers for such purposes as marriage choices or social status. In this context, there are signs that the image of nursing in public consciousness is beginning to change in that other religious groups, particularly Hindu women and men, and Muslims (although to a much smaller degree) are entering nursing (Somjee, 1991, Walton-Roberts, 2012).

Bangalore (Bengaluru¹) provides a useful setting to explore how globalisation and this rapidly changing occupational environment are shaping the profession of nursing in India. Bangalore is the state capital of Karnataka, with a population of some 8.4 million and is India's third largest city. As well as becoming synonymous with India's information technology boom, Bangalore is also a major medical hub, with a large range of research and medical facilities, from ‘super-specialty’ hospitals that offer high quality treatment and facilities for wealthy Indians and foreign clients, to poorly regulated private facilities and government hospitals catering to lower income patients. The growing number of medical and nursing colleges makes Bangalore a migratory destination for people from across south India, and a recruitment centre for medical professionals, including nurses (Khadria, 2004). However, a large number of recruits from its home state, Karnataka, are also trained in Bangalore and, have, to date, rarely been included in studies of nursing. This study therefore aimed to fill a gap in knowledge on the effects of globalisation on the nursing profession in India, in a rapidly changing environment for women at work.