A call for evidence-based reforms in nursing in Bangladesh

Bangladesh achieved independence in 1971, and the nursing profession was formalized shortly thereafter with the sating of a nursing diploma degree at nursing institutes and colleges level but not at any university[1]. The 2-year post-basic bachelor of science in nursing, which was just for the diploma in nursing completed by nurses, and a 4-year bachelor of science in nursing (BScN) degree as a post-secondary school education started in 1977[2]. However, the 4-year BScN program was momentarily halted due to concerns from diploma-holding nurses and students who were concerned that BScN graduates would receive preferential benefits, maybe due to their higher level of education[3]. Nevertheless, the BScN program resumed in 1980 in some private universities on a very small scale, and in 2008, it started in public universities and expanded afterwards[2]. Initially, nurses were deemed a third-class occupation, but nursing was not recognized as a second-class profession in the government payment scale until 2011[4]. Despite this upgrade, in the context of today’s sophisticated healthcare environment, the profession is still considered second-class. While it is within the government’s purview to assign workforce classifications, the continued designation of nurses as second-class requires logical arguments. There needs to be clear evidence demonstrating how this classification benefits the health and well-being of the community and aligns with the goals of contemporary healthcare standards. Clarification is required as to why the nurses have been deemed second class for a long time in Bangladesh. If it is essential to be a nurse as a second-class profession, this must be supported by research and evaluation as well as consider its impact on critical aspects such as inequality reduction, healthcare quality, and the establishment of sustainable healthcare, consistent with Bangladesh’s commitments to the United Nations sustainable development goals[5]. It is worth noting that nurses in Bangladesh are not authorized to administer medications because the country does not recognize nurse practitioner (NP) degrees, including those received from foreign institutions. Furthermore, chances for getting higher education in nursing, such as Master of Science in Nursing degrees (MScN) or PhD in Nursing, have been extremely restricted in Bangladesh, while a few colleges and institutions have recently begun to offer MScN programs, but any research-based program is yet to start in these modern days[6]. As Bangladesh has nearly 174 million people[7], in rural areas with limited healthcare access, the rationale for not allowing a large number of nurses to obtain advanced education and prescribe medication remains mostly unsupported by the literature. On the other hand, with less access to healthcare in rural areas, a large number of patients are compelled to seek medical care in urban centers, imposing considerable financial burdens on the healthcare system and the patients themselves[8]. In this current situation, with the support of literature, it might be a great initiative to enable nurses to become NPs and allowing them to practice independently in rural settings could significantly enhance healthcare services. It may be necessary to reconsider the constraints on nurses’ roles in rural health, possibly creating opportunities for unregulated or unqualified professionals[9]. Even if the government cannot utilize this opportunity to ensure healthcare for all, a pilot program could be implemented to leverage this potential in today’s healthcare environment. Various evaluation methods could also be considered, including policy evaluations, economic evaluations, and comparative analyses with neighbouring countries that have NP programs, such as India. Organizations such as the World Health Organization (WHO), the International Council of Nurses (ICN), and national governmental agencies are ideally suited to undertake these evaluations. Another major issue in the administration of nursing in Bangladesh is the number of individuals without any nursing education and training holding key administrative and managerial positions across clinical environments and up to the Ministry of Health, Bangladesh[10]. These roles are predominantly occupied by non-nurses, posing a significant challenge for nurses to improve their profession in the context of Bangladesh as their inclusivity is very limited. This practice permits individuals lacking the necessary clinical or nursing administrative expertise, often known as the BCS cadre, to fill important positions, thereby marginalizing qualified nurses[11]. Nursing is an established profession worldwide, and there may be no evidence behind such a policy that nurses are unfit for their administrative roles with their nursing education in Bangladesh. Thus, it is crucial to conduct comprehensive research and evaluation to determine the true benefits of the current administrative model on the advancement of nursing in Bangladesh. The prevailing hierarchical structure in the healthcare profession may significantly introduce discrimination against nurses. In both public and private hospitals, leadership roles such as directors or assistant directors are predominantly occupied by other professionals. This arrangement leads to a significant power imbalance in decision-making, often sidelining nurses[11]. For instance, during hospital or health ministry-related deliberations, nurses are commonly left out of teams in Bangladesh, with a marked preference for other healthcare workers during the selection process[12]. Such decision-making decrepitation can heavily favor certain healthcare workers, undermining the valuable contributions and insights of nurses[12]. Therefore, it is critical that the Ministry of Health, Bangladesh, in partnership with international organizations such as the WHO and the ICN, conduct these evaluations to examine the influence of the current administrative model on nursing in Bangladesh. An evidence-based reform that involves nurses in all of their professional decision-making processes around healthcare would result in a supportive environment that empowers the nurses in Bangladesh, ultimately yielding better quality patient care.

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