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Nursing internship in India provides insights into health care inequity

By CN Content posted 07-15-2019 00:00
Jul 15, 2019, By: Anna Foster

Take away messages

  • Be aware of health system factors that shape nursing practice
  • Nurses are well-positioned to use our voices and advocate for more equitable health systems
  • Global health and cross-cultural learning experiences have incredible potential to inform our practice in the Canadian context

As a nursing student, new clinical rotations filled me with both excitement and panic. Day one of this placement was no exception: I turned off the three alarms I set to wake me, donned my postman blue scrubs, and gave myself a little “you can do this” pep talk. The only difference was that this clinical day started in Hyderabad, India and would mark the beginning of an incredible learning adventure that has undoubtedly shaped my current nursing practice.

It has now been almost one year since my time in India came to a close, and I often reflect on this experience on my journey as a new nurse. I carry with me an appreciation for the context in which I practise nursing and a passion to advocate for healthcare systems that deliver inclusive and equitable care.

The diversity in my clinical placements, and the observational nature of my role in India, allowed me to reflect on my beliefs about nursing and health in the context of the healthcare system as a whole. In Canadian clinical placements, my reflections were framed through the lens of individual patient interactions. While this tool effectively helped develop my bedside nursing practice, it limited my ability to make meaningful connections between system-wide healthcare issues and individuals’ experiences of health.

During my five-week placement in India, I visited primary healthcare clinics, community health centres, hospitals, and nursing schools. Some of these institutions were public, others were private; some were located in urban centres, and others in rural villages. I saw facilities in which labour rooms did not have mattresses on the beds, and others in which women could pay for private suites and give birth in Jacuzzi tubs. I visited one-room homes without access to water or toilet facilities, and others that were equipped with private washrooms for each of their bedrooms. Every visit provided new insights into the social determinants of health, health equity, and access to services in India; each site visit gave me exposure to a different component of the health system and lent further meaning to previous clinical experiences. I gained a deeper appreciation for systemic factors that influence healthcare, both in the international context and within Canada.

In India, I was able to link components of individual clinical visits to broader factors that shape health. As an observer of healthcare facilities and patient interactions, I temporarily stepped outside my role as a nurse providing direct patient care and was able to more objectively consider other factors that influence patient encounters.

For example, when the physician at a community health centre conducted assessments in an area where other patients could see and hear the interaction, I initially felt very uncomfortable. At first, it seemed the physician was not protecting patient confidentiality or upholding the privacy that I value as a nurse providing patient care. However, on further discussion with staff, I learned that the physician sees approximately 150 patients per day on a walk-in basis; therefore, patients stand close together so as not to lose their place in line and are able to overhear the interactions. The physician simply did not have the luxury of time or the physical space in the clinic to call individuals into a private counselling area. In this moment, I saw the clear link between the systemic issue of physician-to-patient ratios, building infrastructure, and patient care.

Understanding the broader healthcare context that shaped patient interactions helped me remain open-minded throughout my time in India. Rather than judge nurses or physicians for providing care differently from my Canadian viewpoint, I appreciated the importance of understanding health system factors and the broader context in which healthcare is delivered.

A new perspective

As a soon-to-be-nurse, I applied this new perspective to my role in the Canadian healthcare system, and it has significantly influenced my current practice and career goals. I became more aware of health inequities that persist domestically and the important role that nurses play in either challenging or complying with the status quo. This appreciation influenced my decision to begin my nursing career in a hospital in Northern Ontario. In my short time here, I have witnessed significant disparities in access to services between rural and urban centres. For example, when a patient’s health status begins to deteriorate and we do not have adequate resources to manage the condition onsite, I become acutely aware of system-wide factors that affect my ability to provide care in that context. This includes such factors as the lack of specialty physicians and transportation services, as well as the geographic barriers that directly affect patient care and my nursing practice in rural settings.

Some days, connecting patients’ experiences to systemic factors is tiring. It can feel as though I am taking on the burden of our healthcare system’s flaws in addition to the day-to-day stress of caring for patients. However, in order to improve our patient health outcomes, I believe nurses must engage with these flaws and advocate for meaningful change. Nurses are well positioned to utilize clinical experiences as a guide for policy changes that could improve health outcomes and equity. My duty at the patient’s bedside is crucial in determining health outcomes, but my role should extend beyond that. I believe that a key part of my practice should include challenging existing structures in our healthcare system that create or reproduce health inequities.

Many individuals are compelled to work internationally through a desire to help people in lower-income countries. My time in India certainly made me more aware of inequities between the global north and south, and I continue to be passionate about global health. However, an equally important lesson for me was remembering that our own healthcare system is not perfect. As a nurse who engages with this fact on a daily basis, it is important for me to advocate for changes that ensure I am part of a system that provides equitable and inclusive healthcare services.

Additional Resources

World Health Organization, Health Topics – Health Equity

Social Determinants of Health

Anna Foster is a registered nurse currently working in the Intensive Care Unit at Temiskaming Hospital in New Liskeard, Ontario. Anna’s passion for global health and health equity led her to pursue student placements and internships with True Vision Ghana, the World Health Organization, and the Catholic Health Association of India during her education.