How work pressure forces Nigerian doctors, nurses to relocate abroad

EVERYDAY, over the past few months, Nneka Chukwu, a principal nursing officer at the National Orthopaedic Hospital, Enugu, checks out the latest developments concerning the COVID-19 pandemic in the United Kingdom. She gets alarmed at the rising numbers, particularly the huge death toll recorded among health workers in the European country.  Though she is afraid of the COVID-19 crisis in the UK, which is by far more severe than the situation in Nigeria, Nneka cannot wait to relocate to the UK, where she believes she will get the job satisfaction in nursing that has so far eluded her in her country, Nigeria. 

An investigation conducted ‎by The ICIR in the health sector revealed that despite higher risks associated with the coronavirus pandemic in the developed countries in Europe and North America, many Nigerian doctors and nurses are currently making moves to take their services outside Nigeria, with the UK, United States and Canada as the choice destinations. The investigation also revealed that although poor renumeration has been a longstanding complaint of Nigerian doctors and nurses, ‘job satisfaction’ was the major reason the medical practitioners are leaving the country.

Doctors and nurses who spoke to The ICIR in the course of the investigation said they lacked job satisfaction. They also expressed the belief that job satisfaction in the medical field would be found abroad – in countries such as the US, UK and Canada, among others.

Nneka, who spoke to The ICIR in Enugu in the course of the investigation, which focused on the South-East states, is hoping to relocate to the UK very soon. She told our correspondent that many other nurses are concluding arrangements to leave Nigeria.

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“I prefer (to relocate to) the UK. I have started the process and I believe that very soon I will leave. Even though I am scared of coronavirus and some other things that are happening there, I am going to leave. At the moment I know of so many other nurses that are just waiting for their visa to come out for them to leave Nigeria,” the nurse told our correspondent.

Although ‎it is widely believed that the opportunity to earn higher wages abroad was the major reason Nigerian doctors and nurses are leaving the country, Nneka noted that monetary consideration was a secondary factor. She stressed that the major reason was lack of job satisfaction owing to unsatisfactory working conditions.

Low nurses to patients ratio ‎in Nigeria

Nneka specifically identified the low nurses to patients ratio in the country – a situation which forces one nurse to attend to scores of patients at a time – as the major factor responsible for lack of job satisfaction among Nigerian nurses. She told The ICIR that the low nurses to patient ratio, which imposes an unduly high workload on the available nurses, was one of the reasons nurses are practically fleeing the country for the US, UK, Canada, Germany and other countries where they will do more quality work with less effort.

As of March 2020, the nurse to patient ratio in Nigeria was 1: 1135, which translated to 88.1 nurses per 100,000 persons. ‎The figure was disclosed by Mr. Shakuri Kadiri, deputy director, and head of human resources for health in the federal ministry of health, Abuja.

Analysis of work pressure on Doctors and Nurses in Nigeria
Analysis of work pressure on Doctors and Nurses in Nigeria

The World Health Organisation (WHO) recommended that, going by population size, Nigeria should have not less than 800,000 nurses and midwives, according to President of the National Association of Nigerian Nurses and Midwives (NANNM), Abdrafiu Adeniji. But Adeniji told The ICIR that, at the moment, the country has just 125,000 nurses and midwives.

A nurse attends to more than 10 patients at a time at National Orthopaedic Hospital, Enugu

Giving further insight on how the low nurses to patients ratio affect healthcare delivery in hospitals across the country, Nneka revealed that, at the National Orthopaedic Hospital, Enugu, she and her colleagues attend to more than 10 patients at a time. “Here in the Orthopaedic Hospital (Enugu) you have a situation where as a nurse you are attending to at least 10 to 12 patients at a time,” she told our correspondent.

Nurses can’t give their best when attending to many patients at the same time

Nneka observed that the situation has had a negative effect on healthcare delivery as nurses have difficulties in handling several patients at the same time.

National orthopaedic hospital, Enugu

Speaking further, Nneka said, “As nurses, we are trained to give holistic care. A nurse should provide all round care and for you to be able to do that, you will have to focus all your ‎attention on a particular patient. It is not something you can do when you are attending to more than one person at a time.‎ That is ideal but things are different in reality. For example in this hospital, in a 24-bed ward, you have just two nurses on duty. That means 12 patients under one nurse. Even at that, had it been that the things you need are within your reach it would have been easier but sometimes you will have to take a patient out of the ward to do X-Ray, or you will have to take a patient to the theater, or you have to go out to look for oxygen.”

Continuing, she added, ‎”From my experience, personally you find yourself running helter-skelter in order to meet up with the care you have to provide to several ‎patients at a time. But unfortunately, in the end, you find that you will not be able to give the care. So you find out that you are not satisfied – the job satisfaction that a nurse gets from nursing patients is not there. Everything gets tangled up and you just don’t like what you do. At the end of the day, the nurse goes home tired, weak and in fact feels like not coming to work again. That is what happens as a result of the low nurse to patients ratio. As a nurse, you are not able to do what you should do. And for me and my colleagues, it also makes us to feel sick. We work over-time most of the time. Our work is tense – the number of hours you put in is enormous and again, the pay is not commensurate to the effort put into the work but we just find ourselves doing it. If you overstay your shift, as is the case most of the time, you don’t get paid for that. And you notice that you overstay most times because you are trying to meet up with what you are supposed to do, and still, in the end, you don’t meet up.”‎

  • Unsatisfied patients

‎Between the nurses and the patients, there are no winners in the unfortunate situation. Nneka explained that most times, patients are not satisfied with the level of care they receive in hospitals. “Most of the time the patients are not satisfied. Most times, I will be on one bed attending to a patient and another patient will call me and I will say ‘give me some time I’m coming’ but I can’t divide myself into two so I can’t come immediately. So as a result, that other patient feels you are ignoring them”.

Due to inadequate number of nurses, patients’ relatives get involved in providing care

Patients waiting for the doctor at federal teaching hospital, Abakiliki, Ebonyi State.
Patients waiting for the doctor at federal teaching hospital, Abakiliki, Ebonyi State.

Another unfortunate aspect of the situation is that, because the few nurses available have their hands full, sometimes relatives who are looking‎ after family members in the hospital have no choice than to get involved in providing care for patients. Nneka, who expressed regrets over the development, admitted that some patients prefer their relatives to do certain things for them when they observe that the nurse, who has been over-worked, was becoming irritable.

Nurses are leaving Nigeria in droves

More than 10 nurses employed by the National Orthopaedic Hospital, Enugu, left Nigeria last year, according to Nneka. And many more are waiting to leave in 2021. “This year (2020) alone, from this Orthopaedic Hospital, more than 10 nurses left the country and more than 50 are waiting to leave,” she said.

Nneka insisted that money had nothing to do with her decision to leave. According to her, it is all about job satisfaction. “I want to leave because the work here is not giving me what I want based on what I know I can do. The environment is not just conducive and this is not just about the pay. When the things you are working with are not working, and you have this dedication to do what you are trained to do, you will want to go to a place where you will do better. The truth is when you have a lot of people (patients) under your care, you can’t be effective‎,” she observed.

‎President of the National Association of Nigerian Nurses and Midwives, Adeniji, said healthcare practitioners are not leaving the country just because they want to make more money. In an interview with The ICIR, Adeniji insisted that the ‘brain drain’ has more to do with conditions of service and job satisfaction.

He said, “Migration is a personal choice but it has a lot to do with the condition of service and job satisfaction. People are not leaving the country because of monetary considerations alone. When the condition of service does not allow you to function effectively the interest will be lost and when the interest is lost you will have to look for an alternative. The number of nurses in the country is grossly inadequate and in a situation where the few nurses available are being overworked and the condition of service is so poor, it not surprising that you see many nurses leaving the country.”‎

Number of medical doctors in Nigeria not enough

Investigations by The ICIR across the South-East states further revealed that not only is the number of medical doctors‎ grossly inadequate to meet the healthcare needs of the population, most of the doctors are also leaving the country for better working conditions abroad.‎

The federal government in March 2020 put the doctor to patient ratio in the country as 1: 2753, which translates to 36 medical doctors per 100,000 persons but the World Health Organisation recommends 1: 600 doctor to patient ratio.

Executive secretary of the National Universities Commission (NUC), Abubakar Rasheed, said on January 20, 2021, that Nigeria needs about 300,000 doctors to meet the 1:600 ratio recommended by the WHO.

The total number of medical doctors registered with the Medical and Dental Council of Nigeria as at March 2020 was 74,543, according to figures released by the federal government, although the NUC said less than 40,000 medical doctors are currently practicing in the country. The NUC also put the doctor to patient ratio in the country at 1:3500. However, the website of the Nigerian Medical Association (NMA) said there are over 40,000 medical doctors in Nigeria, and about 19,000 Nigerian physicians in the Diaspora.

Efforts to get the actual number of medical doctors in the South-East states were not successful but chairmen of Nigerian Medical Association (NMA) state branches provided estimates of the number of doctors in their states.

‎Chairman of the Ebonyi State chapter of the NMA, ‎Ben Umezurike, told The ICIR that the state currently has about 650 medical doctors.

Jibe Onyekwelu, chairman of the NMA in Anambra, said there are about 1000 medical doctors in the state.

According to Tony Onyia, chairman of the NMA in Enugu State, there are about 1700 medical doctors in Enugu.

Chairman of the Imo State chapter of the NMA, Chidiebere Okwara, said the number of medical doctors employed by the state government at different levels was just 210. The number does not include medical doctors in the Federal Medical Centre, Owerri, and those working in private hospitals. ‎

Okwuonu Chimezie, NMA chairman in Abia State, refused to disclose the number of medical doctors in the state. He told our correspondent that he was not authorised to disclose such information by the national body of the medical association. Chimezie referred our correspondent to the national leadership of the NMA.

Doctors suffer emotional and physical fatigue due to large number of patients, some fall sick, die 

‎Medical doctors, who spoke with The ICIR in the course of the investigation, said most of them are suffering from ’emotional and physical fatigue’ due to the disproportionately huge number of patients they have to attend to on a daily basis.

‎Shedding further light on the situation, Okwara, Imo State NMA chairman, revealed that in December 2020, a medical doctor at the Federal Medical Centre, Owerri, collapsed while on duty and had to be taken to the Intensive Care Unit (ICU).

‎”The doctor collapsed while on call attending to patients. He was rushed to the Intensive Care Unit and it took almost a week to get him back on his feet. He overstretched himself trying to attend to so many patients at once and didn’t have any time to rest and that was what led to that. He was unconscious for two days in the ICU,” Okwara said.

‎Noting that all the general hospitals in Imo State do not have up to a total of 30 medical doctors, Okwara added that there are only 12 medical doctors in the primary healthcare centres across 27 local government areas in the state.

As a result of the situation, a doctor ‎working at the primary healthcare level covers up to three local government areas at the same time.

“Many doctors are suffering from emotional and physical fatigue,” Okwara observed.

Corroborating O‎kwara’s account, Umezurike, NMA chairman in Ebonyi, said many doctors have developed health complications.

‎”If you look at the faces of medical doctors you will see that all is not well, especially health-wise. ‎Some doctors have collapsed while some have died treating patients. We are doing more than we should do and the incentive is very poor,” Umezurike told The ICIR.

Inadequate number of medical doctors undermine healthcare delivery ‎

Onyekwelu, NMA chairman in Anambra, said the inadequate number of medical doctors has had a negative effect on healthcare delivery. According to him, the knowledge that general hospitals in Anambra have just one medical doctor has made people to opt for patent medicine dealers rather than visiting the hospital, when they are sick.  ‎

‎”That is why many of our general hospitals have very low patronage. The people prefer to go to patent medicine dealers for their treatment,” he observed, adding that in most instances, patients go to the tertiary or specialist ‎hospitals when their health challenges are already serious.

Onyia, Enugu NMA chairman, bemoaned the long period it takes medical doctors to attend to several patients, who also have to ‎wait several hours to see the doctor.  “As a result, doctors begin to get irritable and this affects the doctor-patient relationship. When you have to see patients from 8:00 am to 4:00 pm, there is no way you will give your best. It gets to a point where there will be diminishing returns,” he said, adding that some patients are taking to alternative medicine just because of the lack of easy access to medical doctors.

According to Onyia, several communities in the rural areas have no medical doctor, a situation which he said has provided an environment for quacks and unorthodox medical practitioners to thrive.

    ‘It is the dream of every young doctor to leave Nigeria’

    At the ‎Federal Teaching Hospital, Abakiliki (FETHA), in Ebonyi State, a young doctor, who pleaded anonymity, told The ICIR that no doctor would remain in Nigeria if there is an opportunity to relocate and practice abroad.

    A federal teaching hospital, Abakiliki, Ebonyi State.
    A federal teaching hospital, Abakiliki, Ebonyi State.

    “What I can tell you now is every young doctor’s major priority is to leave Nigeria. Those that want to stay here in the long term probably have personal interests or limitations but the trend now is that young doctors are writing foreign licencing exams to leave Nigeria,” he said, adding that hospitals have gotten used to receiving resignation letters from their young doctors.

    The young doctor suggested that medical practice was better, and easier, abroad. According to him, in the US, UK, Canada and other advanced countries, a doctor can only work for a specified duration at a time and there is a limit to the number of patients to be attended to.

    However, going by Chukwu’s testimony, it is not only young medical practitioners that wish to leave Nigeria, but even the experienced hands are also leaving. And if nothing is done to address the situation, the ‘brain drain’ problem will only get worse for Nigeria, as, according to Nneka, “Every medical practitioner here (Nigeria) is needed out there (abroad). Doctors, nurses, laboratory scientists, physiotherapists – all of them are needed abroad”. ‎

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