Intensive Care Units are struggling with staff shortage
Thinley Namgay
The Intensive Care Unit (ICU) at Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Thimphu is grappling with a critical issue that threatens to undermine the efficiency of the hospital’s intensive care service.
The national referral hospital’s sole ICU specialist (intensivist) is about to go on an extraordinary leave. With his departure, four regular doctors will have to manage the ICU, along with three medical doctors on attachment and two volunteer doctors.
While the ICU staff are hoping that a competent female doctor will take over the role of the outgoing intensivist, they are concerned about the ICU’s daily operations and service quality if staff attrition continues.
Currently, the national referral hospital’s ICU has 28 nurses. After the pandemic, around 16 ICU staff members resigned. Before the pandemic, 34 nurses worked around the clock to manage the ICU.
The ICU in-charge at the national referral hospital, Pema Dorji, said staff shortage is a challenge as nurses have to work extra shifts.
“According to international standards, the nurse-to-patient ratio should be 1:1. However, the hospital cannot meet this requirement. We maintain a ratio of 1:2 or 1:3,” he said.
The ICU has a capacity of 10 beds. When more critical patients arrive, those who are less critical are transferred to other wards. The hospital plans to increase the number of ICU beds in the future.
Currently, the 28 ICU nurses at the national referral hospital manage their duties in six-hour shifts, with six or seven nurses on duty per shift. For additional shifts, nurses receive between Nu 1,000 and Nu 1,500, depending on their grades.
“Staff shortage is our primary challenge. The existing nurses have to take on extra work, which is exhausting. Every day, three of us have to cover additional shifts,” one of the ICU nurses said.
“Even with the extra shifts, it is challenging to meet the patients’ needs,” another nurse added.
The national referral hospital also has an eight-bed high dependency unit – a specialised inpatient unit for managing medical and surgical patients who require constant close monitoring but do not need mechanical ventilation or admission to the ICU.
The situation of ICUs at Gelephu and Mongar regional referral hospitals is no different.
An ICU staff member at the Gelephu hospital mentioned that the current situation is challenging due to staff resignations. “The hospital cannot maintain the nurse-to-patient ratio,” he said.
Although the actual ICU capacity at Gelephu hospital is 10 beds, only five, including an isolation room, are in use due to a lack of resources. Currently, there are 11 nurses, a reduction of four, who manage the ICU.
An ICU staff said that some members take mandatory leave towards the end of the year, hampering service delivery. He said that ICU staff require an additional six months of training in Thimphu. However, out of the 11 current staff members, only four are trained. The hospital compensates those who take extra shifts.
The ICU in-charge at Mongar referral hospital has also departed. Currently, only 13 nurses are managing the facility, whereas the requirement is 24 nurses.
“We are unable to maintain the nurse-to-patient ratio,” said a doctor at Mongar hospital. “Although no doctors have left Mongar hospital since 2022, around 22 nurses have resigned.”
Unlike the national referral hospital, Mongar and Gelephu do not have dedicated ICU doctors.
According to the Ministry of Health’s Attrition Report 2023, Bhutan has witnessed an average attrition rate of 4 percent for health workers since 2018.
As of June this year, the country has a shortage of 69 specialists, 103 doctors, and 824 nurses. Out of approximately 6,000 health workers in the country, about 1,000 of them are working at the national referral hospital.
Why are health professionals in Bhutan resigning?
A doctor at the national referral hospital attributed low pay, especially compared to salaries offered to expatriate doctors, as a major reason for the large number of health professionals resigning. “For instance, the starting salary for a doctor at Apollo Hospital in India is INR 500,000.”
A doctor from a district hospital highlighted that apart from low pay, their workload is significantly heavier compared to international standards. “There are times when a doctor has to remain at the hospital the entire day and night with minimal rest, without any compensation or acknowledgment for the additional duties, unlike nurses who receive night allowances,” the doctor said, pointing out the inconsistency in night allowance payments.
Other factors contributing to the attrition are peer pressure, limited career growth opportunities, and inadequate international training or exchange programmes.
Nurses also cited low pay, excessive workloads, and insufficient training as key reasons for leaving.