Ethical Challenge, Nurses’ Situation, and Quality of Care


Words by Dr. Muna Sharma


Nurses in Nepal are employing resilience strategies such as discussing problems with colleagues, striving for professional competency through self-learning, and sometimes ignoring less critical situations to manage the ethical challenges they face daily.


 “In my night duty I have to take care of all these 37 patients. I cannot approach all patients at the same time, generally I start medication from 5AM and it goes till 8AM, these patients do not have not access to medication on time, how can you ask for other nursing care? You know, sometimes I cannot change intravenous fluid of patients…….” 

 Ethical challenges are an inherent part of the healthcare profession, often presenting nurses with complex dilemmas that require careful navigation. The nurses find themselves at the forefront of ethical decision-making in healthcare settings. This article delves into the experiences of Nepalese nurses as they confront and grapple with ethical challenges in their daily practice, current situation of nurses in Nepal and its link with quality of health service. Nepal’s healthcare landscape is diverse, encompassing a mix of government and private hospitals, each catering to the unique needs of its patient population. Within this context, nurses play a pivotal role in delivering patient-centred care, often under challenging conditions characterized by resource constraints, staff shortage, and infrastructural limitations.

In the heart of Nepal’s healthcare, nurses confront multiple ethical challenges that lead to decreased quality of care, increased job-related errors, and high levels of moral distress and burnout.

Nurses have a clear ethical component to their knowledge and practice and nursing fundamentally is a moral endeavour. Nursing ethics centres on promoting the patient’s welfare, and asks how can a nurse do good and prevent harm to the patient, thus good nursing practice involves good ethics. They are the largest share of hospitals’ human resources in the healthcare system and frequently face complex problems due to their professional role. Among professional jobs, nursing has high physical and mental workload. On the other hand, inadequate ratio of nurse to patient increases work load. In this era, the recent development in science and technology has demanded more specific job including increased general amount of work to be done in a day; amidst all these concentration on specific nursing task at the same time while multitasking becomes increasingly difficult. International data supported that if there is high external work load to nurses there is increased chances of compromised quality care and two-three times more likelihood of medication error.

Situation of Nurses and Health Service Scenario

Based on Nepal Health Workforce Projection, (2022-2030), Nepal will require 43,056 nurses by 2031. However, recent data from Nepal Nursing Council shows that there are currently 82,471 registered nurses, including 849 foreign nurses and 1507 specialized nurses, suggesting an apparent surplus of nursing human resources if all our nurses were to stay in Nepal. Nevertheless, as per International labour organization (ILO) data of 2017, there were only 0.27 nursing professionals per 1000 population in Nepal. Recently, health news of Nepal ( has depicted a ground reality of government hospitals where one nurse is responsible for caring 40 patients per shift, whereas WHO recommends 1 nurse to 6 patients. The serious shortage of nurses compelled hospitals to cut down ICU, emergency, surgery and other health services. This observation suggests a lack of seriousness from Nepal Government and both public and private health stakeholders regarding optimum utilization of nursing professionals, who are crucial resources for health care delivery.  

“You know doctors do not stay 24 hours in this unit.  Nurses have to call them when patients’ condition deteriorates. Once in my duty, a patient went to shock, I called the duty doctor, and until his arrival I had to rescue the patient, but there was no emergency trolley, I ran around, managed oxygen, kept patient in shock position, opened I/V line, and once the doctor arrived, the patient was referred to another health facility….. It’s very stressful….” 


Ethical Challenges and Health Care Delivery   

Furthermore, data collected form 282 nurses employed in government hospitals across Nepal reveals that nurses encounter multiple ethical challenges in their job that lead to a decrease in quality care, increase job related errors, moral distress, and burnout. There is also a tendency to skip duty and an increase in job apathy. During an informal conversation, one of the nursing supervisors working in a public hospital disclosed a high turnover rate among nurses due to abroad migration. As aforementioned nurses perceive inadequate care for admitted patients and witnessing this situation as stressful. 

Despite having a surplus of registered nurses, Nepal faces a severe mismatch in nurse-to-patient ratios with one nurse often caring for 40 patients per shift, far exceeding WHO’s recommended ratio of 1:6.

Other challenging situations the nurses come across are: 

  • Application of inadequate infection prevention precautions; 
  • Doctors late responses to nurses’ call at patients’ emergency; 
  • Need to give medication on doctors’ verbal order; 
  • Less or no information to patients about their treatment; 
  • Inadequate pain management for patients; 
  • Medication error; 
  • Compromised patient’s privacy & confidentiality; 
  • Less competent health professionals and 
  • Discrimination in care. 

In response to the question of why these ethical challenges come across, they answered inadequate supervision and reward system; insufficient number of health human resources; inadequate resources for patient care; unclear job description; lack of clear-cut care protocol and lack of knowledge and skill of health professionals. 

The resilience strategies used at nurses’ individual level were: sharing /discussing problem with colleagues, with healthcare team members & seeking solution. Striving towards professional competency through self-learning strategies, and sharing with seniors in need. Sometimes ignoring or avoiding less important situations, and seeking professional support form organizations in extreme of situations may work. 

Conclusion and Way forward

This insight of the ethical environment within nursing in Nepal emphasizes on the necessity for acknowledgment from all involved parties to address the problems confronted by nurses. The constitution of Nepal has acknowledged health as a fundamental right for its citizens. However, disparities and insufficient utilization of healthcare personnel pose challenges to achieve sustainable development goals. Therefore, Nepal government must update approved job positions and healthcare resources to align with hospital beds and patient numbers. It is equally crucial to ensure the prompt recruitment and deployment of professionals, coupled with continuous capacity building. Collaborative efforts from stakeholders is essential in creating a supportive and conducive working environment for ethical practice is recommended to enhance quality of healthcare services. As this topic is one of the least talked issues, there is need for professional discourse.  Let us all start to talk about it now. 

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