essay on nursing profession in india

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GROWTH OF NURSING IN INDIA: HISTORICAL AND FUTURE PERSPECTIVES

Dr. Punitha Ezhilarasu Consultant Indian Nursing Council

Nurses are two-thirds of health workforce in India. Their central roles in health care delivery in terms of promotion, prevention, treatment, care and rehabilitation are highly significant. Their contributions towards achieving UN millennium development goals (MDG) and sustainable development goals (SDG) are very crucial but not sufficient enough particularly in developing countries like India to create major impact on health outcomes. Achieving universal coverage, increasing health financing, recruitment, training and retention of health workforce are two important goals that have direct relevance to India. Nursing today has witnessed several changes, successes and challenges through a lot of stride and movement. Nurses have widened their scope of their work, however while the roles and responsibilities have multiplied, there are still concerns with regard to development of nursing, workforce, selection and recruitment, placement as per specialization, pre service, in service training and human resource (HR) issues for their career growth. This paper attempts to present the futuristic nursing in the light of historical and contemporary perspectives.

Historical perspectives

Nursing and Nursing Education

In the ancient era, until 17th century, formalized nursing was not traced. Every village had a dai/traditional birth attendant to take care of maternal and child health needs of the people. Military nursing was the earliest type of modern nursing introduced by the Portuguese in the 17th century. In 1664, East India Company started a hospital for soldiers at Fort St. Geroge, Madras. In 1797, a lying-in-hospital (Maternity) for the poor in Madras was built. Some of the other earliest hospitals were the first hospital in Calcutta in Fort William (1708), Calcutta medical college hospital and London mission hospital at Neyyoor (1838), Jamsetjee Jeejeebhoy (J.J) group in Mumbai (1843), Thomasan hospital at Agra (1853), Holy Family Hospital, Delhi (1855), Civil hospital Amritsar (1860), CMC, Ludhiana, Punjab (1881), 1892 Miraj medical school and hospital, Maharashtra (1892) and Bowring hospital in Bangalore (1895).

Florence Nightingale was the first woman to have great influence over nursing in India and brought reforms in military and civilian hospitals in 1861. St. Stevens Hospital at Delhi was the first one to begin training Indian women as nurses in 1867. In 1871, the government General Hospital at Madras was started with the first school of nursing for midwives with four students. Many nursing schools were started in different states of India between 18th and 19th century mostly by mission hospitals, which trained Indians as nurses. At this time there was no uniform educational standards followed in nursing schools. In 1907-1910, in North India, United Board of Examiners for mission hospitals was set up which formulated training standards and rules. Later Mid India (1926) and South India (1913) boards (boards of CMAI) were set up which conducted examination and gave diplomas. The first school of Health visitors was started in 1918 by Lady Reading Health School, Delhi. The first four-year Basic B.Sc. program was established in 1946 at RAK College of Nursing in Delhi and CMC College of Nursing in Vellore. In 1960, M.Sc. was established in RAK College of Nursing, Delhi. In 1951, a two-year ANM course was established in St. Mary’s Hospital at Punjab.

Bombay Presidency Nursing Association was the first state nursing association established in 1890. In 1908, the Trained Nurses Association was formed to uphold the dignity and honor of nursing profession. The first state registration council at Madras Nursing Council was constituted in 1926 and Bombay Nursing Council was constituted in 1935. In 1949, Indian Nursing Council (INC) was established to maintain a uniform standard of training for nurses, midwives and health visitors and regulate the standards of nursing in India. INC act was passed in 1947 that was amended in 1950 and 1957. General Nursing and Midwifery (GNM) syllabus was revised in 1951, 1965, and 1986, ANM in 1974 and B.Sc. in 1981.

The nursing scenario at the time of independence was not bright and there were about 7000 nurses for the population of 400 million. The hospitals were grossly understaffed, nursing lacked professional and social status, and the working and living conditions of nurses were far from satisfactory. The low status can be attributed to the low socio economic status of Indian women and nursing is primarily a women’s profession. In the fifties, more number of girls from different parts of the country joined nursing and slowly there are more entrants from better socioeconomic status. By 2000, nurses’ colony at Delhi was built by Central government; nursing advisor post was instituted at the national level; three nursing posts were increased to five with the introduction of Asst. Director General Nursing and Dy. Asst. Director General. The College of Nursing PGI, Chandigarh and College of Nursing, CMC Vellore were designated as WHO collaborating centers for nursing and midwifery development in 2003.

The development of various committees such as Bhore Committee (1943), Shetty Committee (1954), Mudaliar Committee (1959-61), Kartar Singh Committee (1973), Srivastava Committee (1974), High Power Committee (1987) alongside five year plans have brought about a transition in the status of nursing and midwifery. The recommendations made were in relation to staffing in hospital nursing service, public health settings, and schools/colleges, working and living conditions, infrastructure and equipment, regulations, and intensification of training programmes to meet the staff shortage. The reports of the above mentioned Committees and National Health Policy (NHP, 2002) have put forward very sound recommendations for nursing management capacity. The NHP laid emphasis on improving the skill-level of nurses and on increasing the ratio of degree-holding nurses vis-à-vis diploma-holding nurses. It also recognized the need for establishing training courses for super-speciality nurses required for tertiary care institutions. However, gap existed in actual implementation. This required a strong support at the policy level to ensure implementation of key recommendations.

Following independence, reorganization of the health services took place in the light of the Bhore Committee recommendations (1946). Health services were provided in the rural areas through the establishment of primary health centre (PHC) as a basic unit to provide an integrated curative and preventive health care for the population of 30,000 in the plains (20,000 in hilly areas). The staffing pattern of the PHC was not implemented fully as per the Bhore Committee with regard to nursing until now. As per the Bhore committee’s recommendations, the nursing staff of PHC includes Public health nurses – 4, Institutional nurse -1, Midwives – 4 and Trained Dais – 4. In 1952, a post-certificate Public Health Nursing programme was instituted at the college of Nursing, New Delhi and later transferred to All India Institute of Hygiene and Public Health, Calcutta. Community health nursing was integrated in the curriculum of GNM and BSc Nursing courses.

From 1977-till date, with the introduction of Multipurpose Health Worker’s Scheme following Kartar Singh’s Committee report in 1973, most of the categories of staff under various unipurpose programmes were re-designated for multipurpose work. Until recently, most of the health services in the homes were provided by the Health workers, health visitors, ASHAs and Trained Dais whose activities were and are still concerned primarily with maternity and child welfare. The auxiliary nurse midwife (ANM) gradually replaced the Dais to serve in the village through the primary health centre and its sub-centres. Under NRHM scheme in 1996, every PHC was manned with 2 staff nurses to provide RCH services. In 1977, the Indian Nursing Council revised the curriculum for ANM course, in order to prepare candidates with high school certificate as Health workers (Female) and Health workers (Male) under the multipurpose health workers’ scheme. The formulation and adoption of the global strategy for “Health for All” by the 34th World Health Assembly in 1981 through Primary Health Care approach got of a good start in India with the theme “Health for All” by 2000 AD. In 1987, The Government of India appointed a High Power Committee on Nurses and Nursing Profession to go into the working conditions of nurses, nursing education and other related matters and submitted manpower requirements for nursing personnel.

Contemporary Perspectives

The current healthcare environment is dramatically different from the past and it is the health system that shapes the educational system and pathways. The complexity of the healthcare influenced by the increasing longevity, shortening of hospital stays, scientific and technological advances, equality, poverty, discrimination, disasters, violence and cultural diversity leads to several challenges that threaten the health and wellbeing of the Indian Population. Currently India has only 0.7 doctors (Global average is 1/1000) and 1.7 nurses (Global is 2.5/1000) available per thousand population. The ratio of hospital beds to population in 0.98/1000 against the global average of 3.5 beds/1000 population (WHO). India stands at 67th rank against 133 developing countries with regard to number of doctors and 75th rank with respect to number of nurses. The Physician Nurse ratio is not satisfactory. Thus, International Nurse is 1:3 whereas India is having 1:1. The country needs 2.4 million nurses to meet the growing demand (FICCI report, 2016). The HLEG (High Level Expert Group) group report on UHC (Universal health coverage India) 2011 is increased reliance on a cadre of well- trained nurses, which will allow doctors to focus on complex clinical cases.

The roles of nurses are evolving and changing. Nurses can perform health assessment, actively support patients and families in all settings, create innovative models of care, and enhance work processes to raise quality, lower cost and improve access for our society. Nurses can undertake research to find evidence to support new nursing interventions. Nurses can contribute towards strengthening systems to work efficiently in interdisciplinary teams. They can effectively participate and influence policies related to nursing at local, state and national levels. There is a rising demand in terms of manpower for tertiary and quaternary care, which requires specialized and highly skilled resources including doctors, nurses and other paramedical staff. This is also emphasized in NHP 2017. As a result, the demand for trained manpower, especially nurses will continue to increase every year. The number of registered nurses/midwives was 6.7 lakhs in 1998 and has reached 17,91,285 nurses/midwives in 2014.

In India, nursing educational programs such as Auxiliary Nurse Midwifery, General Nursing and Midwifery, BSc(N), MSc(N), MPhil and PhD(N) exist. INC prescribes uniform standards and syllabi for every educational program to be implemented across the country. However, the implementation by educational institutions having varied capabilities is not uniform resulting in graduates with varying knowledge, attitude and competencies. The last syllabus revision for ANM was done in 2012-13, GNM 2015-16, B.Sc- 2006, PBBSc- 2006 and M.Sc 2008. The growth in nursing educations is phenomenal. From 2000 to 2016, ANM schools have increased from 298 to 1927, GNM schools from 285 to 3040, B.Sc colleges from 30 to 1752, and M.Sc colleges from10 to 611. Although the increase is significant still there is gap between demand and supply. The 12th five-year plan suggested establishing 24 centers of excellence in nursing. The HR efforts included up gradation of schools to colleges, strengthening of existing schools, faculty development, and establishment of 6 AIIMs like institutions.

Some of the INC initiatives and achievement include capacity building of 55 nursing educational institutions, training of 1,20,000 nurses and 3500 faculty in HIV/AIDS & TB through GFATM project. E Learning module was developed as a result of this project. A Live register is being developed for all categories of nurses. Every registered nurse will be provided with a nurse unique ID (NUID). The register will lead to development of a nurse tracking system across the country and aid in reciprocal registration alongside renewal of license linked with CNE. INC has become a member of ICN. A national consortium for PhD in nursing was constituted by INC in 2006 in collaboration with Rajiv Gandhi University of Health Sciences. The main objective is to promote research activities in various fields of nursing. The total number of research scholars enrolled in 12 batches is 268 and 74 have been already awarded Phd degree. There are 8 PhD study centers now namely INC, New Delhi, St John’s College of Nursing, Bangalore, CMC College of Nursing, Vellore, CMC College of Nursing, Ludhiana, Govt College of Nursing, Hyderabad, Govt College of Nursing, Thiruvananthapuram, Govt College of Nursing, SSKM Kolkata, and INE, Mumbai. INC is in collaboration with JHPIEGO has taken initiative to strengthen the foundation of pre-service education resulting in better prepared service provider. In order to promote competency based training INC in collaboration with JHPIEGO is going to set up state of the art simulation center in India.

There is a scope for improving living and working conditions of nurses in the future. Through the efforts and representation by TNAI, Supreme Court has recommended minimum salary of 20,000 per month as starting salary of a staff nurse in private hospitals. Some states have developed mechanism to conduct and record CNE through State nursing councils. Integration of service and education model that is practiced in CMC Vellore is also introduced in a few more institutions particularly in St Johns College of Nursing, Bangalore. INC is in the process of developing a practical model for the country. Florence Nightingale awards instituted by MOH & FW in 1973 to recognize and honor the meritorious services of outstanding nursing personnel in the country are given to 35 nurses every year on May 12, the International Nurses Day. This award includes a medal, certificate, citation and cash award of Rs. 50,000/-.

Some of the top nursing colleges in India today are established in the earliest days and are continuing to maintain standards and quality of education. AIIMS College of Nursing Delhi, CMC College of Nursing Vellore, RAK College of Nursing Delhi, SNDT College of Nursing Mumbai, NIMHANS Bangalore, Manipal College of Nursing Manipal, PGI College of Nursing Chandigarh, AFMC College of Nursing Pune, , BM Birla College of Nursing, Kolkata, , St John’s Bangalore, Govt College of Nursing Thiruvananthapuram, CMC College of Nursing Ludhiana, Father Muller College of Nursing Mangalore, Sri Ramachandra Medical University College of Nursing Chennai, and Apollo College of Nursing, Chennai are some of the top colleges of Nursing today. Many universities are running PhD programmes in nursing and many colleges have been recognized as research departments.

Public Health Nursing

According to the Indian Nursing Council (Snapshots, 2016), 789,740 ANMs and 56,096 LHVs are registered in the different state nursing councils of the Country. About 2.00 lakh ANMs (Auxiliary nurse midwives) and thousands of female health supervisors and public health nurses are working in the public health sector alone. They are responsible for implementing all national and state health programmes at ground level. Critical activities related to maternal and child health, disease control, immunization, epidemic management and health promotion are carried out by peripheral public health nursing personnel. The training of public health nursing personnel varies widely ranging from a broad multipurpose training of less than two years for ANMs to six years education at university level to prepare community health nursing specialists. Currently, community health nursing is offered as a subject in the ANM, GNM (general nursing and midwifery), post-basic B.Sc. Nursing, regular four-year B.Sc. Nursing and M.Sc. Nursing.

The scope of public health nursing is wide in India and their potentials are not fully utilized in our country. Currently, public health nurses at PHC, Block and district levels plan, monitor, and mentor peripheral health staff to implement programmes on health promotion and disease prevention. The Bhore Committee gave a strong recommendation for introduction of public health nurses and the Mudaliar Committee reiterated this. Rather than moving forward into a professional cadre, public health nursing in India became stagnant at the lowest level of ANM due to the political and economical reasons. Shortage of nurses and its impact on the Indian health care delivery system remains a major concern to this day. Adding to the above problem, there is an undersupply of competent public health nurses who are willing to serve in the resource-limited community health care settings.

Future Perspectives

The future of healthy India lies in mainstreaming the health agenda in the framework of the sustainable development and strengthening primary, secondary and tertiary care services to serve the rural (70%) and urban (30%) population. NHP 2017 recommends setting up new Medical Colleges, Nursing Institutions and AIIMS in the country by the government, standardization quality of clinical training, revisiting entry policies into educational institutions, ensuring quality of education, continuing nursing education and on the job support to providers, especially those working in rural areas using digital tools and other appropriate training resources, strengthening human resource governance, regulation of practice, establishing cadres like Nurse Practitioner and Public Health Nurses, specialty training for tertiary care, nursing school/college for 20-30 lakh population, HR policy for faculty, centers of excellence in nursing in each state, career progression to nursing cadre and posting of regular nurses to sub-center in the state where adequate nursing institutions are present. The policy also recommends the use of mid-level service providers to provide comprehensive primary care to the rural community through Health and Wellness centers/Sub centers. Nurses can assume this role provided they undergo a six month bridge course.

In the light of the above recommendations pertaining to nursing and nursing education, INC has prepared curriculum for Nurse Practitioner (NP) programmes in Critical Care and primary care. NP in Critical Care (NPCC) programme is commencing from 2017 and NP in Primary Health Care (NPPHC) from 2018. Both are residency programs aimed at providing clinical training at the real practice settings. State governments are communicated by central government to create posts for nurse practitioners at the state level. The revision of existing BSc and MSc curriculum are being planned to integrate competency based education approach and the process has just begun. The regulation of nursing education and practice will be strengthened through Nursing Practice Act (NPA) for which INC at the direction of the MOH &FW has started the preparation and soon it will be ready. National license exit exam for entry into practice, periodic renewal of license linked with continuing nursing education, and completion of live register are some of the future activities.

Studies of nursing practice have demonstrated that better patient outcomes are achieved in hospitals and community staffed by a greater proportion of nurses with a baccalaureate degree (Benner, Sutphen, Leonard, & Day, 2010). Phasing out diploma programme and making BSc as entry level is being dialogued and this might become a reality in the future too. The WHO strategic directions for nursing and midwifery (SNDM) 2011 – 2015 provide stakeholders with a framework for collaborative action with the vision statement “Improved health outcome for individuals; families and communities through provision of competent, culturally sensitive, evidence based nursing and midwifery services. This should become the future for nursing.

Bibliography

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses : A call for radical transformation. Danvers, MA: Wiley

– FICCI Report, 2016
– Indian Nursing Council, 2016
– Indrani,TK (2004). History of Nursing, New Delhi: Jaypee Brothers
– National Health Policy, 2002 & 2017
– Trained Nurses’ Association of India (2001). History and Trends in Nursing in India, New Delhi: TNAI

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Mini Review Volume 2 Issue 4

Challenges faced by Nurses in India-the major workforce of the healthcare system

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Department of Nursing, Rufaida College of Nursing, India

Correspondence: Merlin Mary James, Tutor, Rufaida College of Nursing, India, Tel +91-9971882433

Received: February 22, 2017 | Published: April 5, 2017

Citation: Chhugani M, James MM. Challenges faced by nurses in india-the major workforce of the healthcare system. Nurse Care Open Acces J. 2017;2(4):112-114. DOI: 10.15406/ncoaj.2017.02.00045

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Nursing binds human society with a bond of care and affection. Nursing is a calling to care, which offers an oasis of poignant stories and pool of challenges. Despite of urbanization and globalization in India, the healthcare system in the country continues to face formidable changes. Nurses play an integral role in the healthcare industry, providing care to the patients and carrying out leadership roles in hospitals, health systems and other organizations. It is of paramount importance that all people everywhere should have access to a skilled, motivated and supportive nursing care within a robust healthcare system. The importance of nurses in healthcare should be underlined for attempting to create a better task force for better quality care for all. There are certain challenges which the Nurses in the present healthcare system face. These challenges arise due to issues at the organizational, state and national level. It is of utmost importance to first recognize and understand each and every possible challenge faced by the nurses in order to deal with them efficiently. Not just recognize and understand them but also find solutions to mitigate them.

Keywords: challenges, nurses and Healthcare system

Mini Review

Nursing binds human society with a bond of care and affection. Nursing is a calling to care, which offers an oasis of poignant stories and pool of challenges. The scope of nursing practice has expanded and extended to different settings other than hospital only. Nurses deal with the most precious thing in this wide world- ‘the human life’ . 1

Nurses are often the linchpin component across a wide continuum of care. A nurse’s professional skills and training contribute significantly to successful patient outcomes in a variety of care settings--from acute and tertiary care to prevention and wellness programs. 2 Their smiling face and compassionate touch and care provides great satisfaction to the patient.

Despite of urbanization and globalization in India, the healthcare system in the country continues to face formidable changes. The healthcare system has become increasingly detached from the curative aspect and more focusing on the satisfaction of material needs and enlarging the profit-earning aspects. This has led to unaffordability of the curative care to many common people due to the present framework of the healthcare system in the country. Subsequently the healthcare system is being plagued with various problems. The solution is to delve deeper into the roots of the problems and explore possible solutions to curb them.

Nurses play an integral role in the healthcare industry, providing care to the patients and carrying out leadership roles in hospitals, health systems and other organizations. Although nursing profession can be very rewarding but it is equally challenging and it entails a huge level of dedication and commitment. Nurses needs to be focused on not only the patient needs but also on the management of system of care. This often creates unfortunate hassles irrespective of how hard the nurse’s works towards patient care. They are coordinators and custodians of patient care. This entails lot of managerial skills where they need to possess apart from technical skills

Reduced workforce and lack of quality care leads to overburdened workforce which further leads to higher morbidity and mortality. It is of paramount importance that all people everywhere should have access to a skilled, motivated and supportive nursing care within a robust healthcare system. The importance of nurses in healthcare should be underlined for attempting to create a better task force for better quality care for all.

However, there are certain challenges which the Nurses in the present healthcare system face. These challenges arise due to issues at the organizational, state and national level. It is of utmost importance to first recognize and understand each and every possible challenges faced by the nurses in order to deal with them efficiently. Not just recognize and understand them but also find solutions to mitigate them.

In India, the healthcare system is undergoing a radical change and there are unmet health targets. The change is due to the change in demographics, advancement in medical technology, profit earning mentality, immigration, task shifting, education-service gap and economic recession to list a few. Subservient to medical fraternity even though long back it has been developed as profession (WHO). Nurses facilitate co-operation from other healthcare providers, for e.g., doctors, paramedical staff and other ancillary staff. There are several daunting challenges faced by nurses at workplace which leave them less efficient in rendering quality care to patients, thereby hoisting an unhealthy reputation to that particular healthcare setting.

Nevertheless, these challenges are arguably the primary motivators for nurses to leave their profession, less students opting for nursing profession, thereby contributing to staff shortage. They move to other countries as remuneration and working condition and respect better.

Challenges faced by nurses at workplace

Workplace mental violence

Workplace violence is widespread in healthcare settings. Huge amount of workload and responsibilities on the staff can often lead to disturbed mental peace which will ultimately lead to less efficient care. Multiple tasks can pose a problem in a healthcare unit. Workplace mental violence can be also in the form of threats, verbal abuse, hostility and harassment, which can cause psychological trauma and stress. At times verbal assault can escalate to physical violence. In a healthcare setting, the possible sources of violence include patients, visitors, intruders and even co-workers. From 2002 to 2013, incidents of serious workplace violence (those requiring days off for the injured worker to recuperate) were four times more common in healthcare than in private industry on average. Patients are the largest source of violence in healthcare settings, but they are not the only source. In 2013, 80 percent of serious violent incidents reported in healthcare settings were caused by interactions with patients. Other incidents were caused by visitors, co-workers, or other people. At many instances workplace violence is under-reported. 3

Shortage of staff

Deficient Manpower leads to unmanageable patient load and disparity in the Nurse: Patient ratio. Nurse: Patient ratio needs to be well maintained as it highly affects the patient care delivery system. When nurses are forced to work with high nurse-to-patient ratios, patients die, get infections, get injured, or get sent home too soon without adequate education about how to take care of their illness or injury. So they return right back to the hospital, often sicker than before. When nurses have fewer patients, they can take better care of them. 4 When there are sufficient number of nurses in a healthcare setting, the nurses have more time to advocate with the patients and their relatives about the plan of patient care and s/he can ensure that the patient gets everything s/he needs, and thereby patients are more likely to thrive in such situations.

Workplace health hazards

Nurses confront a high risk of developing occupational health hazards if not taken proper precautions and care. Nurses are confronted with a variety of biological, physical, and chemical hazards during the course of performing their duties. The level of occupational safety and health training and resources available to nurses, and the incorporation, implementation, and use of such training and resources with management support and leadership are critical factors in preventing adverse outcomes from the occupational safety and health hazards nurses are exposed to on a daily basis. 2

Long working hours

Short staffing pattern in a health care unit often results in long working hours and double shifts of staff nurses. It is evidently affecting the health of the nurses. It is quite difficult for a nurse to provide efficient nursing care with exhausted state of mind and body.

Lack of Synchronicity

Disharmony and lack of teamwork is an emerging challenge in the heath-care sector. Harmonious relationship amongst healthcare workers is an essential requirement for the healthcare system. Nurses bear the indirect opprobrium of every dreadful incident which occurs in the hospital. If the patient is not satisfied by the care rendered in the hospital, all the blame is accrued to the nurses, even if it is not her fault. Inadequacy in the care rendered may vary from ineffective medical care to non-availability of doctors, and yet nurses are being blamed. Non availability of equipment in hospital, which in turns affects the quality of care. Although the responsibility is not necessarily of nurses, yet nurses are ultimately responsible for patient care environment in their wards.

Lack of recognition

Hospitals must be safe places for sick folks and their nursing services carry responsibilities that are not always recognized. 1 There is no support system for nurses and hence their performances are usually not projected well. During inspections conducted in Hospitals by Medical Council of India and Indian Nursing Council, nurses play a vital role in all facilitations, and at the culmination of the inspections, the outcomes are not shared with them and they are not acknowledged for the work performed.

Non-nursing roles

In almost all healthcare settings, nurses undertake roles which are not of their forte, hence they are left with minimal time to carry out their actual roles and responsibilities. They are spending more time than necessary doing non-nursing-related work, for e.g., billing, record keeping, inventory, laundry, diet, physiotherapy, absconding of patient, etc., thereby diminishing time for patient care. If at any instance, there is any fault in these roles, the nurses have to bear the brunt of that in the form of cancellation of leaves, salary deductions etc., Very little efforts have been made in any jurisdiction to explicitly address this.

Solutions to curb the challenges

All the listed challenges are somehow interlinked and interdependent. It is necessary for us to look deep within these problems and to reach to the core of these challenges in order to find resolutions for the same.

Positive practice environment

Work environment: Work environment plays a large role in the ability of providing quality care. It impacts everything from the safety of patients and their caregivers to job satisfaction. There needs to be employer friendly work environment. Safety and security of the nurses should be given importance. To maximize the contributions nurses, make to society, it is necessary to protect the dignity and autonomy of nurses in the workplace. 5 A Healthy Work Environment is one that is safe, empowering, and satisfying. A culture of safety is paramount, in which all leaders, managers, health care workers, and ancillary staff have a responsibility as part of the patient centered team to perform with a sense of autonomy, professionalism, accountability, transparency, involvement, efficiency, and effectiveness. All must be mindful of the health and safety for both the patient and the health care worker in any setting providing health care, providing a sense of safety, respect, and empowerment to and for all persons. 6 Harmonious human relations and incentives in work settings may serve as motivation and encouragement for the nurses.

Equipment/materials : The availability and adequacy of samples of equipment and consumable supplies is often a matter of concern. Usually staff report that they are crippled by unavailability and inadequacy of certain equipment and supplies. The problems ranged from the inadequacy of life saving supplies and equipment including IV drugs adrenaline, oxygen and autoclaves to relatively cheap supplies including gauze and cotton wool. The hospital management should ensure at regular basis that the supplies and equipment are adequately available for the smooth functioning of the hospital.

Positive team work

A team needs to be taught about importance of team work and a good team can always conquer the goal of effective and quality patient care. It can also accelerate the focus on curative care of the patients.

Recruitment/retention policy

A proper and well planned policy for recruitment and retention has to be included in an organization in order to enhance the manpower for better support and care.

Closing education-service gap

Every heath care organization should be focusing on eradicating the difference between what is taught to the nurses during their study period and what is being done practically by them in hospitals. Practical and theoretical things of nursing aspects should be merged to an extent to close the education - service gap. Nursing colleges, year by year are strengthening their educational programs and their supervision in an effort to develop thoughtful nurses and to safeguard patients whom they tend. Students need to be taught reverence for human life, as tragedy lurks round every corner in a hospital-any hospital, good or bad and that price of safety is eternal vigilance. 1

Workload balance (Quality/Quantity)

Workload often leads to unwanted hassles and loss of mental peace which ultimately leads to less efficient care. An organization should try to balance the workload by distributing it equally among all the health care members so as to get the desired results out of a health care team.

Evidence based practice

Nurses should also deviate a part of their focus towards evidence based practice. Various practices have related researches which can be read by the nurses to see if that practice is actually effective or not. Regular reading of research articles and studying various experimental studies can improve the knowledge and practice of nurses and thus can have a huge positive effect of patient health care and curative care too Figure 1 .

Figure 1 Nursing Problems and solutions.

Patient and the public have the right to the highest performance from the healthcare professionals and this can only be achieved in a workplace that enables and sustains a motivated and well-prepared workforce. Catering to the needs of nurses and combating their challenges can make nurses empowered, encouraged, challenged and affirmed to continue doing what they do best without any barriers.

Acknowledgements

Conflict of interest.

The author declares no conflict of interest.

Medical chivalry and team work. American Journal of Nursing . 1927;27(5):367.
Ramsay, D James. A new look at nursing safety: The development and Use of JHAs in the emergency department. The Journal of Sh & e Research . 2005;2(2):1–18.
https://www.osha.gov/Publications/OSHA3826.pdf
http://www.truthaboutnursing.org/faq/short-staffed.html
http://www.nursingworld.org/workenvironment
http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment

©2017 Chhugani, et al. This is an open access article distributed under the terms of the, Creative Commons Attribution License ,--> which permits unrestricted use, distribution, and build upon your work non-commercially.

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The History of Nursing in India: From Ancient Times to Modern Day

The nursing profession plays a crucial role in the healthcare system, providing essential care and support to patients in need. In India, the history of nursing dates back thousands of years and has a rich tradition rooted in ancient healing practices. In this article, we will explore the history of nursing in India, from its ancient roots to its modern-day practices, and the vital role that nurses play in the Indian healthcare system.

Table of Contents

Ancient Roots of Nursing in India

The history of nursing in India dates back to ancient times, when nursing was considered an essential component of healthcare and a noble profession. Despite its long history, nursing in India has undergone significant changes and has evolved over time to meet the changing needs of society.

Ancient Roots of Nursing in India:

Nursing was considered a religious and spiritual practice in ancient India, with references to nursing and healers in Hindu scriptures and holy texts.
Ancient Indian healers, known as "Vaidyas," relied on natural remedies and traditional methods to treat illnesses and injuries.
During the Mughal Empire, nursing was introduced to India through Persian and Central Asian healers, who brought with them new medical practices and techniques.
The arrival of the British in India brought further advancements in medical care, and nursing was formalized as a profession with the establishment of nursing schools and training programs.

These ancient roots laid the foundation for modern-day nursing in India and helped to establish nursing as a respected and essential profession in the country. Despite its long and rich history, nursing in India continues to evolve and adapt to the changing needs of society, providing quality care and improving the health of people across the country.

The Introduction of Western Medicine and the Development of Modern Nursing

With the arrival of British colonial rule in India, Western medicine and nursing practices were introduced to the country. The British established hospitals and nursing schools, which helped to modernize the Indian healthcare system. The first nursing school in India was established in 1868 in Kolkata and was followed by several other nursing schools across the country.

The arrival of Western medicine in India during the 19th century marked a turning point in the history of nursing in the country.
British colonial rule and the establishment of modern hospitals brought new ideas and practices in medicine, as well as new standards for nursing education and practice.
The first training program for nurses in India was established at the Mission Hospital in Kolkata in 1873, and soon after, similar programs were established in other cities across the country.
The early training programs for nurses in India were modeled after British nursing programs and emphasized the importance of hygiene, sanitation, and patient care.
The introduction of Western medicine also led to the development of new specialties in nursing, such as pediatrics, psychiatry, and midwifery, as well as the growth of nursing research and education.
Despite these advances, the nursing profession in India faced challenges in the early 20th century, including a lack of recognition and respect from the medical community, low wages, and limited opportunities for advancement.
Despite these challenges, the nursing profession in India continued to grow and evolve, and today it is a respected and essential part of the health care system, with a rich history that reflects the cultural and medical traditions of the country.

The Evolution of Nursing Education in India

The evolution of nursing education in India has been a gradual process, driven by the changing needs of society and advancements in medical technology. Over the years, nursing education has evolved from informal apprenticeships and on-the-job training to formalized programs and degrees, preparing students for a career in the healthcare field.

The Evolution of Nursing Education in India:

In the early 20th century, nursing education was formalized with the establishment of nursing schools and training programs, offering basic nursing education to students.
With the introduction of western medical practices and technologies, nursing education in India expanded to include more comprehensive and specialized training programs.
The establishment of government and private colleges and universities offering nursing degrees and diplomas, helped to further establish nursing as a respected and sought-after profession in India.
The introduction of distance learning and online nursing programs, has expanded access to nursing education to people across the country, regardless of location.
Today, nursing education in India is highly regulated, with strict standards and requirements for programs and degrees, ensuring that students receive a high-quality education and are well-prepared for careers in the healthcare field.

The evolution of nursing education in India has played a crucial role in improving the quality of care and health outcomes in the country, by providing students with the knowledge, skills, and training they need to succeed as healthcare professionals. The continued development of nursing education in India is vital for the growth and advancement of the nursing profession in the country.

The Vital Role of Nurses in Modern India

Today, nurses play a vital role in India's healthcare system, providing essential services and care to patients in a variety of settings. From urban hospitals to rural health clinics, nurses are at the forefront of providing quality care and improving the health of communities across the country.

The Vital Role of Nurses in Modern India:

Nurses are involved in a wide range of healthcare services, including patient care, disease prevention, and health promotion.
They play a critical role in diagnosing and treating illnesses, managing chronic conditions, and administering medications.
Nurses also provide important support to families and communities, helping to educate and empower people to take control of their health.
In addition to their direct patient care responsibilities, nurses also play a key role in healthcare administration and research, helping to advance the field and improve patient outcomes.

Despite the critical role they play in India's healthcare system, nurses continue to face numerous challenges, including a shortage of trained professionals, inadequate resources and facilities, and limited access to continuing education and professional development opportunities. Nevertheless, the nursing profession remains a vital and rewarding career choice for those who are passionate about improving the health and well-being of others.

In conclusion, the history of nursing in India is a testament to the resilience, dedication, and hard work of the nursing profession. Despite the many challenges and changes that the profession has faced over the years, nurses have remained at the forefront of healthcare, providing essential care and support to patients in need. Today, the nursing profession continues to evolve, as technology and medical practices advance, and nurses are called upon to take on new and increasingly complex roles. Whether working in a hospital, clinic, or other healthcare setting, nurses remain the backbone of the Indian healthcare system and a vital resource for the communities they serve.

At NURSING EXPERT, we are committed to supporting the nursing profession and helping to advance the careers of nurses across India. Our website provides a wealth of information and resources for nurses, including news and articles, training and education resources, and career opportunities. Whether you are a seasoned nurse or just starting out, we are here to support you and help you grow in your career. We invite you to explore our website and join us in our mission to support and advance the nursing profession in India.

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I'm Deepak, an experienced nursing professional with a Master's degree in Medical Surgical Nursing. As the founder of nursing.in, I aim to share my knowledge and expertise in nursing by providing valuable insights and updates on the latest developments in the field. Stay informed and learn about new techniques and treatments through my blog.

Factors Associated with Nursing Professionalism: Insights from Tertiary Care Center in India

Poonam Kumari 1 ,
Surya Kant Tiwari ORCID: orcid.org/0000-0003-4718-0398 2 ,
Nidhin Vasu 1 ,
Poonam Joshi ORCID: orcid.org/0000-0002-7016-8437 3 &
Manisha Mehra ORCID: orcid.org/0000-0001-7699-947X 4

BMC Nursing volume 23 , Article number: 162 ( 2024 ) Cite this article

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Professionalism among nurses plays a critical role in ensuring patient safety and quality care and involves delivering competent, safe, and ethical care while also working with clients, families, communities, and healthcare teams.

Aims and objectives

To assess the level of nursing professionalism and the factors affecting professionalism among nurses working at a tertiary care center in India.

A descriptive cross-sectional study was conducted from October 2022 to March 2023 using a total enumeration sampling technique. Following institutional ethics committee approval, standardized tools were administered consisting of Nursing Professionalism Scale and socio-demographic, personal, and organizational characteristics.

A total of 270 nurses participated, with a response rate of 93.7%. The mean age of the participants was 27.33 ± 2.75 years, with the majority being female (82.6%) and belonged to the age group of 23–27 years (59.6%). More than half of the nurses exhibited high professionalism (53%), with the highest and lowest median scores for professional responsibility (29.0) and valuing human beings (13.0) respectively. Multivariate regression analysis demonstrated that, compared with their counterparts, nurses with a graduate nursing qualification (AOR = 4.77, 95% CI = 1.16–19.68), up-to-date training (AOR = 4.13, 95% CI = 1.88–9.06), and adequate career opportunity (AOR = 33.91, 95% CI = 14.48–79.39) had significant associations with high nursing professionalism.

Conclusion/Implications for practice

The majority of the nurses had high professionalism, particularly in the domains of professional responsibility and management. Hospitals and healthcare institutions can use these findings to develop policies and prioritize opportunities for nurses to attend conferences and workshops to enhance their professional values, ultimately leading to improved patient care outcomes.

Patient and public contribution

No patient or public contribution.

The study addresses the issue of nursing professionalism in a rapidly evolving healthcare landscape, emphasizing its crucial role in ensuring patient safety and quality care.

More than half of the nurses reported having high levels of professionalism. Professional qualifications, up-to-date training, and career opportunities were identified as key factors associated with high nursing professionalism.

The findings can serve as a foundation for developing policies and programs aimed at improving professionalism among nurses, with potential implications for patient outcomes.

The emphasis on the significance of professional qualifications and up-to-date training suggests the need for continuous education and training programs to enhance nursing professionalism.

Peer Review reports

Introduction

In the rapidly evolving healthcare landscape [ 1 ], professionalism among nurses plays a pivotal role in ensuring patient safety and quality care. The nursing profession has undergone a transformation, especially since the onset of the pandemic, evolving from a job into a profession marked by precision and professional independence.

Nursing, as a profession, is characterized by a set of dynamic values, dedication, obedience, commitment to societal betterment, unwavering ethical values, and a strong sense of accountability and responsibility [ 2 , 3 ]. It involves delivering competent, safe, and ethical care while collaborating with clients, families, communities, and healthcare teams.

Professionalism in nursing is guided by a multifaceted set of values that forms the foundation for nurses’ knowledge and practice [ 4 ]. This professionalism extends beyond technical competence and is rooted in ethical decision-making and adherence to practice guidelines and standards [ 5 , 6 ].

Few studies have revealed lacunae in applying the code of ethics in nursing practice among nurses and nursing students [ 7 , 8 ]. Furthermore, a systemic review has indicated that a poorly perceived nursing profession can lead to poor patient outcomes [ 9 ]. Several studies have revealed a gap between personal and professional values among nursing professionals [ 10 , 11 ], emphasizing the need to integrate professional values into nursing education. These discrepancies can significantly impact patient outcomes and influence nurses’ intention to leave the profession [ 12 ].

Thus, there is an urgent need to assess the level of professionalism and its associated factors among nurses. In India, until recently, only a few studies have explored nurses’ perspectives on professionalism. Therefore, we aimed to assess the level of professionalism and explore the factors affecting professionalism among nurses in a tertiary care center, which represents a first step in developing policies and programs for nurses.

Study design and setting

An institutional-based descriptive cross-sectional study was conducted from October 2022 to March 2023 to measure the level of professionalism and associated factors among nurses working at a tertiary care center in Eastern India using a total enumeration sampling technique.

Study participants

The source population for this study consisted of nurses employed in the hospital. The study population included all nurses who met the inclusion criteria and agreed to participate. The inclusion criteria consisted of nurses working in the hospital and available during data collection; those with less than 6 months of working experience were excluded from the study. We distributed a Google Form link to 288 registered nurses via WhatsApp and Gmail to complete the questionnaires. We received responses from 270 nurses, resulting in a response rate of 93.7%. The final data were collected from the pilot study.

Ethical considerations

The Institutional Ethics Committee of the procuring institute reviewed the protocol, and permission was granted to carry out the study vide no- IEC/AIIMS/Kalyani/Meeting/2022/46 dated 22/07/2022. All participants were informed about the purpose of the study and their participation was completely voluntary. Written informed consent was obtained from all the eligible participants. The participants were also assured of the confidentiality and anonymity of the obtained information.

Sample size

The sample size was calculated using the formula; n = Z² P (1 − P)/d². Considering the prevalence of high professionalism among nurses (P) as 68.6% [ 23 ] at a 95% confidence interval (Z = 1.96) with a 6% maximum allowable error (d). By inserting these values into the formula, we got a calculated sample size of 235. Furthermore, for a 10% nonresponse rate, the required sample size was set to 260.

Tool I consisted of sociodemographic, personal, and organizational characteristics such as age, gender, marital status, working experience, personal and job satisfaction, effective interpersonal relationships with patients and healthcare teams, up-to-date training, career opportunities, location of the institute, and satisfaction with the work schedule.

Tool II comprises a 38-item Nurse Professionalism Scale, initially developed by Braganca et al. [ 28 ], which assesses the professional behavior of nurses while performing roles and responsibilities related to the patient care activities on a five-point Likert scale (0 = Not Applicable; 1 = Never; 2 = Rarely; 3 = Sometimes; 4 = Mostly; 5 = Always). This scale includes six domains: professional responsibility and accountability, nursing practice, communication, and interpersonal relationships, valuing human beings, management, and professional advancement with total scores ranging from 0 to 190. A score ≥ 115 indicated high professionalism, 77–114 indicated moderate professionalism and a score less than 77 indicated low professionalism. The Cronbach’s alpha for nursing professionalism in the present study was 0.97.

Statistical analysis

The collected data were checked for completeness and accuracy before analysis and then coded and summarized in the master data sheet. All statistical analyses were performed with SPSS Software version 26.0 utilizing both descriptive and inferential statistics. For descriptive statistics, the frequency, percentage, mean, standard deviation, and range were calculated. The Kolmogorov–Smirnov test was used to evaluate the normality of the distribution of the outcome variables. Due to the nonnormal distribution, nonparametric tests (Mann–Whitney U and Kruskal–Wallis H) were used to compare means. Binary and multivariable logistic regression analyses were carried out to identify factors associated with nursing professionalism. Model fitness was assessed using the Hosmer–Lemeshow goodness-of-fit test ( p = 0.83), which indicated a well-fitted model. Additionally, all variables satisfied the chi-square assumption, and their odds ratios were examined. To assess multicollinearity among continuous variables, variance inflation factor (VIF) values were computed and found within the acceptable range (1 to 2), confirming the absence of multicollinearity. Bivariate and multivariate logistic regression analyses were employed to identify factors associated with outcome variables. Variables with a p-value less than 0.2 in the bivariable analysis were included in the multivariable analysis. Significant associations with outcome variables were determined based on a p-value less than 0.05 with a 95% confidence interval.

The mean age of the nurses was 27.33 ± 2.75 years, with the majority belonging to 23–27 years age group (59.6%), female (82.6%), unmarried (70.4%), and having professional experience of 2 to 5 years (47.4%). Furthermore, the majority of participants reported satisfaction with their current job (67.8%), the location of the institute (66.7%), and work schedule (80.7%). (Table 1 )

Table 2 shows the level of nursing professionalism among the participants. More than half of the nurse participants exhibited high nursing professionalism (53%), while approximately one quarter had moderate (23.0%) or low nursing professionalism (24.0%).

The total median score (Q1-Q3) for professionalism among nurses was 120.50 (77.7–146.0). The highest median score was observed in the area of professional responsibility (29.0), followed by management (28.0), while relatively lower scores were observed in the domains of communication and interpersonal relationships (13.0) and valuing human beings (13.0). (Table 3 )

Table 4 shows the mean differences in nursing professionalism according to sociodemographic, personal, and organizational variables. There was a significant difference in the mean rank between professional qualification, job satisfaction, and career opportunity and nursing professionalism scores.

Table 5 depicts the factors associated with nursing professionalism for the study variables. According to our multivariable regression analysis, three variables, professional qualification, up-to-date training, and career opportunity, demonstrated significant associations with high nursing professionalism. Similarly, compared with those with a diploma, nurses with a graduate nursing qualification had 4.77 times greater odds of having high nursing professionalism (AOR = 4.77, 95% CI = 1.16–19.68). Furthermore, nurses who had received up-to-date training had 4.13 times greater odds of having high professionalism (AOR = 4.13, 95% CI = 1.88–9.06), while those with adequate career opportunities exhibited substantial 33.91 times greater odds of having high nursing professionalism (AOR = 33.91, 95% CI = 14.48–79.39) than did their counterparts.

This study focused on the level of professionalism among nurses and associated factors among 270 nurses working in a tertiary-level hospital in India. The results showed that more than half of the nurse participants exhibited high levels of professionalism, with variations across different domains. Professional qualifications, up-to-date training, and career opportunities were identified as key factors associated with high professionalism among nurses.

Nursing professionalism is a global concern, with variations observed across different countries and healthcare systems. The findings of our study revealed that more than half of the nurses had high professionalism, which was in line with the findings of various studies conducted in Ethiopia [ 6 , 21 ]. This high level of professionalism in our study participants can be attributed to younger age, adequate staffing ratio, resource availability, job security, and support for professional development opportunities in our institute, which could impact nurses’ motivation, job satisfaction, and, consequently professionalism [ 22 ].

Nursing professionalism is multidimensional, dynamic, and culture-oriented [ 5 ]. It may be influenced by various organizational, educational, and societal factors, which can vary significantly across countries. Studies among Japanese and Ethiopian nurses reported low levels of professionalism among nurses [ 23 , 24 ]. Another study showed professionalism as a common factor influencing job satisfaction in Korean and Chinese nurses [ 25 ]. Iranian nurses’ attitude towards professionalism was reported to be at an average level [ 26 ].

In this study, the highest median scores were attributed to the subdomain of professional responsibility and management. In contrast, another study attributed high scores to subdomains such as ‘maintaining the confidentiality of the patient’ and ‘safeguarding the patient’s right to privacy’ [ 2 ]. A Korean study depicted that higher professionalism among oncology nurses may lead to higher compassion satisfaction and lower compassion fatigue [ 18 ].

One of the interesting findings of our study is that nurses with more than 5 years of experience had higher mean scores on professionalism, which is supported by various studies that revealed high professionalism among highly experienced nurses [ 19 , 26 ]. On the other hand, a recent survey in India indicated that nurses with fewer years of experience exhibited greater professional values compared to their more experienced counterparts [ 3 ].

Professionalism in nursing practice is important for ensuring patient safety, quality care, and positive healthcare outcomes. Another intriguing finding of this study is that participants who are personally and job-satisfied and have effective interpersonal relationships with patients attain higher professional median scores. These finding aligns with those of other studies indicating that nurses who are satisfied with their peers have greater job satisfaction and, consequently greater professional value [ 11 , 20 ].

Multivariate regression analysis revealed that professional qualifications, up-to-date training, and career opportunities were significantly associated with nursing professionalism. A previous study showed that nurses with a diploma qualification exhibited high professionalism scores [ 19 ]. This finding contrasts with the present study, which demonstrated that nurses with a graduate degree exhibited high levels of professionalism. Other studies have noted that age, number of years of experience, and length of service significantly contribute to the nursing profession [ 6 ].

Continuous education plays a significant role in making learning more concrete, helping in pouring professional values and fostering deeper commitment to the profession [ 13 ]. Another major finding of this study is that nurses who have undergone up-to-date training exhibit higher levels of nursing professionalism, which has been supported by several studies [ 2 , 14 , 15 ]. These findings may be attributed to the continuous enrichment of knowledge and values through participation in conferences and workshops after graduation [ 16 ].

In our study, we did not find any influence of gender on nursing professionalism. In contrast, a study reported that female nurses had high professionalism [ 23 ]. This discrepancy could be due to differences in participant characteristics, such as professional qualification, age, educational attainment, location, and study period [ 17 ]. A recent study illustrated that nursing professionalism plays a mediating role in the relationship between self-efficacy and job embeddedness [ 27 ].

This comprehensive study provides valuable insights into the factors influencing nursing professionalism, covering various dimensions, such as sociodemographic, personal, and organizational factors. Additionally, we used validated tools for data collection and managed to acquire an adequate sample size with high response rates.

Limitations of the study

Our study has several limitations. The cross-sectional study design and single time point data do not allow for the examination of changes or trends over time. In addition, self-report bias may be introduced due to self-administered questionnaires and convenience sampling may introduce selection bias.

Clinical practice relevance

Our findings have important implications for redefining the roles of nurses in India to be more in line with those in Western countries. In Western countries, individuals are prioritized for continuous education and training, and nurses often have higher educational qualifications, and clear career paths with opportunities for specialization and advancement, which are associated with greater professionalism. Redefining the roles of nurses in India might involve establishing and promoting up-to-date training programs and encouraging the pursuit of advanced degrees. Policies in India could include support for attending conferences, workshops, and international collaborations, practices common in Western countries. Such alignment may improve patient care standards, increase professional satisfaction among nurses, and enhance healthcare outcomes in India.

Conclusions

To conclude, more than half of the nurse participants displayed high professionalism, particularly in domains related to professional responsibility and management. Factors associated with nursing professionalism include professional qualifications, up-to-date training, and career opportunities.

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Acknowledgements

We express gratitude to all the study participants for their cooperation and devotion of time during the data collection period.

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Department of Nursing Services, All India Institute of Medical Sciences, Kalyani, West Bengal, India

Poonam Kumari & Nidhin Vasu

College of Nursing, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India

Surya Kant Tiwari

College of Nursing, All India Institute of Medical Sciences, Kalyani, West Bengal, India

Poonam Joshi

College of Nursing, All India Institute of Medical Sciences, Patna, Bihar, India

Manisha Mehra

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Study conception and design: PK, PJ, and MM designed the study, PK, NV, and PJ collected the data. SKT analysed the data and SKT, PJ, and MM drafted the manuscript. PK, SKT, NV, PJ, and MM review & editing the manuscript. All authors have read and approved the final manuscript. Additionally, SKT and MM share the responsibility of corresponding the manuscript.

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Kumari, P., Tiwari, S.K., Vasu, N. et al. Factors Associated with Nursing Professionalism: Insights from Tertiary Care Center in India. BMC Nurs 23 , 162 (2024). https://doi.org/10.1186/s12912-024-01820-4

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‘Nursing’ a Community into Marginalization: A Study on the Hardships Faced by Medical Nurses in India

It takes global catastrophes like the Covid-19 pandemic and World Wars to get people to realize how the marginalized community of medical nurses toils to safeguard a country’s civilians. It is disheartening that they are hailed as true soldiers only when a disaster strikes. This article aspires to throw light upon that fragment of the Indian nation which is often looked down upon and bring to the forefront the hardships the nursing professionals endure. It is recorded in tribute to Ms. Lini Puthusserry, the brave nurse who lost her life fighting the Nipah virus in Kerala.

Image of Lini Puthussery, a Malayali nurse who sacrificed her life as she battled to protect patients from the fatal Nipah Virus (2018).

The month of May 1942 saw the formation of the Women’s Auxiliary Corps (India) by the British. This welcomed female volunteers into the war front. This was a noteworthy step towards the recognition of women in combat roles which wasn’t possible up until then. However, civilian women had already taken up combat roles all across the globe by then. Women of the orient and occident were filling in as medical nurses many years prior to the formation of the Auxiliary Corps. Yes, being in a uniform had meant more than one thing.

In spite of being so intrinsically bound to the development of a nation, it is debatable whether nurses are given due credit as the man power of the Indian subcontinent. It becomes self-contradictory to explain the realms of injustice faced by this community which is largely constituted by women, in a language that is already gendered. India popularly perceives the profession of medical nurses as being inferior and undesirable, with very little scope for promotions or monetary gain. This also contributes to a commendable portion of professional nurses migrating overseas in search of better wages, working conditions, and respect. More often than not, Indian nurses are romanticized as angels during crises and forgotten once they settle down. This article will explore such discursive constructions and contradictions related to the nursing community of India that faces discrimination on multiple fronts.

An Interaction with an Indian Nurse

Following is a brief interaction with a medical nurse from a private hospital in Palakkad, Kerala (India). Both the nurse and the hospital management do not wish to reveal their identities, in fear of unwanted attention and bad publicity. In a few questions, the professional was able to reveal her apprehensions regarding her vocation and the hardships her community goes through on a regular basis.

How did you get into this profession?

I initially wanted to be a doctor. I had even spared a few years to study for the All India Pre-Medical Test (now, the National Eligibility cum Entrance Test ) as soon as I completed school. But I couldn’t land a merit seat as my rank was pretty low. Also, my family could not have afforded to pay for a management seat. But I knew I wanted to pursue a career in the medical field. So, my next option was to go for B.Sc. Nursing.

How would you define your profession in the years that you have been active in it?

I have been a nurse for more than seven years now. It has been a wholesome journey. I have served in different hospitals and clinics across Palakkad. I have had the opportunity to work with many reputed doctors, helping those who are in need day and night. However, in these years, my vocation has suffered many setbacks. That we (the Kerala community) have had many health emergencies in the recent past is no secret. The medical community was possibly among those who were hit the hardest. We had to deal with two floods, a Nipah attack, and now, COVID-19, which continues until today. During the past four years especially, the workload has been more than hectic. However, in addition to serving an entire state day and night, we receive mediocre wages and no other incentives from hospital management. I work in a private hospital. Government hospitals are, of course, a lot lenient on their staff on the salary front.

Would you be comfortable with sharing your salary details? There have been recurrent debates related to the unfair wage systems nurses often have to comply with. Would you agree that your community is underpaid?

Yes. 100%. In this hospital, for example, we are paid a minimum wage of 5000-6000 INR. Nurses who began their careers recently have to make peace with 5000 INR. Once you hit the 10-year experience mark, you could receive up to 15,000 INR. Eventually, by the time we retire, we could receive a maximum of 49,000 INR. That is the case of public sectors and a few, reputed multi-specialty private hospitals. More often than not, nurses like us, who work in small private hospitals receive a maximum of 15,000-18,000 INR by the time we retire. For a profession as sensitive as ours, I believe this salary is extremely low. Not just the salary, we have to deal with personal and social repercussions as well.

Could you elaborate more?

As a nurse, I am often looked down upon by my family and society. People, strangely, do not regard this as a good profession. I find this prejudice really hypocritical because as a society, we shower accolades and money over doctors. We also fall into the same sector and do a lot of the jobs that doctors do. In fact, without our assistance and constant support, doctors cannot do their job well. I am not saying we should be regarded as highly as doctors. But we would appreciate some respect as well.

Have you ever thought about leaving this job?

It’s easier said than done. I have familial ties to this place, kids to take care of and a home to protect. Like many of my colleagues, I too was fascinated by the idea of leaving India for better job prospects. But I knew I wouldn’t be able to meet many of the criteria required to migrate. For example, I knew I cannot pass the various English proficiency tests necessary to attain a visa to another country. My education did not support me enough to easily qualify for such tests. I could not raise the initial funds required for migration either. So, I thought attending such tests would be in vain. Soon, I was married and was bound to a lot of familial responsibilities. I had to make peace with this job as it caters to a lot of my other comforts. It is true that I have had to compromise on a lot, but this is my life right now. The struggle has become a part of the routine filled with night shifts and unending work hours.

This conversation served as the inspiration for this article. The following sections define the various problematic intricacies associated with this noble profession and expand over the injustice this community faces.

The Indian Healthcare System

Nurses are the hearthstone of the healthcare industry. A well-nurtured and skilled professional force of nursing staff is vital for every hospital. An effective healthcare system is a determining factor for the development of a nation. India is a developing nation with a flawed healthcare system that is downright fragile in places. Our country needs to give precedence to the health of its doctors and nurses amidst the pandemic that has struck the world today. Not just in the Indian subcontinent but all around the world, many healthcare workers are paying the price for the shortcomings of a suffocated healthcare system with their own health and lives. There might not be a more suitable year to analyze the inadequacies of the Indian healthcare system in the early 21 st century than 2020-21.

Marginalization pushes multiple populations to the fringes of society with little to no attention given to their voices. There exists a spatial as well as a temporal aspect of reality associated with marginalization. In the Indian context where 80% of the population lives on a wage of 2.5 USD or less per day, marginalization is the norm. Many communities in the country do not recognize their status and lack basic rights. Communities including Backward Castes aspire for better living conditions and remain ignorant about their right to a proper social standing. They need to be brought in as active participants in policymaking. Apart from ethnic groups, many professional communities also face peripheralization in India. The scavenger community is a prominent example. It becomes overwhelming to study the prevalent marginalization among urban professional groups as well. The case of medical nurses in India can be seen in this light.

Image portraying medical professionals in their hospital attire.

A list published by the National Federation of Orders of Surgeons and Dentists reveals that 66 doctors died of Coronavirus in Italy alone. Nearly 17000 medical professionals were affected in the country. The lack of protective gear is hence a serious concern in contemporary times. The WHO records that nearly 180,000 healthcare workers and professionals may have died between January 2020 and May 2021 . Shifting our focus to India; as of February 2021, 174 doctors, 116 nurses, and 199 healthcare workers have died fighting the Coronavirus last year. India has had more than 400,000 deaths with more than 30 million positive cases recorded so far. If the death rates in superpowers like Italy and USA are baffling enough, considering India’s healthcare facilities (or the lack of it in various states) is scarier. Fear hangs over the medical staff in India and the Indian Medical Association has raised concerns all throughout the two years of lockdowns via various media sources. The threat involved with paramedical workers, nurses, ward assistants, and cleaners is perplexing. Dr. Hemant Deshmukh, Dean of Mumbai’s KEM Hospital , stated how it is vital to view every patient as a potential Coronavirus patient, who can affect the medical workers. To this particular hospital alone, nearly 100 patients are being brought with symptoms of cold, cough, or fever because it is a testing center for Coronavirus. In April, he expressed his worry regarding the mediocre medical facilities in Mumbai that could catastrophically affect the state.

Now as we are talking, the Omicron variant of the Coronavirus has entered the Karnataka state in South India. Eyeing a possible surge in cases due to the new threat, many doctors have begun protesting for the demand to beef up the number of healthcare workers , in case the situation blows up like it did in 2020. The loved ones of the healthcare workers have been clearly going through a fearsome time. Many medical professionals continue to contact their families through social media and video calling. The situation has called for them to be socially distant from their families. There still is an impending risk of exposing aged parents, young ones, and especially infants to the possibility of infection. It is of great relief that the 944 million adults of the country have been vaccinated , reducing the risks of fatal repercussions. While many of us sat in the comfort of our homes, cursing the lockdowns, we conveniently forgot the hardships medical and government staff go through. And no; hailing them on social media doesn’t effectualize into deserving incentives.

Understanding Marginalization

Marginalization came to be put forth as a nursing theory by J. M. Hall in 1994. He first recognized seven properties of marginalization to be intermediacy, power, reflectiveness, liminality, voice, secrecy, and differentiation. After having undergone much change over the years, in 1999, marginalization expanded to be addressed in terms of seven more global yardsticks. They are exteriority, constrain, eurocentrism, economics, testimonies, hope, and seduction. The nursing profession became intricately bound to these gauges.

Hall’s theory expanded over to the study of constraints faced by student nurses by E. P. Anderson in ‘ Marginality: Concept or Reality in Nursing Education? ’ in the Journal of Advanced Nursing in 1995. Entering into the 2000s, the theory helped the study of various patient populations including chronically ill adolescents, the homeless, drug users, and women in general. Hall conceptualizes marginalization as the “process through which persons are peripheralized based on their identities, associations, experiences, and environment”. The Intersectionality Theory proposed by K. Crenshaw posits that different marginalities are mutually inclusive in a way that they need to be conceptualized as one is also relevant in this light. Intersectionality identifies race, class, gender, ethnicity, sexuality, nationality, ability, and age as “reciprocally constructing phenomena that in turn shape complex social inequalities” (Collins, McFadden, Rocco, & Mathis, 2015).

Being a Medical Nurse in India

There is more to nursing than what meets the eye. Imagine a hospital without them and one shall appreciate their worth. A nurse’s professional skills and training contribute significantly to successful treatment outcomes. It is rather appalling that urbanization hasn’t touched the healthcare system in India in all the right places. The remedial aspect often takes a backseat in our healthcare sector. Curative care in India is still unaffordable to the majority of the population. The nursing department has to take up managerial duties over patient care. Reduced workforce and lack of quality care lead to an overburden. The challenges faced by nurses in the country today arise at the organizational, state, and national levels. It is of utmost importance to recognize and address each of their problems individually if they are to be removed at their roots. The change in the demographics of medical ethics is a significant cause of most of such challenges. Advancement in medical technology, profit-earning mentality, immigration, education-service gap, and economic recession are all causes for the same. The ongoing troubles associated with the profession lead to fewer students opting for nursing and for professionals to migrate to other countries for better remuneration and working conditions.

Mental and Physical Repercussions

Dated March 14 th, 2020, a report featured in Times of India read the hitches faced by the community of medical nurses in Kerala amidst the Covid-19 pandemic. While the exposure to the virus itself is a given threat, certain outdated social prejudices also seem to chase them around. The report under scrutiny is one based in Kottayam Medical College. However, since the profession of medical nurses is usually looked down upon, the case study can be viewed with reference to the general attitude the Indian community holds for them. The religious justifications for the aversion would make a whole other story. We are analyzing India’s most literate group of folks here. While most often the nursing community is collectively associated with a group of white-wearing “angels”, the comparison remains ultimately oxymoronic as opposed to the real conduct offered to them. It isn’t a matter of respect they receive alone. They are amongst the most underpaid laborer communities in the country today as opposed to their skill and service.

As far as the case of the nurses based from Kottayam is concerned, they were requested to vacate their rented residence by the landlord who feared their presence in the house due to the risk factors involved. After a long struggle with the Medical College authorities, the nurses were provided with a temporary abode in the isolation ward of the hospital. The report in Times of India narrates the difficulties faced by these nurses who had voluntarily taken up this duty. The nursing officer at the Medical College Hospital raised concerns over the situation of the nursing staff in Kerala today. She throws light upon the reality that if most of the nurses choose to stay at home during the crisis; the situation would tumble down to a catastrophe. While the entire nation was showering praises upon the state government of Kerala for their effective measures during the pandemic, nurses remained an easily forgotten privilege to the commoners.

Inspired by Florence Nightingale, our hardworking nursing staff personify abundant compassion. Today, we also reiterate our commitment to keep working for welfare of nurses and devote greater attention to opportunities in this field so that there is no shortage of caregivers. — Narendra Modi (@narendramodi) May 12, 2020

The occupation involves everything from pushing trolleys and patient beds to delivering personal hygiene to a very heterogeneous society. There is a humongous workload involved in the profession. When the pressure enforced over any employee or laborer exceeds limits, it leads to poor performance; in this case, it would lead to less effective care. Workplaces sadly offer mental violence in the form of threats, verbal abuse, hostility, and harassment. This is strikingly visible in the private sector. Psychological trauma and other repercussions are commonly seen among them. From patients and their visitors to co-workers; there are many sources for such violence. From 2002 to 2013, incidents citing workplace violence were four times more in the healthcare sector than in private industries on average. On top of all this, the long working hours and the assigned tasks of duty affect the staff adversely. Very often, they pay the price with their own lives. The first part of this article pays a tribute to the late Ms. Lini Puthussery, the 31-year old nurse who had to give up her life in the fight against the Nipah virus in Kozhikode. If she isn’t recognized as a martyr, there would be few who could qualify as one. She was awarded the Florence Nightingale Award posthumously.

It also needs to be addressed here that no nurse working in private hospitals in India is given any kind of employment benefits like Provident Fund and gratuity. Even worse, they aren’t even provided health coverage. Their qualifying certificates remain locked with the authorities of the hospital until their contract bond period expires. Having taken into account these realities, it wouldn’t be surprising to note that there is a crippling shortage of nurses in India today.

Shortage of Workforce

Image from a hospital at Siliguri, Bengal where a Covid awareness camp was organized.

Both with reference to revenue and development, the healthcare sector in India is a humungous one. Even though most of its employees face challenges, the nurses apparently go through the hardest of hardships. There is a never-ending need for an ardent workforce in this sector to meet the changing demands. The most appropriate time to commit to this article, hence, would be now; when the entire world, including the superpowers, has fallen to its knees before the Coronavirus pandemic. The healthcare sector is one such area whose requirements never see fulfillment. As far as India is concerned, there exists a shortage of 600,000 doctors and a whopping 2 million nurses. The deficiency in the number of nurses in our nation also accounts for the lack of respect involved in the profession, along with low salaries. Long working hours, overload, and the physical and psychological threats involved in spending hours at a hospital regularly are some of the other complications involved in the job.

Long Working Hours and Poor Work Environment

Nearly 88% of nurses in our country work for about 8-10 hours daily in addition to taking up 2-3 times of overtime duty each week. That means, nearly 35% of nurses do overtime duty more than thrice a month. In the medicine and surgery departments in health care, approximately 53% of nurses are involved. Here, each staff handles more than 6 patients. As per Indian Nursing Council (INC) , the nurse-patient ratio must be 1:3 (in general wards of medical colleges), 1:5 (in district hospitals), and 1:1 (in ICU and other critical areas). For 28% of Indian nurses, a break is availed after 4 hours of work. Nearly 26% take no such breaks and toil up to 8 hours consistently. 74% of nurses stand for about 4-6 hours daily that eventually results in stress over the lower limbs. We should also keep in mind how all this is carried out in a very uncomfortable work environment since India lacks significantly on that front.

Nursing is among the most frowned-upon professions in our country. Alongside dealing with ethical issues that accompany this service-oriented occupation, comes the burden of extremely low income. A fresher would enter a private Indian hospital with a maximum wage of 8000 INR. Usual cases are that they receive only about 3000 INR to 4000 INR per month, despite the working hours. This itself is against the labor standard of 6000 INR (which is still very low). Of course, there are hikes in salary that would come with experience. However, many experienced nurses have expressed concern over how hospital managements often pay them between the margins of 9000 INR to 12000 INR per month. Since the veto power rests with the management of the hospitals, employees are required to sign bonds that would dictate a time period within which they cannot quit. During this time, which could last as long as a few years, nurses would pledge their certificates into the custody of the hospital. Breaking such a bond may entail shelling out 50000 INR to 100000 INR in return for a release.

Many young aspirants take up nursing with the hope of flying abroad for better wages and desirable working conditions. The average salary received by a nurse is about 150000 INR in the GCC Countries. Countries like Australia (56000 USD), Canada (51000 USD), Italy (59500 USD), Ireland (64000 USD), and the like are hence healthy prospects for nursing aspirants. Undoubtedly, the constant demands made by Indian nurses and trade unions seem justified in this light. The various arguments put forward by the nurses of the KVM Hospital (Kerala) who went on strike in 2018 are fair mandates. An impending lack of job security also bothers these professionals all across the country.

Lack of Recognition and Societal Challenges

Nursing as a practice dates back to very ancient history in India. Before the 20th century, nurses were mostly men who were assisted by women as midwives. Today the tables have turned and nursing is largely acknowledged as a feminine vocation. We often hear people frowning upon the idea of men who are nurses. The generalization is so grave that in order to specify the gender, the term “male” nurse is often employed. Men or women, nurses are skilled professionals who undergo vigorous training to graduate. Sadly, they are seldom recognized as such. They are often looked down upon by society as unskilled, morally suspect women who are akin to servants. There is a considerable gap between what they are and how they are perceived. Again, this case holds largely true for women. Coming to think of it, patriarchal prejudices seem to have had a lot to play in establishing the profession as a woman-centric one as well as defaming it. These undesirable tags thrust upon them bring about painful distress in them regarding their status. They are only occasionally given due credit; even by their superiors and co-workers. Clearly, nursing in India is no cakewalk. It is amongst those professions that have the least autonomy. But this is the case of India alone.

There is very little hope for growth in this field as well. In the nation, nursing colleges are increasingly falling vacant due to the lack of interest. This is precisely why there is a lack of an adequate workforce. As for those who are qualified; they are in quest for a better life abroad. India with an already dismal health system is suffering more as nurses are migrating to other countries. If they begin to receive half the respect doctors in the country receive, a repair can be done sooner.

Human Rights Violation

As briefed above, the profession of nursing has highly been regarded as a feminine one. This notion germinated in a very patriarchal soil. Modern nursing dates back to military nursing in India. It runs back as far as when the East India Company initiated a hospital for soldiers in 1664 in Madras. The first among the nurses were sent from London to this military hospital. (Today, nurses of Indian origin leave the country to yesteryear colonial abodes for security.) Such is the history of nursing in India. Today, however, nurses being majorly women, go through sexual harassment. The rape case of Aruna Shanbaug , an Indian nurse who spent 42 years in a coma after being brutally raped and strangled, had taken the nation by storm in 1973. She finally succumbed to death in 2015 in the very hospital where she worked and was raped brutally. At age 25, she was sodomized by a KEM Hospital (Mumbai) cleaner who strangled her with metal chains and left her to die. Although she survived, it was only through a vegetative state till her death. Her struggle with India’s euthanasia law went down in history. The absence of the “right to die” in the Indian legal system was brought to the attention of the nation. Today, our legal system allows passive euthanasia.

While the Prime Minister has called the nation’s healthcare workers the “frontier soldiers” during the Coronavirus outbreak, many women in this professional front struggle. An FIR was filed by a doctor of AIIMS in which she complains how she received rape threats from her landlord when she denied immediately vacating her apartment. Similarly, a doctor was attacked in Telangana by the police on her way to work. Such cases still make headlines despite the gravity of the terror that engulfs the nation. Many nurses have come forward with complaints of how they were sexually assaulted by doctors in the past years. The physical affinity their profession demands off them is often misjudged thus and taken advantage of. There is an underlying tragedy in this.

Making a Difference

Rectifying these errors would not only equip medical staff with a better professional life but also will help improve the country’s healthcare system immensely. To achieve universal health coverage and to ensure access to essential services, the prime focus should be on the workers. We need to improvise pragmatic solutions to meet the needs of nurses and other such workers; a large portion of which are women. As a democratic nation, each citizen is responsible to provide better lives to those who still remain marginalized.

Establishment of a Positive Environment: The environment of most hospitals is patient-centric. The workers perform their duties providing supreme importance to the patient. However, if they are to give their heart to their commitment, the workers too need to be armed with a sense of security, professionalism and transparency. This is practically the only way that could ensure effective care. Not only the health and wellbeing of the patient, but also those of medical staffs need to be given due importance. Especially when nurses are concerned and mostly women; they need to feel empowered and safe in their work milieu. Effective interpersonal communication would provide nurses with a sense of self-importance and help mitigate fear and hesitance, if any. Their opportunities need to be recognized and catered to. In simple words, it is high time they are removed from the bottom of the pyramid.
Workload Balance: Rather than flooding nurses with inhuman work schedules, with an effective distribution system, they need to be democratically dispensed. However this is possible only if and when the lack of workforce is rectified. By establishing nursing as a noble profession which it is and ensuring it as a safe one for women and men, this may be achieved. Non-productive and redundant tasks need to be avoided from their duties. Nurses need to be provided with incentives time to time for the service they do. They shall be given enough autonomy in their spheres. This would only improve their skills and breed sincerity in work. There should also be an efficient technological assistance that nurses should be helped to for clinical support and even inventory backup.
Better Salaries: While government medical faculty members are quite safe in their professional fronts, private sector employees are as unstable as ever; even in hospitals. Health ministry needs to address the low wages nurses are often struggling with in the private firms. Also specialization during studies would ensure better income for nurses. For instance, the health ministry and the Indian Nursing Council should take up the initiative for specialized training of aspirants. This can eventually ensure better wages and more stability.
Closing the Education-Service Gap: The lack of respect received by nurses is a result of the ignorance about their qualification. There is a significant gap between what they learn and what they practice. These two aspects need to meet effectively so that their services are appreciated in society. Colleges need to adapt to a more practical form of learning and hospitals should give nurses their space utilize their theoretical prowess. Many nursing colleges have taken to pragmatic models of teaching that would in turn nurture thoughtful nurses.
Availing Adequate Equipment: There are constant complaints regarding the unavailability of adequate hospital supplies in the nation. The problems range from the inadequacy of live saving supplies and materials. Hospital managements and government should meet these needs to ensure a healthcare system of strong base. The ardent need for protective gears and other such necessities is increasing minute by minute during the pandemic spread.
Availing Easy Educational Loans: Many aspiring nurses suffer the burden of paying off their educational loans since B.Sc. Nursing is not easy on the pocket. To meet this need, nurses are often prompted to migrate in search of better wages as they cannot possibly make monthly installments with the salaries they receive in India. The article by Saritha S. Balan for The News Minute makes the loan crisis clearer. If our country facilitates a relatively convenient option for aspiring nurses to complete their education without such drastic financial repercussions, there would be a large group of youth who would happily commit to the profession.
Change in Outlook: It is high time people begin to introspect how out-dated and silly our prejudices are. If the mentality of the patriarchy shifts stand to something more democratic, not only nurses but a lot of other communities also would benefit from it. A job is after all a responsibility. A person’s ultimate identity cannot be determined by their profession alone.

A successful healthcare system is not just one that delivers the best care to the public. It is also a nurturing environment for its workers to give their best and receive due credit. A well-motivated workforce is a treasurable wealth to any sector. Sufficing to the requirement of nurses and other such disadvantaged communities can make an empowered band of workers that is nothing short of a dependable army. It is up to us to choose to build an army.

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J Family Med Prim Care
v.10(8); 2021 Aug

Role of nurse practitioners within health system in India: A case of untapped potential

Lipika nanda.

Regional Resource Hub, HTA, Indian Institute of Public Health, Hyderabad, Public Health Foundation of India

Aiswarya Anilkumar

Nurses form the pillar of India's healthcare system representing 30.5% of the entire health workforce in India. Amidst a significant shortage in the provision of effective primary care, jeopardizing millions of Indians’ access to basic healthcare services, especially the poorest, it is very evident that nurse practitioners are the need of the hour in India. The current scenario of nursing in India warrants policy reforms to facilitate nurses as valuable primary care providers. It also shows the path towards making the Health and Wellness Centre operational by creating a pivotal role for the cadre in such centres, and it will also be important for the nurse practitioner to have a public health leadership role in a country like India. With additional training and qualification and also recognition of nurse practitioners as essential healthcare providers, a complete quality healthcare could be provided. In this research paper we assess the need for nurse practitioners as primary contact providers; reflect on the global evidence on nurse practitioners linking to health outcomes, effective coverage and access to services. We also try to contemplate on the training needs, their role in home-based care and as enablers of the referral mechanism, their untapped potential, and a plan for evaluating their effectiveness. This policy research paper focuses to build an argument for a policy towards making nurse practitioners the first contact providers.

Introduction

Tracing the roots of nursing as an effective and compassionate profession dates back to Florence Nightingale, known as the “Lady with the Lamp”. Nightingale's service for the promotion of healthcare to humanity provided firm footing to nursing as a profession of vital importance in the field of healthcare.[ 1 ] Nurses form the pillar of India's healthcare system representing 30.5% of the entire health workforce in India.[ 2 ] The 1978 Declaration of Alma-Ata emerged as a breakthrough of the twentieth century in the field of public health and recognized primary healthcare as an essential component for the attainment of Health for all.[ 3 ]

India with an estimated population of 1.3 billion is facing an array of disease burden including lifestyle diseases, infectious and emerging diseases and also pandemics like Covid-19. Communicable diseases, maternal and nutritional deficiencies remain to be major causes of deaths, and non-communicable diseases and mental disorders are also escalating, thereby, challenging the quality of primary healthcare delivery.[ 4 ] Inadequate availability, high underperformance, and poor-quality infrastructure and human resources contribute to the poor performance of the primary healthcare system.[ 5 ]

Rationale and its Linkage to Health Policy

According to the World Health Organization estimates, there is an alarmingly low level of trained health personnel in many of the developing countries and also the doctor population ratio in India is 1.34 doctors for 1,000 population as of 2017.[ 6 ] The Ayushman Bharat Scheme launched by the Government of India (GOI) intended to address healthcare with two major components: Health and Wellness Centre (HWC) and National Health Protection Scheme (known as Pradhan Mantri Jan Arogya Yojana or PM-JAY) under its umbrella.[ 7 ] Though the intent of the program to upgrade the health system is expected to achieve the goal of health for All, there is no evidence of a skilled health workforce in numbers for effective implementation. Considering the scale of importance, a skilled health workforce tops the pyramid of healthcare delivery systems.

With a low doctor-patient ratio, high absenteeism of medical doctors in health centres and inadequate distribution of health workers in rural India compared to urban areas, the healthcare delivery system is unable to effectively provide primary health-care.[ 8 ] Provision of the first contact, patient fixated, ongoing care over time that meets the health-related necessities of people is the need of the hour. Role of nurses in primary healthcare comprises delivery of services, promotion of health, prevention of diseases, and care of sick across all ages, groups and communities.[ 9 ] The WHO is celebrating 2020 as a year of appreciation for the contribution of nurses and their agenda of incorporating nursing leadership occupies a fundamental point in recognizing nurse practitioners.[ 2 ]

The year 2030 is the target for all participant countries around the world for sustainable development goal achievement, and universal health coverage is one way to achieve these goals.[ 7 ] With the rise in demand for health services, effective utilization of the workforce is vital to ensure high-quality cost-effective health service delivery.[ 10 ] The annual growth rate globally for the nurse practitioner workforce is three to nine times greater compared to physicians, therefore, incorporation of nurse practitioners as the first contact point would stand feasible. The current scenario of nursing in India warrants policy reforms to facilitate nurses as valuable primary care provider. This policy research paper focuses to highlight and build an argument for a policy towards making nurse practitioners the first contact providers.

The untapped potential of nurses and their envisaged roles in Health and Wellness Centres

The National Health Policy, 2017, envisioned strengthening the primary healthcare system through the Health and Wellness Centres establishment.[ 9 ] A key addition to the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana was the incorporation of a mid-level health provider, either a Community Health Officer or an Ayurveda practitioner delivering public health and primary care services.[ 7 ] The agenda behind the introduction of this new cadre is to augment the efficiency of HWCs, expand the choice of services for the community, improve access and enhance coverage with a proportionate reduction in out-of-pocket expenditure.[ 11 ] Further, improvement in clinical management, care coordination, dispensing of medications, developing public health activities, and reducing fragmentation of care and workload at secondary and tertiary care activities, also form the rationale behind the new strategic implementations.

Subsequently, similar recent initiatives include the National Medical Commission Bill approved by the Union Cabinet wherein mid-level practitioners will obtain limited license to practice specified medicines in primary and preventive healthcare settings and other settings under the guidance of a medical doctor. This amendment would pave way for a new era of nurse practitioners for the Indian healthcare system.[ 12 ] In the year 2016, Shri J P Nadda, Union Minister of Health and Family Welfare, launched two innovative Nurse Practitioner Courses both in critical care and primary healthcare. These courses aim to enhance their responsibility and accountability for the provision of efficient care.[ 13 ]

Global evidences on role of nurse practitioners

Expertise-mix transformations are receiving widespread interest in the health workforce to fill the gap concerning provider shortages, improvement in healthcare access and cost reduction.[ 14 ] Evidence from systematic reviews estimates the clinical effectiveness and quality of care to be increased among nurses working in advanced roles in comparison to the physicians. Developed countries have consistently shown that task shifting by involving nurse practitioners in primary healthcare delivery has greater efficiency and positive health outcomes.[ 14 ] Systematic reviews from the US, Russia and South Africa also report major findings in terms of higher patient satisfaction with nurse-led care compared to doctors, reduction in hospital admissions, and reduction in mortality.[ 14 ] Likewise, other developed countries also report no significant differences in referrals, pharmaceutical prescriptions, tests and investigations ordered as compared to physician-led care. Nurse-led care lead to better secondary prevention outcomes among patients and a study conducted in the Netherlands and UK also showcase evidence of lower health service cost in comparison to the physician model.[ 14 ]

Task shifting and task supplementation are two significant approaches in terms of nurse practitioner role advancement.[ 15 ] Nurses deliver more information and counseling to patients than physicians, spend more time, and also provide holistic care leading to higher patient satisfaction.[ 14 , 16 ] They also accomplished record management, identification of physical abnormalities, advised on self-care, interpreted X-rays accurately, and scored better on communication than doctors. Patients have reported higher satisfaction with care from a nurse practitioner; provide longer consultations and carry out more investigations than from a doctor, with no difference in health outcomes.[ 16 ]

Consequently, nurses in advanced practice can enhance access to healthcare by strengthening the health workforce cadre. Synthesis of available evidence from countries like Australia, Canada, New Zealand, UK, and the US report nurses to generate clinical outcomes as good as physicians in the emergency and critical settings as they did not have to be on rotation coverage similar to the physicians.[ 17 ] Effective care management is a forte of nursing professionals that requires both interpersonal communication and cooperation.[ 18 ] They tend to institute more subjective and tangible interactions than do general practitioners, thus, performing better care management[ 19 ] Taking advantage of nurses in advanced healthcare settings proves to be beneficial for improving patient outcomes and improving working environment, and thereby, providing definitive roads for the career progression.[ 2 ]

Training needs for nurse practitioners

The necessity for continuing education has been progressively acknowledged in nursing literature and the training needs have to be identified accurately.[ 20 ] Systematic graded training and certification would help nurse practitioners equip themselves with knowledge and also enhance their skills. The primary healthcare team at the HWC would serve as the fulcrum for planning, delivery and monitoring of services. Under the newly envisaged Ayushman Bharat Program, the mid-level health providers would be trained in either Certificate Programme in Community health, managed and certified by IGNOU/state universities, or have a B.Sc. degree in Community Health. Besides, an integrated course, retaining the central proficiencies would also be explored, combining theoretical and pragmatic constituents. This will further facilitate the candidates to use the learning-by-doing approach.[ 11 ]

To improve the quality of training, states shall also institutionalize the District Level Committee of Observers to monitor the ongoing training. These committees will have representation from Service providers of NGO-run hospitals/Nurse Training Colleges/Faculty of Multi Purpose Worker Training Centres/Medical Colleges and Counsellors from program study centres. A strong mentorship program needs to be created including programs like ECHO (Extension for Community Healthcare Outcomes) for supporting the Mid Level Health Workers through handholding, troubleshooting, problem-solving, building technical competencies and supporting motivation. In primary health centres that are not envisioned to arrange for inpatient care, the prevailing nurses would receive integrated training in certificate courses for primary care.[ 11 ]

Streamlining nursing education by upgrading the basic standard qualification for practice, enriching the curriculum, strengthening the teaching faculty, developing a knowledge base through evidence-based research will further strengthen the services to be delivered. In-service training needs to be employed in varied settings and regular continuing medical education programs need to be conducted to enhance knowledge and skills. Innovative training methods including multimedia approach, face-to-face counseling sessions, hands-on training, virtual learning and distance learning could be implemented for effective in-service training.[ 21 , 22 ]

Enabling nurse practitioners as essential health providers

As per reports, approximately 27% of approved positions of doctors in Primary Health Centres and more than half of the sanctioned posts of specialists in Community Health Centres remain vacant.[ 23 ] The National Survey of Nurse Practitioners conducted by the Health Resources and Services Administration (HRSA), listed out the array of the roles nurse practitioners could be instrumental in. They can act as essential healthcare providers in terms of counseling and educating patients and families, conducting physical examinations, obtaining medical histories, prescribing drugs, performing and interpreting lab tests, X-rays, ECGs, diagnosing, treating, and managing illnesses. These well-trained and qualified cadres could also be involved in the provision of preventive care including screening and immunizations, care coordination, making referrals, and also performing simple procedures.[ 22 ]

Nurse practitioners acquire advanced level knowledge and expertise in nursing and apply it in diagnosing and providing therapeutic care to patients. They are competent enough to make admission and discharge from a healthcare facility and also contribute to research in the profession which helps in elevating the quality of care.[ 22 ] They can take a public health leadership role in the public healthcare sector by taking lessons from developed countries that have successfully implemented nurse practitioners in advanced care.[ 13 ] The acknowledgment of nurses in terms of their requisite capacity in healthcare delivery is vital.[ 24 ]

Nurse practitioners in home-based care

Nurse practitioners have been emerging as a key resource in home-based care and have become the most recurrent benefactors of residential medical care.[ 25 ] They can provide fast assessment and treatment when a patient has a change of condition on-site and can also treat the patient as needed.[ 26 ] Studies establish that nurse practitioners offer a sustainable solution by providing cost-effective quality primary care, especially in underserved, vulnerable populations in a home-based care setting.[ 27 ] During the current pandemic, where the hospitals are overburdened with patients and also with an inadequate health workforce, nurse practitioners can be pivotal for treating elderly patients and those with terminal and chronic illnesses in a home-based setting.[ 28 ] To sustain patient well-being, decrease the risk for burnout and staff turnover as well as contribute to the sustainable development of healthcare delivery, the role of nurse practitioners is inevitable.[ 29 ] Their understanding and proficiency have the prospective to deliver effective healthcare services.[ 30 ]

Nurse practitioners as enablers of a functional referral system

The referral system plays a crucial part in the management of diseases in any healthcare system. The chief objective of this referral system is to make cost-effective utilization of healthcare and also to ensure better quality care. In a country like India with a huge disparity in healthcare expenditure, the referral system protocols are not followed.[ 31 ]

The Indian healthcare system is overburdened by population, lack of adequate workforce, and an ineffective referral system. This puts forth a huge toll on higher-level healthcare settings.[ 31 ] Studies report that more than 50% of morbidity could have been treated at the PHC level, thereby, consuming resources that could have been effectively utilized for serious illnesses.[ 32 ] A study by Kyusuk Chung et al .[ 33 ] reported that primary care physicians with nurse practitioners were more likely to treat patients with multifaceted conditions without referring them to specialists; these findings put forth the significant contributions of nurse practitioners.

Plan for evaluating effectiveness

Before implementing the advanced role of nurse practitioners in the healthcare system or escalating an existing role, it is important to consider evaluation from the beginning. Identifying the essential service needs, collecting baseline data, and defining key roles would pave way for well-defined effectiveness evaluation.[ 34 ] A unified data management system that collects information on nursing-sensitive indicators, structures, and procedures needs to be employed for robust monitoring and evaluation. The usage of quality measures specific to the setting can help showcase the ability of nurse practitioners in improving quality, safety and costs in healthcare.[ 35 ] Even though nurse practitioners contribute to the primary health outcomes, they need to be recognized in the healthcare setting.

The Nursing Role Effectiveness Model (NREM) was developed to assess the contribution of nursing to quality care and outcomes.[ 36 ] With the successful implementation of NREM in acute care settings, the model will be beneficial for assessing similar relationships in primary healthcare and also has the potential to identify nursing-specific outcomes, which can be collected and contributed to national health database initiative making the nursing profession more accountable.[ 36 ] To further enhance the process, periodic evaluation must be performed by organizing practical sessions and structured exams. Licensure should be renewed through well-defined credit systems and the curriculum also needs to be updated at par with the international standards.[ 22 ]

Career progression

Nurse practitioners deliver services at par with the physicians and tend to become more productive and experienced each year.[ 22 ] Considering their vital role in the HWCs and as the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana advances, the mid-level health practitioners foresee an ambitious future trajectory and avenues for career progression. All the authoritative administrative positions in the healthcare delivery system at the Central and State levels are occupied by clinicians despite the availability of nursing administrators.[ 24 ] Their integrated role in public health functions at a district and block level would be explored in the new ambitious program and their appropriateness in different settings would also be taken into account.[ 11 ]

The GOI has also taken the first step on approving the policy for announcing a professional cadre of Nurse Practitioners in Midwifery (NPMs), who will improve the quality of maternity care. They will be selected from the prevailing pool of trained nurse-midwives and provide additional specialized clinical training and examination to achieve an NPM license regulated by the Indian Nursing Council (INC).[ 37 ] Their job profile needs to be transformed from a sheer bedside care provider to highly trained and capable decision-makers.[ 22 ] They should not rely only on the diagnostic and treatment sectors but should create unified healthcare decisions, as well as holistic care to the patients. The autonomy of work needs to be achieved to augment their quality of work. Nurse practitioners hold a well-regarded profile and have the advantage of detouring the broad and expensive restorative school training and internship as required for the physicians. These enable them to launch their career in a shorter time range.[ 22 ] After the endorsement of National Health Policy 2015; the INC has put forward an agenda to initiate a Nurse Practitioner program in Critical Care. The prospects of a nurse practitioner include self-governing nurse practitioner-run clinics; governmental standards that agree to take nurse practitioners as primary care providers and their involvement in outreach, clinics, and industries to provide emergency care and also to treat a variety of episodic diseases. A complete quality healthcare will always be provided by a team of qualified professionals and not just by physicians, a fact to be remembered.[ 22 , 24 ]

Amidst a significant shortage in the provision of effective primary care, jeopardizing millions of Indians’ access to basic healthcare services, especially the poorest, it is very evident that nurse practitioners are the need of the hour in India. Their role in advanced practice could allay a significant portion of the shortage in the health workforce ratio, thereby, transforming their role as first contact providers. Taking lessons from well-established systems and evidences on the panoramic impacts of nurse practitioners in terms of cost-effectiveness, accessibility, holistic, and patient-centered approach; their role is very significant for a country like India. Capitalizing on nurses in advanced practice to increasing patient's access to healthcare services will be appealing and beneficial. India is currently at a stage wherein it will need to embark on several reform processes, primarily in the provision of healthcare delivery, post-pandemic scenarios. Health systems are currently hugely burdened and will require the involvement of nurse practitioners as the first point-of-care delivery personnel. This will require nurses to play an active role at the primary, secondary and tertiary levels of care within health systems.

They will also play an active role in the Ayushman Bharat program of the GOI with delineated roles at the HWCs while playing a pivotal role in the hospital-level insurance model of care. Updated training, acknowledgment of nurses, reduced referrals, and home care nursing are a few milestones for expanding the role of nurse practitioners in the healthcare delivery system across the country. The role of nurses in public health administration is also going to take a major role, while the National Health Policy unfolds its features over time. The health sector will eventually experience clear-cut leadership emerging within the nursing personnel as their role in practicing gets deepened and strengthened. This policy paper recommends reskilling and prioritization of nurse practitioners in the Indian healthcare system and the healthcare community needs to be open to and decide to take nurse-led models of the delivery of care for the overall advancement of health indicators across the nation.

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Open access
Published: 09 July 2018

Setting the agenda for nurse leadership in India: what is missing

Joe Varghese 1 ,
Anneline Blankenhorn 2 ,
Prasanna Saligram 1 ,
John Porter 3 &
Kabir Sheikh 1 , 4

International Journal for Equity in Health volume 17 , Article number: 98 ( 2018 ) Cite this article

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Current policy priorities to strengthen the nursing sector in India have focused on increasing the number of nurses in the health system. However, the nursing sector is afflicted by other, significant problems including the low status of nurses in the hierarchy of health care professionals, low salaries, and out-dated systems of professional governance, all affecting nurses’ leadership potential and ability to perform. Stronger nurse leadership has the potential to support the achievement of health system goals, especially for strengthening of primary health care, which has been recognised and addressed in several other country contexts. This research study explores the process of policy agenda-setting for nurse leadership in India, and aims to identify the structural and systemic constraints in setting the agenda for policy reforms on the issue.

Our methods included policy document review and expert interviews. We identified policy reforms proposed by different government appointed committees on issues concerning nurses’ leadership and its progress. Experts’ accounts were used to understand lack of progress in several nursing reform proposals and analysed using deductive thematic analysis for ‘legitimacy’, ‘feasibility’ and ‘support’, in line with Hall’s agenda setting model.

The absence of quantifiable evidence on the nurse leadership crisis and treatment of nursing reforms as a ‘second class’ issue were found to negatively influence perceptions of the legitimacy of nurse leadership reform. Feasibility is affected by the lack of representation of nurses in key positions and the absence of a nurse-specific institution, which is seen as essential for creating visibility of the issues facing the profession, their processing and planning for policy solutions. Finally, participants noted the lack of strong support from nurses themselves for these policy reforms, which they attributed to social disempowerment, and lack of professional autonomy.

Conclusions

The study emphasises that the nursing empowerment needs institutional reforms to facilitate nurse’s distributed leadership across the health system and to enable their collective advocacy that questions the status quo and the structures that uphold it.

Nurses form the backbone of India’s health system representing 30.5% of all health workers in India [ 1 ]. Nevertheless, the inability to train, retain and deploy an adequate number of qualified nurses has been recognized by experts as one of the greatest challenges for achieving health system effectiveness [ 2 , 3 ]. It is estimated that India needs an additional 2.4 million nurses to reach their optimal number in the health system [ 4 , 5 ]. Recent initiatives have attempted to redress the nurses’ shortages in health care delivery and tried to correct imbalances in their geographical distribution [ 6 ].

Nevertheless, the lack of numbers is not the only problem faced by the Indian nursing. Their role in decision making, both in the clinical and public health domains is not recognised in India. Several experts have documented the state of affairs of nursing in the public and private sector and the official apathy towards them. They have described how status hierarchy among various cadres of health professionals which positions nurses at a lower place compared to medical professionals and the nurses’ dominant gender identity within the socio-cultural contexts constrain their ability to take up leadership positions in their own professional realm as well as in health sector [ 7 , 8 ]. Nair and Prescott have argued that nurses’ compromised professional and social acceptance has direct repercussions on their performance and contribution to health system [ 9 ]. The low position of nurses in the hierarchy of health care professionals, poor working conditions, low salary, and out-dated personnel norms, all operate in vicious cycles to create compromised professional position of nurses. Skill development and career progression opportunities for nurses in India are meagre [ 8 ]. Abjuration of several nursing leadership positions at the district and state level in the public sector has been reported in a previous study [ 10 ]. Likewise, the experts who have commented on a major strike of the nurses working in private sector in the national capital had identified exploitative working conditions akin to bonded labour as the reason for their strike [ 9 ].

The current situation of nursing in India warrants several policy reforms to counter the adverse service and social conditions in order to facilitate their overall professional contribution as a valuable human resource. The situation of nurses has special significance for equitable health services in developing country contexts such as in India as most of them are placed as the frontline health workers in remote and difficult locations and play key role in addressing various social determinants of health. Several official committees appointed by government to look into nursing issues in the past have recommended various reform proposals. These recommendations vary from increasing the number of nurses in the health system to establishment of key positions for nurses in the higher bureaucracy. Nevertheless, the recent reforms have only focused on recruiting and deploying more nurses and the leadership challenges faced by nurses are generally overlooked.

The agenda of building nurse leadership occupies a central position in the WHO’s strategic directions for nursing and midwifery globally, in recognition of their potential to act as “agents of change” within health systems [ 11 ]. The 1987 WHO report on nursing promotes a vision of nurse leadership which is about creation of ‘empowered nurses’ who mobilize, influence and collaborate at multiple levels [ 12 ]. Previous studies on nursing have established the link between strengthening nursing leadership and better health system performance [ 13 , 14 , 15 ]. However, nurses’ leadership potential is negatively impacted when their status among the professional hierarchy are compromised compared to medical and other health professionals [ 16 , 17 ].

Most literature on nurse leadership conceptualise leadership as individual ability to influence others towards achievement of relevant organizational goals [ 13 , 14 ]. In this article, we examine nursing leadership as a means to strengthen the health system, by building structures that facilitate and support the leadership potential of every nurse in the system in order to achieve health system goals [ 18 ]. This concept of ‘distributed leadership’ is a shift from focus on the agency of individual leaders to the characteristics and design of the systems that facilitate leadership culture [ 19 , 20 ]. The focus of this paper is on the policy reforms that are required to address the structural and systemic change that could facilitate nurses’ distributed leadership and enhance their roles as “agents of change in the health system”.

This study explored the process of agenda-setting for policies that could facilitate distributed nurse leadership in India, in public and private sector and in clinical and public health field, with the intention of understanding what factors are preventing action to strengthen the nurse leadership in India. Analysing the ‘agenda setting’ process is a way of understanding which issues, under what contexts gain policy attention. A key focus of such research is the attention on the process through which new ideas or policies may or may not be accepted within a political and policy system [ 21 ]. Therefore, research on agenda setting may also help in understanding the dynamics of status quo in policy process and explore potential pathways through which change can be facilitated.

In order to understand the policy propositions for addressing nurses’ leadership crisis, we reviewed various key official documents at the national level and their prescriptions regarding nursing administrations, education and deployment. Two key documents included in this review are a report of the High Power Committee set up by the government of India that recommend several nursing reforms and a review report of status of nursing in five states undertaken by the National Health System Resource Centre, Ministry of Health and Family Welfare and ANSWERS [ 22 , 23 ]. The other documents are Bhore committee report of 1946, the Indian Nursing Council Act of 1947 and its three amendments, the code of ethics and professional conduct prescribed by the Indian Nursing Council, the professional conduct etiquettes by Trained Nurses Association of India, Chadah committee report of 1963, National Health Policies of 1982 and 2002 and Clinical Establishment Act of 2010. The review of these documents helped to identify the reform proposals, status of their implementation and various challenges with respect to the agenda of strengthening nursing leadership.

In addition, nine (09) interviews took place (between 5 and 24 August 2013) in New Delhi, Andhra Pradesh and Kerala with experts who were identified according to their interest in nursing governance and the extent to which they have information and knowledge on decision-making and implementation of policies dealing with nurse leadership. Though three interviews were carried out at the state level, all interviewees had expertise on nurse leadership issues at the national level. Except for three, all the other participants were qualified nurses. The Table 1 describes the characteristics of Key Informants interviewed in the study.

Though this study was based on limited number of expert interviews, it was felt that saturation was reached with each informant identifying similar barriers to nurse leadership and solutions to these.

A topic guide was developed to help conversations with informants and questions were formulated with the aim of obtaining relevant, complete and contextualized information on nurse leadership and on appropriate policy solutions that address nurses’ leadership crisis in India. The interviews were held in August of 2013 and started by exploring the context of nurse leadership in India and structural and systemic constraints in setting the agenda for policy reforms on the issue.

All the interviews were in English and handwritten notes were taken at the time of interview and later transcribed into text format. Data were thematically organized and classified according to ‘legitimacy’, ‘feasibility’ and ‘support’, in line with Hall’s agenda setting model [ 24 ]. The model stipulates that a policy issue needs to fulfil the criteria of legitimacy, feasibility and support in order to be included in the policy agenda. Legitimacy is conceptualised as the “ characteristic of issues which governments believe they should be concerned with and in which they have a right or even obligation to intervene ”. Feasibility is about implementation potential, which is dependent upon i) technical and theoretical knowledge; ii) financial resources and human capital; iii) administrative capability and infrastructure. ‘Support’ denotes the level of public support for government in relation to the issue.

Ethical clearance was obtained from the Ethics Committee of London School of Hygiene and Tropical Medicine, the institutions of two of the authors. Consent was obtained from the study participants interviewed, after providing them with information regarding the study’s aims and objectives. Consent forms ensured their confidentiality and anonymity, and codes were assigned to protect their identity.

Drawing on the document review, we first clarify the structure of nursing institutions in India. Section B then presents main policy reform proposals for advancing nurse leadership extracted from our review of the key documents and the status of these reforms at the time of the study. Based on the core objectives of these reform proposals, we group them under two headings; policies proposed for creating social mobility and policies for strengthening nursing institutions. Under section C, based on expert interviews which reflected on contextualised assessment of the policy process concerning nurses’ leadership reforms in India, we outline our findings about agenda setting using Hall’s agenda setting model.

An overview of nursing in India

Figure 1 shows the hierarchical cadre structure of nurses in the Indian health system organised according to different functions.

Cadre structure and functions of nurses in the health system

The figure shows the complex hierarchical structure of nursing in India and the leadership positions available to nurses at the national, state and district level. There are different hierarchical structures for nursing education and administration as is the case for public health and clinical nursing. The senior most administrative position for nursing at national level is the nursing advisor in the national ministry of health. Nursing councils at the national and state levels are autonomous bodies which are mandated to regulate the nursing education and registration and monitoring of nursing practice. The different leadership positions are also designated separately for community (public health) and clinical nurses at the sub-district level. The leadership positions for community nursing such as Public Health Nurse (PHN) and District Public Health Nurse Officer (DPHNO) positions can be availed by nurses across clinical and community and education sectors as denoted by the dotted lines.

While the above structure depicts the normative requirement, there are a number of inadequacies. For example, senior positions at the level of Director or Joint Director or Deputy Director of nursing, which is the highest nursing official in provinces, are either not created or are officiated by medical doctors in most states. Similarly, a review of nursing sector in five states carried out in 2011 reported that a key public health leadership position at the district level, DPHNO is vacant in most districts [ 23 ]. The same review also identified that only very few Auxiliary Nurse Mid-wife (ANM), the entry level community nurses, are given opportunity to move to the first supervisory position of Lady Health Visitor (LHV) or higher in their entire career.

Principal policy reform agendas for developing nurse leadership

Based on our document review, we identify the reforms that are considered crucial and grouped them under two headings, those help in uplifting the status of nursing and those which strengthen the nursing institutions, both are considered important for distributed nurse leadership.

Policies proposed for creating social mobility

Bhore committee report of 1946 and the High Power committee on nursing of 1987 recommended the need for nurse leaders at all levels of administration for facilitating their active participation in decision making. The pre-independence Bhore committee advocated for giving higher rank to nurses to address the low status of the Indian nursing professionals. These committees have also asked for better salary and living conditions for nurses. Another committee constituted by the government in 1954 specifically to review the service conditions of nurses recommended improvements in service and living conditions so as to attract ‘educated young women from good families’ to the profession.

Enhancing the quality of education was seen as an important step to enhance professional position of nurses among different cadres of health workers. Various committees have recommended reforming the nursing education to professionalise nursing. For example, the high power committee (1987) suggested two streams of nursing namely professional stream of graduate nurses and lesser qualified auxiliary nurses’ stream. Specialization by way of post-graduate and doctorate degrees was also proposed as an important step towards professional development [ 25 , 26 ].

Improving the working conditions and providing definite paths for career progression of nurses to improve the social and professional position of nurses are two long standing demands of various nurses’ associations like Trained Nurses Association of India (TNAI) and Society of Midwifes in India [ 27 ]. The federal ministry of health and family welfare had written several letters, between 1999 to 2011 to state governments on the issue of working conditions of nurses; number of working days; allowances; upgradation of posts; payscales; promotions and study leave. TNAI’s proposal for instituting a separate professional code of conduct for nurses is another attempt to uplift the professional status and to provide distinct professional identity for nurses [ 27 ].

Strengthening nursing institutions

Developing nurses’ leadership relies on the capacities of key nursing institutions to deliver against their mandate and their empowerment in doing so. Different committees that looked into nursing issues have noted that nurses are generally not involved in making policies that govern their status and practice [ 22 , 28 ]. The High Power committee recommended the inclusion of nurse leaders at all levels of administration in order to facilitate their active participation in planning for health sector. Institutional reforms were seen as a central component to operationalizing nurse leadership in the country. The most prominent solution put forward by the High Power committee was the establishment of Nursing Directorates at state level. With this arrangement, the committee had argued for bringing all nursing personnel technically and administratively under the control of nursing personnel themselves. The central ministry of health and family welfare has also issued guidelines in the year 2002 for establishment of separate nursing cadres in states with delegation of administrative and financial powers.

Despite several reform proposals for improving status and strengthening leadership of nurses, realization of such proposals to actual policies and its implementation remained faulty at the time of this study. A 2011 report of the central health ministry which was prepared for an expert group consultation on management capacity at the state and district level had observed this as a critical gap [ 29 ]. “These cadres would be excluded from senior levels of management, even of their own cadre” . Similarly, a situational analysis of status of nursing reforms in five states carried out in 2008–09 shows lack of progress in many of the reform initiatives. The Table 2 provides details on the status of nursing reforms as observed at the time of situational analysis and its implication on nursing profession and health system.

Agenda setting process for policy reforms for nurse leadership

In this section, using the three elements of Hall’s framework, we identify the inadequacies in the agenda setting process of policy reforms and try to identify the reasons and solutions based on our analysis of expert opinion.

The process of determining the legitimacy of nurse leadership reform proposals involves examining the issues that are recognized as a problem by a significant number of policy actors especially the decision makers. Key informants interviewed for this study also noted that most of the issues identified as deficits in the nursing sector could not be resolved without the recognition of the issues by the highest levels of authority. Table 3 describes the issues which are classified as legitimate based on our analysis of key informant interviews.

In the absence of perception of severity of nurses’ leadership issue by national and state level decision makers, the legitimacy of nursing reforms is drawn towards other issues. Interviewees have noted the need for a facilitating factor, a focusing event that would unambiguously call for action and redress by government to bring attention on nursing issues back to policy makers. It was further explained that in government decision making settings, the perceived severity may be inferred from quantitative data or statistics, which allows for an appreciation of the scale of the issues at hand. Prioritization of policies for increasing nursing educational institutions and improving staffing levels in public sector is attributed by experts to the publication of large number of recent researches and data on nurse shortages and migration. The same considerations have also led to an attention on deficits in the reliability, validity and completeness of data regarding workforce quantification, qualifications, registration of nurses. The healthcare areas where nurses could add more value than medical professionals have also received recent policy attention and experts acknowledged increasing legitimacy for nurses’ leadership roles in geriatric and palliative care in recent years.

The policies supporting larger professional roles for nurses and strengthening nurse leadership were not perceived as legitimate in the sight of policy makers. Some informants saw the reason for these as embedded within the country’s socio-cultural context, particularly in relation to “woman’s place in society and her place outside the home”, which affected the perception of nursing issues by government and other stakeholders “as second class issues” (IA; IB; IF; ID; IE; IG). The dominant perception that nursing is an unskilled work, which can be equated with menial jobs is also contributing towards disregard for reforms for empowerment of nursing workforce. Some informants suggested that this lack of recognition of nursing issues is explained by insufficient clarity around what the nursing function actually entails (IG), as their role is often perceived as “limited to taking orders from doctors” (IH). The current division of labour at service delivery point was described as reflecting nursing’s subservience to the medical profession.

Nursing profession came from UK and came as a small group to give care to British soldiers. Nursing was under a very regimented structure, trained to obey, trained to take supplementary role, not to take first role. In India there is very little chance of nursing becoming independent. (ID)

Feasibility

Feasibility of policy reforms for nurse leadership is about the structural and functional capabilities required to carry the agenda of nursing leadership reforms forward. The Table 4 lists the factors identified as important for feasibility.

The experts observed that most of the issues identified as deficits in the nurse leadership sector could not be resolved without allowing nurses to hold positions of hierarchy within the government. In spite of several reform proposals, nurses’ relative position within the hierarchy of health workers has not significantly progressed over the years. “Leadership grows in social contexts and hierarchical settings, but a nurse is the lowest in this hierarchy” (ID). Informants reported that there is currently no position with decision-making power in the nursing sector and therefore, they are excluded from policy making process. “Such a post is yet to be created” (IA) and “leadership will only be achieved if we reach professional equality” (ID).

Leadership of nursing is disempowered by the high number of vacancies at key institutions, including the Ministry of Health and the Indian Nursing Council (INC). At the state level, nurses are neither involved nor represented in decision making (IG; IA; IF). Some informants stressed that the INC, the only national institution represented by nurses, may be better governed and better staffed, but they still lacked the political clout to influence decisions and policies at state level. While some informants referred to INC as the ‘go-to’ institution for nurses, others felt it neither had the constitutional authority nor the power to act upon nursing issues other than matters concerning nurses’ education (IG, IH).

Regarding the feasibility of the national directives to states (province) on strengthening of the nursing sector, the experts identified the division between state and national responsibilities for health as a factor. “Policy direction is given to states but it is up to states to implement and there is little leverage, as the state is the supreme decision-maker in health matters ” (IC). The state nursing councils are described as weak in the state-level political hierarchy, as power is always located at the directorate of health, where nurses are neither involved nor represented. The absence of a nurse-specific institution at the state level, such as directorate of nursing is reported as a key limitation, as a separate directorate for nursing would have highlighted the issues facing the profession and advanced many policy solutions. Absence of separate nursing directorate is perceived as the most glaring gap and its establishment is considered important for allocating funding for the nursing sector and for addressing poor working conditions of nurses. “Without it we are not represented and the powerless cannot lead” (ID).

Improving feasibility of the proposed reform solutions to nurse leadership deficits is described as complex. Informants discussed a number of solutions, yet their feasibility is seen as hampered by a dismembered nurse leadership, corruption and a lack of vision for nursing at the institutional level. The profession is described by one of experts as “weak in the head, led and managed by those who neither have the time or the inclination to invest their efforts at quality improvements ” (ID). The processes by which policy solutions are debated and designed were also characterized as detrimental to agenda setting. The composition of working groups and committees set up to address specific issues was seen as unrepresentative of the nursing profession (II, IB). While the inclusion of new people into such forums was seen as important, it was also recognized that high-level appointments are political and candidates are not selected on the basis of merit but rather on the degree to which they will not disrupt the status quo. “These were systematically led by a group of tightly knit individuals” (II) . “ This reproduces the vicious circle of inaction” , where “nobody wants to take the lead for fear of losing their job” (II) .

In line with Hall’s model, understanding the level of support for policy reforms for nurse leadership is made on the basis of experts’ opinion on nature of support from government and other decision-makers. The position of all key actors, and specifically, their non-objection to the issue were ascertained (Table 5 ).

Informants unanimously and unambiguously reported a lack of high level of support for developing nurse leadership at all levels of the health system. “It is difficult to move people around this issue” (IF) . For example, the long lead-times for application processing, candidate selection and recruitment for key nursing positions (which is described as taking on an average two years) is explained as a reflection of the low prioritization of nursing at the national level (IA).

The majority of informants noted the lack of strong support from nurses themselves for these policy reforms. Lack of buy-ins from nurses and their non-participation in decision making process is described as a systemic weakness of the nursing sector. “Leadership in nursing is dispersed across the country, disjointed in its efforts and lacked the vision, the sustenance and the unity to plead its own cause” (ID) . A lack of belief among nurses that their conditions can be improved and their lack of interest in these matters are given as other reasons for this. The situation is described by experts with statements such as “nurses are being against nursing” (II) or “nurses aspiring to do well… leaving the country” (ID) .

Experts have observed that the interests of the medical profession are steering the directions of debates in health sector. Over-dominance of medical professionals is attributed to nursing profession’s disempowerment, and its lack of autonomy and independence. One respondent felt that the public opinion that shapes the perception of nursing should be challenged. “We need to convince people about our potential” (II). However, at the same time, securing the support of key stakeholders and making use of the current opportunities are seen as strategic. “Beneficial alliances can be forged with the medical profession, we need to work with doctors, not against them, and if doctors take credit, then so be it. But, if it means that our profession will rise, it is worth joining hands” (II) .

Policy reforms needed to address the nursing leadership crisis are challenged by the range and complexity of issues as identified in the study. The limitation of the study is the small number of key informants who participated. The Hall’s framework which analyses the process of agenda setting of policies based on the concept of legitimacy, feasibility and support provides an opportunity to compare and understand the experience of nursing leadership in other settings.

An unclear clinical responsibility assigned to nurses in their healthcare domain is described as a reason for low legitimacy for policies facilitating nurse leadership in Jordan [ 30 ]. Enhancing the image of nursing sector is seen as crucial step towards creating an enabling environment for national structures and processes that facilitate nurses’ leadership [ 31 , 32 ]. The structural forces that shape the perception of nursing will be a major challenge in India. As a 1987 WHO report on nursing highlighted, “the nursing culture remains heavy with subordination without influence…(and) burdened with obligation without power” and had predicted that the nursing sector should “expect to face resistance yet take up positions from where it can voice its opinions at policy and decision-making levels” [ 12 ].

Understaffing at key national-level nursing institutions weakens the feasibility of framing relevant issues and policy solutions. The experience of nursing in other countries point to the need for creating strong leadership among academic nurses as a precursor for changes across the sector [ 33 ]. An attempt in the past to develop nurse leaders in academic setting in India has shown challenges. This isolated effort to build academic nurse leaders met with only limited and unsuitable gains in the context of several structural constrains, including social and organizational constraints [ 34 ].

Gaining support for policy reforms is contingent upon nurses’ ability to collectively demand for change. Absence of tactical advocacy strategy targeting key actors and civil society is seen as a major shortcoming of the nursing sector in India. Nurses should consider building strategic alliances across the health system to push for policy reforms promoting nurses’ leadership within the health system. Carter identifies nurses’ own reluctance to challenge the male domination of the health system as the major hurdle in changing the structural limitations of the nursing profession [ 35 ]. Fletcher argues that the style of leadership in nursing has been a reflection of an oppressed group, shaped by the oppressing social forces. He calls for increased self-reflection and dialogue as a way ahead to break the cycle of oppression and lead to changes in the structures that oppress nurses [ 36 ].

Experiences of the nursing sector in other countries resonate with Indian scenario. For example, the experience of South Africa, which is known for stronger participation of nurses in the health system, shows that nurses’ leadership development during apartheid years was strongly entangled in the political context and depended on their ability to create strategic alliances and protect self-interest [ 16 ]. Another article on Democratic Nursing Organization of South Africa describes the role played by the organization in uplifting the status of nurses by mobilising, unifying and organising nurses as a collective group in South Africa [ 37 ]. Unification of the nurses and their collective power is identified as the way forward for empowering nurses in Iran, where, as in India various contextual factors constrain nurses’ leadership potential [ 17 , 38 ].

Furthermore, the possibility of achieving results with active government support should not be understated. The recent government interventions and reforms that promote scaling-up of nursing education and strengthening of nursing curricula include strong inputs towards communication, policy and planning modules [ 26 ]. The expectation is that empowered by their newly acquired skills, nurses will be able to advocate for their increased role in health sector.

The absence of effective policies that create distributed and bottom-up nurse leadership in India called for this analysis of policy-making processes. This paper specifically sought to examine the agenda-setting process to understand the constraints on policy development for nurse leadership. This paper shows that the agenda of strengthening distributed nurse leadership in India is constrained by both the compromised social position of nurses and the imbalance in distribution of power and influence of nurses within the health system. This analysis also brings to attention the need to go beyond a strategy of creating few nurse leaders at the top. There is consensus among the experts that the nurse participation in decision making from the grassroots to the institutional level requires several facilitating policies targeting various levels of health system.

The study reinforces the argument that the determinants of nursing empowerment and leadership can only be addressed through deliberate attempts to enact institutional reforms that facilitate nurse leadership and through nurses’ collective advocacy to question the status quo and the structures that uphold it. This study further highlights the importance of generating further evidence on linkages between governance and policy reforms for health human resources and its influence of health system performance. A deeper understanding of the health system leadership arrangements, especially the distributed leadership will play a key role in creating equitable, efficient and accountable system.

Abbreviations

Auxiliary Nurse Mid-wife

District Public Health Nurse Officer

Indian Nurse Council

Public Health Nurse

Trained Nurses Association of India

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Acknowledgements

We would like to thank the participants of the study. We acknowledge the contributions of Surekha Garimella, Shinjini Mondal and Venkatesh Narayan for helping with the interviews and analysis.

The study was supported by Department for International Development, UK Government. The preparation of the paper benefitted from discussion at an April 2016 writing workshop organised by the Consortium for Health Systems Innovation and Analysis (CHESAI) to generate deeper Southern-led perspectives on health systems and governance issues, CHESAI is funded by a grant from the International Development Research Centre, Canada.

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The data used for this manuscript were generated from the datasets of transcribed interviews of key informants. However, they are not publicly available due to confidentiality agreements with participants.

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Varghese, J., Blankenhorn, A., Saligram, P. et al. Setting the agenda for nurse leadership in India: what is missing. Int J Equity Health 17 , 98 (2018). https://doi.org/10.1186/s12939-018-0814-0

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Challenges and needed reforms in midwifery and nursing regulatory systems in India: Implications for education and practice

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Current address: Department of Social Statistics and Demography, University of Southampton, Highfield Campus, Southampton, United Kingdom

Affiliation University of Southampton, Southampton, United Kingdom

Roles Conceptualization, Funding acquisition, Supervision, Writing – review & editing

Roles Conceptualization, Supervision, Writing – review & editing

Kaveri Mayra,
Sabu S. Padmadas,
Zoë Matthews

Published: May 14, 2021
https://doi.org/10.1371/journal.pone.0251331
Reader Comments

In India, nursing regulation is generally weak, midwifery coexists with nursing, and 88% of nursing and midwifery education is provided by the private health sector. The Indian health system faces major challenges for health care provision due to poor quality, indeterminate regulatory functions and lack of reforms.

We undertook a qualitative investigation to understand midwifery and nursing education, and regulatory systems in India, through a review of the regulatory Acts, and an investigation of the perceptions and experiences of senior midwifery and nursing leaders representing administration, advocacy, education, regulation, research and service provision in India with an international perspective.

There is a lack of importance accorded to midwifery roles within the nursing system. The councils and Acts do not adequately reflect midwifery practice, and remain a barrier to good quality care provision. The lack of required amendment of Acts, lack of representation of midwives and nurses in key governance positions in councils and committees have restrained and undermined leadership positions, which have also impaired the growth of the professions. A lack of opportunities for professional practice and unfair assessment practices are critical concerns affecting the quality of nursing and midwifery education in private institutions across India. Midwifery and nursing students are generally more vulnerable to discrimination and have less opportunities compared to medical students exacerbated by the gender-based challenges.

Conclusions

India is on the verge of a major regulatory reform with the National Nursing and Midwifery Commission Bill, 2020 being drafted, which makes this study a crucial and timely contribution. Our findings present the challenges that need to be addressed with regulatory reforms to enable opportunities for direct-entry into the midwifery profession, improving nursing education and practice by empowering midwives and nurses with decision-making powers for nursing and midwifery workforce governance.

Citation: Mayra K, Padmadas SS, Matthews Z (2021) Challenges and needed reforms in midwifery and nursing regulatory systems in India: Implications for education and practice. PLoS ONE 16(5): e0251331. https://doi.org/10.1371/journal.pone.0251331

Editor: Kathleen Finlayson, Queensland University of Technology, AUSTRALIA

Received: September 12, 2020; Accepted: April 23, 2021; Published: May 14, 2021

Copyright: © 2021 Mayra et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Unfortunately, we are not allowed to share the data publicly to ensure the confidentiality as agreed with our study participants who hold senior leadership positions which may be identified at the state and national levels. These restrictions are based on the guidance of the University Research Ethics Code of Conduct. The corresponding author is the point of contact for all relevant data related requests. Our non-author point of contact is Prof. Silke Roth, Faculty Research Ethics Chair, who can be contacted at [email protected] .

Funding: This study was funded by The Royal Norwegian Embassy in New Delhi under their Norway India Partnership Initiative’s (NIPI) Scientific Research Project IND-16/0008.

Competing interests: I have read the Journal’s policy and the authors of this manuscript have no competing interests.

Abbreviations: ANM, Auxiliary Nurse Midwife; ANMTC, Auxiliary Nurse Midwifery Training Centre; GNM, General Nursing and Midwifery; GNMTC, General Nursing and Midwifery Training Centre; GOI, Government of India; HRH, Human Resources for Health; ICM, International Confederation of Midwives; ICN, International Council of Nurses; INC, Indian Nursing Council; NHM, National Health Mission; NNMC Bill, National Nursing and Midwifery Commission Bill; NPM, Nurse Practitioner in Midwifery; NRTS, National Registration Tracking System; PSE, Pre Service Education; SNC, State Nursing Council; WHO, World Health Organization

Midwives and nurses are integral to sexual, reproductive and maternal health care provision and are the primary health care providers in India. A comprehensive and strong regulatory mechanism is therefore needed to regulate education, practice and to ensure competent nurses and midwives in the Indian health workforce. The International Confederation of Midwives (ICM) recommends six functions that regulatory bodies should maintain; setting the scope of practice, pre-registration of education, registration, re-licensing and continuing competence, complaints and discipline, code of conduct and ethics [ 1 ]. The Indian Nursing Council (INC) and State Nursing Councils (SNC) play key roles in the regulation of nursing and midwifery education in India. They oversee registration, licensing, inspection and examination. However, there is duplication of these roles at the national and state levels [ 2 ].

In India, nurse-midwives become part of the health care workforce after completing 2–4 years of mandatory Pre Service Education (PSE) which aims to provide skills of both of the professions of nursing and midwifery. Hence, in this paper we address the existing cadre as ‘nurse-midwives’ although they are generally referred to as nurses. Currently, India does not have a cadre of competent independent midwives [ 3 ]. Midwifery education is provided both as a part of a diploma course called General Nursing and Midwifery (GNM) for three years and also as a part of a four year BSc nursing degree. The midwifery component in BSc nursing degree lasts for approximately six months. This compares to the longer duration of 18 months midwifery education elsewhere globally after completing three years of a nursing degree [ 4 ]. There are also elements of midwifery skills education embedded in the Auxiliary Nursing and Midwifery (ANM) certificate course. The curriculum for these three entry-level courses of midwifery education are not comparable with the ICM recommended skill-set [ 1 ]. However, those graduating with a GNM diploma or a degree in nursing are addressed as nurses or nurse-midwives. The National Health Mission (NHM) launched by the Government of India (GOI), recently initiated efforts to formulate operational guidelines to implement midwifery education [ 3 ]. An existing diploma course for Nurse Practitioners in Midwifery (NPM) has been updated to implement midwifery in India, though it is still not completely in line with the ICM recommendations for training competent midwives [ 3 ]. It is essential to understand and tackle the shortcomings of India’s midwifery education, regulation and practice capacities, especially considering that 83% of maternal deaths, stillbirths and neonatal deaths can be averted when care is managed by professionally trained midwives [ 5 ].

Midwives and nurses are often neglected and subjected to discrimination throughout their education and through to their professional careers [ 2 , 6 , 7 ]. Indian nursing and midwifery education is faced with several challenges including a lack of qualified teachers; a mismatch between theory and practice in learning; a lack of opportunities for practice; and gender-based discrimination and stigma [ 2 , 7 – 11 ]. Around 88% of nursing education in India is provided by the private sector where the quality of education is reportedly poorer than that offered in public institutions, especially in the resource-poor large states of northern India [ 8 ]. The private share in nursing education has continued to grow in terms of the number of training institutions and recruitment quota, in response to the global demand of nurse-midwives, thus ranking India the second in terms of nurses’ outmigration [ 12 ]. The uneven distribution of nursing institutes is yet another challenge and the privatization of education has led to a skewed production of human resources for health (HRH) [ 8 ]. Education is concentrated in the six states of Andhra Pradesh, Karnataka, Kerala, Maharashtra, Pondicherry and Tamil Nadu, which represent only 31% of the Indian population yet have 63% of nursing and 58% of medical colleges [ 8 ]. This compares to to the eight low HRH-producing states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Uttar Pradesh, Uttaranchal, Odisha and Rajasthan, which hold 46% of the total population in India, but have only 20% of nursing and 21% of medical colleges [ 8 , 13 ]. The training institutes are further biased toward the urban areas within these states [ 8 ].

Regulatory mechanisms are found to be relaxed to allow training in certain private institutes, despite capacity challenges [ 9 ]. These issues are further reflected in the strength of the nursing workforce. On average, India has only 17 nurses and 9 doctors per 10,000 population [ 14 ], unevenly distributed between states, urban-rural and public-private sectors, with over 70% of the nursing workforce employed in the private sector [ 15 ]. The implementation of a good regulatory framework is therefore essential to address the outstanding issues in nursing and midwifery education and practice.

The current structure of midwifery and nursing regulation also faces many challenges in India. The system is dominated by male medical and non-professionals and provides little authority to nursing and midwifery regulators [ 10 ]. The role of gender in nursing and midwifery is not systematically understood in India [ 7 , 10 ]. The regulation of nurses and midwives’ migration is unclear; the regulation of practice is weak, and there is a failure to improve the quality of education mainly in the private sector [ 8 , 16 – 21 ]. Over the last few years, non-government and international development organizations have coordinated efforts to improve pre-service and in-service education in India [ 21 , 22 ]. However, these efforts have not succeeded in establishing and sustaining a strong regulatory structure. There have been some initiatives focused on improving the quality of nursing and midwifery education and services in India, however, the challenges in regulation remain unaddressed [ 8 , 11 , 19 ].

The goal of this research is to understand the influence of current regulatory system on nursing and midwifery education, practice and development in India. More specifically, the paper has four interrelated objectives: (i) to document the regulatory system of nursing and midwifery in India through a review of the existing regulatory acts; (ii) to understand the challenges and weaknesses in the system of nursing and midwifery education and practice regulation; (iii) to investigate the gender and power based issues underlying the regulatory challenges of midwifery and nursing and (iv) to document the challenges of midwifery education and practice under nursing regulation and governance.

Materials and methods

Study design.

This research adopted a qualitative design involving in-depth interviews to examine the perceptions and experiences of nurse-midwives in senior leadership roles regarding the regulatory systems of midwifery and nursing in India. The study participants were initially selected through a purposive sampling based on contacts with the lead researchers in the field, followed by a snowball sampling in five states in India: Rajasthan, Odisha, Bihar, Madhya Pradesh and West Bengal and at the national level. The five states selected represent different cultural, social, economic and health contexts. All selected states, except West Bengal, are amongst the low HRH-producing states with poor quality of midwifery and nursing education. West Bengal is widely acknowledged for providing good quality nursing and midwifery education and governance, especially in the public sector [ 23 ]. The inclusion criteria for in depth interviews followed a strategy to select nursing and midwifery leaders who represent various domains of administration, advocacy, education, regulation and service provision in the selected states and at the centre. Some of the participants represented multiple domains. We interviewed selected leaders at the national level to understand the larger context of health policy making and nursing governance in India. In addition, we reviewed the nursing and midwifery regulatory acts from all the five selected states and the Indian Nursing Council Act to understand and compare the guiding documents and protocols for regulation. The review is summarised in the results section.

To understand the global experiences and perspectives on the regulatory frameworks of nursing and midwifery, we conducted interviews with eight international experts representing various international organizations that play a key role in guiding the health policy and regulatory frameworks globally. We interviewed senior nursing and midwifery professionals from the World Health Organisation (WHO) headquarters, International Nursing Council (ICN), International Confederation of Midwifery (ICM), United Nations Fund for Populations Activities (UNFPA) and senior midwifery academics from three research intensive higher education institutions in the UK.

Data collection and analysis

In-depth interviews were conducted between July 2018 and January 2019. The participants were informed about the purpose of the study by email or phone before seeking formal appointment for interviews. We approached 43 nursing and midwifery leaders, and of these nine could not participate due to their prior commitments. All the interviews were conducted in person, except three which were done via video conference call. Each participant was interviewed only once. We followed a semi-structured questionnaire guide which included three sections: 1) background information of participants including their education relevant to nursing and midwifery, professional experiences, roles and responsibilities; 2) current and past role and responsibilities of participants in nursing and midwifery regulation and governance and 3) participants’ reflections of nursing and midwifery regulations including their perceptions on the state of education and practice regulation.

All interviews were conducted by the lead author, an experienced qualitative researcher with educational background in nursing, midwifery, public health and with research experience on issues pertaining to nursing and midwifery in India. All participants were aware of the lead researcher’s background, professional qualifications and the rationale of the study. The interviews were carried out in English language in most cases, or in Hindi and Bengali in a few states where the transcripts were translated into English. The female lead researcher is fluent in these languages. Most interviews were conducted in the work place of the participants, except for a few at their homes or in a public place. Each interview lasted approximately for little more than an hour depending on content and information saturation. Data were processed and analysed thematically using NVivo 12 software. The lead researcher conducted coding simultaneously with data collection which helped to clarify emerging themes in subsequent interviews. The codebook consisted of apriori codes which were supplemented by deductive codes, as the analyses progressed. Relevant codes were grouped into themes such as gaps in regulatory functions, gender roles on regulation and other key emergent issues.

Ethical considerations

The study obtained formal ethical clearance from the University of Southampton Faculty of Social Sciences Research Ethics Committee of the Authors’ institution prior to the start of the research. All participants read and signed the written consent prior to data collection. All respondents were provided with a participant information sheet with details about the research. The researcher sought formal permission to audio record the interviews. Three interviews were not audio recorded since the participant refused consent, instead written notes were taken. To ensure confidentiality, study respondents were anonymised throughout the analysis and presentation of results.

The interviews focused on the quality of nursing and midwifery education, regulation, challenges of regulation in education and practice, and recommendations to improve regulation of nursing and midwifery education and service provision.

The age of respondents varied from 46 to 83 years. All respondents were midwives and nurses except one who was not a midwife. Twenty-six participants completed their education in nursing and midwifery in India. Their qualification was the degree that combined nursing and midwifery curricula. Four out of the 34 participants were men, who were all interviewed in Rajasthan, one of the few Indian states where men have historically been permitted to opt for midwifery and nursing education. All respondents held senior level positions, except for two who had retired from service. The total experience of the participants ranged between 24 to 60 years. Table 1 presents relevant demographic qualifications and work profile related information of the participants.

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https://doi.org/10.1371/journal.pone.0251331.t001

The regulatory system of midwifery and nursing in India: A review of Acts

This section presents a review of the regulatory acts implemented in the selected states and centre ( Table 2 ). All the acts are extracted from the respective council’s website.

https://doi.org/10.1371/journal.pone.0251331.t002

As can be seen from Table 2 , most of the state Acts are older than the INC Act of 1947. All the state Acts are similar in content which includes the profile of members, key definitions, membership conditions, information for professional registration, re-registration and service related clauses for practitioners. The membership of the governing body is not uniform across the Acts, ranging from seven members in Odisha to fifteen in Bihar. Every council has a set number of members who are doctors and some members are non-nursing/ midwifery administrators. The ex-officio members, four to seven in every council, can be elected multiple times as long as they hold the position by virtue of which they have been elected. There is no system of direct application unless through nomination, followed by election by members. None of these Acts have been re-created according to the needs of the states, neither have they been adequately amended since they were introduced in the 1930’s and 40’s despite immense changes in the health system and the population. Bihar shared a council with Odisha at the time of its creation (in 1935) and mentions ‘Orissa’ in the title even though Odisha started a separate council shortly afterwards (1938).

The language of the Acts is not gender sensitive and all the Acts refer to the registrar as ‘he’ or ‘his’ despite, historically, the position of registrar in most nursing councils being held by women, including at the time of this study when four out of five SNC’s registrars in the study states are women. The curriculum is not part of the Acts, and is centrally designed by INC and implemented with some variation in the states.

The content varies a little for some Acts. The Rajasthan Nurses, Midwives, Health visitors and Auxiliary Nurse Midwives Act of 1964 is the most detailed Act entrusting the power of council through eight activities, including grounds on which the state government has the right to dissolve the Council and the Act. The language of the RNC Act is relatively gender sensitive. Odisha and Rajasthan’s Act and Council includes ‘midwives’ in the title. None of the other Acts mention independent midwifery practice. Odisha is the only state that registers dais (traditional birth attendants). The Central Provinces Nurses Registration Act of 1936, in Madhya Pradesh discourages private practice, although it does elaborate on it to clarify what it means for nurses working in the private health care provision and education sector.

All six Acts mention regulating education, but none highlight regulating practice or updating the knowledge and skills of practicing professionals. There are no separate Acts at the state or centre that regulate nursing and midwifery practice. The Acts do not mention INC’s role in supervising the SNCs. The accountability mechanism between the INC and the SNCs is unclear. This could be because the state Acts, except Rajasthan, were formed before the INC Act of 1947—although Rajasthan’s Act also does not mention INC’s role. INC’s key activities focus on maintenance of registers for all nursing and midwifery courses, registration at the national level, licencing of nursing training institutes, setting the curriculum for every course and maintaining uniformity. The INC website has information on the National Registration Tracking System (NRTS), which was recently launched to maintain a database of nurse-midwives in the country from every state, to enable tracking and to regulate placement. As of August, 9 th 2020, there were 9, 90,524 professionals enrolled under the NRTS (INC, 2020).

The council Acts do not provide any guidance on nurses’ domestic or overseas migration clarifying the terms of registration while serving in a foreign country, or their practice in India on return, higher education in nursing and midwifery or other health-related education in other countries.

Challenges and weaknesses in the regulatory and governing bodies

The INC regulates nursing and midwifery education in India. The SNCs manage regulation in the respective states. Regulation of nursing and midwifery education covers certificate, diploma and degree courses in the public and private sector. Every council has positions of President and Registrar as the key administrators. Routine administration is in the purview of the Registrar. One participant from the centre objected to the processes and terms of reference of administrators at the councils.

“ These days in nursing council a person can be President for life ! The council seems to be happy with it… elections are conducted in every term but the leadership does not change . They can change that if they want to . ” (National) “ INC president has been in position for 15 years… One term of leadership at INC is 4 years . ” (National)

Most council participants mentioned a lack of human resources as a key challenge to managing the councils work such as admission, examination, inspection, registration and re-registration in each state. The role of the INC is different from the SNCs. The INC sets the national curriculum, oversees registration, implements the NRTS and conducts inspections in all the states. Some of these services overlap, such as institutional inspections which are carried out both by the SNCs and the INC independently to start and maintain a new institution. The reason for this was not clearly explained by the participants. One respondent from Rajasthan commented that this duplication of activity was unnecessary and should be handled solely by the respective SNCs.

Workload challenges were repeatedly mentioned particularly because the number of training institutes are increasing rapidly. Table 3 shows the number of nursing and midwifery educational institutes in each study state (along with seats) and total institutions in India. Between 2005 and 2018, the total percentage increase for ANMTCs is 516% (254 to 1564), for GNMTCs it is 187% (979 to 2812) and for colleges of nursing its 405% (349 to 1761). Bihar has the lowest number of institutes and admission capacity, while Madhya Pradesh has the highest. Bihar has 8.6% of India’s population but only 0.5% of total colleges of nursing. The capacity of Bachelor’s degree in nursing education has increased four times and post-graduate studies in nursing by eleven times in India between 2005 and 2018. This increase has been disproportionate. The number of institutes providing GNM education increased significantly from 22 to 324 in Madhya Pradesh but remained low in Bihar (13 to 21) between 2005 and 2018. The number of GNM places for admission is disproportionately high, ranging from 991 to 12,970, especially given that the population coverage is highest in Bihar followed by West Bengal, Madhya Pradesh, Rajasthan and Odisha.

https://doi.org/10.1371/journal.pone.0251331.t003

Bihar does not provide any higher education opportunities at postgraduate level for its graduating nurse-midwives in the state, thus restricting the growth of educators to impart degree level education. Each of these states have 20–100 seats for GNM and BSc Nursing per institute. The number of training institutions are not proportionate with the state’s population. The INC does not disaggregate the distribution of institutes and admission capacity by public and private sector.

The regulatory challenges in education are different in public and private institutions. Although the curriculum being taught is uniform in every state, the respondents argued that quality of education is not the same in the public and private sector. Respondents from every state shared that regulation of education was comparatively poorer in private sector institutions.

“Practical experience (for students) is zero in private sector” (Bihar) “ Private sector regulation is poor . No one sees that . ” (Bihar)

Health facilities have affiliations to both public and private medical and nursing education institutes. It is difficult for the hospital authority/ staff to ensure that every student receives the required amount of practice as recommended for successful course completion. A respondent from Bihar shared her experience of working in a government tertiary level teaching hospital:

“ Head of the Department (doctor) says my medical students will practice first (in the labour room). The nursing (and midwifery) students observe cases but can only request to give them a chance to practice . 100% cases (births) are conducted by medicine students… the council inspected , yet did nothing to change this . ” (Bihar)

Such issues were shared by participants from all states, except West Bengal. The most common challenge mentioned was students from private institutions not getting an opportunity for practical experience during pre-service education. Data suggests that students often filled up their case books with fabricated cases as a way to pass the course. This practice goes unchecked, though well acknowledged. Even more alarming is the illegal procurement of fake certificates by untrained persons. To address this issue, the councils take precautions before registering candidates from other states. However, the Registrars do not have sufficient resources to tackle such challenges which represent a major barrier in councils’ functioning.

The lack of practical exposure for students in private institutes leads to a lack of knowledge and skills in comparison to those from government-led institutes. This challenge is acknowledged in private hospitals. Most private hospitals have their own education institutes but reportedly they do not have confidence in their own students because of concerns over their lack of skills. A participant from Rajasthan reflected on the poor training quality of students from private institutes and acknowledged that the state council is aware of the problem.

“ The (state) council knows about it and does nothing” (Rajasthan)

The participant further shared that students sometimes pay bribes to their instructors invigilating practical examinations or even bribe by inserting money inside their answer sheets during examination for attracting good credits for their theory papers. Many teachers succumb to this practice, but not all surrender to the pressure as mentioned by a participant:

“ No one fails students… it is all hidden . Student goes to drop the examiner at the train station to pass on an envelope . I have never taken that envelope . I have heard 5000 rupees is minimum per student for BSc and GNM… Everyone wants to be an examiner for private institute , for that extra income and no one wants to go to government institutes cause government students won’t pay to pass . ” (Rajasthan)

Corruption is the underlying reason for such malpractice which is kept in place by promoting nurses who are party to it.

“ When nurses raise their voice , government removes them from their position . They are not scared of us as we don’t have any power . We are dominated from above . We know everything but can do nothing ” (Rajasthan)

A participant from Madhya Pradesh commented on the issue of student non-attendance. Instead of sitting through the classes, students work in smaller nursing homes as assistants for an extra income. These training centres are usually affiliated to big private hospitals, so in terms of requirement, their ‘papers’ are always complete which means the non-attendance goes undocumented. Even though these nursing institutes undergo inspections from the SNC, INC and the state government, they often manage to overcome any regulatory actions. Fig 1 shows the current responsibilities of state and central council, along with the overlap in their role and the gaps in regulatory functions.

https://doi.org/10.1371/journal.pone.0251331.g001

Gender and power influencing midwifery and nursing regulation

The nursing and midwifery professions face some unique gender-based challenges. In a female dominated profession, the leadership in regulation is male dominated. In Rajasthan, the curriculum is regulated under the leadership of a male nursing registrar and practical experience is overseen by a male nursing administrator from the state health ministry. Rajasthan and Madhya Pradesh are amongst the few states that allow male candidates to take up nursing and midwifery education. Although, Rajasthan historically had both male and female candidates in diploma and degree level courses, fewer women opt for nursing careers due to professional stigma associated with nursing and midwifery. The difficulty to ensure the required midwifery practical experience for male candidates has been a persistent challenge. In some institutions, the professor or clinical instructor in charge of midwifery is a male, who is unlikely to have ever assisted a single birth. The issue of the lack of practical midwifery education for male candidates has not been addressed. A participant from Rajasthan, who teaches midwifery, raised this issue faced during his own education:

“ I asked them why are you giving us this training when you won’t let us practice during the training . What is the point of doing this training ?… They (regulatory bodies) are not even thinking in those lines .” (Rajasthan)

The INC recommends for students to assist 25 births each in BSc Nursing and MSc Nursing in Obstetrics. A male participant who teaches midwifery assisted only five births including his BSc in Nursing and Masters in Obstetrics degrees, even though 650 hours of study is required in total for the post-graduate degree. Getting a chance to assist those five births was fraught with difficulties involving persistent efforts to win the trust of the labour room’s team of care providers.

“ There is stigma for men to work in labour room . Families don’t encourage it , so the scope is less .” (Rajasthan) “ This gender related problem has existed for over 30 years but INC is not doing anything to address it… the state nursing councils can not do anything about this . Now INC is implementing an 18 months course in midwifery but not looking into the challenges of men in midwifery… INC needs to take a stand … States can not do anything . INC tells , we do . State council can write to INC , but they don’t care about the quality of education” . (Madhya Pradesh)

The nursing and midwifery leaders representing education, administration and service provision brought up similar issues regarding male students lacking practical midwifery exposure. However, the participants representing regulatory bodies shared no such concerns. West Bengal has recently started enrolling male candidates for nursing and midwifery education. The issue of gender is not just about getting a chance to practice midwifery. A participant mentioned that the apparent gender imbalance in the profession is also a reason for the lack of leadership for women in nursing and midwifery.

“ People in West Bengal used to think men in nursing won’t be accepted by society , but that was a myth . There are two colleges with 50 seats each for male candidates who are also learning midwifery . The 1 st batch training is on and it is very exciting .” (West Bengal)

The role of doctors, who are usually men, is explored in different ways. They are held responsible for the lack of female representation and growth of the profession. There is frustration about doctors holding key positions in nursing councils.

“ Nursing association wants the nursing directorate to be separate so their demands can be addressed . Any demand from a nursing or midwifery association is usually shelved when a doctor policy-maker comes in the picture . ” (Rajasthan) “ The president of Bihar Nursing Council is a Doctor…there is a lot of politics in all of this . There is pressure from the (Health) Secretary as well . ” (Bihar)

An interesting rationale came from a participant in West Bengal on the lack of leadership quality amongst nurse-midwives. According to her, the issue is that “ lesser doctors are falling in love with nurses” as more women are being educated as doctors. Given that more recently male doctors are getting married to female doctors, nurses seem to be falling further down in the hierarchy of healthcare. The position of nurses tends to diminish over time as doctors do not consider them their equal anymore. Participants suggest that the involvement of men in nursing is deemed to uplift the image of nursing in the country to reduce the gender based stigma.

“A s women , we are ruled by our father , brother , husband and son at different stages of our life… It is our lack of confidence and attitude that only if men are there will we succeed . There is a dependence… we surrender too easily . ” (West Bengal)

Midwifery as a part of nursing: A regulatory challenge

Midwifery is usually practiced on rotation with other nursing roles, and is also not part of a direct entry education. Direct entry midwifery is a three year degree course recommended by ICM that provides a license of Registered Midwife (RM). Participants shared mixed opinions on the requirement and future of midwifery in India as an independent profession. While most participants seemed to be in favour of independent midwifery, there were limited and unclear responses on the regulatory challenges it entails. A respondent from Odisha could relate to working independently in the periphery and yet working harder, as the best phase of her career.

“ ANM is our independent midwifery practitioner who is assisting deliveries in rural areas as good as doctors are doing independently in the urban areas . Some ANM’s conduct deliveries much better than doctors and are very famous for their work , people specially request them to assist with their delivery . ” (Rajasthan)

Medical or obstetric domination is reported as a key barrier to independent midwifery practice as the respondent mentioned “ we can not work independently in the tertiary level as the (medical) professors are there” or that “ we can not work without their permission” . Several respondents mentioned alienation and exclusion as key issues in the tertiary level of care, although they have been entrusted with larger responsibilities at the primary and secondary levels.

“ I have done spinal anaesthesia , caesarean section and abortion , under supervision . If a policy is made that we can work independently , it will be uplifting for the profession (of midwifery). ” (Odisha) “ Independent midwifery is key to address the situation with disrespect and abuse during childbirth everywhere . ” (Bihar) “ Nurse and midwife should be separate cadres , like medicine . Rotation is not helping” (National)

Another participant mentioned the lack of a legal framework as a key challenge for independent midwifery in India. This is due to a lack of legal protection for midwifery practitioners, unlike with doctors. At the national level, participants felt that the INC should take charge of regulating nursing and midwifery services. These challenges were echoed unanimously by all participants.

“ If the INC is the (only) regulatory body (in the country) then that should look after practice . In the 10 years that I have been (Nursing) superintendent , no one has come to check the competency level of my nurses” . (National) “ Nothing is happening in terms of nursing regulation . There is no regulation of service . ” (Bihar)

There are challenges of underfunding as well, which were identified by an international expert.

“All of them (councils) are badly underfunded . INC has managed to get some funds but given the size of India , it’s peanuts . It would be effective if they had many more resources . They could really meet , coordinate , re-educate , train , get the evidence and really understand what’s going on . Its sad that what’s all happening at states is registering and re-registering . ” (International expert)

Respondents felt that the councils should work in favour of midwifery and protect midwives’ right to practice as an independent profession. The need for an exclusive midwifery regulatory Act was mentioned a few times. A participant stated that a Nursing and Midwifery Practice Act of India is being drafted without any assurance of when it will be enacted. Meanwhile, another participant commented that the lack of a midwifery model of care is due to the vested interests of national leaders “ … they do not want independent midwifery in India” . The independent status of midwifery is expected to bring more recognition and a boost in salary as is seen in many other countries. Another international participant suggested a way forward:

“I think it would change the status if the public sees that this is a midwife , this is her level of skills . Someone who practices independently , not dependent on doctor . It’s straightforward . It automatically shifts the status of the profession . It is fundamental to have that independent status . I know it’s not easy to organize and make happen . But it’s the way forward… Changes in policies will of course support the midwives but also part of what’s needed is to get midwifery leaders in the profession who sit there at those tables . There are policies being made about midwifery and maternity care without them at the table . We have got to get ourselves at those top tables… There is strong evidence on midwifery with The Lancet series . It doesn’t happen overnight . ” (International Expert)

The ICM identifies education, regulation and association as the three pillars for development and practice of midwifery [ 1 ]. The nursing and midwifery workforce in India faces many challenges in each of these three areas, especially poor quality of education stemming from a weak regulatory structure that needs to adapt to changes over time. The lack of leadership role and decision-making power for nurse-midwives’ further weakens the governance of these professions dominated by doctors [ 8 , 10 , 20 , 30 ].

India does not have a professional midwifery workforce or direct entry midwifery education yet. Hence, regulation is currently targeted at nurses who are playing a dual role of nurse and midwife. As more evidence is generated on the advantages of midwifery for maternal and neonatal health [ 31 ], it becomes important for the INC to make legitimate efforts to start direct entry midwifery education that will create a cadre of midwives independent of their nursing role. The INC’s role will be fundamental in formulating the regulatory structure, which needs to be supported by the respective SNCs in generating evidence and ensuring that culturally appropriate changes are made. This could be done as an addition to the existing INC and the SNCs with appropriate amendments to the current acts, or by creating a separate midwifery council with a midwifery Act.

Our study has a few limitations. In November 2020, the GOI introduced the draft National Nursing and Midwifery Commission (NNMC) Bill [ 32 ]. The new bill is unlikely to address the existing issues, but instead may create additional challenges which include undermining the autonomy and independence of the state regulatory bodies by centralizing decision making, and not allowing diversity in representation in the commission membership and governance. When passed, the NNMC Bill may end the prospects of addressing the several regulatory challenges in nursing and midwifery education and practice in near future. This statement is being made in cognizance that changing regulations is a time consuming process evident from the fact that the upcoming bill will replace the INC Act of 1947 after 74 years. Our study participants included senior level leaders in nursing and midwifery within public institutions at the state level, and organisations/ associations representing public and private at the national level. It is possible that some of the responses based on personal observations or views could be biased. However, we were able to establish convergence in response patterns across participants from different states.

The Acts in the five states and the INC Act have not been appropriately amended for decades, and most of these Acts were created before independence. An independent review pointed out that INC Act addresses only 15 out of 21 general, structural and functional elements recommended by International Council of Nursing (ICN) [ 33 , 34 ]. The current INC Act is mainly educational and lacks many functional elements such as ‘continuing training required’ under education and training; ‘code or standards or conduct/ ethics’, ‘disciplinary procedures’ under fitness to practice; ‘established process under appeals’; ‘offences/ penalties listed’ under offences; and funding of council [ 34 ]. The Acts also need to include key definitions such as nurse, nursing, midwife, midwifery and their specific scope of practice [ 34 ].

Interviewing leaders from different domains of nursing and midwifery governance helped identify many other challenges. The increasing workload was frequently mentioned by participants representing regulatory bodies, also raised as a concern in other countries by international experts [ 34 ]. The participants did not specifically mention the cause of discrimination in education, partial treatment of medical students in comparison to nursing and midwifery students and the powerlessness in nursing, midwifery and health policy making they faced as ‘gender-based’ even though it is clear from their responses. The doctor dominance and political nature of regulation was reported with caution. All these challenges and more, including lack of leadership qualities in the regulatory bodies, were raised by nursing and midwifery leaders representing education, service provision, association and administration. Respondents urged the need for more transparency and inclusivity in the regulatory processes of INC and SNCs. This is essential to ensure accountability [ 1 , 20 ]. The participants felt that a change in leadership at INC might improve regulation and that the key position should not be stagnant.

The regulation of private education is particularly concerning. Note that 88% of India’s nursing education is being conducted in the private sector [ 8 ]. This creates avenues for corruption and lack of control [ 20 ]. There is a dire need for regulatory bodies to address the challenges related to non-attendance of students, working in the nursing homes during pre-service education, lack of qualified teachers, less opportunities to practice and illegal practice with no formal qualification.

The findings from this study confirms the evidence reported elsewhere, and reinforce the urgent need to improve midwifery and nursing education [ 30 , 35 – 37 ]. In the Indian context, shortcomings in regulation have persisted for decades [ 8 , 16 – 19 ]. The participants of this study have clearly identified that key stakeholders have failed to take a gender sensitive approach. The scope of workforce participation for people who identify as transgender or gender non-conforming, and the challenges they face as nurses and midwives, remains unexplored in India. Nursing and midwifery needs a people centric approach to address the existing gender-related barriers. Gender-based discrimination begins with each nursing and midwifery student’s education and extends to their clinical practice or teaching thereafter. When male candidates are given opportunities for graduation and post-graduation in midwifery (gynaecology and obstetrics) and nursing, the SNCs must ensure that they receive enough practical experience without any gender discrimination [ 16 – 18 ]. Men and women in the profession have specific issues that need to be addressed in a way that ensures quality education, opportunities to practice and provide care in line with patients’ rights and choices. Nursing and midwifery being traditionally women dominated professions, adds to the gender based discrimination and stigma, which gets exacerbated because nurse-midwives often come from poor socioeconomic background and backward classes and castes, which has a relevant history behind it on how nursing began and progressed in India [ 7 , 10 , 38 ]. Though it is established that these characteristics have an impact on nurses and midwives education and practice but the extent of it alongside the practice of medicine, owing to the intersectionality based on their personal attributes, remains to be studied in the context of India [ 7 , 10 , 39 ].

A key challenge is discrimination between nursing-midwifery and medical students, as they practice in the same health care delivery system. This discrimination results in inadequate practical experience opportunities for nursing and midwifery students, and establishes a hierarchy in the medical care system from pre-service education onwards. This clearly demonstrates the lack of attention afforded to nursing and midwifery education in comparison with medical education. This hierarchy is often gender-based and creates inequalities within the health care team by centralising decision-making power in the hands of medical profession at every level of care provision [ 6 ]. The powerlessness of nursing and midwifery leaders in health systems policy making, due to the doctor-centric nature of health policy making and regulation, has been a persistent challenge [ 8 , 20 ].

The nursing councils do not play a role in regulation of practice, which is mainly managed by the state and central government bodies. Increasing the SNC’s role in practice regulation, with a new branch or a separate establishment for midwifery, will ensure quality and evidence-based nursing and midwifery care provision, which could be supervised by the INC to ensure uniformity [ 1 ]. Regulation is divided between different bodies including INC, the SNCs, the directorates of medical education and universities. The lack of clarity about this segregated nature of regulation adds to the confusion and decreases rigour when education and regulation is managed by so many different bodies, mostly without the involvement of nursing and midwifery representatives. It results in duplication of functions such as inspection; while other functions including the regulation of practice are completely ignored.

Literature suggests poor working condition and low remuneration as key drivers for nurse migration from India, which could be addressed by better regulation of practice [ 2 , 19 , 34 ]. Nurse (midwife) migration is also an area that needs to be regulated, given India is a major supplier of nurses to the Middle-East and high-income countries, ranking second in nurse outmigration after Philippines [ 8 , 12 , 40 , 41 ]. Information about overseas migration and practice on return is provided in other country Acts [ 34 , 42 ]. An understanding of the magnitude and reasons for nurse-migration will help to improve the quality of working conditions in India and decrease the workforce shortages by retaining more nurse-midwives.

The international experts interviewed presented a global perception mentioning some key challenges that were otherwise missed. The lack of evidence-based education was mentioned by a participant who felt the INC had a role to lead by showing best examples and guiding evidence-based education and practice in the country. They also highlighted the issue of underfunding for nursing and midwifery, from education to practice, and the development of professions and professionals.

Similar challenges as shown in this study have been reported in relation to regulation of medical education, professionals and practice in India [ 43 ]. Although, the new National Medical Council (NMC) presents some scope for improvement, such as in the regulation of fees for medical education in private institutions [ 43 ], which is an area of reform for nursing and midwifery education as well along with regulation of salaries in the private sector. The regulations of fees is mentioned in the draft NNMC Bill, but the regulation of salaries in private sector is not [ 32 ]. The regulation of midwifery, nursing and medical education and practice are crucial for Universal Health Coverage (UHC). Fig 2 summarises areas and actions to reform midwifery and nursing, education and practice regulation in India along with the need for research in the future. It presents overarching areas of reform such as governance, where the establishment of midwifery and nursing directorate will aid many of the reforms suggested in the figure. Four key reform measures are suggested for each of the areas. There are some aspects which need more research and understanding in India, which also have been shown in Fig 2 , such as, gender-based challenges in nursing, midwifery and health policy making; challenges in private sector education, regulation and practice; scope for independent midwifery practice; and implementation of innovative strategies in regulation to ensure good quality and respectful care provision.

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Nurses-midwives are the primary health care providers in India. Regulatory failures lead to nurses and midwives graduating without sufficient knowledge and skills, thereby putting lives and health at risk. This is a serious issue because practice is unregulated, care providers are unsupervised and not updated in a timely way while standards of care gradually deteriorate. The health regulatory structures of the country, including the regulatory bodies of all health care related professions, have a major role to play in maintaining standards of education and practice to ensure good quality of health care to its people. This requires a team approach similar to how a team of care providers with different expertise come together to provide quality health services. The INC, the SNCs, the Indian Medical Association (IMA), the directorates of medical education, public and private universities, nursing and midwifery associations and development organizations have a stake in health care regulation. These entities need to come together to understand the issues and work to address those challenges by creating a strong evidence based regulatory structure guided by midwifery and nursing leadership.

Acknowledgments

We wish to express our appreciation to the midwifery and nursing leaders who have participated in this study.

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23. Bagga R, Sherawat R, Gade J, Nandan D, Mavlankar DV, Sharma B, et al. Comparative analysis of nursing management capacity in the states of Uttar Pradesh, West Bengal and Tamil Nadu. Visaria Ed: Midwifery and Maternal Health in India: Situation analysis and lessons from the field. 2010. Indian Institute of Management, Ahmedabad.
24. Indian Nursing Council. 1947. The Indian Nursing Council Act. Act 48 of 1947.
25. Government of Bengal. 1934. The Bengal Nurses Act. Act X of 934.
26. The Bihar and Orissa Nurses Registration Act 1935. Act 1 of 1935.
27. Government of the central provinces and bear medical department. 1941. The Central Provinces Nurses Registration Act. (XXIII of 1941).
28. Authority of the Orissa Nurses and Midwives Council. 1940. Manual of the Orissa nurses and midwives’ council.
29. Rajasthan Nurses, Midwives, Health Visitors and Auxiliary Nurse-Midwives Registration Act. 1964.
32. Government of India. The draft National Nursing and Midwifery Commission Bill, 2020.
35. NHM, NHSRC, 2017. Nursing policies, reforms, and governance structures. Analysis across five states in India. Available at: http://nhsrcindia.org/sites/default/files/Nursing%20Report%20-%20Final%20Web%20Optimized%20PDF%20Version%20-%2028.08.17.pdf
36. Raman SP, Mavalankar DV, Kulkarni A, Upadhyay M, Deodhar A. Historical perspective of nursing and midwifery: training, education and practice in India. In: Visaria L. editor. Midwifery and maternal health in India: Situation analysis and lessons from the field. Indian Institute of Management; 2010.
39. Cehat, AMCHSS. Gender in medical education. 2002.
41. Wells M. The experiences of Indian nurses in America. PhD Dissertation . Seton Hall University. 2013. Available at: https://scholarship.shu.edu/cgi/viewcontent.cgi?article=2852&context=dissertations
42. Health Professions Regulatory Act, 2013. Ghana Nursing and Midwifery Council (Part III). pp 28–37.

Case Report: Nurses in India, a Lever for Change

A nurse in India wearing a white uniform and a badge stands confidently and smiles.

Nurses around the world, and particularly in India, are professionals who can make a significant impact in reducing the health care burden in rural and high-need areas. That’s why, in 2020, ECHO India launched the Nursing Vertical , a groundbreaking ECHO program offering training, mentorship and professional support.

Innovating with ECHO

The Nursing Vertical establishes a country-wide network of mentoring relationships to transform ongoing education, improve workforce retention, and connect local providers to global experts.

At the time of the Nursing Vertical launch, nurses were already involved in other ECHO India programs, including: oncology care, palliative care, addiction management, and tuberculosis. To bring even more nursing care providers into the ECHO network, these existing ECHO Hubs then expanded their capacity, building on established regional and local knowledge in the areas of:

infection prevention and control
maternal and child health, including midwifery
pediatric nursing
mental health nursing
stroke nursing
critical care
cardiac health
and community health awareness

Partnerships

Critical partners include:

India’s Ministry of Health and Family Welfare
the General Health Service Nursing Division
the National Institute of Health and Family Welfare
Tamil Nadu Nurses and Midwifery Council
the Society of Indian Neuroscience Nurses
and nursing councils in Sikkim, Maharashtra, Manipur, Jhakarkand and Nagaland

The ECHO Impact

To date, more than 85 programs in the Nursing Vertical have reached nearly 300,000 nurses in all 36 states of India through more than 1,000 ECHO sessions. “I appreciate the hard work and diligent effort that ECHO India has put in completing the nationwide training for capacity building of nursing professionals. The Nursing Division would like to recognize the fact that the ECHO India team has extended full support for making COVID-19 management programs successful,” Dr. Rathi Balachandran, Assistant Director General, Nursing Division, Ministry of Health and Family Welfare

“The support of ECHO India was pathbreaking in COVID-19 management when training for nursing personnel was a dire need. The ECHO India team has commendable commitment and dedication toward strengthening the nursing workforce, contributing to improving public health outcomes. I extend heartfelt appreciation for ECHO India’s phenomenal contribution in providing a virtual platform for several mentorship programs building the capacity of nursing professionals,” Dr. Deepika C. Khakha, Nursing Advisor, Directorate General of Health Services, Ministry of Health and Family Welfare

About ECHO India

ECHO India is a nonprofit trust established in 2008 in partnership with Project ECHO.

About This Story

Case Reports are a brief look at some of our most impactful programs or research

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Media contact:.

Ben Cloutier Director of Communications & Marketing Project ECHO (505) 252-4157 [email protected]

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Nursing—the wave of...

Greater role of nurses in Indian health care system

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Nursing—the wave of the future

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Nurses have contributed a lot to the health care system in India. Under the National Health Mission initiative of the Government of India, there is a strong felt need for providing newer roles for nurses in far flung areas where doctors are not available. The presently existing sub-centres catering for a population of 5000 in the plain, valley areas and 3000 population in hilly, tribal areas are being renamed "Health and Wellness centres". Earlier, a male and female health worker were posted to such centres and they were implementing the national health programmes.

Taking cognisance of non-availability of trained manpower and doctors even in the primary health centre, a level above the erstwhile sub-centre, the Government of India has initiated a bridge course to update the knowledge and skills of working nurses (having a qualification of General Nurse Midwifery ). The course is being developed in collaboration with officials of the Ministry of Health and Family Welfare, Government of India (MOHFW) and Indira Gandhi National Open University, New Delhi (India) and titled as BPCCHN programme (Certificate in Community Health). The course is being funded by MOHFW, India and the desiring nurses are selected based on selection test, aptitude for working in rural area. The course is run for 6 months with skill development at the district hospital level. They are taught clinical skills, basic epidemiology of communicable, non communicable diseases, identification, basic management of common health problems (all body systems) and provide referral in case of serious illnesses to higher health facility besides health promotion activities. Once the course is completed after passing a final examination, they are proposed to be placed in the health and wellness centres. During the course work, they are given stipend in addition to their salary and once they are posted in the health and wellness centres incentives in the form of higher pay scale are incorporated so that they stay in the rural areas. Their position is now being referred to as "Community Health Officer". The present initiative is supposed to provide a greater role to the nursing profession and boost the health care delivery in the rural and far flung areas of India.

Competing interests: No competing interests

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Lecturing, numeracy and nursing in India with Nelson Selvaraj

Adult Nursing Lecturer, Nelson Selvaraj, tells us about his nursing career so far and what it meant to win the RCN Wales Nurse of the Year 2023 Nurse Education Award.

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On my nursing background and what inspired me to go into the nursing profession.

I qualified in India in 1998 and straight away started working in critical care. I’ve never worked in any other areas and even during my degree a lot of my clinical placements were in critical care.

In 2003 recruiters came to India and I was selected to come to the UK to work in the critical care unit in Manchester Royal Infirmary – it’s one of the largest critical care units in Europe with 40 beds.

It’s very busy with a lot of research and medical trials taking place so it was a very interesting place to be and it was a very supportive unit. I did a lot of studies and was supported to progress academically and professionally. Eventually I became a band 7 charge nurse and then education and development practitioner where I supported newly qualified nurses (NQNs) in their continuing professional development (CPD).

While in Manchester I started teaching on various university courses and then funding became available for me to do a distance learning master’s degree in Critical Care with Cardiff University, which I completed with distinction. I also did a postgraduate certificate in education (PGCE) and decided my ambition was to become a lecturer. There were plenty of lecturing opportunities in England but the main criteria was that you had a PhD. However, when I applied to Cardiff University I was immediately shortlisted and successful at interview. The good teaching opportunities I had while I was in critical care were really advantageous. And now Wales is my home!

My mum is such a great inspiration and a role model to me and my brother, who is also a nurse. She is so caring and compassionate and I think that's the main factor why I want to do nursing. My mum wanted me to go into medicine but I honestly never even thought about going into any other profession.

On why nursing lecturers are so vital.

Nursing has changed dramatically over the last 30 years and practice has changed as lots of evidence has emerged in terms of how we look after patients, for example new drugs and evolving technology and advancements in surgery.

The lecturer and clinical instructor roles are important because they have the evidence-based knowledge and they are responsible to impart that knowledge to the next generation of nurses. It’s also an important role because you’re developing a powerful workforce that will have the right knowledge, understanding and skills, but also the right attitudes to care for patients.

On why numeracy is so important in nursing.

I'm quite fond of mathematics so the numeracy role is an interesting one. It involves teaching fundamental mathematical skills and preparing the students for the drug calculation exams and ensuring they get the right support and learning materials as they have to achieve 100% for a pass. The application of the particular knowledge to real context is so important so I help the students understand that it’s not simply about passing the numeracy exam – it’s about safe and effective care as they go into the critical areas to do their drugs rounds.

Over the past few years, we’ve started involving the university’s School of Mathematics. They’re such a lovely, friendly group and put the students at ease. When I started in this role, the pass rate was 64% on the first attempt. Following the various interventions, the pass rate has improved to 86%. The students really appreciate the strategies we’ve put in place.

On my review into the impact on nurses during the organ donation process.

Organ donation has been one of my favourite subjects since I started working in critical care. As a staff nurse and as a senior charge nurse, I have had a couple of opportunities to look after patients undergoing organ donation processes as well as supporting their families.

In this review, I’m aiming to discover the challenges experienced by ICU nurses during the organ donation process. The project is going well. I’ve done my initial literature search to find out what are the different challenges that ICU nurses experience and what sort of supporting strategies they receive, locally or nationally. It's very interesting.

Looking back on my own experience of when I looked after that group of patients, there was very minimal support for me so I think that’s why I want to explore this subject in more detail. My initial assumption was that because I didn’t receive support, the same must be true for other nurses too and the literature is showing that my assumption is not incorrect; this is true globally, there are several challenges. Unfortunately, the amount of support ICU nurses receive during the donation process is very little and in some other countries, there's nothing.

On the differences between nursing in India and the UK.

In India, the degree programme is four years and it is very in-depth. In your exams or assignments, you’re expected just to ‘reproduce’ the facts that you learned from the textbooks, and the assignments are very descriptive. Whereas, in the UK, we use a range of teaching and assessment methods, and you’re expected to demonstrate critical argument and synthesis in your assignments.

The culture in the UK is so different; very encouraging, very positive. I have received a lot of encouragement to go for promotions. There are good systems in place for CPD and dialogue with management teams is much freer.

There’s also a lot more autonomous working here and great collaboration. If you’re sitting in a meeting with a multidisciplinary team, you can be confident that your voice will be heard. In India, you literally follow the clinical team’s instructions and are expected to follow their ‘orders’.

On encouraging somebody considering a career in nursing.

I would welcome them in with wide open arms. It’s such a rewarding profession. Nursing will change how you perceive certain things in life and alter your perspective of the world.

Don’t be put off by what you see on social media. Get more information: speak to those working in clinical environments or in lecturing teams, go to university open days. We will explain what a lovely profession this is and give you a better idea of why nursing is so important and is such a rewarding profession.

Every profession has its upsides and downsides and nursing is no different, but in nursing you get to have the huge privilege of making a change in someone’s life. Not just physically, but mentally too; that’s the unique power of nursing.

On winning the RCN Wales Nurse of the Year Nurse Education Award 2023.

I was speechless! I wasn’t sure if I’d heard correctly and I was trying to pinch myself, it was such a shock. But I managed to gather myself and walk to the stage. The compère, Jason Mohammad, talked about the numeracy work I did but also the work I did in a vaccination clinic during the peak of the pandemic – I worked as a volunteer. During this time, I also collaborated with other experienced critical care lecturers and ran a critical care course for the local health board. It was so nice to hear the impact of the work I’ve done and to be recognised for it. It was such an honour. It means a lot.

Nominations are now open for the RCN Wales Nurse of the Year Awards 2024!

Take a look at the categories and nominate now.

Watch our top tips for making sure your nomination stands out and wows the judging panel.

From Scotland to Ghana

Fiona shared her time and expertise to help revolutionise cancer care far from home

RCN Scotland calls for a nursing retention strategy as workforce crisis shows little sign of improvement

In our third instalment of ‘The Nursing Workforce in Scotland’ report published today (15 May), it is evident that Scotland’s nursing workforce crisis is showing little sign of improvement.

RCN helps secure thousands of pounds for wrongly paid nurses

Several intensive care nurses will receive up to £36,000 each after successfully having their jobs evaluated. Many more nursing staff could be eligible.

RCN celebrates Nurses' Day 2024

We’re highlighting our skilled nursing profession and celebrating nursing staff all weekend.

RCN defines levels of nursing beyond registration

These new definitions will help registered nurses as they aspire to practice at these levels, as well as give clarity to employers, higher education institutions and the public. They can be applied across all fields of nursing and in all settings.

HM King Charles announced as new RCN patron

We are honoured to announce His Majesty King Charles III as our new patron, continuing the RCN’s established line of royal support.

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Tuesday, 21 May 2024

Agenda - The Sunday magazine

Cover Story

Nursing in India: Insights from a Male Nurse

In India, nursing remains predominantly female-dominated, but perceptions are changing, breaking stereotypes along the way. Meet Kanishk Yadav, a Nursing Officer at AIIMS, Delhi, whose journey into the profession was sparked by his mother's treatment in a hospital, where he witnessed the profound respect given to healthcare staff. In a discussion with ARCHANA JYOTI , he offers a glimpse into his role, challenges, and aspirations within this evolving landscape

What inspired you to pursue a career in nursing?

My mother's gallstone treatment in a hospital during my 10th grade ignited my interest in healthcare, seeing the respect for the staff there motivated me to become a healthcare worker.

Could you describe your typical workday as a male nurse?

Working in a high-dependency unit, I care for critically ill patients and assist over 50 patients daily with various blood-related treatments across hospitals and departments.

Have you faced any specific challenges or prejudices as a male nurse in a predominantly female-dominated profession in India?

Despite nursing being female-dominated, I've experienced acceptance and support from colleagues. The increasing presence of male nurses globally has positively influenced acceptance by patients over time.

Do you feel your gender influences your career advancement opportunities in nursing?

Once one becomes a professional nurse, opportunities are equal for all, irrespective of gender.

How do cultural norms and societal expectations influence your role as a male nurse in India?

Nursing has its code of ethics based on cultural norms and societal expectations, emphasizing patient comfort, safety, and privacy. These guidelines are easier to follow now with increased male nurse representation.

How do you navigate gender-specific cultural sensitivities while providing care to patients of different genders?

We explain procedures to patients and relatives, offering assistance from female colleagues if needed, ensuring compliance with ethical standards during all medical procedures.

Do you believe there's been a shift in societal perceptions regarding male nurses in India in recent years?

There are few states left where we find only female nurses. Now, we can see representation of male nurses from every corner of the country. This shows the society has accepted male nurses. During Covid-Pandemic we all must have seen many motivational stories of male nurses working tirelessly along with their female colleagues. Many male nurses have received Florence Nightingale for their exemplary work, I think these all have helped us.

What support systems or resources do you feel are necessary to enhance the representation and inclusion of male nurses in Indian healthcare settings?

Patients’ feedback is most important to make our presentation stronger. They all work as ambassadors for us. If they are satisfied with our work then policymakers will start thinking of us as far as our participation is concerned. Second, our work is teamwork, if my team members from bottom to top feel the same, also helps us a lot. All Policymakers (Health) empower a particular group after getting positive feedback from these two. My concern is to give an equal chance to all team members to represent themselves.

How does your workplace promote diversity and inclusion among nursing staff?

Our workplace reflects "unity in diversity," with staff from various states collaborating effectively, fostering an environment conducive to learning and growth.

Have you observed any gender-specific differences in roles or responsibilities among male and female nurses in your workplace?

Roles in the medical field are gender-neutral, but as a male nurse, I may have certain responsibilities towards female patients, such as during CPR procedures. During CPR, I am supposed to take charge of giving compressions and a female colleague can be given the responsibility of medication, calling other team members, activating the alarm, etc.

What strategies do you employ to foster collaboration and teamwork among colleagues, irrespective of gender differences?

We attend training sessions, workshops, and seminars, participate in clinical case discussions, and engage in regular communication to foster a collaborative environment.

What are your career aspirations within the nursing profession?

I aim to inspire change through exemplary work and community service, believing in the principle of leading by example. I learned this during the COVID-19 pandemic when I requested to depute in the COVID-19 ICU and the story went viral after one of the faculty members saw this. I received hundreds of messages and calls from every corner of India and my story inspired them a lot to work for the nation in crisis. Similarly, in the case of blood donation, organizing medical camps, etc.

What advancements and best practices do you find in nursing, particularly in the Indian healthcare context vis-à-vis worldwide?

India's healthcare system is evolving rapidly, with initiatives like the establishment of nursing simulation labs and new nursing colleges, indicating a commitment to producing skilled nurses.

What advice would you give to aspiring male nurses in India, considering the unique challenges and opportunities they might face?

I encourage aspiring male nurses to master their craft, and work with dedication, compassion, and passion, embracing challenges as opportunities for growth.

How do you envision the role of male nurses evolving in Indian healthcare in the coming years?

It's not limited to any gender. I would say that the role of Nurses in Indian Healthcare is increasing and becoming demanding day by day. As the healthcare system in India strengthens, it would require more skilled and empowered nurses to fulfill the requirements and upliftment of the healthcare system.

What changes or initiatives do you believe are necessary to further promote gender diversity and inclusivity in nursing in India?

Recruitment initiatives like the inclusion of male nurses in the Military Nursing Services would promote gender diversity. Exclusionary practices should be addressed to ensure equal opportunities for all nurses.

Do you foresee any specific trends or challenges that might impact the nursing profession, particularly for male nurses, in India?

Gender-specific reservations in nursing vacancies and the need for specialization present challenges. However, initiatives to address these issues and meet the growing healthcare demand are imperative for the profession's advancement.

BREAKING THE SHIELD

Dr T Dilip Kumar, serving as the President of the Indian Nursing Council, and Dr. Ramling B. Mali, holding the position of President at the Maharashtra Nursing Council, stand as notable examples of male leaders in the nursing profession. Stanly Jones is the Chief Nursing Superintendent at the Southern Railways Hospital in Chennai.

Demand for Male Nurses in the Nursing Profession in India, at least 20.5% of nurses in 2018 were male, according to a WHO report.

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Essay on Nurse – 10 Lines, 100, 500, 1000 Words

Essay on Nurse: Explore the critical role and diverse responsibilities of nurses in this insightful Essay . From providing compassionate patient care to navigating complex healthcare systems, the article of Essay on Nurse delves into the challenges and rewards of the nursing profession.

Essay on Nurse highlights the evolving role of nurses as advocates, educators, and integral members of the healthcare team. Gain a deeper understanding of the impact of nursing on patient outcomes and the broader healthcare landscape, emphasizing the indispensable contributions of nurses in promoting well-being and ensuring quality healthcare delivery.

Table of Contents

Essay on Nurse in English in 10 Lines

This Essay on Nurse delves into the multifaceted role of nurses, exploring their vital contributions to healthcare, compassionate patient care, and the evolving dynamics of the nursing profession.

Nurses play a pivotal role in healthcare, providing essential patient care and support.
Their responsibilities range from administering medications to monitoring vital signs.
Nurses serve as advocates, ensuring patients’ needs and concerns are addressed.
Compassion is a hallmark of nursing, fostering a healing and supportive environment.
Continuous education is integral, as nurses stay updated on medical advancements.
Nurses collaborate with healthcare teams, contributing to comprehensive patient care.
The nursing profession encompasses diverse specialties, from pediatrics to critical care.
Nurses navigate challenging situations, demonstrating resilience and adaptability.
The evolving role of nurses includes health promotion, disease prevention, and patient education.
Their commitment to humanity makes nurses unsung heroes in the healthcare system.

Also See – If I were a Doctor Essay – 100, 500, 1000 Words, 10 Lines

Short Essay on Nurse in 100 Words

This Essay on Nurse explores the indispensable role of nurses in healthcare, emphasizing their compassionate patient care, advocacy, continuous education, and pivotal contributions to the evolving dynamics of the nursing profession in a concise 100-word description.

Nurses are the heartbeat of healthcare, providing essential care with unwavering compassion. Their role extends beyond administering treatments to embodying empathy, offering solace to patients.

Advocates for patient rights, nurses navigate complex medical landscapes, ensuring holistic care. Continuous education keeps them abreast of medical advancements. Nurses are pivotal collaborators within healthcare teams, contributing expertise to enhance patient outcomes.

From critical care to pediatrics, the diverse specialties within nursing reflect their versatility. Facing challenges with resilience, nurses are unsung heroes, embodying the human touch in the healthcare system and making an immeasurable impact on individual well-being and the broader healthcare landscape.

Essay on Nurse in 500 Words

This Essay on Nurse delves into the multifaceted world of nursing, exploring the pivotal role of nurses, their compassionate patient care, advocacy, continuous learning, and contributions to the dynamic healthcare landscape within a comprehensive 500-word description.

The Essence of Nursing: A Compassionate Journey in Healthcare

Nursing stands as the heartbeat of healthcare, a profession that transcends clinical duties to embody compassion, dedication, and versatile expertise. At its core, nursing is about providing fundamental care that shapes the patient experience.

From administering medications with precision to vigilantly monitoring vital signs, nurses execute diverse responsibilities that form the bedrock of quality healthcare. The essence of nursing, however, goes beyond technical skills; it’s the ability to infuse these tasks with unwavering compassion, creating an environment conducive to healing and support.

Beyond their clinical roles, nurses take on the mantle of patient advocates. In the labyrinth of the healthcare system, they ensure the voice of the patient is not lost. Advocacy is not just a component of nursing; it’s a commitment to safeguarding the well-being and dignity of those under their care. A nurse’s role extends far beyond the administration of treatments; it involves being a steadfast advocate, navigating the complexities of healthcare on behalf of the patient.

Compassion is the hallmark of nursing. In the emotionally charged realm of illness, nurses provide not only medical care but also emotional support. Their compassionate touch becomes a source of solace in moments of vulnerability, fostering a healing environment that transcends medical treatments. This empathetic connection with patients is what sets nursing apart, turning it into not just a profession but a calling driven by the innate desire to alleviate suffering and promote well-being.

Nursing is a dynamic profession that necessitates continuous education and adaptability. Staying abreast of the latest medical advancements, mastering cutting-edge technologies, and evolving with the ever-changing landscape of healthcare are inherent to nursing practice. The commitment to ongoing education ensures that nurses provide care at the forefront of medical knowledge, contributing to positive patient outcomes in an increasingly complex healthcare environment.

Nurses function as integral collaborators within interdisciplinary healthcare teams. Their expertise extends beyond bedside care; they actively contribute to comprehensive patient management. Effective communication and collaboration with physicians, therapists, and other healthcare professionals are fundamental aspects of nursing practice. This collaborative approach ensures a holistic, patient-centered care model that addresses the myriad dimensions of health and well-being.

The nursing profession spans a vast array of specialties, underscoring its versatility. From critical care units to pediatric wards, nurses adapt their skills to meet the unique demands of various healthcare settings. This diversity in specialties emphasizes the breadth and depth of their impact on patient outcomes, showcasing the adaptability of nursing professionals to different medical contexts.

Despite its rewarding aspects, nursing is not without its challenges. Nurses navigate demanding work hours, emotionally taxing situations, and high-stress environments with resilience. The ability to face adversity with poise and adaptability is a testament to the strength of character inherent in nursing professionals. Their commitment to patient well-being remains unwavering, even in the face of formidable challenges.

In essence, nurses are the unsung heroes of the healthcare system. Their contributions extend beyond the clinical realm, embodying the human touch that distinguishes healthcare from mere medical interventions. While often working behind the scenes, nurses bridge the gap between medical expertise and compassionate, empathetic care. They exemplify the profound difference that compassionate care can make in the journey to health and healing, positioning nursing as an indispensable pillar of the healthcare system.

1000 Words Essay on Nurse in English

This 1000-word Essay on Nurse explores the multifaceted role of nurses, delving into their compassionate patient care, advocacy, continuous learning, collaborative contributions to healthcare teams, and the evolving dynamics within the nursing profession.

The Heart of Healthcare: Exploring the Profound Role of Nurses

Introduction

The nursing profession stands as the heartbeat of healthcare, embodying compassion, expertise, and resilience. This essay delves into the multifaceted world of nursing, exploring its pivotal role, the challenges faced, and the evolving dynamics within the healthcare spectrum.

The Essence of Nurse: Providing Fundamental Care

At the core of nurse lies the provision of fundamental care that shapes the patient experience. This Essay on Nurse explores the diverse responsibilities of nurses, from administering medications to vigilantly monitoring vital signs. The essence of nurse goes beyond technical skills; it is about infusing these tasks with unwavering compassion, creating an environment conducive to healing and support.

Advocacy: Ensuring the Patient’s Voice is Heard

Nurses are not only caregivers but also advocates for patients within the complex healthcare system. This Essay on Nurse delves into how nurses navigate the labyrinth of healthcare to ensure the patient’s voice is not lost. Advocacy is not just a component of nursing; it is a commitment to safeguarding the well-being and dignity of those under their care.

Compassion as a Hallmark: Fostering a Healing Environment

Compassion is the hallmark of nursing, turning it from a profession into a calling. This Essay on Nurse explores how nurses, in the emotionally charged realm of illness, provide not only medical care but also emotional support. Their compassionate touch becomes a source of solace in moments of vulnerability, fostering a healing environment that transcends medical treatments.

Continuous Education and Adaptability

Nurse is a dynamic profession that demands continuous education and adaptability. This Essay on Nurse delves into the necessity of staying abreast of the latest medical advancements, mastering cutting-edge technologies, and evolving with the ever-changing landscape of healthcare. The commitment to ongoing education ensures that nurses provide care at the forefront of medical knowledge.

Collaborators in Healthcare Teams: Enhancing Patient Management

Nurses function as integral collaborators within interdisciplinary healthcare teams. This Essay on Nurse explores how their expertise extends beyond bedside care, actively contributing to comprehensive patient management. Effective communication and collaboration with physicians, therapists, and other healthcare professionals are fundamental aspects of nursing practice, ensuring a holistic, patient-centered care model.

Diverse Specialties, Versatile Roles: Adapting to Healthcare Settings

The nursing profession encompasses a myriad of specialties, showcasing its versatility. This Essay on Nurse delves into how nurses adapt their skills to meet the unique demands of various healthcare settings. From critical care units to pediatric wards, the diversity in specialties emphasizes the breadth and depth of their impact on patient outcomes.

Facing Challenges with Resilience

Despite its rewarding aspects, nursing is not without its challenges. This Essay on Nurse explores how nurses navigate demanding work hours, emotionally taxing situations, and high-stress environments with resilience. The ability to face adversity with poise and adaptability is a testament to the strength of character inherent in nursing professionals.

Unsung Heroes in Healthcare: Bridging the Gap with Compassion

This Essay on Nurse highlights the often-overlooked contributions of nurses as the unsung heroes of the healthcare system. Their impact extends beyond the clinical realm, embodying the human touch that distinguishes healthcare from mere medical interventions. While often working behind the scenes, nurses bridge the gap between medical expertise and compassionate, empathetic care.

In conclusion, nursing stands as an indispensable pillar of the healthcare system. This essay has explored the multifaceted role of nurses, from providing fundamental care to advocating for patients, fostering a healing environment with compassion, and actively contributing to patient management within healthcare teams.

Their adaptability to diverse specialties and resilience in facing challenges exemplify the strength of character inherent in nursing professionals. As the unsung heroes of healthcare, nurses embody the human touch, making a profound difference in the journey to health and healing.

In conclusion, the essay on nurse has illuminated the multifaceted role of nurses in healthcare. From compassionate patient care to critical decision-making, nurses play a pivotal role in promoting well-being. The essay emphasizes the significance of their skills, dedication, and adaptability in a dynamic healthcare landscape. As integral members of the healthcare team, nurses not only provide essential medical services but also contribute to the overall patient experience. This exploration underscores the importance of recognizing and appreciating the tireless efforts of nurses in fostering a healthier society.

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The Economic Times daily newspaper is available online now.

'rising number of skilled indian nurses seek overseas opportunities despite domestic demand'.

The demand for skilled nurses in India is set to grow by 17-18% by 2027. Trained nurses are increasingly opting for opportunities abroad due to better pay and family visa programs, with Kerala playing a key role in healthcare migration.

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How to write a nursing career plan essay, rachel r.n..

May 18, 2024
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Nursing is a highly rewarding and noble career path that allows individuals to make a meaningful impact on the lives of patients and their families. It is a profession that requires a deep sense of compassion, dedication, and a sincere desire to help others. Pursuing a career in nursing is a significant decision that demands a clear understanding of one’s goals and aspirations. Writing a nursing career goal essay is a crucial step in the admission process for nursing programs, as it provides an opportunity for prospective students to articulate their motivations, aspirations, and vision for their future in the nursing profession.

What You'll Learn

What is a nursing career goal essay?

A nursing career goal essay is a comprehensive written statement that outlines an individual’s reasons for choosing to pursue a career in nursing. It serves as a platform for applicants to express their passion, motivation, and commitment to the nursing field. This essay allows admissions committees to gain insight into the applicant’s thought process, values, and long-term goals within the nursing profession.

What’s included in a nursing career goal essay?

A well-crafted nursing career goal essay should encompass the following key elements:

Personal background and inspiration: In this section, applicants should share their personal experiences, life events, or encounters that sparked their interest in the nursing profession. This could include instances where they witnessed the impact of nurses firsthand, or experiences that highlighted their innate desire to care for others.
Career goals: Clearly outlining both short-term and long-term career goals is essential in a nursing career goal essay. Short-term goals may include obtaining a specific nursing degree or certification, gaining experience in a particular healthcare setting, or developing proficiency in a specialized area of nursing. Long-term goals could involve pursuing advanced degrees, such as a master’s or doctoral degree, or aspiring to leadership roles, such as nurse manager or nurse educator.
Strengths and qualities: Applicants should highlight the personal strengths, qualities, and skills that make them well-suited for a career in nursing. This could include attributes such as empathy, critical thinking, problem-solving abilities, effective communication skills, resilience, and the ability to work well under pressure.
Contributions to the field: In this section, applicants should explain how they plan to contribute to the nursing profession and make a positive impact on patient care or the healthcare system as a whole. This could involve discussing their commitment to ongoing professional development, their desire to advocate for patient rights, or their interest in participating in research or quality improvement initiatives.
Educational and professional aspirations: Applicants should discuss their educational goals, such as obtaining a bachelor’s or master’s degree in nursing, as well as their professional aspirations, which could include pursuing specialized roles like nurse practitioner, nurse anesthetist, or nurse educator.

How to write a nursing career goal essay sample:

Reflect and introspect: Take time to reflect on your personal experiences, values, and aspirations that have led you to the decision to pursue a career in nursing. Engage in introspection to identify the key motivations and goals that resonate most strongly with you.
Create an outline : Develop a well-structured outline that organizes your thoughts and ensures that your essay flows logically. This outline should include an engaging introduction, body paragraphs that address each of the key elements mentioned above, and a compelling conclusion.
Craft an engaging introduction: Begin your essay with a captivating introduction that immediately captures the reader’s attention and sets the tone for your essay. Consider using a relevant anecdote, a thought-provoking quote, or a compelling statistic to pique the reader’s interest.
Incorporate examples and personal anecdotes: Throughout your essay, incorporate relevant examples and personal anecdotes that illustrate your points and make your essay more engaging and authentic. These personal stories can help the admissions committee better understand your motivations and connect with your narrative.
Proofread and revise: Carefully proofread and revise your essay to ensure that it is well-written, free of errors, and effectively communicates your message. Consider seeking feedback from trusted individuals, such as mentors, professors, or writing center professionals, to help you refine and strengthen your essay.

Related Articles: ESSAY WRITING SAMPLE: NURSING CAREER PLAN

Tips for writing a good nursing career goal essay:

Be authentic and honest: S hare your genuine motivations, experiences, and goals in your essay. Authenticity and honesty can make your essay stand out and resonate with the admissions committee.
Highlight your unique qualities: Emphasize the unique qualities, experiences, or perspectives that make you a strong candidate for a nursing career. This could include your cultural background, life experiences, or personal values that align with the nursing profession.
Demonstrate your knowledge and passion: Throughout your essay, showcase your understanding of the nursing profession and your passion for helping others and improving patient care. Discuss the specific aspects of nursing that resonate with you and how you plan to contribute to the field.
Tailor your essay: Customize your essay to the specific nursing program or institution you are applying to, and address any prompts or requirements provided. Research the program’s values, mission, and focus areas to ensure your essay aligns with their goals and objectives.
Focus on the future: While reflecting on your past experiences is important, ensure that your essay primarily focuses on your future goals and aspirations within the nursing profession. Discuss how your experiences have shaped your vision and how you plan to continue growing and contributing to the field.
Use appropriate language and tone: Maintain a professional and academic tone throughout your essay, using appropriate language and avoiding colloquialisms or informal expressions. At the same time, strive to write in a clear and concise manner, making your essay engaging and easy to read.
Seek feedback and revise: After completing your initial draft, seek feedback from trusted individuals, such as mentors, professors, or writing center professionals. Use their feedback to refine and strengthen your essay, ensuring that it effectively communicates your message and showcases your qualifications as a strong candidate for the nursing program.

50 Nursing Career Goals

Become a registered nurse (RN) by completing a Bachelor of Science in Nursing (BSN) .
Write a nursing career plan to outline my professional journey.
Choose nursing as a career to make a difference in patient care.
Develop nursing skills to provide excellent nursing care.
Pursue a career in nursing with a focus on holistic care.
Pass nursing school admissions to enroll in a top nursing program .
Specialize in a specific area of nursing , such as pediatrics or oncology.
Write a nursing career essay to articulate my passion for nursing.
Set long-term goals in nursing , such as becoming a nurse educator.
Write an effective nursing personal statement for job applications.
Gain experience as a nurse practitioner to provide advanced care.
Achieve certification as a family nurse practitioner (FNP) .
Write a nursing school essay that highlights my commitment to nursing.
Participate in continuing education to stay current in nursing practice.
Write your nursing career goals in a journal to track progress.
Aim for a leadership role in nursing, such as nurse manager.
Pursue a Master of Science in Nursing (MSN) to advance my career.
Contribute to nursing research to improve patient outcomes.
Focus on patient-centered care throughout my nursing career.
Mentor nursing students to help them achieve their career goals.
Write an essay on why I want to become a nurse to inspire others.
Work in a care home nurse setting to support elderly patients.
Develop a nursing career plan essay to define my professional aspirations.
Aim to become a professional nurse who excels in patient care.
Pursue a doctoral degree in nursing (DNP) for advanced practice roles.
Write your nursing experience essay to reflect on clinical experiences.
Set short-term nursing goals , such as improving specific nursing skills.
Become an advanced practice registered nurse (APRN) to expand my scope of practice.
Provide care for patients with compassion and empathy.
Explore career options in nursing to find the best fit for my skills.
Write a good nursing career path essay to outline future steps.
Aim to work in nursing education to teach future nurses.
Develop a passion for nursing by continually learning and growing.
Focus on nursing goals that improve patient and family outcomes.
Pursue a career in the medical field with a focus on nursing.
Write an essay on the reasons for choosing nursing as a profession.
Work towards becoming a great nurse known for excellent care.
Achieve competence in advanced nursing skills to enhance patient care.
Aim for a rewarding career in nursing that makes a significant impact.
Pursue specialized training in areas like critical care or emergency nursing.
Write a personal statement for nursing school admissions to stand out.
Focus on holistic care to address all aspects of a patient’s well-being.
Engage in professional development opportunities in nursing.
Aim to care for others with the highest standards of nursing practice.
Work towards a leadership role in nursing staff management.
Develop a nursing career goal essay to clarify my objectives.
Pursue advanced nursing degrees to open more career opportunities.
Work on improving nursing practice through evidence-based approaches.
Aim to provide excellent nursing care to every patient.
Write a good nursing career goals essay to inspire and guide others interested in nursing.

What is your ambition as a nurse? Your ambition in nursing should not only be about becoming a nurse but also about evolving into the best nurse you can be. This implies continuous learning and skill enhancement. Pursue professional development opportunities, learn from experienced colleagues, and stay updated with advancements in healthcare

How do you write a career plan essay?

Three elements of a successful career goals essay Highlight specific career achievements. … Explain why your experiences and influences make your career goal a logical and wise choice. Demonstrate why you are suited to a particular field as a result of your education, experience, abilities, and enthusiasm.

What are the 5 nursing plans? The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.

What are the 6 C’s of nursing? The 6 Cs – care, compassion, courage, communication, commitment, competence – are a central part of ‘Compassion in Practice’, which was first established by NHS England Chief Nursing Officer, Jane Cummings, in December 201

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International Nurses Day 2024: 5 challenges faced by nurses; tips to overcome them

Know about the challenges confronting nurses on international nurses day 2024, along with effective strategies to overcome them. learn invaluable tips to support and empower nursing professionals in their vital roles..

1. Workforce Shortages

One of the most pressing issues in nursing is the shortage of skilled professionals. This shortage puts immense pressure on existing nurses, leading to burnout and compromised patient care.

Tip: Organisations can address this challenge by investing in recruitment and retention strategies such as offering competitive salaries, providing opportunities for professional development, and creating a supportive work environment. Additionally, governments and educational institutions should collaborate to increase the number of nursing school graduates.

2. Heavy Workloads

Nurses often face heavy workloads due to staff shortages, high patient acuity, and administrative tasks. This can result in fatigue, stress, and decreased job satisfaction.

Tip: Efficient time management techniques, prioritisation of tasks, and delegation can help nurses manage their workload effectively. Employers should also implement staffing models that ensure adequate nurse-to-patient ratios to prevent burnout and maintain quality care.

3. Workplace Violence

Nurses frequently encounter verbal and physical abuse from patients, families, or even colleagues, posing a significant threat to their safety and well-being.

Tip: Hospitals and healthcare facilities should implement comprehensive violence prevention programmes, including training on de-escalation techniques, conflict resolution, and security measures. It's essential to foster a culture of zero tolerance for violence and provide support services for affected nurses.

4. Technological Challenges

With the rapid advancement of technology in healthcare, nurses must adapt to new electronic health records (EHR) systems, medical devices, and telehealth platforms. However, inadequate training and usability issues can hinder their ability to provide efficient care.

Tip: Continuous education and training programmes should be provided to nurses to enhance their proficiency in using technology. Employers must involve nurses in selecting and implementing new systems to ensure they meet their needs and workflow requirements.

5. Emotional Toll

Nursing is emotionally demanding, requiring nurses to witness suffering, death, and human vulnerability daily. This emotional burden can lead to compassion fatigue, moral distress, and mental health issues.

Tip: Self-care practices such as mindfulness, regular exercise, and seeking peer support are essential for nurses to cope with the emotional challenges of their profession. Employers should offer counselling services, resilience training, and opportunities for debriefing to help nurses process their emotions and maintain their well-being.

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COMMENTS

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The growth in nursing educations is phenomenal. From 2000 to 2016, ANM schools have increased from 298 to 1927, GNM schools from 285 to 3040, B.Sc colleges from 30 to 1752, and M.Sc colleges from10 to 611. Although the increase is significant still there is gap between demand and supply.
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Nursing binds human society with a bond of care and affection. Nursing is a calling to care, which offers an oasis of poignant stories and pool of challenges. Despite of urbanization and globalization in India, the healthcare system in the country continues to face formidable changes. Nurses play an integral role in the healthcare industry, providing care to the patients and carrying out ...
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This blog post provides an in-depth exploration of the history of nursing in India. From its ancient roots to its modern-day practices, the article covers the evolution of the nursing profession and the vital role that nurses play in the Indian healthcare system. The article includes information on the introduction of Western medicine, the development of nursing education in India, and the ...
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Professionalism among nurses plays a critical role in ensuring patient safety and quality care and involves delivering competent, safe, and ethical care while also working with clients, families, communities, and healthcare teams. To assess the level of nursing professionalism and the factors affecting professionalism among nurses working at a tertiary care center in India.
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How To Write A Nursing Career Plan Essay
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GROWTH OF NURSING IN INDIA: HISTORICAL AND FUTURE PERSPECTIVES

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Challenges faced by Nurses in India-the major workforce of the healthcare system

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Factors Associated with Nursing Professionalism: Insights from Tertiary Care Center in India

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BMC Nursing

‘Nursing’ a Community into Marginalization: A Study on the Hardships Faced by Medical Nurses in India

An Interaction with an Indian Nurse

The Indian Healthcare System

Understanding Marginalization

Being a Medical Nurse in India

Mental and Physical Repercussions

Shortage of Workforce

Long Working Hours and Poor Work Environment

Lack of Recognition and Societal Challenges

Human Rights Violation

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