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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Published: 06 March 2024

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.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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

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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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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

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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.

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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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Open Access

Peer-reviewed

Research Article

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.

https://doi.org/10.1371/journal.pone.0251331.g002

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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Design for Tomorrow—Volume 2 pp 733–744 Cite as

Digital Health Interventions to Enhance Patient Care for Indian Nurses

Vydianathan Ramaswami 7 &
Raj Arjunan 8
Conference paper
First Online: 27 April 2021

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Part of the book series: Smart Innovation, Systems and Technologies ((SIST,volume 222))

The health care and nursing profession in India has suffered neglect both historically and in present times. We propose the use of information and communication technology-assisted learning (ICTAL) for creating a large capacity of qualified, skilled, and competent health care workforce in a short period. The “Indian Nursing Knowledge System (INKS)” an online platform uses a blended learning approach with, including, but not limited to customized, individualized digital health content, maximum utilization of smartphones, Web portal, SMART products, simulations, with inter-sectoral coordination with sectors of society addressing health and well-being. We envisage improving nurses’ clinical skills, competence, critical thinking, decision making, and the ability to work in teams.

India nursing education
Shortage of skilled nurses’
Challenges in nursing
Clinical competence; capacity building
Future of Indian nursing

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Dr. Arulalan, MD, DCH, DNB, a community-based Pediatrician and Founder of AA Child Care Center at Vellore with 35 years of experience, shared his experience under Dr. Miss. P. Chandra, MD DCH FIAP, 87 years former Director, Institute of Social pediatrics, Stanley Medical College, Chennai, from 1981-till date, provided timely support, patient guidance, encouragement, and insightful critiques for this paper. His constant advice directly and Dr. Chandra’s support, indirectly, helped us.

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Ramaswami, V., Arjunan, R. (2021). Digital Health Interventions to Enhance Patient Care for Indian Nurses. In: Chakrabarti, A., Poovaiah, R., Bokil, P., Kant, V. (eds) Design for Tomorrow—Volume 2. Smart Innovation, Systems and Technologies, vol 222. Springer, Singapore. https://doi.org/10.1007/978-981-16-0119-4_59

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Gender Stereotypes: A History of Nursing in India

Amongst the health professionals, there exists an implicit gender-based division of labour. Since the beginning of nursing as a profession, woman has been symbolized with the image of a nurse. The feminine characteristics and socially constructed gender roles attribute nursing and care work to a women's domain. The story of nursing services in India has been primarily about social accounts of caste, class, religion, status of women, gendered construction of the occupational realms, and influence of the colonial forces. From the Vedic age to the post-Independence phase, the development of nursing profession in India reproduced the prevailing social norms of society. The subjugated position of women in Indian society has led to the poor professional status of nurses among health professionals. Nurses are seen by others as an unskilled woman with loose morals and doing work equivalent to that of a servant. Along with this, the institutional exclusion and systematized discrimination faced by Indian nurses have reinforced the masculine prejudice denying them rightful opportunities. Thus, unless the partiarchal and other social norms of our society are transformed the pitiable conditions of nurses in our country will continue to exist.

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Trained Army Nurses in Colonial India: Early Experiences and Challenges

Preethi mariam george.

Department of Humanities and Social Sciences, Indian Institute of Technology Madras, Chennai-600036, Tamil Nadu, India

John Bosco Lourdusamy

The paper examines the introduction of trained female nurses for the British army men in colonial India between 1888 and 1920. It discusses the genesis of the Indian Nursing Service (INS), including the background and negotiations leading up to its formation, terms of employment, duties and working conditions of the nursing sisters. The memoir of Catharine Grace Loch, who served as the first Chief Lady Superintendent of the service is used extensively to trace the early experiences and challenges of the nursing sisters. The paper primarily argues that the INS being a new service, the colonial government maintained tight control over its functioning, and extreme conservatism in spending, thus retarding the growth of professional army nursing in India. Secondly, in examining the relations between the sisters and the (male) nursing orderlies, sub-medical and medical officers, the paper argues that the inadequate delineation of the nursing sisters’ position in the military medical hierarchy was an important reason for the undermining of their expertise and status. Thirdly, the paper contends that as an all-women service, nursing constituted an important avenue of female agency within the patriarchal colonial establishment, which subjected the sisters to scrutiny both professionally and socially. The paper analyses the resultant conditions and regulations imposed on the sisters – most of them determined by gender and class notions. Finally, the paper discusses the gradual establishment and recognition of the service as an important cornerstone for the health of the army, while highlighting the shortcomings that yet persisted up until 1920.

Introduction

The advent of western medicine in India was inextricably linked to the colonial requirement to cater to the health of the British population, especially the army, which was adversely affected by a variety of diseases encountered in India. There is a rich and diverse scholarly engagement with several dimensions of medicine and health in the Indian colonial context. 1 But within this, the question of nursing, an important element of western medical practice, has not received commensurate scholarly attention except for a very few works. 2 This paper aims to analyse some aspects of this much neglected domain by focusing on the early years of the introduction of trained nurses for the British army in India.

In Victorian England, the care of the sick was conventionally regarded as one among the feminine responsibilities. 3 Women who undertook nursing, both inside and outside the domestic sphere, were untrained. In the nineteenth century, reforms in the hospital and ward system, along with the development of specialised treatment methods created a need for trained nurses. 4 Nursing reforms gained traction by the second half of the nineteenth century, under the leadership of Florence Nightingale and others. Nightingale insisted on a systematic course for training women as skilled nurses, while maintaining that only women had the aptitude and competence for care that required gentle handling and housekeeping skills. 5 The reforms gradually resulted in the professionalisation and feminisation of nursing.

With regard to the army, the nursing functions were predominantly performed by male orderlies until the mid-nineteenth century. During the Crimean War that began in 1853, the British army lost an alarming number of its soldiers due to insanitary conditions and diseases. Under such circumstances, Nightingale, in 1854, pioneered the work of providing organised female nursing to the British army at Scutari during the course of the war. 6 She went on to become an ardent advocate of the employment of trained female nurses, especially as a major step towards improving the health of the army. Nightingale envisioned female nurses in military hospitals to have the power to give orders to the male ward orderlies, and ensure the obedience and discipline of the male soldiers admitted to the wards for treatment. 7 The idea of female nurses was initially resisted based on the assumption that female presence would ‘excite the passions’ of men. In partial concession to this concern, Nightingale recommended that the nurses attend only to the severely ill or injured. 8 They were not to be employed in wards of patients with venereal diseases or for patients who were just convalescing. Based on these suggestions and recommendations, female nurses came to be employed in the military hospitals in Britain.

In colonial India, nursing was not undertaken by professionally qualified and certified nurses, in either civil or army settings, until the second half of the nineteenth century. Nuns and missionaries offered nursing care to the ailing natives as part of Christian medical mission work. Following nursing reforms in England, there were sporadic attempts to provide trained nurses for government civil hospitals. In this process the government relied heavily on philanthropic efforts. 9 In 1865, Nightingale suggested that a few matrons and head nurses should be sent from England to start training of nurses in civil hospitals. But the colonial government rejected this modest plan on the ground that it was expensive. However, Lord Napier, the Governor of Madras Presidency, who was well acquainted with Florence Nightingale, took up the cause of nursing in the Presidency. 10 Through his initiative, the training of nurse probationers began in 1871 at the General Hospital in Madras. Eventually the Presidencies of Calcutta and Bombay also began to train and employ European, Eurasian and Indian women as nurses in civil hospitals, but an all-India civil nursing service was not formed. 11

Nursing in the military context had its own distinct origin. In 1857, when the interest in army nursing kindled by Nightingale was still fresh, a major military uprising broke out against British rule. Following this, the governance of British India was transferred from the English East India Company to the Crown in 1858. The political ascendancy of the British empire was heavily dependent upon military strength, which in turn depended considerably on the health of the troops. Among other things, the uprising of 1857 exposed the inadequacies in the medical facilities available to the British army. In response to this, the ‘Royal Sanitary Commission on the Health of the Army in India’ was appointed in 1859. It is particularly significant that Nightingale participated extensively in the inquiries of this Commission. 12 The Report of the Commission in 1864 brought to the fore the unsatisfactory state of nursing care provided to the British army in India.

A hospital for the European corps had a ‘hospital serjeant’ (sergeant) for maintaining discipline. 13 Ailing soldiers were often cared for by their ‘comrades’. 14 However, the bulk of the nursing functions were performed by untrained ‘coolies’ (native attendants). The British soldiers despised the native attendants who were described as ‘inattentive’, ‘lazy’ and ‘apathetic’. 15 There are references to women performing nursing functions for the army – but they were not professionally trained. Colonial ladies (wives of colonial officials), took up the nursing of wounded soldiers during the uprising of 1857. 16 Wives and widows of British soldiers, and native women also worked as amateur care-givers in the military hospitals. 17 The Commission recommended the employment of trained female nurses in the British military hospitals in India, - reflecting the professionalisation and feminisation of nursing underway in Britain. 18 But this suggestion was not immediately implemented.

Hesitation towards introducing female nurses in military hospitals

The major reason for the hesitation of the Government of India in introducing female nurses was the financial burden that it would entail. The Controller-General of Military Expenditure prepared an estimate of expenditure required for setting up a complete nursing establishment in India. In 1867, The Medical Times Gazette reported:

[C]alculating the cost on the table given by Colonel Broome, the Controller-General of Military Expenditure, the charge to the State for the maintenance of the estimated number of 280 nurses, with three lady superintendents, for the three Presidencies, exclusive of the expenses of outfit and passages of nurses going out from England, and the maintenance of a home depot, would be about £30,000 per annum – a large sum to pay for a doubtful benefit. 19

Nightingale felt that Colonel Broome’s cost estimate alarmed the Government of India enough to resign from the idea of providing trained female nurses for the army. 20

Apart from considerations of cost, several other points were raised concerning the introduction of a body of female nurses in the British military hospitals in India. Most of the British officers in India came from a middle class background, or from the upper class landed gentry and aristocracy. On the other hand, British soldiers in India were drawn from the lower rungs of the British society. 21 While the officers were considered respectable and of good moral stature by virtue of their class status, the soldiers were portrayed as exhibiting bodily intemperance, and unable to regulate their carnal impulses. 22 Hence, as in Britain, the possibility of soldiers behaving inappropriately with female nurses was expected. But such occurrences in India could affect the image of the British empire as a morally superior and civilised force – an aspect which was touted as one of the many legitimations for colonial rule. 23 Correspondingly, if women were to attend to inmates affected by venereal diseases (VD), it would be morally abhorrent as VDs were considered as resulting from ‘man’s indulgence in his sexual appetite’. 24

Considering such concerns in India, Nightingale commented: ‘Nurses among convalescent soldiers in the wards are quite out of place and always will be. They would become playthings and very improper ones’. 25 Similarly, J. L. Ranking (the Sanitary Commissioner of Madras), while supporting the idea of introducing female nurses to military hospitals, did not want their services to be utilised in either the wards set apart for venereal cases or in the general ward for the treatment of trivial ailments. Rather, ‘it is only in grave cases of disease where strength has to be supported by vigilant administration of restoratives, and by those ministrations that [a] woman only is thoroughly fitted to undertake, that a trained nurse will find her vocation’. 26 This view was reminiscent of Nightingale’s own vision for female nurses in military hospitals in Britain, and reflective of the trends concerning feminisation of nursing underway there.

Another strand of opinion was that employment of female nurses was unnecessary in the military regimental hospitals, where army men, in peaceful times, were in ‘robust health’ except for ‘slight affections’. Moreover, it was claimed that due to the camaraderie in the army, ailing soldiers would prefer to be tended to by their ‘comrades’ rather than by female nurses with whom they would not have the bond of comradeship. 27 There was also opposition to the idea of female superintendence over men. Nightingale understood that welcoming female nurses into such a masculine arena of public service as the army was not going to be easy:

[N]ursing in military hospitals requires painful, careful trial, because it must always be an experiment, and a new experiment every time you try it, to put down a few women among a parcel of men, this being the only occupation where a woman is really in actual charge and control of grown-up men. 28

It is important to note that, contrary to popular belief, the success and recognition received by Nightingale for organising army nursing during the Crimean war, did not immediately guarantee a place for professionally trained female nurses in the army hospitals even in Britain. 29 By the 1860s, as a result of consistent lobbying by the nursing leadership, women were trained as army nurses at the Royal Victoria Hospital at Netley, and appointed to military general hospitals. They were eventually employed during the Anglo-Zulu war in 1879, which served as an impetus for the formation of the Army Nursing Service by 1881. These developments were also favoured by the reforms in the arena of military health and sanitation in the second half of the nineteenth century. 30 By 1883, all the military hospitals with more than a hundred beds were required to employ nursing staff who were responsible for the care of the patients and also for the training of orderlies in the wards. A code of regulations for female nursing service of the Army was published in 1884. All the army nurses were required to have undergone training in a civil hospital. 31 In 1883, the decoration of the Royal Red Cross was instituted to accord public recognition to the British nurses for caring for the soldiers. Such recognition was otherwise denied to women in other arenas of state service. Also, serving the British army in the expanding empire provided a British woman, the greatest opportunity for ‘national service’. 32 Correspondingly, casting the trained British nurses in an imperial role was seen as a way to boost the public image of the nursing profession following an era of reform and reorganisation. 33

The Indian Nursing Service: Organisation and functioning

The developments in Britain were followed by a renewed interest in the introduction of trained female nurses in British military hospitals in India. Lady Roberts (wife of Lord Frederick Roberts, the Commander-in-Chief of British troops in India), was instrumental in lobbying for this cause. 34 In fruition of the efforts since 1860s, the Secretary of State, in 1887, sanctioned the employment of lady nurses in British military hospitals in India. Thus, was born the Indian Nursing Service (INS). On 21 March 1888, Miss Catharine Grace Loch and Miss Oxley, along with eight other trained English ‘nursing sisters’ arrived in India. 35 Their induction into the military can be seen, in a way, as another important step in tightening the British hold on India, in terms of its bolstering the health of the army.

The memoir of Catharine Grace Loch serves as one of the important anchors in this paper’s attempt to capture the various dimensions of the organisation of the INS, and the early experiences and challenges of the trained army nurses in India. Loch was born in 1854, into a family of privileged social background. She showed a strong inclination towards nursing, which in her social sphere was still an uncommon vocation for women. At the age of 25, Loch trained to be a nurse at the Royal County Hospital in Winchester. Following this, Loch was appointed as the Night Superintendent at St. Bartholomew’s Hospital in London, where she got nursing experience in the men’s surgical ward. In 1887, Loch was selected to be a Lady Superintendent charged with the task of inaugurating the INS. After more than a decade of service she returned to Britain in 1902, and functioned as a member of the Committee at India Office which dealt with the appointment of nurses to the INS. 36 Her memoir chronicles the life and work of a professional colonial woman, and her experience of the workings of a predominantly male-run empire. Her story is traced mainly through her official and private letters which provide unusual glimpses into the journey of a pioneering leader of the INS.

The nursing sisters were introduced into British station hospitals in India, which were meant exclusively for the treatment of British men in the army, both officers and soldiers. Their service was not extended to the Indian troops. At the time of their arrival, the hierarchy in a British station hospital was as follows: a medical officer of senior rank had the medical and administrative authority over all functions of the hospital. Other medical officers were in charge of the patients whom they visited generally twice a day. They were also called at other times to attend to emergency cases. Below them was a class of subordinate medical officers designated as assistant-surgeons (or apothecaries), who were responsible for the wards in the absence of the medical officers. They treated the patients according to the orders of the medical officers and were allowed to prescribe treatment in case of emergency. They also supervised the work of untrained orderlies who carried out caregiving activities. The orderlies were assisted by ward ‘coolies’/native attendants who did the menial work in the hospital. 37

The newly introduced nursing sisters of the INS were required not only to care for the patients, but also to train the orderlies in nursing and to supervise their work. According to the registers of the INS candidates, British women who were single, married or widowed applied to the service, but single women were preferred for appointment. 38 Candidates had to apply to the Under Secretary of State for India and were required to have at least three years of training and experience in a civil service hospital in Britain. 39 Nurses trained in India were not preferred as their training was considered inadequate. 40 The agency of the nursing sisters was characterised by their embodied skill and their embodied expertise. 41 The sisters acquired these through their training in, and their experience of western medical practice in the civil hospitals in Britain. In India, the sisters were introduced into conditions which challenged their embodied expertise. Firstly, the medical and nursing services, like the army, were itinerant in nature. Hence in military hospitals the doctors, apothecaries, nurses, and orderlies were all frequently transferred, unlike the civil hospitals in Britain where the doctors and nurses worked together for a long time. 42 The dynamics of work in a military hospital in India was such that mutual trust and confidence could not be cultivated easily. This resulted in a system where the expertise of a nursing sister was not adequately validated or acknowledged. Secondly, western medicine practiced in India was not identical to that practiced in Europe, since it had to adapt according to the conditions and requirements in India. The sisters had to understand and manage the diseases encountered in the ‘tropics’, which had adverse manifestations on European bodies, with their effects intensified by concomitant climatic factors like heat and humidity. 43 Thus, their embodied expertise had to be reinvented to suit the colonial military medical system.

The lady nurses were an integral part of the military-medical department and could be subjected to court-martial. 44 There were three grades in the nursing service – ‘nursing sister’, ‘senior nursing sister’ and ‘Lady Superintendent’. The functioning of the INS was spread across four Circles/commands (with headquarters at Rawal Pindi [sic], Meerut, Bangalore, and Poona), each under the charge of a Lady Superintendent. Each Circle had three or four stations. 45 The promotion of a nursing sister to the position of Lady Superintendent was made by the Chief Medical Officer (CMO) in India on the grounds of ‘experience, administrative capacity, and personal fitness’. 46 In each station, two to four nurses were employed and one of them (a senior nurse), held the position of Deputy Superintendent. A Deputy Superintendent was supposed to consult the Lady Superintendent on all important matters and submit monthly reports to her. The Lady Superintendent of a Circle had to visit all the station hospitals in her jurisdiction at least once a year and inspect the conditions of work there. She also had to submit a confidential report evaluating the work, capabilities and conduct of each sister to the CMO. 47 Loch was the Lady Superintendent of the Rawal Pindi command.

Each Lady Superintendent, senior nursing sister and nursing sister received a monthly pay of 300 rupees, 200 rupees and 175 rupees respectively. 48 The pay was considered quite generous. During a term of service (of five years), a sister was allowed two months of leave on full pay, and sick leave up to a maximum of six months which could be taken in India. After completion of a term, a sister was entitled to one year’s furlough out of India. At the end of each term, she could leave the service or sign an agreement to return for another term. At the end of her full service a sister was given pension based on the duration of her service. 49

The INS sisters did not experience wartime nursing in India due to reduced military conflict in the colony by the end of nineteenth century. Only rarely did nurses have to be on the move alongside troops during military expeditions. The soldiers who needed treatment for injuries or diseases came to the station hospitals where they were nursed back to health. 50 The sisters could afford time for leisure and got the opportunity to travel around India. Thus, according to A. Arkle, a senior nursing sister, the INS was overall an exciting prospect for British lady nurses:

Our quarters are always large and comfortable, the pay is good, the amount of leave is most generous, there is a pension at the end of our service, and there is that home-feeling one has in one’s quarters surrounded by one’s little gods. One can keep a pony-trap or bicycle, and one can have one’s live pets about one. This to an animal-lover means a great deal, and I think a real change is good for one. When off duty we can potter around in the garden, play tennis or any other game we like, – golf is a favorite,– and I think a good canter across the country is about the best medicine for a nurse I know of; after it one goes on duty so fresh. I take it that to really remember the men and give them of our best when on duty, we must try to quite forget them when away from the wards. 51

However, the picture was not entirely rosy. The sisters were placed in charge of special wards in station hospitals which contained the most serious cases. There were healthy months when there were fewer serious diseases and when the work was ‘dull’. Then there were seasons of disease outbreak when the work was ‘wearisome’ which resulted in much exhaustion. 52 The service of the sisters was crucial in handling epidemiological crises in the army. The nurses dealt with diseases like dysentery, heat apoplexy, rheumatism, liver abscess, pneumonia, malarial and enteric fever, and outbreaks of epidemic diseases like cholera and influenza. There was not much surgical work in the hospitals. 53 There were instances when nurses fell ill due to the adverse effects of climate, diseases, and work in India. Despite this, there was a regulation that stated that a nurse who took ‘sick leave’ in India would have a third of her pay cut. 54 Since there were only a few nurses in each station hospital, they worked in three shifts, taking turns on and off duty. Having fewer than three nurses in a hospital was not considered ideal, since it caused the nurses much fatigue especially when faced with circumstances when day and night supervision of patients was required. 55 Yet, the sisters were often transferred at short notice which disturbed the nursing work in the already minimally staffed station hospitals, leading to patients getting neglected and systematic training of orderlies getting impeded. 56 These transfers were ordered without consulting the Lady Superintendent– something which invited dismay.

Frustrated at the sudden and unexplained transfer of nursing sisters from one place to another, Loch wrote: ‘It is ridiculous doing things like that, and if I am not to be consulted at all, or even warned about arrangements, what is the good of my existence? I must stand on my own legs, and the first thing is to establish them and to try to show that I have a voice in the matter’. 57 She also opposed the practice of sisters being arbitrarily ordered by higher authorities, to go to out-stations to nurse individual patients, especially ladies, which was not under the purview of their duties as army nurses. 58 On one such instance, Loch insisted: ‘I think that just because we are professional we should not be called on to do promiscuous work in addition to our own proper duties’. 59 It appears that while Loch was anxious to assert her position vis-a-vis her higher authorities as the Lady Superintendent, she was also concerned about the interests of the nursing sisters at large. She was willing to look beyond some of the perceived slights in the larger interest of the profession and of her co-workers. In addressing the several problems faced by the latter, she attempted to solicit favorable solutions from her superiors – which needed a degree of soft-pedalling.

Along with the conditions of work, climate also had adverse effects on the health of the British lady nurses and impacted the chances of their continuous service. 60 Lady Roberts had anticipated this particular challenge even at the inception of the INS in 1887. She wrote:

Without occasional change to a healthier climate, European ladies could not possibly continue for long to perform the trying and anxious work of nursing in the plains at the most unhealthy seasons of the year. The other alternative is to let the ladies remain in the plains until their health completely breaks down, and then send them to England with more or less chance of recovery. This, besides being cruel to the devoted women who consent to come out for this work, would involve constant change of nurses and an enormous increase of expenditure. 61

Lady Roberts advocated the provision of ‘homes in the hills’ as health resorts for the nursing sisters in India. But again fiscal conservatism tended to colour the attitude of the colonial government in this regard too: ‘The government of India considers that the money required for this purpose might appropriately be left to the active benevolence of private individuals interested in the welfare of the British soldiers in India’. 62 Thus, while the colonial government needed the nursing sisters for ensuring the health of its army, it was reluctant to make any expenditure for a scheme to help the health of the nurses serving the army. It was a common practice to have sanatoria particularly in the hills, for the British population especially for the military personnel. 63 Though the nursing sisters were supposed to be within the military system (in that they could even be court martialed), they were overlooked – in the name of fiscal discipline – when it came to providing them places in the hills to recuperate and rest.

The ‘homes in the hills’ for nurses were set up by private subscription, since the government was not willing to spend for it. 64 However, it has to be noted that these ‘homes’ were not something that the nurses themselves welcomed unreservedly. Loch described how expensive houses were bought and furnished at Murree and other places where nurses could be officially sent during leave or in case of sickness. 65 She considered this ‘an unfortunate mistake’, though well-intentioned. This was because during their leave the nurses preferred to stay with their acquaintances and friends, rather than being isolated at these ‘homes’. Writing about the home at Murree she noted: ‘…only twice during the two years has a Sister gone there for a week’s sick leave, but if the Home had not existed I have no doubt some other arrangement could have been made’. 66 The nurses were sent up to the hill station hospitals to work there during the summer months. At Murree, Loch observed that rather than stay in the ‘Home’ which was far away from their place of work, it was more convenient for the sisters on duty to have their accommodation at the quarters close to the hospital. 67 Hence Loch saw the ‘homes in the hills’ as unnecessary.

Loch rather insisted upon better conditions of work and stay for the nurses. She preferred an increase in the number of nurses in the service, in order to afford rest to the nurses, and thereby enhance their efficiency. In 1896 there were only fifty-two nursing sisters employed in the entire service. 68 Requests for increasing the number of nurses were frequently made, but any positive action was delayed by the government because it was considered expensive. Disappointed with such a state of affairs, Loch wrote: ‘Yet after all the palaver and parade we cannot get even what we want for our patients, and we are considered unreasonable and exacting when we ask for things, and get told that if we make ourselves expensive, we must not expect Government to increase our numbers’. 69 In 1901, it was proposed to provide an increment of twenty-five rupees to the monthly salary of those nursing sisters and senior nursing sisters who had completed five years of service. This proposal was ‘negatived’ by the Government of India on the ground that the pay and allowances granted to the lady nurses in the INS were already considerably high compared to those given in Britain. 70

From the instances noted above, the attitude of the colonial government towards the nursing service can be understood. Firstly, as a newly instituted service, the colonial authorities maintained a tight grip on its functioning. This brought them in conflict with the Lady Superintendent of the service, who was accorded a semblance of power - but with no real authority. The suggestions and opinions of the Lady Superintendent were often ignored or simply not sought. Secondly, the colonial government was reluctant to spend towards the service which was considered as an experimental attempt. The salaries of the sisters remained static, and the quality and welfare of the service was compromised as sufficient numbers were not recruited due to the financial stringency of the colonial government.

Nursing sisters in a male dominated work-place

Before the introduction of the nursing sisters to the military hospitals, many of the orderlies, assistant-surgeons, and medical officers (who were all men), had little or no experience of working with a lady nurse. 71 The presence of female agency in a male-dominated arena of work was bound to create tensions. At the British station hospitals, the sisters were placed in charge of supervising the nursing work of male orderlies drawn from the various local British combatant units. They also were given the responsibility of imparting nursing knowledge to the orderlies and training them for medical work. These nursing orderlies were described as ‘totally ignorant’ of the most rudimentary principles of nursing. Hence the sisters were required to instruct them in every practical and basic detail related to nursing, and by ‘force of example’ help the orderlies to develop interest in nursing duties. 72 This can be counted among the few scenarios in the nineteenth and in the early-twentieth centuries where women were in charge of instructing adult men.

A system of training nursing orderlies evolved in which military men could volunteer to take a course which included lectures by medical officers on first aid and elementary nursing, in addition to a ‘stretcher drill’ course. On satisfactory completion of the course, the trainees were sent, generally for two months, into wards for practical learning under the sisters, after which they received a nursing certificate. 73 The sisters were required to train about ten to twenty probationing orderlies at once, in that very short time, which they found difficult. 74 Loch was concerned about the ‘danger to the system’ whereby, for many people a ‘certificated orderly’ conveyed the idea of a ‘trained orderly’, which he certainly was not to begin with. 75 From her observation, the real gain of knowledge and practical habit formation as nursing orderlies happened only when they joined the job after the so-called training.

The possession of a nursing certificate entitled an orderly to earn an extra pay of four annas per day for hospital work. This gave official recognition to the nursing orderlies, and incentive to learn and perform nursing work. 76 For each ward with an average of twenty-five beds, two orderlies were assigned. Each orderly worked two alternate shifts of six hours each. The opinion of the sisters regarding the orderlies was ambivalent, and swung between appreciation and complaint. Arkle (a senior nursing sister), wrote: ‘I find the orderlies much better and more willing to learn than I expected. I have seen them so infinitely gentle when handling a sick comrade’. 77 This was not always the case. The sisters did face difficulties in managing the orderlies. The supply of orderlies changed frequently with the coming and going of regiments at a station. This was a huge disadvantage to the sisters as they often lost the orderlies whom they had acquainted with hospital work, only to receive a new set of inexperienced ones. The orderlies were also often found to be drunk or sleeping, instead of taking care of the patients in the ward, which required the sisters to take on the responsibility themselves. 78 Loch thus recorded her experience with orderlies at Rawal Pindi in one of her letters:

For one thing we have been going through much tribulation with orderlies. We have some very good men in our original ward, but in the new ward and for the extra cases in the verandah we had a wretched lot belonging to a regiment which was only passing through Pindi. They did not care a fig, and were quite stupid and not civil and frequently drunk. Several times I had to put the night orderly to bed to get rid of him and do his work myself. 79

While the doctors and assistant surgeons had ranks in the military medical system, the nursing sisters were not given any. 80 In the absence of a nominal rank in relation to the orderlies, the sisters often faced instances of insolence and disobedience.

There was a sense of competition in the interaction between the assistant surgeons/apothecaries and the nurses. Loch noted that the assistant surgeons were inclined to view the sisters with ‘very jealous eyes’. 81 This was probably because after the introduction of the nursing sisters, the supervision of nursing work, which was earlier under the purview of the assistant surgeons, had become the responsibility of the sisters. There was a lack of clarity about where the sub-medical charge of an assistant surgeon ended and where the nursing charge of a sister began. Hence the sisters felt that the assistant surgeons interfered with their work and encroached upon their sphere of responsibility.

The inadequate delineation of responsibility in the military medical system, and the refusal of the government to grant a nominal rank to the sisters undermined the authority and position of the sisters in relation to the orderlies and the assistant surgeons. Loch, in her position as Lady Superintendent, was not satisfied with mere praise for the work of the nursing sisters, without actual legitimation by the government. She wrote:

I feel sure that in this horrid country Nursing Sisters never will get a proper recognized position in spite of all the palaver of the military authorities. Of course, we are everything that is delightful and revered and much thought of in conversation, but when it comes to the point, we must be ministering angels only without a definite responsibility or position of any sort or kind, or any recognized status with regard to soldiers, orderlies or apothecaries (members of the Subordinate Medical Department), and naturally they take advantage of it, seeing that everyone else’s rank is fixed to a hair’s breadth. 82

In a hierarchical system dominated by men, the issue of granting a recognized status to female agency was ignored. Quite exasperated with the government on this matter, Loch pondered: ‘Why must it be always thought that in connexion [sic] with women things may be left vague and unbusinesslike?’. 83 However, the nursing sisters did not end up entirely as passive agents. With all the limitations and challenges, they yet constantly sought to define for themselves their place and role in the healthcare structure.

The medical officers tended to treat the nursing sisters as if they were probationers or ‘supernumeraries’, and showed more deference towards the assistant surgeons. The advice of the sisters against unsuccessful methods of treating patients, was often disregarded by the inexperienced young medical officers. In general, Loch maintained a cordial professional relationship with medical officers. According to her, ‘In the abstract, the doctor must always have the authority and the nurse must obey, but when one has worked many years, one often knows best all the same’. 84 But the medical officers tended to behave in an ‘autocratic’ manner towards the sisters. Loch narrates one such instance:

A certain convalescent was ordered by the doctor a dose of castor oil and had it; for some unexplained reason the dose upset the man utterly, started violent irritation and diarrhoea, and the poor fellow, who had been practically well, was getting awfully bad when the Sister on duty gave him a dose of stock astringent, an excellent one always kept ready in the hospital, and in an hour he was all right. But the doctor got furious and declared that we had no business ‘to prescribe’ for patients, and that if so he could not be responsible for them and so on, and he removed every single stock bottle and store thing in our cupboards, so now we have nothing at hand. 85

Thus, it can be understood that a nurse was not supposed to administer any medicine or treatment to the patient unless prescribed by the medical officer himself. This rule was to be followed even in emergency conditions when the patient was likely to collapse and when there were no medical officers or apothecaries available to prescribe treatment. 86 In case of any conflict with medical officers, the nurses often felt unsupported because the head of administration, being a doctor, would back the doctors. Hence as female agents, the nursing sisters faced disheartening instances when their sense of judgment was not trusted, and the expertise they possessed through experience was not given due credit.

Scrutiny and appreciation: Lady nurses as agents of the empire

The sisters of the INS, the pioneering all-women’s service within the army, were under scrutiny not only in their workplace, but also socially. A high standard of conduct and work was expected out of every individual nurse, since their actions could retard or advance the cause of nursing in India 87 :

[E]very individual Nurse who earnestly cares for her profession may feel that she is one of a small band of pioneers in a new sphere, where skilled nursing has hitherto been extraordinarily unknown; that she is watched with interest, both by the public at large and by the Government she is serving; and that the success and encouragement given to trained nursing in India may be immensely forwarded by her individual efforts, which will actually help to bring a real improvement in the nursing of the military hospitals generally a step nearer realization. 88

Negative opinions regarding the whole scheme of nursing service were circulated from time to time in the papers, accusing the nurses of disobedience of orders and mismanagement, which affected the morale of the nurses. 89 Loch wrote: ‘…they keep on writing nasty things in the newspapers. But it is not a bit of good really minding, though it is disheartening, when one knows one works fifteen times harder than anybody else, to be abused in addition’. 90

A military station was a censorious environment for the British nursing sisters who were mostly young unmarried women, devoid of familial regulations in a faraway land. 91 Loch warned the sisters not to be overly excited by their supposedly independent position. She advised them to live ‘quietly and unostentatiously’, and refrain from ‘parading’ their independence. 92 On closer look, it can be understood that the nurses’ being away, in fact, reduced their independence of action and increased their vulnerability and liability to be judged unfairly:

But the fact that they are young women, living without any protection from relations or friends, renders their position in some ways a difficult one. Instead of being more independent, they have practically less safe liberty of action than many a girl living in her father’s house might safely enjoy. Nurses out here are far more prominent in the eyes of the community than Nurses in England. Everyone criticizes them; and should one of them, perhaps from mere thoughtlessness, ‘get talked about,’ as the saying is, there is no one to stand up for her or to vouch for her in any way. Sometimes they are extravagantly admired for the work they do, but a large number of people are always to be found who are only too ready to find fault. 93

The insistence on more probity, conformity, and professional identity within the service was signaled by the introduction of uniform (duty dress) in 1900. The sisters were rendered easily noticeable by their uniform which they were required to wear ‘at all times’, unless they were on leave or attending evening entertainments. 94 The sisters got invited to station gaieties (like dances), arranged for the officers and their families. However, the government discouraged them from engaging extensively in such activities since it invited gossip and criticism against them. They could be accused of being more interested in these pleasures than in the service of patients. Moreover, such amusements were seen as an interruption to the routine, and something which weakened their interest and commitment towards work. 95 Hence, to retain the image of the INS, even the personal activities and desires of the sisters were regulated. 96 The sisters were advised to exercise ‘caution’ and ‘self-restraint’ in both professional and social circles.

At the time of appointment, a nursing sister was required to be over twenty-five and under thirty-five years of age. 97 There was a preference for candidates considered to be ‘ladies’ of unquestionable social position. The candidates applying for appointment in INS were specifically required to produce ‘Original letters of personal recommendation, including one from a lady of position in Society, who must state that the candidate is a fit, and in every way, desirable person to enter a service composed of ladies of good social position with whom she will associate’. 98 Thus, the colonial authorities wanted to confirm the social standing of the nursing sisters, before they could be considered for service in India.

All of this has to be seen in the backdrop of very significant changes in Britain with regard to the social standing of nurses as professionals, which had clear class dimensions too. Prior to the reforms in the field of nursing in the mid-nineteenth century in Britain, nursing as an occupation was only taken up by working-class women, while nursing for the sick in the domestic sphere had been the duty of women in all social classes. It was not considered respectable for women of good social standing to take up nursing as an occupation, as nurses were cast as dirty, drunken and sexually promiscuous women. However, due to the reforms initiated in the mid-nineteenth century, nursing was transformed into an occupation requiring rigorous discipline and organised training. These developments improved the image of nursing and attracted middle-class ‘ladies’ into the occupation, apart from working class women. 99 The participation of ‘ladies’ who were represented as being immune to sexual temptation, especially from lower-class patients, in turn reciprocally helped in elevating the image of nursing to be a respectable occupation. 100

Apart from providing nursing care to both the British officers and soldiers, the sisters were additionally placed in a position of authority over the soldiers, whom they were to supervise and train as nursing orderlies. Under this arrangement, the sisters were expected to be of a superior social standing than the soldiers. It was opined that if sisters were of the same class as the soldiers, they would not be respected or obeyed. 101 Loch preferred ‘lady’ nurses, and was not in favor of nurses from the lower-classes being appointed into the INS. She asserted:

I do think it will be a grave mistake not to send out ladies. First of all, it is hard on those who are not, because naturally they are sniffed at and make no friends; next, it is hard on those who are, because people always charitably judge the many by the few, and they will find themselves thrown out of their proper position in life on account of their colleagues. 102

Hence appointing lower class British women as nursing sisters was considered detrimental to the discipline, unity and quality of the service, which could have adverse effects on the image of INS as a prestigious colonial service.

At this point, it would be useful to delve briefly into the significance of the presence of British ladies in colonial India. During the nineteenth century, the British Victorian middle-class ‘ladies’ in India served a performative function as representatives of the ‘civilised’ culture of the British colonisers. 103 Though British women in India were integral to what constituted the colonial image, Sara Suleri opines that it was a long-standing tradition for them to be on the periphery of colonisation, as they were rarely required to handle any responsibility outside the domestic sphere. Hence, they remained fairly immune to the workings of British imperialism. 104

In the course of the nineteenth century, an arena for ‘women’s work for women’ emerged in colonial India, initially within the realm of missionary activities (both British and American), and later in the field of colonial medicine as well, which focused on providing medical relief for Indian women. 105 This proved to be a favorable avenue especially for educated, middle class British ladies to transition into the public sphere for socially accepted, paid work. 106 These British women associated their work with the idea of the ‘civilising mission’, and played an ideational role in extending the influence of the empire to the ‘natives’.

In contrast, the British ladies employed as army nurses in the INS, were distinctly involved in ‘women’s work for men’, performing a feminised role in a masculine public arena. However, their interaction with the natives was limited. Thus, the nursing sisters add plurality to the trope of the ‘British lady’ in India. Sir James Crichton-Browne described the sisters as ‘handmaidens of humanity’ for their dedicated service to ailing soldiers, while also calling them ‘militants’ fighting against the relentless attack of diseases that affected the soldiers. 107 Loch highlighted the contribution of nurses stating that ‘…many a young soldier, exiled far from home and friends, will owe his life directly to her skill and care’. 108 These comments position the British lady nurses as agents of the empire, who played an instrumental role in maintaining the vitality of the army, which was a prominent axis of colonial power. Thus, unlike the earlier British women on the periphery of colonial activity, the British lady nurses, through their medical engagement with the military, became a more integral element of the colonial machinery.

Progressive developments in the nursing service

By the beginning of the twentieth century, the significance of the army nursing services in both Britain and its colonies came to be recognised. In 1901, the Brodrick’s Committee for the reorganisation of army medical services in Britain recommended the amalgamation of the Army Nursing Service (in Britain) and the INS into the Queen Alexandra’s Imperial Military Nursing Service (QAIMNS). 109 This proposal was rejected by the Indian authorities. In 1903, the INS was just renamed the Queen Alexandra’s Military Nursing Service for India (QAMNSI). 110 One among the four Lady Superintendents was given the new designation of Chief Lady Superintendent. 111 (Catharine Grace Loch was the first Chief Lady Superintendent of the QAMNSI). 112 She was the recognised advisor to the Director of Indian Medical Service in matters concerning ‘interior economy and welfare’ of the nursing service. 113 In 1905, there was a suggestion to appoint a Matron-in-Chief for the QAMNSI. This was rejected on the grounds that owing to the size of India, it was more efficient to maintain the four Lady Superintendents who could provide advice on all matters relating to their charges. 114

In 1902, the Government of India had proposed a plan for the augmentation of the strength of the nursing service by seven senior nursing-sisters and thirty-two nursing sisters in the course of three years. 115 This plan was gradually implemented with considerable success, and by 1906, the total strength of the establishment was eighty-four, with four Lady Superintendents, fifteen senior nursing sisters and sixty-five nursing sisters. 116 The lady nurses worked with hardly any chance of promotion, and some of them worked for more than ten years without obtaining an increment in pay. In 1907, the Government of India sanctioned an increment of twenty-five rupees to the monthly salary of those nursing sisters and senior nursing sisters with over five years of service. At that time there were sixteen senior nurses and seventeen nursing sisters eligible for this increment, the total cost of which was estimated to be 9,900 rupees per annum. 117 These developments point to the reality that the nursing service had become firmly established in the military hospitals in India.

Another significant development was that, by the beginning of the twentieth century, the gendering of the nursing profession as feminine was reaffirmed, and army nursing by women came to be more readily accepted:

Apart from special training, patience, sympathy, gentleness, and devotion are most essential qualities required for successful nursing, and in these respects women excel men. Nursing is a woman’s special sphere. If it takes time to make a soldier it takes much longer to make a really good nurse, the value of whose services when obtained, is however, incalculable. 118

It is interesting to note that the male nursing orderlies, under the supervision of sisters, were advised to observe obedience, truthfulness, cleanliness, temperance, patience, kindness, gentleness and quietness. 119 These qualities, often portrayed as desirable feminine traits, were being expected from male orderlies, but devoid of its gendered associations. Hence it can be assumed that these qualities were, by then, integrated as the core values of nursing practice itself.

An important marker for the progressive professionalisation of the nursing service in India, was the strict insistence on three years of training in nursing. In 1902, the candidates were required to state where and for how long they had undergone training. They were required to produce ‘Original Certificates as to efficiency in Medical and Surgical Nursing from the Medical Officers and from the Lady Superintendent or Matron of the Hospital where the training has been undergone’. 120 By virtue of their training, the nursing sisters, embedded within the western structure of medical knowledge, served as intermediaries between the ‘expert’ medical officer and the ‘amateur’ orderlies who were required to do practical medical activities.

In 1912, Mary R. Truman, a senior nursing sister from the QAMNSI, published her Simple Lectures on Nursing for Soldiers in India, as a ‘record of personal practical experiences’ written for soldiers being trained as nursing orderlies. In its Preface she wrote:

This book is written in the hope that it may prove useful to the various classes of soldiers in India, who annually undergo a course of training in nursing duties to enable them to nurse their sick comrades. It does not aim at being a complete treatise in nursing, but I have tried to include in concise form and in plain language some of the most important facts that have helped me, in the hope that they may help others. 121

Truman provided instructions for nursing several ailments and diseases including wounds and fractures. She explained the meaning of medical terms, the functions of several medical equipments, the modes of administration of medicines, the modes of spread of infectious diseases and their symptoms. Various basic aspects of sick-nursing like maintaining cleanliness, bathing, dressing and nutrition of patients were also explained. 122 The book is a testament to the role of a nursing sister in codifying nursing practice in military hospitals in India, and the effort to build a pedagogic tradition for the nursing orderlies. 123 This was also a result of the nursing sisters’ growing confidence in their expertise, developed through their experiences in India. The expertise of the QAMNSI nurses was acknowledged when in 1916 they were sent to nurse the troops from British India, who were fighting the Mesopotamian Campaign of the First World War. 124

Shortcomings of nursing service for the army

Despite these developments, the nursing service in the army was noted as ‘far from satisfactory’ in the Report of the Committee Appointed by the Government of India to Examine the Question of the Reorganization of the Medical Services in India in 1920. Several factors impeded the quality of nursing in the British military hospitals in India. There was no marked increase in the strength of the nursing service. The establishment consisted of only ninety-one members including four Lady Superintendents, sixteen senior nursing sisters and seventy-one nursing sisters in 1920. 125 The nurses had very limited chances for promotion, and some of them retained the same grade as they had when they joined, even up to their third term. The senior nurses often had no official authority over their juniors by virtue of their experience. A Lady Superintendent had hospital duty alongside her administrative responsibilities, making it difficult for her to exercise disciplinary functions over the members of the service. Thus, the nursing administration suffered from lack of a well-defined ‘chain of responsibility’. There was also a level of ‘professional deterioration’ caused by the want of facilities to keep the nurses updated with ‘modern knowledge and methods’. 126 This was in some ways similar to other areas of colonial knowledge practice whereby, for instance, the practitioners of science in the ‘periphery’ felt deficient and deprived of some of the advantages of the ‘metropolis’ - especially the opportunity of being acquainted with the latest developments in such centers in Europe. 127

A deficiency in discipline was also observed in the work of the nursing orderlies. A soldier was not assigned nursing duty as orderly for more than six months, since a prolonged period in the hospital was regarded as detrimental to his efficiency as a ‘fighting soldier’. Though the orderlies were provided training, it was described to be of a ‘perfunctory’ nature, because of the limited time in which it was conducted. They were ‘at the will’ of the commanding officers who could call them out of their nursing assignment for regimental training or into mobilization. 128 Thus, the trained nursing sisters seem to have had no real authority over the male nursing orderlies.

Apart from partial training of orderlies and frequent change of personnel, the quality of nursing in the British station hospitals was also believed to be affected by the employment of Indian ward servants to perform nursing duties – something that was explicitly considered to be a ‘mistake’. Such servants were described as men of ‘very low caste’ who were ‘venal and dirty’ in their habits, and were portrayed as indifferent and untrustworthy when it came to performing even the most menial nursing tasks. 129 Thus the natives were considered unfit to provide western nursing care. They were not given any nursing training like the British nursing orderlies got.

All this has to be contrasted with the scenario in Indian station hospitals meant for Indian soldiers, and the station family hospitals meant for the families (women and children), of British officers and soldiers. In the Indian station hospitals ‘scientific nursing’ was pronounced ‘non-existent’ since there were no trained nurses employed there. Untrained Indian sepoys were attached to the hospital as ward orderlies. These men were as a rule those who had failed in some ways as soldiers. 130 In the station family hospitals, the nursing functions were the responsibility of a matron who was trained and certified in midwifery. They were also assisted by some ‘menial female servants’. Unlike the nursing sisters in the station hospitals for British army men, the matron in a station family hospital had no training in general nursing. Regarding the matron, it was reported: ‘…though she may be an efficient midwife, she cannot have that knowledge of ordinary sick-nursing which is essential for the proper attendance on the various classes of cases that find admission to the hospitals’. 131 The lack of nursing sisters in Indian station hospitals and station family hospitals further points to the reality that the government was willing to employ trained nurses only for the British men in the army.

The nursing service for the army provided an important arena for the unfolding of female agency in the British empire. The introduction of trained female nurses in colonial India was initially resisted on considerations of cost, and over concerns regarding the moral implication of feminine presence in a masculine military environment. These hesitations were gradually overcome when, as a result of reforms in Britain, nursing work began to be recognised as a feminised profession. These developments coupled with effective lobbying led to the formation of the Indian Nursing Service, through which British nursing sisters were employed in station hospitals meant exclusively for British soldiers and officers.

As a newly instituted service, the patriarchal colonial government maintained a tight hold over its functioning, often repudiating the opinions of the Lady Superintendent in charge of the service - who was granted a semblance of power, but no real authority. The government’s financial stringency impeded the expansion of the service, and compromised the welfare of the sisters. Moreover, the ambiguous framing of the role and status of female nurses in an otherwise rigid, male dominated military medical hierarchy, created tensions in the relationship of the sisters with the male nursing orderlies, sub-medical and medical officers, and undermined the nurses’ agency. Thus, in the initial years of the INS, the government employed female agency without legitimising it.

The agency of the nursing sisters which was characterised by their embodied skill and expertise, acquired through their training and experience in civil hospitals in Britain, was challenged in the colonial setting. The expertise of the sisters had to be adapted to handle the epidemiological conditions in India. Moreover, the itinerant nature of the military, medical, and nursing services in India, along with gender-based tensions, were detrimental for cultivating an environment of mutual trust and confidence between the medical and nursing staff in military hospitals. Due to this the expertise of the sisters was not adequately validated. Despite these challenges, the sisters were instrumental in setting army nursing on a professional footing, by using their expertise for codifying nursing practices for military hospitals, and building a pedagogic tradition for training nursing orderlies.

The nursing sisters as part of a pioneering, all-women service, were held to scrutiny and criticism both professionally and socially. The sisters, who were mostly young single women, were expected to uphold the dignity of their professional identity even while engaging in the social life in military stations. For this purpose, it was insisted that women of ‘good’ social background be appointed to the service, so that they could maintain the ideals of feminine purity while engaging in a masculine military setting, and elicit deference from the nursing orderlies who were British soldiers of ‘inferior’ social class. Thus, in order to maintain the image of the service, the colonial authorities imposed conditions and regulations on the sisters, which reflected the prevalent gender and caste notions.

By the beginning of the twentieth century, the nursing service for the army was firmly established in colonial India. The role of the British lady nurses in maintaining the health of the army, made them an integral part of the colonial machinery. However, the government continually showed an attitude of neglect towards the nursing service and hesitated to spend in that domain. There were no trained nurses employed in the hospitals for the Indian troops. This left the nursing service in the military hospitals with much to be desired even three decades after its inception. However, one cannot deny its foundational role in an important aspect of health care, as also its significant place (however small) in the broader imperial order.

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7 Holton, op. cit. ( note 5 ), 60.

8 Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and in War (London: Harrison and Sons, 1858), 1–133: 15.

9 See Healey, op. cit. ( note 2 ).

10 Gérard Vallée (ed.), Florence Nightingale on Health in India , The Collected Works of Florence Nightingale, Vol. 9 (Ontario: Wilfrid Laurier University Press, 2006), 950–955.

11 See Healey, op. cit. ( note 2 ).

12 Gourlay Jharna, Florence Nightingale and the Health of the Raj (Aldershot: Ashgate, 2003), 28 [ Google Scholar ] .

13 Report of the Commissioners Appointed to Inquire into the Sanitary State of the Army in India; With Abstract of Evidence, and of Reports Received from Indian Military Stations (London: Her Majesty’s Stationery Office, 1864), 330.

14 Reports of the Royal Commission on the Sanitary State of the Army in India. Vol. II (London: Her Majesty’s Stationery Office, 1863), 38.

15 Report of the Commissioners, op. cit. ( note 13 ).

16 Sam Goodman, ‘Lady Amateurs and Gentleman Professionals: Emergency Nursing in the Indian Mutiny’, in Helen Sweet and Sue Hawkins (eds), Colonial Caring: A History of Colonial and Post-Colonial Nursing (Manchester: Manchester University Press, 2015), 18–40: 19.

17 Vallée, op. cit. ( note 10 ), 947; Reports of the Royal Commission , op. cit. ( note 14 ), 38.

18 Vallée, op. cit. ( note 10 ), 953.

19 ‘Female Nurses in Military Hospitals’, Medical Times and Gazettes: A Journal of Medical Science, Literature, Criticism, and News, 2, July to December (1867), 230–231: 231.

20 Vallée , op. cit. ( note 10 ), 969.

21 Razzell P. E., ‘ Social Origins of Officers in the Indian and British Home Army: 1758-1962 ’, The British Journal of Sociology , 14 , 3 (1963), 248–260 [ Google Scholar ] : 248.

22 These differential characterisations of the British officers and soldiers in India was a reflection of the class notions existing in Britain at that time. See Erica Wald, ‘Health, Discipline and Appropriate Behaviour: The Body of the Soldier and Space of the Cantonment’, Modern Asian Studies, 46, 4 (2012), 815–856: 851; Douglas M. Peers, ‘Privates off Parade: Regimenting Sexuality in the Nineteenth-Century Indian Empire’, The International History Review , 20, 4 (1998), 823–854: 836.

23 Waltraud Ernst argues that it was the British anxiety to preserve their image as a superior people that caused them to hide away and send home British lunatics in India, who could tarnish and bring disrepute to colonial rule. See Ernst Waltraud, Mad Tales from the Raj: The European Insane in British India, 1800-1858 (London: Routledge, 1991), 126 [ Google Scholar ] . Also see Stoler Ann Laura, ‘ Making Empire Respectable: The Politics of Race and Sexual Morality in 20th-Century Colonial Cultures ’, American Ethnologist 16 , 4 (1989), 634–660 [ Google Scholar ] .

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25 Vallée, op. cit. ( note 10 ), 965.

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27 ‘Female Nurses’, op. cit. ( note 19 ), 230–231.

28 Vallée, op. cit. ( note 10 ), 965–966.

29 Summers Anne, Angels and Citizens: British Women as Military Nurses, 1854-1914 (London: Routledge & Kegan Paul, 1988), 2 [ Google Scholar ] .

30 See Piggott Juliet, Queen Alexandra’s Royal Army Nursing Corps (London: Cooper, 1975) [ Google Scholar ] .

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32 Summers, op. cit. ( note 29 ), 6.

33 Rosemary Fitzgerald, ‘Making and Moulding the Nursing of the Indian Empire: Recasting Nurses in Colonial India’, in Avril A. Powell and Siobhan Lambert-Hurley (eds), Rhetoric and Reality: Gender and the Colonial Experience in South Asia (New Delhi: Oxford University Press, 2006), 185–222: 186.

34 ‘Lady Robert’s Proposal of Trained Nurses for India’, The British Medical Journal, October (1887), 744.

35 Sarah A. Tooley, The History of Nursing in the British Empire (London: S. H. Bousfield & Co, 1906), 349.

36 Loch Catharine Grace, Catharine Grace Loch, Royal Red Cross, Senior Lady Superintendent , Queen Alexandra’s Military Nursing Service for India: A Memoir , A. F. Bradshaw (ed.) (London: Henry Frowde, 1905), 1–6 [ Google Scholar ] .

37 Ibid. , 338–339.

38 ‘Specimens of Forms Used in Recruitment of Indian Medical Service Officers and Nurses of Queen Alexandras’s Military Nursing Service for India’, 1897-1911, IOR/L/MIL/7/19351, British Library; The nursing sisters were likely to leave the service if they were married. See ‘Indian Nursing Service: Registers of Indian Nursing Service Candidates, 1887-1902, IOR/L/MIL/9/430, British Library.

39 Arkle A., ‘ The Indian Army Nursing Service ’, The American Journal of Nursing , 2 , 9 (1902), 652–655 [ Google Scholar ] : 652.

40 ‘Indian Nursing Service: Registers of Indian Nursing Service Candidates, 1903-1916, IOR/L/MIL/9/431, British Library, 49–50.

41 For more understanding on ‘embodied skill’ and ‘embodied expertise’, see Bertucci Paola, ‘Spinners’ Hands, Imperial Minds: Migrant Labor, Embodied Expertise, and the Failed Transfer of Silk Technology across the Atlantic’ , Technology and Culture , 62 , 4 (2021), 1003–1031 [ PubMed ] [ Google Scholar ] .

42 Loch, op. cit. ( note 36 ), 344.

43 See Harrison, op. cit. ( note 1 ).

44 Arkle, op. cit. ( note 39 ).

45 Loch, op. cit. ( note 36 ), 57.

46 Arkle, op. cit. ( note 39 ).

47 Loch, op. cit. ( note 36 ), 338.

48 ‘Grant of an Increase of Pay to Each Nursing Sister and Senior Nursing Sister After Completing Five Years Service in Either of these Grades’, Government of India (Army Department), Principal Medical Officer’s Division, Medical Department – Nurses-A, Proceedings, July 1907, Nos. 975–981. National Archives of India (hereafter NAI).

49 Arkle, op. cit. ( note 39 ), 653–655.

50 Loch, op. cit. ( note 36 ), 347.

51 Arkle, op. cit. ( note 39 ), 655.

52 Loch, op. cit. ( note 36 ), 326.

53 Ibid. , 347.

54 Ibid. , 70.

55 Ibid. , 57-58.

56 Ibid. , 37-39.

57 Ibid. , 69.

58 Ibid., 37–39.

59 Ibid. , 40.

60 Lovett Verney, Report of the Committee Appointed by the Government of India to Examine the Question of the Reorganization of the Medical Services in India (London: His Majesty’s Stationery Office, 1920), 53 [ Google Scholar ] .

61 ‘Hill Homes for Nursing Sisters in India’, The Indian Magazine , January-December (1887), 509.

63 See Kennedy Dane Keith, The Magic Mountains: Hill Stations and the British Raj (Los Angeles: University of California Press, 1996) [ Google Scholar ] ; Clarke Hyde, ‘ The English Stations in the Hill Regions of India: Their Value and Importance, with Some Statistics of Their Products and Trade ’, Journal of the Statistical Society of London , 44 , 3 (1881), 528–573: 560 [ Google Scholar ] .

64 Lady Roberts’ Fund was started with the objective of providing homes in the hills for nurses working in military hospitals in India. See Tooley, op. cit. ( note 35 ), 350.

65 Murree was a hill station in the Punjab region of British India.

66 Loch, op. cit. ( note 36 ), 45.

68 Lovett, op. cit. ( note 60 ), 100.

69 Loch, op. cit. ( note 36 ), 42.

70 ‘Grant of an Increase of Pay’, op. cit. ( note 48 ).

71 Loch, op. cit. ( note 36 ), 343.

72 Lovett, op. cit. ( note 60 ), 100–101.

73 Loch, op. cit. ( note 36 ), 341.

74 Arkle, op. cit. ( note 39 ), 653; Loch, op. cit. ( note 36 ), 341–342.

75 Loch, op. cit. ( note 36 ), 341–342.

77 Arkle, op. cit. ( note 39 ), 654.

78 Loch, op. cit. ( note 36 ), 41–42.

80 D.G. Crawford, ‘The Indian Medical Service’, The Indian Medical Gazette (May 1907), 192–198: 193.

81 Loch, op. cit. ( note 36 ), 344.

82 Ibid. , 44.

84 Ibid. , 290.

85 Ibid. , 291.

86 Ibid. , 292–293.

87 Ibid. , 351.

88 Ibid. , 328–329.

89 Ibid. , 72.

90 Ibid. , 71.

91 Ibid. , 330.

92 Ibid. , 351.

93 Ibid. , 350.

94 ‘Adoption of an Uniform Dress for the Members of the Indian Nursing Service’, Government of India (Military Department), Proceedings, January 1900, Nos. 2475-2476. NAI. See Jane Brooks and Anne Marie Rafferty, ‘Dress and Distinction in Nursing, 1860–1939: “A Corporate (as well as Corporeal) Armour of Probity and Purity”’, Women’s History Review, 16, 1 (February 2007): 41–57.

95 Loch, op. cit. ( note 36 ), 329–330.

96 For an account on similar experience of British nurses in colonial West Africa, see Dea Birkett: ‘The “White Woman’s Burden” in the “White Man’s Grave”: The Introduction of British Nurses in Colonial West Africa’, in Nupur Chaudhuri and Margaret Strobel (eds), Western Women and Imperialism: Complicity and Resistance (Bloomington: Indiana University Press, 1992), 177–188.

97 The India List and the India Office List for 1902 (London: Harrison and Sons, 1902), 209.

98 Ibid. , 211.

99 Gorham, op. cit. ( note 3 ), 29.

100 Summers, op. cit. ( note 29 ), 4.

101 Loch, op. cit. ( note 36 ), 98.

102 Ibid., 97–98.

103 Claudia Klaver, ‘Domesticity under Siege: British Women and Imperial Crisis at the Siege of Lucknow, 1857’, Women’s Writing, 8, 1 (2001), 21–58: 25; Also see MacMillan Margaret, Women of the Raj: The Mothers, Wives, and Daughters of the British Empire in India (New York: Random House: 2007) [ Google Scholar ] .

104 Goodyear Sara Suleri, The Rhetoric of English India (Chicago: University of Chicago Press, 1992), 8 [ Google Scholar ] .

105 See Kumari Jayawardena, The White Woman’s Other Burden: Western Women and South Asia during British Colonial Rule (New York: Routledge, 1995), 75; Maneesha Lal, ‘The Politics of Gender and Medicine in Colonial India: The Countess of Dufferin’s Fund, 1885-1888’, Bulletin of the History of Medicine, 68, 1 (1994): 29–66; Samiksha Sehrawat, ‘Feminising Empire: The Association of Medical Women in India and the Campaign to Found a Women’s Medical Service’, Social Scientist, 41, 5/6 (May 2013): 65–81.

106 Forbes Geraldine, ‘ In Search of the ‘Pure Heathen’: Missionary Women in Nineteenth Century India ’, Economic and Political Weekly , 21 , 17 (1986), 2–8 [ Google Scholar ] : 3. Also see Rhonda Anne Semple, Missionary Women: Gender, Professionalism, and the Victorian Idea of Christian Mission (New York: Boydell Press, 2003).

107 Loch, op. cit. ( note 36 ), 315.

108 Ibid., 329.

109 William St John Brodrick was the British Secretary of State for War. See ‘The Reorganisation of the Army and Indian Nursing Service’, The Lancet, October-December (1901), 986; Charlotte Dale argues that the need for nursing expertise during the second Anglo-Boer War (1899-1902), provided the impetus for the formation of the QAIMNS. See Charlotte Dale, ‘Traversing the Veldt with ‘Tommy Atkins’: The Clinical Challenges of Nursing Typhoid Patients During the Second Anglo-Boer War, 1899–1902’, in Jane Brooks and Christine E. Hallett (eds), One Hundred Years of Wartime Nursing Practices, 1854-1953 (Manchester: Manchester University Press, 2015), 58–78.

110 Please note the difference between QAIMNS and QAMNSI.

111 Lovett, op. cit. ( note 60 ), 101.

112 Loch died in 1904. R. A. Betty succeeded Loch as the Chief Lady Superintendent of QAMNSI. See Tooley, op. cit. ( note 35 ), 350.

113 Lovett, op. cit. ( note 60 ).

114 ‘Grant of an Increase of Pay’, op. cit. ( note 48 ).

115 ‘Increase to the Establishment of the Indian Nursing Service’, Government of India (Military Department), Medical Department – Nurses-A, Proceedings, December 1902, Nos. 2033–2036. NAI.

116 Tooley, op. cit. ( note 35 ), 350.

117 ‘Grant of an Increase of Pay’, op. cit. ( note 48 ).

118 ‘The Reorganisation’, op. cit. ( note 109 ), 986.

119 Truman M. R., Simple Lectures on Nursing for Soldiers in India (Allahabad: The Pioneer Press, 1912) [ Google Scholar ] .

120 The India List, op. cit. ( note 97 ), 211.

121 Truman, op. cit. ( note 119 ).

123 Anne Marie Rafferty argues that education is an important part of professional work and expertise, that plays a pivotal role in shaping an occupational culture and politics. See Rafferty Anne Marie, The Politics of Nursing Knowledge (London: Routledge, 1996) [ Google Scholar ] .

124 Ashleigh Wadman, ‘Nursing for the British Raj’, Australian War Memorial (blog), October 28, 2014, https://www.awm.gov.au/articles/blog/nursing-british-raj . Sisters of the Australian Army Nursing Service (AANS) were sent to India in 1916, to specifically serve in Indian war hospitals that received British and Indian troops wounded at Mesopotamia. The Indian government saved expenditure by employing Australian nurses as they were not granted the allowances availed by the British nurses. For more on AANS sisters, see Samraghni Bonnerjee, ‘“This Country is Rotten”: Australian Nurses in India during the First World War and Their Encounters with Race and Nationhood’, Australian Journal of Politics & History, 65, 1 (March 2019): 50–65.

125 Lovett, op. cit. ( note 60 ), 101.

126 Ibid. , 53.

127 See David Arnold, Science, Technology, and Medicine in Colonial India , The New Cambridge History of India, III, 5 (Cambridge: Cambridge University Press, 2000).

128 Lovett, op. cit. ( note 60 ), 53.

130 Ibid. , 54.

131 Ibid. , 53.

Competing interest

The authors declare none.

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