The year 2020 has been designated as “International Year of the Nurse and the Midwife” . Nurses and midwives will be central to achieving universal health coverage in India. India’s nursing workforce is about two-thirds of its health workforce. Its ratio of 1.7 nurses per 1,000 population is 43% less than the World Health Organisation norm; it needs 2.4 million nurses to meet the norm. In addition to the low number of nurses, the sector is dogged by structural challenges that lead to poor quality of training, inequitable distribution, and non-standardised practices. Here are the challenges and the potential solutions to them.
Nursing education in India has a wide array of certificate, diploma, and degree programmes for clinical and non-clinical nursing roles. The Indian Nursing Council regulates nursing education through prescription, inspection, examination, and certification. However, the induction requirements vary widely and so does the functioning of regulatory bodies in the States. In addition, 91% of the nursing education institutions are private and weakly regulated. The quality of training of nurses is diminished by the uneven and weak regulation.
The current nursing education is outdated and fails to cater to the practice needs. The education, including re-training, is not linked to the roles and their career progression in the nursing practice. There are insufficient postgraduate courses to develop skills in specialties, and address critical faculty shortages both in terms of quality and quantity. These factors have led to gaps in skills and competencies, with no clear career trajectory for nurses.
Multiple entry points to the nursing courses and lack of integration of the diploma and degree courses diminish the quality of training. A common entrance exam, a national licence exit exam for entry into practice, and periodic renewal of licence linked with continuing nursing education would significantly streamline and strengthen nursing education. Transparent accreditation, benchmarking, and ranking of nursing institutions too would improve the quality.
Though the number of nursing education institutions has been increasing steadily, there are vast inequities in their distribution. Around 62% of them are situated in southern India.
Further, despite the growth, there is little demand for postgraduate courses. Recognising the need for specialty courses in clinical nursing 12 post graduate diploma courses were rolled out. These courses never did well due to lack of admissions, because the higher education qualification is not recognised by the recruiters. Further, the faculty positions vacant in nursing college and schools are around 86% and 80%, respectively.
Gaps in education, services
Most nurses working in the public and private health sector are diploma holders. There is a lack of job differentiation between diploma, graduate, and postgraduate nurses regarding their pay, parity, and promotion. Consequently, higher qualifications of postgraduate nurses are underutilised, leading to low demand for postgraduate courses. Further, those with advanced degrees seek employment in education institutions or migrate abroad where their qualifications are recognised. This has led to an acute dearth of qualified nurses in the country. Compounding the problem, small private institutions with less than 50 beds recruit candidates without formal nursing education. They are offered courses of three to six months for non-clinical ancillary nursing roles and are paid very little.
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The nursing practice remains largely unregulated in the country. The Indian Nursing Act primarily revolves around nursing education and does not provide any policy guidance about the roles and responsibilities of nurses in various cadres. Nurses in India have no guidelines on the scope of their practice and have no prescribed standards of care. This may endanger patient safety. It is a major reason for the low legitimacy of the nursing practice and the profession. Additionally, the mismatch of the role description and remuneration that befits the role sets the stage for the exploitation of nurses.
The Consumer Protection Act which protects the rights and safety of patients as consumers, holds only the doctor and the hospital liable for medico-legal issues; nurses are out of the purview of the Act. This is contrary to the practices in developed countries where nurses are legally liable for errors in their work.
Basic institutional reforms will be required to address the three issues. First, the governance of nursing education and practice must be clarified and made current. The Indian Nursing Council Act of 1947 must be amended to explicitly state clear norms for service and patient care, fix the nurse to patient ratio, staffing norms and salaries. The jurisdictions of the Indian Nursing Council and the State nursing councils must be explained and coordinated so that they are synergistic.
The exodus of qualified nurses must be contained. Incentives to pursue advanced degrees to match their qualification, clear career paths, opportunity for leadership roles, and improvements in the status of nursing as a profession will be key steps to do so. A live registry of nurses, positions, and opportunities should be a top priority to tackle the demand-supply gap in this sector.
Public-private partnership between private nursing schools/colleges and public health facilities is another strategy to enhance nursing education. The National Institution for Transforming India (NITI) Aayog has recently formulated a framework for public-private partnership in medical education that could be referred to develop a model agreement for nursing education. The Government has also announced supporting such projects through a Viability Gap Funding mechanism.
A Bill that could spell hope
The disabling environment prevalent in the system has led to the low status of nurses in the hierarchy of health-care professionals. In fact, nursing has lost the appeal as a career option. The National Nursing and Midwifery Commission Bill currently under consideration (https://bit.ly/2W7ZFP9) should hopefully address some of the issues highlighted. These disruptions are more relevant than ever in the face of the COVID-19 pandemic.
Dr. Vijayashree Yellappa is Senior Specialist, Health Systems Transformation Platform (HSTP), New Delhi and Fellow, National Institution for Transforming India (NITI) Aayog. The views expressed are personal