‘Nursing in India is a very strong profession and has already celebrated more than 100 years of its professional existence. Being the pillar of the healthcare sector, it is unimaginable to look at healthcare delivery without thinking about the nurse,” says Phalakshi Manjrekar, Director – Nursing, PD Hinduja Hospital, Mumbai, who feels proud that by choosing nursing as her career, she has dedicated her life in service of the people. Like Manjrekar, there are many ministering angels who in their own small ways have touched the lives of millions. Yet, the profession still hasn’t managed to gain the glory and continues to remain neglected, battling with several obstacles in its path towards success.
The story so far…
Nursing in India can trace its roots to healthcare practiced since ancient times. However, today, it is predominantly woman’s domain but prior to the 20th century in India, Indian nurses were usually young men, and women were majorly midwives who conducted childbirth. The progress of nursing as a profession in those days was obstructed by the low status of women, the caste system, illiteracy and political unrest.
However, the beginning of the 20th century, brought in the winds of change for the profession. The discipline of nursing slowly evolved from the traditional roles, apprenticeship and humanitarian aims as a professional career with the introduction of nursing education. Nevertheless, as the profession began to progress still further, many roadblocks came in its path. The biggest one being no recognition by the government. This drawback began to discourage many who sought to take up nursing as a career; especially those working in the government sector. The healthcare sector noted a decline in the number of skilled nurses.
The turning point
 “Nurses should be given prominent positions in the State and Central governments’ Health Ministries and as representatives of UN.”Phalakshi Manjrekar Director – Nursing, PD Hinduja Hospital, Mumbai |
After decades of neglect, a respite came when the Government of India recognised the role of nursing as pivotal to the performance of the National Rural Health Mission (NRHM), and consequently a priority policy was issued, during the 9th Five Year Plan, to introduce a new scheme, known as the Development of Nursing Services.
As per the policy, nursing education and nursing services have been given high priority in order to bridge the large gap between requirement and availability of nurses and improve the quality of nursing training.
Some provisions of the policy are highlighted below:
- Appropriate changes in syllabus, curriculum, teaching methods and assessment system (initiated by Indian Nurses Council) will be made through various professional councils to improve the undergraduate and post-graduate training
- New 3500 nursing education institutions have been given an approval on high priority in order to bridge the gap between requirement and availability
- In addition, efforts will be made to meet the increasing demand of specialised and sub-specialised areas for intensive nursing care in the healthcare system.
Current scenario
Despite the efforts taken in the 9th Five Year Plan, the number of nursing professionals kept dipping. In accordance with the statistics provided by the National Institute of Mental Health and Neurosciences (Nimhans) in March 2012, ‘India is currently facing a scarcity of around 40-50 per cent of nursing professionals’. The World Health Organisation (WHO) reveals that the current nurses to population ratio in India is 1:1205 as against 1:100-150 in Europe. The nurse to patient ratio in private healthcare is around 1:5-10 which is slightly better than that in government where it ranges from 1:35-50 patients in general ward.
 “The government needs to allot a separate fund for nursing sector development.”Rekha Dubey COO, Aditya Birla Hospital, Pune |
More so, experts observe that in certain states, shortage of nurses is more severe. Lt Col Saravjeet Kaur, Director- Nursing, Max Healthcare Institute, points out that states of Chhattisgarh, Jharkhand, Meghalaya, Manipur, Mizoram, Tripura, Uttarakhand and Delhi face the maximum shortage of nurses. Rekha Dubey, COO, Aditya Birla Hospital, Pune draws attentions towards the city of Bengaluru which according to her is currently facing a huge shortage of nursing professionals. Alluding to immigration of nurses from India to the Gulf countries, Rajendra Pratap Gupta, Member, World’s Economic Forum’s (WEF) Global Agenda Council; Member, Technical Resource Group (II), Ministry of Health & Family Welfare, Government of India, feels that the southern states of Kerala and Karnataka would have the highest shortage.
Recognising the urgency of the situation and in the interest of patient care, the National Health Policy (NHP) last year, emphasised the need for an improvement in the ratio of nurses vis-a-vis doctors/beds. It also emphasised on improving the skill level of nurses and increasing the ratio of degree-holding nurse’s vis-à-vis diploma holding nurses.
On the other hand, the National Development Council (NDC), along with the Planning Commission, conducted a meeting in December 2012 to discuss on the severe shortage of doctors and nurses in India. During the discussion, the Planning Commission explained that the doctor to nurse ratio ideally should be at least 1:3 for the team to perform optimally. This ratio is currently 1:1.6 and is expected to improve to only 1:2.4 by end of the 12th plan if no new colleges are started. It further highlighted that if India adopts a goal of 500 health workers per lakh population by the end of 13th plan, we will need an additional 240 medical colleges, 500 general nursing and midwifery colleges and 970 auxiliary nurse midwives training institutes. Further, during the discussion, the NDC released a document that stated if work on these new teaching institutions begin from the 2013-14 and is completed by the end of the 12th plan, the ratio of doctors to nurses will then rise from 1:1.6 in 2012 to 1:2.8 in 2017 and reach 1:3 in 2022.
In line with same, Finance Minister, P Chidambaram, while presenting the Union Budget 2013, called education in health as a priority area for this fiscal year and allocated Rs 1650 crores for setting up six AIIMS-like institutes and Rs 4,727 crores for medical education, research and training.
A good move indeed. However, will increasing medical colleges and nursing institutes play a pivotal role in boosting the current state of the nursing sector in India? Is it the only solution that we can find at present?
The answer to this is uncertain. A topic, debated and discussed at several industry meets as well as national forums, without arriving at any productive solutions so far. The huge paucity of nurses is not only due to lack of training institutes but caused by many other factors as well.
Reasons for shortage
 “Research indicates that 35 per cent fewer women would choose nursing as a career in the coming years.”Mugdha Lad Head Nursing, Hinduja Healthcare Surgical |
Industry experts say that the growing number of aging population, high attrition rate among nurses, drop-outs due to poor working conditions, no proper nursing policy and low professional profiles of nurses at workplace are few factors that have contributed to the shortage.
Shedding light on these issues, experts elaborate:
Exodus of nurses to greener pastures: “Opportunity to work in various foreign countries like Dubai, Saudi Arabia, the US, the UK, New Zealand, Australia etc., with attractive facilities, free travel, accommodation, leave and a pay scale which is 10 times more than they obtain in India, better facilities for family, a good life style and affordable education for children are some reason why nurses from India migrate abroad,” observes Manjekar. Sharing some statistics on the attrition rate among nurses in India, Mugdha Lad, Head Nursing, Hinduja Healthcare Surgical states that nearly 50 per cent of the nursing staff leave within two years of service, 30 per cent work for about five years and those continuing beyond five years are less than 20 per cent. Most of the nurses, who join are just out of nursing colleges. They look for some experience to make their resume look better. Once they gain the clinical experience and learn about hospital functioning, they apply for jobs abroad that pay them nearly eight times more than what they get here, besides added benefits such as housing, food and other perks. “It’s the lure of foreign jobs that bring young nurses to hospitals for experience and then takes them away. Most hospitals are treated as training schools by young nurses,” she adds. Referring to a survey conducted at one of the government hospitals, Lad also revealed that nurses working in the government sector seemed to be more worried about being unable to adjust to working conditions abroad, and therefore are less keen to migrate. “The fact that they enjoy better pay scales, a more relaxed work atmosphere and more facilities may have also played a part here,” she chips in.
Professional alternatives: Both men and women these days are weighing their interests with multiple career choices available to ensure worthy compensation as well as enhanced quality of life. Unfortunately, the nursing sector currently lacks this. “Women who once willingly took up nursing as thier career are now entering law schools, medical schools, and the corporate world in droves. Research indicates that 35 per cent fewer women would choose nursing as a career in the coming years,” declares Lad.
Declining enrollment and educators: Lad also observes that in the past six years, new admissions into nursing schools have dropped dramatically and consistently. She says that nursing colleges and universities deny many qualified applicants due to the shortage of nursing educators.
Geographic maldistribution of nurses training capacity: Increase in the number of nursing institutions has been accompanied by deepening geographical imbalances. “The southern states of Andhra Pradesh, Karnataka, Kerala, and Tamil Nadu have 63 per cent of the general nursing colleges in the country, 95 per cent of which are private, with the others distributed unevenly across the rest of the country. The distribution of nursing institutions that offer higher education (ie, BSc and MSc degrees) is even more disproportionately distributed—78 per cent are located in the four southern states, all of which have higher numbers of nurses and midwifes per 10000 population than the national average (7·4 per 10000 population). “States such as Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh have fewer numbers of nurses per 10000 population than the national average, but account for only nine per cent of nursing schools in the country,” notes Lt Col Kaur.
No proper gazette status: Apart from all the other issues that plague the sector, the nursing sector is also apprehensive of the fact that nurses are not involved in making policies that govern their status and practice. “Most of the decisions concerning nursing care and nurses are made by other people, usually physicians without the inputs from nursing professionals. It is possible that this situation is the direct result of lack of appropriate status accorded to the nursing staff. Nearly 97 per cent of nursing staff are given a lower status by the government (Group ‘C’ category). The need of the hour is that the nurse practitioner and our nursing policy must be modified. The job description for the modern nurse needs to be reviewed and revised,” points out Col Binu Sharma, VP-Nursing Services, Columbia Asia Hospitals. Moreover, the current nursing policy focusses only on increasing the number of nursing professionals, but doesn’t seem to have any apropos initiatives to uplift the profession, the industry feels.
Well, as the nursing sector in India bends over backwards in order to improve its current state, there is a lot of scope for betterment in the coming years.
Measures for progress
 “Nearly 97 per cent of nursing staff are given a lower status by the government. The need of the hour is that the nursing policy must be modified.” Col Binu Sharma VP – Nursing Services, Columbia Asia Hospitals |
For sustained improvement within the nursing sector, various steps need to be taken in areas such as education and training of nurses, creating safe and hygienic working conditions, developing policy and regulations that will be beneficial to nursing professionals and other auxiliary healthcare workers, as well as elevate the current image of nurses in India.
Firstly, the government needs to focus on altering the current nursing policy. “There is a need for a national nursing policy within the framework of national health policy and national health planning,” affirms Col Sharma. Manjrekar recommends that nurses should be given prominent positions in the State and Central governments’ Health Ministries and as representatives of UN to give them a platform to voice opinions and influence decisions related to the development of nursing as a profession in India.
Further, Col Sharma points out that the recruitment process in the government sector needs to be made more transparent. Some experts blame the economic reservations within government hospitals for recruiting unskilled nursing and auxiliary staffs. Few nursing professionals opine that these healthcare workers do not have the basic know-how about hygiene and patient safety. Moreover, deserving students do not get the opportunities available at government hospitals. Therefore, a fair and transparent recruitment process for nursing professionals in the government sector is one step that can help generate skilled nursing staff.
With a view to improve healthcare delivery within the hinterlands of India, Manjrekar advocates improving infrastructure of hospitals and PHCs so that nurses stationed at these healthcare set ups have proper infrastructure and a better working conditions there. “The rural areas of India are in dire need of nurses and the present facility already comprises multiple roles developed for the nurses to meet this requirement. However, if the rural nurse-patient ratio is bettered and nurses are given adequate facilities and infrastructure to work, the beneficiaries of rural India will benefit,” she points out.
Lt Col Kaur is of the opinion that there is a need to develop new roles for nurses in the rural areas of India. She says that nurses can work in positions that link hospital and community practice and provide a combination of acute care, health promotion and prevention services. They can also play roles as nurse practitioners, advisers, resource person, liaison and speciality nurses. This will help them to enhance their skill set.
Drawing our attention towards upgrading the image of nursing professionals in India, especially in the private sector, Gupta suggests, “Nurses must be given the opportunities to upgrade not only in their roles but also the scope of work. They must be given the option to improve their skills, take up senior roles and rise up to become hospital administrators, COO’s etc. Also, for critically ill patients, nurses must be authorised to administer certain medications based on the formulary agreed by the hospital doctors as per emergency treatment protocols . We urgently need chronic care certified registered nurse practitioners who can help manage chronic illnesses”. He continues, “India’s healthcare system is built around a doctor and his treatment; however, if nurses and other healthcare workers are also given a pivotal role in public health, this initiative would perk up the nursing sector in India.”
 “Many nurses in India battle with the fact that they do not get the opportunity to grow.”Dr Sheelagh Martindale Head of Professional Development Robert Gordon University |
“Many nurses in India battle with the fact that they do not get the opportunity to grow. We think if nurses are involved in the day-to-day management of the hospital, this not only develops a healthy working environment but also adds value to the healthcare delivery provided at the hospital,” expresses Dr Sheelagh Martindale, Head of Professional Development, Robert Gordon University and Vanessa Smith, Critical Care Nursing Lecturer, Robert Gordon University during their visit to India this February. Speaking about her observation during the Critical Care Nursing Conference, conducted by the Holy Spirit Hospital, Mumbai in association with the Robert Gordon University in February 2013, Dr Martindale informed that nursing education plays a critical role in promoting the profession. She observed during the conference that Indian nurses are very keen in educating and upgrading themselves in specialised courses. So Indian hospital and teaching institutions need to add specialised nursing courses in various medical sub-specialities to create more avenues for nurses as well as uplift the current nursing education curriculum.”
“What the public generally thinks about nursing and how the media portrays nursing shapes the current image of the profession,” adds Lad, talking about the role of media to better the image of nurses in India. She goes on to say, “The public has heard about the stress nurses are experiencing, the shortage of staff, and stories of nursing errors that have injured or killed patients. Needless to say, the images provided by stories such as these do not bolster the desire to enter the profession. Nursing appears as an unstable, unpredictable, and high-risk career option. Two national media campaigns have been launched to refine the image of nursing. ‘Nurses for a Healthier Tomorrow’ is a coalition of 44 healthcare organisations working together to raise interest in nursing careers among high school students. It has often been said that in order to ensure a continuous flow of nursing students, children must be reached at an earlier age. Educators say that students often have their minds made up by the fifth grade about desirable and undesirable careers, thus an early positive image of nursing is imperative. Another market that needs to be pursued is males. Currently, male nurses account for only 5.7 per cent of all nurses. If men were to enter nursing at the same rate as women, shortages would not be a concern. In order to influence men to enter the nursing profession, society and the media must eliminate barriers and stigmas facing men who may choose this career”.
“Apart from creating better working conditions and encouraging men to join the nursing profession, which indeed is a good suggestion, renewal of licenses based on credit points of Continuing Nursing Education (CNE) to be applied all over India should also be considered,” urges Lad. “The government should take an effort to recognise nursing education at par with any other university education programme. A nurse who undertakes a General Nursing & Midwifery (GNM) programme has to successfully pass HSc or its equivalent to enroll in this three and half year course. In equivalence to any other educational programme after 12th, recognition of GNM or converting it into a University Degree Programme or merging it with BSc Nursing Programme is strongly advised to standardise nursing education for these young nurses,” reckons Manjrekar.
Adding few more step toward improving nursing education in India, Dubey lists down her recommendations:
- Allotment of separate fund by government for nursing sector development.
- Permission to open more nursing colleges as well as strengthening the capacity of nursing colleges.
- Making it mandatory that 150-200 bedded hospitals only can establish nursing colleges.
- Upgrading professional standards by laying down proper students selection criteria.
- Strict and regular inspections of nursing colleges.
- Qualified nursing faculty with adequate clinical experience
Lastly…
Just like a stitch in time saves nine, if all these commendations are acted upon by the government and private sector soon, then the nursing sector in India will rise up from its current state. A healthy partnership between the government and private players is the need of the hour
- Advertisement -
