Despite being riddled with several bottlenecks, nursing in India is growing, strength to strength. India is slowly waking up to the reality that the nurses are key to resolving several healthcare issues and are strong partners in any growth and development programmes of the healthcare industry. A positive change is bound to come By M Neelam Kachhap
Debating on the importance of nursing to healthcare delivery is like asking who came first, the chicken or the egg? It is widely recognised that nursing is an integral part of healthcare delivery. It is also true that nurses and nursing have been marginalised within the health system in India. But a change in their status cannot be brought about without their participation. It is not the time to dwell on the notion of nurses as victims, but rather emphasise the possibilities for nurses to take their place and seize the new opportunities being presented to them. This acknowledgement provides a unique opportunity for nursing to demonstrate leadership by developing clinical nurse leaders to collaborate with the multidisciplinary care team in driving evidence-based, safe quality, cost-effective healthcare services. “The nursing role is rapidly evolving as nurses are tasked with an even wider range of healthcare responsibilities. Today’s nurses aren’t just caring for the sick; they are being considered as equal partners in the continuum of patient care,” says Dr Harish Pillai, CEO Aster Medicity, Kochi. There is a significant growth in the number of nursing educational institutions and the number of nurses in India, yet the numbers are woefully inadequate.
Strength in numbers
By no means is the number of nurses small in India. About 23 lakh nurses is a big number, however the availability of nurses is a big issue as we are nowhere close to a nurse-patient ratio of 1:4. As per the report of the Steering Committee on Health for the 12th Five Year Plan of the Planning Commission, India has 19 health workers (doctors-six, nurses and midwives – 13) per 10,000 people in India. WHO norms provide for 25 per 10,000 people. According to yet another estimate the strength of nurses in India is currently 0.8 nurses per 1000 citizens. This, compared to the world average of three nurses per 1000 is quite low. To come closer to the world average, our healthcare system would need to add about two million more nurses to its numbers.
There are approximately 5000 nursing schools in India with varying intake capacity producing about 20,000-25,000 nurses annually. There are many unregistered schools that also function in India but the quality of training and the number of nurses produced by these institutes are not known for sure. Since nurses are the largest workforce in any healthcare organisation, their leadership and empowerment is the foundation on which the quality of care and safety of the patients rest.
Nursing leadership
In the recent years, many nursing leaders have emerged in India. Every year the National Florence Nightingale Nurses Awards recognise the meritorious services rendered by the nurses and nursing professionals in the country. “Our nurses have received numerous awards and recognitions for their excellent performance in their respective fields, both internal and external,” says Dr Alok Roy, Chairman, Medica Group of Hospitals, Kolkata. “Some of the noted recognitions are NABH Excellence Award for Nursing Services and Best Nurse Award of the state government,” he informs.
Speaking about outstanding nurses at the hospital, Valsa Thomas, Director Nursing, Dr LH Hiranandani Hospital, Mumbai says, “The Nursing Department at the Dr L H Hiranandani Hospital continues to be a strong team in this prestigious institute. They do not stop at being ordinary but try to excel at the task assigned to them, may it be at the patient care end or in picking up the trophy for an extracurricular activity. “The nurses who show attributes of knowledge and skill with the right attitude are nominated for Best Employee Award on a monthly basis. There is an annual award function where nurses get nominated and awarded for the ‘Most Valued, Most Improved and the Care Award’. The nurses thus feel appreciated and motivated to become a source of inspiration for others,” she adds.
In addition, the state government also recognises meritorious nurses with state awards. Besides these, many nurses have proved their mettle in developing best practices at their hospitals, securing academic and travelling grants, partnering in research and publishing peer-reviewed papers.
“Jinumol M Varghese, being a staff nurse, got involved in the evolution of our EMR project and today she is an overall champion for the Nursing Informatics and EMR,” informs Dr Pillai.
In 2011, Shanti Teresa Lakra, an auxiliary nurse midwife working among the Ongees tribe in Andaman & Nicobar Islands, became the first nurse to receive Padma Shri, the fourth highest civilian award in India. She is recognised for her exceptional services to the tribes during the devastating tsunami of 2004. Lakra’s determination, dedication and courage to provide health and psychological care to the primitive tribes in distress was recognised and appreciated, for which she was also conferred the prestigious National Florence Nightingale Award in the year 2010. She has also received the Catholic Health Association of Andaman & Nicobar Islands (CHAANI) – Best Nurse of the Year – 2010 Award.
Dr Jothi Clara J Micheal, Group Nursing Director, Global Hospitals’ Group is a well known academician. She was the recipient of the International Travel Award from Midwest Nursing Research Society 2008 (MNRS), US, and the Eta Pi Research Award for the Annual Eta Pi Chapter Research Day held in 2005 at the University of Wisconsin Oshkosh, Gruenhagan.
Emerging technology and nursing
Technological advancements challenge the nurses to be at par with the current times and stay competent. “The nursing practice has to match the rapid pace of advancements in technology,” says Dr Pillai. Nurses today handle technology, starting from a basic cardinal sign assessment to higher level of life-saving technological gadgets. “These type of gadgets have made the nursing professionals more predictive and proactive in detecting the life threatening complications to life taking issues,” informs Partha Das, Group Head, HR, Global Hospitals, Chennai. Large to small, portable, gadgets help nurses during long stressful working hours. Several emerging and existing technologies help the specialised nurses in accurately detecting and diagnosing minor to major aliments in many primary care settings where the nurse forms the first point of contact to the patients. “It’s not just that nursing is becoming a broader field; it’s becoming deeper, too. It’s more than knowing how to perform tasks and procedures; it’s about being a more effective member of the healthcare team and navigating clinical systems. To become more effective, nurses need more time for direct patient care and this is possible with emerging technologies that will help to change the practice of nursing,” says Dr Pillai.
In addition, there are technologies that support nurses with fingertip information and knowledge for appropriate decision making based on evidence. Robotics, genomics and digital technology are all knocking on the doors of nursing.
Electronic health records
The concept of electronic health records (EHR) constitutes a wide range of information systems, from files compiled in single departments to longitudinal collections of patient data. “Electronic health records make the nurses aware of all the patients information at a glance. This timely and user-friendly technology has always been welcomed and cherished as a treasure of innovations,” says Das. Although many nurses find dealing with EHR cumbersome and problematic they know and fully appreciate its values. “Its effective because its time saving and data can be fed and analysed easily,” explains Neelam Dhawan, Nursing Superintendent, Bhatia Hospital, Mumbai. Today, EHRs are used in primary, secondary and tertiary care although its penetration in the Indian market has been slow. “As patient safety is of prime importance the hospital is in the process of incorporating EHR and the first phase has been incorporated in the OPDs for consultants,” informs Thomas.
Seven Steps for continuous quality improvement (CQI)
- Identify standards of nursing care excellence set by accreditation body.
- Explore gaps by matching existing practice with identified standards:
- Categorise gaps and identify relevant measures and metrics:
- Refine SOP’s/ policies identifying strategies to fill gaps and prepare quality task force:
- Monitor quality indicators/ conduct CQI, nursing care and multidisciplinary clinical audits
- Raise the bar of quality indicator to reach higher level of excellence
- Benchmark care excellence
Several data components are documented in EHRs: daily charting, medication administration, physical assessment, admission nursing note, nursing care plan, referral, present complaint (symptoms), past medical history, lifestyle, physical examination, diagnoses, tests, procedures, treatment, medication, discharge, history, diaries, problems, findings and immunisation. In future it will be necessary to incorporate many types of standardised instruments, electronic interviews and nursing documentation systems in EHR systems. “Its advantages include a single consolidated record for each person; capacity for data interfaces and alerts; improved interdisciplinary communication; and evidence-based decision support. Well-designed and well-implemented computerised provider order entry (CPOE) systems can streamline nurses’ work and will help to reduce medication errors and ensure patient safety,” says Dr Pillai. Critical care environment where nurses generate a massive amount of data and the total command of all available information is imperative, they often find it difficult to provide undivided attention to the patient. “Digital charting helps nurses to simplify nursing work flow by eliminating tedious and time consuming job of hourly monitoring of vital signs, infusions and ventilator settings etc. and enable them to focus on what matters most,” says Dr Pillai.
The ability of nurses to use an EHR effectively is critical to patient safety, decreased facility expenditures for training, and reduced healthcare costs. To use EHRs effectively, nurses must have the required knowledge and skills.
Skill enhancement
Learning is a continuous process for nurses. Both clinical skill and technological skill enhancement are part of their life. “Privileging nurses to handle technological challenges from simple to complex demands investment from HR and nursing service departments of the hospital. It is a continuous process as far as our learning and development activities are concerned. We ensure that all our nurses are imparted both functional and behavioural training. Each nurse undergoes the specified number of training man days (eight hours per month). The training policy for nurses is structured and objective specific,” says Das.
Each hospital has its own collection of high-end technology which they like to talk about. “At Aster Medcity, we are giving due preference to technology familiarisation session conducted for the new nursing staffs as a part of their 14-days mandatory Nurses Induction Training Program,” says Dr Pillai. Knowledge of computers is widely recognised as a must have quality in nurses today. “Candidates with computer knowledge are preferred,” says Dr Roy. “The nurses are inducted to use the computer as all the process involved in patient care are online e.g. procurement of medicine, access to laboratory reports, radiological reports and hospital intranet,” informs Thomas.
Nurses recognise the need for updating their knowledge and implementing evidence-based practice for improving the quality of the nursing care. Hence, due importance is given to continuing education programmes. “Continuing education programme is conducted by all the superiors in the nursing field from time to time and also by those nurses who are handling the updated technology throughout their patient care,” says Dhawan.
“Regular classes on advancement of patient care, new installation of electronic biomedical instruments and about inter-departmental communication through system is provided at our hospital. Certified ACLS, BLS courses are conducted for skill enhancement of nurses and various educational programmes, workshops, chart preparing, quizzes are conducted on timely basis,” informs Dr Roy.
Accreditation and certification
Accreditation and certification programmes improve the process of care provided by healthcare services and are much sought after in India today. Nurses are key to the accreditation and certification programmes. “They play a very important role and help us in achieving optimum level of competency in the healthcare system,” says Dhawan.
“In the hospital, the nursing team is critical to a quality programme, due to the significant number of professionals and their direct and permanent practice with internal and external clients. The nurse interacts with all the areas of support, with autonomy and co-responsibility. Furthermore, since the academic formation the nurse is familiar with management issues, leadership, and the clinical audit, being an educator and a researcher they have the unique ability to assist the multidisciplinary team during the implementation and monitoring of a process of accreditation,” says Pillai.
There are various measures of nursing efficiency related to accreditation. “The role of nursing in accreditation is integral to ensure quality of care to the patient, which can be measured through the length of hospital stay of patients, hospital acquired infections, bedsores, bed fall and medication errors,” says Thomas.
However, nurses do not work in isolation and a broad array of departments need to work in tandem for the nurses to succeed. “Nursing care excellence in any healthcare setting is difficult to achieve without the support of the medical and operations team. Hence a Trio (Medical – Operation- Nursing) concept approach is introduced by the support of the management. Nursing leadership team along with the nursing initiative team is empowered to implement continuous quality improvement steps within through puts,” says Das. “Excellence, in this framework is perceived as a dynamic concept involving, raising the bar, defining inputs, strategising processes, and benchmarking outcomes,” he adds.
On the success path
The success and professional excellence of nurses can be achieved by developing a clear universal framework where all aspects of patient care are taken into account. Experts believe that one approach for nursing success is standardising the entry-level education for nurses and developing a uniform professional development and career advancement trajectory with appropriate incentives to encourage participation. Various organisations like the Nursing Council of India and the Trained Nurses Association of India is also lobbying for it. The thrust in enhancing the state of nurses in India should be centred around clinical excellence, continuous quality improvement, preventive and proactive approach, evidence-based practice and error prevention ethical culture.
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