A sector that needs to be nursed back to health - Nursing Education
iasparliament
December 14, 2020
What is the issue?
The year 2020 has been designated as “International Year of the Nurse and the Midwife”.
Nursing education in India suffers poor quality of training, inequitable distribution, and non-standardised practices; needs serious reforms.
What are the shortfalls?
Workforce - 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.
India needs 2.4 million nurses to meet the norm.
Uneven regulation - 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.
Institutions - The number of nursing education institutions has been increasing steadily.
But there are vast inequities in their distribution.
Around 62% of them are situated in southern India.
Education - The current nursing education is outdated and fails to cater to the practice needs.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 career progression in the nursing practice.
Multiple entry points to the nursing courses and lack of integration of the diploma and degree courses diminish the quality of training.
Postgraduate courses - There are insufficient postgraduate courses to develop skills in specialties.
On the other hand, 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.
These factors have led to gaps in skills and competencies, with no clear career trajectory for nurses.
How do these reflect in practice?
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 3 to 6 months for non-clinical ancillary nursing roles and are paid very little.
The above issues have led to the low status of nurses in the hierarchy of health-care professionals in the country.
These disruptions are more relevant than ever in the face of the COVID-19 pandemic.
How efficient are the regulatory provisions?
The nursing practice remains largely unregulated in the country.
The Indian Nursing Act primarily revolves around nursing education.
It 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.
The mismatch of the role description and remuneration that befits the role sets the stage for the exploitation of nurses.
It is a major reason for the low legitimacy of the nursing practice and the profession.
All these may significantly endanger patient safety.
Patient safety - The Consumer Protection Act protects the rights and safety of patients as consumers.
But this 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.
What are the much needed reforms?
Nurses and midwives will be central to achieving universal health coverage in India.
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 defined and coordinated to synergise their roles.
Qualified nurses leaving the country for lack of recognition and work opportunities must be contained.
Incentives to pursue advanced degrees to match qualification, clear career paths, opportunity for leadership roles, and improvements in the status of nursing as a profession are other priorities.
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 would help enhance nursing education.
The NITI Aayog has recently formulated a framework for public-private partnership in medical education.
This 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.
The following would significantly streamline and strengthen nursing education:
a common entrance exam
a national licence exit exam for entry into practice [for persons with a foreign medical qualification, to obtain licence to practice here]
periodic renewal of licence linked with continuing nursing education
Transparent accreditation, benchmarking, and ranking of nursing institutions too would improve the quality.
The National Nursing and Midwifery Commission Bill currently under consideration should hopefully address some of the above issues.
