A sector that needs to be nursed back to health - Nursing Education

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• Education - The current nursing education is outdated and fails to cater to the practice needs.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 –
  1. explicitly state clear norms for service and patient care
  2. 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:
  1. a common entrance exam
  2. a national licence exit exam for entry into practice [for persons with a foreign medical qualification, to obtain licence to practice here]
  3. 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.

Source: The Hindu