Leadership for change

Nurses, midwives and nursing professionals constitute 47 per cent of India's health sector workforce. They carry out 80 per cent of patient care responsibilities and form a cornerstone of the healthcare delivery system. The COVID-19 pandemic highlighted their invaluable service and revealed how the absence of an optimal number of nurses and midwives can debilitate the entire sector. With a fresh surge in Covid cases across India, our nurses have once again acquired the centerstage in managing the health crises — serving as a vital link between the patient and the rest of the healthcare team.

India has over three million registered nurses and midwives who are responsible for the country's 1.3 billion population — falling way short of the WHO norm of three nurses per 1,000 population. The optimum nurse-patient ratio recommended by the Government of India and the Indian Nursing Council (INC) is not maintained. This has resulted in one nurse looking after 20 to 30 patients, which puts the patients' well-being at risk — making the task of nurses and midwives difficult and frustrating. It also impacts the credibility of India's healthcare system.

Today, there is a need to adopt the WHO norms as outlined in the Strategic Direction for Nursing & Midwifery (SDNM) 2021-2025, passed in the World Health Assembly 2021, which focuses on investment in nursing education, creation of positions and leadership. The roles and challenges faced by nursing professionals have multiplied over years. A major impediment to their growth and development is the lack of involvement of nursing professionals in decision-making and policy framing. India needs to add more than 4.3 million nurses by 2024 to meet the prescribed WHO norms.

For decades, nursing professionals have not been included in planning and policy formulation for nursing and midwifery workforce. Strengthening nursing leadership — current and future — to ensure that nurses have an influential role in health policy formulation and decision-making will not only contribute to the effectiveness of health- and social-care systems but also help improve the overall functioning.

While some efforts have been taken to improve the cadre, there is a need to increase the number as well as capacities of nurses and midwives, and recognise their services in the country. Some of the key issues that need to be addressed immediately are:

Filling up of vacant leadership positions at the central level: While nurses enjoy a majority in the health task force, they remain starkly absent from leadership roles in the healthcare sector. They continue to be missing from key leadership roles due to the low number of such positions and even because the sanctioned posts are not filled. Additionally, the limited involvement of nurses and midwives in policy formulation and decision making for their issues has deterred the formation of equitable and fair policies to reduce policy-practice gaps in the healthcare system.

Educational challenges of nursing: Nursing education of high-quality forms the backbone of growth of professionally sound nurses and midwives in the country. The recognition of qualification, code of ethics, professional conduct (and misconduct) continues to be governed by the Indian Nursing Council Act (1947) in all states. The act has not been reviewed or revised significantly for the last 69 years and needs to be suitably amended to meet the needs of the healthcare system prevailing in the country.

Nursing education is also being afflicted by increasing privatisation and a scanty number of government institutions. Almost 88 per cent of nursing and midwifery education is provided by the private health sector. There also exists a lack of quality education and low enrollment due to faculty shortages, lack of focus on soft skills and leadership development. Lack of a proper career progression pathway for nursing and midwifery is also a limiting factor in getting greater enrollments in the profession.

India faces high attrition of nurses: India is witnessing a large-scale brain drain from the country due to varied reasons like poor salary, working conditions, absence of a proper career pathway, and out-dated systems of professional governance. Despite forming a large part of the healthcare force, nurses and midwives continue to be short-staffed across the nation leading to poor nurse-patient ratio, increased workload, long working hours, double shifts and other factors leading to poor quality of services.

Some policy recommendations

Presently, the Government of India has proposed a National Nursing and Midwifery Commission Bill, 2020, for setting up a National Nursing and Midwifery Commission and repealing the Indian Nursing Council Act 1947. The commission will focus on forming regulations, upliftment of education and institutions, standardisation of services provided by nursing and midwifery professionals and others. This is a great step forward. Following suggestions need to be considered by the proposed commission to uplift the nursing and midwifery profession:

• Creating more administrative and leadership positions, including the Directorate of Nursing, in the states will be a progressive step towards strengthening the nursing and midwifery cadre on a sustainable basis

• Ensuring proper implementation of Nursing Registration & Tracking System (NRTS) in all the states for maintaining nurse and midwives' live register.

• Need-based assessment of the number of nursing institutions as per the population of the state to remove skewed distribution in the number of nursing institutions in every state and to avoid migration of nurses to other states for nursing education.

• Improving the quality of nursing and midwifery faculty in teaching institutes by establishing centers of excellence for in-service and pre-service education. Their education should be need-based with knowledge and skills required to provide healthcare services at various levels.

• System of continuing education: There is need for specialised nursing services at secondary and tertiary level which may require higher post-graduate level training in different disciplines like surgery, obstetrics and gynaecology, paediatrics, geriatrics, ophthalmology, cancer management, ICU etc.

• Ensuring pay parity between government and private hospitals can go a long way in ensuring the sustainability of nurses and midwives.

• A proper and well-planned policy for recruitment, career pathway and retention has to be included in an organised manner to enhance their contribution in the healthcare system for providing better care and support.

SDNM needs to be studied and effectively implemented across India for improving the status of Nursing and Midwifery. It will help the country in achieving the UHC and other health-related Sustainable Development Goals.

It can be concluded that India over the years has steadily developed its health services and workforce planning, yet there remains room for improvement. Addressing the above-mentioned key issues can significantly strengthen nursing and midwifery in the country and contribute to the growth of the profession, showing nurses and midwives in their true light as leaders, mentors, collaborators, educators and innovators.

The writer is former Deputy Commissioner, MoHFW, Government of India. Views expressed are personal