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 Table of Contents  
NURSESí SECTION
Year : 2020  |  Volume : 1  |  Issue : 2  |  Page : 147-152

Status of nurses in India: Current situation analysis and strategies to improve


College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission20-Sep-2020
Date of Decision21-Sep-2020
Date of Acceptance25-Sep-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Prof. Suresh K Sharma
College of Nursing, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_164_20

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How to cite this article:
Sharma SK, Thakur K, Rani Peter PP. Status of nurses in India: Current situation analysis and strategies to improve. J Med Evid 2020;1:147-52

How to cite this URL:
Sharma SK, Thakur K, Rani Peter PP. Status of nurses in India: Current situation analysis and strategies to improve. J Med Evid [serial online] 2020 [cited 2021 Apr 13];1:147-52. Available from: http://www.journaljme.org/text.asp?2020/1/2/147/303559




  Introduction Top


The term status is slippery and difficult to define; however in this paper, “status” has been referred to an element of professional “honor” or recognition of nurses in society. The status of the nursing discipline is still viewed as lower-level subordinate, dirty and menial jobs in this country. It could be because of their projection as submissive females in subordination with physicians assisting them in caring and curing the patients without any autonomy. Although nurses are obtaining undergraduate and or postgraduate professional degrees to practice as a nurse in the country unfortunately, they are still socially socially viewed as servants in health-care delivery system. Nurses are continuously striving to achieve a higher status in this patricentric society, but still long journey is waiting a head to achieve honor and respect, which they deserve. Lack of social status, recognition, low pay, poor working conditions, lack of autonomy in practice, lack of recognition as a member of health-care team and exploitation has significantly contributed towards brain drain of nurses to the Western world. Nurses' shortage has been reported by the WHO worldwide and the latest Indian trends suggest shortage of more than two million nurses that give a nurse: Population ratio of 1.7:1000, which is 43% <recommended 03/1000 population.[1],[2] In the recent past, a rapid surge has been recorded in the number of nursing training institutions in India, with approximately 1958 nursing institutes and 98,749 sanctioned seats for annual admissions in basic nursing programmes presently,[3] but still we lack nurses and the most probable reason could be the migration of nurses to western countries, as around 33,147 Indian nurses were working overseas in the year 2016.[4] It has been noted by many into the profession that Indian nurses work more enthusiastically in other countries as compared to their native land and that is surprising. Nurses settled and working as registered nurses (RN) in other countries shared that their hard work and diligence never get recognised and rewarded in India. Fear of unknown while moving to foreign country is always there and it is not an easy task to leave family and everything behind, but the prejudice attitude of health-care professionals and general public towards nurses ignite migration. India is facing dearth of nurses and their positions are filled by incompetent or untrained personnel, which causes negative portrayal of the professional image as well as compromised quality care for patients.[5] Draft to implement new initiatives and policies have been formulated many a times, but till now, no visible change occurred in managing escalating issues of nurses' struggle for their dignity and pride. This article is written with an intention to bring cognizance on challenges and issues faced by a 21st-century nurse for getting the desired professional status in India. Authors also dispensed strategies that could be beneficial in restructuring and upliftment of nursing as a respectable job.


  Current Status of Nurses in India Top


In a country where doctors are considered next to God but on the contrary, nurses who work hard day and night in a close proximity of sick handling all ups and down are just taken for granted. The history of formal training in nursing discipline had begun in 1867 and Indian nurses at that time faced discrimination to a great extent from British nurses as they were excluded from leadership and managerial roles. With no exaggeration, the situation of nurses in India has not changed so far; the only difference which we see now is nurses receive discrimination and humiliation from their own people and medical colleagues and clients. Research findings have clearly recommended that all patients must be taken care by registered and qualified nurse as it minimizes the chances of adverse events and medications error.[6] Unfortunately, there are many functional nursing homes and private health-care units where unqualified people are working as a nurse, and this puts patients in grave danger.

Modernisation has contributed nothing into nursing as it is not uncommon to get doctors who think that taking temperature, blood pressure and assisting in feeding, bathing along with other activities of daily living are the only few things which a nurse can do efficiently and this perception promotes the number of quacks who falsely represent nursing. Supreme Court's order had directed private hospitals in country regarding minimum pay of Rs. 20,000/-to a nurse working in <50 bedded health-care facility and working conditions should be near to nurses working in government hospitals.[7] Moreover, no noticeable changes came after this order because the implementation of such order in a country where nurses' worth are not considered more than a laborer or servant is onerous. Still, nurses are working on salary scale of Rs. 2000-10,000/-per month[5] and this is not the scenario in small health-care setup, but big corporate hospitals who are making huge profits also pay very less to nurses although they are willing to pay handsome salaries to physicians; it is considered that physicians treat patients which adds on to hospital income, but everyone shut their eyes to nurses who care 24 h day and night for patients from admission till discharge. Majority of the nurses working in India are females and their safety is an another area of concern and not much has been done to solve these issues related to workplace safety for nurses working in shift duties by both government and private sector even after a brutal rape of a nurse 'Aruna Shanbaug' by hospital ward boy in 1973. Little disappointing, but it is true that even after >40 years of this incident, scenario has not changed and every now and then, nurses are at the verge of violence by patients, attendants or relatives and co-workers. The nursing profession is a well-recognised and respected discipline in the Western world, where nurses are considered equivalent to doctors and other health care professionals in health-care team, and thus, they have significantly contributed in ensuring quality healthcare, however the situation is not the same in our country [Figure 1].
Figure 1: Reflection of nurses in India versus western world

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Exceptional job done by nurses during this COVID-19 pandemic is highly appreciated by many be it the general public, physicians or hospitals' management and government. However in our opinion, it is all temporary because if we look for working hours and facilities during quarantine, nurses again faced discrimination and better facilities were given to doctors.[8] Nurses in India do not have voice and most of them are not assertive and lack confidence when it comes to talk about their rights as a RN and the one possible reason which we come across more often is that they feel ashamed to be called as a 'Nurse.' There are many nursing professionals who have opted nursing as a secondary choice after failure to reserve seat in the medical entrance and that is why have minimum acceptance for nursing and top of that stagnant carrier instead of higher qualifications make nurses unwilling to do much for their professional growth. Nurses who are working on a reputed position even do not want their children or relatives to be a nurse as this is still not accepted as a reputed profession such as doctors and engineers. Moreover, very few higher secondary school students are aware and interested to join nursing because this discipline lack in popularity and social recognition.[9] Although nursing is a profession based on scientific knowledge and skills, it is still overpowered as a nurturing and caring job for which only women are considered best. These stereotypes are deep-rooted and cause hindrance in professional growth. Reputed institutes in the country like PGIMER and AIIMS do not enroll male students into B.Sc., nursing programme and recent amendment of 80:20 between females and males nurses for AIIMS recruitment in 2019 has become a matter of debate in every other nursing conference or meeting, but no one listens and this also give rise to myth that nursing is a profession that belongs to submissive females. Most of the countries, including India, are already facing serious shortage of nurses and this phenomenon may further expand the gap in demand and supply of this category of workforce and tomorrow world may not find the sufficient number of motivated, capable and competent nurses for the smooth running of their hospitals. Nursing profession in our country lacks dynamic leaders and there are very few unsung leaders who are meticulously putting efforts to represent ignored issues and problems of nurses. There are numerous factors which are contributing to poor status of nurses in our country as illustrated in [Table 1].[10],[11],[12]
Table 1: Barriers and challenges faced by nurses in India

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  Strategies to Improve Status of Nurses in India Top


Appropriate status or professional recognition for nurse is not a one-man job and that is why it requires efforts on all levels with the planning and implementation of short and long-term goals. With the advancement in the number of nursing institutes and availability of seats, infrastructure facilities and skill training have been compromised to a great extent that raised serious concern on quality in nursing education and sanctity nursing degrees. Nursing training and education must be sound and should be entirely outcome-oriented based on desired clinical competencies. Nursing regulatory bodies and the health ministry of India need to take the lead for bringing change in the existing system, whether it is curriculum, licensing for RNs, or cadre structure for nurses. Nurse practitioner course has been started in few of the institutes, but neither there is any law to protect their practices nor separate job or cadre available for their deployment, which ultimately will add on to nurses' disappointment. License issuing system for become a RN in India is an another major area of concern because in the current scenario it is given to everyone who so ever passes nursing diploma or degree from the Indian Nursing Council recognised institutes, which again enhance the number of incompetent and unskilled nurses. Licensing system should be improvised with the provision of stagnant exit or licensing examination like America's National Council Licensure Examination for RNs exam and standardized skill assessment before nurses are considered eligible for getting their license to practice as RN or advanced nurse practitioner. Negative attitude of medical colleagues and fear of wrath by them should not stop nurse leaders to raise their voice. Provision of inter-disciplinary education is the best approach to create awareness among the medical fraternity about scope of nursing practice, a team working culture so that they can work collaboratively, contributing much more in quality care and overall professional growth. Solving an alarming issue of gender discrimination is a prerequisite for professional advancement because people working in a profession should be a clear representation of all sections of society and diversity in the professional discipline and this will also have its impact on quality care and health outcomes. It would not be wrong to mention that somehow status comes with money and nurses who are being paid well for their work will be more satisfied and have better social recognition. Therefore, strict amendments and provisions on minimum wages need to be established and practiced by all health-care organisations. Resolving all these issues with the different but unique approaches are important to promote status and establish recognition of nurses in the country.

Nurses need to work on broader horizon and should try to become an entrepreneur so that they can work in different areas with all their strengths to bring desired prestige and marked contribution in health-care outcomes. There are many areas where nurses need to focus their services and the first and foremost is 'nurse-led clinics' which is best for clients with chronic illnesses such as diabetes, hypertension and palliative care. Adjuvant nurse-led clinics along with physicians are successfully implemented in Western countries and we have enough data to support this but unable to implement because of endless reasons and we have tried to compile list of barriers and challenges in [Table 1]. Tele-nursing, home-based care, independent nurse practitioners, clinical nurse specialist and expanded role of nurses are another area which can be further explored and nurses' role can be expanded in these areas. Surprisingly, nurses are totally missing in policymaking and at top-level administrative roles; there is no presence of nurses, especially in health directorates of centre or states and they are also not seen in governing body or institute of bodies in autonomous institutes like all AIIMS, PGIMER, JIPMER, etc., In spite of being the largest group of health-care workers in these institutes, they are being seriously marginalised and their voice is left unheard. Therefore, nurses should reflect their strong presence in policymaking and at ministerial positions to reiterate themselves properly and bring expected honor and acknowledgement. Nurses with doctorate degrees can also give their remarkable contribution towards professional development by doing evidence-based research, developing new theories or modifying existing theories and putting emphasis on required changes at both public and policy level. All areas of nursing, including education, training, administration, and research, require changes and reforms to incorporate best standards of practice. Sense of self-accomplishment or confidence comes with up-to-date knowledge, competency, well-formulated policies, and laws for practice; only then desired status can be achieved as well [Table 2].[13],[14],[15],[16]
Table 2: Strategies to improve nurses' status in India

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  Conclusion Top


Nurses are the head honchos and lifeline of health-care organisations but still lack recognition. Concern on this has been expressed by many, but till date, no strong recommendations and visible implementation of laws and policies are seen. Nurses need to take leadership and proceed to participate more at higher levels to bring a change in the existing scenario. Adaptation of nurses as a nurse practitioner would not be easy, but it will definitely bring the pride and honor which every nurse desire for. Collaborative working model of nurses and doctors with mutual respect would reflect positively on the health outcomes of the country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
India Facing Shortage of 600,000 Doctors, 2 Million Nurses: Study. The Economic Times. Available from: https://m.economictimes.com/industry/healthcare/biotech/healthcare/india-facing-shortage-of-600000-doctors-2-million-nurses-study/articleshow/68875822.cms. [Last accessed on 2020 Sep 14].  Back to cited text no. 1
    
2.
World Health Organization. The HealthWorkforce in India. Available from: https://www.who.int/hrh/resources/16058health_workforce_India.pdf. [Last accessed on 2020 Sep 14].  Back to cited text no. 2
    
3.
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4.
Spetz J, Gates M, Jones CB. Internationally educated nurses in the United States: Their origins and roles. Nurs Outlook 2014;62:8-15.  Back to cited text no. 4
    
5.
Sharma SK, Parihar S. Magnitude of nurse quackery in private healthcare facilities in Punjab. Nurs J India 2020;10:20-5.  Back to cited text no. 5
    
6.
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7.
HC Asks Delhi government. To Implement Apex Court Order on Nurses' Wages. The Hindu; 2020. Available from: https://www.thehindu.com/news/cities/Delhi/hc-asks-delhi-govt-to-implement-apex-court-order-on-nurses-wages/article28665073.ece. [Last accessed on 2020 Sep 16].  Back to cited text no. 7
    
8.
From Lack of PPE to Discrimination: Nurses Working in Delhi Hospitals on Official Apathy. The News Minute. Available from: https://www.thenewsminute.com/article/lack-ppe-discrimination-nurses-working-delhi-hospitals-official-apathy-122969. [Last accessed on 2020 Sep 17].  Back to cited text no. 8
    
9.
Sharma SK, Kumar R, Meena BS. High school students' perception of nursing as a carrier- a pilot survey. Indian J Adv Nurs 2017;3:15-23.  Back to cited text no. 9
    
10.
Thakre R, Patil PS. To Ride or Not to Ride? Indianpediatrics.net; 2020. Available from: https://indianpediatrics.net/oct2018/oct-919.htm. [Last accessed on 2020 Sep 17].  Back to cited text no. 10
    
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Chhugani M, James MM. Challenges faced by nurses in India-the major workforce of the healthcare system. Nurse Care Open Acces J 2017;2:112-4.  Back to cited text no. 12
    
13.
Nurse Practitioners – India's Answer to Addressing Access to Healthcare. Public H Open Acc 2018;2:000128. Available from: https://www.researchgate.net/publication/327573196_Nurse_Practitioners-India's_Answer_to_Addressing_Access_to_Healthcare. [Last accessed on 2020 Sep 18].  Back to cited text no. 13
    
14.
Sharma SK, Thakur K, Kant R, Kalra S. Nurse-Led diabetes clinics in Southeast Asia: scope, feasibility, challenges and facilitators. J Diabetes Metab Disord Control 2020;7:47-51. DOI: 10.15406/jdmdc.2020.07.00199.  Back to cited text no. 14
    
15.
Stephen S, Vijay V. Metamorphosis of Nursing Profession: An Indian Perspective. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858989/. [Last accessed on 2020 Sep 18].  Back to cited text no. 15
    
16.
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    Tables

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