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Year : 2022  |  Volume : 3  |  Issue : 1  |  Page : 55-59

National nursing and midwifery commission bill: Hopes and challenges

1 College of Nursing, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
2 College of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission23-Mar-2022
Date of Decision31-Mar-2022
Date of Acceptance31-Mar-2022
Date of Web Publication28-Apr-2022

Correspondence Address:
Dr. Rajini Peter
College of Nursing, All India Institute of Medical Sciences, Nagpur, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_25_22

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The purpose of this article is to summarise the major features of the National Nursing and Midwifery Commission (NNMC) Bill, as well as the opportunities and challenges that the proposed legislation presents. We look forward to improved professional standards, title protection, higher quality education, precise scope of practice guidelines and standardisation of nursing and midwifery registration as the Indian Nursing Council gets replaced by the National Nursing and Midwifery Council. We are hopeful for a rapid start and expansion of advanced nurse practitioner programmes, which will allow for increased participation in the country's health system and the advancement of health-care goals.

Keywords: Challenges, hopes, National Nursing and Midwifery Commission, registration, scope of nursing practice

How to cite this article:
Peter R, Sharma SK. National nursing and midwifery commission bill: Hopes and challenges. J Med Evid 2022;3:55-9

How to cite this URL:
Peter R, Sharma SK. National nursing and midwifery commission bill: Hopes and challenges. J Med Evid [serial online] 2022 [cited 2023 Jun 7];3:55-9. Available from: http://www.journaljme.org/text.asp?2022/3/1/55/344289

  Introduction Top

The overarching goal of a nursing and midwifery regulatory agency is to assure the highest quality of care, as well as the public's safety and well-being, as well as to build and sustain people's confidence in the nursing and midwifery professions.[1],[2],[3] The major functions that regulatory organisations will undertake are setting and maintaining standards of practice and conduct, quality assurance of pre-registration education, registration, re-licensing and ensuring continuous competence and devising systems for complaint resolution and discipline.[2],[4]

Poor educational standards, different cadres with the same titles, regional disparity in educational institution distribution, poor regulatory practices, mismatch between theory and practice, poor scope of practice, gender-based discrimination and stigma and other issues plague the nursing profession in India.[5],[6] Nursing leaders, policymakers, civil society and professionals all around the country have been calling for reform of the nursing sector for a long time. The present law governing the nursing professionals, the Indian Nursing Council (INC) Act was passed in 1947. The INC was responsible for ensuring the basic nursing educational standards, recognising nursing qualifications and prescribing entrance requirements and curriculum for nursing courses.[5] On 5 November 2020, the Indian government proposed removing the INC Act and replacing it with a National Nursing and Midwifery Commission (NNMC) Act.[7] The bill is now ready to be introduced in the parliament in the next legislative session. The major objectives of the commission as per the proposed bill are to provide for regulation and maintenance of standards of education and services by nursing and midwifery professionals, assessment of institutions, maintenance of a Central Register and State Registers and creation of a system to improve access, research and development and adoption of latest scientific advancements.[8]

  Governance and Major Functions of the Proposed National Nursing and Midwifery Commission Top

The commission would be chaired by a central government-appointed chairperson drawn from the ranks of eminent nursing and midwifery professionals. The nursing advisor to the Government of India and a military nursing professional with the rank of additional director general or above would be members, as will three representatives from the Directorate General of Health Services, Indian Council of Medical Research and the National Medical Commission selected by the central government. On a biennial basis, the Central Ministry of Health will rotate ten nursing leaders five each from nursing and midwifery service and educational institutes of excellence. A total of 26 eminent nursing experts, including at least two midwifery professionals and a minimum of four from each of the country's six zones, will be nominated by the state or central governments. There will be one member from a charitable institution and one from other relevant fields such as health research, law or ethics nominated by the central government. Additional secretary of the central ministry of health will be the convenor-member.[7]

A Nursing and Midwifery Advisory Council chaired by the NNMC chairperson will advise the Commission on all functions. It will comprise all NNMC members as ex-officio members and also have members to represent all states and union territories, except those already represented on the commission. Members will also include the Chairman of the University Grant Commission and the Director of National Assessment and Accreditation Council. The council will serve as the major forum for states and union territories to express their concerns and opinions to the Commission, as well as to assist in the development of the overall agenda, policy and action relating to nursing education, nursing services, training and research.[7]

The central government will establish four autonomous boards that will work under the NNMC's supervision. There will be a president, two full-time members appointed by the central government, and four part-time members nominated by state or central governments on the nursing and midwifery undergraduate education board, nursing and midwifery post-graduate education board, nursing and midwifery assessment and rating board and nursing and midwifery ethics and registration board. State Nursing and Midwifery Commissions will also be established in each state, which will work with the national commission to carry out all of its functions.[7]

  Major Functions Top

Some of the important functions of the NNMC which will be coordinated through the four boards and state commissions are the following:

  1. Common national entrance examination for diploma, undergraduate and postgraduate nursing and midwifery courses and exit test for professional practice
  2. Setting and maintaining the standards of nursing and midwifery education which will include curriculum, facilities, assessment, research, clinical affiliations and faculty quality and development and approval of institutes
  3. Regulate nursing and midwifery institutions, researches, professionals and associates
  4. Assessing nursing and midwifery requirements in healthcare and advising the government
  5. Regulate professional code of conduct and promote nursing and midwifery ethics
  6. Regulate the standards and scope of practice of registered nurses and midwives, nursing associates, midwifery associates and postgraduates of nursing and midwifery
  7. Regulate the limited prescribing authority for nurse practitioners (NPs) who have obtained the requisite nursing and midwifery qualification and the qualify the criteria prescribed by the PG education board
  8. Maintaining a national register of nursing and midwifery professionals and another register for associates and state commissions will have state registers
  9. Ensuring rights and obligations of registered nursing and midwifery professionals and associates
  10. Provide for mechanisms for receiving complaints and grievance redressal.

The bill has also proposed standardising the nomenclature and scope of work of different nursing and midwifery cadres according to the International Standard Classification of Occupations.[9] They are nursing and midwifery service managers, nursing professionals, midwifery professionals, nurse associates, midwifery associates and nursing care assistants.[7]

  Hopes and Challenges Top

Regulation of entry and exit into the profession through the common national entrance and exit tests

The competencies expected of professional nurses have changed dramatically in response to rapid changes in healthcare. The major reform in the bill of establishing common national entrance and exit tests for entry and exit into the profession is a positive step forward. The quality of student's education and clinical training varies greatly across India, and many institutes have very low standards.[6] Many private institutions were able to readily admit students who could not handle the curriculum of a graduate nursing programme because of liberal entrance criteria and student evaluation standards have also gradually declined.[6] An entrance examination would ensure that students have a minimum level of capability, and educational institutions and universities would be required to improve student education and evaluation standards, as the national exit examination would ultimately determine if the graduate is eligible for registration. The exit examination is crucial for public safety since it will assess the knowledge, skills and competencies required for safe and successful nursing practice at the entry-level. Professionalism, dignity and nursing care quality are expected to improve as a result of this reform. It is important that the systems and procedures for organising the comprehensive exit examination are adequate to ensure that the graduates meet the professional standards of NNMC.

Recognising midwifery practice as a distinct discipline

Although there are auxiliary nurse midwives providing midwifery services at peripheral level, India does not have a professional midwifery workforce.[6] The new bill recognises midwifery as a distinct discipline and recommends that midwives be represented in the NNMC. It is a good step as it has been demonstrated that educated, regulated and licenced midwives can increase the quality of care and have a positive impact on maternal and perinatal outcomes when managed and supervised properly.[10]

The drafting of regulations and standards by the NNMC would have been more efficient if there had been a more mandated representation of midwifery experts. It is all the more important now that the Government of India has released guidelines for the midwifery practitioner programme and midwife-led birthing units.[11] The NNMC bill needs to include legislative provisions for independent midwifery practice and protection of the midwifery practitioner title.

Professional standards and code of conduct

The registered nursing practice revolves around the confidence and capacity to think critically, apply knowledge and skills, and offer competent, evidence-based and direct nursing care.[9],[12] The proposed commission will establish and enforce proficiency standards for registered nurses and midwives, nursing associates, midwifery associates and nursing and midwifery post-graduates. These would be the competencies that professionals and associates will display in accordance with their training while caring for individuals of all ages and in all settings. A well-defined standard would be helpful in improving efficiency and holding nurses and midwives accountable for their work. The guidelines for educational institutions should guarantee that students are prepared to achieve these proficiency outcomes. There should be guidelines also for student supervision and guidance, as well as standards for practitioners, prescribers and specialists, and RNRMs returning to practice. The assessment of these competencies in the exit examinations will be a significant challenge. The processes and mechanisms, as well as the successful execution of the comprehensive exit examination, will be critical to the revival of nursing education and practice and the establishment of a higher benchmark of knowledge and skills for professional registrations.

The professional code of conduct is a set of good practice guidelines for nurses, midwives and associates to observe. It is easy to establish clear norms for professional behaviour; but, establishing methods to ensure that they are followed would be challenging. The guidelines may only exist on paper if close monitoring and corrective measures are not in place. At the same time, it is essential that incorrect interpretations of the same do not lead to harassment of nurses and midwives. Both the codes and the standards are crucial to the credibility and professionalism of nurses and midwives. To ensure that professionals fulfil their responsibilities, processes must be established, including descriptions of non-compliance and grounds for disciplinary and corrective action. There should also be provisions for health-care system support, because, without it, nurses and midwives will be unable to function efficiently, no matter how hard they try. Another crucial consideration is to ensure that professional titles are protected against unregistered individuals. There should be national-level penalty directives and other robust measures in place.

Scope of practice guidelines

The scope of practice is the range of roles, functions, responsibilities and activities that a registered nurse or registered midwife is educated, competent, and has authority to perform.[13] It is through the clearly defined scope of practice guidelines nurse's competencies and obligations are communicated to all stakeholders.[14] The guidelines for scope of practice should enable health professionals to practice to the full extent of their demonstrated professional competency. The regulation of scopes of practice is vital for maintaining public safety while ensuring public's access to the necessary health-care providers.[3]

Leslie et al. argue that when it comes to regulating the scope of practice, there should be clear definitions of professional scope that are sufficiently flexible and responsive to allow for timely innovation and optimisation, as well as transparency and optimising coherence, coordination and communication while furthering the regulator's purpose of preserving public safety. They also push for legitimate stakeholder perspectives to be included in consultations and definitions of the scope of practice.[3]

Other countries can provide some useful examples. Through non-exclusive scope of practice statements and controlled acts, regulatory agencies in Canada have created overlapping scopes of practice, enhancing flexibility in service providers and encouraging interprofessional practice. In Australia, the National Boards do not provide extensive definitions of scope of practice or regulate through restricted acts, but instead, use registration and practice standards to maintain the outer boundaries of practice in check. They also give “endorsements,” which acknowledge that a health professional has a broader scope of practice in a specific field of practice due to additional qualifications approved by the National Board. The boards may also develop specialties and specialist titles in addition to endorsements.[3]

Nurse practitioner programmes

An important change that nurses and other stakeholders are looking forward to is the establishment and expansion of advanced practice nurse programmes (NP) in the country. It is important for two major reasons. With a population of 1.3 billion people, India faces a wide range of diseases, including lifestyle diseases, infectious and emerging diseases such as COVID-19. Communicable diseases, maternal and nutritional deficiencies remain the leading causes of death, while non-communicable diseases and mental disorders are on the rise, posing a threat to the quality of basic healthcare. There is also a significant disparity in the distribution and availability of human resources for health between urban and rural areas, and there are major concerns about the quality of these resources. Expanding NP practice would result in increased health-care coverage, particularly for the underprivileged and rural populations. Their engagement in advanced practice could alleviate a major portion of the health worker and primary care practitioner shortage. In the United States and elsewhere, there is a growing body of evidence that extending the scope of practice can be done without risking patient's safety, and can even improve the quality of care through advanced practice nursing. Taking lessons from well-established health systems and evidence on cost-effectiveness, accessibility, holistic and patient-centered care, NPs' role is crucial for a country like India. Universal health care (UHC) through the health and wellness centres and other services can only be achieved if health professional reforms are implemented in tandem with UHC reforms.[15],[16],[17],[18]

Second, the lack of prospects for career advancement, particularly in the nursing service sector, was one of the major reasons for the lack of interest for nursing profession. The introduction of NP programmes would fill this void and create opportunities for a large number of talented individuals. Hence, the proposed bill should enable efficient NP practice by making provisions for ease of commencement and professional practice for NPs in all areas of nursing. The bill specifies that qualifications will be added to the Central Register in the manner provided by the regulations. It is unclear whether the addition will result in the addition of a practitioner title and a broader scope of practice under the established professional standards. There ought to be unambiguous guidelines on the scope of practice of NPs and nurse specialists. Patient's safety must be prioritised, and rigorous rules for educational programmes and competency assessment must be implemented. The availability of properly trained faculty is going to be a challenge. Online instruction, exchange programmes or visiting faculty for short clinical training sessions from countries where the practice is successful can all be considered.

Limited prescribing authority

There are prescribing rights for nurses in India. However, NPs course has been started and there is a critical need of NPs especially in primary care and midwifery to mitigate the shortage of medical professionals in remote and deprived locations. The National Health Policy-2017 clearly highlights the acute need of NPs and community health nurse specialists in India. Fortunately, NNMC has one of the main functions to 'regulate the limited prescribing authority for NPs who have obtained the requisite nursing and midwifery qualification and qualify the criteria prescribed by the PG education Board'.[7]

  Other Concerns Top

One important principle of a good regulation is transparency,[4] which requires all stakeholders being included in the development of guidelines and regulatory processes. There is a valid criticism that the proposed commission does not adequately represent professional bodies and the private sector. The problems in the nursing sector vary across settings, and this underrepresentation of professionals from various settings may have an impact on the development of good practice regulations for nursing and midwifery, particularly for the massive private sector, which suffers from lack of staffing norms and poor salaries.

According to the bill, there will be a single standard for professional practice, as well as a common curriculum for educational programmes and national exit examinations, thus establishing a national registration or licencing would make sense. Hence, even if individual states perform the registration process, the licensure should be applicable throughout India and the bill should specify that.

One major criticism of the bill is that it makes no provisions for the NNMC to regulate nursing service conditions such as nurse–patient ratios, maximum weekly working hours, leaves and other benefits, minimum compensation and so on. Nurse practice acts around the world do not include provisions for nursing personnel's working conditions. However, through utilising the provisions of advisorship to the government, the NNMC can work to have the Government of India ratify the International Labour Organization's Nursing Personnel Convention, C-149. The Convention and its Recommendation aim to strengthen nursing personnel's rights and provide guidance to policymakers, worker's and employer's representatives in developing and implementing nursing policies within the context of a country's overall health and labour policies.[19]

A major weakness in the bill is the absence of provisions to ensure nurse's continued competence to practice, like, rules for relicensing such as continuing education, minimum practice standards, competence review and professional activities. Requirements for re-licensure of health professionals are becoming more rigorous around the world, including demonstrating continuing competence and upgrading knowledge. This can be accomplished by issuing a practicing certificate to those who meet the requirements for continued competence on a regular basis.[4] Many state councils in the country have put in place standards such as continuing education credits as a requirement for renewal of registration. It would be beneficial if national-level standards and protocols were established.

  Conclusion Top

The NNMC Bill is a hope for Indian nurses that it will augment the growth and autonomy of nursing and midwifery profession in the country. Nurses of the country are eagerly waiting to see this bill to become a reality.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Council for Healthcare Regulatory Excellence. Strategic Review of the Nursing and Midwifery Council. Final Report. London; July, 2012.  Back to cited text no. 2
Leslie K, Moore J, Robertson C, Bilton D, Hirschkorn K, Langelier MH, et al. Regulating health professional scopes of practice: Comparing institutional arrangements and approaches in the US, Canada, Australia and the UK. Hum Resour Health 2021;19:15.  Back to cited text no. 3
International Confederation of Midwives. Global Standards for Midwifery Regulation. Regulation. Hague; 2011. Available from: https://internationalmidwives.org/assets/files/general-files/2018/04/global-standards-formidwifery-regulation-eng.pdf. [Last accessed on 2022 Feb 24].  Back to cited text no. 4
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