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Sister, where art thou?

May 12, 2014

As Florence Nightingale said so many years ago, nursing is not merely a science, but more so an art, write Kavita Narayan and Devaki Nambiar.

New Delhi: Nursing is an art: and if it is to be made an art, it requires an exclusive devotion as hard a preparation, as any painter's or sculptor's work; for what is the having to do with dead canvas or dead marble, compared with having to do with the living body, the temple of God's spirit? It is one of the Fine Arts: I had almost said, the finest of Fine Arts.”— Florence Nightingale, born May 12th 1820.

At about noon 11:00AM today at the Rashtrapati Bhavan, the President will hand over the Florence Nightingale awards to those public health nurses across India who have gone above and beyond their call of duty and made Nightingale and the profession proud. We will all cheer the winners, congratulate several of them individually and, more often than not, turn our minds to our TV shows and cricket matches, forgetting all about these heroes and how they have contributed to our health and well-being, until its show time next year. There is no winner’s after-party for these dedicated souls. Its back to scrubs; back to trying to do the right thing for the patient and tackle at least four times the expected work load, in vain….and for most of them, little to look forward to in terms of lifelong learning, career growth or leadership aspiration.

In India, estimates indicate that these dedicated women (and some men) estimatedly comprise about 30% of the total health workforce. According to 2011 data from the World Bank, we have 1.7 (or barely two) nurses for every 1,000 Indians . This may seem adequate to those of us that feel swarmed by nurses in clinics, dispensaries and emergency rooms or mostly seek care from Auxiliary Nurse Midwives, or ANMs. But by international comparison, we have far fewer nursing professionals (mal)  distributed across our population – less than half the number in Brazil and South Africa.. The recommended ratio of nurses and midwives is 3 per 1000 people – more than six and a half times what we have now. In 2012, India was 2.4 million nurses short; . our Planning Commission states a requirement of over 9 lakh nurses, about a third of whom should be functional public sector facilities. In order to meet the density requirements based on the 12th five-year plan, we need to add close to 2 million nurses and ANMs by 2017; a worthy albeit unattainable goal.

But even at our starting point, there are challenges. Here’s a test. Pick any three reports on any health human resources.  . Unless these reports are citing each other, one can be almost certain that there will be three (if not more!) totally different estimates of nurse shortage. While there are efforts – already bold for the scale of the country – to ascertain the number of nurses in the country, the absence of a live nurse registry means that we are not keeping up with distributional shifts due to rural to urban migration, massive international migration and re-registration of nurses in multiple states across India, possibly paintings a much prettier picture of the nursing shortage situation than reality warrants. Planning for the future with a shakey baseline is a daunting prospect!

The Government has recently approved an investment of ~650 crores towards the establishment of 269 Auxilillary Nurse Midwife (ANM) and General Nursing and Midwifery (GNM) schools and colleges. Needless to add, this is a welcome step and one that is This is expected to create about 20,000 additional nurses annually. But . yoYou guessed it – this is a drop in an ocean-sized empty bucket. India also has a legacy of geographic mal-distribution of nursing schools and colleges as well as higher-level teaching institutions: almost two-thirds are located in our four southern states, which in turn poses a serious challenge towards ensuring equitable care nation-wide.

Focus, positioning and perception management is everything, as any wannabe ad-maker or brand manager would be taught on day 1; and the healthcare profession is no different. Dr Dileep Mavalankar, a veteran on this subject, alludes to this issue in one of his older papers, using the case of the “Auxiliary Nurse Midwife” cadre or ANM. The word “auxiliary” combined with lack of continued professional training as a midwife and diluted role in terms of overall nursing duties in the clinical setting vis-à-vis focus on deliveries alone, may have all contributed to India still being far away from our neighbor Sri Lanka, for instance, in dealing with maternal and child mortality. They referred to the same set of professionals as “public health midwives” and put their job emphasis on delivery alone. So was the label the only issue here? Certainly not…but perception changes with positioning and focus and in turn, could affect overall outcomes: in a society’s health as much as in business.

Following the High Level Expert Group’s report on Universal Healthcare of 2012 and the 12th Plan recommendations specific to health human resources, there is a gradual, but perceptible and welcome shift in mindset among policy makers and planners. Many are concluding that the post-independence doctor-centric approach to healthcare service delivery era, which venerated and perpetuated medical dominance has to senesce into a multi-disciplinary team-based approach that delineates and respects the role of nurses, allied health professionals and other front-line health workers as being just as vital. This is the essence of “health for all” through “all for health.” So where will they come from? Thank ‘God’s own country’ Kerala for producing some of the finest nursing talent that form the backbone of hospitals and healthcare facilities the world over. It’s ironic to note, though, that Kerala itself is struggling majorly to retain its Florence Nightingales. In the last few years, privatization of nursing education has resulted in Karnataka, Andhra Pradesh, Madhya Pradesh, Punjab and Maharashtra beating Kerala in the quantity of production. However, quantity is not quality – a continuing and in fact larger challenge now is the caliber of knowledge and skills imparted and used in this life-saving profession. It is therefore time to stop perennially playing catch-up to fill the ever-growing numerical gap and pause to put in place some fundamental corrective measures.

For starters, we need to know how many of our nurses are still clinically active in our own system; those serving in the Emirates and United States being counted in India’s nursing ratios skew the plan numbers, and therefore policy. Similarly, duplicate registrations and those in non-clinical roles need to be identified and verified.

Let’s move on to the issue of inculcating world-class skills and competencies in our nurses, a mammoth task that is heavily dependent upon both quality and quantity – in equal measure - of investments made in faculty teaching and training methods. The norms for teacher-student ratios in nursing schools may be relaxed without compromising the learning outcomes with the use of simulation-based teaching and other e-learning technologies. Standardized curricula and assessment tools and greater hands-on training must be introduced. Nursing schools must work closely with medical colleges and facilities to ensure placement opportunities in their respective communities where possible. All facilities must be mandated to run a certified on-boarding program using a standard syllabus and duration and recertification of existing degrees/diplomas at 3-5 year intervals.

Most of all, graduating nurses must should be motivated to feel a sense of ownership and purpose towards the profession and patients they will serve by designing appropriate career paths and commensurate compensation for their progress; the key to their recruitment and retention lies in how they are trained, treated and valued.

With 50% of the population already under 25 today, India’s youth will have the answers to achieving universal healthcare for India over the next several decades. Today, more than ever, we need to restore the glory of the noble nursing profession; make it an aspiration for the youth of this country to join the ranks of those that care and make the world a better place. .

As Florence Nightingale said so many years ago, nursing is not merely a science, but more so an art. It requires an exclusive devotion as hard a preparation. India is now preparing her commitment to this life-saving cadre. Nurses now and in the making, get out your canvases…here we go!

(Kavita Narayan, FACHE is the head for hospitals/healthcare services at the Public Health Foundation of India. Devaki Nambiar, PhD, is a research scientist at PHFI.)

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