Some recommendations are documented in different phases of our team discussions and consultations.
I Workplace facilities and safety:
1. 1. Abolish gender-based discrimination: Nurses are recruited on an 80:20 proportion of female to male. There are no democratic countries in the world that do such discrimination. The recruitment rules are attached for your perusal.
2. 2. Formation and active workplace violence cell: Aruna Shanbaug was one of those female nurses who faced severe sexual harassment and spent four decades in bed. There are many such cases reported daily in newspapers. Institutions should form sexual violence prevention committee as per the Vishakha committee. This committee information should be part of the induction program and regular awareness of this committee.
3. 3. Abolition of contractualisation and outsourcing: Non-permanent nurse recruitment created two-three categories of nurses under the same roof. This created conflict within the nurses and also new conflict and power structures. These conflicts and power structures hamper the team and directly harm patient care. There are differences in the financial and non-financial benefits of permanent and non-permanent nurses.
II Working hours and staffing:
1. 1. Working hours: It has been mentioned not to work more than 8 hours. In most hospitals, night shifts were more than 10 hours with one hour pause. There is a need to mention this very discretely in the draft.
2. 2. Working timing: Most nurses are females and reside far from the workplace. They may need minutes to hours in major cities to reach their house. In these cases, institutions working shifts should be prepared to view the staff’s security. Recently AIIMS, New Delhi operation department has extended the evening shift to 9 pm, which is unsafe timing for the nurses to reach home.
3. 3. Biannual review of HRH and recruitment: The number of new beds and caseload HRH should be reviewed per the local population. There is also a need for regular recruitment of nurses.
4. 4. Reforms in the nurse’s duty rotations: Nurses are currently rotated every few months. This rotation, for a while, is good for the new nurses who joined the institutions. Over the period, this will lead to the deskilling of nurses. Many social media and doctors’ interviews state that they have learnt many procedures and skills from senior nurses. Experienced nurses are always an asset to the department and patient quality care. Instead of rotation, they need to enhance their skill based on continuing education and training.
III: Promoting nursing leadership: Need to stop skilled nurses’ brain drain.
Currently, nurses’ promotions are based on their years of service. All the nurses are sanctioned financial up gradation per the Central Pay Commission Rules. (Every ten years, one financial promotion). Available promotions are Sister Grade 2, Additional nursing superintendent and Chief Nursing Superintended. Due to the limited number of promotion posts, most nurses wait for more than 15 years to get their promotions.
Studies reveal that nurses’ dissatisfaction is highly related to promotions, career pathways, interpersonal relationships within the team, and the suggestions their senior managers hear. Additionally, in the last decade, more than 100 experienced nurses (IAPH carried out an online survey) migrated to western countries in search of better skill-based opportunities. Especially nurses from the special units like Intensive care units and Operation theatre.
1. Skill-based promotions to achieve Universal Health Coverage: Under Ayushman Bharat, nurses were recruited at the Sub Centre level to achieve the UHC goals. Studies revealed a positive impact (1). Bagga et al. from the National Institute of Health and Family Welfare, in collaboration with WHO, and TNAI, conducted a study (unpublished report) and recommended developing skill-based career structures for better patient care (2) (3). A working paper from IIM Ahmadabad also revealed the same. After 75 years of independence, we still lack behind the Bhore and High Power committee recommendations for nurses.
Nurses in secondary and tertiary health institutions are rotated between departments and are deskilled (4) (5). A senior nurse says, “I worked more than ten years in the orthopaedic operation theatre and taught many skills to the doctors. These doctors now become associate professors and control them.” He also narrated, “I have been humiliated in front of the residents and junior doctors. I changed my duties to Out Patient Department.”
Our team did an exercise to develop such skill-based promotions with the limited extra financial burden, improve the quality of patient care, and retain skilled nurses abroad. Mr Mallikarjun Kurava presented one such skill-based career promotion during an international conference organized by IAPH and CSMCH, JNU, in Oct 2019.
2. Establishment of nursing directorate: Varghese et al. reveal that nurses’ reforms are considered “second class” majority of nurses’ posts are occupied by senior physicians, and there are hardly any nurses at the policy level (6). Few states established nursing directorates (West Bengal, Karnataka, Gujarat), but either they are dysfunctional or occupied by senior physicians.
3. 3. Establishment of nursing education directorate: Nursing education increased more than 200 times from 2000 to 2019. Currently, there are 1958 Bachelor of nursing and 3155 Diploma in Nursing (General and Midwifery Nursing) nursing institutions with a seating capacity of 2, 27,370 seats. Additionally, there are 40,795 postgraduate seats. Corruption and reduced quality of education are reported very often in all the states. There is a need to regulate this education by creating a nursing education directorate.
4. 4. Nursing University: Few states have more than 500 nursing institutions and are still administered by physician-dominated senate members. A diploma in nursing is not a bachelor’s program, so a separate board manages it—different administrators for the same course. Additionally, administered by physicians provides a lesser opportunity for independence of nursing professional growth.
5. 5. Reforms in Nursing Council: There are conflicts with the scope of responsibilities between the state nursing council and the Indian nursing council. Almost the same administrators have been at the Indian Nursing Council for over a decade. There were reports of corruption in the Indian nursing council and state nursing Council.
1. 1. Credit Hours: Hospitals should have separate Continuing Nursing Education (CNE) departments to organize need-based skill programs and training courses. The institutions should be responsible for providing the required credit hours for their state registration renewal.
2. 2. Create education-based basic entry: A few years before, there was a proposal to upgrade all the diploma of nursing institutions to a bachelor’s degree. This could bring highly skilled nurses and assist in achieving SDG goals. If it is not possible, there should be a separate entry cadre for GNM and BSc to be justified under the pay commission.
1. GARG S, SINGH R, GROVER M. Bachelor of Rural Health Care: Do we need another cadre of health practitioners for rural areas? Natl Med J India. 2011;24(1):35–9.
2. Bagga R, Jaiswal V, Tiwari R. Role of Directorates in Promoting Nursing and Midwifery Across the Various States of India: Call for Leadership for Reforms. Indian J Community Med. 2015;40(2):90.
3. Negi Y, Bagga R. Burnout among Nursing Professionals in Tertiary Care Hospitals of Delhi. J Health Manag. 2015 Jun;17(2):163–77.
4. Mahindrakar Santosh. Why do nurses go for strikes? Wire.
5. Mahindrakar S, Jat M, Varghese. Nurses’ Clinical Skill Utilisation: An Opinion from Public Health Institutions. Int J Nurs Care [Internet]. 2021 Mar 12 [cited 2022 Aug 28]; Available from: http://medicopublication.com/index.php/ijonc/article/view/14001
6. Varghese J, Blankenhorn A, Saligram P, Porter J, Sheikh K. Setting the agenda for nurse leadership in India: what is missing. Int J Equity Health. 2018 Dec;17(1):98