India’s nursing profession touched a critical milestone of one lakh graduation seats across 2,127 colleges in 2021. But that aside, it continues to struggle for attention from mainstream healthcare investors and policymakers to bring about a sustained supply of quality nurses and an improved work ecosystem for them.

“As a country, we are producing a large number of nurses — 1.7 per 1,000 population. But this is still deficient in terms of the WHO [World Health Organization] recommended ratio of 3 per 1,000. The WHO estimates that around 4.3 million more nurses are required to ensure quality care for patients,” says Suresh K Sharma, Principal-Nursing College at All India Institute of Medical Sciences (AIIMS), Jodhpur.

Vicious cycle

This month, for instance, marked International Nurses Day (May 12). But experts say that nursing in India continues to struggle with low pay, migration issues, shortage of skills, delayed government recruitments, and investors’ indifference towards creating quality education infrastructure.

Nurses at some private hospitals are paid ₹3,000-4,000 per month, as against the ₹20,000 minimum pay recommended in 2016 by a committee appointed by the Centre for the protection and safeguarding of nurses’ interests. Government hospitals pay relatively better.

Related Stories
The feisty but unsung women warriors
ASHA workers, on the frontline of the healthcare system, battle prejudice, abuse, and poor compensation
Related Stories
Securing health should have been a priority this Budget
The Centre’s focus on creating e-health records during the pandemic while neglecting the actual public healthcare delivery system is problematic 

The first and second wave of Covid-19 saw nurses at the forefront of India’s healthcare system, treating, monitoring and administering medicines, despite all odds. “I was on duty for 15-18 hours wearing protective gear during the summer of 2021. The hospital had limited staff and there was a constant inflow of patients. Me and many of my colleagues spent about two months away from the family despite being in the same town. And when it came to appraisals or pay hikes, authorities have several excuses,” said Naresh Gamit, a male nurse at a corporate hospital in Ahmedabad.

In Gujarat, epidemiologists had flagged manpower shortage during the second wave. In capital Ahmedabad, the government converted a convention centre into a makeshift 900-bed Covid hospital, but could operate only at a reduced capacity reportedly due to a shortage of nursing and healthcare staff.

“Even after paying extra, we didn’t get skilled manpower at the peak of the second wave,” a doctor at Ahmedabad’s Civil hospital said.

The vicious cycle, experts note, starts with inadequate nursing education, with private institutions dominating the scene, leading to a skill-gap. “The healthcare sector needs manpower that is clinical practice-ready when passing out of nursing college,” said Sharma.

Private college operators counter that they provide basic nursing education and training. They tie up with hospitals for subsequent on-job skill development and training for specific roles, said the principal of a trust-run nursing college in Vadodara district.

Data from Indian Nursing Council shows there were 5,162 nursing institutions in the country as of March 2021. About 13 per cent of it was government-owned and the rest private. In contrast, in medical education, 60 per cent is government-run.

AIIMS-Jodhpur has started an e-learning platform, ‘Skill For Scale’, to train nurses in managing non-communicable diseases, starting with diabetes. Nurses can enrol for the two-month programme at their convenience. The programme is developed by the India-Sweden Innovation Centre, certified by AIIMS-Jodhpur and endorsed by the Directorate General of Health Services (DGHS), and has the Indian Nursing Council (INC), among others, as advisors.

Demand-supply gap

Health is a State subject, but to shore up the number of skilled nurses the Centre has mandated opening one BSc college at each of the 16 proposed AIIMS and the six existing ones. Uttar Pradesh has announced adding about 14,000 nursing seats in five years.

Dr Bharat Gadhavi, President, Ahmedabad Hospitals & Nursing Homes Association (AHNA), attributes the supply gap to nurses going overseas. “Due to inadequate infrastructure at colleges, we don’t get the nurses suited to our expectations. The government spending on nursing colleges is minimal and what we have in the private sector raises questions on the quality of faculty and education,” he says.

With hospitals facing a 15 per cent shortage of nursing staff, he recommends a scoring system for nursing schools to ensure academic quality.

Status of nurses in India
Lack of social status, recognition, low pay, poor working conditions, lack of autonomy in practice, lack of recognition as a member of healthcare team and exploitation have significantly contributed to the brain drain of nurses to the western world.
Continuous downfall in the status of nurses in India
1. Routine patient care: Involved in hygienic or basic care procedures
2. Investigation: Assisting patient and physician during X-ray, ECG and other investigations
3. Diagnosis: Only provide need-based care on hygiene, nutrition and elimination as instructed by physician
4. Treatment: Follow physician’s orders and “no rights“ for prescription and treatment
5. Referral: Assist in preparing client for referral and documentation
6. Discharge: Act as liaison between patient and doctor without active role in discharge of patient
7. Speciality clinics: No autonomy in running independent nurse-led speciality clinics
Continuously escalating status of nurses in western world
1. Routine patient care: Collect detailed history and perform thorough physical examination, along with assisting and providing care for clients' priority needs
2. Investigation: Order, perform and interpret diagnostic tests like X-ray, ECG etc.
3. Diagnosis: Diagnose patient with acute and chronic illness, and also make nursing diagnosis to plan evidence-based care
4. Treatment: Treat patient with acute and chronic illness independently as a nursing practitioner
5. Referral: Refer client for advanced treatment and services
6. Discharge: Take decision for patients’ discharge and manage follow-up visits
7. Speciality clinics: Run independent nurse-led and adjuvant speciality clinic for both acute and chronic clinical conditions
Source: ‘Status of nurses in India: Current situation analysis and strategies to improve (January 2021)‘ by Pastin Pushpa Rani (Christian Medical College, Vellore), Suresh K Sharma (AIIMS-Jodhpur), and Kalpana Thakur (AIIMS-Rishikesh)