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To commemorate International Nurses Day, Christina A D’souza, who leads the vertical for the Healthcare Practice at SPAG, writes about the crucial role that nurses play today in India’s fight against COVID-19. She addresses the issue of the shortage of nurses, and champions the cause of nurse practitioners (NPs).

“Nurses dispense comfort, caring and compassion without even a prescription”

Terri Guillemets, Anthologist

In the middle of the most challenging medical crisis in a century, the crucial role that nurses play in our healthcare system has become so much more visible than it has ever been.

Today, they conjure up images of healthcare warriors, on the frontlines of action in a very tough war against a terrible enemy. Remember Florence Nightingale?

The World Health Organisation (WHO) guidelines say there should be 3 nurses per 1000 people; in India that number is 1.7. In a response to a question in the Rajya Sabha on March 3, 2020, the government told Parliament that there were 3.07 million registered nursing personnel: nurses, midwives, women health visitors, and auxiliary nurse-midwives.

The geographical distribution of nurses is also skewed.

The National Sample Survey Organisation (NSSO) estimates for 2017–18 show that while 66 percent of India’s population lives in rural areas, only 27 percent of doctors and 36 percent of nurses work there. In some states like Bihar, Jharkhand, and Uttar Pradesh, that number is even lower.

This shortage of nurses is not restricted to India.

According to another study, at end-2016, it was estimated that more than 33,000 nurses from India were working overseas in other countries; most had migrated there.

A study by the Indian Nursing Council reported a recent surge in the number of training institutions for nurses. It reported that there were roughly 1,958 institutes, and 98,749 sanctioned seats for admission — it’s higher now, but still short of the WHO guideline.

Among the key reasons cited for both the shortage and nurses’ decisions to move overseas is — low professional status, gender discrimination, and poor pay, all of which are endemic in India. Put another way, their status is less that of a professional, and more that of a servant.

I asked my friends what they remembered of their nurses when they were sick, or in hospital. Several remembered doctors’ names, but their nurses were just ‘Sister’.

But even in those very rural areas, nurses can actually do much more.

The National Health Policy (2017) recognized that the current healthcare delivery system needs redesign. A new cadre of nurse practitioners (NPs) has to be created, the policy said, to increase access in areas and states they were needed most.

NPs can conduct assessments, order diagnostic tests, treat minor ailments like fever, nausea, pain, provide post-natal care and prescribe medicines for them. It has existed in the US since 1965, the UK from 1980, introduced in Australia in 1990, and in the Netherlands from 2010. NPs are a part of the healthcare systems of almost 70 countries including Asian countries like South Korea, Singapore, and Thailand.

The truth is, many registered nurses (RNs) have been functioning as NPs in some districts of Rajasthan, though not legally. In 2002, the government of West Bengal introduced a NP course in midwifery; Gujarat started in 2009. Other states — Telangana and Kerala followed. But they weren’t able to attract enough students.

The National Health Policy suggests it, and in November 2020 the government decided to replace the Indian Nursing Council Act 1947 with the National Nursing and Midwifery Commission (NNMC) Act to address new and unmet healthcare needs of the nursing profession.

Reforming the curriculum and training progammes will have to be a crucial part of putting in place the NP system. The NNMC Act explicitly underlines that as a priority. While putting in place the relevant governance rules, consulting with nursing profession representatives will add considerable value.

The rules should also give NPs the authority to prescribe medicines for minor ailments, with appropriate protocols in place. In most countries that have introduced a NP system, many NPs run independent practices. In states and places that are remote and hard to access, such practices could improve health outcomes significantly.

This is the time — in the middle of our war on Covid-19 — to give the nursing profession the respect and status it deserves.

Let’s give our nurses their due.