BMJ 2013;347:f6881 doi: 10.1136/bmj.f6881 (Published 18 November 2013)
Page 1 of 3
Feature
FEATURE WORKFORCE PLANNING
Can India end the corruption in nurses’ training? India needs more and better nurses if it is to achieve universal health coverage, and for that must raise the standard of training. Soumyadeep Bhaumik reports on the unethical practices that are holding it back Soumyadeep Bhaumik medical doctor, independent researcher, and freelance author, Kolkata, India The World Health Organization has called for universal “access to a skilled, motivated and supported health worker, within a robust health system.”1 But a review commissioned by the UK Department for International Development in 2009 found major shortcomings in nursing in India in terms of quantity and quality.2 “The overall quality of nursing care in India is not up to the mark,” agreed Usha Ukande, principal of Choithram College of Nursing, Indore, and president of the Nursing Research Society of India.
The severe shortage of nurses of all categories and at all levels, the overburdened health system, and deficiencies in infrastructure, compounded by nurses being overworked, underpaid, and exploited are some reasons.3 But quality in any profession depends on education and training.
Workforce planning is not centrally coordinated in India. The federal government publishes statistics and guidelines but state governments and private hospitals can choose how they respond.
Quantity over quality?
The central government has asked all states to invest in more training institutions to increase the numbers of general nurse midwives, auxiliary nurse midwives, as well as nurses trained in super-specialty disciplines, and it has provided subsidies to help.4
“Recent plans for universal health coverage in India have been developed on the expectation of a principal role for nurses, as the backbone of public and essential health services and majority contributors to the health workforce,” Kabir Sheikh, senior scientist and director at the health governance hub of the Public Health Foundation of India (PHFI), told the BMJ. In the past, predictions of shortages of nurses have led to new training institutions being opened by government or in the private sector but often these have lacked “proper understanding of what has to be done to ensure quality in upcoming professionals,” Raman V R, principal fellow at the health governance hub of the PHFI, explained to the BMJ.
“We have regulatory standards [set by the Indian Nursing Council (INC)] for [training] institutions, which speak of numbers and size of physical infrastructure, while keeping silent on ‘substance,’ ‘excellence,’ and ‘commitment’” among nurses themselves, he said. “The motivation of private commercial interests, with some exceptions perhaps, does not appear to have fostered quality in the profession,” he said.
In India’s economic boom in the late 1990s nurses’ education became a profit making industry, with the aim of filling a huge gap in numbers as soon as possible—but with little care for other factors.
“India has witnessed a dramatic proliferation of nursing education institutions in recent years, although there is still an overall shortage. Over 88% of nurse education is now delivered in the private sector,” according to an article in the journal BMC Nursing.5 But this has led to compromises in the quality of nursing education in India. A critical review by the National Institute of Health and Family Welfare (NIHFW), an autonomous federal government think tank and technical institute, in collaboration with the World Health Organization in 2012 identified that nursing degrees are being awarded by institutions at which attendance is not mandatory. Despite this widespread “unethical practice . . . no action [is being] taken,” it concluded.6
Scarcity of nursing teachers Uttar Pradesh’s government allocated funds to build new nursing schools without tackling a shortage of teaching staff. The problem is made worse because many teachers in nursing schools lack minimum qualifications and are there only because of their age.7 The situation is similar in other populous states such as Bihar, Madhya Pradesh, and Rajasthan, which together with Uttar Pradesh have only 9% of the nation’s nursing schools.5
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BMJ 2013;347:f6881 doi: 10.1136/bmj.f6881 (Published 18 November 2013)
Page 2 of 3
FEATURE
The NIHFW-WHO review found a considerable decrease in the supervisory role of nursing educators; they lack accountability and responsibility as practitioners, supervisors, and mentors.6
“One major problem is the non-availability of ‘nursing teachers’ to teach practical (hands on) in the clinical field . . . nursing teachers do not go to the hospital along with students to teach, guide, and supervise,” said Rafath Razia, professor and deputy director of nursing for the government of Andhra Pradesh. This has meant that the essential competencies as prescribed in nursing syllabuses may be taught only for the purpose of passing examinations and might never be used in clinical practice. “In many institutions, when student nurses come for their posting, they have a cupboard where they keep their equipment; once done, the things go back into the cupboard and it is kept locked,” explained Mercy John, principal of the school of nursing in the Christian Hospital, Bissamcuttack, Odisha. That this equipment is not used in routine clinical practice “makes the ward nurse look foolish and inefficient,” she said. John’s experiences paint an abject picture: she has had nurses with bachelors degrees seeking work, but refusing to join her hospital when they find out that they have to start as a clinical nurse before they can teach. A common refrain is, “No, we are trained to teach and not work on the wards.” she told the BMJ. She said that she has also met other nurses “who after completing their degree in nursing, did not even know how to check vital signs.”
“Many of these so called nursing teachers are not fond of nursing so they take up teaching; they are not proud to be nurses; and they have low self esteem as nurses. In such instance the teacher is a very poor role model for the student,” added Razia. Unless the quality of nursing teachers as well as their role in clinical practice and training is ensured by way of integrating teaching with practice, the chasm between theory and practice will only widen.
Curriculum problems? John Oommen, head of the community health department in Christian Hospital, Bissamcuttack, Odisha, said that the 3.5 year training programme for general nurses and midwives includes subjects such as administration, ethics, sociology, communication, research methodology, health economics, professionalism, and pedagogy, making it possibly the “best designed among all health professional courses . . . The MBBS [Bachelor of Medicine/Bachelor of Surgery] has none of this,” he said. But it is critical that everything in the curriculum is learnt and practical skills monitored to ensure satisfactory standards. Students from institutions that adhere to the curriculum are in demand.
Nursing textbooks also pose challenges. Many are available but most borrow heavily from Western practices, with little consideration for local context and skills. “Most nursing books by Indian authors are of questionable quality—not because of the content but because they have failed to include research references from India,” said Ukande, the Nursing Research Society of India president.
Poor infrastructure and security concerns Many nurses’ residences are old buildings, sometimes dilapidated and lacking water, sanitation, or electricity.2 4 6 Nursing students are mostly put up in cramped dormitories.
For personal use only: See rights and reprints http://www.bmj.com/permissions
“Doctors and other professionals have to be given single rooms or even quarters, while for the nurses there are no single rooms. Some institutions have many nurses staying in conditions far less than conducive. Are they not professionals? Do we not demand so much from them?” asked Mercy John, of the Bissamcuttack school. New investment from the government might see this improve.
Nurses and nursing students throughout India have reported being raped and other violence against them.2 8-10 Nurses have to contend with sexual harassment and violence not only from superiors and doctors but also from other healthcare workers, patients, and relatives. This is able to occur because of women’s generally low societal status and might be prompted by nurses “unusual role as breadwinner” and the “deviance of being seen in a public space at night,” a review concluded.11 Ensuring nurses and students’ security is a prime concern, particularly now that violence against women in India is so prominently in the public spotlight.
Corruption Substandard institutions continue to receive accreditation from state nursing councils despite not meeting the standards of the federal INC and universities, a government report has found.12 The study found that this applied to as many as 61% of nurse training institutes.
The review found that the number of teaching institutions was “not commensurate with number of hospitals.” There are cases of multiple nursing institutes being unnecessarily attached to a single hospital, and as Raman Kataria, a community doctor and one of the founding members of Jan Swasthya Sahyog, a non-profit organisation working in central India, added, “Many nursing schools do not [even] have their own clinical facilities, and they run almost like businesses, where hefty fees are charged from students.” Fees in private nursing teaching institutions can cost as much as 120 000 rupees (£1200; €1400; $1900) a year. The NIHFW review6 advocates the “strict implementation of INC guidelines for attachment of teaching institutions with service delivery centre for skill based training” as one of most important actions to be taken in the nursing education sector. The NIHFW review blames this on the lack of coordination between the INC and the state nursing councils but experts throughout India say that corruption plays a part.
Rafath Razia, Andhra Pradesh’s deputy nursing director, said that substandard institutions exist despite it being mandatory for them to obtain recognition from the INC after accreditation by the state nursing council, which entails many inspections by the state government, the state nursing council, the university that awards degrees, and the INC. Razia told the BMJ that substandard institutions are able to achieve certification by means of “factors like cheating, bribing, threats, pressures from above, temptations on the part of inspectors, and also there are strong associations of the private nursing schools.” “There are INC inspectors who like to go for inspections in order to make money,” said Mercy John at the Bissamcuttack school.
“We even hear that there is a whole industry that has developed with event management agencies able to help an owner put up all the props and costumes needed to pass an inspection—of medical colleges or nursing colleges or whatever,” said John Oomen at Bissamcuttack. Indeed, the UK government’s review noted that there are phantom faculties that show up for inspections. Even surprise
Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f6881 doi: 10.1136/bmj.f6881 (Published 18 November 2013)
Page 3 of 3
FEATURE
inspections, which experts suggest may counter this “are unlikely to work due to political pressure and inspector corruption,” the review found.2
“Ambiguities in jurisdictional spaces complicate the regulatory functions of nursing councils. The underlying factor here is poor public visibility and accountability of these agencies, which have been entrusted with important public functions,” added the PHFI’s Sheikh.
These difficulties, as well as their solutions, result from the way the sector and profession are governed. The government, the INC, and the state nursing councils must work together to ensure a better system of governance that will lead to a better structural, operational, and ethical environment for nursing education. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare that I have no relevant conflict of interest to declare. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2
Global Health Workforce Alliance. Health workers for all and all for health workers: an agenda for global action. March 2008. www.who.int/workforcealliance/forum/1_ agenda4GAction_final.pdf. Oulton J, Hickey B. DFID: Review of the nursing crisis in Bangladesh, India, Nepal and Pakistan. Instituto de Cooperación Social, INTEGRARE. Barcelona, Spain, 2009.
For personal use only: See rights and reprints http://www.bmj.com/permissions
3 4 5 6 7 8 9 10 11 12
Bhaumik S. Why is India short of nurses and what can we do about it? BMJ 2013;346:f4024. Nandan D, Mavalankar D, Bagga R, Shahrawat R, Sharma B. Assessment of nursing management capacity in West Bengal. National Institute of Health and Family Welfare. http://nihfw.org/pdf/Nsg%20Study-Web/West%20Bengal%20Report.pdf. Evans C, Razia R, Cook E. Building nurse education capacity in India: insights from a faculty development programme in Andhra Pradesh. BMC Nursing 2013;12:8. www. biomedcentral.com/1472-6955/12/8. Bagga R, Tiwari R, Jaiswal V, Abraham A. Study on nursing and midwifery in India: a critical review. National Institute of Health and Family Welfare. 22 November, 2012. http: //planningcommission.gov.in/data/ngo/csw/csw_nurse.pdf. Raha S, Berman P, Bhatnagar A. Some priority challenges of the nursing sector in India. India Health Beat 2009. https://openknowledge.worldbank.org/bitstream/handle/10986/ 12820/702430BRI0P1020k0Final000Vol010no05.pdf?sequence=1. TNN. Punjab shame piles on: Gang-raped and dumped, nurse critical. Times of India 21 January, 2013. http://articles.timesofindia.indiatimes.com/2013-01-21/india/36461966_ 1_patiala-gang-minor-girl-suicide-case. Swamy HMC. Nursing student gang-raped. Police try to dilute case DNA. 25 April, 2013. www.dnaindia.com/bangalore/1826758/report-nursing-student-gang-raped-police-try-todilute-case. Three arrested in Kerala for raping nursing student. Times of India 26 April, 2013. http:// articles.timesofindia.indiatimes.com/2013-04-26/bangalore/38842318_1_dandupalyamystery-woman-alappuzha. Nair S, Healey M. A Profession on the margins: status issues in Indian nursing. Centre for Women’s Development Studies, occasional paper. 2006. www.cwds.ac.in/ocpaper/ profession_on_the_margins.pdf. Ministry of Health and Family Welfare: Report of the national commission on macroeconomics and health. New Delhi: Government of India; 2005. http://www.who.int/ macrohealth/action/Report%20of%20the%20National%20Commission.pdf.
Cite this as: BMJ 2013;347:f6881 © BMJ Publishing Group Ltd 2013
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Feature
FEATURE WORKFORCE PLANNING
Can India end the corruption in nurses’ training? India needs more and better nurses if it is to achieve universal health coverage, and for that must raise the standard of training. Soumyadeep Bhaumik reports on the unethical practices that are holding it back Soumyadeep Bhaumik medical doctor, independent researcher, and freelance author, Kolkata, India The World Health Organization has called for universal “access to a skilled, motivated and supported health worker, within a robust health system.”1 But a review commissioned by the UK Department for International Development in 2009 found major shortcomings in nursing in India in terms of quantity and quality.2 “The overall quality of nursing care in India is not up to the mark,” agreed Usha Ukande, principal of Choithram College of Nursing, Indore, and president of the Nursing Research Society of India.
The severe shortage of nurses of all categories and at all levels, the overburdened health system, and deficiencies in infrastructure, compounded by nurses being overworked, underpaid, and exploited are some reasons.3 But quality in any profession depends on education and training.
Workforce planning is not centrally coordinated in India. The federal government publishes statistics and guidelines but state governments and private hospitals can choose how they respond.
Quantity over quality?
The central government has asked all states to invest in more training institutions to increase the numbers of general nurse midwives, auxiliary nurse midwives, as well as nurses trained in super-specialty disciplines, and it has provided subsidies to help.4
“Recent plans for universal health coverage in India have been developed on the expectation of a principal role for nurses, as the backbone of public and essential health services and majority contributors to the health workforce,” Kabir Sheikh, senior scientist and director at the health governance hub of the Public Health Foundation of India (PHFI), told the BMJ. In the past, predictions of shortages of nurses have led to new training institutions being opened by government or in the private sector but often these have lacked “proper understanding of what has to be done to ensure quality in upcoming professionals,” Raman V R, principal fellow at the health governance hub of the PHFI, explained to the BMJ.
“We have regulatory standards [set by the Indian Nursing Council (INC)] for [training] institutions, which speak of numbers and size of physical infrastructure, while keeping silent on ‘substance,’ ‘excellence,’ and ‘commitment’” among nurses themselves, he said. “The motivation of private commercial interests, with some exceptions perhaps, does not appear to have fostered quality in the profession,” he said.
In India’s economic boom in the late 1990s nurses’ education became a profit making industry, with the aim of filling a huge gap in numbers as soon as possible—but with little care for other factors.
“India has witnessed a dramatic proliferation of nursing education institutions in recent years, although there is still an overall shortage. Over 88% of nurse education is now delivered in the private sector,” according to an article in the journal BMC Nursing.5 But this has led to compromises in the quality of nursing education in India. A critical review by the National Institute of Health and Family Welfare (NIHFW), an autonomous federal government think tank and technical institute, in collaboration with the World Health Organization in 2012 identified that nursing degrees are being awarded by institutions at which attendance is not mandatory. Despite this widespread “unethical practice . . . no action [is being] taken,” it concluded.6
Scarcity of nursing teachers Uttar Pradesh’s government allocated funds to build new nursing schools without tackling a shortage of teaching staff. The problem is made worse because many teachers in nursing schools lack minimum qualifications and are there only because of their age.7 The situation is similar in other populous states such as Bihar, Madhya Pradesh, and Rajasthan, which together with Uttar Pradesh have only 9% of the nation’s nursing schools.5
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f6881 doi: 10.1136/bmj.f6881 (Published 18 November 2013)
Page 2 of 3
FEATURE
The NIHFW-WHO review found a considerable decrease in the supervisory role of nursing educators; they lack accountability and responsibility as practitioners, supervisors, and mentors.6
“One major problem is the non-availability of ‘nursing teachers’ to teach practical (hands on) in the clinical field . . . nursing teachers do not go to the hospital along with students to teach, guide, and supervise,” said Rafath Razia, professor and deputy director of nursing for the government of Andhra Pradesh. This has meant that the essential competencies as prescribed in nursing syllabuses may be taught only for the purpose of passing examinations and might never be used in clinical practice. “In many institutions, when student nurses come for their posting, they have a cupboard where they keep their equipment; once done, the things go back into the cupboard and it is kept locked,” explained Mercy John, principal of the school of nursing in the Christian Hospital, Bissamcuttack, Odisha. That this equipment is not used in routine clinical practice “makes the ward nurse look foolish and inefficient,” she said. John’s experiences paint an abject picture: she has had nurses with bachelors degrees seeking work, but refusing to join her hospital when they find out that they have to start as a clinical nurse before they can teach. A common refrain is, “No, we are trained to teach and not work on the wards.” she told the BMJ. She said that she has also met other nurses “who after completing their degree in nursing, did not even know how to check vital signs.”
“Many of these so called nursing teachers are not fond of nursing so they take up teaching; they are not proud to be nurses; and they have low self esteem as nurses. In such instance the teacher is a very poor role model for the student,” added Razia. Unless the quality of nursing teachers as well as their role in clinical practice and training is ensured by way of integrating teaching with practice, the chasm between theory and practice will only widen.
Curriculum problems? John Oommen, head of the community health department in Christian Hospital, Bissamcuttack, Odisha, said that the 3.5 year training programme for general nurses and midwives includes subjects such as administration, ethics, sociology, communication, research methodology, health economics, professionalism, and pedagogy, making it possibly the “best designed among all health professional courses . . . The MBBS [Bachelor of Medicine/Bachelor of Surgery] has none of this,” he said. But it is critical that everything in the curriculum is learnt and practical skills monitored to ensure satisfactory standards. Students from institutions that adhere to the curriculum are in demand.
Nursing textbooks also pose challenges. Many are available but most borrow heavily from Western practices, with little consideration for local context and skills. “Most nursing books by Indian authors are of questionable quality—not because of the content but because they have failed to include research references from India,” said Ukande, the Nursing Research Society of India president.
Poor infrastructure and security concerns Many nurses’ residences are old buildings, sometimes dilapidated and lacking water, sanitation, or electricity.2 4 6 Nursing students are mostly put up in cramped dormitories.
For personal use only: See rights and reprints http://www.bmj.com/permissions
“Doctors and other professionals have to be given single rooms or even quarters, while for the nurses there are no single rooms. Some institutions have many nurses staying in conditions far less than conducive. Are they not professionals? Do we not demand so much from them?” asked Mercy John, of the Bissamcuttack school. New investment from the government might see this improve.
Nurses and nursing students throughout India have reported being raped and other violence against them.2 8-10 Nurses have to contend with sexual harassment and violence not only from superiors and doctors but also from other healthcare workers, patients, and relatives. This is able to occur because of women’s generally low societal status and might be prompted by nurses “unusual role as breadwinner” and the “deviance of being seen in a public space at night,” a review concluded.11 Ensuring nurses and students’ security is a prime concern, particularly now that violence against women in India is so prominently in the public spotlight.
Corruption Substandard institutions continue to receive accreditation from state nursing councils despite not meeting the standards of the federal INC and universities, a government report has found.12 The study found that this applied to as many as 61% of nurse training institutes.
The review found that the number of teaching institutions was “not commensurate with number of hospitals.” There are cases of multiple nursing institutes being unnecessarily attached to a single hospital, and as Raman Kataria, a community doctor and one of the founding members of Jan Swasthya Sahyog, a non-profit organisation working in central India, added, “Many nursing schools do not [even] have their own clinical facilities, and they run almost like businesses, where hefty fees are charged from students.” Fees in private nursing teaching institutions can cost as much as 120 000 rupees (£1200; €1400; $1900) a year. The NIHFW review6 advocates the “strict implementation of INC guidelines for attachment of teaching institutions with service delivery centre for skill based training” as one of most important actions to be taken in the nursing education sector. The NIHFW review blames this on the lack of coordination between the INC and the state nursing councils but experts throughout India say that corruption plays a part.
Rafath Razia, Andhra Pradesh’s deputy nursing director, said that substandard institutions exist despite it being mandatory for them to obtain recognition from the INC after accreditation by the state nursing council, which entails many inspections by the state government, the state nursing council, the university that awards degrees, and the INC. Razia told the BMJ that substandard institutions are able to achieve certification by means of “factors like cheating, bribing, threats, pressures from above, temptations on the part of inspectors, and also there are strong associations of the private nursing schools.” “There are INC inspectors who like to go for inspections in order to make money,” said Mercy John at the Bissamcuttack school.
“We even hear that there is a whole industry that has developed with event management agencies able to help an owner put up all the props and costumes needed to pass an inspection—of medical colleges or nursing colleges or whatever,” said John Oomen at Bissamcuttack. Indeed, the UK government’s review noted that there are phantom faculties that show up for inspections. Even surprise
Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f6881 doi: 10.1136/bmj.f6881 (Published 18 November 2013)
Page 3 of 3
FEATURE
inspections, which experts suggest may counter this “are unlikely to work due to political pressure and inspector corruption,” the review found.2
“Ambiguities in jurisdictional spaces complicate the regulatory functions of nursing councils. The underlying factor here is poor public visibility and accountability of these agencies, which have been entrusted with important public functions,” added the PHFI’s Sheikh.
These difficulties, as well as their solutions, result from the way the sector and profession are governed. The government, the INC, and the state nursing councils must work together to ensure a better system of governance that will lead to a better structural, operational, and ethical environment for nursing education. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare that I have no relevant conflict of interest to declare. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2
Global Health Workforce Alliance. Health workers for all and all for health workers: an agenda for global action. March 2008. www.who.int/workforcealliance/forum/1_ agenda4GAction_final.pdf. Oulton J, Hickey B. DFID: Review of the nursing crisis in Bangladesh, India, Nepal and Pakistan. Instituto de Cooperación Social, INTEGRARE. Barcelona, Spain, 2009.
For personal use only: See rights and reprints http://www.bmj.com/permissions
3 4 5 6 7 8 9 10 11 12
Bhaumik S. Why is India short of nurses and what can we do about it? BMJ 2013;346:f4024. Nandan D, Mavalankar D, Bagga R, Shahrawat R, Sharma B. Assessment of nursing management capacity in West Bengal. National Institute of Health and Family Welfare. http://nihfw.org/pdf/Nsg%20Study-Web/West%20Bengal%20Report.pdf. Evans C, Razia R, Cook E. Building nurse education capacity in India: insights from a faculty development programme in Andhra Pradesh. BMC Nursing 2013;12:8. www. biomedcentral.com/1472-6955/12/8. Bagga R, Tiwari R, Jaiswal V, Abraham A. Study on nursing and midwifery in India: a critical review. National Institute of Health and Family Welfare. 22 November, 2012. http: //planningcommission.gov.in/data/ngo/csw/csw_nurse.pdf. Raha S, Berman P, Bhatnagar A. Some priority challenges of the nursing sector in India. India Health Beat 2009. https://openknowledge.worldbank.org/bitstream/handle/10986/ 12820/702430BRI0P1020k0Final000Vol010no05.pdf?sequence=1. TNN. Punjab shame piles on: Gang-raped and dumped, nurse critical. Times of India 21 January, 2013. http://articles.timesofindia.indiatimes.com/2013-01-21/india/36461966_ 1_patiala-gang-minor-girl-suicide-case. Swamy HMC. Nursing student gang-raped. Police try to dilute case DNA. 25 April, 2013. www.dnaindia.com/bangalore/1826758/report-nursing-student-gang-raped-police-try-todilute-case. Three arrested in Kerala for raping nursing student. Times of India 26 April, 2013. http:// articles.timesofindia.indiatimes.com/2013-04-26/bangalore/38842318_1_dandupalyamystery-woman-alappuzha. Nair S, Healey M. A Profession on the margins: status issues in Indian nursing. Centre for Women’s Development Studies, occasional paper. 2006. www.cwds.ac.in/ocpaper/ profession_on_the_margins.pdf. Ministry of Health and Family Welfare: Report of the national commission on macroeconomics and health. New Delhi: Government of India; 2005. http://www.who.int/ macrohealth/action/Report%20of%20the%20National%20Commission.pdf.
Cite this as: BMJ 2013;347:f6881 © BMJ Publishing Group Ltd 2013
Subscribe: http://www.bmj.com/subscribe
