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GROWTH OF NURSING IN INDIA: HISTORICAL AND FUTURE PERSPECTIVES

Dr. Punitha Ezhilarasu Consultant Indian Nursing Council

Nurses are two-thirds of health workforce in India. Their central roles in health care delivery in terms of promotion, prevention, treatment, care and rehabilitation are highly significant. Their contributions towards achieving UN millennium development goals (MDG) and sustainable development goals (SDG) are very crucial but not sufficient enough particularly in developing countries like India to create major impact on health outcomes. Achieving universal coverage, increasing health financing, recruitment, training and retention of health workforce are two important goals that have direct relevance to India. Nursing today has witnessed several changes, successes and challenges through a lot of stride and movement. Nurses have widened their scope of their work, however while the roles and responsibilities have multiplied, there are still concerns with regard to development of nursing, workforce, selection and recruitment, placement as per specialization, pre service, in service training and human resource (HR) issues for their career growth. This paper attempts to present the futuristic nursing in the light of historical and contemporary perspectives.

Historical perspectives

Nursing and Nursing Education

In the ancient era, until 17th century, formalized nursing was not traced. Every village had a dai/traditional birth attendant to take care of maternal and child health needs of the people. Military nursing was the earliest type of modern nursing introduced by the Portuguese in the 17th century. In 1664, East India Company started a hospital for soldiers at Fort St. Geroge, Madras. In 1797, a lying-in-hospital (Maternity) for the poor in Madras was built. Some of the other earliest hospitals were the first hospital in Calcutta in Fort William (1708), Calcutta medical college hospital and London mission hospital at Neyyoor (1838), Jamsetjee Jeejeebhoy (J.J) group in Mumbai (1843), Thomasan hospital at Agra (1853), Holy Family Hospital, Delhi (1855), Civil hospital Amritsar (1860), CMC, Ludhiana, Punjab (1881), 1892 Miraj medical school and hospital, Maharashtra (1892) and Bowring hospital in Bangalore (1895).

Florence Nightingale was the first woman to have great influence over nursing in India and brought reforms in military and civilian hospitals in 1861. St. Stevens Hospital at Delhi was the first one to begin training Indian women as nurses in 1867. In 1871, the government General Hospital at Madras was started with the first school of nursing for midwives with four students. Many nursing schools were started in different states of India between 18th and 19th century mostly by mission hospitals, which trained Indians as nurses. At this time there was no uniform educational standards followed in nursing schools. In 1907-1910, in North India, United Board of Examiners for mission hospitals was set up which formulated training standards and rules. Later Mid India (1926) and South India (1913) boards (boards of CMAI) were set up which conducted examination and gave diplomas. The first school of Health visitors was started in 1918 by Lady Reading Health School, Delhi. The first four-year Basic B.Sc. program was established in 1946 at RAK College of Nursing in Delhi and CMC College of Nursing in Vellore. In 1960, M.Sc. was established in RAK College of Nursing, Delhi. In 1951, a two-year ANM course was established in St. Mary’s Hospital at Punjab.

Bombay Presidency Nursing Association was the first state nursing association established in 1890. In 1908, the Trained Nurses Association was formed to uphold the dignity and honor of nursing profession. The first state registration council at Madras Nursing Council was constituted in 1926 and Bombay Nursing Council was constituted in 1935. In 1949, Indian Nursing Council (INC) was established to maintain a uniform standard of training for nurses, midwives and health visitors and regulate the standards of nursing in India. INC act was passed in 1947 that was amended in 1950 and 1957. General Nursing and Midwifery (GNM) syllabus was revised in 1951, 1965, and 1986, ANM in 1974 and B.Sc. in 1981.

The nursing scenario at the time of independence was not bright and there were about 7000 nurses for the population of 400 million. The hospitals were grossly understaffed, nursing lacked professional and social status, and the working and living conditions of nurses were far from satisfactory. The low status can be attributed to the low socio economic status of Indian women and nursing is primarily a women’s profession. In the fifties, more number of girls from different parts of the country joined nursing and slowly there are more entrants from better socioeconomic status. By 2000, nurses’ colony at Delhi was built by Central government; nursing advisor post was instituted at the national level; three nursing posts were increased to five with the introduction of Asst. Director General Nursing and Dy. Asst. Director General. The College of Nursing PGI, Chandigarh and College of Nursing, CMC Vellore were designated as WHO collaborating centers for nursing and midwifery development in 2003.

The development of various committees such as Bhore Committee (1943), Shetty Committee (1954), Mudaliar Committee (1959-61), Kartar Singh Committee (1973), Srivastava Committee (1974), High Power Committee (1987) alongside five year plans have brought about a transition in the status of nursing and midwifery. The recommendations made were in relation to staffing in hospital nursing service, public health settings, and schools/colleges, working and living conditions, infrastructure and equipment, regulations, and intensification of training programmes to meet the staff shortage. The reports of the above mentioned Committees and National Health Policy (NHP, 2002) have put forward very sound recommendations for nursing management capacity. The NHP laid emphasis on improving the skill-level of nurses and on increasing the ratio of degree-holding nurses vis-à-vis diploma-holding nurses. It also recognized the need for establishing training courses for super-speciality nurses required for tertiary care institutions. However, gap existed in actual implementation. This required a strong support at the policy level to ensure implementation of key recommendations.

Following independence, reorganization of the health services took place in the light of the Bhore Committee recommendations (1946). Health services were provided in the rural areas through the establishment of primary health centre (PHC) as a basic unit to provide an integrated curative and preventive health care for the population of 30,000 in the plains (20,000 in hilly areas). The staffing pattern of the PHC was not implemented fully as per the Bhore Committee with regard to nursing until now. As per the Bhore committee’s recommendations, the nursing staff of PHC includes Public health nurses – 4, Institutional nurse -1, Midwives – 4 and Trained Dais – 4. In 1952, a post-certificate Public Health Nursing programme was instituted at the college of Nursing, New Delhi and later transferred to All India Institute of Hygiene and Public Health, Calcutta. Community health nursing was integrated in the curriculum of GNM and BSc Nursing courses.

From 1977-till date, with the introduction of Multipurpose Health Worker’s Scheme following Kartar Singh’s Committee report in 1973, most of the categories of staff under various unipurpose programmes were re-designated for multipurpose work. Until recently, most of the health services in the homes were provided by the Health workers, health visitors, ASHAs and Trained Dais whose activities were and are still concerned primarily with maternity and child welfare. The auxiliary nurse midwife (ANM) gradually replaced the Dais to serve in the village through the primary health centre and its sub-centres. Under NRHM scheme in 1996, every PHC was manned with 2 staff nurses to provide RCH services. In 1977, the Indian Nursing Council revised the curriculum for ANM course, in order to prepare candidates with high school certificate as Health workers (Female) and Health workers (Male) under the multipurpose health workers’ scheme. The formulation and adoption of the global strategy for “Health for All” by the 34th World Health Assembly in 1981 through Primary Health Care approach got of a good start in India with the theme “Health for All” by 2000 AD. In 1987, The Government of India appointed a High Power Committee on Nurses and Nursing Profession to go into the working conditions of nurses, nursing education and other related matters and submitted manpower requirements for nursing personnel.

Contemporary Perspectives

The current healthcare environment is dramatically different from the past and it is the health system that shapes the educational system and pathways. The complexity of the healthcare influenced by the increasing longevity, shortening of hospital stays, scientific and technological advances, equality, poverty, discrimination, disasters, violence and cultural diversity leads to several challenges that threaten the health and wellbeing of the Indian Population. Currently India has only 0.7 doctors (Global average is 1/1000) and 1.7 nurses (Global is 2.5/1000) available per thousand population. The ratio of hospital beds to population in 0.98/1000 against the global average of 3.5 beds/1000 population (WHO). India stands at 67th rank against 133 developing countries with regard to number of doctors and 75th rank with respect to number of nurses. The Physician Nurse ratio is not satisfactory. Thus, International Nurse is 1:3 whereas India is having 1:1. The country needs 2.4 million nurses to meet the growing demand (FICCI report, 2016). The HLEG (High Level Expert Group) group report on UHC (Universal health coverage India) 2011 is increased reliance on a cadre of well- trained nurses, which will allow doctors to focus on complex clinical cases.

The roles of nurses are evolving and changing. Nurses can perform health assessment, actively support patients and families in all settings, create innovative models of care, and enhance work processes to raise quality, lower cost and improve access for our society. Nurses can undertake research to find evidence to support new nursing interventions. Nurses can contribute towards strengthening systems to work efficiently in interdisciplinary teams. They can effectively participate and influence policies related to nursing at local, state and national levels. There is a rising demand in terms of manpower for tertiary and quaternary care, which requires specialized and highly skilled resources including doctors, nurses and other paramedical staff. This is also emphasized in NHP 2017. As a result, the demand for trained manpower, especially nurses will continue to increase every year. The number of registered nurses/midwives was 6.7 lakhs in 1998 and has reached 17,91,285 nurses/midwives in 2014.

In India, nursing educational programs such as Auxiliary Nurse Midwifery, General Nursing and Midwifery, BSc(N), MSc(N), MPhil and PhD(N) exist. INC prescribes uniform standards and syllabi for every educational program to be implemented across the country. However, the implementation by educational institutions having varied capabilities is not uniform resulting in graduates with varying knowledge, attitude and competencies. The last syllabus revision for ANM was done in 2012-13, GNM 2015-16, B.Sc- 2006, PBBSc- 2006 and M.Sc 2008. The growth in nursing educations is phenomenal. From 2000 to 2016, ANM schools have increased from 298 to 1927, GNM schools from 285 to 3040, B.Sc colleges from 30 to 1752, and M.Sc colleges from10 to 611. Although the increase is significant still there is gap between demand and supply. The 12th five-year plan suggested establishing 24 centers of excellence in nursing. The HR efforts included up gradation of schools to colleges, strengthening of existing schools, faculty development, and establishment of 6 AIIMs like institutions.

Some of the INC initiatives and achievement include capacity building of 55 nursing educational institutions, training of 1,20,000 nurses and 3500 faculty in HIV/AIDS & TB through GFATM project. E Learning module was developed as a result of this project. A Live register is being developed for all categories of nurses. Every registered nurse will be provided with a nurse unique ID (NUID). The register will lead to development of a nurse tracking system across the country and aid in reciprocal registration alongside renewal of license linked with CNE. INC has become a member of ICN. A national consortium for PhD in nursing was constituted by INC in 2006 in collaboration with Rajiv Gandhi University of Health Sciences. The main objective is to promote research activities in various fields of nursing. The total number of research scholars enrolled in 12 batches is 268 and 74 have been already awarded Phd degree. There are 8 PhD study centers now namely INC, New Delhi, St John’s College of Nursing, Bangalore, CMC College of Nursing, Vellore, CMC College of Nursing, Ludhiana, Govt College of Nursing, Hyderabad, Govt College of Nursing, Thiruvananthapuram, Govt College of Nursing, SSKM Kolkata, and INE, Mumbai. INC is in collaboration with JHPIEGO has taken initiative to strengthen the foundation of pre-service education resulting in better prepared service provider. In order to promote competency based training INC in collaboration with JHPIEGO is going to set up state of the art simulation center in India.

There is a scope for improving living and working conditions of nurses in the future. Through the efforts and representation by TNAI, Supreme Court has recommended minimum salary of 20,000 per month as starting salary of a staff nurse in private hospitals. Some states have developed mechanism to conduct and record CNE through State nursing councils. Integration of service and education model that is practiced in CMC Vellore is also introduced in a few more institutions particularly in St Johns College of Nursing, Bangalore. INC is in the process of developing a practical model for the country. Florence Nightingale awards instituted by MOH & FW in 1973 to recognize and honor the meritorious services of outstanding nursing personnel in the country are given to 35 nurses every year on May 12, the International Nurses Day. This award includes a medal, certificate, citation and cash award of Rs. 50,000/-.

Some of the top nursing colleges in India today are established in the earliest days and are continuing to maintain standards and quality of education. AIIMS College of Nursing Delhi, CMC College of Nursing Vellore, RAK College of Nursing Delhi, SNDT College of Nursing Mumbai, NIMHANS Bangalore, Manipal College of Nursing Manipal, PGI College of Nursing Chandigarh, AFMC College of Nursing Pune, , BM Birla College of Nursing, Kolkata, , St John’s Bangalore, Govt College of Nursing Thiruvananthapuram, CMC College of Nursing Ludhiana, Father Muller College of Nursing Mangalore, Sri Ramachandra Medical University College of Nursing Chennai, and Apollo College of Nursing, Chennai are some of the top colleges of Nursing today. Many universities are running PhD programmes in nursing and many colleges have been recognized as research departments.

Public Health Nursing

According to the Indian Nursing Council (Snapshots, 2016), 789,740 ANMs and 56,096 LHVs are registered in the different state nursing councils of the Country. About 2.00 lakh ANMs (Auxiliary nurse midwives) and thousands of female health supervisors and public health nurses are working in the public health sector alone. They are responsible for implementing all national and state health programmes at ground level. Critical activities related to maternal and child health, disease control, immunization, epidemic management and health promotion are carried out by peripheral public health nursing personnel. The training of public health nursing personnel varies widely ranging from a broad multipurpose training of less than two years for ANMs to six years education at university level to prepare community health nursing specialists. Currently, community health nursing is offered as a subject in the ANM, GNM (general nursing and midwifery), post-basic B.Sc. Nursing, regular four-year B.Sc. Nursing and M.Sc. Nursing.

The scope of public health nursing is wide in India and their potentials are not fully utilized in our country. Currently, public health nurses at PHC, Block and district levels plan, monitor, and mentor peripheral health staff to implement programmes on health promotion and disease prevention. The Bhore Committee gave a strong recommendation for introduction of public health nurses and the Mudaliar Committee reiterated this. Rather than moving forward into a professional cadre, public health nursing in India became stagnant at the lowest level of ANM due to the political and economical reasons. Shortage of nurses and its impact on the Indian health care delivery system remains a major concern to this day. Adding to the above problem, there is an undersupply of competent public health nurses who are willing to serve in the resource-limited community health care settings.

Future Perspectives

The future of healthy India lies in mainstreaming the health agenda in the framework of the sustainable development and strengthening primary, secondary and tertiary care services to serve the rural (70%) and urban (30%) population. NHP 2017 recommends setting up new Medical Colleges, Nursing Institutions and AIIMS in the country by the government, standardization quality of clinical training, revisiting entry policies into educational institutions, ensuring quality of education, continuing nursing education and on the job support to providers, especially those working in rural areas using digital tools and other appropriate training resources, strengthening human resource governance, regulation of practice, establishing cadres like Nurse Practitioner and Public Health Nurses, specialty training for tertiary care, nursing school/college for 20-30 lakh population, HR policy for faculty, centers of excellence in nursing in each state, career progression to nursing cadre and posting of regular nurses to sub-center in the state where adequate nursing institutions are present. The policy also recommends the use of mid-level service providers to provide comprehensive primary care to the rural community through Health and Wellness centers/Sub centers. Nurses can assume this role provided they undergo a six month bridge course.

In the light of the above recommendations pertaining to nursing and nursing education, INC has prepared curriculum for Nurse Practitioner (NP) programmes in Critical Care and primary care. NP in Critical Care (NPCC) programme is commencing from 2017 and NP in Primary Health Care (NPPHC) from 2018. Both are residency programs aimed at providing clinical training at the real practice settings. State governments are communicated by central government to create posts for nurse practitioners at the state level. The revision of existing BSc and MSc curriculum are being planned to integrate competency based education approach and the process has just begun. The regulation of nursing education and practice will be strengthened through Nursing Practice Act (NPA) for which INC at the direction of the MOH &FW has started the preparation and soon it will be ready. National license exit exam for entry into practice, periodic renewal of license linked with continuing nursing education, and completion of live register are some of the future activities.

Studies of nursing practice have demonstrated that better patient outcomes are achieved in hospitals and community staffed by a greater proportion of nurses with a baccalaureate degree (Benner, Sutphen, Leonard, & Day, 2010). Phasing out diploma programme and making BSc as entry level is being dialogued and this might become a reality in the future too. The WHO strategic directions for nursing and midwifery (SNDM) 2011 – 2015 provide stakeholders with a framework for collaborative action with the vision statement “Improved health outcome for individuals; families and communities through provision of competent, culturally sensitive, evidence based nursing and midwifery services. This should become the future for nursing.

Bibliography

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses : A call for radical transformation. Danvers, MA: Wiley

– FICCI Report, 2016
– Indian Nursing Council, 2016
– Indrani,TK (2004). History of Nursing, New Delhi: Jaypee Brothers
– National Health Policy, 2002 & 2017
– Trained Nurses’ Association of India (2001). History and Trends in Nursing in India, New Delhi: TNAI

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Advancing Nursing Practice in India

Historical lessons from the united states.

Kumar, Rajesh 1,2, ; Rodney, Tamar W. 3

1 Postdoctrote Fellow at Johns Hopkins School of Nursing, Maryland, USA

2 Assistant Professor, Department of Nursing, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India

3 Assistant Professor, School of Nursing, Johns Hopkins University, Maryland, USA

Address for correspondence: Dr. Rajesh Kumar, Assistant Professor, Department of Nursing, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand - 249 203, India. E-mail: [email protected]

Received May 30, 2021

Received in revised form October 08, 2021

Accepted October 08, 2021

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Nurses, as key health personnel in the health-care industry, play a vital role in the delivery of care. Nurses work with different populations in varied settings to coordinate care aimed at the prevention of disease, promotion of health and care of sick and dying. With the impending rise in demand for quality care, skilled and specialised role of nurses is paramount to ensure high quality. The creation of advanced nursing roles and specialisation in nursing made the nurses independent and more autonomous in their roles. Advanced roles contributed a service model and best fit to the ever-changing demands of patients. At present, nurses participate in clinical research, decision-making and demonstrate clinical leadership skills to improve the safety and quality of care. Dynamic changes in the health-care industry and consumer awareness are other driving forces that influence the need for nurses to be highly competent and skilled to fulfil their responsibilities. This article briefly describes the nursing transformation in the United States and the different nursing programmes offered in India.

INTRODUCTION

Evolution of nursing.

Conventionally, nursing has been considered as a service to the poor, sick and dying person.[ 1 ] Gradually, evolution in medical science expanded nursing to include service to patients with different kinds of disabilities and even healthy people.[ 2 ] Nursing care and service delivery have been revolutionised to include multiple settings, including hospitals, hotels, schools, communities, industry, office and military assistance. In addition, nurses also work in clinics, private hospitals and elderly homes.[ 3 ] As the largest group of health professionals, nurses are enabled to transform the health-care industry in India and globally.[ 4 ] Nurses are the key health personnel and essential member of health-care team. They not only assist or provide care to disabled or sick people but also provide their shoulders to the patient's relatives to cry or grieve from painful situations.[ 5 ] The practice of nursing in India has a long developmental history, which has exploded in the recent decades considering the increasing demand for nurses in different roles as caregivers, family health nurse and hospice nurses.[ 6 ]

Globally, the development of the nursing profession also shares a long history. Dated accounts of nursing care and the nurses role in helping to care for the sick and injured exist long before formerly establishing into practice.[ 2 ] However, that role was limited to care and support for injuries without considering nursing and scientific medical knowledge. In recorded history, nurses also began practicing anaesthesia in the United States during the Civil War.[ 7 ] Nurses often provided sole support to birthing women in the 18 th century.[ 8 ]

Ignoring history is risky

Knowing historical milestones might be discouraging and painful because of the many stories of archived failure. Ignoring this history, however, presents a more significant risk.[ 6 ] Studying the history of nursing allows nurses to understand the present and future challenges, including pay, regulation, the scope of practice, rights and education. Lack of interest in history could be a factor that may explain why Indian nurses have not been empowered to raise their voices to address these burning issues.[ 9 ] In brief, knowing the development of nursing will provide an understanding of nurses essential role in the health-care setting.[ 10 ] Therefore, it is recommended that nurses look to their roots and understand their weaknesses and strengths as a vital part of the health-care team.

The history of American Nursing

Many nursing professionals believe that nursing started with Florence Nightingale's contribution in the Crimean War with the care of injured and wounded soldiers.[ 11 ] Nevertheless, the concept of nursing was in existence before the Nightingale era when the sick and wounded were cared for by family members, friends and neighbours.[ 12 ] The concept of family-centred care was practiced in the United States until the nineteenth century when family members took care of the sick. However, family care was limited during major epidemics and plagues.[ 13 ] In later times, patients received nursing care in hospitals operated by religious nursing orders and other institutions that provided good to haphazard and substandard levels of care.[ 3 ]

Nursing reform began in the late 18 th century after nursing schools opened and formal structured training for nurses began in the United States.[ 14 ] Nevertheless, even as larger cities grew, it was rare to find established hospitals and scientific nursing care before 1860. Nursing demonstrated a growing concern for patient care and that contribution improved patient outcomes.[ 15 ]

Jane Addams (1889) in Chicago rang the bell of social reforms in nursing to advance professional and training opportunities for women in nursing and social work.[ 16 ] Nursing was slow to join this movement, but the insatiable demand by hospitals for formally trained nurses led to the opening of schools for young women from different social and educational backgrounds.[ 17 , 18 ]

Certified Registered Nurse Anaesthetist

In her book, History of Anaesthesia (1953), Thatcher explains the nurse specialist by recognising the contribution of women in the field.[ 19 ] Lawrence (1820-1904) first administered anaesthesia during the Civil War, 1861–1865. She administered chloroform to wounded soldiers on the battlefield during the Battle of Bull Run.[ 19 , 20 ] Nevertheless, it was a long and arduous journey to develop Certified Registered Nurse Anaesthetists (CRNAs) as an independent branch. Nurse Anaesthetists created their own certification board in 1956. In 1986, the Government of the United States of America recognised CRNAs as the first nursing speciality to receive independent reimbursement for their services from federal insurance programmes.

An individual who is a registered nurse (RN) and/or advanced practice RN (APRN) with a graduate degree in nursing is eligible to become a CRNA in the United States. Requirements for admission include a bachelor's degree in nursing or equivalent degree, a valid nursing licence and a minimum of 1 year of experience in critical care nursing. CRNA training programmes are either masters or doctoral level. The programmes take 24–36 months of study and require that students complete 850 h of clinical experience.[ 21 ] CRNAs practice with a high degree of autonomy and professional conduct. They are qualified to make independent judgements regarding all aspects of anaesthesia care services based on their education, licensure and certification.[ 22 ] CRNAs collaborate when necessary with different health professionals, including surgeons, physician anaesthetists, dentists, podiatrists and other certified health-care providers.[ 23 ]

At present, the United States has 116 accredited nurse anaesthesia programmes.[ 24 , 25 ] On January 01, 2020–December 31, 2020, 3130 candidates reported for the National Board of Certification and Recertification, and 2556 were certified with a pass rate of 85.2%.[ 24 , 25 ]

Nurse-midwives or certified nurse-midwives

Nurse-midwives (NM) are licensed, independent health-care providers with prescriptive authority in all 50 states in the United States.[ 26 ] The first certified midwifery programme began in the 1920s through the efforts of public health nurses and other stakeholders who believed in the importance of NM in meeting the needs of the underserved population. Certified Midwives (CMs) and certified NM (CNMs) are graduate-level experts in midwifery and nursing services accredited by the Accreditation Commission for Midwifery Education. It is mandatory to pass the national certification examination conducted by the American Midwifery Certification Board to become a CM or CNM if candidates already have an active RN license.[ 27 ] The American College of Nurse-Midwives created competencies and outlined the scope of practice as defined by the International Confederation of Midwives.[ 28 ]

CNM provides a wide range of services from physical examinations, family planning, pre-conception and care during pregnancy, routine new-born care during the first 28 days of birth, education and counselling services and treatment of sexually transmitted diseases. They are certified to deliver services at a private office, ambulatory clinics, community centres, public hospitals and birth centres.[ 29 ]

Clinical nurse specialist

Specialisation in nursing eventually gained attention as a mark of advancement for the profession. Much of the literature in the early 1960s attempted to define the scope and core competencies of the CNS role.[ 30 ] A clinical nurse specialist (CNS) is an APRN. CNS is a functional role in nursing that demands professional practice and specific competencies in a specialised area. An RN with a bachelor's degree in nursing and/or master's or doctoral degree in relevant specialisation is eligible to pursue a CNS. They teach staff nurses about care for a specific patient, manage care, contribute to research and educate patients, and family members. In addition, CNSs show exemplary leadership qualities and decision- making skills in the care of difficult patients. CNSs work to identify areas that need improvement. A high level of interpersonal skills and an understanding of group dynamics to promote smooth working among members of the health team is another crucial skill reflected in the role of CNSs.[ 31 , 32 , 33 ] Prescription authority is a matter of state law, but CNSs in 39 states may prescribe independently or as a physician collaborator. CNSs have also undergone training in physical assessment, physiology and pharmacology, and their area of speciality.[ 31 ] A CNS can practice in diverse settings, such as clinics, private practice and hospitals. CNSs work in a range of specialities, from adult health/gerontology, paediatrics, psychiatric/mental health, women/gender-specific, neonatal and family individual/across the life span.[ 34 ] The AACN Certification Corporation, the certification organisation of the American Association of Critical Care Nurses, provides a certificate in three CNS; ACCNS-Paediatric, ACCNS-Neonatal, ACCCNS-Adult-Gerontology.[ 31 ] The role of critical care NPs and CNS have merged and most schools offer NP Programmes.

Nurse practitioners

More nurses were hired in hospitals than in public health or private nursing homes in the mid-20 th century, Advances in medicine and surgery required expert nursing care in hospitals after World War II.[ 35 ] At this time nursing roles were not limited and there was no desire to diagnose or prescribe. The major thrust and struggle were to define nursing as a separate profession with unique knowledge base which continued well until the 1990s.

In 1965, Ford and Henry Silver, MD envisioned a nurse practitioner (NP) role to bridge the gap between health care needs and access to primary health care. Ford believed that nurses could be prepared to address the unmet needs of rural parents and children by providing well child care where there was little affordable care.[ 36 ] The first NP Programme began as a training programme for community nurses. Nurses worked collaboratively with physicians in a collegial relationship and provided advanced nursing care to patients.[ 22 ] It will not be a surprise to mention that the concept of NPs was rooted in the Frontier Nursing Service, visiting nurses and the Indian Health Service of the early 20 th century. All areas where most physicians did not work and nurses worked independently to fill in the healthcare gaps. In 1973, the Division of Nursing of the United States Public Health Service invested heavily to develop NP education and career opportunities. Later, study findings reported favourable results that became a benchmark for the continued funding of NP education.[ 37 , 38 ] In 1986, a group of nursing leaders evaluated the feasibility of the NP Programme. They concluded that the advanced nursing role of an NP was essential to improve access to healthcare for every United States citizen.[ 39 ] They created the American Academy of Nurse Practitioners.

Despite many controversies and initial challenges in NP education and practice, NP education has received the attention of graduate nurses in the United States since the 1970s. In 2007, Margaret Flinter created a NP Residency Programme at the Community Health Centre Inc.[ 40 ] In 2018, The National NP Residency and Fellowship Training Consortium was created to provide post-graduate training programmes and recommendations for NPs to achieve the highest standards of quality and consistency to produce an expert health-care provider.[ 40 , 41 ] Following formal training, there is a growing interest in residency programmes in medical centres to enhance the specialised skills of graduate NPs. Currently, there are many more graduates than positions available. The goal for NP education has moved from MSN preparation to preparation at the doctoral level (the doctor of nursing practice [DNP]).[ 42 ]

ADVANCED PRACTICE REGISTERED NURSES

The APRN role applies to a wide range of competencies to improve health outcomes for a patient or population in a specialised area.[ 42 ] APRN are given credentials that depend on the state where they practice. The APRN's preparation includes completing an accredited graduate education in nursing and passing a national certification examination to demonstrate population-specific competencies.[ 43 ] The APRN role has grown from the original Paediatric NP, to Family NPs Adult/Gerontology Primary Care; Adult/Gerontology Acute Care; Women's Health; Paediatric Acute Care; Paediatric Primary Care; Mental Health; CNS, CRNAs, and CNM.[ 44 ] It is an umbrella term that includes all of the graduate-level advanced practice nursing specialties.

The APRN role has also evolved to include nurses prepared at the doctoral level. This expanded role of the DNP allows nurses to assume additional responsibility and accountability in the planning, implementation and evaluation of evidence-based strategies to improve individual patient and population health outcomes.

Doctor of nursing practice

The healthcare industry's dynamic needs and the increased complexity of patient care demand higher level of preparation for clinical nursing leaders. The primary aim of the DNP degree is to prepare APRNs for leadership practice in the clinical setting.[ 45 ] The Institute of Medicines' recommendations to reduce significant medical errors, and increase safety, and quality justified the need for exemplary clinical leadership by nurses.[ 46 ]

The AACN, 2004 Position Statement on the Practice Doctorate in Nursing revolutionised nursing education by calling nursing schools to shift from a master's to a DNP as the degree for APRNs by 2015.[ 47 ] However, an economic recession prevented schools from meeting that deadline. Currently, except for CRNAs, the APRN programmes may decide if they want to offer an MSN or a DNP.

The DNP Programme was intended to prepare the workforce of leaders to transform research into clinical practice. However, in the initial years, most DNP graduates opted for administrative and educational settings.[ 42 ] These DNP graduates can meet the scarcity of nursing faculty; however, having enough doctoral-prepared APRNs remains an on-going area of concern and remains an area for improvement.[ 45 ] The American Association of Nurse Practitioners (AANPs) reports that 79.8% of APRNs with master's degrees, only 14% hold a DNP.[ 48 ] DNP curricula are designed to use a more evidence-based practice approach to fully equip the nurses with current research advancements, and knowledge to meet the national concern about the quality of care and patient safety. At present, 49 states in the United States offer DNP Programme with wide variability in syllabi to practice in the respective state.[ 49 ] However, single certification and accreditation process, practice scope, community demand across the states are largely unaddressed, and the goal of universal DNP remains lofty for nursing leaders in the United States. Table 1 outlines the summary of APRNs.

Doctor of Philosophy in Nursing

In the mid-20 th century, many nurse leaders were engaged in developing theories in nursing and were debating on the science of nursing to create the doctoral level preparation in nursing in the universities. The Doctor of Philosophy (Ph.D) programme gives knowledge and skills in theoretical, methodological and analytical research methods. The degree enables nurses to explore nursing science and health-care knowledge. It prepares nurses at the highest level of nursing science to conduct research that advances the empirical and theoretical foundation of nursing and health care globally.[ 54 ] This programme enables a nurse to obtain expertise in a specific area of the study. The goal of this degree is to build the skills to allow nurses to implement a scientific research programme. The Ph.D programme prepares a nurse to serve as an educator in various classroom and clinical settings within the academic programme.[ 54 , 56 ] Admission requirements include graduation from an accredited bachelor's and master's in nursing programme with an active registration in nursing.

NURSING IN INDIA

Studying the contemporary history of nursing is illuminating and exciting. It shows the pathway of change, showing footprints left by the doyen of nursing to uplift the nursing profession. In India, formal nursing education started in late 1871 in Madras and subsequently stretched its wings to other provinces.[ 57 ] At present, India has more than 2,259,785 Registered NM, 925,016 Auxiliary NM, and 56,819 Lady Health Visitors in 29 state nursing councils.[ 58 ] NPs in critical care and midwifery practice in independent roles and provide compassionate, respectful and competent care.

Nurses are the backbone of the health-care infrastructure worldwide, including India, and play a key role in delivering preventive, promotive and rehabilitative services.[ 55 ] Many developed and developing countries, including India, are facing an acute shortage of their trained nursing workforce.[ 59 ] However, the nurse-to-population ratios in developed countries may substantially differ. Contrasting examples include sub-Sahara African countries having a low nurse-to-population ratio (12.5/10,000) than the UK, where there are 88.3 nurses/10,000, indicating a stark difference in severe nursing shortfalls.[ 60 ] Likewise, the nurse to population ratio in India 1.7/1000 is 43% less than the World Health Organisation (WHO) recommendation (3/1000).[ 61 ] Further, this ratio varies from rural to urban areas, exposing a massive gap in the demand for a trained nursing workforce leading to an increased risk of compromised quality healthcare.

Diploma and degree programmes in nursing

The Indian Nursing Council (INC) currently provides two diploma courses, including Auxiliary Nurse and Midwife (ANM) and General Nursing and Midwifery (GNM) programmes led by respective State Nursing Councils.[ 58 ] ANMs are the nurses trained to deliver maternal and newborn health services at the grassroots level. They work at sub-centres and visit villages to deliver nursing services. Anganwadi Workers and Accredited Social Health Activists (ASHAs) are the most recently created cadre to strengthen the Community Health Workers Programme. ANMs and ASHAs work solely at the village level to provide food supplements and promote maternal and child health care by encouraging institutional deliveries and immunisation.[ 62 ] ANM are RNs and complete 2 years of dedicated training, while ASHA receives 3–4 weeks additional training periodically to deliver services at the village level.[ 63 ]

Further, GNM is a 3-year programme and gets registration in the state and from the INC to work as a RN. GNM nurses work in different settings, including private clinics and hospitals, nursing homes and public hospitals. They provide care in varying roles, including direct care provider to education to patients, families and communities.[ 63 ] However, the contribution of diploma nurses in health-care delivery compared to the early 1980s is less in the present scenario.

Degree programmes

In addition to diploma courses in nursing, the INC provides university degrees to candidates dreaming of pursuing the nursing profession. Since 1946, the country had initiated the Bachelor Nursing Programme with a 4 years duration leading to status as RN and Registered Midwife. There is also a post-certificate baccalaureate degree programme. The candidate completes a 2 year degree programme after their diploma in nursing (GNM) to improve on their theoretical education and competencies.[ 63 ]

A master's degree in nursing is a 2 year programme which orients a graduate nurse to a more specific role and helps to polish clinical competencies in the relevant specialisation. The programme focuses on empowering graduate nurses to take leadership roles in promoting quality in patient care and nursing education. In addition to competencies, the programme also gives an introduction to research methods and a research opportunity to complete thesis work. However, there are no scientific data on the publication of the thesis work of master's nurses in India. Indian nurses need to strategically consider increasing additional research-related work and increase the publication of their research. The authors also recommend creating a culture to support research in terms of environment, resources, mentors and financial aid to encourage budding nurses to pursue these opportunities. Table 2 outlines different nursing courses in India.[ 63 ]

M.Phil programme

M.Phil in nursing is offered as either 1 year (regular) or 2 years (part-time) programme which is meant to be a bridging programme between M.Sc and Ph.D. RAK College of Nursing, New Delhi, started the programme in 1980. Later, few other institutions and universities offered this programme.[ 64 ] This programme is considered as a stepping stone for the doctoral programme as it predominantly deals with research. However, it is not a mandatory requirement to pursue the doctoral programme. Hence, it is not as attractive as doctoral programme. With the implementation of the recent National Educational Policy 2020, the Government of India has scrapped off the M.Phil Programme in India.[ 65 ]

Doctor of Philosophy program

In 1992, doctoral programme in nursing was first started under the Department of Nursing, University of Delhi. The National Health Policy 2002 stressed the dire need to prepare nurses to function in super-speciality areas. With the acute shortage of nursing faculty in under graduate and post-graduate nursing programme in India, it was essential to prepare the nurse scholars with doctoral education. In line with that, INC constituted National consortium for Ph.D in Nursing in collaboration with Rajiv Gandhi University of Health Sciences and WHO, under the Faculty of Nursing to promote doctoral education in various specialities of Nursing in 2005. Six centres across India are connected through video conferencing facilities.[ 66 ] Apart from the Consortium, individual universities also offer Ph.D in Nursing in many states of India.

NURSE PRACTITIONERS IN INDIA: A BEGINNING

The shortage of a trained medical and nursing workforce and the severe deficit of the health-care workforce emphasises the need to transform the health-care delivery system. Nurses hold a key position worldwide and can be best utilised to achieve sustainable development goals.[ 67 ] The union government is in the process of creating an independent cadre of NPs in rural areas to meet the deficit of physicians.[ 67 , 68 ]

The government of West Bengal took the first initiative to start a NP Programme in midwifery in 2002.[ 69 ] Similarly, many other state governments; Gujarat, Telangana and Kerala have initiated similar proposals to start an NPs' course.[ 70 , 71 ] However, a lack of long-term vision, a clear scope of practice, certification and registration and employment opportunities have all factored in delaying the actual start of the programme.

Based on the National Health Policy (2015) INC decided to initiate a NP Programme to support the specialised and super specialised health-care services. By empowering the Nurse with adequate theory and practicum components and creating a cadre at the National and state level, NP will be able to provide safe, cost-effective, competent and quality care. INC had proposed a curricular framework towards the preparation of NP in Critical Care at masters level. The highlight of this programme is the strong emphasis on the clinical component which comprises 85% practicum and 15% of theory. The course is designed based on the competencies suggested by the International Council of Nurses and the National Organisation of NP Faculties.[ 72 ]

It is a residency programme with the focus on three courses namely (1) core course, (2) speciality course and (3) advanced practice course spanned over the period of 2 years. While some universities have accredited the NP Programme, it is yet to be accepted and initiated in many universities across India.[ 72 ]

The scope of practice of a NP is yet to be defined in India. However, they can practice in various settings with similar roles as defined by the AANPs, including private homes, clinics, public hospitals, nursing homes. Further, NPs should be allowed to do various jobs from physical examination to diagnosis, prescription, follow-up and rehabilitation.[ 22 , 69 , 71 ] A clear state comprehensive practice policy and legal authority will allow NPs to work more autonomously.

CONCLUSIONS AND RECOMMENDATIONS

Broadly, the United States started investing in the NP role in the early 1960s. Alhough the journey towards establishing independent practitioners was not easy in the United States, a long-term vision, consistent efforts of nursing leaders and policymakers, and the government's keen interest in improving health-care quality made it successful. Nevertheless, some states in India are formulating policies to define the scope and practice parameters for NPs bringing change in quality health outcomes. In addition, within the United States, the nursing profession has historically played an important role in practicing and maintaining professionalism, professional power, advanced knowledge and influencing social reform.

The health of individuals and their community fundamentally depends on the types of health-care workers and their competencies. In collaboration with many regulatory bodies, Indian nurse policymakers have made meaningful steps towards improving nursing practice; however, this could be enhanced if done as a part of a plan with a long-term vision. The challenges and barriers encountered have significantly hindered these efforts to materialise. One of the considerations for Indian policymakers is to consider creative and innovative solutions to increase advanced practice nurses' role and promote their role in bringing changes to health care. Lack of incentives, the blurred scope of practice, lack of financial benefits and poor recognition of advanced training can be demotivating for nurses and diminishes the importance of their fundamental role. The concept of a NP is deep-rooted in Indian history, especially in, Uttar Pradesh, Bihar and some other states, where RNs routinely diagnose and treat minor ailments. The public in remote areas accepts this nursing role, but the government bodies have not made this a part of legal nursing practice. Nurse policymakers should take the initiative to organise and standardise the NP role with defined scope and practice area.

Instead, it would be better if Indian nurse policymakers defined the scope for master's degree nurses to practice in their specialised area with due incentive. This small initiative could bring significant changes in health care in the subsequent years. The lack of these guidelines contributes to the loss of qualified nurses who have invested their commitment in an educational programme but choose to work in an alternate career path.

The authors recommend streamlining nursing education, increasing funding to nursing education, emphasising in-service education, shifting to competency and module-based training, refining evaluation criteria, investing in research, uniform course syllabi and improved faculties and facilities to strengthen nursing education and practice in India. Stricter implementation of the licence renewal approach on time can also significantly impact the improvement of patient care.

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There are no conflicts of interest.

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Building nurse education capacity in India: insights from a faculty development programme in Andhra Pradesh

Catrin evans.

1 School of Nursing, Midwifery and Physiotherapy, University of Nottingham, Queens Medical Centre, Nottingham NG7 2UH, U.K

Rafath Razia

2 Government College of Nursing Hyderabad, Dr NTR University of Health Sciences, Andhra Pradesh, India

Elaine Cook

India faces an acute shortage of nurses. Strategies to tackle the human resource crisis depend upon scaling up nursing education provision in a context where the social status and working conditions of nurses are highly variable. Several national and regional situation assessments have revealed significant concerns about educational governance, institutional and educator capacity, quality and standards. Improving educational capacity through nursing faculty development has been proposed as one of several strategies to address a complex health human resource situation. This paper describes and critically reflects upon the experience of one such faculty development programme in the state of Andhra Pradesh.

The faculty development programme involved a 2 year partnership between a UK university and 7 universities in Andhra Pradesh. It adopted a participatory approach and covered training and support in 4 areas: teaching, research/scholarship, leadership/management and clinical education. Senior hospital nurses were also invited to participate.

The programme was evaluated positively and some changes to educational practice were reported. However, several obstacles to wider change were identified. At the programme level, there was a need for more intensive individual and institutional mentorship as well as involvement of Indian Centres of Excellence in Nursing to provide local (as well as international) expertise. At the organisational level, the participating Colleges reported heavy workloads, lack of control over working conditions, lack of control over the curriculum and poor infra-structure/resources as ongoing challenges. In the absence of wider educational reform in nursing and government commitment to the profession, faculty development programmes alone will have limited impact.

Introduction

This paper provides a critical account of a nursing faculty development partnership that was implemented in the Indian State of Andhra Pradesh from 2009–2011. It has been written as a joint endeavour by representatives of the UK and Indian nurse educators who were involved.

We begin by contextualising the faculty development programme by providing an overview of the current challenges and opportunities facing nursing education in India – described by a recent Lancet article as ‘in crisis’ and facing near collapse in several poor but highly populous states [ 1 ]: 593. Improving educational capacity through nursing faculty development has been proposed as one of several strategies to address a complex health human resource situation [ 1 ]: 596. We then go on to describe and critically reflect upon our experience of one such faculty development programme and identify lessons for future consideration.

The Indian context

India is undergoing a period of unprecedented social and economic change. Amongst its 1.2 billion population, economic growth has led to a rapidly expanding urban middle class. At the same time, a large proportion of the country’s population still reside in rural areas in conditions of economic hardship, low literacy and poor health. Increasing migration to the cities for work has created large urban slums lacking in basic amenities. This demographic situation means that the country faces the dual challenge of tackling diseases of poverty alongside an increasing incidence of chronic diseases more traditionally associated with westernised affluent lifestyles. The Indian health system is pluralistic, comprising public, private and voluntary sector facilities, of which the private sector is by far the largest provider. Since 2005, there has been enormous government investment into modernising and expanding India’s public healthcare system through the setting up of a new initiative - the “National Rural Healthcare Mission” [ 2 ]. Health system reform is constrained however by an acute shortage of health workers at every level [ 3 ]. In addition, poor health system governance (i.e. inadequate systems to monitor and regulate training institutions, professional practice and clinical standards within different settings) has been identified as a critical factor impeding efforts to improve quality and accountability, in both private and public sectors [ 1 ].

Nursing in India: a profession in transition

India faces an acute shortage of nursing staff with an estimated deficit of 2 million [ 4 ]. In the public sector alone, an additional 140,000 staff nurses are required [ 5 ]. The nurse-population ratio is 1:2,500 compared with ratios of 1:150 to 1:200 in higher income nations [ 6 ]. The nurse-doctor ratio is also poor – at 0.5 nurses per doctor compared with 3 or 5 per doctor in the USA and UK respectively [ 1 , 6 ].

The development of nursing in India reflects the country’s history and complex socio-cultural composition. Traditionally, amongst Hindu and Muslim communities, the need for female nurses to work outside of the home (including at night), to touch strangers, to mix with men, and to deal with bodily fluids (considered polluting within Hindu and Muslim cosmology) has meant that until relatively recently, nursing was a stigmatised and low status profession [ 7 ]. During colonial times, British missionaries attempted to redefine and professionalise nursing as a respectable vocational career [ 8 ]. British mission hospitals established nursing schools and recruited poor women or widows from predominantly Christian communities, many from the southern Indian state of Kerala [ 9 ]. Kerala remains a major supplier of Indian nurses, although this is changing due to a shift in the desirability of nursing as a career that has come about because of increased opportunities for migration to the Middle East and further afield [ 10 ]. As in many other countries, nursing is now seen as a potentially lucrative career choice, a stepping stone to work overseas and towards greater social mobility for the entire family [ 11 , 12 ]. This has led to an influx of men into the profession and to a positive change in the social status of nurses [ 13 ]. Nonetheless, in India and throughout South Asia, the desire to avoid the stigma associated with basic nursing tasks forms a strong cultural backdrop to the way in which clinical nursing is valued and practised today [ 7 , 14 - 16 ].

Research evidence on nurses’ working conditions and job satisfaction in India is limited. However, reports indicate that nursing lacks clear career pathways and mechanisms for promotion; in-service training is rare (except in the best corporate hospitals); pay is low (especially in small private hospitals); and working conditions are often inadequate, lacking sufficient staff, equipment and infra-structure [ 17 - 19 ]. One study in New Delhi, found that nurse:patient ratios of 1:50 were the norm [ 13 ]. In the same study (which was based on over 150 interviews) nurses reported spending much of their time doing administrative, menial or unskilled work [ 7 , 13 ]. In a study of female health workers in Kolkata, more than 50% of respondents admitted experiencing sexual harassment at work [ 20 ]. Nurses in private hospitals in New Delhi recently staged a strike in protest of low pay and exploitative working conditions [ 19 ].

The nursing profession lacks strong strategic representation at key decision making forums at both State and National levels [ 18 , 21 ]. Nursing is governed through the national Indian Nursing Council (INC) and State level Nursing Councils (SNCs) [ 17 ] The INC advises the government on nursing matters, prescribes national nursing education syllabi and specifies minimum quality criteria for educational institutions. State Nursing Councils inspect and accredit training institutions, conduct examinations, monitor rules of professional conduct and maintain an active register. However, the legal authority of the INC is weak [ 17 ]. For example, a recent survey concluded that 61% of all nurse training institutions do not meet INC standards, but it is unable to take action as the institutions have nonetheless been accredited by the SNCs [ 3 ]. Nursing is also represented by a number of state and city based organisations, including the national Trained Nurses Association of India (TNAI). Greater nursing participation in health workforce policy making has been urgently recommended [ 1 ]. The INC is currently not a member of the International Council of Nursing.

Nursing education in India

There are 2 main routes into nurse training in India. The majority of nurses undergo a 3 year diploma training in Schools of Nursing to become a General Nurse Midwife (GNM). A minority undertake a 4 year training in a College of Nursing (affiliated to a University) to obtain a BSc degree, referred to as BSN. Apart from the pre-registration programmes described above, University Colleges of Nursing also offer post-registration BSc courses and MSc courses. A national consortium of 5 universities came together in 2005 to start a collaborative nursing PhD programme [ 22 ].

In most public sector healthcare facilities, staff nurses are recruited from the GNM cadre (diploma-holders) only. Studies suggest that BSc graduates tend to seek clinical work in the private sector but often view this as a short- term strategy to gain requisite experience to enable overseas migration [ 13 ]. Post-registration BSc and MSc graduates are reported to move predominantly into educational positions in the public and private sectors [ 6 ]. Thus, as in many countries where clinical nursing carries a low status, academic qualifications are valued as a potential route out of clinical practice into higher status and better paid jobs in education [ 15 ].

Due to increasing demand for nurses nationally and internationally, 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. There is also a geographical imbalance in nursing education, with most graduate and postgraduate education being delivered in the South. For example, the highly populous but poorer States in the North (e.g. Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh) account for only 9% of nursing schools in the country [ 1 ].

Several reports have highlighted significant problems in nursing education, emphasising that quality must not be sacrificed in the country’s current drive to scale up nurse training provision. Key issues are summarized below [ 1 , 3 , 6 , 10 , 18 , 21 ]:

• Inadequate educational monitoring and governance at State level (for example, sub-standard institutions continue to receive accreditation despite being unable to meet INC and University standards)

• Serious teaching staff shortages

• Poor physical infrastructure

• Poor educational infrastructure and resources, especially for clinical skills teaching

• Lack of continuing professional development for faculty

• Lack of promotion opportunities for faculty

• Over-cluttered curriculum

• Reliance on didactic teaching approaches

• Poor student living accommodation

• Poor links between clinical areas and educational institutions

• Inadequate clinical experiences (e.g. some placements have too many students; medical students take precedence over nursing students in practising key skills such as deliveries; nursing students may never get the opportunity to gain key clinical competencies)

Amidst the challenges, it is important to point out that there are, of course, also many Centres of Excellence in nursing education in India, but there is limited published material documenting their successes, systems and processes.

One commonly recommended strategy to improve nursing education is to recruit more faculty and to support existing faculty to develop their educational provision and practices [ 21 ]. Below, we report on one such initiative from the State of Andhra Pradesh.

The Andhra Pradesh nursing faculty development programme

Andhra Pradesh is a large state on the south-east coast of India with a population of almost 76 million. The main language is Telugu. The capital city is Hyderabad. In the period between 2004–2008, the State Government approached an international non-governmental organisation (with a history of innovation in nursing education in South/Central Asia and east Africa) to assist nursing education. Following a number of needs assessments, a Nursing Faculty Development Programme (NFDP) was initiated in 2008 for faculty from 4 public and 2 autonomous nursing education institutions in Andhra Pradesh. The primary objective of the NFDP was to strengthen the capability and capacity of nursing faculty within the State. A Government College of Nursing in Hyderabad (GCNH) was selected to act as a nodal agency for the NFDP. The School of Nursing, Midwifery and Physiotherapy (SNMP), University of Nottingham (UK) won a tender to act as an international partner to the NFDP. The original plan was for the SNMP to work with the GCNH to provide some faculty development courses along a ‘training of trainers’ (ToT) model, so that subsequent faculty development programmes in the State would be delivered through the GCNH.

Faculty development methodology

A review of previous literature on international partnerships indicated that the NFDP would need to adopt a collaborative approach in order to ensure that the inputs addressed common goals, aligned with local issues and were relevant to the national and local context [ 23 - 26 ]. The NFDP was based on a philosophy of mutual respect and adult learning [ 27 ]. A participatory approach was adopted for the entire curriculum development process so that each input ended with a formative evaluation and a collaborative planning process to shape the next input [ 28 ].

The NFDP included the following steps:

1. Conference in Hyderabad to launch the programme and an initial participatory planning workshop for a core group of Andhra Pradesh faculty to identify and prioritise training and development issues

2. Delivery of a leadership workshop (for senior Andhra Pradesh faculty) by senior SNMP staff in Hyderabad

3. Delivery of 2 modules by SNMP faculty in Hyderabad

4. Visit of 6 Andhra Pradesh nursing faculty to SNMP, UK

5. Delivery of 2 further modules by SNMP faculty in Hyderabad

6. Formative evaluation

Needs assessment and planning

During an initial curriculum development workshop, a group of faculty from across Andhra Pradesh identified 4 main areas of input for the NFDP. These were:

1. Learning about new educational approaches (particularly experiential learning)

2. Being supported to develop their own careers through research, scholarship and publication

3. Strengthening skills in leadership and management

4. Learning about innovations in clinical education

These 4 domains were very similar to those covered in other documented faculty development programmes [ 23 , 26 , 29 - 31 ], and were developed into 4 distinct modules – see Table 1 .

NFDP modules


Advanced and innovative methods in nursing education	To further develop educators’ knowledge, skills and confidence in delivering advanced and innovative teaching methods in order to enhance student learning	● Identify innovative teaching methods;
		● Understand relevant personal resource and environmental issues in ensuring systematic application in learning methods;
		● Explore the role of the teacher in facilitating learning by utilising different teaching methods;
		● Develop and apply advanced and innovative teaching methods in order to enhance student learning;
		● Explore different learning styles and strategies and how they relate to student learning;
		● Evaluate assessment strategies associated with innovative teaching and learning;
		● Examine the advanced and innovative methods of evaluating learning;
Developing and advancing scholarship	To build capacity in nursing scholarship for nursing faculty and propose strategies for improving scholarship in Andhra Pradesh	● Outline a systematic approach to scholarship in order to develop an action plan for future professional advancement;
		● Building knowledge and skills in the scholarship of nursing education, research and practice;
		● Develop advanced skills in writing scholarly papers and funding proposals;
		● Cultivate strategies that support and facilitate scholarship;
		● Progress skills in disseminating scholarly activities;
Developing effective leadership and management in nursing education and practice	To facilitate the development of effective leadership in nursing	● Identify the leadership challenges for nursing in Andhra Pradesh;
		● Analyse self utilising critical reflection in order to develop professionally as a leader;
		● Develop skills and approaches to management and leadership in nursing;
		● Apply effective leadership strategies;
		● Identify the need for and implement change to improve care quality and the educational experience for students;
		● Prepare a professional development plan to promote and evaluate self-progression;
Developing clinical learning	To facilitate clinical learning utilising evidence based practice to enhance the students’ learning experience	● Explore the concept of practice learning within the context of AP;
		● Develop and evaluate an internship programme to facilitate student learning;
		● Develop nursing practice using an evidence base focusing on hand washing;
		● Facilitate partnerships between clinical staff and the Nursing Teaching Faculty;
		● Utilise models and tools to facilitate changes in clinical practice and learning;
		● Facilitate the dissemination of the programme outcomes through scholarly activity;

The faculty were keen to receive updates on particular clinical topics (e.g. critical care). Given the wide variation of interests amongst the teachers however, it was agreed that, although important, the first phase of the NFDP would focus on the generic areas outlined above. The programme subsequently included sessions whereby faculty were encouraged to consider how they could access such updates in future.

From the outset, it was recognised that implementation of any educational innovations as a result of new learning would require support from the senior leadership within the 7 participating nursing institutions [ 32 ]. For this reason, a workshop on “ Strategic Leadership for the Advancement of Nursing Scholarship ” was held for senior Andhra Pradesh faculty (College Deans and Principals) to help them to reflect upon their own leadership styles and challenges and to create an institutional plan of action to support educational innovation.

Upon the advice of the Research Ethics Officer from the University of Nottingham, School of Nursing, Midwifery and Physiotherapy, the NFDP was deemed to be an educational development initiative rather than a research or evaluation study. A formal ethical approval process was not required therefore for the purposes of recording and disseminating project outcomes. However, in accordance with good practice, all participant and institutional information have been anonymised. During one of the programme inputs (the module on ‘Developing and Advancing Scholarship’), participants were encouraged to identify ways in which they could develop their own scholarship and publication strategies. Participants suggested that one immediate action would be to disseminate lessons learnt from the NFDP to the wider nursing community and the second author agreed to take this forward by contributing to a paper.

Programme delivery

The inputs were delivered over a 2 year period (2009–2011). Each module ranged from 7–10 working days and resulted in a certificate of attendance. Each module concluded with the participants developing a detailed but realistic action plan for taking forward relevant learning. Progress with the action plans were then reviewed in the next module.

In total, 25 faculty members attended the modules (including 12 senior faculty). Six senior clinical staff also attended the leadership/management and clinical learning modules.

In addition to the modules, a visit of 6 senior Andhra Pradesh faculty to the SNMP in the UK was also conducted. The aim was to provide the opportunity to explore nurse education and practice outside India in order to consider new ways of working and, particularly, to identify the role of collaborative working relationships between education and clinical practice. This visit also provided time for reflection on the NFDP programme and future planning for longer term sustainability.

Alongside the educational development, the NFDP included funds to upgrade some facilities at GCNH, e.g. purchase of new skills equipment, provision of ten computers with internet access, provision of printing facilities for students and the purchase of books for the library.

Evaluation and reflections on the nursing faculty development programme

Formative participatory evaluations were conducted by the SNMP at the end of each module and at the end of the programme. Participants filled in a brief module evaluation questionnaire and group discussions were held to explore participants’ and facilitators’ views of the module/programme delivery, impact on education and practice and prospects for longer term change. Key issues that emerged from the evaluations are reported below.

Developing innovations in teaching and learning

Overall, the NFDP delivery was evaluated extremely positively both in terms of content and the experiential/student-centred educational approaches adopted by the facilitators. These approaches were initially very challenging for the participants whose previous educational experiences had been predominantly didactic in nature – and this shaped their expectations of the NFDP. Using experiential approaches initially moved many of the participants out of their own comfort zones as the SNMP facilitators used a wide range of techniques to ensure that all members of the group participated.

A related issue was that in all the modules, participants were expected to reflect upon, and share, their existing knowledge and experience in order to identify their own needs for future personal development, and to consider how their institutional processes or practices could change to improve educational quality. Again, this was challenging at times. For some participants, reflection, problem identification, goal setting and action planning were somewhat alien concepts in a context where marked occupational hierarchies as well as rigid bureaucratic processes create a (realistic) sense that change is difficult, and that individual initiative may not always be welcome.

Facilitating the participants’ learning was also demanding at times for the SNMP faculty who were challenged to adapt their teaching style and content. Both participants and facilitators agreed that the relevance of some of the module content would have been improved if the SNMP staff had had greater experience of Indian higher education and nursing contexts. This important issue is addressed further below.

It had originally been envisaged that the participants in the NFDP would complete all of the modules and would thus get used to different teaching styles and techniques over time. In reality however, although some participants completed all 4 modules, there were also different participants each time which affected the group cohesion and learning process. Nonetheless, over time many NFDP participants noted that their confidence and motivation had improved and that they were applying new skills with respect to teaching - particularly in structuring lectures and group work more effectively, evaluating student learning, using new tools, incorporating NFDP module content into their own teaching and in making learning more enjoyable (e.g. by using humour or interactive techniques).

In spite of the challenges, both groups stated that the programme had provided a tremendous opportunity for cross-cultural learning and for creating a deeper understanding of nursing in a global context.

Clinical education, status issues and the theory- practice gap

Although the clinical learning module was evaluated positively, many issues were raised which resonate with the existing literature on nursing in India and which created real challenges for innovation. Due to their critical importance, the key issues that emerged are outlined below.

Clinical teaching was seen as the responsibility of the faculty who were expected to visit the students on the wards every day (and then return to the College to carry on with classroom teaching). However, heavy workloads meant that their time and availability to students was sometimes limited yet little instruction took place in their absence. Staff nurses did not see it as their role to support students’ learning and they were usually busy with their own tasks. Equipment for teaching clinical procedures was not provided to the students from ward stock. Rather, faculty needed to bring their own supplies with them (as is common in times of scarcity, staff nurses tended to lock precious equipment away in case of breakage or loss). In addition, for student cohorts studying to BSc and MSc levels, the fact that staff nurses predominantly had a diploma qualification created status ambiguities in terms of the staff nurses’ deemed ability to support students studying at a higher educational level than themselves.

Lack of resources, capacity and infrastructure also created a deep theory-practice gap in the students’ learning. For example, students would be taught about processes (e.g. nursing assessments, care planning or particular clinical procedures) that had no relation to the realities of practice and that they had never witnessed. Faculty readily admitted that they themselves lacked the clinical skills to teach some of the prescribed procedures. These anomalies had to be perpetuated however due to the need for faculty to follow the prescribed INC curriculum and for students to pass exams based on that curriculum. In some cases, even where opportunities existed (e.g. to conduct a delivery), medical students reportedly took precedence over nursing students. The unregulated proliferation of private Nursing Schools was also creating additional pressures for clinical placements. For example, in some clinical areas there could be up to 50 students, all coming from different institutions, yet there was no evidence of coordination among these institutions.

The SNMP had deliberately suggested including senior clinical staff in the leadership/management and clinical learning modules in the hope that this might open up space for dialogue to consider ways in which faculty and staff nurses could work together more closely to support students’ learning in practice. This required careful facilitation and sensitivity to occupational hierarchies – for example, initially one of the senior clinical nurses remarked that “ educators think that we do not know anything ”. In time, constructive dialogue was achieved and many suggestions were forthcoming as to how education and practice could work in partnership. At the time of writing however, it is unclear as to whether any changes have taken place.

Organisational/institutional context and nursing faculty development

As noted above, the institutional context in which the NFDP took place created real challenges for the possibility of educational development. The new facilities (e.g. computers) at GCNH were reportedly well used and had improved the educational experience for the students. However, other participating institutions reported a similar need to upgrade their facilities. A new building for the GCNH had also been promised – symbolising a real commitment by the state government to nursing development - though this has not yet been realised.

Other innovations were more difficult to achieve. For example, the participants reported feeling relatively limited in their scope for innovation as the nursing curriculum (content, time allocation, teaching and assessment strategies) was prescribed in great detail by the INC, leaving little room for flexibility.

In addition, faculty from 6 out of 7 of the participating institutions reported excessive workloads and staff shortages as severe obstacles to undertaking potentially time/labour intensive innovations in educational practice. For example, during the NFDP period, the GCNH had its MSc intake doubled with no additional staff allocation. A lack of control over working conditions and pressure to meet immediate teaching requirements meant that few participants or institutions reported undertaking any significant educational innovations as a result of the programme.

Another challenge was that there was no mechanism within the NFDP for participating institutions to meet each other or to receive on-going mentorship or support in the time-periods between the modules. This meant that any momentum and enthusiasm built up during a module understandably faltered in the intervening months. Moreover, there was no mechanism within the NFDP for the participating institutions to network with Indian Centres of Excellence in Nursing Education. Although the input from the UK SNMP was appreciated, the vastly differing contexts of healthcare, nursing and the nursing curriculum between the 2 countries created real challenges for the SNMP facilitators to work in partnership with the Andhra Pradesh faculty to identify locally relevant and realistic strategies for change.

The NFDP has brought welcome resources and attention to nursing education in the state of Andhra Pradesh. Amongst faculty, it has achieved an awareness of new educational approaches and enthusiasm for on-going professional development. There have been some innovations made to day to day teaching practice. More significant changes have not been tackled however. The originally conceived ToT model of nursing faculty development seems doubtful as the future trainers have not yet themselves had the opportunities to put new approaches to nursing education into practice, thereby limiting the existing programme to the development of greater theoretical rather than experiential expertise. The deeper, structural problems affecting nurse education quality remain relatively unresolved.

Based on the valuable experience of the NFDP, we conclude this paper with some suggestions for future nursing faculty development initiatives in the Indian context.

First, whilst it is beyond the scope of a faculty development initiative to address national or state level policy, it is clear that educational initiatives alone will have a limited impact in the absence of work to review the nursing curriculum and regulation of nurse training institutions. Our experience shows that the current nursing curriculum is in need of review in order to better equip nurses to manage (and try to improve) the conditions of practice that they encounter, and to provide faculty with the autonomy and motivation to innovate.

Second, enlisting an international partner to support nursing faculty development undoubtedly provides a different perspective on nursing education and a different skill set that can be extremely valuable. Nonetheless, we would suggest that an Indian partner (drawn from recognised Centres of Excellence) should also be included as a key partner in the training team to build up local expertise, to enhance the prospects for longer term sustainability and to ground the module/programme content in the realities of the local context.

Third, it is well recognised in the literature that faculty development works best when faculty are supported in the long term by a system of mentorship to enhance personal development [ 33 , 34 ]. Likewise, mentorship can also be valuable at an institutional level whereby one Nursing School/College recognised for excellence provides on-going support to another [ 32 , 35 , 36 ]. We suggest that future faculty development initiatives include both forms of mentorship. This could, for example, consist of periodic visits from an international partner, coupled with more regular and intensive support from an Indian Centre of Excellence.

Finally, within the existing (relatively limited) literature on nursing education in India, there is a noticeable paucity of research on the student experience and on the views or practices of clinical staff in terms of their educational role. In order to base future faculty development initiatives on locally-relevant evidence, additional research on nursing education (particularly clinical learning) is required.

Abbreviations

ANM: Auxiliary Nurse Midwife; GCNH: Government College of Nursing Hyderabad; GNM: General Nurse Midwife; INC: Indian Nursing Council; NFDP: Nursing Faculty Development Programme; NRHM: National Rural Health Mission; SNC: State Nursing Council; SNMP: School of Nursing, Midwifery and Physiotherapy; ToT: Training of trainers.

Competing interests

The authors declared that they have no competing interest.

Authors’ contributions

CE, EC and RR conceptualised the paper. CE and EC wrote the first draft. RR made modifications. CE wrote the final draft. All authors read and approved the final manuscript.

Authors’ information

CE is a Lecturer in International Health; EC is Associate Professor and Head of the Division of Nursing. Both work at the School of Nursing, Midwifery and Physiotherapy at the University of Nottingham, UK.

RR is Principal of the Government College of Nursing Hyderabad and Director of Nursing in Andhra Pradesh, India.

The views expressed in this paper represent those of the authors alone.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1472-6955/12/8/prepub

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