Short Review

Do We Need Nurse Practitioners in India?

Running Title: Nurse practitioners in India

Dr.Sushma Kumari Saini Lecturer, NINE, Postgraduate Institute of Medical Education and Research, Chandigarh- 160012

Email: [email protected]

Abstract

The lifestyle of people has undergone a drastic change with the advancement of science and technology. It has resulted into increase in the prevalence of non-communicable diseases. These diseases require home and community based long term care. To manage these problems at community level there is shortage of physicians and nurses are available only in hospitals for taking care of indoor hospitalised patients. Though, they are trained to work in hospital as well as in community. Registered nurses were posted in community first time under Ayushman Bharat as Midlevel providers at Health and Wellness Centre. The primary health care services had been the responsibility of ANMs. Initially this has been done because of shortage of nurses but at present there is enough number of nurses trained from Government and private institutes every year. These nurses are not absorbed in hospitals and very few positions are created in community. Hence, they are forced to migrate either in other countries or to work in private sectors at very low wages. They can be retained in the country if task shifting is done and enough positions are created in community. This has been successfully practiced in developed countries by introducing non physician practitioners mainly nurse. Some initiatives are already started in this direction by Government of India but many efforts are needed in this direction to create nurse practitioners to reduce the burden of physician and provide comprehensive care to population at their doorstep.

Keywords: , Ayushman Bharat, Primary Health Care, Human Resources for Health

The science and technology are advancing also percolated down to the rural and the at very fast speed and it has put an impact poor population as well. Hence the on all the sectors. Health sector is equally developing and Low Mid Income countries affected by the advancement as it has have to bear double burden of diseases. brought change in the lifestyle of people They are still fighting with the resulting into bringing change in the management of communicable diseases disease scenario. Prevalence of Non- and maternal & child health issues, but Communicable diseases is increasing at now along with that they need to manage very fast rate. It is not only the problem of non communicable diseases as well. These affluent and urban community, but it has countries are already running short of

International Journal of Health Systems and Implementation Research-2020, Vol. 4(3) 22 Saini Shushma Kumari Nurse practitioners in India health manpower and with the increase of Training of nurses in regard to burden of NCDs, emerging and re- community health emerging of different diseases the health manpower has become a serious challenge As per nursing training is concerned, for them. This has also increased the registered nurses are prepared to work in requirement of community-based services hospital as well as in community. Enough as the NCDs are long term problems and number of hours have allocated to teaching most of the care part is done in the home and clinical hours in the community in setting and community setting only. BSc Nursing as well as General Nursing Hospitalisation is required at short term and Midwives (GNM) curriculum. As per basis only to manage complications. BSc Nursing curriculum 180 theory hours and 465 clinical hours are being allocated Historical perspective of nurses working for community health nursing subject [4]. in the community In GNM curriculum 270 theory hours and 768 clinical hours are allocated for the Doctors and nurses are important wheels subject of Community Health Nursing [5]. of the health sectors. They equally Which shows that nurses are well prepared contribute while taking care of the patients to work in community. in hospitals. In India at community Level the physicians are available at Primary The reason of limiting nurses to the Health Centres to take care of health needs hospitals must be done in the beginning of the community. But if we talk of nurses, era of Independent India because at that they are available only for secondary and time there were very few nursing institutes tertiary care services taking care of indoor and the number of nurses getting through patients only. At community level the were not able to manage the shortage of nursing care part has been managed by nurses in hospitals. Till the end of Auxiliary nurses. The Shetty Committee twentieth century the nursing schools and recommended (GOI 1954) two grades of colleges were mainly limited to nurses, i.e. fully qualified nurses and Government Institutes only. There were midwives (GNM or BSc Nursing) who very few private nursing schools. Hence have undergone training for three and half very few nurses were getting through from to four years, and the other one of nursing institutes and they were Auxiliary Nurses and Midwives (ANM) immediately taken up the hospital usually with a training of two years. Registered the same hospitals who trained them or nurses (GNM or BSc Nursing) were to they were employed by the state work in the hospital setting and ANMs Governments. But in last two decades with were to work in the community. The the privatisation of nursing institutes many Bhore Committee gave a strong nursing schools and colleges are opened, recommendation for introduction of public and a large number of nurses are passing health nurses at PHC, Block and district out of these institutes every year. As per levels to plan, monitor, and mentor Indian nursing Council website updated on peripheral health staff to implement the 12.4.19 there are 1825 nursing Institutes programmes on health promotion and recognised by Indian Nursing council to disease prevention and the Mudaliar award BSc Nursing Degree and 2908 Committee reiterated this. Rather than nursing Schools to award GNM certificate moving forward into a professional cadre, [6 -7]. in India became stagnant at the lowest level of ANM due to the political and economical reasons [1-3].

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Nurses working in community shifting is done. Task shifting is defined as "the rational redistribution of tasks among The need of nurses to work in community health workforce teams" as per WHO is realised when recently under Ayushman "specific tasks are moved, where Bharat Registered Nurses and Midwives appropriate, from highly qualified health are placed in Health and Wellness centre workers to health workers with shorter as Mid-Level Health Care Providers training and fewer qualifications" [9]. designated as Community Health Officers. This is being done through appropriate Experiences of Nurse practitioners from competency-based bridge course. These other countries bridge courses admit graduates from B.Sc. Nurses and BAMS doctors and help them Many developed countries have already in acquiring skills for providing services at worked on this principle of task shifting the Health and Wellness Centre and other successfully by introducing non-physician peripheral levels. This new cadre is practitioners, mostly nurse practitioners to especially available in the rural and under- become primary care providers within the served areas where they are needed the health care systems. The primary care in most. They are to work as team leader in the National Health Services (NHS) health and wellness centre with two system in UK is provided by nurse ANMs/MPHWM, five ASHA workers and practitioners since the 1980s. Similarly, connected to Physician at Primary Health nurse practitioners are providing primary Centre through telecommunication. This care service in the USA health systems was done as per the National Health Policy since the 1960s. Similar examples have 2017 to bring change in the field of been observed in Australia since 1990s primary health care from very selective to and in Netherlands since 2010. They also comprehensive primary health care work as advanced nurse practitioners and package including geriatric health care, physician assistants as well along with palliative care and rehabilitative care primary health care practitioners in these services [8]. countries under the title of ‘’, ‘nurse practitioner’, and Availability of trained nurses in India ‘clinical nurse specialist’ etc [10 - 12]. In last two decades large numbers of Nurse Practitioner nursing Schools and colleges have come up and a huge number of nurses are trained A nurse practitioner is an advanced every year from these educational practice who helps in institutes. The number of unemployed diagnosing and treating patients. Aspiring nurses is increasing day by day while on nurse practitioners usually pursue a other side hospitals are showing shortage nursing master's degree. These programs of nurses. This shortage of nurses in the allow students to specialize in the fields of hospitals is not due to non-availability of pediatric, neonatal, gerontological or trained nurses but it is due to not filling of family nursing. To begin a nurse vacant positions in many hospitals. Every practitioner program, a nurse must have hospital has many vacant positions in already received a bachelor's degree and Nursing. In community very few positions registered nurse credentials. Another of nurses are created. With the result the common prerequisite for admission is nurses are migrating to western and Clinical nursing experience. Nurse Middle East countries or they are forced to practitioners (NPs) undertake many duties work in private sector at very low wages. of a physician which includes assessing These nurses can be retained in the country and diagnosing the patients with different if enough positions are created and task health issues. The different aspects of this course are assessment procedures,

International Journal of Health Systems and Implementation Research-2020, Vol. 4(3) 24 Saini Shushma Kumari Nurse practitioners in India including history taking, physical Concept of nurse practitioner can be a assessment and performing different regular feature of Indian health system. diagnostic tests. Apart from it they use the They can take the responsibility of all the knowledge of pharmacology, anatomy, components of comprehensive primary and physiology in this course. Several health care including maternal and child studies have found that the cost of the health, acute care problems, Screening, health service is much lower with NPs and Prevention, Control and Management of there is no difference between the clinical Non-Communicable diseases etc. This will outcomes with the services provided by not only reduce the rush in the OPD and NPs and general practitioners [13]. hospitals because it will increase adherence to treatment especially long- Need of Nurse practitioner in India term chronic non communicable diseases. The health care sector needs of India are One of the important reasons of non- rising with the increase in the population adherence is the rush in OPD and patient size, dual burden of diseases due to rise in does not want to waste whole day in chronic and non-communicable lifestyle waiting for doctor. Many of poor diseases along with communicable population may need to forgo the daily diseases, emerging and re-emerging wage due to that. Nurse practitioners will diseases. Hence to address the growing be able to provide services near to their demand of the health care sector there is home setting which will help in improving need for reorganization and adherence to treatment. The adherence will decentralization of health care services. also help in reducing number of This can be done by task shifting complications thus reducing the need of approach. To establish nurse practitioners hospitalisation. in India, numerous attempts have been Initiatives towards nurse practitioners made earlier. The West Bengal in India Government established nurse practitioners in midwifery (NPM) as early Recently Indian government have been as 2005 by giving additional training to working towards exploring opportunities diploma and graduate nurses in public in this field. In National Health Policy service. After this, Government of Gujarat 2017 this has been initiated by establishing in 2009 introduced a post basic diploma on cadres of Nurse Practitioners and Public nurse practitioner in midwifery (NPM). Health Nurses. Union Minister for Health Similar measures were taken over the past and Family Welfare has also launched two years by the state governments of new Nurse Practitioner Courses in 2016. Telangana and Kerala by training One of it is a two-year residential M.Sc. registered nurses as NPM, along with degree in Nurse Practitioner in Critical nursing council of India. JHPIEGO (Johns care. After completing the program Nurses Hopkins Program for International will be qualified to take up responsibility Education in Gynecology and Obstetrics) and accountability for the care of critically founded in 1973 is an international non- ill patients. Indian nursing Council has profit health organization affiliated with already given recognition to 18 nursing Johns Hopkins University. This Institutes to run this programme. This organisation is working in India in programme is a nursing residency maternal and newborn health with the programme with a focus on competency- public-private sector for almost a decade. based training. The special feature of this This organisation has been promoting the programme is that it is a clinical residency role of nurse practitioners in managing programme emphasizing a strong clinical public health programmes [14]. component with 20 per cent of theoretical instruction including skill lab and 80 per

International Journal of Health Systems and Implementation Research-2020, Vol. 4(3) 25 Saini Shushma Kumari Nurse practitioners in India cent of clinical experience. The duration is to Maternal and child health. As per WHO of two years with the curriculum data global midwives are known to consisting of theory that includes core provide quality care during pregnancy and courses, advanced practice courses and childbirth by averting 83% maternal and clinical courses besides clinical practicum child deaths. These courses will give as a major component. These nurses will autonomy to nurses by increasing their be working in the critical care units and accountability and responsibility along will be able to provide cost effective, with focusing their collaborative roles in competent, safe and quality driven health system [17 - 20]. specialized nursing care to patients in a variety of settings in tertiary care centres. Conclusion The Nurse Practitioners in Critical Care Learning lessons from other developed will be allowed to have prescriptive countries, it has become important for authority to certain drugs as per India to have Nurse practitioners to work institutional protocols. They will be in community as Primary Health Care accountable for problem identification provider so that the shortage of doctors in through appropriate assessment; rural areas can be taken care. Being selection/administration of medication or Developing country it is difficult to afford devices or therapies; evaluation of so many doctors, hence the task shifting is outcomes; and recognition and an answer to it. It will also reduce the management of complications and burden of physician in secondary and untoward reactions and collaborate with tertiary care institutions if the Nurse other health care professionals in the practitioners are there in all specialities. critical care team, across the continuum of Though the efforts are already started in critical care [15, 16]. this direction but still there is long path to Another nurse practitioner course go. proposed by Ministry of Health and References Government of India is Nurse Practitioner in Primary Healthcare Program i.e. a one- 1. Tiwari RR, Sharma K, Zodpey SP. year residential Post Graduate diploma Situational analysis of nursing program. This programme is designed for education and work force in India. nurses to work as ‘Nurse Practitioners’ for Nursing Outlook. 61 (2013) 129 -36. providing comprehensive care at the PHCs http://dx.doi.org/10.1016/j.outlook.201 and community levels. Recently in 2.07.012 ‘Partner Forum’ in December 2018 the 2. Kumar TD. Ezhilarasu P. Growth of new guidelines on midwifery is released. It nursing in India: historical and future states that there will be a cadre of Nurse perspectives. Healthy India Chronicle. Practitioner in Midwifery (NPM) will be [cited on 21.4.19] available at created who will be skilled in accordance http://healthyindiachronicle.in/shri-t- with International Confederation of dileep-kumar-president-indian- Midwives standards. To become Nurse nursing-council-growth-nursing-india/ Practitioner in Midwife (NPM) an 3. Gill R. in India with additional post basic training of 18 months special reference to International will be provided to registered nurses. The Migration of Nurses. Social Medicine. Nurse Practitioner Midwife cadre will help 2011:6 (1): 52-9 overburdened secondary and tertiary 4. Indian Nursing Council. BSc Nursing health care institutes where the syllabus pdf. [cited on 4.4.2020] obstetricians are not enough in number. available at This cadre will help India to meet https://www.scribd.com/doc/30506999 Sustainable Developmental Goals related 6/B-Sc-nursing-syllabus-INC-pdf

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5. Indian Nursing Council. GNM controlled trial comparing cost Syllabus pdf. Revised in 2015. [cited effectiveness of general practitioners on 4.4.2020] available at and nurse practitioners in primary care. http://apnc.nic.in/pdf/syllabus/GNM_S BMJ 2000; 320 doi: yllabus.pdf https://doi.org/10.1136/bmj.320.7241.1 6. Indian Nursing Council. List of G N M 048 Nursing Institute for the year 2018-19 13. Pulcini J, Jelic M, Gul R, Loke AY. (12th April, 2019) [cited on 21.4.19] An international survey on advanced available at practice nursing education, practice, http://www.indiannursingcouncil.org/r and regulation. J Nurs Scholarsh. 2010 eg-ins/BSC_12042019.pdf Mar;42(1):31-9. doi: 10.1111/j.1547- 7. Indian Nursing Council. List of B.Sc. 5069.2009.01322.x The print. Sep 17, Nursing Institute for the year 2018-19 2018. [cited on 21.4.19] available at (12th April, 2019) [cited on 21.4.19] https://www.ncbi.nlm.nih.gov/pubmed/ available at 20487184 http://www.indiannursingcouncil.org/r 14. Interest in Advance Practice Nursing in eg-ins/GNM_12042019.pdf India. [cited on 19.4.19] available from 8. NHSRC. Ayushman Bharat https://international.aanp.org/Content/d Comprehensive Primary Health Care ocs/India.pdf through Health and Wellness Centers: 15. Shankar R. Health ministry launches operational guidelines. [cited on 'Nurse Practitioner in Critical Care' 21.4.19] available at course to meet growing needs of nhsrcindia.org/sites/default/files/Opera tertiary healthcare services. [cited on tional%20Guidelines%20For%20Com 4.4.2020] available from prehensive%20Primary%20Health%20 http://pharmabiz.com/NewsDetails.asp Care%20through%20Health%20and% x?aid=91763&sid=1 20Wellness%20Centers.pdf 16. Indian Nursing Council. List of Nurse 9. Task shifting explained: a viable Practitioner Critical Care Institute for solution to health worker shortage. the year 2018-19 (12th April, 2019) Support the Guardian. [cited on [cited on 21.4.19] available at 19.4.19] available from http://www.indiannursingcouncil.org/L https://www.theguardian.com/global- istof-Nursing- development-professionals- Institution.asp?show=NPCC network/2014/may/12/task-shifting- 17. Healthy Newborn Network. India health-development-shortage Readies A New Cadre Of Certified 10. Indian Nursing Council. Nurse Midwives To Improve Maternal, Infant Practitioner in Critical Care (post Care. [cited on 21.4.19] available at graduate Residency programme). https://www.healthynewbornnetwork.o [cited on 21.4.19] available at rg/news-item/india-readies-a-new- https://mohfw.gov.in/sites/default/files/ cadre-of-certified-midwives-to- 57996154451447054846_0.pdf improve-maternal-infant-care/ 11. Nanda L, Lobo E. Nurse Practitioners 18. Chandna H. As India struggles with – India’s Answer to Addressing Access doctor shortage, govt gives a push to to Healthcare. Public H Open Acc nurse-led clinics. The print. Sep 17, 2018, 2(2): 000128. [cited on 19.4.19] 2018. [cited on 21.4.19] available at available at https://theprint.in/india/governance/as- https://medwinpublishers.com/PHOA/ india-struggles-with-doctor-shortage- PHOA16000128.pdf govt-gives-a-push-to-nurse-led- 12. Venning P, Durie A, Roland M, clinics/118535/ Roberts C, Leese B. Randomised

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19. Interest in Advanced Practice Nursing Nadda launches new Nurse in India. Updated November 13, 2017. Practitioner courses and ‘Live [cited on 21.4.19] available at Register’ for Nurses. Press Information https://international.aanp.org/Content/d Bureau, 27-June-2016. [cited on ocs/India.pdf 21.4.19] available at 20. Government of India, Ministry of https://medwinpublishers.com/PHOA/ Health and Family Welfare. Shri J P PHOA16000128.pdf

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