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Nursing in India
Shubhada Sakurikar*
Nursing as a Profession
Nursing is not simply a collection of specific skills, and the nurse is
not a person trained to perform specific tasks. Nursing is a profession.
No one factor absolutely differentiates a job from a profession, but the
difference is important in terms of how nurses practice. When we say a
person acts “professionally,” for example, we imply that the person is
conscientious in actions, knowledgeable in the subject, and responsible
to self and others. Professions possess the following primary
characteristics:
- A profession requires an extended education of its members, as well as
a basic liberal foundation.
- A profession has a theoretical body of knowledge leading to defined
skills, abilities and norms.
- A profession provides a specific service.
- Members of a profession have autonomy in decision making and practice.
- The profession as a whole has a code for practice.
The practice of professional nursing and nursing knowledge has been
developed over time through development of nursing theories and
research. Theoretical models serve as frameworks for nursing curricula
and clinical practice. Nursing research increases the scientific basis
of nursing practice through the systematic inquiry into healthcare
problems and issues. The history of nursing profession in India is
indeed in synch with the history of nursing profession elsewhere.
Early on
The recorded history of nursing in India dates back to about 1500 BC in
the Atharva veda (AV). The AV is the first Indic text dealing with
medicine. It identifies the causes of disease as living causative
agents. It is recorded that chikitsalaya (halls of healing) were
existing by about 700 BC.
Susrata (500 BC) and Charaka (300 BC) were the leading authorities of
ayurveda (the science of life). Their teachings were preserved in
samhitas (treatises). The ancient Hindus laid more emphasis upon the
prevention of disease than upon its cure. Doctors were well versed not
only in medicine and surgery but in measures for the prevention of
disease. Amongst various remedies were practiced including inoculation
for smallpox.
The books of the ayurveda are in eight parts. They cover the whole field
of medicinal science, including nursing treatment. There are more
details of nursing in the old Indian records than in those of any other
country in the world. Susrata defined the ideal relations of doctor,
nurse, patient and medicine as the four feet upon which a cure must
rest. The Charaka Samhita described the function of a nurse as
“knowledge of the manner in which drugs should be prepared or compounded
for administration, cleverness, devotedness to the patient waited upon,
and purity (both of the mind and body), are the four qualifications of
the attending nurse.”
Practice of medicine rose to a great height in the reign of Asoka (304
BC–232 BC). Compassion for all living creatures, which was an essential
part of the creed of Buddha, showed itself in ministration to all
sufferers. In the rule of life of a Buddhist monk assistance to the sick
was a part. Asoka established a large number of hospitals. Nursing-homes
were also built for housing the sick. With the disintegration of Gupta
Empire (647 AD) and arrival of Huns, a deterioration of Tradition set
in, from which it would take centuries to recover.
In 16th Century Unani Tibb system of medicine arrived with Mughals. Also
known as Hikmat, this system was developed by Hippocrates (460 BC–370
BC) from the medicine and traditions of the ancient Egypt and
Mesopotamia. Hikmat sees illness as an opportunity to serve, clean,
purify and balance the physical, emotional, mental and spiritual planes.
In Islam taking care of a sick person is a blessing. However, there was
little trace of female nurses in ancient and medieval India.
Colonized Era
The modern medicine, including nursing was introduced by the Portuguese
in the 17th Century when Albuquerque conquered Goa and established the
Royal Hospital. The East India Company opened its first hospital for
soldiers in 1664 at Madras and built another in 1688 for civilians. For
many years nursing training was given to only Europeans and Ango-Indians.
The Jamsetjee Jeejeebhoy (JJ) Hospital was first to train nurses in
Western India. The first Indian lady to come forward for nursing
training was Bai Kashibai Ganpat in 1891 in Bombay. In the succeeding
years, nursing schools were established all over the country in
collaboration with the government and private hospitals.
During the Second World War, there was an acute shortage of nurses of
one nurse for every 50 to 60,000 of the population. Hence a short course
of intensive training in nursing was initiated in 1942 which was called
as the auxiliary nursing service. About three thousand young women of
India, of all casts and creed, were given this intensive training and
enrolled. After independence, the MNS grew into a full fledged service.
Development of Nursing and Health Care
The nursing scenario at the time of independence was not very bright. It
is estimated that there were only about 7000 nurses in the entire
country with a population of about 350 million. The hospitals were
understaffed and nursing lacked professional and social status.
Just before independence a high power committee was set up by the
British Government to survey the health care services. In 1943, the
Health Survey & Development Committee was appointed under the
chairmanship of Sir Joseph Bhore. It laid emphasis on integration of
curative and preventive medicine at all levels and recommended for
remodeling of health services in India. As a result, Indian Nursing
Council (INC) was established in 1947 to regulate the standards of
nursing education. Later, AB Shetty committee in 1954 and High Power
committee for Nursing Profession in 1989 established guidelines and
directions on the working conditions, education and nursing services.
In the first and the second five year plan periods (1951-1961), because
of the pressure of growing needs, there had been a comparatively rapid
development in nursing. Grants from Central Government had given a great
impetus to the training of nurses, Auxiliary Nurse- Midwives and health
visitors. The most significant development had been the extension of
nursing and midwifery to the rural areas. Only in the third plan
(1961-1966) emphasis could be laid on education for nursing and
supervision in the public health field.
A study of health services was carried out in connection with the
revision of syllabus of general nursing and midwifery by the Indian
Nursing Council in 1963. The study provided valuable insights into: the
trends in the health services and implications for nursing. The study
observed that much of the ill health in the country has its roots in
conditions of a socio-economic nature so that diseases such as
malnutrition, dysentery, typhoid and cholera, are as dependent for their
eradication on fundamental changes in living habits and a higher per
capita income as they are on health services. Results are being achieved
however from improved environmental sanitation, health education and
other related activities, but the nature of the problem does not lend
itself to dramatic changes in the overall picture.
The preponderance of preventable diseases and conditions emphasizes the
nurse’s role as a health teacher both in the hospital and the community;
infant and maternal mortality indicate a need for improved midwifery
practice as well as promotion of maternal and child health; the changing
pattern of treatment in tuberculosis places the emphasis on home care
rather than hospital care; increase in hospital beds poses problems in
regard to the nursing staff, and the addition of specialties has
implications for the preparation of the nurse at basic and post- basic
levels. Lastly, the emergence of the Primary health care as a vital
organ in community health services and the consequent need for qualified
nursing personnel focuses attention on present attitudes to this branch
of nursing and how it can be changed.
Nursing Education
The period between 1950 and 1970 could be considered as a period of
renaissance. Considerable steps were taken to reform the Nursing
Services, Education, Medical and Paramedical Services. International
agencies like WHO, UNICEF, USAID, which were established in the late 40s
were all set to mobilize the international efforts, coordination and
cooperation to tackle health problems of their member countries like
communicable diseases such as Smallpox, Malaria, Cholera, Typhoid,
Meningitis, Leprosy, Infant and Maternal Mortality, General Mortality
and Morbidity. These agencies provided lot of monetary and material
help. Consultants (medical experts) were deputed to provide guidance in
organizing or reforming health services, medical, Nursing and
paramedical education.
The member countries were also supplied with equipments, vehicles and
capital investments in building certain institutions. Many Schools of
Nursing buildings were constructed with funding received. Nurses and
doctors were given study grants for taking up advanced education abroad,
Nurses were sent to western countries, especially USA and Canada, for
degree courses. For advanced specialty courses like Paediatric Nursing,
Maternal and Child Nursing, Midwifery, Psychiatric Nursing invariably
Nurses were sent to UK, Australia, New Zealand and other European
countries (these countries started their degree courses in the late 70s
onwards). As the Nurses were becoming better qualified, they were also
becoming more conscious of their rights and privileges. The
socio-economic and political changes in the country and the world over
also influenced their thinking. The International Labour Organization in
1964 passed a Resolution on Working and Employment Conditions of Nurses
and requested the member countries to pay attention to the conditions of
service of Nurses.
The College of nursing at the Post-Graduate Institute of Medical
Education and Research (PGIMER) came into being in 1964. The College of
Nursing at The All India Institute of Medical Sciences, New Delhi was
established in 1969. By the end of the Fourth Five Year Plan
(1969-1974), the Government of India and the Indian Nursing Council
proposed to take various measures to integrate psychiatric nursing in
the basic nursing curriculum throughout the country. Broadly speaking
the psychosomatic viewpoint of illness and the nurse-patient
relationship were considered the most important factors, which created
the need for this integration. By 1975 the States were also trying to
have similar State level institutions. Along with the development of
National Medical institutions, came up the Colleges of Nursing also.
Nursing Research
The Association of Nursing Superintendents was founded in 1905 at
Lucknow. The organization was composed of nine European Nurses holding
administrative posts in hospitals. At the Annual Conference held in
Bombay in 1908, a decision was taken to establish Trained Nurses’
Association. The Association was inaugurated in 1909. The Nursing
journal of India (Nurs J India) started in 1912. The Association of
Nursing Superintendents and Trained Nurses’ Association were amalgamated
in 1922 and called The Trained Nurses’ Association of India (TNAI).
In early sixties TNAI undertook preparing of short abstracts of nursing
research studies done on Indian nursing problems, at master’s or
doctoral level. Nursing has been dependent on other disciplines such as
sociology, psychology for the knowledge as well as techniques of
research. Considerable contribution to nursing research has been made by
sociologists, psychologists and educationists.
Though the status of the Nursing profession has been raised to some
extent by having gazetted positions from the Deputy Nursing
Superintendent level onwards, at present there is a marked deterioration
in the Nursing and Medical Services provided by various institutions,
particularly Government institutions. This process of gradual
deterioration and dehumanization had set in- the 60s and 70s. Mission
institutions and other private institutions are still regarded better in
providing Nursing, Medical and Health services, on the whole. In 1974
the TNAI became a member of the Commonwealth Nurses Federation (CNF).
There has been a tremendous increase in the private Nursing Homes and
Hospitals. The growth could of these be attributed to a surplus of
Doctors, availability of loans to start Nursing Homes and
dissatisfaction of the public, particularly the upper strata, with
inefficient services provided, by and large, by the Government
institutions.
In 1994 the CNF initiated a movement to strengthen Nursing and Midwifery
in its various member countries. Representatives of Nurses' Associations
of various countries and Chief Nursing Officers met in Malta to discuss
matters related to strengthening of Nursing and Midwifery. The
recommendations made by this group were accepted by Heads of States of
various countries. The National Associations were asked to do the
follow-up with the Chief Nursing Officer in the Ministry of Health of
their respective countries. As a result of this many countries have
launched initiatives to strengthen the Nursing and Midwifery components
of Health Services and the personnel.
In 1999, the Ministry of Health and Family Welfare, Government of India,
initiated a project through the Indian Nursing Council to look into the
possibility of having independent Midwifery Practice. With the help of
Australian Nurses this project has been initiated.
The Nursing profession has yet to go a long way to be comparable with
the other western and developed countries. Nursing has to keep pace with
modem Information Technology. Though it has achieved desired heights in
Nursing Education, Nursing Services, the other side of the coin, have
yet to be raised to an acceptable standard and quality.
Present Nursing Services
The nursing service of the country comprise of four main categories: the
nurse, the health visitor, the auxiliary nurse- midwife and the midwife.
The other personnel who also contribute to the nursing services are the
Dais, trained and untrained, the nursing assistants, orderlies, ward
boys, and ayahs.
There were 1,283,775 RN in 2002-03; about 2/3rd are active in practice.
About 50,000 nurses are added each year into the practice. The ratio of
nurse to population is approximately 1:13,000. Of which one third of the
total nurses are associated with institutes associated with training and
the remaining are distributed throughout the thousands of other
hospitals and dispensaries both government and private, and relatively
very few are giving service in the rural areas. The nursing industry is
currently growing by about 6% annually. The annual growth is expected to
touch 10% by year 2010.
Nursing today demands a high level of knowledge and skill, and basic
nursing education aims at providing learning experiences which will
equip the student to perform at this professional level. There are only
200 nursing colleges across the country with limited number of seats.
These colleges offer a four-year BSc in nursing (eligibility: standard
XII), with a handful of them offering M Sc and M Phil in nursing. The
700-odd nursing schools are offering diploma in nursing care. These
schools offer a three-year diploma in GNM (eligibility: standard XII))
and a two- year certificate course in Auxiliary Nurse Midwifery or ANM
(eligibility: standard X). Now the government took a decision not to
open any new nursing school, and the converting the existing all nursing
schools to colleges by 2010. Running a degree course would need
well-qualified teachers, hostel facility, vast library and other such
infrastructure, which most nursing schools lack. BSc in nursing is
likely to remain an unfulfilled dream of many aspirants.
In February 2006, President A.P.J. Abdul Kalam visited College Of
Nursing At University Of Philippines in Manila. He said, “The old split
between graduate, educated nurses and vocational nurses is not going to
be put to rest unless nursing itself tackles the problem. Also, nurses
will continue to be governed by non-nursing administrators, who are most
of the time, lesser educated and unskilled in handling emotions.” In
April 2006, Dean Josefina A Tuazon met him in New Delhi commencing
Indo-Filipino cooperation in Nursing Research. Care Foundation
established a Chair to honour legendary Filipino Nurse Julita V. Sotejo.
Conclusion
The development of professionalism among any group of persons depends on
the organization's success in insulating itself from or relating itself
to its social context in order to retain a free hand in setting
standards and policies. Both structural (i.e., training and professional
organization aspects) and attitudinal (i.e., attitudes of the
practitioners toward their work and attitudes of the community toward
the work of the practitioners) attributes are important in the
professionalism of any group. Nursing personnel have not succeeded in
professionalism due to a number of cultural constraints. Planners for
health services in India have been hindered in their attempts to
professionalize medical personnel because the supply of trained
personnel is so limited and because these trained personnel are largely
concentrated in urban areas, leaving the rural areas to the care of
traditional health personnel. Traditional midwives are included in this
number. Nursing personnel suffer from inadequate autonomy due to the
socialization of girls within the community; they are encouraged to be
dependent. The most serious obstacle to professionalism of nursing in
India is the low status, low pay, and poor working conditions, offered.
All these conditions are culturally determined.
*Chief of Nursing at Care Hospital, Banjara
Hills, Hyderabad and Julito V. Sotejo Chair of Cardiovascular Nursing. |
