Nursing Education

INTRODUCTION

The retarded development of nursing and nursing profession seems to be mainly due to the fact that no serious thought has been given to this discipline by the government over the years. Timely action on the various reports submitted to the government  would have prepared nurses  to take care of all areas of health care  delivery and would have also avoided multiplication of other categories like occupational therapists, physiotherapists, social worker , health educator etc. All these are doing nursing duties.

RECOMMENDATIONS OF HIGH POWER COMMITTEE ON NURSING AND NURSING PROFESSION

Working conditions of nursing personnel

1. Employment

Uniformity in employment procedures to be made.

Recruitment rules are made for all categories of nursing posts. The qualifications and experience required or these be made thought the country.

There should not be a bond for nursing students as some of the states do not give them employment during the stipulated period. Keeping in view of the shortage of nurses in hospitals and community health field states should create posts and appointment these nurses in the appropriate positions.

2. Job description

• Job description of all categories of nursing personnel is prepared by the central government to provide guidelines.

3. Working hours

§  The weekly working hours should be reduced to 4o hrs per week. Straight shift should be implemented in all states. extra working hours to be compensated  either by leave or by extra emoluments depending on the state policy .nurses to be given weekly day off and all the gazetted holidays as per the government rules.

4. Work load/ working facilities

• Nursing norms for patient care and community care to be adopted as recommended by the committee.
• Hospitals to develop central sterile supply departments, central linen services, and central drug supply system. Group D employees are responsible for housekeeping department.
• Policies for breakage and losses to be developed and nurses not are made responsible for breakage and losses.

5. Pay and allowances

Uniformity of pay scales of all categories of nursing personnel is not feasible. However special allowance for nursing personnel, ie; uniform allowance, washing, mess allowance etc should be uniform throughout the country.

6. Promotional opportunities

For promotion to the post of ward sister, post basic Bsc Nursing is made an essential qualification. The principle of possessing higher qualification than the category to be supervised, should apply fro all levels and categories of nursing personnel in the rural and urban areas.  The committee recommends that along with education and experience, there is a need to increase the number of posts in the supervisory cadre, and for making provision of guidance and supervision during evening and night shifts in the hospital.

Each nurse must have 3 promotions during the service period.

Promotion is based on merit cum seniority.

Promotion to the senior most administrative teaching posts is made only by open selection.

In cases of stagnation, selection grade and running scales to be given.

7. Career development

-provision of deputation for   higher studies after 5 yrs of regular services be made by all states.  The policy of giving deputation to 5 -10 % of each category be worked out by each state. Every nursing personnel must have an opportunity to attend at least one refresher course every 2 years.

8. Accommodation

As far as possible, the nursing staff should be considered for priority allotment of accommodation near to work place. Hospitals should not build nurse's hostel for trained nurses. Apartment type of accommodation is built where married/unmarried nurses can be allowed to live. Housing colonies for hospital s must be considered in long run.

9. Transport

During odd hours, calamities etc arrangements for transport must be made for safety and security of nursing personnel.

10. Special incentives

Scheme of special incentives in terms of awards, special increment for meritorious work for nurses working in each state/district/PHC to be worked out.

11. Occupational hazards

Medical facilities as provided by the central govt. by extended by the state govt to nursing personnel till such times medical services are provided free to all the nursing personnel. Risk allowance to be paid to nursing personnel working in the rural $ urban area.

12. Other welfare services

Hospitals should provide welfare measures like crèche facilities for children of working staff, children education allowance, as granted to other employees, be paid to nursing personnel.

Additional Facilities For Nurses Working In The Rural Areas

Family accommodation at sub centre is a must for safety and security of ANM's /LHV.

Women attendant, selected from the village must accompany the ANM for visits to other villages.

The district public health nurse is provided with a vehicle for field supervision.

Fixed travel allowance with provision of enhancement from time to time.

Rural allowance as granted to other employees is paid to nursing personnel.

NURSING EDUCATION

Nursing education     to be fitted into national stream of education to bring about uniformity, recognition and standards of nursing education. The committee recommends that;

1. There should be 2 levels of nursing personnel - professional nurse (degree level) and auxiliary nurse (vocational nurse). Admission to professional nursing should be with 12 yrs of schooling with science. The duration of course should be 4 yrs at the university level. admission to vocational /auxiliary  nursing should be with 10 yrs of schooling .The duration of course should be 2 yrs in health related vocational stream.
2. All school of nursing attached to medical college hospitals is upgraded to degree level in a phased manner.
3. All ANM schools and school of nursing attached to district hospitals be affiliated with senior secondary boards.
4. Post certificate BSc Nursing degree to be continued to give opportunities to the existing diploma nurses to continue higher education.
5. Master in nursing programme to be increased and strengthened.
6. Doctoral programmes in nursing have to be started in selected universities.
7. Central assistance be provided  for all levels of nursing education institutions  in terms of budget( capital and recurring)
8. Up gradation of degree level institutions be made in a phased manner as suggested in report.
9. Each school should have separate budget till such time is phased to degree/vocational programme. The principal of the school be the drawing and the disbursing officer.
10. Nursing personnel should have a complete say in matters of selection of students. Selection is based completely on merit. Aptitude test is introduced for selection of candidates.
11. All schools to have adequate budget for libraries and teaching equipments.
12. All schools to have independent teaching block called as School Of Nursing with adequate class room facilities, library room, common room etc as per the requirements of INC.
13. Adequate accommodations are provided to students. A maximum of 3 students to share a room. Rooms to be furnished   with light, study  table , chair etc. Adequate dining room, toilets and bathrooms facilities to be provided in each hostel as per norms recommended.
14. Students should learn under supervision in the wards. Tutors/clinical instructors must go to the ward with students. Students should not be used for the service of the hospital.
15. Community nursing experience should be as per INC requirements. Necessary transport and accommodation at PHC be made available for safety, security and meaningful learning of students.
16. INC requirements for staffing the schools and meeting the minimum requirements are followed by all schools as these are statutory requirements.
17. Speciality courses at post-graduate level be developed at certain special centres of excellence eg; AIIMS.
18. Institutes like National Institute of Health and Family welfare, RAK College of Nursing   and several others may develop courses on nursing administration for senior nursing leading to doctorate level.
19. Provision for higher training abroad and exchange programmes is made.

Continuing Education And Staff Development

• Definite policies of deputing 5-10% of staff   for higher studies are made by each state. Provision for training reserve is made in each institution.
• Deputation for higher study is made compulsory after 5 yrs.
• Each nursing personnel must attend 1 or 2 refresher course every year.
• Necessary budgetary provision be made,
• A National Institute for Nursing Education Research and Training needs to be established like NCERT, for development of educational technology, preparation of textbooks, media, / manuals   for nursing.

NURSING SERVICES: HOSPITALS/INSTITUTIONS (URBAN AREAS)

1. Definite  nursing policies  regarding nursing practice be available in each institution .These policies include:

a)    Qualification/recruitment rules

b)    Job description/job specifications

c)    Organisational chart of the institutions

d)    Nursing care standards for different categories of patients.

1. Staffing of the hospitals should be as per norms recommended.
2. District hospitals /non teaching hospitals may appoint professional teaching nurses in the ratio of 1; 3 as soon as nurses start qualifying from these institutions.
3. Students not to be counted for staffing in the hospitals
4. Adequate supplies and equipments, drugs etc be made available for practice of nursing. The committee strongly recommends that minimum standards of  basic equipment needed  for each patient be studied , norms laid down  and provided to enable nurses  to perform some of the basic nursing functions .  Also there should be a separate budget head for nursing equipment and supplies in each hospitals/ PHC. The NS and PHN should be a member of the purchase and condemnation committee.
5. Nurses to be relieved from non -nursing duties.
6. Duty station for nurses is provided in each ward.
7. Necessary facilities like central sterile supplies, linen, drugs are considered for all major hospitals to improve patient care. Also   nurses should not be made to pay for breakage and losses. All hospitals should have some systems for regular assessment of losses.
8. Provision of part time jobs for married nurses to be considered. (min 16-20hrs/week)
9. Re-entry by married nurses at the age of 35 or above may also be considered and   such nurse be given induction courses for updating their knowledge and skills before employment.
10. Nurses in senior positions like ward sisters, Asst. nursing superintendents, Deputy NS; N.S must have courses in management and administration before promotions.
11. Nurses working in speciality areas must have courses in specialities. Promotion opportunities for clinical specialities like administrative posts are considered for improving quality nursing services.

The committee recommends that Gazetted ranks be allowed for nurses working as ward sister and above (minimum class II gazetted). Similarly the post of Health Supervisor (female) is allowed gazetted rank and district public health nurse be given the status equal to district medical/ health officers.

Community nursing services

• Appointment of ANM/LHV to be recommended.
• ANM/LHV promoted to supervisory posts must undergo courses in administration and management.
• Specific standing orders are made available for each ANM/LHV to function effectively in the field.
• Adequate provision of supplies, drugs etc are made.
• Recording system be simplified.
• Posts of public health   nurses and above are given gazetted status.

Norms recommended for nursing service and education hospital setting.

1. Nursing Supdt -1: 200 beds (hospitals with 200 or more beds).
2. Dy. Nsg. Supdt. - 1: 300 beds ( wherever beds are over 200)
3. Asst. Nsg . Supdt  - 1: 100
4. Ward sister/ward supervisor - 1:25  beds 30% leave reserve
5. Staff nurse for wards -1:3 ( or 1:9 for each shift )  30% leave reserve
6. For nurses OPD and emergency etc - 1: 100 patients ( 1 bed : 5 out patients)   30% leave reserve
7. For ICU -1:1(or 1:3  for each shift)    30% leave reserve

For specialised depts such as operation theatre, labour room etc- 1: 25 30% leave reserve.

Community nursing services

1 ANM  for 2500 population ( 2 per sub centre)

1 ANM  for 1500 population  for hilly areas

1 health supervisor  for  7500 population( for supervision of 3 ANM's)

1 public health nurse  for 1 PHC ( 30000 population to supervise 4 Health Supervisors )

1 Public Health Nursing Officer for 100000 population ( community health  centre)

2 district public health nursing for each district.

Teaching staff for schools/colleges of Nsg as per INC

1 Nurse Teacher to 10 students for post graduate programmes.

NURSING LEGISLATION

1. INC and state nursing council acts be amended to provide for control by INC on states nursing councils.
2. Provision of   more nurse members.
3. Provision for regulation of nursing education standards by timely inspections and follow up.
4. Provision of maintaining of minimum standards  of nursing practice
5. Provision of regulation for nursing care standards in private nursing homes.
6. Provision for regulation for private nursing bureaus and practice by unqualified nurses.
7. Provision of approval of INC before opening a SON or CON.
8. Provision of renewal of registration every 5 yrs.
9. Provision of independent practice of nursing by nurses.
10. INC to set up a national examination system in about 10 yr time to regulate standards of nursing education.

Ø  Also, the positions up to the DADG level are proposed to be at the office of the Directorate General of Health Services. The positions below the level of DADG are to exist at the institutions governed by the central govt.

Ø  The Principal, College Of Nursing will be equal to the rank of ADG (N)   and will be eligible for promotion to the post of DDG (N)/ Addl. (N). The salary scales and structure of the staff of colleges of nursing will be as per norms of INC   and the UGC.

ORGANISATION OF NURSING SERVICES

The position and status of nursing personnel working in   the directorates need up gradation and expansion of the nurse to enable the nurses to participate in policy making and decision making. Total nursing components, i.e., nursing education, nursing service and community nursing should be under the control of nursing personnel at all the levels. I.e. At centre, stateand district level. At every level adequate provision of budget should be made for development of nursing profession.

The organisational structure recommended for centre, state and district level is as follows.

1. Each ADG level nurse to deal with continuing education /research component for specialised areas.
2. Selection to these posts is made on merit and not by seniority alone.
3. Nurses appointed these posts must have courses in administration, management and fiscal management.
4. Railway board, state insurance (labour minister), post $ telegraph union, territories (Delhi), municipal corporations etc to create such posts for control, co-ordination and development of nursing personnel.

NB: The principal, college of nursing will be equal to the rank of ADG (N) and will be eligible for promotion to the post of DDNS/ DNS. The salary and structure of college of nursing will be as per as norms of INC and UGC.

NATIONAL NURSING POLICY

There is a need for national nursing policy within the framework  of national health policy and national health planning.

Eg. High Power Committee by Government of West Bengal

Government of West Bengal, constituted a High Power Committee with Justice Chittatosh Mookerjee, formerly Chief Justice of Bombay High Court, as Chairman and five other members on 7th January, 2004with the following terms of reference :

i) The Committee shall examine the State medical infrastructure available within the State:

ii) The Committee while examining the State medical infrastructure facilities, may invite written representation/memorandum from any individual, organization, association and local body:

iii) The Committee may examine any other aspects of the State health care system as may be considered necessary in the light of the judgement of Hon'ble Court:

iv) While giving its report, the Committee shall suggest the measures to be taken by the Government.

Recommendations on preventive and primary health care.

i) The epidemiological surveillance system should be geared up with the support of the field staff as well as the Panchayat Raj Institutions.

ii) Primary health care, public health programmes, nutrition schemes, and school health programmes should be coordinated with a view to reducing incidence of diseases.

iii) Steps should be initiated to ensure the effective functioning of rural hospitals by placement of Specialists, particularly Anaesthetists and Radiologists.

iv) Simple labour cases without complication should be tackled in BPHCs and rural hospitals for which necessary infrastructure is to be organized.

v) Special hands-on training programmes need to be organised in a nodal institution for newly recruited medical officers for at least one month. Management/administrative training programmes also need to be organised for the Superintendents of secondary level hospitals.

vi) Refresher training programmes on public health should be organized regularly for CMOH, Dy. CMOH, ACMOH and Programme Officers.

vii) Speciality and super speciality facilities outside the Kolkata metropolitan area should be organised on a regional basis, most importantly in the area of Neurosurgery and Trauma Centre, Dialysis units, Cardiology, Cardiac Surgery, Casualty and ICCU, preferably on public private partnership.

viii) Regular periodic visits of senior level health administrators to the field units for the purpose of implementation, monitoring, supervision and evaluation should be insisted upon.

ix) The present nurse-bed ratio (1:5) which was laid down in 1957 should be reviewed in the light of developments since and a more realistic ratio arrived at.

x) Adequate supply of modern Tissue Culture Anti-rabic Vaccine (ARV) is to be ensured at the earliest in the interest of a better health care delivery system.

xi) The fact remains that almost 50% of deliveries still take place in home situations. Recognising this fact it is necessary that facilities for ante-natal checkups and home delivery should be augmented in terms of expertise and infrastructure

CONCUSION

It was observed that nurses are not involved in making policies that govern their status and practice. They are invariably excluded from the govt bodies that decide decide these policies. Most of the decisions concerning nursing care and nurses are made by other people, usually physicians without the benefit of professional input from by nurses. It is possible that this situation is the direct result of lack of appropriate status accorded to the nursing staff. Nearly 97% of nursing staff are in group "c "category and their status are too low.