Do We Need Nurse Practitioner in India?

The science and technology are advancing at very fast speed and it has put an impact on all the sectors. Health sector is equally affected by the advancement as it has brought change in the lifestyle of people resulting into bringing change in the disease scenario. Prevalence of Non-Communicable diseases is increasing at very fast rate. It is not only the problem of affluent and urban community, but it has also percolated down to the rural and the poor population as well. Hence the developing and Low Mid Income countries have to bear double burden of diseases. They are still fighting with the management of communicable diseases and maternal & child health issues, but now along with that they need to manage non communicable diseases as well. These countries are already running short of health manpower and with the increase of burden of NCDs, emerging and re-emerging of different diseases the health manpower has become a serious challenge for them. This has also increased the requirement of community-based services as the NCDs are long term problems and most of the care part is done in the home setting and community setting only. Hospitalisation is required at short term basis only to manage complications.

Historical perspective of nurses working in the community

Doctors and nurses are important wheels of the health sectors. They equally contribute while taking care of the patients in hospitals. In India at community Level the physicians are available at Primary Health Centres to take care of health needs of the community. But if we talk of nurses, they are available only for secondary and tertiary care services taking care of indoor patients only. At community level the nursing care part has been managed by Auxiliary nurses. The Shetty Committee recommended (GOI 1954) two grades of nurses, i.e. fully qualified nurses and midwives (GNM or BSc Nursing) who have undergone training for three and half to four years, and the other one of Auxiliary Nurses and Midwives (ANM) with a training of two years. Registered nurses (GNM or BSc Nursing) were to work in the hospital setting and ANMs were to work in the community. The Bhore Committee gave a strong recommendation for introduction of public health nurses at PHC, Block and district levels to plan, monitor, and mentor peripheral health staff to implement the programmes on health promotion and disease prevention 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 [1-3].

Training of nurses in regard to community health

As per nursing training is concerned, registered nurses are prepared to work in hospital as well as in community. Enough number of hours have allocated to teaching and clinical hours in the community in BSc Nursing as well as General Nursing and Midwives (GNM) curriculum. As per BSc Nursing curriculum 180 theory hours and 465 clinical hours are being allocated for community health nursing subject [4]. In GNM curriculum 270 theory hours and 768 clinical hours are allocated for the subject of Community Health Nursing [5]. Which shows that nurses are well prepared to work in community.

The reason of limiting nurses to the hospitals must be done in the beginning era of Independent India because at that time there were very few nursing institutes and the number of nurses getting through were not able to manage the shortage of nurses in hospitals. Till the end of twentieth century the nursing schools and colleges were mainly limited to Government Institutes only. There were very few private nursing schools. Hence very few nurses were getting through from nursing institutes and they were immediately taken up the hospital usually the same hospitals who trained them or they were employed by the state Governments. But in last two decades with the privatisation of nursing institutes many nursing schools and colleges are opened, and a large number of nurses are passing out of these institutes every year. As per Indian nursing Council website updated on 12.4.19 there are 1825 nursing Institutes recognised by Indian Nursing council to award BSc Nursing Degree and 2908 nursing Schools to award GNM certificate [6 -7].

Nurses working in community

The need of nurses to work in community is realised when recently under Ayushman Bharat Registered Nurses and Midwives are placed in Health and Wellness centre as Mid-Level Health Care Providers designated as Community Health Officers. This is being done through appropriate competency-based bridge course. These bridge courses admit graduates from B.Sc. Nurses and BAMS doctors and help them in acquiring skills for providing services at the Health and Wellness Centre and other peripheral levels. This new cadre is especially available in the rural and under-served areas where they are needed the most. They are to work as team leader in health and wellness centre with two ANMs/MPHWM, five ASHA workers and connected to Physician at Primary Health Centre through telecommunication. This was done as per the National Health Policy 2017 to bring change in the field of primary health care from very selective to comprehensive primary health care package including geriatric health care, palliative care and rehabilitative care services [8].

Availability of trained nurses in India

In last two decades large numbers of nursing Schools and colleges have come up and a huge number of nurses are trained every year from these educational institutes. The number of unemployed nurses is increasing day by day while on other side hospitals are showing shortage of nurses. This shortage of nurses in the hospitals is not due to non-availability of trained nurses but it is due to not filling of vacant positions in many hospitals. Every hospital has many vacant positions in Nursing. In community very few positions of nurses are created. With the result the nurses are migrating to western and Middle East countries or they are forced to work in private sector at very low wages. These nurses can be retained in the country if enough positions are created and task shifting is done. Task shifting is defined as "the rational redistribution of tasks among health workforce teams" as per WHO "specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications" [9].

Experiences of Nurse practitioners from other countries

Many developed countries have already worked on this principle of task shifting successfully by introducing non-physician practitioners, mostly nurse practitioners to become primary care providers within the health care systems. The primary care in the National Health Services (NHS) system in UK is provided by nurse practitioners since the 1980s. Similarly, nurse practitioners are providing primary care service in the USA health systems since the 1960s. Similar examples have been observed in Australia since 1990s and in Netherlands since 2010. They also work as advanced nurse practitioners and physician assistants as well along with primary health care practitioners in these countries under the title of ‘advanced practice nurse’, ‘nurse practitioner’, and ‘clinical nurse specialist’ etc [10 - 12].

Nurse Practitioner

A nurse practitioner is an advanced practice registered nurse who helps in diagnosing and treating patients. Aspiring nurse practitioners usually pursue a nursing master's degree. These programs allow students to specialize in the fields of pediatric, neonatal, gerontological or family nursing. To begin a nurse practitioner program, a nurse must have already received a bachelor's degree and registered nurse credentials. Another common prerequisite for admission is Clinical nursing experience. Nurse practitioners (NPs) undertake many duties of a physician which includes assessing and diagnosing the patients with different health issues. The different aspects of this course are assessment procedures, including history taking, physical assessment and performing different diagnostic tests. Apart from it they use the knowledge of pharmacology, anatomy, and physiology in this course. Several studies have found that the cost of the health service is much lower with NPs and there is no difference between the clinical outcomes with the services provided by NPs and general practitioners [13].

Need of Nurse practitioner in India

The health care sector needs of India are rising with the increase in the population size, dual burden of diseases due to rise in chronic and non-communicable lifestyle diseases along with communicable diseases, emerging and re-emerging diseases. Hence to address the growing demand of the health care sector there is need for reorganization and decentralization of health care services. This can be done by task shifting approach. To establish nurse practitioners in India, numerous attempts have been made earlier. The West Bengal Government established nurse practitioners in midwifery (NPM) as early as 2005 by giving additional training to diploma and graduate nurses in public service. After this, Government of Gujarat in 2009 introduced a post basic diploma on nurse practitioner in midwifery (NPM). Similar measures were taken over the past years by the state governments of Telangana and Kerala by training registered nurses as NPM, along with nursing council of India. JHPIEGO (Johns Hopkins Program for International Education in Gynecology and Obstetrics) founded in 1973 is an international non-profit health organization affiliated with Johns Hopkins University. This organisation is working in India in maternal and newborn health with the public-private sector for almost a decade. This organisation has been promoting the role of nurse practitioners in managing public health programmes [14].

Concept of nurse practitioner can be a regular feature of Indian health system. They can take the responsibility of all the components of comprehensive primary health care including maternal and child health, acute care problems, Screening, Prevention, Control and Management of Non-Communicable diseases etc. This will not only reduce the rush in the OPD and hospitals because it will increase adherence to treatment especially long-term chronic non communicable diseases. One of the important reasons of non-adherence is the rush in OPD and patient does not want to waste whole day in waiting for doctor. Many of poor population may need to forgo the daily wage due to that. Nurse practitioners will be able to provide services near to their home setting which will help in improving adherence to treatment. The adherence will also help in reducing number of complications thus reducing the need of hospitalisation.

Initiatives towards nurse practitioners in India

Recently Indian government have been working towards exploring opportunities in this field. In National Health Policy 2017 this has been initiated by establishing cadres of Nurse Practitioners and Public Health Nurses. Union Minister for Health and Family Welfare has also launched two new Nurse Practitioner Courses in 2016. One of it is a two-year residential M.Sc. degree in Nurse Practitioner in Critical care. After completing the program Nurses will be qualified to take up responsibility and accountability for the care of critically ill patients. Indian nursing Council has already given recognition to 18 nursing Institutes to run this programme. This programme is a nursing residency programme with a focus on competency-based training. The special feature of this programme is that it is a clinical residency programme emphasizing a strong clinical component with 20 per cent of theoretical instruction including skill lab and 80 per cent of clinical experience. The duration is of two years with the curriculum consisting of theory that includes core courses, advanced practice courses and clinical courses besides clinical practicum as a major component. These nurses will be working in the critical care units and will be able to provide cost effective, competent, safe and quality driven specialized nursing care to patients in a variety of settings in tertiary care centres. The Nurse Practitioners in Critical Care will be allowed to have prescriptive authority to certain drugs as per institutional protocols. They will be accountable for problem identification through appropriate assessment; selection/administration of medication or devices or therapies; evaluation of outcomes; and recognition and management of complications and untoward reactions and collaborate with other health care professionals in the critical care team, across the continuum of critical care [15, 16].

Another nurse practitioner course proposed by Ministry of Health and Government of India is Nurse Practitioner in Primary Healthcare Program i.e. a one-year residential Post Graduate diploma program. This programme is designed for nurses to work as ‘Nurse Practitioners’ for providing comprehensive care at the PHCs and community levels. Recently in ‘Partner Forum’ in December 2018 the new guidelines on midwifery is released. It states that there will be a cadre of Nurse Practitioner in Midwifery (NPM) will be created who will be skilled in accordance with International Confederation of Midwives standards. To become Nurse Practitioner in Midwife (NPM) an additional post basic training of 18 months will be provided to registered nurses. The Nurse Practitioner Midwife cadre will help overburdened secondary and tertiary health care institutes where the obstetricians are not enough in number. This cadre will help India to meet Sustainable Developmental Goals related to Maternal and child health. As per WHO data global midwives are known to provide quality care during pregnancy and childbirth by averting 83% maternal and child deaths. These courses will give autonomy to nurses by increasing their accountability and responsibility along with focusing their collaborative roles in health system [17 - 20].

Conclusion

Learning lessons from other developed countries, it has become important for India to have Nurse practitioners to work in community as Primary Health Care provider so that the shortage of doctors in rural areas can be taken care. Being Developing country it is difficult to afford so many doctors, hence the task shifting is an answer to it. It will also reduce the burden of physician in secondary and tertiary care institutions if the Nurse practitioners are there in all specialities. Though the efforts are already started in this direction but still there is long path to go.

References

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