the story of nursing: a revered profession and service

the history of nursing 

The profession of nursing can be traced back to 300 AD when the Roman Empire undertook the task of building hospitals in every town under its sovereignty. This led to increased demand for nurses to assist the doctors and provide patient care before, during and after treatments.

Spain saw the requirement for hospitals and towards the end of 500 AD the first hospital was built in Merida.

By the 10th and 11th century hospitals become a part of religious centers and monasteries. The duties of nurses expanded to include a wide range of healthcare services.

evolution of nursing – the timeline 

• In 1664 Sisters from the St. Thomas Hospital, London arrived at the newly started military hospital in Fort. St. George, Madras. Military Nursing became the most prominent type of nursing at that time.
• In 1797 with great help from John Underwood, a maternity hospital for the poor of Madras was built. By 1854 the government allowed training schools for the Midwives in Madras.
• In 1850’s the nursing profession saw a significant change predominantly because of the legendary nurse Florence Nightingale and her substantial role in caring for injured solders of the Crimean War.

Around this time nurses’ tasks included caring for soldiers in the front lines of war. The conditions were gruesome, hygiene standards were questionable and often led o many fatalities.

• By 1860, the very first nursing school was opened in London. Nurses could now get full medical training and provide better assistance in the filed of healthcare.
• In 1865, Nightingale set forth detailed suggestions for nursing in hospitals. Training as per these guidelines for nurses began in Nightingale School of Nurses at St. Thomas’ Hospital England. By 1867, St. Stephan’s Hospital in Delhi started training nurses in India.
• In 1871, The Government General Hospital of Madras initiated a 6-month diploma course for midwifery.
• In 1893 Mrs. Lystra E. Gretter joined forces with a committee for Farrand Training School for Nurses in Detroit, Michigan and created the “Nightingale Pledge”. It is a modified version of the “Hippocratic Oath” for doctors, in honour of Florence Nightingale, the founder of modern nursing.

the florence nightingale pledge 

Up until 1970, this pledge was recited all cross graduation ceremonies in North America. Recently though the pledge has been greatly modified or even dropped in some cases due to its lines about loyalty to physicians.

The prevailing opinion is that any loyalty should be to the patient and their care even in the face of opposition from the Physicians.

nursing in india in the 20th century – a brief snapshot of the milestones

1905 – Association of Nursing Superintendents founded at Lucknow.

1908 – Trained Nurses Association of India (TNAI) was established. Their purpose was to uphold the dignity of the profession of nursing and nurturing the professional, economic, educational and general welfare of all nurses.

1910 – The Nursing Journal of India published.

1917 – Trained Nurses Association of India was registered under the Societies Registration Act XXI of 1860.

1918 – English nurses Griffith and Graham oversaw the nurses and their training in new training schools at Delhi and Karachi..

1925 – Trained Nurses’ Association of India becomes the amalgamation of Association of Nursing Superintendents and Association of Trained Nurses.

1926 – State Nursing Councils formed in Madras providing standards and guidelines for the education and training of nurses.

1929 – Student Nurses Association established.

1931-1931 – Rockefeller Foundation set up seven health centres in Delhi, Madras, Bangalore, Lucknow, Trivandrum, Calcutta and Pune.

1946 – 4 year Bachelor program for nursing was established in Vellore Christian Medical College and Hospital (CMCH) and in Delhi.

1947 – Indian Nursing Council was established on December 31st. The Act was to “establish a uniform standard of training for nurses, midwives and health visitors”. Hospital services were officially expanded to include auxiliary nurses, midwives and administrators, tutors and supervisors for nursing.

1956 – Nursing adviser to Government of India was appointed.

1960 – Two-year Post Graduate programme for nursing was established in Rajkumari Amrit Kaur College of Nursing, Delhi.

1963 – Two-year post certificate bachelor’s degree for nursing launched at The School of Nursing in Trivandrum.

1974 – TNAI becomes member of Commonwealth Nurses Federation (CNF)

nursing in india – a bird’s eye view of the current situation

The World Health Organization estimates that the nursing workforce in India is insufficient to meet the growing demand. The FICCI-EY report of 2016 estimates that 2.4 million more nurses would be required to adequately cover tertiary and quaternary care. As of now studies indicate that only 1.7 nurses are available for every thousand patients. This puts India in the 75th position of 133 developing countries with regards to nursing care.

the demand and supply gap can be summarized succinctly by the following diagram.

Although the number of institutions providing courses for nursing has increased since early 2000’s their spread does not correspond uniformly to population density.

The zone wise distribution of registered institutions where aspirants can pursue an education for nursing is as follows:

This further challenges nursing aspirants as lack of resources, language barriers employment opportunities etc. may stand in their way of working towards a career in nursing.

challenges faced by the nursing community in india

Some of the key challenges faced by the nursing community include

1. Quality Education – The Indian Nursing Council (INC) records of 2016 indicate that 59% of educational institutions geared towards nursing are providing Auxiliary Nurse Midwife (ANM) and General Nursing & Midwifery (GNM) courses while 21% are teaching BSc Nursing.
2. Exposure to medical technology – Nurses in urban areas and private healthcare facilities have a greater chance of exposure to new and emerging medical technologies. Their skills get honed faster. Whereas the same is not true of nurse practitioners in rural or non-funded facilities. So there is no equanimity when it comes to technical knowledge and thereby professional growth.
3. Competitive compensation – There is a wide disparity in compensation when it comes to nurses based on where they are employed. Furthermore, their remuneration does not compensate them for their investment in a nursing education. Nurses in India get paid Rs.3000 – Rs.4000 a month, which is much lower than the already low labour standard of Rs.6000. The most experienced of nurses may make around Rs.8000 but their working hours are usually around 10-11 hours a day. To top it all off they are not provided employment benefits like gratuity or ironically health coverage despite the fact that they serve in high-risk infection prone environments.
4. Professional advancement – The lack of established career growth plans prevents nurses from thinking about higher education in nursing. Although research studies can provide a path to recognition, the INC does not have any Phd. or M.Phil courses in nursing. Furthermore, as the need for specialized care in nursing is rising, there are no proper resources for continuous nursing education to facilitate this.
5. Public perception on nursing in India – Nurses represent the largest share of the healthcare providers in India that totals to almost 38%. But due to various socio-economic and cultural factors, the nursing profession is not held in the highest regard, despite the community’s positive contributions to society.

instigating reform and re-direction in the field of nursing

For the nursing division of the healthcare sector to take it’s proper place in the medical field short-term and long term strategies would be required to address the challenges that the nursing community faces today. The FCCI summarizes 30 recommendations that will pull up the field of nursing as follows:

• In Nursing education – Competency based learning, integrating nursing with medical colleges, improving the faculty in nursing education and licensing for skilled nurses are some ideas
• In Nursing service – Ensuring competitive compensation, partnerships between nursing colleges and health facilities, standardization of nursing protocols, following the National Accreditation Board for Hospitals & Healthcare Providers (NABH) standards in teaching hospitals and strengthening health programs where in nurses can provide basic healthcare and make referrals.
• In nursing administration – Make room for empowered decision making roles for nurses, streamlined performance review metrics and a rewarding career plan
• In research – Special consideration should be made for research in the field to be a shared pool of knowledge geared towards better patient care.

nurses – the backbone of the healthcare industry

Dr. K Aggarwal, the Secretary general of the Indian Medical Association (IMA) acknowledges that a shortage of nurses will have a disastrous impact in the long-term. It will make it extremely challenging to get good healthcare in the future if the interest in nursing sector keeps dropping.

The IMA recommends the following actions to raise the profile of the nursing sector in the healthcare industry –

• Elimination of gender biases
• Uniform pay scales
• Better education and training
• Practical training so nurses can provide basic healthcare

The Union Ministry on September 20, 2016 has tasked the Chief Secretaries of all States and Union territories to formulate a legislation that will address issues of wage, work hours and medical facilities.

With the involvement of the government, the nursing community is sure to get the reverence due to their profession and service.

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