Building nurse education capacity in India: insights from a faculty development programme in Andhra Pradesh

India is undergoing a period of unprecedented social and economic change. Amongst its 1.2 billion population, economic growth has led to a rapidly expanding urban middle class. At the same time, a large proportion of the country’s population still reside in rural areas in conditions of economic hardship, low literacy and poor health. Increasing migration to the cities for work has created large urban slums lacking in basic amenities. This demographic situation means that the country faces the dual challenge of tackling diseases of poverty alongside an increasing incidence of chronic diseases more traditionally associated with westernised affluent lifestyles. The Indian health system is pluralistic, comprising public, private and voluntary sector facilities, of which the private sector is by far the largest provider. Since 2005, there has been enormous government investment into modernising and expanding India’s public healthcare system through the setting up of a new initiative - the “National Rural Healthcare Mission” [2]. Health system reform is constrained however by an acute shortage of health workers at every level [3]. In addition, poor health system governance (i.e. inadequate systems to monitor and regulate training institutions, professional practice and clinical standards within different settings) has been identified as a critical factor impeding efforts to improve quality and accountability, in both private and public sectors [1].

India faces an acute shortage of nursing staff with an estimated deficit of 2 million [4]. In the public sector alone, an additional 140,000 staff nurses are required [5]. The nurse-population ratio is 1:2,500 compared with ratios of 1:150 to 1:200 in higher income nations [6]. The nurse-doctor ratio is also poor – at 0.5 nurses per doctor compared with 3 or 5 per doctor in the USA and UK respectively [1, 6].

The development of nursing in India reflects the country’s history and complex socio-cultural composition. Traditionally, amongst Hindu and Muslim communities, the need for female nurses to work outside of the home (including at night), to touch strangers, to mix with men, and to deal with bodily fluids (considered polluting within Hindu and Muslim cosmology) has meant that until relatively recently, nursing was a stigmatised and low status profession [7]. During colonial times, British missionaries attempted to redefine and professionalise nursing as a respectable vocational career [8]. British mission hospitals established nursing schools and recruited poor women or widows from predominantly Christian communities, many from the southern Indian state of Kerala [9]. Kerala remains a major supplier of Indian nurses, although this is changing due to a shift in the desirability of nursing as a career that has come about because of increased opportunities for migration to the Middle East and further afield [10]. As in many other countries, nursing is now seen as a potentially lucrative career choice, a stepping stone to work overseas and towards greater social mobility for the entire family [11, 12]. This has led to an influx of men into the profession and to a positive change in the social status of nurses [13]. Nonetheless, in India and throughout South Asia, the desire to avoid the stigma associated with basic nursing tasks forms a strong cultural backdrop to the way in which clinical nursing is valued and practised today [7, 14‐16].

Research evidence on nurses’ working conditions and job satisfaction in India is limited. However, reports indicate that nursing lacks clear career pathways and mechanisms for promotion; in-service training is rare (except in the best corporate hospitals); pay is low (especially in small private hospitals); and working conditions are often inadequate, lacking sufficient staff, equipment and infra-structure [17‐19]. One study in New Delhi, found that nurse:patient ratios of 1:50 were the norm [13]. In the same study (which was based on over 150 interviews) nurses reported spending much of their time doing administrative, menial or unskilled work [7, 13]. In a study of female health workers in Kolkata, more than 50% of respondents admitted experiencing sexual harassment at work [20]. Nurses in private hospitals in New Delhi recently staged a strike in protest of low pay and exploitative working conditions [19].

The nursing profession lacks strong strategic representation at key decision making forums at both State and National levels [18, 21]. Nursing is governed through the national Indian Nursing Council (INC) and State level Nursing Councils (SNCs) [17] The INC advises the government on nursing matters, prescribes national nursing education syllabi and specifies minimum quality criteria for educational institutions. State Nursing Councils inspect and accredit training institutions, conduct examinations, monitor rules of professional conduct and maintain an active register. However, the legal authority of the INC is weak [17]. For example, a recent survey concluded that 61% of all nurse training institutions do not meet INC standards, but it is unable to take action as the institutions have nonetheless been accredited by the SNCs [3]. Nursing is also represented by a number of state and city based organisations, including the national Trained Nurses Association of India (TNAI). Greater nursing participation in health workforce policy making has been urgently recommended [1]. The INC is currently not a member of the International Council of Nursing.

There are 2 main routes into nurse training in India. The majority of nurses undergo a 3 year diploma training in Schools of Nursing to become a General Nurse Midwife (GNM). A minority undertake a 4 year training in a College of Nursing (affiliated to a University) to obtain a BSc degree, referred to as BSN. Apart from the pre-registration programmes described above, University Colleges of Nursing also offer post-registration BSc courses and MSc courses. A national consortium of 5 universities came together in 2005 to start a collaborative nursing PhD programme [22].

In most public sector healthcare facilities, staff nurses are recruited from the GNM cadre (diploma-holders) only. Studies suggest that BSc graduates tend to seek clinical work in the private sector but often view this as a short- term strategy to gain requisite experience to enable overseas migration [13]. Post-registration BSc and MSc graduates are reported to move predominantly into educational positions in the public and private sectors [6]. Thus, as in many countries where clinical nursing carries a low status, academic qualifications are valued as a potential route out of clinical practice into higher status and better paid jobs in education [15].

Due to increasing demand for nurses nationally and internationally, India has witnessed a dramatic proliferation of nursing education institutions in recent years, although there is still an overall shortage. Over 88% of nurse education is now delivered in the private sector. There is also a geographical imbalance in nursing education, with most graduate and postgraduate education being delivered in the South. For example, the highly populous but poorer States in the North (e.g. Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh) account for only 9% of nursing schools in the country [1].

Several reports have highlighted significant problems in nursing education, emphasising that quality must not be sacrificed in the country’s current drive to scale up nurse training provision. Key issues are summarized below [1, 3, 6, 10, 18, 21]:

Amidst the challenges, it is important to point out that there are, of course, also many Centres of Excellence in nursing education in India, but there is limited published material documenting their successes, systems and processes.

One commonly recommended strategy to improve nursing education is to recruit more faculty and to support existing faculty to develop their educational provision and practices [21]. Below, we report on one such initiative from the State of Andhra Pradesh.

Andhra Pradesh is a large state on the south-east coast of India with a population of almost 76 million. The main language is Telugu. The capital city is Hyderabad. In the period between 2004–2008, the State Government approached an international non-governmental organisation (with a history of innovation in nursing education in South/Central Asia and east Africa) to assist nursing education. Following a number of needs assessments, a Nursing Faculty Development Programme (NFDP) was initiated in 2008 for faculty from 4 public and 2 autonomous nursing education institutions in Andhra Pradesh. The primary objective of the NFDP was to strengthen the capability and capacity of nursing faculty within the State. A Government College of Nursing in Hyderabad (GCNH) was selected to act as a nodal agency for the NFDP. The School of Nursing, Midwifery and Physiotherapy (SNMP), University of Nottingham (UK) won a tender to act as an international partner to the NFDP. The original plan was for the SNMP to work with the GCNH to provide some faculty development courses along a ‘training of trainers’ (ToT) model, so that subsequent faculty development programmes in the State would be delivered through the GCNH.

A review of previous literature on international partnerships indicated that the NFDP would need to adopt a collaborative approach in order to ensure that the inputs addressed common goals, aligned with local issues and were relevant to the national and local context [23‐26]. The NFDP was based on a philosophy of mutual respect and adult learning [27]. A participatory approach was adopted for the entire curriculum development process so that each input ended with a formative evaluation and a collaborative planning process to shape the next input [28].

Formative participatory evaluations were conducted by the SNMP at the end of each module and at the end of the programme. Participants filled in a brief module evaluation questionnaire and group discussions were held to explore participants’ and facilitators’ views of the module/programme delivery, impact on education and practice and prospects for longer term change. Key issues that emerged from the evaluations are reported below.

The NFDP has brought welcome resources and attention to nursing education in the state of Andhra Pradesh. Amongst faculty, it has achieved an awareness of new educational approaches and enthusiasm for on-going professional development. There have been some innovations made to day to day teaching practice. More significant changes have not been tackled however. The originally conceived ToT model of nursing faculty development seems doubtful as the future trainers have not yet themselves had the opportunities to put new approaches to nursing education into practice, thereby limiting the existing programme to the development of greater theoretical rather than experiential expertise. The deeper, structural problems affecting nurse education quality remain relatively unresolved.

Based on the valuable experience of the NFDP, we conclude this paper with some suggestions for future nursing faculty development initiatives in the Indian context.

First, whilst it is beyond the scope of a faculty development initiative to address national or state level policy, it is clear that educational initiatives alone will have a limited impact in the absence of work to review the nursing curriculum and regulation of nurse training institutions. Our experience shows that the current nursing curriculum is in need of review in order to better equip nurses to manage (and try to improve) the conditions of practice that they encounter, and to provide faculty with the autonomy and motivation to innovate.

Second, enlisting an international partner to support nursing faculty development undoubtedly provides a different perspective on nursing education and a different skill set that can be extremely valuable. Nonetheless, we would suggest that an Indian partner (drawn from recognised Centres of Excellence) should also be included as a key partner in the training team to build up local expertise, to enhance the prospects for longer term sustainability and to ground the module/programme content in the realities of the local context.

Third, it is well recognised in the literature that faculty development works best when faculty are supported in the long term by a system of mentorship to enhance personal development [33, 34]. Likewise, mentorship can also be valuable at an institutional level whereby one Nursing School/College recognised for excellence provides on-going support to another [32, 35, 36]. We suggest that future faculty development initiatives include both forms of mentorship. This could, for example, consist of periodic visits from an international partner, coupled with more regular and intensive support from an Indian Centre of Excellence.

Finally, within the existing (relatively limited) literature on nursing education in India, there is a noticeable paucity of research on the student experience and on the views or practices of clinical staff in terms of their educational role. In order to base future faculty development initiatives on locally-relevant evidence, additional research on nursing education (particularly clinical learning) is required.