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Status of nurses in India: Current situation analysis and strategies to improve

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DOI: 10.4103/JME.JME_164_20

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Nurses’ Section

Status of Nurses in India: Current Situation Analysis and

Strategies to Improve
Suresh K. Sharma*, Kalpana Thakur, Pastin Pushpa Rani Peter
College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Introduction nurses (RN) in other countries shared that their hard work and
diligence never get recognised and rewarded in India. Fear of
The term status is slippery and difficult to define; however
unknown while moving to foreign country is always there and
in this paper, “status” has been referred to an element of
it is not an easy task to leave family and everything behind,
professional “honor” or recognition of nurses in society. The but the prejudice attitude of health‑care professionals and
status of the nursing discipline is still viewed as lower‑level general public towards nurses ignite migration. India is facing
subordinate, dirty and menial jobs in this country. It could dearth of nurses and their positions are filled by incompetent
be because of their projection as submissive females in or untrained personnel, which causes negative portrayal of the
subordination with physicians assisting them in caring and professional image as well as compromised quality care for
curing the patients without any autonomy. Although nurses patients.[5] Draft to implement new initiatives and policies have
are obtaining undergraduate and or postgraduate professional been formulated many a times, but till now, no visible change
degrees to practice as a nurse in the country unfortunately, occurred in managing escalating issues of nurses’ struggle for
they are still socially socially viewed as servants in health‑care their dignity and pride. This article is written with an intention
delivery system. Nurses are continuously striving to achieve a to bring cognizance on challenges and issues faced by a
higher status in this patricentric society, but still long journey 21st‑century nurse for getting the desired professional status in
is waiting a head to achieve honor and respect, which they India. Authors also dispensed strategies that could be beneficial
deserve. Lack of social status, recognition, low pay, poor in restructuring and upliftment of nursing as a respectable job.
working conditions, lack of autonomy in practice, lack of
recognition as a member of health‑care team and exploitation
has significantly contributed towards brain drain of nurses
Current Status of Nurses in India
to the Western world. Nurses’ shortage has been reported In a country where doctors are considered next to God but on
by the WHO worldwide and the latest Indian trends suggest the contrary, nurses who work hard day and night in a close
shortage of more than two million nurses that give a nurse: proximity of sick handling all ups and down are just taken for
Population ratio of 1.7:1000, which is 43% <recommended granted. The history of formal training in nursing discipline had
03/1000 population.[1,2] In the recent past, a rapid surge has begun in 1867 and Indian nurses at that time faced discrimination
been recorded in the number of nursing training institutions to a great extent from British nurses as they were excluded
from leadership and managerial roles. With no exaggeration,
in India, with approximately 1958 nursing institutes and
the situation of nurses in India has not changed so far; the only
98,749 sanctioned seats for annual admissions in basic nursing
difference which we see now is nurses receive discrimination
programmes presently,[3] but still we lack nurses and the most
and humiliation from their own people and medical colleagues
probable reason could be the migration of nurses to western
and clients. Research findings have clearly recommended that all
countries, as around 33,147 Indian nurses were working
overseas in the year 2016.[4] It has been noted by many into
the profession that Indian nurses work more enthusiastically
Address for correspondence: Prof. Suresh K. Sharma,
in other countries as compared to their native land and College of Nursing, All India Institute of Medical Sciences,
that is surprising. Nurses settled and working as registered Rishikesh ‑ 249 203, Uttarakhand, India.
E‑mail: skaiims17@gmail.com

Received: 20‑09‑2020 Revised: 21‑09‑2020 Accepted: 25‑09‑2020 Available Online: 16-12-2020

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DOI: How to cite this article: Sharma SK, Thakur K, Peter PP. Status of nurses
10.4103/JME.JME_164_20 in India: Current situation analysis and strategies to improve. J Med Evid
2020;1:147-52.

© 2020 Journal of Medical Evidence | Published by Wolters Kluwer - Medknow 147

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Sharma, et al.: Status of nurses in India

Continuously Downfall in the Routine Patient Care: Involved in hygienic or basic care procedures
Status of Nurses in Indian
Investigation: Assisting patient and physician during X-ray, ECG
and other investigations
Diagnosis: Only provide need based care on hygiene, nutrition and
elimination as instructed by physician
Treatment: Follow physicians order and "NO RIGHTS " for
prescription and treatment
Referral: Assist in preparing client for referral and documentation
Discharge: Act as liaison between patient and doctor without much
active role in discharge of patient
Speciality Clinics: No autonomy in running independent nurse-led
speciality clinics

Routine Patient Care: Collect detailed history and perform

thorough physical examination along with assisting and providing
care for clients' priority needs
Investigation: Order, perform and interpret diagnostic tests like X-
ray, ECG etc.
Diagnosis: Diagnose patient with acute and chronic illness and also
make nursing diagnosis to plan evidence based care
Treatment: Treat patient with acute and chronic illness
independently as a nurses practiotioner
Referral: Refer client for advanced treatment and services
Discharge: Take decision for patients’ discharge and manage
follow-up visits
Speciality Clinics: Run independent nurse-led and adjuvent
Continuously Escalating Status of
speciality clinic for both acute and chronic clinical conditions
Nurses in Western World

Figure 1: Reflection of nurses in India versus western world

patients must be taken care by registered and qualified nurse as it been done to solve these issues related to workplace safety for
minimizes the chances of adverse events and medications error.[6] nurses working in shift duties by both government and private
Unfortunately, there are many functional nursing homes and sector even after a brutal rape of a nurse ‘Aruna Shanbaug’
private health‑care units where unqualified people are working by hospital ward boy in 1973. Little disappointing, but it is
as a nurse, and this puts patients in grave danger. true that even after >40 years of this incident, scenario has not
changed and every now and then, nurses are at the verge of
Modernisation has contributed nothing into nursing as
violence by patients, attendants or relatives and co‑workers.
it is not uncommon to get doctors who think that taking
The nursing profession is a well‑recognised and respected
temperature, blood pressure and assisting in feeding, bathing
discipline in the Western world, where nurses are considered
along with other activities of daily living are the only few
equivalent to doctors and other health care professionals in
things which a nurse can do efficiently and this perception
health‑care team, and thus, they have significantly contributed
promotes the number of quacks who falsely represent nursing.
in ensuring quality healthcare, however the situation is not the
Supreme Court’s order had directed private hospitals in
same in our country [Figure 1].
country regarding minimum pay of Rs. 20,000/‑to a nurse
working in <50 bedded health‑care facility and working Exceptional job done by nurses during this COVID‑19
conditions should be near to nurses working in government pandemic is highly appreciated by many be it the general
hospitals.[7] Moreover, no noticeable changes came after this public, physicians or hospitals’ management and government.
order because the implementation of such order in a country However in our opinion, it is all temporary because if we look
where nurses’ worth are not considered more than a laborer for working hours and facilities during quarantine, nurses
or servant is onerous. Still, nurses are working on salary scale again faced discrimination and better facilities were given
of Rs. 2000‑10,000/‑per month[5] and this is not the scenario to doctors.[8] Nurses in India do not have voice and most of
in small health‑care setup, but big corporate hospitals who them are not assertive and lack confidence when it comes to
are making huge profits also pay very less to nurses although talk about their rights as a RN and the one possible reason
they are willing to pay handsome salaries to physicians; it which we come across more often is that they feel ashamed to
is considered that physicians treat patients which adds on be called as a ‘Nurse.’ There are many nursing professionals
to hospital income, but everyone shut their eyes to nurses who have opted nursing as a secondary choice after failure
who care 24 h day and night for patients from admission till to reserve seat in the medical entrance and that is why have
discharge. Majority of the nurses working in India are females minimum acceptance for nursing and top of that stagnant
and their safety is an another area of concern and not much has carrier instead of higher qualifications make nurses unwilling

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Sharma, et al.: Status of nurses in India

Table 1: Barriers and challenges faced by nurses in India

Organizational or institutional level
Low pay, poor working conditions and long working hours
Lack of defined cadre structure and career progression for nurses with different qualification and experience
Nurses are posted in wards as per shortage not according to their area of interest or speciality training
Minimum or no representation of nurses in policy and decision-making at institutional, state and national level
No practice law or positions for independent nurse practitioners or clinical nurse specialists.
No retention policies and protocols for nurses to prevent brain drain
Unequal opportunities for continuing education and training
Gender discrimination in enrollment and recruitment of male nurses
Stagnant carrier with no promotional opportunities for nurses at all levels
Rewards and appreciation are never given or considered for nurses
Nursing manpower is utilised in basic care rather than patient treatment
Involvement of nurses in non-nursing roles like duties at reception and excessive documentation
Violence by patients, visitors and co-workers at workplace
More efforts are given on nurses’ grooming rather than skills
Unavailability of basic facilities such as water, food, canteen, parking and washroom at working place
No facilities for campus or residential accommodation
Physician dominated health-care system, where nurses’ potentials are under-recognised and underutilised
Unchecked productions of incompetent nursing manpower due to rapid mushrooming of private nursing institutes
Individual level
Poor self-concept and self-image as a nurse or about nursing profession
Ignorant attitude of nurses towards proactive role of nurses in patient care and treatment
Nurses are always in dilemma out their roles and responsibilities
Majority of nurses choose nursing about of compulsion and in hope of job security at abroad or govt. hospital
Poor knowledge, skills and competence to match with development in medicine discipline in India
No programmes for career guidance and enhancement in nursing discipline
Lack of dynamic or influential leaders who can be a great role model
Lack of motivation, assertiveness, collective bargaining and lobbying among nurses
Media and societal level
People in the country do not consider nursing as a professional and respectable job
Male dominated society considering nursing as feminine and thus menial
Derogatory remarks and labeling of nurse as ‘aayaa’
Unawareness in society regarding diverse and advanced role of nurses
Vicious cycle- poor social image and recognition fails to attract best talent, which leads to poor development of profession and thereby lack of
recognition and status
Media portraying nurses as sensual females in submissive, subservient roles with low intellect
Nurses are never interviewed and given media coverage for their opinion on health policies or reforms

to do much for their professional growth. Nurses who are females. Most of the countries, including India, are already
working on a reputed position even do not want their children facing serious shortage of nurses and this phenomenon may
or relatives to be a nurse as this is still not accepted as a reputed further expand the gap in demand and supply of this category
profession such as doctors and engineers. Moreover, very few of workforce and tomorrow world may not find the sufficient
higher secondary school students are aware and interested to number of motivated, capable and competent nurses for the
join nursing because this discipline lack in popularity and smooth running of their hospitals. Nursing profession in our
social recognition.[9] Although nursing is a profession based country lacks dynamic leaders and there are very few unsung
on scientific knowledge and skills, it is still overpowered as a leaders who are meticulously putting efforts to represent
nurturing and caring job for which only women are considered ignored issues and problems of nurses. There are numerous
best. These stereotypes are deep‑rooted and cause hindrance factors which are contributing to poor status of nurses in our
in professional growth. Reputed institutes in the country like country as illustrated in Table 1.[10-12]
PGIMER and AIIMS do not enroll male students into B.Sc.,
nursing programme and recent amendment of 80:20 between Strategies to Improve Status of Nurses in India
females and males nurses for AIIMS recruitment in 2019 has Appropriate status or professional recognition for nurse is not a
become a matter of debate in every other nursing conference one‑man job and that is why it requires efforts on all levels with
or meeting, but no one listens and this also give rise to the planning and implementation of short and long‑term goals.
myth that nursing is a profession that belongs to submissive With the advancement in the number of nursing institutes and

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Sharma, et al.: Status of nurses in India

Table 2: Strategies to improve nurses’ status in India

Organizational and policy level
Uniform cadre structure, high pay, defined carrier path, career progression, state of art working conditions, flexible working hours and safety measures
for nurses in government as well as private health-care facilities
Government must spend on developing few centers of excellence in nursing education and research on lines of developed countries to produce best nurse
clinicians, nurse educators, nurse administrators and nurse researchers
Adequate representation of nurses in policy, and decision-making at institute, state and national level
Equal opportunities for nurses for top leadership roles in ministry, directorates and institutions
Government must immediately implement national nursing and midwifery commission with strong provision of nursing practice laws
Private sector must pay nurses at least in highly skilled category as per updated labour laws of the country for minimum wages
Implementation of competency based curriculum and production of specialised nurses
Mandatory training for nursing faculty to make them competent to train nurse practitioners and clinical nurse specialists
Strengthening nursing directorates and nursing councils at central and state level and revision of nursing council acts to incorporate nursing practice laws
to regulate not only nursing education but also nursing practice
Major revision required in issuing licensing for registered nurses and midwives by implementing exit/licensing examination like NCLEX-RN and skill
assessment
Indian Nursing Council to maintain updated online register of nurses working in the country
Strict monitoring the quality of nursing education and nursing practices by regularities bodies
Permission and approval for nurse-led clinics run by nurse practitioners or clinical nurse specialists
Strict adherence with prescribed norms of working hours and day offs for nurses
Qualified and experienced nurses need to be considered for higher managerial positions
Need to create jobs and designation for specialised nurses
Nurses with training in specific speciality should be posted in their specialty clinical areas
Equal opportunities for males to enter and advance into nursing profession
Encourage nurses for clinical research and good clinical practices
Rewards, awards and appreciation for high achievers in nursing profession
Defined job specification and job delegation for different category of personnel like delegation of hygienic care role to nursing orderly rather than a
registered nurse
Every organisation should have written policies to prevent and report workplace violence
Bridging programme, online continuing nursing education for nurses to update their knowledge and skills
Team working culture of health-care professions rather than hierarchical model
Individual level
Developing professionalism and practicing code of ethics
Taking up specialised nursing education and practices as independent nurse practitioner and clinical nurse specialist
Taking up nurse entrepreneur roles to create wealth and social recognition
Nurse leaders should encourage youth in the family or relatives to consider nursing as a carrier choice
Practicing an art of assertiveness at workplace
Enthusiastic participation of nurses in adapting new roles and responsibilities for advance care
More focused in learning clinical competency and skill in managing patients
Clear aim and goals for the development of nursing profession
More interest should be given to evidence-based treatment and care
Nurses should idealise their role model in the field
Need to update their knowledge and skills regularly to provide quality care
Nurses also need to move towards politics and lobbying for nurses nominated as Rajya Sabha member
Media and societal level
Media needs to be little sensitive and responsible while projecting nurses in any role
Primetime show of most successful nurses in the country as nurse professional or nurse entrepreneur
Nurses working in frontline or putting their life in danger need to be recognised by media
People should refrain themselves from providing derogatory remarks and labelling nurses
Counselling and awareness programme for students to increase awareness about nursing profession

availability of seats, infrastructure facilities and skill training in the existing system, whether it is curriculum, licensing for
have been compromised to a great extent that raised serious RNs, or cadre structure for nurses. Nurse practitioner course
concern on quality in nursing education and sanctity nursing has been started in few of the institutes, but neither there is any
degrees. Nursing training and education must be sound and law to protect their practices nor separate job or cadre available
should be entirely outcome‑oriented based on desired clinical for their deployment, which ultimately will add on to nurses’
competencies. Nursing regulatory bodies and the health disappointment. License issuing system for become a RN in
ministry of India need to take the lead for bringing change India is an another major area of concern because in the current

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Sharma, et al.: Status of nurses in India

scenario it is given to everyone who so ever passes nursing professional development by doing evidence‑based research,
diploma or degree from the Indian Nursing Council recognised developing new theories or modifying existing theories
institutes, which again enhance the number of incompetent and putting emphasis on required changes at both public
and unskilled nurses. Licensing system should be improvised and policy level. All areas of nursing, including education,
with the provision of stagnant exit or licensing examination training, administration, and research, require changes and
like America’s National Council Licensure Examination for reforms to incorporate best standards of practice. Sense of
RNs exam and standardized skill assessment before nurses are self‑accomplishment or confidence comes with up‑to‑date
considered eligible for getting their license to practice as RN knowledge, competency, well‑formulated policies, and laws
or advanced nurse practitioner. Negative attitude of medical for practice; only then desired status can be achieved as
colleagues and fear of wrath by them should not stop nurse well [Table 2].[13-16]
leaders to raise their voice. Provision of inter‑disciplinary
education is the best approach to create awareness among Conclusion
the medical fraternity about scope of nursing practice, a Nurses are the head honchos and lifeline of health‑care
team working culture so that they can work collaboratively, organisations but still lack recognition. Concern on this
contributing much more in quality care and overall professional has been expressed by many, but till date, no strong
growth. Solving an alarming issue of gender discrimination is recommendations and visible implementation of laws and
a prerequisite for professional advancement because people policies are seen. Nurses need to take leadership and proceed
working in a profession should be a clear representation of all to participate more at higher levels to bring a change in the
sections of society and diversity in the professional discipline existing scenario. Adaptation of nurses as a nurse practitioner
and this will also have its impact on quality care and health would not be easy, but it will definitely bring the pride and
outcomes. It would not be wrong to mention that somehow honor which every nurse desire for. Collaborative working
status comes with money and nurses who are being paid well model of nurses and doctors with mutual respect would reflect
for their work will be more satisfied and have better social positively on the health outcomes of the country.
recognition. Therefore, strict amendments and provisions on
minimum wages need to be established and practiced by all Financial support and sponsorship
health‑care organisations. Resolving all these issues with the Nil.
different but unique approaches are important to promote status Conflicts of interest
and establish recognition of nurses in the country. There are no conflicts of interest.
Nurses need to work on broader horizon and should try to
become an entrepreneur so that they can work in different References
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