Jibin T C

The Indian government is ready to revamp the nursing and midwifery rules with launching the proposed National Nursing and Midwifery Commission Bill 2020. Nursing leaders have multiple views about the content of the draft NNMC Bill 2020. Jibin TC, State President UNA, is answering the questions from the letter he sent to the ministry of health.

Q. Based on your letter to the Health Ministry, UNA stated the prevalent similarities between the National Nursing and Midwifery Commission and National Medical Commission. Would you please explain the same?

A. At a glance, if I look at the National Nursing and Midwifery Commission and National Medical Commission Bill, the constitution of the commission remains almost the same, except for a few things. All the committee members or the people sitting in the national medical commission will now be nominated by the central government. There are no democratic ways of electing members or no election process has been held in the national medical commission. In a similar manner, the government has drafted the bill for the National Nursing and Midwifery Commission and one thing that they have still retained is the state medical commission. However, in the case of the National Nursing and Midwifery Commission, even the state nursing council will be dissolved and instead of state nursing council, there will be a state nursing and midwifery commission.

So, this is the only difference which the draft bill has made in the National Nursing and Midwifery Commission. Apart from this, almost everything is the same and in the nursing commission, they have included the doctors also. Here I mean the representatives from the NMC and representation from the ICMR.

In medical commissions, only medical doctors and the health secretory will be present as committee members. So, this is the main difference we can find out when you consider both the bills. The medical commission was just introduced a year ago and after a year, they are trying to impose another one which is the nursing commission. So, we see that both the bills are similar.

Q. It seems that the medical commission and nursing commission are similar. This means that nursing professionals will be empowered more. What are your thoughts on this?

A. Ok see as I said, there are only a few questions like medical commission, especially the constitutions of medical commission and in the constitution they have only nominated members as in the commission. In the similar manner, they have made this system for the Nursing Commission also. This does not mean that the profession will have a better future. It never said that when you really go deep into the workings of the Commission, you will understand the deficiencies currently there and how it will be helpful for the general public and nursing fraternity at large.

When we come up with any kind of commission, especially medical and nursing commissions, it should be beneficial for the public. Because we are making it for the use of public above everything else. So, here when I read this nursing commission regulation, I can really tell you that this is not beneficial for anybody except the government and private lobby. So, I don’t see this commission doing anything to increase the standard of nursing in India and neither is it going to decrease the nursing standards in the country. It remains in the middle; this is all that I can tell you.

Q. You said in your letter that it should be a vision document having rights for nurses with legal empowerment and recognition. What do you want to indicate here?

A. OK, rights for the nurses means a lot of things. I said earlier that all the positions have been nominated by the central government and that also the nurses working with central government institutions will be nominated which means they are already working under the government of India. Hence, Government will have complete control over these nurses and they will have nomination to the Commission as well. Suppose if they wished to expressed any issues of nurses, then they will be unable to do this since they are already under the Ministry of Health and Family Welfare with a duty to follow Government regulations. They will thus not have any voice for expressing themselves since they will actually have zero power.

Another thing that I can say is that if the Government will allow us to become elected members so elections from the nursing fraternity itself can be held. There are several nurses, good leaders in India and they will then be part of the Commission. They can raise their voices for patient and nurse rights so this will make a huge difference. And of course, the bill also mentioned that you cannot legally fight against the Government. This goes against fundamental rights of India and none of the Governments can come up with regulations like this. If the Government takes wrong steps, then we will certainly have to fight against the same. We have seen numerous cases against the Government going to even the Supreme Court so this is something important. Nurses should be given the opportunity based on their merit and quality and not on the basis of Government recommendations. There should be a nominated member but this should be done in an equal manner. Suppose if the Government wishes to nominate 5 members and the rest of the 5 members can then be elected accordingly. The nursing fraternity should decide upon who should rule them and not the Government.

Q. As per your letter, Nursing Associate, Midwife Associate and Nursing Care Assistants should have a separate organization such as paramedic council, would you please explain this point in detail?

A. First of all, my simple question to the Government is that why do you wish to add this into our profession? Why do you want to use nurses or midwives along with other people who are not trained? Nurses and midwives have their own syllabus and after their completion, they should get a license from the State Nursing Council and if you do not have a license, you cannot practice. However, these associates will be people who have cleared maybe the 10th standard or so and they will be going for training after 3-6 months. They will then be called nursing associates or midwifery associates and these people will be working in the hospital or clinical setup where they will be directly handling patients also. So patient care is also being hugely compromised and patient safety will be a matter of concern as well.

You cannot identify, as a patient, who is an associate and who is a trained nurse, when you visit the hospital. Ideally, for the public, everybody is a healthcare provider and private hospitals will exploit this perception greatly. They will replace qualified nurses and midwives with nursing and midwifery associates at lower packages which will earn them some profit in the bargain. This is now being unfortunately promoted by the Government and they wish to have more manpower in the private arena as well. However, Government will not appoint such people in its own public hospitals since registered nurses are needed there. But there will be no such criteria in private hospitals and they will definitely make use of this fact so this will never be acceptable to the nursing fraternity. This should always be excluded from the Commission and you can take them in other names, i.e. the associates, or in different departments. We will not mind that but you can consider creating a paramedical board or another board under which you can start these courses but the names of midwifery and nursing should not come under the same. It should be completely under our Council or Commission.

Q. If we see things in another way, physicians may have physician assistants, mainly when we compare with western countries; let’s take an example of RN, LPN, they have different categories of licenses, even some advance licenses are also there for nurses in America. Separation of profiles are there in other countries, do you think if government bring separate licenses, it will similarly solve your concerns about the engagement of associates by private hospitals?

A. This is a good thought but the problem lies in some basic aspects which the Government in India is supposed to take care of, i.e. regulation of private hospitals. You need to take them under a law which states exactly what a nurse should do or not do like in other countries they already have LPN and registered nurses. They have nursing practitioners, anesthetic nurses and so on. The country has definitely made a nursing practice act there which clearly lists all roles, job profiles and responsibilities likewise, described clearly under specific designations. In India, it is not described properly what the job of a nurse is supposed to be. This is the reason why every hospital is exploiting nurses, making them do all kinds of jobs in the bargain. Nurses working in private hospitals do both nursing and non-nursing jobs with the latter being against all norms of ethical practices. This act is absent in India in its proper form. This is a major reason behind such exploitation. If the Government makes proper laws and regulates the private players, then the scenario may change and we are ready to welcome the same as professionals.

You must have heard about NABH accreditation and nowadays you will find most of the hospitals, major players in the country from metro cities, possessing NABH or JCI accreditation but the fact is that NABH does not oversee high-quality nursing care. They always say that they provide the best quality but do not ensure adherence to these standards on part of the hospitals. Based on the rules of the Indian Nursing Council, there is a regulation for every hospital with regard to the patient ratio vs. nursing staff and ideally in a critical care zone, for each patient, there should be 1 qualified nurse and in a regular ward, there should be a qualified nurse for 6 patients. These norms are not followed in most hospitals in the country. How does then NABH rate hospitals and state that everything is absolutely fine with the quality of health or nursing care? Who gives accreditation to such hospitals not following all basic norms? This is happening randomly and particularly in the private sector. India recently did a survey where it shows that one nurse has to care for 70 patients and above in public hospitals.

So these things should be considered very well because we are compromising the quality of patient care to the needy ones, especially when a patient comes to the hospital, he/she will depend heavily on healthcare providers

If a Nurse has been allotted 70 patients, how would she take care of them in 6-8 hours for a shift? How many minutes will be available with a single patient? These are challenging questions for the Government which does not want to answer them. They only want to build something irrelevant and not useful for the nursing fraternity or general public. We are completely opposing the bill and have mentioned all our comments to the ADG Nursing and we do not know whether they will even reply or not. We have only 30 days or less to reply to the NNMC Bill which is a small period considering the huge size of the nursing community in the country. We have almost 18 lakh nurses in the country and for reaching them, the Government expects replies in just 30 days. This is not a workable solution and the Government should change the NNMC Bill.

Q. One more point you have indicated in the letter to the ministry that Grievances redressal system parallel to the boards should be created, can you please shed light on this.

A. Ok, currently if you look at our system you will understand. Let us talk about state wise aspects, especially the State because health is the subject of every state. So, the state should have a redressal system in place. Suppose a nurse has an issue at the workplace; it could be a public or private hospital. He/she should be able to make the grievance to somebody in the right place who can tackle these issues. Now the scenario is that nurses raising complaints to the Nursing Council have not received speedy redressal in several cases.

They do not have any authority to intervene on these issues and come up with the solutions. So that is the reason we are demanding for these kinds of redressal systems for nurses so that it will be helpfulfor all the people who can raise their issues and highlight it and maybe we can come up with the solution for them. Because if I just wanted to highlight something recently, you know, when I look at some of the incidents happening in Maharashtra itself in the last three months, there are four nurses who committed suicide and these are all young nurses. Okay. Why did they commit suicide? Nobody had done an enquiry? Why did we give into the pressure? What was the reason behind those suicides? Nobody went and asked for it because we personally inquired with a lot of people and came to know that there was a lot of pressure from their seniors within the hospital. 

And their working environment was not favorable and there was no proper support for them. That is the reason they decided to leave. And this is not happening in one state. This is happening across the Nation and nurses are going under tremendous pressure. We are not looking at them because we don’t have any system to address these issues. And that is the reason we clearly demanded that yes, we want a system for nurses to address their issues and I hope the government will listen to it. 

Q. Another point you made was related to the Implementation of nursing practices. What do you want to say here?

A. As I said earlier every country have implemented this nursing practice act which clearly mentioned in that act the definition of a nurse and what are the nurses job responsibilities or the job description. So that should be mentioned so that the hospital cannot exploit them or the hospitals cannot insist them to work a non-nursing job. 

Now if you take any nurses, the job offer letter, maybe their appointment letter you would clearly see that the responsibility which includes almost all the works pertaining to the patient care and non patient care also. So, if the nursing practice comes in place then it will have a clear understanding. Yes. These are the things the things that you are not supposed to do in the hospital setup or maybe in-home healthcare setup or maybe in any scenarios. So then which will clearly regulate everything and then the hospital also cannot tell them- Okay, you’ll have to do all the work. No, then ultimately the nurses will have a better area to practice, also because recently our government started nursing practitioner courses which have completed almost about 2 years now. I think that first batch also is already out but after completing these courses, where are these nurses going to practice it? Well, the hospital is going to allow them to sit in an OPD and treat the patient. I don’t think so because the hospital is not going to entertain the nurses sitting in OPD and look at the patient. This is not going to happen.

For that we are demanding a nursing practice act which will clearly mention that these nurse practitioners will act as so and so and this area or maybe he or she will be responsible for maybe community health centers, maybe public care centers or maybe clinics. They can start independent practices. That is also another area. This will only happen if the nursing practice come in place.That’s the reason we demanded for it.

Even just one thing I would like to add now is that they should be given a degree of nursing under the Nursing Council. Get registered as a nursing practitioner but under our Council which currently does not have this particular designation or cadre. Right now, they are given a Masters in Nursing Practice which is a Masters Degree. They have already done their Masters Degrees upon joining as a nursing practitioner so why add one more Masters course? Rather you should give a degree with the name of Nursing Practitioner with registration as the same.

Q. When we talk about the American nursing profession, we see nurses practice in their own offices, open their own clinics and there are popular segments for certified registered anesthesiologist or CRNA as well. They work in the absence of a physician. Similarly, if nurses are allowed to open their clinics as primary caregivers, can this bring a balance within the healthcare industry? It should be noted with care since on one side, we see just 7 lakh physicians while there are 2 million nurses on another. In a similar instance recently, the Government is attempting to bring Ayurveda physicians into its fold for receiving training relating to surgery. If nurses are allowed to become primary caregivers, do you think healthcare workforce shortages can be filled?

A. See when we look at our nation, we have like a 1.3 billion population and when we deeply go into rural areas, maybe the tier 3 cities, there could be more. So the accessibility to Health Care is highly absent these days and you would find the corporate hospitals or maybe the multi-specialty hospitals in only Tier 1 cities, which is Metro cities. But when I go to a village area, I see that there is improper accessibility to health care. Hence, in these places, if there are nurse practitioners present, then they will be highly beneficial for the general public. This is because the nurses can start their own independent practices in these areas. People from these locations do not wish to come to a multi-specialty hospital that is private and will charge an exorbitant fee while not being sure about the quality of care that is provided.

But at the same time the nurses working in a village, working in tier 2, tier 3 cities, they provide better care and we have seen that earlier The Midwives used to handle the deliveries. They used to handle independently nowadays we hardly see that. Why? Because of the dominant nature of the medical fraternity who will not allow us to do anything today. That is the reason that now in India you don’t seen a nurse practitioner. Any nurse anesthesiologist or maybe the woundcare nurse etcetera because they know that ok if they give an opportunity to nurses, definitely the nurses make use of it. The best nurses from India, I mean, have migrated to different countries like USA, Canada and other places and they doing wonderful jobs. They are working as practitioners, in nurse anesthesia, nurse wound care, experts in different areas and they are all Indian nurses. Why are we not giving ample opportunities to these nurses to flourish in India? That’s the reason they are moving abroad. So, our sincere request to the government is to retain these nurses by giving more opportunities; we are not demanding them in metro cities, let us at least start with rural areas and Tier-2 or Tier-3 cities. Let ourselves grow and work in these areas where the public will be greatly benefited.  

Q. In your letter you stated that nursing professional groups like UNA and others should be included in this commission. However, when a clause in the draft bill is seen, namely stating “One person, representing charitable institutions engaged in education or services in connection with any recognised category, having such qualifications and experience as may be prescribed by the Central Government, to be nominated by the Central Government. – member”, then do you feel that this indicates an inclusion of professional groups like UNA and others?

A. No, no, no as per their interest, the charitable organization, which means it might be a charitable Hospital or it might be a charitable group Also, it is not necessary that it’s only from a nursing organization. They have not mentioned it so they can include anybody which is in their favor. So, our demand is that the government has to include nursing associations and unions since they can raise their voices without any fear. Okay, because we don’t work for someone’s interest. We work for only public needs and professional betterment. So, we don’t have any vested interest in here. And if all posts are nominated by the government then how would you raise the issues, because there is no platform. Ultimately, the government decides everything and all the people in the commission are government nominated and they are government employees. So, this inclusion of nursing associations and Union, that is most important because earlier in the Indian nursing council also there was association called Train Nurses Association of India. They were one of the members of Indian nursing Council and they are the member of every state nursing council. So that is the reason we are suggesting that okay the state nursing commission and central nursing commission should have unions and associations. That’s an important request to the government. 

So, the reason we are demanding is that when we wanted to raise some major issues, if all the members belong to one government body or are maybe govt nominated, then they will not be able to tell them properly because they are under pressure from the government since they’re already government employees.

However, if we, like a UNA or maybe other association or union are included into the group, then we can raise our issues without any fear because we do not have any vested interest and neither are we pressurized by anybody. And the other thing is that there was an Indian nursing Council. TNAI was one of the members and even in every state nursing council too. So considering that factor, definitely the nursing fraternity should have representation from their side through these unions and maybe Associations. That is our major demands. 

Q. You have stated that there should be a National nursing directorate at Central level and State Nursing Directorate at State level.Can you please explain this?

A. Right now if you look at the medical directorate which is only for the medical professionals and which only covers the public hospitals. So, what I demand is that the government has already approved the nursing directorate for all the states and I think Odisha is the one of the states that implemented the nursing directorate in the state. So, what our demand is that every state should have nursing directorate which will be controlled by the nurses. There also we don’t want doctors to be holding all positions in the directorate. What is currently going on? Why because if the nursing director has been headed by a doctor then he or she would not be interested in nursing profession. You would rather be interested in supporting the private hospitals because all the private hospitals are owned by medical doctors. They would have a favorable approach towards their colleagues and why we are demanding the nursing directorate is because then it will be only for the nurses working in the private and public sectors. They will be making the policies and norms related to the hospitals and other institutions. 

So, nurses can really highlight, they can raise their issues to the nursing directorate and the nursing directorate will have power to intervene on these issues and come to a conclusion and this is something very much in need in the current times.  

Q. You had some concerns about licensing exam that is called National Exit Test as well, what are your points here?

A. In the current scenario, every nurse who completed their graduation or it may be a diploma from a recognized university or not recognized colleges under the state nursing Council are allowed for registering under any nursing council in India. But after this nursing commission what it says you need to have an exit exam. So, once you clear the exit exam then you will be eligible for getting your license. So, our question is very simple- here you have already done your course and your University exam has been over and after that why do you need an exit exam for getting your license?

That is a question first thing because why we are asking this because now again the govt is giving a chance for the public player to exploit nurses by keeping this exit exam again. The nurses have to run around they’ll have to pay lot of fees to the private players and it’s a time-consuming process.

Our syllabus itself is a very elaborate syllabus which covers most of the topics in the medical profession. And after that the government wants an exit exam which we cannot accept. Another thing is about the registration licensing.  The government is demanding Central registration and a State registration now.

Currently we have every state govt as state nursing council and recently Indian nursing of Council came up with national registration for the nurses and till date they could not complete even 30% of it.

Now the Government is talking about something new. From next year, the Government will have nurses running behind them by doing a central and state nursing registration alike. Why are nurses supposed to follow two registrations? E demand single registration which they can keep till 5 years. Post 5 years, they will have to renew this and then only will there be an exact count of people working in the sector.

So, we always demand that single registration for nurses in India, they cankeep it up to five years, after five years, they will have to renew it, we understand hen only we will be having a exact count of people working in the industry.

Because every nurse was asking me the same question. Why would we need two registrations? Okay if a doctor can practice with a single registration. Why cannot the nurse practice it or work anywhere in India? Even there are a lot of judgments from the high court saying that the nurse can practice anywhere in India under any state nursing Council with one registration, but the government is not allowing us to do that. 

Q. What is your opinion on the process of Recognition of Colleges and institutions?

A. Okay, so they have mentioned that the board can hire a third party or a private player for the inspection purpose or maybe for the recognition of colleges and institutions So currently what the council does is that they prepare a committee, they called it as Inspection committee under the state and Central nursing Council and these people are nurses; they go on physically verifying the condition of every Institute and this depends on upon the feasibility levels as well. They provide them with affiliations if they found the Institute is not feasible, then they reject it if the found Institute is feasible, then of course they approve it and they’ll be getting the affiliation accordingly. But now what is going to happen with hiring a third party for recognition and affiliation. There are chances of favoring those institutions maybe for monetary benefits or maybe for other reasons which will reduce the quality of Nursing education in India because if you start giving Affiliation to all the colleges and School of Nursing in India without looking at the Quality, it will not have good results. Then of course, you are going to reduce the quality of Nursing education in India, which ultimately reduces the quality of Nursing Care in the hospitals and the sufferers would be the patients so we demand those third parties should not be allowed to do any kind of inspections or they should not be allowed to do any kind of affiliation to the institutions and colleges in India.

Q. What do you want to say about the overall Indian Healthcare system?

A. Okay. So, what I was trying to tell you is that like US we always believe and our politicians believe mostly because they take treatment from US When they are in need of it and majority of our Healthcare people migrate to the US and Canada because they have a stabilized Health Care System in their country.

Similar way-out- our Nation also needs established Health Care which is Affordable and accessible to the Public. Public means the people who are from the villages and who are from the tier-3 cites and they should be in a position to afford those better-quality care and treatments so that our nation will stand ahead of US And tomorrow we can definitely say that we have the best health care system as compared to other countries and for that our people are working tirelessly and we will definitely achieve that through a collective approach from our end for the development of a Nation.