Executive Summary

Assessment of Nursing Management Capacity in the States of Uttar Pradesh, West Bengal and Tamil Nadu

Principal Investigators

NIHFW IIM, Ahmedabad Prof. Deoki Nandan Prof. Dileep Mavalankar

Research Investigators

Prof. Rajni Bagga Mrs. Bharati Sharma Dr. Renu Sehrawat Mrs. Jyoti Gade Mr.Sherin Raj T.P

(Department of Management Sciences) National Institute of Health and Family Welfare

Munirka, New Delhi-110 067 and

Centre for Management of Health Service (CMHS) Indian Institute of Management, Ahemdabad

With support from SIDA

PREFACE Since Nurses and Midwives are the back bone for the delivery of quality Maternal and Child Health care services, their major contributions to health care development and to achieve the Millennium Development Goals is extremely crucial. India is committed to Millennium Development Goal 5, to improve maternal health by reducing Maternal Mortality Rate ¾ by 2015. But managing effective nursing care for maternal and child health in the health care institutions and at the community level, necessarily needs appropriate organizational and management structure at the state level. Various Committees and reports have pointed to the need for strengthening the nursing management capacity at the State Directorate level but there is a gap in policy formation documents and its actual translation. The nursing management capacity, in the country, is quite weak. This gets reflected, in lack of active participation by human resources in nursing in any of the policy decision making processes. Issues and concerns being sidelined though no doubt, nursing constitutes one of the largest health workforces in the country. It is important to identify the best practices of different states in order to develop a mechanism for its sharing and replication in other states. To address this issue, an exploratory study was undertaken in three selected states of India i.e., Uttar Pradesh, West Bengal and Tamil Nadu with an aim to review the management of nursing and midwifery issues at the State Directorate, Teaching Institutions, Health Care Institutions and other Nursing Professional Bodies; and identify variations, bottlenecks and gaps, if any, in the Nursing Management Capacity at the state level. The study was a joint effort of the National Institute of Health and Family Welfare, New Delhi and the Indian Institute of Management, Ahmedabad. The study, in its findings, comes out with recommendations to have a separate nursing division at the state Directorate and preferably to be headed by a nursing professional on the post of 'Director Nursing' or its equivalent. The senior most nursing post must have total autonomy in decision making and to a member of all policy making bodies dealing with health and family welfare issues. The immense human potential among nursing professionals needs to be converted into reality by creating an enabling work environment for them in terms of providing more power in decision making, and sound Human Resource policies. This requires a complete image changeover, keeping in line with the ever emerging importance of nursing profession, accorded universally. The contribution of the nursing to the overall health of the nation demands more visibility. Today the nurses need to be the equal partners in the betterment of health care delivery system.

Deoki Nandan Director, NIHFW

ACKNOWLEDGEMENT The pleasurable part of writing the research report is the opportunity to offer our profound gratitude to many individuals. It would not have been possible to complete this research work without the support and inspiration of these people.

We are delighted to submit this study as a part of SIDA project ‘Developing Inter-Institutional Collaboration between Institutions in India and Sweden for Improving Midwifery and EmOC Services in India improve maternal health’. We sincerely thank with gratitude to Prof. Deoki Nandan, Director, NIHFW and Prof. Dileep Mavalankar, IIM-A for providing expert guidance from inception to completion of this study. Their constant support and inspiration has been extremely valuable for the study. Our special appreciation and thanks for the states of Uttar Pradesh, Tamil Nadu and West Bengal officials and the nursing professionals at the State Directorate, nursing schools, hospitals, training institutions, professional bodies, etc for extending active support to facilitate the research team in data collection. We are particularly grateful to each of the interviewees who provided their valuable time and shared the relevant information to make this study meaningful. The study could be successfully carried out due to the active support and involvement of research team members and faculty members from NIHFW and IIM-A and particularly put on record the sincere efforts of Prof. K. Kalaivani, Mr. Ramesh Gandotra, Mr. G.S. Karol and Mrs. Reeta Dhingra during the process of data collection and analysis. We particularly like to express our special appreciation for the sincere hardwork put in by Ms Deepti T.V. for tirelessly working on the computer to put in shape all the figures and tables and typing the documents and without her hard work and patience the report could not have been compiled. We are very grateful for the technical support provided by Mr. Ravi Tewari for putting the report in its present shape. Last but not the least we appreciate the efforts of the accounts and administrative sections of the NIHFW who actively supported for timely logistic arrangements. Finally, we are grateful to all those who supported in this study directly or indirectly and whose names are not reflected but without their support completion of the study was not possible. In the end we sincerely hope that the study would meet the expectations of those involved in this profession and desirable changes are made in our approach and attitudes towards nursing. Together, definitely we will contribute in reducing maternal deaths and morbidities by improving management capacities of nursing/midwifery professionals.

Research Team from NIHFW and IIM-Ahmedabad

EXECUTIVE SUMMARY

The study was undertaken by NIHFW in collaboration with IIM-Ahmedabad; with support from SIDA. The study was initiated in the last quarter of 2007. The study is part of the SIDA project. Since nurses and midwives are the backbone for the delivery of quality MCH care services, their major contributions to health care development and to achieve the Millennium Development Goals is extremely crucial. Organizing effective nursing care for maternal and child health in the health care institutions and at the community level, necessarily needs good management and administrative practices. The present study was undertaken in selected states of India i.e. Uttar Pradesh, West Bengal and Tamil Nadu with an aim to describe the current nursing organizational/administrative structure, the key nursing management issues at the state Directorates, Teaching Institutions, Health Care Institutions and other Nursing Professionals Bodies. The study focused on the key objectives as: i) To review the current Nursing and midwifery Organizational/administrative structure and highlight issues in the states of Uttar Pradesh, West Bengal and Tamil Nadu and identify variations and best practices, if any in the states, ii) To review the management of nursing and midwifery issues at the state Directorates, Teaching Institutions, Health Care Institutions and other Nursing Professionals Bodies and identify any constraints, iii) To obtain a perspective and the ideas to strengthen nursing and midwifery management capacities to address maternal health issues appropriately, iv) To draft the recommendations to strengthen nursing and midwifery management capacities. This being an exploratory study, both primary and secondary data were collected utilizing both qualitative as well as quantitative techniques of data collection. The data collection focused on identifying the management structures and the management processes, especially human resource issues of nursing from the State Health Directorates, service delivery institutes (District and Civil hospitals), Nursing Educational and Training Institutions (especially the Nursing Schools and Nursing Colleges, and SIHFWs), professional bodies (especially Nursing Council and nursing associations) and other local institutions in both the states. Relevant information was collected by interviewing the senior officials/administrators and nursing functionaries from these institutions/bodies. In addition, the research team also interviewed and interacted with the key nursing professionals at the centre, holding important positions and with vast experience of the nursing profession.

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Findings/Observations of the Study Uttar Pradesh as one of the largest States of India with almost double the population of West Bengal has poor maternal and child health indicators. Whereas in West Bengal and Tamil Nadu, the health and MCH indicators are not only better than Uttar Pradesh but are also more progressive in comparison to the National indicators. These better socio-demographic and health indicators in both WB and TN are reflective of good MCH/ midwifery services and better organizational structure of the health and family welfare in the state.

� The study identified a relatively better nursing set up in West Bengal in comparison to

Uttar Pradesh and Tamil Nadu. The position of the Joint Director, Nursing in Uttar Pradesh though is a higher position compared to the Deputy Director Nursing in West Bengal, but the Directorate of West Bengal has a proactive nursing division with 15 sanctioned nursing posts in comparison to skeletal nursing posts in the other Directorates of Uttar Pradesh and Tamil Nadu.

� TN appears to have a unique organizational setup wherein nursing issues are taken

care of by the three Directorates viz, Directorate of Medical Education, Directorate of Medical and Rural Health Services, and the Directorate of Public Health and Preventive Medicine, indicating an positive impact on better rural health care services and more enhanced nursing and midwifery services.

� In both Uttar Pradesh and Tamil Nadu and more specifically in UP, the office of the

Joint Director, Nursing lacked adequate resource and facilities and moreover a very submissive approach. In contrast to these two states, the WB set up was not only well staffed but also have all the infrastructural resources.

� Leadership and Role Behavior: All the 3 states do not have the post of Director

Nursing. The final decision making still rests with the secretaries and other additional director and mainly with the non-nursing administrators. The Deputy Director (Nursing) in West Bengal, with decision making powers had active involvement in matters related to nursing. The decision making is more participatory involving nurses and midwives in West Bengal compared to Uttar Pradesh and Tamil Nadu. But these decision-making powers were found to be lacking with the JD, Nursing in UP and only for partially with JD, Nursing in Tamil Nadu.

� But the team did observe a huge potential for leadership among the nursing division

of the WB which was evident from the responsibilities and functions assigned to DD, Nursing who is playing a very active role in contributing to decision making process.

� In West Bengal, the nursing cadre is 100% female dominated whereas in Uttar Pradesh

and Tamil Nadu, there are male nurses but the number is very small. This is an interesting observation keeping in mind the socio-cultural ethos that defines the status of women in the society.

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� The Directorate level posts in West Bengal are selection as well as promotion posts with well defined job responsibilities, whereas in both UP and TN, these posts are only by promotion and no job responsibilities exist.

� There are proportionately more nursing colleges (both B.Sc and M.Sc) in West Bengal

and Tamil Nadu, whereas UP has more nursing schools in comparison to nursing colleges. But UP has relatively more private teaching institutes in the Private sector than the Government aided institutes.

� Though both the states i.e., Uttar Pradesh and West Bengal are affected by shortage

of nursing teachers, the situation is grave in UP where the availability of nursing teachers doesn’t match with the mushrooming of large number of nursing schools especially the private ones. Initiatives are being taken by the West Bengal State Health Directorate to strengthen the pre-service nursing education in the state.

� In Tamil Nadu, most of the teachers in nursing schools/colleges are highly educated,

experienced and enthusiastic, and some also have a doctorate degree. � All the three states have only training guidelines but no training policy. The in-service

training and particularly CNE is very ad hoc and not linked to performances, career growth and placement opportunities.

� The lack of promotional growth based on merit and qualification, acts as a deterrent

to acquire more qualification. There are disparities in pay scales of nursing at all the levels, e.g. the pay scale of JD nursing in UP, (which is a higher post), lower than that of the DD nursing in WB and TN.

� There is a disparity of nurse bed ratio in the states. The recommended nurse bed ratio

is 1: 4 in WB and 1:5 in Uttar Pradesh. But in both the states, these ratios do not take in to account the nurses requirement for specialized areas.

� In Tamil Nadu as such there is no shortage of human power and recently upgraded

24X7 PHCs, where the 24 hour midwifery services are provided by nurses, are functioning well. Good infrastructure and quality services being provided at these PHCs by nurses posted there, has resulted in increase in number of institutional deliveries conducted in PHCs.

� In all the three states i.e. Uttar Pradesh, West Bengal and Tamil Nadu, there is lack of

decentralization of decision-making power with Nursing Superintendent/Sr. Matron/Matron. They are not delegated any financial powers and this often lead to unnecessary delays in administrative and other managerial affairs of the hospital.

� Shortage of nursing staff was noticed in the states of Uttar Pradesh and West Bengal,

especially for the higher level positions. This has translated into lack of assertively, and apathy at the higher positions.

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� In Uttar Pradesh, the nursing personnel expressed a desire for more sensitivity from higher authorities for issues like security, provision of accommodation and transportation. But in West Bengal and Tamil Nadu, such concerns were not raised but the demand for staff quarters was felt.

� Since SIHFW, Uttar Pradesh has a regular full-time Director, there are more training

initiatives in the institute. In WB since the SIHFW does not have regular full-time Director, such initiatives are lacking.

� Due to lack of financial support and no separate budget, the physical infrastructure of

nursing schools visited in Uttar Pradesh and Tamil Nadu, was found to be highly inadequate. Whereas in West Bengal, the overall physical infrastructure of the nursing schools visited, was adequate by way of better demonstration laboratories and well equipped libraries.

� The state nursing council of the Uttar Pradesh State is headed by a medical person as

its Registrar and there is no nursing person posted in the council but in West Bengal and Tamilnadu, the Registrar of the council is a nursing person.

� In WB, since the Director, Health Services and DD Nursing at the Directorate are the

ex-officio president and Vice-President respectively of the State Nursing Council, the nursing issues are more streamlined. But in Uttar Pradesh, the JD Nursing is not represented in the council and only DG and Additional Director, (Medical and Health Services) are holding the President and vice-President positions respectively in the Nursing Council. This does reflect the marginalization of the nursing profession in the key nursing body.

� The Tamil Nadu Nurses and Midwives Council is the earliest Nursing Council in the

whole South-East Asia. This Council is an autonomous statutory registering body for the Nurses, Midwives, and Auxiliary Nurse Midwives/Multipurpose Health Workers/Health Visitors. In TN the State Nursing Council is headed by President and is consisting of total 18 members including - 8 government ex-officio, 5 elected members and 5 are nominated. A very pro-active Registrar, in position presently, looks after the day to day affairs of the council but is not a council member. The council has 9 administrative staff members whose salaries are paid by the council.

� The SWOT analysis, attempted in the study, shows a vast contrast in the strengths of

West Bengal and Tamil Nadu with those of UP and this also presents a very peculiar picture that how the strengths presented for West Bengal and Tamil Nadu get its reflection in the weaknesses of UP nursing scenario.

� But the strengths are not optimally capitalized due to the certain inbuilt weaknesses

of the health system e.g. in the organizational structure of the policy making body of the Directorate in the states. In the absence of any nursing position at the top decision making level in the Directorates, all the policy decisions are framed by the non-nursing personnel. The systems apathy towards building nursing capacities has

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translated in to human power shortage in both the teaching as well as service delivery sector. Lack of decentralization and with no financial powers delegated, have led to unnecessary delays in the administrative and other managerial affairs. The current scenario shows that how the weaknesses tend to overpower the strengths due to the systems apathy to address the ground realities.

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RECOMMENDATIONS

� Nursing profession needs a complete image changeover keeping in line with the ever emerging importance of nursing profession accorded universally. The contribution of nursing profession to the overall health of the nation demands more visibility. Today the nurses need to be the equal partners in the process of health care delivery to achieve the United Nations’ Millennium Development Goals.

� From the image of being submissive and at the receiving end, they need to shift to play the more proactive role. This requires a change in the mind set right from the top level of the planners to the community and stake holders.

� Their immense human potential needs to be converted in to reality by creating an enabling work environment for them in terms of providing more power in decision-making, and sound HR policies.

� The professional bodies need to apply more concern for protecting the rights of

nursing personnel and this also needs more gender sensitivity among the policy planners. This requires suitable laws, if needed, to be enacted.

� The state Directorate should have a separate nursing division and preferably, to be headed by a nursing professional at the post of ‘Director Nursing’ or its equivalent. The senior most nursing post must have total autonomy in decision making and to be member of all policy making bodies dealing with health and family welfare issues.

� The structure of the nursing division to have Joint Directors/Additional Directors

each for Nursing Services, Nursing Education and Training’ and Public Health Nursing/Community Nursing.

� Clear cut job profiles to be developed for all levels of the nursing cadre from top to bottom.

� There should be uniformity in the pay scales preferably at par the central pay scales.

� ACR and performance appraisal needs reforms to give due recognition to the conduction and documentation of research carried out by nursing personnel. The criteria for work performance should be objectively linked to the job profile.

� For effective manpower planning and development for nursing, its extremely

important to develop the human resource (HR) policy which will take in to consideration future human resource planning for nurses. The HR policy also to focus on developing guidelines for training and development of the nurses keeping in view the demand generation.

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� The Career path should provide flexible opportunities i.e., transfer from service delivery side to educational and vice versa. But the transfer and placement should be supported by the requisite skill development.

� The nursing transfer policy to emphasize nurses with the specialized and super-specialized training to be transferred to the other service delivery set ups in their area of specialization.

� Higher educational qualifications should be linked to career growth. But seniority should not be completely ignored, and there can be a certain percentage for seniority-based promotions.

� Since the working and enabling work environment are the pre-requisites for the quality of nursing services, the nursing service rules must re-frame guidelines for issues like security, accommodation and transportation.

� For the service delivery set up, the nurse bed ratio calculation should take in to account the requirement for specialized areas e.g., for labour room, ICU and other super speciality areas.

� The hospitals also need to have a nursing division headed by senior nursing administrators with more leadership and management skills to make nursing workforce more proactive.

� More decentralization with budgetary powers to senior nursing functionaries in the hospitals.

� The government need to focus on creating more nursing educational institutions (both schools and colleges), keeping in mind the demand and supply gap for nurses in the service as well as education sector.

� The skills of the teaching faculty of the institutions should be strengthened, and the infrastructure and other resources to be provided to facilitate quality nursing education.

� With the emerging demand for super specialization in the health sector, the need is to increase the number of super specialty skill-based courses.

� For continuous updating of the skills, it will be beneficial to have a separate

Continued Nursing Education (CNE) Cell, both at the centre and state level.

� Along with developing the clinical skills of the nurses, it is extremely important to provide Behavioral skill training especially in Leadership Skills, Assertive Skills, Communication Skills, Conflict Management and Negotiation Skills etc.

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� Adequate opportunities for development of midwifery skills for hands on training need to be worked out.

� To address the need for providing quality health services, the feasibility of

developing nurse practitioners and their placement needs to be worked out. WB has already initiated the process.

� Moreover teaching posts also need to be created for adequate placement. This can

be compensated by the creation of more nursing colleges i.e. both B.Sc and M.Sc.

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