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Table of Contents
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 115-122

Advancing nursing practice in India: Historical lessons from the United States

1 Postdoctrote Fellow at Johns Hopkins School of Nursing, Maryland, USA; Assistant Professor, Department of Nursing, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India
2 Assistant Professor, School of Nursing, Johns Hopkins University, Maryland, USA

Date of Submission30-May-2021
Date of Decision08-Oct-2021
Date of Acceptance08-Oct-2021
Date of Web Publication03-Dec-2021

Correspondence Address:
Dr. Rajesh Kumar
Assistant Professor, Department of Nursing, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand - 249 203

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcn.ijcn_41_21

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Nurses, as key health personnel in the health-care industry, play a vital role in the delivery of care. Nurses work with different populations in varied settings to coordinate care aimed at the prevention of disease, promotion of health and care of sick and dying. With the impending rise in demand for quality care, skilled and specialised role of nurses is paramount to ensure high quality. The creation of advanced nursing roles and specialisation in nursing made the nurses independent and more autonomous in their roles. Advanced roles contributed a service model and best fit to the ever-changing demands of patients. At present, nurses participate in clinical research, decision-making and demonstrate clinical leadership skills to improve the safety and quality of care. Dynamic changes in the health-care industry and consumer awareness are other driving forces that influence the need for nurses to be highly competent and skilled to fulfil their responsibilities. This article briefly describes the nursing transformation in the United States and the different nursing programmes offered in India.

Keywords: Advanced practice, nurse, specialisation

How to cite this article:
Kumar R, Rodney TW. Advancing nursing practice in India: Historical lessons from the United States. Indian J Cont Nsg Edn 2021;22:115-22

How to cite this URL:
Kumar R, Rodney TW. Advancing nursing practice in India: Historical lessons from the United States. Indian J Cont Nsg Edn [serial online] 2021 [cited 2023 May 31];22:115-22. Available from: https://www.ijcne.org/text.asp?2021/22/2/115/331766

  Introduction Top

Evolution of nursing

Conventionally, nursing has been considered as a service to the poor, sick and dying person.[1] Gradually, evolution in medical science expanded nursing to include service to patients with different kinds of disabilities and even healthy people.[2] Nursing care and service delivery have been revolutionised to include multiple settings, including hospitals, hotels, schools, communities, industry, office and military assistance. In addition, nurses also work in clinics, private hospitals and elderly homes.[3] As the largest group of health professionals, nurses are enabled to transform the health-care industry in India and globally.[4] Nurses are the key health personnel and essential member of health-care team. They not only assist or provide care to disabled or sick people but also provide their shoulders to the patient's relatives to cry or grieve from painful situations.[5] The practice of nursing in India has a long developmental history, which has exploded in the recent decades considering the increasing demand for nurses in different roles as caregivers, family health nurse and hospice nurses.[6]

Globally, the development of the nursing profession also shares a long history. Dated accounts of nursing care and the nurses role in helping to care for the sick and injured exist long before formerly establishing into practice.[2] However, that role was limited to care and support for injuries without considering nursing and scientific medical knowledge. In recorded history, nurses also began practicing anaesthesia in the United States during the Civil War.[7] Nurses often provided sole support to birthing women in the 18th century.[8]

Ignoring history is risky

Knowing historical milestones might be discouraging and painful because of the many stories of archived failure. Ignoring this history, however, presents a more significant risk.[6] Studying the history of nursing allows nurses to understand the present and future challenges, including pay, regulation, the scope of practice, rights and education. Lack of interest in history could be a factor that may explain why Indian nurses have not been empowered to raise their voices to address these burning issues.[9] In brief, knowing the development of nursing will provide an understanding of nurses essential role in the health-care setting.[10] Therefore, it is recommended that nurses look to their roots and understand their weaknesses and strengths as a vital part of the health-care team.

The history of American Nursing

Many nursing professionals believe that nursing started with Florence Nightingale's contribution in the Crimean War with the care of injured and wounded soldiers.[11] Nevertheless, the concept of nursing was in existence before the Nightingale era when the sick and wounded were cared for by family members, friends and neighbours.[12] The concept of family-centred care was practiced in the United States until the nineteenth century when family members took care of the sick. However, family care was limited during major epidemics and plagues.[13] In later times, patients received nursing care in hospitals operated by religious nursing orders and other institutions that provided good to haphazard and substandard levels of care.[3]

Nursing reform began in the late 18th century after nursing schools opened and formal structured training for nurses began in the United States.[14] Nevertheless, even as larger cities grew, it was rare to find established hospitals and scientific nursing care before 1860. Nursing demonstrated a growing concern for patient care and that contribution improved patient outcomes.[15]

Jane Addams (1889) in Chicago rang the bell of social reforms in nursing to advance professional and training opportunities for women in nursing and social work.[16] Nursing was slow to join this movement, but the insatiable demand by hospitals for formally trained nurses led to the opening of schools for young women from different social and educational backgrounds.[17],[18]

Certified Registered Nurse Anaesthetist

In her book, History of Anaesthesia (1953), Thatcher explains the nurse specialist by recognising the contribution of women in the field.[19] Lawrence (1820-1904) first administered anaesthesia during the Civil War, 1861–1865. She administered chloroform to wounded soldiers on the battlefield during the Battle of Bull Run.[19],[20] Nevertheless, it was a long and arduous journey to develop Certified Registered Nurse Anaesthetists (CRNAs) as an independent branch. Nurse Anaesthetists created their own certification board in 1956. In 1986, the Government of the United States of America recognised CRNAs as the first nursing speciality to receive independent reimbursement for their services from federal insurance programmes.

An individual who is a registered nurse (RN) and/or advanced practice RN (APRN) with a graduate degree in nursing is eligible to become a CRNA in the United States. Requirements for admission include a bachelor's degree in nursing or equivalent degree, a valid nursing licence and a minimum of 1 year of experience in critical care nursing. CRNA training programmes are either masters or doctoral level. The programmes take 24–36 months of study and require that students complete 850 h of clinical experience.[21] CRNAs practice with a high degree of autonomy and professional conduct. They are qualified to make independent judgements regarding all aspects of anaesthesia care services based on their education, licensure and certification.[22] CRNAs collaborate when necessary with different health professionals, including surgeons, physician anaesthetists, dentists, podiatrists and other certified health-care providers.[23]

At present, the United States has 116 accredited nurse anaesthesia programmes.[24],[25] On January 01, 2020–December 31, 2020, 3130 candidates reported for the National Board of Certification and Recertification, and 2556 were certified with a pass rate of 85.2%.[24],[25]

Nurse-midwives or certified nurse-midwives

Nurse-midwives (NM) are licensed, independent health-care providers with prescriptive authority in all 50 states in the United States.[26] The first certified midwifery programme began in the 1920s through the efforts of public health nurses and other stakeholders who believed in the importance of NM in meeting the needs of the underserved population. Certified Midwives (CMs) and certified NM (CNMs) are graduate-level experts in midwifery and nursing services accredited by the Accreditation Commission for Midwifery Education. It is mandatory to pass the national certification examination conducted by the American Midwifery Certification Board to become a CM or CNM if candidates already have an active RN license.[27] The American College of Nurse-Midwives created competencies and outlined the scope of practice as defined by the International Confederation of Midwives.[28]

CNM provides a wide range of services from physical examinations, family planning, pre-conception and care during pregnancy, routine new-born care during the first 28 days of birth, education and counselling services and treatment of sexually transmitted diseases. They are certified to deliver services at a private office, ambulatory clinics, community centres, public hospitals and birth centres.[29]

Clinical nurse specialist

Specialisation in nursing eventually gained attention as a mark of advancement for the profession. Much of the literature in the early 1960s attempted to define the scope and core competencies of the CNS role.[30] A clinical nurse specialist (CNS) is an APRN. CNS is a functional role in nursing that demands professional practice and specific competencies in a specialised area. An RN with a bachelor's degree in nursing and/or master's or doctoral degree in relevant specialisation is eligible to pursue a CNS. They teach staff nurses about care for a specific patient, manage care, contribute to research and educate patients, and family members. In addition, CNSs show exemplary leadership qualities and decision- making skills in the care of difficult patients. CNSs work to identify areas that need improvement. A high level of interpersonal skills and an understanding of group dynamics to promote smooth working among members of the health team is another crucial skill reflected in the role of CNSs.[31],[32],[33] Prescription authority is a matter of state law, but CNSs in 39 states may prescribe independently or as a physician collaborator. CNSs have also undergone training in physical assessment, physiology and pharmacology, and their area of speciality.[31] A CNS can practice in diverse settings, such as clinics, private practice and hospitals. CNSs work in a range of specialities, from adult health/gerontology, paediatrics, psychiatric/mental health, women/gender-specific, neonatal and family individual/across the life span.[34] The AACN Certification Corporation, the certification organisation of the American Association of Critical Care Nurses, provides a certificate in three CNS; ACCNS-Paediatric, ACCNS-Neonatal, ACCCNS-Adult-Gerontology.[31] The role of critical care NPs and CNS have merged and most schools offer NP Programmes.

Nurse practitioners

More nurses were hired in hospitals than in public health or private nursing homes in the mid-20th century, Advances in medicine and surgery required expert nursing care in hospitals after World War II.[35] At this time nursing roles were not limited and there was no desire to diagnose or prescribe. The major thrust and struggle were to define nursing as a separate profession with unique knowledge base which continued well until the 1990s.

In 1965, Ford and Henry Silver, MD envisioned a nurse practitioner (NP) role to bridge the gap between health care needs and access to primary health care. Ford believed that nurses could be prepared to address the unmet needs of rural parents and children by providing well child care where there was little affordable care.[36] The first NP Programme began as a training programme for community nurses. Nurses worked collaboratively with physicians in a collegial relationship and provided advanced nursing care to patients.[22] It will not be a surprise to mention that the concept of NPs was rooted in the Frontier Nursing Service, visiting nurses and the Indian Health Service of the early 20th century. All areas where most physicians did not work and nurses worked independently to fill in the healthcare gaps. In 1973, the Division of Nursing of the United States Public Health Service invested heavily to develop NP education and career opportunities. Later, study findings reported favourable results that became a benchmark for the continued funding of NP education.[37],[38] In 1986, a group of nursing leaders evaluated the feasibility of the NP Programme. They concluded that the advanced nursing role of an NP was essential to improve access to healthcare for every United States citizen.[39] They created the American Academy of Nurse Practitioners.

Despite many controversies and initial challenges in NP education and practice, NP education has received the attention of graduate nurses in the United States since the 1970s. In 2007, Margaret Flinter created a NP Residency Programme at the Community Health Centre Inc.[40] In 2018, The National NP Residency and Fellowship Training Consortium was created to provide post-graduate training programmes and recommendations for NPs to achieve the highest standards of quality and consistency to produce an expert health-care provider.[40],[41] Following formal training, there is a growing interest in residency programmes in medical centres to enhance the specialised skills of graduate NPs. Currently, there are many more graduates than positions available. The goal for NP education has moved from MSN preparation to preparation at the doctoral level (the doctor of nursing practice [DNP]).[42]

  Advanced Practice Registered Nurses Top

The APRN role applies to a wide range of competencies to improve health outcomes for a patient or population in a specialised area.[42] APRN are given credentials that depend on the state where they practice. The APRN's preparation includes completing an accredited graduate education in nursing and passing a national certification examination to demonstrate population-specific competencies.[43] The APRN role has grown from the original Paediatric NP, to Family NPs Adult/Gerontology Primary Care; Adult/Gerontology Acute Care; Women's Health; Paediatric Acute Care; Paediatric Primary Care; Mental Health; CNS, CRNAs, and CNM.[44] It is an umbrella term that includes all of the graduate-level advanced practice nursing specialties.

The APRN role has also evolved to include nurses prepared at the doctoral level. This expanded role of the DNP allows nurses to assume additional responsibility and accountability in the planning, implementation and evaluation of evidence-based strategies to improve individual patient and population health outcomes.

Doctor of nursing practice

The healthcare industry's dynamic needs and the increased complexity of patient care demand higher level of preparation for clinical nursing leaders. The primary aim of the DNP degree is to prepare APRNs for leadership practice in the clinical setting.[45] The Institute of Medicines' recommendations to reduce significant medical errors, and increase safety, and quality justified the need for exemplary clinical leadership by nurses.[46]

The AACN, 2004 Position Statement on the Practice Doctorate in Nursing revolutionised nursing education by calling nursing schools to shift from a master's to a DNP as the degree for APRNs by 2015.[47] However, an economic recession prevented schools from meeting that deadline. Currently, except for CRNAs, the APRN programmes may decide if they want to offer an MSN or a DNP.

The DNP Programme was intended to prepare the workforce of leaders to transform research into clinical practice. However, in the initial years, most DNP graduates opted for administrative and educational settings.[42] These DNP graduates can meet the scarcity of nursing faculty; however, having enough doctoral-prepared APRNs remains an on-going area of concern and remains an area for improvement.[45] The American Association of Nurse Practitioners (AANPs) reports that 79.8% of APRNs with master's degrees, only 14% hold a DNP.[48] DNP curricula are designed to use a more evidence-based practice approach to fully equip the nurses with current research advancements, and knowledge to meet the national concern about the quality of care and patient safety. At present, 49 states in the United States offer DNP Programme with wide variability in syllabi to practice in the respective state.[49] However, single certification and accreditation process, practice scope, community demand across the states are largely unaddressed, and the goal of universal DNP remains lofty for nursing leaders in the United States. [Table 1] outlines the summary of APRNs.
Table 1: Advanced practice registered nurse programmes in the United States

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Doctor of Philosophy in Nursing

In the mid-20th century, many nurse leaders were engaged in developing theories in nursing and were debating on the science of nursing to create the doctoral level preparation in nursing in the universities. The Doctor of Philosophy (Ph.D) programme gives knowledge and skills in theoretical, methodological and analytical research methods. The degree enables nurses to explore nursing science and health-care knowledge. It prepares nurses at the highest level of nursing science to conduct research that advances the empirical and theoretical foundation of nursing and health care globally.[54] This programme enables a nurse to obtain expertise in a specific area of the study. The goal of this degree is to build the skills to allow nurses to implement a scientific research programme. The Ph.D programme prepares a nurse to serve as an educator in various classroom and clinical settings within the academic programme.[54],[56] Admission requirements include graduation from an accredited bachelor's and master's in nursing programme with an active registration in nursing.

  Nursing in India Top

Studying the contemporary history of nursing is illuminating and exciting. It shows the pathway of change, showing footprints left by the doyen of nursing to uplift the nursing profession. In India, formal nursing education started in late 1871 in Madras and subsequently stretched its wings to other provinces.[57] At present, India has more than 2,259,785 Registered NM, 925,016 Auxiliary NM, and 56,819 Lady Health Visitors in 29 state nursing councils.[58] NPs in critical care and midwifery practice in independent roles and provide compassionate, respectful and competent care.

Nurses are the backbone of the health-care infrastructure worldwide, including India, and play a key role in delivering preventive, promotive and rehabilitative services.[55] Many developed and developing countries, including India, are facing an acute shortage of their trained nursing workforce.[59] However, the nurse-to-population ratios in developed countries may substantially differ. Contrasting examples include sub-Sahara African countries having a low nurse-to-population ratio (12.5/10,000) than the UK, where there are 88.3 nurses/10,000, indicating a stark difference in severe nursing shortfalls.[60] Likewise, the nurse to population ratio in India 1.7/1000 is 43% less than the World Health Organisation (WHO) recommendation (3/1000).[61] Further, this ratio varies from rural to urban areas, exposing a massive gap in the demand for a trained nursing workforce leading to an increased risk of compromised quality healthcare.

Diploma and degree programmes in nursing


The Indian Nursing Council (INC) currently provides two diploma courses, including Auxiliary Nurse and Midwife (ANM) and General Nursing and Midwifery (GNM) programmes led by respective State Nursing Councils.[58] ANMs are the nurses trained to deliver maternal and newborn health services at the grassroots level. They work at sub-centres and visit villages to deliver nursing services. Anganwadi Workers and Accredited Social Health Activists (ASHAs) are the most recently created cadre to strengthen the Community Health Workers Programme. ANMs and ASHAs work solely at the village level to provide food supplements and promote maternal and child health care by encouraging institutional deliveries and immunisation.[62] ANM are RNs and complete 2 years of dedicated training, while ASHA receives 3–4 weeks additional training periodically to deliver services at the village level.[63]

Further, GNM is a 3-year programme and gets registration in the state and from the INC to work as a RN. GNM nurses work in different settings, including private clinics and hospitals, nursing homes and public hospitals. They provide care in varying roles, including direct care provider to education to patients, families and communities.[63] However, the contribution of diploma nurses in health-care delivery compared to the early 1980s is less in the present scenario.

Degree programmes

In addition to diploma courses in nursing, the INC provides university degrees to candidates dreaming of pursuing the nursing profession. Since 1946, the country had initiated the Bachelor Nursing Programme with a 4 years duration leading to status as RN and Registered Midwife. There is also a post-certificate baccalaureate degree programme. The candidate completes a 2 year degree programme after their diploma in nursing (GNM) to improve on their theoretical education and competencies.[63]

A master's degree in nursing is a 2 year programme which orients a graduate nurse to a more specific role and helps to polish clinical competencies in the relevant specialisation. The programme focuses on empowering graduate nurses to take leadership roles in promoting quality in patient care and nursing education. In addition to competencies, the programme also gives an introduction to research methods and a research opportunity to complete thesis work. However, there are no scientific data on the publication of the thesis work of master's nurses in India. Indian nurses need to strategically consider increasing additional research-related work and increase the publication of their research. The authors also recommend creating a culture to support research in terms of environment, resources, mentors and financial aid to encourage budding nurses to pursue these opportunities. [Table 2] outlines different nursing courses in India.[63]
Table 2: Nursing programmes in India

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M.Phil programme

M.Phil in nursing is offered as either 1 year (regular) or 2 years (part-time) programme which is meant to be a bridging programme between M.Sc and Ph.D. RAK College of Nursing, New Delhi, started the programme in 1980. Later, few other institutions and universities offered this programme.[64] This programme is considered as a stepping stone for the doctoral programme as it predominantly deals with research. However, it is not a mandatory requirement to pursue the doctoral programme. Hence, it is not as attractive as doctoral programme. With the implementation of the recent National Educational Policy 2020, the Government of India has scrapped off the M.Phil Programme in India.[65]

Doctor of Philosophy program

In 1992, doctoral programme in nursing was first started under the Department of Nursing, University of Delhi. The National Health Policy 2002 stressed the dire need to prepare nurses to function in super-speciality areas. With the acute shortage of nursing faculty in under graduate and post-graduate nursing programme in India, it was essential to prepare the nurse scholars with doctoral education. In line with that, INC constituted National consortium for Ph.D in Nursing in collaboration with Rajiv Gandhi University of Health Sciences and WHO, under the Faculty of Nursing to promote doctoral education in various specialities of Nursing in 2005. Six centres across India are connected through video conferencing facilities.[66] Apart from the Consortium, individual universities also offer Ph.D in Nursing in many states of India.

  Nurse Practitioners in India: A Beginning Top

The shortage of a trained medical and nursing workforce and the severe deficit of the health-care workforce emphasises the need to transform the health-care delivery system. Nurses hold a key position worldwide and can be best utilised to achieve sustainable development goals.[67] The union government is in the process of creating an independent cadre of NPs in rural areas to meet the deficit of physicians.[67],[68]

The government of West Bengal took the first initiative to start a NP Programme in midwifery in 2002.[69] Similarly, many other state governments; Gujarat, Telangana and Kerala have initiated similar proposals to start an NPs' course.[70],[71] However, a lack of long-term vision, a clear scope of practice, certification and registration and employment opportunities have all factored in delaying the actual start of the programme.

Based on the National Health Policy (2015) INC decided to initiate a NP Programme to support the specialised and super specialised health-care services. By empowering the Nurse with adequate theory and practicum components and creating a cadre at the National and state level, NP will be able to provide safe, cost-effective, competent and quality care. INC had proposed a curricular framework towards the preparation of NP in Critical Care at masters level. The highlight of this programme is the strong emphasis on the clinical component which comprises 85% practicum and 15% of theory. The course is designed based on the competencies suggested by the International Council of Nurses and the National Organisation of NP Faculties.[72]

It is a residency programme with the focus on three courses namely (1) core course, (2) speciality course and (3) advanced practice course spanned over the period of 2 years. While some universities have accredited the NP Programme, it is yet to be accepted and initiated in many universities across India.[72]

The scope of practice of a NP is yet to be defined in India. However, they can practice in various settings with similar roles as defined by the AANPs, including private homes, clinics, public hospitals, nursing homes. Further, NPs should be allowed to do various jobs from physical examination to diagnosis, prescription, follow-up and rehabilitation.[22],[69],[71] A clear state comprehensive practice policy and legal authority will allow NPs to work more autonomously.

  Conclusions and Recommendations Top

Broadly, the United States started investing in the NP role in the early 1960s. Alhough the journey towards establishing independent practitioners was not easy in the United States, a long-term vision, consistent efforts of nursing leaders and policymakers, and the government's keen interest in improving health-care quality made it successful. Nevertheless, some states in India are formulating policies to define the scope and practice parameters for NPs bringing change in quality health outcomes. In addition, within the United States, the nursing profession has historically played an important role in practicing and maintaining professionalism, professional power, advanced knowledge and influencing social reform.

The health of individuals and their community fundamentally depends on the types of health-care workers and their competencies. In collaboration with many regulatory bodies, Indian nurse policymakers have made meaningful steps towards improving nursing practice; however, this could be enhanced if done as a part of a plan with a long-term vision. The challenges and barriers encountered have significantly hindered these efforts to materialise. One of the considerations for Indian policymakers is to consider creative and innovative solutions to increase advanced practice nurses' role and promote their role in bringing changes to health care. Lack of incentives, the blurred scope of practice, lack of financial benefits and poor recognition of advanced training can be demotivating for nurses and diminishes the importance of their fundamental role. The concept of a NP is deep-rooted in Indian history, especially in, Uttar Pradesh, Bihar and some other states, where RNs routinely diagnose and treat minor ailments. The public in remote areas accepts this nursing role, but the government bodies have not made this a part of legal nursing practice. Nurse policymakers should take the initiative to organise and standardise the NP role with defined scope and practice area.

Instead, it would be better if Indian nurse policymakers defined the scope for master's degree nurses to practice in their specialised area with due incentive. This small initiative could bring significant changes in health care in the subsequent years. The lack of these guidelines contributes to the loss of qualified nurses who have invested their commitment in an educational programme but choose to work in an alternate career path.

The authors recommend streamlining nursing education, increasing funding to nursing education, emphasising in-service education, shifting to competency and module-based training, refining evaluation criteria, investing in research, uniform course syllabi and improved faculties and facilities to strengthen nursing education and practice in India. Stricter implementation of the licence renewal approach on time can also significantly impact the improvement of patient care.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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