Lack of Nursing Leaders Hinders India's Healthcare System

By Arunima Rajan

Nursing leaders play a crucial role in providing quality medical care, but lack of further training hinders their development in India. We explore reasons behind this absence and discusses potential solutions to address the issue and improve India's healthcare system.

The Indian healthcare industry is facing a new challenge: an absence of strong nursing leadership. Across the country, hundreds of thousands of nurses are employed at both public and private hospitals, providing millions of Indians with crucial care, support, and guidance during their most urgent times of need. However, despite this large pool of talented nurses ready to work on the front lines in service to society’s greater good, nurses are not provided with any formal opportunities for advancement—creating a dearth of potential nurse leaders among their ranks. This lack is particularly concerning when one considers just how critical it is for India’s health services system that its nurses have equally vital management roles: from overseeing in-hospital operations to influencing public health policies and everything in between.

Sumani Ajay, Head of Nursing Services and Principal of Fernandez School of Nursing, highlights several challenges facing nursing leadership in India. One is a lack of recognition, as there is a lack of quantifiable evidence on the nurse leadership crisis and nursing reforms are often treated as a lower priority. Another challenge is a lack of visibility in policymaking, as nursing professionals are not often involved in decision-making and policy framing for their profession. Nursing leadership courses are also not seen as equal to other industry courses, and management at many organisations does not prioritise building nursing leaders through this training. Nurses also face a lack of access to working at strategic levels and are not always seen as revenue generators. Additionally, nursing leaders have historically struggled against oppression and suppression of their values, inflexible organisational cultures, feeling undervalued, and a need to be constantly available are all barriers to professional success and fulfilment. Finally, nursing is an autonomous profession, but nurses are often trained to be dependent and instruction-led, which can lead to a lack of empowerment and poor advocacy.

Importance of Nursing Leadership

Judith Vasan, the Cluster Chief Nursing Officer at BGS Gleneagles Global Hospital in Bengaluru, agrees with this assessment and adds that there are several problems to developing nursing leadership in India, including creating plans for training future leaders, utilising evidence-based practices, keeping up with new technologies, preventing burnout, promoting emotional well-being, and advocating for the nursing profession.

Current State of Nursing Leadership in India

In India, 5162 nursing institutions are approved by the Indian Nursing Council. These institutions offer a variety of nursing courses, and the number of students who graduate each year with a diploma, Bachelor's degree, post-introductory course, or Master's degree are 134949, 107814, 25485, and 13971, respectively. India is believed to lack 4.3 million nurses to have an optimal number for their healthcare system. Various initiatives have been implemented to address this shortage and distribute nurses more evenly across the country.

Minimole Varghese, the Chief Nursing Officer at Fortis Hospital in Mulund, points out that nursing reforms in developed countries like the US, UK, Singapore, and Canada have led to many advancements in the profession, including the creation of various leadership roles for nurses. Varghese also notes that although advanced nurse practitioner programs have been introduced in India, they have not been effectively implemented due to a lack of visibility and hiring of practitioners. Furthermore, there are few nurses in leadership positions above the nursing superintendent level in India's hospitals, and even those who hold leadership roles cannot significantly contribute to healthcare policies and decision-making processes.

Impact of the Absence of Nursing Leaders on the Healthcare System

Varghese notes that the absence of strong leadership can lead to errors in routine processes and negative patient consequences. The evolving work environment requires nursing leaders to balance patients’ needs and nurses’ satisfaction to retain staff, and changes in the healthcare industry can exacerbate shortages and turnover rates.

Noninvolvement of nursing leaders in planning and decision-making in hospital administration

The root cause for these hurdles is the medical profession’s dominance of power and governance and reporting structures to the medical directors in the

healthcare setup. The medical fraternity also holds higher positions which nurses should hold in the hospitals. The involvement of nurse leaders in the decision-making and professional development of nurses, along with the right succession planning, would provide a podium for nurses to be empowered and rise to greater heights in decision-making and planning to improve the nursing profession further.

Phalakshi Manjrekar, the Director of Nursing at P. D. Hinduja Hospital & MRC in Mahim, Mumbai, believes that there are not many nursing leaders in Indian healthcare institutions because nurses are not typically acknowledged or supported to lead autonomously. However, the culture has long supported nurses in leadership positions at Hinduja Hospital. The hospital has implemented measures to groom nurse leaders, such as providing structured management programs and encouraging nurses to pursue master's degrees in healthcare management. Senior nurses also undergo leadership training programs conducted by established nursing directors. This gives nursing leaders a strong foundation to practise effectively, make decisions, and evaluate their work’s effectiveness by measuring patient outcomes.

Addressing the Quagmire: Strategies for Promoting Nursing Leadership in the Indian Healthcare Sector

According to Sumani Ajay, the Think Change Forum has released recommendations to improve the state of nursing and midwifery in India. These recommendations include implementing the WHO's Strategic Direction of Nursing and Midwifery (SDNM) guidelines, investing in nursing education, creating leadership positions, filling sanctioned nursing leadership positions at the central and state levels, fast-tracking the National Nursing and Midwifery Commission Bill, repealing the India Nursing Council Act, and implementing a live register for nurses. The recommendations also include establishing a Nurse’s Human Resources Management System, a technology-based platform for maintaining a live register of nurses and midwives and conducting a need-based assessment of nursing institutions in each state.

To empower nurses, hospitals must bring out existing leaders and motivate young nurses by highlighting their achievements. Nursing empowerment also requires institutional reforms to facilitate distributed leadership across the healthcare system and enable collective advocacy that challenges the status quo. Nurses should be given job roles such as Nurse Clinicians, Clinical Nurse Specialists, and Researchers to utilise their skills and knowledge. Professional nursing organisations should recognise leadership as a key competency for nurses in all settings and offer leadership courses, resources, and support, focusing on general leadership rather than health equity. These organisations

should also undertake initiatives to develop and support nurse leaders, including content related to health equity.

The dilemmas faced by the Indian nursing community indicate a larger issue in the country's healthcare system. Nurses are essential to any health services setup, but they are often not given the opportunity to lead or participate in decision-making. This lack of leadership results in several problems, including poor hospital operations and ineffective public health policies. To address these issues, we need to provide nurses with formal training opportunities and empower them to take on leadership roles. Only then will India be able to improve its healthcare system and ensure that its nurses play a central role in shaping it for the better.