Nurse Practitioner as Cadre in Bengal : Doctors Hope There is no Devil in the Details

West Bengal’s chief minister, who is also in charge of the health portfolio, has announced her intention to introduce a new cadre to be called nurse practitioners (NPs) in the public health services hierarchy even as there is no firm indication yet as to how soon the National Nursing and Midwifery Commission Bill 2020 (NNMC) will be legislated by Parliament.

Given Mamata’s penchant for christening, the proposed cadre may also be called sister practitioners if her announcement regarding the new cadre on August 26 is any indication of her thinking.

The NNMC bill, on which the Union health ministry elicited comments from the general public and all stakeholders in early November last year, is an offshoot of the National Health Policy 2017. The bill, which was approved by the parliament’s standing committee on health and in which new professional health categories have been listed in Schedule 1, provides for a category called NPs under ISCO code 2221. ISCO is the abbreviation of The International Standard Classification of Occupation devised by the International Labour Organisation for listing jobs into clearly defined set of groups according to the tasks and duties undertaken by those engaged in the job.

By administratively formalising an arrangement for NPs even when the more specific NNMC Bill is yet to become an Act, the West Bengal chief minister seems to be taking recourse to the existing provisions in various Acts that govern public health services. When enacted by parliament it will replace the Indian Nursing Council Act 1947.

Mamata’s announcement seems to imply her intention to elevate those nurses who have a proven track record of service and commitment as NPs. They will be a significant addition to the health service professionals in the context of persisting shortage of qualified doctors, particularly in the rural areas, she has claimed.

“It’s not a big barrier to having a cadre of NPs just because the NNMC Bill is yet to be enacted. There are a number of Acts that govern the public health delivery system. Moreover, public health and sanitation ; hospitals and dispensaries figure in the State List of the Constitution. I repeat it’s not a big barrier, said Dr Sundararaman, former executive director in the National Health systems Resource Centre, an autonomous outfit under the Union health ministry. When NNMC becomes an Act, the arrangement can be finetuned under the new legal framework, Dr Sundararaman told NewsClick from Puducherry when asked to give his assessment about the West Bengal government’s move.

Surjakanta Mishra, West Bengal state secretary of the Communist Party of India (Marxist) and former health minister in the Buddhadeb Bhattacharjee ministry , who is himself an MBBS said: “I don’t know how is she is proceeding. To the Left Front government goes the credit of introducing for the first time in the country in 2002 a ‘nurse practitioner in midwifery course with provision for 18 months’ training to diploma holders and graduate nurses, but we failed to get what you may call the authenticity stamp. Do not forget there is the Medical Council of India”, Mishra told NewsClick when asked about the chief minister’s announcement. Possibly, she wants to steal a march over other states, he added.

“She has promised to issue guidelines about how the arrangement will work. Remember, several courses and entry as also exit tests have to be conducted. It just cannot be a question of promotion of those nurses found efficient and committed. I see several grey areas in her move”, Mishra observed.

Dr Vandana Prasad, who is associated with Jan Swasthya Abhiyan (People’s Health Movement – India) in New Delhi told NewsClick : “Nurses are trained personnel. Responsibilities have to devolve. We have to reach out to the largest sections of unfortunate people who cannot access even minimum healthcare even in times of emergencies”.

She added: “But, I agree careful planning must precede building up of capacity in the NPs category and a whole set of workable regulatory practices have to be in place”. Asked about the possibility of ego clash between doctors and NPs, she said : “Possible ; therefore, there has to be in-built mechanisms for dialogues between them. Chances of matters being smooth will be greater if there is no devil in the details”.

For a large section of doctors, the devil is infact in the details( guidlines). General secretary of West Bengal Association of Health Service Doctors Dr Manas Gumta said : “We are not averse to having a cadre called NPs but it cannot be a ‘if not this, then that’-type situation. This will be demoralising for us. We are eagerly waiting for the guidelines. We will give representation, if need be, after the details are published by the government”.

Gumta added:“Why does not the government create the required infrastructure including proper education facilities in those areas to address the grievances of doctors ? There should be at least minimum facilities for a decent existence and education of their children. Governments find resources to fund this scheme and that, but when the question arises of creating infrastructure that will facilitate movement of doctors to distant places, they plead paucity of resources. In the prevailing situation, it becomes a kind of punishment posting to which they react"

Some organisations, however, of nurses have reacted strongly to certain provisions in the NNMC Bill. Nurses associations in Karnataka have demanded that categories, such as, nursing assistants, midwifery associates and home-based care personnel be excluded from its ambit as they are not equivalent to nurses. “By coining these terms, the system may end up having cheap labourers hired as nurses”, they have contented.

The All-India Government Nurses Federation has pointed out that there is no provision for election of neither members of the commission nor in the state-level boards / other outfits. Also, there is no provision for representation of clinical nurses and public health nurses. Which means democratisation is not intended. This is not desirable.

NPs as a concept is in vogue in 70 countries which include, among others, the US (1965), the UK (1980), Australia (1990), the Netherlands (2010, South Korea, Singapore and Thailand. According to a blog posted on October 25, 2018 by one Michael Barber, NPs in the US are trained, licensed and independent clinicians devoted to managing patients’ health conditions including treatment of injuries and illnesses. They specialise or even “sub-specialise” and the areas include, inter alia, paediatrics, women’s health, dermatology, behavioural health, psychiatry etc They require a master’s degree in nursing to practise. But, in recent years, a doctoral degree in nursing practice is a sought-after “track”. A registered nurse cannot prescribe medications but NPs are licensed to do so and even diagnose conditions.

A paper titled Realities, scope, challenges and facilitators for implementation of NPS’ role in India : a review written by Malar Kodi S and Suresh K Sharma of the department of nursing at the All India Institute of Medical sciences at Rishikesh and AIIMS, Jodhpur respectively has made the following observations :

A physician generally “refuses” to accept NPs due to their poor knowledge in pharmacology, pathology, anatomy and physiology. Also, they are deficient in assessment skills, diagnosis, critical thinking and decision-making. “It indicates that there is a need to restructure our basic nursing curriculum into a competency-based one. NPs have also to be equipped with “soft skills” for therapeutic communication, maintaining inter-personal relationship and ability to “break bad news”. The paper was accepted by International Journal of Nursing Science in March this year.