|Year : 2015 | Volume
| Issue : 2 | Page : 90-96
Role of Directorates in Promoting Nursing and Midwifery Across the Various States of India: Call for Leadership for Reforms
Rajni Bagga1, Vaishali Jaiswal2, Ritika Tiwari3
1 Department of Management Sciences, National Institute of Health and Family Welfare, New Delhi, India
2 Assistant Research Officer, National Institute of Health and Family Welfare, New Delhi, India
3 Programme Officer-Academic Programmes, Public Health Foundation of India, New Delhi, India
|Date of Submission||20-Aug-2013|
|Date of Acceptance||19-Oct-2013|
|Date of Web Publication||24-Mar-2015|
Prof. and Head Rajni Bagga
Department of Management Sciences, National Institute of Health and Family Welfare, New Mehrauli Road, New Delhi - 110 067
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: While the roles and responsibilities of nursing professionals have multiplied over the years, but there are huge concerns with regard to the development of the nursing workforce and human resources (HR) issues for their career growth. The major lacuna is in not involving the nursing professionals in policy framing and decision-making. As a result, there is a leadership crisis of the nursing workforce across India. Objectives: The paper, is part of the WHO supported study, entitled "Study on Nursing and Midwifery in India: a critical review", is developed with the objective to review the current organizational and management structure for the nursing positions at the State Directorates in India and obtain a Leadership perspective to strengthen nursing management capacities to address maternal health issues. Materials and Methods: The study descriptive and qualitative in nature and the sources of information were both primary and secondary collected from 16 states of India. Results: Since none of the states have neither a Nursing Cell nor the post of Director Nursing, final decision-making powers rest with state health secretaries and medical directors. The nursing management structure majorly managed by senior policy makers from the medical fraternity, and provides very little scope for nursing professionals to participate in policy decision making to bring about reforms. There is no uniformity on HR issues concerning career graphs and pay structures across the states. Conclusions: In order to strengthen nursing as a profession and for facilitating their role at the policy level, more powers and autonomy needs to be given to them and this requires HR policy guidelines for nurses. Setting up a separate nursing directorate, to be headed by a senior nursing professional, is suggested in every state along with a strong nursing division at the National level. This total paradigm shift will empower nursing professionals to take up the leadership role at the policy level to bring about necessary reforms. Across the country, nursing professionals repeatedly echoed one requirement: To reframe nursing leadership at all levels.
Keywords: Career graph, human resource management, leadership, nursing workforce management, policy decision making
|How to cite this article:|
Bagga R, Jaiswal V, Tiwari R. Role of Directorates in Promoting Nursing and Midwifery Across the Various States of India: Call for Leadership for Reforms. Indian J Community Med 2015;40:90-6
|How to cite this URL:|
Bagga R, Jaiswal V, Tiwari R. Role of Directorates in Promoting Nursing and Midwifery Across the Various States of India: Call for Leadership for Reforms. Indian J Community Med [serial online] 2015 [cited 2021 Jun 16];40:90-6. Available from: https://www.ijcm.org.in/text.asp?2015/40/2/90/153870
| Introduction|| |
The nursing workforce is the largest component of health care delivery in India. The health sector, which is human resource (HR) intensive, accounts for 70% of a state government's health expenditure. National policies and programs like the National Rural Health Mission (NRHM) has recognized that meeting the challenges of assuring sufficient numbers of well-trained and motivated health workers is essential for improving health outcomes for India's poor. The National Commission on Macroeconomics and Health,  while acknowledging that 'Nurses and midwives can make major contributions to health care development and achieve the Millennium Developments Goals (MDG) only if there is strong support at the policy level to ensure policy implementation'.
However, while their roles and responsibilities have multiplied over the years, there are huge concerns with regard to the development of the nursing and midwifery workforce, viz. selection, recruitment, placement as per specialization, pre-service and in-service training and HR issues for their career growth. The major lacuna is in not involving the nursing professionals in policy framing and decision-making. For decades, nursing professionals have not played any role in planning and policy formulation for the nursing and midwifery workforce. All the decision-making related to the nursing workforce, viz. services and education, rests with the medical directorates, with the result that nursing issues are diluted at all levels. There is a leadership crisis of the nursing and midwifery workforce across India. Though it has immense potential for decision-making, the nursing workforce has not been allowed to emerge as an independent professional body, mainly due to over-domination by the medical fraternity.
There has been an increasing research evidence to suggest the need to develop leaders in today's rapidly changing healthcare environments. ,,,, Several countries are conducting leadership training programs for nurses ,, but there are very few intervention studies to develop leadership of nurse managers.
Leadership development depends in part on organizational context and conditions, and previous research outside nursing has shown a reciprocal relationship between organizational factors and leadership development.  A recent systematic review of leadership to foster a healthy work environment carried out by Pearson A. et al., 2004  described organizational climate and supportive structures as two of eight themes that were considered more important.
But even though, its widely recognized that supportive leadership is necessary to manage context and quality patient care, there have been few studies examining the impact of leadership on innovation, adoption, and patient outcomes. ,,,
Various committees and reports such as the High Power Committee on Nursing ,, have put forward very sound recommendations for strengthening the nursing management capacity; however, there is a gap between producing policy documents and their actual implementation. This requires strong support at the policy level to ensure implementation of the key recommendations. It is important to identify the best practices and innovations across various states of India in order to develop a mechanism for their sharing and replication in other states.
In a study in 2010 by Bagga, R. et al., 2007-2009,  highlighted the key nursing management issues at the state directorates, teaching institutions, health care institutions and other professional nursing bodies and concluded that the nursing professionals need to play a more proactive role in the process of health care delivery for achieving the MDGs.
The present paper is aimed at obtaining a leadership perspective to strengthen nursing management capacities to address maternal health issues across the various states of India. For critically analyzing the role of the Health Directorates of various states in India, in promoting nursing and midwifery in India, it is important to review some of the states from both the high-focus and non-high-focus categories. The authors of the present paper, have carried out two other studies entitled Comparative Analysis of Nursing Management Capacity in the States of Uttar Pradesh (UP), West Bengal (WB) and Tamil Nadu (TN),  and Nursing Management for reproductive and child health (RCH) services in the selected North Eastern (NE) states of India  and the present Paper, hence includes the primary data collected from the states included in these studies, The analysis thus drawn, can help in assessing the current structure, HR issues and leadership status of nursing in various states of India.
The paper is developed with the objective to review the current organizational and management structure for the nursing positions at the State Directorates in India and obtain a leadership perspective to strengthen nursing management capacities to address maternal health issues.
| Materials and Methods|| |
The study was descriptive and qualitative in nature and the data was collected from both primary and secondary sources. Data was collected from 16 states of India including four high focus NE states such as Assam*, Manipur*, Tripura* and Nagaland; six high focus states such as Bihar, Chhattisgarh, Madhya Pradesh* (MP), Orissa, Rajasthan, UP*; and six non-high focus states such as Gujarat*, Haryana, Kerala*, Punjab, TN* and WB*.
For the primary data, out of these 16 states, study team visited the nine states to collect the primary data and these are marked as * and from the other seven states, information was collected through secondary sources. For the secondary data, policies and practices related to HR issues such as job description of different cadres of nursing personnel at state/district levels, recruitment/transfer rules and performance appraisal systems in the states were studied. The secondary sources of data also comprised of State-specific studies carried out in the field of nursing and midwifery by different agencies and the information so compiled from the states of Haryana, Chhattisgarh, Rajasthan, Bihar, Orissa was also analyzed.
The key informants for primary data included policy makers and senior administrators from state health departments, nursing administrators at the state directorate, eminent nursing and public health professionals at the central and state levels.
The study team used more than one approach to validate and triangulate the information collected by using both quantitative and qualitative methods such as desk review of various reports, research documents on nursing and midwifery; and the primary data collected by making use of the qualitative tools and techniques such as In-depth interviews and observation method.
The key variables used in the study were such as: Nursing positions at the state directorates, job description of different cadres of nursing personnel at state/district levels, selection/recruitment and transfer rules, performance appraisal systems, job profile, involvement in decision making, career graphs, pay structure, transfer and placement policy, supervisory and mentoring roles, leadership role and infrastructure available with the Nursing administrators in the Directorate.
Based on the primary and secondary data collected, detailed notes were prepared and information categorized into themes against the pre-decided categories.
| Results and Discussion|| |
Organizational structure and administrative positions at the policy level at the directorates, at the state level, in india
At the state level, the Department of Health and Family Welfare (DHFW) is headed by a Minister, under whom there are one/two Principal Secretaries. Below them is the Commissioner of Health, who heads the technical wing of the DHFW, assisted by Directors/Additional Directors for Medical Education and Health services. All the administrative and HR issues related with the management of maternal and child health services are looked after by the Directorates of Health Services (DHS), Medical Education and Family Welfare. The post of Deputy Director (DD)/Joint Director (JD) Nursing is either with the DHS or Medical Education (DME). There is no uniformity in the number of Directorate level Nursing Administrative positions across the states, and the nomenclature of these posts also varies across the states and the overall organizational structure appears to be quite similar.
Though some states have created the posts of DD/JD Nursing for looking after nursing teaching and nursing services' issues, it is important to critically evaluate the authority that these positions actually wield in decision-making on policy matters pertaining to nursing and midwifery issues. There is also a need to assess the leadership role of these posts in taking initiatives for bringing about desirable changes to achieve the MDGs.
It was observed, that in most of the states, either the DHS or DHFW directly looks after matters related to nursing. It was surprising to observe that despite the increasing awareness and leadership among nursing professionals in the country, a separate Nursing Division did not exist in any of the State Directorates except WB and there also the separate nursing divisions is under the supervision of Director, Health Services.
Across the country, nursing administrative positions at the health and family Welfare directorate are minimal in number for example in various states, only one post of JD or DD is available. Moreover, due to the slow pace of filling up senior level nursing posts, these posts are lying vacant. In some states, for example in UP, the JD level post for nursing is held by the medical professional.
Organizational set up and nursing positions at the directorates of various states of india
With regard to nursing positions in the organizational set-up of the state health directorates, there is a lack of uniformity across different states. There are senior level posts of JD Nursing in UP, Assam, Manipur, TN and Kerala as compared to the post of DD Nursing in WB, Orissa and Rajasthan  and Gujarat.  However, this does not reflect in their involvement in the decision-making process. Not only does the level of posts differ but also their job responsibilities, e.g. the JD Nursing in TN looks after nursing education in the State, whereas in UP, JD Nursing is the overall in charge of nursing affairs in the State. In the State of Manipur, the post of JD Nursing is only concerned with nursing education in the State and has no networking whatsoever with the Department of Family Welfare or with nursing services. The best nursing setup undoubtedly appears to be in WB which has a separate nursing division within the State Health Directorate and 15 sanctioned posts of nursing administrators in comparison to only two such posts in UP and three in TN. In Kerala, there are three nursing posts under Director Health Services and one under Director Medical Education. In TN, a unique organizational setup exists whereby nursing issues are taken care of by three directorates: DME, Directorate of Medical and Rural Health Services and Directorate of Public Health and Preventive Medicine, indicating a positive impact on better rural health care services and more enhanced nursing and midwifery services. On the other hand, Bihar has no nursing position at the state level.  There is also discrepancy in the pay scales for the JD level posts in various states, e.g. JD Nursing, UP is drawing lower pay in comparison to DD Nursing in WB.
The High Power Committee of the Govt. in 1989 had reviewed the principal challenges facing the nursing workforce and indicated reforms for developing the directorates of nursing in the states. This committee recommended that a single directorate of nursing should be created in each state with a structure for clinical nursing, public health nursing and nursing education, with the intention of bringing about better governance and accountability to key functions. However, in the last two decades, these policy directions have not been translated into action. This calls for strong leadership and political will at the top.
The states, which have had the post of JD/DD Nursing, over the last many years along with an active profile have attempted to initiate more nursing development issues in comparison to the other states. For example, in WB the post of DD Nursing came into existence in 1975, and this state was the first to start the nurse practitioner in midwifery (NPM) course along with strengthening its nursing teaching. By far the best nursing structure in the directorate appears to be in WB. But here too, the nursing division is headed by a DD Nursing and more reforms are required to upgrade this post to JD or Director Nursing.
Leadership and decision-making powers of senior nursing administrators at the directorate level in various states
Since none of the states have neither a Nursing Cell nor the post of Director Nursing, the final decision-making powers rest with the senior state health administrators and medical directors who are mainly the non-nursing administrators. The JD/DD nursing positions in most of the states, lack any involvement in the policy level decision making and are quite demotivated. This shows its direct impact on lack of initiatives/reforms for the nursing education and nursing services in the states.
There is, however, potential for leadership from within the nursing divisions of various states, e.g. WB, Kerala and MP, to name a few. This is evident from the responsibilities and functions currently assigned to the posts of DD/JD Nursing of these states, as indicated in their job profiles. In the states where the DD/JD Nursing is very proactive, she does play an active part in the decision-making process for all matters relating to formation of policy for betterment of nursing services. All the proposals related to nursing branch are processed and initiated from the nursing section and submitted to DHS/DME and the Secretariat, as the case may be. The active role played by the nursing administrators, of some of the states, e.g translate in to making attempts for increasing the number of posts of nurses and also for starting some new courses. In recent years, the states of WB and Gujarat have taken initiative to start the NPM program.
During the collection of primary data for the study, a mass consensus emerged from the nursing and midwifery fraternity across the country that repeatedly echoed one requirement: To reframe nursing leadership at all levels. There is a strong need to develop and identify nurse leaders in the existing health system, and to strengthen their leadership skills further to get the desired outcomes. These voices and needs, as emerging from across India, are reinforced through the number of research studies carried out and reported in a recent systematic review of leadership, described organizational climate and supportive structures as the main important themes.  Simultaneously, a positive organizational culture and strong supportive managers have been described as essential to incorporate research findings into nursing practice. ,,
Management processes and HR issues
Job profile and role of JD/DD nursing at state level
The job profiles of JD/DD Nursing are specified in most states (Manipur, TN, WB, UP and Kerala), and in certain other states do not exist in writing. The involvement of DD/JD Nursing in various task forces and in policy decision-making is partial and varies from state to state. This in turn inhibits the representation of nursing professionals in decision-making at the state level.
Selection criteria, career planning and promotional avenues
There is no uniformity in promotional guidelines across the states for senior-level directorate positions. Some states like Kerala and MP have very clear guidelines for selection of the post of DD Nursing in the state directorate. Promotion to the directorate- level posts in some states is on merit rather than seniority. In Kerala the post of DD Nursing Education (DDNE) is merit-cum-seniority based and is given to the senior most principal of a government nursing college. Generally, as a policy there is very little lateral movement or transfer of professionals between the teaching and clinical sides. The reason could be the salary structures, which are higher on the teaching side. For example, the tutor in a nursing school gets a higher salary as compared to a head nurse in a hospital, although their educational level is the same. Promotions are based on seniority at all levels, and additional/higher qualifications do not lead to promotional/service benefits for the senior level nursing posts including the directorate level posts. The absence of merit and qualifications as the criteria for promotional growth has led to de-motivation among the nursing professionals to acquire more qualifications. In various states, the seniority lists, for the senior level positions are not being kept updated, and the departmental promotion committees (DPCs) are not held in time. This has resulted in senior level positions lying vacant in various states, e.g. the posts of district public health nursing officer (DPHNO) and public health nurse (PHN) are not filled for certain period of time.
There is no uniformity in the pay scales across states. In most of the states the teaching cadre is relatively better paid than the non-teaching cadre. These ambiguous and non-uniform guidelines need consideration.
There is partial implementation of the policy guidelines for transfers and in various states like e.g. in UP and MP, the decision-making for transfers is often politically influenced. In the other states like WB, Kerala and TN, posting and transfer guidelines are available and are followed. These senior level administrative post do not enjoy any administrative or financial power neither are they part of any policy decision making body.
These nursing administrative positions are deprived of decent infrastructure resources and in most of the offices the official resources are minimal. There is skeletal supportive staff made available to these posts.
Key conclusion drawn from the role of the state directorates
- The nursing management structure is majorly managed by senior policy makers from the medical fraternity, and provides very little scope for nursing professionals to participate in policy decision making and to bring about any reforms.
- Across the country, the study identified very weak organizational structures of the policy making bodies at the Directorate levels, in terms of nursing positions. West Bengal is the only state that has a separate nursing division. In the absence of any nursing position at the top decision-making level in the Directorates, all policy decisions are framed by medical professionals and administrators, with nursing professionals having only a marginal say. This has translated into lack of reforms being initiated in the states for improving the capacities of nursing workforce and a common example of this, across the states is the shortage of nursing human power in both teaching as well as service delivery setups. Lack of decentralization, autonomy and financial powers with the Nursing administrators has led to unnecessary delays in administrative and other managerial affairs of the nursing workforce.
- As learnt during interaction, there does not seem to be any coordination between the senior nursing positions under the Department of Family welfare/Department of Medical Services (DMS) and DME.
- There is no uniformity on HR issues concerning career graphs and pay structures across the states. At a time when India has set reforms in place with its flagship program, the NRHM, and is making attempts to achieve the MDGs, it is crucial to focus on strengthening the nursing services by bringing about reforms in the key HR issues for building the Nursing positions in the states.
- The absence of nursing leadership positions at the state directorates has also led to the weak supervisory structure for nursing staff, both in clinical and public health cadres. The need of the hour is to bring about institutional reforms by creation of nursing directorates in each state.
Recommendations: Strengthening nursing leadership at the directorates for policy level reforms
- The contribution of the nursing cadre to the overall health of the nation demands more visibility. Today, nurses need to be equal partners in the process of health care delivery to achieve the United Nations' MDG. This requires a complete image changeover, keeping in line with the ever-emerging importance accorded universally to the nursing profession.
- As per the detailed report on "The future of nursing: Leading change, Advancing Health  stresses upon the requirement of strong leadership on the part of nurses. Today, there is a need to bring about sustained change but this can only happen if we have systematized leadership in the education sector, service delivery, within the councils and associations and above all with the policy makers at the Directorates.
- In order to strengthen nursing as a profession and for facilitating their role at the policy decision level, more powers and autonomy needs to be given to them. Setting up a separate nursing directorate is suggested in every state. This will empower nursing professionals to take up the leadership role at the policy level to bring about necessary reforms. The directorate should be headed by a senior nursing professional in the post of Director Nursing. She should enjoy powers similar to that of the Director Medical Education and Director Health/Medical Services. The nursing division should be adequately staffed and should have three (JDs), one each for Nursing Education, Nursing Services (Clinical), and Public Health Nursing. Each JD should be supported by two DDs Nursing. It is suggested that promotions to the administrative posts in the Directorates be based on both seniority and merit. The senior most principals of the colleges of nursing can aspire to get the post of DD Nursing Education; similarly, the senior most nursing superintendents of the hospitals can aspire for the post of DD Nursing Services. The JD Nursing and Director level posts should be purely based on merit. It is suggested that the post of DDHR (HR) be created under Director Nursing for promoting HR issues. Again, this post has to be a selection post based on merit, and the candidates can be from the teaching as well as the services side.
- While suggesting for setting up a state level Nursing directorate, it is very vital to first set up a strong nursing division at the National level, in the central Ministry of Health and Family Welfare, to be headed by Director. It is hoped that establishing such a directorate will not just ensure professional credibility of the nursing workforce but also empower them to take Leadership role as key decision makers for policy level reforms.
- The government health system accordingly needs to re-design its HR policies and strategies for increasing the various nursing positions from the periphery to the tertiary level, while also revising the norms for career growth and retention of the nursing workforce.
Limitations of the study
The observations should be viewed in light of the fact that this was a descriptive study based on the interviews of key informants. Primary data were not collected through sample surveys. The study results derive from the opinions and personal experiences of the key informants, and the researchers' interpretations of the interviews and secondary data.
| Acknowledgement|| |
The study was awarded and funded by WHO. The research team is thankful to the WR- WHO, Ms Nata Menabde and Dr Paul Francis NPO, and to late Prof. Deoki Nandan, the former Director of NIHFW for their support and guidance for conduction of the study.
| References|| |
Kumar D. Nursing for the Delivery of Essential Health Interventions in India: Background paper for the Report of the National Commission on Macroeconomics and Health. Ministry of Health and Family Welfare, Government of India; 2005. p. 175-83.
Antrobus S, Kitson A. Nursing leadership: Influencing and shaping health policy and nursing practice. J Adv Nurs 1999;29:746-53.
Dixon DL. Achieving results through transformational leadership. J Nurs Adm 1999;29:17-21.
Dunham-Taylor J. Nurse executive transformational leadership found in participative organizations. J Nurs Adm 2000;30:241-50.
Porter-O′Grady T. A different age for leadership, part 2: New rules, new roles. J Nurs Adm 2003;33:173-8.
Kilty HL. Nursing leadership development in Canada: A descriptive status report and analysis of leadership programs, approaches and strategies: Domains and competencies; knowledge and skills; gaps and opportunities. Ontario, Canada; 2003:Canadian Nurses Association.
Cunningham G, Kitson A. An evaluation of the RCN Clinical Development Programme: Part 2. Nurs Stand 2000;15:34-40.
Tourangeau AE, Lemonde M, Luba M, Dakers D, Alksnis C. Evaluation of a leadership development intervention. Nurs Leadersh (Tor Ont) 2003;16:91-104.
Yukl GA. Leadership in organizations. 6 th
ed. Upper Saddle River: Pearson Prentice Hall; 2006. p. 320.
Pearson A, Laschinger H, Porritt K, Jordan Z, Tucker D, Long L. Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in health care. Int J Evid Based Healthc 2007;5:208-53.
Perra BM. Leadership: The key to quality outcomes. Nurs Adm Q 2000;24:56-61.
Snow JL. Looking beyond nursing for clues to effective leadership. J Nurs Adm 2001;31:440-3.
Vance C, Larson E. Leadership research in business and health care. J Nurs Scholarsh 2002;34:165-71.
Patrick A, White P. Scope of nursing leadership. In: McGillis Hall L, editor. Quality Work Environments for Nurse and Patient Safety. Sudbury: Jones & Bartlett Publishers International, Mississauga,ON ; 2005. p. 181-212.
Report of High Power committee on Nursing and Nursing Profession. Ministry of Health and Family Welfare. Government of India, Manager of Publications; 1989.
In: Visaria L, editor. Bagga R, Shehrawat R, Gade J, Nandan D, Mavalankar D, Sharma B ,Sherin R. et al
. Comparative analysis of nursing management capacity in the states of Uttar Pradesh, West Bengal and Tamil Nadu. Midwifery and Maternal Health in India: Situation Analysis and Lessons from the Field. Ahmedabad; Centre for Management in Health Services, IIM, CMHS Monograph no.1; 2010.
Bagga R, Jaiswal V. NIHFW, Nursing Management for RCH services in the selected North Eastern states of India. Final report. New Delhi; ICMR: 2013. Contract No:. Adhoc/2010/05/HSR.
Bagga R, Tiwari R, Jaiswal V, Abraham A. NIHFW, Study on Nursing and Midwifery in India: A Critical Review; Final report. New Delhi WHO; 2011. APW Regn. No. 2011/150503-0, Purchase Order No: 200376607.
ANSWERS, Study Report on Nursing Services in Orissa, Current Situation, Requirements and Measures to Address Shortages. National Health Systems Resource Centre, National Rural Health Mission, Ministry of Health and Family Welfare; Government of India; 2009.
Sharma B,Sweta R, Mavalankar D,Ranjan P, Trivedi P. The District Public Health Nurses: A time and activity study from Gujarat. Midwifery and Maternal Health in India: Situation Analysis and Lessons from the Field. Ahmedabad, Center for Management in Health Services, IIM: 2010. W.P. No. 2010-02-04 February 2010. Available from: http://www.iimahd.ernet.in/publications/data/2010-02-04Sharma.pdf
[Last accessed on 2013 Mar 20].
Stetler CB, Brunell M, Giuliano KK, Morsi D, Prince L, Newell-Stokes V. Evidence-based practice and the role of nursing leadership. J Nurs Adm 1998;28:45-53.
Udod SA, Care WD. Setting the climate for evidence based nursing practice: What is the leader′s role? Nurs Leadersh (Tor Ont) 2004;17:64-75.
Pepler CJ, Edgar L, Frisch S, Rennick J, Swidzinski M, White C, et al
. Unit culture and research-based nursing practice in acute care. Can J Nurs Res 2005;37:66-85.