The recent tragic incident in a Karachi hospital, where a child lost her life because of an injection given by a nurse aid/paramedic (not a qualified nurse), is one of the many cases taking place all over the country. Wrong administration of injections by trained and untrained health workers is a cause of mortality and morbidity in a number of cases. This time it was reported because the incident took place in the parents’ presence and they chose to speak out.
All over the country, government and private hospitals are full of untrained health workers performing nursing duties without proper training and with no supervision. We face an acute and persistent shortage of trained, skilled and competent nurses, as a result of which hospitals and other health facilities have to rely on these inept health workers.
In such a dire situation, the President of Pakistan — himself a member of the medical community — initiated a 3.5 billion-rupee project by abolishing the Diploma of Nursing programme, without realising its consequences. The project entails starting a degree programme in nursing which will produce 100,000 nurses in four years, as well as establishing a nursing university. Instead of strengthening the ongoing nursing, midwifery and special nursing programme, the president opted for the above-mentioned project without the infrastructure for a degree programme or the availability of competent faculty.
Tragic incidents of errors leading to loss of life continue in hospitals because of the lack of trained nurses and paramedics
To understand nursing care and nursing education in Pakistan, it is important to have some idea of its background in the subcontinent. In the early 16th century, the Portuguese army brought some nurses to look after injured soldiers posted on Malabar and Cochin coast. In 1664, the East India Company started a military hospital for soldiers in Fort St George in Madras, for which nurses were brought in from St Thomas Hospital, London.
Another hospital was built for the poor of Madras in 1797 by the British, and Dr John Underwood was appointed as its administrator. A nursing and midwifery school was opened in this hospital in 1854. In 1858, the Queen Alexandria Military Nursing Services programme was initiated for military hospitals in India.
After Florence Nightingale gave her suggestions, in 1865, to organise a system of nursing in hospitals of India, St Stephen Hospital in Delhi, in 1867, became the first to start a nursing training programme for Indian girls, for which British nurses and midwives were brought in as faculty. From 1890 to 1900, many schools of nursing were opened in missionary hospitals all over India.
In the early 20th century, men had begun to be accepted for nursing training. In 1908, the Trained Nurses Association of India was established to organise the nursing profession. In 1918, training schools were started for health visitors and dais in Karachi and Delhi, under the supervision of English nurses. In 1926, the first registration council to register nurses was established in Madras. At about the same time, big hospitals, health centres, medical colleges and nursing schools were opened in different parts of India.
In 1943, the British government formed a committee under the chairmanship of Sir Joseph Bhore, who submitted his report in 1946. He recommended that medical services should be free for all without distinction, doctors should work to protect people and health services should act on the principle of prevention rather than cure. He recommended provision of one primary healthcare centre for a population of 40,000 with two doctors, four primary healthcare nurses, two midwives, one general nurse, four trained dais, two sanitary inspectors, two health assistants and one pharmacist. He also recommended th training of a large number of nurses for hospitals.
Unfortunately, the governments of the newly founded states of India and Pakistan ignored most of Bhore’s recommendations regarding health as a right of people and the training of health workers. Medical education and hospitals became big business and we started producing doctors who were more interested in money-making and who were least bothered about protecting people from disease. The training of nurses, midwives, paramedics and other health workers are not among government priorities.
In India, the parliament passed an ordinance to create the Indian Nursing Council (INC) on December 31, 1947 and the council was established in 1949. The INC started training auxiliary nurses, midwives and general nurses to expand the healthcare system, and a Bachelors and Masters degree programme was started in 1960.
Presently, in India they have a nursing examination board, which awards a diploma after two years of training to auxiliary nurses and after three years of training to general nurses and midwives. The universities conduct two-year Bachelors, two-year Masters, one-year M.Phil and three- to five-year PhD programmes in different branches of nursing.
In Pakistan, the Pakistan Nursing Council (PNC) Act was passed in 1948, but the PNC was only established after the constitution of 1973 to regulate nursing education and training in the country. Unfortunately, the nursing profession was not considered a respectable profession among the Muslim majority population of the country. Half-hearted steps were taken for the promotion of nursing education and training; midwifery was totally ignored and there was no concept of specialised nurses.
The majority of nurses came from the Christian community, and the missionary hospitals played an important role in their training. Initiated by international donor agencies, attempts were made to improve the curriculum of the diploma in general nursing. Unfortunately, the new curriculum was not implemented and no attention was given to develop human resources to run schools of nursing and midwifery as per the revised curriculum.
In 2006, the PNC — with the help of the Higher Education Commission (HEC) — developed a new curriculum for Bachelors in Nursing (BScN). Both the PNC and the HEC were not interested in reviewing the curriculum of midwifery. Neither did they bother to develop a degree programme for teaching faculty for nurses interested in administration or other growing branches of nursing such as intensive care, anaesthesia, infectious diseases or neonatal care.
Surprisingly, after a few years, the PNC suddenly came up with the idea of abolishing the diploma and certificate programmes in nursing and midwifery and asked the nursing schools to start the BScN programme and obtain affiliation with medical universities.
The PNC did not realise that there is no trained faculty available to teach students in institutes that are often without a library, skill labs, proper classrooms and basic facilities such as drinking water and toilets. Such decisions were taken without consultation of the nursing profession or understanding ground realities regarding healthcare or the important role of nursing. The decisions were taken by doctors with a vested interest in medical colleges and universities.
It seems that the same kind of vested interest group is controlling the president’s 3.5 billion-rupee initiative. It does not address the real issues related to nursing/midwifery teaching and training, which can produce competent human resource that can ensure that incidents such as the one mentioned above do not occur anywhere in the country.
It’s high time that the president should form a powerful, competent task force for the proper utilisation of 3.5 billion rupees. The task force should address the following issues as soon as possible:
• Continuation of diploma and certificate programme for auxiliary nurses, midwives and general nurses.
• Uplifting of all nursing and midwifery schools and provision of facilities such as classroom furniture, libraries, skill labs, clean drinking water, toilets and hostels for students.
• Closure of all those schools of nursing and midwifery in the public and private sector that are not fulfilling the minimal recommended criteria and requirements of the PNC.
• Appointment of teachers for English, Urdu and science subjects (foundation education) during the diploma programme to prepare students for Bachelors, Masters, MPhil and PhD programmes. It seems that the federal and provincial governments will not be able to control the treacherous mafia in school and college education in the near future, hence training must include arrangements for this foundation education for their students.
• Initiation of a massive programme to develop competent faculty to teach and train students in nursing and midwifery schools. A tutor training programme can be started with the help of existing senior faculty and experts in the field of education.
• A merit-based career structure should be developed for teaching faculty, nurses and midwives, with handsome salaries on the basis of qualification and performance. Recently, the health ministry of Sindh has developed an attractive career structure for nurses and midwives which awaits legislation.
• There is no need for a university of nursing for blue-eye candidates to become vice and pro-vice chancellors, deans, registrar and professors, as this model has not improved medical education and healthcare at hospitals attached to medical universities in the country.
• Lastly and very importantly, a powerful, independent, autonomous and meritorious Nursing and Midwifery Council is required to run the affairs of nursing and midwifery, in consultation with the profession and without the interference of vested interest groups and government.
It will be a pity if the 3.5 billion rupees announced by the president are wasted because of bad planning and a lack of realisation about the real issues related to life and death of the poor people of Pakistan.
The writer is ex-secretary general of Pakistan Medical Association. He and his team have translated more than 20 books of nursing and midwifery from English to Urdu and Sindhi for local students
Published in Dawn, EOS, June 2nd, 2019