The yearly ‘thank you’ to nurses is not enough
Meena Putturaj
is an Assistant Professor, DBT/Wellcome Trust India Alliance Fellow at the Institute of Public Health Bengaluru
More needs to be done in India’s health system so that nurses are seen not only
as caregivers but also as leaders
May 12 has passed, an annual day where we honour Florence Nightingale and celebrate the
unsung heroes of health care — nurses. We praised nurses on this day (International Nurses
Day), but the urgency to truly empower the stars of our health-care system quickly fades.
Nursing beyond tradition
Nurses and midwives form nearly 47% of India’s total health workforce, yet remain under-
represented in leadership, policymaking, and autonomous clinical roles. The perception of
nurses as being mere assistants to doctors still prevails, limiting their potential, despite global
trends that prove otherwise. The role of Nurse Practitioners (NPs) as independent, advanced
care providers capable of addressing health-care gaps has been embraced in Australia,
Botswana, Brazil, South Africa, Thailand, the United Kingdom, the United States and Zambia.
NPs are advanced practice registered nurses (such as clinical nurse specialists, certified nurse
midwives and certified registered nurse anaesthetists) with specialised training, usually at the
master’s level. They are certified to diagnose, treat, and prescribe independently in many
settings. India has recognised the need for NPs, particularly to expand health-care access in
underserved areas. The National Health Policy 2017 has acknowledged that mid-level
providers, including NPs, are crucial to primary care. Despite the Indian Nursing Council (INC)
initiating structured NP programmes, notably the Nurse Practitioner in Critical Care (NPCC) in
2017 and also the Nurse Practitioner in Primary Health Care (NPPHC), integration remains slow.
Initiatives such as the NP in Midwifery programme (2002) in West Bengal and similar efforts in
Telangana and Kerala have struggled in the absence of a clear legal framework, defined roles
and protected titles. Although some institutions have developed in-house training for extended
roles (stoma nurses, diabetes educators, stroke nurses), these positions lack regulatory backing
and national recognition.
India’s NP education programmes are designed to focus on advanced clinical skills, diagnosis,
treatment, limited prescribing authority, and community engagement. However, there are
challenges, a key barrier being the absence of a clear legal framework defining the NP scope of
practice, including prescriptive rights. Resistance within some in the medical community, driven
by fear of losing power, complicates integration. The curriculum emphasises clinical skills but
leaves regulatory frameworks, licensure clarity, and career pathways murky. Who will licence
NPs? Will they be recognised legally? Will they be absorbed into public systems or left out? This
ambiguity is not just administrative, but is also existential for nurses.
Lessons from Australia
The NP movement in Australia is instructive, having begun with a clear goal to improve access
in underserved areas and provide clinical autonomy to qualified nurses. But what made it work
was more than just policy; it was politics. Nursing movements were part of the policy dialogues.
Legislation protected the NP title. Licensure was formalised. Career ladders were created.
Importantly, nurse-led models such as walk-in centres demonstrated that care does not always
need a physician’s stamp to be effective, safe, and appreciated.
Resistance to nurse autonomy in India stems not only from policy gaps but from entrenched
cultural, gender, and hierarchical biases that position nurses, predominantly women, as
subordinates to doctors. This mindset influences policy decisions, including opposition to NP
roles by the medical community, despite global evidence of their effectiveness. There is also a
crisis in the nursing education sector due to lax regulation and corruption. Although the
National Nursing and Midwifery Commission Act, 2023, signals reform, its real impact remains
uncertain. Compounding these challenges is the lack of strong, unified nursing movements,
limiting the profession’s power to engage in policy processes.
Let nurses lead
NPs are formally recognised in a number of high-income, low- and middle-income countries.
Ironically, while Indian nurses excel abroad in NP roles, their potential remains untapped at
home. Evidence shows NP-led care matches those with physician outcomes, with high patient
satisfaction and lower costs. For India, adopting a collaborative, team-based care model, where
nurses practise to their full scope, is progressive and essential to delivering equitable and
quality health care.
Realising NP roles in India demands urgent reforms in nursing education, regulation and
nursing leadership. This includes closing substandard colleges, enhancing faculty competency,
bridging the theory-practice gap, and integrating ethics and leadership, and policy engagement
components into nursing curricula. Legal recognition of NPs, with defined licensure and
accountability, is crucial. Clear career pathways, fair pay and advancement opportunities must
replace the stagnation in nursing roles. Addressing the gender-based undervaluation of
nursing is also essential. Critically, nurses must lead nursing reforms through sustained policy
engagement. Given their lived experiences, nurses are uniquely positioned to advocate change
and challenge medical hierarchy. To achieve this, grassroots nursing movements that are
bolstered by strategic alliances and driven by courage, commitment, and the capacity to speak
truth to power are needed.
A yearly “thank you” is not enough. India needs a health system that sees nurses not just as
caregivers but also as leaders. Honouring them means confronting hard truths about power
and privilege.
