Setting the agenda for nurse leadership in India: what is missing

Nurses form the backbone of India’s health system representing 30.5% of all health workers in India [1]. Nevertheless, the inability to train, retain and deploy an adequate number of qualified nurses has been recognized by experts as one of the greatest challenges for achieving health system effectiveness [2, 3]. It is estimated that India needs an additional 2.4 million nurses to reach their optimal number in the health system [4, 5]. Recent initiatives have attempted to redress the nurses’ shortages in health care delivery and tried to correct imbalances in their geographical distribution [6].

Nevertheless, the lack of numbers is not the only problem faced by the Indian nursing. Their role in decision making, both in the clinical and public health domains is not recognised in India. Several experts have documented the state of affairs of nursing in the public and private sector and the official apathy towards them. They have described how status hierarchy among various cadres of health professionals which positions nurses at a lower place compared to medical professionals and the nurses’ dominant gender identity within the socio-cultural contexts constrain their ability to take up leadership positions in their own professional realm as well as in health sector [7, 8]. Nair and Prescott have argued that nurses’ compromised professional and social acceptance has direct repercussions on their performance and contribution to health system [9]. The low position of nurses in the hierarchy of health care professionals, poor working conditions, low salary, and out-dated personnel norms, all operate in vicious cycles to create compromised professional position of nurses. Skill development and career progression opportunities for nurses in India are meagre [8]. Abjuration of several nursing leadership positions at the district and state level in the public sector has been reported in a previous study [10]. Likewise, the experts who have commented on a major strike of the nurses working in private sector in the national capital had identified exploitative working conditions akin to bonded labour as the reason for their strike [9].

The current situation of nursing in India warrants several policy reforms to counter the adverse service and social conditions in order to facilitate their overall professional contribution as a valuable human resource. The situation of nurses has special significance for equitable health services in developing country contexts such as in India as most of them are placed as the frontline health workers in remote and difficult locations and play key role in addressing various social determinants of health. Several official committees appointed by government to look into nursing issues in the past have recommended various reform proposals. These recommendations vary from increasing the number of nurses in the health system to establishment of key positions for nurses in the higher bureaucracy. Nevertheless, the recent reforms have only focused on recruiting and deploying more nurses and the leadership challenges faced by nurses are generally overlooked.

The agenda of building nurse leadership occupies a central position in the WHO’s strategic directions for nursing and midwifery globally, in recognition of their potential to act as “agents of change” within health systems [11]. The 1987 WHO report on nursing promotes a vision of nurse leadership which is about creation of ‘empowered nurses’ who mobilize, influence and collaborate at multiple levels [12]. Previous studies on nursing have established the link between strengthening nursing leadership and better health system performance [13‐15]. However, nurses’ leadership potential is negatively impacted when their status among the professional hierarchy are compromised compared to medical and other health professionals [16, 17].

Most literature on nurse leadership conceptualise leadership as individual ability to influence others towards achievement of relevant organizational goals [13, 14]. In this article, we examine nursing leadership as a means to strengthen the health system, by building structures that facilitate and support the leadership potential of every nurse in the system in order to achieve health system goals [18]. This concept of ‘distributed leadership’ is a shift from focus on the agency of individual leaders to the characteristics and design of the systems that facilitate leadership culture [19, 20]. The focus of this paper is on the policy reforms that are required to address the structural and systemic change that could facilitate nurses’ distributed leadership and enhance their roles as “agents of change in the health system”.

This study explored the process of agenda-setting for policies that could facilitate distributed nurse leadership in India, in public and private sector and in clinical and public health field, with the intention of understanding what factors are preventing action to strengthen the nurse leadership in India. Analysing the ‘agenda setting’ process is a way of understanding which issues, under what contexts gain policy attention. A key focus of such research is the attention on the process through which new ideas or policies may or may not be accepted within a political and policy system [21]. Therefore, research on agenda setting may also help in understanding the dynamics of status quo in policy process and explore potential pathways through which change can be facilitated.

In order to understand the policy propositions for addressing nurses’ leadership crisis, we reviewed various key official documents at the national level and their prescriptions regarding nursing administrations, education and deployment. Two key documents included in this review are a report of the High Power Committee set up by the government of India that recommend several nursing reforms and a review report of status of nursing in five states undertaken by the National Health System Resource Centre, Ministry of Health and Family Welfare and ANSWERS [22, 23]. The other documents are Bhore committee report of 1946, the Indian Nursing Council Act of 1947 and its three amendments, the code of ethics and professional conduct prescribed by the Indian Nursing Council, the professional conduct etiquettes by Trained Nurses Association of India, Chadah committee report of 1963, National Health Policies of 1982 and 2002 and Clinical Establishment Act of 2010. The review of these documents helped to identify the reform proposals, status of their implementation and various challenges with respect to the agenda of strengthening nursing leadership.

In addition, nine (09) interviews took place (between 5 and 24 August 2013) in New Delhi, Andhra Pradesh and Kerala with experts who were identified according to their interest in nursing governance and the extent to which they have information and knowledge on decision-making and implementation of policies dealing with nurse leadership. Though three interviews were carried out at the state level, all interviewees had expertise on nurse leadership issues at the national level. Except for three, all the other participants were qualified nurses. The Table 1 describes the characteristics of Key Informants interviewed in the study.

Though this study was based on limited number of expert interviews, it was felt that saturation was reached with each informant identifying similar barriers to nurse leadership and solutions to these.

A topic guide was developed to help conversations with informants and questions were formulated with the aim of obtaining relevant, complete and contextualized information on nurse leadership and on appropriate policy solutions that address nurses’ leadership crisis in India. The interviews were held in August of 2013 and started by exploring the context of nurse leadership in India and structural and systemic constraints in setting the agenda for policy reforms on the issue.

All the interviews were in English and handwritten notes were taken at the time of interview and later transcribed into text format. Data were thematically organized and classified according to ‘legitimacy’, ‘feasibility’ and ‘support’, in line with Hall’s agenda setting model [24]. The model stipulates that a policy issue needs to fulfil the criteria of legitimacy, feasibility and support in order to be included in the policy agenda. Legitimacy is conceptualised as the “characteristic of issues which governments believe they should be concerned with and in which they have a right or even obligation to intervene”. Feasibility is about implementation potential, which is dependent upon i) technical and theoretical knowledge; ii) financial resources and human capital; iii) administrative capability and infrastructure. ‘Support’ denotes the level of public support for government in relation to the issue.

Ethical clearance was obtained from the Ethics Committee of London School of Hygiene and Tropical Medicine, the institutions of two of the authors. Consent was obtained from the study participants interviewed, after providing them with information regarding the study’s aims and objectives. Consent forms ensured their confidentiality and anonymity, and codes were assigned to protect their identity.

Drawing on the document review, we first clarify the structure of nursing institutions in India. Section B then presents main policy reform proposals for advancing nurse leadership extracted from our review of the key documents and the status of these reforms at the time of the study. Based on the core objectives of these reform proposals, we group them under two headings; policies proposed for creating social mobility and policies for strengthening nursing institutions. Under section C, based on expert interviews which reflected on contextualised assessment of the policy process concerning nurses’ leadership reforms in India, we outline our findings about agenda setting using Hall’s agenda setting model.

Policy reforms needed to address the nursing leadership crisis are challenged by the range and complexity of issues as identified in the study. The limitation of the study is the small number of key informants who participated. The Hall’s framework which analyses the process of agenda setting of policies based on the concept of legitimacy, feasibility and support provides an opportunity to compare and understand the experience of nursing leadership in other settings.

An unclear clinical responsibility assigned to nurses in their healthcare domain is described as a reason for low legitimacy for policies facilitating nurse leadership in Jordan [30]. Enhancing the image of nursing sector is seen as crucial step towards creating an enabling environment for national structures and processes that facilitate nurses’ leadership [31, 32]. The structural forces that shape the perception of nursing will be a major challenge in India. As a 1987 WHO report on nursing highlighted, “the nursing culture remains heavy with subordination without influence…(and) burdened with obligation without power” and had predicted that the nursing sector should “expect to face resistance yet take up positions from where it can voice its opinions at policy and decision-making levels” [12].

Understaffing at key national-level nursing institutions weakens the feasibility of framing relevant issues and policy solutions. The experience of nursing in other countries point to the need for creating strong leadership among academic nurses as a precursor for changes across the sector [33]. An attempt in the past to develop nurse leaders in academic setting in India has shown challenges. This isolated effort to build academic nurse leaders met with only limited and unsuitable gains in the context of several structural constrains, including social and organizational constraints [34].

Gaining support for policy reforms is contingent upon nurses’ ability to collectively demand for change. Absence of tactical advocacy strategy targeting key actors and civil society is seen as a major shortcoming of the nursing sector in India. Nurses should consider building strategic alliances across the health system to push for policy reforms promoting nurses’ leadership within the health system. Carter identifies nurses’ own reluctance to challenge the male domination of the health system as the major hurdle in changing the structural limitations of the nursing profession [35]. Fletcher argues that the style of leadership in nursing has been a reflection of an oppressed group, shaped by the oppressing social forces. He calls for increased self-reflection and dialogue as a way ahead to break the cycle of oppression and lead to changes in the structures that oppress nurses [36].

Experiences of the nursing sector in other countries resonate with Indian scenario. For example, the experience of South Africa, which is known for stronger participation of nurses in the health system, shows that nurses’ leadership development during apartheid years was strongly entangled in the political context and depended on their ability to create strategic alliances and protect self-interest [16]. Another article on Democratic Nursing Organization of South Africa describes the role played by the organization in uplifting the status of nurses by mobilising, unifying and organising nurses as a collective group in South Africa [37]. Unification of the nurses and their collective power is identified as the way forward for empowering nurses in Iran, where, as in India various contextual factors constrain nurses’ leadership potential [17, 38].

Furthermore, the possibility of achieving results with active government support should not be understated. The recent government interventions and reforms that promote scaling-up of nursing education and strengthening of nursing curricula include strong inputs towards communication, policy and planning modules [26]. The expectation is that empowered by their newly acquired skills, nurses will be able to advocate for their increased role in health sector.

The absence of effective policies that create distributed and bottom-up nurse leadership in India called for this analysis of policy-making processes. This paper specifically sought to examine the agenda-setting process to understand the constraints on policy development for nurse leadership. This paper shows that the agenda of strengthening distributed nurse leadership in India is constrained by both the compromised social position of nurses and the imbalance in distribution of power and influence of nurses within the health system. This analysis also brings to attention the need to go beyond a strategy of creating few nurse leaders at the top. There is consensus among the experts that the nurse participation in decision making from the grassroots to the institutional level requires several facilitating policies targeting various levels of health system.

The study reinforces the argument that the determinants of nursing empowerment and leadership can only be addressed through deliberate attempts to enact institutional reforms that facilitate nurse leadership and through nurses’ collective advocacy to question the status quo and the structures that uphold it. This study further highlights the importance of generating further evidence on linkages between governance and policy reforms for health human resources and its influence of health system performance. A deeper understanding of the health system leadership arrangements, especially the distributed leadership will play a key role in creating equitable, efficient and accountable system.