To mark the 200th birthday of Florence Nightingale, the World Health Organization (WHO) designated the year 2020 as the Year of the Nurse and Midwife. Nurses and midwives play a critical role in providing health services, by dedicating their lives to caring for mothers and children, giving lifesaving immunisations and health advice, looking after older people, and generally meeting everyday essential health needs. They are often the first and only point of care in their communities.
Since mid-March 2020 we have witnessed surreal images of a world that appears to have come to a standstill in response to COVID-19. The number of COVID-19 cases in India rose from a single case which was detected in Kerala in January 2020 to over 84,62,080 by the first week of November 2020. In India, as in many other countries, lockdown was enforced to minimise transmission of the virus but nurses continued to report to work every day to care for the sick, while risking their own lives. COVID-19 has mandated the need for every nation to invest in nurses and midwives as part of their commitment to achieve Universal Health Coverage. At the time of writing, nurses continue to work on the frontline of this pandemic.
The demand on healthcare
As Professor in the Department of Community Health Administration at the National Institute of Health and Family Welfare (NIHFW), the apex technical institute of public health in India, I am involved in the teaching and training of health professionals, including doctors and nurses, as well as conducting research in public health and specialised projects, including Reproductive and Child Health (RCH) and skills-lab training for health professionals in Reproductive, Maternal, Newborn and Child and Adolescent Health (RMNCH+A).
In India, nurses constitute two-thirds of the health workforce and 90% are female. Through various movements and technological developments, nursing today has witnessed several changes and the role and responsibilities have expanded. In 2018, the Government of India introduced the Ayushman Bharat Mission, a scheme to provide free access to healthcare for 40% of the population as part of the National Health Policy. Following this, the demand on healthcare services and for healthcare workers with appropriate skills has increased.
Challenges on several fronts
The education gained pre-service often does not equip nursing students with the requisite practical knowledge and skills to meet health needs. To fulfil multiple roles and responsibilities, efforts have been taken by the Government and regulatory body to strengthen nursing education and services. As a core group member constituted by the Ministry of Health & Family Welfare, I was given the opportunity to contribute to the advancement of nursing education in India. This has included curriculum development of induction and promotional training for nurses, preparation of Operational Guidelines for Strengthening Pre-Service Education in Nursing and Midwifery, guidelines for the implementation of Skills-Lab Training, the development of a curriculum for nurse practitioners in midwifery, and a training module for mid-level health care providers in community health nursing.
Despite these advancements, the current pandemic has made it necessary for teachers and trainers of public health professionals like myself to move onto online platforms to deliver urgent teaching and training on various aspects of COVID-19, and to equip workers with the skills and practical knowledge needed to deliver healthcare during this time. Though they have been taught about the prevention and control of infection and infectious diseases in their regular practice, due to the scale of the epidemic, speed of its spread, and lack of pre-existing scientific data, nurses are facing several challenges in efficient management of patients with COVID-19 and protecting themselves from infection.
Challenges have included a lack of resources and personal protective equipment (PPE), with many working in non-critical care units relying on homemade or bought face protection, and others re-using one-use masks due to shortages; the exposure risks involved in putting on and taking off PPE; and with the rise in the number of cases, increasing demand for nurses to work longer hours, resulting in the limitations on exposure time
to infected patients becoming redundant. In addition, the lack of scientific data on COVID-19 transmission and its symptoms has meant patients receiving treatment for unrelated reasons are later being diagnosed with COVID-19, with nurses and fellow patients having unknowingly been exposed.
In response to the pandemic, new training has been developed by the Department of Personnel and Training (DOPT), involving information on how the virus is transmitted, how to manage patients with COVID-19, and how nurses should protect themselves, including how to put on and take off PPE safely. We have also been involved in coordinating and monitoring training activities related to COVID-19 management across states with the help of the State Institute of Health and Family Welfare (SIHFW).
For current students, all teaching has moved online to enable them to continue their studies, however this poses a new challenge for medical and nursing students. Due to COVID-19 restrictions, students are facing a lack of experience in clinical and field exposure, which ranges from time usually spent in Outpatient Departments and ward posting, to peripheral health facilities where they interact with patients and teachers to present cases and enhance their communication and clinical skills.
To manage this gap, we have used simple virtual reality and computer simulations, websites, and blogs to host
videos demonstrating essential skills, such as procedural clinical and communication skills. While these changes are enabling teaching to go ahead, we still face challenges in fully implementing online teaching and training, which include economic constraints, lack of infrastructure and resources, and a lack of knowledge in the use of online platforms amongst teaching staff and students.
In order to adapt to the latest technology and integrate it into teaching practice, we are organising faculty development workshops. Though we are in the early phase of using online technology in medical and nursing education, there is a progressive acceptance by both teachers and students that this will continue to be the way forward in teaching delivery. Training institutes are therefore committed to the use of
technology in the enhancement of teaching and learning.
Beyond the virtual realm
States have also taken action to increase accessibility to protective equipment for healthcare workers and this in part has been achieved by use of technology. All nurses now at risk of exposure or in direct contact with infected patients have been provided with respirators to carry out their duties, and in some cases, solutions have been introduced for nurses to use respirators beyond the recommended shelf life. To help prevent the spread of infections, hospitals have introduced surveillance systems and a mobile app for the safe wearing and removal of
PPE, with a camera and audio system giving instructions on safety aspects. Nurses have also now been provided access to infection prevention measures. Financial incentives, such as insurance, could help mobilise nurses to serve in priority areas and is a very judicious step towards financial protection for health workers across India.
In any public health emergency, the organisation of standardised, short, and regular training is essential to promote better patient care and support health care workers, in addition to adequate and requisite medical supplies, financial and social protection, and psychological support. Protecting healthcare professionals fighting on the forefront of COVID-19 and preparing future healthcare professionals is a national and global priority. In India, the NIHFW will continue to deliver training courses and research activities to address a wide range of public health issues and equip healthcare professionals to face all future challenges.