You are on page 1of 43

Human Resources Division

National Health Systems Resource Centre


National Rural Health Mission, Ministry of Health and Family Welfare
Government of India

Study Report of Nursing Services

Chhattisgarh
Current situation, requirements and measures to address shortages

Conducted by
ANSWERS
Academy for Nursing Studies and Women’s Empowerment Research Studies,
#215, Amruthaville Apartments, Rajbhavan Road, Somajiguda,
Hyderabad-82, Andhra Pradesh, India.

1
2
Contents
Section One - Background and methodology Pages
1.1. Demographic, socio-economic and health profile of Chhattisgarh: .................................................................. 6
1.2. Objectives of study ........................................................................................................................................... 7
1.3 Methodology of Study ....................................................................................................................................... 8

Section Two Nursing personnel: Availability, requirements and shortfall


2.1 Auxiliary Nurse Midwives or Multipurpose Health Workers (F) ................................................................... 12
2.2 Lady Health Visitors (Female Health Supervisors) ......................................................................................... 12
2.3. Public Health Nurses (PHNs) .......................................................................................................................... 12
2.4 District Public Health Nursing Officers (DPHNOs)........................................................................................ 12
2.5. Requirements and shortfall for staff nurses ..................................................................................................... 13
2.6. Shortfall of head nurses ................................................................................................................................... 13
2.7. Shortfall of Assistant Matrons ......................................................................................................................... 13
2.8. Shortfall of Deputy Nursing Superintendents.................................................................................................. 13
2.9. Shortfall of Matrons /Nursing Superintendents ............................................................................................... 14
2.10. Shortfall of nursing faculty .............................................................................................................................. 14
2.11. Shortfall of faculty for college of nursing ....................................................................................................... 15

Section Three - Nursing workforce policies and working environment: An analysis of the
situation in Chhattisgarh
3.1 Nursing services organization, management and career pathways.................................................................. 16
3.2 Working environment and facilities of nursing personnel............................................................................... 21
3.3 Nursing in the Private Sector .......................................................................................................................... 27

Section Four - Nursing education in Chhattisgarh: Availability, capacity and quality


4.1 Availability of nursing education programmes .............................................................................................. 29
4.2. Facilities in nursing institutions in Chhattisgarh: Findings from study of institutions .................................... 30
4.4 Profiles, perception and practices of teachers.................................................................................................. 31
4.5 Perceptions and problems expressed by students ........................................................................................... 32

Section Five - Recommendations for strengthening nursing in Chhattisgarh


5.1. Proposals to address shortages in nursing personnel ...................................................................................... 34
5.2. Addressing shortage of nursing teachers ......................................................................................................... 36
5.3. Career pathways and progression ................................................................................................................... 38
5.4 Strengthening nursing management ............................................................................................................... 39

3
Acknowledgments
The Academy for Nursing Studies is grateful to NHSRC for providing an opportunity to conduct the
Nursing Situation Analysis in the state. It gave an enriching experience and better understanding of the
nursing situation in the state. I am especially grateful to Dr. Sundraraman T. (Director NHSRC), Dr.
Thamma Rao D. (Senior Consultant NHSRC) and Mrs. Sushma Rath for their valuable suggestions,
technical inputs and comments.

The task of data collection for the study would not be made possible without the cooperation
received from the State health organizations and its different departments.

The Academy for Nursing Studies is thankful and appreciates and acknowledges the arduous task of
field investigation by the Faculty, Research Team, Investigator, editors during data collection in the state
and the respondents (State level officers, ANMs, Staff Nurses, Teachers, Students, etc,.) who could spare
their time and respond to various queries with endurance.
The Academy for Nursing Studies is especially grateful to Dr. Sarva Director - Health and Family
Welfare, Dr. Adile DME, Mrs. Singh Registrar, Mrs. Alka Gupta and Mr. R. N. Varma for their support at
the state level.
I thank Dr. Anthony (Director SHRC), Mr. Kamalesh (Consultant NRHM), Mr. Anand Sahu (Data
Manager), Ms. Kamal Vaishnav (Sister Tutor), Mrs Patlia (Principal PG College of Nursing, Mrs. Sudha
Kiran Dan (Sister Tutor) and Mr. Seerajuddin (Data Assistant).
I deeply appreciate Ms. Sandhya Rani (Program Officer), Ms. Hannah Ranjani (Research Assistant)
and our faculty, staff, research team, review team of Ms. Sapna Thakur (Asst. Prof), Ms. Prabha George
(DPHNO) and Mrs. Kumari V Senior Nursing Consultant, Mrs. Laxmi B Senior Nursing Consultant,
colleagues and friends who were important cheerleaders.

Dr. M. Prakasamma
Hyderabad Director

4
Abbreviations
ACR Annual Confidential Report
ADN Assistant Director of Nursing
ANC Antenatal Care
ANM Auxiliary Nurse Midwife
ANMTC Auxiliary Nurse Midwife Training Centre
ANS Assistant Nursing Supervisor
ANSWERS Academy for Nursing Studies and Women’s Empowerment Research Studies
AV Audio Visual
B.Sc. (N) Bachelor of Science in Nursing
BP Blood Pressure
CCU Critical Care Unit
CDMO Chief District Medical Officer
CHC Community Health Centre
CMO Chief Medical Officer
CNC Continuing Nursing Education
CNO Chief Nursing Office
CNS Chief Nursing Superintendent
CON College of Nursing
CSSD Central Sterile Supplies Department
CT Computerized Tomography
DA Daily Allowance
DDN Deputy Director of Nursing
DFW Director of Family Welfare
DH District Hospital
DHE Diploma course in Health Education
DHH District Headquarter Hospital
DHS Director of Health Services
DMET Director of Medical Education and Training
DN Director of Nursing
DNEA Diploma in Nursing Education and Administration
DNS Deputy Nursing Supervisor
DPHN District Public Health Nurse
DPHNO District Public Health Nursing Officer
ENT Ear, nose and throat
FHS Female Health Supervisor
FW Family Welfare
GNM General Nursing and Midwifery
GoI Government of India
GPF General Provident Fund
H&FW Health and Family Welfare
HDR Human Development Report
HFWTC Health and Family Welfare Training Centre
HIV / AIDS Human Immuno-deficiency virus / Acquired Immuno Deficiency Syndrome
HPC High Power Committee
HQ Head Quarter
HRM Human Resource Management
HV Health Volunteer
ICU Intensive Care Unit
IFA Iron and Folic Acid
IGNOU Indira Gandhi National Open University
ILR Ice Line Refrigerator
IMNCI Integrated Management of Newborn and Childhood Illness
IMR Infant Mortality Rate
INC Indian Nursing Council
IPHS Indian Public Health Standards
ITU Intensive Therpeutic Unit
IUD Intra Uterine Devices
IV Intra Venous
JD Joint Director
LCD Liquid Crystal Display
LHV Lady Head Visitor

5
LHVTC Lady Health Visitor Training Centre
LTC Leave Travel Certificate
LUCS Lower Uterine Cesarean Section
M. Phil Master of Philosophy
M.Sc. (N) Master of Science in Nursing
MBA Master of Business Administration
MCH Maternal and Child Health
MMR Maternal Mortality Rate
MoU Memorandum of Understanding
MPHS Multipurpose Health Supervisor
MPHW Multipurpose Health Worker
MTP Medical Termination of Pregnancy
NFHS National Family Health Survey
NGO Non Governmental Organization
NICU Neonatal Intensive Care Unit
NRHM National Rural Health Mission
NS Nursing Superintendent
ODA Overseas Development Agency of the British Government
OHP Over Head Projector
OPD Out Patient Department
OT Operation Theatre
PB B.Sc Post Basic Bachelor of Science
PCO Public Telephone booth
PEP Post Exposure Prophylaxis
PH Public Health
Ph. D. Doctor of Philosophy
PHC Primary Health Centre
PHN Public Health Nurse
PM Preventive Medicine
PNC Postnatal Care
PPF Public Provident Fund
PSE Public Service Examination
PV Per vaginal
RHTC Regional Health Training Centre
RTI Regional Training Institute
SBA Skilled Birth Attendant
SHC Sub-health centre
SDH Sub-divisional Hospital
SEBC Socially Economically Backward Class
SIHFW State Institute of Health and Family Welfare
SN Staff Nurse
SOMI Society of Midwives, India
SON School of Nursing
SRS Sample Registration System
ST Schedule Tribe
TFR Total Fertility Rate
TNAI Trained Nurses Association of India
TT Tetanus Toxoid
UGC University Gran Commission
USG Ultra Sonography
UTP Universal Immunization Programme
VCTC Voluntary Counselling and Testing Centre
VP Vice Principal

6
Definitions

Job description: Formal, written description of the work expected of an individual. A job description
defines what is expected of a person in a particular position and consequently what
that person can expect of other people in their positions.
Organizational
structure: The pattern or network of relationships between the various positions and the
position holders within the organization.
Organization: A deliberatively established social unit composed of people who co-ordinate their
activities to achieve common objectives.
Post: A job in a company or organization.
A place where someone is on duty or where an activity is carried out.
Personnel: The people who are employed in a company / organization.
Career: An occupation that a person undertakes for a substantial period of their life.
A job or series of jobs that a person does during their working life.
Cadre: A small group of trained people who form the basis unit of an organization.
A small group of people chosen and trained for a particular purpose.
Position: A rank or level in a company or society.
Staff: The group of people who work for an organization.
Employee: Someone who is paid to work for some-one else.
Professional: A person who has the type of job that needs a high level of education and training.
Role: A position or purpose that someone has in a situation, organization or society.
Contract: To have formally agreed to work for an organization or person on a stated job for a
stated period of time.
Abolition: The official ending of a system, law or custom.
Downgrade: To reduce someone or something to a lower rank or position.
Responsibility: To have a duty to make certain that particular things are done.

7
Section One
Background and methodology

1.1. Demographic, socio-economic and health profile of Chhattisgarh:


Chhattisgarh is a land-locked state located in the middle of India surrounded by six other states – Madhya
Pradesh, Andhra Pradesh, Orissa, Bihar, Jharkhand and Uttar Pradesh. This new state was formed on 1st November
2000 by carving out sections from the southeastern part of Madhya Pradesh. There are 18 districts and 20,000 villages.
Chhattisgarh is rich in natural resources and has vast unexplored forest regions and a wide range of wildlife. A number
of rivers flow through the State resulting in spectacular scenery.
Table 1 gives some details of the State. Chhattisgarh covers an area of 1,35,194 sq.km and has a population of
20.83 million (as per census of 2001). The population density is 154 per sq.km (as against the national average of 312
persons per.sq.km). People live a predominantly rural life with 79.9% of the population living in villages. In addition,
a large proportion of the population of Chhattisgarh belongs to tribal groups indicating that there is a vast vulnerable
population in the State.
Chhattisgarh lags behind the Country as a whole on several socio-economic and health indicators. The crude
birth and death rates are higher than the national average. TFR, according to SRS 2007 is slightly higher. Chhattisgarh
also lags behind the Country in terms of IMR and MMR. Only 14% of the total childbirths in the State take place in
institutions indicating the critical need for improving access to public health services. Female literacy rates are almost
on the same level as the national average. On the positive side, the sex ratio of the state is higher than the national
average and indicates a more favorable climate for women.

Table 1. Demographic, social and health profile of Chhattisgarh compared to India


Indicator Chhattisgarh India
1 Total population (Census 2001) (in millions) 20.83 1028.61
2 Population density (persons per sq. km) 154 324
3 Rural population (% of total) (Census 2001) 79.9 72.2
4 Decadal Growth (Census 2001) (%) NA 21.54
5 Crude Birth Rate (SRS 2007) 26.5 23.1
6 Crude Death Rate (SRS 2007) 8.1 7.5
7 Total Fertility Rate (SRS 2007) 3.1 2.7
8 Institutional deliveries (% -NFHS III) 14 38.3
9 Infant Mortality Rate (SRS 2007) 59 55
Maternal Mortality Ratio (SRS 2004 - 2006) 335 254
10
Contraceptive Prevalence Rate among currently married women
11 53 56
(NFHS-III) (%)
12 Sex Ratio – number of females per 100 males (Census 2001) 989 933
13 Schedule Caste population (%) 11.6 16.2
14 Schedule Tribe population (%) 31.8 8.2
15 Female Literacy Rate (Census 2001) (%) 51.9 53.7

Availability of health facilities and human resources in adequate numbers and of the right skill mix is essential
to the functioning of any health system. Table 2 presents data on availability of health care infrastructure and human
resources for delivering health services at three levels in rural areas: Sub-health centres (SHCs), primary health centres
(PHCs) and community health centers (CHCs). Chhattisgarh currently has 4741 sub-health centres, 721 PHCs and 136
community health centres. There is a shortfall of 28 CHCs. There is an excess of SHCs and PHCs in the State
compared to the number sanctioned.

8
Chhattisgarh does not have adequate number of key frontline health care providers and specialists, especially
for maternal and child-health services. There is a shortfall of 612 ANMs and 2227 male health workers. Contrary to
this, there appear to be a surplus of female supervisory personnel and doctors at PHCs. While there are 721 PHCs,
there are 862 doctors giving a surplus of 141 doctors at PHC level.

The number of specialists available at CHCs is negligible with only 35 obstetricians, 6 physicians, 33
pediatricians – a total of only 107 specialists against the 544 required. The shortfall of laboratory technicians is also
high (only 383 out of 857 are available). The nurse midwife is critical to providing round-the-clock service to women
in childbirth and to their newborn babies at PHCs and CHCs. However, only 639 staff nurses are available against the
1673 required. The shortfall is almost two third – 1034 more staff nurses are required for rural health services.

Table 2. Health infrastructure and human resources in rural Chhattisgarh


Particulars Required In position Shortfall
Sub-health centre 4164 4741 -
Primary Health Centre 659 721 -
Community Health Centre 164 136 28
Multipurpose worker (Female)/ANM at Sub Centres & PHCs 5462 4850 612
Health Worker (Male) MPW(M) at Sub Centres 4741 2514 2227
Health Assistant (Female)/LHV at PHCs 721 749 -
Health Assistant (Male) at PHCs 721 114 607
Doctor at PHCs 721 862 -
Obstetricians & Gynaecologists at CHCs 136 35 101
Physicians at CHCs 136 6 130
Paediatricians at CHCs 136 33 103
Total specialists at CHCs 544 107 437
Radiographers 136 108 28
Pharmacists 857 791 66
Laboratory Technicians 857 474 383
Nurses/Midwives 1673 639 1034

Source: RHS Bulletin, March 2008, Ministry of Health & F.W., GOI. The state gave a figure of 4622 ANMs
at subcentre, PHC and other hospitals upto district level.

The present study was undertaken by the research wing of the ANSWERS (Academy for Nursing Studies and
Women’s Empowerment Research Studies) on behalf of the National Health Systems Resource Centre of the NRHM,
Government of India, with the overall objective of identifying gaps in nursing workforce in Chhattisgarh and
recommending alternative measures for addressing deficiencies of frontline service providers as well as supervisors
and teachers.

1.2. Objectives of study


a. To review the organization of nursing and midwifery services in the state public health system.
b. To review the workforce management policies in place in the state public health system as relates to
nursing and midwifery, including issues of career progression, their working conditions in government as
compared to that in private sectors, their reasons for discontinuing the profession where this is the case.
c. To compare workforce management policies between contractual staff and regular staff and see the
differing experience and utilization between them.
d. To assess the workforce performance and assess how it relates to workforce conditions and to skills of the
workforce.
e. To conduct situation analysis of nursing and midwifery services requirements of health centers and
hospitals both in public and private sectors, their current availability in the state, within the system and in
the open market.
f. To assess the current capacities (public and private sectors) of training institutions and feasibilities within
the state to meet the short fall of nurses, ANMs and LHVs for the immediate needs as well as midterm

9
and long term requirements, to also assess the requirements in terms of faculty development programmes,
and quality assurance measures to ensure quality in nursing education.
g. To evaluate the different options available for expanding nursing and ANM and LHV education and the
necessary conditions that would be needed to ensure that a substantial part of those trained in these
institutions become available to serve within the public system or outside it in rural areas. This includes
the important issue of the availability of faculty for running these schools.
h. To draw up a detailed project report for starting up of ANM schools and nursing schools in some (about
20 such schools per state within one year) tribal blocks/districts such that educated women resident in the
tribal blocks/districts are able to access ANM and nursing education.

1.3 Methodology of Study

The study used a comprehensive methodology that included both qualitative and quantitative techniques.
Several brain-storming sessions were held to clarify the thematic issues to be studied in order to fulfill the objectives.
These sessions resulted in three broad issues that formed the conceptual background for the study - working
environment, learning environment and organizational environment of nursing personnel in Chhattisgarh. The entire
nursing workforce of the state of Chhattisgarh became the focus of study. This included clinical nursing as well as
public health areas; all levels of teaching institutions; teachers and students; primary care providers-ANMs and staff
nurses and their supervisors. Figure 1 depicts the framework on which the methodology of the study was developed.

Figure 1. Diagram of major themes and sub themes included in the study

1.3.1. Sites and sample included in the Study: The sample included four levels: Service providers (ANMs and staff
nurses), health care facilities, training institutions and, state and district level officers. Table 3 gives the details of the
sites and sample. Four districts were selected for assessment of health facilities and interviews with ANMs and staff
nurses: Raipur, Durg, Ambikapur (Sarguja) and Dantewada. The criteria for selection of districts were geographical
location, size, and availability of health facilities and training institutions.
Within each district, DHs, CHCs, PHCs and sub- health centres were selected for study. In total four district
hospitals, eight CHCs, 16 PHCs and 38 sub-health centres were assessed. Nursing personnel interviewed comprised
74 staff nurses and 80 ANMs. Observations were made in five colleges of nursing, four schools of nursing for GNMs,
and four ANM training centres in order to assess the capacity of nursing educational institutions and interact with
students and teachers. Within these training institutions, 115 students and 34 teachers were interviewed. Interviews
were also conducted with 10 state level officers and other key stakeholders.

10
A series of focus group discussions was conducted with different groups both from government and private
institutions in order to understand performance-related issues, working conditions and career progression. The
participants in the FGDs included eight ANMs, two LHVs, eight staff nurses, 53 teachers, and 11 postgraduate nurses.

Table 3. Sample of facilities and personnel included in the study


Category Number included
Facilities
District hospitals- one in each district 4
Community health centers- two in each district 8
Primary health centres 16
Sub-health centres 38
Colleges of nursing- throughout the state 5
GNM schools- throughout the state 4
ANM training centres – throughout the state 4
Personnel
Staff nurses 74
ANMs 80
Nursing students 115
Nursing teachers 34
Officials and stakeholders- state level 10
Participants in focus group discussions- State level 82

1.3.2. Tools and techniques used in data collection: Semi structured interview schedules and observation checklists
formed the two main methods for primary data collection. Guidelines were prepared for conducting focus group
discussions with different categories and for interviews with key stakeholders and officers. Series of workshops was
conducted with experts at MyTRI Institute (Training centre of ANSWERS) for conceptualization, tool development,
identifying gaps for primary data collection, revision of tools etc. Table 4 lists the tools used for data collection with
different groups and from different facilities.

Table 4. List of tools used for data collection


Sl. No Category Tools used
State and Semi structured interview schedule for data on personnel, number and type of
1
district level institutions, different policies related to nursing personnel administration
Training Semi structured interview schedule and observation checklist for information on
2
Institute level physical facilities, teaching facilities and living conditions of students
Health care Observation checklist for quality of facilities and working conditions of nurses at
3
facility level different levels
Service Interview schedules to assess working environment, conditions of work,
4
providers performance and problems.
Teachers and Interview schedules for obtaining information from students and teachers in
5
students different institutions
Focus group discussion guideline for ANMs, LHVs, staff nurses, teachers and
M.Sc. Nursing students

Besides the above, secondary data were collected on organizational environment through review of policies,
documents and official circulars and manuals.

The following officials and key stakeholders were interviewed at the state headquarters in Raipur: Director,
Health and Family Welfare, Director of Health Services, Dy. Directors of Nursing, Director of State Health Resource
11
Centre, Registrar, Director State Institute of Health and Family Welfare; Mission Director NRHM, Joint Director
NRHM and Director of Medical Education. At the district level the officials interviewed were DPHNOs, district
hospital nursing superintendents and Civil Surgeons.

1.3.3. Research Team: Two categories of teams were involved in data collection. The first team or the ‘Research
Team’ consisted of two research assistants who conducted the quantitative study in the four districts and training
institutions with the help of local field investigators and resource persons. The second team consisted of two senior
nursing consultants (M.Sc. nursing) called the “Consultant Team” who started data collection six weeks after the
Research Team in order to build on preliminary findings from questionnaires and interview guides. They conducted
focus group discussions and interviews with state level officers, senior nurses, and key stakeholders and focused on
the organizational environment.

1.3.4. Brief description of data collection process: Pilot study of the research design and tools was carried out in the
last week of September, 2008 in one district and two training institutions. This helped clarify the tools and plan out
data collection process in detail. Primary data collection was done over a period of eight weeks between October and
December, 2008. Secondary data were reviewed throughout the study period between October 2008 and August 2009.

Data collection at training institutions: The total number of institutions of each category (ANM, GNM and Colleges
of Nursing) in the state was listed and about 20 percent of the institutions were selected for study throughout the state.
Both government and private institutions were selected. Three types of tools were used in each institution: an
observation checklist for information about the institution, an interview schedule for teachers and an interview
schedule for students. Only final year or last semester students were selected for interview in each institution. The
institutional assessment checklist had questions for assessing adequacy of teachers (student-teacher ratio), intake of
students in each course per year, facilities for conducting the training programs, accommodation, syllabus related to
midwifery teaching, availability of community field for practical experience, availability of student welfare
programmes. Observations were focused on the building, midwifery and newborn skill lab, classrooms, hostel and
student facilities. Students were questioned about their awareness of rotation plan, clinical posting, supervision and
guidance, case book maintenance, adequacy of clinical teaching, and satisfaction with teaching. The interview
schedule for teachers contained questions for assessing teachers’ profile, in-service education, teaching style and
quality, clinical teaching, evaluation methods used and satisfaction with teaching.

Data collection in health facilities: Data were collected from facilities as well as from personnel within each selected
district. The tools assessed details regarding the residence and mode of transport to work, working conditions and
working environment for nurses and their patients. Some questions were framed to identify issues related to
availability of drugs, articles and health teaching aids and availability of forms/charts and registers and their regular
maintenance and supply. Questions were framed to identify satisfaction about pay and allowances, facilities such as
electricity and water supply and the functioning of labor room and operation theatre. Special emphasis was laid on
maintenance of universal precautions for infection prevention.

1.3.5. Data management, analysis and plan of report: Besides the research and consultant team , there was a Core
Team consisting of senior consultant, coordinator, data manager and support persons who analyzed the data and
helped in report writing. A team of data managers took up the task of analysis after obtaining data from different parts
of the state for all categories. One person from the field was included in data management team to help in data cross-
checking, compilation and editing. Statistical Package for Social Sciences (SPSS) was used for preparing structure for
entry and analysis. The qualitative information was analyzed on the basis of major themes and sub themes.

A structure was prepared for reporting findings and this was discussed at different levels, revised and refined
to provide a comprehensive picture of nursing, midwifery and public health nursing in Chhattisgarh. Draft reports
were prepared through workshops. The findings were discussed with key stakeholders in the State before finalizing the
report for presentation to state policy makers and programme managers.

12
Section Two
Nursing personnel: Availability, requirements and shortfall
Nursing personnel in India work in two broad fields – public health facilities and hospitals. Norms for nursing
personnel that are accepted nationally and internationally need to be met in order to facilitate standards of care. One
set of norms do not fit all settings since needs, workloads and working conditions differ. This report therefore uses
three sets of norms: Indian Public Health Standards, 2007; Indian Nursing Council Guidelines, 2002 based on Bajaj
committee recommendations; and Government of India Guidelines, 2006. Where applicable recommendation of the
High Power Committee on Nursing (Govt of India,1989) are referred to. Tables 5 and 6 present norms prescribed by
IPHS and INC respectively.

Table 5. Norms for nursing personnel at different facilities (IPHS 2006, 2007)
S. Staff Ward Asst.
Type of Hospital ANMs LHVs PHNs Matrons
No Nurses Incharge Matrons
1 SHC 2 - - - - - -
2 PHC 1 1 3 - - - -
3 CHC 1 - 7 1 - - -
4 SDH 31-50 Beds - - 21 - - 1 -
5 SDH - 51-100 Beds - - 51 - 5 1 1
6 DHH - 101-200 Beds 6 - 88 to 113 - - 2 1
7 DHH 201 - 300 Beds 4 - 115 - - - 7
8 DHH - 301-500 Beds 4 - 217 to 267 - - - 9

It is important to observe that the IPHS does not mention the DPHNO or district public health nursing officer.
There are other gaps, discrepancies and paradoxes. For example the nurses ward in charge are not mentioned at district
hospital with 201 -300 and 301 -500 beds. In such cases the norms recommended by INC are referred since most of
these are also teaching hospitals. Another point to be mentioned is that 30 percent leave reserve has not been used
while calculating requirements. A further delimitation in this paper is that only current numbers of health facilities in
government sector have been considered. The paper does not give calculation for requirement in private hospitals.

Table 6. Norms for nursing personnel in teaching hospitals (INC, 2002)


S.No Categories Requirements
1 Nursing Superintendents 1: 200 beds
2 Dy. Nursing Superintendents 1: 300 beds
3 Departmental Nursing Supervisors / Sisters 7: 1000 + 1 for every addl. 100 beds
4 Ward Nursing Supervisors / Sisters 8: 200 + 30% leave reserve
5 Staff Nurses for wards 1: 3 (or 1:9 each shift)+30% leave reserve
6 Staff Nurses for OPD, Blood Bank, X-Ray,
Diabetic Clinics, CSR etc 1: 100 outpatient + 30% leave reserve
7 Staff Nurses for Intensive Care Unit (8 beds
ICU/200 beds) 1:1 (or 1:3 for each shift) + 30% leave reserve
8 Staff Nurses for specialized departments and
clinics such as OT, Labour Room 8: 200 + 30% leave reserve

13
2.1 Auxiliary Nurse Midwives or Multipurpose Health Workers (F): According to Indian Public Health Standards
each sub-health centre must have two ANMs. Further, there should be one ANM at PHC and one at CHC. There
should be six ANMs at district hospitals with 101-200 beds and four each at district hospitals with 201-300 beds and
301-500 beds. Based on this norm, Chhattisgarh requires a total of 10,501 ANMs. The existing number of ANMs in
Chhattisgarh is 4850 according to RHS Bulletin March 2008. The shortfall is 5651 ANMs or 54%. Table 7 presents
the calculation of requirement in different facilities.

Table 7. ANMs available and additional ANMs required (IPHS)

Health care ANMs Required as Total ANM Existing


Sno Sanctioned Shortfall
institution per IPHS required ANMs

1 Sub-health centres 4741 4741x 2 = 9482


2 PHC 721 721x1=721
3 CHC 136 136 x 1 = 136 5651
10501 4850*
4 SDH(101 –200 beds) 17 17x6 = 102 54%
5 DHH(301 -500beds) 15 15x4=60
Total 5630 10501

* refer page 3

2.2 Lady Health Visitors (Female Health Supervisors): The IPHS recommend one LHV or female health
supervisor for every PHC. Currently there are 749 female health supervisors in Chhattisgarh against the required 707.
There are 28 additional LHVs in the state.

Table 8. Availability of health supervisors

Health care Required No. of Existing LHVs Shortfall


institution LHVs as per IPHS

PHC 721 749 Nil

2.3. Public Health Nurses (PHNs): The IPHS recommend one PHN in every CHC and one in regional training
centre. This means Chhattisgarh requires atleast 136 PHNs. However, currently there is no PHN post in the State. The
shortfall is therefore 136 PHNs or 100%. The absence of the PHN creates a big gap in supervision and guidance to
peripheral health service providers and needs to be addressed urgently.

Table 9. Shortfall of PHNs


Health care Existing Required PHNs Existing Short fall
institution CHCs (IPHS norms) PHNs
CHC 136 136 Nil 136
100%

2.4 District Public Health Nursing Officers (DPHNOs): The IPHS do not mention the DPHNO- a key post that was
created in every district with support from GOI in 1983. The presence of the DPHNO in every district is essential to
supervise and guide PHNs, LHVs and ANMs to render quality services for maternal and child health and to monitor
services related to reproductive health and family welfare. There are only five DPHNOs in Chhattisgarh since no
promotion was given after the first posting in early 1980s. The state requires 36 DPHNOs at the rate of two per
district. The shortfall is 86% or 31 DPHNOs.

Table 10. Requirement and shortfall of DPHNOs


District Number Required * Total Existing number Shortfall
as per HPC of DPHNOs
Districts 18 36 36 5 31
86%

14
2.5. Requirements and shortfall for staff nurses: According to IPHS norms Chhattisgarh needs 8996 staff nurses at
PHC, CHC, sub-divisional and district hospitals combined together. Currently there are only 866 staff nurses and the
shortfall is 8130 or 90%. In addition 1093 staff nurses are required for the three teaching hospitals. At present there
are 913 staff nurses in these hospitals and so the shortfall is 180 staff nurses (16%) for teaching hospitals. The overall
shortfall for staff nurses in the state is 8310 (82%).

Table 11. Shortfall of staff nurses working in PHCs, CHCs, SDHs, DHHs and teaching hospitals
Staff nurses Existing
S. Total
Category of hospital required staff Shortfall
no required
(IPHS norms) nurses
1 PHCs – 721 3 x 721 = 2163
2 CHCs – 136 7 x 136 = 952 8130
8996 866*
3 SDHs - 101-200 beds - 17 113x17 =1921 90%
4 15 DHHs - 301-500 beds – 15 264 x 15 =3960
5 Raipur Med college hospital- 800 beds - 1 441x1=441
6 Bilaspur medical college hospital- 700 beds 375x1=375 180
1093 913
16%
7 Jagdalpur medical college hospital- 500 beds 277x1=277
8310
Total 10089 1779
82%

*-The number of existing staff nurses is based on data in the office of Director of Health Services collected during on 18-11-2008.
** The number of existing staff nurses is based on data in the office of Director of Medical Education.

2.6. Shortfall of head nurses: Chhattisgarh has 17 sub-district hospitals with 101-200 bed strength and 15 district
hospitals with 301-500 bed strength. In addition, the state has three teaching hospitals at Raipur, Bilaspur and
Jagdalpur. Currently 124 head nurses are available in the state against 294 required. On the whole, the state has a
shortfall of 170 head nurses (58%).

Table 12. Shortfall of nursing sisters at SDH and DHH as per as IPHS Norms
Head nurses Existing
Total
S.No Category of hospitals required head Shortfall
required
(IPHS norms) nurses
1 SDHs - 101-200 beds- 17 5 x 17=85 161
190 29*
2 DHHs- 301-500 beds-15 7 x 15=105 85%
3 Raipur medical college hospital-800 beds 42x1=42
4 Bilaspur medical college hospital-700 beds 36x1=36 9
104 95**
9%
5 Jagdalpur medical college hospital-500 beds 26x1=26
170
Total 294 124
58%

2.7. Shortfall of Assistant Matrons: At present there are 10 assistant matrons in the entire state. As per IPHS norms
one post of assistant matron is proposed in each SDH and DHH with 201 to 300 beds and two for DHH with 301 to
500 beds. According to INC two assistant matrons are required in teaching hospitals with 500 beds and one additional
assistant matron is required for every additional 50 beds. Hence 14 assistant matrons are needed for teaching hospitals.
Overall, 51 assistant matrons are needed for the State. Only ten posts are currently available. The shortfall is 51 posts
i.e. 83%.

15
Table 13. Shortfall of Assistant Matrons
Existing
Number of Required as Total
Institution (Beds) Assistant Shortfall
institutions per IPHS required
Matrons
SDH- 101-200 beds 17 1x17=17 47
47 Nil
DHH- 301-500 beds 15 2 x15=30 100%
Raipur MC hospital - 800 beds 1 8x1=8
4
Bilaspur medical college hospital - 700 beds 1 4x1=4 14 10
29%
Jagdalpur medical college hospital- 500 beds 1 2x1=2
51
61 61 10
Total 83%

2.8. Shortfall of Deputy Nursing Superintendents: As per INC norms, three deputy nursing superintendents are
required for 800 bedded hospitals and two are required for 700 and 500 bedded hospitals. The state requires seven
deputy nursing superintendents for its three teaching hospitals. But only one post is available. Hence there is a
shortfall of six deputy nursing superintendents in the State.

Table 14. Shortfall of Deputy Nursing Superintendents


Bed Required as per Total Shortfall
Health care institutions Existing
strengths INC Norms required
Raipur Medical College hospital 800 3
6
Bilaspur Medical 700 2 7 1
85.7%
Jagdalpur Medical College Hospital 500 2

2.9. Shortfall of Matrons /Nursing Superintendents: IPHS recommend one matron for hospitals with 51-100 beds
and 101-200 beds and 9 matrons for 301-500 bedded hospitals. As per as INC norms one CNO is required for each
teaching hospital. Chhattisgarh has three teaching hospitals but no CNO post. Overall, 35 posts of matrons including
three CNOs are required for Chhattisgarh but only 15 are available. Hence the shortfall for this post is 57%.

Table 15. Shortfall of Matrons and Chief Matrons


S.No Category of hospitals Number Required Existing Shortfall
1 SDH- 101-200 1x17=17 20
32 12
2 DHH - 301-500 1x15=15 63%
3 Raipur MC hospital -800 beds 1x1=1
4 Bilaspur medical college hospital -700beds 1x1=1 3 3 Nil
5 Jagdalpur medical college hospital- 500 beds 1x1=1
20
Total 35 35 15
57%

2.10. Shortfall of nursing faculty: Faculty shortage has been a chronic problem in Chhattisgarh since the beginning
of the State in 2000. Table 16 presents the overall shortage of the teaching faculty in Chhattisgarh for ANM and GNM
training institutions. This shortfall is based on the existing number of training schools. But to cover the huge shortfall
of ANMs and staff nurses the State requires many new schools i.e the requirement of teaching faculty will increase
sharply.
Table 16. Shortfall of nursing teachers for ANM and GNM centres
Sno Category Required number Existing number Shortfall
1 Principal 4+7 - 11
2 Vice principal 4 - 4
3 Nursing tutors 60+21 25+23 33
4 Additional tutors 4 - 4
52
Total 100 48
52%

16
2.11. Shortfall of faculty for college of nursing: There is only one college of nursing in the government sector. The
government has initiated several measures to meet the serious shortage of nursing teachers by opening a new college
of nursing in 2004 with intake of 50 students. The Director of Medical Education employed four regular staff and 19
demonstrators on contractual basis for two years for addressing shortfalls. The present college of nursing, though a
good initiative, is being managed by two lecturers and 19 fresh B.Sc (N) graduates working on contract. The existing
faculty of college of nursing is extremely inadequate as per as INC norms. The present college needs a principal, one
vice principal, one reader and three lecturers. With the additional requirements for nursing teachers in ANM training
centres and GNM schools of nursing – more colleges will have to be opened and this will increase the requirement.

Table 17. Shortfall of faculty - College of Nursing as per INC norms


INC Existing
Sno Category Shortfall
norms faculty
1 Principal 1 - 1
2 Vice principal 1 - 1
3 Reader / Asst professor 1 - 1
4 Lecturer 5 2 3
5 Clinical instructor / demonstrator 14 19 -
6
Total 22 21
27%

Summary:
The overall shortfall of nursing personnel in different levels in Chhattisgarh is enormous. The State needs
5651 ANMs, 136 PHNs, and 31 DPHNOs to fill current shortages in the public health facilities. The State also needs
8310 staff nurses, 170 head nurses, 51 assistant matrons, 6 deputy nursing superintendents and 20 matrons for
inpatient services at different levels. The current shortfall of teaching faculty is 52 at ANM and GNM level and six at
collegiate level. Overall the shortfall is acute at the senior level and at faculty level. Not a single senior faculty or
principal post is filled – these jobs are handled by persons who are placed incharge of the post.

17
Section Three
Nursing workforce policies and working environment: An analysis of the
situation in Chhattisgarh
This section deals with a range of issues related to nursing workforce policies and working environment:
Cadres and posts, recruitment, career progression, organization and management, and the working environment of
nursing personnel that affects their performance. The data and analysis are based on primary and secondary sources
and review of government documents at different levels. Information collected with different tools using both
quantitative and qualitative techniques has been triangulated to cull out the themes related to nursing workforce in
Chhattisgarh. Indepth interviews with a range of personnel and focus group discussions with key nursing groups
helped in identifying the issues. Interaction with stakeholders and key nursing personnel helped in clarifying problems
and assessing needs for improvement. The section is organized into three subsections.

3.1 Nursing services organization, management and career pathways


3.2 Working environment, facilities and problems: Findings from observations
3.3 Nursing in private sector

3.1 Nursing services organization, management and career pathways


3.1a Nursing cadres, posts and recruitment including contractual recruitment: Government posts, including
nursing posts, are organized into four different classes in Chhattisgarh. The number of posts in class I and II categories
indicate that the profession has a higher status. From table 18 it is clear that there are very few higher class posts for
nurses in Chhattisgarh. Almost all nurses in Chhattisgarh fall into class III category. The posts available in class I
officer category are from college of nursing or the nursing council – these are not involved in providing nursing care
in hospitals or outreach services in the community. Most of the class I and II posts have remained vacant due to the
lack of adequately qualified personnel.
In class III category, one finds a range of posts from ANM to Assistant Nursing Superintendent (18 posts)
indicating a dumping down of all posts irrespective of experience and job functions. Clearly, there is a need for
reviewing, analyzing and regrouping the posts according to qualification, service and job responsibilities. (Note: The
State recently initiated measures for preparing qualified nurses for filling vacancies. The state is also formulating job
descriptions for all nursing posts).

Table 18. Existing nursing personnel and their status in Chhattisgarh


Class Director of Medical Education Director of Health services Total
Class I Two lecturers One 3
All others are in-charge Registrar Nursing Council
Class II 20 (on contract) Nil 20
(Demonstrators/assistant lecturers,
DNS -1
Class III 1131 (ANMs -5, LHV-1, Wardens 7823 (ANM/FHWs-5585 LHVs-1034, staff 8954
– 2, staff nurses -980, sister tutors - nurses-935, nursing sisters -189, sister tutors -
3, nursing sisters -122, Assistant 34, public health tutors -28, and matrons -18)
Nursing Superintendents – 18)

Note: Data for the above table was collected from the state health directorates.

Review of documents and interactions at state level showed that no development has taken place for
increasing the number of posts or upgrading existing posts since independence. No major enhancement in nursing
cadres has taken place after the formation of the State. On the other hand, some key posts that existed when
Chhattisgarh was part of Madhya Pradesh have been abolished. For example, when the state was separated from
Madhya Pradesh there were seven DPHNOs but the post was discontinued in 2007. It was felt that the DPHNO was
not necessary and so vacancies were not filled.

18
Some posts are missing. For example, there is no post of PHN. The IPHS recommend one post of PHN at
every CHC. In neighbouring states such as Orissa, the post of PHN bridges the gap between field services (ANM and
LHV) and administration at the district. Absence of this post deprives the field staff of supervision, guidance and on
the job training.

3.1b Recruitment: Recruitment of nurses in Chhattisgarh is done on the same principles as other categories:
Registration, educational qualification, years of experience and reservation of seats for SC/ST. General conditions and
steps for recruitment of para medical posts are:
 Proposals for new posts along with recurring expenditure in the yearly budget are prepared and sent to the
government for approval and sanction.
 After the sanction of a post by the government, the number of vacancies in that post are announced through
advertisements in newspapers.
 Director of health and family welfare services in Chhattisgarh adopted the “Madhya Pradesh Health and
Family Welfare Department class III Nurses Service Recruitment Rules” dating back to August, 1989 of
Madhya Pradesh.
 Director of medical education follows the “Chhattisgarh non gazetted Recruitment Rules” to fill the non-
gazetted posts in nursing, and “Chhattisgarh Gazetted Recruitment Rules” to fulfill the gazetted posts.
3.1c Nurses on contract: In 2002, the government filled the vacant posts of nursing staff by contract through Jeevan
Deep Samitis or local bodies, with a fixed pay of 6000/- and 13 casual leaves per year by the “contract basis rule
adhiniyam of 1965”. The contract period was for one year and the candidates were to be domicile of Chhattisgarh. The
appointment on contractual basis was done again in 2004 with the same rules and regulations. Around 300 staff nurses
were recruited in this manner upto 2008. Considering the acute shortage in the State, the government regularized the
contractual staff nurses through counseling in April, 2008. But these nurses are not entitled for pension.
There were no major differences between contractual and regular staff in Chhattisgarh since the contractual
staff also felt they would become regular employees in time. In terms of work, the contractual employees were given
evening and night shift and assigned direct patient care functions. In contrast, regular staff took up
management, recording and supervisory functions and did morning shift. Interactions also showed that
contractual staff usually came on time, completed the allocated function and waited till the regular staff
came to relieve them. In terms of knowledge and skill, contractual staff had fresh information but stated that
it was sometimes difficult to use this since they felt regular staff would not appreciate it. Unlike this, regular
staff were skilled, especially in specific tasks such as conducting deliveries. Contractual staff said that they
did not have adequate skills since there were gaps in their basic training. A few of the contractual staff
interviewed in this study, said they did not get adequate exposure for conducting deliveries but were
learning now. For this reason, perhaps it makes sense to assign them to night shift and give them direct
patient care duties. However, one has to have measures in place to avoid exploitation and burnout.

3.1d Organization and management of nursing services: The total nursing workforce in Chhattisgarh is 8977
(public health centres and hospitals combined). However, there is no administrative post for nurses in the directorate
of health services or the directorate of medical education. The existing organization of nursing in Chhattisgarh
indicates the low position of nurses in administrative and policy matters. The highest positions at state level available
to nurses are faculty of the college of nursing under the DME. Most of these positions are vacant because qualified
candidates are not available.
Analysis of the management structure of nursing at state level reveals three main problems
1. Large frontline workers with weak positions at the top.
2. Distributed in different departments
3. Low capacity and inadequate professional growth.
Top too weak: Strong and capable nursing administration at the state headquarters would guide and support nursing
personnel in the entire state and ensure professional development. This is not the case with nursing in Chhattisgarh.
There are very few positions at state level for undertaking management functions efficiently and for representing
nursing care and nurses in policies and programmes. Though one post of joint director and two posts of deputy
director of nursing are available under the director of health services, these could be filled only by class I officers and
since there is no nurse in class I category these are occupied by doctors: deputy director of nursing (establishment) and

19
deputy director of nursing (training). Most day to day administration related to nursing is carried out by the
incumbents of these two posts. This results in a paternalistic working atmosphere even at the state headquarters where
nursing personnel become habituated to doctors deciding for them and representing them.
Logically, human resource development requires that nurses, just like other professionals, need to be given the
opportunity to gain qualification and experience required to occupy higher posts. If personnel policies do not facilitate
professional growth, there will always be a lack of qualified personnel to take senior posts. Hence even if posts are
created, no one will be available to occupy them. After some time, since qualified persons are not available the post is
discontinued, converted or occupied by others. This vicious “chicken or egg first” cycle is responsible for keeping
nursing at a sub profession level. This type of organizational climate will not nurture professional growth and
autonomy.
Even when there is a higher class post filled by a nurse, one observes that the candidate occupying the post is
often assigned lower position and authority and given lesser facilities further lowering the status of the post. For
example, the post of Nursing Registrar in Chhattisgarh is under the DHS. The post of Registrar of Nursing Council is
a senior and responsible post that carries with it several responsibilities and risks at state level. Responsibility for
inspecting training institutions and conducting examinations lies with this post. Most of the work is confidential.
Ideally this post should be supported with an adequate administrative system. However, the post does not carry the
facilities and support that it requires. The Registrar is assigned very little office space with a table and a cupboard in a
room shared by other para medical officers and one grade III clerk for secretarial assistance. This indicates the lower
value assigned to this senior post. The secretarial assistance is low though workload is heavy. While trying to keep
pace with the examinations and subsequent work, she hardly has time for maintaining quality records and reports.

Promotions to senior posts are delayed for a long time. In the meantime, someone is posted as “acting or
incharge” giving the occupants very little administrative decision-making power or opportunity for representation in
policy making. The result is low level of leadership and capacity at the top with inadequate technical guidance and
monitoring of services. There is very little opportunity for capacity development through training and attending
workshops because they are always kept overworked and busy.
Nursing posts are scattered in different departments:. Nursing personnel are distributed in two different
departments – DME and DHS - resulting in low level of professional sharing and interaction. Clinical nursing
personnel from staff nurses to matron are under the control of Director of Health Services. All nursing personnel
working in public health areas (ANMs, LHVs and DPHNOs) numbering a total of 7824 are under the control of the
Director of Health Services. The teaching faculty of college of nursing are under the management of DME, whereas
ANM and GNM training institutions are under DHS.
Being in two different departments, development is sometimes faster in one department compared to another.
There is usually faster growth and facilities for nurses working under DME compared to those working under the
DHS. Similar posts are present in both departments. For example, there are 34 sister tutor posts under directorate of
health services and three posts under the directorate of medical education. Sister tutor and PHN tutor are present in
teaching institutions as well as in clinical areas. The lack of opportunities and unequal access to promotions raises
mistrust and conflict among nurses in different departments. This pitting the lower cadres one against the other is
another factor that hinders cooperation, sharing and professional growth. Unifying nursing services under one
technical head of nursing services would ensure that nursing services are organized and administered using
professional principles and ethics. This would also ensure uniform access to opportunities and professional growth.
Low capacity in management: The educational preparation and work atmosphere of nurses does not prepare them to
tackle administrative issues and participate in policy discussions. For example, they have very little opportunity for
higher education, to attend national and international conferences and organize professional meetings. Humble social
backgrounds and lower position in the health system hierarchy do not enable them to lead, prepare proposals or make
elaborate plans. Due to problem in English they do not speak in official meetings even when “asked to participate”.
They hesitate to interact with officials and do not take up advocacy even for the patients under their care. Since their
entry into service they have worked as team member and subordinate, not as team leader or manager. Consequently,
even when they reach positions of leadership they hesitate to lead and do not actively represent nursing personnel for
improving their working conditions, their career paths and their professional development.
Administrative matters and decisions are not attended by nurses as the highest post in the state capital – joint
director -is not filled. Even in nursing education, currently, the class I nursing post of Principal of College of Nursing
is held by a senior person with B. Sc (nursing) qualification who is acting as in charge. Within the teaching hospitals,
there are three nursing superintendents that belong to class II cadre since there is no post of CNO. Hence they do not
feel eligible to administer.
20
In short there are many management issues that need to be sorted out at the state administrative level before
nursing can be strengthened and nurses can contribute effectively to providing quality health services. Management
capacity has to be developed for nurses to become administrators and actively participate in management.

3.1e Career pathways and opportunities for professional growth


Qualified nursing personnel enter into Government health services at two entry points in nursing. These are
ANM / MPHW (F) in public health side and the staff nurse in clinical side. The ANM enters at the average age of 18
years and the staff nurse enters at about 21 years if they get appointed immediately after completion of studies.
One basic principle of career progression is that personnel entering into a job stream should steadily progress
up the stream through a series of administrative steps that enable them to acquire skills and qualification. The career
ladder for nursing personnel in Chhattisgarh has too few steps spread out too far apart to enable career progression.
The ANM can climb one step, the staff nurse, perhaps two steps, in their entire service spanning nearly 40 years. A
staff nurse however has opportunity to become a tutor if she completes post basic BSc (Nursing) or Diploma in PHN.
Such opportunities are not available to the ANM leading to career stagnation. The following paragraphs and graphs
demonstrate the stagnation in the professional development of nursing personnel in the State.
Existing career pathway for ANMs: In Chhattisgarh, assuming that there are 4850 ANMs and 749 posts of LHV,
only 16 % ANMs have the chance to become LHV provided they complete LHV course and are promoted without
administrative delays. There is no LHV training centre within the state. ANMs are given the opportunity to undergo
this training in the other states on deputation.
The next post after LHV is PHN. But Chhattisgarh currently does not have posts of PHN in the PHCs or
CHCs. So almost all LHVs retire as LHVs. The qualification for DPHNO is B.Sc (Nursing) or Diploma in Public
Health Nursing. PHN tutor and sister tutor are eligible for the post of DPHN if they complete B.Sc nursing. Public
health tutors are available in training centres. The door to DPHNO is closed to the ANM since it is almost impossible
for her to undergo additional courses during her service.

Figure 8. Existing career ladder for ANMs of Chhattisgarh

If the posts of PHN are created and the post of the DPHNO is revived, a small percent of ANMs will be able
to reach this higher technical and administrative post at the district level provided they are enabled to obtain the
necessary qualification. Above this, it is essential to have a series of state nursing posts for public health nursing.
Currently there are nonexistent.

The DPHNO post is critical to providing public health nursing leadership and guidance to ANMs, LHVs and
PHNs in the district. The DPHNO is the professional role model for the ANMs and LHVs to whom they look up for
support. With a well constructed career pathway, the ANM can one day aspire to become the DPHNO of her district.
The post was created when MCH and family planning services were integrated along with the introduction of
multipurpose health worker scheme in the early 1980s. No new DPHNO was recruited or promoted since the first
posts were created and filled when Chhattisgarh was part of Madhya Pradesh. At present there are five DPHNOs in
Chhattisgarh attached to the district health offices (Ambikapur, Jagdalpur, Raigarh, Rajnandgaon, and Durg).Three of

21
the five have a B.Sc. Nursing qualification that equips them to engage in public health planning and management as
well as in training, guidance, supervision and monitoring. It is essential that the post be revived and the potential of
the DPHNOs used for achieving health goals.

b. Existing career ladder for staff nurses: The staff nurse enters training after completing class 12 and goes through
a three year training and a six months internship to get a diploma in general nursing and midwifery. The minimum age
for entry into the training is 17 years. Assuming they are employed immediately after passing the GNM training they
are likely to enter service at the age of 21 years.
The first promotion post for a staff nurse is nursing sister/ward sister/head nurse/ward in charge. The existing
number of nursing sisters is 124 (refer table 12) which is only 7% of nurses. Most staff nurses get this post when they
are nearly 50 years old resulting in the majority of staff nurses becoming stagnant. The next step on the career ladder
is Assistant Nursing Superintendent- there are only 10 posts in the entire state. The next post is Deputy Nursing
Superintendent. This post is available only under the DME and not in DHS. The number of Deputy Nursing
Superintendents - the feeder post for Nursing Superintendent - is too few. This creates confusion because the number
of nursing superintendents is more than the number of feeder posts-DNS and hence senior posts is nearly always
vacant.

Figure 9. Existing career ladder for Staff Nurses of Chhattisgarh

3.1f. Workforce problems: Statements of nursing personnel. The research team conducted focus group discussions
and held workshops with different categories of nursing personnel. A total of 8 staff nurses, 9 ANMs participated in
FGDs conducted. In addition 10 state and district level officers were interviewed. A summary of the findings related
to workforce policies, practices and problems is given below under the main themes that out of the discussion.
· Many staff nurses working in the PHCs and CHCs are not aware of their promotional policies. Some staff
nurses stated that promotional avenues are available only for the SC/ST candidates. They said nurses were not
moving up the career ladder because promotion was linked to reservations. Sometimes staff nurses were
compelled to refuse promotion due to socio cultural and family problems – safety and security, family
presence, children’s education or posting in remote areas.
· The staff nurses felt that they too should be given opportunities for in service education like ANMs to update
their skill and knowledge. As there are two different appointing authorities for staff nurses they are not given
equal opportunities for higher education. Some staff nurses who had been sent on deputation for higher
education by the government, were not recognized for promotion or other allowances after training. Staff
nurses posted in the rural health centres felt that they had no opportunities for pursuing higher education on
deputation from the government.

22
· Staff nurses expressed that they like to be involve in the case discussions with doctors during rounds to obtain
knowledge on that issue. They expressed their disappointment when specialists who ordered treatment and did
not involve them in discussions about the case or did not explain the rationale for the new treatment.
· During FGDs, many ANMs said that they should have one LHV training centre in their state to enable them to
get training and become eligible for promotion. Some ANMs and LHVs stated that they had interest to pursue
their GNM training but in the existing system there are no opportunities for them.
· One of the ANMs said that she did not conduct a single delivery during her training period but was appointed
to serve immediately after training. She learnt delivery skills from LHV and nearby resident ANM and dai.

Position but not facilities or authority: The nursing officers strongly felt that the line of authority for nursing should
be handled by the nursing personnel and separate nursing directorate should be established. The existing DPHNOs felt
that their post had no authority. It allowed for supervisory and teaching functions, some of them hardly received
facility like government vehicles for supervision in rural centers. They are clubbed with teams visiting the field for
various other programmes. When they visit the field this way they are not able to achieve their own objectives.

3.2 Working environment and facilities of nursing personnel:

The research team visited four districts for in-depth understanding of the working environment of nursing
personnel at the periphery as well as in clinical areas in different hospitals. They observed health facilities, interacted
with nursing personnel and conducted discussions with related officers. Details of facilities, equipment and supplies
and the services provided in these centres are presented in table 19 and discussed separately for the four levels. Data in
table 19 show that infrastructure and facilities were a problem at subcentres and PHCs. For example, buildings needed
repair, toilet and other facilities for staff were not available, water and electricity were not present round-the-clock.

Table 19 – Working environment in different health facilities


Sl.No SC PHC CHC DH
(n=38) n =13 n=8 n=4
1 Building – functional 27 10 8 4
2 Electricity – regular 28 10 8 4
3 Separate labour room NA 7 8 4
4 Safety and security 11 7 1 4
5 Toilet for clients and staff 12 6 4 4
6 Separate Laboratory NA 6 3
7 24 hours water supply 21 5 4 4
8 Quarters for residence of nursing personnel NA 5 5
9 Operation theatre NA 5 7 4
10 Generator NA 2 1
11 Phone 12 2 6 3
12 Separate baby resuscitation room 2
13 Ambulance / hired vehicles 6

3.2a. Facilities and services at sub-health centres:


· Outreach health services are provided through 4741 sub-health centres that cover around 20,000 villages, hamlets
and tribal areas of the State. The research team visited 38 sub-health centres in four districts – ten each in Raipur,
Durg and Ambikapur and eight in Dantewada. The team observed facilities and interacted with ANMs.
· Physical facilities and amenities: Among the 38 sub-health centres visited only 27 had buildings. In some
buildings were available in many but these were old and no plans were available for repairing or rebuilding. Three
fourths had electricity but only 21 had quarters and water supply round the clock. Only twelve out of the 38 sub-
health centres had toilet. Telephone was available in twelve out of the 38 sub-health centres. Not even half of the
sub-health centres had safe or secure environment for the ANMs to stay at night and work comfortably. As a
consequence majority of the ANMs were not living in the space provided but in rented houses in the main village
or town.

23
· Facilities for MCH services: Furniture was not adequate in most of the sub-health centres. Equipment required for
providing care to patients was not adequate. Though most sub-health centres had thermometer, adult weighing
machine, stethoscope, blood pressure apparatus, child weighing scale, and foetoscope, many did not have critical
life saving equipment. For example, baby resuscitation kit was found in only three centres and mucus suckers
were seen in only six centres. None of the centres had ambu bag, only 11 had 100 watt lamp for baby warming.
· Drugs for managing emergency maternity conditions (misoprostol, methergin, magnesium sulphate) were
available only in seven sub-health centres and I.V fluids were found in 29 sub-health centres. Drugs for minor
ailments, iron and folic acid tablets for anemia prevention and correction, and TT injection were available in most
of the sub-health centres. Vaccine carriers, disposable syringes, and AD syringes were available in all sub-health
centres. Immunization cards and registers were found in all sub-health centres. This indicated that facilities for
antenatal care and immunization services were nearly adequate.
· Infection control: Color coded bins for biomedical waste management were available in only five out of the 38
sub-health centres. Sterilizer was available in 13 sub-health centres. Gloves were observed only in 11 sub-health
centres. Disinfectant was available but it was inadequate. Mackintosh was found in 18 out of 38 sub-health centres
but none of the sub centres had linen. Lack of facilities for cleaning, autoclaving and disposing waste material was
observed in all the centres.
· Facilities for childbirth services: Deliveries were being conducted by 30 out of 38 ANMs usually in homes. None
of the ANMs was plotting partograph and documenting details of the process of child birth. Equipment and
facilities for childbirth were inadequate. Out of 38 sub-health centres, 34 had labour tables, 30 had delivery sets
and 23 had B.P. apparatus. Only 16 had fetoscopes.
Overall, ANMs were providing basic maternal and child health services in the sub-health centres. But services
were provided on demand or adhoc day-to-day basis rather than in an organized or systematic plan. Nearly all were
conducting antenatal clinics and immunization sessions and assessing birth weight. Twenty one of the sub-health
centres were providing IUD insertion service and almost all reported that they were referring high risk cases. Lack of
adequate facilities, irregular monitoring and absence of supportive supervision and guidance were the major factors
contributing to poor performance in SHCs according to responses in FGDs as well as interviews with ANMs.

3.2b. Facilities and services at Primary Health Centres:


Thirteen PHCs were visited in the four districts. The research team observed facilities and interacted with the
PHC staff nurses and doctors. All the 13 primary health centres visited had buildings with electrical supply but it was
not regular. Round the clock water supply was available in only five out of 13 PHCs. Only six out of the 13 PHCs had
toilet facility. Telephone and generators were available in only two out of the 13 PHCs visited. Operation theatre was
available in five PHCs. Laboratory was present in only six out of 13 PHCs.
Separate labor room was available in seven PHCs. Eleven out of 13 PHCs had labor table. Thermometer and
stethoscopes were available in eight PHCs, blood pressure apparatus and fetal doppler machine were available in 11
PHCs. Adult weighing machine was available in nine PHCs, but child weighing machine was available in only six
centres. Foetoscope was found in only five out of the thirteen PHCs. Drugs like misoprostol, methergin and
magnesium were available only in six centres.
Baby intubation set was available in only one of the 13 PHCs. Ambu bag was available only in two centres.
Some essential items for emergency care such as 100 watt lamp, mucus sucker, suction apparatus, and oxygen
cylinder with key were found in four PHCs. Boyle’s apparatus was not available in any of the thirteen PHCs though
five had operation theatres. Suturing materials were found in eight centres. With regard to family planning services,
IUD insertion instruments were available in nine out of 13 centres.
Drugs for minor ailments, I.V. fluids, iron and folic acid tablets, tetanus toxoid injections were available in
almost all primary health centres. Twelve PHCs had all the vaccines. PEP (post exposure prophylaxis of HIV) drugs
were not available in any of the PHCs. All the primary health centres visited had adequate supply of immunization
equipment and articles such as vaccine carrier, disposable syringes, AD syringes and ice packs. ILR/ deep freezer/cold
box are found in nine PHCs. Immunization cards and registers were available in twelve centres.
Health teaching material in the form of posters and flash cards were found in only eleven out of 13 PHCs.
Temperature charts were present in only one PHC. Referral cards were available in six out of thirteen centers.
Biomedical waste management was a major issue in PHCs. Color coded bins for biomedical waste disposal
were available in only four out of the thirteen PHCs. Only five of the thirteen centers had adequate linen for patient
care. Sterilizer and adequate disinfectants were available only in seven centres.

24
Only eight out of the 13 PHCs were providing round the clock delivery services. Beds were available in only
four PHCs. Doctors were available in nine PHCs. Nurses or pharmacists were assessing the patients and dispensing
drugs in the absence of doctors.

Case study of Goburanavarapara PHC

When the team visited Goburanavapara PHC in Durg district during noon time one staff nurse was on duty. While we
were interviewing her a rickshaw came with the two persons carrying an unconscious lady. The staff nurse went out of
the PHC and checked the vital signs. The pulse was not felt and the whole body appeared bluish. The staff nurse called
the medical officer on her personal mobile since there was no office telephone. He arrived within 15 minutes. In the
meantime the staff nurse did not allow the woman to be taken into the PHC. The Medical officer came and declared
death. He suspected poisoning and said he’ll inform the police. The husband and other female relatives who
accompanied the dead woman left the body in the PHC and went away. The staff nurse told the team that she can’t
provide first aid for a MLC case without doctor’s advice and the centre is not equipped to meet such emergencies. This
revealed that the peripheral centres are not equipped adequately to provide the necessary emergency services or even
first aid round the clock.

Case Study of a PHC in Ambikapur district

This PHC in Ambikapur district had a separate building for


childbirth services but utilized it as a store. A rusted labor
table was present inside a small room. The PHC did not have
a staff nurse. The doctor and ANM were living in a nearby
area and visited the PHC. The ANM visited the PHC during
the day. The doctor came during emergencies.
The room had inadequate lighting and was also highly damp
and dusty. The ANM said that they used the room for doing
IUD insertion. They could not keep the room clean since
there were no class IV workers. They were not conducting
deliveries in the PHC because there was no one to help in
cleaning and there were no toilet facilities. When questioned
about AN clinics the ANM said that the Anganwadi worker
usually took care of antenatal care. The ANM said that they
did not conduct deliveries in the houses or in the PHC. All The observation room became the store room of the PHC
cases were referred to nearby CHC.

25
Rusted basins and dirty walls indicated that these had Rusted labor table covered with a dirty mackintosh.
not been used or cleaned for several months.

3.2c. Facilities and services at Community Health Centres:


The research team visited eight CHCs in the four selected districts. Most of them had electricity and round the
clock water supply. Most of the CHCs had residential quarters in the hospital complex but safety and security was
available in only one CHC. Toilet was available in the ward for clients, but no separate arrangements were made for
hospital staff.
Operation theatre was also present in seven out of the eight CHCs. A separate baby resuscitation room was
available in only two of the CHCs visited. Generator was available in one of eight CHCs only. Telephone facility was
available in half of CHCs. None of the CHCs visited had centralized oxygen supply and blood bank. None of the
CHCs had Boyle’s apparatus though seven of eight CHCs had operation theatre. Basic articles like BP apparatus,
stethoscope, adult weighing machine and child weighing machines were available in all CHCs. Dressing trolley was
found only in six CHCs. Fetal Doppler machine was available in three CHCs only. Injection Tetanus Toxoid was
available in seven CHCs and PEP drugs were present in only three CHCs.
All the CHCs had separate labour room. Normal delivery sets and episiotomy suturing materials were found in
almost all CHCs. Instruments for tubectomy were available in seven CHCs. Seven out of eight CHCs had instruments
for LUCS or forceps delivery. Vacuum extractor was available in three of the CHCs. It was observed that I.V fluids,
emergency drugs like magnesium sulphate, misoprostol, methergine, drugs for minor ailments were available in most
of the CHCs. Instruments for medical termination of pregnancy and instruments for IUD were not adequately
available in CHCs.
All the eight CHCs provided 24 hours services. There were several shortages of specialists. Physicians were
available in only six CHCs. Obstetricians were available in seven CHCs and pediatrician was available in only four
CHCs. Anesthetist was not available in any of the CHCs. Though doctors were available round-the-clock, it was
observed that adequate staff nurses for 24/7 services were available in only six out of eight CHCs. Lab technician was
available only in three CHCs though round the clock laboratory was present in six CHCs. Most of the CHCs had
health teaching material and AV aids. Only one CHCs had television facility for displaying health related information.
Infection control: Only two CHCs had color coded bins for biomedical waste disposal, and sterilizer for autoclaving.
Only three of the eight CHCs had adequate supply of disinfectant. Overall universal precautions were being
maintained in only two CHCs.
Childbirth services: All the CHCs were conducting normal deliveries, antenatal and postnatal clinics and
immunization clinic. Partograph plotting was observed in one of the eight CHCs. Seven out of eight CHCs were
performing IUD insertion for eligible couples.

Case study of Lakhanpur CHC

A delivery had just taken place when the team visited. The staff nurse had
completed assisting the woman. But due to lack of class IV workers the room
was dirty and the nurse reported that it can be cleaned only the next morning.
The floor was also dirty. This CHC had two new warmers but the staff nurse
said they were not used since their purchase and now they needed to be
repaired if they wanted to use them. The ambulance of CHC was in
condemned condition. Though it had building and personnel for 24 hours
services maintenance was poor and equipment was not in working condition.
The repaired ambulance of the CHC

26
One of the non working warmers Waste and dirt remained due to lack of class IV workers on 24 hours
basis.

3.2d. Facilities and services at district hospitals:

The research team visited four district hospitals: Raipur, Durg, Ambikapur and Dantewada. All the four had
casualty and laboratory facilities for rendering emergency services round the clock. They also provided referral
support to cases from PHCs and CHCs of surrounding areas. All four hospitals had separate post-operative ward.
Three of the four had separate emergency operation theatre and in other two hospitals, emergency operations were
being performed in general OT whenever an emergency case needed surgery. But only two hospitals out of four had
blood bank.

All the four hospitals had family welfare ward and outpatient department. Only three hospitals had facility for
providing drugs, equipment and supplies as a centralized system. Sterilization department and oxygen cylinders were
available in all the four district hospitals. Incinerator was found in only one of the four hospitals.

Maternal and child care: All the four hospitals had separate maternity unit with labor room, antenatal and postnatal
ward and antenatal and postnatal OPD. Instruments related to MCH services and normal deliveries were available but
the number of sets was inadequate. Only one hospital had separate eclampsia room for giving intensive and
specialized care to mothers with eclampsia. Facilities for new born care, especially for sick and premature babies,
were observed in three out of four district hospitals. Critical life saving equipment like baby ambu bag, open radiant
warmer, oxygen cylinder with key were found in all four district hospitals. Baby resuscitation sets were available in
two hospitals and baby intubation sets were available in three of the four district hospitals. But some of these were not
in working condition.

All the district hospitals had general care equipments like BP apparatus, stethoscope, weighing machine etc.
PEP (Post Exposure Prophylaxis) to HIV infection for the hospital workers was available only in one district hospital.
Two hospitals had VCTC facility.

Though all the hospitals were providing routine and emergency care for maternal and child health problems
and for general medical, surgical conditions, facilities for special investigations for acute and chronic cases were not
available in any of the selected district hospitals. Out of four, two had USG facilities but none of the hospitals had CT
scan facilities.

Service delivery: Staff nurses were available round the clock in all four district hospitals. But the number of staff
nurses was extremely inadequate compared to IPHS. For example in Raipur hospital with 121 beds ______ staff
nurses were available for providing care round the clock. According to IPHS the number of staff nurses should be 88
[75+9 (for OT) + 4 (for blood bank / storage) = 88]. Only one ANM was working in the district hospital whereas six
ANMs are required. Nursing Supervisors were available in two out of four hospitals. Lab technicians were available in
all four district hospitals. Pharmacists were managing the store in the hospitals. Personnel were not available for
operating telephone exchange, air condition, workshop, etc

27
Overall, the study showed that there are many gaps in facilities and equipment and their quality at all levels. In
most places, emergency equipment and their quality was poor and inadequate. There were shortages of staff. For
example though obstetricians were available in seven CHCs and pediatricians were available in four CHCs,
anesthetists were not available in any hospital. Nursing personnel were inadequate at all levels-PHCs, CHCs and
district hospitals.

3.2e Work related problems of ANMs and staff nurses

The research team interviewed 80 ANMs and 74 staff nurses in the four districts. The mean age of ANMs
was 40.4 years and the mean age of staff nurses was 39 years. Majority of the ANMs and staff nurses were married.
Few not only fulfilled basic educational qualification but had higher education. All the ANMs fulfilled the educational
requirement of class X. Though 10th class was the requirement for ANM training 33 out of 80 ANMs had completed
intermediate education. Four out of 74 staff nurses and one out of 80 ANMs were post graduates. Two staff nurses had
completed graduation.

28
Table 20. Age, marital status, and educational status of sample ANMs and Staff Nurses
S.No Category Characteristics ANMn=80 SNn=74
Less than 35years 9 21
1 Age 36-45 years 61 28
More than 45 years 10 25
Marital Married 74 63
2
Status Unmarried 6 11
10th class 46 3
General
3 Intermediate 33 65
education
Graduate or higher 1 6

Job clarity: The staff nurses and ANMs were requested to comment on the work and factors that influenced them.
Only 38 out of 80 ANMs and 40 out of 74 staff nurses said that they knew about the written job description. None
received any written documents. Only 23 out of 80 ANMs and 40 out of 74 staff nurses were aware about the duty
roster. Very few (4 out of 80 ANMs and 5 out of 74 staff nurses) said that they had written protocols for managing
emergency maternal conditions.

Only 34 out of 80 ANMs and 50 out of 74 staff nurses expressed their satisfaction with present pay and
allowances. Most of the ANMs got in-service education through RCHII and NRHM. Compared to this less than one
third (27 out of 74) staff nurses were getting in-service education for their professional development.

Thirty nine out of 74 staff nurses said that they were getting adequate supply of equipments and articles.
However, only 32 ANMs and 51 staff nurses said that they were in working condition. Supply of essential drugs was
also a problem for ANMs and staff nurses. Thirty three out of 80 ANMs said that the supplies of essential drugs was
adequate in amount. Thirty two out of 74 staff nurses interviewed said that they are not getting the essential drugs as
required.

Most of the ANMs said that they faced problem for communication since said land phone is not available in
the clinical field. Only 18 ANMs and 25 staff nurses expressed that the working environment was safe for them to
work comfortably and securely. Only 30 ANMs were getting adequate recording materials for documentation of their
services. 29 out of 80 ANMs and 69 out of 74 staff nurses said that though some workers were available they were
inadequate for maintaining cleanliness and quality in the wards.
 ANMs who had worked in the tribal areas said they had never received any visits of supervisory staff to their
sub- health centres. They met the LHVs only in the block meetings. Hence in remote areas, supervision
depended on road connectivity and willingness of HVs to travel.
 The staff nurses in the district hospitals felt that supervision was mainly for the purpose of making sure that
the days work has been done or not and not for the purpose of identifying the problems of the staff nurses and
providing guidance and counseling.

“Safety and security, where?...”


 The ANMs in the remote tribal areas felt insecure to work in the sub centres. One of the medical officer
suggested that if the supervisors visited the ANMs in their workplaces regularly that itself would help in
reassuring the safety of them.
 Most of the staff nurses in the DHs and CHCs felt that the environment was safe but in only one DH though
they had a watchman for the hospital in night shift they felt insecure about the nearby arrack shops and
goondas.

Problems in maintaining universal precautions


 The staff nurses working in the tertiary hospitals were having more workload and hence it was difficult to
maintain quality. They often managed with help of students.
 Their working environment was very dirty and stale due to inadequate number of class IV workers and short
supply of disinfectants and cleaning solutions.
29
 They received inadequate articles to maintain aseptic precautions. Usually they were provided only gloves.
But masks and gowns were in limited supply.
 Some of the ANMs stated that since they were not given building for the sub centre their performance was
reduced greatly. Most of the ANMs complained that they had no toilet facilities in their health centres.
Transportation in the remote tribal villages was problematic. Many times they had to leave early and there
were no facilities for food and snack near subcentres.

Pay and allowances:


 The ANMs were highly unsatisfied over their salary and allowances since they felt that their field work is
hectic and being in charge of sub-health centre they are loaded with additional responsibilities like procuring
drugs, vaccines and essential articles, maintaining accounts of the untied funds etc.
 Staff nurses said they have no facility for other allowances like patient care, allowances, night duty
allowances, risk allowances, special ward allowances and extra higher studies allowances. There were no
adequate Quarters for staff nurses and ANMs. No canteen for nurses in the hospital campus and no safe
drinking water facility.
 ANMs said they faced problems in getting travel allowances from the government since the intermediate
people take bribe for that . They suggested that government can pay a consolidated amount for example Rs
500/ every month in their salary.
 ANMs have to spend from their own pockets for their local travel and reimbursement are delayed. This was a
burden for them.
Recognition and status
 The nurses (both ANMs and Staff nurses) felt that their services are not recognized by the officials. Though
they serve the community at the periphery levels they were never appreciated or motivated. One of the staff
nurses stated that the image of the profession will improve only when the public recognizes them and respects
them. One ANM during the FGD said that they are not recognized even in the villages because they have to
get their salary from the Sarpanch “falling on his feet”.

Grievances and conflict resolution: Some of the staff nurses interviewed were not aware of their rights and did not
know how to express their problems. In the state of Chhattisgarh a fixed grievances day is present to meet the health
secretary to put for the grievances for the following:
a. Harassment –The cases are not coming into limelight.
b. Village posting – Staff nurses / ANM are posted in far places from the home, they can refuse post for these
grievances.
c. Promotion – The scope of promotion is very less. Some are working as acting especially in principal post and
not getting permanent post. Most of ANMs, LHVs, and Staff Nurses are retired in the same post.
d. Salary – Salary is provided as per the state government norms for different cadres of nursing, sometimes
LHVs, ANMs and contractual nurses are not getting their salaries in due time.
e. Regularization of contractual nurses – State had a huge shortfall and deficit of nurses, the services of the
contractual nurses are regularized gradually.

3.3 Nursing in the Private Sector

The research team visited three private hospitals (including one mission hospital) and requested hospital
authorities to permit the research team to interview nursing personnel and observe facilities for nursing care including
working conditions. Most of the hospital authorities refused to allow the research team to interact with nurses.
Permission was obtained from only two hospitals for detailed observation and interaction with the nursing staff. Seven
staff nurses (4 GNM and 3 B.Sc) and five ANMs were available for discussion. The findings below are based on these
interactions.

The two hospitals each had 150 beds and reported around 30 to 35 nurses but declined to list them or
categorize them as staff nurses and ANMs. Interactions with the sample nurses indicated that very few
nurses were actually trained or had valid certificates. Majority of the nurses interviewed claimed that they
were trained from other states like Jharkhand, Orissa but declined to reveal the details.

30
One staff nurse working in a labor room for five years was drawing a salary of Rs 5,000/. She expressed her
disappointment over the low salary. When enquired why she did not opt for other hospitals, she said that since she was
trained in a private unrecognized institute in Orissa, her certificate was not recognized by the Nursing Council and so
she was forced to continue in the same hospital. In the second hospital staff nurses and ANMs were put into the same
category and given the same uniform. By clubbing the two categories together, one is given an impression that they
are all qualified nurses.
The chart below presents a few features of nursing in the private sector in Chhattisgarh
Recruitment and · Most of the private hospitals had very few trained staff nurses or ANMs. They had a
availability of higher proportion of untrained persons acting as staff nurses and ANMs. Nurses working
personnel in private hospitals are recruited on need basis through advertisements in local
newspapers and through social networks. The hospitals refrained from providing details
of the recruitment policies. These policies were formulated by doctors who were often
the owners of the hospitals.
Career pathways, · Nurses in private hospitals said that they were not sure of promotional avenues since they
promotion and were not regular employees. They said they faced uncertainty about continuation in the
professional job. Promotions were given only when the management decided to do so.
growth · There is generally no scope for formal higher education for nurses working in private
sector unless they themselves initiated it. In one hospital nurses were allowed to pursue
post basic BSc (nursing) in the nursing college attached to their hospital provided they
signed a contract for five years service to the hospital. Students were incharge of patient
care when they attended classes. Though this method did not allow them to focus on
studies, they took the opportunity because they would get a degree.
· Inservice education was not well planned or regular. The administration organized in
service training usually to orient the nurses to the new equipments they purchased.

Positive · The infrastructure was well planned and organized. Telephone connectivity was good.
expression about · They had adequate supplies and equipment to provide care and also well structured forms
private sector for documentation.
· Nurses felt safe and secure in these hospitals because security personnel were appointed
by the hospital authorities.
· They were provided hostel facilities located close to the hospital or inside the campus.
Negative · They received low salaries compared to those in government employment – the salary
expressions about ranged between Rs 3000 to 5000 when they had three years of clinical experience. They
private sector usually received a consolidated pay with no additional benefits.
· They felt insecure about their job since they did not have many rights and were not an
organized group as each hospital had only a few nurses and there was very little time for
organizations. Their participation in professional development activities was dependent
on the authorities’ interest.
· They were unsatisfied with the monotonous routine and lack of appraisal, guidance and
recognition. They were over loaded with additional working hours with no extra benefits.
· There did not have residential quarters. Families could not stay with them.
· Technical guidance was rare. They were frequently punished for their mistakes, rarely
guided. They felt stressed during hours of supervision especially during nursing rounds.

In summary, the findings in this section indicate the urgent need to initiate measures for strengthening nursing
services in the interest of equity as well as positive outcome for health. An unhappy and frustrated nursing workforce
stagnant in their career; inadequately equipped with knowledge and skill; hampered by shortage of supplies,
equipment and facilities; neglected by officials and policy makers cannot be expected to demonstrate enthusiasm and
commitment for high quality care.

31
Section Four
Nursing education in Chhattisgarh: Availability, capacity and quality
4.1 Nursing education programmes

The first hospital to be opened in the State was Bilaspur Mission Hospital in 1885. Dhamtari Christian
Hospital and Tilda Hospital were established in 1910 and 1929 respectively. General nursing training was started in
Bilaspur Mission Hospital in 1932 under the Mid India Board of Education. In 1930, the first ANM training centre
was started in the Government Jubli Hospital, Raipur. The same hospital started giving GNM training in 1947. For
nearly four decades after independence, nursing education was limited to only a few ANM and GNM schools attached
to government and mission hospitals.

The Chhattisgarh Nursing Council came into being in August, 2003 and started the registration of nurse
midwives in the State. At present, though Chhattisgarh has proportionately lesser number of nursing educational
institutions compared to many other states, the State witnessed a sharp rise in B.Sc. and M.Sc nursing colleges during
the last decade. The latest INC data reveal that there are 30 B.Sc. and eight M.Sc. Nursing colleges in the State.
Compared to this, there are only six ANM and 10 GNM training institutions in the whole state. Table 20 provides
some details of the institutions. (Note: When assessing the number of training centres one should take into
consideration that there are some discrepancies between the list published by the Indian Nursing Council on its
website and the list available at the State Nursing Council and directorate).

Table 21. Availability of nursing educational programmes in Chhattisgarh and India as per INC (2008)
Total in India according
Sno Course Government Missionary Private Total to INC statement
ANM or MPHW (F) 606
1 training 4 1 1 6*
2 GNM training 4 2 4 10 1916
3 B.Sc. Nursing training 4 1 25 30 1167
4 Post basic B.Sc. Nil Nil 7 7 226
5 M.Sc. Nursing Nil Nil 8 8 247

*The Registrar, Chhattisgarh Nurses’ Registration Council gave a figure of eight ANM training centres

This phenomenon of sudden and steep rise of B.Sc. and M.Sc. colleges of nursing and not ANM and GNM
schools in Chhattisgarh needs to be further studied and analyzed. The same is also the case with number of institutions
offering post basic B.Sc. nursing – seven institutions. Interactions with senior nursing personnel in the State and
officers of the colleges indicated that this was a continuation of the trend in Madhya Pradesh of which Chhattisgarh
was a part. It was observed that majority of the students in the colleges of nursing in Chhattisgarh were from Kerala.

According to the government of Chhattisgarh and the State Council there are seven ANM Training Centres in
the government sector and one run my Missionaries - Holy Cross Hospital in Kunkuri. One private ANM Institution
was given permission by INC in August 2009. Latest interaction with state level resource persons in August 2009
showed that three more private institutions were given permission to start ANM training in August 2009 – P.G
College of Nursing, Shreyas College of Nursing at Bhilai and CG School of Nursing at Raipur. This takes the total
number of ANM training institutions to 11 in Chhattisgarh.

There are ten training centres for GNM training in Chhattisgarh according to INC– four in the government
sector, two run by missionaries and four managed by private institutions. The four GNM schools of nursing managed

32
by the government sector are attached to the three medical colleges – Dr. Bhim Rao Ambedkar Memorial
Hospital,Raipur, CIMS Medical College Bilaspur, and Medical College Jagdalpur. One more school is attached to
District Hospital at Durg. In addition, two schools of nursing are run by Missionary Groups – Christian Hospital,
Dhamtari and Mission Hospital, Tilda both of which are established training institutions. There are two other schools
of nursing run by the private sectors – MMI school of nursing and Chandulal Chandrakar school of nursing. Two more
private institutions were given permission to start the GNM course in 2009.

Collegiate Nursing: Collegiate nursing programme in Chhattisgarh started in 1986 with the PG college of nursing
under the Bhillai Steel Plant Hospital. This college gradually became an autonomous institute with paying students.
Since then there have been several developments, especially after separating from Madhya Pradesh. Recently there
have been discussions in the government to establish a medical university to bring all the health related colleges under
its purview. The first government college of nursing in the state was started in Dr.Bhim Rao Amdedkar Memorial
Hospital, Raipur in a rented building. Land was procured for the construction of the college building and foundation
stone was laid in September, 2008 by the Chief Minister. Discussions with local officials indicated that the delay was
administrative due to PWD. The College is still being run in a rented building after having shifted from the first
building. Shifting the college from one rented building to another did not help in enhancing the quality of training.

Recently, education in this government college of nursing has become partly private because they have 50 %
government seats and rest is on payment. The allotment is based on merit for both the categories. In the payment seats,
they pay Rs 35,000 extra whereas the free seats pay only tuition fees. The students have to sign a bond for one year
service in the government health facilities such as MCHs, DHs, CHCs and PHCs. The stipend during the bond period
is approximately Rs 5000.

According to the latest information the college of nursing is to be strengthened into a centre of excellence in
nursing and a proposal has been sent in this regard from the Director of Medical Education to the Government of
India. The college has been facing an extreme shortage of teachers. The State has started sponsoring candidates to
pursue M.Sc (N) in other states and also in the private institutions within the state. Recently, the government decided
to start three more colleges of nursing at Bilaspur, Jagdalpur and Ambikapur. There is one college of nursing run by
missionaries – Holy Cross Hospital at Ambikapur.

Postbasic B.Sc. Nursing: In 1997 the Dhamtari training centre started postbasic B.Sc. nursing with an initial intake of
four students. Currently its intake has been increased to 20 per year.

M.Sc. Nursing: In the private sector postgraduate course in nursing was at first started at the Bhillai PG College of
Nursing with an annual intake of 30 per year. M.Sc nursing was started in Shreyas College of Nursing in 2009. The
Director of Medical Education started sponsoring candidates to the private institutions both within and outside the
state since 2006 because there are no post graduate institutions in the government sector. Initially two candidates were
sponsored. Currently five teachers from the state are undergoing M.Sc. Nursing in different private college of nursing
in Chhattisgarh.

4.2. Facilities in nursing institutions in Chhattisgarh: Findings from study of institutions

The research team visited 13 institutions to observe facilities and to interact with teachers and students. The
number visited included four ANM training centres (three government and one private); four GNM schools of nursing
(two government and two private) and five college of nursing (one government and four private).The chart gives some
points of comparison between nursing education in government and private institutions.

33
Comparison of nursing education in government and private institutions
Category Govt. Training Centres Private Training Centres
Class · The CON and one SON had only rented · Most of them had own buildings. The number of
rooms buildings. Number of classrooms are adequate class rooms are adequate, spacious and free from
but not spacious. Electricity is present but the outside noise. Rooms are well ventilated.
number of lights and fans were not adequate Electricity and adequate number of fans are present
· Table and chairs are adequate.
Library · One small room is allotted for library. Racks · Library facilities are adequate though they were not
with books occupy most of the space. There is updated by journals and new books.
no sitting arrangement for students. Librarian
is not available
Skill lab · There is no skill lab for midwifery practical · Some have separate skill lab whereas others have it
classes. The same room is used for theory and combined with other labs for example fundamentals
practical demonstration. Only a female of nursing. They have updated models that are
dummy and pelvis and fetal skulls are routinely used by teachers for demonstration and
available in most of the centres. for the students to perform return demonstration
Teaching · Only few charts are available Electronic · They have a range of teaching aids like OHP, LCD
facilities A.V.Aids such as OHP, LCD projectors and projectors, computers etc.
computer are not available in most of the
schools. In some OHP projector is present but
it is under cover or closed.
Hostel · Hostel accommodation is available in most of · Hostel accommodation is available in the training
the centres. But they are away from the centres. Though they are away from clinical they
clinical area because these are in rented have good transportation facilities. Students are
buildings. They have poor transportation staying in crowded rooms.
facilities due to lack of funds for fuel. Rooms · Facilities like toilet, tables, chairs, cup board and
in the hostel are congested with inadequate safe drinking water are adequately available
toilet facilities and poor water supply. Safe
drinking water is a problem

4.3 Profiles, perception and practices of teachers:

Thirty four nursing teachers were interviewed in 13 institutions. Effort was made to include teachers involved
in midwifery teaching, community health and child health. Ten out of 34 teachers had M.Sc qualification, one had
Post Basic B.Sc Nursing, 13 had Basic B.Sc Nursing and six teachers had completed a diploma course after GNM
course. More than half had less than ten years’ teaching experience. Only 14 out of 34 teachers had opportunity for in-
service education related to midwifery though most of them were teaching this subject. Only 20 out of 34 teachers
participated in national conferences related to the subject they were teaching. It was observed that 12 out of 34
teachers conducted delivery regularly to demonstrate the procedure to students posted in the labour room. Twenty four
out of 34 teachers said that they supervised their students in the labour room. Supervision in antenatal and postnatal
units was not as regular as that in labour room according to teachers. Teachers said that only 28 out of 34 teachers
participated in clinical teaching regularly.

Most of the teachers demonstrated steps of antenatal and postnatal examination, care of the breast and perineal
care in the clinical area. Childbirth assistance was first demonstrated in the lab and then in the labour room by most of
the teachers. Only 18 out of 45 teachers said they demonstrated partograph plotting. Half of the 45 teachers
interviewed said that they demonstrated baby resuscitation, kangaroo mother care, and breast feeding and health
education about home-based care. Class test was the most frequently used method of evaluation of students. In
addition to class test, 37 out of 45 teachers used return demonstration to evaluate the students’ skill. Thirty five out of
45 used case presentation as a method for evaluation of students. Seminar and panel discussion method were also used
by 28 out of 42 teachers. Very few teachers used case method or case study method to assess students’ understanding
the condition and the care provided to clients.

34
4.5 Perceptions and problems expressed by students:
The research team interviewed 115 students from various institutes - 36 students from ANM training centres,
30 students from GNM training institutes, and 49 students from college of nursing. The students were selected from
final year or final semester of the programme so that they were aware of midwifery subjects.
Most of the ANM students received clinical posting and completed experiences in labour room and postnatal
ward. Fewer (about one third) had experiences in antenatal ward and family unit. Most of the GNM students of third
year fulfilled the requirement of clinical posting at antenatal clinic, newborn unit, antenatal ward and postnatal ward.
Most of the B.Sc. (Nursing) students also said that they completed clinical posting in postnatal ward, newborn ICU,
labour room and antenatal clinic. Here too, less than half completed clinical posting at family planning units.

The data show that students in different programmes were given experience according to the syllabus.

Table 22. Student’s performance in MCH care


ANM N=36 GNM N=30 B. Sc (N)N=49
S.
Learning area Under Indepen- Under Indepen- Under Indepen-
no
supervision dently supervision dently supervision dently

1 Conducting delivery 29 13 28 13 38 3
2 Antenatal examination 24 17 28 24 41 25
3 Post natal care 21 29 30 27 32 41
4 Newborn resuscitation 29 21 26 0 35 17
5 Prevention of hypothermia 12 4 17 23 30 30
6 Immunization 24 25 32 17 27 24
7 IUD insertion 19 0 13 0 12 5

Though most of the students completed witnessing key components of maternal and child health there was
gaps in actually practicing the skills. Most of the students completed their required number of deliveries. Larger
number of students witnessed deliveries compared to actually assisting during child birth (38 and 13). None
performed episiotomy suturing and neo natal resuscitation or IUD insertion.

Postnatal care experiences showed more gaps compared to antenatal or intranatal. Students did not get enough
opportunity to practice resuscitation of newborn and hypothermia prevention. Perhaps they need to make observations
in abnormal or high risk cases and practice more on dummies and simulators. Reports of students also showed that
most of them were able to complete experiences under supervision but they did not get opportunity to complete the
required number of cases independently.

Supervision and guidance: Most of the students of all categories expressed satisfaction with classroom teaching.
About half of the students of all three categories said that they were supervised and guided regularly in the clinical
areas. Besides teachers, staff nurses, ward sisters and doctors guided students during clinical experiences. About one
third of the B.Sc. Nursing students said they were not satisfied with the quality of supervision in the clinical area and
most of them said they were not satisfied with the clinical evaluation system.

In summary, nursing education in Chhattisgarh is faced with a range of problems - poor facilities, inadequate
teachers, incomplete practical experiences. Above all, students did not get adequate experience in independent
performance of skills. Library and skill labs are almost non-existent especially in the ANMTCs. Teaching aids and
material are out dated. There is an urgent need to review the teaching and evaluation systems in nursing so that
students have meaningful learning experiences.

35
Section Five
Recommendations for strengthening nursing in Chhattisgarh
Nursing personnel are required in every sphere and level of the health care delivery system. Nursing personnel
work in wide ranging situations from sub-health centres to medical college hospitals. Nurses are essential for health
promotion and disease prevention in the periphery as well as to carry out sophisticated medical interventions in
tertiary hospitals. Nurses are crucial to patient treatment and recovery because they provide continuity of care in
hospitals due to their unbroken presence round the clock. Moreover, they are links in the continuum of care from
preventive to rehabilitative, from community to hospital and back to community.

The scope of work of nursing personnel is enormous. Chhattisgarh has 4741 sub-health centres, 721 primary
health centres, 136 community health centres, 17 sub district hospitals, 15 district headquarters hospitals and three
medical college hospitals. Besides the above, there are eight ANM Training Centres, four Schools of Nursing, and one
College of Nursing. Nurses are required for the smooth functioning of each of these government health facilities and
training institutions. In addition, there is a significant and ever growing private health sector which is increasingly
absorbing trained nursing personnel. Sufficient numbers of nurses equipped with appropriate skills and knowledge are
essential for achieving goals set by NRHM. In Chhattisgarh,
there are acute shortages in almost all categories of nursing The Government of India recognized that the
personnel hampering the achievement of NRHM goals. availability of human resources in rural areas “is
one of the serious challenges faced by the National
Rural Health Mission” (Official Communication,
It is within this context that the assessment of nursing GOI, 2006) and stated, “… a possible solution to
workforce in Chhattisgarh was undertaken by the Academy for this problem, would be to encourage the selection,
Nursing Studies on behalf of the National Health Systems recruitment, training and placement of nurses in a
big way by the states. In fact, it would be desirable
Resource Centre (NHSRC) in 2008-09 with the approval of the
to constitute a Nursing Cadre by all States, so that
NRHM, Government of India and with the cooperation of the their selection, training, placement, career
government of Chhattisgarh. Findings showed that Chhattisgarh progression etc. could be taken up in a systematic
is facing an acute shortage of nursing personnel. way”.

The findings of the situational analysis provide a framework for addressing shortages and preparing an action
plan for strengthening nursing, midwifery and public health nursing in Chhattisgarh. Urgent action is required to
address shortfalls and meet immediate needs and also prepare concrete action plans for preventing shortages, reducing
discrepancies and inequities in the future.

Nursing workforce in Chhattisgarh consists of personnel working in three distinctly different areas: public
health, clinical services and teaching. The recommendations for strengthening nursing should focus on all these areas.
This section is organized into two broad sub sections. The first part gives the recommendations and the second part
presents a draft action plan.

Key issues to be addressed:


· Acute shortages in all cadres of nursing.
· Highly inadequate faculty at all levels.
· Inadequate promotional policies.
· Weak nursing management at state and district level.
· Inadequate and poor quality of nursing education.
· Discontinued courses and cadres in public health nursing and midwifery.

36
The recommendations are detailed below in four sections:
5.1 Addressing shortages in nursing personnel
5.2 Addressing shortages of nursing teachers
5.3 Designing career progression
5.4 Strengthening nursing workforce management

5.1. Proposals to address shortages in nursing personnel


The findings of the nursing situational assessment revealed huge shortfalls in frontline workers and
supervisors - ANMs and LHVs - for delivery of public health services; and staff nurses and head nurses for hospital-
based services. The findings also revealed the absence of PHNs. The number of DPHNOs is also too small to make
any observable improvement in public health nursing in the State. In the teaching institutions there is a shortfall of
tutors and clinical instructors. The present recommendations attempt at addressing these problems.

Table 23. Overall shortage of nursing personnel


Teaching faculty
ANM,GNM and
Nursing personnel Required LHV Required College of nursing Required
ANM 10501 Principals 11 Principals 1
LHVs Nil Vice principals 4 Vice principals 1
PHNs 136 Nursing tutors 81 Readers 1
DPHNOs 36 Additional tutors 4 Lecturers 5
Staff nurses 10089 Total 100 Clinical instructors 14
Head nurses 294 Total 22
Assistant matrons 61
Deputy nursing superintendents 7
Matrons 35

5.1a. Proposals to increase the number of ANMs:

ANMs are vital frontline health workers critical for programme implementation, technical service provision
for mothers and children, giving first aid and treating minor ailments and gathering vital information. Most
importantly they act as agents of change and promote health through education and information. Different options are
presented here to increase number of ANMs in Chhattisgarh.

· All the eight ANM Training Centres in the government sector and the training centre in Holy Cross Mission
hospital can admit additional students with some renovations, additional facilities, and increased number of
teachers. If the intake per year is doubled in these centres, 600 ANMs can be trained within 18 months from
the date of starting this scheme.

· As an alternate measure, the government of Chhattisagrh could start eight new ANM schools preferably in the
tribal areas like Mahasamund, Korba, and Dantewada where minimum 101to 200 bedded sub-divisional
hospitals are present. This could be undertaken in collaboration with the tribal welfare department.

37
· There is only one mission ANMTC in Kunkuri, Jashpur. But they are conducting the courses only to obtain
the man power required for the Mission Hospital. The government can hold discussions with the authorities of
Holy Cross Mission Hospital to double the number of admissions for a period of at least three years with some
additional support from the Government of Chhattisgarh through signing MoU.

Table 24. Year wise plan to produce adequate number of ANMs as required
ANMTCs Intake / school Intake / Expected number of ANMs passed out Total
(present) 2009 school ANMs in different years
from 2010
2009 2010 2011 2012 2013 2014
Eight Intake varies 80 in 390 390 600 600 600 600 3180
Existing between government
government sector 40 in
30 to 60
ANMTCs private
and Holy 20x1=20 sector
Cross 30x1=30
Mission
Hospital 40x1=40
60x5=300
Total=390

5.1b. Proposals to meet the shortfall of PHNs and DPHNOs:

Chhattisgarh does not have posts of PHNs in the field at present. The shortfall of the PHNs is 136.
The state needs 31 more DPHNOs. The qualification for DPHNOs is a diploma in Public Health Nursing or B. Sc
(Nursing). The government could depute interested candidates for DPHN course in other states to overcome the
immediate shortfall.

5.1c. Proposals for addressing shortage of staff nurses:

Chhattisgarh needs 8310 staff nurses in addition to the ones available currently. At the current level of
intake into GNM Course, it will take more than 10 years to fill the gap. Immediate steps should be planned for
increasing intake so that the current gaps are filled within a short period and future needs are met.

Option 1 - Increasing intake in existing government schools of nursing:

· Yearly intake of students in four government schools of nursing- Raipur, Durg, Bilaspur and Jagdalpur could
be increased from the existing capacity 25 to 50 with some improvement in the physical structure of the
school building and with the existing hostel after some renovations. Students of these two schools can be
allowed as day scholars. By the end of 2015 it is expected that 5500 students will pass out from the four
government schools of nursing.

· The yearly intake of the two mission schools of nursing Tilda and Damthari may be increased from the
existing capacity of 5o to 100. By the end of the 2015 a total of 500 qualified students will be available for
taking up posts.

· There are two private schools of nursing in Chhattisgarh having an admission capacity of 40 and 20 in each.
The seats could be increased from the existing capacity of 60 to 100. By the end of the 2015 a total 540
qualified students will be ready for absorption as staff nurses.

38
Option 2- Opening of new GNM schools in the government Sector:

At present there are four schools existing in the government sector. Government of Chhattisgarh could also
open new 12 school of nursing with 100 in take per year in 12 districts where there is no school of nursing at present.
At the end of the 2015, it is expected that 3600 students will be available from the 12 new schools. Later the
admission capacity could be reduced as required. Overall if all the above measures are followed 5,508 staff nurses will
be available by 2015.

Table 25. Calculation of recruitment to meet shortfall of staff nurses at Chhattisgarh


Existing schools Candidates passing out after increasing intake
S. Name of the Total
No school of Nursing Proposed
No Intake Total 2009 2010 2011 2012 2013 2014 2015
intake / yr
1 Raipur 1 22 22 50 22 22 22 22 50 50 50 238
2 Durg 1 10 10 50 10 10 10 10 50 50 50 190
3 Bilaspur 1 10 10 50 10 10 10 10 50 50 50 190
4 Jagdalpur 1 25 25 50 25 25 25 25 50 50 50 250
Mission school of
5 2 20+ 30 50 100 50 50 50 50 100 100 100 500
nursing
6 Private institutions 2 20+40 60 100 60 60 60 60 100 100 100 540
1200
7 New institutions 12 - - - - - - 1200 1200 1200 3600
(100 x 12)
8 Grand total 20 177 177 177 177 177 177 1600 1600 1600 5508

5.1d. Proposal to fill posts of head nurses and matrons:

Quality of supervision and guidance are essential in skill based professions. Chhattisgarh needs 170 head
nurses, 51 assistant matrons, six deputy nursing superintendent and 20 matrons. All these are promotional posts.
Interviews with staff nurses and FGDs with different groups of nurses indicated their frustration at not being promoted
even after 20 years of service. Administrative steps have to be initiated to prepare eligibility or seniority lists and
promote them. This will of course create further vacancies of staff nurses that needed to be filled.

5.2. Addressing shortage of nursing teachers:

The most critical issue for increasing number of personnel is the very low availability of nursing teachers.
Table below shows the overall shortfall of faculty for proposed (new and old) ANM training centres and GNM School
of nursing.

Table 26. Overall shortfall of nursing teachers for proposed new


and old ANMTC and GNM school of Chhattisgarh
Required as
Type of school No. of schools Total per INC Total Existing Shortfall
norms
Old – 8
16 8 x 16 = 128 128
ANMTCs New –8
Old – 4 17x4 =68
16 452 48
Schools of Nursing New – 12 32x12=384
Total 32 580 48 532 (92%)

39
There in a shortfall of 128 teachers are needed to prepare 5651 ANMs through 16 ANM schools. Similarly
another 452 nursing faculty are needed to prepare 8310 staff nurses through 16 schools. An additional number of 532
nursing teachers are urgently required in Chhattisgarh to prepare nursing personnel to fill gaps (ANMs and GNMs).

5.2a. Proposal for addressing shortfall of teachers at ANM training Centres:


 Interested and willing staff nurses can be deputed for DNEA course to nearby state (for e.g. Madhya
Pradesh) where the seats for this training are remaining vacant.
 Candidates passing B.Sc. Nursing course from IGNOU can be absorbed.
 Existing DPHNOs can be involved in taking classes and in community field experiences in their
respective districts.
 All candidates from Government College of nursing in Raipur may be recruited.
 Qualified candidates with B.Sc. Nursing from private sector can be recruited.
 At least two Colleges of Nursing can be started for post basic B.Sc. Nursing with 50 intake per year.
 Interested and willing staff nurses can be deputed to the private Colleges of Nursing for two years to
complete post-basic B.Sc (N).
 B.Sc (N) graduates from states where there are many colleges may be recruited through open
advertisement.

Chhattisgarh needs at least two more Colleges of Nursing besides the one in Raipur to prepare graduates to
take up teaching posts. INC norms are to be followed to calculate the requirement for opening of two more colleges of
nursing. The two new College of Nursing could be started with the medical colleges at Bilaspur and Jagdalpur .

Table 27. Year wise plan for increasing number of nursing teachers
Intake Proposed intake Candidates Passing out
Proposed
Course Existing per CON per / yr Total
intake 2009 2010 2011 2012 2013
year 2009
B Sc(N) 1 2 50 50X3=150 50 50 50 50 150 350
P Bsc
- 3 30 30x3=90 - - 90 90 90 270
(N)
MSc(N) - 1 20 20x20 - - 20 20 20 60
Total 50 50 160 160 260 680

Table 28. Shortfall of faculty for existing and proposed colleges of nursing
Category INC norms Required faculty for 3 CON Existing faculty Shortfall
Principal 1 1*3=3 1 (in charge ) 3
Vice principal 1 1*3=3 - 3
Reader 5 5*3=15 - 15
Lecturer 7 7*3=21 2 19
Clinical
18 18*3=54 19 35
instructor
Total 32 96 21 75

( INC norms -1;10 – one teacher to ten students – with annual intake of 50 or less in BSc(N) and 30 or less in
post basic BSC(N) and ten or less in MSc(N).

40
5.2b. Proposed plan for addressing shortfall of teachers for collegiate programmes:
 Already there is proposal to start PG course in the Government CON, Raipur. This can commence as
planned with an intake of 20 per year.
 In the meantime, the state can continue deputation of the interested and willing candidates for higher
education to neighboring states and private institutions with an intention to prepare faculty for proposed
college of nursing.
 For immediate action faculty can be borrowed from private sector in Raipur and Bhilai or neighbouring
where more M.Sc (N) passed candidates are available with various specialties.
 For the time being fresh M.Sc (N) candidates can be deputed and later on after their results can be posted
permanently faculty in the college of nursing.
 Depute willing candidates to other states for M.SC (N) course with either fellowship or through
government deputation with assured promotion after completion of course.
 Recruitment from the open market by advertising in national newspapers with attractive remuneration
and benefits. There are hundreds of candidates with M.SC(N) available in southern states.
 Launch a faculty development programme so that skilled and committed teachers are attracted to remain
in the state and those working outside the state return back.

5.3. Career pathways and progression

It is critical that the massive nursing workforce be reviewed and reorganized so that clear pathways are
constructed and opportunities made available to those who wish to move up the career ladder. Unfortunately, career
pathways have not been clearly defined or established and majority end up at the bottom or close to it. The main
problems are: the number of posts are far lower than required according to norms; the number of steps on the career
ladder are too few and far apart; the processes and eligibility for upward mobility are too difficult or not available.
Vacant posts have not been filled; new posts have not been created. On the other hand key posts have been left vacant
for too long – so long that they have been abolished or labeled as dying cadre. Training programmes for preparing
nurses to take on teaching and supervisory responsibilities have not been strengthened.

Career progression is built on the principle of fulfilling human aspirations for a higher and better life and self
actualization in the chosen career. According to this:
 Employees must have equal opportunity to move upward in his /her cadre.
 Provision must be made for lateral mobility within the same career among different streams. This lateral
movement helps to balance the different posts and the skills and experiences that staff have.
 Employees must have opportunity for climbing at least five steps on the career ladder during the entire
period of service (30- 35 years) if they chose to remain in the same profession or occupation.
 Equity principle should be followed- equal remuneration and opportunity for equal work and qualification
but facilities and encouragement for those who are disadvantaged.

 Those who do not attain the required higher skills or qualifications must also be facilitated to move on the
career ladder and adjustment must be made for experience.

Career progress is crucial for satisfying the aspirations and needs of personnel. If this does not take place at
regular intervals, staff turnover will be high and staff performance will be low. The two primary care providers in
nursing –ANMs and Staff Nurses – get very little opportunity to progress in their career spanning almost four decades.
Career stagnation is one of the factors responsible for the poor situation in nursing workforce today.

41
A detailed exercise is essential for formulating a career progression programme that clearly defines pathways
for upward career mobility for each cadre. The first step in this direction is to define cadres. The study revealed
ambiguity in understanding cadres and posts in Chhattisgarh. Nursing is a service profession just as medicine or
teaching or armed forces. Clarity is required as to what cadres are needed and how they should be structured and
positioned, paid and rewarded. Based on extensive discussions and review of the situation in Chhattisgarh today, and
keeping long term need, four cadres of nurses are recommended general nursing cadre, public health nursing cadre,
clinical nursing specialization and midwifery and teaching cadre. Each cadre will have several posts.

Recommendations for career progression


It is proposed that staff nurses and ANMs – have three career options when they join government employment
based on their interests, entry qualifications and additional education and experience:
1. Clinical nursing specialization and midwifery
2. Supervision and management
3. Teaching

Recommended cadres and career pathways for nursing personnel

5.4 Strengthening nursing management

The senior most position at the state level is the Principal College of Nursing which is vacant due to lack of
adequately qualified personnel now handled by an in charge person. Although there are nearly 10,000 nursing
personnel in the state, there is no directorate of nursing Chhattisgarh. It is essential that senior posts are available and
that they are located at the state headquarter for critical reasons. They provide a sense of identity and access to

42
leadership to the lower cadres. These posts also help in assuring that nursing professions not only provide inputs into
decisions related to patient care but also take part in policies and plans involving nursing personnel. Above all senior
posts help individual nursing personnel to higher professional achievement as these positions help in role modeling.
As part of this study an attempt was made to organize nursing services into different levels according to qualifications,
service seniority and posts.

Administration Joint Director Nursing, Deputy Directors- DDN(PH), DDN(HN), Principal


CON, Chief Matrons in Teaching Hospitals (TH)
Management level AD Nursing CNE and quality, AD (programmes), Principal- ANM, Principal
LHV, DPHNOs, AND- GNM training; AND- Nursing care quality and CAN;
Principal –SON; Matron of DHH, Vice Principal-CON; Matrons and THs
Supervisory level Nursing Tutors clinical instructors, Community Health Officers or Block PHN,
Head nurses
Service providers and Staff nurses, LHVs, PHNs, ANMs
field supervisors

At the state level, one Joint Director Nursing (JDN) will be the head of all nursing personnel and will be
supported by two Deputy Directors of Nursing (DDNs). One DDN will look after MCH services in public health and
another DDN will look after nursing service and education. All the Chief Matrons or CNOs of the teaching hospitals
and the principal of the college of nursing will report directly to the JDN. Most of the recommendations suggested
here do not require additional posts to be created- some level of upgradation is required to lift up the nursing services
in the State for achieving better quality performance.

In conclusion, this section has attempted to provide number to be prepared and the means through which they
can be prepared. Human resource development is however, not about numbers alone, but also about visualizing a
career chart through which personnel are encouraged to give their best and achieve individual aspiration as well as
organizational goals. If an efficient workforce is to be developed, a long term should be adopted.

43