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Health and medicine cannot be understood without considering the role of nurses, both as professionals and as working women. In India, unlike other countries, nurses have suffered an exceptional degree of neglect at the hands of state, a situation that has been detrimental to the quality of both rural and urban health care. Charting the history of the development of nursing in India over 100 years, Indian Sisters examines the reasons why nurses have so consistently been sidelined and excluded from health care governance and policymaking. The book challenges the routine suggestion that nursing’s poor status is mainly attributable to socio-cultural factors, such as caste, limitations on female mobility and social taboos. It argues instead that many of its problems are due to an under-achieved relationship between a patriarchal state on the one hand, and weak professional nursing organisations shaped by their colonial roots on the other. It also explores how the recent phenomenon of large-scale emigration of nurses to the West (leading to better pay, working conditions and career prospects) has transformed the profession, lifting its status dramatically. At the same time, it raises questions about the implications of emigration for the fate of health care system in India. An important contribution to the growing academic genre of nursing history, the book is essential reading for scholars and students of health care, the history of medicine, gender and women’s studies, sociology, and migration studies. It will also be useful to policymakers and health professionals. List of Tables . List of Figures . List of Abbreviations . Acknowledgements . Introduction 1. The Institution of Modern Nursing in Indian Society 2. Lighting India’s Lamp: Nursing Leadership and the Colonial State, 1905–47 3. ‘Seeds That May Have Been Planted May Take Root’: International Aid Nurses and Projects of Professionalism, 1947–65 4. From Green Park to Bollywood: The Development of Nursing Organisation, 1947–2006 5. The Indian State and the Disappearing Nurse 6. ‘Nurses Anytime’: Emigration and the Status Question . Conclusion: The Four Feet upon which a Cure must Rest. Bibliography . About the Author . Index Madelaine Healey is an independent researcher based in London.

Appropriate and adequate staffing is critical in Australian Residential aged care facilities (RACFs). The multicultural workforce in RACFs is constantly increasing to address workforce shortages and maintain the quality of care provided. Indian nurses comprise a significant proportion of the registered nurses (RNs) working in RACFs in Australia. As we work to enhance staffing levels in RACFs, it is equally essential to provide proper support for overseas-trained nurses in their roles. This research aims to explore the experiences of RNs trained in India and working in or have worked in Australian RACFs, focusing on the factors that have influenced their work in these facilities. This study adopted a qualitative descriptive methodology. Fourteen Indian nurses (  = 14) who had completed their basic nursing qualifications in India and worked in the aged care sector in Australia participated in this study. The diversity of the participants was maintained in terms of years of experience and work location (metropolitan and regional). One-on-one semistructured interviews were conducted via a virtual platform (Teams or Zoom). The interviews were transcribed and coded descriptively. This study identified various vulnerabilities, challenges, supportive factors, and opportunities experienced by Indian nurses at the Australian RACFs. Five themes emerged from this study: \"The journey through a challenging transition,\" \"psychological impact,\" \"rewarding experience,\" \"support system,\" and \"pathways to improve.\" Working in RACFs is a rewarding experience despite the challenges associated with transition issues, workload, and cultural diversity. Specific experiences can even psychologically impact nurses working in aged care facilities. The availability of support personnel, orientation programs, and feedback opportunities positively impacts the effective transition and overall experience of Indian nurses in residential care settings.

With a subtle yet penetrating understanding of the intricate interplay of gender, race, and class, Sheba George examines an unusual immigration pattern to analyze what happens when women who migrate before men become the breadwinners in the family. Focusing on a group of female nurses who moved from India to the United States before their husbands, she shows that this story of economic mobility and professional achievement conceals underlying conditions of upheaval not only in the families and immigrant community but also in the sending community in India. This richly textured and impeccably researched study deftly illustrates the complex reconfigurations of gender and class relations concealed behind a quintessential American success story.

Background The BetterBirth trial tested the effect of a peer coaching program around the WHO Safe Childbirth Checklist for birth attendants in primary-level facilities in Uttar Pradesh, India on a composite measure of perinatal and maternal mortality and maternal morbidity. This study aimed to examine the adherence to essential birth practices between two different cadres of birth attendants—nurses and auxiliary nurse midwives (ANMs)—during and after a peer coaching intervention for the WHO Safe Childbirth Checklist. Methods This is a secondary analysis of birth attendant characteristics, coaching visits, and behavior uptake during the BetterBirth trial through birth attendant surveys, coach observations, and independent observations. Descriptive statistics were calculated overall, and by staffing cadre (staff nurses and ANMs) for demographic characteristics. Logistic regression using the Pearson overdispersion correction (to account for clustering by site) was used to assess differences between staff nurses and ANMs in the intervention group during regular coaching (2-month time point) and 4 months after the coaching program ended (12-month time point). Results Of the 570 birth attendants who responded to the survey in intervention and control arms, 474 were staff nurses (83.2%) and 96 were ANMs (16.8%). In the intervention arm, more staff nurses (240/260, 92.3%) received coaching at all pause points compared to ANMs (40/53, 75.5%). At baseline, adherence to practices was similar between ANMs and staff nurses (~ 30%). Overall percent adherence to essential birth practices among ANMs and nurses was highest at 2 months after intervention initiation, when frequent coaching visits occurred (68.1% and 64.1%, respectively, p  = 0.76). Practice adherence tapered to 49.2% among ANMs and 56.1% among staff nurses at 12 months, which was 4 months after coaching had ended ( p  = 0.68). Conclusions Overall, ANMs and nurses responded similarly to the coaching intervention with the greatest increase in percent adherence to essential birth practices after 2 months of coaching and subsequent decrease in adherence 4 months after coaching ended. While coaching is an effective strategy to support some aspects of birth attendant competency, the structure, content, and frequency of coaching may need to be customized according to the birth attendant training and competency. Trial registration ClinicalTrials.gov: NCT2148952 ; Universal Trial Number: U1111–1131-5647.

Antibiotic misuse is widespread and contributes to antibiotic resistance, especially in less regulated health systems such as India. Although informal providers are involved with substantial segments of primary healthcare, their level of knowledge, attitudes, and practices is not well documented in the literature. This quantitative study systematically examines the knowledge, attitudes, and practices of informal and formal providers with respect to antibiotic use. We surveyed a convenience sample of 384 participants (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) over a period of 8 weeks from December to February using a validated questionnaire developed in Italy. Our team created an equivalent, composite KAP score for each respondent in the survey, which was subsequently compared between providers. We then performed a multivariate logistic regression analysis to estimate the odds of having a low composite score (<80) based on occupation by comparing allopathic doctors (referent category) with all other study participants. The model was adjusted for age (included as a continuous variable) and gender. Doctors scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed poorly in practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n = 82) reported prescribing them in this situation. Nurses, pharmacy shopkeepers, and informal providers were more likely to perform poorly on the survey compared to allopathic doctors (OR: 10.4, 95% CI 5.4, 20.0, p<0.01). 30.8% (n = 118) of all providers relied on pharmaceutical company representatives as a major source of information about antibiotics. Our findings indicate poor knowledge and awareness of antibiotic use and functions among informal health providers, and dissonance between knowledge and practices among allopathic doctors. The nexus between allopathic doctors, pharmaceutical company representatives, and informal health providers present promising avenues for future research and intervention.

Background Current policy priorities to strengthen the nursing sector in India have focused on increasing the number of nurses in the health system. However, the nursing sector is afflicted by other, significant problems including the low status of nurses in the hierarchy of health care professionals, low salaries, and out-dated systems of professional governance, all affecting nurses’ leadership potential and ability to perform. Stronger nurse leadership has the potential to support the achievement of health system goals, especially for strengthening of primary health care, which has been recognised and addressed in several other country contexts. This research study explores the process of policy agenda-setting for nurse leadership in India, and aims to identify the structural and systemic constraints in setting the agenda for policy reforms on the issue. Methods Our methods included policy document review and expert interviews. We identified policy reforms proposed by different government appointed committees on issues concerning nurses’ leadership and its progress. Experts’ accounts were used to understand lack of progress in several nursing reform proposals and analysed using deductive thematic analysis for ‘legitimacy’, ‘feasibility’ and ‘support’, in line with Hall’s agenda setting model. Results The absence of quantifiable evidence on the nurse leadership crisis and treatment of nursing reforms as a ‘second class’ issue were found to negatively influence perceptions of the legitimacy of nurse leadership reform. Feasibility is affected by the lack of representation of nurses in key positions and the absence of a nurse-specific institution, which is seen as essential for creating visibility of the issues facing the profession, their processing and planning for policy solutions. Finally, participants noted the lack of strong support from nurses themselves for these policy reforms, which they attributed to social disempowerment, and lack of professional autonomy. Conclusions The study emphasises that the nursing empowerment needs institutional reforms to facilitate nurse’s distributed leadership across the health system and to enable their collective advocacy that questions the status quo and the structures that uphold it.

The India Hypertension Control Initiative (IHCI) is a multi‐partner initiative, implementing and scaling up a public health hypertension control program across India. A cohort of 21,895 adult hypertension patients in 24 IHCI sentinel site facilities in four Indian states (Punjab, Madhya Pradesh, Maharashtra, and Telangana), registered from January 2018 until June 2019 were assessed at baseline and then followed up for blood pressure (BP) control and antihypertensive medication use. Among all registrations, 11 274 (51%) of the patients returned for a follow‐up visit between July 2019 and September 2019. Among patients returning for follow‐up, 26.3% had BP controlled at registration, and 59.8% had BP controlled at follow‐up (p < .001). The absolute improvement in BP control was more than two times greater in primary care (48.1 percentage point increase) than secondary care facilities (22.9 percentage point increase). Most IHCI patients received prescriptions according to state‐specific treatment protocols. This study demonstrates that a scalable public health hypertension control program can yield substantial BP control improvements, especially in primary care settings. However, high loss to follow‐up limits population health impact; future efforts should focus on improving systems to increase the likelihood that patients will return to the clinic for routine hypertension care.

Most of the evidence on antimicrobial stewardship programmes (ASP) to help sustain the effectiveness of antimicrobials is generated in high income countries. We report a study investigating implementation of ASP in secondary care across low-, middle- and high-income countries. The objective of this study was to map the key contextual, including cultural, drivers of the development and implementation of ASP across different resource settings. Healthcare professionals responsible for implementing ASP in hospitals in England, France, Norway, India, and Burkina Faso were invited to participate in face-to face interviews. Field notes from observations, documentary evidence, and interview transcripts were analysed using grounded theory approach. The key emerging categories were analysed iteratively using constant comparison, initial coding, going back the field for further data collection, and focused coding. Theoretical sampling was applied until the categories were saturated. Cross-validation and triangulation of the findings were achieved through the multiple data sources. 54 participants from 24 hospitals (England 9 participants/4 hospitals; Norway 13 participants/4 hospitals; France 9 participants/7 hospitals; India 13 participants/ 7 hospitals; Burkina Faso 8 participants/2 hospitals) were interviewed. Across Norway, France and England there was consistency in ASP structures. In India and Burkina Faso there were country level heterogeneity in ASP. State support for ASP was perceived as essential in countries where it is lacking (India, Burkina Faso), and where it was present, it was perceived as a barrier (England, France). Professional boundaries are one of the key cultural determinants dictating involvement in initiatives with doctors recognised as leaders in ASP. Nurse and pharmacist involvement was limited to England. The surgical specialty was identified as most difficult to engage with in each country. Despite challenges, one hospital in India provided the best example of interdisciplinary ASP, championed through organisational leadership. ASP initiatives in this study were restricted by professional boundaries and hierarchies, with lack of engagement with the wider healthcare workforce. There needs to be promotion of interdisciplinary team work including pharmacists and nurses, depending on the available healthcare workforce in different countries, in ASP. The surgical pathway remains a hard to reach, but critical target for ASP globally. There is a need to develop contextually driven ASP targeting the surgical pathway in different resource settings.

Background Investment in human resources for health not only strengthens the health system, but also generates employment and contributes to economic growth. India can gain from enhanced investment in health workforce in multiple ways. This study in addition to presenting updated estimates on size and composition of health workforce, identifies areas of investment in health workforce in India. Methods We analyzed two sources of data: (i) National Health Workforce Account (NHWA) 2018 and (ii) Periodic Labour Force Survey 2017–2018 of the National Sample Survey Office (NSSO). Using the two sources, we collated comparable estimates of different categories of health workers in India, density of health workforce and skill-mix at the all India and state levels. Results The study estimated (from NHWA 2018) a total stock of 5.76 million health workers which included allopathic doctors (1.16 million), nurses/midwives (2.34 million), pharmacist (1.20 million), dentists (0.27 million), and traditional medical practitioner (AYUSH 0.79 million). However, the active health workforce size estimated (NSSO 2017–2018) is much lower (3.12 million) with allopathic doctors and nurses/midwives estimated as 0.80 million and 1.40 million, respectively. Stock density of doctor and nurses/midwives are 8.8 and 17.7, respectively, per 10,000 persons as per NHWA. However, active health workers’ density (estimated from NSSO) of doctor and nurses/midwives are estimated to be 6.1 and 10.6, respectively. The numbers further drop to 5.0 and 6.0, respectively, after accounting for the adequate qualifications. All these estimates are well below the WHO threshold of 44.5 doctor, nurses and midwives per 10,000 population. The results reflected highly skewed distribution of health workforce across states, rural–urban and public–private sectors. A substantial proportion of active health worker were found not adequately qualified on the one hand and on the other more than 20% of qualified health professionals are not active in labor markets. Conclusion India needs to invest in HRH for increasing the number of active health workers and also improve the skill-mix which requires investment in professional colleges and technical education. India also needs encouraging qualified health professionals to join the labor markets and additional trainings and skill building for already working but inadequately qualified health workers.