The Business Nursing Complex : Understanding nursing training in Nepal.

Transcription

1 The Business Nursing Complex : Understanding nursing training in Nepal. Radha Adhikari School of Health in Social Science University of Edinburgh Introduction This paper looks at nursing training in Nepal. I discuss the rapid proliferation of nursing colleges, and the question of training resources. Over the last few years there has been a spectacular increase in demand for places at nursing schools and colleges. Nursing is increasingly seen as an attractive career choice for young Nepali women 1. The number of training applicants has been increasing every year 2. This paper explores the rise of these colleges in relation to this demand, assesses some of the socio-political forces driving the phenomena, and attempts to evaluate the impact of this. I begin by articulating the context and scale of the issues to be addressed. The subsequent section describes the historical growth and development of nursing as a professional training in order to provide a background to the current situation. I review the history of regulation from 1958 to the present. The number of nursing courses available and their recent growth is then described. I go on to address the institutional capacity of the training schools to teach their students, particularly in relation to the numbers of senior faculty members and clinical placement facilities. The final section looks at the question of nursing school affiliation to both government regulatory bodies, particularly the Centre for Technical Educational and 1 Nursing is still a female only profession in Nepal. There was a short experimental period of training male students: From % of places were reserved for male nursing students, but later in 1992 this was cancelled and places were only for female students. 2 For example, in 2007, B.P. Koirala Institute of Health science (BPKIH), Dharan received over 1900 applications for 40 staff nurse training places; similarly, the Bir Hospital Nursing Campus in Kathmandu received over 3000 applications for 40 places; one of the TU run colleges in Kathmandu received 548 applications for 45 training places. 1

2 Vocational Training (CTEVT) 3, and to private universities 4 in relation to the oversight of the quality of the educational process. This article then seeks to both describe and explain the recent proliferation of institutions and programmes for the training of nurses in Nepal. This rise in numbers is mirrored by a rise in other colleges catering to the health sector s human resource needs. These colleges train a range of health workers, including Health Assistants (HAs), Community Medical Assistants (CMAs), Pharmacists and Auxiliary Nurse Midwives (ANM) and medical doctors, amongst others. As such the paper also addresses a broader educational phenomenon, with implications for the whole of the health sector. Research methods I am a trained nurse, qualifying in 1984 from Lalitpur Nursing Campus. I worked there after in the United Mission to Nepal (UMN), Tansen Hospital, and went on to teach in Biratnagar Nursing Campus under Tribhuwan University (TU). I have a degree in Community Health Nursing from Maharajgung Nursing Campus. As such I have lived through much of the recent nursing history that I reflect upon in this paper. Further research into these issues has been conducted as part of my ongoing PhD research in Nursing Studies at the University of Edinburgh. The chosen methodology is based on qualitative, ethnographic style research. The main aim was to map out the present situation of professional nursing training, and review government policy on this. Research field work was done in three stages: five months in 2006 (from August till December) and another three months in 2007 (between July to December) and a follow up/ update visit for two months in the summer of Information was collected from eighteen nursing colleges, the Nepal Nursing Council (NNC), the Nursing Association of Nepal (NAN), the Ministry of Health, Nursing Department, Tribhuwan University Teaching Hospital (TUTH), and the CTEVT. Available records and policy documents were obtained wherever possible and reviewed. In-depth open ended interviews were conducted with senior academic staff. Informal discussions, focus groups and interviews were also conducted with staff nurses and BSc nursing 3 Set up in Three new universities opened in the 1990s: Kathmandu University in 1991, Purwanchal University in 1995 and Pokhara University in

3 students. Formal letters were written to nursing colleges and relevant organisations asking for permission to obtain research information. Permission was also given to review records and documents from them. Some research informants and organizations have been anonymised to protect their identity. The development of professional Nursing in Nepal 5. The history of the nursing profession in Nepal is intertwined with the emergence of western allopathic medicine. The first official state-run allopathic medical services in Nepal were started in the Bir Hospital, established in At that time, the Royal Family and upper class social elites had their own health care providers consisting of personal attendants and nannies, private western-trained medical doctors and local Ayurvaedic practitioners (Leichty 1997; Dixit 2005). The Bir Hospital began with 15 in-patient beds for male patients and a dispensary. Some years later (the exact date is not clear) 15 more beds were added for female patients. The hospital was run by male staff only. They were called dressers in that they changed wound dressings and compounders, who dispensed medicine. According to the two published works on the history of Nursing in Nepal (NAN 2002; Maxwell with Sinha 2004), for 38 years after the Bir Hospital was established, there were still no female staff to nurse or care for the patients there. The first reference to female nurses can be found in 1928, with the need to have female staff perceived by the Ranas. At this time, four Nepali women were sent to India for 18 months of midwifery training (NAN 2002; Maxwell with Sinha 2004). These women were accompanied by their male guardians, as at that time it was not acceptable for women to travel on their own. They completed their training and returned to Nepal eighteen months later in Upon return, they were posted to work in the Bir Hospital in the female ward. Over the next few years a few more women went to India for similar training. 5 To date there are only two specific written histories of nursing in Nepal, Nurses were needed at the Top of the World by Maxwell with Sinha, published in 2004, and History of Nursing in Nepal published by the Nursing Association of Nepal (NAN) in This section draws heavily on these accounts. Additional information was provided from interviews with many of the key senior nurses who lived through these times, as well as being supplemented by my own experience of training and work in nursing from the early 1980s. 3

4 In 1933, for the first time in Nepal, the Civil Medical College was established at the Bir Hospital to train dressers and compounders. Nine women were enrolled in the first group who trained here. However, the qualification or level of education for this training is not reflected on or described in the published literature. A number of these women were later sent to India for additional midwifery training and, when they returned to Kathmandu, they were posted to the Bir Hospital as the previous midwives had been. The Bir Hospital at this time was staffed by locally trained dressers and compounders; midwives trained in India and staff from Bengal, formerly in India, now the present Bangladesh (Maxwell with Sinha 2004). Modern nursing training started in Nepal only in the mid 50s, after the major political changes of This links with the arrival of foreign aid in Nepal, at a time when the country became more accessible to foreign missions for aid and development interventions. The new government of Nepal led by King Tribhuwan had a more liberal attitude towards foreign aid and development and, following the end of the Rana regime and their self-imposed isolation, the government opened its doors to foreign assistance. For the history of nursing, missionary presence was particularly important. Christian missionaries who were already working in neighbouring India and who were preaching, teaching and healing (Lindell 1997) were then allowed to come to Nepal to help the new government develop health care and social infrastructure (Harper, in press; Lindell 1997). One key event that led to the preparation for and start of nursing training occurred in 1951, when the US administrator, Mr. Paul Rose, came to Nepal with his pregnant wife. Mr Rose found no qualified midwives to assist his wife during birth. He requested a qualified and experienced western-trained midwife from the British High Commission in Delhi, India (NAN 2002; Maxwell with Sinha 2004). A midwife called Junita Owen was sent to Kathmandu to assist the Roses during the birth of their baby. Ms Owen felt that there was a pressing need to start training for nurses and midwives in Nepal and made recommendations to the His Majesty s Government of Nepal and the World Health Organisation (WHO) to set up a nursing training programme. This request was taken seriously and agreed by the Government. As a consequence, the WHO sent two British nurses to Kathmandu to start preparation for 4

5 the training (Maxwell with Sinha 2004; NAN 2002) 6. Preparation for the training started in 1954 and nurse training began in 1956 for the very first time in Nepal. A further foreign nurse was drafted in later to teach midwifery. She was from Canada and worked for USAID. So there were three foreign nurses and their three Nepali counterparts; six nurses / midwives in total. The training began in a rented house in Chhetripati, Kathmandu 7. As Maxwell with Sinha (2004) and Lindell (1997) state, Dr. Bethel Fleming with a team of three nurses, all Christian missionaries, also came to Nepal from a mission in India. They were given permission by the government to start medical work in Nepal. The United Mission to Nepal (UMN) was set up and started health services in The first services were maternal and child care clinics in the Kathmandu valley. In 1956 they set up a hospital called Shanta Bhawan Hospital. They found an old Rana palace to rent and started offering medical services, but were in need of assistants to help run the services. In 1957, three locals, two men and a woman were selected for training, in order to assist in the running of the hospital. These trainees completed their three-year training and were awarded Hospital Certificates. Meanwhile UMN had issued a call for workers in their new hospital to the Christian community, across Nepal s eastern boarder in Darjeeling and Kalimpong India (Maxwell with Sinha 2004). In January 1959, Margaret Fleming, a missionary nurse who had previously worked in India started Shanta Bhawan Hospital (SBH) School of Nursing. It was located in Surendra Bhawan first and later was moved to Nir Bhawan, next to the Shanta Bhawan hospital. In the early years, the majority of students for nursing training were from Darjeeling and Kalimpong in India. Shanta Bhawan Hospital School of Nursing thus becomes the second nursing training programme in Nepal. These two training programmes above remained the only two institutions for training nurses until the mid 1980s (Maxwell with Sinha 2004; Thakur 1999). Both these programmes had a very challenging start, and for decades very few women were attracted towards the profession in Nepal. In the HMG School of Nursing for the 6 I have met with one of these early Nepali nurses who was trained in India, and she claims that it was her initiative. She requested the King and then the government of Nepal to set up a training programme in the country. She also said that she was a private nurse for the royal family, and indeed visited America with King Tribhuwan and his wives. 7 Interview with Ms Lamoo Amatya, one of the Nepali counterparts for the WHO nurses, September

6 first few years almost all of the early candidates were from the Kathmandu valley, but the UMN programme received most of its candidates from Darjeeling and Kalimpong, in India. As Maxwell with Sinha (2004) state, the nurse trainers had to go around looking for suitable candidates. There were no particular selection or recruitment criteria. Any woman who had at least eight years of schooling, or who could read and write well and was interested in joining the training school would get a place. Foreign nurses did not speak Nepali and local girls did not speak English so Nepali counterparts (available only through the HMG School of Nursing) acted as translators for the whole process as well 8. When the programmes first began, there were only ten to twelve students in each group in the HMG School of Nursing and six or seven in Shanta Bhawan School of Nursing (NAN 2002). The intake in both schools was sporadic and opportunistic in nature. For example, there were three candidates who started in the second batch in the HMG School of Nursing, and later they were put together with the third batch 9 (so the third batch became the second batch). In the next batch there were ten candidates. A senior nurse who was from the third batch in the HMG School of Nursing shared her experiences, and explained: I was interviewed for the training, and they told me that I was successful in the interview but had to wait until there were enough candidates to make a group. I waited and waited for that. It took them a full six months to get ready and start the programme. I was so worried; I came from outside Kathmandu and was staying with our family friend s house for six months 10. I was told the same ten years ago by a senior nurse, who was in the second batch at the UMN nursing training, that the nurse trainers went around districts outside the valley in a helicopter as a part of campaign to attract young women to join nursing 11. They also had to negotiate with candidates guardians/ parents, and reassure them that it would be safe for their young daughters to join the training and stay in students hostels (Maxwell with Sinha 2004). In those days, nursing was popularly perceived by many as a job for women from the 8 Interview with a third batch student from the HMG School of Nursing (August 2008). 9 Interview with a third batch student from the HMG School of Nursing (August 2008). 10 Interview with a third batch nurse from the HMG School of Nursing (August 2008). 11 Interview second batch nurse, SBH School of Nursing in

7 lower social castes and classes and indeed was considered an inauspicious profession (NAN 2002). When nursing first started, many high caste Hindus would not eat food touched by a nurse (KC 2061 vs). KC in interviews with first batch nurses from Shanta Bawan School of Nursing, was told that, after any length of hospital stay, many people would perform a ritual cleansing ceremony at home in order to become socially and religiously acceptable again (KC 2061 vs). It was not only the hospitals were considered inauspicious but the whole profession was considered ritually unclean also, so unsuitable for high caste Hindu women. Ms L Amatya, one of the counterparts for the WHO nurses shared her experience. She said: I was born and brought up in Darjeeling and went to Calcutta Medical College for nursing training. I met my husband there; we got married and came to Kathmandu. My husband was then working in the Royal Palace. When there was a chance for me to work with the WHO nurses, my mother in-law said no, I should not work as a nurse and I should not wear white uniform. White colour is worn by Hindu widows, my husband was still alive, and so it seemed very inauspicious, my mother in law was very unhappy, she said my son is alive and you should not wear a white Sari 12. The first group of nurses trained in Nepal qualified in Training institutions were not only responsible for training but also for the complete wellbeing and security of all student nurses. Developing this greater security for student nurses was one of the ways that these institutions used to persuade families that the profession was an acceptable one into which to send their daughters. A very senior nurse from the third group of training shared her experience in the following way: It used to be like a contract between the parents and the training authority that parents send their daughter for training and in return the training authority would provide them a safe and protective environment. All student nurses had to stay in a hostel with no access for any outsiders and their letters were censored to make sure that they were not having communication with anybody 12 Interview with Mrs Amatya, the first WHO Nurse counterpart to Nepal, 10 th August

8 (particularly men) outside their families 13. In the 1960s, as a part of the national development programme during the Panchayat era, education for all children including girls was encouraged. Gradually more girls, particularly from urban but also some from rural districts started attending schools. Slowly literacy rates began to increase. This had a major impact on nursing training. After the first few batches of trained nurses entered general employment there were significant changes in perception. Mrs Joshi continued to recollect her early experiences: These early nurses were deemed smarter than ordinary women in the society, and they had relatively good earnings. Even during the training period we would get some pocket money, and we started getting opportunities to go to foreign countries for further training. Mrs Joshi qualified in In 1963 she was given the opportunity to go to Beirut for further public health training 14. Many of these early nurses got scholarships to study abroad and later received respectable positions in the Ministry of Health, as there were very few qualified nurses. By the 1970s, the number of young women completing School Leaving Certificate (SLC) level education had increased further and more women (and their families) started becoming interested in nursing. Those few training programmes that existed began to receiving better-educated candidates, and had some choice therefore for selection. In 1972, the whole education system in Nepal was modernised. Nursing training became a university degree course run by the Tribhuwan University (TU), which came under the Ministry of Education (Maxwell with Sinha 2004; NAN 2002). Until then nursing training had been run by the Ministry of Health. As a consequence, nursing acquired the status of university level education. The degree is known till today as Proficiency Certificate Level (PCL). Nursing had become not just a professional vocational training. In addition to this a significant event occurred in the mid 70s when HRH Princess Prekchhaya went into nursing. Nursing became not just 13 Interview with Mrs Joshi, a third batch nurse, who qualified in 1962, 10 th August As well as Beirut, others went to Lebanon and India, funded by the WHO and USAID (NAN 2002) 8

9 a university degree course but one that could even be considered by the royal family, which at this time for many people was a further incentive and a good advertisement. By the 1980s nursing as the profession was becoming more fully accepted, but there were still only two Staff Nurse colleges in the country, with the capacity to train around 50 nurses a year. There were five Auxiliary Nurse Midwife (ANM) extension colleges in the districts 15. These were then upgraded to SN programmes as a part of an improvement programme to raise nursing professional standards. By the end of 1989 there were six SN training programmes across the country (Maharajgunj, Pokhara, Nepalgunj, Birgunj, Biratnagar, and Lalitpur Nursing Campuses). The first college had by now become the mother campus run by TU, based in Maharajgunj, Kathmandu. The second college was run by the UMN administratively, but was academically under TU control from I turn now to the historical precedents for regulation. During this early period of nursing history, the WHO nurses with their Nepali counterparts worked towards the establishment of a temporary Nursing Council in Nepal, which was housed under the Ministry of Health. This body, established in 1958, was named Nepal Nursing Council. It became responsible for awarding nurses training certificates and maintaining professional standards and regulation. Initially, these two training institutions: the HMG School of Nursing (run by the Government of Nepal with the help of WHO), and the second college run by the UMN at Shanta Bhawan, had very little professional or institutional communication. Neither the Nepal Nursing Council (NNC) nor the HMG accepted nurses trained in Shanta Bhawan Hospital (SBH) School of Nursing. So, the first two groups (1962, and 1963) of SBH graduates were registered with the Bihar Nursing Council (India) as the main nurse trainer had connections with the Nursing Council there (Maxwell with Sinha 2004). Later in 1964 the SBH programme gained full recognition by the NNC and the WHO. The SBH went on to adopt the curriculum which was designed for and used by the HMG School of Nursing. Later in 1972 when the TU took over responsibility for examinations, the council was dismantled and there was no professional licensing and regulatory body there after until the mid 1990s (Maxwell with Sinha 2004; NAN 15 This research does not explore the training details of ANM programmes 9

10 2002). At the same time as the NNC was being established in 1958, the Trained Nurses Association of Nepal (TNAN), a trade union body for all professional nurses, was set up with the help of WHO nurses and Nepali counterparts and student nurses. This remained fairly active throughout nursing history and started to represent Nepali nursing professionals in the international arena. TNAN became a member of the International Nursing Council (ICN) in In the years when the Nepal Nursing Council did not exist from 1972 till 1996 TNAN acted like a Nursing Council 16, but had no authority to regulate and maintain professional standards. It was involved mainly in advocacy work. It organised a few conferences and represented as Nepali nurses professional body internationally. In the 1990s the TNAN constitution was amended and its name changed to Nepal Nursing Association (NAN). Currently it operates as a nurses trade union body was a major milestone for the profession. The Nepal Nursing Council Act was passed by the parliament and the Nepal Nursing Council (NNC), a professional regulatory body, was finally established. Then NNC started keeping records of all professional nurses who were trained and practising in the country. After the council came into place, all nurses who wanted to work in Nepal had to be registered with the NNC by law 17. The NNC has been keeping all professional records and has been closely involved in establishing professional standards and regulations. In just a decade the NNC has achieved a lot, although much remains to be done in reaching internationally recognised professional standard and regulation, as I discuss below. Current records (April 2008) shows that there are a total of 10,017 qualified nurses (staff nurses) registered with the NNC 18. In addition, there are other categories of nurses registered with the council: 11,097 Auxiliary Nurse Midwives (ANMs) and 529 foreign trained nurses by the end of April There are over 1,560 general 16 In its keeping records of all nurses in Nepal. Later in the early 1990s, NAN played a major role in establishing the Nepal Nursing Council. 17 NNC Information booklet, 2053 (1997); NNC Act 2052 (1996). 18 NNC registration is mandatory now for nurses who want to register with foreign nursing councils. Many foreign nursing councils require a professional verification letter from the NNC when Nepali nurses apply for foreign nursing licenses. 19 NNC records were obtained on 13 th May 2008 from the NNC website. ( 10

11 staff nurses trained annually (from both the private and government sector), and there will be an additional 300 BSc Nurses trained each year from the end of It is to the growth of the private sector that I turn next. Nursing Education and the growth of the private sector Currently, there are five levels of nursing training, from ANMs to MSc in Nursing, available in Nepal. A brief outline of each of these training follows: The Auxiliary Nurse Midwife (ANM). This course is currently run by institutions affiliated with the CTEVT. Today there are 40 institutions around the country, over 50% of which are in Kathmandu. Opportunities for ANM work are available both in rural areas, throughout the hills,, as well as in urban areas. In the late 1960s, when ANM training began, the course lasted two years and any young woman who had passed their grade eight at school could apply for this state-run training. Many candidates who did not have the requisite SLC pass and were unable to apply directly to the staff nurse courses saw this as a route to becoming staff nurses, a pass as an ANM training qualified a woman to apply for the staff nurse training. Many of the senior nurses in Nepal today travelled this very route to their current positions. The Proficiency Certificate Level in Nursing (PCL) or Staff Nurse. As already discussed, prior to the establishment of CTEVT, there were six staff nurse campuses in Nepal: Maharjganj and Lalitpur, Biratnagar, Pokhara, Nepalgunj and Birgjunj Nursing Campuses all under the purview of the TU. They trained a total of just over 250 nurses per year; the idea being to train enough staff nurses for the district centre hospitals and other government hospitals through the country. This was consequent upon a review of the nursing curriculum in 1987, after which primary health care concepts were included in nursing training (Thakur 1999). Exact figures are not available as there are unregistered training colleges opening each year with a few having been closed recently. However from interviews and data gathering it is 20 I calculated this figure based on the following data. In the academic year 2006/7 there were 15 institutions running BSc Nursing programme, with 20 students in each group. This is a four-year training and the first group are expected to be qualified by the end of

12 estimated that about 1,565 staff nurses are trained annually from 39 institutions colleges are registered under the CTETV, of which only one is not private; 6 are affiliated with the TU, Institute of Medicine, one registered with Kathmandu University, one with the Bir Hospital, and one with BP Koirala Institute of Health Sciences in Dharan. Bachelor of Science in Nursing (BSc. Nursing). There are currently seventeen programmes in the country that have received university affiliation: one in the TU IOM in Maharajgunj; eleven are affililiated with Purbanchal University; three with Kathmandu University (in Dhulikhel, Banepa, and Kathmandu). A further programme is run by BPKMH in Dharan and another is affiliated with Pokhara University. The first BSc nursing programme was started at the BP Koirala Memorial Institute of Health Sciences (BPKIHS) in Dharan in 1993 and this remained the only one for over a decade. The programme was attached to BPKIHS and the number of students was low, as they started with an intake of only ten students a year. The early graduates were mostly employed by the training hospital and some by nursing training institutions (nationally). In the following decade, as the private sector in Nepal began to get increasingly involved in health workforce training, more BSc nursing training programmes opened. These new courses are four-year courses, and are accessible only through gaining a 10 plus 2 in Science pass 22. The rationale for these courses is to produce nurses better versed in science, which in part allows nursing as a profession to compete with medicine. Bachelors Degree in Nursing (BN). The route to this level of training is after three years PCL training and two to three years work experience (two years experience for PU run programmes and three years for TU), and this training has been around for many years. It used to be run by TU and started in Currently post liberalisation, there are fourteen BN programmes. Three are under the Institute of Medicine (Maharjgunj, Lalitpur and Pokhara); ten are affiliated with Purbanchal University (nine in the Kathmandu valley, one in Biratnagar); and one is run in the Bir Hospital nursing campus in Kathmandu. 21 This number will change from 2011 as five to six new programmes have started in School education in Nepal lasts ten years (School Leaving Certificate), and additional 2 years majoring in science is known as 10+2 science. 12

13 MSc. in Nursing (MSc Nursing). Currently there are two Masters Degree programmes in nursing available in Nepal: one in TU, IOM Maharajgunj and the other one in BPKIHS, Dharan (from 2008 only). The MSc is aimed at those who want to teach, for which there are plenty of opportunities emerging. Table 1: Overview of total nursing training programmes in the 2007/2008 academic session. Nursing Programme Total number of colleges Affiliation with ANM 40 CTEVT 40 each Staff Nursing BSc Nursing* Bachelors in Nursing (BN) CTEVT 6- TU 1- NAMS Bir Hospital. 1- BPKIH Dharan 1- KU, Dhulikhel TU Maharajgunj 3. KU (Banepa, Dhulikhel and KMC) 11 - PU 1- BPKIHS (Dharan) 1-Pokhara University (Nobel College) 14 3-TU MNC, LNC and Pokhara NC 10- PU 1- NAMS (Bir Hospital NC) MN 2 TU- MNC started in 1996 and BPKIHS in Dharan started in Training capacity Mostly 40 each but there are colleges which take between students in a group. 20 each Started with an annual intake of 4 but presently 12 a year in TU Plan to start with 4 seats in BPKIHS *There have been some changes in the 2008/2009 academic session. Two of the above BSc Nursing programmes were stopped from taking students in 2007/8, but they have advertised for new admissions in They are Nobel Academy (affiliated with Pokhara University), and Yeti Health Science Academy (affiliated with PU). I wish now to focus on SN and BN as post basic training programmes and also most recently designed BSc nursing programmes and discuss these two streams of nursing training. My reason for focusing on these is that these courses have been designed 13

14 with the purpose of equipping nurses with qualifications, not just for nursing in Nepal but also with international nursing opportunities in mind. As can be seen, these have been the fastest growing programmes. It could be argued that this is seen as a particularly profitable form of business investment in the country. Table 2, below, shows the current growing trend of nursing training programmes since Table: 2 Growth of Nursing training programme: SN, BN and Bsc from SN BN BSc From the total of seventeen institutions running BSc nursing training, only nine of them had full approval from the Nursing Council as of the 13 th May 2008, and the remaining eight colleges do not meet even the basic minimum required standard set by the council 23. Nonetheless these non-registered programmes have been running since Practically this route is viewed as the best towards gaining the qualifications for working overseas. I asked a co-ordinator for the BSc Nursing programme in one of the government-run institutions why this BSc in nursing is 23 These minimum requirements include the following: A programme should have enough full time faculty members, have access to hospital for clinical practice, and physical facilities to cater for students training needs. 14

15 needed in Nepal, as to date there is not a single position planned for BSc Nursing graduates in the government- run health service. The question posed was where are the jobs for these BSc graduates? The coordinator s reply was very revealing: This is to improve the nursing standard in Nepal, to bring it to international standards by teaching more science, and to prepare nurses who are fit for the global market 24. With this global market in mind, starting a nursing training programme is now perceived as a very profitable business venture by an increasing number of individuals and organisations that investing in the proliferating private health sector. This market is not regulated. The process of setting up a programme is simple, as long as one has enough cash to invest first and has the right political and social connections to get a CTEVT and or a University affiliation. A nurse lecturer who works in one of the colleges in East Nepal explained: There are quite a few new colleges started around here (in the east) in the past three or four years, it is truly a ghata nakhane business (does not go into loss at all) in Nepal. There is a guaranteed return with a large profit margin 25. Seeing such a market, the number of programmes growing uncontroledly and rapidly after 2000, continued to expand in Money was also coming from abroad for this. I visited one training college which was set up by Non Resident Nepali (NRN), who brought in hard currency as investment and had purely a business interest 26. I turn next to the issues around human resources for these new programmes. Human resource implications of the expansion of nursing services As the NNC record of 2006, shows the full size of the nursing workforce in Nepal is relatively small: only just over 21,000 in total, ranging from ANMs to foreign nurses 24 Interview, with a BSc nursing programme coordinator, August Interview with a nurse lecturer in a privately run SN college in East Nepal, November This issue emerged in the press in 2005 (see Pariyar 2005). The training was designed to start in Nepal, and be completed in the US. However, these trainee nurses failed to get visas for the US.( Data from an interview with the Principal of a private nursing college in Kathmandu, Summer 2006). 15

16 (NNC website, April 2008). From the small reserve of only 10,017 staff nurses, there are between 20-30% already out of the country, and about the same number preparing to leave 27. Nurses who have left have various degrees of experience, from newlyqualified nurses to those with up to three decades of work experience in Nepal. However this has created an adverse effect on the small pool of senior and experienced nurses. From the total of just over 10,000 qualified staff nurses, the percentage with BN and Masters level qualifications and ten or more years of work experience is very small. This is because the total annual production of nurses until ten years ago, in 1998, was small. Now fast growing private sector colleges are headhunting this group. This has caused a severe shortage of senior and experienced nurses in the country with the capacity to teach. With more colleges trying to run higher degrees in Nursing, there is a demand for more experienced academic faculty members, but the available numbers are limited, and increasing international migration has escalated the problem. The system is chronically under-resourced, and has been since its establishment. The situation was bad in 1999 (Thakur 1999) and now it appears to be getting worse, an issue which I explore shortly. According to the NNC guidelines, to run a BSc Nursing and Bachelors degree in Nursing (BN) programme, academics with at least Masters Degree qualifications are needed. To run a Masters Degree programme they need to have at least one faculty with a PhD. There has been no effort (at least in the private sector) to prepare academics and managers to cope with the increased work load. My research indicates that experienced and senior nurses with Masters level qualifications, who have remained in the country, tend to do a lot of moonlight teaching in a range of institutions rather than staying and establishing services in one. The whole nursing education industry is thus completely over stretched. Traditionally, nurse teachers would give a classroom teaching and simulation demonstration then take the trainee to a relevant clinical designation. There the students would get the chance to see how nursing care is provided in a real- life situation in the presence of their teachers. With the increased workload, not all teachers can fully supervise students in clinical areas, 27 The above figure is estimated from the records I have obtained from Maharajgunj Nursing Campus, Lalitpur Nursing Campus, Biratnagar Nursing Campus, Pokhara Nursing Campus, Om Institute for Health Science, TUTH, NNC records. Also, there are already Nepali nurses presently living and working in the UK, with similar numbers in the US, and Australia, New Zealand, Canada, and smaller numbers in some South Asian countries. 16

17 as many teachers teach various modules in multiple places. To offer all the students the required amount of supervision has become a physically impossible task 28. The following case study of Ms A (a pseudonym), shows how much nursing education is struggling. Ms A, a senior lecturer at TU, was trained in a very well- respected nursing school in Kathmandu in the late 80s. She managed to advance her career fairly swiftly. As she had excellent academic achievements, she awarded a scholarship to study for her BN and Masters degree in nursing relatively quickly, compared to many of her classmates. When I met her, in the summer of 2006, she said that she was working as the Principal (a full time position) in a privately-run nursing college in the Kathmandu valley. She was also running a whole module of her speciality in a TU run Nursing College (another full-time post) in Kathmandu, and teaching the same module in another TU- run college outside the Kathmandu valley. She went to the private college in the morning, working there until lunch time and then went to another college for the afternoon. She said that she has to teach on public holidays as well. She flies outside the valley to teach, sometimes during her holidays. Sometimes she is there for a week and at other times for longer. When she is out there she teaches her course for the whole day, from 7am till 7pm, with some hours in the weekend too. She has to do it, she says, as there is nobody else in the country qualified to teach this particular module. She praises her students for their understanding and patient. If she did not do as she does, the students would not be allowed to sit their final exam, and the college would not be able to run Bachelors degree in nursing course, she rationalised. She also said that she would not choose to work this way but she does so as she can t say No to any request. In addition a TU lecturer s salary is 12,000-15,000 Nepali rupees a month, and hourly going rates for teaching part-time in a private colleges in 2006 was 400 rupees an hour. She needs this extra money to pay for her child s private school fees, rent, and to buy food and for everything else. She continued by stating that she has her own family responsibilities too, and that she feels exhausted. She asked me if I could suggest to her any way to get out of this system and get leave the country. 28 Also see Adhikari

18 I met her again several times in the summer and autumn of 2007, each time in a different college. She was teaching in these institutions as well, although she had not mentioned this earlier. I could not fathom how one person could teach in so many places, and maintain any semblance of quality in the teaching process. I started asking other senior nurses if they teach in more than in one place, to look at the networks of teaching. These ethnographic observations led me to realise that the majority of senior nurses with master s level qualifications teach in multiple sites. For example, there are only seven or eight nurses who have an MSc. in Psychiatric Nursing. There are over fifty five nursing programmes (if only SN, and BSc are included); but if we count all levels nursing including Bachelors degree in Nursing (BN) and Masters degree in Nursing (MN), there are over 70 programmes that have some amount of psychiatric nursing theory and clinical hours. With very limited human resources all these modules have to be covered. Currently, colleges are trying to employ teachers with the right qualifications to cover at least the degree level programmes. It seems almost impossible to find a specialist nurse teacher to teach staff nurse specialist modules like paediatrics, community health nursing. In one of the colleges I met a psychiatrist (doctor) teaching psychiatric nursing to BSc nursing students. Other staff members (with nursing backgrounds) were questioning, not unreasonably, as to how a doctor could teach nurses on the provision of nursing care? In December 2007, I visited a TU run nursing campus in Pokhara and met with the Campus Chief (CC) and many nursing faculty staff. There I was informed (in a collective voice) that this campus faces a chronic shortage of academic staff. There are a total of 26 teaching positions but only 16 posts are filled, leaving a total of 10 vacancies, 6 of these being lecturer posts. They also run BN programme (under TU) and, this requires faculty members with MSc qualifications. They have recently employed three new staff, but need more staff with Masters degree qualifications. They have lost one very experienced teacher to international migration. They made a special request for more support from the Dean s office and Central Campus Maharajgunj. As a result, quite a few teachers from Maharajgunj Nursing Campus went to Pokhara and cover some of the courses there. For example a lecturer comes to cover psychiatry nursing course for BN programme. She is supposed to supervise BN students in their psychiatry field placements, but she cannot stay in Pokhara for that, so students have to come to Kathmandu for this instead. The Campus Chief stressed: 18

19 there are genuinely not enough qualified staff in the country and also the unstable political situation does not help either to get full benefit from the available resources. The situation is very complex. There are many other examples of how complex this situation is. Two further examples are very illuminating however. In the autumn of 2006, I was visiting the NNC office. Somebody came in with an application letter with a detail proposal to set up a nursing school in western Nepal. As per the NNC guidelines, all training colleges have to be accredited by the NNC, and are assessed for their suitability to run programmes effectively. This application however was to set up a private college as soon as possible. The proposal was reviewed by the Council Registrar. I was sitting next to the applicant (and I was permitted to remain present). When he was asked about who was to be the Principal for this college, he gave the name of somebody quite well-known, a senior academic staff member, already working full time in one of the TU run campuses in that region. The NNC indicated that it is mandatory for the Principal to be full-time and that he/ she should not hold more than one full-time post. The applicant s response was that this proposed Principal is quite happy to quit the TU job or take unpaid leave to work for this new private college 29. In reality this rarely happens. Instead principles often have more than one senior post. This incident illustrates how private colleges are trying to fish out senior nurses from a very small pool. Finally, when I visited the MoH in the summer of 2006, there were two nursing officers working in the nursing focal point. This is the contact point for all nurses working under the Ministry of Health in the country. I visited there again in August 2007, and this time there was only one staff member there. I asked where the other nursing officer was, and whether she was on holiday or unwell. I was told that this officer has now been transferred to Janakpur, a town in the Tarai and she had gained promotion and become the nursing officer for Janakpur Hospital. She was, in addition running a nursing college in the same town, as there was nobody suitable to do both 29 I did not hear the final decision or any explanation from the NNC but my feeling is this application was not approved, as there has been no new college in this part of Nepal and this has not been recorded in NNC web site as at end of

20 of these jobs. These observations give some sense of the serious shortage of senior nurses in the country. The situation is mirrored in other specialist areas such as community health nursing, hospital nursing and paediatric nursing. In interview, nursing students constantly complained to me about these issues and the difficulties they face in getting hold of their clinical and course supervisors to help with and review assignments. I present an account from both teacher and student perspectives in order to explore the phenomenon further. Ms S. Chhetry (name changed) is a final year Bachelors in Nursing (BN) student, in one of the private colleges in the Kathmandu valley. As a part of the course requirements for all BN students, she has to conduct a small research study and submit her thesis, which will count towards her overall final grade. She explained that her teacher teaches this module in several colleges and so is responsible for supporting many students from many colleges (a physically impossible job surely if one were to provide adequate supervision and support to all students). Ms Chhetry complained that she had been trying to phone her supervisor and arrange a time for supervision, which had proved very difficult. She was given an appointment to see her supervisor at least one and half hours away from her college. She had to travel there, but on her arrival the teacher was too busy with other students. Ms Chhetry had to wait for hours, but still she did not get the chance to meet with her supervisor on that day. She was asked to come back the next day, and the same thing happened again. Finally, towards the end of the week she met her supervisor for about ten minutes. She travelled to many different colleges where her teacher worked, and it took her a full week to get ten minutes time from her teacher. She said understandably this is a terrible and unacceptable situation, as she pays over 2 lakh in course fees for this two-year BN course, yet she clearly does not get enough support from her teachers but has to put up with all of this in order to complete her course 30. On another occasion I met Ms R. Sharma (name changed) a full-time senior lecturer in one of the TU affiliated colleges. She also teaches in multiple colleges and is responsible for supervising BN students research and thesis writing. Like Ms A. I mentioned above, Ms R. shares her personal experience. She feels that she has to do 30 Interview with a final year BN student, studying in a private college in Kathmandu Valley in August

21 all this as there are not enough teachers to teach the research module. She feels obliged to take on this extra responsibility. She said: Sometimes I have to ask students to come and meet me in another college, as I cannot always be available in the college where they study; I have asked students to come to see me even in a hotel during my lunch break while I was in a workshop. It is not easy but we all have to do it, otherwise students can t complete their training 31. As had a previous lecturer she expressed her appreciation for her students understanding. But how long will such understanding last before there are more overt protests. From the above examples, it is evident the teachers work in multiple sites and nursing students have little option but to accept the harsh reality of training in a resourceconstrained environment. My next focus is the clinical training and placement situation in this fast-growing market of nursing training. Clinical placement and experience Clinical placements are where students should learn good nursing skills. Many private colleges do not have their own hospital for students to practice clinical nursing skills. In the Kathmandu valley, where the majority of training colleges are located, I found colleges in a rat race for clinical placements for their programmes. This section will examine the clinical placement facilities for students and the issues at stake. One problem is simply that the total number of hospitals beds has not increased to keep pace with the increased intake of nursing students (and other health professionals). As mentioned above, until 2000 there were only seven SN training colleges across the country. Geographically, they were located quite far apart and all were attached to government run hospitals for clinical placement. There were, as already detailed, only three colleges in the Kathmandu valley (Bir Hospital Nursing Campus, Maharajgunj and Lalitpur Nursing Campus) and these gave plenty of opportunity for students clinical placements. The problem started when many new 31 Interview with a senior lecturer in nursing, September

22 colleges opened under the CTEVT. When the first batch of all seven new staff nurse programmes started in one year ( ), not all of them had their own hospital. When the ANM programme numbers peaked in 2000 and no more ANM colleges were allowed to open, there followed another wave of staff nurse colleges. From 2000 many ANM colleges and new Staff Nurse (SN) colleges in Kathmandu valley (and in some bigger cities like Biratnagar, Pokhara) started running programmes simultaneously. Initially these new SN colleges negotiated for the few available placements. In these institutions there were already students from other programmes like medicine, and other paramedic and health-related training programmes and so not just nursing programmes. Until 2000, the clinical placement situation was just about manageable, but later when the number of SN colleges increased further in , the hospitals started becoming seriously overcrowded with the trainees. It became a general public concern and the issue appeared in the press. Professionals started commenting that training standards were compromised, and that some hospitals in the Kathmandu valley had more students than the number of hospital beds and patients occupying them (Pariyar 2062 vs). There has been some effort by the NNC to resolve this problem. The NNC has set some guidelines for nursing colleges running a programme, from basic minimum requirement of faculty, physical space, library and resources to clinical placement facilities. It started regular inspection and auditing of these programmes at all level of nursing (from ANMs to MN). NNC guidelines and criteria were reviewed in , new guidelines were made, and all the above areas are now more closely scrutinised. According to these new guidelines, in order to run a nursing programme (for example SN training with the capacity to train 40 students), they need to have an affiliation with a 50 bedded general hospital with specialist clinical facilities. Many colleges could not meet this basic requirement. The response to this has been varied. Some of the new colleges were closed soon after they opened; some have moved the whole college to a different city; and some programmes have merged with other colleges. However, there are still some colleges in the valley that run programmes without full accreditation from the NNC. There is still pressure for these institutions to provide specialist clinical placements like Obstetrics & Gynaecology, Paediatrics, Eye and, ENT. As regard Obstetrics and Gynaecology, nursing students, other medical and 22