Nurses play a critical role in health promotion, disease prevention, and delivery of primary and community care. Nurses and midwives account for nearly 50 percent of the global health work force. They provide care in emergency settings and are key to the achievement of universal health coverage. Ensuring the adequate availability of midwifery services is among the most effective ways to reduce maternal, new-born, and infant mortality. And yet, the country has always been faced an acute shortage of competent auxiliary nurse midwives (ANMs) and staff nurses. This problem is further perpetuated by the sub-optimal quality of pre-service education (PSE) delivered at nursing educational institutions. 

To respond to this need for improving the quality of nursing education and to develop a cadre of competent and confident nurses and midwives, the Indian Nursing Council (INC) and the Ministry of Health and Family Welfare, Government of India (MOHFW, GoI) along with development partners developed a roadmap for improving the quality of pre service education.

The Approach

The strategic approach adopted under this program included the establishment of centres of excellence for nursing and midwifery education- six at the national level, called national nodal centres (NNCs), and ten at the state level called state nodal centres (SNCs) in seven of the ten high focus states that were chosen as invention states under the program. It was envisioned that these nodal centres, besides serving as model teaching institutions, would also serve as academic resource centres for the Auxiliary Nurse Midwife and General Nursing and Midwifery schools in their region and provide support in the strengthening of these schools.

Programmatically, the strengthening of the NNCs, SNCs, and the ANM and GNM schools was being done through the use of simple and measurable performance standards which served as a guide to quality improvement. These standards provide a structure for program support and a criterion-based monitoring system which allowed the INC, through its nodal centres of nursing and midwifery education, to provide specific ongoing technical support. The program uses Jhpiego’s Standards-Based Management and Recognition (SBM-R) approach to performance and quality improvement as an overarching mechanism for implementing the INC approved educational and clinical standards across the NNCs/SNCs and ANM/GNM schools.

State level interventions

  1.  Technical Advisory Groups: TAGs were constituted in the intervention states of Bihar, MP, UP and Odisha to guide the overall process of PSE strengthening. The TAG members hold meetings at the state level on a monthly basis to discuss the progress made with the district level institutions and guide them in the process with help from the department and development partners.
  2.  Autonomous Nursing Directorate / State Nursing Cells: Establishment and operationalization of these cells in Odisha, Bihar, MP and UP for led the process of empowering the nursing midwifery cadre. Independent nursing directorates were established in the intervention states with the help of the INC and development partners and constant advocacy for their need was carried out at the state level.
  3. Technical support to the State Nursing Councils of Bihar, Rajasthan, MP and Odisha for implementation of a revised ANM curriculum and examination guidelines as mandated by INC, initiating competency based practical examinations for ANMs and piloting the ANM internship. OSCE (Objective Structured Clinical Examination) techniques were used to examine the clinical knowledge and outcomes and to know about the program impact during the study tenure (baseline, midline and end line)
  4.  Establishment of State Nodal Centres (SNCs): State nodal centres served as centres of excellence in the states for intervention supporting other institutions to achieve the performance standards as desired by INC   

National level interventions:

  1. National level Technical Advisory Group: A national TAG with representation from MoHFW, INC, NIHFW, state governments and development partners  is constituted for strengthening of PSE. 
  2. Memorandum of Understanding: An MoU was signed by Jhpiego (the development partner) with the INC and selected state governments at the beginning of the project implementation
  3. Development of Operational Guidelines for PSE strengthening. 
  4. Development and implementation of a roadmap for nursing midwifery cadre; including development of standards for guiding the quality improvement process at the nodal centres and the ANM/ GNM schools
  5. ANM curriculum revision and introduction of competency-based examination for ANM students.
  6. Advocacy for greater clinical and programmatic autonomy for nurses for ensuring inclusion of District Public Health Nurses and State Nursing Officers as an integral part of NHM District and State Program Management Units.

Impact Assessment

The project ran in the intervention states from 2013-2019. Data  was collected during doing baseline, midline and end line for evaluation and assessment. The maternal neonatal health (MNH) related competences of the nursing students were assessed using the OSCE method (Objective Structured Clinical Examination) along with mandatory standards predesigned by the Government of India and the INC in classroom and practical instructions, clinical instruction and practice, school infrastructure and training materials, school management and clinical site practices. There’s a total of 79, 80 and 81 standards for ANM, GNM and Bsc nurses and the INC recommends that an institution should achieve 70 percent of those standards to declare itself as a strengthened institution.  A standardized pre-tested OSCE checklist was developed in-line with the latest Government of India guidelines for assessing the clinical skills of the student nurses. The OSCE covered six key MNH practices:  

  1. Management of the second stage of labour 
  2. Active management of the third stage of labour (AMTSL) 
  3. Essential new-born care (ENBC) 
  4.  New born resuscitation (NBR) 
  5.  Plotting of partograph 
  6. Infection prevention 

The first four practices were evaluated using mannequins and models while the remaining two practices were assessed through administration of scenario-based questions.

The effect of PSE strengthening program on institutional performance as well as MNH competences of nursing midwifery students and faculty using OSCE were considered while conducting the evaluations during baseline, midline and end line. 

The findings revealed a significant improvement in institutional performance as well as competences of students from baseline to end line. None of the institutions assessed met 70 percent standards (standards of INC) at baseline and which improved to 87 percent during the end line assessment. Similarly, the mean OSCE scores for students and their level of competences improved significantly across all the six practices from baseline to end line.


The PSE strengthening interventions were effective in improving the institutional performance of public sector nursing midwifery institutions. However, as a major share of India’s health workforce comes from the private sector, it is important to ensure optimal quality of education in the private institutions as well. 

Although the intervention of the program have shown results, actual deployment, regular follow-up and tracking of these students are needed in understanding the long-term impact of the program in improving standards of facility-based care and ultimately on maternal and new-born health outcomes

By Shatabdi Das


  1. Cover page (nhm.gov.in)
  2. https://www.jhpiego.org
  3. Agrawal, N., Kumar, S., Balasubramaniam, S.M., Bhargava, S., Sinha, P., Bakshi, B., Sood, B., 2016. Effectiveness of virtual classroom training in improving the knowledge and key maternal neonatal health skills of general nurse midwifery students in Bihar, India: a pre- and post-intervention study. 
  4. Balasubramaniam, S.M., Bhargava, S., Agrawal, N., Asif, R., Chawngthu, L., Sinha, P., Kumar, S., Sood, B., 2018. Blending virtual with conventional learning to improve student midwifery skills in India
  5. Chan, S.W., Chien, W., Tso, S., 2009. Evaluating nurses’ knowledge, attitude and competency after an education programme on suicide prevention. Nurse Educ. Today 
  6. GoI, 2011. Ministry of Home Affairs, Government of India. Annual Health Survey (AHS) in EAG States and Assam 
  7. GoI, 2013. Ministry of Health and Family Welfare, Government of India. Strengthening Pre-Service Education for Nursing Midwifery Cadre in India. Operational guidelines 
  8. GoI, 2015. Ministry of Health and Family Welfare, Government of India, DAKSHATA Empowering Providers for Improved MNH Care During Institutional Deliveries. Operational Guidelines [online]
(PDF) Evaluating the effect of strengthening nurse midwifery pre-service education in two Indian states: A single group pre – and post-intervention study (researchgate.net)

Photo Credit: The Straits Times

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