Why General Nursing Diploma should not be extended until the year 2035?

by Khalil Ahmed Jatt

Recently, a document remained in circulation over the social media. The authors of the document have stressed upon the need to extend the General Nursing Diploma till the year 2035 based on the reasons that are mentioned below. The document was written by two of my favourite nursing professionals. I have enormous respect for both the authors, but with utmost respect, I would beg to differ with them on the basis of the rationales that are given in the yellow cells in the table below.

Potential Advantages if tenure extended up to 2035 (3 Year General Nursing Diploma)	Potential Disadvantages if tenure not extended up to 2035 (3 Year General Nursing Diploma)
1. Service Structure:  The Service structure of “Staff Nurse BPS-16” was already been defined by Ministry of Health Government of Pakistan, 2008 and respective provinces already notified. The FPSC and SPSC appointed nurses based of those rules.  Secondly promotion also lies under those criteria’s defined under the base line of 3-year diploma in Nursing	For Generic BSN no specific service Structure for Staff Nurse BPS-16 was not defined till yet In the current Scenario this sort of Degree only, supports the BPS-17 Grade Nurses.
My Response Nurses, all over the country, are already demanding a comprehensive service structure. In order to attract more competent people towards the nursing profession, it is very important to offer 17-grade to the nurses at entry-level. Why someone, who believes in their capabilities, would like to join a profession which would appear to be inferior (16-grade) than other professions (medical, engineering etc.)?
2. Orientation of the nomenclature at national and international level: 3 Years General Nursing diploma is well known oriented Diploma and acceptable to both National level Government   /   Private   sector   and   some   of   the developing countries like Saudi Arabia, UAE and other demanding nurses from Pakistan holding 3 year General nursing Diploma for Direct patient care. It is also Helping our country in generating revenue for through overseas employment services.	Generic BSN is now emerging concept at International Level under developed countries. For developing countries Stopping of 3 year Nursing diploma can boost nursing shortfall in next consecutive years. Hence parallel program may be recommended
Generic BSN is really emerging, whereas, the boat of nursing diploma appears to be sinking all around the world. I am not able to comprehend why do we wish to ride a sinking boat again. The world is changing fast. If we would not be able to adapt to this rapid pace of change, we would not be able to survive. “It is not the strongest of the species that survives, but rather, that which is most adaptable to change” – Charles Darwin
3. Four-tire formula:  The four tire Formula for the promotion of “Staff Nurse BPS-16” is applicable on the same nomenclature.	4-tire formula may be ineffective in condition   for   Staff   Nurses   BPS-16, because Generic BSN is the requirement of „Direct Promotion 10% Quota‟ for BPS-17.
It is not compulsory that we should have a specific four-tire service structure. The whole service structure of nursing requires transformation.
4. Finance burden on Government/ Private Sector: 3 Year General Nursing related appointed financial burden was already defined by the Government. (lower costing as compared to BSN)	As   generic   BSN   is   required for administrative post, hence if the staff nurse   appointed   through   BPS-16   on Generic BSN may require more finance under the head of salary due to them higher tenure of qualification as compared to General Nursing.
It appears that this rationale is built on the idea that quality does not matter. If it is so, there should also have an MBBS diploma, BDS diploma, a pharmacy diploma, and a physiotherapy diploma. As a result, diploma holder physicians, dental surgeons, pharmacists, and physiotherapists may be hired. It would save more money.
5. Opportunity for Higher Education: The leader has already defined under PNC for the students who wanted to upgrade their knowledge from Staff Nurses to Graduate to Master Nurses and to PhD. (The limitation is only lies in curriculum Subject and Hours revision under HEC criteria)	Limit the opportunity for Staff Nurse BPS-16 biased with Generic BSN Nurses may be possible that higher educated nurses   lack   Direct   patient  care   as compared to Diploma Nurses because such education under Government law pertains to Administrative post as Indirect Patient Care.  Secondly Poor Student/ Family may deprive of higher education and poor become poorer.
It is pertinent to clarify that Generic BSN graduates are not required to be posted on administrative posts only. Primarily they are expected to be competent registered nurses who can provide safe and effective nursing care.
6. Reduces 5 time more Nursing Shortage: It is submitted that sudden phasing out of 3 Year General Nursing” may not be in favour of National Interest” because it could initiate huge shortage of Nurses in future specially in Sindh, which may lead to increase the mortality and morbidity rate in Pakistan.	Although Generic BSN is promoting Quality   Standard under International criteria BUT on immediate basis not enough to overcome the sever nursing Shortage. Hence, Parallel program may be initiated by extending the phasing out date of General Nursing till 2035.
Phasing out of diploma programme is not sudden. More details can be found here. https://pakistaninurses.blogspot.com/2019/05/nursing-diploma-to-bsn-facts-and-rumours.html A new deadline for phasing out the diploma would be disastrous.
7. Beneficial for the Middle Class and Poor Family: Majority of the students who took admission in General Nursing are from the poor Family. It would be highly effective for the poor students to take Admission in General Nursing after completion of their Mamatriculation. After 3-year completion of training, they easily get jobs at national level and becoming the independent member support family, help in reducing literacy rate of Pakistan.	Generic BSN provide opportunity to Intermediate candidates only, and matriculate poor student may deprive off for opportunity in nursing field. Most of the mothers may afraid by the name of universities as compared to school due to the sense of huge “Fees” requirement for the program. In General Nursing as the tenure is completing in 3 hear hence after the completion of training student can avail Nursing graduation along with job in adjustment of their duties.
Firstly, poverty alleviation is not the aim of the nursing profession. One of the basic objectives of the nursing profession may be providing safe and effective healthcare services. Generic BSN would better serve this purpose. Secondly, even if the beneficence of the middle class and poor families is intended, there may be many other ways to do that. For example: providing scholarships to the BSN students, subsidies for the private nursing institutions to reduce fees etc. Thirdly, many mothers and fathers are reluctant to induct their children into the nursing profession because of the stigmas related to the nursing profession. Some of those stigmas are about being matriculate, diploma holders, and less educated etc.
8. Period for Completion of Training: The Period for the completion of General Nursing Diploma is only 3 years.  (similarly Diploma in Computer Sciences, Diploma in Electronics, Diploma in Mechanical etc. are follow the same rule)	As the Period of Generic BSN is 4 Year hence need more time, energy and finance for poor family of Pakistan.
Though the BSN programme takes more time than the diploma programme, most people consider the three-year general nursing programme only. However, most of the female nurses do one-year midwifery diploma straight after the nursing diploma, therefore, they require four years in their training. Furthermore, in most institutions, most candidates who apply for the nursing diploma program have an intermediate certificate (FSc); but their education goes unrecognized because the minimum requirement for the diploma is Matriculation. These candidates will be advantaged if offered a BScN degree. More details can be found here. https://pakistaninurses.blogspot.com/2019/05/nursing-diploma-to-bsn-facts-and-rumours.html
9. Reduces Mortality/Morbidity rate of Pakistan: It is submitted that the mortality rate of Pakistan is extremely High “The value for Mortality rate, adult, male (per 1,000 male adults) in Pakistan was 178.54 as of 2015” (https://www.indexmundi.com/facts/pakistan/mortality-rate) Moreover, Nurses   are   the   Backbone   of   health profession, phasing out of Nursing Diploma (which is producing approximate 5000-6000 Nurses/Year” will be stopped. May lead to boost this mortality rate.	Generic BSN is currently producing 1000- 2000 Nurses/Year not sufficiently helpful for producing Quantitative value but if 3 Year General Nursing program will be initiated in parallel to General BSN then it may enhance the registration of Nurses up to 6000-10,000/Year to recovered us quantitative national need.
No doubt, morbidity and mortality rates are very high in Pakistan. In order to produce the required number of nurses in Pakistan, the capacity building of the nursing institutions & Pakistan Nursing Council is very important. In addition, efforts to portray a positive image of the nursing profession is also very important to attract more candidates. Whereas, a U-turn towards the diploma programme would only support the mushrooming of substandard nursing schools.
10. Increases revenue for Nurses examination Board: Approximately 80% revenue of the Board was generated through 3 Year General Nursing Diploma. After phasing out it may block the functioning of the Board.	80%    reduction    in Revenue    of Provincial Examination Boards: After initiating BSN most of the institute will register with Universities and SNEB will be unable to generate that 80% Fund from the same.  In future Employees of SNEB may be deprived off from them salary.
After the abolishment of the nursing diploma, the nursing examination boards may be transformed into regional extensions of the Pakistan Nursing Council. The infrastructure of the boards may also be utilized to deal with the Licensure examinations and the post-basic specialization programmes.
11. CNA Vs 3-year diploma in nursing: 3 Year Diploma is Higher Quality standard as Compared to CNA/LPN. (Certified Nursing assistant/License practical nurse)	Although it was good step to initiate, CNA/LPN Nurses but it cannot replace General Nursing. CNA/LPN Helpful for poor family but in low quality. CNA/LPN   service   structure is   not available on the record till yet.
It appears that instead of promoting professionalism in nursing, the nursing diploma, LPN, and CNA programmes best serve the purpose of acquiring cheap labour for private hospitals. Therefore, along with the general nursing diploma, there must be a plan to phase out the CNA and LPN programmes in Pakistan.
12. Curriculum Helpful for Direct patient care: The Curriculum designed in 1998 was found highly Helpful for Direct patient care because of higher Credit hour in Practical/Viva.	The curriculum for BSN has less hours of Practical as compared to 3 year General nursing. The limitation for 3 Year General Nursing only lies in curriculum revision. Hence (1998) 3 Year General nursing diploma and Post RN BSN only need revision under HEC criteria/ IBCC for further equivalency.
If there are any deficiencies in the BSN curriculum, the curriculum may be revised accordingly.
13. Active issue on National Media/National Interest: “More than 30,000/Year Doctors are registered, but only 5000-6000 Nurses registered/Year. In the 22 Caro population there is a need for 20 Lac Nurses. There are only    85,000 nurses currently registered in Pakistan”. (Hum Tv, 09:21 A.M, 2nd January 2019)	The Active issue on Social media and in national interest is “Shortage of Nurses” instead our focus is on 4-year Generic BSN Vs. phasing out of 3 year General Nursing Diploma” We suggest parallel program like others (e.g. DBA, DCS, DIT, Etc.)
If one would inquire from youngsters about their career choices, at present, the nursing profession would merely be a career choice for them. In order to attract competent candidates towards the profession, it is very important to portray a positive image of the nursing profession. It may only be possible with enhancing quality in the profession.  Phasing out of the diploma programme would not only raise the standards of the profession but, in the long run, it would also help in dealing with the shortage of nurses in the country.
14. Diploma Vs. Associate Degree for Graduation: According to international standard there is deference Between Diploma and Associate Degree” “A Diploma is one type of certification, and an Associate degree is another type (e.g.  Post Basic Specialization” “A Diploma can be said to be a document awarded to a student after completion of a course.  (E.g.  3 year General Nursing”. “On the other hand, an Associate degree (E.g. Post Basic Specialization” is a title conferred on a student when he completes a Nursing college study” “Diploma is usually given in vocational or professional courses”, like General Nursing, DBA, DIT, etc. High Nursing schools and Allied Health sciences confer Diploma certificates.  On the other hand, Nursing colleges and universities award the Associates degree. (Based on Post Basic Specialization) (Quoted) Hence, it may be concluded that limitation lies in the revision of Nursing curriculum for General nursing, Post Basic Specialty nursing and Post RN BSc nursing under HEC/IBCC Level for international need.	Phasing out of 3-year Diploma stopped the opportunity for the Associate Degree (e.g. 2 years Post Basic Specialization in nursing) and poor student will not be able to get higher education.
The duration to acquire a bachelor’s degree in nursing is given bellow: FSc (optional):                        2 years Nursing Diploma:                   3 years Midwifery/specialization:       1 year Experience:                             2 years Post RN BScN:                       2 years Total:                           8 to 10 years FSc:                                         2 years BSN:                                       4 years Internship:                               1 year Total:                           7 years Therefore, the Post RN BSN route is disadvantageous for the candidates.
15. No permission from Sindh province was taken for phasing out of Nursing diploma: Sindh Province has never recommended for the phasing out of 3-year Nursing diploma. It was pre-planned to phase out the diploma but the reservation from Government of Sindh are not available on record. The Sindh Province who is already facing health related issues and registering more than 70% Nurse for all provinces.	Generic BSN is Quality standard program but in terms of Quantity is not enough to register the nurse’s equivalence to Diploma nurse / Years.
I agree that all relevant stakeholders should be taken on board. However, it is evident that the Sindh province was taken on board.
16. Low Cost of Education for Poor Student/Family: 3 Year General Nursing is low cost as compared to Generic BSN	Generic BSN is 2-4 times more costly as compared to 3-year General nursing may be ineffective for poor family.
Explained in point # 7.
17. Help in generating revenue for Pakistan: As 3 years General Nursing registering 5000-6000 Nurse/Year most of them got opportunity through overseas employment services.  Helped in generating revenue for Pakistan.	Generic BSN only registered 1000-2000 Nurse/Year may not be effective hence parallel program may be recommended.
Instead of resisting the change, all efforts should be concentrated on the successful execution of the BSN programme. Enrolment in the programme will increase with time. Whereas, BSN programme has the potential of generating more revenue than the diploma. With a diploma, we would be selling only cheap labour; with BSN programme, we would be able to export competent professionals.
18. Registered Midwifery Nursing 2000-3000 /Year: The mortality rates of maternal in Pakistan 178 per 100,000 (Dawn ness 12-05-2019)   is very high as compare to other countries. Phasing out of Diploma leads to severe shortfall of Midwifery nurse as 4th Year Specialty. May lead to increase maternal mortality rate in Pakistan.	Generic BSN is not highly effective to produce the same detail a side.
In the wake of such high infant and maternal mortality rates, it is crucial to produce professionals instead of amateurs. If we really wish to improve our statistics, it is necessary to upgrade Midwifery diploma to Bachelor of Science in Midwifery (BSM).
19. Effect on Critical Care nursing in Pakistan: Student who completed their 3-year Nursing get opportunity for Post Basic Specialization like Cardiac, Critical care, psychiatry, ICU, Renal and other support specialized department and critical care units.	Generic BSN required Post Graduate diploma instead post basic diploma due to conflict   with   board   vs.   university education. Secondly, Postgraduate diploma is not initiated for Critical / Specialized unit.
The required measures should be taken to initiate post-graduation specialities as it happens in the College of Physicians and Surgeons of Pakistan (CPSP). Nursing Examination Boards can also be helpful in this regard. Specialized BSN programmes may also be an option.

 

In brief, the diploma chapter should be over now and all of our efforts should be concentrated towards the successful executions of the BSN programme, taking a U-turn towards the diploma would be a disaster.