The Profession and Education of Nurses in South Africa pptx

List of tables and figures vPreface vii Acknowledgements viiiAcronyms and abbreviations ix 1 IntroductIon 1 A conceptual framework for the study of nursing 1Research design 7 Limitations

FA NURSING MONOGRAPH 3 3/31/09 4:28 PM Page 2

C M Y CM MY CY CMY K

Nursing

in a New Era

The Profession and Education

of Nurses in South Africa

Mignonne Breier, Angelique Wildschut

& Thando Mgqolozana

First published 2009ISBN (soft cover) 978-0-7969-2274-8ISBN (pdf) 978-0-7969-2275-5

© 2009 Human Sciences Research CouncilCopy-edited by Lisa Compton

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List of tables and figures vPreface vii

Acknowledgements viiiAcronyms and abbreviations ix

1 IntroductIon 1

A conceptual framework for the study of nursing 1Research design 7

Limitations 11Overview of the monograph 14

2 Growth and profIle of the nursInG professIon 15

The growth of nursing as a profession 15The growth of nursing in numbers 16Profile of the profession 19

Distribution of nurses 23Conclusion 28

3 the demand for nurses 29

Who says there is a shortage? 29Vacancy rates in the nursing profession 32Demand for nurses due to HIV and AIDS 33Conclusion 42

4 mIGratIon of south afrIcan nurses 43

Nurse migration as an international phenomenon 43Statistics on the migration of South African nurses 44

A qualitative view of nurse migration 51Views of academics and students on emigration 60Conclusion 63

5 nursInG educatIon 65

An overview of the production of nurses 65Geographical distribution of nursing training 70Trends in the production of nurses 73

Growth in SANC registers versus growth in production of nurses 77Conclusion 81

7 nursInG In a new era 93

Working with HIV/AIDS and TB patients 94Professional relations 97

Nurse/patient abuse 102Salaries 107

Non-monetary rewards 110Conclusion 110

8 standards, ImaGe and status 112

Have standards dropped? 112Views on status and image 113Positive views 120

Conclusion 121

Method 122Findings 122Conclusions and recommendations 125

List of tabLes and figures

Tables

Table 2.1 Growth in SANC registers by professional category, 1996–2006 17 Table 2.2 Proportions of different categories of nurses on SANC registers, 1996–2006 19 Table 2.3 Numbers and percentages of registered nurses, 1960–1990 21

Table 2.4 Racial distribution of nursing staff in the public sector by occupational category,

2006 21 Table 2.5 Age distribution of nursing staff by occupational category, 2006 23 Table 2.6 Total registrations with SANC versus nurses in employment, 2001 and 2005 24 Table 2.7 Population of South Africa, nurses in public and private sectors, and medical aid

beneficiaries, 2001 and 2005 24 Table 2.8 Nurses in South Africa and neighbouring countries, various years 26 Table 2.9 Nurses in OECD countries, various years 27

Table 3.1 Department of Health targets for the production of nurses, by category 30 Table 3.2 HIV prevalence among respondents by sex and age group, 2005 35 Table 3.3 Antiretroviral therapy treatment roll-out (for adults) in the provinces 39 Table 4.1 Nurses and midwives trained in sub-Saharan Africa working in seven OECD

countries, 2004 45 Table 4.2 Doctors trained in sub-Saharan Africa working in eight OECD countries, 2004 46 Table 4.3 Documented nurse immigrants and self-declared nurse emigrants, South Africa,

1999–2003 47 Table 4.4 Self-declared emigrant nurses by gender and age, South Africa, 2003 47 Table 4.5 Verifications of qualifications and transcripts of training issued by SANC to countries

specified, 2001–2004 48 Table 4.6 Summary of statistics on nurse emigration from South Africa 49 Table 4.7 Approved work permits for South African nurses, 2000–2004 50 Table 5.1 Output from all nursing courses and bridging programme, 1997–2006 66 Table 5.2 Output of professional nurses from four-year and bridging programmes, 1996–2006

68 Table 5.3 Output of enrolled nurses by year, 1997–2006 69 Table 5.4 Output of enrolled nursing auxiliaries by year, 1997–2006 70 Table 5.5 Output for nursing courses by province, 2006 72

Table 5.6 Increase in registrations of PNs compared with number of PNs that qualified in

previous year, 1997–2006 79 Table 5.7 Increase in registrations of ENs compared with number of ENs that qualified in

previous year, 1997–2006 80 Table 5.8 Increase in registrations of ENAs compared with number of ENAs that qualified in

previous year, 1997–2006 80

Figure 1.1 A model for the analysis of a profession and professional education, applied to the

nursing profession and the education of nurses 2 Figure 1.2 Waiting area of a public hospital in Manenberg, Cape Town 4 Figure 1.3 Waiting area of a private hospital in Constantia, Cape Town 4 Figure 2.1 Growth in SANC registers, 1996–2006 18

Figure 2.2 Gender distribution of nursing staff by occupational category, 2006 20 Figure 2.3 Gender distribution of nursing staff learner category, 2006 20

Figure 2.4 Comparison between nurse and population distribution, 2006 26 Figure 5.1 Overall professional nursing output, 1997–2006 68

Figure 5.2 Output of pupil nurses (ENs) by year, 1997–2006 69 Figure 5.3 Output of pupil auxiliaries (ENAs) by year, 1997–2006 71

Many of the hopes and aspirations of South Africa’s new democracy depend upon the production of professionals who not only have globally competitive knowledge and skills but also want to stay and work in the country and contribute to the national development effort and social transformation This quest has particular significance in the nursing profession, which has lost many thousands of nurses to developed countries that are already better supplied with health professionals than South Africa In this country, nurses are struggling to cope with the demands of a population that has high levels of diseases related to poverty and underdevelopment, injuries and HIV/AIDS, as well as chronic diseases Conditions are particularly bad in the public sector, where only 60%

of nurses are serving potentially 85% of the population, who are uninsured and largely reliant on public services

At the same time, the role of the public sector in the training of nurses has diminished

At present only public colleges and universities are licensed to offer the four-year programme that trains professional nurses, but together these institutions produced fewer professional nurses in 2006 than 10 years earlier in 1997 This has serious implications, as these are the only institutions that are allowed to offer the four-year professional nurse programmes that include training in midwifery, psychiatric and community nursing as well as general nursing

By 2006, the majority of professional nurses were being produced through the two-year bridging programme that is offered in the private as well as the public sector However, this programme, which upgrades enrolled nurses (ENs), trains only for general nursing

The private sector has also become the major provider of training for enrolled nurses and enrolled nursing auxiliaries (ENAs) Private colleges were responsible for 70% of EN output and 78% of ENA output in 2006

These are just some of the issues that are explored in detail in this monograph, which is the fourth in the HSRC’s research project on Professions and Professional Education The

first was a study of the medical profession, titled Doctors in a Divided Society (Breier &

Wildschut 2006), the second was a study of social workers, titled Social Work in Social

Change (Earle 2008) and the third was on engineering titled Engineering in a Developing Country (Du Toit & Roodt, 2009) The studies are intended to explore issues relevant to

the future development of the profession concerned and to bring our findings to policy, academic and public attention

This study would not have been possible without the cooperation of many individuals, including:

The academics and students who agreed to be interviewed or who participated in

• focus group discussions They were from the following educational institutions:

the South African Nursing Council

Finally, we would like to thank Atlantic Philanthropies for their financial support and Christine Downton and Khosi Xaba, in particular, for their encouragement

aCronYms and abbreViations

AIDS acquired immunodeficiency syndromeART antiretroviral therapy

BCur Baccalaureus CurationisDENOSA Democratic Nursing Organisation of South Africa

ENA enrolled nursing auxiliary

HAART highly active antiretroviral therapyHEMIS Higher Education Management Information System

HSRC Human Sciences Research Council

HWSETA Health and Welfare Sector Education and Training AuthorityKZNCN KwaZulu-Natal College of Nursing

MDR TB multi-drug-resistant tuberculosis MSF Médecins Sans FrontièresNEHAWU National Education, Health and Allied Workers UnionNHR Plan National Human Resources for Health Planning FrameworkNQF National Qualifications Framework

NSFAS National Student Financial Aid SchemeOECD Organisation for Economic Co-operation and DevelopmentOSD Occupation Specific Dispensation

UKZN University of KwaZulu-Natal UNAIDS Joint United Nations Programme on HIV/AIDSUSA United States of America

UWC University of the Western CapeVCT voluntary counselling and testingWCCN Western Cape College of NursingWHO World Health OrganizationXDR TB extensive drug-resistant tuberculosis

This study of nursing forms part of the HSRC’s Professions and Professional Education research project in which a number of professions are being researched with the aim of addressing this question: How is this profession and its professional education

programmes responding to the needs and challenges of a transforming South Africa?

A conceptual framework for the study of nursing

In the HSRC research project, professions and their professional education programmes are viewed from two broad perspectives1 which are summarised below and illustrated in Figure 1.1:

The first conceptual lens focuses on the current state of the

market and explores the extent to which the supply of professionals from

educational institutions meets or exceeds demand The local professional market is the major concern, but international conditions and markets are also taken into account The broader local labour market is also relevant to the extent that it includes other supporting or competing professions

The second conceptual lens focuses on the

the socio-economic and political conditions that affect the practice of the profession,

as well as the discourses that determine what it means to be a ‘professional’

behaving ‘professionally’ in the particular profession concerned An examination of the professional milieu starts with a consideration of the structural arrangements that underpin the practice of the profession: what it takes to become a professional and what rules, bodies and professional associations govern practice

Obviously this is a very broad remit and it is beyond the scope of this study – or any of the professions studies – to discuss all of these features in depth They provide starting points for preliminary, macro-level research from which key issues for detailed

exploration can be identified

Figure 1.1 illustrates the relationships between the various features of the dual foci of the professions studies Although the basic structure of the diagram can be applied to other professions, the specific details in this diagram relate to nursing in particular The following description of the diagram is designed to provide a very brief overview of the

1 See Breier and Wildschut (2006: 2–8) for further discussion of the methodology.

factors affecting nursing in South Africa today It is from these factors that particular issues were identified for detailed exploration in micro-level, case study research.

At the heart of all the HSRC professions studies is the professional education sector seen

in the context of the local professional labour market In Figure 1.1, the nursing education sector, which encompasses students, academics, nurse educators and clinical facilitators, is indicated in the centre oval The inclusion of educational issues in the HSRC professions studies is one of their most distinguishing and unusual features In our preliminary research on nursing, we found that the following features of the education system are crucial in the shaping of (and are also being shaped by) the professional labour market:

changes in the public institutional landscape, including the closure or merger of

• colleges and an increasing emphasis on university education of nurses;

changes in the locus of training, with the private sector assuming the major role in

• the training of lower-level nurses;

changes in the qualifications for professional nurses, with an increasing emphasis on

• degree programmes and on comprehensive training

These features are among the major foci of our study and are discussed in depth in Chapter 5

All of these educational issues are seen in relation to the national professional labour

market for nurses, which has two main divisions: the public sector and the private sector

The dotted lines in the second oval in Figure 1.1 indicate the proportions of nurses working in each of these sectors: about 60% of the nursing workforce in South Africa is

Figure 1.1 A model for the analysis of a profession and professional education, applied to the

nursing profession and the education of nurses

Legislation and health system

Undersupply/

good conditions (e.g UK, USA, Saudi Arabia) Socio-economic

and political conditions

Socio-economic and political conditions

Legislation and health system

Public

education

Discourses on healthcare/

professionalism

Poor conditions (e.g other African countries)

Discourses on practice/

professionalism

Disease burden Disease

burden

Internation al professional milleu

Nationa l professional milleu

Intern ational professional labour marke t

Rul es f or profe ss ion a l a dmission

Nat iona l general labour marke t

employed in the public sector, and the remaining 40% in the private sector The education

of nurses straddles both sectors, with increasing numbers of nurses at lower levels being trained by private training institutions (by the major hospital groups and private nursing colleges)2 while four-year programmes that produce comprehensively trained professional nurses are offered by public institutions (universities or colleges)

Beyond the national professional labour market is the national general labour market

with all the professions that compete for the attention of young school leavers and graduates today Whereas in the past nursing was one of very few professional options open to women, it is now just one of many possibilities However, an enduring advantage

of nursing training is that it enables one to work in many other parts of the world because of the universality of knowledge and skills associated with the profession There

are many opportunities for trained nurses in the international professional labour market,

particularly in developed countries with low birth rates that lack sufficient health professionals to care for their ageing populations

The national professional milieu provides the broad context in which nursing in South

Africa finds itself today This context has four main dimensions:

the structural arrangements governing the nursing profession and the health system

•

of which it forms a part;

the socio-economic and political conditions that affect the health of the nation;

• the disease burden;

• the prevailing discourses on nursing practice and professionalism

• Each of these dimensions deserves closer scrutiny

Firstly, the structural arrangements include the legislation that governs nursing; the policies and practices of the two government departments that affect it (the Department

of Health [DoH] and the Department of Education [DoE]); and the role of the South African Nursing Council (SANC) in setting and maintaining standards and of professional organisations in representing nurse members The latter organisations include the Democratic Nursing Organisation of South Africa (DENOSA) and the trade union National Education, Health and Allied Workers Union (NEHAWU) Given the focus of this

monograph on nursing in the post-apartheid era, it is important to consider the ways in which these structural elements have evolved since the transition to democracy in 1994

Van Rensburg and Pelser (2004: 162–165) list and evaluate the major reforms in the South African health system since 1994 Health policy and health legislation have been

overhauled in order to dismantle apartheid institutions and remove discriminatory measures Progress has been made towards the consolidation of fragmented and segregated services, and the district-based primary healthcare (PHC) system is now the basis of the health system Large numbers of staff have been PHC-trained The move to PHC has shifted the emphasis of healthcare policy and practice from biases towards urban-, hospital-, physician- and high-technology-oriented healthcare towards ‘more equitable geographical locations for health care and more appropriate and accessible care for all’ (2004: 162) Free healthcare policies have brought greater access to healthcare in the public domain There has been greater legitimisation of complementary and

alternative forms of healing, including strategic support for African traditional healing, and greater community involvement and participation in health matters

2 Students in independent private colleges might be contributing to the public sector workforce if the college gains placements in public sector institutions However, those who train in the nursing schools of the big hospital groups also work in their hospitals.

Van Rensburg and Pelser also list a number of constraints and failures Most importantly, the

‘two-class’ character of the health system remains, characterised by a weak and overburdened public sector offering ‘second-class services’

and a much stronger private sector offering ‘first-class services’ (2004: 163) There is little evidence of a strengthening

of the public sector Indeed, the sector is becoming even more overburdened as increasing numbers of patients switch from the private to the public sector because of increasing costs and diminishing returns of medical aid schemes As indicated by data provided in Chapter 2, approximately 85% of the South African population is served by the public sector, where 60% of the country’s nurses and only 40% of its doctors are employed

Figures 1.2 and 1.3, showing waiting areas of a public hospital and a private hospital respectively, illustrate the stark contrast between the public and private sectors

The second dimension is the socio-economic conditions that affect the health of the nation Van Rensburg and Pelser note that health reforms and improved healthcare play but a small part in the enhancement of health:

Health and ill health are as much and even more the result of prevailing economic conditions and lifestyle and thus do not necessarily respond to biomedical and health care interventions…evidence is lacking to convincingly conclude that the general living, working and health conditions of the majority

socio-of the South African population have improved significantly since 1994 or that such improvements reflect in health indicators (2004: 165)

The third dimension of the professional milieu concerns the state of health of the nation

or, to put it another way, the burden of disease South Africa is said to have a ‘quadruple burden of disease’, which includes diseases related to poverty and underdevelopment, chronic diseases, injuries and HIV/AIDS (Norman et al 2006: 27) In this monograph, much attention will be paid to the impact of HIV/AIDS and TB, in part because of the sheer scale of the epidemics (see Chapter 3) but also because they were frequently referred to in interviews and focus group discussions (see Chapter 7) Briefly, in 2007 an estimated 5.5 million South Africans were living with HIV or AIDS, and the HIV

prevalence rate was around 11% overall and as high as 33% among women in their early 30s TB is the most serious HIV/AIDS-related opportunistic infection and South Africa has

Figure 1.2 Waiting area of a public hospital in Manenberg,

undernourished; levels of crime, violence and trauma remain high; the HIV/

AIDS and TB epidemics are still skyrocketing, and so are co-infection and MDRTB [multi-drug-resistant TB]; the disruption of family life, of safety nets and

of social support structures is surging; mass labour migration and illegal migration persist; and South Africans are smoking more Amid these broader trends, improvements in health care would have minor effects, if any, on the health of South Africans (2004: 165)

The fourth dimension of the professional milieu invites one to consider discourses

on nursing practice and professionalism – specifically, the ways in which these discourses shape and are shaped by events in the nursing profession, as well as the interrelationships between these discourses and demand and supply in the professional labour market Against this background, an important concern in this monograph is the image and status of nursing (which has declined), the relationship between image and status and conditions in the health sector (both have been affected by the nature of diseases and conditions in the public sector as well as by poor salaries) and the corresponding effects on the supply of nurses (there is a large discrepancy between the numbers of nurses in the education system and the numbers of registrations in the profession itself) Trends in nursing education are discussed in Chapter 5; Chapter 8 explores the image and status of the profession

The international professional milieu is shaped by similar factors on a global scale:

The legislation, policies and structures that shape the nursing profession and the

• type of health system in the country concerned

Prevailing discourses on healthcare and professional nursing practice In this context

• the worldwide shift to primary healthcare that followed the 1978 Alma-Ata Declaration is of fundamental importance, contributing ultimately to changes in the structure and emphasis of the South African health system and, in the case of nursing, to the current emphasis of nursing education on comprehensive training that equips nurses for primary healthcare settings The Declaration, drawn up at an international conference at the Russian town of Alma-Ata, argues that health is a fundamental human right and that

the gross inequality in the health status of the people, particularly between developed and developing countries, as well as within countries, is

politically, socially and economically unacceptable and is, therefore, of common concern to all countries (WHO 1978: 1)

The international burden of disease

• The socio-economic and political conditions that shape the health of nations, which

• are closely related to processes of globalisation and the international professional labour market

The existence of the international professional labour market is one of the many

double-edged features of globalisation On the one hand, it offers opportunities for individual travel and advancement, the acquisition and exchange of new knowledge (through study

programmes, academic exchanges and conferences, for example) and valued remittances for some developing countries that export professionals as a source of national income

On the other hand, the global professional market also presents severe threats for many developing countries that are losing the professionals they educate to countries that can pay them more and offer better working and living conditions The existence of shortages

at both ends of the development spectrum contributes to the international pull and push

In the worst scenarios, the donor country is poor and has many great infrastructural, health and economic needs that are exacerbated by the loss of its professionals It has to rely on expatriate contractors and international development organisations to meet its skills needs

International recruitment alleviates shortages (from the perspective of the recipient country) but exacerbates shortages in donor countries, often leading to further disaffection and emigration This is the plight of many poor African countries

In considering the international labour market, one must take into account the universality of the body of knowledge associated with particular professions and the rules

of the country governing the admission of professionals from other countries In this respect, a South African nursing qualification, acquired through the medium of English and entailing a relatively universal body of knowledge and skills, is highly marketable in many mainly English-speaking countries

Against this background, it is not surprising that many South African nurses, with highly marketable qualifications but low salaries and unsatisfactory working conditions, have left the country either temporarily or permanently to work abroad It is also not surprising that there is widespread recruitment of South African nurses by international recruitment agencies, despite some government-to-government agreements that prohibit recruitment

by the foreign country’s public sector

Poor salaries have been recognised as a major cause of dissatisfaction, and in September

2007 the government concluded a historic agreement, called the Occupation Specific Dispensation (OSD), with various trade unions including DENOSA that raised the salaries

of public service nurses substantially It is expected that these changes will do much to elevate the status of nursing and bring back into the public sector the nurses who went into other fields of work or into private sector nursing, including lecturers who left the profession after the closure of colleges DoH (2004a).3

The arrows in Figure 1.1 show the flow of nurses from South African training institutions (centre oval) into the local professional labour market, the migration of nurses from the public to the private sector, and from the local labour market to the international market,

in particular to countries such as the UK, the USA and Saudi Arabia, where there are shortages of nurses The arrows from the international labour market into the country depict those foreign nurses who come into South Africa, or who wish to come – for example, nurses from other African countries who want to work in South Africa but are unable to obtain the necessary verification of their professional qualifications According

to Bateman (2007b: 82), this is mainly because of ‘poor compliance with application

3 Unfortunately, our research was already at an advanced stage when the increases were introduced and we were not able to discuss them with all the interviewees or focus group participants However, we gained the impression from those who did speak to us that there were some hiccups in the implementation of the increases and not all categories

of nurses were satisfied Nurse educators in particular felt they had not been recognised sufficiently.

Research design

The conceptual framework detailed above arises out of a particular research methodology that was piloted in the HSRC’s first professions study on doctors and was subsequently followed, with variations, in the studies of social workers and engineering professionals

In terms of this methodology, the first task in a professions study is to conduct a preliminary scoping exercise, which involves reviewing major current literature and secondary sources and conducting preliminary interviews with principal stakeholders in order to identify key issues that are subsequently explored in greater depth using various research methods as deemed appropriate Qualitative case studies at selected education sites, which include in-depth interviews and focus group discussions, are undertaken to focus on the issues identified

In the nursing study, our review of statistics and our preliminary stakeholder interviews,

as well as a specific brief from the Department of Labour (DoL),4 encouraged us to focus

on two key elements: first, the existence, nature and extent of a shortage of nurses in the country and possible reasons for this; and second, the large discrepancy between the number of nurses who graduate each year and the number of new professional registrations In our case studies we chose to pay particular attention to student views on nursing and on their future careers, in an effort to shed some light on the gap between graduation and entry into the profession

Data sources

Our exploration of the nursing shortage in South Africa required attention to a range

of statistical databases Statistics on the nursing workforce based on nurse registrations were collected from SANC and the Health Systems Trust (HST), which draws on the government’s human resource database, PERSAL Figures on trained nurses were obtained from SANC, from the DoE’s Higher Education Management Information System (HEMIS) database and from private providers Statistics South Africa (Stats SA) was the main source

of statistics on the South African population, while the World Health Organization (WHO) provided statistics on international health trends We used figures from the Labour Force Survey (LFS) for 2001 and 2005 to estimate the number of nurses on the SANC register who were in employment

4 As part of a separate study on scarce and critical skills commissioned by the DoL, the researchers analysed data collected across both studies in a manner that sought to address the following question: Is there a shortage of nurses in South Africa? These data included statistics on nursing supply and demand as well as a review of policy documents, Skills Education and Training Authority (SETA) reports, newspaper cuttings and other relevant secondary sources This research led to a report by Wildschut and Mgqolozana (2008) and a chapter for a monograph that will consist of similar chapters on 12 different professions, each addressing the same questions on shortage of human resources (Erasmus &

Breier, 2009).

Where possible, we tried to disaggregate figures by population group and gender to show the extent of transformation, a major concern in most professions in South Africa today

International literature on professions barely touches on race issues, although the feminisation of professions is addressed Given South Africa’s history of enforced racial segregation, it is important to see whether the racial profiles of the professions are changing To do this, we unfortunately needed to continue to employ the racial classifications that were used to separate and discriminate against people during apartheid In many contexts, people are still asked to provide their racial details for the purposes of monitoring progress towards equity However, it is becoming increasingly common for people to refuse to do so This is why we have not been able to give a racial breakdown of SANC figures, although we are able to give a gender breakdown To get an idea of racial splits in the nursing workforce, we had to rely on figures from the HST for the public sector (taken from the PERSAL database) and figures from HEMIS for university nursing programmes In this monograph, we use the terms ‘African’, ‘coloured’,

‘Indian’ and ‘white’ to denote the different population groups indicated in the data sources (usually based on forms completed by individuals) Where we wish to refer to all population groups other than the white cohort, we use the term ‘black’.5

The literature that we reviewed comprised both national and international sources and included

policy documents and legislation;

• books on the history of the profession and the BCur (Baccalaureus Curationis)

• nursing degree programme;

academic journal articles on a range of topics relevant to the profession, including

• gender issues, migration, salary issues and international trends in the profession;

professional publications, including DENOSA’s own magazine,

its accredited journal, Curationis.

We also subscribed to a newspaper cutting service run by the University of the Free State that provided us with newspaper articles on nurses and nursing during the first nine months of 2007 Thereafter we continued to compile our own collection of articles from local daily papers and national weekend papers The newspaper articles provided coverage of most of the major public debates that affect nursing: the nurses’ strike, the new salary dispensation, emigration of nurses and other health professionals, abuse by and of nurses, and conditions in the private and public health sectors

Interviews

Preliminary discussions were held with key players in the nursing profession, such as members of the DoH and SANC, a director of the HST, and the head of the HSRC’s Social Aspects of HIV/AIDS programme These discussions informed our selection of additional individuals to interview formally, as well as our selection of case study institutions

Formal interviews were conducted with representatives of DENOSA; NEHAWU; the provincial government of the Western Cape; the major hospital groups Netcare, Life Healthcare and Medi-Clinic; and a major nursing agency, Nursing Services of South Africa

These interviews took place at the headquarters of the various organisations

5 We are aware that increasing numbers of South Africans of all races wish to be identified as African In our usage, the term ‘African’ refers to black Africans only

In addition, for the case studies we conducted interviews with university and college lecturers and clinical nurse educators We also conducted interviews and focus group discussions with students These are discussed in detail in the following section

Case studies: Interviews and focus group discussions

Central to each of the HSRC’s professions studies are case studies of educational institutions that offer professional education programmes These institutions are selected purposively, to show how certain professional issues, identified in the preliminary research, are taken up in the professional education programmes Selection for illumination

of theories or issues, rather than generalisation, is an accepted form of purposive sampling commonly used in case study research (Maxwell 1996; Yin 1984, 1993)

In the case of nursing we decided to do case studies at each of the three major types of nursing education institution: universities, colleges and private training schools (including those training programmes run by big hospital groups as well as smaller operations) The selected institutions were:

University of the Western Cape (UWC);

• University of KwaZulu-Natal (UKZN);

• Western Cape College of Nursing (WCCN);

• KwaZulu-Natal College of Nursing (KZNCN);

• the Bellville campus of the private nursing education provider Healthnicon;

• Netcare Training Academy, Bellville branch

•

At these institutions we conducted interviews with lecturers and held focus group discussions with students (see the list of respondents in Appendix 2) The exceptions were at UWC, where we did not hold focus group discussions but interviewed students (a requirement of the university), and at Netcare, where we interviewed the director of nursing services rather than lecturers The reason for the change of procedure at UWC was that the dean of research at that institution refused to give permission for focus group discussions on the grounds that the students participating would not be able to remain anonymous Although our focus group questions did not ask students to speak about HIV/AIDS in a personal way, it was felt that there could be embarrassing or compromising disclosures that might have far-reaching stigmatising effects for the student(s) concerned

All interviewees were asked to sign a consent form, granting permission for the interview and stipulating whether they were prepared to be identified and whether they agreed to the use of a tape recorder in the interviews (see the sample consent form in Appendix 1)

In the interviews with academics, interviewees were asked to give a brief summary of their career before stating what they thought were the major issues in the nursing profession and nursing education today and how these were being addressed in nursing education programmes Interviewees were asked to give the responses that first came to mind before being prompted to respond to specific questions on various themes, including choice of career, salaries, conditions, emigration, abuse, stress, relationships with doctors and the status of the profession Similar broad questions and prompts were used in the interviews with clinical nursing staff, nursing managers, and representatives of selected organisations and nursing agencies Most interviews lasted between 40 and 90 minutes The interviews were fully transcribed and summarised according to their key themes for purposes of analysis

The questions posed in the focus group discussions with students were more specific than those used in interviews with academics It was felt that students would not be as informed about issues in the profession as their lecturers were and would therefore need more specific prompts from the outset The questions covered themes such as reasons for choosing nursing education, the status of nursing, nurses’ salaries, what students thought

of nursing strikes, emigration, gender relations and cases of abuse (of and by nurses)

In the end we held focus group discussions and interviews with a total of 180 students

We conducted in-depth interviews with 41 academics and 13 representatives of various stakeholders including the major hospital groups, SANC and DENOSA

Division of labour

Three researchers were involved in the research that informs this monograph All three participated in the literature review and secondary data gathering Angelique Wildschut and Thando Mgqolozana wrote the DoL report that informed much of the quantitative analysis for this study They also conducted interviews at UKZN, KZNCN and Healthnicon

as well as focus group discussions with students at WCCN, KZNCN and Netcare

Mgqolozana also conducted interviews with students at UWC, while Wildschut interviewed senior staff at UWC and Medi-Clinic Mignonne Breier conducted interviews with senior staff and/or representatives at UWC, WCCN, DENOSA, NEHAWU, SANC, the Western Cape provincial government, and the private hospital groups Life Healthcare and Netcare

Collaborative writing is notoriously difficult, and the writing up of this study was no exception Breier, the project leader of the professions studies, assumed the responsibility for the writing of the report, drawing on her own research and that of the other two researchers as well as further research (literature, statistics, policy documents) as new issues that had not been anticipated in the original planning of the research unfolded

The development of new insights is one of the features of qualitative research: one frequently finds that as new issues emerge the data and literature with which one embarked on the research may no longer be as relevant as first anticipated

In order to share the knowledge among the research team, Wildschut and Mgqolozana each compiled sub-papers on certain key themes: the new salary dispensation, the public service strike, HIV/AIDS and nursing, gender relations in nursing and two papers

analysing quantitative data on population groups and gender in public nursing education

Mgqolozana also wrote a personal account of his own experience as a university student training to be a professional nurse

In addition, most of the interviews were transcribed in full Wildschut and Mgqolozana also made summaries of the interviews and focus group discussions Breier read through the summaries and transcripts to identify the key themes and the responses to them The qualitative responses were then organised under the following key themes: what the respondents felt were the key issues (the range and the most common), reasons for becoming a nurse, attitudes towards emigration, and views on working conditions Files were created under these headings, and responses were copied into them and then summarised and analysed in the light of the quantitative and secondary research

usually academics or prominent individuals in the field concerned Reviewers are required

to submit detailed critiques with suggestions for improvement This nursing study was formally reviewed by two nursing professors Having said this, we also need to make clear that they are not in any way responsible for the final monograph Although we tried

to do justice to their recommendations, ultimately this monograph reflects our analysis and viewpoints, not those of the reviewers

as gaps from one year to the next In the end we made use of data for only one year (2005), where the data were found to be reasonably reliable Another concern was the fact that the totals on the SANC register included nurses who were not active (those who had retired, left the profession, gone abroad, and so on) Thus LFS data for the years 2001 and 2005 were used to get the numbers of nurses who were actually working as nurses

in South Africa These LFS data are problematic in themselves, as they also have many gaps (see Breier 2007 and Wildschut & Mgqolozana 2008)

Emigration data (discussed in detail in Chapter 4) are even sketchier Many different information sources were used to estimate the extent of nurse migration, including a count of letters of verification of qualifications, which are kept by SANC, and statistics from WHO and the Organisation for Economic Co-operation and Development (OECD) about nurses in foreign countries A caveat in regard to these data is that it is not always clear what level of ‘nurse’ is referred to by these data sets

Outsider research

The HSRC professions studies have been conducted by outsiders to the professions concerned – that is, by researchers specialising in research on education and the nexus of education and work It is debatable whether this is more appropriate than having an insider (a practitioner or educator in the profession) conduct the research An insider would contribute many insights, but might also bring biases associated with his or her professional involvement, whereas a professional researcher could present a broader and hopefully more dispassionate view Yet no perspective can be all-encompassing and each

approach presents its own problems The professions studies so far have chosen to pursue the ideals of breadth of vision and objectivity rather than the kind of detail that only an insider can provide

In the nursing study we deviated slightly from this model by including on the research team a professional nurse who is also a graduate from UWC Thando Mgqolozana’s insider experience provided background and depth on issues relating to university education of nurses However, we have to accept the possibility that it might also have influenced the trajectories of his interviews and focus group discussions Certainly he encountered more reserved responses from students at UWC, where he was known to many students, than at UKZN, where he was not known However, this reserve is more likely to be the result of the requirement at UWC that only interviews and not focus group discussions be conducted Students generally seemed more outspoken in focus group discussions than in individual interviews

Another feature of the student interviews and focus group discussions needs to be mentioned Many students spoke openly about their plans to leave nursing after graduating and considerable attention is paid to their views in this monograph There are obvious limitations to seeking to find reasons for attrition after graduation from students who are still in the education system They are speaking about their plans, not what they have actually done post graduation Obviously the latter focus would have been ideal but was beyond the scope of our project in terms of time and budget We can only urge that this gap be taken up in future research

Categories of nurses

It is important that we define the various categories of nurses to which we will refer in this monograph Nursing has a complex hierarchical structure with associated terminology, which has been further complicated by recent changes in legislation governing the profession and its educational programmes In addition, nursing education in South Africa takes place in a particularly complex education and training terrain that includes

universities and technikons (now universities of technology), public stand-alone nursing colleges, nursing schools attached to public hospitals, private colleges run by the major hospital groups, private colleges attached to old-age homes and private colleges that train for profit The latter type of college generally does not have its own facilities for clinical experience and must make arrangements with other facilities where nursing students can gain the 1 000 hours of clinical experience per year that is required for all levels

All nurses are required to register with SANC, which maintains two different registers: one

is called a register and the other a roll Nurses must have gone through at least four years

of training to qualify to be registered on the SANC register These will include nurses who

have passed a four-year programme in a university or a public nursing college, leading

to a nursing degree or diploma respectively Or they might have qualified through a bridging programme, which is a two-year course designed to upgrade the qualifications

of nurses who have already trained for two years and are working as ‘enrolled’ nurses

The bridging programme can be offered by private as well as public nursing education institutions, but the four-year programme is offered only at public institutions

(universities/universities of technology, and public nursing colleges) The entrance requirement for the degree is normally a senior certificate with endorsement (exemption) and for the four-year diploma a senior certificate To enter the bridging programme one must have already qualified as an enrolled nurse (see below)

Registration on the SANC register entitles one to be called a registered nurse (RN) or professional nurse (PN) These terms are often used interchangeably, but the strict distinction is that the term ‘professional nurse’ should be used only for those who have been through a four-year programme that includes training in community nursing, midwifery and psychiatric nursing as well as general nursing A nurse who has completed

a bridging programme is qualified to practise only general nursing In some contexts such nurses are referred to as registered rather than professional nurses In the clinical setting, PNs and RNs are addressed as ‘sisters’, as in ‘Sister Mgqolozana’, regardless of whether they are male or female

SANC provides for two categories of nurses on its roll of nurses: enrolled nurses (ENs)

and enrolled nursing auxiliaries (ENAs) ENs have completed a two-year certificate programme that has an entrance requirement of at least grade 10 This programme can be offered by private as well as public training providers ENAs have completed a one-year certificate programme that also has an entrance requirement of at least grade 10

There are also special terms for nurses in training: ‘student nurses’ are those studying four-year programmes at universities or colleges, ‘pupil nurses’ are studying to be enrolled nurses and ‘pupil auxiliaries’ are studying to be enrolled nursing auxiliaries

The categories described above date back to the Nursing Act of 1978 and to government regulations in the 1970s and 1980s pertaining to the minimum requirements for registered, enrolled and auxiliary nurses

The Nursing Act of 2005 (Act No 33 of 2005) and the Draft Regulations Regarding the

Scope of Practice of Nurses and Midwives (SANC 2007a) present new categories of nurses,

all on the same register: professional nurse, professional midwife, staff nurse, auxiliary nurse and auxiliary midwife The Act and revised scope of practice reflect a new approach to nursing education, in which professional nurses are better prepared for

primary healthcare settings and trained to practise comprehensively At the time of writing,

professional nurses are still being trained in terms of Government Regulation 425 of 1985, which provides for training in community, psychiatric nursing and midwifery as well as general nursing by means of separate courses of study on each of these aspects In contrast, comprehensive training ‘does not imply or focus on attaining separate qualifications but rather on the ability to integrate knowledge and skills for the provision

of comprehensive nursing care’ (Subedar 2005: 98)

At this stage, nursing qualifications have yet to be aligned with the revised scope of practice A new four-year qualification has been developed and registered on the National Qualifications Framework (NQF) of the South African Qualifications Authority (SAQA)

However, this new qualification envisages that the basic qualification for a registered nurse will in future be a bachelor’s degree The implication is that only higher education institutions (universities and universities of technology) would be able to offer this qualification The underlying reason for this change is that the nursing education system

is required to align itself with the NQF and the NQF does not allow for a four-year qualification that is a diploma

In its report Nursing Strategy for South Africa 2008 (DoH 2008), the DoH notes that

SANC has expressed concern about the new Bachelor of Nursing qualification, the implementation of which would have a serious impact on the production of registered nurses as the bulk of them are produced by nursing colleges which are not permitted to

award degrees in their own right.6 The DOH has requested that the qualifications be realigned with the revised scope of practice.

What are the implications of this discussion for this monograph? Although at the time of writing there are many moves afoot to change nursing qualifications and titles, they are not yet fully in force Our quantitative data refer to the period 1996 to 2006, when the old categories were in place For this reason, we use the ‘old’ terminology throughout the monograph, and the training we discuss is that which prevailed at the time, even though

it was based on regulations dating back to the 1970s and 1980s

Overview of the monograph

The chapter-by-chapter content of the monograph can be briefly summarised as follows:

Chapter 2 provides a quantitative profile of the nursing profession We analyse the

• growth in the profession over a 10-year period, as well as the numbers of nurses by category, gender, population group and age, public or private sector and provincial location The nurse-per-population data are then compared with those of other countries, indicating that South Africa is better off than its immediate neighbours but undersupplied in relation to developed countries and its own needs

In Chapter 3 we attempt to establish whether there is in fact a shortage of nurses in

• South Africa by looking at vacancy rates and estimates of the demand for nurses owing to the prevalence of HIV/AIDS

In Chapter 4 we use various statistical sources to estimate the extent of nurse

• emigration Drawing on secondary research as well as our own interviews and focus group discussions, we consider reasons for emigration as well as the quality of experience for nurses working abroad

In Chapter 5 we present a quantitative overview of nursing education, in particular

• the output of nurses disaggregated by sector (private or public), programme (ENA,

EN and PN), province, gender and, where available, population group We conclude with a brief account of private sector training

In Chapter 6 we explore the reasons why young people choose to become nurses,

• drawing on interviews and focus group discussions as well as secondary research

We note the concerns of academics who state that they are unable to find sufficient numbers of students who are truly suited to a nursing career despite the thousands

of applicants to nursing education each year

In Chapter 7 we present the views of students on what it is like to be a nurse in

• South Africa today, based on their experiences in clinical practice We note their concerns about working with HIV/AIDS patients, about professional relations in the hospital setting, about nurse and patient abuse, and about salaries We end the chapter with a consideration of the rewards of being a nurse

In Chapter 8 we examine the standards, image and status of the profession We note

• that older academics and nurses who we interviewed were concerned about the drop in standards, and all interviewees, including students, were concerned about the image and status of nursing as a profession We examine possible reasons for these declines

In Chapter 9 we present conclusions and recommendations based on our research

• findings

6 The bridging programme would also be phased out.

(Van Rensburg 2004: 7)This chapter considers the growth of the nursing workforce in South Africa in quantitative terms in relation to the growth of nursing as a profession It is argued that the patterns of quantitative growth reflect the emphasis on developing nursing firstly as the work of

‘better educated’ women (Sweet 2004: 176) but subservient to the work of doctors, and much later as a profession equal to other medical professions in worth and status, albeit different The high proportions of professional nurses compared with nurses in sub-professional categories could be seen as an outcome of this professionalisation process

The chapter also considers the profile of the nursing workforce, bearing in mind that its development has been intimately enmeshed with the ‘racial, class and gender divisions of

a divided society’ (Marks 1994: 14)

The growth of nursing as a profession

Institutionalised nursing7 in South Africa has its origins in the mid-seventeenth century

as a very lowly job in the ranks of the Dutch East India Company, which had sent a surgeon, Jan van Riebeeck, to found a refreshment station at the Cape of Good Hope

One of his first tasks was to set up a hospital for the starving and desperately ill sailors that the company had press-ganged into crewing its ships to the East The tasks that might now be considered ‘nursing duties’ were first performed by an apprentice surgeon, until replaced by the work of slaves and later by soldiers who were recruited on three-year contracts to be ‘attendants on the sick’ (Searle 1965: 34)

The modern and largely female profession of nursing as it is known today dates back to the latter decades of the nineteenth century, when an Anglican nun, Sister Henrietta Stockdale, began training nurses in Kimberley The first trained nurses were nuns of religious orders and English ‘ladies and god-fearing women’ (Marks 1994: 15) and eventually black middle-class women The latter were brought into the profession only when the health of the black labour force became a matter of considerable concern, and the laying of white hands on black bodies even more so At a time when only around 6%

of African women could read or write (1994: 90), Cecilia Makiwane passed the Nursing Certificate of the Cape Colonial Medical Council and became the country’s first African professional nurse in 1908

Afrikaner women began to enter the profession in sizeable numbers only in the 1930s

By then their secondary education was compulsory, the Afrikaner population had largely been driven off the land and one in five were classified ‘poor white’ (Marks 1994: 70)

Coloured nurses began to be trained in earnest in the Cape around 1939, and their numbers rose rapidly in the 1960s and 1970s, in line with the government’s coloured

7 As opposed to the home-care practices and folk medicine of the settler population or the traditional healthcare practices and traditional medicines of the indigenous populations.

preference policy Indian nurses have never formed more than a very small proportion of the total nursing workforce Writing in 1965, Searle argues that for various cultural reasons the profession was not viewed favourably by Indian parents, who believed ‘an educated girl could do better for herself than to nurse’ (Searle 1965: 281–282) In contrast, a sizeable number of Indian women have become medical doctors (see Breier and Wildschut 2006)

Rispel and Schneider (1991: 111) argue that the early growth in the professionalisation

of nursing can be attributed ‘partly to the need for social recognition of the nurse as an educated, professional woman’, but in the last few decades of the twentieth century nursing professionalisation has moved away from the ‘womanly’ role defined by Florence Nightingale to other, more technical aspects ‘Higher educational standards, stressing theory and research, and greater self-regulation and the status of being separate from but equal to medicine have become the touchstones of the present professionalization process’ (1991: 111)

The concept of the ‘nursing process’, which excludes medical diagnosis but provides for holistic patient care and meticulous written records, has provided a basis for the increasingly academic conceptualisation of nursing (Rispel & Schneider 1991) In her textbook on nursing, Uys (1999) presents the following version of the process, emphasising that every step must be written down in a nursing history, nursing care plan and progress report:

Determine the client’s problems (assessment phase)

• Make plans to solve the problems (planning phase)

• Execute the plans (implementation phase)

• Evaluate to what degree the actions were effective in solving the identified problems

• (evaluation phase) (Uys 1999: 25)This conceptualisation has both formalised the practice of nursing – what many nurses were already doing – and provided a ‘scientific’ framework to study and improve nursing practice Uys herself calls it a ‘scientific problem-solving process’ (1999: 25)

The growth of nursing in numbers

The nursing profession has grown phenomenally since its formal inception.8 In 1892, largely owing to the efforts of Sister Henrietta Stockdale, who started training nurses in Kimberley in 1877, there were a total of 49 trained nurses in South Africa (Searle 1965:

265) Between 1933 and 2006, the country’s population increased fivefold, but the number

of registered nurses and midwives in service rose more than 10 times (Searle 1965; SANC, 2007c)

Searle argues that the growth in nursing can be attributed to various factors, including changing social attitudes towards Western medical care, which was usually supplied by a medical doctor assisted by a trained nurse, and improvements in hospital conditions, which meant that hospitals became the accommodation of choice for acutely ill persons even if they could afford home care (Searle 1965: 387)

8 See Marks (1994), Mashaba (1995), Rispel and Schneider (1991), Searle (1965) and Van Rensburg (2004) for further historical details

growth and profile of the nursing profession

In recent years, however, the growth in the profession has slowed considerably Table 2.1 provides a breakdown of SANC registrations by professional category between 1996 and

2006, showing a modest (14.1%) growth overall in the 11-year period During this period the South African population increased by 17%, PNs/RNs by 15.4%, ENs by 18.5% and ENAs by 9.2%

By 2006 there were a total of 196 914 nurses on the SANC registers Of these, 51% were PNs/RNs and the remaining were ENs (20%) or ENAs (29%) About 82% of the total, or

157 501 nurses, were actively working in the country.9

Table 2.1 Growth in SANC registers by professional category, 1996–2006

Year

ENA = enrolled nursing auxiliary.

Figure 2.1 provides a graphic illustration of the recent slow rate of growth in the nursing registers

Table 2.1 shows there was virtually no growth in the profession between 1996 and 2003, when the register grew by a total of only 5 201 nurses However, there was substantial growth thereafter, with the overall register increasing by 19 194 nurses between 2003 and

2006 The 15% growth in PNs/RNs was fairly steady across the 11-year period, but ENAs decreased by 12% between 1996 and 2002 before starting to increase again in 2003 By

2006 there were 18.5% more ENs than in 1996 ENs also decreased between 1996 and

2002 (by 2%) and then increased by 20.5% between 2002 and 2006

There are two main reasons for these changes (discussed in more detail in Chapter 5): the bridging programme, which enables enrolled nurses to become registered nurses, and the

9 Calculated on the basis of LFS data for 2005, which showed that only about 82% of the nurses registered with SANC were actually working that year.

increasing involvement of the private sector in nursing education The drop in enrolled nurses relates to the progression through the bridging programme, and the drop in enrolled nurse auxiliaries reflects the drop in numbers training for this qualification because of concerns that the qualification would be phased out

At the same time the proportion of professional/registered nurses to enrolled nurses and enrolled nursing assistants has remained fairly constant, only changing marginally from

51 : 19 : 30 in 1996 to 51 : 20 : 29 in 2006 However, as indicated in Table 2.2, PNs/RNs as a proportion of the total increased to as much as 55% by 2002, with a corresponding decrease in the proportion of ENAs But by 2006 the proportions had returned to a ratio similar to that of 1996 The growth in proportion of PNs/RNs, which peaked at 55% in

2001 and 2002, can be ascribed to increasing numbers of nurses graduating from the bridging programme Graduates from the bridging programme, which was introduced in

1989 to allow enrolled nurses to upgrade to registered nurses, increased rapidly between

1996 and 2006 (see Table 5.1 in Chapter 5) The number of ENs dropped 2% between

1996 and 2002, before increasing again At the same time there were 11% fewer ENAs in

2002 than in 1996, as they too began to register for further training These numbers started increasing again from 2003

Note that Table 2.2 includes all registrations, whether the nurse is active or not – that is,

it includes nurses who have retired or gone overseas, provided they have maintained their SANC registration From LFS data we estimate that there were a total of 155 484 nurses in 2001 and 157 501 nurses in 2005 who were actually working in the country as nurses (Stats SA 2001, 2005) These constituted 81.6% of the total registrations in 2001 and 82.3% in 2005 (This breakdown is presented in greater detail in Table 2.6.)

An important consideration in relation to Table 2.2 is whether the proportions of the different types of nurses are appropriate for the health conditions in South Africa

Unfortunately, there are no clear guidelines about what ratios are acceptable According

to Subedar (2005), the DoH specified a ratio of 1 RN/PN : 2 EN in a report of a national

Figure 2.1 Growth in SANC registers, 1996–2006

Source: Compiled from SANC (2007c)

40 60

growth and profile of the nursing profession

human resources task team, but the subsequent planning framework did not specify any ratio Hall and Erasmus (2003) identify the desired RN/PN to EN ratio for hospitals to be

1 : 3 Van Rensburg (2004) refers to a ‘desired’ ratio of registered nurse to sub-professional nurse (EN and ENA combined) of 1 : 3 the SANC registers and HST data show a ratio that

is nearly the reverse: 2.7 RN/PN : 1 EN in 2005 overall and 2.1 RN/PN : 1 EN in the public sector If one considers ENs and ENAs as sub-professionals combined, then the ratio of RN/PN to sub-professional overall is 1.08 : 1, which is an improvement but still not ideal

Subedar (2005) estimates that in order for South Africa to obtain the ratio recommended

by the DoH task team in 2004, the number of enrolled nurses would have to increase nearly sixfold However, as we show later in this monograph when presenting the estimates of shortage by various stakeholders, there is no consensus as to whether the country actually needs this many enrolled nurses or whether more professional/registered nurses are required

Profile of the profession

The profile of the South African nursing workforce has changed dramatically since its inception The profession remains largely female, although numbers of males are increasing in certain contexts About 60% of nurses, most of them African, work in the public sector, where they serve about 85% of the population The profession has high attrition levels (between enrolment at a training institution and graduation, as well as between graduation and registration), and the nursing workforce is ageing – about two-thirds of nurses are over the age of 40 In the following sections of this chapter we discuss these trends in greater depth

Gender

Figure 2.2 shows that, as in the past, the vast majority of nurses on SANC registers are female The highest concentration of males is at ENA level, where they form 9% of the total, in comparison with 8% of ENs and 6% of PNs/RNs These proportions could change

in future owing to increased numbers of men choosing to study for the four-year programme, a trend that is discussed below and in Chapter 5

Table 2.2 Proportions of different categories of nurses on SANC registers, 1996–2006

Source: Compiled from SANC (2007c)

Figure 2.2 Gender distribution of nursing staff by occupational category, 2006

Source: Compiled from SANC (2007c)

Figure 2.3 shows that there are greater proportions of men in the learner category of SANC registrations In 2006, 20% of those studying the four-year programme (student nurses, in SANC terminology) were males, compared with 12% of pupil auxiliaries and 11% of pupil nurses (studying to be ENs and ENAs respectively) In Chapter 5, we discuss possible reasons for this trend that were put forward by interviewees Briefly, they

suggested that males were attracted to the four-year programmes because of the sizeable bursaries offered and were not necessarily intending to stay in nursing permanently

Population group

We know from figures reported in DENOSA’s submission to the Truth and Reconciliation Commission (DENOSA 1997) that the numbers of African registered nurses increased nearly six times between 1960 and 1990, with their proportion of the workforce rising from barely one-fifth in 1960 to 42.7% in 1990 The numbers of coloured and Indian registered nurses increased eightfold, although from a much lower base By 1990 they formed 11.3% of the registered nursing workforce The numbers of white registered nurses increased by 81.9%, but their proportion of the total registered nurse workforce dropped from 74.5% to 46.0% (See Table 2.3.)

Thousands

Auxiliaries Enrolled Professional

Figure 2.3 Gender distribution of nursing staff learner category, 2006

Source: Compiled from SANC (2007c) Note: These totals are for enrolments, not graduates, and include those entering nursing for the first time but not those who are upgrading their qualifications through bridging programmes.

Thousands

Pupil auxiliaries Pupils Students

10 587

2 685

7 549 934

5 418 751

growth and profile of the nursing profession

Table 2.3 Numbers and percentages of registered nurses, 1960–1990

During the late 1980s we were instructed to remove reference to race from the Council register We lived to regret that decision later when the question of employment equity arose…Although we have tried to gather this data several times, most respondents just ignore the question or are highly offended by it and respond accordingly.10

We have to rely on HST figures for nurses in the public service to give us some sense of racial breakdown Table 2.4 shows that in 2006 about 83% of public sector nurses (of all categories) were African

Table 2.4 Racial distribution of nursing staff in the public sector by occupational category, 2006

historical educational privilege, white nurses are more likely to have been appointed to those jobs On the other hand those same educational advantages might also have enabled them to take greater opportunity of careers other than nursing that have opened

10 Personal communication, March 2008.

up to women in recent decades Unfortunately, without private sector data that disaggregate the workforce by race and gender, we are unable to address these questions satisfactorily.

In the education system, we are able to provide race figures only for university students

According to HEMIS data, in 2005, for all nursing degrees (including the generic undergraduate BCur programme and other bachelor degrees designed for students who are already registered nurses) 71% of enrolments were African, 11% coloured, 3% Indian and 15% white In the same year, the graduates for all these programmes were 68%

African, 9% coloured, 5% Indian and 19% white

The HEMIS figures confirm the predominantly African profile of professional nurses on the SANC register (see Table 2.4), although the proportion of Africans is lower among the university graduates than among the PN/RNs, and the proportion of whites much higher

This could indicate that while the degree is a popular route to PN/RN status for whites, Africans are reaching their very substantial majority on the PN/RN register by qualifying through the bridging programme However, without a racial breakdown of bridging programme figures it is impossible to establish this trend categorically

The figures for individual institutions indicate that the legacy of apartheid is lingering on

in the higher education system, in that the historically black (African) institutions (HBIs) (University of Limpopo, Walter Sisulu University, University of Venda, University of Fort Hare and University of Zululand) continue to be exclusively or almost entirely African

The University of the Western Cape (UWC), which was created under apartheid for the population classified ‘coloured’ but since the 1980s has also been home to many thousands of African students, continues to attract the most coloured enrolments

Historically the University of Pretoria has had the highest proportion of white enrolments and, although white numbers have generally dropped, there has been some growth at the universities of Pretoria, Johannesburg and Free State, North West University11 and Nelson Mandela Metropolitan University (DoE HEMIS data for 2006)

Age

According to the SANC 2006 data presented in Table 2.5, across all nursing categories the highest concentration of nurses is in the 40–49 year age group, amounting to one-third of South Africa’s nurses Most worrying is that nurses under 25 comprise scarcely 1% of the total nursing workforce, illustrating the small number of young nurses entering the profession, effectively turning nursing into an ageing workforce

Moreover, these nurses are entering and practising the profession mostly at auxiliary level

This trend would be justifiable if there were indications that these young nurses are planning to continue their studies and become PNs/RNs However, the very low proportions continue into the 25–29 and 30–34 age groups of PNs/RNs If most of South Africa’s professional nurses are nearing retirement age and presumably will leave the profession soon, and the nurses now entering and practising the profession are doing so mostly at the lower categories of nursing, then the country might be facing a dire shortage of professional nurses in future

11 Potchefstroom combined with North-West University

growth and profile of the nursing profession

Distribution of nurses

In South Africa there is a substantial maldistribution of health personnel across the rural–

urban and public–private divides Most health personnel (particularly doctors) are in the private urban sector, while the majority of the population depends on the public sector and some of the poorest and sickest are in the rural areas In this section we consider the distribution of nurses in the public and private sectors and then compare distribution across the various provinces of the country in terms of nurse-to-population ratios

The public–private divide

Table 2.6 draws on LFS data for 2001 and 2005 to distinguish firstly between those nurses

on the SANC register who are active and those who are not The table shows that approximately 18% of nurses registered with SANC (all professional categories) were not active, in both years The LFS data also enable us to show the divide within the active workforce between nurses in the public and private sectors: a 2.2% increase in numbers

of nurses in the private sector and a 2.2% decrease in numbers of nurses in the public sector According to these estimates, the proportions of public to private nurses have changed from 63 : 37 in 2001 to 60 : 40 in 2005

In gauging the impact of the public–private sector divide among nurses, we need to take into account the number of people who are dependent on each of these sectors We can

do this by considering the number of people who are medical aid beneficiaries and presuming that most of these beneficiaries rely on the private sector for their medical care Figures from the Council for Medical Schemes show that approximately 16% of the population was on a medical aid scheme in 2001, dropping to 15% in 2005 (Council for Medical Schemes 2001, 2006) At the same time the LFS data show that 37.3% of nurses were in the private sector in 2001, rising to 39.5% in 2005 (see Table 2.6) The 3% drop in medical aid beneficiaries is of particular concern given that (1) increasing numbers of

Table 2.5 Age distribution of nursing staff by occupational category, 2006

medical aid schemes are requiring members to make use of public services and (2) the number of nurses in the private sector has increased by 7% and the number in the public sector has decreased by 2% Table 2.7 provides the figures behind these trends

Table 2.7 Population of South Africa, nurses in public and private sectors, and medical aid

% of total active workforce N % of population

Source: Compiled from HST (2007); Stats SA (2001, 2005); Council for Medical Schemes (2006)

While Table 2.6 shows that approximately 60% of the nursing workforce is in the public sector, the ratio is less favourable when we consider the category of professional/

registered nurses The HST (2007: 310) reports that of the 99 534 PNs/RNs on the SANC register in 2005, only 43 660 (44%) were in the public sector

Nurses will soon be required to do one year’s remunerated community service in specified public health facilities after completing their four-year programmes Like the community service requirement for doctors, pharmacists and physiotherapists, community service for nursing is designed to increase provision in understaffed public facilities The implementation was planned initially to commence in January 2008, but this programme has received substantial resistance from students, and up to this point has not been entirely resolved (SANC 2008a,b)

Nurse-to-population ratios

When presenting a profile of a professional workforce, one ideally needs to know what proportions of professional to population are desirable International norms are a useful point of comparison, particularly those of countries in similar income and socio-economic brackets

The World Health Report 2006 (WHO 2006) argues that at least 2.5 healthcare

professionals (counting only doctors, nurses and midwives) per 1 000 population are

Table 2.6 Total registrations with SANC versus nurses in employment, 2001 and 2005

Year

Registered with SANC A

Active nurses (LFS) B

Registered with SANC but not active

C (A−B)

Active nurses (B) Public sector Private sector

Source: Compiled from SANC (2007c); Stats SA (2001, 2005)

growth and profile of the nursing profession

required to achieve a very basic minimum of health services There are 57 countries that fall below this threshold and are defined as having a critical shortage, 36 of them in sub-Saharan Africa; South Africa is not included among these countries (WHO 2006: 12)

Hall and Erasmus (2003: 540) referred to a WHO norm for nurses specifically of 200 nurses per 100 000 population (2 : 1 000) and found that in 2001 South Africa had a ratio

of 343 : 100 000, based on LFS data and population figures for that year Similar data for

2005 reveal a ratio of 336 : 100 000, which represents a decrease on the earlier figures

Thus, using this WHO minimum norm and taking into consideration only active nurses, there seems to be an adequate number of nurses for the South African population

However, this norm is a very low minimum and the countries that fall below it are among the poorest in the world One also needs to keep in mind the specific health needs in South Africa, including the demographics of disease in the country

The rural–urban divide

SANC provides figures that show provincial differences in nurse-to-population ratios and give a sense of the relative deprivation of rural areas Note, however, that SANC calculates nurse-to-population ratios based on its own lists of registered and enrolled nurses, which include nurses who are not in active service in the country According to SANC, in 2006 the nurse-to-population ratio was 1 : 241 nationally This translates into 414 : 100 000, which appears to be more favourable than the previous figure of 336 : 100 000, but again, the calculations are not confined to active nurses

SANC’s national ratio also conceals many regional disparities, which are depicted in Figure 2.4 According to SANC figures, the proportion of nurses in KwaZulu-Natal, Gauteng and the Western Cape is higher than these provinces’ proportions of the national population The Free State and the Northern Cape have roughly the same proportion of nurses as they do of population The Eastern Cape, Limpopo, North West and

Mpumalanga are all in a desperate situation, having an under-representation of nurses compared to their proportion of the population

It should be noted that while SANC has used the population-to-nurse ratio to make comparisons across provinces, in much international literature the ratio of nurse to 1 000 population is preferred (This is the measure we use later in this chapter when comparing South Africa’s nurse provision with international figures.) Thus, the figure of 241 : 1 for the country as a whole (public and private sectors together) translates into 4.15 nurses per

1 000 population in 2006 At the other extreme, considering professional nurses in the public sector only, there is less than 1 public sector professional nurse (0.9) to 1 000 public-sector-dependent population

Comparison with other countries

Another way to judge a nurse-to-population ratio is to compare it with ratios in other countries Table 2.8 provides nurse-per-1 000-population figures for 2004 (or thereabouts, depending on availability) and shows that South Africa compares favourably with

neighbouring countries, having 4.08 nurses per 1 000 population in 2004 Note that these figures refer to all nurses of all categories on the register in the year concerned

Table 2.8 Nurses in South Africa and neighbouring countries, various years

Figure 2.4 Comparison between nurse and population distribution, 2006

Source: Compiled from SANC (2007c)

growth and profile of the nursing profession

ratio of nurse to 1 000 population (4.08 in 2004 or 4.15 in 2006) falls between those of Greece and Portugal.12

In considering these ratios, we need to consider the particular needs of a country for nurses There are many factors that might lead to one country needing a higher ratio of nurses than is required by other countries Most prominent is the general state of health

of the nation With more than 5 million HIV-positive people in South Africa and an average life expectancy of 48 years, there is little doubt that the country needs many nurses The availability of other health personnel, particularly doctors, is another

12 It is not clear from the WHO report whether the figures are confined to nurses in active employment and whether they are registered/professional nurses only or from all categories If they reflect only active registered/professional nurses, then South Africa’s ratio compares even less favourably, as it includes all nurses on the SANC register, including inactive nurses and those at the lower levels of EN and ENA.

Table 2.9 Nurses in OECD countries, various years

Source: Compiled from WHO (2007)

important consideration South Africa has a very low doctor-to-population ratio (7.7 per

10 000), which places an extra burden on other health personnel, in particular nurses

This does not mean, however, that developed countries are not in need of nurses

Norway, with its 14.84 nurses and 3.4 doctors per 1 000 population, may need many health professionals for different reasons With a life expectancy of 80 years (WHO 2006), Norway has many older people who might be in hospital for long periods of time and need nurses to look after them

Conclusion

The quantitative analysis presented in this chapter provides the following broad profile of the nursing profession in South Africa Firstly, it is predominantly female, although male numbers are beginning to increase It is also an ageing profession, with about two-thirds

of nurses above the age of 40 About 60% of nurses are working in the public sector, where they serve approximately 85% of the population We do not have a racial breakdown of nurses in the private sector, so it is difficult to provide an overall view of the racial composition of the nursing workforce However, we do know from PERSAL figures that 83% of those in the public service are African, and it is widely presumed that Africans form the majority of nurses overall Numbers and proportions of white nurses appear to have diminished quite drastically

Professional nurses formed 51% of the nurse workforce in 2006, compared with 29%

enrolled nurses and 21% nursing auxiliaries in the same year This could be an outcome

of the professionalising process that has emphasised the attainment of nursing degrees and four-year diplomas It could also be the result of the bridging programme that has enabled many enrolled nurses to upgrade their qualifications and become registered nurses Whether this is a favourable ratio is debatable Available estimations suggest that for South Africa the number of ENs and ENAs together should be double that of PNs/RNs, rather than roughly on a par However, there are also views that South Africa needs more professional nurses, especially if they are to play a greater role in the administration of antiretrovirals (ARVs)

South Africa’s nurse-to-population ratio is favourable compared to neighbouring countries (which are among the poorest in the world), but the country is very undersupplied when compared to developed countries, including those that recruit nurses from South Africa

The nurse-to-population ratio is most favourable in the highly urbanised provinces of Gauteng, Western Cape and KwaZulu-Natal, in that order, and least favourable in the most rural and poorest provinces of Limpopo, Mpumalanga and North West The situation

is exacerbated by the shortage of doctors, particularly in the public and rural sectors

Only 40% of South Africa’s doctors work in the public sector, and so few work in rural areas that the government imports doctors to shore up rural services

Whether South Africa has a shortage or a maldistribution of nurses has been a topic of

debate rooted in the lack of appropriate benchmarks for health human resources In the next chapter we consider the arguments on both sides of this debate, and come to the conclusion that, in terms of population norms that are more reasonable than those commonly propounded, nurses are indeed in short supply in the country

CHaPter 3

The demand for nurses

I think the major issue in the nursing profession in this country is definitely the shortage of nurses (Interview with Thembeka Gwagwa, general secretary, DENOSA)

South Africa, like any other developing country, [is] faced with a gross shortage

of health professionals, but above all, nurses And with that problem we foresee that we’ll not be able to realise our vision for a better life for all

(Interview with Isaac Zulu, national nurses’ coordinator for NEHAWU)

If one asks leading figures in South Africa’s nursing profession what they think is the major issue facing the profession today, the chances are very high that they will say ‘the shortage of nurses’ This view is backed by many academic researchers and has been cited frequently in the press The shortage is seen as part of a global shortage of health personnel

Despite the widespread assertion that there is a shortage of nurses in South Africa, there

is a lack of consensus about the extent of the shortage and the category of nurse the country needs most The tools used by government to assess shortage in the profession

do not seem to be based on a comprehensive assessment of demand that takes account

of different areas of nursing, skills levels and specialisations In this chapter we consider some of the assessments of shortage by various departments and statutory bodies, an analysis of job vacancies that was conducted by the HSRC and the projected increase in demand arising from the HIV/AIDS pandemic

Who says there is a shortage?

According to many different sources, there is an international shortage of health workers (Dal Poz et al 2006; Simoens et al 2005; WHO 2006) The WHO has estimated an international shortage of more than 4 million ‘doctors, nurses, midwives and others’

(WHO 2006: 11) Scholarly studies and media sources citing a nursing shortage in South Africa are abundant (Hall & Erasmus 2003; McGrath & McGrath 2004; Woolard et al

2003).13 Similar assertions are also made by stakeholders in the field, including SANC and DENOSA

According to Hasina Subedar, registrar of the SANC, there are shortages of nurses in

general in South Africa, as well as particular shortages at the professional nurse level

However, she believes it is ‘very difficult to quantify if there is a shortage or not…The only way you can…is if the health services identify what is their need.’14 Unfortunately, there have been many different and conflicting estimates of need, and the National Human Resources for Health Planning Framework (hereafter referred to as the NHR Plan) (DoH 2006) has not provided clarity

13 For media sources, see, for example, ‘More doctors, nurses needed in Aids fight’, Mail & Guardian Online, 16 August 2006, accessed 9 July 2007, http://www.mg.co.za; ‘More needed to win Aids war’, News 24, 24 May 2007,

accessed 9 July 2008, http://www.news24.com.

14 Interview

The NHR Plan states that traditionally staffing levels have been determined by using ratio statements described as norms and standards It does not specify what those norms and standards are in relation to the health professions but criticises this approach for failing to take account of the demographics of disease The plan suggests the need for a new approach to determine the staffing of health facilities but does not specify how this should be done Nonetheless, the NHR Plan does identify a shortage of health personnel (in general and in the public sector particularly) and the inequitable skills distribution between urban and rural areas as key challenges for the South African health sector

On nursing specifically, the report asserts that ‘South African nursing has increasingly been described as experiencing a serious crisis’ with ‘a reported decline in nursing care’

in general and in public health facilities particularly (DoH 2006: 65) The plan provides rough figures for ‘current’ (presumably 2005 or 2006) annual national production of the three different categories of nurses – PNs, ENs and ENAs – and proposes increases in annual production of 58%, 60% and 52% respectively, bringing the proposed annual national production of PNs to 3 000 by 2011, ENs to 8 000 by 2008 and ENAs to 10 000

by 2008 This would increase total annual production of nurses to 21 000, a 56% increase

on the DoH’s estimate of current production and an even larger increase when compared with our own more specific figures (Analysis of SANC registers indicates that an increase

of 63% would be necessary to bring the 2005 production of 12 837 nurses to 21 000.) Table 3.1 sets out the specific targets outlined by the DoH

Table 3.1 Department of Health targets for the production of nurses, by category

Nursing category Duration of training Location of training Current annual national production (N) national productionProposed annual

Source: DoH (2006: 60)

What this plan does not seem to take into explicit account is the impact of HIV/AIDS and

associated treatment and management needs The subsequent HIV and AIDS and STI

Strategic Plan for South Africa, 2007–2011 (DoH 2007b), on the other hand, has less than

one page out of 133 pages on human resource needs This document states thatthe major threat to the implementation of the NSP’s [National Strategic Plan’s]

interventions…is the unavailability of skilled personnel Human resource shortages, however, are not a justification for paralysis South Africa has already found innovative ways to mobilise local communities for the provision of services (2007b: 121)

It then proceeds to recommend ‘task shifting’ (the delegation of activities to less qualified staff) as one means of addressing the issue

The earlier Operational Plan for Comprehensive HIV and AIDS Care, Management and

Treatment for South Africa, however, indicated ‘significant shortages of professional

nurses, medical officers, lay counsellors, and managerial/administrative personnel’ (DoH 2003: 103) It estimated that for the effective care, treatment and management of HIV and