The nursing profession in South Africa is facing significant challenges around education, staffing and regulation. The national department of health has been working to provide the country with staffing norms for the past five years, but continues to miss the final mark. There is a shortage of registered nurses, a critical shortage of specialist nurses and there is the possibility that training may not even be possible thanks to a sudden stall by the department in implementing new legislation.
South Africa has undergone a wide array of legislative and policy changes over the past few years, introducing both revised and entirely new policies as part of the Nursing Education, Training and Practice Strategy that demand specific competencies for nurses and legislative changes for a revised scope of practice in education and training programmes. This is further complicated by the fact that all nursing programmes are now based in the higher education sphere, which places nursing on par with the other health professions within a single educational system.
“No change process is without its challenges,” says Nelouise Geyer, chief executive of the Nursing Education Association. “Challenges of the transition [are] that the public nursing colleges, producing 80% of the graduates, need more time to fulfil the criteria in order to be accredited as higher education institutions. There is also slow progress with the higher education accreditation of nursing programmes, as of those submitted, the majority have not been accredited.”
Considering that 2019 is the date set for the phasing out of current programmes, the achingly slow submission of new programmes is a pressing concern.
“The country is heading for a disaster,” says Dr Sue Armstrong, senior lecturer at the department of nursing education at the University of the Witwatersrand. “Compounding the issues around shortages, staffing norms and legislation is that the new category of staff nurse, which will assist in supporting the registered nurses to a significant degree, cannot be trained because of delays in the implementation of new legislation. We have a big problem in that nursing education was moved into the higher education bands in order to align nursing education with the National Qualifications Framework. This in itself was welcome, but it impacts on the nursing colleges that produce the majority of registered nurses. They need to move to [reach] a national competency, but the government has delayed in effecting these changes.”
The South African Nursing Education Stakeholders, in their positioning document on public nursing colleges in higher education, point out that the developments in the education landscape since 2008 mean that current legislative frameworks see nursing education as a national competence administered by the department of higher education and learning. However, public nursing colleges, like many other institutions that offer nursing education programmes, are in a position where they cannot meet the new requirements – and cannot continue to provide nursing education programmes after 2016.
“The Council for Higher Education and the South African Nursing Council (SANC) will both be required to accredit nursing education institutions in the future,” says Armstrong. “Even if the government managed to sort out the positioning of the nursing colleges in a hurry, the problem remains that few, if any, of the existing nursing colleges meet the requirements of the Higher Education Quality Committee (HEQC), and the curricula that the SANC gave provisional approval to were rejected by the HEQC, which indicates a discrepancy in standards.
“The private nursing colleges have been training their own staff and contributing greatly to nursing numbers, but they are now prevented from training new nurses until the legislative problems are resolved.”
For the nursing institution there are two ways in which they can become a higher education institution — autonomously, or through an agency agreement with an organisation that is already accredited. The former could result in lengthy and costly procedures — the nursing colleges jump through as many fill-out-in-triplicate hoops as the government can find. The latter would be a more seamless solution, as it would allow for nurse to continue being trained with minimal impact from June 2015, but would undergo as time-consuming a process to see it come to fruition.
South Africa’s burden of disease
In addition to this, the burden of disease in South Africa – HIV, tuberculosis, maternal and child mortality, non-communicable disease and injury – has changed patient profiles and therefore the educational needs of those who provide their care.
“The quadruple burden of disease has brought about the need to prepare nurses with a different skill set than in the past,” says Geyer. “So one of the most important trends impacting nursing education today is possibly that it must produce more nurses, with different competencies, to meet the healthcare needs of the population.”
The latter challenge was outlined in the National Strategic Plan for Nurse Education, Training and Practice, which runs until 2017 and also saw the minister of health commit to the reconstruction and revitalisation of the nursing profession in South Africa. The strategic plan also found that there were several distinct, problematic themes impacting the nursing profession: nursing education and training, resources in nursing, professional ethos and ethics, governance leadership, legislation and policy, positive practice environments, compensation, benefits and conditions of employment, and nursing human resources for health. The findings of the report and the recommended courses of action accurately reflect the concerns of the nursing profession.
“In years long past, the basic nursing diploma was three years in general nursing based at a nursing college in a training hospital,” says Dave Woods, emeritus associate professor of neonatal medicine at the University of Cape Town’s school of child and adolescent health. “It was practical, being in the ward from day one, and produced confident, caring and capable nurses. They earned a small stipend from the start and a further year could be done in midwifery, psychiatry or community nursing, after which they were very competent indeed. Then the course was changed to four years at a university or university-linked college. There was very little practical exposure and all three specialities were included in the four years. The result has been an expensive theoretical training, with nurses often having little confidence, a poor attitude towards work and many leaving the profession.”
Woods points out that currently the continuing education tends to be done off-site at a centralised teaching hospital; it’s mainly theoretical and doesn’t meet the real needs of rural areas. Many nurses cannot be released for courses, as these are expensive and include travel, accommodation, tutors and more. The result is little improvement in healthcare.
Elsamari Botha, academic convenor of Educate24, adds: “In principle, national curriculum plans for degrees and certificates is a great way to make sure that everybody gets taught the same skills in a particular vocation, and that these skills are up to date. To be able to further standardise the education, these courses, degrees and certificates were housed in either universities or technikons. However, with the resource challenges that these institutions are facing, the distinction between these institutions has become blurred. The result is that they now teach very similar programmes and students gain very little hands-on experience. This leaves a massive gap to fill in terms of getting employees ‘job ready’.”
In addition the basic schooling system is failing to produce students able to cope with the demands of the nursing curriculum.
“This has resulted in a high attrition rate and the average time taken to finish, for those who are successful, is 4.5 years instead of the four years it should take,” says Armstrong. “In some nursing education institutions the attrition rate is up to 50% and, as nurses are paid during their training at public nursing colleges, many apply to become nurses as they are seemingly attracted by the free education and salary. As a result, nursing is often viewed as a poverty alleviation scheme, rather than [as] a system to educate professional people.”
The nursing education system faces a number of challenges that could potentially see the sector undergo significant changes, many not for the greater good. While the shift to higher education places the nursing profession into a well-deserved and more prestigious space, there is an urgent need to resolve the accreditation, legislation and education issues before it can achieve its ultimate goals.
The current state of nursing
The department of health’s Strategic Plan: Nursing Education, Training & Practice 2012/13 – 2016/17 outlined a wide array of reforms in the field of nursing, but many of these do not seem to have made much of an impact on the ground.
The department’s intention to overhaul nursing education and training has been most obvious in nursing now being considered to be a higher educational qualification. The intention behind this move was to improve the quality of training, ensure universal norms and standards are followed, and clamp down on disreputable nursing schools.
Apart from this, the Strategic Plan highlights six other areas of concern for the field:
Nurses need better resources to perform their duties well, and the interests of nurses should be better represented at all levels of government.
· Professional ethos
Nursing is a caring profession, and nurses need training and support in being ethical and diligent.
· Governance, leadership, legislation and policy
The South African Nursing Council needs support in exercising its mandate, and community health workers require improved regulation.
· Positive practice environments
Nurses in South Africa cannot always perform at their best as a result of staff shortages, high workloads, a lack of equipment and unsafe working conditions.
· Compensation, benefits and conditions of employment
Nurses need to feel motivated and appreciated to do good work, and above all, their work environment needs to meet the basic conditions of employment.
· Nursing human resources for health
Many nurses have left the profession, and especially the public health service, and it needs to be made more attractive as a career.