/ 1 June 2021

Employing more nurses can reduce total health costs

Gauteng Department Of Health Unveils Charlotte Maxeke Johannesburg Academic Hospital's Icu Ward In South Africa
In the ever-evolving landscape of global health, two crucial aspects often overlooked are how gender plays out in care-giving and in decision-making. In the context of World Social Justice Day on February 20, I have tried to unknot this conundrum: gender justice lies at the foundation of health justice which lies at the foundation of social justice. Are we doing enough in either of the first two spaces to win the fight ahead in the third? It should be no surprise to anyone that periods, pregnancy and childbirth aside, the mere fact of being a woman has profound consequences for one's health. In a country such as South Africa (as with so many other countries worldwide) gendered power dynamics, status and societal roles are key to a woman's care-seeking behaviour, her experience of care and health outcomes. Before a woman even reaches a facility, factors such as education, economic power and traditional roles mean that there is a high likelihood that she has avoided essential care she should have had earlier in her health journey and her diagnosis, when given, will be late. And while we would love to think that the gender barrier ends there, studies have shown that bias is pervasive in clinical care. This results in knowledge gaps regarding the presentation and treatment of health conditions in women compared to men because healthcare workers, regardless of gender, are more familiar with how they present symptomatically in men and with treatment protocols for the male body. And it doesn’t end there. When it comes to medical research, scientific bias is towards males to the extent that research into female health is all but neglected. Distressingly, this manifests in the serious abuse and neglect of women at every stage in the healthcare system due to the dismissal of their concerns. A prime and anger-inducing example is the medical studies into how male partners are impacted by the debilitating gynaecological condition endometriosis. Endometriosis is an often misdiagnosed condition that affects approximately 10% of women (although this is probably an underestimate). Treatment is symptomatic and there is no cure. Regularly, patients report that their symptoms are dismissed at various stages in the healthcare system before they finally receive a diagnosis. This is something I relate to from personal experience. I was diagnosed with endometriosis at the age of 32 after 20 years of misdiagnoses. Surely a better focus for research funding would be improving diagnostics and treatment for endometriosis sufferers? Given the uproar over the studies that prioritise the wellbeing of men over the women who directly suffer due to the condition, it appears I am not the only person to think so. While this anger in no way negates the need for holistic approaches to health conditions and an understanding of the impact of health and disease on support systems, the prioritisation of men in conditions primarily impacting women, that are still so poorly understood in how they impact women, warrants closer scrutiny. Which brings me to my current workspace — global policy and advocacy. In recent meetings about North-South health collaboration, it was impossible not to notice that the Global North team members were predominantly white men, while those from the Global South were predominantly women of colour. While women make up a significant portion of the health workforce, again due to predominant narratives around nurturing and care-giving, this proportionality diminishes in management and leadership positions. Out of the 66% of women occupying entry-level roles, less than half progress to C-Suite level. Why? Again — periods, pregnancy and childbirth, as well as gendered power dynamics, status and societal roles. This time, coalescing in the lack of workplace policies for women and biased hiring and employment practices. Why should we care? Because in order to ensure social justice, we need the very people we’re making decisions for to start being represented in decision-making spaces. In South Africa’s healthcare system, these are the frontline health workers in primary healthcare spaces. We need to be turning to them for realistic ideas on how women’s health should be addressed. It is these women healthcare workers who will advocate for the endometriosis sufferer over, or alongside, their partner. And who will understand the intersectional complexity of being a woman — whether in need or in charge. The clock is ticking. Addressing gender inequities in South Africa’s health system is not just about justice; it's about saving lives and shaping a healthier future. And if we cannot ensure that women are adequately represented in a female-dominated field, what hope do we have for other sectors? Dr Atiya Mosam is an independent public health medical specialist with experience in health system strengthening initiatives from national policy development to health management and implementation of interventions. She is also an honorary lecturer at the University of the Witwatersrand’s School of Public Health; chair of the InterAcademy Partnership Young Physician Leaders Alumni Committee and a member of the World Health Organisation’s Roadmap for the Public Health and Emergency Workforce. (Photo by Sharon Seretlo/Gallo Images via Getty Images)

A recent study published in The Lancet medical journal suggests that employing more nurses can result in cost savings double the cost of employing the additional nurses. The study was conducted in Australia but may well have important implications for nursing in South Africa.

The study, conducted across 55 hospitals in Queensland, suggests that a recent state policy to introduce a minimum ratio of one nurse to four patients for day shifts has successfully improved patient care, with a 7% drop in the chance of death and readmission and a 3% reduction in the length of stay for every one less patient a nurse has in their workload. It is these reductions in readmissions and the length of hospital stays that resulted in the cost savings.

The study compared 27 hospitals where the policy was implemented with 28 hospitals where it was not implemented.

“Despite some evidence that more nurses in hospitals could benefit patient safety, similar policies have not been widely implemented across the globe, partly due to an absence of data on the long-term effects and costs, as well as limited resources,” read a press release from The Lancet.

“Our findings plug a crucial data gap that has delayed a widespread roll-out of nurse staffing mandates. Opponents of these policies often raise concerns that there is no clear evaluation of policy, so we hope that our data convince people of the need for minimum nurse-to-patient ratios by clearly demonstrating that quality nursing is vital to patient safety and care,” said Matthew McHugh, a professor at the University of the Pennsylvania School of Nursing in the United States and lead author of the study.

Similar in SA?

While we are not aware of similar research in South Africa, it seems plausible that meeting minimum nursing ratios here too could result in substantial cost-savings – through fewer readmissions and shorter hospital stays as observed in Australia, but potentially also by reducing the number of medico-legal claims against the government. 

“Nurses offer a comprehensive service package in preventing diseases, promoting health, curing diseases and rehabilitative services. Healthcare costs will therefore be greatly reduced if more nurses were employed, especially with the revitalisation of primary healthcare and strengthening of community-based healthcare services,” says Khaya Xaba, spokesperson for the National Education, Health and Allied Workers’ Union. He adds that staff shortages in the nursing profession impact directly and negatively on the quality of nursing care and the delivery of quality healthcare services to healthcare users.

Rich Sicina, a paediatric nurse and general secretary of the Young Nurses Indaba Trade Union, agrees that readmissions are an avoidable problem.

“Where I work, it’s like they take turns to use the bed, two weeks in and two weeks out. Patients are in and out because we can’t look after them thoroughly. Patients are discharged not because they are better, but [because] they have to open space for the next patient who is worse at that time. The system now forces nurses to choose who will be given more care and who will not. With this kind of care, we can only see more and more readmissions. All this can be avoided if there were more nurses,” he says, adding that most nurses, deep down, know that most of the deaths could have been avoided if there were more of them.

The big picture

That the world needs more nurses is not news. In its State of the World’s Nursing report, the World Health Organization (WHO) estimates there was a global shortage of 5.9 million nurses in 2018, a slight improvement from the 6.6 million shortage in 2016.

In South Africa, according to the 2030 “Human Resources for Health” strategy, there were 71 707 professional nurses, 31 039 enrolled nurses and 33 821 nursing assistants by 2019. The report further states that the density for all nurses combined is 282 per 100 000. A South African Nursing Council (SANC) report shows a slight decrease in the number of nurses in 2020.

According to the SANC, in 2020 there was one nurse (registered, enrolled or auxiliary nurse) for every 213 people in the country in both the public and private sector – a far cry from Australia’s one nurse for every four patients per shift. The pressures are especially high in the Northern Cape, with one nurse for every 350 people, and in Mpumalanga, which had one nurse for every 313 people. 

Melanie Alperstein, steering committee member of the People’s Health Movement, says it has been well established that the number of nurses is way below the number needed. This, she says, impacts the work to be done as nurses are then overloaded with the amount of work they need to do.

“Mistakes may be made. It is difficult to be caring and compassionate, and nursing care cannot be at the standard that nurses would like. Anxiety increases and affects the mental wellbeing of the nurses due to overload and not being able to practise in the way that needs to be done to meet patient safety and needs,” she says.

“Health budget cuts are one aspect outside of the profession and affect the number of all health workers needed for the country to be at an optimal level. Posts are frozen and qualified nurses are sitting at home without work. An example of this was the extra nurses employed in the Eastern Cape for a temporary period during Covid-19. 

“There are more qualified nurses that could be employed, but budget cuts and possible bureaucracy have prevented this,” says Alperstein, adding that factors within nursing that need attention relate to policy, leadership, education, systemic fault lines in the health system such as stock-outs of supplies, crumbling and inadequate infrastructure, and therefore poor working conditions as well as low pay.

‘Silent moratorium’

Democratic Nursing Organisation of South Africa spokesperson Sibongiseni Delihlazo says the number of nurses in the country’s healthcare system is extremely low. He says the vacancy rate is very high, and what’s even worse is that even the funded positions no longer get filled as the government tries to reduce the so-called bloated public sector wage bill, including in the health sector.

“Contributing to non-filling of vacant posts is the silent moratorium in provinces [on] filling vacant positions. This is costing the healthcare system severely because it lowers its effectiveness in fighting community infections and illnesses. It also leads to work overload and staff burnout, depression and anxiety among healthcare workers who are overworked,” he says.

Delihlazo fears that this was the case even before the Covid-19 pandemic.

“Fortunately for the country, there are still nurses that are available for employment who are sitting at home and not willing to go abroad like others. These are nurses who, mostly, have been funded by the government for their studies. But they are never employed, and the government would have wasted its own investment in human resources because over time they would have to let them go find work elsewhere,” he says.

Sicina says there is a gross shortage of staff. Where he works, he is the only professional nurse. He works with an enrolled nurse and two enrolled nurse assistants. “We look after about 45 kids in a ward at [any] given time. Ideally, we should be 12. Imagine the chaos in the hospital because there are gross shortages of staff. Nurses have to make sure that those that go to theatre are ready for theatre, those that need a scan are ready for a scan, and those that need drips are [having them] inserted. 

“But we can’t do it all, because the number of patients outnumbers the nurses. There are mistakes made and some people die because a nurse noticed the dropping of all vital signs late and he or she was busy giving medication to other patients, or preparing another patient for a procedure. When you see there is something wrong with another patient, it is too late to do anything,” he says. 

Change of curriculum

Xaba says the change in the nursing curriculum informed by the phasing out of legacy nursing programmes and introducing new nursing qualifications has resulted in almost six years in which no new nurses were produced.

“Producing fewer specialised nurses results in fewer skilled nursing professionals to respond adequately to the health needs,” he says. “Also, the accreditation of nursing education institutions has been rather slow progress and few nursing colleges have been able to provide new training programmes.” 

Sicina echoes this and adds that with an intake of about 200 students across all the colleges in Gauteng, there is no way that the country will be able to produce enough nurses at this rate.

“The change of the curriculum has messed up things. What is an intake of 200 students for all the colleges? Even if that is the intake number, it doesn’t mean all 200 will graduate. Nursing is tough and most of the students study while working and it becomes too much and they drop out. Even worse, with this new curriculum, universities are not taking in students because they can’t teach this new curriculum.

We need to increase the intake and produce more nurses,” he says, adding that with his intake in 2009, there were 356 students starting the course but fewer than 200 graduated. Many fell in love with the idea of being a nurse but the real work was tough, hence not everyone graduated.

The SANC had not responded to questions from Spotlight by the time of publishing. However, in a statement, Sizo Mchunu, SANC registrar and chief executive, said: “As the statutory body, the SANC is committed to assist in ensuring the production of competent nurse practitioners who will provide scientific, comprehensive and quality nursing to patients, families and communities within the legal and ethical framework. It is vital that the country trains enough nurse practitioners to replace those retiring so that the country continues to deliver quality care.”

During the SANC’s presentation at the National Health Insurance public hearings in Parliament recently, Mchunu, when pressed about nursing shortages, reminded the members that the SANC is not an employer but can support the government. The SANC, she says, is doing important legwork in raising awareness and providing information on nursing as a profession.

Do more to produce more

Delihlazo says the capacity of universities and colleges should be increased to ensure that we produce enough nurses as a country. “[The] WHO together with [the] International Council of Nurses last year on 7 April released a report on the State of World Nursing where it indicated that for every country to avoid crisis levels in terms of a severe shortage of nurses by the year 2030, each country must increase the intake of its nursing production each year by at least 8%. If not, then the world is likely to experience a global shortage of 10 million nurses by 2030. South Africa is not going according to this advice – in fact, it is going completely against it.”

Xaba says the inability to provide mentorship to nursing students impacts the quality of nursing cadres currently being produced. 

“[There is] inequitable skills distribution because the training of nurses has also been reduced as a result of staffing shortages. Nurses are overburdened due to increased workloads, contributing to negligence, high absenteeism and low staff morale. Therefore, this results in sub-optimal care rendered to patients and clients and high litigation rates, which impact on the scarce budget currently allocated to the health sector.”

Alperstein says nurses are not given respect and appreciation for the work they do. “Transforming nursing education has not been given the resources and urgency it needs in comparison with medical education transformation. 

“Both medical and nursing education still focus on disease and illness, instead of how to deliver a comprehensive primary healthcare service through interdisciplinary health teams and intersectoral collaboration within communities [and] with community structures to deal with the social determinants of health that cause the increased burden of disease in the first place,” she says, adding that all these issues need to be tackled to improve the nursing profession.

*This article was first published in Spotlight and published off New Frame