A profession in peril? Revitalising nursing 9 in South Africa Authors: Laetitia Rispeli Judith Bruceii he chapter provides an analytical perspective on nurses and nursing in South The challenges faced by Africa, and the critical issues to be addressed by health policy-makers and nurses and the nursing T practitioners in order to revitalise the profession. The chapter draws on the research findings of a four-year research programme known as Research on the profession include State of Nursing (RESON), which aimed to develop and strengthen the research weaknesses in the policy evidence for improved nursing policy development and practice in South Africa. capacity of the main The evidence shows that nursing is a profession in peril, which requires major attention and revitalisation. The challenges faced by nurses and the nursing profession include institutions responsible for the weaknesses in the policy capacity of the main institutions responsible for the leadership leadership and governance and governance of nursing in South Africa, and a nursing practice environment that is fraught with resource, management and quality of care problems. The practice of nursing in South Africa, environment is also influenced directly by agency work and moonlighting, which in and a nursing practice turn contribute to poor staying power, low energy levels, abuse of leave, sub-optimal environment that is fraught nursing care, split loyalties and accountability, and erosion of professionalism. Revitalising nursing requires concerted efforts by government and key stakeholders with resource, management to improve and modernise resources for a positive work environment. quality of care problems. A major crisis is looming unless issues of curriculum quality and relevance, nurse educator quality, educational resources, and governance of nursing education are addressed. This means that nursing education reforms must be implemented without further delay. There must be high-level investment in preparing nurses for and in practice through appropriate training that emphasises ethical value systems and social accountability, adequate staffing in different healthcare settings, and enabling work environments. South Africa’s quest for universal health coverage to improve population health and achieve equity and social justice cannot be achieved unless these issues are confronted. i Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg ii School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 117 Introduction Human Resources for Health (HRH) are critical to health systems 44 780 in the public health sector.10 This suggests a severe shortage development and functioning, and to patient and population of professional nurses across all healthcare services. Existing SANC health outcomes.1 Nurses in South Africa, as elsewhere, make information also shows a decrease in the production of nurses with up the largest single group of health service providers and their specialist qualifications, particularly clinical specialisations.2 The role in promoting health and providing essential health services is new health sector reform policies will further increase the demand undisputed.2 The country has three categories of nurses: professional for professional nurses with specialised skills. For example, nurses (registered) nurses with four years of training; enrolled nurses with are envisaged to play a key role in the re-engineering of primary two years of training; and nursing assistants or auxiliaries with one health care (PHC), specifically the community-based (Ward-based) year of training. The majority of professional (registered) nurses Outreach Teams, School Health Services and District Clinical are also midwives, and the terms ‘nurse’ and ‘midwife’ are used Specialist Teams. The 2011 government Green Paper on National interchangeably in the Nursing Act.3 In contrast, in high-income Health Insurance (NHI)11 lays the foundation for health system countries such as Australia, Canada, the United Kingdom and reforms towards universal coverage, with PHC as the core of the the United States of America (USA), midwifery is regarded as a proposed reforms. At the same time, the absence of national norms profession distinct from nursing, and nursing and midwifery require and standards makes it difficult to determine the real shortage and separate training programmes.4 Direct-entry midwifery is legally the number of nurses required of all categories.12 recognised in 29 states in the USA and is currently being debated Although nurses are more equitably distributed between urban and (and hotly contested) in South Africa. Table 1 shows the numerical rural areas compared to other health professional categories (e.g. dominance of nurses when examined against the total number of doctors), the gross maldistribution between urban and rural areas is filled posts of health professionals in the South African public health illustrated by the fact that in 2014, the urban provinces of Gauteng sector in 2014.5 and Western Cape combined produced 1 234 professional nurses, As can be seen from Table 1, in 2014, 76.8% of all health pro- compared to the three rural provinces of Limpopo, North West and fessionals in the public sector (excluding general assistants) were Northern Cape combined that produced 501 professional nurses.8 nurses of all categories: 38.7% were professional nurses; 17.7% Another challenge is an ageing nursing workforce. The current were enrolled nurses; and 20.4% were nursing assistants. national nursing strategy indicates that 43.7% of professional nurses However, the country faces a ‘nursing crisis’, characterised by are over 50 years of age.2 This was borne out by a large survey shortages, declining interest in the profession, lack of a caring ethos, which found that the average age of participants was 41.5 years.13 and an apparent disjuncture between the needs of nurses on the one The context of this nursing crisis is South Africa’s quadruple hand and those of communities served on the other hand.6,7 disease burden,14 the multiplicity of health sector reforms,15 gender Statistics from the South African Nursing Council (SANC) illustrate stratification, and the existence of strong professional silos and that the existing outputs of nursing education institutions do not hierarchies.16 Progress towards universal health coverage (UHC) in match the health and service demands for nurses and midwives.8,9 South Africa, which aims to ensure that everyone is able to access In 2010, 3 595 professional nurses with four years of training the healthcare services they need irrespective of their ability to pay,17 registered with the SANC.8,9 In the same year, the National is therefore dependent on addressing these nursing challenges. Department of Health estimated a professional nurse shortage of Table 1: Number of filled health professional posts in the South African public health sector, 2014 Category EC FS GP KZN LP MP NC NW WC ZA % Clinical associates 71 5 39 28 9 26 4 39 221 0.1 Dental practitioners 122 74 247 128 156 108 33 61 126 1 056 0.6 Dental specialists 1 116 1 4 1 32 155 0.1 Dental therapists 9 2 41 117 87 23 9 16 2 306 0.2 Enrolled nurses 3 124 839 6 262 10 784 4 189 1 769 220 909 2 474 30 571 17.7 Environmental health practitioners 50 85 153 174 151 153 32 43 4 850 0.5 Medical practitioners 1 489 716 3 184 3 537 1 185 875 419 627 1 541 13 593 7.9 Medical researchers 8 20 9 3 1 34 103 0.1 Medical specialists 170 328 1 868 791 92 70 29 117 1 423 4 893 2.8 Nursing assistants 5 399 2 098 6 664 6 251 5 125 1 752 916 2 853 4 089 35 147 20.4 Occupational therapists 120 76 306 210 197 95 56 49 141 1 250 0.7 Pharmacists 408 297 1 052 722 436 268 135 233 880 4 516 2.6 Physiotherapists 145 68 200 299 160 88 59 73 147 1 239 0.7 Professional nurses 10 008 2 435 12 171 16 126 9 093 5 049 1 332 4 494 5 130 66 711 38.7 Psychologists 62 36 232 115 101 35 17 48 86 1 213 0.7 Radiographers 344 186 676 568 167 116 100 120 456 2 735 1.6 Student nurses 258 4 233 1 815 443 765 234 7 748 4.5 Public sector (filled) 21 779 7 254 37 464 41 675 21 598 11 192 3 363 9 916 16 565 172 307 100.0 Source: Day, 2015.5 118 SAHR 2014/15 Revitalising nursing in South Africa 9 This chapter provides an analytical perspective on nurses and nursing training and practice.12 There is also a well-established system in South Africa, and the critical issues that need to be addressed of regulation and accreditation of nursing education through the by health policy-makers and practitioners in order to revitalise the SANC.12 However, with respect to health workforce planning and profession. These issues are: nursing education reforms; enhancing governance, policy and funding, key informants criticised the lack of the participation of nurses in policy-making; casualisation of the national staffing norms, sub-optimal governance by both the SANC nursing profession; ethics; quality of care; and the work experiences and the National Department of Health, and poor co-operation of nursing managers at primary health care clinics. between key government departments, notably Health and Higher Education. They pointed out that education transformation is The chapter draws on the research findings of a four-year research difficult when SANC as the regulatory body is largely dysfunctional programme, known as Research on the State of Nursing (RESON).18 and provides sub-optimal leadership in policy development and The research aimed to develop and strengthen the research evidence implementation.12 The study also found gaps in the building blocks for improved nursing policy development and practice in South focusing on national standards on accreditation, regulation, and Africa.18 Different methodologies were used to collect the data, qualifications, and curricula and faculty (staff).12 Key informants ranging from the use of reflective diaries to large-scale surveys.