Unfortunately, your trial period has expired! Please buy a license if you want to continue using it.

Transforming nursing in South Africa

Johannesburg, 12 May 2015 -Nearly 80 nursing stakeholders attended the launch of the special edition of Global Health Action on “Transforming Nursing in South Africa” at the Wits School of Public Health (WSPH) in celebration of International Nurses Day on 12 May 2015. The special edition was the culmination of a four-year research project of the Centre for Health Policy/Health Policy Research Group (HPRG) on “Research on the State of Nursing (RESON)” funded by The Atlantic Philanthropies and led by Professor Laetitia Rispel, the HPRG's Scientific Director and head of the WSPH.

The 11 articles in this special edition now provide much-needed evidence for improved nursing policy development and practice in South Africa, and place nursing squarely in the spotlight as the profession is about to embark on profound changes in nursing education.

The Dean of the Wits Health Sciences Faculty, Professor Martin Veller, said it was also significant that a number of articles were by first time authors. He urged the team to continue work into this field and encouraged them to find ways to introduce the findings into policy and practice.

Guest Editor, Professor Rispel, said this research was a very useful mechanism to develop the next generation of African scholars, and it was important to promote access to this work by publishing in Global Health Action, an open access journal with readership in over 100 countries. It focused on nurses who, as the largest single group of health service providers, were critical in promoting health and providing essential health services, yet nursing was in a crisis in South Africa.

In her keynote address, Professor Judith Bruce, head of the Wits School of Therapeutic Sciences, concluded that nursing was a profession in peril.

“There are concerns about leadership inertia that delays progress and implementation. There’s a lag in policy implementation due to a lack of will and capacity in the SA Nursing Council. We have to strengthen registered nurses’ capacity to participate in policy development, implementation and feedback to debunk the myth of ‘pseudo consultation’. Undergraduate education must include political policy and planning,” she said.

The audience called for nurse advocates to be ‘emboldened by the results’ to make a difference with the knowledge generated in the research. Nurses were urged to stand together as a united force to ‘make health in this country happen.’ Copies of the report will be disseminated to participating institutions, nursing departments at universities and colleges, the SANC and the DOH.

The research explored themes relevant to a global audience of nurses and policy makers and included nursing education reforms, enhancing the participation of nurses in policy making, moonlighting among nurses, utilisation of agency nurses in hospitals, and its costs to the health sector, ethics, quality of care, and the work experiences of nursing managers at primary health clinics.

Nursing education, reforms and health policy participation

In the first of three papers under this theme, Armstrong and Rispel use a social accountability framework, specifically the World Health Organization’s six building blocks for transformative education to explore key informants’ perspectives on nursing education in South Africa. Study participants acknowledged that South Africa has strategic plans on human resources for health and nursing education, training and practice. There is also a well-established system of regulation and accreditation of nursing education through the South African Nursing Council (SANC). However, key informants criticised the lack of national staffing norms, sub-optimal governance by both the SANC and the Department of Health, outdated curricula that are unresponsive to population and health system needs, lack of preparedness of nurse educators; and the perceived unsuitability of the majority of nursing students. These issues would need to be addressed in order to enhance social accountability, an essential component of transformative education. A small window of opportunity now exists to make changes which reflect social accountability. Failure to do so will compromise the health of the nation.

Using a policy analysis framework, Blaauw et al analyse nursing education reforms that culminated in a new Framework for Nursing Qualifications in 2013. The revision of nursing qualifications was part of the post-apartheid transformation of nursing but was also influenced by changes in South Africa’s higher education sector. The two most important changes are the requirement for a baccalaureate degree to qualify as a professional nurse, and the abolishment of the enrolled nurse with two years of training in favour of a staff nurse with a three-year college diploma. The policy process took more than 10 years to complete and the final Regulations were promulgated in 2013. Respondents criticised slow progress, weak governance by the SANC and the Department of Health, limited planning for implementation, and the inappropriateness of the proposals for South Africa.

In the third paper within this theme, Ditlopo et al analyse the dynamics, strengths and weaknesses of nurses' participation in four national health workforce policies: the 2008 Nursing Strategy, the revision of the Scope of Practice for nurses, the new Framework for Nursing Qualifications, and the Occupation-Specific Dispensation (OSD) remuneration policy. The study found that nurses' participation in policy-making is both contested and complex. There was a disjuncture between nursing leadership and front-line nurses in their levels of awareness of the four policies. There was also limited consensus on which nursing group legitimately represented nursing issues in the policy arena.The success of the health sector reforms currently underway in SA will depend on nurses. Strategies to increase nurses’ participation will require a combination of proactive leadership, health policy capacity and skills development.

Understanding casualisation in nursing

Rispel et al examine whether moonlighting is a determinant of South African nurses’ intention to leave their primary jobs.The study found that almost one third of 3 784 survey participants (30.9%) indicated that they planned to leave their jobs within the 12 months following the survey. Intention to leave was higher among the moonlighters (39.5%) compared to non-moonlighters (27.9%).Moonlighting was found to be a predictor of intention to leave, and would need to be addressed as part of nurse retention strategies.

In the second paper, Rispel and Blaauw examine the potential health system consequences of agency nursing and moonlighting among South African nurses. In the cross-sectional survey of 3 784 participants, 40.7% of nurses reported moonlighting or working for an agency in the year preceding the survey, 51.5% of all participants reported feeling too tired to work, 11.5% paid less attention to nursing work on duty, while 10.9% took sick leave when not actually sick in the preceding year. In a multiple logistic regression analysis, the differences between moonlighters and non-moonlighters were not statistically significant after adjusting for other socio-demographic variables. The authors conclude that although moonlighting did not emerge as a statistically significant predictor, the reported health system consequences are serious, and need to be addressed by health managers and policy-makers.

Rispel and Angelides conducted a provincial survey on nursing agency utilisation and analysed provincial health expenditure on nursing agencies from 2005 until 2010 in the third paper on casualisation in nursing. The study found that1.49 billion South African Rands (R) (US$ 212.64 million) was spent on nursing agencies in the public health sector in the 2009/10 financial year. In the same period, agency expenditure ranged from a low of R36.45 million ($5.20 million) in Mpumalanga Province (mixed urban-rural) to a high of R356.43 million ($50.92 million) in the Eastern Cape Province (mixed urban-rural). In that financial year, a total of 5 369 registered nurses could have been employed in lieu of nursing agency expenditure.

However, there are also indirect costs associated with agency nursing. Complementing the direct costing study,Rispel and Moorman examined the direct and indirect costs of agency nurses, as well as the advantages and the problems associated with agency nurse utilisation in two public sector hospitals in South Africa. The study found that the indirect cost activities at both hospitals in one week exceeded the weekly direct costs of nursing agencies. Agency nurses assisted the selected hospitals in dealing with problems of nurse recruitment, absenteeism, shortages and skills gaps in specialised clinical areas. The problems experienced with agency nurses included their perceived lack of commitment, unreliability, and providing sub-optimal quality of patient care.

Olojede and Rispel, in the final paper under the casualisation theme, explore the characteristics of nursing agencies in South Africa, and their relationship with clients in the health sector. Although a small sample of nursing agencies was selected, the study found that 27% of these nursing agencies provided services to old-age homes. Nursing agencies were more likely to have contracts with private-sector clients (84%) than with public sector clients (16%). In terms of quality checks and monitoring, 81% of agencies agreed with a statement that they checked the Nursing Council registration of nurses, 82% agreed with a statement that they requested certified copies of a nurse’s qualifications, but only 21% indicated that they conducted reference checks of nurses with their past employers.

Ethics, quality of care and work experiences of nursing managers

Three papers highlight the importance of an enabling practice environment for nurses. White et al explore hospital nurses’ perceptions of the international Code of Ethics for nurses, their perceptions of the South African Nurses’ Pledge of Service; and their views on ethical practice. The majority of study participants agreed with a statement that they will promote the human rights of individuals (98%), and that they have a duty to meet the health and social needs of the public (96%). More nuanced responses were obtained for some questions, with 60% agreeing with a statement that too much emphasis is placed on patients’ rights as opposed to nurses’ rights, and 32% agreeing with a statement that they would take part in strike action to improve nurses’ salaries and working conditions. The dilemmas encountered by nurses in upholding the Code of Ethics and the Pledge in the face of workplace constraints or poor working conditions were revealed in nurses’ responses to open-ended questions.

Munyewende and Rispel explore the work experiences of PHC clinic nursing managers through the use of reflective diaries. Although inter-related and not mutually exclusive, the main themes that emerged from the diary analysis were: health system deficiencies; human resource challenges; unsupportive management environment; leadership and governance, and the emotional impact on the manager.

In the final paper in the Special Issue, Armstrong et al examine whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals. The study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management and 11.8% on miscellaneous activities such as searching for stock, keys or other staff members. These managers also experienced numerous interruptions and distractions. The current health sector reforms provide a golden opportunity to address health system inefficiencies.

The special edition is available athttp://www.globalhealthaction.net/index.php/gha/article/view/28205