The cry for more nurses can be heard around the world, and South Africa is no different. But here the pipeline of student nurses has paused and working conditions discourage retention.
In a paper written on the subject, Professor Mokgadi Matlakala raises concerns on the shortage, noting that the health system was short of 20 815 nurses in 2015.
As of December 31 2016, there were 287 458 nurses registered with the South African Nursing Council (SANC) and 21 339 students. Gauteng had the highest numbers, followed by KwaZulu Natal and the Western Cape.
From 2007 to 2016, the total number of registered nurses grew 46% from 203 948, while the SA population grew 16% from 47.850 million to 55.909 million. Thus ratios have improved, but still there were only 5.14 nurses per 1 000 people in 2016, well below global averages.
It’s estimated 18% of SANC-registered nurses don’t practice due to poor working conditions. This is a global trend, says Dr Joan Dippenaar, Health Systems Trust’s training unit technical advisor. It goes without saying that there are more nurses in urban areas, with posts in rural areas remaining unfilled.
Dippenaar attributes the shortage to two factors: The late 1990s’ merger and closure of nursing colleges, resulted in significantly fewer nurses trained in State facilities. Secondly, the pipeline from private hospitals, which filled this gap with their own colleges, is being halted.
Nursing education now falls under higher education (formerly DoH). The Strategic Plan for Nursing Education, Training and Practice (2013) came into effect in 2013, with new qualifications. “Private [nursing education institutions] are still to be accredited … and for those accredited, the new curricula are yet to be approved,” says Matlakala. There’s also a shortage of nurse educators.
Until SANC accredits and, together with government, finalises and publishes updated scopes of practice, the new qualifications can’t be offered.
Therefore, as of 2016 private training facilities have discontinued all programmes and not taken new students in. This will apply to the public sector from 2019.
There’s also a licensing hold up. Professional nurse training requires one-year practical experience in the public sector. “On a year-to-year basis there are not enough posts in the public sector for the students that complete their studies,” says Laetitia Rispel here.
The solution’s obvious. “If we want to provide access to health for the total population, we will need to seriously increase our training outputs,” says Professor Hester Klopper, Stellenbosch University deputy vice chancellor of strategic initiatives and internationalisation. Aggravating the shortage, she says, is the fact that thousands of posts are been frozen by government and cannot be filled.
It’s not clear how much of a brain drain we have, but emigration doesn’t seem to be a major problem. Our nurses tend to work in Saudi Arabia, UAE and UK. Many go on short or medium-term contracts to earn foreign income and return.
South Africa has three categories of nurses: professional (registered) nurses with four years training; enrolled nurses with two years; and nursing assistants/auxiliaries with a year’s training.
“There is a significant shortage of qualified professional nurses, although there appears to be an oversupply of auxiliary nurses … and the shortage is about to become critical,” says Debbie Regensberg from the Society of Private Nurse Practitioners of SA.
It’s estimated that one nurse does the work of three to four others, due to staff shortages in public health facilities. “We have raised the staff shortage issue … with the Department of Health on numerous occasions with little response,” said Noel Desfontaines, general secretary of trade union Hospersa in a May statement.
Politicians have also raised concerns about the shortage. According an article by Dr Wilmot James, Democratic Alliance shadow minister of health, having a critical mass of professional nurses in hospitals reduces the risks of patients dying by 8% and significantly cuts the incidence of urinary tract infections, gastro-intestinal bleeding, hospital acquired pneumonia, shock and cardiac arrests.
“The need and skill mix of nurses are influenced by the shortage and uneven distribution of doctors in the healthcare system between sectors, provinces and urban rural areas, compounded by the shortage of resources,” says Dippenaar.
The SA nursing population’s also ageing, she adds. Approximately 50% of licensed nurses are over 50 years old. Only 5% are under 30 years old.
“There will be a critical shortage of nurses in the near future when all the skilled professionals, teachers, managers and clinical specialists retire. There is a critical shortage of nurses is in the education, research, management and clinical specialties, midwifery, new-born care and primary health care fields.”
Nursing is notoriously poorly paid. In particular, lower categories of nurses work long hours for poor salaries often in substandard conditions, particularly in the public sector and rural areas, says Dippenaar.
Those who graduate with a post basic degree are able to find higher remuneration, while specialists like theatre-trained and critical-care nurses can demand higher salaries.
“A newly-qualified pharmacist with a four-year degree and two years of practical has a starting salary of R35 000 per month, while a professional nurse is fortunate to earn R18 000, but has to take responsibility for life and death decisions in the absence of other healthcare professionals on a seven-day 12-hour shift basis,” Regensberg says.
Nurses also “moonlight” with two jobs to make ends meet (e.g. working both in public and private sector).
Not that it’s much consolation, but compared with developing countries, SA nurses are better paid, says Tawanda Makombo, an Institute of Race Relations research analyst.
Creating a favourable workplace environment could go a long way in retaining professional nurses in their posts. “Poor working conditions and being overworked are driving many health care workers to leave public health for better opportunities. What is more alarming is that the DoH is not filling these vacant posts, while many qualified health care workers remain on the unemployment lines,” added Desfontaines.
Working conditions were so poor at public health facilities that the Department of Labour (DoL) issued the DoH with a section 7 notice over Occupational Health and Safety contraventions.
As for the private sector, a large number of overseas, qualified nurses have applied to SANC for registration, which may take three to five years. Some private hospital groups are bringing in professional nurses from India and other English-speaking Asian countries to supplement staff, particularly in operating theatres and ICU, says Regensberg.
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