The increased “professionalisation” of nursing in South Africa, in recent years, marks a significant shift in the perception and practice of this essential healthcare field. As the country grapples with a critical shortage, though, and the ongoing challenges of aligning nursing education with new higher education standards, Thabo Molelekwa, writing in Spotlight, asks local experts about nursing’s future in the country.
The critical shortage of nurses is exacerbated by an ageing workforce – all while provincial health budgets for hiring nurses are under constant pressure, while it hasn’t helped that the transition to a “more professional” educational framework for nursing over the past four years has been beset with hiccups.
Training qualifications have changed and institutions now have to be accredited by both the South African Nursing Council (SANC) and the Council for Higher Education. In some places, accreditation delays have dramatically slowed training, and private hospitals have complained that they are not being allowed to train more nurses.
Push to professionalise
Professor Champion Nyoni from the University of the Free State told Spotlight that the legacy and history of nursing, especially in SA, has profoundly influenced how the profession is perceived today. Nursing was not always recognised as a profession, he added.
“Historically, it was commonly believed that one had to be born a nurse or have a natural inclination for it, which led to the perception that nursing required minimal formal education.”
Dr Sharon Vasuthevan, a healthcare and leadership consultant, said the professionalisation of nursing is about recognising it as both a science and an art.
“This transition aims to ensure nurses are trained and educated on par with other professions, following the levels outlined in the Higher Education Qualification Framework (HEQF),” she said. The HEQF regulates all higher education qualifications and programmes or curricula in South Africa.
Nyoni said the aim was to move nursing beyond being seen as merely a vocation and empowering nurses to think critically and make decisions independently. This, he said, is crucial for improving patient outcomes.
“With this shift to higher education, entry requirements have changed; specific matric certificates are now required for different levels – higher certificate, diploma, and bachelor’s degree. These requirements reflect the academic performance of school leavers and ensures that those entering the field meet the necessary standards,” Vasuthevan said.
Rocky transition
But the nurse training transition has not been without challenges. Most notably, delays in the accreditation of institutions for the new qualifications have resulted in reduced numbers of nurses being trained in recent years.
“Nursing education institutions had to rewrite their programmes to meet new standards,” Nyoni said. This process has taken longer than anticipated, affecting the start of new programmes and the number of students who can be admitted.
Vasuthevan said these changes have been identified as a key driver of the lower output from training institutions. She expressed optimism, however, that numbers would increase again as more institutions come online with the new qualifications.
Deputy Registrar of SANC Jeanneth Nxumalo said that with the new curriculum, the Council has to evaluate nursing education providers based on new criteria to ensure they are equipped to handle proposed student numbers.
These criteria include the adequacy of human, financial, and infrastructure resources, whether clinical facilities can accommodate the proposed student numbers for work integrated learning, and a letter of support from the provincial Department of Health, specifying the number of students each clinical facility can accommodate.
But Simon Hlungwani, president of the Democratic Nursing Organisation of South Africa (Denosa), said the situation with nurse training has regressed under the new system.
“In the past, institutions like Baragwanath could take around 300 students. Now, they are approved to take only around 80. It’s a regression, and at a time when our country needs more nurses.”
And apart from managing the training transition, there are other challenges, like training capacity. Nyoni said there was already a shortage of nurse educators, adding pressure on those tasked with setting up and working on new programmes.
Retiring nurses not being replaced
“Nationally, we are in a critical situation because since the legacy programmes were stopped, we have not been training as many nurses as we did previously,” cautioned Dr Sue Armstrong of the University of the Witwatersrand. “This has resulted in significant gaps in the system, particularly as a large percentage of registered nurses over 60 will retire within the next five years.”
She said not training enough nurses has resulted in a net deficit of nurses, while simultaneously, the population is also increasing. “So the situation is worsening.”
According to the SANC website, numbers of registered nurses increased from 260 698 in 2013 to 271 047 in 2022 – about 4%.
Over the same 10-year period, the population of South Africa is estimated to have increased by around 14%.
While the number of general nurses in the new diploma programme is expected to increase gradually, Armstrong warned that a proper plan must be devised to counterbalance the declining number of professional nurses, especially in specialist areas.
She said South Africa may not have enough nurses to meet even the minimum requirements for the sustainable development goals and the WHO requirements for quality nursing care.
Hlungwani also raised the alarm about the looming shortage of nurses due to retirements. “We know that 48% of them will retire in the next 15 years. We need to draw up a plan to replace them…and maintain the health system in the face of a growing disease burden and population,” he warned.
Numbers and norms
Experts appear to agree that South Africa has a nursing shortage, but just how bad the shortage is, is not clear. This is partly because there are different ways to calculate a country’s nurse requirements. As argued by Armstrong, however, it is also because we haven’t actually calculated the need for some time.
“One of our problems here is that we haven’t calculated the norms. But the private sector has calculated nursing norms, determining how many nurses you should have per patient. In the public sector, we have not done that,” said Armstrong (“Nursing norms” in this context refers to the number of nurses required to deliver healthcare services effectively.)
One method for calculating nursing norms promoted by the WHO is the Workload Indicators of Staffing Need (WISN). As described in a 2021 paper, the WISN system was used to calculate norms for primary healthcare in South Africa, but the calculated norms were found to be unaffordable and are not used.
As soon as you have regulated norms and you can’t meet them, which we can’t at the moment, then you open yourself to litigation, said Armstrong. “So nobody wants to regulate nursing norms, and very few countries have actually done it for that very reason.”
In the absence of such more sophisticated norms, a cruder solution is to look at healthcare worker-to-population ratios. The WHO recommends a minimum ratio of 445 healthcare workers (including doctors, nurses, and midwives) per 100 000 population (the WHO states it as 44.5 per 10 000 – we have converted to “per 100 00” to ease comparisons with the below numbers).
According to the National Department of Health’s 2030 Human Resources for Health Strategy, there are around 503 health workers for every 100 000 public sector users in South Africa, placing us above the WHO’s minimum threshold. The density for all nurses combined is 282 per 100 000, whereas there are 43 doctors and 30 allied health workers per 100 000 public sector population.
Armstrong said the situation varies greatly across provinces and sectors. Shortages are also more acute for certain categories of specialist nurses.
To address the looming shortage of nurses, the SANC’s Nxumalo suggested provincial health departments work more closely with training providers. “The SANC publishes the number of accredited providers for all institutional types and approved student numbers on its website quarterly. It is the responsibility of provincial Departments of Health to assess the categories of nurses needed and, with the providers, ensure that adequate numbers are trained.
“This can be done by applying for an extension of the accreditation scope, increasing the number of students, and expanding the number of programmes and clinical facilities.”
The brain drain
Apart from older nurses retiring, South Africa’s nursing numbers are also affected by many opting to work oversees.
Nyoni is particularly concerned over the loss of experienced nurses from the brain drain. “This exodus has a direct impact on the healthcare system… it takes years for newly graduated nurses to gain the competence needed to fill these gaps,” he said.
“Many return with enhanced knowledge and experience, but the greater concern is when nurses emigrate permanently with their families, representing a total loss to the country,” said Vasuthevan. She said there was a need for policies that make nursing attractive, particularly for young people.
Armstrong pointed out that salary disparities contribute to the brain drain, with many South African nurses seeking better opportunities abroad.
And Denosa is also concerned about this. “A high number of nurses go to Saudi Arabia, the UK, the UAE, and the US,” Hlungwani said. “South African-trained nurses are sought after worldwide, but we need them here to sustain our health system.”
‘Regression for the profession’
Meanwhile, while most people seem to accept that the country will have to move forward within the parameters of the new qualifications, Denosa would like to see a major change in direction.
“We believe that the changes in nursing training here in Africa are a flop and a regression for the profession,” Hlungwani said. “We’ve made it clear to the Health Minister, to the Nursing Council, and we’ve called for a dialogue to change the system.
“In the past, with the curriculum from 1987 until it was phased out in 2020, we produced nurses who were well-rounded…. These were professionals equipped with qualifications in midwifery, psychiatry, community nursing, and general nursing.”
This training, Hlungwani added, ensured that a nurse could handle diverse patient needs, even in rural areas with limited resources.
“The training was so comprehensive that a nurse could manage mental health cases, provide antenatal and postnatal care, deliver babies, and even handle immunisations and paediatric care.”
However, he claimed the current changes only produce generalists with no specialisation.
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