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The obstacles stifling nurse training in SA

South Africa’s nursing workforce is ageing, and existing nurse shortages may well get worse rather than better in the coming years, writes Thabo Molelekwa for Spotlight.

But while nurse shortages are a challenge globally and the need to train and sustainably employ more nurses is widely recognised, in South Africa, however, their training has been complicated by several changes in how their qualifications are regulated and approved.

A two-body problem?

One problem, says Lerato Mthunzi, chairperson of the Young Nurses Indaba Trade Union (YNITU), is that the Nursing Act and the Higher Education Act give two different bodies the authority to accredit and regulate nursing education: the South African Nursing Council (SANC) and the Council for Higher Education.

“This sluggish move of transitioning to higher education is not just holding the profession to ransom, but also the quality of care that can be given to patients and our ability to improve the quality of our country’s healthcare system,” she says.

Dr Sue Armstrong, a lecturer at the Department of Nursing Education at Wits and chairperson of the Nursing Education Association, said before 1994, all provincial nursing colleges were constituted under a provincial ordinance. With the National Qualifications Framework, she says, all nursing education courses were then moved to higher education, meaning they became subject to the Higher Education Act.

“The nursing council had to change the qualifications to fit into this new qualification framework,” she says. “It was not just a whim, it was to fit into national legislation. So to qualify as a professional nurse the person must have a degree, and this has to fit into the National Qualifications Framework.”

Accordingly, every nursing programme an educational institution offers must now be approved by both SANC and the Council for Higher Education.

“But provincial nursing colleges were not higher education institutions yet and technically, they couldn’t offer any nursing courses,” she says. “The Higher Education Minister then promulgated them – as a temporary measure – as higher education institutions. So currently, they are still under provincial governments, which they should not be, but are allowed to run until the whole of nursing education moves into national government, where it should be.”

The requirements for acquiring a qualification approved by higher education are more stringent than the nursing council’s, one of the reasons why public colleges battle to get curricula approved and why they are very nervous about starting the degree programme, which ultimately affects their output. She says the colleges decided to start with auxiliary training (one-year training) and then the new category, a three-year diploma in general nursing.

“The young nurses (trade union) are right. We’ve got a desperate shortage now because the only people who can train professional nurses are the universities – they are the only ones offering the course,” she says.

Fewer career options

Another concern is that the reforms have, in some respects, curtailed career prospects in nursing.

Armstrong says under the new arrangements there’s no career path (as before) between auxiliary nurse to enrolled nurse and enrolled nurse to general nurse anymore. “It’s not just the SANC which has disallowed this, but the whole new education set-up.

“Now, if you enroll for a course, you have to finish it. For example, if you enroll for the four-year degree and only finish two years, previously you used to be able to enroll as a nurse, but now you can’t. So, in that sense, there’s no career path for them.”

Even more tragic, she adds, “is that those professional nurses already in the system can’t even specialise because they’re sitting on a level six at the moment and need a level seven qualification to be able to specialise”.

This means existing enrolled and auxiliary nurses are stuck where they are. Level five is a certificate course, level six, a diploma, and level eight is a degree.

Armstrong says it does not mean nurses in these categories (enrolled) won’t have a job for the rest of their lives, but they will have the same job for the rest of their lives unless they pursue a completely new qualification. She says at some institutions, however, there are some opportunities for recognition of prior learning, which would enable them to upgrade.

Under the National Qualifications Framework, you currently either do a one-year course to become an auxiliary nurse or a three-year course to become a general nurse or four years to become a professional nurse. General nurses, Armstrong believes, will be very useful because they can run hospital wards and do lots of things – just not specialise.

“But we are going to be desperately short of registered nurses,” Armstrong warns, as only registered nurses can specialise. “So, if you land up in intensive care, or your child needs specialised paediatric care, there may be staff nurses – who are general nurses, but they do not have a speciality qualification and knowledge that may be needed.”

What is behind the reforms?

In South Africa, like elsewhere, there has been a shift towards professionalising nursing, which is why several nursing education policy reforms were implemented after 1994 – changing the scope of practice for nurses, revising qualifications, and rationalising nursing training institutions. It meant, among other things, those study periods towards a nursing qualification were extended and training moved away from “a hospital-based apprenticeship to higher education institutions”.

Historically, in SA, hospitals used to have their own nursing colleges training their own nurses – a practice that some say helped curbed the gross staff shortages experienced currently.

Before the policy reforms, there were three nurse categories, including professional (registered) nurses who trained for four years, enrolled nurses who trained for two years and nursing assistants (auxiliaries,) with one year of training, said Professor Laetitia Rispel from Wits and the South African Research Chair for the Health Workforce. Among the policy reforms (from 2001) was that a baccalaureate degree was required to qualify as a professional nurse. Enrolled nurses with two years of training were scrapped as a category and replaced with the staff (general) nurse category with a three-year college diploma.

Some of the current friction may be due to how this shift to “professionalising nursing” has been implemented.

Rich Sicina, president of YNITU, says with the move to higher education there are various policies and new rules. “New rules, for example, stated that only lecturers with a Master’s degree are allowed to teach nursing students,” he says. “So many of these lecturers left nursing education. They went back to hospitals.

“Previously, as long as you wanted to be a nurse, were passionate about it, and passed matric – the subjects were not that important to say how well you did.

“Now, the requirements have changed to strictly biology, maths, and science. This means if you don’t have these subjects, you don’t qualify to do nursing.”

Nursing Council responds

SANC Registrar and CEO Sizo Mchunu says these changes were intentional.

“Previously, some nursing qualifications were below NQF level five (the equivalent of grades nine to 12 in high school) and in ensuring that the nursing programmes are on a par with other health professionals and for easy progression and articulation, the profession agreed that during this period of transformation, all qualifications should be pegged at the Higher Educations Qualifications Sub-Framework (HEQSF) – meaning that the qualifications fall within higher education,” says Mchunu.

The SANC is still the professional body that regulates nursing education and practice in South Africa, she adds. “The Department of Higher Education hasn’t taken that responsibility from the SANC but because all the nursing qualifications are pegged at the Higher Education Qualifications Sub-Framework, the nursing programmes must also be accredited by the Council for Higher Education, the quality council established in terms of the Higher Education Act.”

The phase-out-phase-in plan started with the gradual phasing out of the legacy programmes as the HEQSF-aligned qualifications are phased in. “Currently, producing nurses is both through the legacy and the new HEQSF-aligned qualifications. The legacy qualifications are going to be phased out by 2026.” The overlap, she says, has ensured a smooth transition.

Some of the current friction may be due to how this shift to “professionalising nursing” has been implemented.

Concerning numbers

Behind all these debates is a ticking time bomb: South Africa has a shortage of nurses and, for now, at least, there is little evidence sufficient numbers will be trained and employed in the coming years.

In December last year, Health Minister Dr Joe Phaahla said there were 10 nursing colleges in SA, one in each province, the tenth being the SA Military Health Service. “These colleges have 45 campuses and 40 sub-campuses in district and sub-district levels in each of the provinces to ensure access to nursing education by local communities,” he said.

Based on numbers from the nursing council, he added, 52 887 specialist nurses had completed their studies and registered as nursing specialists over the past decade. It’s not clear how many are in the public sector.

Based on the public service’s PERSAL system numbers, by 31 March 2021, 144 090 nurses were recorded as employed in the public health sector, including all categories of nurses in all nine provinces, as well as the National Department of Health. According to SANC statistics, however, the total nursing workforce registered by December 2021 was 276 415, with 15 469 professional nurses in training at the time. The output of nurses who have completed the four-year degree has hovered around 3 500 annually since 2017. The output for specialist nurses was 3 372 in 2020 and 4 445 last year.

There are, however, reports of worrying hiccups in the transition to the new system.

Sicina says previously, under the Department of Health, Gauteng’s four nursing colleges had an intake of around 400 students per college, or more than 1 000 students per intake in the province (all colleges combined). Currently, he says, the colleges under the new system are taking only about 50 students per college, so the province only has about 200 students at the moment.

There are six public colleges in Gauteng. Two mainly offer additional qualifications (specialist programmes) and four offer undergraduate programmes.

“The SANC has approved the number of students for the new programmes in line with the request from the Gauteng College of Nursing,” said Mchunu. The request is that the numbers increase by 50 students annually as the legacy programmes are being phased out. Gauteng’s first cohort of students for the Diploma in Nursing will graduate toward the end of the year.

Problems and solutions

It appears the bottleneck is with the training and sustainable employment of nurses, rather than with a shortage of people eager to study nursing.

“Thousands of young people apply, who meet the entry requirements both for this new diploma and for the degree, so that’s not the issue,” says Armstrong. “What is an issue is that the nursing council has limited the numbers in both the private and public sectors. The private sector has been doing a lot of training, mostly at its own expense, and now it has been limited. So, the qualifications or the entry requirements are not the problem. It’s the Nursing Council putting a block on numbers – not allowing the nursing education institutions to take as many as they would like to.”

Armstrong also flagged limited resources as a big factor in the public sector. “A big issue is finance because they (government) can’t afford to employ as many student nurses as they had before. We have a shortage of nurses, but we have nurses who are unemployed – it’s crazy. The financial situation in government is a big part of the problem.”

What needs to happen, she says, is that the Nursing Council must become more “facilitative”. The council is being “very authoritarian” and seems to believe it has a right to control the numbers being trained.

“In some ways, the SANC is there to protect the public and yes, we would not want anyone to train thousands of nurses if they weren’t being trained properly but those institutions with capacity should be allowed to train the maximum number.” However, without additional nurse educators and bigger facilities to take in more students, increasing the numbers will be difficult.

She said the private sector has huge capacity to train nurses and since these nurses do not all end up in the private sector, they will also be available to the public sector. “It’s very short-sighted not to allow the private sector to train as many as they can,” she says.

Another way is to capacitate nursing colleges to do degree training and take more students. “It’s not an easy solution, she says, “but some capacity could be created if the nursing council were more open-minded.”


Spotlight article – In-depth: What are fuelling concerns over nurse training in South Africa? (Creative Commons Licence)


See more from MedicalBrief archives:


Retirement boom and training drought — SA’s looming nursing crisis


Private sector asks SANC to be allowed to train more nurses


Changed qualification requirements will exacerbate nursing shortage


SANC delays on private nursing colleges threaten NHI plans




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