Looming retirements, training amendments and provicial budget problems are all contributing to the critical nurse shortages in the country.
The dire situation, as well as training of nurses, were the focus of a two-day conference hosted by the South African Nursing Council (SANC) in Johannesburg last month. But the issue is not a new one, observes Thabo Molelekwa in Spotlight.
In October 2021, for example, Spotlight reported that almost half of the country’s nurses would retire within 15 years, with national spokesperson for the Democratic Nursing Organisation of South Africa (Denosa) Sibongiseni Delihlazo calling the situation a “ticking time bomb”.
The 2030 Human Resources for Health Strategy (HRH strategy), first made public in 2020, also raised the alarm about healthcare worker shortages in South Africa and called for dramatically increased investment in human resources in the sector.
However, as of mid-2023, this hasn’t materialised – although there was some additional investment to help cope with the pandemic.
Finding the money, both for the training and for the employment of nurses, is one aspect of the crisis, while another has to do with the highly contested terrain of how nurses are trained in South Africa and who is accredited to train how many and what role the private sector plays in all this.
Not employing those we train
Dr Matlou Molepo, chairperson of the SANC, conceded there were nurse shortages and training challenges, but that ultimately, not all of those they train are absorbed into the public health system – mainly due to funding constraints.
“We are training them but provincial departments cannot absorb them,” said Molepo. “The training is expensive, during which time they utilise a lot of health equipment …which costs money. So we are training nurses, but then they are not absorbed because the provincial departments or the private hospitals don’t have money to employ them. So… we’re training more than we can absorb, yet we have a shortage.”
Dr Anban Pillay, deputy director-general for health regulation and compliance in the Department of Health, told the conference an investment case had been made to the National Treasury to boost funding.
“So we have made a case but the budget we’ve been given is reduced from what we had before in nominal terms, meaning …we are going to battle to keep the people we have. That’s how bad this is,” he said.
Foster Mohale, spokesperson for the National Department of Health, confirmed this. “The point he (Pillay) made is that our budget has been cut. Then National Treasury says we must absorb the 7.5% wage increase from the allocated budget. This decline means we now have less than in the previous year. And if you consider inflation, the situation is even more serious.”
Dr Kobie Marais, director for Nursing Education and Training in the national Health Department, said their HR department was working on a costing for the HRH strategy to cover all public sector healthcare workers. “It’s quite a big process since we have thousands and thousands of health workers,” Marais said.
Health Minister Dr Joe Phaahla recently said that “in immediate basic needs, we did indicate that across the board … that we need about R950m just to be able to meet the basic needs”.
Too few specialist nurses
Nursing shortages are particularly acute in several sub-specialities, for instance theatre nurses.
Understanding the exact extent of the problem is not straightforward. As pointed out by Professor Ntombifikile Mtshali, CEO of the SANC, the number of retired nurses with additional qualifications is not known since even after retirement, some nurses prefer to maintain their licence to practice.
Some specific big-picture figures for from 2013 to 2022 paint a worrying picture, showing the number of nurses on the register has grown by 4%, from 260 698 to 271 047. The SANC quotes StatsSA figures indicating that over the same period, SA’s population has grown by around 14%. Combined, this means that in 2022, we had fewer nurses per person than in 2013.
The SANC figures also show a worrying dip in the number of student nurses in the categories in 2021 and 2022.
Knowing how many nurses we have in different categories is just a starting point. For future planning, we also need to know how many we need in the various specialisations.
The HRH strategy provides some estimates of the numbers needed – making the National Department of Health’s costing of the strategy an important next step toward the country budgeting for and employing more staff.
A disruptive transition
Molepo said the number of nurses SA can produce has been affected by changes in their training, which is going through a major transition. Qualifications have changed and institutions now have to be accredited by both the SANC and the Council for Higher Education.
The changes, intended to speed up the professionalism of nurse training, have in some instances contributed to major disruption, for example, in the Eastern Cape.
Molepo said there has been “a gap created in the middle” so specialisation programmes could not continue. Additionally, older nurses who were specialists were already retiring.
“We are producing more nurses, but because we changed from the post-basic nursing programmes to the post-graduate diploma programmes, that gap in between also affected us, thus the shortage,” she said.
“The figures have been affected by different institutions and the ending of the legacy qualifications. Basically, public nursing colleges are producing 80% of the nurses and the specific figures will then depend on which province and which public nursing institution ended their legacy qualification and started on new programmes.”
The transition could not be completed because more training colleges might be opened or private hospitals might want to open nursing training institutions. This will then make the accreditation process continue so the transition will be ongoing.
On the shortages, especially of specialist nurses, Marais said: “This is particularly evident in some categories, which is why we do training plans according to the needs of health services. Previously, there was overproduction of some of the lower categories.”
Private sector’s role
One of the most contentious issues has been the role of the private sector.
Marais, there are some nurse training colleges in the private sector, some of them affiliated to the big hospital groups, like Netcare, Life Healthcare and Medi-Clinic. There are also independent private nursing colleges.
She said that Hasa-affiliated Nursing Colleges (Netcare, Life Healthcare and Mediclinic) have been conditionally accredited by the SANC to train nurses in specialties like Critical Care, Emergency Nursing, Peri-operative Nursing and Health Service Management, over and above basic programmes such as Nursing Auxiliary and General Nursing Programmes.
“This means that if the Council on Higher Education also accredits them, they can offer these programmes,” she said.
But Life Healthcare Group CEO Peter Wharton-Hood has said that while Life Healthcare has capacity to train up to 3 000 nurses per annum, they are currently only accredited to train 800.
The Netcare group has raised similar concerns.
In a statement, Life Healthcare reaffirmed its commitment to investing in nurse training and development and ensuring a sustainable pipeline of nursing professionals for the future. However, they wrote, the organisation cannot achieve this without support from regulators.
“There is a scarcity of specialised skills for several reasons,” said Merle Victor, chief nurse officer at Life Healthcare. “One is that not enough training opportunities have been made available. That is a serious problem, considering SA’s burden of disease.
Additionally, to ensure our patients get adequate care, we need specialist nurses with the appropriate knowledge, skills and competence.”
The SANC said that “the (Life Healthcare) statement depicting SANC as the stumbling block for nurse training is unfounded”.
“The SANC is mandated to protect the public on matters relating to health and in particular nursing. Therefore, it is duty bound to ensure quality nursing education and training is provided and cannot compromise this obligation for any other interest outside production of safe and competent practitioners for patient safety”.
Although the SANC does not state this outright, the implication is that more private training is not being accredited because it does not meet all of the requirements.
But is the SANC over-managing nurse training? It’s hard to tell, although the general view from outside says it is.
Dr Sue Armstrong, a lecturer at the Department of Nursing Education at the University of the Witwatersrand and chairperson of the Nursing Education Association, previously told Spotlight that the council must become more “facilitative”. She described it as “very authoritarian”.
“In some ways, it 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 nursing education institutions with capacity should be allowed to train the maximum number,” she said.
2030-HRH-strategy-19-3-2020
Spotlight article – Analysis: Is SA on track to solve its nursing crisis? (Creative Commons Licence)
See more from MedicalBrief archives:
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Urgent call for state to invest in more nurses to avoid catastrophe
Netcare again warns of SA’s critical nursing shortage
Department has no plan to deal with nursing crisis – Denosa president