As previously reported by Spotlight, South Africa's nursing workforce is ageing and existing nurse shortages may well get worse rather than better in the coming years.
Nurse shortages are a challenge globally and the need to train and sustainably employ more nurses is widely recognised. In South Africa, however, the training of nurses has been complicated by several changes in how nursing qualifications are regulated and approved.
A two-body problem?
One problem, according to 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 in the country - the South African Nursing Council (SANC) and the Council for Higher Education. "This entire sluggish move of transitioning to higher education is actually not just holding the profession ransom, but it's also holding ransom the quality of care that can be given to the users of healthcare and our ability to improve the quality of our healthcare system in our country," she says.
Dr Sue Armstrong, a lecturer at the Department of Nursing Education at Wits and Chairperson of the Nursing Education Association, explains that prior to 1994, all the provincial nursing colleges were constituted in terms of 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," says Armstrong. "So, it was not just a whim of theirs, 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 that an educational institution wants to offer 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 Minister of Higher Education 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 all of nursing education moves into national government where it should be."
Armstrong says that the requirements for getting a qualification approved by higher education are much more stringent than the nursing council's and this is one of the reasons the public colleges have been having so much trouble getting curricula approved and why they have been 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 which is 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 that are 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 that under the new arrangements there's no career path (as before) between auxiliary nurse to enrolled nurse and enrolled nurse to general nurse anymore. "And that's not just the SANC who has disallowed this, but the whole new education set up. Now, if you enrol for a course, you have to finish it. For example, if you enrol for the four-year degree and you only finish two years, previously you used to be able to enrol as a nurse, but now you can't. So, in that sense, there's no career path for them," she says.
"And what is even more tragic," Armstrong says, "is that those professional nurses that are already in the system can't even specialise because they're sitting on a level six at the moment and they need a level seven qualification to be able to specialise. This means the 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 in the world, there has been a shift towards professionalising nursing. It is as part of this shift that several nursing education policy reforms were implemented after 1994 - changing the scope of practice for nurses, revising nursing 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 South Africa, hospitals used to have their own nursing colleges training their own nurses - a practice that some say went a long way in curbing the gross staff shortages experienced currently.
Before the policy reforms, there were three nurse categories, including professional (registered) nurses that trained for four years, enrolled nurses that trained for two years and nursing assistants (auxiliaries) that had one year of training, explains Professor Laetitia Rispel from Wits and the South African Research Chair for the Health Workforce in an article published in a special edition of Global Health Action. Among the policy reforms (from 2001) was that a baccalaureate degree was required for someone 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 to adhere to. "New rules, for example, stated that only lecturers with a Master's degree are allowed to teach nursing students," he says. "As a result, many of these lecturers left nursing education. They went back to hospitals." He says.
"previously - as long as one wanted to be a nurse, was passionate about it, and passed matric - the subjects were not that important to say how well one did," he says. "Now, the requirements have changed to strictly biology, maths, and science. This means if you don't have these subjects, then you don't qualify to do nursing."
Nursing Council responds
As explained by SANC Registrar and CEO Sizo Mchunu, these changes were intentional.
"Previously, some nursing qualifications were below NQF level 5 (the equivalent of grades 9 to 12 in high school) and in ensuring that the nursing programmes are on par with other health professionals and for easy progression and articulation, the nursing profession consciously agreed that during this period of transformation, all the nursing qualifications should be pegged at the Higher Educations Qualifications Sub-Framework (HEQSF) - meaning that the qualifications fall within higher education," says Mchunu.
Clarifying the roles, Mchunu says the SANC is still the professional body that regulates nursing education and practice in South Africa. "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 which is the quality council established in terms of the Higher Education Act."
According to Mchunu, 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.
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 that sufficient numbers of nurses will be trained and employed in the coming years.
Health Minister Dr Joe Phaahla in a response to a parliamentary question in December last year, said there are ten nursing colleges in South Africa - one in each province with the tenth being the South African Military Health Service. "These colleges have 45 campuses and 40 sub-campuses located in district and subdistrict levels in each of the provinces to ensure access to nursing education by local communities," he said.
In responses to other questions relating to nurse numbers in the country, Phaahla said that based on numbers from the nursing council, there were 52 887 specialist nurses who 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 last year, there were 144 090 nurses recorded as employed in the public health sector, which included all categories of nurses in all nine provinces, including the National Department of Health.
Based on SANC statistics, however, the total nursing workforce registered in the country by December last year is 276 415 and there were 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 every year 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 before, under the Department of Health, the four nursing colleges in Gauteng used to have an intake of around 400 students per college, which amounted to over 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, which means the province only has more or less 200 students at the moment.
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Mchunu says there are six public colleges in Gauteng. Two are mainly offering 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. The request from the college is that the numbers would be increased by 50 students annually as the legacy programmes are being phased out," she says. Gauteng's first cohort of students for the Diploma in Nursing is expected to graduate toward the end of the year.
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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.
"There are thousands of young people applying 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 their own expense and now they've been limited. So, it's not really the qualifications or the entry requirements that are 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." (The SANC last week released a statement on this issue in response to an article published on BDLive.)
Armstrong also flagged limited resources as a big factor in the public sector. "What I believe is 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 that 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". Armstrong says the council is being "very authoritarian" and seems to believe they have a right to control the numbers that are 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 nursing education institutions with capacity should be allowed to train the maximum number." But, says Armstrong, without additional nurse educators and bigger facilities to take in more students, increasing the numbers will be difficult.
According to her, 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. "So, it's all very short-sighted not to allow the private sector to train as many as they can," she says.
Another thing that can help is to capacitate nursing colleges to do degree training and take more students. "It's not an easy solution, she says, "but I do believe some capacity could be created if the nursing council was more open-minded."
