FA NURSING MONOGRAPH 3 3/31/09 4:28 PM Page 2 Composite C M Y CM MY CY CMY K Nursing in a New Era The Profession and Education of Nurses in South Africa Mignonne Breier, Angelique Wildschut & Thando Mgqolozana Nursing monograph.indd 1 4/23/09 2:59:45 PM Free download from www.hsrcpress.ac.za Published by HSRC Press Private Bag X9182, Cape Town, 8000, South Africa www.hsrcpress.ac.za First published 2009 ISBN (soft cover) 978-0-7969-2274-8 ISBN (pdf) 978-0-7969-2275-5 © 2009 Human Sciences Research Council Copy-edited by Lisa Compton Typeset by Simon van Gend Cover design by Jenny Young Printed by Logo Print South Africa Distributed in Africa by Blue Weaver Tel: +27 (0) 21 701 4477; Fax: +27 (0) 21 701 7302 www.oneworldbooks.com Distributed in Europe and the United Kingdom by Eurospan Distribution Services (EDS) Tel: +44 (0) 20 7240 0856; Fax: +44 (0) 20 7379 0609 www.eurospanbookstore.com Distributed in North America by Independent Publishers Group (IPG) Call toll-free: (800) 888 4741; Fax: +1 (312) 337 5985 www.ipgbook.com Nursing monograph.indd 2 4/23/09 2:59:46 PM Free download from www.hsrcpress.ac.za List of tables and figures v Preface vii Acknowledgements viii Acronyms and abbreviations ix 1 In t r o d u c t I o n 1 A conceptual framework for the study of nursing 1 Research design 7 Limitations 11 Overview of the monograph 14 2 Gr o w t h a n d p r o f I l e o f t h e n u r s I n G p r o f e s s I o n 15 The growth of nursing as a profession 15 The growth of nursing in numbers 16 Profile of the profession 19 Distribution of nurses 23 Conclusion 28 3 th e d e m a n d f o r n u r s e s 29 Who says there is a shortage? 29 Vacancy rates in the nursing profession 32 Demand for nurses due to HIV and AIDS 33 Conclusion 42 4 mI G r a t I o n o f so u t h af r I c a n n u r s e s 43 Nurse migration as an international phenomenon 43 Statistics on the migration of South African nurses 44 A qualitative view of nurse migration 51 Views of academics and students on emigration 60 Conclusion 63 5 nu r s I n G e d u c a t I o n 65 An overview of the production of nurses 65 Geographical distribution of nursing training 70 Trends in the production of nurses 73 Growth in SANC registers versus growth in production of nurses 77 Conclusion 81 6 wh y c h o o s e n u r s I n G ?83 Nursing students’ reasons for choosing nursing 83 Academics’ views 88 Choices of school learners 91 Conclusion 92 7 nu r s I n G I n an e w e r a 93 Working with HIV/AIDS and TB patients 94 Professional relations 97 Nurse/patient abuse 102 Salaries 107 Non-monetary rewards 110 Conclusion 110 Nursing monograph.indd 3 4/23/09 2:59:46 PM Free download from www.hsrcpress.ac.za iv 8 st a n d a r d s ,I m a G e a n d s t a t u s 112 Have standards dropped? 112 Views on status and image 113 Positive views 120 Conclusion 121 9 co n c l u s I o n s 122 Method 122 Findings 122 Conclusions and recommendations 125 ap p e n d I c e s Appendix 1 Consent form for interviewees 129 Appendix 2 Interviewees and focus group participants 131 re f e r e n c e s 134 Nursing monograph.indd 4 4/23/09 2:59:47 PM Free download from www.hsrcpress.ac.za v Tables Table 2.1 Growth in SANC registers by professional category, 1996–2006 17 Table 2.2 Proportions of different categories of nurses on SANC registers, 1996–2006 19 Table 2.3 Numbers and percentages of registered nurses, 1960–1990 21 Table 2.4 Racial distribution of nursing staff in the public sector by occupational category, 2006 21 Table 2.5 Age distribution of nursing staff by occupational category, 2006 23 Table 2.6 Total registrations with SANC versus nurses in employment, 2001 and 2005 24 Table 2.7 Population of South Africa, nurses in public and private sectors, and medical aid beneficiaries, 2001 and 2005 24 Table 2.8 Nurses in South Africa and neighbouring countries, various years 26 Table 2.9 Nurses in OECD countries, various years 27 Table 3.1 Department of Health targets for the production of nurses, by category 30 Table 3.2 HIV prevalence among respondents by sex and age group, 2005 35 Table 3.3 Antiretroviral therapy treatment roll-out (for adults) in the provinces 39 Table 4.1 Nurses and midwives trained in sub-Saharan Africa working in seven OECD countries, 2004 45 Table 4.2 Doctors trained in sub-Saharan Africa working in eight OECD countries, 2004 46 Table 4.3 Documented nurse immigrants and self-declared nurse emigrants, South Africa, 1999–2003 47 Table 4.4 Self-declared emigrant nurses by gender and age, South Africa, 2003 47 Table 4.5 Verifications of qualifications and transcripts of training issued by SANC to countries specified, 2001–2004 48 Table 4.6 Summary of statistics on nurse emigration from South Africa 49 Table 4.7 Approved work permits for South African nurses, 2000–2004 50 Table 5.1 Output from all nursing courses and bridging programme, 1997–2006 66 Table 5.2 Output of professional nurses from four-year and bridging programmes, 1996–2006 68 Table 5.3 Output of enrolled nurses by year, 1997–2006 69 Table 5.4 Output of enrolled nursing auxiliaries by year, 1997–2006 70 Table 5.5 Output for nursing courses by province, 2006 72 Table 5.6 Increase in registrations of PNs compared with number of PNs that qualified in previous year, 1997–2006 79 Table 5.7 Increase in registrations of ENs compared with number of ENs that qualified in previous year, 1997–2006 80 Table 5.8 Increase in registrations of ENAs compared with number of ENAs that qualified in previous year, 1997–2006 80 Nursing monograph.indd 5 4/23/09 2:59:47 PM Free download from www.hsrcpress.ac.za vi Figures Figure 1.1 A model for the analysis of a profession and professional education, applied to the nursing profession and the education of nurses 2 Figure 1.2 Waiting area of a public hospital in Manenberg, Cape Town 4 Figure 1.3 Waiting area of a private hospital in Constantia, Cape Town 4 Figure 2.1 Growth in SANC registers, 1996–2006 18 Figure 2.2 Gender distribution of nursing staff by occupational category, 2006 20 Figure 2.3 Gender distribution of nursing staff learner category, 2006 20 Figure 2.4 Comparison between nurse and population distribution, 2006 26 Figure 5.1 Overall professional nursing output, 1997–2006 68 Figure 5.2 Output of pupil nurses (ENs) by year, 1997–2006 69 Figure 5.3 Output of pupil auxiliaries (ENAs) by year, 1997–2006 71 Nursing monograph.indd 6 4/23/09 2:59:47 PM Free download from www.hsrcpress.ac.za vii Many of the hopes and aspirations of South Africa’s new democracy depend upon the production of professionals who not only have globally competitive knowledge and skills but also want to stay and work in the country and contribute to the national development effort and social transformation. This quest has particular significance in the nursing profession, which has lost many thousands of nurses to developed countries that are already better supplied with health professionals than South Africa. In this country, nurses are struggling to cope with the demands of a population that has high levels of diseases related to poverty and underdevelopment, injuries and HIV/AIDS, as well as chronic diseases. Conditions are particularly bad in the public sector, where only 60% of nurses are serving potentially 85% of the population, who are uninsured and largely reliant on public services. At the same time, the role of the public sector in the training of nurses has diminished. At present only public colleges and universities are licensed to offer the four-year programme that trains professional nurses, but together these institutions produced fewer professional nurses in 2006 than 10 years earlier in 1997. This has serious implications, as these are the only institutions that are allowed to offer the four-year professional nurse programmes that include training in midwifery, psychiatric and community nursing as well as general nursing. By 2006, the majority of professional nurses were being produced through the two-year bridging programme that is offered in the private as well as the public sector. However, this programme, which upgrades enrolled nurses (ENs), trains only for general nursing. The private sector has also become the major provider of training for enrolled nurses and enrolled nursing auxiliaries (ENAs). Private colleges were responsible for 70% of EN output and 78% of ENA output in 2006. These are just some of the issues that are explored in detail in this monograph, which is the fourth in the HSRC’s research project on Professions and Professional Education. The first was a study of the medical profession, titled Doctors in a Divided Society (Breier & Wildschut 2006), the second was a study of social workers, titled Social Work in Social Change (Earle 2008) and the third was on engineering titled Engineering in a Developing Country (Du Toit & Roodt, 2009). The studies are intended to explore issues relevant to the future development of the profession concerned and to bring our findings to policy, academic and public attention. Dr Mignonne Breier Project leader and series editor Professions Project Education, Science and Skills Development Programme Human Sciences Research Council Nursing monograph.indd 7 4/23/09 2:59:48 PM Free download from www.hsrcpress.ac.za viii This study would not have been possible without the cooperation of many individuals, including: The academics and students who agreed to be interviewed or who participated in • focus group discussions. They were from the following educational institutions: University of KwaZulu-Natal• KwaZulu-Natal College of Nursing• University of the Western Cape• Western Cape College of Nursing• Healthnicon• Netcare Training Academy. • The representatives of various organisations associated with the nursing profession. • They include: the South African Nursing Council • the Democratic Nurses Organisation of South Africa • National Education, Health and Allied Workers Union • the Department of Health• the private hospital groups: Life Healthcare, Netcare and Medi-Clinic• private nursing agencies and schools.• We are grateful to Professor Laetitia Rispel of the Centre for Health Policy, School of Public Health at the University of the Witwatersrand, and Professor Sophie Mogotlane, academic chairperson of the Department of Health Studies at UNISA, for reviewing the first draft of this monograph and providing valuable comments and suggestions. Finally, we would like to thank Atlantic Philanthropies for their financial support and Christine Downton and Khosi Xaba, in particular, for their encouragement. Nursing monograph.indd 8 4/23/09 2:59:49 PM Free download from www.hsrcpress.ac.za ix AIDS acquired immunodeficiency syndrome ART antiretroviral therapy ARV antiretroviral BCur Baccalaureus Curationis DENOSA Democratic Nursing Organisation of South Africa DoE Department of Education DoH Department of Health DoL Department of Labour EN enrolled nurse ENA enrolled nursing auxiliary GDP gross domestic product HAART highly active antiretroviral therapy HEMIS Higher Education Management Information System HIV human immunodeficiency virus HSRC Human Sciences Research Council HST Health Systems Trust HWSETA Health and Welfare Sector Education and Training Authority KZNCN KwaZulu-Natal College of Nursing LFS Labour Force Survey MDR TB multi-drug-resistant tuberculosis MSF Médecins Sans Frontières NEHAWU National Education, Health and Allied Workers Union NHR Plan National Human Resources for Health Planning Framework NQF National Qualifications Framework NSFAS National Student Financial Aid Scheme OECD Organisation for Economic Co-operation and Development OSD Occupation Specific Dispensation PHC primary healthcare PN professional nurse RN registered nurse SADC Southern African Development Community SAMP Southern African Migration Project SANC South African Nursing Council SANNAM Southern African Development Community AIDS Network of Nurses and Midwives SAQA South African Qualifications Authority SETA Sector Education Training Authority Stats SA Statistics South Africa TB tuberculosis UK United Kingdom UKZN University of KwaZulu-Natal UNAIDS Joint United Nations Programme on HIV/AIDS USA United States of America UWC University of the Western Cape VCT voluntary counselling and testing WCCN Western Cape College of Nursing WHO World Health Organization XDR TB extensive drug-resistant tuberculosis Nursing monograph.indd 9 4/23/09 2:59:49 PM Free download from www.hsrcpress.ac.za Nursing monograph.indd 10 4/23/09 2:59:49 PM Free download from www.hsrcpress.ac.za [...]... which has two main divisions: the public sector and the private sector The dotted lines in the second oval in Figure 1.1 indicate the proportions of nurses working in each of these sectors: about 60% of the nursing workforce in South Africa is 2 Nursing monograph.indd 2 4/23/09 2:59:51 PM Introduction employed in the public sector, and the remaining 40% in the private sector The education of nurses straddles... features In our preliminary research on nursing, we found that the following features of the education system are crucial in the shaping of (and are also being shaped by) the professional labour market: • changes in the public institutional landscape, including the closure or merger of colleges and an increasing emphasis on university education of nurses; • changes in the locus of training, with the private... and practices of the two government departments that affect it (the Department of Health [DoH] and the Department of Education [DoE]); and the role of the South African Nursing Council (SANC) in setting and maintaining standards and of professional organisations in representing nurse members The latter organisations include the Democratic Nursing Organisation of South Africa (DENOSA) and the trade union... leave the profession soon, and the nurses now entering and practising the profession are doing so mostly at the lower categories of nursing, then the country might be facing a dire shortage of professional nurses in future 11 Potchefstroom combined with North-West University 22 Nursing monograph.indd 22 4/23/09 3:00:01 PM Growth and profile of the nursing profession Table 2.5 Age distribution of nursing... salaries) and the corresponding effects on the supply of nurses (there is a large discrepancy between the numbers of nurses in the education system and the numbers of registrations in the profession itself) Trends in nursing education are discussed in Chapter 5; Chapter 8 explores the image and status of the profession The international professional milieu is shaped by similar factors on a global scale: • The. .. all the HSRC professions studies is the professional education sector seen in the context of the local professional labour market In Figure 1.1, the nursing education sector, which encompasses students, academics, nurse educators and clinical facilitators, is indicated in the centre oval The inclusion of educational issues in the HSRC professions studies is one of their most distinguishing and unusual... nursing remains the foundation of healthcare in South Africa and needs to be nurtured and strengthened if the country is to overcome the health challenges facing it This monograph aims to contribute to the future development of the profession by presenting in detail the trends outlined above and suggesting possible causes and solutions This study of nursing forms part of the HSRC’s Professions and Professional... and Professional Education research project in which a number of professions are being researched with the aim of addressing this question: How is this profession and its professional education programmes responding to the needs and challenges of a transforming South Africa? A conceptual framework for the study of nursing In the HSRC research project, professions and their professional education programmes... of males are increasing in certain contexts About 60% of nurses, most of them African, work in the public sector, where they serve about 85% of the population The profession has high attrition levels (between enrolment at a training institution and graduation, as well as between graduation and registration), and the nursing workforce is ageing – about twothirds of nurses are over the age of 40 In the. .. flow of nurses from South African training institutions (centre oval) into the local professional labour market, the migration of nurses from the public to the private sector, and from the local labour market to the international market, in particular to countries such as the UK, the USA and Saudi Arabia, where there are shortages of nurses The arrows from the international labour market into the country . for the analysis of a profession and professional education, applied to the nursing profession and the education of nurses 2 Figure 1.2 Waiting area of. in each of these sectors: about 60% of the nursing workforce in South Africa is Figure 1.1 A model for the analysis of a profession and professional education,