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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
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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
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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
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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
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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
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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
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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
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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.
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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
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[...]... 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,
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