Nursing in SA is changing, but is it enough to avert an anticipated crisis?

Nursing in SA is changing, but is it enough to avert an anticipated crisis?A nurse in mask and gloves. (Photo: Laura James/Pexels)
News & Features
26th September 2024 | Thabo Molelekwa

The increased professionalisation of nursing in South Africa in recent years marks a significant shift in the perception and practice of this essential healthcare field. As the country grapples with a critical shortage of nurses and the ongoing challenges of aligning nursing education with new higher education standards, Thabo Molelekwa asks local experts about the future of nursing in the country.

South Africa faces a critical shortage of nurses, exacerbated by an ageing workforce – all while the budgets provincial health departments have for employing nurses are under constant pressure.

It hasn’t helped that the transition to a “more professional” educational framework for nursing over the last four years has been beset with hiccups. As we previously reported, the qualifications nurses train for have changed and training institutions now have to be accredited by both the South African Nursing Council (SANC) and the Council for Higher Education. In some places, accreditation delays have dramatically slowed nurse training and private hospitals have complained that they are not being allowed to train more nurses.

Push to professionalise

In an interview with Spotlight, Professor Champion Nyoni from the University of the Free State said that the legacy and history of nursing, especially in South Africa, have profoundly influenced how the profession is perceived today. He said nursing was not always recognised as a profession. “Historically, it was commonly believed that one had to be born a nurse or have a natural inclination for it, which led to the perception that nursing required minimal formal education.”

Dr Sharon Vasuthevan, a healthcare and leadership consultant, told Spotlight that the professionalisation of nursing is about recognising it as both a science and an art. “This transition aims to ensure that nurses are trained and educated on par with other professions, following the levels outlined in the Higher Education Qualification Framework (HEQF),” she said. The HEQF regulates all higher education qualifications and programmes or curricula in South Africa.

Nyoni said the aim is to move nursing beyond being seen as merely a vocation and empowering nurses to think critically and make decisions independently. This, he said, is crucial for improving patient outcomes.

“With this shift to higher education, entry requirements have changed; specific matric certificates are now required for different levels – higher certificate, diploma, and bachelor’s degree. These requirements reflect the academic performance of school leavers and ensure that those entering the field meet the necessary standards,” Vasuthevan said.

Rocky transition

But as we previously reported, the nurse training transition in South Africa has not been without challenges. Maybe most notably, delays in the accreditation of training institutions for the new qualifications have resulted in reduced numbers of nurses being trained in recent years.

“Nursing education institutions had to rewrite their programmes to meet new standards, requiring approval from both the South African Nursing Council and the Council for Higher Education,” Nyoni said. This process, he said, has taken longer than anticipated, affecting the start of new programmes and the number of students that can be admitted.

These changes, according to Vasuthevan, have been identified as a key driver of the lower output from nurse training institutions in recent years. She did however express optimism that the numbers will increase again as more institutions come online with the new qualifications.

Deputy Registrar of the South African Nursing Council (SANC) Jeanneth Nxumalo, said that with the new curriculum, the council has to evaluate nursing education providers based on new criteria to ensure that they are equipped to handle their proposed student numbers. These criteria include the adequacy of human, financial, and infrastructure resources, whether clinical facilities can accommodate the proposed student numbers for work integrated learning, and  a letter of support from the provincial department of health, specifying the number of students each clinical facility can accommodate.

But according to Simon Hlungwani, president of Democratic Nursing Organisation of South Africa (Denosa), the situation with nurse training has regressed under the new system. “In the past, institutions like Baragwanath could take in around 300 students. Now, the same institutions are approved to take only around 80. It’s a regression, and at a time when our country needs more nurses,” he said.

And apart from managing the training transition, there are other challenges such as training capacity. Nyoni said that there is already a shortage of nurse educators, which adds pressure on those tasked with setting up and working on new programmes.

Retiring nurses not being replaced

“Nationally, we are in a critical situation because since the legacy programmes were stopped, we have not been training as many nurses as we did previously,” cautioned Dr Sue Armstrong of the University of Witwatersrand. “This has resulted in significant gaps in the system, particularly as a large percentage of registered nurses are over the age of 60 and are expected to retire within the next five years.”

She said not training enough nurses has left us with a net deficit of nurses, while at the same time the population is also increasing. “So if you look at the number of nurses in relationship to the population, the situation is getting worse and worse as time goes on,” said Armstrong.

According to figures on the SANC website, the number of registered nurses increased from 260 698 in 2013 to 271 047  in 2022 – an increase of about 4%. Over the same 10-year period, the population of South Africa is estimated to have increased by around 14%.

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While the number of general nurses in the new diploma programme is expected to increase gradually, Armstrong warned that a proper plan must be devised to counterbalance the declining number of professional nurses, especially in specialist areas. She warned that South Africa may not have enough nurses to meet even the minimum requirements for the sustainable development goals and the World Health Organization (WHO) requirements for quality nursing care.

Hlungwani also raised the alarm about the looming shortage of nurses due to retirements. “We know that 48% of our nurses will retire in the next 15 years. We need to draw up a plan to replace them, ensuring that we can maintain the health system in the face of a growing disease burden and population,” he warned.

Numbers and norms

Experts appear to agree that South Africa has a nursing shortage, but just how bad the shortage is, is not clear. This is partly because there are different ways in which the country’s nurse requirement can be calculated. As argued by Armstrong, however, it is also because we haven’t actually calculated the need for some time.

“One of our problems in South Africa is that we haven’t calculated the norms. But the private sector has calculated nursing norms, determining how many nurses you should have per patient. In the public sector, we have not done that,” said Armstrong (“Nursing norms” in this context refers to the number of nurses required to deliver healthcare services effectively.)

One method for calculating nursing norms promoted by the WHO is the Workload Indicators of Staffing Need (WISN). As described in a 2021 paper, the WISN system was used to calculate norms for primary healthcare in South Africa, but the calculated norms were found to be unaffordable and are not used.

As soon as you have regulated norms and you can’t meet them, which we can’t at the moment, then you open yourself to litigation, said Armstrong. “So nobody wants to regulate nursing norms, and very few countries have actually done it for that very reason,” she said.

“The private sector has calculated norms based on nurse-patient ratio rather than nurse to population but the public sector has not conducted this exercise since the early 1990’s when work studies were conducted by observing activities performed by nurses in various wards and timing them – these resulted in activity based norms which is the system the private sector uses together with calculations of patient acuity,” she said.

In the absence of such more sophisticated norms, a cruder solution is to look at healthcare worker-to-population ratios. The WHO recommends a minimum ratio of 445 health care workers (including doctors, nurses, and midwives) per 100 000 population (the WHO states it as 44,5 per 10 000 – we have converted to “per 100 00” to ease comparisons with the below numbers).

According to the National Department of Health’s 2030 Human Resources for Health Strategy, there are around 503 health workers for every 100 000 public sector users in South Africa, which places us above the WHO’s minimum threshold. The density for all nurses combined is 282 per 100 000, whereas there are 43 doctors and 30 allied health workers per 100 000 public sector population.

Armstrong emphasised that the situation varies greatly across provinces and sectors. Shortages are also more acute for certain categories of specialist nurses.

The SANC’s Nxumalo said that nursing shortages is not an issue unique to South Africa. “The shortage of nurses is a global phenomenon, especially among nurse specialists and midwife specialists, coupled with an ageing population of nurses,” she said.

To address the looming shortage of nurses, Nxumalo suggested that provincial health departments work closer together with training providers. “The SANC publishes the number of accredited providers for all institutional types and approved student numbers on its website quarterly. It is the responsibility of the Department of Health in each province to assess the categories of nurses needed and, together with the providers, ensure that adequate numbers are trained. This can be done by applying for an extension of the accreditation scope, increasing the number of students, and expanding the number of programmes and clinical facilities.”

The brain drain

In addition to older nurses retiring, South Africa’s nursing numbers are also impacted by nurses opting to work oversees.

Nyoni said he is particularly concerned over the loss of experienced nurses because of the brain drain. “This exodus has a direct impact on the healthcare system, as it takes years for newly graduated nurses to gain the competence needed to fill these gaps,” he said.

“Many return with enhanced knowledge and experience, but the greater concern is when nurses emigrate permanently with their families, representing a total loss to the country,” said Vasuthevan. She said we need policies that make nursing attractive, particularly for young people.

Armstrong pointed out that salary disparities contribute to the brain drain, with many South African nurses seeking better opportunities abroad.

And Denosa are also concerned about this. “We are noticing a high number of nurses going to Saudi Arabia, the UK, the UAE, and the US,” Hlungwani said. “South African-trained nurses are sought after worldwide, but we need them here to sustain our health system.”

‘Regression for the profession’

Meanwhile, while most people interviewed for this article seem to accept that the country will have to move forward within the parameters of the new qualifications, Denosa would like to see a major change in direction.

“We hold the view that the changes in nursing training in South Africa are a flop and a regression for the profession,” Hlungwani said. “We’ve made it clear to the [health] minister, to the [South African ] Nursing Council, and we’ve called for a dialogue to change the system,” he added.

“In the past, with the curriculum from 1987 until it was phased out in 2020, we produced nurses who were well-rounded…. These were professionals equipped with qualifications in midwifery, psychiatry, community nursing, and general nursing,” he said.

This training, Hlungwani said, ensured that a nurse could handle diverse patient needs, even in rural areas with limited resources. “The training was so comprehensive that a nurse could manage mental health cases, provide antenatal and postnatal care, deliver babies, and even handle immunisations and pediatric care.” However, he claimed the current changes only produce generalists with no specialisation.

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