Public nursing training in neglect

South Africa's public health system is overworked and understaffed. There are severe shortages of doctors, dentists and allied health professionals such as pharmacists. Nurses, also in short supply, are nonetheless the largest single category of professional in the health sector, and are bearing the brunt of public healthcare, particularly in rural areas. Yet the training of nurses in the public sector has been neglected. Mignonne Breier, Angelique Wildschut and Thando Mgqolozana report.

A new HSRC monograph on nursing shows that public nursing training has declined substantially in recent years, due mainly to cuts in provincial budgets and the restructuring of the higher education system

The cuts put a halt to many public hospital training programmes while the restructuring led to the closing or merger of public nursing colleges and the increasing emphasis on the university nursing degree rather than the four-year college diploma. College output has dropped while university output has increased slowly, and from a low base.

Today the private sector is playing a very large - and often lucrative - role in the production of nurses. The major hospital groups, in response to their own severe shortage of nurses and accusations that they poach from the public sector, expanded their own training programmes, producing increasing numbers of nurses to meet their own specific needs. At the same time, small private colleges have mushroomed.

Concerns about training in the private sector

The rapid growth of the private sector and decline of the public sector are cause for concern, for various reasons.

At this stage no private training school has been able to meet the requirements to offer a four-year degree or diploma, which must include midwifery, community and psychiatric nursing as well as general nursing. In private hospitals, babies are generally delivered by doctors, not nurses, and the hospitals do not have facilities for community and chronic psychiatric care. They can produce professional nurses (PNs) through a two-year bridging programme which upgrades enrolled nurses (ENs) but trains only for general nursing. Most of the private sector courses are for enrolled nurses and enrolled nurse auxiliaries. The private hospital academies also offer post-basic and other specialised courses that are geared to their specific needs. private training school has been able to meet the requirements to offer a four-year degree or diploma, which must include midwifery, community and psychiatric nursing as well as general nursing

While some of the training, by the major hospital groups in particular, is of very high standard, the quality of nursing training in some of the small independent colleges is a matter of concern. They have difficulty securing adequate clinical placements (often sending students to old age homes for practical experience) and some require students to undergo expensive, unapproved ‘home-care', ‘health worker' or ‘pre-nursing' programmes before being admitted to a regular course in nursing.

Furthermore, training in a private hospital setting, no matter how high the quality, is not necessarily a good preparation for a public, particularly primary, healthcare setting and few nurses who have experienced the relative opulence of private hospitals will want to switch to the spartan conditions of the public sector.

Decline in qualified professional nurses

Between 1997 and 2007, the annual production of professional nurses overall increased by 19% due to the doubling of the output from bridging programmes (from 1 033 to 2 093 over the period). At the same time the output of professional nurses through four-year college and university courses fell 13% - from
2 682 in 1997 to 2 342 in 2007.

Most of the bridging training has occurred in the public sector but the numbers declined from 1 381 in 1998 to 1 261 in 2007, while private sector output increased more than fivefold, from 158 to 832.

Proportionally, the contribution of public colleges to the production of professional nurses declined from 62% to 37% of the total output, while university output rose from 10% to 16% and output from the  bridging programme increased from 28% to 47%.

Training of sub-professional nurses

The importance of sub-professional nurses (ENs and enrolled nurse auxiliaries or ENAs combined) in the healthcare system is underscored in several research and policy documents, some of which have proposed a ratio of three sub-professional nurses to each professional nurse. Yet the ratio in 2007 was roughly one to one - despite a dramatic increase in the production of ENs and ENAs in the previous decade.

While the output of professional nurses overall increased by less than one-fifth between 1997 and 2007, the output of sub-professional nurses more than tripled. However, from 2000, the increase occurred mainly in the private sector. Private-sector output increased more than ten-fold, whereas public-sector output increased by only 28%, and dropped substantially in 2000 and 2001.

Erosion of the nursing profession

With the increases in output from nursing training institutions in general, one could expect that the profession has grown proportionally. This is not the case. A major concern is the gap between the numbers of nurses who qualify in a given year and the increases in registration for the years in which they should register. Between 1997 and 2006, the South African Nursing Council (SANC) register of professional nurses grew by only 35% of the numbers produced in the relevant years (1996 to 2005). This amounts to an attrition rate of 65%. The attrition rates for ENs and ENAs were even higher - 72 % and 84% respectively.

A major concern is the gap between the numbers of nurses who qualify in a given year and the increases in the registration for the years in which they should register

The SANC has listed retirement, morbidity, mortality and migration to other professions, or out of the country, as possible reasons for the very high rates of attrition. The figures indicate that more nurses are leaving the profession - and actually de-registering - than entering. As many nurses who leave the country still maintain their registration, emigration might be less of a factor in attrition than is sometimes presumed. This puts greater weight on other factors, including retirement and death.

Surveys showing a high prevalence rate among health workers suggest that HIV/AIDS might be taking a significant toll. It is also possible that many use nursing qualifications, particularly at the lower levels, as stepping stones to other training programmes or careers.

...the output of professional nurses through
four-year college and university courses fell 13% - from 2 682 in 1997 to 2 342 in 2007.

HSRC qualitative research suggests there might also be large-scale dropping out immediately after completion of training. Interviews and focus groups with nursing students revealed that many did not really want to become nurses but had been attracted to studying nursing by the bursaries or salaries paid while studying. For many, nursing was a second career choice at best. Often, they had not been able to meet the entrance criteria for another first choice programme, usually medicine.

But this is not uncommon, as many of the older nursing professionals and academics said in interviews that nursing had also not been their first choice, but rather one of the few options available for women at the time. Nonetheless, they had grown to love the work and were happy that they had remained in the profession. The difference, it seems, lies with the quality of clinical experience compared with former times.

Fear of contracting HIV and TB

The research suggests that many nurses in training are distressed by the extent of HIV/AIDS and TB, afraid of contracting the diseases themselves and believe that they are often not sufficiently protected (for example, through shortages of gloves).

Academics said those who are already HIV positive are particularly vulnerable, both emotionally (particularly when treating AIDS patients) and physically (in that they are more likely to contract contagious infections). Nursing students also complained to researchers about:

  • Poor communication and interpersonal relations between doctors and nurses, and verbal abuse by nurses towards other nurses, nursing students and patients;
  • Incidents of physical abuse of patients by nurses, which they had observed;
  • Their own experiences of being physically assaulted or verbally abused by patients.

The way forward

The study urges the government to play a greater role in the training of nurses at all levels. It suggests that the new emphasis on a professional nursing degree as the qualification of choice should not be at the cost of deterring young people who would make excellent professional nurses but do not meet the academic criteria for university study, or who see the university degree as too theoretical. It also urges the profession to pay attention to students' perceptions of clinical practice and address their concerns and fears, to ensure they remain in the profession.

The authors found there were widespread perceptions that standards and conditions in nursing had declined, leading to loss of status and poor public image. The very low salaries traditionally paid to nurses and the fact that there are many other career opportunities for talented women have contributed to the state of the profession.

The increases in nurses' salaries, which were implemented in the course of the HSRC research, should help to retain and regain nurses in the public sector but it remains to be seen whether they will have any impact on the overall standards and status of nursing.

Some of the students who were interviewed after the increases did not seem particularly impressed. It appeared that salaries would continue to be an issue, given the ongoing increases in the cost of living and the much higher salaries paid in other professions with four year's training.

Dr Mignonne Breier is a chief research specialist in the Education, Science and Skills Development programme, and Angelique Wildschut and Thando Mgqolozana are both interns in the same programme. Nursing in a New Era: The profession and education of nurses in South Africa, by Breier M, Wildschut A and Mgqolozana T (2009), Cape Town: HSRC Press, is available at: