Nursing education in South Africa has undergone significant reforms over the last two decades, the most radical of which are the reformative regulations pertaining to specialist nurses. While the merits of the objective driving these reforms is not in question, South Africa’s current higher education framework and regulatory red tape are simply incapable of supporting the implementation of these regulations – including articulation, programme design, accreditation and implementation of the new programmes. The complexities and scope of the regulations would make their premature implementation in SA analogous to trying to fit a square peg into a round hole. This article by journalist Christ Bateman details the regulatory and administrative challenges in the specialist nursing education programmes; and demonstrates how the South African Nursing Council and Council for Higher Education’s failure to work together on accreditation presents the biggest obstacle to resolving the specialist nursing crisis which is increasingly threatening the quality of healthcare in the country. This article first appeared on Medbrief Africa. – Nadya Swart
The sorry tale of SA’s specialist nursing crisis
By Chris Bateman
South Africa’s dire shortage of specialist nurses is largely due to the inability of the Council for Higher Education, (CHE), and the South African Nursing Council (SANC) to work efficiently together.
This emerged when Medbrief Africa interrogated the reasons for the treacle-slow output of trained specialist nurses by interviewing hospital group nursing managers and the CEO of the Nursing Education Association, Dr Neloise Geyer.
A dramatic example of the expensive education and training red tape nightmare comes from Netcare, which runs five nursing and ancillary healthcare campuses, training over 2,000 students annually.
Last year they were forced by stringent new SANC requirements to reduce their first-year intake to 130 out of 23,000 applications, a situation mirrored across most nurse training facilities, public and private.
Mediclinic currently has a 30% vacancy rate in its specialist units (adult critical care, neonatal ICU, Theatre and Emergency Centres combined). Mediclinic’s Nursing Executive, Hendrica Ngoepe, said the situation was exacerbated by most professional nurses not having a postgraduate qualification, meaning they could not meet the criteria for a post basic specialist course.
Netcare’s Education Manager, Toy Vermaak, told the Hospital Association of South Africa (HASA’s) annual conference last year; “There’s no shortage of interest, it’s a shortage of opportunity. Postgraduate training is in crisis. When we complain about their restrictions, the SANC has no rationale. The new qualifications training has been cut by fivefold or more, who I turn out. They (the SANC) are our biggest obstacle. At least the Council for Higher Education engages and listens,” she said.
According to Geyer, part of the problem lies in overlapping accreditation demands from the two bodies – and a bureaucratic nightmare brought about by changes to education legislation in 2013.
Navigating a winding, rutted road
The new laws require all four-year Higher Education programmes and curricula to match national education criteria. Nursing was formerly exempt from this requirement. With just 23% of specialist nurses trained by universities, provincially run public and private nursing colleges had to scramble for Higher Education accreditation nationally, with dire transitional implications. Many were hamstrung by the additional financial and administrative burden of moving from what was a provincial competence to a national one – and having to overhaul their specialist learning curricula. New IT and management systems also took years to put in place. Regulations were finally promulgated in June 2020, severely delaying the submission of new curricula to the CHE for approval.
Says Geyer, “The Department of Health was probably one of the main culprits, but several nursing institutions were also slow to submit their programmes. The SANC meets quarterly, so it took many applicants six months or more to get their curricula accredited (the SANC being responsible for the quality of patient care).”
Significantly, she added, “the SANC and the CHE promised on several public fora that they’d work together on accreditation, but it never happened, which is a great pity. We can only hope for the future.”
Mediclinic’s mind-numbing wait
Ngoepe said Mediclinic’s (private) Higher Education institutions had yet to be accredited to offer bachelor programmes and were hamstrung by the requirement for nurses to complete a course in midwifery before being allowed to enter further postgraduate courses.
“On completion, they have to work for at least a year in the specialised units before being able to register for postgraduate courses. The SANC’s accreditation process can take up to 18 months and the numbers of students allowed are limited, making it a challenge to fill the gap in specialised skills. With the Diploma in Neonatal Care being phased out, this also has had a negative impact on skills required in Neonatal ICUs.
Ngoepe said the current requirements for entry to the postgraduate courses denied most nurses with legacy qualifications, as well as new general nurses, access to these courses. Combined with the lengthy course accreditation process and limitations on student numbers, the net result was major delays in the training of specialist nurses.
Burnout threat ever present
Mediclinic currently augmented their nursing staff with agency staff to support safe staffing levels and avoid burnout.
Ngoepe pleaded with the SANC to eradicate unnecessary training obstacles and allow both public and private institutions to train more nurses.
“We also believe it’s vital to declare all nurses, not just specialist qualified ones, as a scarce skill to support efforts to recruit foreign nurses. High income countries are currently draining our specialist nurse complement,” she added.
According to an executive summary of the SA Nursing Workforce Planning paper (2021), co-authored by Geyer, the estimated workforce gap in 2019 stood at between 26,000 and 62,000 nurses, with professional nurses accounting for 50% of this gap. Dire shortages exist in all provinces but are particularly severe in the major economic hubs; Gauteng, the Western Cape and KwaZulu Natal.
By 2030, the study projects that the demand for nurses will increase to between 305,000 and 340,000, primarily driven by population growth. The supply of nurses meanwhile, is expected to reach a mere 174,000 as the anticipated rate of retirement and immigration outpaces crippled training facility output.
The SANC’s own figures reveal 47% of all currently registered nurses to already be over 50 years old.
Dr Nceba Ndzwayiba, group director of Netcare’s Human Resources and Transformation, told the HASA conference that COVID exposed major shortages in specialised nursing clinical skills with highly skilled staff constantly transferred between provinces “until our resources were completely exhausted.”
National Health Director General, Dr Nicholas Crisp has talked down the nursing supply quandary, blaming massive budget cuts for the lack of specialised posts. Asked by MedBrief Africa about the SANC ‘dysfunction’ he responded, “All these councils need to be done away with.”
One example of the SANC’s widely resented ‘policeman’ role came when Netcare and Life Healthcare took to recruiting nurses with specialist experience from India several years ago. They had to resort to the courts to get the SANC to allow the nurses to write appropriate specialist exams in India.
Several private hospital groups are again on the verge of an overseas recruitment drive after their last bid in March 2020 was thwarted by COVID. Medbrief Africa learnt that the project is being kept strictly under wraps for strategic reasons.
Professor Shabir Madhi, Dean of Wits University’s Faculty of Health Sciences, has said there does not appear to be any uniformly applied strategy to address the human resource needs of the health sector across provinces.
“Overall, specialised medical care – more so in the public sector – remains under severe duress with the shortage of specialised nurses a threat to the quality of care,” he added.
The Acting CEO of the SA Nursing Council, Jeanette Nxumalo, failed to respond. This story was mailed to her Communications Department which promised to show it to her “after the usual protocols are observed” more than a week ago. Medbrief Africa will share the SANC’s response if or when it arrives.
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