Nurses make up the largest group of healthcare providers in South Africa. The performance of any healthcare system is directly dependent on the quality of care afforded by these healthcare professionals. Yet in 2015, a report by the University of Witwatersrand revealed that over 60% of nurses admitted reporting that they felt too tired to work while on duty. According to the study, this could be linked to the 70% of South African nurses who admitted to ‘moonlighting’ or working overtime due to a massive skills shortage in this under-resourced sector.
These statistics depict a profession in crisis and have alarming implications for the level of patient care provided. Abel Pienaar, Professor of Nursing at the North-West University, Chairperson: Education Committee South African Nursing Council (SANC) and speaker at the 6th annual Health Exhibition & Congress 2016, says that if South Africa is to meet its goal of achieving universal health, it first needs to address the skills shortage and the resulting casualisation of nurses.
In 2010, there were an estimated 81,925 public sector vacancies for all categories of nurses in the country. “The key dimensions of the nursing crisis in South Africa are well-recognised,” says Pienaar. “Between the slow uptake of young men and women into the profession and an ageing workforce, the skills pool is currently under tremendous pressure.”
Both public and private sectors face major challenges to produce, recruit, and retain skilled nurses. In a bid to keep bright medical professionals, young nurses are often fast tracked into senior positions by management. However, this practice often deprives these capable nurses of clinical expertise and the opportunity to specialise.
“To train young nurses you need to draw on clinical experience and competence because nursing is a clinical profession. However, the current trend, especially in universities, is to retain talented young graduates for teaching and learning. Subsequently when these talented individuals are eventually reabsorbed into the nursing education system, they are unable to offer great insight into the profession because they lack the necessary clinical experience,” points out Pienaar.
He also points out that the National Health budget for nursing has not been adjusted for two consecutive years. “Budget constraints lead to skill shortage. The lack of investment in clinical specialisation, both in the public and private sector, puts additional pressure on an already shrinking pool of expertise. If we don’t train and educate these health professionals we run the risk of producing nurses with mediocre competency. This will inevitably result in the delivery of sub optimal patient care.”
However, the nursing crisis is not unique to South Africa. Described by both the Global Health Workforce Alliance and the World Health Organization (WHO), the worldwide shortage of nurses is the result of the recruitment of top-quality nurses from developing countries around the world to work in developed countries.
Nurses with the best education and the resources to fulfil international requirements are the most likely to emigrate for better pay and improved working conditions. “South African nurses are one of the most sought after health professionals in the world,” says Pienaar. “Unlike their global counterparts, South African nurses receive comprehensive training across all nursing disciplines. They graduate as well rounded medical professionals with the flexibility to work in any nursing discipline.”
“This loss of expertise results in a shortage of skilled labour from where it’s most needed, leaving already fragile health systems even more vulnerable and adds a tremendous amount of pressure on the remaining workforce to meet the ever-growing healthcare demands,” he adds.
But, Pienaar believes that while the skills problem in South Africa is exacerbated by global competition for health workers, the casualisation of nurses is an immediate problem that needs to be addressed.
A 2010 cross-sectional study found that agency nursing and ‘moonlighting’ – two manifestations of casualisation in nursing – were common. The term ‘casualisation’ refers to the employment of workers on short-term contracts, without the rights and benefits associated with the standard contract of employment.
Despite the Basic Conditions of Employment being the only legal framework in place to regulate working hours and prevent nurse fatigue, many in a primary full-time job will moonlight and hold a supplementary position with a temporary employment service provider or nursing agency.
“In theory, approval for moonlighting should only be granted if it does not impede the effective or efficient performance of the employee and, once approval is granted, implementation requires careful monitoring. But, this is often not the case,” says Pienaar.
Unregulated, many South African nurses are working excessively long hours. Pienaar explains that overwork, however, leads to fatigue and fatigue leads to a greater chance of mistakes. Excessive overtime has been shown to impact negatively on patient care and increase the risk of ‘compassion fatigue’ which includes desensitisation and loss of empathy.”
In the University of Witwatersrand study, nurses also reported high rates of unauthorised absences leading to further understaffing, overwork, and health worker exhaustion. Of all nurses, 10.9% indicated that they had taken sick leave when not actually sick and 5.6% had missed work without permission.
While a minority of nurses in the study (2.9%) reported a medico-legal incident, the study found that 33.7% of those who had done moonlighting or agency nursing were involved in any of the negative incidents.
Among moonlighting nurses, 11.9% of the respondents in the study indicated that they had used their vacation leave to do agency work or moonlighting, further contributing to fatigue.
“To maintain and improve standards of care and patient safety in South Africa, it’s imperative that we address low rates of clinical training in the profession and the casualisation of our nursing workforce. The argument for addressing the nursing crisis is supported by well-documented evidence that the number, competencies and effectiveness of nurses is critical in determining the quality of care, patient outcomes, as well as improving the performance of our current weak health system,” concludes Pienaar.
Professor Abel Pienaar will be speaking at the Nursing Conference, which will form part of the 6th annual Africa Health Exhibition & Congress taking place 8-10 June 2016 at the Gallagher Convention Centre in Johannesburg, South Africa. More than 7,000 regional and international healthcare professionals and medical experts are expected to attend the event.