This guest blog was written by Michelle Robinson and Jeanette Strydom of Africa Health Placements, a member organization of GHC based in Johannesburg. Recently, AHP published an article entitled “Addressing the South African Nursing Crisis,” which tackled some of the issues surrounding the dysfunctional nursing situation in South African health care facilities. The article, amongst other things, discussed the distinction between the different nursing qualifications (a practical-based, diploma course versus a four-year theoretical degree qualification) and identified some reasons why the diploma qualification can be problematic, leading to under-qualified and under-motivated nurses. However, in response to this article, AHP was contacted by Emily Melk, a registered nurse who began her career as an enrolled (diploma) nurse. An interview conducted with her provided deeper insight into the nursing profession in South Africa and its profound challenges – and indicated that the idea of “diploma nurses vs. degreed nurses” is perhaps a false dichotomy, with the problem being more complex, and far more contingent on how individual nurses cope with a taxing work environment.

JOHANNESBURG, South Africa — The challenges that nurses in South Africa face on a daily basis cannot be downplayed or ignored. Being a nurse means being faced with a constant inundation of patients, as many as 500 per day, in hospitals that are very understaffed. At any given time, one single nurse is assigned to care for as many as 32 patients, with some of these patients being extremely ill and requiring extensive attention. Combined with a lack of adequate facilities and other resources, nurses end up drained, exhausted and struggling to cope with the overwhelming workload. The end result is a mentality where nurses are forced to “treat the numbers, not the patient” and ultimately, patient care is compromised. The health, morale and emotional well-being of the nurses also suffer.

The biggest problem – making ends meet
Despite being faced with stressful and demanding working conditions, many nurses are passionate and committed to their profession, and to delivering quality patient care. However, the salary scale in nursing is not very high, especially in public institutions, and the struggle to stretch a limited salary is exacerbating an already difficult situation.

Global Health Council (2009) statistics show that the private sector accounts for 41.1% of all South Africa’s nurses and 72.6% of the country’s general practitioners. Often health care workers may leave the public sector to work for a non-government organisation or other private entities as private sector salaries are considerably higher than public sector wages, making it easier to support a family when employed by the private sector.

Another worrying trend has developed: Nurses are taking on additional part-time or night-shift work in private hospitals to supplement their low income, or are signing up for far too much overtime. This leads to nurses who are constantly fatigued and have no time to rest, and subsequently do not perform at full capacity. The inevitable result is a decline in the quality of patient care and in the health of these nurses, who feel that they have no choice. As Emily succinctly puts it: “Nurses are very underpaid. It’s disgusting. And we have children to feed.”

It is clear that the situation needs to be addressed, and that the amount of additional work that nurses take on needs to be monitored and regulated, at least as a short term measure. Hospital management certainly needs to play a role, for example, in preventing nurses from logging excessive amounts of overtime. However, this does not go to the root of the problem, which is that nurses are struggling to afford to live on their current salaries. If they are cut off from subsidising insufficient income, and no solutions are provided, many will be forced to leave nursing or attempt to move out of the public sector, causing an even larger problem.

All qualifications are not created equal
It seems that the discrepancy between the education that some college nurses receive, as opposed to those who have a four year degree, can be attributed to some of the public nursing schools which offer “diploma qualifications.” These schools are unregistered and unscrupulous, attracting school leavers who haven’t been provided with the correct information to make an informed decision, or who have financial difficulties and perceive these schools as being more affordable. The diplomas they receive from these schools are not worth anything, and the training given is sub-standard. Once the nurses graduate from these “fly-by-night” institutions, they struggle to cope in the professional environment and need a lot of coaching and assistance from the other nurses, putting additional strain on an under-resourced system. These unregistered nursing schools need to be identified, and school leavers need to be provided with adequate career guidance and information about reputable schools so that they can attend a school where they can obtain a proper qualification.

The second issue is that of nurses being employed in positions for which they are incorrectly qualified. Placement agencies don’t always check qualifications, or an under-qualified nurse may be asked to take up a certain position due to staffing shortages. Emily herself gives an example where she was offered a position as a sister even though she did not have the right qualification. She has seen many instances of this, for example, nurses who are untrained to work in the ICU will accept an ICU position because they need the money. This practice of employing untrained nurses in specialised positions greatly decreases the standard of nursing, but the Catch-22 is implicit. If these nurses aren’t employed, then patient care is ultimately compromised anyway due to staffing issues.

So what defines a competent nurse?
Emily, herself an enrolled nurse who went on to do a bridging course to become a registered nurse later in her career, vehemently denies that a diploma nurse is inherently less capable or less educated than a degreed nurse. She claims that while degreed nurses have extensive theoretical knowledge, they have no practical experience, which is crucial in a competent nurse. She points out, “I have taught registered nurses and doctors how to do their jobs,” underscoring the fact that theory cannot replace practical experience. The balance has to be there – a sound theoretical background needs to form the platform for plenty of hands-on training. She also makes the point that while degreed nurses train for four years learning a combination of the theory behind the various specialisations in nursing such as midwifery or ICU nursing, diploma nurses will spend a year on a particular field, which is potentially the better strategy for training skilled nurses.

It seems that the pressures that face nurses in South Africa have a far greater effect on their ability to care for patients than the origin of their education, although this certainly does play a role. Emily speaks of nursing as a “noble profession” – one that requires passion as well as compassion, and plenty of resolve. She maintains that nurses with these qualities do exist, regardless of where they obtained their qualification, and that the systemic problems, which are undermining the nursing profession and the ability of nurses to do their jobs well, affect all nurses. The lack of structure and support, and the demoralising conditions under which they work, all take their toll.

Although the financial aspect is important, it is equally imperative to motivate nurses with recognition and efforts to boost their morale. A strong support system that begins with inspiring nurses to enter the profession as students and that recognises the difficulties that nurses face, is crucial in shifting the balance towards nurses who are physically, emotionally and mentally able to do their jobs well.