The Profession and Education of Nurses in South Africa pptx

FA NURSING MONOGRAPH 3 3/31/09 4:28 PM Page 2
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C M Y CM MY CY CMY K
Nursing
in a New Era
The Profession and Education
of Nurses in South Africa
Mignonne Breier, Angelique Wildschut
& Thando Mgqolozana
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Published by HSRC Press
Private Bag X9182, Cape Town, 8000, South Africa
www.hsrcpress.ac.za
First published 2009
ISBN (soft cover) 978-0-7969-2274-8
ISBN (pdf) 978-0-7969-2275-5
© 2009 Human Sciences Research Council
Copy-edited by Lisa Compton
Typeset by Simon van Gend
Cover design by Jenny Young
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List of tables and figures v
Preface vii
Acknowledgements viii
Acronyms and abbreviations ix
1 In t r o d u c t I o n 1
A conceptual framework for the study of nursing 1
Research design 7
Limitations 11
Overview of the monograph 14
2 Gr o w t h a n d p r o f I l e o f t h e n u r s I n G p r o f e s s I o n 15
The growth of nursing as a profession 15
The growth of nursing in numbers 16
Profile of the profession 19
Distribution of nurses 23
Conclusion 28
3 th e d e m a n d f o r n u r s e s 29
Who says there is a shortage? 29
Vacancy rates in the nursing profession 32
Demand for nurses due to HIV and AIDS 33
Conclusion 42
4 mI G r a t I o n o f so u t h af r I c a n n u r s e s 43
Nurse migration as an international phenomenon 43
Statistics on the migration of South African nurses 44
A qualitative view of nurse migration 51
Views of academics and students on emigration 60
Conclusion 63
5 nu r s I n G e d u c a t I o n 65

An overview of the production of nurses 65
Geographical distribution of nursing training 70
Trends in the production of nurses 73
Growth in SANC registers versus growth in production of nurses 77
Conclusion 81
6 wh y c h o o s e n u r s I n G ?83
Nursing students’ reasons for choosing nursing 83
Academics’ views 88
Choices of school learners 91
Conclusion 92
7 nu r s I n G I n an e w e r a 93
Working with HIV/AIDS and TB patients 94
Professional relations 97
Nurse/patient abuse 102
Salaries 107
Non-monetary rewards 110
Conclusion 110
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8 st a n d a r d s ,I m a G e a n d s t a t u s 112
Have standards dropped? 112
Views on status and image 113
Positive views 120
Conclusion 121
9 co n c l u s I o n s 122
Method 122
Findings 122
Conclusions and recommendations 125

ap p e n d I c e s 
Appendix 1 Consent form for interviewees 129
Appendix 2 Interviewees and focus group participants 131
re f e r e n c e s 134
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Tables
Table 2.1 Growth in SANC registers by professional category, 1996–2006 17
Table 2.2 Proportions of different categories of nurses on SANC registers, 1996–2006 19
Table 2.3 Numbers and percentages of registered nurses, 1960–1990 21
Table 2.4 Racial distribution of nursing staff in the public sector by occupational category,
2006 21
Table 2.5 Age distribution of nursing staff by occupational category, 2006 23
Table 2.6 Total registrations with SANC versus nurses in employment, 2001 and 2005 24
Table 2.7 Population of South Africa, nurses in public and private sectors, and medical aid
beneficiaries, 2001 and 2005 24
Table 2.8 Nurses in South Africa and neighbouring countries, various years 26
Table 2.9 Nurses in OECD countries, various years 27
Table 3.1 Department of Health targets for the production of nurses, by category 30
Table 3.2 HIV prevalence among respondents by sex and age group, 2005 35
Table 3.3 Antiretroviral therapy treatment roll-out (for adults) in the provinces 39
Table 4.1 Nurses and midwives trained in sub-Saharan Africa working in seven OECD
countries, 2004 45
Table 4.2 Doctors trained in sub-Saharan Africa working in eight OECD countries, 2004 46
Table 4.3 Documented nurse immigrants and self-declared nurse emigrants, South Africa,
1999–2003 47
Table 4.4 Self-declared emigrant nurses by gender and age, South Africa, 2003 47
Table 4.5 Verifications of qualifications and transcripts of training issued by SANC to countries

specified, 2001–2004 48
Table 4.6 Summary of statistics on nurse emigration from South Africa 49
Table 4.7 Approved work permits for South African nurses, 2000–2004 50
Table 5.1 Output from all nursing courses and bridging programme, 1997–2006 66
Table 5.2 Output of professional nurses from four-year and bridging programmes, 1996–2006
68
Table 5.3 Output of enrolled nurses by year, 1997–2006 69
Table 5.4 Output of enrolled nursing auxiliaries by year, 1997–2006 70
Table 5.5 Output for nursing courses by province, 2006 72
Table 5.6 Increase in registrations of PNs compared with number of PNs that qualified in
previous year, 1997–2006 79
Table 5.7 Increase in registrations of ENs compared with number of ENs that qualified in
previous year, 1997–2006 80
Table 5.8 Increase in registrations of ENAs compared with number of ENAs that qualified in
previous year, 1997–2006 80
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vi
Figures
Figure 1.1 A model for the analysis of a profession and professional education, applied to the
nursing profession and the education of nurses 2
Figure 1.2 Waiting area of a public hospital in Manenberg, Cape Town 4
Figure 1.3 Waiting area of a private hospital in Constantia, Cape Town 4
Figure 2.1 Growth in SANC registers, 1996–2006 18
Figure 2.2 Gender distribution of nursing staff by occupational category, 2006 20
Figure 2.3 Gender distribution of nursing staff learner category, 2006 20
Figure 2.4 Comparison between nurse and population distribution, 2006 26
Figure 5.1 Overall professional nursing output, 1997–2006 68
Figure 5.2 Output of pupil nurses (ENs) by year, 1997–2006 69

Figure 5.3 Output of pupil auxiliaries (ENAs) by year, 1997–2006 71
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Many of the hopes and aspirations of South Africa’s new democracy depend upon the
production of professionals who not only have globally competitive knowledge and skills
but also want to stay and work in the country and contribute to the national development
effort and social transformation. This quest has particular significance in the nursing
profession, which has lost many thousands of nurses to developed countries that are
already better supplied with health professionals than South Africa. In this country, nurses
are struggling to cope with the demands of a population that has high levels of diseases
related to poverty and underdevelopment, injuries and HIV/AIDS, as well as chronic
diseases. Conditions are particularly bad in the public sector, where only 60%
of nurses are serving potentially 85% of the population, who are uninsured and largely
reliant on public services.
At the same time, the role of the public sector in the training of nurses has diminished.
At present only public colleges and universities are licensed to offer the four-year
programme that trains professional nurses, but together these institutions produced fewer
professional nurses in 2006 than 10 years earlier in 1997. This has serious implications, as
these are the only institutions that are allowed to offer the four-year professional nurse
programmes that include training in midwifery, psychiatric and community nursing as
well as general nursing.
By 2006, the majority of professional nurses were being produced through the two-year
bridging programme that is offered in the private as well as the public sector. However,
this programme, which upgrades enrolled nurses (ENs), trains only for general nursing.
The private sector has also become the major provider of training for enrolled nurses and
enrolled nursing auxiliaries (ENAs). Private colleges were responsible for 70% of EN
output and 78% of ENA output in 2006.
These are just some of the issues that are explored in detail in this monograph, which is

the fourth in the HSRC’s research project on Professions and Professional Education. The
first was a study of the medical profession, titled Doctors in a Divided Society (Breier &
Wildschut 2006), the second was a study of social workers, titled Social Work in Social
Change (Earle 2008) and the third was on engineering titled Engineering in a Developing
Country (Du Toit & Roodt, 2009). The studies are intended to explore issues relevant to
the future development of the profession concerned and to bring our findings to policy,
academic and public attention.
Dr Mignonne Breier
Project leader and series editor
Professions Project
Education, Science and Skills Development Programme
Human Sciences Research Council
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This study would not have been possible without the cooperation of many individuals,
including:
The academics and students who agreed to be interviewed or who participated in •
focus group discussions. They were from the following educational institutions:
University of KwaZulu-Natal•
KwaZulu-Natal College of Nursing•
University of the Western Cape•
Western Cape College of Nursing•
Healthnicon•
Netcare Training Academy. •
The representatives of various organisations associated with the nursing profession. •
They include:
the South African Nursing Council •
the Democratic Nurses Organisation of South Africa •

National Education, Health and Allied Workers Union •
the Department of Health•
the private hospital groups: Life Healthcare, Netcare and Medi-Clinic•
private nursing agencies and schools.•
We are grateful to Professor Laetitia Rispel of the Centre for Health Policy, School of
Public Health at the University of the Witwatersrand, and Professor Sophie Mogotlane,
academic chairperson of the Department of Health Studies at UNISA, for reviewing the
first draft of this monograph and providing valuable comments and suggestions.

Finally, we would like to thank Atlantic Philanthropies for their financial support and
Christine Downton and Khosi Xaba, in particular, for their encouragement.
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AIDS acquired immunodeficiency syndrome
ART antiretroviral therapy
ARV antiretroviral
BCur Baccalaureus Curationis
DENOSA Democratic Nursing Organisation of South Africa
DoE Department of Education
DoH Department of Health
DoL Department of Labour
EN enrolled nurse
ENA enrolled nursing auxiliary
GDP gross domestic product
HAART highly active antiretroviral therapy
HEMIS Higher Education Management Information System
HIV human immunodeficiency virus
HSRC Human Sciences Research Council

HST Health Systems Trust
HWSETA Health and Welfare Sector Education and Training Authority
KZNCN KwaZulu-Natal College of Nursing
LFS Labour Force Survey
MDR TB multi-drug-resistant tuberculosis
MSF Médecins Sans Frontières
NEHAWU National Education, Health and Allied Workers Union
NHR Plan National Human Resources for Health Planning Framework
NQF National Qualifications Framework
NSFAS National Student Financial Aid Scheme
OECD Organisation for Economic Co-operation and Development
OSD Occupation Specific Dispensation
PHC primary healthcare
PN professional nurse
RN registered nurse
SADC Southern African Development Community
SAMP Southern African Migration Project
SANC South African Nursing Council
SANNAM Southern African Development Community AIDS Network of Nurses and
Midwives
SAQA South African Qualifications Authority
SETA Sector Education Training Authority
Stats SA Statistics South Africa
TB tuberculosis
UK United Kingdom
UKZN University of KwaZulu-Natal
UNAIDS Joint United Nations Programme on HIV/AIDS
USA United States of America
UWC University of the Western Cape
VCT voluntary counselling and testing

WCCN Western Cape College of Nursing
WHO World Health Organization
XDR TB extensive drug-resistant tuberculosis
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Introduction
The nursing profession in South Africa today is in need of care. Thousands of nurses
have left the country, either temporarily or permanently, to seek better conditions abroad.
Those who remain face increasingly demanding workloads as HIV/AIDS and tuberculosis
(TB) take their toll. Although many young people choose to study nursing and
applications for nursing education programmes far outnumber available places, the
profession itself is not growing in proportion. Attrition, both during and after training, is
high, and two-thirds of all practising nurses are over the age of 40. At the same time, the
image and status of nursing is low. Once regarded as an elite profession for women, it is
now overshadowed by other more attractive and lucrative careers. Yet nursing remains
the foundation of healthcare in South Africa and needs to be nurtured and strengthened if
the country is to overcome the health challenges facing it. This monograph aims to
contribute to the future development of the profession by presenting in detail the trends
outlined above and suggesting possible causes and solutions.
This study of nursing forms part of the HSRC’s Professions and Professional Education
research project in which a number of professions are being researched with the aim of
addressing this question: How is this profession and its professional education
programmes responding to the needs and challenges of a transforming South Africa?
A conceptual framework for the study of nursing
In the HSRC research project, professions and their professional education programmes
are viewed from two broad perspectives

1
which are summarised below and illustrated in
Figure 1.1:
The first conceptual lens focuses on the current state of the• professional labour
market and explores the extent to which the supply of professionals from
educational institutions meets or exceeds demand. The local professional market is
the major concern, but international conditions and markets are also taken into
account. The broader local labour market is also relevant to the extent that it
includes other supporting or competing professions.
The second conceptual lens focuses on the • professional milieu, which encompasses
the socio-economic and political conditions that affect the practice of the profession,
as well as the discourses that determine what it means to be a ‘professional’
behaving ‘professionally’ in the particular profession concerned. An examination of
the professional milieu starts with a consideration of the structural arrangements that
underpin the practice of the profession: what it takes to become a professional and
what rules, bodies and professional associations govern practice.
Obviously this is a very broad remit and it is beyond the scope of this study – or any of
the professions studies – to discuss all of these features in depth. They provide starting
points for preliminary, macro-level research from which key issues for detailed
exploration can be identified.
Figure 1.1 illustrates the relationships between the various features of the dual foci of the
professions studies. Although the basic structure of the diagram can be applied to other
professions, the specific details in this diagram relate to nursing in particular. The
following description of the diagram is designed to provide a very brief overview of the
1 See Breier and Wildschut (2006: 2–8) for further discussion of the methodology.
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factors affecting nursing in South Africa today. It is from these factors that particular issues

were identified for detailed exploration in micro-level, case study research.
At the heart of all the HSRC professions studies is the professional education sector seen
in the context of the local professional labour market. In Figure 1.1, the nursing education
sector, which encompasses students, academics, nurse educators and clinical facilitators, is
indicated in the centre oval. The inclusion of educational issues in the HSRC professions
studies is one of their most distinguishing and unusual features. In our preliminary
research on nursing, we found that the following features of the education system are
crucial in the shaping of (and are also being shaped by) the professional labour market:
changes in the public institutional landscape, including the closure or merger of •
colleges and an increasing emphasis on university education of nurses;
changes in the locus of training, with the private sector assuming the major role in •
the training of lower-level nurses;
changes in the qualifications for professional nurses, with an increasing emphasis on •
degree programmes and on comprehensive training.
These features are among the major foci of our study and are discussed in depth in
Chapter 5.
All of these educational issues are seen in relation to the national professional labour
market for nurses, which has two main divisions: the public sector and the private sector.
The dotted lines in the second oval in Figure 1.1 indicate the proportions of nurses
working in each of these sectors: about 60% of the nursing workforce in South Africa is
Figure 1.1 A model for the analysis of a profession and professional education, applied to the
nursing profession and the education of nurses
Legislation and
health system
Undersupply/
good conditions
(e.g. UK, USA,
Saudi Arabia)
Socio-economic
and political

conditions
Socio-economic
and political
conditions
Legislation and
health system
Public
sector
Private
sector
Nursing
education
Discourses on
healthcare/
professionalism
Poor
conditions
(e.g. other
African
countries)
Discourses on
practice/
professionalism
Disease
burden
Disease
burden
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employed in the public sector, and the remaining 40% in the private sector. The education
of nurses straddles both sectors, with increasing numbers of nurses at lower levels being
trained by private training institutions (by the major hospital groups and private nursing
colleges)
2
while four-year programmes that produce comprehensively trained professional
nurses are offered by public institutions (universities or colleges).
Beyond the national professional labour market is the national general labour market
with all the professions that compete for the attention of young school leavers and
graduates today. Whereas in the past nursing was one of very few professional options
open to women, it is now just one of many possibilities. However, an enduring advantage
of nursing training is that it enables one to work in many other parts of the world
because of the universality of knowledge and skills associated with the profession. There
are many opportunities for trained nurses in the international professional labour market,
particularly in developed countries with low birth rates that lack sufficient health
professionals to care for their ageing populations.
The national professional milieu provides the broad context in which nursing in South
Africa finds itself today. This context has four main dimensions:
the structural arrangements governing the nursing profession and the health system •
of which it forms a part;

the socio-economic and political conditions that affect the health of the nation; •
the disease burden; •
the prevailing discourses on nursing practice and professionalism.•
Each of these dimensions deserves closer scrutiny.
Firstly, the structural arrangements include the legislation that governs nursing; the
policies and practices of the two government departments that affect it (the Department
of Health [DoH] and the Department of Education [DoE]); and the role of the South
African Nursing Council (SANC) in setting and maintaining standards and of professional
organisations in representing nurse members. The latter organisations include the
Democratic Nursing Organisation of South Africa (DENOSA) and the trade union National
Education, Health and Allied Workers Union (NEHAWU). Given the focus of this
monograph on nursing in the post-apartheid era, it is important to consider the ways in
which these structural elements have evolved since the transition to democracy in 1994.
Van Rensburg and Pelser (2004: 162–165) list and evaluate the major reforms in the South
African health system since 1994. Health policy and health legislation have been
overhauled in order to dismantle apartheid institutions and remove discriminatory
measures. Progress has been made towards the consolidation of fragmented and
segregated services, and the district-based primary healthcare (PHC) system is now the
basis of the health system. Large numbers of staff have been PHC-trained. The move to
PHC has shifted the emphasis of healthcare policy and practice from biases towards
urban-, hospital-, physician- and high-technology-oriented healthcare towards ‘more
equitable geographical locations for health care and more appropriate and accessible care
for all’ (2004: 162). Free healthcare policies have brought greater access to healthcare in
the public domain. There has been greater legitimisation of complementary and
alternative forms of healing, including strategic support for African traditional healing, and
greater community involvement and participation in health matters.
2 Students in independent private colleges might be contributing to the public sector workforce if the college gains
placements in public sector institutions. However, those who train in the nursing schools of the big hospital groups also
work in their hospitals.
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Van Rensburg and Pelser also
list a number of constraints and
failures. Most importantly, the
‘two-class’ character of the
health system remains,
characterised by a weak and
overburdened public sector
offering ‘second-class services’
and a much stronger private
sector offering ‘first-class
services’ (2004: 163). There is
little evidence of a strengthening
of the public sector. Indeed, the
sector is becoming even more
overburdened as increasing
numbers of patients switch from
the private to the public sector
because of increasing costs and
diminishing returns of medical
aid schemes. As indicated by
data provided in Chapter 2,
approximately 85% of the South
African population is served by
the public sector, where 60% of
the country’s nurses and only
40% of its doctors are employed.
Figures 1.2 and 1.3, showing

waiting areas of a public hospital and a private hospital respectively, illustrate the stark
contrast between the public and private sectors.
The second dimension is the socio-economic conditions that affect the health of the
nation. Van Rensburg and Pelser note that health reforms and improved healthcare play
but a small part in the enhancement of health:
Health and ill health are as much and even more the result of prevailing socio-
economic conditions and lifestyle and thus do not necessarily respond to
biomedical and health care interventions…evidence is lacking to convincingly
conclude that the general living, working and health conditions of the majority
of the South African population have improved significantly since 1994 or that
such improvements reflect in health indicators. (2004: 165)
The third dimension of the professional milieu concerns the state of health of the nation
or, to put it another way, the burden of disease. South Africa is said to have a ‘quadruple
burden of disease’, which includes diseases related to poverty and underdevelopment,
chronic diseases, injuries and HIV/AIDS (Norman et al. 2006: 27). In this monograph,
much attention will be paid to the impact of HIV/AIDS and TB, in part because of the
sheer scale of the epidemics (see Chapter 3) but also because they were frequently
referred to in interviews and focus group discussions (see Chapter 7). Briefly, in 2007 an
estimated 5.5 million South Africans were living with HIV or AIDS, and the HIV
prevalence rate was around 11% overall and as high as 33% among women in their early
30s. TB is the most serious HIV/AIDS-related opportunistic infection and South Africa has
Figure 1.2 Waiting area of a public hospital in Manenberg,
Cape Town
Figure 1.3 Waiting area of a private hospital in Constantia,
Cape Town
Mignonne Breier Ian Landsberg
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the fifth highest number of TB cases in the world. Van Rensburg and Pelser describe the
conditions shaping the health of the nation in the following terms:
Poverty and unemployment are still rife; backlogs in housing, pure drinking
water and sanitation persist; large proportions of the population are
undernourished; levels of crime, violence and trauma remain high; the HIV/
AIDS and TB epidemics are still skyrocketing, and so are co-infection and
MDRTB [multi-drug-resistant TB]; the disruption of family life, of safety nets and
of social support structures is surging; mass labour migration and illegal
migration persist; and South Africans are smoking more. Amid these broader
trends, improvements in health care would have minor effects, if any, on the
health of South Africans. (2004: 165)
The fourth dimension of the professional milieu invites one to consider discourses
on nursing practice and professionalism – specifically, the ways in which these
discourses shape and are shaped by events in the nursing profession, as well as the
interrelationships between these discourses and demand and supply in the professional
labour market. Against this background, an important concern in this monograph is the
image and status of nursing (which has declined), the relationship between image and
status and conditions in the health sector (both have been affected by the nature of
diseases and conditions in the public sector as well as by poor salaries) and the
corresponding effects on the supply of nurses (there is a large discrepancy between the
numbers of nurses in the education system and the numbers of registrations in the
profession itself). Trends in nursing education are discussed in Chapter 5; Chapter 8
explores the image and status of the profession.
The international professional milieu is shaped by similar factors on a global scale:
The legislation, policies and structures that shape the nursing profession and the •
type of health system in the country concerned.
Prevailing discourses on healthcare and professional nursing practice. In this context •
the worldwide shift to primary healthcare that followed the 1978 Alma-Ata
Declaration is of fundamental importance, contributing ultimately to changes in the
structure and emphasis of the South African health system and, in the case of

nursing, to the current emphasis of nursing education on comprehensive training
that equips nurses for primary healthcare settings. The Declaration, drawn up at an
international conference at the Russian town of Alma-Ata, argues that health is a
fundamental human right and that
the gross inequality in the health status of the people, particularly between
developed and developing countries, as well as within countries, is
politically, socially and economically unacceptable and is, therefore, of
common concern to all countries. (WHO 1978: 1)
The international burden of disease.•
The socio-economic and political conditions that shape the health of nations, which •
are closely related to processes of globalisation and the international professional
labour market.
The existence of the international professional labour market is one of the many double-
edged features of globalisation. On the one hand, it offers opportunities for individual
travel and advancement, the acquisition and exchange of new knowledge (through study
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programmes, academic exchanges and conferences, for example) and valued remittances
for some developing countries that export professionals as a source of national income.
On the other hand, the global professional market also presents severe threats for many
developing countries that are losing the professionals they educate to countries that can
pay them more and offer better working and living conditions. The existence of shortages
at both ends of the development spectrum contributes to the international pull and push.
In the worst scenarios, the donor country is poor and has many great infrastructural,
health and economic needs that are exacerbated by the loss of its professionals. It has to
rely on expatriate contractors and international development organisations to meet its
skills needs.
International recruitment alleviates shortages (from the perspective of the recipient

country) but exacerbates shortages in donor countries, often leading to further disaffection
and emigration. This is the plight of many poor African countries.
In considering the international labour market, one must take into account the
universality of the body of knowledge associated with particular professions and the rules
of the country governing the admission of professionals from other countries. In this
respect, a South African nursing qualification, acquired through the medium of English
and entailing a relatively universal body of knowledge and skills, is highly marketable in
many mainly English-speaking countries.
Against this background, it is not surprising that many South African nurses, with highly
marketable qualifications but low salaries and unsatisfactory working conditions, have left
the country either temporarily or permanently to work abroad. It is also not surprising
that there is widespread recruitment of South African nurses by international recruitment
agencies, despite some government-to-government agreements that prohibit recruitment
by the foreign country’s public sector.
Poor salaries have been recognised as a major cause of dissatisfaction, and in September
2007 the government concluded a historic agreement, called the Occupation Specific
Dispensation (OSD), with various trade unions including DENOSA that raised the salaries
of public service nurses substantially. It is expected that these changes will do much to
elevate the status of nursing and bring back into the public sector the nurses who went
into other fields of work or into private sector nursing, including lecturers who left the
profession after the closure of colleges DoH (2004a).
3

The arrows in Figure 1.1 show the flow of nurses from South African training institutions
(centre oval) into the local professional labour market, the migration of nurses from the
public to the private sector, and from the local labour market to the international market,
in particular to countries such as the UK, the USA and Saudi Arabia, where there are
shortages of nurses. The arrows from the international labour market into the country
depict those foreign nurses who come into South Africa, or who wish to come – for
example, nurses from other African countries who want to work in South Africa but are

unable to obtain the necessary verification of their professional qualifications. According
to Bateman (2007b: 82), this is mainly because of ‘poor compliance with application
3 Unfortunately, our research was already at an advanced stage when the increases were introduced and we were not
able to discuss them with all the interviewees or focus group participants. However, we gained the impression from
those who did speak to us that there were some hiccups in the implementation of the increases and not all categories
of nurses were satisfied. Nurse educators in particular felt they had not been recognised sufficiently.
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requirements and an inability by war-torn, dysfunctional African governments to verify
professional qualifications’.
The complexity of Figure 1.1 illustrates the magnitude of the task of trying to depict the
state of the nursing profession at a particular point in time. However, not all factors were
treated in the same depth in our study. From preliminary research, certain key issues
were identified for detailed exploration, as discussed in the next section.
Research design
The conceptual framework detailed above arises out of a particular research methodology
that was piloted in the HSRC’s first professions study on doctors and was subsequently
followed, with variations, in the studies of social workers and engineering professionals.
In terms of this methodology, the first task in a professions study is to conduct a
preliminary scoping exercise, which involves reviewing major current literature and
secondary sources and conducting preliminary interviews with principal stakeholders in
order to identify key issues that are subsequently explored in greater depth using various
research methods as deemed appropriate. Qualitative case studies at selected education
sites, which include in-depth interviews and focus group discussions, are undertaken to
focus on the issues identified.
In the nursing study, our review of statistics and our preliminary stakeholder interviews,
as well as a specific brief from the Department of Labour (DoL),
4

encouraged us to focus
on two key elements: first, the existence, nature and extent of a shortage of nurses in the
country and possible reasons for this; and second, the large discrepancy between the
number of nurses who graduate each year and the number of new professional
registrations. In our case studies we chose to pay particular attention to student views on
nursing and on their future careers, in an effort to shed some light on the gap between
graduation and entry into the profession.
Data sources
Our exploration of the nursing shortage in South Africa required attention to a range
of statistical databases. Statistics on the nursing workforce based on nurse registrations
were collected from SANC and the Health Systems Trust (HST), which draws on the
government’s human resource database, PERSAL. Figures on trained nurses were obtained
from SANC, from the DoE’s Higher Education Management Information System (HEMIS)
database and from private providers. Statistics South Africa (Stats SA) was the main source
of statistics on the South African population, while the World Health Organization (WHO)
provided statistics on international health trends. We used figures from the Labour Force
Survey (LFS) for 2001 and 2005 to estimate the number of nurses on the SANC register
who were in employment.
4 As part of a separate study on scarce and critical skills commissioned by the DoL, the researchers analysed data
collected across both studies in a manner that sought to address the following question: Is there a shortage of nurses in
South Africa? These data included statistics on nursing supply and demand as well as a review of policy documents,
Skills Education and Training Authority (SETA) reports, newspaper cuttings and other relevant secondary sources. This
research led to a report by Wildschut and Mgqolozana (2008) and a chapter for a monograph that will consist of similar
chapters on 12 different professions, each addressing the same questions on shortage of human resources (Erasmus &
Breier, 2009).
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Where possible, we tried to disaggregate figures by population group and gender to show

the extent of transformation, a major concern in most professions in South Africa today.
International literature on professions barely touches on race issues, although the
feminisation of professions is addressed. Given South Africa’s history of enforced racial
segregation, it is important to see whether the racial profiles of the professions are
changing. To do this, we unfortunately needed to continue to employ the racial
classifications that were used to separate and discriminate against people during
apartheid. In many contexts, people are still asked to provide their racial details for the
purposes of monitoring progress towards equity. However, it is becoming increasingly
common for people to refuse to do so. This is why we have not been able to give a
racial breakdown of SANC figures, although we are able to give a gender breakdown. To
get an idea of racial splits in the nursing workforce, we had to rely on figures from the
HST for the public sector (taken from the PERSAL database) and figures from HEMIS for
university nursing programmes. In this monograph, we use the terms ‘African’, ‘coloured’,
‘Indian’ and ‘white’ to denote the different population groups indicated in the data
sources (usually based on forms completed by individuals). Where we wish to refer to all
population groups other than the white cohort, we use the term ‘black’.
5
The literature that we reviewed comprised both national and international sources and
included
policy documents and legislation; •
books on the history of the profession and the BCur (Baccalaureus Curationis) •
nursing degree programme;
academic journal articles on a range of topics relevant to the profession, including •
gender issues, migration, salary issues and international trends in the profession;
professional publications, including DENOSA’s own magazine, • Nursing Update, and
its accredited journal, Curationis.
We also subscribed to a newspaper cutting service run by the University of the Free State
that provided us with newspaper articles on nurses and nursing during the first nine
months of 2007. Thereafter we continued to compile our own collection of articles from
local daily papers and national weekend papers. The newspaper articles provided

coverage of most of the major public debates that affect nursing: the nurses’ strike, the
new salary dispensation, emigration of nurses and other health professionals, abuse by
and of nurses, and conditions in the private and public health sectors.
Interviews
Preliminary discussions were held with key players in the nursing profession, such as
members of the DoH and SANC, a director of the HST, and the head of the HSRC’s Social
Aspects of HIV/AIDS programme. These discussions informed our selection of additional
individuals to interview formally, as well as our selection of case study institutions.
Formal interviews were conducted with representatives of DENOSA; NEHAWU; the
provincial government of the Western Cape; the major hospital groups Netcare, Life
Healthcare and Medi-Clinic; and a major nursing agency, Nursing Services of South Africa.
These interviews took place at the headquarters of the various organisations.
5 We are aware that increasing numbers of South Africans of all races wish to be identified as African. In our usage, the
term ‘African’ refers to black Africans only.
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In addition, for the case studies we conducted interviews with university and college
lecturers and clinical nurse educators. We also conducted interviews and focus group
discussions with students. These are discussed in detail in the following section.
Case studies: Interviews and focus group discussions
Central to each of the HSRC’s professions studies are case studies of educational
institutions that offer professional education programmes. These institutions are selected
purposively, to show how certain professional issues, identified in the preliminary
research, are taken up in the professional education programmes. Selection for illumination
of theories or issues, rather than generalisation, is an accepted form of purposive sampling
commonly used in case study research (Maxwell 1996; Yin 1984, 1993).
In the case of nursing we decided to do case studies at each of the three major types of
nursing education institution: universities, colleges and private training schools (including

those training programmes run by big hospital groups as well as smaller operations). The
selected institutions were:
University of the Western Cape (UWC);•
University of KwaZulu-Natal (UKZN);•
Western Cape College of Nursing (WCCN);•
KwaZulu-Natal College of Nursing (KZNCN);•
the Bellville campus of the private nursing education provider Healthnicon;•
Netcare Training Academy, Bellville branch.•
At these institutions we conducted interviews with lecturers and held focus group
discussions with students (see the list of respondents in Appendix 2). The exceptions
were at UWC, where we did not hold focus group discussions but interviewed students
(a requirement of the university), and at Netcare, where we interviewed the director of
nursing services rather than lecturers. The reason for the change of procedure at UWC
was that the dean of research at that institution refused to give permission for focus
group discussions on the grounds that the students participating would not be able to
remain anonymous. Although our focus group questions did not ask students to speak
about HIV/AIDS in a personal way, it was felt that there could be embarrassing or
compromising disclosures that might have far-reaching stigmatising effects for the
student(s) concerned.
All interviewees were asked to sign a consent form, granting permission for the interview
and stipulating whether they were prepared to be identified and whether they agreed to
the use of a tape recorder in the interviews (see the sample consent form in Appendix 1).
In the interviews with academics, interviewees were asked to give a brief summary of
their career before stating what they thought were the major issues in the nursing
profession and nursing education today and how these were being addressed in nursing
education programmes. Interviewees were asked to give the responses that first came to
mind before being prompted to respond to specific questions on various themes,
including choice of career, salaries, conditions, emigration, abuse, stress, relationships
with doctors and the status of the profession. Similar broad questions and prompts were
used in the interviews with clinical nursing staff, nursing managers, and representatives of

selected organisations and nursing agencies. Most interviews lasted between 40 and 90
minutes. The interviews were fully transcribed and summarised according to their key
themes for purposes of analysis.
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The questions posed in the focus group discussions with students were more specific
than those used in interviews with academics. It was felt that students would not be as
informed about issues in the profession as their lecturers were and would therefore need
more specific prompts from the outset. The questions covered themes such as reasons for
choosing nursing education, the status of nursing, nurses’ salaries, what students thought
of nursing strikes, emigration, gender relations and cases of abuse (of and by nurses).
In the end we held focus group discussions and interviews with a total of 180 students.
We conducted in-depth interviews with 41 academics and 13 representatives of various
stakeholders including the major hospital groups, SANC and DENOSA.
Division of labour
Three researchers were involved in the research that informs this monograph. All three
participated in the literature review and secondary data gathering. Angelique Wildschut
and Thando Mgqolozana wrote the DoL report that informed much of the quantitative
analysis for this study. They also conducted interviews at UKZN, KZNCN and Healthnicon
as well as focus group discussions with students at WCCN, KZNCN and Netcare.
Mgqolozana also conducted interviews with students at UWC, while Wildschut interviewed
senior staff at UWC and Medi-Clinic. Mignonne Breier conducted interviews with senior
staff and/or representatives at UWC, WCCN, DENOSA, NEHAWU, SANC, the Western Cape
provincial government, and the private hospital groups Life Healthcare and Netcare.
Collaborative writing is notoriously difficult, and the writing up of this study was no
exception. Breier, the project leader of the professions studies, assumed the responsibility
for the writing of the report, drawing on her own research and that of the other two
researchers as well as further research (literature, statistics, policy documents) as new

issues that had not been anticipated in the original planning of the research unfolded.
The development of new insights is one of the features of qualitative research: one
frequently finds that as new issues emerge the data and literature with which one
embarked on the research may no longer be as relevant as first anticipated.
In order to share the knowledge among the research team, Wildschut and Mgqolozana
each compiled sub-papers on certain key themes: the new salary dispensation, the public
service strike, HIV/AIDS and nursing, gender relations in nursing and two papers
analysing quantitative data on population groups and gender in public nursing education.
Mgqolozana also wrote a personal account of his own experience as a university student
training to be a professional nurse.
In addition, most of the interviews were transcribed in full. Wildschut and Mgqolozana
also made summaries of the interviews and focus group discussions. Breier read through
the summaries and transcripts to identify the key themes and the responses to them. The
qualitative responses were then organised under the following key themes: what the
respondents felt were the key issues (the range and the most common), reasons for
becoming a nurse, attitudes towards emigration, and views on working conditions. Files
were created under these headings, and responses were copied into them and then
summarised and analysed in the light of the quantitative and secondary research.
Reviewers
It is a condition of the methodology of the HSRC professions studies that the monographs
are subjected to at least two external reviews prior to publication. The reviewers are
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usually academics or prominent individuals in the field concerned. Reviewers are required
to submit detailed critiques with suggestions for improvement. This nursing study was
formally reviewed by two nursing professors. Having said this, we also need to make
clear that they are not in any way responsible for the final monograph. Although we tried
to do justice to their recommendations, ultimately this monograph reflects our analysis

and viewpoints, not those of the reviewers.
Limitations
While the study has attempted to provide a broad and comprehensive view of nursing, it
has been subject to a number of limitations. There were logistical limitations arising out
of the limited time and budget available to conduct the study. There were also other
limitations related to the nature of the enquiry. Preliminary research indicated the
importance of the views of students and academics, and thus our empirical research
focused on case studies at selected educational institutions. This led to considerable
emphasis on the perceptions of those involved in nursing education, with national
stakeholders in the profession speaking for the profession in general. Another focus might
have placed greater emphasis on the perceptions of nurses themselves, but the research
questions and objectives would have been different.
Data limitations
As indicated earlier, statistics supplied by SANC did not provide the racial composition of
the nursing workforce or of nurses in training. We made use of a number of data sources
to get some sense of the racial profile: pre-1990 figures from SANC, which were still
disaggregated by population group, PERSAL data for the public sector as reported by the
HST and, in relation to university students, data from the DoE’s HEMIS. However, there
were large discrepancies between the HEMIS totals and those reported by SANC, as well
as gaps from one year to the next. In the end we made use of data for only one year
(2005), where the data were found to be reasonably reliable. Another concern was the
fact that the totals on the SANC register included nurses who were not active (those who
had retired, left the profession, gone abroad, and so on). Thus LFS data for the years 2001
and 2005 were used to get the numbers of nurses who were actually working as nurses
in South Africa. These LFS data are problematic in themselves, as they also have many
gaps (see Breier 2007 and Wildschut & Mgqolozana 2008).
Emigration data (discussed in detail in Chapter 4) are even sketchier. Many different
information sources were used to estimate the extent of nurse migration, including a
count of letters of verification of qualifications, which are kept by SANC, and statistics
from WHO and the Organisation for Economic Co-operation and Development (OECD)

about nurses in foreign countries. A caveat in regard to these data is that it is not always
clear what level of ‘nurse’ is referred to by these data sets.
Outsider research
The HSRC professions studies have been conducted by outsiders to the professions
concerned – that is, by researchers specialising in research on education and the nexus of
education and work. It is debatable whether this is more appropriate than having an
insider (a practitioner or educator in the profession) conduct the research. An insider
would contribute many insights, but might also bring biases associated with his or her
professional involvement, whereas a professional researcher could present a broader and
hopefully more dispassionate view. Yet no perspective can be all-encompassing and each
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approach presents its own problems. The professions studies so far have chosen to
pursue the ideals of breadth of vision and objectivity rather than the kind of detail that
only an insider can provide.
In the nursing study we deviated slightly from this model by including on the research
team a professional nurse who is also a graduate from UWC. Thando Mgqolozana’s
insider experience provided background and depth on issues relating to university
education of nurses. However, we have to accept the possibility that it might also have
influenced the trajectories of his interviews and focus group discussions. Certainly he
encountered more reserved responses from students at UWC, where he was known to
many students, than at UKZN, where he was not known. However, this reserve is more
likely to be the result of the requirement at UWC that only interviews and not focus
group discussions be conducted. Students generally seemed more outspoken in focus
group discussions than in individual interviews.
Another feature of the student interviews and focus group discussions needs to be
mentioned. Many students spoke openly about their plans to leave nursing after
graduating and considerable attention is paid to their views in this monograph. There are

obvious limitations to seeking to find reasons for attrition after graduation from students
who are still in the education system. They are speaking about their plans, not what they
have actually done post graduation. Obviously the latter focus would have been ideal but
was beyond the scope of our project in terms of time and budget. We can only urge that
this gap be taken up in future research.
Categories of nurses
It is important that we define the various categories of nurses to which we will refer in this
monograph. Nursing has a complex hierarchical structure with associated terminology,
which has been further complicated by recent changes in legislation governing the
profession and its educational programmes. In addition, nursing education in South Africa
takes place in a particularly complex education and training terrain that includes
universities and technikons (now universities of technology), public stand-alone nursing
colleges, nursing schools attached to public hospitals, private colleges run by the major
hospital groups, private colleges attached to old-age homes and private colleges that train
for profit. The latter type of college generally does not have its own facilities for clinical
experience and must make arrangements with other facilities where nursing students can
gain the 1 000 hours of clinical experience per year that is required for all levels.
All nurses are required to register with SANC, which maintains two different registers: one
is called a register and the other a roll. Nurses must have gone through at least four years
of training to qualify to be registered on the SANC register. These will include nurses who
have passed a four-year programme in a university or a public nursing college, leading
to a nursing degree or diploma respectively. Or they might have qualified through a
bridging programme, which is a two-year course designed to upgrade the qualifications
of nurses who have already trained for two years and are working as ‘enrolled’ nurses.
The bridging programme can be offered by private as well as public nursing education
institutions, but the four-year programme is offered only at public institutions
(universities/universities of technology, and public nursing colleges). The entrance
requirement for the degree is normally a senior certificate with endorsement (exemption)
and for the four-year diploma a senior certificate. To enter the bridging programme one
must have already qualified as an enrolled nurse (see below).

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Registration on the SANC register entitles one to be called a registered nurse (RN) or
professional nurse (PN). These terms are often used interchangeably, but the strict
distinction is that the term ‘professional nurse’ should be used only for those who have
been through a four-year programme that includes training in community nursing,
midwifery and psychiatric nursing as well as general nursing. A nurse who has completed
a bridging programme is qualified to practise only general nursing. In some contexts such
nurses are referred to as registered rather than professional nurses. In the clinical setting,
PNs and RNs are addressed as ‘sisters’, as in ‘Sister Mgqolozana’, regardless of whether
they are male or female.
SANC provides for two categories of nurses on its roll of nurses: enrolled nurses (ENs)
and enrolled nursing auxiliaries (ENAs). ENs have completed a two-year certificate
programme that has an entrance requirement of at least grade 10. This programme can be
offered by private as well as public training providers. ENAs have completed a one-year
certificate programme that also has an entrance requirement of at least grade 10.
There are also special terms for nurses in training: ‘student nurses’ are those studying
four-year programmes at universities or colleges, ‘pupil nurses’ are studying to be enrolled
nurses and ‘pupil auxiliaries’ are studying to be enrolled nursing auxiliaries.
The categories described above date back to the Nursing Act of 1978 and to government
regulations in the 1970s and 1980s pertaining to the minimum requirements for registered,
enrolled and auxiliary nurses.
The Nursing Act of 2005 (Act No. 33 of 2005) and the Draft Regulations Regarding the
Scope of Practice of Nurses and Midwives (SANC 2007a) present new categories of nurses,
all on the same register: professional nurse, professional midwife, staff nurse, auxiliary
nurse and auxiliary midwife. The Act and revised scope of practice reflect a new
approach to nursing education, in which professional nurses are better prepared for
primary healthcare settings and trained to practise comprehensively. At the time of writing,

professional nurses are still being trained in terms of Government Regulation 425 of 1985,
which provides for training in community, psychiatric nursing and midwifery as well as
general nursing by means of separate courses of study on each of these aspects. In
contrast, comprehensive training ‘does not imply or focus on attaining separate
qualifications but rather on the ability to integrate knowledge and skills for the provision
of comprehensive nursing care’ (Subedar 2005: 98).
At this stage, nursing qualifications have yet to be aligned with the revised scope of
practice. A new four-year qualification has been developed and registered on the National
Qualifications Framework (NQF) of the South African Qualifications Authority (SAQA).
However, this new qualification envisages that the basic qualification for a registered
nurse will in future be a bachelor’s degree. The implication is that only higher education
institutions (universities and universities of technology) would be able to offer this
qualification. The underlying reason for this change is that the nursing education system
is required to align itself with the NQF and the NQF does not allow for a four-year
qualification that is a diploma.
In its report Nursing Strategy for South Africa 2008 (DoH 2008), the DoH notes that
SANC has expressed concern about the new Bachelor of Nursing qualification, the
implementation of which would have a serious impact on the production of registered
nurses as the bulk of them are produced by nursing colleges which are not permitted to
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award degrees in their own right.
6
The DOH has requested that the qualifications be
realigned with the revised scope of practice.
What are the implications of this discussion for this monograph? Although at the time of
writing there are many moves afoot to change nursing qualifications and titles, they are
not yet fully in force. Our quantitative data refer to the period 1996 to 2006, when the old

categories were in place. For this reason, we use the ‘old’ terminology throughout the
monograph, and the training we discuss is that which prevailed at the time, even though
it was based on regulations dating back to the 1970s and 1980s.
Overview of the monograph
The chapter-by-chapter content of the monograph can be briefly summarised as follows:
Chapter 2 provides a quantitative profile of the nursing profession. We analyse the •
growth in the profession over a 10-year period, as well as the numbers of nurses by
category, gender, population group and age, public or private sector and provincial
location. The nurse-per-population data are then compared with those of other
countries, indicating that South Africa is better off than its immediate neighbours but
undersupplied in relation to developed countries and its own needs.
In Chapter 3 we attempt to establish whether there is in fact a shortage of nurses in •
South Africa by looking at vacancy rates and estimates of the demand for nurses
owing to the prevalence of HIV/AIDS.
In Chapter 4 we use various statistical sources to estimate the extent of nurse •
emigration. Drawing on secondary research as well as our own interviews and focus
group discussions, we consider reasons for emigration as well as the quality of
experience for nurses working abroad.
In Chapter 5 we present a quantitative overview of nursing education, in particular •
the output of nurses disaggregated by sector (private or public), programme (ENA,
EN and PN), province, gender and, where available, population group. We conclude
with a brief account of private sector training.
In Chapter 6 we explore the reasons why young people choose to become nurses, •
drawing on interviews and focus group discussions as well as secondary research.
We note the concerns of academics who state that they are unable to find sufficient
numbers of students who are truly suited to a nursing career despite the thousands
of applicants to nursing education each year.
In Chapter 7 we present the views of students on what it is like to be a nurse in •
South Africa today, based on their experiences in clinical practice. We note their
concerns about working with HIV/AIDS patients, about professional relations in the

hospital setting, about nurse and patient abuse, and about salaries. We end the
chapter with a consideration of the rewards of being a nurse.
In Chapter 8 we examine the standards, image and status of the profession. We note •
that older academics and nurses who we interviewed were concerned about the
drop in standards, and all interviewees, including students, were concerned about
the image and status of nursing as a profession. We examine possible reasons for
these declines.
In Chapter 9 we present conclusions and recommendations based on our research •
findings.
6 The bridging programme would also be phased out.
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15

Growth and profile of
the nursing profession
The nursing profession represents more than 50 per cent of the total
professional human resources of health services in South Africa;…moreover,
nurses provide the bulk by far of health services in the public sector.
(Van Rensburg 2004: 7)
This chapter considers the growth of the nursing workforce in South Africa in quantitative
terms in relation to the growth of nursing as a profession. It is argued that the patterns of
quantitative growth reflect the emphasis on developing nursing firstly as the work of
‘better educated’ women (Sweet 2004: 176) but subservient to the work of doctors, and
much later as a profession equal to other medical professions in worth and status, albeit
different. The high proportions of professional nurses compared with nurses in sub-
professional categories could be seen as an outcome of this professionalisation process.
The chapter also considers the profile of the nursing workforce, bearing in mind that its
development has been intimately enmeshed with the ‘racial, class and gender divisions of
a divided society’ (Marks 1994: 14).

The growth of nursing as a profession
Institutionalised nursing
7
in South Africa has its origins in the mid-seventeenth century
as a very lowly job in the ranks of the Dutch East India Company, which had sent a
surgeon, Jan van Riebeeck, to found a refreshment station at the Cape of Good Hope.
One of his first tasks was to set up a hospital for the starving and desperately ill sailors
that the company had press-ganged into crewing its ships to the East. The tasks that
might now be considered ‘nursing duties’ were first performed by an apprentice surgeon,
until replaced by the work of slaves and later by soldiers who were recruited on three-
year contracts to be ‘attendants on the sick’ (Searle 1965: 34).
The modern and largely female profession of nursing as it is known today dates back to
the latter decades of the nineteenth century, when an Anglican nun, Sister Henrietta
Stockdale, began training nurses in Kimberley. The first trained nurses were nuns of
religious orders and English ‘ladies and god-fearing women’ (Marks 1994: 15) and
eventually black middle-class women. The latter were brought into the profession only
when the health of the black labour force became a matter of considerable concern, and
the laying of white hands on black bodies even more so. At a time when only around 6%
of African women could read or write (1994: 90), Cecilia Makiwane passed the Nursing
Certificate of the Cape Colonial Medical Council and became the country’s first African
professional nurse in 1908.
Afrikaner women began to enter the profession in sizeable numbers only in the 1930s.
By then their secondary education was compulsory, the Afrikaner population had largely
been driven off the land and one in five were classified ‘poor white’ (Marks 1994: 70).
Coloured nurses began to be trained in earnest in the Cape around 1939, and their
numbers rose rapidly in the 1960s and 1970s, in line with the government’s coloured
7 As opposed to the home-care practices and folk medicine of the settler population or the traditional healthcare
practices and traditional medicines of the indigenous populations.
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