It was around 4am when the rhythmic peace in an Intensive Care Unit at Groote Schuur hospital in Cape Town was disturbed by the ear-shattering crash of a metal bin smashing onto the vinyl floor as Sister Aileen Turner accidentally tripped over it.

She was returning from an hour-long ‘€œlunch break’€ when she tangled with the bin. Concerned that the awful clattering might have alarmed her colleagues or any of the seriously ill patients, Sister Turner rushed to the nurses’€™ console in the ward.

She needn’€™t have worried. The three on-duty nurses were sound asleep, one balancing her head on a rolled up towel, the other sprawled in her chair and the third resting her head on a defibrillator (used to shock the heart if the patient goes into cardiac arrest).

All of the staff had started their shift at 7pm and were due to knock off at 7 that morning. Sister Turner said that as much as she was angered by what she describes as the unprofessional behaviour of the nurses she understood their predicament.

‘€œI was angry because I realized that they were so overworked and exhausted from working shift after shift without any breaks. I had taken my break even though the matron in charge had informed me that I would not be paid for that hour. I was expected to work 12 hours non-stop,’€ said Turner recalling the incident that took place last year.

Turner, a highly trained and experienced ICU nurse, bade nursing a final good-bye at the start of this year, joining 760 of the 3 800 ICU and trauma nurses who have left the profession.

In a recent article in the South African Medical Journal, Nicki Fouché of the Division of Nursing and Midwifery at the Faculty of Health Sciences at the University of Cape Town warned that this haemorrhaging of professional nursing staff would have a catastrophic effect on the delivery of health care in South Africa over the next decade.

‘€œThere are approximately 93 000 registered nurses in South Africa, of whom only about 3 800 have an intensive care/critical qualifications registered with the South African Nursing Council (SANC). Of this pool, 20 percent are either non-practising or in non-related employment,’€ said Fouché.

She added that the SANC estimates that there are 2 300 registered nurses working overseas and that they receive about 200 applications per month for overseas registration. In 1999, 3 300 nurses left South Africa.

‘€œThe numbers of nurses leaving the country are in excess of numbers of potential graduating students,’€ Fouché added.

The cause of the crisis is not easy to identify but driving forces include the alarming numbers of staff leaving the profession; poor working conditions in hospitals and clinics; increased pressure on remaining staff because of critical staff shortages; low and inequitable salaries and little scope to further training.

A further complaint from nurses is the lack of respect or acknowledgement from other medical professionals, including doctors.

Lydia Botha (51) has been involved in nursing for almost 30 years. This month (Feb) she leaves for Damman, a city on the east coast of Saudi Arabia where she will work as a matron in a 120-bed hospital.

Her salary? R34 000, including accommodation and two tickets home every year.

An equivalent post in a South African private hospital would have put R12 000 to R14 000 in her pocket. In the public sector her package would have been closer to R8 500 (before tax). Botha said that many nurses who returned from working overseas were amazed at how differently they were perceived.

‘€œIn most South African hospitals nurses are shouted at and treated like dirt by some doctors. You are seen as a lackey. This is not the case overseas,’€ she said.

Nelouise Geyer, deputy director at the Democratic Nursing Organisation of SA (Denosa), said the organisation had threatened to report this type of conduct by doctors to the S A Medical Association as well as the Human Rights Commission and that this had had favourable results.

Geyer said research had shown that over 60% of health care workers in South Africa had experienced some form of emotional violence, be it verbal abuse and harassment or sexual harassment. Colleagues (doctors, matrons and fellow nurses), patients or relatives of patients were the main perpetrators. The research, a collaboration between the World Health Organisation, the International Labour Organisation and the International Council of Nurses and Public Services International, also revealed that up to 17% of health care workers in the public sector had reported incidents of physical violence. Geyer charged that the state was ignoring these complaints and that this was one of the key reasons nurses were leaving the profession.

But despite these seemingly unfavourable conditions, Gauteng last year received 100 000 applications for it’€™s first year intake at the nursing colleges. The province loses between 800 and 850 nurses annually, only managing to train 600 in return.

In the face of the looming crisis, some provinces have begun to seek solutions.

Dr Sue Armstrong, Director of Quality Assurance in the Gauteng Health Department, said although not enough nurses were being produced to meet the demand, the province was training proportionally more than other provinces.

Authorities in the Gauteng Department of Health have implemented measures that they hope will have positive, long-term effects. One such measure is a change of entry criteria to nursing colleges.

‘€œThere is no real evidence that a good matric is an indicator of success so we are rather opting for people who we think have the traits to make good nurses,’€ Armstrong explained.

Gauteng had also implemented multiple entry and exit criteria ensuring that those who drop out early were not lost to the profession. For example, if a student leaves after completing her first year she could be employed as a nursing assistant, returning later to complete her studies.

The province has also managed to tie students into working back half their study time. ‘€œIt’€™s almost like community service. If a nurse studied for four years she has to work back two years on a rotational basis where they are sent to the less popular, rural clinics or hospitals,’€ said Armstrong.

Armstrong was also adamant about allowing nurses to further their training.

‘€œWe are also in the process of upgrading the facilities our staff work in and we hope that it will play a role in retaining many of them,’€ she said.

In an effort to give nurses a taste of overseas work, earning foreign currency, the province has started an exchange programme with Kings College Hospital Trust in the United Kingdom. Nurses are sent over annually for a two-year stint in specialist units.

‘€œI think this adds a sense of commitment and improves their skills.’€ The nurses are tied into a three-year contract to the province on their return.

Armstrong said that although they did not have reliable figures it was clear they were losing a lot of staff to overseas hospitals as well as the AIDS epidemic.

According to predictions by Dr Nono Simelela to the SANC, by 2015 around 40 percent of student and 21 percent of registered nurses will be HIV positive, placing even further pressure on the country’€™s capacity to deliver health care.

Fouché pointed out that temporary arrangements and solutions to the shortage challenged the integrity of the profession and could lead to unsafe and sometimes illegal delivery of nursing care.

The traditional response would be to increase salaries and benefits, but experts agree that this would not address the problem. ‘€œIt would be like sticking a band aid on a gaping, festering sore,’€ said a nurse.

* Several attempts by Health-e to contact the National Department of Health for input were unsuccessful.


Nursing numbers

Nurses are not permitted to work in the profession unless they are registered with the South African Nursing Council (SANC) in Pretoria. According to the council’€™s latest figures, 172 338 nurses were registered in 2001. The council is unable to give a breakdown of how many of these nurses actually work in the profession.

In 2001, 45 666 people registered as enrolled nursing auxiliaries (nursing assistants). Nursing auxiliaries have undergone a years’€™ training and receive a certificate from the council. In 1997, the council had 51 538 nursing auxiliaries on its register.

Of the 45 666, 37 upgraded their training to become enrolled nurses or midwives (staff nurses). In 2001, 32 120 enrolled nurses had registered with the nursing council. An enrolled nurse has undergone two years’€™ training and has to work under the supervision of a registered nurse. There were 94 552 registered nurses in 2001. This was over 4 000 nurses more than in 1997. A registered nurse has a three-year diploma or a nursing degree. Alan Green, Senior Manager Information Technology at the nursing council, said they had not been able to determine how many nurses were dying of Aids-related illnesses. Deaths reported to the SANC revealed that 208 nurses had died in 2001, compared to 234 in 2000 and 201 in 1999.

 What nurses are paid

 Nurses’€™ salaries in the public sector (per month)  

Nurses on training (Std 8 level)   R2 641 ‘€“ R2 825
Nurses on training (Std 10)     R3 033 ‘€“ R3 306
Enrolled nursing assistants  R2 641 ‘€“ R3 306
Senior nursing assistants R3 560 ‘€“ R4 538
Staff nurse  R3 560 ‘€“ R4 538
Senior staff nurse     R5 214 ‘€“ R5 843
Professional nurse R5 214 ‘€“ R5 843
Snr professional nurse R6 494 ‘€“ R7 149
Chief professional nurse   R8 066 ‘€“ R8 945
Assistant Director   R9 631 ‘€“ R13 056
Deputy Director   R14 024 ‘€“ R18 782

Provincial breakdowns

Provincial breakdowns supplied by the South African Nursing Council (from 2001) show that provinces such as Gauteng, Western Cape and KwaZulu-Natal were much better off than their counterparts.


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Registered Enrolled Auxilliaries Total     Population
Limpopo       6 482   2 966 2 765   12 213   5 671 050
North West  6 156  2 077  3 675     11 908    3 604 472
Mpumalanga 4 077  1 913 1 541   7 531 3 090 945
Gauteng 26 973  6 290  12 837 46 100 7 966 711
Free State  7 044 1 457 3 119 11 620 2 817 076
KZN 17 531 8 761  7 605  33 897  9 070 458
N/Cape  1 784 648 901  3 333  879 676
W/Cape  12 948 4 090  7 833     24 871 4 249 547
E/Cape 11 557 3 918   5 390  20 865  6 978 387