Acting Registrar Mrs T Manganye along with two representatives presented to the panel Health Market Inquiry on the role and functions of the Nursing Council of South Africa.
What is the Nursing Council?
The Nursing Council is a statutory body set up and operating in terms of the Nursing Act. In 1998, the first democratic Nursing Council was established. The Council is made up of various committees and includes significant membership of nurses who are nominated based on their expertise by members of the nursing profession. Other members include representatives of the Department of Health, members with expertise in law, consumer affairs and education and three community representatives. Details about different committee’s membership can be found on the Council’s website.
The Council has various statutory responsibilities, which include understanding and applying national health policy, managing the quality of the training of nurses, publishing a register of nursing practitioners and receiving complaints about members of the profession. The Council also determines the scope of practice for nurses with different specialisations and has produced a code of conduct for the nursing profession. The exact scope of the Council’s “jurisdiction” and the scope of its mandate was interrogated by Panel members throughout the Council’s presentation.
The Acting Registrar of Nursing Council explained that the Council can investigate complaints about nurses from hospitals, medical professionals and even members of the public. The Council will also act on complaints emerging in the media. Nurses can also be report directly to committees within the Council such as its ethics committee and its professional conduct committee.
Though the Council does receive “a lot of complaints” the Council’s representative noted that “not all are valid”. Some may be in-fights or complaints people’s neighbours who happen to be nurses for example. There are, however, “many serious complaints”. The Council makes statistics available on its website and publishes some findings in the government gazette. The Council’s representative indicated that as it stands “most complaints are about maternity” but that “there are also many complaints about basic nursing care”. The Panel asked the Council to provide it with a summary of details of the complaints for the last five years.
Jurisdiction and role of the Nursing Council
A member of the Council presenting on its behalf initially noted that the Council has “no jurisdiction to regulate private nurses”. Questioned further about this by Chief Justice Ngcobo, the Council clarified that the problem was essentially not about jurisdiction but rather that the Council does not even know how many private practitioners are operating in South Africa or where they operate from. “We only discover problems when we receive complaints”, she noted, adding that the nurses could be operating from anywhere – even a garage or Wendy house. Without “more information and regulations”, she added, it is not possible for the Council to effectively monitor how nurses are practicing, for example to determine if nurses are using incorrect equipment or medication or are not properly licensed.
When questioned by the Chief Justice about whether the Nursing Act gave it jurisdiction over nurses in both the private and public sector, the Council representative clarified that what she was referring to is the fact that there are currently only draft regulations specifically governing private practitioners. They are therefore simply regulated like all other nurses. This, she noted has been the case since at least 2008 when the new Act was promulgated and the Department of Health has the responsibility to promulgate the draft regulations.
The Chief Justice then asked why it is that nurses operating in the private sector are not asked for the relevant information – such as where the nurse will be operating their practice – when they apply to the Nursing Council for registration.
The Council’s representative answered that although the register is updated every year, it did not include this information. The Acting Registrar added that the Council is speaking to the Private Practitioners Association who does have a detailed list of its members which may be able to assist the Council. Though in the absence of a detailed register it could not be said exactly how many private nurses were working in South Africa she acknowledged that it is a “sizeable number”. After more questioning the Registrar conceded that it was the Council’s responsibility to complete the task of finding this information.
Shortage of nurses
Several panelists questioned the Council on the extreme shortages of nurses reported by participants in the inquiry consistently thus far. Initially, and curiously, the Acting Registrar denied that there was a shortage of nurses in South Africa. Later she explicitly retracted this statement saying “one would agree that there is a shortage of nurses”, when pushed to do so by Professor Von Gent in particular.
This initial denial, however, led Chief Justice Ngcobo to ask directly whether it is not in the interests of the Council to ensure that nurses perform duties in circumstances in which they can fulfil their obligations. This question was intended to probe both the issue of shortages of nurses in both private and public hospitals but also the conditions under which they are forced to operate.
The Acting Registrar noted that the Council does bring the problems it uncovers to the attention of the employer in the case of a private hospital and the MEC or Minister of Health in the case of public hospital.
Later on, prompted by a suggestion from Chief Justice Ngcobo, the Council agreed that there are mostly shortages of nurses with specialisations and that certain specialisations are also the area in which “moonlighting” – public nurses working additional hours in private practice to supplement their income – is more prevalent.
Accreditation of facilities for nurse-training
The Council emphasised the importance of its role in accreditation of facilities that provide opportunities for the practical training of nurses. The Acting Registrar noted that the Nursing Council can assist in addressing shortages in a number of ways including the accreditation of sufficient facilities for training and fast-tracking of the accreditation of these clinical facilities.
Professor Fonn questioned the curriculum currently used to train nurses noting that it has been criticised for a range of reasons including that it is “old fashioned”, does not consider health problems in South Africa, lacks context, does not sufficiently take into account healthcare legislation, and ultimately does not produce the kind of nurses that are needed in South Africa.
A third member of the the Council responded that the Council has made some strides in regards to curriculum review to deal with these criticisms. He noted that the curriculum review process requires consideration by both Nursing Council and the Council for Higher Education (CHE) in terms of legislation. The CHE’s participation is to ensure that the curriculum meets academic standards. He therefore concluded that though he understood that to “the person on the street” it may look like there is an inordinate “delay” it is because of “these hurdles that have to be crossed before it becomes a curriculum”.
Monitoring of conditions
The Panel took a specific interest in the Council’s ability to monitoring the conditions under which nurses were forced to operate in the private sector. When asked by the Chief Justice whether the Council regularly monitors conditions, the Council’s representative answered the Council is in the process of setting up an “inspectorate” to do so. However, at present, the Council only monitors conditions at a facility level when it receives specific complaints or when they are asked to accredit a facility as a place at which a nurse can do the practical component of their training. If the standards are “not conducive” accreditation is withheld. The Council is also working with the Office of Health Standards Compliance to improve upon this situation.
For clarification, the Chief Justice asked the Council to confirm whether it generally, in other words, has to wait for a complaint or “until somebody has been injured” before it can investigate conditions at a facility. The Council’s representative confirmed that this was the case because “that is the reality of the Nursing Act”.
Nurses performing non-traditional functions
Section 56 of Nursing Act to allows certain nurses who are specifically qualified to perform functions that other nurses do not including to “assess, diagnose, prescribe treatment, keep and supply medication for prescribed illnesses and health related conditions”. Given the challenges faced by many people in South Africa in accessing healthcare the Panel showed a keen interest how this section, and the nursing profession, could assist in ensuring that the right to healthcare of each person in South Africa is made a reality.
Dr Bhengu, initiating this conversation, attempted to elicit comment from the Council on the non-traditional nursing roles that nurses can and have played in the effective implementation of South Africa’s world-renowned antiretroviral programme. He asked specifically for comment on “where a change of the traditional role of nurses may help improve access to healthcare” more generally.
The Acting Registrar explained that the “Nurse Initiated Management of Treatment” is a process through which nurses were trained to initiate ARVs. The Nursing Council, she said, supported this initiative and it had a major impact on the treatment of HIV. She said that nurses qualify to initiate ARV treatment through short courses or programmes at present and that the Council is talking to the the Department of Health to see how this can be improved, perhaps by introducing a full year qualification that combines various short courses of this nature. When asked about an example about how a nurse’s day-to-day job might be altered by taking on non-traditional functions, the Acting Registrar responded that, for example a nurse may be empowered to write scripts which could be taken to pharmacists to dispense medication. At present a nurse cannot write a script to be taken to a pharmacist and there are advanced discussions with the Pharmacy Council to try and empower nurses to do so.
A representative of the Council however noted that the Nursing Council does have some reservation about “task shifting” from other medical professionals to nurses because of the both the capacity of nurses and the increased risk that it would produce to both nurses and patients. Later on the Acting Registrar emphasised that there are some things the Council thinks that nurses can do and some that they will not be able to do.
Chief Justice Ngcobo, apparently unsatisfied with these responses, questioned whether the Nursing Council had engaged with the provisions of the Nursing Act that allowed nurses to perform other functions in certain circumstances. He emphasized that exercise of this power is the responsibility of the Nursing Council. He asked directly “What steps has the council taken to explore giving effect to these provisions to ensure that access to healthcare is at least accessible to the majority of people?”
The Acting Registrar replied that “there is a lot of work that has been done”. She then gave more information interactions of the Nursing Council and the Medicines Control Council in this regard, assuring the Panel that “we hope within this year we will have moved quite a bit” toward the implementation of this aspect of the Act.
Ultimately, the Nursing Council indicated, that it is the Department of Health that is responsible for human resources planning, including for nursing professionals. It is therefore also responsible to address the shortage of nurses. A representative of the Council also noted that in her personal view nurses are not “paid enough for what they are doing. They are doing a big job and work long hours” and are not paid in accordance with a professional salary.
One of the major challenges noted throughout by the Acting Registrar is the turnaround time for the Nursing Council in addressing complaints and other issues. She explained that this could partially be attributed to the fact that the Council’s systems are largely still manual. However, she assured the Panel that an “improvement plan” was instituted in 2015.
The Council thanked the Panel for the opportunity to make presentations and indicated that it had noted several issues that it had not properly considered raised by the Panel. The Chief Justice cautiously commented that it sometimes seemed as if the Nursing Council, as is the case with other Councils, “do wait for somebody to do something [or some other entity] before it reacts”. He suggested that “sometimes it may be better for Council to take proactive measures in the interests of its members.”