Nursing Colleges: Presentation by the South African Nursing Council

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Health

01 September 2009
Chairperson: Mr B Goqwana (ANC)
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Meeting Summary

The South African Nursing Council delivered a presentation to the Portfolio Committee on Health on the issue of nursing colleges. Council representatives explained the function of the Council as well the challenges it faced regarding nurse education in South Africa. The Council did not limit itself to nursing colleges alone, but gave a far broader picture of all nursing education institutions, thus making it clear that these ranged from nursing schools, to colleges, to universities and further education and training institutions, each of whom could offer quite a divergent range of qualifications. This contextualised the challenges faced by the Council. The Council also gave a detailed description of the various pieces of legislation that gave the power and responsibility to accredit institutions of higher learning, which made it clear that the Council had to deal with a number of different bodies and stakeholders, forming strategic partnerships, for the purposes of avoiding conflict and trying to streamline the processes. The same held true of recognition of foreign qualifications.

Committee members raised their concerns around the quality and quantity of nurses in South Africa, and asked where exactly the role and the functions of the Nursing Council lay. They enquired into the reasons for and the likelihood when the existing moratorium on establishment of private nursing schools would be lifted. They also questioned whether nurses were likely to be permitted to dispense medication and pointed out the reality that nurses were so overstretched by the shortage of other medical personnel that they were being called upon to undertake functions beyond their scope. Members also asked how often the Council went on oversight visits to health facilities and schools, how it attended to the registration and accreditation process, and the Council acknowledged that there were some shortcomings, but that it was trying to address them.  Further questions related to the time taken to give accreditation and registration, the process in respect of foreigners training in South Africa, and being accredited to work in the country after completing their training, whether the Council also attended to placement of nurses, and what action it would take in cases where there were complaints of misconduct.

Meeting report

Nursing Colleges: South African Nursing Council (the Council)presentation
Ms Nonhlanhla Makhanya, Council Chairperson, South African Nursing Council,  gave an overview of what the Council did. She said the Council was a statutory body established in terms of the Nursing Act of 2005. The main purpose of the Nursing Council was to regulate the nursing profession, particularly to ensure the safety of all users of healthcare facilities by making sure that these users were attended to by skilled and competent nurses. The education of nurses, as well as the practice of nursing, had to be well-regulated. Regulating the practice was a delegated function from the Minister of Health.

In regard to training of nurses, the Council liaised with the Department of Health (DOH) whose functions included the establishment of training colleges. Such colleges had been established in all nine provinces. The Department was also responsible for the provision of clinical sites. Once nursing colleges had been established, the Council played an oversight role in ensuring that those colleges met the minimum requirements for the quality training of nurses. The Council also did accreditation of both training institutions and clinical facilities. The next critical stakeholder was the South African Qualifications Authority (SAQA). SAQA had been established in order to be a custodian of all qualifications in South Africa, and the Council sought to ensure that its qualifications met SAQA requirements. The Council also had a relationship with the Department of Education (DOE). This Department had established two structures: the Council on Higher Education (CHE) and Umalusi. When the Council offered a qualification that fell under higher education, it would have to conform to the prescripts of CHE. The Umalusi component dealt with further education and training, and so the Council would have to conform to the prescripts of these bodies.

Ms Sizeni Mchunu, Acting Registrar and Chief Executive Officer of the Council, said that the Council wished to deal with all Nursing Education Institutions (NEIs). Nurse training in South Africa was located in NEIs as outlined in the Nursing Act of 2005. These NEIs were all institutions that had been accredited by the South African Nursing Council. To be accredited, the NEIs had to go through a process of accreditation. Categories of NEIs included universities which had nursing science units, Universities of Technology, nursing colleges and nursing schools, both public and private. The first three of these categories could offer any qualification, but nursing colleges could not offer degrees. Nursing schools were further education and training facilities. Depending upon the type of institution, the programmes offered anything ranging from short course certificates, to one- or two-year certificates, pre- and post-graduate diplomas, to degrees.

According to the Council, a nursing college was a post-secondary institution to whom the Council had granted college status because it met the necessary requirements. These colleges, although not defined as HEIs, could be declared as such by the Minister of Education, as set out in the Higher Education Act. The Council recommended that these colleges should forge co-operative agreements with Universities of their choice, so that the quality of curriculum development, delivery and assessment was overseen by the Universities. Each college was also required to have its own Council and Senates, which would oversee processes, delivery and assessments. These policies were a competency of the Provincial Department of Health.

Universities and Universities of Technology with nursing science units were established by the Minister of Education, not the Minister of Health. These were a national competency and had a separate budget from the Department of Education. They offered all nursing programmes and awarded anything from certificates to degrees. Well-functioning colleges were given their own budgets, which came from the provincial Department of Health and were used for everything from personnel and operations to bursaries for students.

Public Nursing Schools and their budgets were entities falling under hospital groups or individuals or groups of persons. They were usually administered by nursing service managers. Over the years a number of these schools had become inactive as the programmes they were offering had been taken over by Nursing Colleges.

Although the Council had been asked to provide the number of nursing colleges, it felt that it would be useful to provide the total number of NEIs. Mr Mchunu therefore summarised that there were 21 Universities and Universities of Technology, 34 campuses of Nursing Colleges, 88 public Nursing Schools and 81 private Nursing Schools, giving a total of 224 active NEIs. There were also 145 inactive NEIs. He also gave the provincial breakdown (see attached presentation). Mr Mchunu noted that the Constitution provided for the right to education, but the right for service providers to offer education was balanced by the responsibility to maintain standards.

Ms Mchunu noted that although the Council did not have the responsibility for funding of the nursing colleges it was necessary to examine this, as it affected training. Nursing colleges in different provinces used various models of funding. One model was the college budget, which came from the provincial Department of Health. This budget catered for operations, personnel, affiliation and agency agreements. Another model was the bursary system, which were in some cases provided both for tuition and other extra-mural needs, whereas other were limited to tuition only with a small stipend being paid to the student. Self funding was mostly used by post-graduate students. Public/private partnership models (PPPs) were also used, where private institutions paid for their students to attend public NEIs.

Ms Mchunu stated that prior to the promulgation of the SAQA Act of 1995, accreditation and registration of Nursing Colleges was the sole mandate of the Council, in terms of the Nursing Act. When SAQA was established, it was given the task of establish a national framework for all qualifications in South Africa. The Council for Higher Education (CHE), in terms of the Higher Education Act of 1997, said that overall responsibility for education in all twelve sectors of higher education lay with the Ministry of Education. Umalusi, established by the Further Education and Training Act of 1998, was given the overall responsibility for education in Further Education and Training (FET) in all learning fields. Private nursing schools had to be registered with the Department of Education.  As a result of these overlapping laws, the Council had to have several strategic partners with differing legal mandates. Cooperation between the Ministries of Health and Education was therefore of critical importance.

Because the accreditation fell to several stakeholders, it was a long and complex process. Discussions were, however, under way to try to streamline this process. Council, on receiving a written application, would give the NEIs self-assessment tools so that they could assess whether they met the necessary criteria, and they must provide documentation and other information. Site visits were also very important in ensuring that clinical facilities were adequate in every respect. Accreditation was then either granted or denied, depending on the overall capacity evaluation. Council had tried to revise the documentation that was required to avoid as much duplication as possible and for the future the processes would accord with the amended legislation passed in 2008.

Discussion
Mr M Waters (DA) asked why there was a moratorium on establishing new nursing colleges, and how long this was likely to remain in place. He also asked if private and public NEIs had to meet the same standards when it came to accreditation, and how often the NEIs were evaluated.

Ms Mchunu answered that the moratorium on accreditation of private nursing schools was first instituted in 2003. At this time it was decided that, rather than forming new schools, the old ones should be kept but they must function at the required levels. At that stage, the quality of education and standard of students attending the private nursing schools had been low. Once this had been raised, the field was to be opened up to new entrants. However, when the new Act was introduced, bringing new qualifications, it was decided that there was no point in offering qualifications that were shortly to be phased out, and therefore no point in lifting the moratorium. At the moment the Council was satisfied that the majority of the 81 private schools were performing as well as the public nursing schools.

Ms Makhanya added that there were private providers who had taken legal action against the Council on the basis that it was their constitutional right to provide education. Three of these were found not to be complying with the necessary standards. The de-accreditation process was also more difficult than the accreditation process. It was therefore better for the Council to act in a preventative way.

Mr Waters asked what was the current situation around trained nurses being allowed to dispense medication and what was being done to speed up the process of registering foreign nurses.

Ms Mchunu said that dispensing was beyond the scope of training for a nurse, although it was a reality that sometimes, owing to the shortage of doctors and pharmacists, nurses were often called upon to perform duties outside their scope. Training for dispensing was a competency of the Pharmacy Council of South Africa. A nurse could only dispense if he or she had attained the necessary dispensing qualification. There were problems because of the shortage of doctors and pharmacists, but this issue would need to be addressed by the Department of Health.

Ms Makhanya added that in terms of the Health Act, it was the responsibility of the Director-General for Health to determine areas of need and allocate people accordingly.

Ms Mchunu said that registering of foreign nurses was a very challenging area, and was the only area that the Council was involved in during the process of recruiting health professionals into South Africa. The Council was working on aligning its policies and supporting the policies of the National Department of Health when it came to the recruitment of health professionals. Government had entered into agreements with other countries allowing their foreign nationals to study in South Africa, but on completion of their studies they must return to their countries of origin, and then could, from those countries, apply to re-enter South Africa for the purposes of employment for a limited time – usually three years. South Africa would thus play a developmental role in terms of resources, but would not poach other countries’ resources. Council dealt solely with registration of the nurses. It did not allocate them to health facilities. There had been some difficulty in registering foreign nurses, due to internal process problems, but these had been improved. The Council was satisfied with the turnaround time for foreign registration, given the number of roleplayers involved in the process, and given the need to attend to verification of all qualifications. Some institutions where applicants had studied were slow to give responses. Some applicants from many First World countries had only undergone training at a secondary, not tertiary level, which meant that they would not be recognised in South Africa. Some forged documents, which was a further problem. The Council accepted that there was room for improvement on this issue.

Ms E More (DA) asked how often the Council did accreditations and oversight visits and where these results were published. She asked what the role of the Council was in eradicating ‘fly-by-night’ nursing schools and what happened to the students who, in good faith, had studied there. She also asked how long it would take to register nurses.

Ms Mchunu answered that the Council had gone on inspections when the NEIs were newly formed, and now did so on a five-yearly basis. Each NEI would, every five years, have to review its curriculum, as there were health policies that must be factored into curriculums. She admitted that though this was not happening as it should be, the Council was giving the matter its attention. The Council visited institutions at which problems had been reported.

Ms Makhanya said that the Council wanted accreditation to be decentralised to a provincial level. A facility would need to be made available to execute Council’s work regarding accreditation. Council also intended to establish an inspectorate to deal with healthcare facilities.

Ms M Segale-Diswai (ANC) asked how the Council monitored the allocation of nurses at certain institutions. She enquired how accreditation was sustained, and she also asked what the involvement of the Council was in the antiretroviral (ARV) programme.

The Chairperson asked whether the curriculum for nurses’ studies was designed specifically for South Africa. He also asked whether nurses carrying out work over and above their duties should be given additional remuneration.

Ms Makhanya said that several very real complexities had been highlighted in the Members’ questions. The Nursing Act was promulgated as a result of consultations with the health sector, which culminated in Chapters 2 and 3 of the Act, which focussed on nursing education, particularly accreditation, quality control, practice, and ethics. She said the separation of areas of responsibilities was beyond the Council. There needed to be conciliation at a national level between the Departments of Education and Health, as well as SAQA, in terms of who held what responsibility. The Council was in the process of working with the Department of Health, trying to set up a meeting with the Department of Education, in order to eradicate conflicting areas of responsibility. The Council had traditionally been responsible for quality assurance in terms of both programmes and sites. However, now that SAQA and CHE were also involved, it was difficult to decide who should take which responsibility. Although sites belonged to the Department of Health, the new Act would give Council permission to inspect sites. The Council was in the process of developing regulations to guide it on how to implement the new Act.

Ms Luthuli asked whether South Africa was producing the quality of nurses needed as a developing country. There should be a basic training for nurses, and specialisation afterwards. She also asked what was at the root of the bad attitudes of nurses.

Ms Mchunu answered that the extended roles that nurses were often called upon to play resulted from the shortage of other health professionals. There were compounding factors that removed a nurse from her core duties and affected her ability to provide quality care. The Council had set out a set of ethical rules governing this, though the employer also had a responsibility to maintain quality care.

Ms More asked what the exact role of the Council was.

Ms Mchunu replied the role of the Council was primarily to regulate the profession and make sure that all training in South Africa complied with the standards set by the Council. Training institutions were also monitored and reviewed by the Council, in order to ensure that nurses remained competent.

The Chairperson asked what the Council did with a nurse who was guilty of misconduct.

Ms Mchunu answered that the Council had a department that dealt with preliminary investigations when transgressions by nurses were reported. The public had the right to report any transgressions. There were instances in which nurses had to be removed from the register as patients died through their lack of care. For lesser infractions, nurses were suspended or given warnings, depending on the severity of the transgression.

The Chairperson said that it was clear that there were challenges in the Council, but that some of these challenges were beyond the Council’s control
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Ms Margaret Ravhengani, Director: Human Resource Stakeholder Relations and Management, Department of Health, said that the Department acknowledged its part in addressing these issues. She confirmed that the different sectors were working on coming together to find solutions, as the current situation was not good for any of the parties nor for the country.

The meeting was adjourned.


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