Nursing Bill: briefing and public hearings

Meeting report

HEALTH PORTFOLIO COMMITTEE
11 October 2005
NURSING BILL: BRIEFING AND PUBLIC HEARINGS

Chairperson: Mr L Ngculu (ANC)

Documents handed out:
Department of Health briefing
Nursing Bill [B26-2005]
Medi-Clinic Group PowerPoint presentation
Medi-Clinic Submissions on Nursing Bill
DENOSA presentation on its submission
DENOSA submission on the Nursing Bill

SUMMARY
The Health Department briefed the Committee on the Nursing Bill. The purpose of Professional Councils was to protect and promote the public’s interests, and ensure delivery of quality healthcare. The Bill made provision for Continuing Professional Development and the introduction of community service. Nursing education would to be brought into line with the National Qualifications Framework (NQF). Specific challenges were a shortage of skilled nurses, and the lack of healthcare facilities in rural areas. The Committee agreed that the importance of healthcare professionals, especially in rural areas, needed further discussion.

In the afternoon, the Committee began public hearings on the Bill with submissions from the Medi-Clinic Group and the Democratic Nursing Organisation of South Africa (DENOSA). Medi-Clinic outlined their training programmes and raised concerns with the clauses in the Bill dealing with the one-year community service as they would be losing staff that they had trained. Also raised was the appointment of the South African Nursing Council (SANC) chairperson by the Minister and private sector representation on SANC.

DENOSA supported the thrust of the Bill, but raised concerns about preserving the autonomy of SANC, the norms and values in the health care sector, especially in developing adequate staff to patient ratios, the need for the composition of the Council to be weighted towards nurses and midwives, and a reasonable time period for community service. DENOSA’s biggest concern lay with professional conduct hearings, whose procedures they considered unfair, and whose panel members were both incompetent and ill prepared

MINUTES

Department briefing
Dr P Mahlathi (Department Deputy Director-General: Human Resources) stated in a brief overview that amendments to the Nursing Act were long overdue. They were necessary to improve the functioning of the Nursing Council, public confidence in the Council, and to ensure that the mandate of the Council to protect the public was fulfilled. The Department and the Council should work together to improve healthcare services. Specific challenges were shortages in high skill nursing, and lack of healthcare facilities in rural areas. He observed that there had been close co-operation with the Nursing Council in drafting the amendments. The Department was confident that the Council would concur with the issues raised.

Ms T Manganye (Department Deputy-Director: Professional Liaison) briefed the Committee on the Nursing Bill [B26-2005]. She gave a brief history of the Nursing Council, a background to the Nursing Bill and the main recommendations of the Task Team. These recommendations formed the basis of the Bill. The main purpose of the Professional Council was to protect and promote the public’s interest, and to ensure the delivery of quality care. The Bill aimed to serve and protect the public in services provided by the nursing profession.

Chapter 1 of the Nursing Bill stated that the Council existed to serve and protect the interests of the public, not the nurses. The number of Council Members would be reduced from 39 to 25, and the Chairperson would be appointed by the Minister, and accountable to the public. Eighteen of the 39 members would be appointed by the Minister, the rest would be elected by the profession or nominated by interest groups. Twelve of the professional nurses would be elected by the profession itself. However, in the last two elections eleven of the twelve elected members had been white and representation was therefore skewed.

The section on corporate governance spelt out the responsibilities of the Council. It was important to highlight this as previously it had not been well articulated.

Chapter 2 dealt with education, training, research, registration and practice. It also made provision for Continuing Professional Development (CPD), and the introduction of community service for nurses registering for the first time. Nursing education was to be brought into line with the National Qualifications Framework (NQF). Criteria set for the renewal of licences would improve the quality of nursing.

Chapter 3 dealt with unprofessional conduct, while Chapter 4 stipulated penalties for non-regulated individuals, false representation and impersonation. Chapter 5 dealt with special provisions, established the Appeals Committee, and a list of regulations to be promulgated. If passed into law, the present Council would be dissolved but would continue to function until the names of the new Council members had been gazetted.

Discussion
Ms C Dudley (ACDP) requested more detail on Clause 56 (special provisions relating to nurses and midwives). More background, and the aims and purposes of this section were needed. Dr Mahlathi replied that the overall intention was described in Clause 56 (1). In the current situation, nurses were not necessarily permitted to dispense medicine on their own. In reality, they ran the majority of primary healthcare facilities. This section made provision for nurses in special circumstances to assess, diagnose, and prescribe treatment. This would provide greater access to healthcare, and better management of facilities, especially in remote rural areas.

The Chairperson asked what was meant by not keeping an open shop or pharmacy. Dr Mahlathi replied that nobody would operate a facility without legal provision and permission to do so. A pharmacy would have to be declared when there was a professional present. No nurse could operate such a facility without the necessary permission.

Ms D Kohler-Barnard (DP) asked what the procedure would be to deal with a situation where a nurse misdiagnosed and put a patient at risk. Dr Mahlathi replied that there were currently very few cases of this as the nursing profession was very experienced. He was confident that there would not be serious problems.

Ms M Manana (ANC) pointed out that there were two very similar definitions for nursing education institutions. Dr Mahlathi agreed that they both meant that no institution could operate without being accredited. It was a duplication and would be altered.

Ms P Tshwete (ANC) expressed concern about the implications of the Bill and the dissolution of the present Council. There was no clear timeframe for implementation, and the arrangement was too open. Mr M Motsapi (Department Director: Legal Services) pointed out that Clause 58(1)(a) made provision for appointments by the Minister and timeframes would be indicated there.

Ms M Madumise (ANC) asked what incentives were being offered to attract nurses to rural areas and thus alleviate the shortages in these areas. Dr Mahlathi replied that it was a challenge to attract people to the public service. It was a complicated issue as there was a demand for nurses, with a number of vacancies in rural areas and the public sector. Many of the nursing schools were over-subscribed. However, many experienced nurses had been lost to the private sector, or had gone overseas.

This had affected nursing educators. Also with urbanisation, professionals wanted to live in urban areas. It was a challenge to address the issue of healthcare provision in the rural areas. Although it was possible to get workers, it was necessary for newly qualified nurses to have supervision or mentoring from experienced nurses. For community service to be successful, the presence of experienced nurses was essential.

Continuing Professional Development (CPD) aimed to assist in the maintenance of skills and competency and would add to the quality of the healthcare service. Community Service needed supervision, and investments would have to be made in CPD, especially in rural areas. The Department was making preparations and believed that by providing larger numbers of nursing staff in rural areas the load on present staff would be reduced. The Department was looking at remuneration as an incentive and was in discussions with the National Treasury.

Ms Tshwete pointed out that the term used for mental illness was too broad. A nurse could be disqualified from membership if she was suffering from a mental illness, even if she was still capable of working. Dr Mahlathi replied that he did not have a copy of the Mental Health Care Act to hand but that usually a diagnosis of mental illness had to be clinically confirmed and had to be serious enough to cause temporary incapacity. The legal section would examine the definition of mental illness in the Bill. It was important to protect the patients, as well as to make sure that professionals suffering from some form of mental illness were cared for.

Ms Dudley suggested that copies of the Mental Health Care Act be made available so that definitions could be examined. This was later made available and after examining it, Mr Motsapi announced that the Clause 6(d) paragraph on mental illness could be misinterpreted. The Department had agreed to exclude the "or" and substitute "and". This meant that if a person had a mental illness "and" was a declared mental health care user he/she could be excluded from working as a nurse.

Ms Manana asked why learners were not represented on the Council. Dr Mahlathi replied that the composition of the Council and its reduction in size were based on the practical issues of managing a council – cost, and its ability to meet. The final decision had been made with a lot of input from the Nursing Council. The presence of students on the Council was difficult as student politics was volatile, and membership changed regularly. Also, if students were allowed on the Council, then organised labour would also have to be represented. This would cause problems as there were issues that could result in conflict.

Ms Manana asked why nurses had not taken part in voting in the previous two elections. Were they not informed? Ms Manganye replied that only 7-10% of nurses had voted in the previous two Council elections. This was problematic as it was then questionable whether those elected were representative. Members that had been elected were from a particular race group. The Nursing Council had assured the Department that nursing professionals had been encouraged to participate.

Ms Tshwete was concerned about what would happen if a Minister responsible for appointing members to the Council changed while those members were still in office. Dr Mahlathi replied that a change in Minister would not affect the Council. Members were appointed for five years, with the option of being appointed for a further five-year term.

Mr S Njikelana (ANC) asked what remedial action was being taken to solve the problem of human capacity, and the loss of nurses to the private sector and overseas. The Chairperson asked where such interventions should be made and suggested looking at the CPD and community service. Mr Njikelana responded that monitoring of the process should have been done. Pointing to Clause 5 (1(b); he observed that there must be a provision for how the implementation would be monitored and reviewed. The composition and appointment of the Council also needed careful examination. He also felt that the significance of the healthcare professionals, especially in the rural areas, needed to be examined in more depth. The Chairperson agreed that this needed further discussion as it was very substantive and could raise a number of issues.

Dr Mahlathi added that rural healthcare was difficult. Rural health was part of primary healthcare. It involved a balancing act as it was important not to overload the Council in subdividing various categories, but the Council should not be just urban-based and dominated by representatives from urban areas.

Mr Njikelana pointed out that once the Council had been set up it would be divided into sub-committees. Had this been considered, at the operational level, when reducing the size of the Council? Dr Mahlathi agreed that the size of the Council would impact on the number of sub-committees. The Council’s challenge was to identify major thematic areas to focus on.

Ms Dudley referred to Clause 31 (5)(a) regarding proof of identification and citizenship. Was this specifically referring to South African citizenship or was it broader? While there was a shortage of nursing professionals, there were professional people from other countries who were struggling to use their skills in South Africa, especially in the nursing profession. Was this availability being taken into consideration?

Dr Mahlathi replied that the question of citizenship was a major challenge because it related to the utilisation of foreign qualified healthcare professionals. It was important to have proof of identification and qualifications verified. Whatever laws were proposed had to be in line with the Immigration Act. The provisions in the Bill would not necessarily exclude deserving foreign professionals.

Ms Dudley asked if the terms "citizenship" and "proof of identification" were not specifically referring to South African citizenship. Would it block foreigners? Mr Motsapi replied that read in conjunction with other sub-sections it was not intended to exclude foreign professionals. South African citizens would have to comply with community service requirements. Clause 58(1)(d) and (e) and the regulations would deal with foreign qualified nurses as opposed to foreign nurses, and how those qualifications would be evaluated by the Council. The issue of citizenship was not intended to exclude foreigners.

The Chairperson asked whether only registered South African nurses would have to do community service, and if this meant that foreigners, or foreign qualified professionals could register here without doing community service. Mr Motsape replied that it was the intention that only South Africans registering for the first time would have to do community service.

The Chairperson asked what would happen to newly qualified foreign citizens who were granted work permits and had registered but had not done any "housemanship" or community service? Dr Mahlathi replied that foreigners would not be allowed in without a minimum of three years experience. An issue with Namibia had arisen because there had been a request for a dispensation for people to do their internship in Namibia, but be recognised in South Africa. Legal clarity was being sought on this. It was the Department’s experience that newly qualified nurses usually did not want to leave the country where they had trained immediately after qualifying.

Mr Motsapi added that there were plans in the Department to restrict foreigners to public sector work for a minimum of three years. They could then move into the private sector. Dr Mahlathi pointed out the distinction between foreigners and those with foreign qualifications (South Africans who had studied abroad). The Chairperson stated that the Committee would re-examine the proposed amendment when it went through the formal process of considering the Bill. He had noted the proposal and agreed that it made sense.

Dr Mahlathi pointed out that the Council could prescribe CPD. (Clause 39). Recognition of CPD activities would have to be approved. There would be regulations in place to ensure that CPD was properly regulated. The Department would take into account the lessons learnt from CPD for the medical profession. The intention was to keep healthcare workers up-to-date with knowledge and skills so that patients were provided with competent care.

Ms D Kohler-Barnard asked for details of the phasing in of community service. Some people had been given exemption and did not have to do it, for instance older people, or women with families. There were no details about its implementation. There was also no reciprocal arrangement, or details of what would be provided by the Department of Health for community workers, such as safe accommodation.

The Chairperson asked if she was suggesting that the legislation should include conditions of service for community service. Ms Kohler-Barnard replied that something was needed because at present the interpretation was very wide. The Chairperson disagreed and said only broad parameters should be put in the Bill which spelt out what needed to be considered. Conditions of service would be detailed elsewhere.

Ms Kohler-Barnard also expressed concern that where previously the Council had been considered competent to choose their own head of Council, now the Minister could appoint him/her. But the members had to work with this leader. With this new structure nurses had lost control of their Council, as they would have few representatives. Dr Mahlathi replied that the composition of the Council would not exclude nurses as it would have fourteen nurses, which was a majority. The nurses would have to have knowledge in special areas. Also, the Chairperson would come from the ranks of the elected Council, as the Council would make a proposal for the Chairpersonship and the Minister would then make the appointment.

The Chairperson observed that it was not clear that the Council Chairperson would come from the nursing profession. Mr Motsapi referred to Clause 10(1)(a) that stated that the Minister must appoint one of the members of the Council. The Chairperson pointed out that the Council would be comprised of a number of people including doctors and pharmacists. There was no clear statement that the Chairperson had to be a nurse. He said that this was an area that needed to be examined carefully, and clarified.

Dr Mahlathi replied that the Department understood the concerns. He realised that if for instance, a doctor was appointed Chairperson, it could lead to conflict because of the history of the relationship between doctors and the nursing profession. This matter would be discussed further and the implications examined.

Ms Kohler-Barnard commented on the point that had been made regarding the previous two elections where only one black nurse had been elected. She asked if there were plans for a racial quota if the Minister did not like the colour of the person elected. Mr Njikelana objected to this wording, as he felt South Africa should be moving forward. He added that affirmative action was in place to assist structures to reflect the demographics of South Africa. He requested a demographic breakdown of nursing personnel from the Department. He also asked where the nomination procedure was provided for.

The Chairperson requested that this matter be left for the moment as he did not want to be diverted. He observed that the culture of voting amongst blacks was very limited and there was a need to mobilise voting. There was a process for the election of the Council and interested parties could make submissions. There was also a need to ensure that the composition reflected the demographics of South Africa. A further problem was the lack of access experienced by the poor – often only the privileged were in a position to make submissions. Mr Motsapi pointed out that the nomination process was dealt with in Clause 58 (1)(a). Provision for regulations for nominations had been made. The regulations would be formulated after consultation with the Council.

The Chairperson requested more information on the training of nurses. Dr Mahlathi replied that there had been several activities. A nursing standards body was looking at realigning the nursing qualifications. There was a procedure in place to define scopes of practice. The qualifications of midlevel workers (nursing assistants) were being realigned to meet the National Qualifications Framework (NQF). There were discussions taking place with various bodies. A major aspect of the Human Resources plan was the streamlining of nursing qualifications.

A Member commented that very little had been written about how training institutions were going to be controlled. Accreditation seemed to be very lax. Was the Department planning to examine the issuing of certificates? Ms Manganye replied that although there was little in the Bill, a lot of detail had been included in the regulations regarding education and training, and the accreditation of schools. The Human Resources plan would offer guidance to professional councils and training institutions as to who needed to be trained and in what fields. Mr Motsapi pointed out that Clause 58(1)(g) dealt with the certification of nursing institutions.

Ms Tshwete asked about the annual renewal of nursing licences. Ms Manganye replied that the present system was being reviewed. At present nurses paid a renewal fee but were not tested in any way. With the introduction of CPD this would change, and the goal was to keep nursing professionals up-to-date with new developments. Dr Mahlathi pointed out that this would also help with the planning process.

The Chairperson asked how the Council was protecting itself and the nursing profession. Dr Mahlathi replied that this was another issue. The National Health Act was in place to regulate these professions. It was also the responsibility of the employer to make sure that employees worked in acceptable conditions. There were adequate mechanisms in place to protect professionals. Adherence to corporate governance would ensure proper accountability and would provided adequate safeguards for people serving on the Council. Professionals protected and guarded their integrity. The Council would be able to protect itself by adhering to the provisions of the Bill, and would assist professionals to provide proper services.

Afternoon session:
Medi-Clinic Group submission
Ms A Meiring (Director Medi-Clinic) presented an overview of this Proudly South African company which operated 46 hospitals in eight provinces and Namibia. The Group employed 6 500 nurses and ran an extensive training programme. These included formal Post-Basic courses run in collaboration with tertiary institutions, the in house Medi-Clinic courses and the staff development programmes. The Company employed 40 tutors and assessors, 50 training and development consultants, maintained six fully equipped nursing schools and six vehicles to transport tutors to remote hospitals. On basic courses for enrolled and auxiliary nurses, preference was given to permanent employees. The majority of bridging course students were older employees with families.

Medi-Clinic raised two concerns with the Nursing Bill. The first referred to Clause 10(1)(a) ‘The Minister must appoint one of the members of Council as chairperson of the Council’ where Medi-Clinic argued that it would be good practice for the Council members to appoint their ‘natural leader’. The second issue referred to Clause 40(1) regarding community service. Medi-Clinic noted firstly, that training in their hospitals was based on their work force needs and secondly, successful learners were offered positions in the company and had the opportunity to further their studies. Community service would result in the private sector having to revisit the training it offered, at a time when nursing shortages in South Africa required more training opportunities.

Discussion
Ms M Madumise (ANC) enquired whether the Medi-Clinic Certificate for Anaesthetic and Recovery Room Nursing enabled nurses to give anaesthetics or just care for anaesthetic patients and was the course only available for staff and auxiliary nurses. Ms Meiring explained that the Medi-Clinic certificate was a one-year course for enrolled and professional nurses, teaching them to look after those patients and care for them after theatre. It was important the nurses knew what to do if anything went wrong in the Recovery Room. The nurses were trained to assist the anaesthetist and therefore needed a thorough knowledge of medications. The terminology of ‘enrolled nurse’ would be changed to staff nurse as the regulations came into effect. The Chairperson added that the course outlines would obviously have to change to fit the new definitions as the legislation came into effect.

Ms Madumise asked in which provinces the six nursing schools were situated. Ms Meiring listed the schools as being in Bellville, Sandton, Pretoria, Polokwane, Nelspruit and Bloemfontein.

The Chairperson raised Medi-Clinic’s concern with Clause 10(1)(a) that nursing leaders were being deprived of giving input in their own profession and asked how the Company saw the relationship between the Council Chairperson and the Minister playing out. Ms Meiring felt that as the Minister appointed most Council members, there would be a relationship of trust between Members and the Minister. However, if Council could decide on their natural leader, it would bode better for the functioning of the group.

Mr S Njikelana (ANC) asked, based on past experiences, if Medi-Clinic had been satisfied with the processes that had taken place regarding leadership appointments. Ms Meiring responded that in the past the selection and election of Council Members had been very different to the process outlined in the new Bill. Nurses had tended to give quite a lot of thought to nominations for people who would make a great impact and took patient care very seriously. Some nominees were unknown and votes tended to be for the known candidates. Nurse leaders on the Council had at times been unpopular. Now, nurses could nominate candidates, but the Minister made the final decision. There was a concern that the choice might not be as representative of the private sector as it had been in the past. There was concern about the make-up of the 25 person Council including private sector representation.

Ms Meiring added that Council Members would probably mostly come from the Public Sector and would surely be able to elect a Chairperson that could be trusted. The Minister may not know all the Members and if the Council elected a natural leader, it would surely be someone who would work closely with the Department in the interests of the masses and public.

Ms P Tshwete (ANC) suggested that the Minister electing a Chairperson might guard against individual Council Members lobbying for the position in unfavourable ways. Ms Meiring agreed that the rules would need to be clearly established at the first meeting, but that the Minister could be lobbied in the same way. However, the Minister had the final say in the nomination process and would ensure all Council Members were honourable.

Ms Madumise clarified that Ms Meiring’s main concern seemed to be that the independence of the Council might be at stake if the Minister appointed the Chairperson, and would wish to ensure that the Council served independently of the Minister’s initiatives. Ms D Kohler-Barnard (DA) noted that if the Council were unhappy with the Minister’s choice, it would not function effectively and a ‘hands off’ approach seemed the sensible one. The Chairperson concluded that the issue would be flagged for further discussion.

The Chairperson called for discussion around Medi-Clinic’s concerns about community service. Ms Meiring explained that the four-year training of registered nurses was an expensive exercise. Nurse training involved rotation in various disciplines at both private and public hospitals, a cost borne by Medi-Clinic. Medi-Clinic spent 3.7 percent of payroll on training, which amounted to about R43 million. If all students were to leave their organisation for a year of community service, the hospital would have to employ someone else at extra cost to the company. The Company might well rather choose to focus training on Post-Basic courses where community service had already been completed. This would be unfortunate, as the country needed basic training. She concluded that Medi-Clinic still had to discuss the way forward more thoroughly.

Ms R Mashigo (ANC) asked what steps Medi-Clinic had taken to be the socially responsible corporation it claimed to be. Ms Meiring responded that Medi-Clinic would rather have their students work in communities to relieve shortages during their two to four year training period, than be forced to leave the organisation and do one year community service. Medi-Clinic students were currently volunteering in communities. Students worked in public hospitals and clinics to both increase their hours to qualify and have more exposure to what was happening in the communities.

Ms Meiring expressed their concern at sending staff, especially older women with families, away from their homes to do community service. Fewer people would be prepared to do the Bridging Courses if they had to leave their homes afterwards. In addition, the Bill does not state who will remunerate the staff or how much remuneration they would receive. It would be a financial burden for a nurse to receive less than her pay scale while doing community service. Medi-Clinic also wondered what would become of their Pension Funds and Medical Aids.

The Chairperson noted that according to the Bill, community service had to first be completed in order to register as a nurse. Ms Meiring wanted clarity on what was meant by "register for the first time to practice a profession in a prescribed category". Would nurses have to repeat a year of community service every time they qualified in a new category?

After some discussion Mr Motsapi clarified, that a nurse would only be required to do community service once, when first registering. Dr Mahlathi added that nurses had to do community service irrespective of who funded their training. The Chairperson suggested that it might be necessary to alter the clause and make it easier to understand. Ms Kohler-Barnard suggested the clause read that no person was expected to do more than one-year community service. Dr Mahlathi noted that room could be made in the regulations to address the concern, rather than change the wording in the clause.

Ms Kohler-Barnard asked if a nurse of 40 doing a new training course would be expected to do community service. Mr Motsepi explained that, as in the case of doctors’ community service, there would be a cut off period at a certain year and experienced nurses would not be expected to do community service.

DENOSA submission
The team of DENOSA representatives consisted of Ms N Geyer, Ms T Gwagwa and Mr E Mafalo. They noted the greater emphasis being placed on patient safety and quality of care, the increasing shortages in the health workforce and consumer demand for greater transparency in health care delivery and regulation.

DENOSA had detailed comments on all chapters of the Bill, understanding that the health care system was nurse centred and the Bill defined the scope of a nurse. DENOSA chose to highlight some of the issues detailed further in their complete document. In general, DENOSA supported the content and thrust of the Bill, but there were areas they did not support and felt would compromise the profession and the health services.

The first area highlighted, regarded the autonomy of the South African Nursing Council (SANC). Clauses 5(2)(a) and (b), and Clause 10(1)(a) and 18(1) addressed the Minister appointing the members, Chairperson and Registrar of the Council, and would in DENOSA’s view, severely compromise the autonomy and independence of the Council. At present Council funding was raised entirely from nurses and midwives and the profession should therefore have more input in terms of setting up structures and Council autonomy.

The second area highlighted was that of norms and values, the determination of which was an important object of the Council. DENOSA argued that there had been no co-ordination of training initiatives, and the health care system and infrastructures were not supporting health care professionals to provide safe and quality care. DENOSA proposed the establishment of a Task Team to do a skill audit in order to begin developing adequate staff to patient ratios.

The third area of concern was the composition of the Council. DENOSA felt that the smaller Council proposed by the Bill, would be more effective, but argued that nursing/midwifery expertise must outnumber the other members of the Council. The work may become too great for the 25 members, and DENOSA proposed that SANC developed a bank of nursing expertise for co-option into the working committees. They also argued that students should be consulted on various issues as a stakeholder group. The Bill was not clear on whether the community members and Department of Health member would or could be nurses.

DENOSA supported the underlying philosophy behind community service but raised certain concerns. In general, they questioned what was a reasonable time period for community service, given that nurses were expected to do more hours of service in the community than many other health professionals both during their training and through contractual funding obligations to the Health Department. They also raised logistical concerns around accommodation and supervision in the provinces when placing nurses.

DENOSA’s biggest concern lay with Professional Conduct hearings, whose procedures they considered unfair, and whose panel members were both incompetent and ill prepared. They strongly recommended that outsourcing be considered or that a national panel of reviewers with a variety of expertise be trained to carry out hearings with a high level of accountability and regulation.

Finally, DENOSA addressed Clause 56, on the prescribing of medications by nurses. While they understood the aim as being increased access to health services, the section was unclear and confusing. They recommended rephrasing of Clause 56(1) to (4) and the removal of Clause 56(6).

DENOSA had tabled in their document detailed specific amendments to the wording in the Bill in the areas discussed above. The Committee was taken through these proposed amendments by DENOSA although the Chair noted that they would deliberate on the suggestions only after the hearings.

[The discussion on DENOSA's proposed amendments to each clause was continued after 5pm but was not minuted by PMG].