An ode to the nurses

TWICE, sometimes three times a day. For almost four weeks. Through the glass doors, up the stairs and down the passage. Towards the red wall with the ICU sign beckoning me like an ominous beacon.

“Patients in this ward are more prone to infection…" The words on the door knock me every time. I disinfect my hands and push through into the eight-bed ward. For a while, it's touch and go. The specialist physician, Dr Mbijekana, has a calming bedside manner, but he doesn't offer false hope. “She is gravely ill. We haven't been able to get her infection under control. But she is in good hands here."

How serious is the looming shortage?

South Africa, like the rest of the world, has a severe shortage of skilled nurses. The UK poaches Zimbabwean nurses, and Australia grabs British ones. We import skills from India and elsewhere. It's a global problem, but the situation in South Africa is becoming more critical every year because we are not training enough nurses — even though we could. Why?

South Africa has just one nurse per 213 people. Of these, less than a third are under the age of 40, and within 15 years, 47% of nurses working today will have retired. We also losing nurses to emigration and richer countries. 

The current nursing shortage has been estimated at more than 26,000 but this number could rise to between 131,000 and 162,000 by 2030. It is a mind-boggling number.

They tell me they might have to intubate my mother, and I have to compose myself in the passage. Sister Yoliswa Dingela comes to sit with me and holds my hands while I cry. She speaks with such kindness that it makes me cry even more. “I want you to know that we are committed to seeing every patient leave this ICU. Leave her in our hands; it all looks scarier to you than to us," she says.

Why are we not training more nurses?

“There is a scarcity of specialised skills for several reasons,” says Merle Victor, chief nurse officer at Life Healthcare. “One of them is that not enough training opportunities have been made available. That is a serious problem for our country, considering our burden of disease. Additionally, to ensure our patients get adequate care we need specialist nurses with the appropriate knowledge, competence and skills.”

Life Healthcare group CEO Peter Wharton-Hood says the company has the capacity to train up to 3,000 nurses a year but is accredited to train only 800. He says Life Healthcare is committed to investing in the training and development of nurses to ensure a pipeline of professionals for the future, but “the organisation cannot achieve this without the support of regulators". 

“Today’s investment in these critical skills does not stack up against the growth of our population,” he says. “If no immediate action is taken and we cannot develop a sustainable pipeline of nursing talent, the problem is going to get worse. Nurses are the backbone of any healthcare system and we are being denied the opportunity to invest in the next generation of nurses.”

One of the greatest needs lies in trained specialist nurses in areas such as intensive and emergency care and oncology. These are the very people who pulled my mother through the two weeks when her life was hanging by a thread. But unless significantly more nurses are allowed to enter the profession, it goes without saying that the scarcity at the apex of the profession — highly trained specialised nurses — will also worsen.

By week two, the staff feel like family. Sisters Mabasa, Mathebesa, Dingela and Ndyoko have become Dumi, Nosi, Yoli and Lucy. They call her Oumie. I am deeply grateful for their professionalism and unflappability, but also for their patience and kindness. They nurse. But they also rub her back and do her hair and feed her. In a particularly bad week, they have to clean and dress and strip the bed multiple times a day. I am there during one of these events. They draw the curtains for privacy. I wait on a chair outside. I listen to Dumi and Nosi singing while they attend to my mother.

What is the problem?

South Africa trains only 3,000 nurses a year. By 2030, that means we will have trained 21,000 new nurses, which is 100,000 fewer than we need on the most basic of predictions.

Last year, Home Affairs added specialist nurses to the critical skills list, which in theory allows hospitals to recruit nurses from places such as India. It would seem, however, that this process is so tightly bound in red tape that the list is not worth the paper it is written on. 

Business Day's health and science reporter, Tamar Kahn, explains:

“At issue are qualifications required of foreign-trained nurses by the statutory body charged with overseeing the profession, the SA Nursing Council (SANC). In a sharp departure from the past, it now requires all foreign-trained nurses who want to work in specialist units to have a postgraduate specialist qualification, in line with a new qualifications system introduced in 2020.

“That means private hospitals can no longer hire nurses readily for their specialist units from India, the key market from which they recruited in the past, because their qualifications don’t align with SANC requirements. Most nurses working in specialist units in India have a basic qualification and acquire their niche skills on the job."

The ups and downs of four weeks in an ICU are harrowing for any patient. But my cousin, who is an ICU nurse, says it is often more traumatic for the family because they don't always understand what is necessary to pull a patient through a life-threatening illness. At some point in the first week, I stand helplessly next to my mother's bed as she begs me for water. It breaks my heart. Dumi is gentle and kind as she explains the medical reason why withholding fluid is necessary. At another point, my mother becomes delirious, and the staff have to use wrist restraints to keep her from pulling out her IV lines. It kills me to see my mother tied up. I think it was the lovely Nosi who talked me down.

Why are we not training more?

All of this begs a simple question: why are we not jumping at the opportunity to train more of our own? And if public hospitals have fiscal constraints (although the greatest need for additional nursing capacity lies in the public sector), why are we not allowing a private hospital group like Life Healthcare to train an additional 2,200 nurses a year when it says it is willing and able to do so?  

Judith Bruce is Wits University’s head of therapeutic sciences, and in this interview on 702 she explains where the crux of the problem lies.

“Government has placed restrictions on the number of nurses that can be trained per institution. SANC uses certain metrics to determine the numbers that an institution can train, but in my view, these metrics are incorrect. You cannot predict future numbers in a burgeoning population based on the existing capacity of institutions to train."

The main issue seems to be the regulatory framework that came into effect with the new nursing education strategy in 2021. Before they can begin to train nurses, institutions need approval from the Council on Higher Education, SANC, the SA Qualifications Authority and the Department of Higher Education & Training.

The new strategy was aimed at “raising the level" of nurses' training, but the result has been that some private and public nursing colleges do not meet the new requirements for SANC accreditation.

One example outlined in this excellent article is that lecturers are now required to have a master's in nursing education. Those unable to get a master's have returned to practical nursing in hospitals or are working for pharmaceutical companies. A good intention, but with far-reaching consequences.

Life Healthcare's Wharton-Hood says: “New regulations enacted by the SA Nursing Council and Council on Higher Education are turning off the taps of training. Out-of-touch regulations permit us to train just 800 nurses a year — in no way enough to reduce the effect of the shortage. 

“[We] are being denied the opportunity to invest in the next generation of nurses. The bureaucrats will simply not listen."

It all remains as clear as mud to me. And it feels like so much of what the government does — well-meaning regulations and grandiose policies that are, at the end of the day, a case of fiddling while Rome burns.

* The South African Nursing Council was unavailable for comment this week, as officials were all attending an event.

Over the past four weeks, I have seen, in the conduct of the specialist staff in the St Dominic's Hospital's ICU, the very best of humankind. Two days ago, when my mother was finally wheeled to the ambulance that would take her to a step-down facility for rehabilitation, she told me she was sad to leave the staff with whom she felt she had forged an indelible bond. It leaves me choked up with gratitude. Thank you, Dumi, Nosi, Yoli and Lucy. I wish our government would allow there to be more of you.

♦ VWB ♦

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