Posted by: davidjolson | 02/08/2011

The South African nursing crisis

This guest blog was written by Michelle Robinson and Jeanette Strydom of Africa Health Placements, a member organization of GHC based in Johannesburg. Recently, AHP published an article entitled “Addressing the South African Nursing Crisis,” which tackled some of the issues surrounding the dysfunctional nursing situation in South African health care facilities. The article, amongst other things, discussed the distinction between the different nursing qualifications (a practical-based, diploma course versus a four-year theoretical degree qualification) and identified some reasons why the diploma qualification can be problematic, leading to under-qualified and under-motivated nurses. However, in response to this article, AHP was contacted by Emily Melk, a registered nurse who began her career as an enrolled (diploma) nurse. An interview conducted with her provided deeper insight into the nursing profession in South Africa and its profound challenges – and indicated that the idea of “diploma nurses vs. degreed nurses” is perhaps a false dichotomy, with the problem being more complex, and far more contingent on how individual nurses cope with a taxing work environment.

JOHANNESBURG, South Africa — The challenges that nurses in South Africa face on a daily basis cannot be downplayed or ignored. Being a nurse means being faced with a constant inundation of patients, as many as 500 per day, in hospitals that are very understaffed. At any given time, one single nurse is assigned to care for as many as 32 patients, with some of these patients being extremely ill and requiring extensive attention. Combined with a lack of adequate facilities and other resources, nurses end up drained, exhausted and struggling to cope with the overwhelming workload. The end result is a mentality where nurses are forced to “treat the numbers, not the patient” and ultimately, patient care is compromised. The health, morale and emotional well-being of the nurses also suffer.

The biggest problem – making ends meet
Despite being faced with stressful and demanding working conditions, many nurses are passionate and committed to their profession, and to delivering quality patient care. However, the salary scale in nursing is not very high, especially in public institutions, and the struggle to stretch a limited salary is exacerbating an already difficult situation.

Global Health Council (2009) statistics show that the private sector accounts for 41.1% of all South Africa’s nurses and 72.6% of the country’s general practitioners. Often health care workers may leave the public sector to work for a non-government organisation or other private entities as private sector salaries are considerably higher than public sector wages, making it easier to support a family when employed by the private sector.

Another worrying trend has developed: Nurses are taking on additional part-time or night-shift work in private hospitals to supplement their low income, or are signing up for far too much overtime. This leads to nurses who are constantly fatigued and have no time to rest, and subsequently do not perform at full capacity. The inevitable result is a decline in the quality of patient care and in the health of these nurses, who feel that they have no choice. As Emily succinctly puts it: “Nurses are very underpaid. It’s disgusting. And we have children to feed.”

It is clear that the situation needs to be addressed, and that the amount of additional work that nurses take on needs to be monitored and regulated, at least as a short term measure. Hospital management certainly needs to play a role, for example, in preventing nurses from logging excessive amounts of overtime. However, this does not go to the root of the problem, which is that nurses are struggling to afford to live on their current salaries. If they are cut off from subsidising insufficient income, and no solutions are provided, many will be forced to leave nursing or attempt to move out of the public sector, causing an even larger problem.

All qualifications are not created equal
It seems that the discrepancy between the education that some college nurses receive, as opposed to those who have a four year degree, can be attributed to some of the public nursing schools which offer “diploma qualifications.” These schools are unregistered and unscrupulous, attracting school leavers who haven’t been provided with the correct information to make an informed decision, or who have financial difficulties and perceive these schools as being more affordable. The diplomas they receive from these schools are not worth anything, and the training given is sub-standard. Once the nurses graduate from these “fly-by-night” institutions, they struggle to cope in the professional environment and need a lot of coaching and assistance from the other nurses, putting additional strain on an under-resourced system. These unregistered nursing schools need to be identified, and school leavers need to be provided with adequate career guidance and information about reputable schools so that they can attend a school where they can obtain a proper qualification.

The second issue is that of nurses being employed in positions for which they are incorrectly qualified. Placement agencies don’t always check qualifications, or an under-qualified nurse may be asked to take up a certain position due to staffing shortages. Emily herself gives an example where she was offered a position as a sister even though she did not have the right qualification. She has seen many instances of this, for example, nurses who are untrained to work in the ICU will accept an ICU position because they need the money. This practice of employing untrained nurses in specialised positions greatly decreases the standard of nursing, but the Catch-22 is implicit. If these nurses aren’t employed, then patient care is ultimately compromised anyway due to staffing issues.

So what defines a competent nurse?
Emily, herself an enrolled nurse who went on to do a bridging course to become a registered nurse later in her career, vehemently denies that a diploma nurse is inherently less capable or less educated than a degreed nurse. She claims that while degreed nurses have extensive theoretical knowledge, they have no practical experience, which is crucial in a competent nurse. She points out, “I have taught registered nurses and doctors how to do their jobs,” underscoring the fact that theory cannot replace practical experience. The balance has to be there – a sound theoretical background needs to form the platform for plenty of hands-on training. She also makes the point that while degreed nurses train for four years learning a combination of the theory behind the various specialisations in nursing such as midwifery or ICU nursing, diploma nurses will spend a year on a particular field, which is potentially the better strategy for training skilled nurses.

It seems that the pressures that face nurses in South Africa have a far greater effect on their ability to care for patients than the origin of their education, although this certainly does play a role. Emily speaks of nursing as a “noble profession” – one that requires passion as well as compassion, and plenty of resolve. She maintains that nurses with these qualities do exist, regardless of where they obtained their qualification, and that the systemic problems, which are undermining the nursing profession and the ability of nurses to do their jobs well, affect all nurses. The lack of structure and support, and the demoralising conditions under which they work, all take their toll.

Although the financial aspect is important, it is equally imperative to motivate nurses with recognition and efforts to boost their morale. A strong support system that begins with inspiring nurses to enter the profession as students and that recognises the difficulties that nurses face, is crucial in shifting the balance towards nurses who are physically, emotionally and mentally able to do their jobs well.


  1. Our experience of nursing in South Africa is dire. If an infant or young child does not have a family member in the hospital with them, there is a high chance that they will remain in soiled clothes on soiled beds and not be given food to eat. We have had depressed children who could not or would not feed themselves and food was placed next to them at one meal time and taken away untouched at the next mealtime, with no effort being made to feed them nor to encourage them to eat if they were able to feed themselves (e.g. if their hands were bandaged or amputated). Just look at the hip size of the average nurse and wonder how much work she does. Phone Coronation Hospital wards at TV soapie time and see if the phone is even answered. They don’t even administer ARVs to one of our 12 year olds – he has to remember to take them himself and he wisely turned down the medication of another named child when the nurse in Charlotte Maxeke ward 275 gave it to him last month! Most of the nurses we meet, just don’t care. They leave children crying in pain and seem not even to hear the noise.

  2. It may be that the reason why the nurse is not answering the phone is that she / he is too busy with patient care to get to the phone. Yes, there are known problems in hospitals, and not all nurses are able to give the quality care they set out to give when they decided to become nurses. But as described in the article, there are complex reasons for this. It would be interesting to hear an offered solution to these problems.

  3. Nursing in South Africa is governed by rule of law. Anyone one who attains qualifications from an unregistered nursing school will not be allowed to practice professional nursing anywhere in South Africa. I am a South African trained and registered nurse, and work abroad. I have seen many underqualified registered nurses in some first world countries. The nursing education in South Africa is second to none. The problems of overworked and underperforming individual nurses is not unique to South Africa. South African nurses are well trained, if anything. How many first world countries are poaching nurses down there? South African nurses are the best. Every sober employer wouldn’t mind spending a couple of thousand pounds to get a South African-trained nurse.

  4. The most disgusting thing about being a nurse in south africa is lack of recognition. A nurse with 15 years of experience earns the same salary as a physiotherapist who just graduated from varsity, or even less. Other health professionals work in air conditioned offices but nurses are sweating in the wards with no aircon in the nurses’ station. This is referring to the public sector. Another epidemic is that of nurse managers who treat nurses like their maids in the way they talk to them. The government implemented OSD in an effort to retain nurses and recognise their skills but this also has its problems. The pay rate will not be the same but the job description is the same. If nurses want to study and be in the same level with their colleauges the managers refuse to release them to go and study saying this would cause shortage of staff. Who wants to be at the bottom of the ladder while others are enjoying at the top? On the issue of degree vs diploma, varsity nurses lack the practica of diploma nurses but they gain it over time.

  5. Heya i want to work as a nurse in africa when im older but first im going to work in the army as a nurse and get some qualifications first . do you think it will help me???

  6. also a nursing science student at up.i would like to know how much underpaid are we talking here for a RN.

  7. several articles have been published on subject matter and few if not none of them bring about practical solutions to the matter at hand. the South African Nursing Council, Universities, Health department and all relevant stakeholders need to have a rigorous discussion on this matter and come up with practical solutions. The issue of the diploma and degree is another dilema that leads to conflicting views amongst the nursing professionals in different ares of practice. What is need is a single qualification that is equal, accredited, respected and such qualification should be able to provide answers to the challenges facing the health care system in this country. another reality is that we need need nurses that are able to critique, analyse and influence health policies and who are able to comprehend and understand why things are done. the perception that diploma trained nurses are better that their degree counterpants is flawed and has no basis in professional nursing, hence the title professional nursing. exploitation of nurses by the health department can be attributed to the perception that nurses train in hospitals and there is nothing else that they can do except giving bedpans and cleaning patients. whereas allied health professional have degrees e.g. physitherapy, occupational therapy e.t.c. and earn more that what nurses with degrees earn. the was a call in the last sumit that the government must salaries must be the same as other health professionals, but it appears that call will die in vain as there are few nurses who stand up against the government in terms of advocating for nurses. however, with the existing confusion within the profession itself, that call may just dissapear along the line.

  8. I am a registered nurse with a post-basic qualification. I have been in the private sector for ten years now. I am a devoted and caring nurse. I love my patients. I make it my mission to solve their problems. Whenever I work, I am firstly there for the patient/s and then the other professions and or people.
    It is my opinion that in the private health sector, we as nurses, are cheap labour and are exploited for the fact that we love it to care for others. The longer I move in this circle, the more I am starting to get the idea that we are treated in very much the same way as 20+years back, the way the old apartheids goverment treated the black people of South Africa.

  9. What is the anuual average salary of a nurse?

  10. great article guys love this verry informative

  11. Do we need a healthier country? Obviously, we do; but contrary to this obvious need, we never respond to it as a need! That is, we collect tax revenues, and instead of sufficiently funding the health-care industry, we suffer the nurses and the doctors, and the patients, with what we’ve come to know as the health-care penalty! We say if they care, 1. they’ll overlook all the unnecessary problems we all know they suffer, 2. they’ll remain psychologically and physically fit enough to care about health-care, and 3. they’ll continue caring for patients! If they care! Makes you wonder: Who cares about the ones who care?

    We train a few number of nurses, that’s one cost-cut; under pay them, another cut; burden them with overloads of work, an even painful cut; then, negate their dying-efforts, and illogically expect them not to run out of compassion; a killer cut! And we keep cutting costs, being cost effective, at what cost? At the cost of our own health! Don’t we care about health? If we do, then it should be expressed in our investment in it, in our respect for health-care workers, in our health state as a Nation! We are clearly unhealthy, we lack nurses, even worse, we abuse the ones who are there; we make them feel brutally enslaved! We don’t make them feel significant, although we expect them to somehow dwell in such a feeling! I don’t blame them nurses; their structured working environment is not conducive enough to sustain the light of their passion!

    What would the lady with lamp say today? She would tell the nurses to keep on…but she would be disappointed by how for granted government and society takes The Nurses!

    I’m going for the four year diploma in Nursing next year, and already, I can feel the heavy-weight of the Health-Cross upon my young shoulders…

  12. Practice, Experience, and the Documentation thereof, form the textbooks! There’s no substitute for experience! Practise makes perfect! Theory is only as good as its application; if it can’t be applied, then what good is it? Real life situations are the best sources for learning and gaining experience! Books require a lot of imagination, ideation, speculation; but real life situations require a lot more quick and actual responses!

    With all that said, I mean: A heavy BSN theoretical load still needs to be confirmed through practice, and a thorough clinical ADN/Diploma experience still needs to be translated into concisely constructed theory; so, you see, there’s always room for further development! Pro’s and Cons may vary for the much needed and appreciated ADN, Diploma, and BSN, entrants into Nursing practice; but at the end of the day, provided learning gateways remain open, they can all further their development! I thank you!

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