APPENDICIES
3.3. The Nursing Profession within the Re-engineered Public Health Care Model
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understood concerns that require interrogation when developing a retention strategy for the occupation to match the same opportunities as migration affords them. As Partab (2015) challenges, the failure to engage in the factors that precipitate nurse migration can potentially result in the value of the nursing profession being honoured internationally but not locally.
Moreover, the investment of training a nurse has to pay dividends for the country, instead of that nurse migrating with her/his skills and offering it to a community that can afford to employ its own personnel.
With the proposed rollout of the NHI scheme, South Africa is on the precipice of a revolutionary health care financing policy; however, the human resource crisis will prove to be a huge challenge that potentially can hamper the efforts of the NHI and the re-engineered PHC system as nurses are integral to the new system. Unless South Africa can recruit more health professionals to work in rural areas, many of the programmes within the Re-
engineered PHC model will be hard to implement.
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this new shift in policy requires nurses to be at the forefront of every new initiative proposed by the DoH.
The current PHC system requires a nurse to be multi-skilled with the ability to not only diagnose and treat common ailments, but also recognise complex health problems, provide health promotion and counselling to patients, and follow-up with patients regarding their treatment and manage chronic conditions. With the increase in access to services and health care being free for all, the case load that nurses have to handle on a daily basis will have to be increased. With this, no provision has been made for handling the increased patient load and little to no support for services have been introduced to assist nurses with their workload (Geyer, 1999).
A clear example of how the role of a nurse has changed is provided in how the scope of practice for a nurse is defined in the South African Nursing Act of 2005. According to Nursing Act of 2005, the definition of the role of a nurse is:
A professional nurse is a person who is qualified and competent to independently practice comprehensive nursing in the manner and to the level prescribed and who is capable of assuming responsibility and accountability for such practice (p. 25).
Comprehensive services refers to a nurse providing more integrated services at the PHC level as outlined in various policies such as the ICDM, the NHI White Paper (2015) and the Re-Engineering Policy Discussion Document that were discussed in chapter2 of this study above.
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Within the domain of the Re-engineered PHC, nurses are seen to have three key roles:
(i) they are the leaders of the WBOT; (ii) they form part of the DCST and (iii) they head up the ISHP (Pillay & Barron, 2011). This is separate from their role as primary health care providers at the clinic level. How these roles will work, whether they are interchangeable, fixed or fluid has yet to be confirmed by either DENOSA, SANC or the NHI White Paper.
One can only assume that a nurse who leads the WBOT would not be expected to work in the clinic itself, but be based in the community. However, based on the PHC narrative, the professional nurse who leads the WBOT is facility-based with the staff nurse (a cadre of health workers that do not presently exist) based in the community (see Figure 3.1). The ambiguity of the placement of the nurses who form part of these WBOTs, further adds to the stress and strain experienced by nurses in the system who are left to perform multiple roles with little guidance on what is expected of them within the new system.
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Figure 3.1. Public Health Care Outreach Team. Adapted from Rispel et al., 2010, p. 12.
Thus far, the creation of the WBOTs have not lead to professional nurses being taken out of the clinics to head up these teams, as the DoH has hired retired nurses to fill these posts. However, whether retired nurses will always lead these teams is yet to be confirmed.
The Human Resources for Health Strategy 2012∕13-2016∕17 defines the different cadres of health workers that need to be trained and recruited in order to implement the Re- engineered PHC system (Department of Health, 2012). In their report, the DoH is cognisant of the fact that currently South Africa does not have the required number of professional nurses, trained midwives or PHC trained nurses to fully implement all aspects of the Re-
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engineered PHC system. The report recognises that a re-orientation of nurses towards the new scope of practice is thus required in conjunction with posts being redefined for the new PHC model (p. 67). However, the document does not elaborate further on the role of the
professional nurse in the clinic setting, the WBOT setting or the ISHP setting. The report does however detail how the DCSTs will function and who will form part of this team.
According to the HRH document, the DCST will comprise of an Advanced Primary health Care Nurse, Advanced Midwife and Advanced Paediatric Nurse in addition to a Family Physician, Obstetrician and Gynaecologist, Paediatrician and Anaesthetist. Their primary role as discussed above, will be to strengthen the clinical governance of maternal, neonatal and child health services at hospitals, community and primary health care and at the home-based level in order to promote the wellbeing of the population within the geographical catchment area of a regional hospital (Department of Health, 2015; Department of Health, 2012).
3.3.1. Why Was It Necessary To Change?
The PHC system of South Africa is nurse-driven, with nurses having to assume roles and functions that were previously undertaken by medical doctors. The role of a nurse has undergone immense transformation, from that of a supportive role to that of a main health care provider. Nurses have to contend with an ever-increasing population, as well as an
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attendant increase in their daily workload as the scope of their practice is ever expanding to include even more duties (Mayers, 2010).
The changing disease profile in South Africa has also required nurses to adopt a broader role in all aspects of patient care. While nursing is seen as a dynamic field, constantly changing and seeking ways to better meet the needs to their patients, the current burden of disease facing South Africa has forced nurses in PHC settings to be the main and sometimes sole providers of health care services. Taking on additional tasks is nothing new to the nursing profession, as nurses for centuries have had to take on additional roles and responsibilities to meet the changing needs of their patients in settings where there were shortages of physicians (Willard, 2009). However, by placing a greater workload on a profession already characterised as overburdened with the influx of new and old patients can lead to the complete collapse of the health care system (Van Rensburg, 2014).
It is this transformation and increase in workload that has encouraged the WHO to advocate for the practice of “task shifting” in public health care facilities (WHO, 2008a). The first recommendation the WHO makes in its published guideline document is that countries should look at:
Implementing and/or extending and strengthening a task shifting approach where access to HIV services, and to other health services, is constrained by health
workforce shortages. Task shifting should be implemented alongside other efforts to increase the numbers of skilled health workers (WHO, 2008a, p. 3).
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This recommendation is crucial in light of the challenges the South African Health System faces in terms of the burden of disease and attendant shortage of skilled health workers.
3.3.2. Task Shifting vs. Task Sharing
One of the challenges that face low and middle income countries (LMIC) in achieving better health outcomes is the shortage of health care workers. In an effort to help redress this shortage, the WHO (2008a) proposed that LMIC adopt a task shifting or sharing approach as a viable solution for improving health care coverage by using the current human resources more efficiently.
Task shifting has been defined as a process of delegation whereby tasks are moved, where appropriate, to health workers with shorter training and fewer qualifications (WHO, 2008a). Task shifting is different from task sharing, as the latter involves the process of supervision and mentoring of non-specialist workers and emphasises the role of the
supervisor as “sharing” the task of caring for the patient (Lund et al., 2014; Pillay & Barron, 2011; Rispel et al., 2010) Task sharing, as opposed to task shifting, is an ideal solution for addressing the many challenges that face state health care systems, including the high rate of NCDs that afflict the South African system as the latter has the potential risk of tasks being
“dumped” on lower level health care workers.