How nurses who moonlight and do agency work strain the health system

Between 2009 and 2010, the South African government spent over US$212.6million (about R1.49 billion) hiring nurses for the public health sector from nursing agencies.

In the same period, the provincial spend on agency nurses ranged from a low of just under US$5.2million (R36.45 million) in Mpumalanga Province to a high of US$50.92million (R356.43 million) in the Eastern Cape Province.

In that financial year, more than 5300 registered nurses could have been employed instead of agency nurses, according to our research.

The government’s spending on agency nursing is a result of nursing vacancies, poorly managed staff absenteeism, sub-optimal planning for patient loads, and not involving nurses in decisions on their shifts or how best to cover hospital wards.

Nursing agencies provide a vehicle for nurses to moonlight, as they could be employed concurrently in a public or private sector hospital as well as the nursing agency. These agencies are not obliged to ask nurses whether they have concurrent employment.

The problems with nursing

The nursing agency spending is, however, an indication of the bigger crisis in South African nursing. The profession is plagued with problems of too few new nurses, insufficient nurses with specialised qualifications (for example, in intensive care), and an ageing workforce that is unequally distributed between urban and rural areas, and between the public and private health sectors.

South Africa’s public health sector faces major challenges in producing, recruiting and retaining health professionals. This is especially true for nurses, who form more than 70% of the professional health work force. The nursing workforce includes professional nurses with four years of training, enrolled nurses with two years of training and nursing assistants, who only have one year of training.

Statistics from the South African Nursing Council show that not enough nurses are being produced to match the health and service demands for nurses and midwives in the country.

The severe shortage of professional nurses across all health care services came to the fore in 2010. Although more than 3500 professional nurses had registered with the South African Nursing Council, in the same year, the National Department of Health estimated that 44 780 professional nurses were needed in the public health sector.

The council’s statistics also show there has been a decrease in the number of new nurses with specialist qualifications.

And although nurses are more equitably distributed between urban and rural areas than other health professionals such as doctors, there is still a gross mal-distribution between the two areas. In 2014, the urban areas of Gauteng and Western Cape combined produced 1234 professional nurses. In comparison, only 501 professional nurses were produced in the three rural provinces of Limpopo, North West and the Northern Cape.

Another challenge is an ageing nursing workforce. Currently, more than 43% of professional nurses are aged 50 and above.

After hour activities

To add to this crisis, nurses in South Africa are also turning to extra work after hours through moonlighting, working overtime and doing agency work.

This means that nurses work excessive hours, which in turn affects the way they perform, thus impacting negatively on patient care.

Some of the significant health system consequences include that nurses are too tired when they are on duty, that they sometimes stay away from work without authority, and these impact on the quality of care provided to patients.

There has been limited information on moonlighting and agency nursing in the country and sub-Saharan Africa. Our study was the first large cross-sectional survey on the extent of agency nursing, moonlighting and overtime in South Africa.

The survey was done with 3784 nurses at 80 hospitals across four provinces in South Africa. The nurses worked in critical care, emergency units, the operating theatre, maternity, general and surgical wards in both public and private hospitals. Each were asked to fill out a questionnaire.

Close to 70% of the nurses interviewed were moonlighting, working overtime or doing agency nursing in the year before the study. Of these, one-fifth did all three.

The survey shows these practices are widespread in the South African health care system. However, it showed that more nurses from the private sector were moonlighting compared to those in the public sector.

More critical care nurses were moonlighting compared to those in maternity units. More nurses were moonlighting in Gauteng – the country’s economic hub – than any of the other three provinces. Nearly 40% of nurses had worked through a commercial nursing agency in the 12 months before the survey.

The impact on the health system was serious. Of all participants, half said they felt too tired to work and 10% admitted to paying less attention to their nursing work on duty. Another 10% took sick leave when they were not sick.

At least 10% also took their holiday leave to do agency work or moonlighting, and just under 10% reported conflicting schedules between their primary and secondary jobs.

Although the majority of nurses said they did the extra work to take care of patients, learn new skills and because of their relationships with their co-workers, more than 70% agreed that more money was a factor.

Of the nurses interviewed, almost one-third of participants indicated that they planned to leave their jobs within the year following the study. Nurses who were moonlighting expressed the strongest intention to leave.

Changing the status quo

The heavy reliance of critical care (intensive care) units on agency nurses and the high rate of moonlighting among critical care nurses reflect the demand for skilled nursing care in the public and private health sectors.

Moonlighting needs to be addressed and there needs to be better regulation of commercial nursing agencies. Professional nursing bodies need to give nurses better support and guidance.

The new health sector reform policies will further increase the demand for professional nurses with specialised skills. At the same time, the absence of national norms and standards makes it difficult to determine the real shortage and the number of nurses required of all categories. Hence, the development of national staffing norms and standards must receive the utmost government priority.

Laetitia Rispel received funding for the study from the Atlantic Philanthropies. She is employed by Wits University.