Why South African nurses should no longer be sidelined in policymaking

If nurses had more say in the policies that affect them and their working environments, it would enhance their job satisfaction and keep them in the health care sector. It would also contribute to the smooth running of the health care system.

Many nurses believe they are excluded from these processes because policymakers don’t recognise the importance of their clinical knowledge.

Since the advent of democracy, South Africa has made considerable progress to advance nurses' presence, roles and influence in developing health policies. However, nurses' involvement has been complex.

What’s stopping participation

Nurses can be involved in policymaking in various forms. This could range from policies that govern nursing practices in wards. They could also help determine the roles of different categories of nurses or how nursing qualifications should be aligned.

But there are several challenges that stand in their way.

One challenge is that the nursing profession is divided about which groups of nursing stakeholders should legitimately represent nursing issues in the policy arena. There is also a lack of collective action within nursing groups, so nurses do not have a unified voice.

Tensions have arisen because nursing divisions nationally and provincially report to three different entities instead of one. And power relations influence who participates in the policy, how this happens and how much nurses’ inputs are considered and incorporated.

The appointment of the chief nursing officer in 2014 and the creation of the Nursing Directorate in the National Health Department could be the glue the nursing fraternity needs to bind together its inputs in policies.

South Africa must learn from other countries

Globally, there is an increased emphasis for nurses to get involved in health policy and systems development. In countries where it has happened, the contribution from nurses to develop patient care and population health policies has been significant.

Australia, Canada, the UK and the US all have professional nursing associations through which individual nurses and the nursing profession can exercise power and influence policy.

There are also several examples in low- and middle-income countries where nurses, through professional organisations, have advocated for health policies.

In Rwanda, the chief nurse and the national nursing association garnered support for legislation to improve the quality of nursing education and professional standards. In Kenya, the Nursing Council was critical in developing the national electronic database on the nursing workforce.

Although South Africa has a nursing council, it does not fulfil the same roles as councils in other countries.

How much South African frontline nurses know about policy

That frontline nurses in South Africa do not engage in policymaking enough is reflected in their knowledge about key policies. To gain an understanding of this, our research looked at how much nurses understood four national health workforce policies:

• the 2008 Nursing Strategy;

• the revision of the Scope of Practice for nurses;

• the new Framework for Nursing Qualifications; and

• the Occupation Specific Dispensation remuneration policy.

Nurses and key informants were interviewed in four South African provinces: the Eastern Cape, Free State, Gauteng and Western Cape. To assess the impact of nursing policy issues on the ground, frontline nurses and shop stewards were quizzed on the policies.

We found the nature of the policy determined their level of awareness.

All the enrolled, professional and operational nurses and shop stewards and close to 90% of the nursing assistants knew about the occupation-specific dispensation policy. This may be because it affected them directly and involved money. The policy provides for financial incentives designed to attract and retain health professionals.

Nurse managers and shop stewards were more likely to know about the other policies compared to other nursing categories. This was possibly because managers who attended meetings discussing policies did not provide feedback.

Nurses without voices

The research also sought to understand how nurses' viewed their involvement in policy formulation. While democracy created opportunities for nurses to participate in policy development, our respondents felt nurses participation was sub-optimal.

The respondents felt that:

• nurse leaders were not assertive;

• they were reactive rather than proactive;

• often they only participated in policy-making when decisions were concluded;

• there were too few nurses in leadership positions; and

• there was a lack of training in policy and networking skills.

In addition, frontline nurses were excluded from contributing to the broader health workforce policies. As a result, policymakers were not tapping into their clinical expertise. When frontline nurses were involved, they seldom participated because they were intimidated by the presence of their managers and the dominance of physicians, hospital chief executives and human resource managers.

Changing the status quo

South African Health Minister Aaron Motsoaledi has emphasised that nurses will play a critical role in implementing the changes in the run-up to the country’s plans for universal health coverage.

The health system reforms will create different work demands. Nurses should be provided with opportunities to influence and direct policies that affect them.

But to increase nurses’ participation in future policy, the chief nursing officer must provide proactive leadership. Strong support will also be needed from the national nursing association.

This study was funded by the Atlantic Philanthropies.