Date added : 22 April 1997

THE NURSING AMENDMENT BILL, 1997

Introduction

The Nursing Amendment Bill (1997) was passed by the National Assembly on 13th March 1997. In accordance with article 73 (5) of the constitution, it has now been referred for debate to the National Council of Provinces. This Bill was introduced by the Ministry of Health, to provide for the establishment of a transformed South African Nursing Council. It has given rise to much controversy, most of which has centred around the composition of the Council.

The need to transform the South African Nursing Council

The Nursing Council, and hence the nursing profession, require profound transformation. The Council, like other statutory institutions, was subject to legislation passed by the previous political dispensation. Although theoretically autonomous and not politically aligned, the Council was in fact biased towards the interests of an elite minority of the public and of the profession. While the first Nursing Act of 1944 made no reference to race, the Act of 1957 introduced indirect representation of "black" and "coloured" nurses by "white" nurses. Separate Councils were set up in Bophuthatswana, Transkei and the Ciskei, and various amendments were subsequently passed, affecting beneficiaries and professionals in other so-called homelands.

In addition, research has demonstrated a tendency for the organisation and distribution of biomedical roles to follow the class, racial and sexual stratification of society. In South Africa, the majority of medical doctors are white males, while the nursing profession is overwhelmingly female. The higher positions within the nursing profession tend to be dominated by white females, while black females are concentrated in occupations with the lowest status and remuneration, and the least possibility for advancement (D.M. Gibson, submission to National Assembly Portfolio Committee on Health, 1997).

This tendency is embodied in the three main categories of nurses in South Africa:

• Registered nurses, RNs (otherwise known as sisters), of whom there were 88 764 in 1994: they are independent practitioners at the end of a 4-year degree or diploma course;
• Enrolled nurses (otherwise known as staff nurses), of whom there were 33 302 in 1994: they work under the supervision of RNs after a 2-year training course;
• Enrolled nursing auxiliaries, of whom there were 51 676 in 1994: they are also supervised by RNs, after a 1-year course.

In 1990, the last year for which figures were made available in "racial" categories, 148 558 nurses were registered with the South African Nursing Council, including 76 277 Africans, 3 122 Indians, 21 192 Coloureds and 47 967 Whites. 68% of White nurses were in the RN category, while only 40% of Africans, 30% of Coloureds and 53% of Indian nurses were in this category (South African health review, 1995).

Despite the emphasis on the superiority of registered nurses' professional skills and knowledge, the boundaries between RNs and other categories are seldom maintained in practice in the workplace. Enrolled nurses are often in the position of being delegated responsibility for the duties of RNs, without having their power or privileges. Although 2 year bridging courses are available to enrolled nurses, access is dependent on reports on their work by RNs. In addition, all categories of nurses must register or enroll with the South African Nursing Council and pay fees to it.

The legislative reform process

A Nursing Amendments Act, assented to on 6th April 1995, was one of the first acts to emanate from the Ministry of Health (Act No. 5 of 1995). Its main objectives were to abolish previous Councils and to provide for an Interim Nursing Council. This was to have a 24-month life span, and was mandated to advise the Minister of Health on the constitution of a permanent Council, and on amendments, where necessary, to existing legislation governing the profession. Greater emphasis was to be placed "on professional practice, democracy, transparency, equity, accessibility and community involvement" (para (g),s.3 of Act no. 5 of 1995). The other objects and powers of the Council, which aims to protect the public by ensuring that the standards of education and practice of nurses and midwives are safe and ethically based, were little modified by the 1995 Act; nor have fundamental changes been proposed in the 1997 Bill, whose main focus has been the composition of the Council.

The Ministry of Health's initial draft of the 1997 Nursing Amendment Bill was informed by recommendations made by the Interim Nursing Council, which first met on 23rd August 1995. The Bill (GG No. 17194 of 24 May 1996) was debated during 1996 within the ranks of the nursing profession. The original proposal was accepted by part of the organised profession, notably by the Democratic Nursing Association of South Africa, DENOSA, which has a membership of over 86 000 nurses. However, deep divisions emerged among key stakeholders concerning the governance issue at hearings on the Bill held by the Portfolio Committee on Health on 6th March 1997. The Portfolio Committee made some amendments to the composition of the Council, which were passed by the National Assembly on the 13th March 1997.

The key issues
Composition of the Council

In the version of the Bill passed by Parliament, there are 37 members of the Council, who hold office for 5 years, with the exception of 2 student nurses in their third academic year, who hold office for one year. Eighteen members are elected, each category of nurses being elected by their own professional category. The remaining members are appointed: 18 by the Minister of Health and one attorney by the Association of Law Societies. All members are eligible for reappointment or re-election. The main contentious changes have been:

• Only 13 members are guaranteed to be registered nurses, whereas the original proposal allowed the Minister to appoint 7 RNs in addition to the 15 elected RNs
• Appointed members outweigh elected members in the Council, which is intended to be autonomous and self-regulatory
• Community representation has been increased from 6 to 9 (these persons are to be appointed by the Minister from lists submitted by members of Provincial executive councils responsible for health)
• The doctor and pharmacist have been removed from the Council.

Part of the nursing community, spearheaded by DENOSA, is unhappy with both the content of these changes and the process by which the Bill underwent change. They maintain that the original proposal "was widely debated by the nursing fraternity, it should be seen as a mandate from the nursing profession".

The National Education Health and Allied Workers' Union (NEHAWU) on the other hand, supports the changes, and in fact advocated for more radical amendments to the Bill, including parity of representation for registered nurses, enrolled nurses and auxiliary enrolled nurses.

The debate in the National Assembly highlighted these differences in approach. Opposition speakers stated that minority representation of registered nurses on the Council would harm the profession, while the Minister of Health reiterated the need for transformation of the Council. The Bill was voted by 145 members in favour and 65 members against.

Other issues

Beyond the contentious governance issue, other questions have been raised during the debate surrounding this bill. The future Council will no doubt be a major stakeholder in tackling these issues. They include:

The table below summarizes the successive proposals for the composition of the Council, and is compared to the membership of the last Council before South Africa's democratic elections:

• The future of the Council

NEHAWU, in its representation to the Portfolio Committee, suggested that "there should be one council that represents all health professionals". It calls for further legislation to address this. NEHAWU also criticises the Council's role in regard to the disciplining of nurses, and its funding mechanisms. It is worth noting that the administration which supports the Council employed 135 people in 1996. It is headed by a registrar, who will cease to work for the new Council at the end of its first meeting, unless the Council decides at that meeting to reappoint that person.

While these views represent one end of the spectrum, the future of health professions' Councils is currently being debated in other arenas. The parliamentary portfolio committee on education has recently studied recommendations for the reform and regulation of education and training of health personnel. In particular, the Health Sciences Working Group recommended closer cooperation between the Departments of Education and Health, for the balanced, efficient and effective training of health professionals. It proposed that curriculum should no longer be prescribed by health professions' Councils.

• The future of the profession

NEHAWU argues further "that ultimately there should be one category of nurses in the profession". This suggestion has far-reaching implications, which would ultimately need to be addressed by national legislation.

The way forward

The Bill, which is classified as an ordinary Bill affecting provinces, has now been referred to the National Council of Provinces for consideration. In accordance with constitutional procedure, the Council can either pass the Bill, pass an amended Bill, or reject the Bill. Stakeholders are currently lobbying Provincial institutions in order to influence the outcome of this debate which is due to take place in the National Council of Provinces on the 12 May 1997.

PHILA is supported by grants from the Henry J. Kaiser Family Foundation.

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