Nursing attrition and the work environment in South African health facilities

A number of media reports appeared on the shortages of professional health workers in the public health sector. Unsatisfactory working conditions in health facilities were mentioned as one of the key aspects responsible for the shortages. Literature indicates that stress caused by unsatisfactory work environments may play a major role in em ployees’ decision to resign their jobs, in spite of enjoying the nature of their work. The aim of this article is to explore the current human resource situation in nursing i.e. to determine if a short­ age of nursing skills exists, to establish the challenges that nurses have to face in performing their duties and to establish the potential effect of the work environment on attrition. Currently 155 484 nurses are practicing in South Africa at a rate of 343 nurses per 100 000 of the population, which compares favourably with the World Health Or­ ganisation minimum of 200:100 000. The lack of reliable data on the supply of and demand for nurses makes it difficult to determine whether real shortages exist. How­ ever the supply of nursing services is influenced by the uneven distribution of skills across regions and the out­ flow of professional skills. It seems that the existing situation will deteriorate because fewer people are inter­ ested in taking up or pursuing nursing as a career in South Africa. At the same time a need for more nurses was identified because of the growth in the population as well as a change in health care needs. Workplace conditions for health workers employed at hospitals and clinics in South Africa were explored as part of a recent national study on the impact of HIV/ Aids on the health sector. Health workers’ opinions on aspects such as workload, staff morale and working hours were obtained during personal interviews, which were conducted at 222 health facilities. Nine hundred and twenty four professional nurses, enrolled nurses and nursing assistants, who were mostly employed in the public health sector, participated. A stressful work environment was identified in public hospitals and clinics. An increase in the number of patients visiting these facilities, accompanied by a lack of equipment, unsatisfactory work environment and a shortage of nurses were pointed out. Many patients cannot be accommodated elsewhere because of a lack of finance and alternative health care options. Nurses also indicated that they do not get much support from their employers. The effect of all these factors culmi­ nates in a stressed workforce who may be forced to consider alternative career options. This will be to the detriment of health care in the country.

ested in taking up or pursuing nursing as a career in South Africa.At the same time a need for more nurses was identified because of the growth in the population as well as a change in health care needs.Workplace conditions for health workers employed at hospitals and clinics in South Africa were explored as part of a recent national study on the impact of HIV/ Aids on the health sector.Health workers' opinions on aspects such as workload, staff morale and working hours were obtained during personal interviews, which were conducted at 222 health facilities.Nine hundred and twenty four professional nurses, enrolled nurses and nursing assistants, who were mostly employed in the public health sector, participated.A stressful work environment was identified in public hospitals and clinics.An increase in the number of patients visiting these facilities, accompanied by a lack of equipment, unsatisfactory work environment and a shortage of nurses were pointed out.Many patients cannot be accommodated elsewhere because of a lack of finance and alternative health care options.Nurses also indicated that they do not get much support from their employers.The effect of all these factors culmi nates in a stressed workforce who may be forced to consider alternative career options.This will be to the detriment of health care in the country.

Introduction and aim
"Florence Nightingale's lamp went out long ago."This alarming allegation was recently made in a media report on the insensitive be haviour of health workers towards patients at a public health institution (Greyling, 2003:8).
Various reports have also appeared in recent times on the shortages of professional health workers in the public health sector (Swanepoel, 2002:11), the loss of medical practitioners and nurses to foreign countries (Swanepoel, 2001a:9); Retief, 2001:21), and the shocking conditions in public health facilities (Swanepoel, 2001 b:9).In most of these reports, the shortage of health profession als was linked to an increase in emigration.The working conditions in health facilities were also mentioned as one of the key aspects responsible for the apparent exodus of health workers.Issues relating to health often evoke emotional responses without there being real evidence or hard facts to support claims.In this article, the author intends to explore the current human resource situation in nursing and to deter mine if a shortage of nurses really exists, as well as estab lishing what challenges nurses face in performing their duties.The potential effect of the work environment on attrition will also be addressed.

Nursing resources in South Africa
Current  , 2002).While it is difficult to determine whether or not shortages exist because of a lack of reliable data on the supply of and demand for nurses, shortages are more likely to be found in rural areas, with imbalances showing in regional and pro vincial figures.A lthough the overall provincial nurse:population ratio compares favourably to the WHO's minimum norm of 200:100 000, provinces with large rural areas (such as the Northern Cape, Mpumalanga, Limpopo and Eastern Cape) have a ratio below the current average for South Africa (see Table 1).
As the demand for nurses in South Africa is escalating, and as the output of newly qualified nurses is the major source of future growth in the profession, it is therefore of great concern that there has been an average decrease in the total number of enrolments for nursing courses (1,2%), as well as in the number of new entrants into the field (0,9%) for the period 1990 to 2000 (see Tables 2 and 3).

Factors affecting the demand for nurses
Several factors affect the demand for nurses.Some of these relate to the replacement of nurses.For example, nearly a   1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 1990 Brannigan, 2000:45), which estimated the non-active component in nursing at 19%.South Africa has also lost a number of nurses to other countries, although the exact figures are not known.The official migration statistics of nurses from 1995 to 2000 re vealed an increase in annual net losses (see Figure 1).However, emigration figures for nurses are probably higher than officially recorded.For example, Brown, Kaplan & Meyer (2002:102) compared data from the five major recipi ent countries of South African emigrants with local infor mation, and came to the conclusion that only 35% of emi grants were being captured by official data-col lection meth ods.Nurses that left the country temporarily to practice their professions outside South Africa were also not in cluded in the numbers in Figure 1.Nurses who will die of HIV/AIDS will also need to be re placed.While there is still uncertainty among the experts on the exact extent of the HIV/AIDS epidemic in South Africa, the ING Barings study (2000:7) estimated that HIV prevalence rates would peak at 13,1 % for highly skilled and at 22,8% for skilled categories of the labour force.
There are indications that more nurses will be needed in future.Although the popular view is that South Africa is going to experience a negative growth rate because of H1V/ AIDS, this is not ac tually the case.Ac cording to Van Aardt et al (1999:4) the population will con tinue to grow, but at a slower rate than ini tially projected.Rehle and Shisana (2003:4) predicted that by 2020 the South Afri can population would be 23% smaller than what it would have been w ithout HIV/AIDS, yet they do not expect a negative population growth rate.One of the factors contribut ing to growth is the change in the health system , with large sections of the popu lation who never had access to health care before, now entitled to receive health services free of charge.What is more, the increase in the incidence of communica ble human diseases such as HIV, cholera and tuberculosis (TB) means that additional nurses are going to be needed to attend to the health needs of the infected.According to Girdler- Brown (2001:43), the incidence of TB has shown an annual increase of 5-10% over the past decade, while the most recent outbreak of cholera in KwaZulu-Natal appeared to be the largest and most serious one to date.At the same time, the rate of HIV infection continues to increase and HIV prevalence in the labour force is projected by some analysts to peak only in 2006 (Bureau for Economic Re search, 2000:3).

General factors
Studies conducted outside the field of health often draw links between work context and the attrition or retention of employees.In investigating the rate at which waste collec tors and municipal workers left their jobs, Lund, Iversen and Poulsen (2001:167) found that physical and psychoso cial work environment factors were the most common fac tors affecting people's decisions to their jobs.Billingsley (1993:146) (Webb, 2002:36-37).Burnout among nursing staff, caused by a "toxic health care environ m ent2" has also been found to contribute to employee attrition in nursing (Cullen, 1995:23).However, the decision to remain in a job is not necessarily directly linked to job satisfaction.For example, Brown, Schultz et al (2002:48-54) estab lished that job satisfaction was not a reliable pre dictor of a person's intention to remain in a job, while Landman, Mouton & Nevhutalu (2001:60) found that although hospital staff were "gener ally satisfied with their jobs and found [them] interesting and stimulating", 40% of staff fre quently thought about leaving their jobs.In summary, it appears that stress caused by challenging conditions in the work environment -such as work overload, lack of support, staff shortages, inadequately equipped work environ ments and the absence of proper incentivesmay persuade nursing employees to leave their jobs even if they enjoy the nature of their work.

Factors affecting nurses at health facilities in South Africa
Stressful working conditions in the South African public health system were reported in an investigation by TURP (2001:1-7) into the reasons for emigration by South African nurses.Although the number of responses was limited, the results of the investigation nevertheless showed that aspects such as a lack of competitive incentives, work pres sure, lack of opportunities for promotion and inadequately resourced working environments led to the loss of profes-2.Cullen (1995:23) uses this term to refer to "the pressure that's put on to nurses by external organisational forces that determine the conditions under which they work".3 Health workers were questioned on work-related issues that could be affected by the prevalence of HI V/AIDS, without reference being made to the disease.4 Weighted percentages.Percentages may not add up to 100 owing to rounding.5 Confidence interval (95%).

32
C ura tio n is Novem ber 2 0 0 4 sional nursing skills.A study conducted by the Ethics Institute of South Africa (Landman et al, 2001:1 -167) at the Chris Hani Baragwanath Hospital showed that most staff members found their work environment unacceptable and unsafe.Their opinions were based on factors such as neglect, poor maintenance of buildings and insufficient and outdated equipment.The majority also expressed dissatisfaction with their workload, salaries and the problem of staff shortages.Workplace conditions for health workers employed at hos pitals and clinics across the nine provinces of South Africa were explored as part of a recent study on the impact of HIV/AIDS on health workers (Shisana, Hall, Maluleke, Stoker, Schwabe, Colvin, Chauveau, Botha, Gumede, Fomundam Shaikh, Rehle, Udjo & Grisselquist, 2002).Health workers' opinions3 on aspects such as workload, staff morale and working hours were obtained during personal interviews, which were conducted at 222 health facilities representative of the public and private health sector in South Africa.The sample was designed to provide nation wide representation of professional and non-professional health workers.However, for the purpose of this article only the responses of nurses were considered.Nine hun dred and twenty four professional nurses, enrolled nurses and nursing assistants participated (see profile in Table 4).Most of the respondents (84,3%) were employed in the public health sector.
The majority of nurses (79,2%) who participated in the study said that they had experienced an increased workload dur ing the past year.Of these, 49% indicated an increase in their workload of between 50% and 75%, while nearly a fifth felt that their workload had doubled.One third of par ticipating nurses (33,6%) stated that they often worked longer than their official working hours, providing further evidence of heavy workloads.They mainly attributed this situation to staff shortages and a higher patient load, as well as increases in numbers of patients with HIV-related diseases.As a result, they experienced increased stress, physical exhaustion, dissatisfaction and a lack of motiva tion.Less than half (48,8%) indicated that support from their employers (such as counselling) was available to them if and when they needed it.In a number of cases, what sup port was available had to be paid for from the nurses' medi cal funds.Respondents also believed that the increase in patients who take longer to recover, impacted negatively on the quality of their work.Although the emphasis should be on holistic health care, nurses at public clinics said that they could barely find the time and the resources (medication, for example) to attend to the physical needs of the daily turnout of patients, let alone provide quality care.Other responsibilities, such as administration and record-keeping, have to be dealt with after hours.Absenteeism has increased due to stressful working con ditions, which has made the burden even heavier on those members of staff who report for work.Not surprisingly, 16,2% indicated that they had been treated for stress or stress-related illnesses in the year prior to the survey.Study results indicated further that the prevalence of HIV/ AIDS has had a major impact on nurses, as well as on their jobs as health caregivers.Nearly half (46,4%) were afraid that they might infect their partners or children because of their exposure at work to HI V/AIDS-infected patients; and 16,2% indicated that they would consider leaving their cur rent jobs if they believed the risk of contracting the disease in their workplace would escalate.Furthermore, 65,8% of nurses pointed out that the fact that HIV/AIDS is not a notifiable condition posed challenges to them in caring for their patients.These challenges were not only linked to fear of infection, but were also caused by the cultural, so cial and educational background of patients, as well as their lack of money.For example, the stigma attached to the disease led to many HIV sufferers being rejected and iso lated by families and friends.As a result, nurses had to take care of aspects relating to patient care other than their medical needs.Most of the people living with HIV/AIDS (PLWA) could not afford alternative (private) care and were dependent on subsidised health care.Due to a shortage of supplemen tary care such as facilities (such as hospices) and volun teers to assist, public health facilities were overcrowded with HIV cases.This situation has had a negative impact on the workload and emotional wellbeing of nurses in pub lic health facilities.On top of the heavy workloads, no cure or healing could be offered to the majority of their patients -a fact that depressed people who generally regarded themselves as healers.Another factor that upset nurses was that patients with treatable non-HIV-related conditions could not always be accommodated in hospitals due to overcrowding.The unsatisfactory work situation of nurses was further illustrated by the fact that only 40,9% nurses who partici pated in the study believed that staff morale was high in the health facilities where they were employed.These nurses linked satisfactory working conditions, as well as factors such as the ability to provide high-quality health care, low absenteeism and adequate remuneration, to high morale.Low morale, on the other hand, was associated with a stressful work environment characterised by heavy workloads, low salaries, staff shortages, a lack of manage rial support and unhappy and frustrated colleagues.In spite of the challenges encountered in their work envi ronment, the majority of nurses (81,3%) enjoyed their work and experienced job satisfaction.It is clear from their com ments that their contentment results from putting their pro fession as health care givers into practice, rather than their specific working conditions.Nevertheless, nurses who lacked job satisfaction explained this in terms of heavy workloads, stressful conditions, staff shortages, the lack of time for quality care and low salaries.The study confirmed that a stressful work environment of ten existed in hospitals and clinics in the health sector, particularly in the public health sector.An increase in the number of patients visiting these facilities, poorly equipped work environments and a shortage of nurses were identi fied as stressors.The situation was aggravated by the fact that many of patients could not be accommodated else where because of a lack of finance and alternative health care options.By and large, PLWA took longer to recover from illnesses, and nursing staff generally spent more time and energy on these patients due to the seriousness of their condition and the lack of support they received from their families and friends.Nurses also indicated that they generally did not receive much support from their employ ers, in spite of their difficult working circumstances.These factors have culminated in a stressed and exhausted workforce who in many cases no longer believes that they can provide quality health care.While nurses may still be satisfied with the content and nature of their jobs as health care providers, many of them felt powerless and on the verge of burnout in their current job situation.

Concluding remarks
Decreases in the supply of nurses Nursing enrolments and outputs from institutions of higher education show a decline for the period 1990 to 2(X)0.South Africa is also losing an increasing number of nurses to other countries, as well as to mortality as a result of HIV/ AIDS.At the same time, the need for nurses is expected to increase because of the growth in the population, the sys tem of free health care and an expected increase in the inci dence of communicable diseases.More people need to be recruited and trained in order to ease the workload of nurses in the public health sector.Recruitment could start with registered nurses who no longer practise their profession.Incentives such as re fresher courses and acknowledgement of past experience should be offered when persuading these professionals to return to nursing.At the same time training institutions should try to increase nursing output by ensuring that more candidates complete their studies successfully.According to Brannigan (2000:45), the normal dropout rate over the four-year training period for registered nurses is 20%.Although more comprehen sive data on the number of nurses who fail to complete their training could not be obtained, a comparison of the enrolment and output figures indicates that many nursing students do not complete their training.If more of these candidates could finish their studies, the supply of nurses would increase.In an effort to address this situation, it is recommended that more details on students (such as pro file, progress after enrolment, reasons for failure) and stu dent support services (such as career counselling) should be collected from training institutions.As the nursing profession competes with other serviceoriented occupations in terms of recruiting new applicants and retaining existing skills, the salary and benefit pack ages of nursing staff should be addressed.Traditionally, career decisions were influenced by a sense of vocation towards a specific occupation, while job opportunities for women were limited to a few occupational areas, the most obvious being nursing and teaching.These days, women have a wide range of career options to choose from.Their decisions are influenced by various factors, including in centives, work environment, opportunities for further de velopment and family commitments.Employment equity legislation also encourages employers to appoint more women.If one assumes that the inactive nurses on the S ANC register are employed elsewhere, it seems that nurses have a combination of skills that they can successfully apply in other occupations.The profession should be promoted through a marketing process that will stimulate the interest of young people by focusing not only on job content, but also on the possibili ties and benefits attached to nursing.For example, apart from job related information, the possibilities for career de velopment, opportunities to combine a career in nursing with a family, as well as the opportunity to earn an income while studying, should be pointed out when information on a career in nursing is compiled.It should be kept in mind that practicing nurses also play an important role in the marketing (both negative and positive) of their profession.Although they may remain in nursing because of factors such as the lack of available alternative employment, they may discourage prospective new entrants from joining.Improvements in the work environment and working con ditions of nurses are therefore vital not only in attracting new interest to the profession, but also to encourage the current pool of skills to remain in nursing.

Stressful w ork environm ent
The work environment of nurses employed at health facili ties operating in the public health sector, is stressful and unsupportive.As a result, many nurses believe they are no longer able to provide proper health care.This is mainly due to factors over which they have no control, such as staff shortages, an increase in the number of patients and the prevalence of HIV/AIDS.These factors may force nurses to consider alternative career options, such as practising their profession elsewhere or moving out of nursing.The outflow of nursing staff and the lack of interest shown in the profession will not turn around unless improvements occur in the workplace.Hospitals and clinics should be equipped with the necessary infrastructure and logistics to increase health workers' performance and their job satis faction In the current work environment, where a limited number of nurses have to provide health services to in creasing numbers of patients, the facilities should contain sufficient resources (including equipment, medicine and support such as management information systems) to en able nurses to operate effectively.Employers should also support staff by offering stress management programmes and counselling services to help them to cope with stress in their work environment.Such services should be free of charge and accessible to all lev els of staff.Nurses should be encouraged to seek help, while employers need to reject the old-fashioned but per sistent belief that nurses who find it hard to cope do not belong in the nursing profession.

Uneven distribution of skills across regions
According to the World Health Organization minimum re quirements, South Africa does not have a shortage of nurses.There is, however, a disproportionate distribution of nurses within the country, with below average numbers in those provinces with a large rural population.The workload of nurses operating in rural areas is particu 34 Curatio n is N ovem ber 2 0 0 4 larly affected because of the shortages of nurses as well as other health professionals in those areas.In many cases, nursing staff are forced to provide services outside the scope of their jobs or proficiency because of a lack of ap propriate professionals (Pick et al, 2001:81).It is recom mended that nurses should be provided with assistance in the areas of their work that do not require health-related skills (such as record-keeping and administration).In healthrelated areas, assistants with lower skills levels can be re cruited and trained to perform routine tasks under profes sional supervision.Apart from easing the workload of health workers in rural areas, a uniform quality of health care can be provided by this approach.It will also have a positive impact on the creation of sustainable employment at lower skills levels.Furthermore, the burden of institutionalised care that is currently carried mostly by public health facili ties could become more manageable if health caregivers and volunteers are recruited from the local communities.Such volunteers could help with home-based health care, including home or follow-up visits to the chronically ill, as well as providing health education and awareness cam paigns under professional supervision.
A lack of data on the supply of and demand for nurses The lack of reliable data on the supply of and demand for nurses should be addressed to ensure effective human re source planning over time.The SANC register is the most comprehensive source of data on nurses; however, no data is available from the register on the number of profession als currently actively employed in nursing in South Africa.It is also difficult to determine the number of first-time en tries into the profession, as this information is mixed with data on those who upgrade their existing skills.Employ ment data on the private health sector is not available.To increase effective human resource planning, it is recom mended that the register collect more detailed information on the current employment and qualification profiles of nurses.
reviewed the literature on teacher re tention and attrition in special and general education, and 31 C ura tio n is Novem ber 2 0 0 4

Table 1 :
Geographic distribution of nursing s ta ff per 10 0 000 of the population: Septem ber 2001 *The calculation for each province was based on an estimated distribu tion (calculated from LFS figures) of nurses per 100 000 of the provincial population.The nurse/population ratio for South Africa is a 'weighted' average.

Table 2
Enrolm ents for nursing courses: 19 90 -2 0 0 0 *# * Excluding those qualifying from bridging courses.# Excluding enrolments from nursing schools due to gaps in the data and small numbers.

to 2000 qualification NNNNNNNNNNN
* Excluding those qualifying from bridging courses.# Excluding outputs from nursing schools due to gaps in the data and small numbers.30 Curatio n is N ovem ber 2 0 0 4 Figure 1 Official emigration and immigration of nurses: 1995 fifth (34 965 or 18,4%) of nurses on the SANC register no longer appear to practise their profession.The number of inactive nurses was calculated by subtracting the total number of employed nurses on the LFS ( 155 484) for 2001 from the total number of nurses on the register (190 449) for the same year.This figure correlates with a 1990 study by Pim Goldby management consultants (cited by

Table 4
Profile of nurses4