THE SOUTH AFRICAN NURSING COUNCIL : 50 YEARS OF PROFESSIONAL SELF-REGULATION WJ Kotze

Self-regulation of the professions of nursing and midwifery became a reality in South Africa on 8 November 1944, when the first council meeting of the South African Nursing C ouncil took p lace in P re to ria . M ost appropriately, the opening speaker on this occasion was Mr Harry Gordon Lawrence, the Minister of Welfare and Demobilization, who had piloted the Nursing Act, No.45 of 1944, through Parliament. Exactly 50 years later, on 8 November 1994 the Council held its 108th meeting, this time in its own building, with a magnificent view of the venue where that historic first meeting took place the west wing of the Union buildings.

As was the case 50 years ago, a time of transition is at hand, and it seems appropriate to pause alongside the bequest that the Council is passing on to a new dispensation, and to venture a b rie f resum e o f some of the developments which have formed this legacy.

T H E R E S E A R C H P R O C E SS
Data to describe the development of statutory control of the nursing profession in South Africa were obtained through reviewing the following Original sources - • Policy documents of the South African Nursing Council • N ew spaper clippings and professional journal reports • Assembly debates of the South African Parliament of 1944,1957,1978,1992 • Minutes of the Task Force for a new Regulatory Body, 1994 Data gathering was followed by analysis, in te rp retatio n , critical com parison and determining of interrelationships to validate the factual accuracy.What follows in this article is a formulation of the events which preceded the creation of a nursing council and the developments over the following fifty years to culminate in what we know today as the South African Nursing Council.

STA T U T O R Y C O N T R O L : T H E F IR S T 53 YEARS
The p rom ulg atio n o f the M edical and Pharmacy Act, No 34 of 1891 on 21 August 1891, heralded a century of growth and development for nursing as a profession in South Africa.The basic intention of the Act was to extend the powers of the Cape Colonial Medical Council to protect the public by co n tro l o f the nu rsin g and m idw ifery p ro fe ssio n s.The sig n ifican ce o f state registration for nurses and midwives was its anchoring in the standards it demanded.Momentum was given to the evolution of nursing by a collective drive to meet these standards.
Act 34 of 1891 contained aU the elements needed to place nursing squarely on the road to true professional development.No other mechanism could have improved on this.In addition to the network of support that the Act could provide for the young developing profession through the established medical structure of the time, provision was also made for:- • the setting of registration requirements for the training, examination and certification of nurses and midwives • the recognition of further training and re g is tra tio n o f a d d itio n a l n u rsin g qualifications • p ro te c tio n o f the p u b lic a g a in st misrepresentation and protection of the rights attached to the title of registered nurse or midwife • ethical control over nursing practice and • the keeping of registers, the creation of regulations and the issuing, revoking and cancellation of certificates by the Medical Council.
In view of the important role played by the midwife in the life of the South African people, it is natural that the Act paid particular attention to the establishment and control of practice standards for the midwife.
The further stipulation that a list of registered nurses and midwives be published annually provided this country for the first time with an identifiable corps of professional nurses and midwives.An important conclusion which co u ld be draw n from this is th a t the development of a professional corps must have led inevitably to consciousness of a group identity, and this in turn, stimulated the aspirations which culminated in the formation of a professional association in 1914.
Legislation for the registration of nurses and midwives in the other colonies followed over the ensuing thirteen years - The committee trfter making investiga tions including a statement from Nurse "N" in which she admitted having ad ministered an anaesthetic ... when the patient was in great pain AGREED that Nurse "N" be i^orm ed that she must not give chloroform without the instruc tions and without the presence o f a medical practitioner"* The fact that since 1891 provision was made only for voluntary registration of nurses and mid wives meant that the interests of the public were partially protected only.Unqualified persons could still practice freily -they were just not permitted to represent themselves as registered nurses or midwives.It is also true that many who were eligible for registration did not avail themselves of this privilege.
Despite the resolute efforts of Henrietta S tockdale to m ake reg istratio n legally enforceable from the outset, this was only accomplished with the promulgation of the first Nursing Act in 1944.The ineffectiveness of voluntary registration to protect the public is obvious in the following example from the September 1942 minutes,  12 from the nursing profession was clearly evident in the parhamentary debates during the second reading of the Draft Bill on 29 and 31 May 1944.Over and over, the Minister used the opinions of the Trained Nurses Association to support his arguments, for example, he argued inter alia as follows -"U nder the present system , in the opinion o f the Nursing Association, there is no means o f ascertaining how many unregistered but qualified rmrses are practising; and, in regard to the registered nurses, there is no record o f how many are practising and how many are not.Therefore to make a computa tion o f the strength o f the nursing profession o f the country at the present time is very difficult indeed.The com pulsory registration o f practising nur se s p r o v id e d fo r in the B ill w ill immediately enable an estimate to be made o f the active nursing force in the country; it will enable the output o f trained nurses and midwives to meet the demand to be planned; arui it will mean that all practising qualified nurses arui midwives will be under control"^* Judging from the records of the parliamentary debates, it seems clear that the nurse leaders of the time had enlisted wide fXDUtical support for the passage of nursing legislation.In the course of the debates, the high regard in which the politicians held the nursing profession was also obvious.Mrs Margaret Ballinger was a leading proponent in this regard.In the course of a turn to speak she said -"/ think anyone who has had experience o f the nurses o f this country knows that the impulse behind this Bill is simply the genuine and sincere desire to provide the country with the services on which alone can be built up that standard o f public health and public health services the whole public is now desirous of." Another parliamentarian.Dr Swanepoel, had this to say -

"On several occasions when I was in Pretoria I was interviewed by the rep resenta tives o f the South A frican Trained Nurses Association, and judg ing by the evidence which they placed before me I can only say that I was th o r o u g h ly im p r e s se d w ith th e thoroughness o f the work which these people do."^T
he first Nursing Act, No.45 of 1944, was approved for promulgation on 22 June 1944, and the South African Nursing Council, established in terms of section 2 of that Act, began its activities under the direction of 24 Council members appointed by the Minister for a two-year term of office.
At the first meeting, not only were the office bearers and standing committees elected, but Mr J A H van Niekerk, was also appointed as the first Registrar.The Council was housed in offices made available by the Medical Council and the fin an ces en ab lin g it to begin operations came from a £1 000 donation from the South African Nursing Association, together with further small donations of cash and office furniture.For the first two years of its existence, the staff of the Council consisted of 11 people -the Registrar and a further 8 permanent and 2 temporary members of staff The pioneering work of these first council members and staff laid the foundation for the activities of the subsequent councils.One of the first tasks was the creation of election regulations with a view to the coming into being of a council in which the nursing profession would have a share by their participation in the election of its members.The first elections duly took place during the second half of 1946.
It quickly became apparent that amendments to the Act were necessary and a number of these were promulgated during 1946 while others were submitted to the Minister in 1948.However, the Government itself, in keeping with the policy of apartheid, introduced other amendments which radically altered the spirit o f th e 1944 A ct. T h o se a m en d m e n ts culminated in the Nursing Act, no.69 of 1957, d e s p ite o p p o s itio n fro m th e n u rsin g profession.
The documentation of meetings of the Nursing Council, newspaper reports and records of the parliamentary debates demonstrates that there w ere serio u s p ro b lem s and d issen sio n regarding the content of the Nursing Bill, not only among members of the Council, but also among the public and members of the nursing profession as a whole.
Press reports such as those illustrated appeared under such headlines as "WP Nurses reject bill's racial discrimination proposals", "Race discrim ination rejected by WP N urses", "Nurses march in city apartheid Bill protest", "Nurses to defy protest march ban" and "Nurses seek no colour bar".Mrs Ballinger's reaction was described as follows in the Cape Times of 13 June 1957 -

"Speaking as a former vice-president o f the Nursing Council and the member o f Parliament who was asked by the nurs ing profession to introduce the Nursing Bill o f 1943, Mrs Margaret Ballinger y e s te r d a y f l a t l y d e n ie d th e Government's assertion that the white nurses o f South Africa wanted a colour bar in their profession ...M rs Ballinger warned the Government that its Nursing Apartheid Bill was 'not only wicked but incredibly dangerous' ... Reading a telegram from prominent senior nurses urging her to oppose 'all the racial dis crimination clauses' o f the Bill, Mrs Ballinger said that this was typical o f the feeling among rutrses to-day.
, 16 In her parliamentary speech Mrs BaUinger stated - • separate registers for Whites, Coloureds and Blacks (Section 12(4))

"Our difficulty in discussing this Bill is not in discussing what the rmrses have asked for, but what the Government has done with
• the Council acquired the authority to prescribe different distinguishing devices and uniforms for Whites, Coloureds and Blacks (Section 11(1 )(k)) • prohibition of the control of or supervision over White registered or enrolled persons by persons who were not White (Section 49).
In the report of the Third Council, the Registrar pointed out that the Council had not asked for any of these amendments.The Council had discretionary powers regarding distinguishing devices and uniforms and could thus resolve not to prescribe separate distinguishing devices.O th e r c h a n g e s in c lu d e d the following - • Increasing the membership of the Council to 33 of which 16 would be appointed and 17 elected • Election according to 10 regions, with national nominations but regional election, so that each registered person would have voting rights only in heiMiis region (one vote only) • Election of office bearers for the 5-year term of office instead of the previous annual election • Provision for the training and enrolment of auxiliary nurses and midwives.
The legislation did not include the Council's recommendation that the practice of Nursing and Midwifery for gain be hmited to registered and enrolled persons.This meant that p>ersons not qualified in nursing could still practice for gain in some parts of the country at that timea situation which was untenable in the public interest.
The Nursing Amendment Act, No.50 of 1972 addressed this important deficiency by making provision for a roll for nursing assistants, conUolling the training of nursing assistants and lim iting the practice of nursing and midwifery for gain to persons who were registered or enrolled by the Council.This provision made nursing a "closed firofession".
Terminology which was amended in this Amendment Act includes that of "enrolled nurse" instead of "enrolled auxiliary nurse", and in th e A frik a a n s te x t, " s tu d e n tverpleegster" and "leerling-verpleegster" in the place of, "leerling-" and "leerlinghulpverpleegster" respectively.This Act also provided for an Advisory Board for Indians.A fu rth e r im p o rtan t am endm ent was the requirem ent that the president and vice president of the Council should be persons registered in terms of the Act -a measure which had not previously existed.

A D M IN IST R A TIV E D E V E L O PM E N T O F T H E C O U N C IL
In 1994 the administrative structure of the Council^^ is illustrated in Figure 1.chief source of income for the Council is from the annual fees paid by the various categories of nurses and midwives to maintain their re g is tr a tio n s andXor e n ro lm e n t.It is illuminating to note that the Council achieved financial viability within 10 years of its inception.

D E V E L O P M E N T O F T H E PR O FE S SIO N A L R E G IS T E R S AND R O L L S
One o f the key functions of the Council in its service to the South African population is the establishment and maintenance of registers and rolls of all qualified persons who practise n u rsin g and m id w ife ry fo r g ain .T he signiTicance of this lies in establishment of an identifiable nursing corps whose training and practice can be controlled in the interest of the public.
At The growth over the past 50 years is indicated in Table 3. Figure 3 shows the situation when the enrolled categories, student and pupil numbers are taken into account.

Some of the important aspects reflected by
Registered nurses and midwives constitute 53% and the total nursing corps 72% of the total num ber o f reg istered health care professionals indicated in these figures.Please Table 4 shows the ratio of population to the total number of nurses, registered nurses and certain other professional health practitioners according to regional distribution.
The unfavourable availability of qualified health practitioners in the rural areas and the high degree of dependence on nurses are reflected in this table.It is significant that in only three of the regions the ratio of population to re g is te r e d n u rse fa lls w ith in th e recommended ratio of 416; 1, namely Western Cape, Eastern Cape and Central Transvaal.These regions are also best off as far as doctors and dentists are concerned.Table 4 further reflects the high dependence of the rural areas on the enrolled category nurse with her limited scope of practice.

=10%
As far as students are concerned, there were 5 614 student nurses and 1 196 student m idw ives in 1994*.T he to ta l stu d en t population has been in the region of 13 000 during recent years and the total pupils (both categories) have been some 5 000 -giving a total nursing corps of 175 072.
In 1944 the training was offered in training hospitals throughout the country.This was followed by a college-cum-training hospital system.In 1956, the system of a University in co-operation with a training hospital came into being.In 1984 the old college system was replaced by one of a college in association with a university in terms of a legal agreement.Currently there are 29 such nursmg colleges o ffe rin g d ip lo m a p ro g ram m es and 13 university departments of nursing offering degree programmes, preparing nurses and midwives to function in a comprehensive health care service.Thus, since 1984 (the transition period for implementation lasted till 1986), nurses and midwives in South Africa have been trained in a 4 year programme for comprehensive basic registration.
The nursing college referred to here differs radically fiom the college prior to 1984, which was sim ply a classroom com plex with teaching staff under the direction of a principal responsible for the theoretical component of the programme.Instead of the training hospital and its administrative chief nurse being the tra in in g sc h o o l an d head o f tra in in g respectively, the college is now the training school and the principal is head of training.
Although the diplom a courses for basic registration in nursing are at present still part of the national health service system in South A frica, they actu ally co m p ly w ith the requirem ents for form al p)ost-secondary education, and are acknowledged as such.following table illustrates the extent to which these activities have increased since the first Nursing Council commenced its functioning.
Obviously this increase must be viewed in relation to the growth in the numbers on the registers and rolls.
One hundred and eighty-eight disciplinary hearings were held during the first twenty five years.In the 25 years following that, 1111 hearings were held.Please note that individual hearings in the case of strike action cases were not calculated as such in this number.In one such hearing hundreds of individuals were involved resulting in 1 583 individuals handled within the total of 7 hearings indicated in this table.
The number of disciplinary hearings has increased markedly, particularly during the last ten years.

TRANSFORMATION OF THE COUNCIL IN A NEW SOUTH AFRICA
With the advent of the new constitutional dispensaton in South Africa, the question of am algam ating the four existing nursing councils (South African Nursing Council, Bophuthatsw ana Nursing Council, Ciskei N ursing C ouncil and T ranskei N ursing Council) needed to be resolved.
The preparatory work for this amalgamation had begun in 1993 when the four councils commenced formal discussions with this in view.
In Johannesburg in January 1994, at a national convention of nurses representing all nursing organisations, including the four councils, the following important decisions taken, among others - • that it will undertake and conclude the amalgamation and rationalisation of the four Councils, including the assets and liabilities • that it will transform the Nursing Act and regulations, and • that it will undertake the election for a new Council within two years.
It is expected that the new A ct w ill be promulgated by the end of March 1995 and that the period of office of the Interim Council will commence not later than May 1995.The existing 4 Councils will continue to operate until the day before the first meeting of the Interim C ouncil.Thus there w ill be no interruption in the functioning of the Councils.The various registers and rolls of the four Councils are abeady being amalgamated and mutual recognition o f qualifications and distinguishing devices is in operation.
To eliminate the last traces of the 1957 legislation, it was resolved at the October 1994 meeting of the Executive Committee of the South African Nursing Council that persons in possession of Council certificates containing a reference to racial group should be given the opportunity to have these replaced by the Council, upon request and return o f the original certificate.

CONCLUSION
T he m ost im portant ch aracteristic o f a profession is that of service to the community, the second being that of self-regulation, i.e. regulation of the profession by the profession.In this regard nursing and nurses have a history of which they can be proud in many respects.
We have 50 years of experience in self r e g u la tio n .T h e re w ere im p o rta n t achievements, but there were also serious mistakes.The Council was unavoidably manipulated by the system within which it functioned -what better examples than the 1957 legislation and the coming into being of separate councils which now have to be reunited with much effort and considerable cost?Much has been learned from these experiences.The author believes that it has brought strength and renewed consciousness of duty -and undoubtedly renewed unity.Nurse leaders have battled in this country in difficult times for the cause in which they believe.It is vital that this passion for and commitment to the justness of their cause should not be tempered, because it is exactly this that harbours the essential seed for change to meet the needs of the country and its c o m m u n itie s.It is th is p a s s io n and commitment which will make sense of the tran sfo rm atio n o f the C o u n cil.T his is important because the Council enjoys wide recognition, and has much to offer in the field of professional regulation both nationally and internationally.
The nursing profession in South Africa in 1994 is an established profession.However, there never comes a time when renewal is not necessary.The profession has the structures and means to maintain itself in a dynamic developing society.The registered nursing corps forms the largest portion of the total professional health manpower.Niu^e leaders have distinguished themselves in many fields -in service, academic, social and other areas.
In this very special time in oiu^ national life, nursing and the professional nurse in South Africa have the potential to be a powerfiil

W
. P .j n u r s e s r e j e c t ^^b i l u s r a c i a l D I S C R I M I N A T I O N P R O P O S A L S ; O u t -v o t i n £ f e a r s a r e i i ' i s e e n a s o r o m i d l e s s ^ V o '^ .yv* .m m / B y 2 3 0 voles 10 2 9 , a sp ec ia l m eeting of the S o u th A fric a n N u rsin g A ss o c ia tio n (W e s te rn P ro v in ce b ra n c h ) in C a p e T o w n a d o p te d last night a resolution re je c tin g th e in tro d u ctio n o f ra c ia l discrim ination in the f>fciiion.. ^u g u si \995 an agreement existed with both the General Nursing Council for England and Wales and the New Zealand Nurses and Midwives B oard for rec ip ro c al reco g n itio n of qualifications.'

19 •
it.There are two sections to this Bill...The one is administrative ... and then there are the colour bar provisions.Thus the clauses o f the Bill fa ll into two categories, one asked for by the rutrses arui one imposed upon the nurses by the Government... / tU nk this is the most tragic irUerference with the p r iv a te r ig h ts o f a p r o fe s s io n a l b o d y... .17The division within the Council itself is illustrated by the equality of votes when a motion against the discriminatory provisions in the proposed legislation was considered during the March 1955 Council meeting.The motion was rejected with the casting vote of THURSDAY, JU N E 13, 1957 'NURSES SEEK NO COLOUR BAR' er 'Warns of 'Dangerous Bill' C ape T iiiie» P a r lia m e n ta r y C o rr e s p o n d e n t HO U SE O F A SSE M B L Y .-Speaking.« fo rm e r vicep re sid en t of tlie N ursing C ouncil and th e m em b e r o£ P a rlia m e n t wlio w a i asked by th e n u rsin g profession to in tro d u c e llie N ursing B ill of 1943, Mrs. M argaret B a llin g er yesterday flatly d en ied th e G o v ern m en t's asser tion th a t th e W h ite n u n e j of S o u th .\fric a w anted b a r iu th e ir profession.And speaking as a N a ti v e s '1 Mr», R alllnger s a id .E C IA L m eeting called by the "T rstern Province brancii o f ith e South Afric.iu.N'ursin" A ssociation last nig iit passed a-m otion by 230 votes to 20 rejectin g racial d iscrim inatiba-, in tlie n u r« in ; profession.T n e n ie e tii^-'^a s cailcd to d isciisa th e N u rsin g .'Vniendm ent Bilfc-^which last n i" h t pa<fc<l the c o m m itte e a n d re p o rt stai:e9 in ih c H o u se " f A aacrably.A lto g etlic r. a b o u t ZoO p e o p le of d ille r c n l ra c e s attcn ilcil.T h e m o tio n r e a d : " T h is b r.m cit rralT iriu s its ilain l in tro d u c tio n of ra c ia l < iisc rin iiiia iiu n iiilo iii*n, .iii'l'i n ^'n in oi:aII%' r r j r r t '' " " '..I ..r<iv (lie the President.The discriminatory provisions of the 1957 legislation were as follows: 18 membership of the Council was limited to White persons (Section 4) • only White registered nurses and midwives and students had voting rights in the election of Council members (Section 3) • the creation o f A dvisory Boards for Coloured and Black persons (Section 16) Each of these Advisory Boards elected a White person, registered as both nurse and midwife, to the Council (Section 3) FIGURE 2 NUMBERS OF REGISTERED NURSES AND MIDWIVES IN RELATION TO OTHER HEALTH CARE PROFESSIONALS -1992-12-3127

FIGURE 3
FIGURE 3 NUMBERS OF NURSES IN RELATION TO OTHER HEALTH CARE PROFESSIONALS ■ 1992-12-31 instrument in creating stability and in the stimulation and nurturing of growth, the necessary change and development in the interest of the public whom we serve.L IS T O F R E F E R E N C E S F O O T N O T E S * Section 61(l)(c) ofAct 13 of 1928: "No person shall....administer, prossess for the purpose of sale or supply or in any manner whatever supply or receive for the purpose of sale or supply any such drag, plant or portion o f such plant."This se c tio n w as d e le c te d in 1971 w ith the promulgation erf Act 41 of 1971.• • Equivalent of section 32 of Act 50 of 1978 (the right to obtain a full record of the court of court proceedings).*** Equivalent of section 36 of Act 50 of the 1978 (p ro v isio n fo r an in v e stig a tio n in to the competence/incompetence of a nurse/midwife to practice her profession due to ill health) Masseurs, as well as on the Northern and Southern Disciplinary Committees, so that there was at least partial input by nurses in the control of training and the investigation of complaints relatijig to the behaviour of nurses and midwives.Miss Alexander served as itinerant nurse examiner for the Council from September 1933.The involvement of nurses in the control of their own affairs was further strengthened in 1943 by the co-opting of the Misses M.G.Borcherds and S.M. Marwick to the Training, Examination and Registration Committee.
were denied general voting rights in the Council but minutes of meetings demonstrate clearly that they were deeply involved in and had a significant influence on decision making.The first two nurse representatives w ere M rs.L.L. Bennie and M iss B.C. Alexander.In addition both served on the T raining, Exam ination and Registration C o m m ittee for N u rses, M id w iv es and The investigation of complaints of alleged misconduct or negligence by registered nurses and midwives and the exercising of discipline was the one area that showed deficiencies during these pioneer years.Between 1928 and 1943 -a period of 15 years -approximately 19 complaints were investigated by the Medical Council.Many of these complaints which justified action against the practitioners were d ealt w ith by m erely issuing a w ritten adm onishm ent to the guilty party.The following are two examples taken from the 1931 and 1932 minutes -"T h e ( D is c ip lin a r y ) C o m m itte e AGREED:'That the midwife be in form ed that she was not justified in leav ing the case; that she should have stayed there until relieved, and that in attending cases she should see that she was properly equipped with neces saries, such as Lysol.""

TABLE 4 RATIO OF POPULATION TO SELECTED HEALTH PRACTITIONERS'^D
the time of the transfer of the registers from the South African Medical and Pharmacy Council in 1944, the registrations amounted to 9 352 nurses and 5 644 midwives.^^The total registrations for 1994 amount to 138 022.Up to 1959 the Council data do not provide for persons on the register.However, it can be estimated that in 1944 there were some 11000 persons on the register.This figure has increased to 79 350 in 1994.At present, there are 29 557 enrolled nurses and 48 219 enrolled nursing auxiliaries on the rolls of the Council.

Table 3
The task group commenced its activities on 28 March, with amendment of section 5 of the Nursing Act 1978 -that is the section dealing with the constitution of the Council, as its first priority.For this purpose, the profession was consulted as widely as possible in the very limited time available.The final proposals for these amendments were submitted to the Minister of Health in June 1994.In the course of its activities, the task group also drew up a code of conduct for Council members which reads as follows - (76% Nurses) (24% non-nurses) • termination of the terms of office of the present SATBC Nursing Councils and • the institution o f an Interim Nursing Council;