A PROFILE OF PROFESSIONAL NURSING PRACTICE IN THE PRIVATE SECTOR IN THE R . S . A

A bs tract The purpose o f this study was to develop a profile o f professional nursing practice in private enterprise health care services in the Republic o f South Africa. In the light o f the fu ture health care needs and the relationship between the private and public sector health care establishments, information about the role and task o f the I professional nurse was needed. * Information would provide a data base about the registered nurse and so facilitate fu tu re health care planning. A n exploratory fie ld study was undertaken to locate the various work environments o f the registered nurse in fo u r statistical urban regions. Questionnaires were handed out and collected fro m a proportional stratified sample o f professional nurses who were working in thirteen types o f health care environments in the period between I June 1983 and 30 September 1983. A return rate o f 68 percent yielded 340 completed questionnaires fro m 501 registered nurses. The study revealed that the majority o f nurses in the private sector were relatively young. White, female, English-speaking professionals who were practising in fo u r broad areas o f health care: I • Custodial care environments such as " residential homes fo r the aged, institutions fo r the chronic sick and fra il aged, homes fo r children and homes fo r the adult handicapped. • Hospitals and related special health centres catering fo r drug addicts, alcoholics and patients suffering fro m psychiatric!nervous disorders. • Institutions fo r child and adult education which included creches! nursery schools, primary and secondary hoarding schools, special schools fo r the handicapped, and university based student health centres. • Medical and dental consulting room practices. • Other entrepreneurial employment settings such as business and industrial occupational health care services, nursing service agencies, and mobile emergency care units.


A bs tract
The purpose o f this study was to develop a profile o f professional nursing practice in private enterprise health care services in the Republic o f South Africa.In the light o f the fu tu re health care needs and the relationship between the private and public sector health care establishments, inform ation about the role and task o f the I professional nurse was needed.* Inform ation w ould provide a data base about the registered nurse and so facilitate fu tu re health care planning.
A n exploratory fie ld study was undertaken to locate the various work environm ents o f the registered nurse in fo u r statistical urban regions.Questionnaires were handed out and collected fr o m a proportional stratified sam ple o f professional nurses who were working in thirteen types o f health care environm ents in the period between I June 1983 and30 Septem ber 1983.A return rate o f 68 percent yielded 340 com pleted questionnaires fr o m 501 registered nurses.
The study revealed that the majority o f nurses in the private sector were relatively young.White, fem ale, English-speaking professionals who were practising in fo u r broad areas o f health care: I • Custodial care environm ents such as " residential hom es fo r the aged, institutions fo r the chronic sick and fra il aged, hom es fo r children and hom es fo r the adult handicapped.

IN T R O D U C TIO N
South Africa is one of the few countries in the world where the free enterprise system of health care prevails.This type of health care system, once com m on, was typical of the United States of America during the early forties and, until a decade ago, in Australia.
Because of the apparent lack of a comprehensive picture of the type of service provided by professional nurses in various organisations a n d /o r institutions which are conducted as (profit-making) businesses, this research attem pted to provide a starting point for those in search of such a perspective.
The primary purpose of the study was to collect data to develop a profile of professional nursing practice in all types of health care and related settings in the private sector.Inform ation is needed to identify the present role and responsibilities of this highly skilled professional health care w orker whose field of practice lies within South Africa's free enterprise health care system.A greater involvement of nurses in both the public and private sectors is necessary if the provisions of the Health Act are to be realised within a stable economic milieu.
This abstract is based on the major findings derived from the analysis of the data related to five broad areas of nursing practice in the private sector.Due to the extensive nature of the study, the findings pertinent to each area of practice will be dealt with in subsequent abstracts.

A IM S O F TH E STUDY
The study sought to develop a profile of professional nursing practice in all fields of nursing identified in health care services in the private sector.The study particularly attem pted to answer the following questions:

STUDY PROCEDURES
A review of the literature was undertaken to determine the breadth of the problem and in order to give some orientation to the study in terms of w hat should be investigated.The research questions were decided upon and a questionnaire developed for the purpose of gathering the data.An exploratory field study was undertaken and the target population of 3 140 professional nurses identified in four urban statistical regions, one in each province.

Development o f the research methodology
In order to be able to generalise about the registered nurse working in the private enterprise health care system, one requires a sample which, one must be reasonably sure, will accurately represent the total population of such nurses working in both urban and rural areas.A survey of the literature revealed that no significant research had been done in this field.
Various factors contributed tow ards defining the research area, developing the method used to identify work environm ents, and selecting the population elements.

Determining the target population
A num ber of key factors related to population distribution patterns and trends in urbanisation and industrialisation played an im portant role in determ ining the target population.R ural-urban differentials were examined and carefully weighed in the pre-selection phase.The geographical distribution patterns of different population groups with increased urbanisation tendencies were prim ary factors which had to be carefully considered before delineating the target population.
Secondary factors that were taken into account centred around work opportunities and the general socio economic development of population groups.U rban areas usually offer more and better jo b opportunities and training facilities for all population groups.Large concentrations of health service personnel are usually found in these urban areas While cities generally offer specialised services, particularly hospital and nursing services.
After studying the population distribution patterns with the concom itant socio-economic factors, it was decided to select a geographic region with the highest W hite population count in each of the four provinces.

Identifying the population
An extensive field search was undertaken to locate the various work environm ents in which professional nurses could be working, and to ascertain the total num ber of registered nurses from which a reliable sample could be taken.A total of 3 140 professional nurses were identified.
The sample elements were divided into relevant sub-units according to the types of work environm ents identified.
The sample size selected constituted ten percent of the finite population of registered nurses (3 140) identified in Table I and five percent of the total num ber of medical practitioners identified.
The sample W ork settings were stratified according to type of nursing field and a total of 535 registered nurses comprised the total sample.The selection process ensured that the final num ber was a random sample of the total num ber available.Thirty four registered nurses were sampled in the statistical region in the O range Free State which was ultimately used for the pilot study.(See table I)

Categorisation of practice areas
The sample of professional nurses practising in thirteen fields of nursing were categorised according to five broad areas of practice in the private sector which offered em ployment opportunities to the registered nurses.(See table 1) Custodial health care settings offer work opportunities for nurses in homes and institutions for the aged and chronic sick, homes for children and homes for adult handicapped persons.Private hospitals and special health centres are likewise prim ary em ployment settings for registered nurses in this country.Institutions for child and adult education offer em ployment opportunities for nurses in crëches/nursery schools, in private prim ary and secondary boarding schools, special schools for the handicapped and in student health care centres.O ther entrepreneurial organisations such as business and industrial firms, private nursing service agencies and mobile emergency care units, offer job opportunities for professional nurses in specialist health care areas.Medical and dental solo and partnership practices are m ajor em ployment settings for this category of nurse.

Data collection
The seven part questionnaire containing both closed and open-ended questions was handed out and collected from a proportional stratified sample of professional nurses in the period between 1 June 1983 and 30 Septem ber 1983.A return rate of 68 percent yielded 340 completed questionnaires from 501 registered nurses.

Statistical analysis o f responses
Analysis of the d ata was perform ed in two parts.The first stage was the analysis of the responses to the pilot study.
The second stage was the analysis of the 340 usable questionnaires.The processing, grouping and com putation of the descriptive statistics was accomplished with the use of the Statistical Package for the Social Sciences (SPSS). FINDINGS,

CONCLUSIONS A ND RECOMMENDATIONS
The findings, directed towards elucidating the m ajor objectives of the study as represented by the research questions, together with the conclusions and the recom m endations formed as a result of the analysis of the d ata are subm itted to improve health care delivery by nurses working in private enterprise health service settings.

What are the biographical characteristics o f the professional nurses who have elected to work in health care or related nursing service settings in the private sector?
The registered nurse practising in health care fields in the private sector may be described as a relatively young to middleaged, W hite English-speaking professional who holds two basic nursing q u a lific a tio i^* Sex It was found th at the distribution according to sex within each type of em ploym ent setting was unbalanced -as figures in Table II show.A lthough the nursing profession in this country is predom inantly female, recent figures show that the percentage of male registered nurses in the nursing force is steadily increasing; in 1981, they represented 2,94%, and in 1983, 5,97% of the total num ber of persons on the register (6, p. 1-6).
The rise in male participation rates could be attributed to and influenced by the current economic climate; fewer job « )ortunities including retrenchm ent terns together with the improved salary jctures and conditions of service for nurses in governm ent employment.

* Ethnicity
The large m ajority of nurses in the sample were W hite (92%); most were Englishspeaking (84%); thirty-nine were A frikaans (11%); six spoke another European language as a home language (2%), while nine spoke a Black ethnic language as a home language (5%).
The twenty-seven nurses who represented the three other population groups (8%) and who were employed in White private sector health services were mainly hospital-based.The num ber of Coloured and Black nurses in the sample were twice the num ber of Asian nurses.It should be noted however that the registered nurse population in South Africa is lowest am ong the Asiatic nurses, ^^n the health sector in this country both -^^l i c and private sectors are employers of professional nurses and will in future be obliged to take into account the dem ands for nurse manpower requirem ents in order to m aintain a dynam ic equilibrium.The percentage of nurses who were solo wage earners was highest in the groups of nurses working in hospitals, special health centres, and institutions for child and adult education.

*Age
• Children Fifty-two percent of the respondents had children but most of the tw o-hundred-andone children were 13 years and older (47%).O f the remaining children, twentynine percent were of schoolgoing age, twelve percent were in their third year and older, while only twenty-four were younger than two years of age (12%).Fifty-eight percent of the one-hundred-and-sixtyseven nurses who had children had need of child m inders/care services for their children.M ost of those nurses made use of either a dom estic or a family member as a child m inder for this purpose while they were at work.The reason for this could be the lack of creche facilities in the work place, coupled with the high cost of child care services.

• Spouse
The largest m ajority respondents reported that the spouse supported their decision to work and follow a career.Paul M ontagna m aintains that men are becoming more willing to share housework and child rearing and to help their wives to find occupational fulfilment.But he points out that, for working class wives, the situation is different.They have to work to help support the family (4, p. 403).It was found that most nurses in all practice areas were married to spouses who were in whitecollar occupations.

Which basic and post-registration nursing qualifications do they hold?
The registered nurse in South Africa is a professional person who carries out diagnostic and therapeutic nursing procedures according to legislation in an independent or (where necessary) in an interdependent capacity.To obtain registration in one of the three basic nursing courses, the nurse must have had at least twelve years schooling and have undergone at least three to four and a half years post-secondary instruction in nursing to obtain a basic nursing diplom a or degree.

* Basic nursing registrations
Responses revealed that three-hundredand-thirty-seven registered nurses (99%) in the sample were general trained; twohundred-and-twelve were qualified midwives (62%).The percentage of nurses holding the three basic nursing registrations in each practice area is illustrated in Figure It is evident that a large proportion of professional nurses who were w orking in private sector health services at the time of the survey are not fully equipped to provide a comprehensive health service within their em ployment settings.The Health Act, No. 63 of 1977, together with the announcem ent of the National Health Facilities Plan in 1980, provided the medium for a comprehensive health service for the total population of the Republic of South Africa.To meet this challenge, the S. A. Nursing Council introduced a comprehensive basic diplom a course at the end of 1982.This four-year course includes General Nursing, Midwifery, Psychiatric Nursing, and Com m unity Nursing.All these specialities will prepare and enable future nurses to deliver a comprehensive service in both public and private sector health services.

* Post-registration qualifications
A wide variety of post-registration courses for registered nurses are available in this country to provide for a com petent nursing force.These courses equip the nurse to provide specialist and comprehensive services to meet the growing needs of the population.

Clinical qualifications
The following table reflects the type of qualification held by the sample of nurses in each area of practice.(See overleaQ Figures reveal that all practice areas have a small num ber of nurses with specialised knowledge and skills which can benefit the service if they are fully utilised.Excluding the three nurses who hold the D iplom a in O perating Theatre Technique and who are employed in custodial ere settings and institutions for child and adult education most of these nurses were practising in environm ents where the patient will benefit directly the additional skills and knowledge the professional nurse had gained for herself through post registration studies.

University qualifications
Findings revealed that fourteen nurses were university graduates.Thirteen nurses reported that they held basic bachelor's degrees in nursing (4%); six of these were working in hospitals; two were employed by entrepreneurial organisations; four were in medical consulting room practices.One nurse in a custodial care setting held an honours degree in addition to her bachelor's degree.The only other nurse with a degree was working for a doctor and held a non-nursing bachelor's degree.

What is her socio-economic status?
Findings concerned with the social and economic conditions of the nurses practising in each of the five practice areas revealed that, although the nurse in the private sector is able to make an independent decision regarding her practice field, place of work, direct patient care opportunities, and work shifts, the work week schedules were found to be similar to those in governmental heahh services.Responses also revealed that nurses in private enterprise health services have limited fringe benefits, prom otion and continuing education opportunities.

Where a nd in what capacity is this category o f nurse working?
Although the large majority of nurses in five areas of practice were employees (97%), eleven were found to be working proprietors (3%).These nurses were the owners of institutions for the aged, small private hospitals, a crëche, and a nursing service agency.O f interest regarding jo b titles was that while most held nursing titles only a small num ber of nurses held non-nursing titles such as director, nursery school teacher, child care worker, medical secretary, and dental secretary.These titles denote jo b status and the type of work performed.

What is the pattern o f em ploym ent?
Only thirty nurses in the study were employed in tem porary posts (9%).The remaining num ber all occupied perm anent positions in their respective employment organisations.O f interest is that a num ber of nurses were in perm anent part-tim e posts; fifty-six nurses reported th at they were part-tim e workers (16%).Eighty-four percent of the sampled nurses employed in private sector health services were in full time posts; only fifty-four nurses occupied part-tim e posts.A com parative profile of all the employed registered nurses in ^ America in 1980 revealed that six ty -se v e n ^ percent of the nurses in that country worked full time (2, p. 486).
The num ber of nurses working fiexi-time hours is insignificant (3%), if one considers choice of work hours as a factor for selecting private sector employment.O f the ten nurses who had this privilege, two were hospital-based, four were in custodial care settings, three were private duty nurses, while one was a medical secretary.

H ow fa r is the place o f work fr o m the hom e environm ent?
In this country, the vast m ajority of registered nurses are not only female; a significant num ber are also either married in dual career families or are solo parents who have to balance the dem ands of home and a career.M ontagna m aintains that if the wife takes on a professional role, this does not imply a dram atic change for t h e ^^ family.Studies have revealed that wives are still expected to m aintain their domestic roles as house cleaners, child minders and cooks, while the husbands assist when necessary.The w oman who follows a career has to channel energies into two roles -home and profession.The increasing num ber of hours worked by professional people further complicates the difficulties encountered by women in these dual career families.W hen the decision is made about where the family should live, the husband's jo b is generally always given prior consideration (4, p. 225).
It was believed th at distance from the work place and travel time were influential factors which would determ ine the choice of work place by the nurse electing to work in the private sector.Findings revealed however that only half the sample of nurses in the study lived relatively close to their em ployment settings.
The sample of nurses employed by private boarding schools lived in flats or cottages on the school premises, but a few nurses in other practice areas also lived on the work premises.

What k in d o f shift does the nurse work?
Findings revealed that most nurses in all five areas of practice worked straight shifts.A num ber of nurses in the following em ploym ent settings still, however, work the broken-type shift: three in hospitals for the chronic sick and aged; thirty-one in hospitals and special health centres (20%); one boarding school nurse; three mobile emergency care nurses, and one nurse employed in a medical consulting room practice.Hospital-based nurses are generally required to provide patient care services seven days a week for 24 hours a day.The social, psychological and physiological problems associated with providing a 24 hour nursing service for the institutionalised patient is perhaps one of the negative aspects of nursing and a determ ining factor in career selection.Between 1979 and 1983 there was an average total decrease of 5,3% per annum in all student nurses in South Africa, with the highest average yearly decrease of 9% in White student nurses (5, p. 35).
which days o f the week does the nurse generally work?It was found that the sample of nurses worked twenty different shift patterns with the greatest variation in custodial type care settings, l^ess than forty percent of the nurses in custodial care and hospital settings had weekends free whereas about sixty percent employed in the other settings had this privilege.
It was evident that, in areas where twenty-four hour patient care services are provided, such as custodial care settings and in hospitals and related institutional settings, relatively fewer nurses have the privilege of having every weekend free.It is evident from responses, however, that even in this type of environm ent in the private sector every consideration was given to the most appropriate type of shift and shift rotation pattern for the service and the personnel.^ It was found, in addition, that while IP io st nurses in all fields of nursing were satisfied with their present jobs, many would consider returning to public sector employment.Specified work hours according to conditions of employment ranged from a six-hour work week up to sixty-eight hours per week, with most nurses working a 40-44 hour week.The hours actually worked by a num ber of nurses exceeded, however, their specified hours.A num ber of nurses were expected to be on call during their off-duty hours; some reported that they were reimbursed or given com pensatory time off for overtime work, but a num ber of nurses in all practice areas received no com pensation.

H ow long has the nurse been working in her present job?
Findings with regard to tenure revealed that the nurse who provided nursing care for patients in special health centres and in homes and institutions for the aged had been with their employers the longest; between 10 and 18 years.Nurses employed in hospitals, medical consulting rooms, homes for the handicapped and private duty nurses, 6 years.Those in children's homes, dental rooms and creches, 4 years.Tenure in the remaining settings varied from 3 m onths to 2 years.
What type o f fringe benefits exist and how im portant are fringe benefits to the professional nurse?Findings revealed that occupational health nurses as a group were the only respondents am ong whom about fifty percent of the nurses received the highest number of fringe benefits: ten in all.O f the other nurses employed by entrepreneurial organisations, above fifty percent of the mobile emergency care nurses received three types, while less than half the sample of sixteen private duty nurses received one or more fringe benefits, above fifty percent of the nurses in custodial care settings received three types, while those working in institutions for education received three.
The three types received by most nurses were paid sick leave, weekends off, and medical scheme benefit.Figure 2 will show the percentage of nurses who received fringe benefits and the im portance attributed to each type.
Three fringe benefits were rated as im portant by above fifty percent of the sample of 340 nurses who received them, namely, sick leave, weekends free, and uniform allowance.Of interest in the findings on the response to the open-end question on fringe benefits is that other types of benefits were received by some nurses.These were mainly free housing facilities, parking, and school holidays.No respondent indicated that they had the  Although one percent of the nurses sampled did not indicate w hat the level of authority of the post they held was, and four percent did not reveal their gross earnings.Figure 3 (overleaQ shows clearly that the largest percentage of nurses earned R5 000 and more, but less than R 10000 per annum .It may be assumed that these were the nurses who occupied professional service-level posts.
The salary scale com pares favourably with salaries earned by nurses in the public sector holding a sister's post, now known as the professional nurse rank, with a salary adjustm ent of R2000.It became evident that, at the time of the survey, the salary of this level of nurse had not been increased in private health services.
O f interest regarding the higher incomes is that only four of the eleven nurse proprietors were earning in the same salary range as the nurse in the public sector who holds the post of Director-N ursing Services (whose salary is fixed at R30 255).

Why has the registered nurse entered the private sector?
It was found that reasons for taking a post in the private sector varied according to the practice area of the nurse to a limited extent.The nurse employed in custodial care settings and mobile emergency care nurses reported that being able to make their own decisions about the work had been a very im portant reason.Hospitalbased nurses and private duty nurses reported that it was because they had more opportunity to give direct patient care, while the nurses in special health centres stated that the work place was nearest their homes.Nurses employed in institutions for education and in medical and dental consulting room s revealed that the work hours suited their family life styles.The next bar diagram depicts the rate of Curationis Vol.11, No. 2, Julie 1988

LEGEND
Above R 30000 per annum R20000 and m ore, bul less th an R30000 R i 5 000 and m ore, but less th an R20000 R 10000 and m ore, but less th an R15000 R 5000 and m ore, but less than R 10000 R2000 and m ore, but less th an R5000 Relatively few nurses make use of child care facilities but tend to leave their children in the care of a domestic or family member while they are at work.Choice of work hours no doubt plays a role here together with the current economic climate since child care services are expensive.Few nurses in the private sector have, in addition, free or cheap creche facilities as a fringe benefit.
Although nearly all the nurses are registered general nurses and more than half hold a second basic registration, very few nurses are psychiatric trained and even fewer hold post-registration clinical qualifications which will enable them to provide a com prehensive health care service.
A limited num ber of nurses in the private sector receive study leave benefits to enable them to acquire nursing skills which will assist them to meet the comprehensive needs of their patients.Only nine nurses (one in the O FS, one in the Cape, two in Natal and five in the T ransvaal statistical regions) held the D iplom a in Com m unity Health Nursing Science.Provision has been made for the professional nurse in this country to acquire additional knowledge and skills through post-registration courses.A wide variety of post-registration courses for registered nurses have been established by the SA Nursing Council.M ost universities offer post basic degrees in nursing which can be taken either full time or part time.The University of South Africa provides unlimited opportunities for the nurse who is unable to leave her home or work environm ent through distance teaching instruction.The nursing education program m e in South Africa has provided for the needs of the professional nurse to practice in a variety of health service fields.

Recommendations
• Employing authorities and employers: should provide opportunities for the professional nurse to undertake relevant nursing courses which will enable her to provide a more effective health service within the work setting.• Employers of nurses in occupational settings which cannot provide a prom otion pyramid should offer an additional increment as an incentive m otivating factor for each additional nursing qualification through post degree courses obtained.• Employers of nurses should bring fringe benefits on to a par with those offered by governm ental services -particularly m aternity leave benefits, overtime pay, free or low-cost creche facilities.
How concerned is the nurse in the private sector with professional affiliation and selfdevelopment Findings revealed that most nurses in the study registered annually with the SA Nursing Council, but a num ber reported that they did not change their registration to that of "non-practising m em ber" when they were not employed: a total of one hundred and eighteen nurses (35%).This figure is relatively high and will affcct the num ber of professional nurses on the register of the SA Nursing Council.

What is the extent of the nurse' s interest in the affairs o f the nursing profession?
Only forty-nine nurses voted for Council and Board members on the two statutory nursing bodies (14%).The low voting rate of professional nurses was highlighted when the voting percentages for Council members were revealed in February 1984.
Only 8,5% of all W hite professional nurses in the country had cast their vote.The President of the SA Nursing Council, com m enting on the low voting rate, pointed out that in many countries nurses did not have the privilege of voting for those who determine the standards of the profession.To be worthy of her professional status, the registered nurse must take an interest in and accept responsibility for the affairs of their profession (7, p. I).

How actively does the nurse participate at branch level in the SA Nursing Association?
A minimal num ber of nurses in the study reported that they attended their local branch meetings.The largest num ber of nurses only paid their membership fees and took no further interest in the affairs of their Association.
Reasons for non-attendance varied according to nursing field.Ranked in order from highest percentage response down, the following reasons had applied to less than one-hundred-and-thirty nurses in all practice areas (40%): • It is irrelevant to my working situation.40% • My family com mitm ents do not permit me.37% • I am doubtful about benefits to be gained.36% • It is too risky to travel at night.34% • I do not know anyone there.30% • I do not believe in professional associations.19% O ther reasons which were reported by fewer than nine nurses (3%) in each area of practice included such factors as: • I have no transport at night.• The meetings are boring/frustrating.• I have not been invited.• I have no idea where and when meetings are held.Although a member of branches have made an attem pt to overcome the difficulties posed by transport and meetings which are held at night by holding meetings at accom m odating times, it is known that this has not increased the professional nurse's participation rate.It is evident that none of the reasons listed in the questionnaire, nor those given by the respondents, are the real cause of the apparent apathy by nurses tow ard their professional Association.In a study undertaken by Philip M arden on the • ientations of registered nurses toward e American Nurses Association, he found that a lack of career dedication resulted in the alienation of nurses from American Nursing Association.Total career dedication is based on the willingness to recommend nursing as a career to one's daughter and friendly feelings tow ard one's colleagues.He found furtherm ore that "on-the-job dedication" had little or no effect upon com m itm ent, as this refers to such characteristics as willingness to do more than is expected of one in the daily life on the job (3, p. 192).The high percentage response to the factor "It is irrelevant to my work situation", suggests a lack of com m itm ent to the affairs of their Association at this level, not becaue of perceived deficiencies in these meetings but merely because of indifference and presumed irrelevance to their current life circumstances.A disturbing factor which emerged was the ^^m b e r of professional nurse immigrants ^^o reported that they were not aware of SANA meetings at this level and had no idea where these meetings were held.

What m ethods does the nurse use to keep professional know ledge and skills updated?
The large m ajority of respondents in all five areas reported that reading professional literature was the only method used to keep their professional knowledge and skills updated (68%).A small percentage of nurses made use of informal study m ethods (27%) or had attended formal courses (9%).Findings regarding fringe benefits revealed that few nurses had the privilege of undertaking form al studies in their work situation.

Conclusions
The registered nurse in the private sector has little interest in the activities of the SA Nursing Association, either at national or branch level, since few vote for board members while even fewer attend branch meetings.A pathy tow ards their professional Association is seen as indifference caused by current life styles since few nurses were found to be members of other social organisations or special interest nursing groups.Findings revealed that group cohesion is more evident in special interest groups such as the field of occupational health nursing: most of the sampled nurses working in business/industrial health settings were members of the SA N ational Society of O ccupational Health Nurses.Professional self-development tends to be minimal as few nurses attend nursing sem inars/sym posia or undertake formal courses as a form of continuing education.M ost rely heavily on the reading of professional literature to keep their knowledge and skills upgraded.While inservice education programmes appear to be available in institutional health service settings, few nurses attend lectures on a regular basis.

Recommendations
• Employing authorities should institute in-service education programmes where required or else reappraise the efficacy of their current program m e in order to encourage attendance.• Employers should give registered nurses the opportunity to attend workshops, seminars or refresher courses so that they may upgrade their knowledge and skills with regard to the type of nursing service which they provide.• Employers should provide opportunities for the professional nurse to become efficient in autom ation techniques since com puters are in operation in many health agencies and will become com m on in most nursing areas.• The SA Nursing Association should improve their image by highlighting the benefits offered to members other than negotiation.They should determine what the actual needs of the nurse who seeks assistance are.
W hat is the extent of the nurse's adm inistrative managerial responsibilities?
The largest percentage of professional nurses in the study were practising in hospital settings (45%) -an environm ent in which it is generally assumed that the nurse in a leadership position on different management levels has the most adm inistrative responsibilities.Findings revealed that professional nurses in all fields of nursing have numerous adm inistrative responsibilities associated with managing human and material resources.

What is the type and extent o f perform ance o f adm inistrative activities within each type o f work environm ent?
Twenty-two adm inistrative activities directly concerned with the m anagem ent of a work area were selected.

A dm inistrative activities concerned with managing a nursing section
Responses indicated that the nurse employed in medical and dental practice settings with operating theatre facilities has the same organisational responsibilities as her colleagues in other areas of practice which provide patient care services.Of interest is th at more than half the sample of nurses in each of the remaining practice areas perform ed the following activities: • developing policies for the nursing area • form ulating nursing care objectives • developing nursing care standards • providing an effective system of recording and reporting • providing and m aintaining an effective com m unication system • undertaking periodic inventories • prom oting good interpersonal relations • reviewing and mediating staff conflicts.
From the analysis moreover it became apparent that only the nurse who is at the head of a service is concerned with budgeting activities.Responses revealed that a num ber of nurses are participating in research activities in each of the five areas of practice.

Adm inistrative activities associated with m eeting direct j indirect patient needs
Eleven activities were listed.It was found that the professional nurse whose practice field lies within an institutionalised setting has relatively more adm inistrative responsibilities concerned with meeting patient needs.Encounters with patients in am bulatory health care services are of a situational nature resulting in less adm inistrative activities related to meeting patient needs.

Personnel-centred activities
Findings revealed, in addition, that the intensity of personnel adm inistrative responsibilities the nurse has is influenced by the type and size of health service settings.Professional nurses in work environm ents where they are the only health care professional and have a smaller span of control perform ed relatively fewer personnel-centred activities.

A ctivities associated with the general m anagem ent o f supplies including other supervisory tasks
The professional nurse in charge is responsible for the ordering and general m anagem ent of supplies in the nursing or health service unit.Findings revealed that most nurses in all five areas of practice were responsible not only for controlling m aterial resources but also for undertaking other supervisory functions which are generally the task of ancillary service staff in large governm ental hospitals.
A num ber of respondents in all practice areas reported that they were responsible for supervising the activities of non nursing staff who provided patient support services.It was found that in all fields of nursing practice the nurse is responsible for the food-provision, laundry and cleaning services.It is evident that clerical and related secretarial work is not restricted to the professional nurse in an office-based health service only.It was found that a num ber of nurses in all areas of practice in the private sector had secretarial-type' responsibilities which included draw ing and paying employee wages, bookkeeping, typing, banking money for the firm /practice, writing out receipts, and making patient appointm ents.

Conclusions
In all nursing fields in the private sector, excluding medical and dental office nursing settings, the registered nurse has extensive supervisory and adm inistrative responsibilities associated with managing hum an and m aterial resources in the work place.The type of adm inistrative responsibilities perform ed by most nurses in private enterprise health service settings are those concerned with meeting direct/indirect patient needs and the general m anagem ent of supplies.Nurses in the Cape, N atal, Transvaal and the O FS are not participating in the budgeting process.Budgeting is a means of directing efforts tow ards improving productivity since it reveals how well resources are utilised.
While clerical and secreterial tasks form a m ajor part of the duties of the officebased nurses, these non-nursing activities are perform ed by a large proportion of nurses practising in all fields of nursing.

Recommendations
Employing authorities and employers should: • encourage registered nurses to obtain m anagem ent skills by offering, as a fringe benefit, to pay for the cost of subject fees for each nursing adm inistration course passed at university level; • involve nurses in the budgeting process since both inter-and intra-departm ental activities and interpersonal contact broadens the experience of nurse managers; • create opportunities for nurses to attend supervisory and m anagem ent programmes.Professional seminars and w orkshops and management program m es are offered by continuing education departm ent of various universities.

What is the extent of the nurse's teaching role?
Teaching is an im portant part of nursing care since the prim ary responsibility of every practising professional is to provide patients with quality health care and give guidance to those in need.The teaching role of the registered nurse implies responsibility tow ards the patient and the employing authority.

How m uch and what type o f teaching is undertalcen?
. The large m ajority of nurses in all five areas of nursing practice reported that teaching was an im portant activity in their work field.Findings revealed, however, that relatively few nurses were actively involved with teaching people/groups with whom they had contact.Excluding the hospital based nurses and those in related curative care settings, most other professional nurses in the sample were in health care settings where patient care contact is incidental and on an am bulatory basis.
Although findings revealed that the people who benefited most from the teaching of the nurses in private health care settings were the aged and the nursing staff, teaching is not limited to one type of nursing field.Twenty-eight nurses in homes and institutions for the aged (8%) always taught as a m ajor part of their work, but responses indicated that nurses in other fields also teach aged citizens.Ten occupational health nurses indicated that they always teach business and industrial employees (3%); however in other health fields nurses indicated that they also teach this category of worker.A num ber of respondents reported that they had teaching contact with people outside the immediate work place, such as with people in welfare groups/voluntary workers and com m unity groups.
The type of health care teaching which was done in each practice field is illustrated in the column chart.
It was found that nurses employed by medical and dental practitioners do relatively little teaching in their practice setting.This is no doubt due to the am ount of clerical and secretarial work which they are responsible for.It is evident that the teaching done by nurses in hospital settings is mainly curative.

Are nurses involved with in-service education?
A num ber of nurses in all five areas of practice reported that they were responsible for giving (33%) or assisting with (23%) in-service education when asked.Seventy-four respondents reported that it was the responsibility of their inservice departm ent (22%), while twentytwo percent did not have this type of staff development program m e in their work environm ents.Findings revealed that few nurses attended in-service education lectures of professional interest.
It was found that more than half the sample of hospital-based nurses never attended in-service education lectures.This type of staff development program m e has long been a part of hospital nursing services in the public sector and seems to identify and meet staff needs.

Conclusions
The nurse in the private sector acknowledges her teaching role but few are actively involved with teaching as most feel that this should be included in their job descriptions.M ost nurses in all practice are as concentrate more on curative health care teching than do nurses in institutions for child and adult education; these latter nurses provide relatively more prom otive health care teaching than do nurses in other work settings.Little active teaching is done by nurses in medical and dental office-based practice settings.

Recommendations
The nurse must; It was found that a num ber of nurses in medical consulting rooms other than those working in operating theatre units also examined patients in this way.

What k in d o f diagnostic! therapeutic procedures are undertaken?
O f interest is the type of diagnostic/therapeutic activity which nurses perform ed as independent/ interdependent nursing functions.It was found that activities which are generally perform ed by a radiographer and a num ber of medical diagnostic tests were performed by hospital-based nurses and the nurse who is working in a medical practice setting.Only four percent of the nurses in the sample were actively involved with family ^^^n n i n g .

Conclusion
The main type of nursing care provided in all health care settings is basic nursing care.Few nurses hold post-registration qualifications which enable them to give specialist nursing care.Rehabilitative nursing care forms a small part of the nursing care provided.A num ber of nurses performed activities in private hospitals and in medical practice settings which are medical diagnostic procedures.Although the professional nurse who performed these acts appears to have accepted a specific prescription or direction from the doctor for these procedures and appears to have made an independent decision, this nurse must accept full responsibility and remains accountable for her actions.

Recommendation
Employing authorities and employers should utilise the professional knowledge and skills of the nurse by giving her as much clinical responsibility as she seeks and is able to cope with.H ow m uch responsibility and authority is attached to the post occupied?Findings revealed that five distinct authority levels emerged in each practice field, excluding medical and dental practice settings.(See Table IV) Almost half the sample of nurses were employed as professional service level workers with no supervisory responsibilities other than patient care or secretarial duties in medical and dental office practice settings.
How confident is the nurse about selected professional practice aspects?Respondents reported that most had com plete responsibility for deciding how and when their work was done.O f interest is that, while most nurses were confident of aspects related to professional practice this item in the questionnaire received the highest non-response scores, reflecting uncertainty on the part of the respondents.
Findings revealed that the largest percentage of nurses in the study reported that they were uncertain of the way in which nursing policy decisions, rules and regulations were made and how their work was evaluated.This reflects a breakdown in com m unication between top management and employee.The percentage of nurses who are uncertain of activities that are dependent upon a doctor's prescription is noteworthy.

Conclusions
Nurses in private sector health services function on five levels of management: proprietorship, top-level, mid-level, firstlevel and service-level.The largest proportion of nurses in the study revealed that the authority and responsibility attached to the post occupied was that of a professional service-level worker.These nurses are mainly responsible for giving direct patient care and have few supervisory responsibilities.While a large num ber of professional nurses in the private sector have job descriptions and are confident of professional practice aspects related to decision-making, authority and responsibility in the work place, a num ber of nurses are uncertain of how their work is evaluated and how decisions concerning nursing policies and regulations are made.

Recommendations
Employing authorities and employers should: • provide policy manuals which are updated at regular intervals and are used as in-service and staff development tools in work settings, where these are not available; • introduce the constructive perform ance appraisal method which is appropriate for most health care institutions.The nurse will know well in advance the basis for evaluation if she has already participated in establishing the objectives; • consider using self-appraisal methods along with the existing appraisal system to gain insight into employee strengths and weaknesses; • provide jo b descriptions which outline adm inistrative, teaching and professional responsibilities in settings where these are not available.

CONCLUDING REMARKS
This has been an exploratory study in which an attem pt was made to develop a profile of professional nursing practise in private health services in this country.The registered nurse in private enterprise is currently providing essential health care services in all forms of private organisations.It is hoped that the findings will provide answers for future health service planning in the private sector and create a more co-operative relationship between private and public health care sectors.While health providers benefit from the utilisation of the nursing skills of registered nurses, of greater im portance is the benefit to society from the comprehensive nursing care which can be provided by this highly qualified health care professional.Employing authorities should provide avenues for the registered nurse to upgrade her knowledge and expand her services to meet the health care challenge.

T
A B E L II: D IS T R IB U T IO N O F R E S P O N D E N T S BY SEX A C C O R D IN G T O A R EA O F P R A C T IC E (N lo m a/C ertin catc General nurse instructor O rthopaedic nursing O perating theatre technique G eriatric nursing science District nursing C om m unity health nursing Intensive nursing O phthalm ic nursing Paediatric nursing Advanced M idwifery and N eonatal Nursing O ccupational health nursing Advanced Psychiatric N ursing Science Advanced Paediatric and N eonatal N ursing D qualifications A num ber of private hospitals in each of the three statistical regions selected for the study offered training facilities for certain categories of nurses.Responses revealed that only two nurses in the sample of hospital-based nurses had non-clinical qualifications.One nurse held the D iploma in Nursing A dm inistration while the other held the D iplom a in Nursing Education.O f interest is the fact that the only other nurse who held a D iplom a in Nursing Education was employed in a medical consulting room practice.
id e n t In s uran c e L ife In s u ra n c e ' l ú r É ' i i 4 1 SledicaJ schem e .K i: : ' i r T ^. ■ "• 1 M o to r car -i r -w -* !P e tro l jllo w a n c e ' !0 5 1 H o u s in g s u b s id y Findings revealed th at the nurse in custodial care settings has num erous clerical functions, apart from her extensive adm inistrative responsibilities revealed in the foregoing.C urationis Vol.11, No. 2, Julie 1988 TA BLE IV: LEVKI.S O F A U T H O R IT Y ATTAC H E D TO P0.ST S H E I.D BY P R O K E SSIO N A I, N U R SE S IN FO U R A R E A S OK P R A C T IC E This is the period when the professional nurse has the most responsibilities to cope with in regard to occupational advancement and caring for older children.While most nurses in the sample were younger than 49 years, the largest percentage were in the age group 21-29 years.
in custodial care settings.The nurse in this setting often works in isolation and is solely responsible for the m otivational and situational events that confront their patients.The highest num ber of nurses in the age group 30-39 years were working in hospital and related special health centres.• A few of the larger private hospitals in the study offered training facilities for nurses who were undergoing basic courses.
To determine the nursing role structure within each of the thirteen fields of nursing, respondents were requested to indicate what level of authority they attached to the post occupied.