TRENDS IN NURSING IN SOUTH AFRICA AND THEIR IMPLICATIONS FOR NURSING EDUCATION

Die klem in Suid-Afrikaanse gesondheidsorg moet verskuif vanaf die kuratiewe na voorkomende en bevorderende gesondheidsorg. Dit is waarop die besluit vir die nuwe omvattende basiese verpleegkursus berus het. Met die nuwe kursus sal die student se roi verander daarin dat sy nie meer dieselfde lading in die kliniese area sal kan dra nie. Die geregistreerde verpleegkundige sal weer meer van die direkte pasiëntsorg moet doen. Terselfdertyd moet sy bewus wees van haar onderrigfunksie ten opsigte van toesig oor en leiding aan die student in die kliniese area. Dit is onrealisties om te glo dat die opgeleide personeel nie jaloers sal wees op die nuwe studente wat na kwalifikasie in al vier basiese rigtings registreer nie. Hulle moet egter verseker word dat hulle poste nie in gedrang is nie en dat hulle ’n belangrike rol in die oorgangstydperk het. Die nuwe stelsel hou verskeie administratiewe en opvoedkundige implikasies in wat nog aandag moet kry. Die skrywer voorsien egter dat met die klem op omvattende gesondheidsorg en die uitbouing van hierdie beginsel in verpleegonderwys ons moontlik die WGO se doelwit van “ Gesondheid vir Almal teen die jaar 2000” sal kan bereik.


Introduction
In South Africa there is a unique and difficult problem in that sparse ly populated, outlying areas con stitute a m ajor load for health ser vices.Varied cultures and degrees of tribalism and seemingly inaccess ible terrain often deter or prohibit the extension of health services.Thus, with an ever increasing popu lation (Black populations in dire need of preventive health educa tion) and the influence of urbanisa tion and industrialisation, preven tive and promotive services have seriously lapsed behind the more dramatic field of curative medicine, and may be considered a major reason for the unabating social breakdown in our community.
Therefore, the main emphasis in our health services needs to move over from the curative aspect to the more positive aspects of preventive and promotive health in the inte rests of human welfare, resources and the national economy.The de cision, with this goal in mind, to for mulate an extended, but compre hensive nurse training, with in creased accent on the nurse's pre ventive and p ro m o tiv e h e a lth function, has encountered strong and varied reactions.It is, however, a very necessary preparation for South Africa's future and will per haps reduce the demand for cura tive services and a proportionate number of nurses in this field.

Changes in the student role
The envisaged new course encom passing general, community health and psychiatric nursing and midwif ery, of approximately four years du ration, will produce a different type of nurse.Her training will differ substantially from that of present day students.
At present, it is perhaps fair to say, student nurses of all categories provide for the bulk of the clinical workforce.Recent moves to create part-time posts for married/non practising nurses, in an attempt to place professional nurses back into ward work and prevent the em pha sis on the administrative realm of the duty room, has to a large extent failed.
To afford all four disciplines their necessary time span during the four-year training it is clear that stu dents on the new course may have fewer hours of clinical experience.
In addition, professional nurses have been quick to realise that they will now be obliged to revert to their more practically orientated role in providing patient care.At the same time it is m andatory that each is fully aware of, and responsi ble, for her teaching function so that the hours the student spends in the clinical situation represents valuable learning experiences.
A nother im portant factor, which recent investigations into conditions of service for nurses have revealed, is that in many clinical situations students receive little or no supervi sion.They are delegated tasks un suitable for their level of training and competency which frequently results in discontent.This contri butes to lack of confidence due to bad experiences for which they were unprepared.
Supervision of and interest shown in the students by their trained col leagues encourages the form er to be motivated and keen to acquire new skills and to progress in their train ing.This in turn fosters good inter personal relationship and an atmos phere conducive to the rehabilita tion of the patient.It also serves to inspire those just beginning their training when they are at their most impressionable.

The attitudes of professional nurses
In describing the subtely different role of students on the proposed new system of training, these stu dents have been called supernumary, which has triggered mixed re actions from professional nursesmost of them negative.Perhaps supernumary is an undesirable term.Whilst the student will retain a certain observatory capacity du ring her time in the ward, the only way she can truly learn something is by actively participating and experi encing the situation.
There is no doubt that if the Nursing Process is to be successful, a team approach to patient care is essential.Therefore professional nurses must contribute in a more practical manner.A t the same time, however, they must be reassured that students will be available to fulfil nursing tasks as at present.The emphasis must be on teaching and by example to the student, rather than on tasks to be accom plished as soon as possible as just another chore and not as an ele ment of the patient's total care regi men.

Interpersonal relationships
Will there be professional parity?
The fact that students graduating from the new course will autom ati cally be qualified in all four basic disciplines, will probably spark off feelings of resentment by profess ional nurses trained under the old system.
In many instances, due to m ar riage, children and other commit ments the older nurses have been unable to complete or undertake courses after registration.Certainly not in all four basic disciplines.Many feel that the nurses complet ing the new course will not be as proficient in these areas as they might be.Besides, post-registration experience and maturity are consi dered desirable and most helpful factors at present.It would be un realistic to think that the profess ional nurses trained at least twenty or more years ago, who now hold senior positions, would not harbour feelings of professional jealousy or inadequacy towards these students.
This could affect future professional in te rp e rso n a l re la tio n sh ip s very seriously and hamper the progress of our profession, for the sake of trying to upgrade standards in the best intended way.
Therefore, the oldies must be re assured and that their posts are not in jeopardy and made to feel even more needed.In retrospect, experi ence can never be underestimated.
It is probably not intended that the new course will cover the disci plines in as much detail as may be accomplished in the present oneyear diplomas.A strong advantage lies in the fact that a certain amount of repetition could be avoided in the new system (for example: in Anatomy, Physiology and the Social Sciences).Repetition is a drawback in the present system when a student undertakes the courses after basic registration.
Post-registration specialisation by nurses after their four year training, will ensure a more detailed know ledge, as is also the case at present.Experience is the most reliable and best learning/teaching tool.Thus the main aim of the new curriculum would be to train nurses with a varied and comprehensive body of knowledge, to better equip them for South Africa's health needs.They will be able to function in any environment.
If the transition is to be as smooth as possible, nurses trained under the old system have a very impor tant part of play.Whilst they may not be officially qualified in all the besic disciplines, they have strug gled to maintain health services until now in many and varied roles.They have helped our inadequate numbers of doctors to fulfil their roles by extending and developing their independent nursing func tions.

Student attraction: screening of applicants
Proposals that nursing colleges will be allied to a university infers two main considerations.
Firstly, as the university already has so many responsibilities to wards its other faculties, it appears CURATIONIS that a maximum of two nurse in takes per year would be practical, also bearing in mind the setting and marking of examinations associated with the number of intakes each year.
Secondly, due to the comprehen sive nature and extended duration of the proposed new course, organ isation and financial coverage for each student will be much greater.Because the number of prospective students does not far exceed intake posts, screening of candidates is very inadequate and unlikely to be practised in the larger centres at present.
Hopefully, emphasis on the stu dent as a major contributor to the clinical workforce will be displaced under the new training system and intakes, although large, will be more selective.This would be to try and ensure that fewer students drop out of training and that a maximum percentage complete the course and practice thereafter.

Conditions of service
Besides the need to improve and consolidate nursing services in South Africa, measures to improve and modernise conditions of service for students and trained staff alike are indicated.Already, as investiga tions into this aspect of health ser vices have revealed, there is a strong, unfavourable undercurrent of dissatisfaction among nurses.Some nurse leaders have even gone as far as to suggest that unless im provements are realised in working conditions, besides the develop ment of the new nursing curricu lum, nurses may become an extinct phenomenon.Special attention must now be focused on hours of work, favourable rates for night duty, unsociable hours and over time, living conditions and public transport.

Private versus provincial/State
The possibility exists that the number of trained nurse posts may be limited or diluted with other nurse categories (nursing assistants, for example) in the future.This poses the question whether the ad ministrative bodies concerned will create more professional nurse posts to cover the workload pre viously supported by students to the tune of forty-four hours per week, on a significantly lower wage scale.For private training schoolswhose main drawcard for trained nurses is a competitive salary com pared to that offered by provincial or state hospital services (married nurses do not qualify for the socalled perks offered by the latter in stitutions) -this extra cost could be prohibitive.
A limited number of trained nurse posts in both private and pro vincial/state establishments could have a negative influence on pro motion prospects and make the competitive salaries and opportuni ties offered in commerce and indus try seem even more attractive by comparison.

Proposed educational requirements
It is hoped that the co-operation be tween nursing colleges and univer sities will significantly raise the pro fession in the public's esteem.An added benefit would be to raise nurses' morale country-wide (dis persing many ill-founded and inac curate public suppositions about nurses' educational requirements and capacity).It should also en courage enrolment of prospective students, who may have been reluc tant to do so for fear of diverging from their schoolfriends' aspira tions of higher education or univer sity.
There may be a move to simplify the categories of nurses presently practising in South Africa.For example by retaining the nursing as sistant (but hopefully raising educa tional and practical requirements) but discontinuing the two-year en rolled nurse training.However, there must be no threat to those al ready trained under the present system.
It may be necessary for university entrance requirem ents to modify and raise our existing requirements for students undertaking the basic diploma course.It must be ensured that students will be able to grasp and integrate scientific principles, of which the number is steadily in creasing alongside strides in re search and medical technology.

Course content and determination of priorities
The professional nurse of the future will require far more knowledge of the physical and social sciences than she did in the past.Correlation and integration of these principles learnt in the classroom situation will require very careful and trained supervision if they are to be cor rectly applied in the clinical envi ronment.
More extensive preparation in Pharmacology, Biophysics, Nutri tion, Physiology, Bacteriology, So ciology and so on will be necessary if the nurse is to be competent in the physical care and emotional support the patient will require and in assist ing the doctor in duties he may de legate.
Already the quantity and use of drugs is exceeding the nurse's thera peutic knowledge.She cannot expect to render a high standard of care without a greatly increased knowledge of Pharmacology.This forms an exacting part of her inde pendent and inter-dependent roles.The advent and increasing use of labour-saving electronic monitoring aids demands of the nurse a tho rough practical knowledge of the principles underlying the function ing of this equipment if she is to be an effective member of the clinical team interpreting and evaluating her patient's progress.
These are but a few of the impli cations for the clinical situation.However, the nature of curative and preventive medicine across South Africa's provinces and the African states differs enormously and therefore each will set a differ ent list of priorities for health care in hospitals and in the field.This could present a potential problem for the examining board and its cri teria for curriculum planning.
It is generally accepted that no nurse training school should train its students to m eet its hospital's personal requirem ents.This would have serious repercussions when those nurses moved away, only to discover that they cannot function adequately.For example, infectious diseases, and nutritional disorders may be the most commonly encoun tered hazards in the African states, whilst in the European m etropoli tan centres, a different picture of degenerative heart disease and em physema may present.The choice will not be an easy one, but presumably the university nursing examining board must com prise a fair cross-section of training schools, so that the papers devised represent current world trends and the country's interests as a whole, excluding bias.

The South African Nursing Council
A greater or lesser role to play?
The current educational/examining, statutory and registering functions of the S.A. Nursing Council (S.A .N .C .)represents an immense load.The proposed decentralisa tion of examining boards should ease this responsibility greatly.
Presumably, nurse educators re presenting a cross-section of training schools would be selected to form the examining board under the auspices and inspection of the S.A .N.C. and the faculty for nurs ing education at the university con cerned.
Thus the S.A .N .C .would be re lieved of a m ajor responsibility, but would still be required to partici pate in curriculum planning, course content and as examination mode rator.The Council's statutory and registering functions would remain.

PLANNING FOR THE FUTURE?
The chief implications for nursing education primarily in the curative aspects of health care have been discussed.However, it is important to re-emphasise that the main changes envisaged for future health services in South Africa will have to be in community preventive and promotive health and our approach to it.
As mentioned above technologi cal advances should continue to en courage and maintain higher levels of clinical practice, but an enor mous amount of work still has to be done in providing adequate public health fields will only be carried ideal concept would be that public health and clinical medical practices merge to form a new pattern of comprehensive medical care.
The holistic concept envisages a dynamic and practical union be tween the public health specialist and medical scientist, but does not necessarily mean that education in Die Navorsingskomitee van die SA Verpleegstersvereniging het twee p rio rite ite in v e rp le eg n a v o rsin g onder die aandag van die D eparte ment van Samewerking en Ontwikkeling gebring.Die prioriteite was: • Transkulturele onderwysprobleme in verpleging veral met betrekking tot die beskikbaarheid van fasiliteite, dosente en beursposte; • tekort aan poste vir Swart opgeleide verpleegkundiges.
'n Komitee insake Ontwikkelingsnavorsing (KION) met die Afdeling: Navorsing, as uitvoerende arm, is by die Departe-V 0 L 7 N 0 2 health fields I will only be carried on outside the hospital.So great is the demand on curative services and available hospital beds, that every nurse must be forced to con sider her essential function as a health worker and all her educa tional goals should be orientated to this end.
More decentralised clinics (espe cially in the African states) and out patient centres, would ensure early detection, diagnosis and possible outpatient treatment of many ill nesses.This would greatly reduce the demand on hospital beds and in ment ingestel met die doel en funksie om: • navorsing oor die ontwikkeling van Swartes, die Swart volkere en die Nasionale state te kodrdineer.
The spiralling cost of medical care and the provision of medical aid schemes which proportionately in crease the demand for medical care deserves mention.To conquer and reduce the cost burden imposed on these schemes, it is essential that the general standard of health of the community be improved.
With the emphasis on compre hensive health care and deve lopment of this concepthrough nursing education, we may yet real ise the World Health Organisation's goal of " Health for all by the year 200 0 ."met die oog op moontlike finansiering; • navorsing wat finansiëel ondersteun word te monitor en waar moontlik hulp te verleen; • die navorsingsbevindinge na belanghebbende instansies insluitende kliënt (of opdraggewerdie gebruikmaker) deur te voer met die oog op implementering; • die Minister in alle opsigte ten opsigte van ontwikkelingsnavorsing te adviseer.