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South Africa take note: Employing more nurses can slash total health costs, study suggests

Meeting minimum nursing ratios could result in substantial cost savings — through fewer readmissions and shorter hospital stays, but potentially also by reducing the number of medico-legal claims against the government. (Photo by Gallo Images / Darren Stewart)

A recent study published in ‘The Lancet’ medical journal suggests that health cost savings resulting from employing more nurses would be double the cost of hiring them. The study was undertaken in Australia, but might have important implications for nursing in South Africa.

A study conducted across 55 hospitals in Queensland suggests that a recent state policy to introduce a minimum ratio of one nurse to four patients for day shifts has successfully improved patient care, with a 7% drop in the chance of death and readmission and a 3% reduction in length of stay for every one less patient a nurse has on their workload. These reductions resulted in the cost savings.

The study compared 27 hospitals where the policy was implemented with 28 hospitals where it wasn’t.

“Despite some evidence that more nurses in hospitals could benefit patient safety, similar policies have not been widely implemented across the globe, partly due to an absence of data on the long-term effects and costs, as well as limited resources,” the study authors said.

“Our findings plug a crucial data gap that has delayed a widespread roll-out of nurse staffing mandates. Opponents of these policies often raise concerns that there is no clear evaluation of policy, so we hope that our data convince people of the need for minimum nurse-to-patient ratios by clearly demonstrating that quality nursing is vital to patient safety and care,” said Professor Matthew McHugh of the University of the Pennsylvania School of Nursing in the US and lead author of the study.

Similar in South Africa?

While we are not aware of similar research in South Africa, it seems plausible that meeting minimum nursing ratios here too could result in substantial cost savings — through fewer readmissions and shorter hospital stays as observed in Australia, but potentially also by reducing the number of medico-legal claims against the government.

“Nurses offer a comprehensive service package in preventing diseases, promoting health, curing diseases and rehabilitative services. Healthcare cost will therefore be greatly reduced if more nurses were employed, especially with revitalisation of primary healthcare and strengthening of community-based healthcare services,” says Khaya Xaba, spokesperson for the National Education, Health and Allied Workers’ Union (Nehawu). He said staff shortages in the nursing profession directly and negatively affected the quality of nursing care and the delivery of quality healthcare to patients.

Rich Sicina, a paediatric nurse and general secretary of the Young Nurses Indaba Trade Union, agrees that readmissions are an avoidable problem.

“Where I work, it’s like they take turns to use the bed, two weeks in and two weeks out. Patients are in and out because we can’t look after them thoroughly. Patients are discharged not because they are better, but they have to open space for the next patient who is worse at that time. The system now forces nurses to choose who will be given more care and who will not. With this kind of care, we can only see more and more readmissions. All this can be avoided if there were more nurses,” he says, adding that most nurses know deep down that most of the deaths could be avoided if there were more of them.

The big picture

That the world needs more nurses is not news. In its State of the World’s Nursing report, the World Health Organization (WHO) estimated there was a global shortage of 5.9 million in 2018, a slight improvement from 6.6 million in 2016.

In South Africa, according to the 2030 Human Resources for Health Strategy, there were 71,707 professional nurses, 31,039 enrolled nurses and 33,821 nursing assistants by 2019. The combined density was 282 per 100,000. A South African Nursing Council report shows a slight decrease in the number of nurses in 2020.

According to the South African Nursing Council, in 2020 there was one nurse (registered, enrolled or auxiliary) for every 213 people in the country in the public and private sectors — a far cry from Australia’s one nurse for every four patients per shift. The pressures are especially high in the Northern Cape, with one nurse for every 350 people, and Mpumalanga, with one nurse for every 313 people. See a further breakdown here.

Melanie Alperstein, steering committee member of the People’s Health Movement, says it has been well established that the number of nurses is way below what is needed. This, she says, affects the work to be done since nurses are overloaded.

“Mistakes may be made. It is difficult to be caring and compassionate, and nursing care cannot be at the standard that nurses would like. Anxiety increases and affects the mental wellbeing of the nurses due to overload and not being able to practise in the way [needed] to meet patients’ safety and needs,” she says.

“Health budget cuts are one aspect outside of the profession and affect the number of all health workers needed for the country to be at an optimal level. Posts are frozen and qualified nurses are sitting at home without work. An example of this was the extra nurses employed in the Eastern Cape [temporarily] during Covid-19. There are more qualified nurses who could be employed, but budget cuts and possible bureaucracy have prevented this,” Alperstein says.

Factors that need attention relate to policy, leadership, education, systemic fault lines within the health system such as stockouts of supplies, crumbling and inadequate infrastructure and therefore poor working conditions, as well as low pay, she adds.

‘Silent moratorium’

Democratic Nursing Organisation of South Africa spokesperson Sibongiseni Delihlazo says the number of nurses in the country’s healthcare system is extremely low. He says the vacancy rate is extremely high and, worse, even the funded positions are no longer filled as a way for the government to reduce the “so-called bloated public sector wage bill”, which includes health.

“Contributing to non-filling of vacant posts is the silent moratorium in provinces [on] filling vacant positions. This is costing the healthcare system severely because it lowers its effectiveness in fighting community infections and illnesses. It also leads to work overload and staff burnout, depression and anxiety among healthcare workers who are overworked,” he says.

Delihlazo fears this was the case even before the Covid-19 pandemic.

“Fortunately for the country, there are still nurses available for employment, who are sitting at home and not willing to go abroad like others. These are nurses who, mostly, have been funded by the government for their studies. But they are never employed, and the government would have wasted its own investment in human resources because over time they would have to let them go find work elsewhere.”

The Young Nurses Indaba Trade Union’s Sicina says there is a gross shortage of staff. Where he works he is the only professional nurse. With an enrolled nurse and two enrolled nurse assistants “, we look after about 45 kids in a ward at each given time. Ideally, we should be 12. Imagine the chaos in the hospital because there are gross shortages of staff. Nurses have to make sure that those that go to theatre are ready for theatre, those that need a scan are ready for a scan, and those that need drips [have them] inserted. But we can’t do it all. Because the number of patients outnumbers the nurses. There are mistakes made and some people die because a nurse noticed the dropping of all vital signs late [because] he or she was busy giving medication to other patients or preparing another patient for a procedure. When you see there is something wrong with another patient, it is too late to do anything.”

Change of curriculum

Nehawu’s Xaba says the change in the nursing curriculum informed by the phasing out of legacy nursing programmes and introduction of new nursing qualifications has resulted in almost six years during which new nurses have not been produced.

“Producing fewer specialised nurses results in fewer skilled nursing professionals to respond adequately to health needs. Also, the accreditation of nursing education institutions has been a rather slow process and few nursing colleges have been able to provide new training programmes,” he says.

Sicina echoes this, adding that with an intake of about 200 students annually across all the colleges in Gauteng, there is no way the country will be able to produce enough nurses.

“The change of the curriculum has messed up things. What is an intake of 200 students for all the colleges? Even if that is the intake number, it doesn’t mean all 200 will graduate. Nursing is tough and most of the students study while working and it becomes too much and they drop out. Even worse, with this new curriculum, universities are not taking in students because they can’t teach this new curriculum. We need to increase the intake and produce more nurses,” he says, adding that with his intake in 2009, 356 students started the course, but fewer than 200 graduated because, although many fell in love with the profession, the real work was tough.

The South African Nursing Council had not responded to questions from Spotlight by the time of publication. However, in a statement, Sizo Mchunu, council registrar and CEO, said: “As the statutory body, the [council] is committed to assist in ensuring the production of competent nurse practitioners who will provide scientific, comprehensive and quality nursing to patients, families and communities within the legal and ethical framework. It is vital that the country trains enough nurse practitioners to replace those retiring so that the country continues to deliver quality care.”

During the council’s presentation at the National Health Insurance public hearings in Parliament last week, when pressed about nursing shortages, Mchunu reminded MPs that the council is not an employer, but can support the government. The council was doing important legwork in raising awareness and providing information on nursing as a profession.

Do more to produce more

The Democratic Nursing Organisation’s Delihlazo says the capacity of universities and colleges should be increased to ensure the country produces enough nurses. “The WHO together with the International Council of Nurses last year on 7 April released a report on State of World Nursing where it indicated that for every country to avoid crisis levels in terms of a severe shortage of nurses by 2030, each country must increase the intake of its nursing production each year by at least 8%. If not, the world is likely to experience a global shortage of 10 million nurses by 2030. South Africa is not going according to this advice — in fact, it is going completely against it.”

Nehawu’s Xaba says the inability to provide mentorship to nursing students affects the quality of nursing cadres being produced. 

“[There is] inequitable skills distribution because the training of nurses has also been reduced as a result of staffing shortages. Nurses are overburdened due to increased workloads contributing to negligence, high absenteeism and low staff morale. This results in suboptimal care rendered to patients and clients and high litigation rates which impact on the scarce budget currently allocated to the health sector.”

Alperstein, of the People’s Health Movement, concludes by saying nurses are not given respect and appreciation for the work they do. 

“Transforming nursing education has not been given the resources and urgency it needs in comparison with medical education transformation. Both medical and nursing education still focus on disease and illness, instead of how to deliver a comprehensive primary healthcare service through interdisciplinary health teams and intersectoral collaboration within communities with community structures, to deal with the social determinants of health that cause the increased burden of disease in the first place,” she says. DM/MC

This article was produced by Spotlight — health journalism in the public interest.

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