Organisation, strengths and difficulties of South African intensive care nursing
Article Outline
This editorial will describe the organisation, strengths and difficulties of South African Intensive Care Nursing. In South Africa, health care services are pluralistic comprising a public sector and well developed private sector. Public sector hospitals consist of three types of hospitals, primary, secondary and tertiary hospitals. There are intensive care units (ICUs) in public sector secondary hospitals, however, mainly tertiary hospitals and private sector hospitals. The majority of these ICUs are managed on the ‘open intensive care unit’ principle by medical specialists, such as anaesthesiologists, physicians, surgeon and others, as there are few accredited intensivists (Scribante et al., 2004). Registered nurses provide the majority of care in the ICUs, although only 25% are registered intensive care nurses. There are no nationally prescribed nurse ratios, however, nurse to patient ratios are usually one nurse to one patient in public sector tertiary hospitals and private hospitals, but may vary to mean one nurse to two or even three patients in some ICUs. South Africa is currently facing an acute crisis of a shortage of registered intensive care nurses, which in part can be explained by attrition of these nurses to more lucrative employment opportunities out of nursing or abroad.
Intensive care nursing was established as an official nursing training programme in 1966. In order to place South African intensive care nursing into the context of the international community a brief overview of the organisation of nursing will be provided. In South Africa, there are three categories of nurses; registered nurses, enrolled (staff) nurses and enrolled nurse auxiliaries (assistants). In addition, there are many post registration qualifications for registered nurses in specialised clinical and non-clinical categories. Intensive care nursing falls into one such category. As the statutory body for nursing, the South African Nursing Council defines both, the professional, ethical and legal responsibilities of all nurses, as well as the regulation for the post registration qualifications. There is no specific scope of practice for registered nurses who hold additional qualifications they are, however, expected to provide a higher quality of care than can be expected from a nurse who does not hold the qualification. Intensive care nursing programmes are conducted either on diploma or graduate degree level by public and private colleges and university departments of nursing. The duration of training varies from one year for the diploma course and two years for a graduate degree.
A number of positive aspects may be derived from the South African intensive care nursing situation. There are well-established infrastructures for clinical practice and training that have been tested and developed over time. This has lead to good collegial relationships between colleagues from training institutions and clinical settings. More recently, the shift of nursing into higher education has resulted in the development of national standards for training by the South African Nursing Council. The twin tracking of training programmes as a diploma or graduate degree option provides not only for, ongoing availability of registered intensive care nurses, but also the growing body of intensive care nursing research. Ten university nursing programmes are focused on nursing scholarship and offer graduate higher degree programmes. The Critical Care Society of Southern Africa has guided the development of intensive care nursing in the past, and continues to provide intensive care nurses with an important multidisciplinary platform to voice their concerns. The Society now has four intensive care nurses on its National Council and recently co-hosted the 4th World Federation Critical Care Nursing Congress in South Africa.
The most significant difficulties for intensive care nursing in South Africa are related to the shortages of registered intensive care nurses. This has lead to an increasing reliance on registered comprehensive (general) nurses and newly qualified nurses, particularly in tertiary hospitals, in order to maintain service delivery. Scribante et al. (2004) reported 53% of all nurses working in South African ICUs, are registered comprehensive nurses. These nurses undertake a four-year training programme leading to simultaneous registration in general nursing, psychiatry, midwifery and community health. Based on the comprehensive nature of the programme and focus on primary care these nurses do not have an orientation towards intensive care nursing or critically ill patients. A number of international studies (Ball and McElligott, 2003, Dang et al., 2002) have consistently shown a lack of appropriate nursing skills are associated with an increased risk to patients. No empirical studies to-date have been published on the effect of altering the composition of the nursing ICU team or the effect that this might have on the practices of registered intensive care nurses. Severity of illness is of concern as HIV/AIDS affects a large portion of the population, thus increasing the risk for sepsis in immuno-compromised patients. High levels of violence, motor vehicle accidents and multiple trauma, adds to severity of illness and complexity of care in our situation.
Due to the ongoing shortage of registered intensive care nurses coupled with cost constraints, plans are already underway for the placement of more readily available enrolled nurses in the ICUs. Scribante et al. (2004) reported 21% of all nurses working in ICUs are enrolled nurses. The potential role of the enrolled nurse lacks clarity within the high intensity and high complex environment of ICU. Enrolled nurses have a restrictive scope of practice and are often expected to assume responsibilities that are far beyond their scope of practice in clinical settings. Intensive care nurses are increasingly voicing their concern over the use of enrolled nurses and the roles and tasks they undertake. However, there is a need for empirical studies on which to base important decisions and future directions. This situation is probably one of the biggest challenges currently facing South African intensive care nursing.
Despite these difficulties intensive care nurses remain positive and view change as a creative opportunity to test new directions. This has lead to a heightened awareness and an increasing need to support each other in the pursuit of quality of care. Recent strategies by intensive care nurses, under the auspices of the Critical Care Society of Southern Africa has lead to the development of a national nursing forum. A national database of research studies undertaken on graduate level has also been created. A recent publication (Scribante and Bhagwanjee, 2006) reported that intensive care nurses are undertaking research, but to-date only 15.6% have been published. Moreover, only 18% of all projects were presented at national and international congresses. These results are of concern as failure to disseminate research findings detract from the value of graduate work. Research studies are largely undertaken for personal achievement of a higher degree and perhaps not necessarily designed to find solutions to common everyday problems. Although nursing scholarship is highly revered in South Africa, funding opportunities for nurses are minimal or non-existent. Intensive care nurses in South Africa are more highly committed than ever before, actively seeking opportunity to engage in discussion with organisational management and policy makers, to find the best possible solutions to their current problems.
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PII: S0964-3397(07)00076-6
doi:10.1016/j.iccn.2007.07.001
© 2007 Published by Elsevier Inc.
