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19 June 2001

This report replaces the interim report submitted to DENOSA on 23 March 2001 Written by Jantjie Xaba and Gary Phillips


0 0 0 0 0 0 0 Introduction Methodology and comments on the research Existing measures of nurse emigration Profile of nurses who are emigrating Reasons given by nurses for emigrating Impact of nurse emigration Conclusions and recommendations

Introduction DENOSA commissioned TURP to investigate the extent of nurse emigration and to suggest why this is happening. This report draws out the findings of the research conducted by TURP, and also uses information from newspaper reports. The report covers the extent of the problem as well as considering why nurses are leaving.

Methodology and comments on the research

This research was designed around using DENOSA elected members in the research. This is an approach often used with research for labour organisations. A sample of 100 institutions was drawn up where DENOSA had elected members. These elected members were contacted and supplied with two questionnaires. The first questionnaire was to be directed at the institution and the elected member had to submit this to their employer. The second questionnaire was directed at nurses who planned to emigrate and questioned them on their reasons. The research also consisted of two other legs. The first was to gather official and other statistics that estimated the extent of nurse emigration. TURP made use of statistics from the Department of Health, Department of Home Affairs and the South African Nursing Council (SANC). The second leg included interviewing nurses who had already emigrated.

The study proved very difficult to complete and even with the assistance of DENOSA head office, few questionnaires were returned. In summary, the responses received included: Questionnaire for institutions Planned I Actual 100 T 29 Questionnaire for nurses considerim: emiaration Planned Actual

100 10

Interviewwith nurses who have alreadv emiarated Planned Actual

20 16

The lack of responses obviously weakened the research results. This is unfortunate but did not arise as a lack of effort on the parts of TURP or the DENOSA head office. Despite the problems experienced in gathering the information, the findings do include some useful and insightful information for which the organisation can draw conclusions. Existing measures of calculating nurse emigration The existing measures used to calculate number of nurses leaving South Africa are sensationalised by the media, fragmented, and generally not reliable. This makes it difficult to assess the extent of the problem. Currently, there are three official methods used to calculate the extent of nurse emigration. These include those used by SANC, the Department of Health and the Department of Home Affairs. Official statistics used by the British government (quoted in the London Sunday Times) contradicts these figures released by the South African government (this will be shown below). This is obviously cause for concern and makes it difficult to know exactly how large the problem is. A conclusion that can be drawn, however, is that the government is undercounting the number of nurses who are emigrating. The discussion below analyses the official statistics used in South Africa to measure nurse emigration. 1. SANC calculates nurse emigration from statistics of nurses that apply for verification of their qualifications. Nurses do this when they are planning to apply for overseas employment. Therefore, this information shows only how many nurses plan to leave South Africa each year and it cannot show how many applications have been approved or where nurses intend to go. Below, is a table indicating statistics of nurses that have submitted their application to SANC from 1991 to 2000.

Year 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Number of applications for verification of Qualifications 455 578 595 547 511 957 1359 1746 3672 2543 Percentage change year on year 27.0% 2.9% -8.1% -6.6% 87.3% 42.0% 28.5% 110.3%

- 30.7%

What the figures do show is that over the ten years from 1991 to 2000, is that applications for verification of qualifications have increased by 458.9%. This would suggest that at least the interest in emigration has significantly increased over the past decade. 2. The Department of Health relies on SANC statistics and agrees with the Council about nurse emigration. In addition, however, the Department of Health also uses on the October Household Survey conducted annually by Statistics South Africa (StatsSA). StatsSA requested the Department of Home Affairs to leave questionnaires at airports to be filled by South Africans leaving the country. Such a method is likely to release inaccurate figures. Firstly, migrants are classified in terms of occupation and not specific job; thus it cannot be known how many nurses specifically have left the country. Secondly, since nurses are not compelled to fill those questionnaires, it is likely to report only a small number of nurses leaving. (See appendix for the latest information on nurse emigration from the StatsSA.) See below figures of nurse emigration from Department of Health. The latest figures are the 1999 (figures for 2000 were not yet released by the time of writing the report).

Year Male nurses who have emigrated Number 1995 1996 1997 1998 1999 5-vear total 7 10 1 5 6 29 Percentagechange, year on year 42.9% - 90.0% 400.0% 20.0% Female nurses who have emiarated Number Percentagechange, year on year 85 114 34.1% 100 - 14.0% 128 28.0% 111 - 13.3% 538

Taking these figures together with the SANC figures, it would suggest that in 1995 only 18% of nurses who applied for verification of qualifications actually emigrated. For 1996, this figure is 13%. This figure continues to decline to 7.4% for 1997, 7.6% for 1998 and 6.7% for 1999. This means that there are a large percentage of nurses in the country who are ready to go but have not left. The Department of Home Affairs, however, has released contradictory figures as is shown below. 3. The Department of Home Affairs provides statistics about nurses emigrating to foreign countries and those immigrating into South Africa.

YEAR 1997 1998 1999 TOTAL Emigrated 101 103 177 411 TOTAL Immiarated 10 10 1 21


In shocking contrast to the above figures, British government figures quoted in the London Sunday Times reveal that 1 640 nurses came from South Africa to work in Britain for the year 2000 alone.

ProfIles of nurses who are emigrating

Of the 29 medical institutions that participated the study, the majority of them (about 38%) were public hospitals. The rest of the breakdown is indicated below:







"E :::J 0 U

0 Public hospital Public clinic Academic hospital Private clinic Private hospital Community hospital Education instittuti

Type of institution

The high incidence of response from educational institutions is unfortunate because their experience of nurse emigration is different to other medical institutions. In fact, one educational institution reported that they saw the emigration as a credit to their institution that their students' qualifications were internationally recognised. On the negative side, loss of staff to international destinations was a problem to these institutions so there was some benefit to interviewing them. From this sample, we identified that a total of 273 nurses have left employment there to seek work overseas. A breakdown of the jobs these nurses were in reveals that it is mainly the skilled practitioners that are emigrating:

Level Chief NursinaServicesManaaer SeniorNursina ServicesManaaer NursinaServices Manaaer

Chief Professional Nurse Senior Professional Nurse Professional Nurse Senior Staff Nurse Staff Nurse Senior Nursina Assistant Nursina Assistant

Number who have emiarated 0

Percentageof total in sample



35 29 207 1 0 0 1


12.8% 10.6% 75.8% 0.4%



There were too few responsesto assesswhether more the nurses are leaving from public institutions than private institutions.

In most of the cases (58.6%) where institutions had lost staff to emigration, the nurses had left for the United Kingdom. The second most popular destination revealed by the survey was Saudi Arabia (41.4% of the institutions interviewed reported that nurses from their institution had emigrated to Saudi Arabia). Other popular destinations included New Zealand (24.1% of the institutions reported this), Australia (20.7% of institutions) and the USA (10.3% of institutions ).1 In minor cases, the institutions also reported nurses emigrating to the Seychelles, Portugal, Dubai, Israel and ocean liners. Reasons given by nurses for emigrating The responses given by nurses interviewed can be grouped into the following categories. They include: 0 Lack of competitive incentives in the public service. The nurses contacted by TURP stated that they were leaving South Africa because foreign countries offer better remuneration than South Africa. Moreover, some nurses felt that benefits such as overtime and night duty allowances are not adequately provided in South African hospitals. Work pressure. From the TURP research, nurses also complained that South African hospitals have long working shifts (ordinary hours), hospitals are poorly resourced, and the nurse to patient ratio in South Africa is very high. In 1998, according to SANC's estimates of population per qualified nurse, one nurse in South Africa was responsible for 243 patients. This number increased in 1999 to 253 per one nurse2. One respondent that left for Britain said that the nurse to patient ratio there is 1.1. Nurses therefore do not feel distressed by this patient load compared to South Africa. Even though nurses have been leaving, some hospitals it appears have slow to replace those nurses - the result is staff shortage. In the light of above, the remaining nurses feel severe pressure and often complain about 'burn-out', stress, exhaustion and failure to function effectively in their families.


1Naturally the figures won't add up to 100% since some institutions would have lost staff to more than one international destination.


SANC 1998/1999. Geographical distribution of the population of South Africa versus nursing manpower.


Some nurses feel that there is little space for them to grow in their profession in South Africa. Firstly, respondents complained about lack of opportunities for promotion/upward mobility in hospitals. Secondly, they stated that it was not easy for nurses in South Africa to get study leave. This factor is compounded by the fact that nursing education is not subsidised. In Saudi Arabia in the Middle-East, they claimed, education and health services are free. This provides an opportunity for nurses with families to emigrate and make living there. This would also explain why it is the skilled band of professional nurses who make up most of nurses are emigrating. Nurses are looking for better resourced working environments. Some respondents from the research said part of the reason they left South Africa was to accumulate more experience by working at highly resourced hospitals in a highly educated environment with sophisticated equipment. Through such learning, they think that they will be well positioned to improve nursing care in South Africa. Escalating crime and rise of mv IAids in South Africa. Some nurses felt that their safety was compromised at hospitals when they gave care to criminals, and that little was done to protect them from potential harm. The research also found that overcrowding in hospitals with HIV/Aids patients, and the spread of the infection in South Africa are factors contributing to nurses' emigration to other countries.



Impact of nurse emigration In most cases, nurses who remained behind after others had emigrated were impacted in two ways: 0 0 They felt envious or demotivated by the emigration - frustrated both by seeing others go overseas and the fact that they were remaining behind; and, Increased work stress from having to cover for the missing nurses, this was particularly in the case of public institutions where it is very difficult to employ new nurses. Issues of overtime and other benefits are also raised as concerns here.

Another big impact on remaining nurses was that they felt that there was an increased mismatch between their pay and their work after emigration of nurses. Some institutions believed that nurses who emigrated also pulled others into emigration by their stories of improved working lives. The gap in skills left by the emigrating nurses was an added frustration. The key impact on the institutions according to the survey was 0 0 the loss of skills (and therefore the loss of quality service); and, increased staff shortages that were difficult to solve.

The administrative and cost burden on institutions in terms of recruiting and selecting nurses to replace those who had left was another major impact on institutions. In fact, 60% of the institutions surveyed felt that it was difficult to replace nurses who have left.

- .~.......

When nurses leave, there are some shortages in hospitals that must be filled by the government. However, the shortage of staff is not only a result of nurse emigration. Nurses continue to leave the profession for other reasons than emigration. According to the Department of Health, there were 1006 nurses in 2000 that left the public service. This is a problem since the number of nurses enrolling is virtually stagnant while the number of nurses being trained is declining as shown below by figures from SANC:

Year 1998 1999

Population estimate 42 130000 43 053000

Nurses Registered 91011 92390

Enrolled 32744 32925

Students trained 11289 10398

Secondly, although nurse emigration has been a feature as early as 1991 as evidence given above in the report shows, the implementation of voluntary severance packages in 1995 by the government increased the movement of nurses.

Conclusions and recommendations

The emigration of nurses appears to be a symptom of stresses and strains experienced by the South African health care sector. The transformation of health care provision is a complex and difficult task which appears to be frustrating the professional aspirations of a critical band of nurses - skilled professional nurses. While there is great effort to tackle the problems associated with health care provision and health care services in South Africa, attention also needs to be given to the problem of nurse emigration. Attention should be given to: 0 Developing accurate measures for assessing the extent and nature of nurse emigration. StatsSA should be commissioned to do a sectoral study on this issue and assess ways to improve statistics on nurse emigration. The impact of nurse emigration on remaining nurses and nursing services provision needs to be softened. It appears from the survey that this can done in two ways: providing overtime pay and other benefits that cater for the increased workload and stress associated with nurse emigration; and, unblocking government processes (for example, unfreezing posts) to replace nurses who have emigrated more speedily. Improving skills development, particularly with regards to producing greater numbers of skilled professional nurses. The Health and Welfare SETA needs to be strongly tackled on this issue. The exodus of skills appears to be greater than the supply of skills and this situation urgently needs to be addressed.




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