CHAPTER 2 LITERATURE REVIEW
Chapter 1 provided the rationale for this study, the history of public health service delivery (PHSD) in the Republic of South Africa (RSA), a map of the different service areas in the Tshwane Metropolitan area and the background to the practice of nursing in the public health sector (PHS). This chapter discusses the literature review on discontent among registered nurses (RNs) in the PHS. The literature review covered national and international issues including transformation of health care services; management and leadership problems; career development; registered nurses as medical assistants; workplace violence; stress; registered nurses and international migration; registered nurses and unions; the Occupational Specific Dispensation (OSD) for nurses, and nurses and politics.
In the South African society, public health issues and discontent among RNs in the PHS are political issues because health care services (HCS) form the largest part of social services. The success of HCS is dependant on national and provincial legislative competency because HCS derive their finances directly from government through nationally collected general taxes and other revenues. As a result, they are issues often included in political debates, which sometimes do not promote objective, clarifying discourse.
Among other variables, international migration and unionization of the PHS are considered RNs‟ constitutional rights in the RSA (South Africa 1996:10). This would then seem to indicate that these privileges should also be exercised in moderation, since only when nurse migration is influenced by personal interests other than the existence of „push factors‟ from the PHS, can discontent be ruled out. For this reason, the researcher examined whether nurse migration and unionization of the PHS among other things, had gone beyond merely exercising constitutional rights to becoming national problems that could signify the existence of discontent among RNs in the PHS.
As a general principle, RNs are obliged under the following policies and laws not to abandon their patients:
Their ethical code with regard to care of the patients Patients‟ Rights Charter
South African Nursing Council‟s (SANC) rules on the acts and omissions of RNs in the Nursing Act, 33 of 2005
The 1997 Batho Pele White Paper on Public Service Delivery The Labour Relations Act (LRA), 66 of 1995 The National Health Bill
TRANSFORMATION OF HEALTH CARE SERVICES
The process of restructuring HCS to ensure equity in resource allocation, with decentralized management and local accountability in the provision of high quality care, had a significant impact on the South African health care system (ANC 1994; Department of Health [DOH] 2001). The government‟s aim was to build a unitary but decentralized national health system in which the centre and the periphery work together to ensure efficiency and equity with the delivery of health care (DOH 1997a). In addition, the Batho Pele White Paper on transforming public service delivery introduced an approach that puts pressure on “systems, procedures, attitudes and behaviour” to put customers first in public service (South Africa 1997c:12). These policies promote relationships that foster unity, efficiency and coherence between management in HCS, employees and the community in order to attain the goals of a progressive and effective health care system.
The South African health care system has competent, committed and highly skilled health care professionals, who have made significant contributions to the transformation of HCS in the PHS (Sait 2001:5). At the same time, however, national and global factors negatively impacted policy implementation in the RSA, immediately after 1994 when the RSA was undergoing transformational changes. Opportunities for alternative vocations or incomes became available to most health professionals, particularly RNs with different specialties in nursing. Consequently, significant numbers of RNs migrated from the PHS to the private sector, laboratory services, case management and abroad.
To counteract international migration, the Gauteng Department of Health (GDOH) introduced an Exchange Programme for South African RNs with Kings College Hospital in London in 2001. The main objective of this venture was to provide RNs with the opportunity to learn new skills, with specific reference to areas of specialty in which the South African HCS was deficient. It was hoped that this would allow them to return at the end of the contract to plough back into the country (Gauteng DOH 2002; Kingma 2006:135). To follow up on this endeavour, the South African Health Minister and her British counterpart sought ways to combat poaching of health professionals by the British HCS from developing countries, including the RSA. They further explored ways on how to strengthen the International Code of Practice on Ethical Recruitment of Health Workers, which provides guidelines for the international recruitment of health workers by considering the potential impact of recruitment on health services in the source country. This was revealed in a media address after deliberations that took place in the „SA/UK‟ Bilateral Forum in Parliament in 2004 (Kingma 2006:126-127; Pretorius 2004).
The following discussions highlight developments in other countries, issues and problems surrounding RNs, strategies followed in the restructuring processes, how they handle nursing workforce shortages, and how legislation affected RNs positively or negatively in their endeavour to find better places of employment.
Restructuring initiatives in the United Kingdom (UK)
In the UK, health professionals were at some stage emotionally drained by restructuring initiatives and daunting top-down instructions, which were thought to undermine nurses‟ value and self-worth (Doult & Scott 2007:6). These authors further indicate that Prime Minister Gordon Brown took a bold step when he committed to giving nurses an opportunity for major contributions to strategic planning for the National Health Service (NHS) in order to enhance their professionalism. The main purpose for this move was to solicit nurse‟s opinions regarding salaries, entitlements and conditions of service, among other issues (Doult 2007:9). This was intended to bring a period of stability among health professionals so that they would spend more time with patients, be empowered, their professionalism respected and they would have a major say in how the NHS should develop (Doult & Scott 2007:1). These promises were later followed by his appointment of Ann Keen, a registered nurse, as Minister of Health (Snow 2008:12-13).
Regarding aspects of foreign policy, the British Health Minister fortified the International Code of Practice on Ethical Recruitment of Health Workers by signing a memorandum of understanding with the Minister of Health in 2004 in the RSA. Among other things, it was agreed that Britain would not expand the NHS by taking advantage of South Africa and other developing countries, and that they would use bi-literal agreements with countries of high volume and impact. This bi-lateral agreement was a commitment to create education and practice opportunities within the NHS for South African health professionals for specific periods. Furthermore, failure to comply with the Code would cause ties with recruiting agencies to be severed, particularly regarding health professionals targeted for private hospitals in Britain (Aiken, Buchan, Sochalski, Nichols & Powell 2004:69; Health Services Union (HSU) 2007: 6; Kingma 2006:126-127; Pretorius 2004). However, this decision was short-lived in that two years later, the level of recruitment from South Africa once again increased tremendously (Kingma 2006:131).
In the Philippines, the export of nurses to developed countries has been practised for years with government sanction because overseas employment is a key source of economic growth. The Philippines trains nurses in order to post them to developed countries as an attempt to boost the country‟s economy with wages that are regularly sent home to family members. This factor therefore makes the Philippines the largest source country. To enhance this effort, the Philippine government has established protective government offices in countries where most Filipino migrant workers are located, as an attempt to service these workers in their destination countries. On the other hand, what makes the pattern of migration of the Philippine nurses unique is that once they have settled abroad, they bring their families, parents and siblings for permanent citizenship, consequently leaving serious staff shortages in their HCS (Kingma 2006:203).
In contrast, the International Council of Nurses‟ (ICN) position regarding migration is that quality health care has a direct link to adequate supply of suitably qualified and committed nursing personnel in all countries (ICN 2007). While the ICN recognizes the right of individual nurses to migrate and the potential benefits derived from nurse migration, it also acknowledges the adverse effects that could be imposed by international migration on HCS in the source countries, which are usually immensely depleted of their nursing workforce. At the same time discontent with low salaries and staff shortages could possibly be largely responsible for nurse migration. Because the Filipino nurses‟ education provides them a college degree with good communication skills and English proficiency, there is a great demand for nurses from the Philippines around the world. Saudi Arabia, the UK, Ireland, the USA and Singapore are the common „receiving‟ countries that benefit from the Philippines development plan (Aiken et al 2004:69).
Less developed countries like China, India, and some of the newly independent States of the former Soviet Union aspired to follow the Philippines example of training nurses to export them to developed countries, but were restricted by limitations to provide suitable infrastructure for nursing education consistent with world standards (Aiken et al 2004:75).
The Kingdom of Saudi Arabia (SA)
Mufti (2000:37-38) examined HCS in the kingdom of Saudi Arabia and found that the country was completely dependent on foreign human resources. Hospitals mushroomed due to increased wealth from oil revenues, which was devoted to development of the country. The huge expansion in health facilities and services placed great pressure on health planners to deal with staffing matters by recruiting foreign personnel from different parts of the world. This shortage of nurses and health personnel was a major concern for health authorities, who were devoted to the process of Saudisation of human resources within the kingdom. Since Saudisation was a long-term process, tentative measures had to be put in place to run the services. Concomitantly, the number of physicians, nurses and allied health personnel increased tremendously, especially with regard to high technology facilities within the kingdom. This increase was reportedly comparable to developed countries, which revealed progress made within the kingdom (Kingma 2006:107; Mufti 2000:36-37). In order to keep RNs on the cutting edge of nursing practice, continuing education as a tool of human resources planning and development was instituted with annual recertification of RNs in their specific fields of specialty. This practice was consistent with the recommendations of the ICN (2007) that opportunities be made available for nurses to access programmes that ensure competence, advancement, skill and high level of knowledge that guarantees the provision of quality care.
CHAPTER 1 OVERVIEW OF THE STUDY
1.2 Parameters of the study
1.3 Background information
1.4 Purpose of the study
1.5 Research questions
1.6 Research objectives
1.7 Significance of the study
1.8 Problem statement
1.9 Thesis statement
1.10 Research methods
1.11 Definition of concepts
1.12 Outline of the thesis
CHAPTER 2 LITERATURE REVIEW
2.2 Transformation of health care services
2.3 Management and leadership problems in nursing
2.4 Career development
2.5 Registered nurses as medical assistants: an extended role
2.6 Workplace violence
2.8 Registered nurses and international migration
2.9 Registered nurses and unions
2.10 The occupational specific dispensation
2.11 Nurses and politics
CHAPTER 3 THEORETICAL FRAMEWORK
3.2 General Systems Theory
3.3 Components of a health care system
3.4 Input-process-output-feedback of the system
3.5 Activities within the organization
CHAPTER 4 RESEARCH DESIGN AND METHODOLOGY
4.2 Purpose of the study
4.3 Research design
4.4 Triangulation of the qualitative and quantitative methods
4.5 Descriptive and exploratory
4.6 Data collection
4.9 Sample and sample size
4.10 Pilot study
4.14 Data management and analysis
4.15 Ethical considerations
CHAPTER 5 DATA ANALYSIS AND INTERPRETATION OF RESEARCH FINDINGS
5.2 District hospital “A”
5.3 District hospital “B”
5.4 District hospital “C”
5.5 A comparison of the hospitals in the district cluster
5.6.1 Quantitative data analysis for regional hospital
5.7 Academic hospital
5.8 Private hospital
5.10 Individual and focus group interviews
CHAPTER 6 FINDINGS, CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS
6.2 Discussion and synthesis of the main findings
6.3 Authenticity of collected data
6.4 Conclusions drawn on findings
6.5 Limitations of the study
6.6 Areas for further research
7. List of Sources
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