THE PRIVATE SECTOR CONTRIBUTION TO NURSING EDUCATION ( 1990 – 2010 )

The purpose of this article is to describe the contribution of private hospital groups and individuals to the education and training of nurses in South Africa over the last 20 years. The sector has two major components: the private hospital groups and the individual entrepreneurs, and these are described separately. In total, the sector concentrates on non-professional categories and produces 68% of Enrolled Nurses, 82% of Enrolled Nursing Assistants and 48% of Bridging Students. The three private hospital groups train primarily for their own needs and continually try to improve quality through innovations such as introducing Continuing Professional Development. Their challenges include a lack of clarity from the regulator, and staffing. The 41 members of the association for entrepreneurial providers train for the market-place and are involved in communities to a limited extent. They face the same challenges as the rest of the sector. The private sector should be seen as a strategic partner in the quest to meet the demand for qualified nursing staff. Looking at the future of the nursing profession and the demand for nurses successfully to implement the National Health Insurance, the contribution by the independent nursing education institutions cannot be ignored.


Introduction
Private sector nursing education consists of two major components: hospital-group-based nursing education and the entrepreneurial endeavours of individuals.The three major hospital groups embarked on formal nurse training as a solution to the critical shortage of nurses.The training institutions have been in existence for the last twenty-five years.Life Healthcare, Mediclinic and Netcare are private hospital groups with a national footprint and each have a nursing college with decentralized learning centres or campuses.Each learning centre operates as an independent nursing education institution with centralized management and academic structures.The Gold Mining Industry has also been involved in the training of nurses since 1946.Today, the Gold Fields Nursing College is still training nurses to meet the demand for nurses, not only in the mining industry, but also in the country at large.Private nursing education is also provided by independent nursing education institutions where it is not hospital-based.

Size and activities of this sector
The nursing education activities of the private sector are focused mainly on non-professional training and, in the case of the hospital groups, also on post-basic education.Table 4.1 summarises the contribution of private schools to the production of three categories of nurses, and this varies between 48 and 82%.The private hospital groups All three hospital group nursing education institutions are accredited by the S.A. Nursing Council (SANC) to offer basic and post basic nursing programmes and are registered with the Department of Higher Education as private providers.Both Life Healthcare and Mediclinic offer programmes that have been accredited by the Council for Higher Education, while Netcare is in the candidacy phase of the same accreditation.Most of them have registered a single college, but have multiple campuses in different provinces.
Students are trained according to the need of the respective hospital groups, and the need for specialist training is seen as a priority.All three groups also sponsor students undertaking undergraduate and postgraduate studies at the various universities.The student numbers are allocated to the hospital groups by the SA Nursing Council, based on clinical learning opportunities available in their respective hospitals and additional learning opportunities in public sector institutions.

Staffing
Recruiting and appointing suitably qualified nurse educators remains a challenge for the private sector groups.They compete with the salaries offered by the public sector and the academic benefits of working in the universities.Nurse educators in the private sector are performance managed and are less dependent on administrative staff due to many of their processes being automated.
Limited administrative staff are therefore employed, making nurse educators responsible for their academic-related administrative duties.On the positive side, much emphasis is placed on leadership and development of nurse educators, with specific programmes being designed to allow nurses involved in education to pursue a career path both in clinical areas as well as in the college.
There is also the availability of training and development consultants, clinical facilitators, preceptors or clinical training specialists, who all ultimately perform a similar function.Their main duty is the clinical supervision and accompaniment of students and the support of qualified nurses in the learning environment.

Community Outreach
At Life Healthcare, there is an annual selection of a community outreach project by Learning Centre teams, together with their Student Representative Council.The projects are aimed at creating an awareness of the health and social needs of a community and how the community can be assisted in providing for their own needs through education and other appropriate activities.Each group is allocated a budget and, in addition, learners are expected to raise funds to cover additional costs; for example, Christmas parties.All learners are involved with community projects and visit their respective projects monthly.The idea is to teach students to learn to give back to their communities with support from the company.
Both Life Healthcare and Mediclinic utilize the Phelophepa Train for students in Pretoria and Bloemfontein respectively.The Phelophepa Train is an initiative of Transnet, a parastatal company that chose to take healthcare to various remote communities within South Africa.The health facility, including accommodation for staff, has been organized on the train and is serviced by a multidisciplinary team who offer primary healthcare to communities while the train moves to various destinations within the country.

Innovation
In 2008, the Life College of Learning established Centres of Excellence as a way of improving the standards of nursing education within its Learning Centres.Each of the Learning Centres is working towards becoming a Centre of Excellence for a particular aspect of nursing education.This has facilitated the development of experts in aspects of nursing education including assessment, student recruitment, research, and curriculum design.
The College is in the process of piloting the new model for clinical nursing education developed by the nursing education stakeholders as part of its implementation plan for the revised Nursing Strategy.The clinical education model addresses the learning needs of students in the clinical area and separates the clinical learning aspects of clinical placement for learning and clinical placement for role-taking.It further clarifies the distinct role-players required for effective clinical education.
Life Healthcare has taken the model and customized it to suit the needs of their respective hospitals, and has seen a significant improvement in establishing a clinical environment conducive to learning.
The College is setting up a formal process for continuing professional development for all Life Healthcare hospitals, in keeping with the requirements of the Nursing Act.The aim of the riskbased programme is to create a culture of learning which will enhance the nursing profession as well as contribute to a greater level of clinical competence.
Mediclinic Education developed continuous professional development (CPD) courses for their nursing and non-nursing personnel.Since 1996, various short and CPD courses were delivered for nursing and other staff based in the hospitals.This grew to 12 short courses and 40 CPD courses, which included management and leadership courses for nursing, as well as non-nursing heads of departments, pharmacy and other managers.In 2010, Mediclinic Education was accredited by the American Heart Association (AHA) to offer Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) training to all personnel.The concept of facilitated practical activities (FPA) which goes beyond a traditional simulation methodology, to support the transition of students from the theoretical environment to the real world of clinical practice, has been evolving over the last few years at Netcare, where it is now an integral part of the education model for all students.The FPA is targeted towards very specific aspects identified in each year of study; e.g. from basic observation skills to advanced skills such as ventilation, unit management and leadership.The successes are evidenced by the high accolades received from the ward staff who work with the students and have shown a significantly more positive attitude towards teaching them.
In order to support the career aspirations of educators, a detailed job profiling and career path was developed and created by Netcare Education.What is unique about this aspect is that it ensures the inclusion of aspects relating to the Council for Higher Education (CHE) accreditation criteria for educators, including a detailed research programme for the individual as well as for the institution.Also included are the competencies related to business acumen which are relevant not only for a private NEI, but also for the knowledge and understanding of anyone working in a college.Each level has been job graded with a detailed job description and is aligned to an enabling and positive individual employee development plan and process.
Since 2006, Netcare Education identified the need to transform and support technically competent professionals in a private sector organization by developing and delivering various in-service certificate programmes for educators, as well as nursing and other staff based in the hospitals.These programmes are customized to ensure direct relevance and applicability to the division and level of work required: e.g.shift leaders, unit managers, nursing managers, as well as non-nursing heads of departments, catering, pharmacy and other managers.

Challenges
Currently, the main challenge facing Netcare Education as a private nursing education institution are the changes and slow implementation process of legislative changes within health, nursing, nursing education and education in general.This is exacerbated by the uncertainty and inconsistent application of requirements relating to the Council for Higher Education for nursing education institutions.
The issue of staff retention -especially in the form of experienced educators who leave to go to government colleges, due to the salary differential created by the Occupation Specific Dispensation (OSD) remuneration package developed by the government for public service employees -is currently being addressed.Clinical facilities for areas such as midwifery are a challenge for the private groups.Many of their deliveries are done by obstetricians and they must obtain permission to utilize public hospital facilities.Delays are often experienced at provincial department levels.

Private Health Education Providers of South Africa Introduction
The establishment of independent private nursing education institutions commenced in the late 1990s.Entrepreneurial nurses identified a gap in the market and established nursing education institutions based on free enterprise business principles.Soon the need for a professional organization to represent the voice of the independent private nursing education institutions arose.The organization, Private Health Education Providers of South Africa (PHEPSA), was launched in May 2001.It has grown in membership and is recognized as the spokesperson for more than 40 private independent nursing education institutions throughout South Africa.

Size and activities of this sector
All members of PHEPSA are accredited by the South African Nursing Council to offer basic nursing programs, namely the courses leading to enrolment as a Nursing Auxiliary, a Nurse, as well as the bridging course for Enrolled Nurses leading to Registration as a General Nurse.Some PHEPSA members are also accredited for post-basic programs such as Operating Theatre Nursing Science and the Diploma in Midwifery.Empilweni Education is registered as a Higher Education Institution with the Department of Higher Education and Gold Fields Nursing College, Healthnicon and various other institutions are in the candidacy phase of higher education registration.The numbers reflected in Table 1 also include nurses trained by the independent private nursing education institutions.PHEPSA has 41 registered members (see table 4.2), although there are still a large number of independent private nursing education institutions that are not members.Student numbers are allocated by the South African Nursing Council based on the suitability of the infrastructure, staff component and clinical placements.Each nursing education institution has a strategic and business plan which determines the direction of the company.Courses are also based on the needs of the healthcare industry.These are reflected in the National Skills Development Strategy, with scarce and critical skills being identified by the Health and Welfare Seta.Individual clients will also request nursing education institutions to enrol their employees for certain courses according to their internal skills gap analysis, workplace skills plan and skills development strategy.Applications for enrolment in a course at the independent nursing education institutions are subjected to a rigorous selection procedure.Applications are screened to ensure that minimum requirements according to the South African Nursing Council requirements are met.Admission tests, aptitude and psychometric testing are done, and a panel then interviews candidates before they are admitted into the course.Although these students are mostly self-funded, there is a waiting list of more than one year at most independent private nursing education institutions.
It is most rewarding to see a student progress from being a care-giver to becoming a professional nurse and even nurse educator or other specialist in nursing.

Staffing
In the entrepreneurial nursing education institutions, staffing is also a challenge.Salaries cannot always compete with those offered by the government and hospital-based companies.Some institutions recruit and employ registered nurses with an interest in nursing education and then assist them to obtain educational qualifications.In other cases, they employ retired nurses.An attractive advantage is that educators may be entitled to shares in the company, while others may become directors.
The tutor to student ratio ranges between 1:15 to 1:30 ratios.Nurse educators are also responsible for clinical accompaniment of students according to a structured clinical guidance plan.Students (not more than six per day) are accompanied on a weekly basis.
Nursing education institutions are self-sustainable and provide both academic and administrative services to students.Some nursing education institutions have developed very sophisticated systems to manage the academic and administrative aspects of student administration according to corporate governance and regulatory standards.

Community Outreach
Independent nursing education institutions are involved in various community outreach projects:

Innovation
PHEPSA members meet on a quarterly basis.The meetings ensure that information on the latest developments in nursing and nursing education are disseminated to its members and also cater for their development needs.Guest speakers are invited to present contemporary topics.PHEPSA hosted its first seminar in May 2013 with them "Destined for Greatness".The focus was on greatness in partnerships, education and people.The seminar was attended by more than eighty delegates.

Challenges
PHEPSA members face the same kind of challenges as indicated by hospital-based nursing education institutions.Clinical placements for students are a scare commodity, with a large number of education institutions competing for a limited number of clinical facilities.Certain Provincial Governments refuse even to consider the possibility of placing self-funded students from independent nursing education institutions.In other cases, the independent nursing education institutions must pay a pre-determined amount per student to secure the placement.In spite of service level agreements, clinical placements with government institutions may be cancelled at short notice.
Another big challenge is the tendency to label all independent nursing education institutions as "fly by nights" or "bush colleges".All independent nursing education institutions had to go through the cumbersome registration process for Private Further Education and Training Institutions.Moving to the new dispensation in nursing education, these private nursing education institutions (PNEs) will also have to comply with Higher Education criteria.The lengthy accreditation process and restrictions by the regulatory authorities make it difficult to expand the business.The South African Nursing Council (SANC) determines the number of students and types of course and prohibits diversification of the business so as to offer any other forms of training courses.There is still a notion that nursing education should not be offered as a business enterprise.
The independent nursing education institutions do not qualify for government or skills development grants or subsidy which is a challenge.The intention is to keep tuition fees affordable but still to cover operational costs.PHEPSA strives to empower its members with regard to nursing education standards and best practice guidelines.Institutions apply for membership based on strict criteria.Membership can also be terminated by the organisation should independent nursing education institutions not comply with legal and industry standards.

Conclusion
Implementing nurse training in the private sector is most rewarding and challenging.Students are trained in environments that are conducive to recovery and learning, and they receive optimum exposure and support.In addition, because of the patient profile, students are taught very early in their training the importance of customer service, as both patients and doctors are customers of the private hospital groups.
Challenges centre around the fact that accrediting bodies often treat private providers differently and create unnecessary delays in accreditation and approval processes.
The private sector should be seen as a strategic partner in the quest to meet the demand for qualified nursing staff.Looking at the future of the nursing profession and the demand for nurses successfully to implement the National Health Insurance, the contribution by the independent nursing education institutions cannot be ignored.

Table 4 .1 Contribution of the private sector schools to provision of nurses in 2012 (SANC.co.za)
Students from various health sciences programmes are accommodated on the train and have excellent learning experiences.Students completing the bridging programme leading to registration as a general nurse are able to go on the train for one week, accompanied by their nurse educator.Students thoroughly enjoy the experience.The students work under the supervision of a registered nurse.Health screening is done, and patients referred to the relevant medical services.Netcare supported Mpumalanga Nursing College with 160 students who required clinical placement for the third and fourth years of their training in order to meet requirements to complete their programme.Netcare has sponsored a programme for the Free State Department of Health, where 45 students successfully completed the Enrolled Nursing Auxiliary programme.35 students are completing their second year of the Enrolled Nursing programme in May 2013.Mediclinic is in discussions with the Western Cape Provincial Department of Health to offer the bridging programme.
post-basic nurses, with the idea of ultimately allowing the Limpopo College to obtain SA Nursing Council approval.The project was extremely challenging for both students and nurse educators, with joint teaching, assessment and placement in private facilities.The project was extremely successful and allowed the Limpopo College to build sufficient capacity to offer their own programmes from 2007.Netcare's PPP in Lesotho with Tsepong Hospital had 45 delegates successfully complete the sixmonth in-service certificates in critical care, accident and emergency and operating skills which has enabled many of these delegates to register for programmes that will lead to post-basic qualifications.

Table 4 .2: Members of PHEPSA per province KWAZULU-NATAL (18)
Khanyisa Nursing School 2009/FE07/034 Bushbuckridge bagcinile.khumalo@yahoo.comSome of the independent private nursing education institutions have service level agreements with provincial government departments for education and training of their employees.
Health screening and promotion initiatives in shopping centres, Universities and Further Education and Training colleges  Bursaries to disadvantaged students  Support to old age homes and other worthy causes  Support to government initiatives, e.g.immunisation campaigns  Donations to worthy causes  Home-based care support  In-service training and up-skilling of staff at clinical facilities  Food parcels to disadvantaged studentsMembers of PHEPSA have different private public partnerships.These vary from training employees in nursing to continuing professional development for staff, as well as service delivery at community health centres and hospitals.There is also involvement with non-governmental organisations, churches, schools, day-care centres, old age homes and many more.The members of PHEPSA view community involvement as responsible citizenship.