There is global emphasis on transforming health workforce education in support of universal health coverage.This paper uses a social accountability framework, specifically the World Health Organization's six building blocks for transformative education, to explore key informants’ perspectives on nursing education in South Africa.Using a snowballing sampling technique, 44 key informants were selected purposively on the basis of their expertise or knowledge of the research area. Semi-structured interviews were conducted with the key informants after informed consent had been obtained. The interviews were analysed using template analysis.South Africa has strategic plans on human resources for health and nursing education, training, and practice and has a well-established system of regulation and accreditation of nursing education through the South African Nursing Council (SANC). Key informants criticised the following: the lack of national staffing norms; sub-optimal governance by both the SANC and the Department of Health; outdated curricula that are unresponsive to population and health system needs; lack of preparedness of nurse educators; and the unsuitability of the majority of nursing students. These problems are exacerbated by a perceived lack of prioritisation of nursing, resource constraints in both the nursing education institutions and the health training facilities, and general implementation inertia.Social accountability, which is an essential component of transformative education, necessitates that attention be paid to the issues of governance, responsive curricula, educator preparedness, and appropriate student recruitment and selection. Nursing education reform is identified as an important strategy for enhancing health workforce performance, and thereby improving the functioning of health systems. Globally, a predominant trend in such reform is towards greater professionalisation and university-based education. Related nursing education reform in South Africa culminated in a new Framework for Nursing Qualifications in 2013.We undertook a policy analysis study of the development of the new Nursing Qualifications Framework in South Africa.We used a policy analysis framework derived from Walt and Gilson that interrogated the context, content, actors, and processes of policy development and implementation. Following informed consent, in-depth interviews were conducted with 28 key informants from national and provincial government; the South African Nursing Council; the national nursing association; nursing academics, managers, and educators; and other nursing organisations. The interviews were complemented with a review of relevant legislation and policy documents. Documents and interview transcripts were coded thematically and analysed using Atlas-ti software.The revision of nursing qualifications was part of the post-apartheid transformation of nursing, but was also influenced by changes in the education sector. The policy process took more than 10 years to complete and the final Regulations were promulgated in 2013. The two most important changes are the requirement for a baccalaureate degree to qualify as a professional nurse and abolishing the enrolled nurse with 2 years of training in favour of a staff nurse with a 3-year college diploma. Respondents criticised slow progress, weak governance by the Nursing Council and the Department of Health, limited planning for implementation, and the inappropriateness of the proposals for South Africa.The study found significant weaknesses in the policy capacity of the main institutions responsible for the leadership and governance of nursing in South Africa, which will need to be addressed if important nursing education reforms are to be realised. There has been increased emphasis globally on nurses’ involvement in health policy and systems development. However, there has been limited scholarly attention on nurses’ participation in policy-making in South Africa.This paper analyses the dynamics, strengths, and weaknesses of nurses’ participation in four national health workforce policies: the 2008 Nursing Strategy, revision of the Scope of Practice for nurses, the new Framework for Nursing Qualifications, and the Occupation-Specific Dispensation (OSD) remuneration policy.Using a policy analysis framework, we conducted in-depth interviews with 28 key informants and 73 front-line nurses in four South African provinces. Thematic content analysis was done using the Atlas.ti software.The study found that nurses’ participation in policy-making is both contested and complex. The contestation relates to the extent and nature of nurses’ participation in nursing policies. There was a disjuncture between nursing leadership and front-line nurses in their levels of awareness of the four policies. The latter group was generally unaware of these policies with the exception of the OSD remuneration policy as it affected them directly. There was also limited consensus on which nursing group legitimately represented nursing issues in the policy arena. Shifting power relationships influenced who participated, how the participation happened, and the degree to which nurses’ views and inputs were considered and incorporated.The South African health system presents major opportunities for nurses to influence and direct policies that affect them. This will require a combination of proactive leadership, health policy capacity and skills development among nurses, and strong support from the national nursing association. Staff retention and turnover have risen in prominence in the global discourse on the health workforce. Moonlighting, having a second job in addition to a primary job, has not featured in debates on turnover.This paper examines whether moonlighting is a determinant of South African nurses’ intention to leave their primary jobs.® 13.During 2010, a one-stage cluster random sample of 80 hospitals was selected in four South African provinces. On the survey day, all nurses working in critical care, theatre, emergency, maternity, and general medical and surgical wards completed a self-administered questionnaire, after giving informed consent. In addition to demographic information and information on moonlighting, the questionnaire obtained information on the participants’ intention to leave their primary jobs in the 12 months following the survey. A weighted analysis of the survey data was done using STATAn=3,784) were predominantly middle-aged with a mean age of 41.5 (SD±10.4) years. Almost one-third of survey participants (30.9%) indicated that they planned to leave their jobs within 12 months. Intention to leave was higher among the moonlighters (39.5%) compared to non-moonlighters . In a multiple logistic regression, predictors of intention to leave were moonlighting in the preceding year, nursing category, sector of primary employment, period working at the primary job, and number of children. The odds of intention to leave was 1.40 (95% CI: 1.16–1.69) times higher for moonlighters than for non-moonlighters. The odds ratio of intention to leave was 0.53 (95% CI: 0.42–0.66) for nursing assistants compared to professional nurses and 2.09 (95% CI: 1.49–2.94) for nurses working for a commercial nursing agency compared to those working in the public sector.Survey participants  and to pay less attention to nursing work on duty (p=0.035). However, in a multiple logistic regression analysis, the differences between moonlighters and non-moonlighters did not remain statistically significant after adjusting for other socio-demographic variables.In the survey, 40.7% of nurses reported moonlighting or working for an agency in the preceding year. Of all participants, 51.5% reported feeling too tired to work, 11.5% paid less attention to nursing work on duty, and 10.9% took sick leave when not actually sick in the preceding year. Among the moonlighters, 11.9% had taken vacation leave to do agency work or moonlighting, and 9.8% reported conflicting schedules between their primary and secondary jobs. In the bivariate analysis, moonlighting nurses were significantly more likely than non-moonlighters to take sick leave when not sick  from the national Basic Accounting System database, and analysed using Microsoft Excel. Each of the 166,466 expenditure line items was coded. The total personnel and nursing agency expenditure was calculated for each financial year and for each province. Nursing agency expenditure as a percentage of the total personnel expenditure was then calculated. The nursing agency expenditure for South Africa is the total of all provincial expenditure. The 2009/10 annual government salary scales for different categories of nurses were used to calculate the number of permanent nurses who could have been employed in lieu of agency expenditure. All expenditure is expressed in South African rands .Only five provinces reported utilisation of nursing agencies, but all provinces showed agency expenditure. In the 2009/10 financial year, R1.49 billion (US$212.64 million) was spent on nursing agencies in the public health sector. In the same year, agency expenditure ranged from a low of R36.45 million (US$5.20 million) in Mpumalanga Province  to a high of R356.43 million (US$50.92 million) in the Eastern Cape Province . Agency expenditure as a percentage of personnel expenditure ranged from 0.96% in KwaZulu-Natal Province  to 11.96% in the Northern Cape Province . In that financial year, a total of 5369 registered nurses could have been employed in lieu of nursing agency expenditure.The study findings should inform workforce planning in South Africa. There is a need for uniform policies and improved management of commercial nursing agencies in the public health sector. Globally, flexible work arrangements – through the use of temporary nursing staff – are an important strategy for dealing with nursing shortages in hospitals.The objective of the study was to determine the direct and indirect costs of agency nurses, as well as the advantages and the problems associated with agency nurse utilisation in two public sector hospitals in South Africa.Following ethical approval, two South African public sector hospitals were selected purposively. Direct costs were determined through an analysis of hospital expenditure information for a 5-year period from 2005 until 2010, obtained from the national transversal Basic Accounting System database. At each hospital, semi-structured interviews were conducted with the chief executive officer, executive nursing services manager, the maternity or critical care unit nursing manager, the human resource manager, and the finance manager. Indirect costs measured were the time spent on pre-employment checks, and nurse recruitment, orientation, and supervision. All expenditure is expressed in South African Rands .In the 2009/10 financial year, Hospital 1 spent R38.86 million (US$5.55 million) on nursing agencies, whereas Hospital 2 spent R10.40 million (US$1.49 million). The total estimated time spent per week on indirect cost activities at Hospital 1 was 51.5 hours, and 60 hours at Hospital 2. The estimated monetary value of this time at Hospital 1 was R962,267  and at Hospital 2 the value was R300,121 , thus exceeding the weekly direct costs of nursing agencies. Agency nurses assisted the selected hospitals in dealing with problems of nurse recruitment, absenteeism, shortages, and skills gaps in specialised clinical areas. The problems experienced with agency nurses included their perceived lack of commitment, unreliability, and providing sub-optimal quality of patient care.Hospital managers and policy-makers need to address the effective utilisation of agency nurses and quality of patient care in tandem. Nursing agencies are temporary employment service providers or labour brokers that supply nurses to health establishments.This study was conducted to determine the characteristics of nursing agencies and their relationship with clients in the health sector.® 12.During 2011, a cross-sectional national survey of 106 nursing agencies was conducted. After obtaining informed consent, telephone interviews were conducted with a representative of the selected nursing agency using a pretested structured questionnaire. Questions focused on the following: ownership, date of establishment, province of operation, distribution of clients across private and public health facilities; existence of a code of conduct; nature of the contractual relationship between nursing agencies and their clients, and numbers and cadres of nurses contracted. The survey data were analysed using STATAp = 0.04). Although 98% of nursing agencies reported that they had a code of conduct, the proportion was higher for private-sector clients (73%) compared to public-sector clients (27%). In terms of quality checks and monitoring, 81% of agencies agreed with a statement that they checked the nursing council registration of nurses, 82% agreed with a statement that they requested certified copies of a nurse's qualifications. Only 21% indicated that they conducted reference checks of nurses with their past employers.Fifty-two nursing agencies participated in the survey, representing a 49% response rate. The study found that 32 nursing agencies (62%) served private-sector clients only, which included private hospitals, homes for elderly people, patients in private homes, and private industry/company clinics, and only four (8%) of the agencies served the public sector only. Twenty-seven percent of nursing agencies provided services to homes for elderly individuals. Nursing agencies were more likely to have contracts with private-sector clients (84%) than with public-sector clients (16%)  was 39 years (SD=9.2), and the majority were female (96%). The majority agreed with a statement that they will promote the human rights of individuals (98%) and that they have a duty to meet the health and social needs of the public (96%). More nuanced responses were obtained for some questions, with 60% agreeing with a statement that too much emphasis is placed on patients’ rights as opposed to nurses’ rights and 32% agreeing with a statement that they would take part in strike action to improve nurses’ salaries and working conditions. The dilemmas of nurses to uphold the Code of Ethics and the Pledge in face of workplace constraints or poor working conditions were revealed in nurses’ responses to open-ended questions.The mean age of survey participants . Nursing managers will play a critical role in these reforms.The aim of the study was to explore the work experiences of PHC clinic nursing managers through the use of reflective diaries, a method hitherto under-utilised in health systems research in low- and middle-income countries.During 2012, a sub-set of 22 PHC nursing managers was selected randomly from a larger nurses’ survey in two South African provinces. After informed consent, participants were requested to keep individual diaries for a period of 6 weeks, using a clear set of diary entry guidelines. Reminders consisted of weekly short service messages and telephone calls. Diary entries were analysed using thematic content analysis. A diary feedback meeting was held with all the participants to validate the findings.Fifteen diaries were received, representing a 68% response rate. The majority of respondents (14/15) were female, each with between 5 and 15 years of nursing experience. Most participants made their diary entries at home. Diaries proved to be cathartic for individual nursing managers. Although inter-related and not mutually exclusive, the main themes that emerged from the diary analysis were health system deficiencies; human resource challenges; unsupportive management environment; leadership and governance; and the emotional impact of clinic management.Diaries are an innovative method of capturing the work experiences of managers at the PHC level, as they allow for confidentiality and anonymity, often not possible with other qualitative research methods. The expressed concerns of nursing managers must be addressed to ensure the success of South Africa's health sector reforms, particularly at the PHC level. Improving the quality of health care is central to the proposed health care reforms in South Africa. Nursing unit managers play a key role in coordinating patient care activities and in ensuring quality care in hospitals.This paper examines whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals.n=36). Following informed consent, each unit manager was observed for a period of 2 hours on the survey day and the activities recorded on a minute-by-minute basis. The activities were entered into Microsoft Excel, coded into categories, and analysed according to the time spent on activities in each category. The observation data were complemented by semi-structured interviews with the unit managers who were asked to recall their activities on the day preceding the interview. The interviews were analysed using thematic content analysis.During 2011, a cross-sectional, descriptive study was conducted in nine randomly selected hospitals  in two South African provinces. In each hospital, one of each of the medical, surgical, paediatric, and maternity units was selected (The study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management, and 11.8% on miscellaneous activities. There were also numerous interruptions and distractions. The semi-structured interviews revealed concordance between unit managers’ recall of the time spent on patient care, but a marked inflation of their perceived time spent on hospital administration.The creation of an enabling practice environment, supportive executive management, and continuing professional development are needed to enable nursing managers to lead the provision of consistent and high-quality patient care. Human Resources for Health (HRH) are critical to health systems development and functioning, and to patient and population health outcomes . Nurses However, the country faces a ‘nursing crisis’, characterised by shortages, declining interest in the profession, lack of a caring ethos, and an apparent disjuncture between the needs of nurses on the one hand and those of communities served on the other hand , 5. The In July 2008, the Centre for Health Policy (CHP) in the School of Public Health, University of the Witwatersrand, Johannesburg, obtained funding from The Atlantic Philanthropies (AP) for a four-year research programme to develop and strengthen the research evidence for improved nursing policy development and practice in South Africa. Known popularly as Research on the State of Nursing (RESON), the overall research programme consisted of three focus areas: nursing management and quality of care; nursing policy; and the process of casualisation in nursing, specifically nursing agencies and moonlighting, and how these have an impact on nurses and on the health system. Capacity building and policy influence and engagement were important cross-cutting focus areas.Global Health Action, we present a series of papers that describe selected research findings of the various components of the RESON project. The Special Issue brings together 11 scholarly articles that explore themes that are relevant to a global audience of nurses and health policy-makers: nursing education reforms; enhancing the participation of nurses in policy-making; moonlighting among nurses; utilisation of agency nurses in hospitals and its costs to the health sector (both direct and indirect); ethics; quality of care; and the work experiences of nursing managers at primary health care clinics.In this Special Issue of Three papers under this theme focus on nursing education, reforms in nursing education, and nurses’ participation in policy-making.In the first paper, Armstrong and Rispel use a social accountability framework, specifically the World Health Organization's six building blocks for transformative education , to explUsing a policy analysis framework, Blaauw et al. analyse nursing education reforms that culminated in a new Framework for Nursing Qualifications in 2013 . The revIn the third paper within this theme, Ditlopo et al.  analyse The second theme focuses on the process of casualisation in nursing, specifically the relationship between moonlighting and intention to leave, the potential health system consequences of agency nursing and moonlighting, the direct and indirect costs of nursing agencies, and the characteristics of nursing agencies in South Africa.In the first paper, Rispel et al., examine whether moonlighting is a determinant of South African nurses’ intention to leave their primary jobs . The stuIn the second paper, Rispel and Blaauw examine the potential health system consequences of agency nursing and moonlighting among South African nurses . In the Rispel and Angelides conducted a provincial survey on nursing agency utilisation and analysed provincial health expenditure on nursing agencies from 2005 until 2010  in the tHowever, there are also indirect costs associated with agency nursing. Complementing the direct costing study, Rispel and Moorman  examine Olojede and Rispel, in the final paper within the casualisation theme, explore the characteristics of nursing agencies in South Africa, and their relationship with clients in the health sector . AlthougThree diverse papers conclude the special journal issue, but all three highlight the importance of an enabling practice environment for nurses.White et al. explore hospital nurses’ perceptions of the international Code of Ethics for nurses, their perceptions of the South African Nurses’ Pledge of Service, and their views on ethical practice . The majMunyewende and Rispel explore the work experiences of PHC clinic nursing managers through the use of reflective diaries . AlthougIn the final paper in the Special Issue, Armstrong et al. examine whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals . The stuIn this Special Issue we have reported on the findings of selected research studies done as part of RESON. Using different methodologies that range from the use of reflective diaries to large cross-sectional surveys, the papers in this volume have enhanced our knowledge and understanding of nursing in South Africa in three research areas: policy analysis; casualisation, agency nursing, and moonlighting; and nursing management and practice environments.A common strand that runs through all the papers is the importance of leadership, governance, and management from three important policy actors: national government; the Nursing Council; and the national nursing association –21. The The Special Issue underscores the importance of conducting health workforce research that contributes to health system transformation, and highlights neglected policy issues, such as the process of casualisation in nursing, and the implications for the health system. As is the case with many health workforce studies, the papers in this volume are based on cross-sectional rather than longitudinal data. There is need for investment in long-term, longitudinal studies of the health workforce to enable measurement of progress over time and enhance research contribution to evidence-informed health policy-making.The papers also highlight the importance of involving nurses at the coal-face of service delivery and continuing professional development to enable nursing managers to lead the provision of consistent and high-quality patient care , 21.Many of the issues foregrounded in this Special Issue have relevance for nurses and health policy-makers in other low- and middle-income countries. Collectively, the study findings suggest that South Africa's quest for UHC to improve population health and achieve equity and social justice cannot be achieved unless the issues facing nurses and nursing in South Africa are confronted.Laetitia C. Rispel Centre for Health Policy & Medical Research Council Health Policy Research Group School of Public Health Faculty of Health Sciences University of the Witwatersrand 27 St. Andrew's Road, Parktown, 2193 Johannesburg, South Africa As the largest single group of health-care providers in any country, nurses have the potential to bridge the gap between communities and the health-care system, coordinate care for patients with increasingly complex disease profiles, and accelerate the achievement of universal health coverage –4. HowevAround the world, the discourse on the education of health professionals has intensified, focusing on the need to increase numbers and to improve the quality, relevance, and retention of graduates , 5–8. HoNonetheless, there is a convergence of ideas that these challenges could be overcome through the transformative scale-up of medical, nursing, and midwifery education –8. Critiinter alia on the following: professionalisation through the shift from a hospital-based apprenticeship model to baccalaureate nursing degrees in higher education institutions  nurses with 4 years of training; enrolled nurses with 2 years of training, and nursing assistants or auxiliaries with 1 year of training. The majority of professional (registered) nurses are also midwives, and the terms ‘nurse’ and ‘midwife’ are used interchangeably in the Nursing Act . NursingGiven the global discourse on transforming health workforce education in support of universal health coverage , this paThe study was approved by the University of the Witwatersrand Human Research Ethics Committee . All participants received a study information sheet and gave informed written consent. Using a snowballing sampling technique, 44 key informants were selected purposively on the basis of their expertise or knowledge of the research area.Semi-structured interviews were conducted with the key informants after informed consent had been obtained, using an interview guide developed specifically for the study by the research team and an advisory committee. In addition to questions on casualisation, the interview covered the following: achievements or progress by nurses or in nursing; challenges faced by nurses, both individually and by the nursing profession as a group; perceptions of changes in nursing in the 5 to 10 years preceding the interview; and recommendations for change. A member of the research team contacted each person identified as a potential key informant and requested an interview. If the person agreed to be interviewed, an appointment was set up for an interview at a place and time convenient for the informant. All interviews were conducted in English. Interviewers used probes to clarify responses and to obtain more detailed information.Two researchers conducted the interviews between June and October 2009. Each key informant interview lasted about one hour, although the duration varied in some cases depending on the responses by informants. Interviews were recorded digitally, but interviewers also took detailed notes during the interview and wrote a synopsis of the interview. In some instances, respondents provided additional, relevant documentation to the interviewers.The recorded interviews were transcribed verbatim. Data cleaning took 1 month and consisted of an iterative process of checking the transcribed interviews against the original recordings, correcting the text, checking the recordings again, and making final corrections. Prior to analysis, an audit of key informants was done, and each key informant was allocated a code number to ensure confidentiality of information. The coded interviews were consolidated into one file for ease of analysis.a priori themes that were determined in advance of coding ; executive nursing managers from the private sector or non-governmental organisations (n=10); nursing academics in universities or nursing colleges (n=8); representatives from the nursing council, nursing association, and/or health sector unions (n=5); and other health professionals, mainly doctors (n=5). Only two key informants from two health sector unions failed to respond to repeated requests for an interview.The 44 key informants were drawn from six categories: national and provincial government officials I think that before we start to look at moonlighting the first thing we have to get [are] proper norms and standards … we are just working with what different people are saying and doing, but we haven't come up with proper staffing norms and standards for our own country and our own facilities … both in the private and public sectors. I am glad the Nursing Strategy is beginning to speak to that. The staffing norms are not in place to say this is how we would like to staff either a primary health care centre or the medical ward or the general ward. The staffing norms are either outdated or unknown to the managers. This building block measures the existence of information on the health status of the population or of individual subgroups as well as detailed information on health workforce demand and need, because these have an impact on health professional education . At the This building block focuses on broad governance arrangements for health professional education (including collaboration across government ministries), policy development, and information on the funding of health workforce education .Our Nursing Council is dysfunctional … we basically can't increase our numbers, open new centres, start new courses. You know we've tried to get permission to increase our numbers and to start satellite centres, while we wait for the new Regulations to be published, but we're just not getting there. The last few [Nursing] Councils that we've had, we've really had problems with leadership. We were hoping that the new Council would be different, but when I listen to some of the things that people say, it's not different. It's about self-interest or self-serving interest rather than looking at the interest of the profession. So what is it that we doing wrong? I don't know. I mean how do we change that kind of culture? A substantial number of key informants were of the opinion that the sub-optimal leadership provided by the Nursing Council as the regulator was the primary cause of many of the nursing problems experienced, as can be seen in the following excerpts:The SANC was also criticised for the perceived delays in the implementation of the revised scopes of practice for the different nursing categories and the related training Regulations that guide nursing education institutions with regard to the preparation of these nurses. Key informants indicated that such delays stifle attempts to improve or expand nursing curricula and contribute to a state of inertia in the nursing education system, which had remained static instead of changing to meet the needs of the population or the health system. The Nursing Council was also criticised for its apparent reluctance to work with other government structures responsible for higher education.I think there's a huge urgency to have leadership to take that on [an increase in nurse production] … both from the National [Department of Health] and also from the Nursing Council. And the fact that both institutions continue to be in disarray is worrying because we so need leadership and nobody else can really do that. The National Department of Health was also blamed by the key informants for much of the lack of planning and coordination as well as slow implementation, which hampers nursing education from moving forward.The political people [in the provinces] don't talk to one another about health because they own the colleges. They [provinces] and higher education [Ministry] are not talking to one another. We don't get the feedback. So it's a major vacuum of uncertainty and everybody is now getting despondent. The provincial health departments responsible for the implementation of nursing education in the public sector were also criticised for exacerbating fragmentation and contributing to a feeling of despondency among nurses:I think the biggest challenge that I have seen facing all nurses, regardless of whether you are in a rural area or the urban area – nurses in the public sector, I don't know about the private sector – is the frequency of the policy initiatives that contradict each other, and don't get seen through and don't have proper support and all of that; these lead to incredible transformation fatigue. And what I've seen happen is that nurses simply withdraw. Although policy development is important, the problems of health workforce production were exacerbated by insufficient resources in the public health sector and what some termed ‘transformation fatigue’ among nurses.We keep on saying that nursing is the backbone of the health system, but when it comes to financing, it's difficult for them to finance nursing issues. For example, if we talk of training of nurse managers or the training of nurses, I have to go and knock on other people's doors and say, listen, I need to train nurses … but there is no specific budget. Key informants were also of the opinion that there is lack of prioritisation of nursing, illustrated by the lack of funding for nursing strategic priorities. A senior provincial government manager commented as follows:inter alia on the need for accreditation, regulation, and quality control mechanisms for health workforce education in the country The majority of key informants expressed concerns about the quality of teaching and learning, and there was some concern about the impending reforms in nursing education. In general, the medical doctors interviewed were of the opinion that the proposed reforms in nursing education have not been thought through, and one said the following:The proposed Regulations also raised concerns among key informants about the lack of alignment between nursing training and the service or work environment. Some were of the opinion that nurses are inadequately prepared for the burden of disease that they face in hospitals or for working in a district health system.This building block focuses on appropriate curricula; community participation in health workforce education; the demographic profile of faculty and teaching staff; support for educators to engage in lifelong learning and continuing professional development; and community-based, interprofessional education based on principles of PHC and focusing on the social determinants of health .Some of the key informants were of the opinion that nursing curricula are unresponsive to changes in disease burden and in the health system and that there is a disjuncture between government's emphasis on PHC and the training of nurses. These stated curriculum problems were exacerbated by the perception of the lack of skills among newly trained nurses, with many key informants pointing to skills gaps. These missing skills included inadequate social skills, lack of initiative, inability to apply theoretical knowledge to patient care, lack of basic nursing skills, and lack of understanding of professional practice.If I think back of our educational programmes, by the time you were a third-year nurse you would be in charge of the ward and run and manage the ward so well. We had mentors and we had people that we wanted to emulate … I don't think they [student nurses] have adequate mentors. They might be going out there to go and meet their clinical objectives but where are the mentors to [make sure] they achieve those clinical objectives? Key informants also mentioned problems related to practical training, which included an insufficient number of good-quality practical training facilities, coordination of practical placements, and insufficient resources. A critical aspect mentioned was the lack of supervision and mentoring of students. One key informant said:Really the training of nurse educators has been left behind. If we look at the standards, if we look at some of the resources in colleges, what the politicians expect … they [politicians] increase the [student] numbers by 100% but they don't provide the resources. The practical training is nearly non-existent and the supervision during training is scary and this is why they [nursing students] are not learning. They haven't got role models, they haven't got good teachers in the wards, and they are not learning how to do the job. The nurse educators are so busy trying to cope with these large groups now and they hardly ever get out into the hospitals, they themselves do not keep up to date, they are not even using up-to-date prescribed books or even South African-based prescribed books. The key informants were critical of the quality of the nurse educators within many of the nursing education institutions, especially in the nursing colleges, who have not kept abreast of the practice environment and also lack modern teaching skills. There was a suggestion that because nurse educators have not kept abreast of these developments, they are not teaching up-to-date nursing procedures, which makes it difficult for the students to execute nursing tasks when they arrive in the hospitals. The shortages of nurse educators were seen as another significant challenge.This building block focuses on the need to retain health workers particularly in underserved areas and to encourage their career development, as reflected in policies and plans and supportive measures in the workplace .The majority of key informants pointed to resource constraints in nursing education institutions, particularly the lack of budgets, teaching infrastructure, student accommodation, and teaching equipment. Importantly, a similar lack of resources was experienced at the health facilities, which provide clinical training. Key informants pointed to the impact that resource constraints have on the quality of the nursing graduates. For example, in the public sector, they might not have exposure to new technology. In some instances, nursing education institutions based at universities have found creative alternatives, such as patient simulators. It was felt that the lack of resources has an impact on the retention of nurses, particularly in the public sector.This building block focuses on student recruitment that is based on a combination of formal qualifications and transversal skills, reflective of underserved populations .The other thing around [nursing] education is trying to get the right kind of nurse for this country. I think we put [too] much emphasis on the 4-year programme, whether a 4-year diploma or degree nurse – and they [nurses] get over-qualified and then they have aspirations to go all over. And what does the South African health-care system need in terms of the nurse? We really need to revisit the kind of nurse we need and what are the numbers we need to train. Key informants were very vocal about the problems of selection and suitability of applicants for entry into nursing. One said the following:Nursing was a coveted job by young black women, so we used to get the best matriculants … so there was a time when we had quality people and they were in fact quite dedicated as well. Then I think over time there was an erosion of that, and it became a less attractive profession, poorly paid, long working hours, inflexible working hours, it lost its lustre and then young women looked for other career opportunities rather than doing nursing. There was a general perception that there is a problem in attracting nursing recruits who meet the selection criteria, because young people in South Africa have more career opportunities open to them. One commented as follows:Key informants mentioned other factors that impact on student selection. These include the advanced age of students on commencement of training, which reduces the pool of nurses for further specialised training, and the relatively high attrition rate of students resulting in wastage of time and money in training them.I think the number one thing [problem] is the issue of the values in nursing, which perhaps may be different for different people but generally nursing was perceived to be a vocation for many of us – not the only choice of career. The values of caring for people and the importance of integrity and accountability were very important to us. Almost one-third of the key informants were of the opinion that that the values and ethos of the current nursing students were different (and worse) compared with those held by nurses of the older generation and that the new generation was less caring towards patients and less committed to staying in nursing, as captured by the following quote:In South Africa, there is a well-established system of regulation and accreditation of nursing education through the SANC . This isUsing the six building blocks for transformative education and the voices of the 44 key informants, the study found sub-optimal governance on nursing education, thus confirming the findings of a policy analysis study that examined nursing education reforms in South Africa . The polKey informants also pointed to problems with workforce planning, curricula, faculty and education, and student selection and training, which impact on nursing education. The issue of national staffing norms remains as important today as it was in 2009 when the interviews were conducted. Although South Africa has updated strategic plans on Human Resources for Health  as well The comments from key informants suggest that curricula in nursing education institutions require revision so that they are more appropriate for the population and health system needs of South Africa. However, the lack of finalisation of the training Regulations and the scopes of practice was a major barrier to transformation of nursing education curricula. Although the training regulations were released at the end of 2012, the scopes of practice remain outstanding. The SANC continues to postpone the phasing-out of the legacy qualifications and, although the training of enrolled nursing auxiliaries and enrolled nurses will end in June 2015, a new date has been set for 2018 for the phasing-out of the programme leading to registration as a nurse  and midwife. Hence, the implementation inertia described by some key informants continues. This inertia means that there has been little progress in implementing the 2009 global standards on nursing and midwifery education with regard to curriculum reform .Nursing educator preparedness is another major issue that requires attention. Although key informants acknowledged the constraints within which nursing educators have to work, they were critical of the quality of the nurse educators. The views of key informants are borne out by the situation analysis of the 5-year Strategic Plan for Nursing Education, Training and Practice, which noted problems of insufficient numbers, heavy workloads, inadequate continuing professional development, outdated knowledge and skills, and an exodus from nursing education institutions due to the Occupation-Specific Dispensation, a public-sector financial incentive . ExperieKey informants were of the opinion that the recruitment and selection of entrants to professional nursing accounted for some of the problems experienced in nursing. Another South African study also found that, although there are many more applicants to nursing courses than could be accommodated, they either did not meet the admission criteria, or nursing was the second or third choice . NonetheThe study findings suggest that nursing education in South Africa is grappling with getting the basics right for many of the building blocks considered essential for transformative education, with social accountability as a key feature. This paper makes an important contribution to the debate on issues that need to be addressed in the implementation of the impending nursing education reforms in South Africa, from the perspective of key opinion leaders in nursing and in the health sector. However, the findings are not generalisable, as the key informants were selected purposively. The information also represents the perceptions of key informants at a particular point in time, and hence we do not know how these perceptions have changed since the interviews were conducted in 2009. Nonetheless, it is one of the first studies using the WHO building blocks on transformative education and exploring the notion of social accountability as it relates to nursing education.What then are the implications of the study findings for the implementation of the impending nursing education reforms in South Africa? The delays in the implementation of the proposed nursing education reforms provide a window of opportunity to incorporate the social accountability principles of responsiveness, relevance, quality, cost-effectiveness, and impact , 40, 42 The appointment of a Chief Nursing Officer at the beginning of 2014 is encouraging. We recommend that this incumbent draws on the skills and expertise of the nursing education structures, the national nursing association, student associations, and the many nurses who are keen to contribute to the current nursing education reform processes.A great deal of research has been done on various factors relating to student selection, such as academic and non-academic predictors of success among student nurses , motivesAccountability for teaching and learning has to lie predominantly with the nursing education institutions themselves . The immProgramme assessment is equally important, as it provides evidence of educational effectiveness and therefore meets the demand for accountability . A thirdTransformative education of nurses is critical in the move towards universal health coverage. Social accountability, which is an essential component of transformative education, necessitates that attention be paid to the issues of governance, curricula, nurse educator preparedness, student recruitment, and selection raised by key informants. Nursing education in South Africa is about to embark on profound changes with the move to the higher education sector. This transition provides a window of opportunity to address some of the issues that have troubled nursing education in the past, while embracing the concept of social accountability. There is global recognition of the urgent need to scale up educational programmes for the production of more health professionals in order to address patient and population health priorities and improve health system performance –4. ArounGlobally, the predominant trend in nursing education over the last century has been towards greater professionalisation through the lengthening of training periods, and the shift from a hospital-based apprenticeship model to professional education in institutions of higher learning , 8. NeveIn recent years, an important development in the professionalisation of nursing education has been the call for a baccalaureate degree as the minimum requirement for entry to the profession . ProponeIn South Africa, increasing professionalisation and a shift to university education have been important features of the reform of nursing education , 17. TheSince South Africa's democracy in 1994, there has been a renewed focus on nursing education as part of the post-apartheid transformation of both the health and higher education sectors . The nurIn light of South Africa's health care reforms to achieve universal health coverage  and the Contemporary policy analysis is based on the premise that policy-making is inherently political in nature and seeks to provide a systematic method for analysing policy processes and the factors that influence them . AlthougAlthough there have been a number of reforms in nursing education in South Africa since 1994 , this stThe study reported in this paper was part of a larger project to examine the dynamics, strengths, and weaknesses of nursing policy-making in South Africa . It consThe focus of this study was primarily on national policy processes. Although actors at the national level may drive nursing policy development, the responsibility for implementation is with provincial managers and the ultimate impact of policies is on front-line nurses. Therefore, the project collected data from all three levels. Sub-national data collection focused on four provinces: Gauteng, Eastern Cape, Free State, and Western Cape.The overall study design was an in-depth, qualitative, case study of the new Nursing Qualifications Framework in South Africa. Case study methodology allows for a detailed exploration of the complex dynamics and relationships within a real-life context . The resThe research team reviewed relevant legislation, regulations, government and nursing council documents, and inputs made by nursing education stakeholder groups in order to understand the context and content of the new Nursing Qualifications Framework.n=14), nursing managers from the private sector and non-governmental organisations (n=5), nursing academics in colleges and universities (n=6), and representatives from the SANC and other nursing organisations (n=3).The research team conducted interviews with 28 purposively selected key informants, drawn from six categories: national and provincial government officials (Semi-structured face-to-face interviews were conducted in English after obtaining written informed consent. If the key informant (KI) agreed, the interviews were recorded to improve accuracy and to support more detailed analysis. The interviewer also kept detailed notes of each interview. The issues covered with each KI included: aims of the policy; policy design and content; contextual factors influencing policy development; important milestones in the policy process; the roles, interests, and influence of different actors; motivation for the strategies adopted; factors influencing the policy process; and key informants’ interpretation of the success or failure of the policy initiative.Documents, interview transcripts, and written notes were analysed using standard approaches to qualitative data analysis , 36. TheNational and international ethical standards were followed throughout the research. The University of the Witwatersrand Human Research Ethics Committee , and the relevant provincial health authorities granted permission to conduct the study.Respondents were provided with a study information sheet explaining the purpose of the study and the terms of their consent. Those who agreed to be interviewed were asked to sign the study consent form. Separate consent was also obtained for any recording of interviews. Personal identifiers were removed from all transcripts and results.The context, process, content, and actors relevant to the development of the new Nursing Qualifications Framework are described briefly, followed by respondents’ main criticisms of the policy process.The development of the new qualifications is about updating, modernising the practice of nursing. For the profession we need a professional nurse that's a graduate nurse that is in line with the rest of the world and the new qualifications would give us that. KIs argued that the revision of nursing qualifications was an important part of the on-going transformation of nursing in South Africa, and not only a response to changes in the higher education sector .The deveWe have got a challenge of high maternal and child mortality. When you ask people what could be the cause of that, they will then begin to look at this 4-year programme and ask whether it produces competent midwives or not? The post-apartheid transformation of nursing legislation culminated in the passing of a new Nursing Act in 2005. Although the Act was promulgated in 2007, many provisions of the Act required further specification in Regulations. KIs pointed out that an important contextual factor was the development of draft Regulations outlining the Scopes of Practice of different categories of nurses and the qualifications required for each category. Nursing stakeholders were dissatisfied with the Scope of Practice Regulations and qualifications inherited from the previous Nursing Act of 1978 and had strongly advocated for an overhaul of these provisions. KIs explained that the main motivations for education reform included: insufficient distinction in the roles of different nursing categories; the need to address changing disease patterns and health system priorities; and the need to reflect the more independent practice of contemporary nurses. Others saw it as an opportunity to review the 4-year comprehensive nursing course introduced in 1986 which paradoxically had been criticised both for excessive training in all four areas of care, and for inadequate preparation of graduates for competent practice in all of these areas, particularly midwifery.The post-apartheid era also brought broader challenges for nursing that needed to be considered in the revision of the nursing qualifications. These included increased service demands, easier international migration, staff shortages, decline in the image and status of the profession, difficulties in attracting good recruits, an ageing workforce, and generally low staff morale , 24.Another critical contextual factor was the development of a new NQF by the Department of Education. Prior to 1995, the SANC was the main regulator of nursing training and qualifications but the introduction of the South African Qualifications Authority (SAQA) and the new NQF meant that nursing qualifications now had to comply with broader Department of Education policy.A 2007 review of SAQA and the NQF resulted in a significant revision of the NQF to develop the new Higher Education Qualifications Framework (HEQF). The revised NQF consists of ten levels, instead of the previous eight, with each level providing a broad indication of the types of learning outcomes and assessment criteria that are appropriate to a qualification at that level . KIs expThe timeline in The reform of nursing education and training can be divided into two main phases.The first phase of the reform process occurred between 2001 and 2009 and was primarily concerned with aligning existing nursing qualifications with the NQF. These were the so-called legacy qualifications inherited in 1994 for the training of enrolled nursing auxiliaries (1 year training), enrolled nurses (2 years of training), and diploma- or degree-qualified professional nurses with 4 years of training. SAQA had defined specific processes for this that involved the establishment of a Nursing Standards Generating Body (SGB). The Nursing SGB produced various draft qualifications between 2002 and 2004 but the process stalled because of lack of resources. A further difficulty was the change from the NQF to the HEQF, which meant that the work done so far had to be revised. The SANC took over finalising the registration of the legacy qualifications with SAQA, eventually completing the task in 2009.The second phase of reform from 2008 to 2013 dealt with the development of a completely new Nursing Qualifications Framework, also aligned with the HEQF which was meant to be led by SANC. Timeframes were not adhered to, and despite an initial deadline of 30 June 2010 being set for the phasing out of the legacy qualifications, the process has continually been extended. The new deadline, at the time of writing, is the 30 June 2015.We call upon SANC in collaboration with the National Department of Health, CHE [Council for Higher Education] and SAQA to fast-track the processing and implementation of the new Nursing Qualifications’ Framework and appropriate transitional arrangements.Although the involvement of nurse educator groups resulted in some increased momentum, respondents argued that progress has been sporadic and the process laboured. In April 2011, a national Nursing Summit was held where the following statement regarding the new Nursing Qualifications Framework was made :We call Following the summit, the Minister of Health appointed a Ministerial Task Team on Nursing Education and Training which finally provided the impetus to complete this phase of the policy process. Regulations for the new nursing academic qualifications were released for public comment in December 2011 and finally promulgated in March 2013. The Minister of Health also released the new Strategic Plan for Nursing Education, Training, and Practice in March 2013 . HoweverEnrolled nursing auxiliary: 1-year certificate at a training hospital;Enrolled nurse: 2-year certificate at nursing college;Professional nurse: 4-year diploma at nursing college or 4-year baccalaureate degree at university.A bridging programme also made it possible for enrolled nurses to complete a 2-year diploma at a nursing college and qualify as a registered general nurse. Specialised nurses completed either a postgraduate diploma or master's degree, and doctoral nursing programmes were available at universities.I understand that the needs of the country are about an expanded scope of practice for an enrolled nurse. The new Qualifications Framework includes two fundamental changes . First, The Scope of Practice of the new staff nurse has been broadened so that they will be able to work more independently and provide basic nursing care to uncomplicated patients in all settings.The key actors involved in the nursing qualifications policy process are represented in Overall governance and leadership of the nursing sector is shared between the SANC and the Human Resources Division of the National Department of Health (NDoH). Other important actors from the health sector included nursing educators, nursing practitioners, nursing organisations and the national nursing association, and health sector unions. Nursing educators include individual training institutions, as well as educator groupings such as the Forum of University Nursing Deans in South Africa (FUNDISA), the Nurse Educators Association (NEA), the College Principals and Academic Staff (CPAS) forum, and the Private Health Education Providers of South Africa (PHEPSA)  represenIn 2001, there was the Nursing SGB which played a great role in developing the Nursing Standards. The very new qualifications that we are talking about now, they were given birth to by the Nursing SGB. Various actors have played a central role at different stages of the process. Phase 1 of the process was initially driven by the Nursing SGB, a sub-structure of SAQA, intended to ensure broader representation in the development of national qualifications.Not surprisingly, the SGB came into conflict with SANC, which had previously been the only actor responsible for the regulation and development of nursing qualifications. Ultimately, the SANC reasserted its role and the Nursing SGB was abandoned.One of the success stories that FUNDISA has played a critical part in is coming up with a Nursing Qualification Framework that SANC has now adopted. Nursing educators dominated the phase 2 process. The so-called Nursing Education Stakeholders (NES), a group representing all nurse educator organisations, developed the initial proposals and advocated and lobbied extensively for the new Nursing Qualifications Framework. A workshop held by the NES in February 2010 defined the subsequent development of the debate and they played a prominent role in the presentations and discussions on the Qualifications Framework at the Nursing Summit in April 2011. Despite initial differences within the NES group, particularly from PHEPSA and CPAS, the NEA-FUNDISA proposals came to be accepted and disseminated.Our Minister at one point said, ‘the way that South Africa is going with its academic qualifications, very soon we will be saying that Agricultural Extension Officers must train at university, and the country will be without food because how can someone who comes from the university know how to farm, how to till the soil.’ That is the way it is. The finalisation of the Regulations was subsequently taken forward by the Ministerial Task Team on Nursing Education and Training. The influence of the NDoH, particularly the Human Resource Division, has been uneven. At an earlier stage some officials appeared uncomfortable with the shift to greater professionalisation through the baccalaureate degree.Nevertheless, the Minister of Health signed the final Regulations, including the requirement of a baccalaureate degree for professional nurses.I mean the Council has always had a Qualifications Framework, but it belonged to the Council and now it had to start merging with the education system of the country. With regard to contextual factors, SANC and nursing stakeholders have grappled with the introduction of the Department of Education into the regulation of nursing education.We were busy writing those nursing qualifications of the previous Council and then they got them complete and ready to implement and then they realised the NQF had changed. Some informants also highlighted the difficulties of dealing with the ongoing changes in the education sector.Although the ground work has been done, the implementation is completely at a standstill. There is absolutely no implementation in any aspect of the Nursing Act or any of those draft Regulations that are there. Not surprisingly, in terms of process, a major concern has been the very slow pace of policy development, particularly in relation to producing the enabling Regulations required by the new Nursing Act.Some respondents were also concerned about the limited planning for the implementation of the new qualifications, which will have a significant impact on nursing education, workforce planning, and existing nurses. Education institutions still need to develop and implement new curricula and training programmes, for example. A more fundamental problem is that it is envisaged that the staff nurse diploma will be provided by nursing colleges, but HEQF level 6 is in the Higher Education band and most public and private nursing colleges are not currently registered as higher educational institutions – and the process for changing this is neither quick nor simple.So for me I am not very sure if enough research was done in terms of making a point that the new qualifications are actually tailor-made to suit the current demands of the country. A few interviewees questioned the evidence-base for the content of the policy recommendations:This echoed concerns about whether the current educational proposals meet South Africa's health needs. Some respondents were of the opinion that the tendency towards professionalisation reflected a preoccupation with international comparability, status, and earning potential rather than local health priorities.And why they [Regulations] were not published, I think there were challenges in the Department of Health. The case study revealed a number of problems with key policy actors. The policy process stalled between SANC and the NDoH, but it was unclear which organisation was primarily responsible for the delay. SANC blamed the NDoH:It's a matter of just passing them I think it has been more the Council problems that have stood in the way of those Regulations. At the same time, the NDoH blamed the SANC:I really think that it seems as if one body waits for the other instead of there being somebody that drives the process and then takes it through to completion. Other interviewees highlighted weaknesses of both of these key actors in relation to governance of the nursing sector. They were blamed for the poor coordination between them and their failure to provide leadership to complete the policy process:It's a dysfunctional body I have to say. The sad thing is that it has been going on for years; it's not just this Council. When I was on the Council both terms were relatively dysfunctional. With regard to SANC, problems with the appointment of a registrar, internal divisions, weak administration, changes in the SANC board, and the subordinate role of the new Council in relation to the Minister were blamed for the slow progress:The NDoH also came in for criticism due to their limited capacity in driving the policy reform processes, and the fact that there was no dedicated unit or senior manager responsible for nursing issues. Some respondents felt that the NDoH had not been sufficiently involved in the planning of the new nursing qualifications.In that discussion the unions and the practitioners have not been involved. It's really been agreed by the Nursing Council and universities. Finally, other actors complained about being side-lined in the qualification framework process, and argued that there had been inadequate consultation on an issue that would have significant long-term consequences for all nurses in South Africa:This is one of the first policy analysis studies in South Africa concentrating exclusively on policy development and implementation in the nursing sector. This case study of the development of a new Nursing Qualifications Framework indicates significant weaknesses in the political and technical capacity of the main institutions that are supposed to provide leadership and governance for policy-making in the nursing sector in South Africa.The final Nursing Qualifications Framework developed for South Africa, in proposing both a baccalaureate degree for professional nurses and new general staff nurses, is an interesting compromise that follows the global trend towards more professionalisation, but also attempts to address nursing shortages and the significant deficit in basic nursing care in the country.A few high-income countries, including Belgium, Italy, Spain, Norway, Canada, the United Kingdom, Australia, and New Zealand, have recently made the baccalaureate degree a requirement for registration , 38–40. The influence of nursing educators in the South African policy process contributed to acceptance of the baccalaureate degree requirement for professional nurses, despite initial concerns from NDoH officials that this was not appropriate or cost-effective for South Africa . AlthougThere are some limitations of this policy analysis case study. Although many of the key stakeholders involved in the policy process were interviewed, it was sometimes difficult to cover all of the issues within the time constraints of a single interview. Another difficulty was KI recall bias and the reliance on a retrospective report of events, some of which happened many years previously. Where possible, we corroborated accounts between different respondents and compared the interviews with the documentary evidence. A further limitation is that the analysis focuses mainly on the policy development phase – policy implementation has barely begun and is likely to present additional challenges. Nonetheless, the policy analysis approach of this case study, and its focus on broader systems of governance and leadership within nursing, are unusual in the nursing literature. Most of the available international literature linking nursing and policy-making is concerned with the absence of nurses in broader health policy processes –58. TherReports outlining the most urgent priorities for nursing education reform are frequent , 61–63. A few other authors have commented on the capacities and processes required to support reform in nursing education, at the macro and meso levels. For example, the WHO guidelines on transformative scale-up of health professional education emphasise the importance of national leadership, governance, and planning of health education reform . SpitzerIt is encouraging that nursing stakeholders eventually finalised a new Framework for Nursing Qualifications in South Africa and produced the Regulations required by the Nursing Act of 2005. Also, the Strategic Plan for Nursing Education, Training, and Practice released by the NDoH in March 2013  thoroughThe performance and health outcomes of the South African health system are disappointing given the country's level of economic development. There is renewed commitment and energy to addressing the problem and a number of health system reforms are currently underway , 67. How Notwithstanding the extraordinary and influential roles of many nurse leaders in the development of patient care and population health policies –3, severIn high-income countries such as Australia, Canada, the United Kingdom, and the United States of America, professional nursing associations are important platforms for individual nurses and the nursing profession to exercise power and influence policy –18. A reDespite these encouraging developments, Leavitt  has arguPhaladze  found thIn South Africa, the Ministry of Health has emphasised the critical role of nurses in the implementation and success of health sector reforms towards universal health coverage . HoweverThe study was approved by the University of the Witwatersrand Human Research Ethics Committee  and the Provincial Health Research Ethics Committees in the four participating provinces . Hospital managers also provided permission to access their facilities. All participants received a study information sheet and gave informed written consent.A multiple descriptive case study design, informed by the Walt and Gilson policy analysis framework , was useThe study focused on four national policies: the 2008 Nursing Strategy, the Scope of Practice for nurses, the Framework for Nursing Qualifications, and the OSD.The 2008 Nursing Strategy aimed to address the national nursing crisis by proposing action in six key strategic areas: nursing practice, nursing education and training, nursing leadership, nursing regulation, social positioning of nursing, and resources for nursing . The revThe selection of these four policies was influenced by two factors: prioritisation by key nursing stakeholders at a consultative workshop held in 2008 ; and theThe study was conducted between 2009 and 2011 in four provinces in South Africa: Gauteng, Eastern Cape, Free State, and the Western Cape. The selected provinces were already part of a broader multi-year programme of research on nursing, initially chosen to allow for geographical comparisons  and possible variations in the interpretation and implementation of the selected policies. In each province, we selected one hospital randomly from each of the clusters of academic, regional, district, and specialised hospitals. The final sample consisted of 16 hospitals, four in each province.n=6), provincial government (n=8), private sector (n=1), nursing educators/academics (n=7), statutory body (n=1), nursing association (n=4), and international non-profit global health organisation (n=1). The selected key informants were interviewed using a pilot-tested, semi-structured interview guide focusing on: the extent and nature of nurses’ participation and involvement in policy-making ; the roles, interests, and influence of different nursing actors on these policies; and recommendations for improving nurses’ participation and involvement.Using a snowballing sampling technique, 28 key informants were selected purposively on the basis of their knowledge, involvement, or influence with the policy-making processes of the policies of interest. The key informants comprised the following groups of stakeholders: national government (n=15), professional nurses (n=15), enrolled nurses (n=13), enrolled nursing assistants (n=16), and shop stewards (n=14). The questions focused on the respondents’ awareness and knowledge of the policies under investigation, perceptions about the extent and nature of front-line nurses’ participation and involvement in nursing policy-making, and recommendations for improving nurses’ participation and involvement.Semi-structured interviews were also conducted with 73 front-line nurses in the 16 selected hospitals, consisting of operational managers There was recognition and appreciation amongst several key informants that democracy created numerous opportunities for nurses’ participation in policy development. This was in contrast to the imposition of policies under apartheid. This increased ‘policy space’ occurred within the context of South Africa's rights-based Constitution. One key informant (KI) noted that:[The] Nursing Strategy is driven by nurses themselves because it started nationally when nurse leaders were called in to start with the Strategy. When asked about nurses’ participation in the development of the four policies of interest, all key informants pointed to the wide range of policy actors involved to a greater or lesser degree in the development of these policies. However, there were contradictory views on participation, particularly in the case of the 2008 Nursing Strategy. Key informants from the National and Provincial Departments of Health were of the opinion that the process was nurse-led and that nursing leaders and representatives from all sections of the nursing profession had been involved, as can be seen from the excerpt below:Very few nurses were involved in the development of the Nursing Strategy. Nurses were not at the policy table. This was in contrast to respondents from outside the National and Provincial Departments who were of the opinion that the process and development of the Nursing Strategy were led by staff in the National Department who were not nurses. One said:I don't understand how they [policy-makers] make decisions about nurses without involving the nurses. There are things that are decided by National [the National Department of Health] but when you are in the ward you see things practically and when you compare it to the policies, these [policies] are unrealistic. There was also a strong sense amongst front-line nurses and several key informants that front-line nurses were excluded from participation in broader health workforce policies. Front-line nurses believed they were excluded from policy processes because of the failure of policy-makers to recognise the importance of their clinical knowledge and expertise in informing policies. Some of these nurses commented that:I think that in policy development, it would be impossible to get all the 120 or 140,000 nurses into one room and say ‘do you agree with this policy that has been proposed’. Although respondents acknowledged that the participation of front-line nurses is important, some informants were of the view that it is impractical to involve all the nurses considering that they are the largest group of health professionals.The study found that the nature of the policy determined the level of awareness of front-line nurses. One hundred percent of enrolled nurses, professional nurses, operational managers, and shop stewards, and 88% of enrolled nursing assistants, reported that they have heard about the OSD policy. This was in contrast to the other three policies, where the level of awareness on policies was much lower. Operational managers and shop stewards were more likely to know about policies than other categories of nurses. The level of awareness among operational managers ranged from a low of 29% for the new Qualifications Framework to 71% for the new Scope of Practice for nurses. In the case of shop stewards, the level of awareness ranged from a low of 33% for the new Qualifications Framework to 67% for the Nursing Strategy. It was a very top down approach such that those of us who were academics from the universities, I remember we actually left that meeting feeling like ‘what's the point’? There has always been a doctor behind it and telling nurses in a very top down way of saying ‘this is what the DoH [Department of Health] has decided and you shall do that!’ The majority of study participants were of the opinion that there was insufficient involvement of nurses in policy development. One key informant, reflecting on the OSD policy processes, commented that even though there was consultation with nursing leaders, their views were not incorporated into the policy, thus leading to unintended consequences during policy implementation.When I think of nurse leaders, I think we are reactive because policies are being made in different areas, be it health, be it education, and we always seem like we come at a point when it is done and dusted; that's where we always find ourselves most of the time. We are happy to respond to what people say about us rather than challenge them. A number of key informants were also of the view that nurse leaders are reactive rather than proactive when it comes to nursing policy processes. With regard to the Scope of Practice and Qualifications Framework policies, one key informant commented that nurse leaders often participate in policy-making when decisions have already been concluded:The challenge in South Africa about nursing is that, while we have nurses that are holding key positions, those nurses sometimes don't even have ‘teeth’ to change whatever they want to change. Another key informant was of the view that even though some nurses hold senior positions in provincial government and have the potential to influence policy, these nurses are not assertive enough to ensure that changes that could affect the nursing profession are achieved:I made comments as an individual …. I participated as a consultant I was involved and worked in a province but I wasn't representing a province – just sitting as an individual. The key informants’ interviews thus identified two main categories for describing the nature of nurses’ participation in the policy processes. Individual participation happened when participants felt that their invitation to participate and be involved was on an individual basis and not intended to represent any specific interest group in nursing. Collective or representational participation happened when participants viewed their invitation to participate and be involved as representing a specific nursing interest group, such as the national nursing association, educators, or academia. Hence, participants’ views on the level and nature of participation differed depending on the policy of interest. For example, with regard to the Scope of Practice, the Qualifications Framework, and the OSD, the key actors were of the opinion that they either represented a particular nursing structure or interest group. With regard to the development of the Nursing Strategy, some informants were consulted in an individual capacity:And I was involved in the Nursing Strategy after that, I was swallowed up in the OSD stories. Most of my time went into the OSD. Hence these informants appeared to view individual participation in the Nursing Strategy as a relatively minor contribution as it did not represent the views of the majority of nurses. According to key informants, the general approach to involving nurses in some of these policies tended to be formal and included activities such as serving on committees or boards, providing inputs into draft policy documents, chairing committees and/or trade union representation in collective bargaining processes. Because of the small pool of nurse leaders to draw from, the tendency of policy-makers to focus on multiple nursing policy issues in a short space of time required those involved to shift their attention constantly from one policy to another. They indicated that the OSD was introduced in 2007 but was implemented in 2008, whereas the Nursing Strategy was introduced in 2008. Around the same time period, debates around the Scope of Practice and the Qualifications Framework were also happening. One informant commented:The other issue that I really see as a problem is that nurses as a whole are not trained in policy, they don't understand what policy is about and they don't understand the policy cycle. If you don't understand the policy cycle, then you will not know when there is a window of opportunity to influence policy. We need to learn to be politically clever. Nurses don't have the skills of networking like businessmen do at the golf course. With regard to the non-participation of front-line nurses, some informants were of the view that in a few instances where platforms were created to involve these nurses – such as inviting them to workshops – they seldom participated because they were intimidated by the presence of their managers. Overall, some of the reasons provided by key informants for the perceived limited participation of the broader nursing community in nursing policy processes include: the dominance of physicians and ‘others’ such as hospital CEOs and human resource managers, the under-representation of nurses in leadership positions, the predominantly female nature of the profession, and lack of training in policy and networking skills.Unless the profession claims back what is ours, people shouldn't have this thing of, ‘you know we have not been consulted when the policy was being made?’ If you really stand your ground as the leader in your profession, and taking leadership in that regard, you will be involved in policy development. On the one hand, we are saying we are the backbone of the health care service, but we don't behave like we are the backbone. I think every nurse leader should make it her business to get involved in policy development. She should be staying close to debates and know exactly what is going on. In general, a number of key informants commented that nurses themselves are to blame for their limited involvement and participation in policy-making processes because they tend to adopt a passive role in the policy-making process. This is mainly indicated through statements such as ‘nurses are not given an opportunity’ to participate in nursing policy processes or that ‘policies are developed without us’. Interestingly, some informants were optimistic that if nurses changed their way of thinking, they could turn the situation around and achieve maximum participation in health policy processes. Some informants commented that:We wanted to see the Minister of Health, but the Minister indicated that ‘Until the nurses have got one voice, I don't want to see them because sometimes there will be DENOSA [Democratic Nursing Organisation of South Africa] whose approach is more trade union kind of, there will be a group from the college, a group from the clinical side, a group from all those private sector people and you are all talking different things. Can you nurses just make up your mind and come as one voice to see me?’ The majority of key informants complained about the lack of cohesion or lack of collective action amongst different nursing stakeholders, which include the national nursing association, professional interest groups, university nursing academics, nursing college educators, nursing managers, the nursing council, and private sector nurses. These internal divisions discouraged collaboration among different nursing groups and made it difficult for nurses to have a unified voice, thus having a negative impact on how nurses were viewed by external actors, especially by key policy-makers. One informant explained:Most of the provinces, Nursing Directorates are reporting to the Hospital Service Managers who have a different mandate altogether because their interests is about hospitals, it's not about nurses only. There were also apparent tensions expressed with regard to the position of nursing within the organisational structure of the National and Provincial Departments of Health. Depending on the province, the Nursing Division could report to Corporate Services, Hospital Services, or Human Resources for Health Directorates. A consistent view was that this hierarchy and lack of seniority of the designated nurses made it even more difficult to influence policy:Who is the Nursing Leadership because when I go there, they don't see me as representing a nursing voice? They would say ‘No, you are an academic’. In addition, some key informants also discussed the contestations around representation and the perceived legitimacy of some nursing groups. This was influenced by status and power relations within the profession. For example, there was a strong perception amongst some key informants that nurse academics or private sector nurses, had more prestige than those from nursing colleges or public health services. Therefore, there was a sense amongst these informants that prioritisation of nursing issues depended on how influential a certain group was and the agenda being pursued by a particular group. This tension was most prominent in relation to the Nursing Qualifications Framework.We keep on allowing other people to make decisions for us, people who don't understand how we work, people who don't understand how we are trained or how we think sometimes. Several key informants expressed concerns about officials in the Human Resource Directorate of the National Department of Health who were leading the development of these four national policies, but who had limited or no understanding of the needs and expectations of nurses and the complexity of the nursing profession.This study found that South Africa's democracy created opportunities and increased nurses’ participation in health policy development. Different nursing stakeholders – the national nursing association, professional interest groups, university nursing academics, nursing educators, nursing managers, the nursing council, and private sector nurses – were involved to a greater or lesser degree in the development of the four national policies of interest.However, the study found that nurses’ participation in policy-making is both complex and contested. There was a disjuncture between nursing leadership and front-line nurses in their levels of awareness of the four policies analysed. Front-line nurses were generally unaware of the 2008 Nursing Strategy, the revised Scope of Practice for nurses, and the new Framework for Nursing Qualifications. The exception was their awareness of the OSD remuneration policy as it affected them directly. However, even within this group of front-line nurses, there were different levels of awareness with operational managers and union shop stewards more likely to know about the four policies of interest, compared to other categories of nurses. A minority of front-line nurses were aware of the new Framework for Nursing Qualifications which will change nursing education radically when implemented. These findings were in contrast to studies in Thailand  and BotsThe majority of key informants and front-line nurses were of the opinion that nurses’ participation in nursing policy development was sub-optimal, thus supporting the findings of other studies of limited nurses involvement in health policy development , 12, 22.Shifting power relationships influenced who participated , with contestations regarding the legitimacy of the different nursing stakeholder groups. This is not surprising as Buse et al.  have poiThe degree to which nurses’ views and inputs were considered and incorporated was also contested, with the OSD policy given as an example of the unintended consequences that occurred during policy implementation, because these perspectives or insights from nurses were ignored. These consequences included demoralisation of front-line nurses; and adverse relationships between managers and nurses, and among different categories of nurses , p. 141.The sub-optimal involvement of nurses in health policy development was exacerbated by both internal and external barriers. Internal barriers to nurses’ participation or involvement in broader health policies included the perceived reactive (as opposed to a more proactive) approach of nursing leadership; their relative lack of assertiveness and notions of victim mentality, even when they held senior provincial government positions; the small number of nurses with policy and/or advocacy skills; and the lack of cohesion or lack of collective action amongst different nursing stakeholders. A major external barrier was the position of nursing within the health hierarchy and organisational structures in South Africa. For example, at the time when this study was conducted, there was no chief nursing officer (CNO) or nursing directorate in the National Department of Health, the human resource division was headed by a medical doctor, and there were no nurses dealing with any of the four policies that primarily affected nurses. Buse et al. have noted that doctors were often more influential in public health policy either as civil servants or as health ministers , while SThis paper makes an important contribution to both the national and international literature on health policy analysis. However, the findings may not be generalisable as the study was limited to four South African provinces and key informants were selected purposively. The data gathered also represent the perceptions of key informants and front-line nurses at a point in time. Nonetheless, the study provides rich insights into the dynamics, strengths, and weaknesses of nurses’ participation in four national health workforce policies.Since the study was conducted, the first CNO in democratic South Africa has been appointed. The appointment of the CNO is a positive development, as the experience in other countries has shown the impact of such an appointment on cohesion and collective action by the nursing profession , 14. In The importance of nurses to the success of health sector reforms in South Africa is unquestionable. There is evidence of the benefits to the health care system, patients, and the nursing profession when nurses are involved in health policy development , 40, 41. In recent years, staff retention, or the extent to which health care providers remain in the health system, has risen in prominence in the global discourse on the health workforce, because of its potential to improve their availability and accessibility –3. The rIn the health system, high turnover of skilled health professionals has both economic and non-economic consequences , 13, 14.The reasons for high nurse turnover remain complex, and may vary over time . NonetheNotwithstanding the voluminous literature, there are knowledge gaps in the studies on nurse turnover. These gaps include limited empirical information on the cost of nurse turnover to a health facility or the system as a whole and the impact of turnover on patient outcomes . OrganisIn South Africa, the shortages and high turnover of nurses  impede tDuring 2010, a one-stage cluster random sample of 80 hospitals was selected from the four South African provinces of the Eastern Cape , Free State , Gauteng (urban), and the Western Cape (predominantly urban). The Human Research Ethics Committee  of the University of the Witwatersrand in Johannesburg provided ethics approval for the study. The relevant public and private health care authorities also provided the necessary study approvals. All participants provided written, informed consent.In each of the four provinces, the sampling frame consisted of all public and private hospitals, stratified by type of hospital for public hospitals; and by ownership and hospital bed numbers for private hospitals. A random sample of public and private sector hospitals was then selected from each stratum proportional to the total number of hospitals in that stratum.On the 24-hour survey day, all nurses working in critical care, theatre, emergency, maternity, and general medical and surgical wards completed a self-administered questionnaire after giving informed consent. In addition to demographic characteristics and information on moonlighting, the questionnaire obtained data on the participants’ intention to leave their primary jobs in the 12 months following the survey. Further details of the survey methodology are provided in the previous article .In the study moonlighting was defined as additional paid work – whether of a nursing or non-nursing nature – done by nurses in a private health facility, another government health facility, an insurance company, private health laboratory, or in the same health care facility while holding a primary, paid nursing job, but excluding overtime . Intenti® 13. We also adjusted for the clustering and stratification introduced by the sampling design. Frequency tabulations were done to describe the socio-demographic characteristics of the respondents. Cross-tabulations were done to investigate associations of each of the factors, including moonlighting, with the intention to leave employment in the 12 months following the survey, our main outcome of interest. Bivariate logistic regression models were fitted and only factors found to be statistically significantly associated with intention to leave at a conservative 20% level were considered in the final model-building process using a multiple logistic regression model. All other statistical tests were carried out at 5% significance level.Data were weighted to reflect the population distribution of nurses between the public and private health sectors, and the four study provinces, and analysed using STATAThe unweighted demographic and background characteristics of the 3,784 nurses recruited in the four study provinces are shown in In the study, 1,086 participants (30.9%) indicated that they planned to leave their primary jobs in the 12 months following the survey. Of these, 15.4% indicated that they planned to go overseas, 36.7% to move to another public sector job, and 13.5% to another private sector job. The remainder were made up of smaller proportions planning to work in nursing agencies or non-governmental organisations, or who planned to study, retire, or stay at home in the following year.p<0.001) compared to those with between 5 and 9 years of service (39.2%).The study participants’ intention to leave their primary jobs varied by age, province, years at the primary job, nursing category, number of children, and moonlighting status . 37.7% op<0.001). It was highest among professional or registered nurses with 4 years of training (36.2%), than among enrolled nurses with 2 years of training (32.5%) or among nursing assistants with 1 year of training (22.1%). Lastly, the proportion of participants with intention to leave in the 12 months following the survey was higher among the moonlighters compared to non-moonlighters . Among those planning to go overseas, 18% (82) of moonlighters, compared to 13.8% (89) of non-moonlighters planned to go overseas, but this difference was not statistically significant (p=0.06).In the multiple logistic regression analysis, predictors of intention to leave were: moonlighting in the preceding year, nursing category, sector of primary employment, period working at the primary job, and number of children .The weighted crude (unadjusted) odds for intention to leave the primary job in the 12 months following the survey were 1.69 (95% CI: 1.41–2.02) times higher among the moonlighters compared to the non-moonlighters. This was still significant  after adjusting for other factors such as nursing category, sector of primary job and years working in the primary job, sector and province of primary employment.The adjusted analysis shows that individuals working for a commercial nursing agency  were more likely to express intention to leave, compared to those working in the provincial government. Enrolled nurses  or nursing assistants  were less likely to report intention to leave compared to professional nurses. The odds of individuals who have worked for 1–4 years to report intention to leave their primary job in the 12 months following the survey were 2.21 (92% CI: 1.59–3.07) times higher compared to those who have worked for less than 1 year. The intentions peak among those with 5–9 years’ experience . In later years of working experience, although the odds of participants reporting intention (ORs: 1.61–1.70) to leave were higher, the results show a fall in such intentions in relation to the reference group. The adjusted results also show a decline in nurses’ intentions to leave their primary jobs with increasing number of children. The odds ratios range from 0.71 (95% CI: 0.54–0.95) among those with one child to 0.59 (95% CI: 0.40–0.87) among those with four or more children compared to those with no children.We found that almost one-third (30.9%) of respondents indicated their intention to leave their primary employment in the 12 months following the survey. This figure was lower than the turnover intent of nurses found in other studies done in South Africa in recent years , 26. A 2There are wide variations in study findings on turnover intent. The finding of 30.9% turnover intent in our study is similar to that found in Belgian hospitals done as part of a multi-country study – 30% of Belgian registered nurses indicated that they planned to leave their jobs . The mulIn the multiple logistic regression analysis, the predictors of intention to leave were: category of nurse, primary employment in a commercial nursing agency, working for between 1 and 10 years at the primary job, and moonlighting in the preceding year .Enrolled nurses or nursing assistants were less likely to report intention to leave compared to professional nurses . This maSurprisingly, nurses working for a commercial nursing agency were more likely to indicate their intention to leave, compared to those working in the public health sector. This may be related to the timing of the study, as there was a major public sector financial incentive policy implemented 2 years prior to the survey, which assisted in attracting large numbers of nurses back to the public health sector , 54.The study found that those nurses working for between 1 and 10 years at the primary job were more likely to indicate their intention to leave. A 2005 study to examine the relationship between job satisfaction, turnover intent, and demographic variables among primary health care nurses in a rural area of South Africa found that turnover intent was significantly and inversely correlated with the number of years of nursing . HoweverThis is one of the first studies to examine the relationship between moonlighting and nurses’ intention to leave. We found a significant association between moonlighting and nurses’ intention to leave their primary jobs (39.5% among the moonlighters compared to 28% among non-moonlighters). The adjusted odds for intention to leave the primary job in the 12 months following the survey were 1.40 times higher among moonlighting nurses compared to the non-moonlighters. Organisational development researchers have suggested that moonlighting provides workers with an alternative source of income, training, and benefits, thus influencing turnover . This thThe limitations of the study include: the cross-sectional study design which can only capture nurses remaining in their jobs; the possible social desirability bias resulting in lower disclosures of dissatisfaction, moonlighting, or intention to leave; and the fact that nurses who had not formally obtained permission for moonlighting may have been reluctant to admit to it. These limitations are discussed in more detail in the previous article . AlthougOur study findings have implications for health workforce policies and management, and for quality of care. As indicated above, high nurse turnover has the potential to affect health care provision to patients , 30, 31 South Africa's five-year plan on human resources for health emphasises the importance of staff retention, both as a strategic imperative and as an outcome . SimilarAlthough both staff retention and mechanisms to address quality of care are highlighted in various policy documents , 56, 57,A first step in the management of moonlighting is to recognise that it is widespread  and motiIn the medium term, a uniform national monitoring and evaluation system should be developed, which includes indicators such as nurses’ absenteeism rates and trends, and total number of hours worked by each nurse, through improved employer personnel or nursing council information systems.Both the public and private health sectors in South Africa have a statutory duty to provide the best possible health care to patients within available resources and to achieve a balance between the rights and duties of health care providers . The stu Achieving universal health coverage to enable everyone to access the health services they need irrespective of ability to pay  and ensuOne aspect that has received inadequate attention in the description of the nursing crisis, by both the Global Health Workforce Alliance and the World Health Organization (WHO), is the casualisation of the nursing workforce and its implications for the nursing profession and for health system performance –4. The tinter alia on the commitment, roles, job satisfaction, conflict, perceived organisational support, organisational citizenship behaviours, health and well-being of contingent workers, and their performance in the workplace . Free State , Gauteng (urban), and the Western Cape (predominantly urban). The Human Research Ethics Committee  of the University of the Witwatersrand in Johannesburg provided ethics approval for the study. The relevant public and private health care authorities also provided the necessary study approvals. All participants provided written, informed consent.In each of the four provinces, the sampling frame consisted of all public and private hospitals, stratified by type of hospital for public hospitals and by ownership and hospital bed numbers for private hospitals. A random sample of public and private sector hospitals was then selected from each stratum proportional to the total number of hospitals in that stratum.In the study, moonlighting was defined as additional paid work – whether of a nursing or non-nursing nature – done by nurses in a private health facility, another government health facility, an insurance company, private health laboratory, or in the same health care facility while holding a primary, paid nursing job, but excluding overtime . Agency On the 24-hour survey day, all nurses working in critical care, theatre, emergency, maternity, and general medical and surgical wards completed a self-administered questionnaire after giving informed consent. The questionnaire obtained information on demographic characteristics, agency nursing and moonlighting, and participants’ experiences of health system incidents in the 12 months preceding the survey. These incidents are proxy indicators of health system consequences of agency nursing and moonlighting, identified in the international literature and in the formative research conducted prior to the survey. All participants were asked to indicate whether they had felt too tired to work while on duty; paid less attention to nursing work while on duty; taken sick leave when not sick; stayed away from work without authority to do so; or been involved in a medico-legal incident, for example administration of the wrong medication or a patient death (type 1 indicators). In addition, those participants who indicated that they had done moonlighting or agency nursing in the 12 months preceding the survey were asked to indicate whether they had argued with doctors or other nurses, experienced conflicting schedules between their primary and secondary jobs, taken sick leave to do agency work or moonlighting, taken vacation leave to do agency work or moonlighting, stayed away from work without authority to do agency work or moonlighting, or treated patients differently (e.g. shouted at patients) in their primary compared to their secondary job (type 2 indicators). Further details of the survey methodology are provided in a previous article .® 13. We also adjusted for the clustering and stratification introduced by the sampling design. Frequency tabulations were done to describe the socio-demographic characteristics of the respondents. Cross-tabulations were done to investigate associations of each of the factors, including agency nursing and moonlighting, with the type 1 and type 2 proxy indicators of health system consequences in the 12 months preceding the survey, our main outcomes of interest. Bivariate logistic regression models were fitted and only factors found to be statistically significantly associated with the health system consequences at a conservative 20% level were considered further in the final model-building process using multiple logistic regression. All other statistical tests were considered significant at the 5% level.Data were weighted to reflect the population distribution of nurses between the public and private health sectors and the four study provinces; and analysed using STATAt-tests and ANOVA.We also used multiple correspondence analysis (MCA) to derive two indices of health system consequences (for type 1 and type 2 indicators). MCA is a data reduction method similar to principal component analysis but more appropriate for categorical data , 44. TheThe majority of survey participants were female (92.7%) and employed in provincial government (52.8%). The participants were predominantly middle-aged, with a mean age of 41.5 (SD: 10.4) years. The unweighted demographic and background characteristics of the 3,784 nurses recruited in the four study provinces are shown elsewhere in this special journal issue . ImportaIn the study, 51.5% of all participants said that they felt too tired to work while on duty, 11.5% paid less attention to nursing work while on duty, 10.9% had taken sick leave when not actually sick, 5.6% had stayed away from work without authority, and 2.9% reported being involved in a medico-legal incident . More thp=0.011) and to pay less attention to nursing work while on duty , but there were no significant differences between the two groups for any of the other type 1 indicators. The MCA composite index was higher for moonlighting nurses but again the difference was not statistically significant. Type 2 indicators were only collected among those participants that had done moonlighting or agency nursing in the year preceding the survey . In thisInstead, the multiple logistic regression analysis found that the differences for these variables were explained by province , age, sector of employment, nursing category, and the number of years at the primary job .In terms of geographical location and relative to Gauteng, those participants from the Western Cape were significantly less likely to report that they stayed away from work without authority ; felt too tired to work while on duty ; or paid less attention to nursing work while on duty . Participants from the Free State province were also less likely to report that they felt too tired to work while on duty, took sick leave when not actually sick, or paid less attention to nursing work while on duty .Interestingly, those nurses over 55 years old were much less likely to report that they stayed away without authority to do so ; felt too tired to work while on duty ; had taken sick leave when not actually sick ; or paid less attention to nursing work while on duty .Relative to the public sector participants, those nurses from the private sector were less likely to report that they stayed away from work without authority , felt too tired to work while on duty ; or had taken sick leave when not actually sick . However, they were more likely to report that they paid less attention to nursing while at work . Those from a commercial nursing agency were also less likely to report that they felt too tired to work while on duty .The analysis found that nursing assistants were less likely than professional nurses to report any of the incidents measured in the study. However, there were differences related to the number of years of employment at the primary job, with nurses who had been working for between 1 and 14 years reporting higher likelihoods of taking sick leave when not actually sick .Similar variations by province, sector, nursing category, and unit were found in the multiple regressions of health system consequences relevant to the moonlighting group only .In terms of geographical location and relative to Gauteng, those moonlighters from the Western Cape were less likely to report that they had conflicting schedules between primary and secondary jobs (OR: 0.34: 95% CI: 0.23–0.51); taken vacation leave to do agency work or moonlighting ; treated patients differently in the primary compared to the secondary job  or argued with doctors or other nurses . Participants from the Free State province were also less likely to report that they had taken sick leave to do agency work or moonlighting or that they argued with doctors or other nurses .Those working for a commercial nursing agency were more likely to report that they stayed away without authority to do agency work or moonlighting, with an odds ratio of 5.44 (95% CI: 1.31–22.63).Relative to professional nurses, enrolled nurses, and nursing assistants were less likely to report that they had taken vacation leave to do agency work or moonlighting .p=0.011) and pay less attention to nursing work while on duty . However, these differences did not remain statistically significant after adjusting for other socio-demographic variables in the multiple regression analysis, even though the odds ratios for these two variables were greater than 1 for moonlighters compared to non-moonlighters . Although this logic makes sense, our analysis did not find consistent statistically significant differences in self-reported health system incidents between moonlighting and non-moonlighting nurses. The bivariate analysis found that moonlighters were more likely to take sick leave when not sick  contributes to the fatigue and burnout of permanent staff, who have to cover for or assist these temporary nurses; reduces the quality of patient care; and increases the risk of liability . Our stuAlthough there is increasing policy attention to the performance of the health workforce , 40, theIn the bivariate analysis, factors associated with nurses reporting feeling tired at work were geographical location (province), age group, marital status, public sector employment, category of nurse, and the number of years qualified as a nurse . InteresThe reported fatigue among nurses is exacerbated by other negative health system consequences found in this study. Among moonlighting nurses, 11.9% indicated that they had used their vacation leave to do agency work or moonlighting, contributing to fatigue. Nurses also reported unacceptably high rates of unauthorised absences leading to further understaffing, overwork, and health worker exhaustion. Of all nurses, 10.9% indicated that they had taken sick leave when not actually sick, and 5.6% had missed work without permission. These incidents were more common among moonlighting nurses who indicated that the unauthorised absences were sometimes used to do agency work or moonlighting.A minority of nurses in the study (2.9%) reported a medico-legal incident, with category of nurse being the main predictor of reporting such an incident . NursingThe study found that 33.7% of those who had done moonlighting or agency nursing were involved in any of the negative incidents . There wThere are a number of limitations of the study. As with all cross-sectional surveys, the temporal sequence between moonlighting or agency nursing and health system consequences could not be determined, leading to uncertainty as to whether these proxy indicators were causally related to moonlighting. Also, the consequences were self-reported, and we did not have objective measures of leave taken, absenteeism (staying away without authority), or medico-legal incidents. We also did not use a pretested instrument to measure fatigue. With self-reported data there is also always the possibility of social desirability bias resulting in lower disclosures of moonlighting or of negative health system consequences. The fact that the questionnaires were self-administered and anonymous provided greater privacy, which should have led to more accurate reporting of practices that are subject to social sanction. However, if moonlighting nurses were less likely to report health system consequences than non-moonlighters, it may also explain the lack of consistent statistical differences between the groups. Other limitations of the general survey are discussed in more detail in the previous article .Notwithstanding these limitations, this study makes a number of important contributions. Our study is one of the first representative studies in South Africa and in Africa to examine the health system consequences of agency nursing and moonlighting – examples of casual or contingent work. The self-reported information on nurse fatigue in this large survey provides a basis for future comparisons of this aspect, which is a risk factor to patient safety and nurse well-being. The study also assisted in putting moonlighting and agency nursing on the health policy agenda in South Africa. However, further research is needed to assess the impact of moonlighting and agency nursing on more objective measures of nurse performance and ultimately on patient outcomes.Our research has implications for health workforce policies and management and for quality of care. In South Africa, the Basic Conditions of Employment Act regulates the number of hours of employment in both the public and private health sectors , hence tIn terms of moonlighting, the South African Public Service Act stipulates the conditions for additional, paid employment in the public sector . In theoLastly, South Africa's emphasis on patient safety and quality of care  necessitThis study has investigated the negative health system consequences of agency nursing and moonlighting using a number of self-reported proxy indicators. Although we did not find consistent statistically significant differences between moonlighting and non-moonlighting nurses, the reported health system incidents are serious and further research is warranted. Although the process is complex, the casualisation of the nursing workforce cannot be viewed in isolation of South Africa's overall health system challenges, in particular its human resource challenges. In both the public and private health sectors, agency nurses are used to address nursing shortages . At the  The global quest for universal health coverage has once again put the spotlight on the centrality of the health workforce to achieving this goal . New modWorldwide, the management of nursing shortages in health facilities is a major problem . In AustMuch of the literature on nursing agencies is concerned with high-income countries , 11–16. There are few empirical studies on nursing agencies , 6, 8, aCost information is important for the management of temporary staff in a health facility, for shaping policy responses, monitoring trends, and/or benchmarking the performance of nursing agencies in the health system , 30. CosThe study setting was the nine provincial health departments in South Africa, which were classified as follows: urban (Gauteng and Western Cape), rural , and mixed urban-rural . The study was approved by the Human Research Ethics Committee  of the University of the Witwatersrand in Johannesburg. The provincial health authorities also provided approval for the study.survey was conducted among all nine provincial health departments in South Africa to determine the utilisation and management of nursing agencies. The survey aimed to develop an understanding of the drivers of agency nurse utilisation and to explore the policies on, and management of, nursing agencies. Four face-to-face interviews and three telephonic interviews were conducted, using a semi-structured interview schedule. In the case of one province, the human resource manager in the province completed the interview schedule and faxed it back to the researchers. The interview schedule focussed on utilisation of nursing agencies in the province; the type of health facilities or services that utilise agency nurses; policy frameworks that guide the use of nursing agencies, including the existence of a specific provincial policy; and the perceived advantages and disadvantages of nursing agencies. The information from the interviews was coded and analysed using thematic content analysis.A expenditure on nursing agencies. Data on provincial health expenditure were obtained for five financial years (2005/6–2009/10) from the national transversal Basic Accounting System (BAS) database . The financial year in government commences on 1 April each year and ends on 31 March of the following year. The data were exported into Microsoft Excel in order to facilitate uniform coding of the expenditure information and to do trend analysis across the entire period (2005/06 to 2009/10). Each financial year was put into a separate worksheet. The number of expenditure line items ranged from 30,595 in the 2005/6 financial year to 34,978 in the 2009/10 financial year, totalling 166,466 line items for coding over the 5-year period. Each line item was coded meticulously, depending on the type of expenditure, and similar items were grouped and aggregated. The coding also took into account the province or health facility where the expenditure occurred. Once each item was coded, cross-tabulations and calculations were done to ensure that the same total expenditure was obtained for each provincial health department, thus ensuring both validity and reliability of the study results.A cost analysis of nursing agencies was done for the 5-year period from 2005 until 2010. We assumed that the direct costs of nursing agencies were equivalent to Overall provincial health expenditure consists of all expenditure items, including compensation of employees, goods and services , transfer payments , and capital expenditure. Personnel expenditure, also called compensation of employees, consists of salaries, staff benefits, and overtime payments. Nursing agency expenditure consists of all expenses paid to commercial nursing agencies (including administration fees) and is paid from the goods and services budget of each provincial health department.For each of the nine provinces, the total personnel and nursing agency expenditure was calculated for each financial year. Agency nursing expenditure as a percentage of the total personnel expenditure was then calculated, for each province and for each financial year. The nursing agency expenditure for all provinces was totalled to arrive at agency expenditure for South Africa for each financial year, and over the 5-year period.In order to calculate the number of full-time-equivalent (FTE) nurses who could have been employed for the given nursing agency expenditure for that province, the 2009/10 government salary scales for different categories of nurses  were obtained. The median salary for each nursing category was calculated. Assuming standard benefits such as health insurance and housing subsidy, 30% was added to the amount. This amount for each nursing category was then used to calculate the number of FTE nurses. All expenditure is expressed in South African rand .Eight out of nine provincial health departments responded to the provincial survey on nursing agencies (89% response rate). The team tried unsuccessfully for 18 months to get a response from the Northern Cape Provincial Health Department.The provincial survey  found thAs can be seen from Eastern Cape and Western Cape Provinces show more than 50% declines in nursing agency expenditure as a percentage of personnel expenditure over the study period. In Northern Cape, nursing agency expenditure constituted 11.96% of personnel spending in the 2009/10 financial year, whereas in North West, agency expenditure was 15.13% of the personnel expenditure in the 2008/9 financial year. In Gauteng, nursing agency expenditure as a percentage of personnel spending showed a similar pattern to overall spending, with increases between 2005/6 and 2007/8, and declines in the 2008/9 and 2009/10 financial years. There was no consistent spending pattern in the other provinces.In 2009/10, the annual salary package of a professional nurse (4 years of training) was R277,226 , an enrolled nurse (2 years of training) earned an annual salary of R154,471 , and an auxiliary nurse (1 year of training) earned an annual salary of R119,646 . Using these salary packages, As can be seen from The provincial survey revealed wide variations in the utilisation and management of nursing agencies across the nine provinces , despiteagency nursing staff during 2004/5, and £773 million on all temporary nursing staff (The costing study found that nursing agency expenditure in the South African public sector ranged from R914.29 million (US$130.61 million) in the 2005/6 financial year to R1.49 billion (US$212.64 million) in the 2009/10 financial year. This total amount of R6.47 billion (US$924.01 million) that was spent on nursing agencies for the 5-year study period was more than the 2009/10 provincial health budget of Free State, Mpumalanga, Northern Cape, or North West Province . We coulng staff . HoweverThe costing study found that each of the nine provincial health departments spent considerable sums of money on nursing agencies that supply temporary staff . There wIn the 2009/10 financial year, nursing agency expenditure as a percentage of personnel expenditure ranged from 0.96% in KwaZulu-Natal to 11.96% in Northern Cape. The reasons for the variations in expenditure are not clear. In the provincial survey, KwaZulu-Natal indicated that budgetary constraints prevented them from utilising nursing agencies. This could explain the relatively low percentage of nursing agency expenditure, relative to personnel spending. Northern Cape did not respond to the survey, thus its reasons for the utilisation of nursing agencies could not be elicited. A study in Melbourne, Australia, found that expenditure on agency staff ranged from 5 to 10% of the monthly staffing budget, but this figure was as high as 35% in some institutions . In EnglThere are several limitations of the study. In the costing study, we assumed that direct costs were equal to expenditure. We also used public sector vacancies as a proxy for staff shortages, which is reasonable in the absence of national staffing norms. However, there is no standard definition of a ‘vacancy’, and in some instances a vacancy could be measured against an old, outdated organisational structure or against the available budget . FurtherThe study also relied on self-reported information from senior government officials, which was shown to be inaccurate in at least two of the provinces. Although financial statistics tend to be more accurate than other information, the study used official government statistics that the provincial health departments submitted to the National Treasury, and data quality remains a challenge.Notwithstanding these limitations, the study has numerous strengths. The study is novel in combining and contrasting information obtained through a provincial survey, with a detailed analysis and interpretation of expenditure on nursing agencies, and the trends in such expenditure over a 5-year period. A major strength of the study is its national focus, thus making an important contribution to the knowledge and understanding of the expenditure, management, and utilisation of nursing agencies in the South African public health sector. The study provides empirical evidence of the extensive utilisation of temporary agency staff in the South African public health sector, which is illustrated by the high expenditure on nursing agencies in all provinces. An important finding of the study is that 5369 professional or registered nurses with 4 years of training could have been employed in the South African public health sector in 2009/10 in lieu of nursing agency expenditure. The study also illustrates the usefulness of a trend analysis of routine financial data, and the potential of such analysis to inform policy or decision making.Notwithstanding these limitations, the study has numerous strengths. The study is novel in combining and contrasting information obtained through a provincial survey, with a detailed analysis and interpretation of expenditure on nursing agencies, and the trends in such expenditure over a 5-year period. A major strength of the study is its national focus, thus making an important contribution to the knowledge and understanding of the expenditure, management, and utilisation of nursing agencies in the South African public health sector. The study provides empirical evidence of the extensive utilisation of temporary agency staff in the South African public health sector, which is illustrated by the high expenditure on nursing agencies in all provinces. An important finding of the study is that 5369 professional or registered nurses with 4 years of training could have been employed in the South African public health sector in 2009/10 in lieu of nursing agency expenditure. The study also illustrates the usefulness of a trend analysis of routine financial data, and the potential of such analysis to inform policy or decision making.patient safety, clinical governance, and clinical care in the national core standards focusses on ‘how to ensure quality nursing and clinical care and ethical practice, and reduce unintended harm to health care users or patients in identified cases of greater clinical risk’ . Although the utilisation of temporary agency nurses is a short-term solution to staffing shortages, there is a growing body of evidence that casual or temporary staffing contributes to poor quality of patient care  has published an action framework to enhance the capacity of nurses and midwives to contribute to global health targets, people-centred care, universal health coverage, and health workforce policies . This isn-making .Globally, flexible work arrangements, through the use of temporary nursing staff or the working practices of permanent staff, have emerged as an important strategy for dealing with nursing shortages, particularly in hospitals –15. TempAlthough the guidelines of the Africa region on strengthening nursing and midwifery services emphasise the importance of expanding the discourse beyond nurse shortages, and examining expenditure, among other issues , there iHowever, there are also indirect costs associated with agency nursing, defined as an ‘expense (e.g. supervision or staff orientation) incurred in joint usage and, therefore, difficult to assign to or identify with a specific cost centre, function, or programme’ (in this case nursing agencies) . SeveralIn light of the considerable amount of money spent on nursing agencies in the South African public health sector , the objTwo public sector hospitals – one central hospital providing tertiary services and one large regional hospital – were selected purposively in Gauteng Province, South Africa.The University of the Witwatersrand Human Research Ethics Committee  granted ethical approval for the study. The public healthcare authorities and the chief executive officers (CEOs) at the two hospitals also provided study approval. All participants received a study information sheet and were required to sign an informed consent form to indicate their willingness to participate in the study.This was a financial costing study conducted in 2011. There were two components to data collection: analysis of expenditure information at the two hospitals for a 5-year period from 2005 until 2010 to determine direct costs; and in-depth interviews with executive and middle managers at each of the hospitals to determine indirect costs.A trend analysis of nursing agency expenditure was conducted at the two selected hospitals. We analysed provincial health expenditure data for the 5-year period from 2005 until 2010, obtained from the national transversal Basic Accounting System database . The reaThe financial data were exported into Microsoft Excel in order to facilitate uniform coding of the expenditure information and to do trend analysis across the entire period (2005/6 through 2009/10). Each financial year was entered into a separate worksheet. The total number of expenditure line items ranged from 30,595 in the 2005/6 financial year to 34,978 in the 2009/10 financial year, totalling 166,466 line items for coding over the 5-year period .Each line item was coded meticulously, depending on the type of expenditure, and similar items were grouped and aggregated. The coding also took into account the healthcare facility where the expenditure occurred. Once each item was coded, cross-tabulations and calculations were done to ensure that the same total expenditure was obtained for each hospital, thus ensuring both validity and reliability of the study results .Overall hospital expenditure consists of all expenditure items, including compensation of employees, goods and services , transfer payments , and capital expenditure . PersonnFor each hospital, the overall hospital, personnel and nursing agency expenditure was calculated for each financial year. Agency nursing expenditure as a proportion of the total hospital expenditure and of the personnel expenditure was then calculated, for each hospital and for each financial year . All expIn the study, an agency nurse was defined as a nurse registered with the South African Nursing Council (SANC) who is employed by a commercial nursing agency, providing temporary cover in a hospital. The nurse is paid by the agency, which, in turn, charges the hospital a fee. Agency nurses may be registered with several agencies as well as having a job in a public or private healthcare facility .During 2011, semi-structured interviews were conducted with the following individuals in each hospital: the CEO (1), the executive nursing services manager (1), the nursing manager of the maternity or critical care unit (1), the human resource manager (1), and the finance manager (1). Ten people were interviewed at the two hospitals.Following informed consent, the interview schedule, which was pilot-tested at another hospital, collected the following information: background characteristics, including any outstanding features or peculiarities; the number of nursing agencies on contract; the utilisation of nursing agencies for the provision of temporary nursing staff; the temporary nursing cover arrangements used in the hospital ; the indirect costs of using agency nurses; the advantages of agency nursing; and the challenges experienced with the use of temporary nursing staff within the hospital.In this study, the indirect costs measured were the time taken or spent on: pre-employment checks ; identifying the need for agency nurses; recruitment; orientation of the nurse; supervision required, including dealing with any problems related to the agency nurses (e.g. patient or doctor complaint); and the administration related to the agencies, which includes checking, processing, and paying invoices. The time taken was expressed in hours per week and respondents were only asked about their own time spent on each of these activities. One working week was assumed to be equal to 40 hours, in line with the requirements of South Africa's Basic Conditions of Employment Act . This tiAs shown in The nursing managers interviewed indicated that agency nurses needed considerably more supervision than did permanent staff. Agency nurses were not allowed to administer medication unless supervised. They also required supervision with report-writing and patient care documentation, wound dressings, and the use of highly specialised equipment in critical care units. As Hospital 1 renders highly specialised tertiary services, they also provided additional supervision for agency nurses taking care of women with high-risk pregnancies.Hospital 1 nursing managers indicated that they did not spend time on the verification of invoices, whereas Hospital 2 estimated that 4 hours per week were spent on this activity.At both hospitals, the finance managers were responsible for processing invoices. The actual payments were done centrally at the provincial shared services centre, which existed at the time of the study. The finance manager at Hospital 1 indicated that 4 hours were spent per agency to process invoices, there were five agencies on contract, and these agencies sent invoices every 2 weeks. This amounted to a total of 40 hours per month, averaging 10 hours per week. The finance manager at Hospital 2 indicated that half a day or 4 hours per week were spent on processing invoices.Hence, the total estimated time spent per week on indirect cost activities at Hospital 1 was 51.5 hours, and 60 hours at Hospital 2. The estimated monetary value of this time at Hospital 1 was R962,267 , and at Hospital 2 the value was R300,121  . At bothNursing agencies assisted hospitals in dealing with problems of nurse recruitment, shortages, and skills gaps, particularly in specialised areas such as critical care units. The CEO at Hospital 1 was also of the opinion that there is some transfer of risk to the agency, in that they are obliged to provide nurses to hospitals upon request. It was also felt that agency nursing enables nurses with young children to work in a flexible manner and that it enables public hospital nurses who do agency nursing in the private sector to gain skills such as inventory control.The CEOs and nursing managers at both hospitals listed several negative experiences with and disadvantages of utilising agency nurses. Three themes emerged from the responses: human resource issues, quality of care, and cost. These themes overlap and are elaborated below.The extra demands on supervision are huge. Most patients are high-risk, and they [agency nurses] need extra supervision when they take care of high-risk patients with eclampsia, induction of labour, and so on. Agency nurses need additional supervision, especially for procedures such as assisting with the insertion of a central line. They are not allowed to do everything – we always have to co-check medication, and they do limited administration. They often have limited experience with technology. Human resource issues tended to dominate the negative experiences or disadvantages. These included: poor attitudes of agency nurses, their perceived lack of commitment, disloyalty, unreliability, reluctance to take on ‘extra duties’ or perform certain nursing tasks, time taken on supervision, poor relationship with doctors, and perceptions that they do not have the same ‘culture of caring’ compared to permanent staff. The qualitative comments provide insights into hospital managers’ views, whereas There are more serious adverse events with agency nurses – they are bad-tempered with patients. They are tired and sleep all the time. They do not have the right skills … [patient care] policies change and they need updates. They do not take responsibility or accountability, and these [performance] gaps are much greater at night. I think there are definitely more adverse events. Those interviewed were of the opinion that the quality of care provided by agency nurses leaves much to be desired.The CEO at Hospital 1 was of the opinion that the risks of using agency nurses outweighed the benefits and that the cost was much higher than would be incurred if they had permanent staff. Furthermore, the hospital overspent its allocated budget consistently, and nursing agencies were seen as a contributing factor. The CEO of Hospital 2 indicated that their overall experience with nursing agencies was poor, with little value for money, and noted that they had stopped all agency nurses during 2010, a decision accelerated because of hospital cash flow problems.This case study of the indirect costs of two large public sector hospitals found that there was extensive utilisation of agency nurses in these hospitals in the critical care and maternity units. These agency nurses assisted the two hospitals in dealing with the difficulties of nurse recruitment and shortages. Hospital 1, a large teaching hospital providing tertiary care services, spent R38.86 million (US$5.55 million) on agency nurses in the 2009/10 financial year, or 5.34% of the personnel budget. Hospital 2 spent R10.40 million (US$1.49 million) in the same period, or 4.14% of the personnel budget.At face value, it appears that this was a reasonable proportion of the personnel budget spent on agency nurses, comparing well to the UK National Health Service trusts where the average agency expenditure across all NHS trusts was 3.85% of personnel expenditure in the 2007/8 financial year . HoweverNursing managers indicated that the time taken to recruit nurses was compounded by the inability of the nursing agencies to supply them. This was despite the fact that Hospital 1 had contracts with five separate nursing agencies. Other factors, such as the preference of nurses to work in private hospitals rather than the public sector, delays in payment, and the location of Hospital 2 in a socio-economically disadvantaged area, also hindered the recruitment of agency nurses.In both hospitals, managers indicated that a considerable amount of time was spent on supervision of agency nurses. There was a general perception that the performance of agency nurses was sub-optimal, compared to permanent hospital staff. At the same time, nursing managers indicated that little time was spent on induction, as it was not seen as a worthwhile activity for temporary staff, who may never return to the hospitals. The UK NAO also found that the average induction time for agency nurses was low, as senior managers tended to weigh up the benefits of the induction versus the costs in terms of time . HoweverThe study found that the two hospitals did not do pre-employment checks, including nursing council registration, nurse identity, and nurse qualifications. This could jeopardise patient safety, thus exacerbating the negative impact on the quality of care. The UK NAO has cautioned about the potential risks of deception and has suggested that hospitals should ensure that the nurses are competent to perform the tasks asked of them, because incompetence could add to the workload of permanent staff, and jeopardise patient care and safety . Hence iThe qualitative comments revealed managers’ perceptions of the poor attitudes of agency nurses, the lack of a caring attitude, their perceived lack of commitment, unreliability, and their reluctance to perform certain nursing tasks. Although this was a two-hospital case study, these findings are similar to those highlighted by other authors , 15–20. Although they could not produce evidence, there was a general perception among managers in the two hospitals that agency nurses provide sub-optimal quality of care. These perceptions might be justified, as studies in the US and UK have found that casual or temporary staffing contributes to poor quality of patient care –34.There are a number of study limitations. The study was conducted in two public sector hospitals and cannot be generalised to other hospitals. This was a financial costing study, rather than a full economic evaluation which would require the externality costs of various forms and quantifiable indirect costs, such as administration. In the analysis of direct costs of agency nurses, we assumed that these were equal to expenditure. Although financial statistics tend to be more accurate than other information, the study used official government statistics that the provincial health department submitted to the National Treasury . The stuNotwithstanding these limitations, this case study has numerous strengths. The focus on indirect costs of agency nurses is unique and gives managers an idea of the risks that need to be managed. Another interesting feature of the case study is the detailed analysis of nursing agency expenditure at the two hospitals, and the trends in such expenditure over a 5-year period. The study adds to the empirical evidence and knowledge base on the widespread use of temporary agency nurses in South African public sector hospitals. The study also illustrates the usefulness of a trend analysis of routine financial data at hospital level, combined with qualitative insights on indirect costs, in informing hospital management approaches.The study findings have implications for quality of care and human resource management. The findings suggest that the quality of patient care may be compromised by utilisation of agency nurses. However, the impact of the high use of agency nurses on the quality of patient care was not measured, and this is an area for further research. It is of concern that there is no risk management and no formal system to monitor the quality of care provided by agency nurses at the two case study hospitals. It is therefore recommended that both hospitals put in place systems to monitor the performance of agency nurses. This should include: giving feedback to the agency on the performance of nurses, and improving the quality of pre-employment checks, such as nursing council registration, identity checks, verification of qualifications, and previous work experience. In light of the direct and indirect costs associated with the use of agency nurses, in particular the time taken by managers to arrange temporary cover, it is important that they are used effectively. For this reason, agency nurses need appropriate orientation to the ward and hospital.The utilisation of agency nurses is influenced by various factors, including staff shortages, changing patient disease profiles, poor staff planning, staff absenteeism, and lack of involvement of nurses in decision-making , 19, 35.The delivery of safe and effective patient care in hospitals is dependent on the availability of competent and motivated nurses , 37. Thi inter alia, changes in disease patterns; growing demand for health-care services; an ageing nursing workforce; a shortage of nurses; and an increasing process of casualisation of nursing work, evidenced by practices such as moonlighting  and agency nursing  defines a nursing agency as ‘a business which supplies registered nurses or midwives or enrolled nurses or nursing auxiliaries to any person, organisation or institution, whether for gain or not and whether in conjunction with any other service rendered by such business or not’ .Much of the literature on nursing agencies comes from Australia, Canada, the United Kingdom, and the United States , 15–24. Little is known about nursing agencies except that they play the role of labour brokers in the health sector. At the time of the study, there were heated debates in South Africa on the future of labour brokers and on the negative impact of nursing agencies on the public health sector –28. In lDuring 2011, a cross-sectional national survey of nursing agencies was conducted. Ethical clearance for the study was obtained from the University of the Witwatersrand's Human Research Ethics Committee . Standard ethical procedures were adhered to. These included a detailed information sheet, informed consent, and voluntary participation.The sampling frame consisted of all registered nursing agencies on the 2010 database of the South African Nursing Council (SANC). The latter is a regulatory authority established in terms of the Nursing Act that governs the nursing and midwifery professions in South Africa . HistoriNursing agencies that were members of the Association of Nursing Agencies in South Africa (ANASA), a voluntary umbrella body set up to represent the industry, were excluded because a separate study focused on ANASA members. Agencies that had closed and were no longer in operation were also excluded. In cases where agencies had multiple branches, only one branch was selected to represent the agency.Previous information indicated that the majority of nursing agencies were located in the urban provinces of Gauteng and the Western Cape. The agencies were grouped into three strata, namely ‘Gauteng’, ‘Western Cape’, and ‘Others’. A stratified random sample of agencies was then selected from each stratum, proportional to the number of agencies in each stratum, totalling a sample of 106 nursing agencies. The details of the sampling procedure are shown in An introductory call was made to each of the selected agencies to explain the purpose of the study and to invite their participation. The information sheets and consent forms were sent by email or fax to the agencies. Once the agency representative had agreed to participate, the questionnaire was completed over the telephone.The survey questionnaire was pretested and structured to focus on the following: agency ownership, date of establishment, province(s) of operation, distribution of clients across private and public health facilities, the existence of a code of conduct , the nature of the contractual relationship between nursing agencies and their clients, and the number and categories of nurses employed. Using a seven-point Likert scale, the advantages and challenges of agencies were elicited using a series of statements to which a representative of the agency was asked to indicate the extent of agreement or disagreement. A final open-ended question elicited any comments or suggestions about nursing agencies or the health system.To ensure a high response rate, an average of three follow-up calls on three separate days were made during office hours to each agency, but in some instances up to nine calls were made to an agency.® 12. The Likert scale options of strongly agree, agree, and slightly agree were pooled into one group labelled ‘agree’, while strongly disagree, disagree and slightly disagree were grouped as ‘disagree’. A descriptive analysis was conducted that included frequency tabulations of characteristics of nursing agencies and further cross-tabulations of each of these characteristics by province to investigate any statistical associations. The Fisher's exact test or the Chi-square test was used to test associations between variables. All tests were done at a 95% confidence interval. The qualitative information from the response to the open-ended question was analysed using thematic content analysis  in the study: 18% of the agencies were not operational or were closed, and this aspect only became known during the actual fieldwork; 16% of agencies did not answer the phone, despite a minimum of three phone calls on three separate days during office hours; 2% of agencies were ineligible because they were members of ANASA, and this only came to light during the survey; and 15% of agencies refused to participate in the study.n = 40; 77%) were established between 2000 and 2009. Most of the agencies surveyed were not owned by larger organisations (90%); only five agencies had a parent organisation (10%), and 83% of agencies had only one branch. One agency from Gauteng Province had five branches.The overall characteristics of responding nursing agencies are shown in At the time of the survey, 27% of nursing agencies had homes for elderly people as clients, followed by the provincial departments of health (19%). At least 10 agencies supplied casual staff to at least one provincial department of health. A total of 23 (44%) nursing agencies served private patients in their homes. There were no statistical significant differences between the characteristics of the nursing agencies and the province in which they were located .In terms of categories of casual staff, 86% of agencies reported that they contracted professional nurses, 65% contracted enrolled staff nurses, whereas 61% and 67% of agencies contracted nursing assistants and caregivers, respectively. The median number of casual staff (nurses or caregivers) registered with agencies was 50 (IQR = 15–120).p=0.04). Although 98% of nursing agencies reported that they had a code of conduct, the proportion was higher for private-sector clients (73%) than for public-sector clients (27%). However, this difference was not statistically significant. Similarly, the majority of agencies (96%) stated that they had a reporting mechanism for client complaints, and this applied to 72% of private-sector clients, as opposed to 28% of public-sector clients. This client reporting mechanism was primarily verbal, rather than in writing  than with public-sector clients (16%), and this difference was statistically significant , rather than on the individual nurse's preference (35%). Nursing agencies reported that the median number of nursing staff or caregivers allocated on a daily basis to clients was 15 (IQR = 5–31.5).In terms of clinical services (closely related to the types of clients), 37% of agencies provided nurses for geriatric care, followed by adult intensive care units (35%) and other services (10%). Other services included HIV testing in some private organisations and occupational health services.In terms of quality checks and monitoring, 81% of agencies agreed with a statement that they checked the SANC registration of nurses, 82% agreed with a statement that they requested certified copies of a nurse's qualifications. Only 21% indicated that they conducted reference checks of nurses with their past employers.Three themes emerged from the responses to the open-ended question: governance of nursing agencies, client-related issues, and issues related to individual nurses. These topics overlap and are elaborated on below.Fifteen of the comments related to issues of governance of nursing agencies, with 10 commenting on the perceived lack of support from the SANC when complaints about nurses were submitted or information about their registration was requested. They also commented on the SANC's lack of support for caregivers . Minor comments related to the policy uncertainty in light of the debates at the time regarding the proposed ban on labour brokers, lack of recognition of nursing agencies, and the high membership fees of ANASA, the voluntary association for nursing agencies.n=7); lack of nurse orientation in some private hospitals (n=1); inability to meet clients’ demand (n = 1).Another set of comments related to the clients of nursing agencies, notably the high competition for clients among the various agencies, especially those owned by the large private hospital groups , the alleged misconduct of nurses (n=2), and the quality of care provided by nurses (n=1).With regard to individual nurses, agencies complained about the unreliability of nurses  of the surveyed agencies served private clients only and did not have any public-sector clients. Just over one-quarter (27%) of nursing agencies' clients were homes for elderly people, and geriatric care comprised an important component of the clinical services that these agencies provided. These findings suggest that homes for elderly people and geriatric care could be the niche areas of these smaller nursing agencies. It might be that ANASA members are the main providers of nursing services to large hospitals, particularly in the public sector, and that the smaller agencies could or would not compete with the larger agencies for the patronage of hospitals. As the findings of the ANASA study have not yet been analysed, it is not possible to compare the findings in this study with that of the ANASA study. However, any legislative or policy initiative on nursing agencies would need to take account of the nursing care needs of private homes or those for elderly people.In this study, all but four nursing agencies (98%) indicated that they had a code of conduct, and 77% of agencies indicated that they had formal contracts with clients. Although this is a requirement of the Basic Conditions of Employment Act (BCEA), which states that labour brokers are to be jointly responsible for an employee , it is eThe study found that nurses or caregivers were allocated based on clients’ demands, rather than on the nurse or caregiver's preference or skills. Other studies have found that when nurses are not allocated to clients according to their preferences, the quality of care is compromised , 20, 32.The highest reported challenges by agencies were nurse-related, notably shortages of specialised nurses (94%) and recruitment of nurses (83%). This suggests that the country's overall shortage of nurses, especially in specialised areas, also affects nursing agencies . This coThis study has found that a monitoring system for agency nurses was lacking. In theory, a nurse could register and work with more than one agency within a short time period or the registration or qualifications of a nurse might not be checked, thus impacting on quality of care, a finding supported by an Australian study . The nurThis study has revealed that this group of agencies that are not members of ANASA provided services to homes for elderly people and private homes, similar to the findings of a study done in a UK health district . BecauseDespite careful planning and specific steps to minimise bias, which included doubling of the required sample size from 53 agencies to 106 agencies, a major weakness of the study was the low response rate of 49%. However, this response rate is much higher than an Australian study that had a response rate of 23% . In thisThe study did not ask for the reasons why these agencies were not operational, but one reason could be a lack of sustainability of smaller agencies. This is an area for further research. Only 15% of agencies contacted refused to participate, hence it is possible that with an accurate and updated database, the actual response rate would have been much higher. ANASA members were excluded, which limits the generalisability of the study findings to all nursing agencies.Telephone surveys do not allow anonymity of responses, hence there could be social desirability bias, particularly in the responses to questions about the code of conduct and quality checks on nurses. Some of the questions might have been misunderstood by respondents and the person being interviewed may have had limited knowledge on the agency they worked for. The study was limited by the small sample size, which may explain some of the findings that were not statistically significant. In the analysis, some responses were not mutually exclusive, which limited the type of analysis conducted. Future studies regarding nursing agencies can build on the questionnaire used in this study and refine the questions to ensure that they are mutually exclusive.Nevertheless, there are many study strengths. The focus is novel, and it is one of the first studies to focus on the nursing agency industry in South Africa. The findings provide a basis for future research on the nursing agency industry and sheds light on the characteristics of the industry. Selecting a stratified random sample, rather than a convenient sample of agencies, is a strength. The study provides unique information on agencies that are not part of ANASA.There are a number of recommendations that flow from this study. A first step in strengthening the management of nursing agencies should be the development of a comprehensive database of all registered agencies in the country, which should be updated on a yearly basis. In terms of the National Health Act , a comprNursing agencies are health establishments  but are The South Africa health system faces numerous problems of recruitment, management, and retention of health-care providers . Casuali A recent focus of the global discourse on the health workforce has been on its quality, including evidence of regulatory bodies in countries and the existence of codes of ethics . EthicalThe International Code of Ethics for Nurses was developed in 1953 by the International Council for Nurses (ICN) . The CodThe International  Nurses’ Pledge is a promise undertaken by nurses to uphold the core values and principles of nursing, and is aligned to the ICN Code of Ethics. It refers to promoting the rights of patients and the promotion of health, protection of information, refraining from endangering the life and health of patients, maintaining professional competence and continuing education, and sustaining good working relationships with colleagues . The PleIn South Africa, the South African Nursing Council (SANC) Pledge of Service  is an adapted version of the Nightingale Pledge . The SANThe importance of ethics and value systems in nursing was emphasised at the 2011 National Nursing Summit, that brought together close to 2000 nurses in South Africa  and Free State  Provinces in South Africa. The choice of the two provinces, Gauteng and the Free State, was purposive, and influenced by geographical proximity to the researchers, prior health authority approval, and budgetary constraints. Gauteng is the most urbanised and densely populated province with a population of 12.2 million, while the Free State Province is a mixed urban–rural, largely agricultural province, with a population of 2.7 million .Because the larger study was already underway when the ethics protocol was finalised, the ethics component of the study was done in the two remaining private hospitals in Gauteng Province, and the three public hospitals in Free State Province. Hence the five hospitals, although randomly selected as part of the larger study, could be considered as a convenience sample for the ethics study.The Human Research Ethics Committee  of the University of the Witwatersrand in Johannesburg provided ethics approval for the study. The relevant public and private health care authorities also gave the necessary study approvals. All participants received a study information sheet and provided written, informed consent.At each hospital, one medical, surgical, paediatric, and maternity  unit was selected ; hence, 20 units were part of the study. Emergency and critical care units were excluded because the focus of the larger study was on nursing unit managers. In the ethics study, the population of interest was all categories of nurses registered with the SANC. On the survey day, all day duty nurses working in the selected units were invited to participate in the study. Night duty nurses were excluded because of logistical difficulties in conducting fieldwork at night at the selected hospitals.Following informed consent, each nurse completed a self-administered questionnaire that contained both closed and open-ended questions. The questionnaire consisted of four sections. The first three sections contained closed-ended questions that elicited information on: participant characteristics; perspectives on the ICN Code of Ethics; and perspectives on the South African Nurses’ Pledge of Service. The Code of Ethics section in the questionnaire consisted of 14 questions, which related to each of the four elements of the ICN Code . The sec® 13. Frequency tabulations were done to describe the socio-demographic characteristics of the respondents, and the responses to questions on the Nurses’ Code of Ethics and Nurses’ Pledge. A thematic content analysis of transcripts was conducted . The majority of participants were female (96%) and employed in public hospitals (61%) .As can be seen from the table, 100% of respondents agreed with the statement ‘I play an active role to maintain good relationships with co-workers’. High levels of agreement were found for promotion of the human rights of the people in their care (95%); the nurses’ duty to meet the health and social needs of the public (96%); maintaining the standards of personal conduct required by the nursing profession (96%); and ‘getting upset’ when lacking necessary equipment to provide good patient care (95%).Similarly, high levels of disagreement were found in negative statements such as ‘nurses do not have a responsibility to maintain professional competence’ (94%), ‘it is not my role to implement acceptable standards of clinics nursing practice’ (88%), ‘providing care to homosexuals is against my ethical values’ (86%) and ‘patients should not receive a lot of information about their care as it confuses them’ (81%). More nuanced responses were obtained for the three questions that elicited responses on nurses versus patients’ rights, strike action, and a trade union versus a professional association .As can be seen from Similarly, high levels of disagreement were found in the negative statement ‘I cannot respect the religious beliefs of patients under my care’ (97%) and that ‘People who pay for their care should get better services than those who do not pay’ (94%).Although overlapping, three broad themes emerged from nurses’ responses to the open-ended questions. These were: insufficient awareness or knowledge on what constitutes good ethical practice; the need for a strong ethics focus in nursing education and training; and the dilemma of nurses to uphold the code of ethics and service pledge in face of workplace constraints or poor working conditions.Nurses of today have got no clue of the word ethics. One could see with the way they lack professionalism, etiquette and confidentiality. The Nurses’ Pledge is only for registered or professional nurses, other categories of nursing do not know about it, but they are also practising as nurses. They should also be taught about ethics and pledge. The majority of participants were of the opinion that there is insufficient awareness or knowledge among students or younger nurses on what constitutes good ethical practice.The ethical practice must be improved. All [nurses] must know about the rules and regulations and the Code of Ethics. I think they must start in the colleges, the learning centres – they must start to tell these people what is ethics, because I don't think they know – they write exams, but I don't think they know how to practise this in the operational field. Training and education on ethical practice in nursing should be done regularly to all nursing personnel, maybe after every six months. The study participants were also of the opinion that nursing education and training programmes should place a greater emphasis on ethical behaviour and practice.Ethical dilemmas mentioned by study participants included: providing care in the face of disrespect from patients, the problems created by individuals who do nursing for the wrong reasons; and being blamed by managers for errors or mistakes, despite staff shortages or health system deficiencies, especially in public hospitals.New nurses’ attitudes are completely different than 20 years ago. There is need for a complete turnaround and thorough sifting of individuals before they enter the [nursing] profession. I think the problem lies with the nurses that start to nurse for the wrong reasons – nursing has become a money-spinning thing, but the deep passion and that deep born thing for caring is missing. Some respondents were of the opinion that patients have a ‘bad attitude towards nurses’, and their disrespectful behaviour, makes it more difficult for nurses to practise ethically. Several study participants lamented about the perceived ‘poor’ calibre of new entrants to the nursing profession, as can be seen from the following comments:The ethical practice of nurses is not up to standard due to shortage of staff. Hire more staff to boost nurses’ morale and reduce stress periods. People lose [their] morale in the nursing profession. There must be enough staff, equipment, and nurses must get enough support from the government–financially and psychologically. Some study respondents, particularly in public hospitals, mentioned health system deficiencies as hindering ethical practice by nurses.Nursing students should practise professionalism at an early level in the college or university. All nursing educators and registered nurses must be role models for nursing students and other subordinates, such as enrolled nurses. The overwhelming number of responses related to a ‘practice what you preach’ approach to the Code of Ethics and the Pledge, illustrated by the comment below:Recommendations included the need for continuous professional education on ethical behaviour and practice; using health service events  to remind nurses of good ethical practice; and addressing nurses’ salaries and working conditions, resource constraints and health system deficiencies such as the lack of functioning equipment.This study found that there were high levels of awareness among nurses in the selected hospitals on the Code of Ethics and the Pledge, illustrated by their responses to a series of proxy statements on the Code of Ethics and Nurses’ Pledge. The questions on the Code of Ethics  elicitedMore nuanced responses were obtained for the three questions that elicited responses on nurses versus patients’ rights, strike action, and a trade union versus a professional association. The majority of respondents (60%) agreed with the statement ‘I think too much emphasis is placed on patients’ rights at the expense of nurses’ rights’. This was borne out by the qualitative comments made in the open-ended questions, with some nurses indicating that perceived disrespect from patients influenced their ability to provide optimal quality of care. The finding could reflect the emphasis on the government's core national standards that aim to improve patients’ experiences of public sector care at the time of the study , and misAlthough a minority of nurses agreed with the statements that they will embark on strike action to improve nurses’ salaries (32%) and that a trade union is better than professional association to improve the socio-economic conditions of nurses (26%), the results are not surprising. Another South African study also found that 32.5% of study participants supported strike action by nurses as a constitutional and legal right . StudiesThe three themes that emerged from the analysis of the open-ended questions: insufficient awareness or knowledge on what constitutes good ethical practice; the need for a strong ethics focus in nursing education and training; and the dilemma of nurses to uphold the Code of Ethics and the Pledge in the face of workplace constraints or poor working conditions contradicted the participants’ responses to the closed-ended questions. There are several reasons for this apparent contradiction. Firstly, the responses might be a reflection of social desirability bias , with paThis was one of the first studies in South Africa to explore nurses’ views on the ICN Code of Ethics and the Nurses’ Pledge, following the 2011 National Nursing Summit in the country. The paper makes an important contribution to the discourse on ethical behaviour and practice of nurses and midwives. However, the findings are not generalisable as the study was small and limited to five South African hospitals that constituted a convenience sample. Although the statements that served as a proxy to determine nurses’ views on the Code of Ethics and the Pledge of Service were phrased carefully to avoid non-reflective responses, the contradictory responses indicate some social desirability bias . The croNotwithstanding the limitations of the study, the findings support the recommendations contained in the strategic plan on Nursing Education, Training and Practice . These rOther studies have also recommended raising awareness of professionalism and ethical behaviour as a means of strengthening ethical nursing practice , 37. OurHowever, some scholars have pointed out that raising awareness is important, but that a holistic understanding of ethical practice includes the four components of ethical sensitivity, ethical judgement, ethical motivation and ethical action . SpecifiOther nursing scholars have warned about the imposing position that pledges and oaths may bring  and haveImportantly, the health system deficiencies alluded to by study participants would need to be addressed in order to facilitate ethical nursing practice. The appointment of the Chief Nursing Officer at the beginning of 2014 and a detailed strategic plan for Nursing Education, Training and Practice provide a good foundation in South Africa for strengthening ethics training and enhancing ethical nursing practice.In light of the numerical dominance of nurses in South Africa, and their role in the health and well-being of patients and communities, the importance of their technical and ethical competence is undisputed. The study participants displayed high levels of awareness of the ICN Code of Ethics and Nurses’ Pledge of Service. However, the responses revealed contradictions between knowledge and awareness, and contemporary nursing practice within a value-based, ethical framework. Continuing education in ethics and addressing health system deficiencies will enhance nurses’ professional development and their ethical decision-making and practice. Primary health care (PHC) has re-occupied centre stage in the global efforts towards universal coverage and improved health system performance , 2. WithSouth Africa is on the brink of another wave of major health sector reforms towards universal health coverage that underscore the centrality of PHC , 10. NurThere is a plethora of literature on management and the different conceptual approaches to management –18. The In terms of nurse managers, there have been several empirical studies that have examined the relationship between their management styles and the impact on staff job satisfaction and turnover, patient satisfaction, and quality of care –31. ThesThere are several reasons for focusing on PHC clinic nursing managers. Firstly, they are responsible for overseeing the strategic direction of health service delivery, and hence, they play a critical role in the implementation of any health sector reforms , 8. SecoThe diary study was carried out in Gauteng (GP), an urban province, and Free State (FS), a mixed urban–rural province, as part of a larger doctoral study that included a job satisfaction survey . These tThe study was approved by the University of the Witwatersrand's Human Research Ethics Committee , as well as the relevant provincial and municipal health authorities. The researchers adhered to standard ethical procedures, including detailed participant information sheets, informed consent, and ensuring confidentiality of information.The population of interest was professional nurses (with 4 years of training) in charge of 8-hour (day) PHC clinics. These clinics serve catchment populations that range from 10,000 to 180,000 . The clinics provide preventive services , basic curative care for acute and chronic conditions, health promotion, and community outreach services.During 2012, a sub-set of 22 nursing managers, 10 in FS and 12 in GP, was selected randomly from an overall survey sample of 111 PHC nursing managers in charge of these 8-hour clinics . The detThe event-contingent diary method was used, as participants were asked to record an event that answers a specific research question . In our Each selected clinic nursing manager was given an information sheet and the voluntary nature of study participation was explained to them. Following informed consent, the diary entry guidelines were explained verbally to each nursing manager. The selected clinic manager was then given an attractive diary, with the guidelines pasted in the front of the diary. Participants were assured of confidentiality and asked not to write their names in the diary.Each manager was requested to write once a week for a period of 6 weeks about an event that happened at the clinic and that stood out for him/her. Once a week was considered reasonable and realistic for nursing managers who work with limited human resources, and it was done to avoid getting limited or no data at all. Participants had to reflect on why they chose that event, how it made them feel, what they learned from it and what the implications were for their current or future management practice. Clinic managers were also asked to write down the date of the diary entry so that these could be counted during analysis. Participants were encouraged to see the diary as their own personal diary, and the researchers undertook to return the diary to them after completion of data capturing. Participant reminders consisted of mobile text messages and weekly telephone calls.The diaries were collected from participants and were stored safely at the researchers’ offices in Johannesburg. The diaries were assigned number codes to prepare for analysis and to ensure confidentiality when returning them to their owners. The diaries were also grouped by province to allow for qualitative comparisons.The diary entries, hand-written in English by each nursing manager, were typed and saved as individual Microsoft Word documents. During data capturing, we noted that diary entries were longer and more detailed in the first week and shorter in subsequent weeks.The diary entries were analysed using thematic content analysis . The firTo ensure reliability, two researchers  participated in the development of the themes by reading the diary entries independently from the first researcher in order to establish inter-coder agreement , 41. Foln=10 and FS, n=5). The reasons cited for non-participation by the remaining seven clinic managers were: handing over the individual diary to the courier company who lost it (n=5), stolen diary (n=1) and lost diary during a motor vehicle accident (n=1).Diary entries were all hand-written in English. Fifteen clinic nursing managers participated in the diary study, representing a 68% response rate  and a similar number were above the age of 51 (45% n=10), and the remainder were in the 21–30 age group. Participants’ work experience ranged from 5 to 15 years. The majority had been qualified as professional nurses for more than a decade and possessed a PHC clinical training qualification.The majority of diary participants were female, with only one male respondent. Close to half of the participants were between the ages of 41 and 50 years , shortage of medicines, to lack of an enabling environment for service delivery, such as lack of running water. These deficiencies contributed to the difficulties in managing the clinics, as can be seen from the diary excerpts below.There is no water in the clinic for three consecutive days …. How will you implement infection control and prevention principles when you work without running water for three days? The clinic gets water cuts frequently – almost every 2–3 weeks …. In some clinics in the FS, diary entries show that clinics would sometimes run out of water and this affected the functioning of the clinic. Managers pointed out that hand washing and other infection control measures were dependent on the availability of water. One FS clinic manager had sought support from the clinic supervisor and the municipality but the problem was not being addressed. Eventually, with support from the community, the clinic had obtained a large plastic water container, to serve as a contingency measure for lack of running water. The example below shows the frustration of this FS nursing manager as she wrote about the lack of water as a recurrent problem:I came to work at 7:30 am today realising again nobody came to work. Some are off sick, some just phone to say they will not be coming. Staff shortages are a big problem. I tried to get help again. Nobody from the other clinic can assist. So I must see patients again. All my work is piling up and I did not attend to it yet because of the shortage of staff. Patients are more important than the paper work so I saw patients. Human resource challenges were the second major theme that emerged, and the diary entries reflected the negative impact on their management activities. Nursing managers documented wide-ranging responsibilities, including patient consultations, with an apparent disjuncture between their job descriptions and the actual roles they performed in the clinic. Staff shortages impacted on management functions, as managers had to perform clinical duties, in addition to the management functions. In those situations where a staff member was absent or there was a vacant post, nursing managers reported that they had to take on that role, for example, as a pharmacist to dispense medication. High rates of planned and unplanned absenteeism among nursing staff affected clinic operations, and exacerbated the difficulties of PHC clinic management.My blood pressure was 156/102 and my glucose level 2.0 mmol/L, I was feeling dizzy and tired. I was unable to go to the doctor because that will mean only one professional will be left at the clinic with more than 100 patients. I never reported the shortage to anyone. The answers that we mostly receive when reporting shortages are “where do you think we will get nurses, find one if you can” that is why we do not report [staff] shortage problems. It was a hectic week, only three nurses on duty on Wednesday and Thursday. I was doing curative [care], adults and children at the same time and I was also busy with statistics in the office. Staff shortages also led to increased patient waiting times, and in some instances impacted on managers’ health and well-being.The reported staff shortages were exacerbated by perceptions of disabling provincial policies (such as the moratorium on filling posts), staff absenteeism, and an unsupportive management environment.My supervisor brought an action plan with time frames. Some of the interventions are not realistic. The clinic was full and staff members were not enough. I was juggling from dispensary, [patient] consulting and solving patients’ minor queries and attending to my supervisor. I feel that I had to give priority to my patients. It was not her [supervisor] visit day according to the schedule. I was disorganised and had to accommodate her …. The third major theme that emerged from the diary entries was perceptions of an unsupportive management environment. Clinic managers expressed their disillusionment with their supervisors, who were perceived to be uncooperative and who lacked an understanding of the difficulties faced by them.She [supervisor] said there would be no replacement as I only have one entry point in the clinic … she shouted at me that whether I agree or not, she is going to instruct my clerk to go to another clinic which she did … she was so rude and dropped the phone in my ear …. At times, the diary entries reflected the perceived disrespect, punitive behaviour and verbal abuse from supervisors:I had informed the clinic supervisor a month prior to arrange someone for relief [staff] and she had promised to do so. Two weeks before and a week prior, I again reminded her and she still did not know who she was going to send to my clinic to relieve the PHC sister on leave … they sent me someone else whom I was only made aware of that morning. Another professional nurse from the clinic where the relief sister works called demanding that she returns back to her clinic  … harassing her that she should return to the clinic. When I checked on her she was tearful and threatening to resign. She found herself torn between wanting to assist at my clinic and being recalled back to her original clinic. This frustrated me even more … the pain … I realised I was … emotionally drained. I called my supervisor who at that time was actually changing from what she said … she now wanted the relief sister to go back to her original clinic while she searched for another one … I refused that the professional nurse leaves the clinic before the relief arrived. After two hours no one arrived. I called again … the nurse was restless and having her bag in hand and was on her way out. This really frustrated me …. On one occasion an FS supervisor did not keep the scheduled appointment, despite calling the clinic manager at her home and giving her instructions for the visit. Nursing managers also complained that clinic supervisors had a top-down approach to supervision and were prescriptive of what needed to be done in the clinics. Supervisors appeared to be unresponsive to requests from clinic managers, especially about additional staff. The excerpt below gives a glimpse of an unpleasant experience of a GP clinic manager.The above quote reflects the unsupportive approach of clinic supervisors regarding staff shortages and the impact it has on the emotions of nursing managers.I was exhausted … I asked God why I had to come to work with such demotivated staff. I'm starting to hate my work. I know why they are demotivated … they couldn't get study leave, there is no performance management system, even though the population is increasing steadily. It's hard to work with demotivated staff because you must always follow after them for things to be done properly. The thing that hurts the most is that there is no support from co-ordinators of programmes. It's just complaints from patients then staff and from management. Nobody understands the depression we are going through. [My] sleeping patterns are changed because one has to wake up in the early hours of the morning to catch up with administration and [to] meet deadlines. It does not mean one has poor time management but there is a lot of pressure that the manager is subjected to. Family life is also affected by this. Because you come home exhausted, household chores during the week become a challenge. I have sacrificed my weekends and public holidays in order to do my administration. The multitude of health system problems, human resource challenges, an unsupportive management environment and a range of other problems, coalesced in an overwhelming expression of negative emotions in the diaries, and revealed the emotional impact of PHC clinic management. In some instances, nursing managers wrote about ‘incompetent’ staff reporting to them, and the negative impact on their morale and family life. Importantly, the diary entries reflected the personal stress experienced by these managers at clinics.I was very upset on Wednesday. They called me and said there was an urgent meeting and all facility managers must attend. All my plans for the day messed up. We were called for an urgent meeting whereby one of our colleagues was together with the supervisor questioning our Regional Health Manager's authority to delegate authority to us as operations managers. Assessing the whole deliberation, I realised that we were caught up in an ongoing misunderstanding and poor communication between the two senior managers … it causes paralysis PHC clinic managers were frustrated by poor communication from regional and provincial health managers, who often requested information at short notice or summoned them to unplanned meetings. Nursing managers reflected on the perceived burden of these unplanned meetings, despite careful planning on their part. They lamented the lack of control over their average working day as this could be interrupted by ‘an urgent meeting’:On that morning, the clinic was so full and there were many babies for immunisation and sick adults in the main hall. The passage leading to my office was packed! I had to ask 13 antenatal clients (three new cases) to wait inside the small fourth consultation room. I had to attend to family planning clients and to ARV initiation clients who need to be assessed and have their bloods taken for baseline, to TB patients who were collecting their medication and also referring one very sick (TB/HIV) patient which took almost an hour. My “little voice” told me to check the BP (blood pressure) again – it was 240/160!! Severely, severely raised! Apart from now having to treat and refer a pre-eclamptic patient I also realised the terrible risk we take by relying on vital signs taken by a nursing assistant. Despite the experience of negative emotions caused by an unsupportive management environment, health system deficiencies and unplanned meetings, clinic managers recognised their important role in health service delivery. They reflected on their responsibilities of: implementing health programmes in the clinic, managing human resources, liaising with community members and relevant stakeholders, and ensuring that clinic operations run smoothly. Notwithstanding the challenges experienced by nursing managers, the diary entries suggest nursing managers who have great concern for patients and the quality of care delivered. One made the following diary entry:It was a clinic managers meeting where we were given feedback on programme performance for each clinic. I was told that our tuberculosis (TB) programme had improved since I allocated two professional nurses with the intention of making the programme a success. I came on duty in my culture day dress and it was very nice. No problems this far. Two nurses did not pitch for work but clinic was not that full so I can do my work. I worked out the off duties and started on my report. It was a lovely day and I got all my things done. I had local area meeting on Wednesday. I am feeling good because the manager mentioned that our clinic does the best we can with limited resources (staff). I am just glad she realises it. Despite their crucial role at the PHC level, nursing managers indicated that they seldom receive positive feedback or feel appreciated in the health system. Three entries showed the appreciation of clinic managers when they received positive feedback from their managers or when they felt a sense of achievement:Some nursing managers reflected on feelings of disempowerment, and at times ‘paralysis’, caused by the lack of strategic planning at higher levels of the health system and the difficulties of managing staff reporting to them, the absence of teamwork and their perceptions of a general lack of caring and professionalism on the part of front-line nurses. They complained of the ‘poor work ethic’ among many nurses reporting to them, changing value systems, resistance to change, and lack of accountability. They also reflected on the importance of leadership in nursing given the constant changes in the healthcare system.The budget is centralised, one has no power over it. The financial year comes and goes with little improvement … shortages of medicines occur because suppliers are not being paid. However, the diaries revealed that nursing managers do not hold the chain of command in clinics as this power resides with the clinic supervisor and in most instances with the district manager. The local area manager, who oversees several clinics, is responsible for the clinic budget. PHC clinic managers bemoaned the centralisation of the clinic budget, and their lack of control thereof, despite their responsibilities for the day-to-day management of the clinic. The clinic managers were often not consulted on spending priorities, despite compiling annual budget requests. One said the following:Clinic managers also receive instructions from doctors, pharmacists, social workers, and vertical health programme co-ordinators responsible for HIV or tuberculosis. All these combine to add further pressure on the clinic manager.This is one of the first studies to explore the work experiences of PHC nursing managers in two South African provinces using diaries as a research method. The major recurring themes in the diary entries were health system deficiencies, human resource challenges, and an unsupportive management environment – these problems are inter-related and contributed to the difficulties of working in or managing these PHC clinics.PHC clinic managers expressed frustration with EMS problems and the unpredictable turnaround times, which in one case resulted in a seemingly avoidable patient death. Reliable EMS services have been found to be a critical component of health systems strengthening . The nurThe issues highlighted in the diaries resonate with health system deficiencies found in other studies , 44, 45.The reported staff shortages were made worse by nursing managers’ perceptions of largely unsupportive supervisors. PHC nursing managers wrote about the lack of understanding, disrespect and at times verbal abuse from their supervisors. Notwithstanding the existence of the detailed clinic supervision manual , there aIn light of the reported challenges experienced by PHC nursing managers, it is not surprising that the diary entries were dominated by an expression of negative emotions, which could be a symptom of the stress experienced by these managers. In response to the question on how the recorded event made them feel, the most frequent responses were: exhausted and frustrated, angry, sad, burnt out, and demotivated. This was borne out by the larger job satisfaction survey, which found that being tired at work and the experience of verbal abuse were predictors of low job satisfaction of these nurses . A studyThere are limitations of this diary study, which was undertaken among a sub-sample of 22 PHC nursing managers. The majority of study participants were from GP, which is the economic powerhouse of South Africa. These clinics are likely to be much better resourced, compared to deep-rural clinics in other parts of South Africa. We had fewer diaries from the FS Province, due to the logistical problems experienced with the courier company. Hence, the study findings may not be transferrable to other PHC clinics in South Africa or elsewhere.Nonetheless, the findings from the diary study are borne out by the findings of national health system assessments which have highlighted health system deficiencies, human resource challenges and supervision and management problems at the PHC level , 45. TheThe diary entries have given a glimpse into the difficulties of policy implementation at the local level, from the perspective of PHC nursing managers. These managers give effect to high-level government policies as they are at the interface of community members (and patients) and the formal health system. The PHC nursing managers are expected to manage the bulk of PHC reforms. Their experiences of disempowerment and paralysis need to be addressed through a participatory and inclusive approach, which could simply mean eliciting their views and opinions regarding prerequisites and implementation strategies. This is important because they have to mediate or manage complex health system problems, while ushering in the proposed reforms.The human side of the managers found expression in a deluge of negative emotions recorded in the diaries. This study has shown that relationships matter and that how they are managed has an impact on how services are delivered or managed. The diary study has also illustrated the resilience among PHC nursing managers and their strategies for coping with a sub-optimal health care system in order to provide adequate care to patients or users. Inflexible hierarchies or policies (e.g. around staff recruitment) appear to make clinic work more onerous, with potential negative consequences for patients and clinic managers. Nursing managers are also curtailed by the centralisation of budget control, and they have to rely on supervisors who do not seem to know how to communicate effectively with them. This lack of delegation of authority, particularly of the clinic budget, exacerbated the reported health system deficiencies. The sense of disempowerment and paralysis experienced by PHC clinic managers was illustrated by the many negative emotions recorded in all the diaries. The relationship between the inability to manage or control the budget and feelings of disempowerment was also found in a 2008 assessment of district managers .Although this was a small, qualitative study, the realities experienced by nursing managers point to issues that need to be addressed as part of the universal health coverage reforms in South Africa. Firstly, efforts to improve the performance of the health system must be comprehensive and recognise that PHC revitalisation must be accompanied by effective and efficient EMS, and appropriate delegation of authority. Secondly, chronic staff shortages require creative strategies, and there appears to be room for improved performance management to reduce staff absenteeism. Thirdly, there are clear guidelines for supportive clinic supervision, which appear to be largely ignored at present. Supervisors may need to be reoriented to the guidelines or receive additional training to enhance their supervision skills. Clinic managers have long experience in the health services, and the health system needs to find a way of harnessing their wisdom in support of current health reforms. Lastly, the identified challenges need to be addressed by policy-makers working together with managers at all levels of the health system, given that health system reforms will create different work demands and diverse experiences for nursing managers.This study has highlighted the work experiences of PHC nursing managers, using diaries, a hitherto under-utilised research instrument. The PHC clinic managers’ negative emotions expressed in the diaries have the potential to affect or derail health system reforms, as demoralised PHC nursing managers are unlikely to be champions for change or be committed to such change. At the same time, the PHC nursing managers who participated in the study highlighted the importance of sufficient numbers of health workers, supportive supervisors, and optimal functioning of the health system. The current reform process of South Africa's healthcare system provides a golden opportunity for policy-makers to address the root causes of health system inefficiencies in a participatory manner and through the creation of enabling work environments. To this end, the critical role of the health workforce requires much more attention than is currently the case. Addressing the challenges identified in the work experiences of PHC nursing managers would go a long way in ensuring the successful implementation of health sector reforms. Improving the quality of health care delivery is an important global priority . Around There is well-documented evidence globally that the number, competencies, and effectiveness of nurses are critical in determining the quality of care in hospitals and the nature of patient outcomes –14. NursNotwithstanding the importance and commonality of time as an economic resource available to all managers , most ofThe University of the Witwatersrand Human Research Ethics Committee  granted ethical approval for the study. The public and private health care authorities in the two study provinces also provided study approval. All participants received a study information sheet and were required to sign an informed consent form to indicate their willingness to participate in the study.Two South African provinces, Gauteng and the Free State, were selected purposively because of geographical proximity to the researchers, health authority approval, and budgetary constraints. Gauteng is the most urbanised and densely populated province with a population of 12.2 million, while the Free State province is a mixed urban–rural, largely agricultural province with a population of 2.7 million .The study sample was not intended to be representative of all unit managers in the country, but rather to explore issues of nursing management, quality of care, and clinical governance at hospital unit level that could serve as a basis for future research. Budgetary constraints also influenced the number of hospitals and units selected for in-depth study.In the Gauteng province, three hospitals were selected from the public health sector, and three from the private health sector. In the case of the public sector hospitals, one hospital was selected randomly from each cluster of tertiary, regional, and district hospitals . All specialised psychiatric and tuberculosis hospitals were excluded. In the case of the private hospitals, only non-specialised hospitals with more than 100 beds were included in the sampling frame. One hospital was selected randomly from each of the three major private hospital groups in South Africa .In the Free State province, only public hospitals were included, with one hospital selected from each of the cluster of tertiary, regional, and district hospitals . At each hospital, one medical, surgical, paediatric, and maternity  unit was selected . In hospitals with more than one of these units, a simple random sampling technique was used to select the unit. A total of 36 units were selected.The final sample consisted of six public sector hospitals out of a total of 54 public hospitals, and three private hospitals out of a total of 99 private hospitals in the two study provinces.n=36) in charge of the selected hospital units were invited to participate in the study.All the nursing unit managers  and the activities recorded on a minute-by-minute basis. The fieldworkers were trained to be as discreet as possible and not to interfere with the work of the unit manager.Hence, there was a total of 72 hours of observation. The activities were entered into Microsoft Excel and coded into categories. The research team used thematic content analysis to develop the themes or categories . One resAfter agreement was reached on the categories, the activities were coded and analysed according to the time spent on activities in each category. Microsoft Excel was used to analyse the data and to determine the time spent on the various categories of activity by each unit manager and the average time spent on each category of activities when the data was combined for all nursing unit managers.A semi-structured in-depth interview was conducted with each nursing unit manager, who was asked to think about and reflect upon the previous working day. The manager was asked to indicate which three activities or tasks took up most of their time, and whether there were any activities or tasks that they wanted to get done, but just could not find the time to do. They were also asked whether there were daily tasks that take up too much of their time; and/or tasks that they do not have time to get round to. Each interview was recorded and transcribed verbatim. The information related to their perceptions of the activities in which they had engaged the previous day were analysed using thematic content analysis . The actFollowing the generation of themes, a workshop was held with the nursing unit managers. They were asked to comment on the analysis of their daily activities, the categories and themes, and to reflect on whether the results obtained represented their management experiences. The feedback meeting provided space for reflectivity and ensured the credibility of the research findings.All nursing unit managers agreed to participate in the study. Eight categories of activity were identified from the observations of the unit managers’ activities. The time and motion study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management, and 11.8% on miscellaneous activities .As can be seen from Nursing unit managers spent an average of 16% on hospital administration. Meetings took up a significant part of the unit manager's time, particularly in the public hospitals where all the unit managers would be called to meetings with the nursing service manager, lasting more than 1 hour at a time. At the time of the fieldwork, the one province was expecting accreditation visits to be carried out within the month. The time spent on quality assurance activities at these provincial hospitals was significant with one unit manager spending her entire day making sure that all hospital records were ready for the inspection.Only 3.6% of unit manager's time was spent teaching staff and students despite all of the selected hospitals being training facilities. Nursing students were present in many of the wards but the unit managers did not appear to see teaching as part of their responsibilities. However, the managers corrected staff and students when they observed the provision of inadequate care.Unit managers spent an average of 3.9% on managing stock and equipment, but this varied depending on the presence of a ward clerk in the unit. One hospital had devolved the management of stock and equipment to the responsible department and did not hold the unit manager accountable for managing stock. For example, in the case of medicines, the pharmacist was responsible for checking stock levels, ordering, and supplying the appropriate medicines.The study found that 11.8% of the nursing unit manager's time was spent on miscellaneous activities, with almost half of this proportion (48%) spent on walking and in search of stock, keys or other staff members. In several of the units, the unit manager was the only person entrusted with the stock and medicine keys resulting in her having to walk back to the cupboards every time a junior staff member needed medication or other items for patient treatment. Unit managers preferred to record information in patient files in their offices or at the nurses’ stations, hence time was spent time fetching these patient files. In the public hospitals, unit managers collected medicines or consumables personally from the pharmacy or store-rooms respectively, because they reportedly had greater powers of persuasion, compared to junior staff members who were less likely to obtain these necessary items.As can be seen from The time and motion study found that a nursing unit manager had to deal with 36 different types of activities in 1 hour. In one instance, it took a nursing manager 30 minutes to make an entry in a patient record, because of all the interruptions that ranged from answering the telephone, responding to patient visitors, providing support to doctors or assisting junior nurses. In order to prevent these interruptions, unit managers frequently completed their management reports in an area away from the unit.The interviews revealed that several issues influenced the time spent by nursing managers on the various activities, as well as the management of their time. These were: health workforce issues ; sub-optimal communication; resource constraints; and unplanned activities and interruptions. Each of these is explored briefly.I was so short staffed I didn't do any managerial duties. I didn't get round to off duties. I was particularly understaffed yesterday as the staff nurse was on a [training] course and students were in class. A recurring theme that emerged from the interviews was issues related to the health workforce, particularly staff shortages and sub-optimal staff performance, the latter influenced by their perceived competencies. Unit managers particularly in the public hospitals made several references to staff shortages which reportedly interfered with their management responsibilities, illustrated by the following comments.I didn't have time to sit and talk with a nurse who other staff members have been complaining that she isn't doing her work. I need to deal seriously with this issue. Keep a record of complaints etc. Need to build a case – and work out what to do. Letting it linger could lead to a problem with a patient. The performance of staff was another concern for unit managers. Absenteeism of nurses with little or no notice and seemingly suspect reasons caused a lot of frustration among the nursing unit managers. A private hospital maternity unit manager gave an example of the incompetence of a nurse in her unit, whom she felt she could not trust, and this impacted on the time she (the nursing manager) spent on various activities.We (have to) compensate for the fact that the doctors can't explain clearly to the patients. Nursing managers in both public and private hospitals reported problems of sub-optimal communication, particularly poor record-keeping that influences patient care, as well as inadequate communication between doctors, patients, and nurses. A manager from a private paediatric unit said:Supervision- you waste so much time … checking records that keep being wrong. This same problem was reported in another private hospital paediatric unit where the manager said:I spent 2 hours with the CEO [chief executive officer] trying to sort out beds and equipment issues. Although the nature and magnitude of resource constraints were different between public and private hospitals, all the unit managers complained that this aspect made their jobs more challenging. In both the public and private hospitals, unit managers complained about the time taken, and difficulties, of finding beds. The bed shortages resulted at times in premature discharge of some patients, and admission of new, very ill patients.Finding beds and finding agency staff takes a lot of time. I didn't have time (for important issues because I was) checking agency staff – hours worked, salaries paid etc. In the private sector, unit managers complained about the time spent in finding agency nurses.I spent lots of time with a patient who needed to be sent to ICU because she didn't have an [urine] output. I had a resuscitation that I didn't expect – it took 2 hours of my time. I had two critically ill babies and I struggled to get a doctor. All unit managers raised unplanned activities and interruptions as a major problem. Some of these were unforeseen, such as the suicide of a staff member or medical emergencies such as cardiac arrests, unplanned caesarean sections or transfer of patients to intensive care units. These were common to both public and private hospital unit managers, as can be seen from the comments below:Medical emergencies had occurred in four of the units on the day prior to the fieldwork.Unit managers also complained about the time taken for orientation of new staff members or community service nurses, record audits, and quality assurance activities. They also indicated that telephone enquiries from relatives or staff, in the absence of support staff such as clerks, take up a great deal of time and detract from patient care and management activities.There is so much admin, and meetings. For the ward and hospital, I spend a lot of time travelling between hospitals and capturing data for the DHIS [district health information system]. We could do with some secretaries and supervisors for support staff. We keep talking about the problem – but it is never solved - the meetings, meetings, meetings, take up a lot of time. More than one third of nursing unit managers complained about administration and that meetings take up too much of their time. One said that there is so much administration that she feels like a clerk at time, while others said the following:The executive nurse manager of one of the hospitals was also in charge of another hospital, 50 km away. This meant that every time a meeting of the unit managers was called, at least one set of nursing managers had to travel, resulting in an entire day away from their units.The time and motion study found that on average, nursing unit managers in the selected hospitals spent around one quarter (25.8%) of their time on patient care activities. This was similar to the proportion (26%) that the unit managers estimated to spend on patient care. When probed about the amount of time spent on patient care, they indicated that they had to care for the patients themselves as there was no alternative, either because of the complexity of the nursing task or because of staff shortages. We could not find similar studies focusing on nursing unit managers in other LMIC settings. Although not directly comparable, a 2008 study in a medical ward in Australia found that nurses spent 33.2% on direct patient care , while aThere is no norm of the proportion of time that nursing unit managers should spend on patient care. Although it is encouraging that unit managers spent such a large proportion of their time on patient care, it could mean that they may not have enough time to carry out their primary management responsibilities. These duties include the strategic management of patient care activities in the unit , teaching and mentoring of students and junior staff, and the management of human resources, finances, equipment, pharmaceuticals, and other resources.Although unit managers spent 25.5% of their time on patient care, our study found that they engaged in 36 different tasks per hour, averaging less than 2 minutes per task. Although this was better than the average of 72.3 tasks per hour in an Australian study, our study finding implies that unit managers perform numerous, fragmented tasks of short length. This could mean that changes in a patient's condition may not be noticed. Nursing scholars have argued that fragmented patient time is not conducive to nursing surveillance , 35, whiIn our study, unit managers spent a sizeable proportion of their time on hospital (16%) or patient (14%) administration. The perceptions of nursing managers were that they spent around 30% of their time on hospital administration, with meetings being the most frustrating aspect mentioned. The discrepancy between actual (observed) and perceived proportion of time spent on hospital administration could be due to different perceptions of roles and responsibilities among nursing managers, lack of knowledge on these roles and responsibilities, and/or because they found administration to be less satisfying, than providing direct patient care. Other studies have found that the proportion of time spent on administration ranged from a low of 6% in an Australian study  to 33.1%One of the most striking aspects of this study was the number of interruptions the unit managers experienced. An interruption is defined as a ‘a break in performance that occurs in response to a source that is external or internal to a person, e.g. daydreaming, suspension of the initial task, performance of another task, and resumption of the primary task’ 36, p. 2). While the interruptions and the unplanned activities were not unexpected, the nature of some of these gave insight into the practice environment of the unit managers. Other studies have demonstrated that task interruptions affect patient safety as they could increase medication errors or adverse events , 28, 36., p. 2. WThe study found that nursing unit managers spent 11.5% on staff management, but the self-assessment of the unit managers was that they spent only 5% on this aspect. The 1934 US study found that the head nurses spent 22.5% on ‘supervision’ , but theWe also found that 11.8% of time was spent on miscellaneous activities , but thiDuring the interviews, unit managers discussed the factors impacting on their time management and they spoke passionately about their frustrations with time-consuming activities, which they believe have a negative impact on the quality of patient care in their units. The four major themes were health workforce issues, resource constraints, sub-optimal communication, and interruptions and unplanned activities.There are limitations of this study, which was undertaken among 36 nursing unit managers in nine hospitals. The study sample is small, and no analysis of variance was possible between the public and private hospitals, urban and rural hospitals, or among different hospital units. The findings may have limited generalisability to other hospitals, both in South Africa or other LMIC settings. The observation period was relatively short, and this may have influenced the results obtained. Although the fieldworkers tried to be discreet during the observation of nursing managers, their presence could have influenced the behaviour of the nursing managers. The data collection instruments were designed for our study aims, making cross-study comparability difficult. The in-depth interviews elicited self-reported information from nursing unit managers on their time management and the time spent on different types of activities. The results may reflect social desirability bias, with nursing unit managers over-estimating the time spent on hospital administration. We did not ask nursing managers about their perceptions of their roles and responsibilities, or what they considered to be the ideal time to spend on different types of activities. We are unable therefore to determine whether the results obtained could be explained by possible differences in unit managers’ perceptions of their roles and responsibilities. This is an area for further research.Nonetheless, there are several study strengths. This was one of the first studies in South Africa and in a LMIC setting to examine the work activities of nursing unit managers, and to combine direct observation with in-depth interviews with these managers. The study findings could be used as a baseline for larger, national studies on clinical governance at hospital unit level, and the methods could be validated and/or enhanced in future research. The study findings were validated during a workshop with the nursing managers, thus giving voice to these individuals. The interaction with nursing managers also allowed the nursing managers to be reflective, and to learn from the experiences of other managers, both in the public and private health sectors.The study findings provide a glimpse into the difficulties of achieving a quality of care revolution as envisaged by the establishment of the independent OHSC in South Africa. Nursing unit managers are the custodians of professional nursing practice, quality patient care, and safety in hospitals. Hence, the issues identified in this study must be addressed to ensure that they fulfil their clinical leadership role in hospitals.In the short-term, support from the hospital executive management, particularly the executive nursing manager, is critical. At the very least, a forum that brings together the different unit managers in each hospital would be a step in the right direction. Such a forum would allow for sharing of good practices, peer-to-peer mentoring, and the development of solutions to common problems such as dealing with difficult staff members or mechanisms to improve communication among all members of the health team.In those study hospitals that employed ward clerks or that used an electronic patient information system, the workload of unit managers was eased considerably. In the public hospitals, the idea of ward clerks to relieve the unit manager of routine administrative work has been revived, but implementation has been patchy. The employment of ward clerks would be an important intervention. Another approach, which appears valuable in one province and in the private health sector, was the requirement that medicines and supplies were managed by the relevant departments and not by the unit manager. Unit managers were involved in determining minimum and maximum stock levels, after which other categories of staff keep control of ordering and delivery of stock.In the private sector, the employment of a ‘shift leader’ appears to assist with the problem of interruptions of the nursing unit manager. This individual is a registered nurse who takes responsibility for coordinating patient care, thus allowing the unit manager to concentrate on her management or leadership responsibility. Although this solution depends on the budget availability for an additional registered nurse, the additional cost of employing a shift leader may be off-set by an increase in patient satisfaction and a reduction in adverse events. However, this is an area for further research.inter alia, training or coaching in delegation, conflict management , human resource management, time management, organisational skills, leadership for quality assurance, as well as unit management. The roles and responsibilities associated with unit management should also be emphasised. These aspects should also be addressed in the pre-service education and training of registered nurses.We recommend that continuing professional development programmes be developed for nursing unit managers to enhance their management skills and abilities. These should include, Although our study concentrated on the nursing unit manager, our study findings suggest that problems in the practice environment affect all categories of staff, including junior nurses. In the primary health care environment, a survey found that positive practice environments influence the job satisfaction of managers . GloballThe study examined whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals. The answer is not straightforward. On the positive side, the study found that 25.5% of the time of the nursing unit managers is spent on patient care. Although this proportion compares well with the findings of studies among nurses providing direct care in high-income countries , 24, 33,This study has highlighted the work activities of nursing unit managers, and has explored its relationship to the provision of quality care in selected hospitals. The creation of an enabling practice environment, supportive executive management, and continuing professional development are needed to enable nursing managers to lead and oversee the provision of consistent and high-quality patient care in these South African hospitals.