What's behind the Eastern Cape’s nursing training crisis?

Lecturers doing administrative work instead of teaching, uninhabitable student accommodation, campus break-ins, an exodus of staff since 2017 and campuses with no students. These are among the challenges at Lilitha College of Nursing in the Eastern Cape that the provincial legislature’s health committee flagged as highly concerning after an oversight visit.

Established in terms of the provisions of the Education and Training of Nurses and Midwives Act, Lilitha has five campuses and 19 sub-campuses in the Eastern Cape.

The health committee tabled its findings and recommendations in June. The former demonstrated a dire situation in a province where nursing shortages impact the quality of care people receive and contribute to medico-legal claims against the provincial health department.

According to the provincial legislature's health committee chairperson, Nozibele Nyalambisa, it expected a written response from the department on progress in addressing its concerns, but had not received one.

It has been more than two months since the report was tabled.

“The department is arrogant, since we consistently make these types of findings and they do not bother to respond. We have been struggling to get a response from the department since 2020. They keep saying they have noted our findings. The committee will make sure the department responds to issues raised during the Lilitha nursing college oversight [visit],” she told Spotlight.

“This is very concerning,” Nyalambisa said, “because we cannot have a nursing college that is questionable. Bringing Lilitha nursing college back to its former glory is what we are looking for. It is unacceptable that an institution funded by the government cannot produce quality nurses and the same department that trained these individuals does not recommend them when vacancies arise.”

What the health committee found

In March, members of the health committee visited the college's campuses in Gqeberha, East London, Komani, Mthatha and Lusikisiki, where they met college administrators, campus heads, lecturer forums and labour union representatives.

A report with a litany of red flags followed.

It noted that 22 staff members had left the college since 2017 and none had been replaced. There were insufficient finance personnel, leading to the Gqeberha campus struggling to manage its budget. Apart from excessive municipal service fees, the institution also has poor security, resulting in break-ins, especially during the holidays.

The report noted that exam papers were sometimes handwritten and that at the Komani campus infrastructural challenges included dilapidated structures and unsanitary ablution facilities. Also, due to poor management of students’ results, their exam statuses were conflicting.

Lecturers managed the student management system at the Mthatha campus, leaving it compromised, the report noted.

The same campus was subject to serious fraud by a staff member, it added.

During the committee's visit to the East London campus, there was no acting principal to receive its members, who found the facility had spent R118,000 on a workshop in Gqeberha, about 290km away. Relations between staff were strained regarding finance and procurement, resulting in the campus receiving incorrect stationery last year, a waste of resources and operational delays, the report said.

It also flagged that there were no students at the St Patrick and Butterworth sub-campuses as there had been no intakes since April 2021. Several positions at Madzikane kaZulu sub-campus in Lusikisiki were vacant, including posts for a finance officer, HR practitioner, admin clerk and data capturer. Staff at Butterworth and St Patrick were underutilised because there were no students, with head office aware of the problem, the report added.

The committee said issues including accreditation that hamstrung the production of graduates at the college threatened the provision of quality healthcare in the Eastern Cape.

Staff and accreditation issues

“South African Nursing Council (SANC) non-accreditation is another dark cloud hanging over the college. Almost all campuses are filled with acting senior management personnel. In the province, nursing education is in crisis and the grand plan to establish main and sub-campuses has been derailed,” read the report.

“The department must fill all vacant positions with qualified personnel as soon as possible. There is a need for the department to explore the best ways to address infrastructural challenges at the Komani campus. To ensure proper management of student affairs, the department must ensure the respective personnel are employed. A progress report must be submitted to the committee within 30 days after the adoption of this report by the house.

“To restore human dignity and uphold institutional policies at Lilitha nursing college, the department must intervene and resolve the current pandemonium.”

A staff member at the Gqeberha campus, who asked not to be named, said: “Lilitha college played a crucial role in producing nurses who are badly needed, but poor management is putting an end to nursing careers in the province. This situation will lead to a future crisis if the department does not address poor management and administration.”

“There are always break-ins on campus and nobody seems to care,” the staff member said. “The books are arriving late and we are expected to produce quality nurses. When there is not enough equipment for teaching and learning, how do you produce a good product?

“The problems started when the nursing regulatory and accreditation bodies reported that management was lacking in qualifications. As a result, it was not possible for the college to be accredited under the new system.”

The staff member said since the department of higher education and training was involved in the accreditation process, it could, “if ... keen, speed things up”. “I don’t understand why the accreditation issue took over two years to be resolved. The colleges in KwaZulu-Natal and elsewhere are accredited and they are preparing for their intake, but here at Lilitha we are stuck.”

‘Headed for disaster’

Chairperson of the Democratic Nursing Organisation of South Africa (Denosa) in the province, Sivuyile Mange, said the situation clearly indicated that Eastern Cape health services are headed for disaster.

“Denosa is concerned about what is happening in Lilitha College because there are only final-year students there. There are no first- or second-year nursing students since the college stopped taking students two years ago. This means the healthcare system in the province is facing a bleak future as we have a huge shortage of nurses. As a result of staff and working equipment shortages, the department is overwhelmed with medico-legal claims, yet there is no annual intake of students to ensure a supply of nurses,” he said.

“Every year nurses leave the department through natural attrition and resignations ... this leaves a big void. The annual intake ensures these gaps will be closed. The stoppage of the annual intake is depriving the people of the Eastern Cape of quality nursing care.

“This is not only affecting students, but lecturers, as they face a bleak future because soon they will also be told they are redundant due to the absence of students to train. This — having people paid every month for doing nothing — is fruitless expenditure, yet the same department [cries bankruptcy],” said Mange.

Call for independent probe

EFF provincial legislature member Yazini Tetyana has called for an independent probe into the dysfunctional institution.

“Lilitha College is badly run, from building (infrastructure) to the curriculum and administration to management. In the next two years it will be dead. We believe the college is collapsing because of political interference. We want the issue of Lilitha college to be investigated and a commission created if needs be, so we can [uncover] who is responsible for the collapse of that institution,” said Tetyana.

“Provincial health is in a state of paralysis. For example, how do you run a health institution that is not accredited by the SA Nursing Council? The department has high medico-legal claims, but we still have people who are not accredited and registered with the body that regulates the nurses. When these lawyers want to litigate, they look at those things and say these nurses are coming from an institution that is not accredited.”

No accreditation, no training

SA Nursing Council (SANC) registrar and CEO Sizo Mchunu confirmed to Spotlight that Lilitha would not be able to offer new programmes until it receives accreditation from the Council on Higher Education (CHE).

“All nursing programmes must be accredited by the South African Nursing Council and the Council on Higher Education because all nursing qualifications are now under higher education. The Nursing Education Institutions (NEI) must first submit their curricula to SANC and if accredited, then they submit to CHE. The NEIs cannot offer the programmes if not accredited by both institutions,” said Mchunu.

“Lilitha nursing college was fully accredited by SANC to offer the diploma in nursing at all five campuses. Full accreditation was subject to the submission of proof of accreditation by CHE. So far, there is no proof that the campuses are accredited by CHE. The campuses cannot, therefore, offer the programme until accredited by CHE and the qualification has been registered with the South African Qualifications Authority (Saqa),” she said.

According to Mchunu, the sub-campuses of each main campus were conditionally accredited by the SANC to offer the higher certificate in nursing programme. The sub-campuses had not yet fulfilled the conditions and therefore could not offer the programme.

“SANC has jurisdiction over NEIs that have been duly accredited to offer nursing programmes and to ensure they meet SANC standards, criteria and requirements. The individual NEIs must ensure they maintain accreditation standards, criteria and requirements all the time and not rely only on SANC for monitoring and evaluation.”

Mchunu declined to say Lilitha was operating illegally, only that it was not accredited. “Whenever an institution operates illegally, a criminal investigation can be initiated,” she said.

Despite SANC not recognising the college’s programmes, it held a graduation ceremony on August 4 for 370 students who completed the four-year diploma programme, 146 who completed the bridging course, 14 who completed the post-basic programme, four who completed the enrolled nursing assistant programme and three who completed one year of study in midwifery.

In August last year, 725 students graduated despite conflicting accreditation statuses of programmes.

Health department responds

Eastern Cape health spokesperson Yonela Dekeda insisted the college was accredited to offer some qualifications.

She said Lilitha received full accreditation for the nursing diploma from the SANC and conditional accreditation for the higher certificate in nursing. In keeping with the new qualifications system, the college had applied for accreditation and the department was awaiting Saqa's approval. Training could not commence and the college continued to follow up with accreditation bodies for the process to be finalised. 

Lilitha sub-campuses had reduced activity for a time to phase-out legacy programmes in preparation for the new qualifications stream. The situation would change once Saqa had given the green light for training to resume, she said. The college still had students who were completing their studies and graduations had taken place every year since 2020, despite new qualifications having commenced.

Dekeda said the department was aware of the situation at the Komani campus and a new building project was prioritised, but budget constraints saw it shelved. In the meantime, the department’s 2022/23 infrastructure plans included the Komani campus (for repairs, upgrades and maintenance). With all planned activities going well, the contractor could be on-site during November or early December 2022, she said.

“Lilitha, like all entities of the department, faces similar constraints with respect to staffing. This situation has been mitigated by bringing staff from satellite campuses, where work had either scaled down or no programmes are provided,” she said. “Lilitha is part of the 2022 health department’s annual recruitment plan to fill some of its key posts, such as campus management.”

Dekeda said the department and management of Lilitha understood “anxieties about the college commencing with the training activities”. Notwithstanding, it was gearing up to commence training in 2023.

— This article was first published by Spotlight