Nursing in South Africa

Kai Tiaki : the journal of the nurses of New Zealand, Volume 01, Issue 4, 1 October 1908, Page 97

Nursing in South Africa

M. F. WEBB

(BY

N. Z. R. N.

This paper should more properly be called "Nursing in the Transvaal," as, during a stay of a year in South Africa, I have seen very little of the other colonies. I spent a few days in Durban on my way up, but did not visit any of the hospitals, nor have I met any of the nurses from Natal, Cape Colony, or the Orange River Colony, so I know' very little about the conditions of nursing in those parts of vSouth Africa. In the Transvaal I have met a few hospital nurses, a few private nurses, and a few trained midwives. They all agree that the country, at the present time, is not by any means an ideal one for nurses, and that anyone who is thinking of taking up nursing here, should be strongly discouraged from doing so. For one thing the country is now suffering from a period of extreme depression. Doubtless it is only temporary, but in the mean time money is scarce, and persons in all professions are finding it hard to make a living. On all hands one hears of Civil Servants being retrenched, and clerks, typists, shop assistants, and others, losing their employment, not because they are incompetent, but because business is so bad that their employers have ceased to have work for them to do, or money to pay their salaries ; and when once a billet is lost it is very hard to find a fresh one. Even those who still keep their positions have had their salaries reduced, and live in constant fear of dismissal. In this country the accepted fee for a trained nurse is five guineas a week, it can therefore readily be seen that until times improve none but the rich can afford to employ a nurse, except in cases of the most urgent necessity. Apart from the heavy fees, the cost of living is so high that the nurse's board alone is a serious addition to the expense of an illness. For instance, the plainest biscuits are one and sixpence a pound, and eggs, even in the country, and at the plentiful season, are never less than twopence each. Everything else is dear in proportion, and the " tickey "or threepennybit is the coin of smallest value in circulation, the penny not being used. Even one's daily paper costs a " tickey."

Five guineas a week for private nursing no doubt sounds attractive to the New Zealander, accustomed to two guineas, or three guineas at the most, but the difference is merely nominal. In New Zealand a properly qualified nurse may be sure of constant employment, provided that she is conscientious, and that her manner is not such as to cause patients to unfortunately take a dislike to her. Here cases are few and far between, from the causes already mentioned, combined with the fact that nurses are plentiful, and a most competent woman may find herself idle for half her time ; and when not at a case money soon goes. At the time of the war hundreds of nurses flocked to the Transvaal from England and the various British possessions : numbers of these have gone home, but numbers remain. lam told that in Johannesberg alone there are over six hundred nurses to a population of about eighty thousand. I do not know whether this number includes midwifery nurses, but even so it is obvious that the chance of a new-comer being able to make a living is small. I was told by one competent to express an opinion that for a nurse to succeed out here it is essential that she should undertake midwifery cases as well as general nursing. The same lady also told me that there is a large amount of what she described as " God reward you " work : nurses go to cases where the people are very badly off, and can ill afford the heavy expenses. The nurse, for her own and other nurses' sake, does not wish to reduce her fee, at the same time she recognises the fact that the patient cannot afford it, so she compromises by saying " I can't reduce my fee, but I will work °f or three weeks and only charge you for two." However, supposing a nurse is able to obtain her full fee, she goes to her case, and is sure to find it a fairly serious one,' otherwise the relations would have tried to manage without her. At the first moment possible her services are dispensed with, and perhaps she does not get another case for a few weeks. In the meantime her board and washing will cost her at least £8 a month, so what she has earned soon gees.

Again, there is the expense of keeping on her room while at a case, unless she packs everything up and leaves her boxes in someone's charge, a most uncomfortable and unsatisfactory arrangement. A private nurse in Pretoria told me that she has had to pay as much as £5 a month to retain her room while away, but as rents are coming down, to keep pace with the general depression, I daresay this could be managed more cheaply now. In regard to midwifery nursing, few patients care to keep their nurse more than ten days, or at most a fortnight. The conscientions nurse, knowing the uncertainty of these cases, is afraid to book more than one case in a month, with the result that she is idle two weeks for every two she works. Some nurses are daring enough to book two or even three cases for one month, and refuse to go unless the patient requires their services on the exact date arranged, consulting their own convenience rather than that of the patient. Needless to say they are seldom engaged a second time. Altogether, considering the serious drawbacks to nursing as a profession in this country, there being many more that I have not space to deal with, I think that any nurse who feels attracted to this country-, tmt who can get fairly constant work at home, will be wise to remain w r here she is. With regard to hospital nursing, there are only two or three hospitals supported or subsidised by Government. The salaries of the nurses in these are by no means good, a sister only getting about £80 a year. Recently it has been announced that only registered nurses will receive appointments in these hospitals, so that all nurses will be required to speak Dutch as well as English. The best paid work is undoubtedly that in the mine hospitals. On the Rand are numerous mines, each, with a few exceptions, maintaining its own private hospital, or visually two hospitals, one for white men, and one for natives. It seems a great pity that some scheme cannot be devised by which these hospitals could be amalgamated. At present there are numbers of small hospitals, some only distant about a mile from each other, each with its own staff, and many of them without patients for days and weeks at a time. Were five or six of them put together there could be a really good hospital, worked with half the staff at present scat-

tered among the separate hospitals, and still quite accessible to all the mines concerned. In some cases this has been done, but as these hospitals are maintained by a sort of benefit system of payment by the miners, the larger number of the mines prefer to have the sole control of their own hospital. The matrons of the mine hospitals receive salaries varying from £15 to £25 a month, and sister's salaries average about £10 a month. There are, however, many disadvantages. For one thing the outlook and suroun dings of many of the mine hospitals are gloomy and uninteresting in the extreme, consisting mainly of small miners' cottages, and the head-gear and " dumps }: of the mines, and whenever there is much wind the air is filled with fine dust. Some, however, are exceptions to this. Another great drawback is the lack of congenial society. I have one small mine hospital in my mind, the matron of which receives a salary of over £200 a year. This sounds very nice, but consider the drawbacks ! She is the sole nurse in a hospital of about eight beds, and frequently all these beds are empty, perhaps for two or three weeks. The life then must be dull and lonely in the extreme, although this particular hospital is very pleasantly situated. Even though there are no patients the matron is tied to the spot, as who knows, on a mine, when there may be a dreadful explosion, or other accident seriously injuring several men. After a period of comparative inaction there may perhaps be a couple of patients : the matron then has to do all the cooking, as well as looking after them, as she has no assistant with the exception of a Kaffir " house boy " (a grown up man, though called a boy), who does the sweeping, scrubbing, washing-up, and other rough work. The nurse rejoices that she is at last kept busy, but often her joy is short-lived. Very probably a serious case may be sent in for immediate operation, and the work of preparing the theatre and patient, assisting at the operation, and watching a critical case night and day, is complicated by having a couple of hungry men, perhaps, to cook for and attend to. The work now is arduous, anxious and " killing " in the extreme, and we see that every penny of the large salary is hard-earned. If a very bad case comes in a night-nurse may be procured, but perhaps it will be a

day or two before one can be found — in the meantime the solitary nurse has to undergo a great strain. So we see that the lot of even a well paid nurse is not always as charming as might be supposed.

The system of registration of nurses here is very akin to our own ; in some ways it seems to me to be inferior to ours, in others superior. I find that many of our registered nurses would be excluded from registration here, as training in a hospital of less than 50 beds is not recognised. It has always seemed rather an absurdity in our own Act that a three year's training in any of our public hospitals is recognised as sufficient, even though it may have been taken in a hospital containing only half a dozen beds,* and those perhaps usually filled with patients of the chronic type. A nurse might " train )] in some of our smaller hospitals for ten or fifteen years, and perhaps at the end of that time know very little, except in theory, of the nursing of some of the most acute medical cases, while her experience of surgical nursing might be practically limited to a few fractures, and the poulticing of one or two whitlows. Of course small hospitals vary, and in some she might gain a considerable amount of experience, but it is certain there are some where a nurse might be turned out hallmarked " trained " who has never nursed a case of enteric, or a patient after an abdominal operation, or at best perhaps one or two. There is no hospitals department, or special State department for registration in this country. By an Ordinance passed in 1904, a Medical Council was established, consisting of eight medical men and two dentists. Of the medical men two are nominated by the Governor, and the remaining six are elected by the registered medical practitioners of the Colony. They hold office for three years. To this body is entrusted the registration of medical men, dentists, nurses and mid-

wives. The Ordinance lays down the main points of the law affecting members of these professions, and the Council has power to make regulations and hold examinations. The machinery of registration is rather more cumbrous than ours. Nurses and midwives desirous of registering must send in an application on a special form to the Secretary of the Medical Council. They must enclose original certificates, and must establish proof of their identity with the holder of the certificates by a declaration sworn before a Justice of the Peace, a similar declaration must be sworn to the effect that the applicant has never been debarred from practising in any country by reason of misdemeanour or misconduct. These declarations carry a half-crown stamp. The applicant must also send in certificates of good character, and a certificate from a medical man to the effect that her state of health is such that no danger to her patients would be involved by her admission to practice. If the Council decides that the applicant's qualifications are satisfactory, a Certificate of Competence is issued, her name is sent in to the Colonial Secretary, and she is registered by him on payment of a fee of £1. The foregoing applies to those nurses and midwives who rely on certificates gained in England, or any of the British possessions. They must satisfy the Council that their certificate has been granted, after examination, by an institution or body competent by its course of training and material, to grant such certificate. If a nurse does not hold a certificate from a training school, she must send in certificates regarding character and health, and satisfy the Council that she has been through a course of training (including the actual nursing of patients) for not less than three years in an institution, used for medical and surgical purposes, and containing not less than 50 beds, and that she has received lectures from the medical staff and matron during that time. She is then allowed to sit for examination. A midwife must send a certificate showing that she has attended twelve confinements, and continued her attendance during the lyingin period. (Strange to say she does not seem to be required to have attended her twelve cases under competent supervision ; the number of cases also seems too small to afford sufficient experience). Examinations for both nurses and midwives are held in

April and October of each year, and names must be entered by the first day of the month preceding that in which the examination is held. The syllabus for the midwives' examination does not differ much from ours. The syllabus of the nurses' examination differs in two important particulars. One is that there is no separate paper for anatomy and physiology; questions on these subjects being included in the paper on general nursing. This makes a great deal of ground for a nurse to cover at once, especially as the syllabus for these subjects seems to include most of what our nurses are expected to know. Our plan, of making it optional to take anatomy and physiology at the end of the second year's training seems much better, there is less temptation to loiter during twothirds of the time, hoping to cram everything in at the last. Another important addition to the syllabus is " monthly nursing, such as care of lying-in patient, diet, and care of infant." The examination consists, as with us, of a written and also a practical part. A rather curious regulation is to the effect that "in the case of applicants possessing unquestionable evidence of training, the Council may, at discretion, dispense with the written portion of the examination/' I will give specimens of recent papers set in the Transvaal, as being interesting to compare with our own : — EXAMINATION FOR TRAINED NURSES. All the questions to be attempted. Time allowed : Three hours. 1. You are ordered to give a quarter of a grain of morphia subcutaneously : (1) you are given a 1 in 22 solution, how many minims would you give ? (2) You have only gr. 1/3 tabloids, how would you manage to give the correct dose ? (3) You are given a2O per cent, solution, what quantity would you use ? 2. What bones form the elbow joint ? What are the names of the different parts of the bones concerned, and with what bones do they articulate ? 3. Give the different kinds of enemata. How would you prepare them ? What are the special indications for each ? How would you give an enema of plain warm water if the doctor ordered one "as large as possible J "

4. In the case of a fractured spine, what is the nurse's treatment ? What special care should be observed, and to what particular points should her attention be directed ? The doctor only visits once a day. 5. Give the preparation of a patient to be operated on to-morrow at 10 a.m. (a) for haemorrhoids ; (b) amputation of thigh ; (c) mastoid disease. 6. Give the tests for blood, pus, sugar, albumen, and bile-pigment in urine. 7. What is meant by crisis, lysis, hyperpyrexia, incubation, epidemic, endemic, and sporadic ? 8. Describe the signs and symptoms of inflammation. 9. Describe briefly the heart : (1) The walls ; (2) The cavities; (3) The course of the blood. EXAMINATION FOR MIDWIVES. Time allowed : Three hours. All questions to be attempted. 1. Enumerate the bones of the pelvis and their articulations. 2. Give the preparation of a woman for childbed. 3. What are the stages of labour ? How would you diagnose them without vaginal examination ? 4. How would you treat post-partum haemorrhage, and on the arrival of the doctor what would you expect him to do ? 5. How would you deal with swollen, painful breasts about the fourth day ? (a) The nipples being good ; (b) The nipples being so retracted that the mother cannot suckle. 6. Enumerate the different presentations. What would lead you to suppose the case you were dealing with was a cross birth ? In what cases would you think it necessary to send for a doctor ? 7. Describe how you would treat an infant who did not breathe when born. 8. Suppose you thought it necessary to use a vaginal douche, what precautions would you take ? 9. What would you do to minimise the chance of a ruptured perineum ? Registration is optional here both for nurses and midwives, and very few seem to have availed themselves of the privilege. When the Ordinance had been in force for two years (1 have not been able to get later

figures) only 42 midwives had registered on over-sea qualifications ; 77 trained nurses had registered, of whom 62 were trained in the Transvaal. So the numerous over-sea nurses here, unlike the midwives, have not thought it worth while to register. I noticed among thetrainednurses' names, one only from New Zealand, trained in Christ church hospital. The examination fee is rather high, viz., £3 3s, which includes the registration fee of £1 Is. Although the registration of midwives is hot compulsory, as with us, there are clauses in the Ordinance of so far-reaching a character that I think the measure will in practice be more effective than our own Midwives' Act. By the regulations any " person who submits certificates of good character and health, and can prove that she has been in the practice of midwifery for five consecutive years before the coming into force of the Ordinance may be registered, provided that she shall pass a satisfactory viva voce examination in : (1) Normal and abnormal labour ; (2) Simple mechanism of labour ; (3) Nursing mother and child; (4) Use of antiseptics." There is no regulation permitting women of the " Gamp " type to register without passing this simple examination, no matter how long they may have practised. But there appears to be no limit set to the time during which this clause of the five year's practice is operative. I believe that our clause, giving a year of grace during which the old midwives who have been practising for three years might register without further proof of qualification than the production of certificates of good character, was not even heard of (in spite of the pains taken to spread the information), by many of the back-block midwives until long after the year had expired, and although a further extension of the time was practically granted, by allowing those who passed a simple examination to register later, there must now be many up-country districts, remote from a medical man, where there are no registered midwives, and where those who practise unregistered, do so in defiance of the law. Yet if the law be strictly enforced great hardship will result to the residents. Here the midwife may continue to practice, but if by her incompetence or carelessness she endangers her patients' life or health, the law can deal with her with a firm hand. When I left New Zealand our Act did not, I believe,

give any such power to the supervising authorities. Section 28 of the Transvaal Ordinance empowers the Council to make fresh regulations for registered midwives from time to time, and section 29 seems most useful, though somewhat drastic. It runs : — " If any person practising as a midwife shall through culpable uncleanliness, or failure to take ordinary precautions for preventing, or safeguarding against puerperal fever or any similar disease, cause injury or serious ill-health to any lying-in woman, such person shall, on conviction, be liable to a fine not exceeding £50, or failing payment of such fine to imprisonment without hard labour for a period not exceeding three months, provided that proceedings under this section shall not be pleadable in bar of any civil or criminal proceedings against the same person." The penalty for a woman representing herself falsely to be a certificated midwife is heavy, viz, a fine not exceeding £25, or in default, imprisonment, with or without hard labour, for a period not exceeding three months ; and by section 31 of the Ordinance, " The Council may at any time withdraw or cancel a certificate granted to a midwife in terms of section 28 of this Ordinance, if it shall be proved to the satisfaction of the Council that the holder thereof is incompetent, or has been guilty of improper conduct as in the opinion of the Council renders it inadvisable that she should continue to practise as a certificated midwife." As far as I remember there is no such power in New Zealand, a midwife being only struck off the register if guilty of " gross misconduct." Nurses are similarly treated, by section 33 of the Ordinance : " The Council may at any time withdraw or cancel a certificate granted to a trained nurse if it shall be proved that the holder is incompetent or has been guilty of such improper conduct as in the opinion of the Council renders it inadvisable that he or she should continue to practise as a trained nurse." (It will be observed that in this country the male nurse is eligible for registration.) I have to express my indebtedness to Miss Paterson, the Head of a leading Nurses' Cooperation in Johannesberg, who has ever been willing to assist New Zealand nurses in any way in her power, for kindly giving me information and papers with regard to registration.