Original Research

Transformation in South African professional nursing organisations: The strive for unity

Johanna M. Esterhuizen, Gisela H. van Rensburg

Received: 08 Apr. 2024; Accepted: 10 Sept. 2024; Published: 29 Nov. 2024

Copyright: © 2024. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

South Africa’s professional nursing organisations and consequently the profession itself, underwent two major periods of transformation. The first period from the 1950s to the 1980s, was shaped by a political system that forbade multiracial workers’ organisations and mandated racially segregated nursing associations. The statutory position of the South African Nursing Association (SANA), combined with the country’s autocratic socio-political environment, limited the ability of nurse leaders to openly challenge the status quo. Instead, these leaders developed strategies and professional structures to minimise the impact of socio-political influences on the development of nursing as a profession. The second period of transformation began in the 1980s, driven by broader socio-political changes in South Africa. The racial fragmentation caused by the first transformational period, coupled with SANA’s statutory status, made this second period particularly challenging. Over time the nursing profession experienced further division because of differing philosophical and socio-political views. From 1944 to 1985, nurse leaders opted for a single, mandatory professional association to represent professional nurses’ interests. However, after 1985, professional nurses in South Africa chose to prioritise freedom of association and their socio-economic needs, which led to the erosion of a unified, collective professional identity.

Contribution: The authors contribute to the history of nursing by describing how South African professional nursing organisations were subjected to two transitional periods that significantly influenced the nature of the organisations and the nursing profession itself. The purpose of this article is to narrate these events not yet disseminated in South African nursing history literature.

Keywords: history; nursing; organisations; political; social; South Africa; trade union; transformation.

Introduction

Members of a profession must engage in continued development of their professional skills and in discussing matters affecting their profession, and the society they serve. In this regard, membership of professional organisations is essential as these organisations act as collective voices on behalf of the profession. This implies that professional organisations must periodically transform and adapt its purpose and role to effectively serve their members and by extension, greater society. Throughout its first 100-year history (1914–2014), there is evidence that South African nursing organisations re-aligned their purpose and transformed its nature. In this article, the authors summarise the origin of professional nursing organisations and then discuss two important transformational periods in the history of South African nursing.

The British Medical Association (BMA), established in 1832, was the first professional organisation in the world. Later, under the leadership of Mrs Ethel Gordon Bedford Fenwick, the Royal British Nurses Association (RBNA) was established on 10 December 1887.¹ Given South Africa’s colonial status at the time, the British ideals of care and nursing were brought to the country by the religious sisterhoods who participated in mission work conducted at the time. Sister Henrietta Stockdale, friend of Mrs Bedford Fenwick and member of the Community of St. Michael and All Angels, established the first nursing training school and a branch of the RBNA in Kimberley in 1888. Sister Henrietta encouraged her trained nurses to join the RBNA so that their professional expertise could be recognised internationally. Professional expertise would increase their professional status and ensured trained nurses of a better financial renumeration. Sister Henrietta, with the assistance of Sister Mary Agatha from Somerset hospital and supportive medical doctors campaigned successfully for the recognition of trained nurses by the state. In 1891, the new Medical and Pharmacy Act (no. 34) granted trained nurses in the then Cape Colony state registration² – the first group of nurses in the world to achieve such status.

Sister Henrietta endeavoured to establish a nursing organisation that could voice the professional needs of the registered nurses, but their small number and the great distances between towns (by 1899 there were only 3000 trained nurses in South Africa, Matabeleland [Zimbabwe] and Bechuanaland [Botswana]), unreliable and slow communication, and the second South African War (1899–1902) made the process frustratingly slow.³ Such circumstances necessitated Sister Henrietta to act on behalf of trained nurses in the absence of a professional nursing organisation in South Africa. Only after her death in 1911, would the first professional nursing organisation be established. Until then, the (female) nursing profession had to depend on the (male) medical profession for leadership – and their voices were barely heard.

In 1914, the first influential regional professional nursing organisation, namely the South African Trained Nurses’ Association (SATNA) was instituted with the aim of achieving professional autonomy for nurses. Over time, SATNA succeeded in creating a distinct nurses’ voice that campaigned for nurses’ professional status, improved educational standards in nursing and consequently, for better socio-economic status. South African nurses’ long-sought professional independence was obtained when the first Nursing Act (45 of 1944) was promulgated and the South African Nursing Council (SANC) as well as the South African Nursing Association (SANA) were established in 1944. Since then, professional nurses in South Africa govern themselves and their profession.

The first Nursing Act (45 of 1944) provided for the formation of a professional nursing organisation with compulsory membership. The South African Trained Nurses’ Association transformed into the SANA and all practising nurses in South Africa were compelled to be members of the new association; thus, implementing the closed-shop principle. The South African Nursing Association’s statutory (in law) status was beneficial in the early years after the establishment of the association, because it ensured a large membership and the nurse leaders had governmental support. However, their statutory status also made them vulnerable to the socio-political (during apartheid) system that was gradually taking hold of the country. Given that SANA had to function within the prescriptions of the law, any suggested changes required law makers in parliament to accept amendments to existing legislation. To further complicate matters, in a conservative, male-dominant society, female leaders often opted to work within the social system; never openly challenging male authority but rather opting for a more diplomatic approach.

South African nurses seldom conduct historical inquiry,⁴ resulting in a small data base with mainly older sources. As a result, the professional history is not accessible to current and future generations of nurses. The in-depth researched studies about the history of South African nursing are Searle (1965), Potgieter (1988), Mellish (1990), Marks (1994) and Mashaba (1995). There is a need to record nurses’ current, post-apartheid history, and therefore the authors themselves conducted formal historical inquiries between 2013 and 2019 and continue to publish the history widely.

In this article, the authors contribute to the history of nursing by describing how South African professional nursing organisations were subject to two transitional periods during the 1950s to the 1990s that significantly influenced the nature of the organisations and the nursing profession itself. Although both transitional periods are evident in the article, the first (1950s–1970s) period acts as a background, setting the scene to explain the significance of the most recent (1980s onwards) transitional period. Figure 1 and Figure 2 provide a visual timeline of the two transformation periods. The events of the second transitional period have not yet been comprehensively described in nursing history literature (e.g. books, journal articles); hence, the authors opted to add footnotes to serve as source reference for future nurse researchers.

FIGURE 1: Nursing organisations from 1914 to 1989.

FIGURE 2: Nursing organisations from 1993 to 2014.

Research method and design

The researchers conducted historical inquiry with the purpose of describing the influence of professional nursing organisations on the nature of the South African nursing profession. One of the primary objectives was to describe South African nursing organisations’ functions (e.g. professional, social and political) and to identify those factors which, over time led to change. An extensive purposive literature search was conducted in private collections and South African archives that provided primary sources, while libraries were accessed for secondary sources. Online data bases also contributed to the secondary source collection. Repetitive cycles of data collection, analysis and reflection ensured that data, rich and thick in descriptions of historical events, were recorded. Informed by critical realism philosophy, the research findings go beyond the mere recording of historical events; rather the hidden, often unobserved structures and relationships that influence historical events were identified and described.⁵ Approval of the research was obtained from the Research Ethics Committee of the university where the study was registered.

The first transitional period as historical background

The research findings revealed that, historically, the professional nursing organisations in South Africa, and by extension the nursing profession itself, were influenced by socio-political (e.g. apartheid), socio-economic (e.g. trade unionism) and socio-cultural (e.g. gender) factors. In turn, the professional nursing organisations themselves had influence in that they acted as the collective political voice for nurses in matters of professional concern. In this article, only the socio-political transformation of the profession is discussed starting with the circumstances that lead to the apartheid system in South Africa creating a political divide in the nursing profession.

In the 1950s, SANA was criticised by the International Council of Nurses (ICN) for the newly promulgated Nursing Act (69 of 1957) that required South African nursing to introduce racial segregation in the workplace. At the 1959 ICN Congress in Mexico City, SANA was given an ultimatum: reform or be expelled. Although SANA leaders explained their statutory position and professed their political neutrality, criticism of the association did not lessen over time. South African Nursing Association formally withdrew their membership of the ICN on 21 July 1973 citing several reasons for their decision. The SANA Board reiterated that they were unable to change the Nursing Act (69 of 1957) independently; it required an act by parliament. Furthermore, SANA suffered financial strain because of the expenses incurred to set up racially segregated SANA branches as dictated by apartheid law and the increased cost of ICN membership. The SANA Board also opposed the (in their view) ethically unsound suggestion that they should protest government policy by means of strike action.⁶ Striking nurses potentially place patients in harm’s way.

The SANA leaders expressed their fear of losing South African nursing’s professional status; a statutory position held since 1891 when the first (in the world) register for trained nurses were established in the then Cape Colony. Professor Charlotte Searle, the SANA President in 1973, in later years explained that nursing losing its statutory status would have resulted in ‘representation of the profession’s interests would pass [passing] to a variety of diverse non-professional organisations’.⁷ The decision by SANA to withdraw its ICN membership was based on political, financial and ethical factors. South African nurses thus became isolated from the activities of the international nursing community.

Within South Africa, splinter groups such as the Federation of SA Nurses and Midwives, the SANA Witwatersrand non-European Discussion Group, and Die Afrikaanse Verpleegstersbond publicly voiced their dissatisfaction with SANA’s management of professional affairs. These splinter groups mirrored the political divide that was evident in South Africa itself. The organisation, Die Afrikaanse Verpleegstersbond urged SANA to implement apartheid policies in nursing, while the other groups supported non-racialism in nursing. The Federation of SA Nurses and Midwives, for example was established after a non-racial conference convened and passed a vote in which they objected to SANA’s implementation of government policy.⁸ Others chose a form of silent disapproval: SANA became burdened with having a large membership, many of whom were inactive in the association. South African Nursing Association’s compliance to government policy unintentionally politicised the profession: polarising nurses based on race, which during the second transformation period (1980s–1990s) would create barriers almost too difficult to overcome.

In judging SANA’s decisions taken during the 1950s to 1970s, one must consider the socio-political climate of the time. The Nursing Act (69 of 1957) formalised racial segregation in the nursing profession and proscribed that members of the SANA Board must be white, registered nurses, and midwives of both genders.⁹ The Minister of Health had the power to rectify board nomination and appointments. Advisory Boards for black and coloured nurses were established and were in communication with the SANA Board. No primary archival evidence is available to indicate that the SANA Board themselves actively encouraged the government’s segregation policies (this would have been contrary to their professed political neutrality). Instead, the association adjusted its professional activities and chose to follow a path of quiet diplomacy. South African Nursing Association continued to engage with new racially segregated branches, financially assisted them and creating, on 30 April 1982 an organisation called the League of Nursing Organisations of Southern Africa (LONASA) to ensure continued interaction with neighbouring states’ nursing associations. To not challenge government policy, the pilot committee met on international ground – the then Jan Smuts (now OR Tambo) Airport. Chairmanship of LONASA rotated yearly, with Mrs A.N. Lekgetha from the Bophuthatswana Nursing Organisation (BONA) as the first Chairperson of the organisation. However, SANA leaders never openly challenged government rule; knowing that if they do, they will be met with fierce resistance. In later years, one nurse leader declared that:

[A]lthough the Association has repeatedly taken a stand against issues such as the fragmentation of health services and the racial discrimination against some of its members, perhaps these protests were put in such a submissive way that they were not even heard.¹⁰

Discussion

Because of the gradual waning of apartheid, South Africa’s political landscape changed and so did the country’s nursing organisations. Opportunities created by socio-political changes in the 1970s to 1990s enabled the nursing profession to move into the second transformation period.

In the early 1980s, South African legislations that prohibited multiracial trade unions were revised after numerous objections from labour. There was no reference in the new Labour Relations Amendment Act (57 of 1981) to race. Provision was made for the establishment of multiracial trade unions, provided they did not actively participate in politics. Already engaged in the political affairs of the day, many black trade unions chose not to register.

The changes in South African labour legislation influenced SANA and by extension the nursing profession in the country. Since its inception in 1944, SANA’s powers and functions were prescribed in law. The Nursing Act (50 of 1978) departed from the established standard by not prescribing the functions of SANA. For the first time, the nursing association was allowed to regulate its own affairs. Although the Minister of Health still had the final say, the nursing association was allowed to pen their own constitution.¹¹ Transformation became possible; albeit slowly. Nurses were allowed to join trade unions, although in the workplace, SANA retained their commanding role as the only entity who represented nurses in professional matters and in salary negotiations. Many nurses deemed SANA to be ineffective in this role and voiced the need to discuss alternative forms of representation, such as a trade union. South Africa’s socio-political transformation in the 1980s to 1990s created fertile ground for nurses of the country: the calls to debate SANA memberships and trade unionism gained momentum.¹²

Factors affecting transformation in South African nursing organisations

The calls for transformation in professional nursing organisations compelled SANA to adapt its constitution in the early 1980s. Several internal and external factors were identified as being influential in the decision.

External factors included opposition to South Africa’s segregationist political system, changes in labour law, the country’s high inflation rate and an economic recession. The financial woes created pressure on the healthcare system as nursing and medical tariffs had to be reduced or at least stabilised. Nurses became concerned about the number of nurses trained, the availability of posts and their conditions of service.¹³ In their 1983 members’ guide, SANA called on all to actively engage in professional matters in order to increase their negotiation power but reiterated their policy of socio-political neutrality in their new constitution: ‘[N]either the Association nor any of its regions, professional societies or branches shall affiliate with any special, cultural, religious, social or political organisation’.¹⁴ South African Nursing Association critics declared that such neutrality dissuaded nurses from voicing opposition to apartheid’s unfair healthcare system, while others insisted that nurses had to comply with the rules to ensure their professional and economic survival.¹⁵ Uys avers that the ‘workplace became part of the political battle-field’.¹⁶

South African Nursing Association’s constitutional change was also motivated by internal factors. Non-paying members, low voting numbers during board elections and low turnout at branch meetings challenged the status quo (interestingly, SANA members attended the association’s specialist discussion groups better than they did the branch meetings).¹⁷ However, the most important factor was SANA members’ belief that negotiations for conditions of service should be conducted by a trade union. In the workplace, nurses were also encouraged to join trade unions, which were establishing a presence in the healthcare sector.

The conservative SANA Board was open to change, but they did not consider trade unionism as a viable option. Although they accepted that a profession exerts political influence, SANA differed from trade unionists in that they did not approve of nurses going on strike. South African Nursing Association leaders asserted that industrial action would harm the nurse–patient relationship and that the vulnerable patient (society) cannot be considered a bargaining tool. The President of SANA for 10 years, Professor Charlotte Searle (1973–1983), opined that professionalism was about wisdom, knowledge and ‘great moral certitude’.¹⁸ Similarly, the first President of the Democratic Nursing Organisation of South Africa (DENOSA), Professor Philda Nzimande, later reiterated that ‘[e]very profession should rest upon a professional base of service to the community, a body of knowledge and adherence to a code of ethics’.¹⁹ Therefore, SANA opted to decentralise their organisational structure and to introduce multiracial regional and central boards. In 1985, SANA’s first multiracial Central Board took control of the association; but it was unable to immediately remove racial references from their constitution or to integrate their racially segregated SANA branches. Only in 1989 could the SANA Constitutional Congress finally remove all reference to race from their constitution. This was because of the South African citizen classification system that was still in place. Only South African citizens (as defined in law) could serve on the SANA Board at that time; not citizens from the self-governing or the homeland states.²⁰

Times are changing: 1980s to 1993

Discussion about SANA relinquishing the compulsory membership principle and their exclusive right to negotiate on behalf of nurses (the closed shop principle) gained momentum in the late 1980s. Uys²¹ predicted that ‘if the profession gives up this privilege, there is almost no chance at all of ever getting it back’. It was a conundrum: although strengthened by the closed shop principle in terms of negotiation power SANA was also weakened by it because employers were aware of the association’s aversion to strike action. Any change therefore required acceptance of hitherto taboo trade union mechanisms such as collective bargaining. The professional nursing association’s focus had to shift from ‘professionalism first’ to accommodating and prioritising nurses’ socio-political and economic needs in a changing South African landscape.

Initiated by the Concerned Nurses of South Africa (CONSA), South African nurses held their first National Consultative Conference from 12 to 14 February 1993 at the Lionsdale Hotel in Durban. The keynote speaker at the conference was Mrs Albertina Sisulu.²² The conference primarily concerned itself with the fact that nurses were not consulted when healthcare plans were being drawn up for South Africa and that because of the apartheid system, the nursing profession was splintered into numerous organisations.²³ Attendees asked: Should nurses remain neutral as professed by SANA, or should nurses become politically vocal about the injustices evident in the South African healthcare sector? Conference attendees resolved to create a structure, named the Nurses’ Forum, that had:

[T]o formulate a vision for the nursing profession in Southern Africa that will lead to a planning process for change in order to meet the future needs and challenges of the profession.²⁴

The steering committee met on 24 February 1993 with Professor Philda Nzimande as primary facilitator. All nursing organisations who participated in the Durban National Consultative Conference had representation in the Nurses’ Forum.

Achieving professional unity – A complicated matter

The Nurses’ Forum had several complex issues to deal with before professional unity could be achieved. Firstly, the participating nursing organisations had to agree on what they considered to be common ground and what to do about SANA’s statutory status. Secondly, the Forum also had to consider the professional activities that SANA was already engaged in, for example, the election of a new SANA board and planned amendments to the Nursing Act (50 of 1978).²⁵ Furthermore, South Africa was preparing for its first democratic election in 1994, and it was essential that a professional nursing organisation represent nurses on the National Health Forum where the country’s new healthcare dispensation was being discussed. South African Nursing Association, in collaboration with SANC, already drew up a provisional discussion document and it was offered to the Nurses’ Forum for use. The Nurses’ Forum approached the chairpersons of the National Health Forum to request representation and tasked Professor Rachel Gumbi and Miss Sarie Human (later professor) to represent the nursing profession in the national discussions.²⁶

Despite these challenges, the Nurses’ Forum persisted in their undertaking to enable the nursing profession to plan their envisioned transformation process. From 28 to 30 January 1994, nurses gathered at the first National Convention of Nurses of South Africa. Mrs Albertina Sisulu delivered the welcoming speech and Professor Philda Nzimande the opening address. A temporary structure called the Transitional Nurses’ Committee (TNC) was formed on the last day of the Convention.²⁷ The TNC was tasked with leading and overseeing the transformation of nursing organisations and to this end planned a congress to elect an interim board and to create a draft constitution for the envisioned, integrated professional nursing organisation. The TNC’s first meeting was held a month after the Convention, from 24 to 25 February 1994. Elected as leaders were Professor Philda Nzimande as chairperson, Miss Thembeka Gwagwa as vice-chairperson and Professor Leana Uys as secretary.²⁸ South African nurses were invited by the TNC to submit in writing their suggestions for the draft constitution. During a 2-day workshop held from 25 to 27 July 1994, the designated TNC committee discussed the 67 submissions and drafted a constitution. The committee consisted of nurses from all categories (registered, enrolled, auxiliary), student nurses; nurses from all provinces (excluding the Northern Cape and Free State who were unable to attend); nursing administrators, nurse educators and clinical nurses.²⁹

The TNC committee recommended three basic models for the new professional nursing organisation, namely a labour union, a purely professional organisation or an organisation containing both a non-labour union section and a labour union section. From 26 to 28 January 1995 a Constitutional Conference was held, and the majority of the 680 delegates voted for option number three, namely an organisation containing both a non-labour union section and a labour union section. With this vote, the work of the TNC was completed: a new professional organisation, the DENOSA was established. South African nurses were the first professional group in the country to hold such a conference and to take steps towards uniting their profession in the post-apartheid era.³⁰ It was the completion of a professional journey that started in 1985. On 11 March 1995 the DENOSA Interim National Board (INB), that would initially lead the new professional organisation, met for the first time. Professor Philda Nzimande was elected as chairman, and Professor Marie Muller was elected as vice-chairman.³¹

A merger between South African Nursing Association and Democratic Nursing Organisation of South Africa

After the new integrated nursing organisation was formed, South African nurse leaders were tasked to commence with the process of dissolving SANA – and for the SANA Board to negotiate terms with the DENOSA INB. Negotiations commenced on 24 April 1995 but were problematic because of financial matters and SANA’s assets. The Democratic Nursing Organisation of South Africa would have incurred transfer duty (tax) if SANA’s assets had to be transferred to it. After consultation with the Commissioner of Inland Revenue and attorneys and to avoid taxation, SANA proposed a merger with DENOSA (instead of a dissolution of the 50-year-old association). This move implied that SANA would change its name and adopt the DENOSA constitution. Because only the name of the organisation and its constitution would change, SANA as a legal entity would not be affected and no tax will be incurred. The South African Nursing Association’s would transfer their membership list and assets to the new professional organisation. The DENOSA INB refused to accept the financially sound proposal because it might have damaged their credibility in the eyes of the nursing profession; the new organisation at first glance might be viewed as simply an extension of the old.³² The politicalisation of nurses and the resultant mistrust that originated in the 1950s because of SANA’s compliance to apartheid policies now negatively affected the unification process.

Matters were further complicated in that SANA members on 17 October 1995 voted against dissolving the association. An impasse in the process of unification was reached as neither SANA nor DENOSA had a mandate from their members to continue negotiations. Furthermore, the SANA constitution provided for a dissolution of the association, not a merger. The SANA Board called for a national management structure meeting, which was held on 03 November 1995. At that meeting, Professor Marie Muller, the President of SANA, explained that the association could not be dissolved because of the Board not obtaining the 75% majority member vote required for such an action. She reiterated that the primary goal was the unification of the South African nursing profession and that to achieve that goal, the SANA Board supported a merger with DENOSA. The SANA Board therefore proposed an amendment to the association’s current constitution; to allow a merger with another professional organisation. Most (124) of the 135 delegates attending the meeting accepted the Board’s proposals. By the end of January 1996, consultation with the SANA branches were completed, and the proposals accepted. The Board received their mandate.³³

While awaiting the branches’ mandates, the SANA Board forced ahead with negotiations. On 23 November 1995, SANA and DENOSA agreed that discussions between the two largest professional organisations will be focussed on a potential merger. The new negotiations soon became problematic with thorny issues being the constitution of the new organisation, the name of the new organisation and the continued employment of the current SANA personnel. Negotiations again reached a deadlock.³⁴

The two nursing organisations each had something to gain and something to lose. Both organisations were morally vested in the unification of the South African nursing profession. The Democratic Nursing Organisation of South Africa, being a new organisation was in a strong position; increasing their socio-political power and membership, but they were financially weak. The South African Nursing Association (being a legal entity), on the other hand, was financially stronger but stood to lose socio-political power and members. The South African Nursing Association’s corporate and administrative responsibilities were time sensitive, for example, adding news about the merger in the latest edition of the Nursing News and posting accounts timeously to guarantee an income for the next fiscal year. Resolving the deadlock in the negotiations was therefore of utmost importance. The South African Nursing Association urged DENOSA to inform them before 02 September 1996 at 10:00 whether the negotiations for unification (merger) will go ahead. DENOSA was also asked to commit to joining SANA in a management meeting scheduled for 07 September 1996 to conclude negotiations.³⁵

A joint media statement was released on 09 September 1996 in which DENOSA and SANA announced that a merger between them were agreed upon. The merger agreement was formally signed on 26 September 1996. From 01 October 1996, the new organisation called DENOSA would have trade union and professional functions. Democratic Nursing Organisation of South Africa would continue to engage with smaller nursing associations; inviting them to join and therefore unite the country’s nursing organisations. It was further agreed that the SANA’s Nursing News would be used as the formal information source during the transitional phase and that as long as DENOSA exists as a unifying organisation, the SANA head office building in (the then) Church Street, Pretoria, will not be disposed of. The DENOSA will also continue with the Institute for Professional Development, a subject close to SANA’s heart.³⁶ The DENOSA was officially launched on 05 December 1996 by President Nelson Mandela.³⁷

South African nurses’ engagement in trade union activities

With the merger completed, SANA members automatically obtained DENOSA membership. The unification process occurred in two phases: firstly, a unifying Joint National Board would manage activities and later a new National Board would take over leadership of the organisation. Democratic Nursing Organisation of South Africa’s first Board meeting was held from 25 to 26 July 1997 and elected Professor Philda Nzimande as the organisation’s first president.

Referring to the future role of DENOSA, Professor Nzimande rejected the notion that the new organisation was simply another trade union: ‘DENOSA has always been, and still is, the only professional nursing organisation for nurses of South Africa’.³⁸ Nurses were reminded of the organisation’s Institute for Professional Development, which focussed on providing courses for nurses’ professional development. The DENOSA president also reiterated the organisational aims, including to ‘achieve progress for nursing and midwifery in South Africa in all areas of importance to them’.³⁹ Not all DENOSA members agreed with her. In a letter published later that same year, a member expressed their concern about a reference by the Nursing Update editor (the organisation’s new publication for members) to DENOSA as a professional association: ‘It was registered from the start as a union’ and demanded a retraction to prevent ‘harm [to] the organisation’s image’.⁴⁰

Transformation in the 1990s was not only evident in the South African nursing profession, but in the country itself. Nurses working in the public sector did not have a bargaining council addressing their specific socio-economic needs. To represent these nurses, DENOSA therefore needed access to the new bargaining structures, namely the National Economic Development and Labour Council (NEDLAC) and the Public Service Bargaining Council (PSBC). Moreover, DENOSA needed financial support to develop the trade union leg of the organisation, and they needed to affiliate with a strong socio-political entity that was able to influence government policy. The Board therefore opted to join the Congress of South African Trade Unions (COSATU) in November 2001. Also joining COSATU were other smaller trade unions with nurse members, for example, the South African Municipal Workers Union (SAMWU), the National Education, Health and Allied Workers’ Union (NEHAWU) and the South African Democratic Nurses’ Union (SADNU). Critics of this decision by DENOSA feared that nurses would lose their independent, distinct and collective professional voice and that professional matters would be placed on the back burner in favour of collective non-nursing workers’ interests that benefit the majority of COSATU members. Many nurses who opposed trade unionist principles left DENOSA and joined newly created professional organisations, leaving the (originally) unifying nursing organisation struggling to maintain or increase their membership numbers. By 2014, South African nursing’s professional organisations were predominantly engaged with political and trade union activities. By affiliating themselves with a powerful and influential trade union, South African nurses gained economic bargaining power but gave up their historically collective (in one professional organisation only) professional bargaining power.

For the first time in their professional history, South African nurses officially joined industrial action activities during the COSATU-led labour protests of 02 to 03 October 2002.⁴¹ In later years, DENOSA’s outgoing President reflected on the progress of the nursing profession after 1996 and concluded that nurses’ involvement in politics was a two-edged sword. Although political appointees could positively influence policymaking, being engaged in politics also caused damage to the nursing profession: ‘We gradually are drifting away from our responsibilities as professional people to a lesser position as ordinary labourers’.⁴²

Conclusion

The 100-year history of South African nursing organisations illustrates how these organisations had to transform themselves to continue serving the needs of their professional members. In 1914, nurses opted for a professional association (SATNA) that prioritised their need to become a recognised profession with professional status and a collective political voice. Amid an autocratic socio-political system in the 1950s–1990s, SANA showed resilience and transformed itself into a professional organisation with a trade union section to unite a socio-politically divided profession. This article illustrates the inescapable influences that social and political systems exert.

Since the 1950s, the then SANA was heavily criticised for their apparent support of the government’s segregationist laws. The South African Nursing Association’s nurse leaders chose a path of quiet, diplomatic resistance and refused to condone trade unionist forms of protests such as strike action. Over time, this policy of quiet diplomacy bore fruit in that the South African nursing profession, starting in the 1980s, was the first group to initiate changes and implemented actions to unify the nursing profession and to remove racial segregation concepts from its constitution. The transformational process was slow because of socio-political circumstances and SANA’s statutory status. In establishing DENOSA, the South African nursing profession forego the closed shop principle practised by SANA. This implied that nurses in the country were free to join any (or more than one) trade union and/or professional associations of their choice. In the post-1996 era, South African nurses gained freedom of choice in respect of professional organisations and increased their socio-economic bargaining power, at the cost of their collective, professional voice.

Highlighting the results of external pressure, the first historical period of transformation divided the South African nursing profession, while the second period of transformation initiated a strive for professional unity that is yet to be concluded. The value of unity lies in the nursing profession’s potential to advocate as a collective for healthcare policies that not only benefit nurses and the nursing profession but also the society they serve.

Acknowledgements

This article is partially based on J.M.E.’s thesis entitled ‘The influence of nursing organisations on the development of the nursing profession in South Africa: 1914–2014’ towards the degree of Doctor of Literature and Philosophy in Health Studies at the University of South Africa, in June 2019, with supervisor Prof G.H. van Rensburg. It is available at: https://uir.unisa.ac.za/bitstream/handle/10500/26157/thesis_esterhuizen_jm.pdf?sequence=1.

The authors wish to thank Ms Nathma Samie for the graphic presentation of the timelines in the historical period discussed.

The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.

J.M.E. conducted the historical inquiry in her capacity as a doctoral candidate. G.V.R. acted as supervisor of the doctoral candidate. After completion of the doctoral thesis, J.M.E. and G.V.R. collaborated and contributed equally to the writing of this article.

Ethical approval to conduct this study was obtained from the University of South Africa Health Studies Higher Degrees Committee College of Human Sciences (No. REC-012714-039).

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors

Data sources (archive material) will be made available on request. Some archival sources may not be readily available and might require physical visit to libraries.

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

References

Footnotes

1. Charlotte Searle, Towards Excellence: The Centenary of State Registration for Nurses and Midwives in South Africa 1891–1991 (Durban: Butterworths, 1991), 6, 15–16.

2. I. Loots and M. Vermaak, Pioneers of Professional Nursing in South Africa (Bloemfontein: PJ de Villiers, 1975), 110.

3. Shula Marks, Divided sisterhood (London: MacMillan, 1994), 45, 63, 68; and B. G. Alexander, “Nursing Conditions in South Africa,” The American Journal of Nursing 26, no. 12 (1926): 935.

4. G. H. Van Rensburg and J. M. Esterhuizen, “Historical Inquiry: Overcoming Interdisciplinary Methodological Challenges in Health Sciences,” Journal for Transdisciplinary Research in Southern Africa 19, no 1 (2023): 1817–4434. https://doi.org/10.4102/td.v.19i1.1325

5. Johanna Maria Esterhuizen, “The Influence of Nursing Organisations on the Development of the Nursing Profession in South Africa: 1914–2014” (D Litt et Phil., UNISA, 2019), 16–56.

6. Johanna Maria Esterhuizen, “The Influence of Nursing Organisations on the Development of the Nursing Profession in South Africa: 1914–2014” (D Litt et Phil., UNISA, 2019), 16–56.

7. Charlotte Searle, Aspects of Selected Nursing Issues (Durban: Butterworths, 1988), 77.

8. Marks, Divided Sisterhood, 151, 161.

9. “Comparison between the 1944 and 1957 Nursing Acts, Indicating the Major Changes Which Have Taken Place,” South African Nursing Journal XXIV, no. 8 (1957): 10–14; and “Points in the Nursing Bill,” South African Nursing Journal XXIV, no. 7 (1957): 4.

10. Leana Uys, “The Future of Nursing Organisations in South Africa,” in Nursing at the Crossroads: Organisation, Professionalisation, Politicisation, ed. L. C. Rispel (Johannesburg: University of the Witwatersrand, 1990), 76.

11. Susan J. Du Preez and Eileen Brannigan, “The South African Nursing Association,” in State of the Art of Nursing, ed. Leana Uys, Heilie H. M. Uys and Wilma J. Kotzé (Pretoria: SANA, 1991), 39.

12. Laetitia Rispel and Eric Buch, “Nurses’ Opinions of Different Organisations: Conflict or Cohesion,” in Nursing at the Crossroads: Organisation, Professionalisation, Politicisation, ed. Laetitia C. Rispel (Johannesburg: University of the Witwatersrand, 1990), 62–63.

13. SANA Long Term Plan 1984–1988, Presented 28 October 1983, SB/OB15–10/83, DENOSA Archives, Minutes of Central Board Meetings 1983, Pretoria; and Commission of Inquiry into Health Services, 1980, Government Gazette no 6969/1980, Pretoria.

14. South African Nursing Association Constitution, [Sa], 610.730606 8 SOUT, UNISA library, Pretoria.

15. Submission on Nursing by DENOSA to the TRC, 1997, Private Collection Prof Sarie Human, Pretoria.

16. Leana Uys, “The Future of Nursing Organisations in South Africa,” in Nursing at the Crossroads: Organisation, Professionalisation, Politicisation, ed. L. C. Rispel (Johannesburg: University of the Witwatersrand, 1990), 72.

17. P. Harrison, “Reorganisation of the South African Nursing Association and the Implications Thereof,” Curationis 5, no. 1 (1982): 4–6. www.curationis.org.za/index.php/curationis/article/download/379/319; and SANA Long Term Plan 1984–1988, DENOSA Archives, Pretoria.

18. Charlotte Searle, “The Criteria for Professionalism for Nursing in South Africa,” Curationis 1, no. 1 (1978): 5. http://www.curationis.org.za/index.php/curationis/article/view/196

19. Philda Nomusa Nzimande, “Professionalism and Continuing Education – An Imperative for Nurses,” Nursing RSA Verpleging 2, no. 11/12 (1987): 20.

20. Leana Uys, “Racism and the South African Nurse,” Nursing RSA Verpleging 2, no. 11/12 (1987): 55–56.

21. Uys, “The Future of Nursing Organisations,” 75.

22. The First National Consultative Conference Programme, Concerned Nurses of South Africa (Pretoria: Private Collection Prof Sarie Human, 1993).

23. Nursing Meeting the Constitutional Changes, Speech Delivered by A Bruwer at the Concerned Nurses of South Africa 1st National Consultative Conference, 1993, Private collection Prof Sarie Human, Pretoria.

24. Minutes of the Provisional Steering Committee Meeting Held on 24 February 1993 at 15:00 in Pretoria, 1993, SB/CB 31–3/93, Private Collection Prof S Human, Pretoria.

25. Nelouise Geyer, “The Rise of DENOSA,” Nursing Update 30, no. 4 (2006): 28; and Correspondence from Philda Nomusa Nzimande, 02 July 1993, Private Collection Prof Sarie Human, Pretoria.

26. Report: Nurses Planning for the Future Forum Meeting Held on 03 September 1993 at Protea Range Hotel, Berea, 1993, CB/SB 21–10/93, Private Collection Prof S Human, Pretoria.

27. Programme of the Event, First National Convention of Nurses of South Africa (Pretoria: Private Collection Prof Sarie Human, 1994).

28. Schedule of the Transitional Nurses Committee Working Group, 17 May 1994, Private collection Prof Sarie Human, Pretoria.

29. Minutes of the Fourth Meeting of the Transitional Nurses Committee Held on Thursday and Friday (23 and 24 June 1994) at the Protea Hotel and XB Holdings, Johannesburg, 1994, Private Collection Prof Sarie Human, Pretoria; and Correspondence from Leana Uys, 03 August 1994, Private Collection Prof Sarie Human, Pretoria.

30. “New Democratic Organisation Constituted for the Nurses of South Africa,” Nursing News/Verpleegnuus 19, no.3 (1995): 2.

31. The South African Nursing Association, SANA DENOSA Negotiations (DENOSA Archives, Pretoria, 1995).

32. Stegmanns Attorneys’ Correspondence to SANA, 01 August 1995, CB/SB 11 – 8/95, SANA DENOSA Negotiations, DENOSA Archives, Pretoria; and Memorandum from SANA Negotiating Committee to the Central Board re dissolution of SANA, 16 August 1995, SANA DENOSA Negotiations, DENOSA Archives, Pretoria.

33. Report of the National SA Nursing Association Meeting Held in the HSRC Conference Centre, of the HSRC Building 124, Pretorius Street on 03 November 1994 at 14:00, SANA DENOSA Negotiations, DENOSA Archives, Pretoria; and SANA Media Release, 08 November 1995, SANA DENOSA Negotiations, DENOSA Archives, Pretoria.

34. Memorandum of Agreement Entered into by and between South African Nursing Association and Democratic Nursing Organisation of South Africa, 26 September 1996, Private Collection Prof Sarie Human, Pretoria; and Correspondence from Philda Nomusa Nzimande, 20 May 1996, SANA DENOSA Negotiations, DENOSA Archives, Pretoria.

35. Correspondence from Eileen Brannigan, 29 August 1996, SANA DENOSA Negotiations, DENOSA Archives, Pretoria.

36. Joint Media Release, 09 September 1996, SANA DENOSA Negotiations, DENOSA Archives, Pretoria; and Memorandum of Agreement, 26 September 1996, Private Collection Prof Sarie Human, Pretoria.

37. “Message by President Nelson Mandela at the Launch of the Democratic Nursing Organisation of South Africa (DENOSA),” Nursing News 21, no. 2 (1997): 4.

38. “Transformation towards the Next Millennium,” Nursing Update 23, no. 2 (1999): 4.

39. “Transformation,” 4.

40. “Concern Expressed Over Editor’s Comment,” Nursing Update 23, no. 8 (1999): 17.

41. B. Mzolo, “DENOSA Marches with COSATU,” Nursing Update 26, no. 9 (2002): 2.

42. E. Mafalo, “Time to Stick to Standards,” Nursing Update 37, no. 7 (2012): 40–41. http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=108139780&site=ehost-live