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The Criteria for Professionalism
in Nursing in South Africa
Charlotte Searle
Professor and Head of the Department of Nursing,
University of South Africa
OPSOMMING
Daar bestaan heelwat verwarring oor die kriteria wat op professionele status toegepas word sowel as oor
die korrekte gebruik van die woord “professie” of “beroep”. Dit het onsekerheid by verpleegsters
veroorsaak waarvoor daar sowel in Suid-Afrika as in ander lande geen grond bestaan nie.
Yerpleging word alte dikwels volgens die tradisionele beeld van vroeére professioneles beoordeel van
wie beweer word dat almal aan universiteite studeer het. In werklikheid het talle van daardie hoogs
gekwalifiseerde persone hulle opleiding by en volmag om te praktiseer van Gem agtigde Verenigings
verkry.
Die bewering dat verpleging semi-professioneel is omdat verpleging 'n afhanklike funksie t.o.v. die
geneeskunde het, is ’n bevooroordeelde opvatting aangesien geneeshere net soveel afhanklike funksies as
die verpleegster het.
Uit die kriteria vir verpleging in Suid-Afrika blyk baie duidelik dat die verpleegberoep in die land op
professionele erkenning geregtig is.
T
he professional status of nursing has been questioned
in some countries by some sociologists, and health
service administrators and even by some nurses. This arises
from the fact that there is much confused thinking about the
criteria by which professional status is measured as well as
from the incorrect use of the word “ profession” .
Chief amongst the proponents of the concept that nursing
(at least in the countries wiui wmcn they are familiar) is not a
profession, but a semi-profession, are such authors as
Buick-Constable (1969)2 who maintains that nursing in New
Zealand is semi-professional, Etzioni (1969)5 and Bernard
and Thompson (1969)1 in America who propound the same
viewpoint about American nursing.
These statements and others like them have obviously
caused uncertainty in the ranks of nurses. Nurses in
Page Four
developing countries are exposed to this type of uncertainty
that exists amongst their colleagues in the moe economically
developed countries, and health administrators and doctors
accept such statements at face-value without analysing the
facts in terms of the situation in the particular country.
Nurses should not allow themselves to be confused.
Nurses must believe in what they are. Nurses in Southern
Africa, and 1 believe in some other parts of the world, need
not fear that their professional status is questionable. Admit
tedly there are some countries where nursing cannot be
classified as professional according to the criteria recognised
in Southern Africa.
Ward Darley, (1969)4 an American researcher, has made a
careful analysis of nursing in America, and he main
tains that American nursing is a profession. He says “ the
truly professional person is one, who, by virtue of intellec
tual capacity, education and moral outlook is capable of the
exercise of intellectual and moral judgement at a high level of
responsibility” . He makes the very important point that
judgement is based on broad knowledge, penetrating wisdom
about the particular circumstances, and great moral certitude
about one’s actions. This is a daily feature of the practice of
the nurse.
Similarly Charlotte Towle ( 1954)10 argues that nursing is a
full profession.
In Britain nursing has frequently been described as an
“ established profession” and midwifery as a “ monopolistic
profession” . In South Africa the statement is frequently
heard from members of the medical profession, from
sociologists and health service administrators that nursing
and midwifery in South Africa are powerful monopolistic
professions. Critics of the professionalism of nursing, in
cluding nurse critics, invariably base their arguments on a
comparison of the relatively young profession of nursing
with the early traditional professions of the law, the church
and medicine.
Millerson (1964)7 rejects this approach and states that
“ the term professional ought to be applied freely to anyone
able to demonstrate a high standard of competence, experi
ence, achieved responsibility and good education” . Carr-
Saunders and Wilson (1964)3 list nursing in Britain in their
standard work on the professions as a “ skilled and dignified
profession” .
The traditional image
Nursing is being measured against the traditional image of
the early professionals. This traditional image is provided by
the “ learned” professions, namely, the law, medicine and
church ministry. The profile that is projected depicts these
learned professionals as “ gentlemen” and independent prac
titioners providing an important and essentiafpublic service.
They have a university background and their competence is
determined by examination and by licensure. Their integrity
is ensured by a strict code of professional ethics.
Are the criteria for professionalism as applied to “ the
learned professions” strictly in accordance with the facts? I
query the universality, or even the absolute validity of these
criteria. It is a well documented fact in English and Western
European literature and in public records that surgeons and
even physicians and lawyers were latecomers to the univer
sities.
Lawyers were not subjected to examinations in Britain
until 1872, and medical practice was not regulated in Europe
until 1858, though such control had been introduced by 1807
in that part of South Africa previously known as the Colony
of the Cape of Good Hope. Prior to 1858, qualifications were
not required for medical practice and only a few universities
in Britain and Europe offered courses leading to medical
doctorates. The majority of doctors in Great Britain obtained
their qualifications via the professional associations. A great
many had no qualifications but practised medicine and en
joyed the attendant status.
Although many clergy attended university and obtained a
degree this was not a strict requirement. Before 1850 a priest,
or a minister of the church was not required to submit himself
to an educational test before ordination. Many clergymen to
this day receive their education at theological seminaries that
are not attached to universities.
The Law Society in Britain was established in 1825. Only
after 1835 did the courts conduct the examinations for sol
icitors. After 1877 the Law Society undertook this task.
Barristers were only asked to submit themselves for examina
tion after 1853. At this stage this was still a voluntary exami
nation. It was not until 1872 that it was made compulsory by
the British Inns of Court which conducted the examination.8
To this day many members of the medical profession in
Britain obtain their basic and their specialist qualifications
from the Royal College of Surgeons (England) and the Royal
College of Physicians (London) or from their Scottish or Irish
counterparts. (M.R.C.S. Eng., and L.R.C.P. London). The
Apothecaries’ Society of London still awards a Licentiate in
Medicine, Surgery and Midwifery, (L.M .S.S.A. London)
and Apothecaries’ Hall, Dublin awards a Licenciate (L.A.H.
Dublin).
Some of the world’s most outstanding medical practition
ers and lawyers have obtained their professional qualifica
tions and status from qualifying associations.
The concept of independent practice
The concept of a professional person being an independent
practitioner has never applied to the clergy. The priest and
the minister of religion have always been subject to control
by the church or the presbytery and each has always been a
“ salaried officer” , in that he was granted “ the gift of liv
ing” , i.e. either a benefactor or the congregation provided
him with a livelihood. Whilst doctors and lawyers were
traditionally independent practitioners this was not univer
sally the case. Many were employed by the state e.g. for
military purposes, or by commercial organizations such as
the.Dutch East India Company, and the British East India
Company as early as the 16th century.
Today the practice of salaried employment for these pro
fessions is widespread. All churchmen work for a salary. The
majority of doctors in a socialist society are salaried persons.
Even in South Africa there are several thousand doctors who
hold salaried, pensionable appointments. Even in such
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capitalist societies as the USA, Canada, the EEC Countries,
Japan and other eastern countries, thousands of doctors are
employed on a salaried basis.
Many lawyers hold salaried positions in industry, com
merce, universities, the armed forces and in public adminis
trations. Judges, the highest grade of legal officer, are
salaried persons.
How valid then are the criteria by which professionalism is
judged? The criteria for professionalism as ascribed to the
three “ learned professions” have never been universally
true, and are certainly not valid in the present systems of
social organization.
Basis for regarding nursing as a semi-profession
The four main arguments generally used in American
literature to assign a semi-professional status to nursing are:
— all nurses are not educated at universities and only those
who have had this type of education can claim to be
professionals. Persons who have obtained their educa
tion at hospital nursing schools, or at community col
leges, are not professional but technical personnel, even
though they have passed the examinations for registra
tion by the state;
— very few nurses are self-employed and part of their
function is dependent on another category of health
professional;
— the percentage of nurses who have attained high intellec
tual status through research, and scholarly authorship is
small;
— there is no clearly defined theory of nursing as a science.
Nursing can only be classified as an applied science that
utilizes the scientific findings of other sciences.
These arguments may be true in respect of American
society but are not universally acceptable. These assump
tions have done some harm to nursing in some developing
countries and may ultimately have a deleterious effect on the
production of nurses through ill-considered and unrealistic
attempts to force nursing development into a strait-jacket that
is tailored to clothe the definition of a profession in verbal
raiment that has little texture.
Let us examine each of these points and refute the assump
tion that nursing, (at least in Southern Africa and in the
English system of nursing from which nursing in Southern
Africa derives) is not a profession as much as any of the
age-old learned professions, or the newer professions that
have emerged from the universities of the 20th century.
University education not a universal criterium for profes
sionalism
The first argument that nursing is not a profession because
all nurses are not educated at universities, may be true in
some societies, but it certainly is not true in all societies, if
comparisons are made with other “ fully recognized profes
sions” . Some 120 qualifying associations that prepare pro
fessional personnel of high calibre and standing exist in Great
Britain. They approve educational centres, prescribe cur
ricula, conduct examinations, register successful candidates
and exercise disciplinary control over their members, who
are given a recognised professional status in their society
both legally and by consensus of their members and of John
Citizen. Among this group are such élite professionals as
architects, surveyors, accountants, barristers (including
judges), solicitors, actuaries, veterinary surgeons, en
gineers, many physicians, many surgeons, and obstetricians
and a large number of other categories of highly qualified
health service personnel.
No one can deny the recognized professional status, ethics
and accountability of these highly qualified persons, yet
their education was attained from Qualifying Associations
and not from universities. Their status is in no way less than
that of their counterparts who may have qualified at univer
sity. In the majority of cases the first teachers in these fields
at the universities were drawn from the ranks of the persons
holding the qualifications of the Qualifying Associations. In
many cases the holders of degrees in these fields cannot be
admitted to practice until they have also passed the qualifying
examinations of the particular professional Qualifying As
sociation.
Every university that offers a professional qualification
must establish a link with a professional organization or
institution which lies outside the university to provide the
professional experience dimension or the professional exper
tise that will ensure recognition of its qualification. Univer
sity education is not a critical criterium for professional
status, recognition or accountability although it may be very
desirable. If the person has passed the examinations for
admission to a professional register and has produced proof
by this means of his knowledge and competency, the arbit
rary point of view as to where he received his education,
provided it was approved and strictly controlled by the regis
tering authority concerned, is not valid. The issue at stake is
not the learning milieu. It is the personal integrity, the wealth
of knowledge, the appropriateness thereof, the ability to
integrate, internalise and utilise the required level of know
ledge and skills and the social purpose of it all, that is the core
of professional effectiveness.
The fallacy of independent practice as a criterium for
professional recognition and status
It is also argued that few nurses and midwives practise as
independent practitioners. The fundamental question to be
asked is “ what is independent practice?” If it means “ setting
up in the business of providing health care” , i.e. being
self-employed, then the issue is debatable. Many nurses and
midwives work as private practitioners, own small private
hospitals and homes for the aged or are shareholders in such
institutions. So do doctors, dentists and other categories of
health professionals.
To judge the validity of the claim to professional status on
such slim grounds is absurd. Although lawyers, doctors and
dentists amongst others, have long functioned as indepen
dent practitioners, two of the oldest categories of élite profes
sionals have never functioned as “ independent practition
ers” in the sense of being self-employed. The priest or
clergyman has always been the servant of the church. He was
in salaried employment, even though such remuneration at
times consisted of gifts in kind. With rare exceptions the
judge in the ecclesiastical dr the civil court has always been
the salaried servant of the church in the former and of the
King or the State in the latter.
With the advent of socialist principles of national organi
zation on the one hand, and the growth of great commercial
and industrial organizations on the other, and with the in
creasing complexity of the services provided by the state and
local authorities, large numbers of professional persons are
taking up salaried employment in such organizations to pro
vide the specialised skills needed in such ventures. Doctors,
dentists, lawyers, architects, engineers, veterinarians, ac
countants and a host of highly qualified professional experts
‘are working as salaried personnel in such service. In all
countries judges still are salaried persons because they act on
Page Six
behalf of the state. In socialist and communist countries the
professional, like any other worker, is a salaried person and
not an independent practitioner. Yet their professional rec
ognition is secure. It is likely that there will be no so-called
“ independent” practitioners in any of the professions by the
year 2000 A D.
The core of the “ independent practice” concept
There is, however, a very important aspect of the indepen
dent practice concept that is vitally important as a criterium
for professional practice. The independent function, in the
way modem professional persons view it, and in the light of
its meaning in relation to the public good, is something quite
different to earning one’s living in private practice. The real
meaning of “ the independent function” refers to the sole
right which a professional person has to decide whether he
will, or will not, undertake a particular professional act, and
how he will carry it out. Nobody else can decide this. The
responsibility rests squarely on the professional person him
self to decide this, for in the final analysis, it is he, and only
he, who is held accountable for his professional acts and
omissions. It is he, and only he, who will have to submit to
the disciplinary judgement and control by his peer-group
within the professional control body, which in the case of
nurses is the state registration authority.
In this context the independent function of the nurse and of
the midwife is exactly the same as that of doctors, dentists
and other categories of health professional. Even this level of
“ independent function” has certain limitations for in all
professions the controlling authority has the right to limit the
actions of the members of the profession in the interest of the
community, and may consider any act to be prejudicial to the
good name and standing of the profession and the welfare of
the community. The professional is therefore less “ free” or
“ independent” than other categories of citizens. His profes
sional code of ethics is all-powerful and all-pervasive. The
only freedom the professional has is “ the freedom of choice
to act” and to be willing to accept the consequences of his
action.
Fallacy of the dependent dimension
The claim by some sociologists that nursing is semi-
professional because nursing has a dependent function on
medicine borders on a prejudiced assumption. The doctor’s
status as a professional is not generally questioned, yet he has
as many dependent functions as has the nurse. The modem
doctor cannot function unless he has a wide variety of sup
plementary health service personnel (paramedicals) to sup
port him. In innumerable situations he cannot make a diag
nosis or prescribe treatment if he is denied the assistance of
such other health personnel as biophysicists, laboratory
technicians and bio-engineers to name but a few. Has the
doctor, since the dawn of time, not been utterly dependent on
the nurse (or the mother in the family) for the care and
treatment and observation of the patient in his absence, or for
direct assistance with many aspects of work? This point can
be applied to all professions.
The advocate (i.e. the barrister-at-law) is totally depen
dent for his briefing on the attorney (solicitor). The clergy
man is dependent on his church council, the accountant, on
the book-keeper. It must be reiterated that no professional
person is totally independent in the practice of his profession.
He has to practise within the broad legal framework of his
country, and within the limitations imposed upon him by
John Citizen in the enabling legislation. He can only practise
within the limits of the ethical code of his profession and
within the terms of his registration. Because of the ethical
constraints he is obligated, in the interests of those he serves,
to refer to more knowledgeable members of the same profes
sion, if his own knowledge, skill and registration limit his
contribution to the care of the patient.
Fallacy of lack of theory of nursing as a science
Much is made of the allegation that there is no clearly
defined theory of nursing as a science. But what is a theory?
Webster’s dictionary defines it as “ that branch of an art or
science consisting in a knowledge of its principles and
methods rather than in its practice; pure as opposed to applied
science” .
There are a variety of critical analyses of the concept
“ nursing” that meet the above definition6. The conceptual
framework within which the practitioners of nursing formu
late the meaning of nursing and its theory and methodology
are as well defined as that of medicine.
Fallacy that too few nurses write and do research to classify
nursing as a profession
Much is also made of the fact that too small a percentage of
nurses attain high intellectual status through writing and
research. All women’s professions show this tendency, be
cause the woman professional invariably also has to fulfil the
role of wife and mother in addition to her difficult profes
sional role. Yet hundreds of nurses in the world are authors of
note whose work has made a lasting impact on the health
services and on the society they serve. In the research field
they have been the reliable assistants who have made high
quality clinical medical research possible.
Many also have made lasting contributions to historical,
social and educational research. These groups recognised the
vital role of the nursing profession in the overall development
of the nation. They consequently required professional stan
dards from a group which plays such a vital role in the life of
the nation. As early then as 1891 the nursing profession in
South Africa received both statutory recognition and social
recognition as a profession. The basic principles underlying
the education and training, examination, certification, regis
tration, recognition of further study, the protection of the
rights of the person registered, the protection of the public
and the ethical code to be observed, were all either directly or
indirectly contained in the provisions of Act No. 34 of 1891.
In 1944 when the Nursing Act was passed the Act referred
to “ the profession of a nurse or midwife” . The South Afri
can Parliament was quite clear in its mind that nursing in this
country, at least, is a profession.
Criteria for professional recognition in South Africa
The criteria by which a profession is recognized by the
legislature, by other recognized professions such as
medicine, dentistry, teaching, the law, social work and all
the other professional groups in this country are the
following10-
1. The specialized knowledge and skills pertaining to the
profession of nursing are based on a broad foundation of
theoretical knowledge. This theoretical knowledge is
drawn from:
— the sciences basic to medicine (the biological, physical,
medical and social sciences);
— the age-old accumulation of empirical knowledge
about the instrumental and expressive functions of the
Page Seven
nurse at any point along the continuum of health care;
— the legal and ethical foundations on which the practice of
the profession rests;
— the specialized function it fulfills in society.
2. The expertise known as nursing is based on a clearly
defined and well-organized body of knowledge with a
controlled system of education and training of the
neophyte.
3. The aspirant to professional status must prove his com
petence by submitting proof of the education he has
undergone for the purpose and must successfully com
plete a professional examination. That part dealing with
the practice of the profession and with the synthesis of
all the knowledge which culminates in professional acts
must be conducted by members of that profession. If the
education has not been received at a university, the
registration body itself conducts the examinations in
each year.
4. The professional integrity of the practitioner is regulated
by the observance of an ethical code and by the norms of
his peer-group, as well as the norms of society. The
protection of society is a paramount feature in such
norms and ethics.
5. The designation registered (professional) nurse is a tem
porary one, i.e. it can be removed from the holder under
certain circumstances. A nurse whose name is removed
from the register for whatever reason, either for volun
tary or disciplinary reasons, or for non-payment of re
gistration fees, may not use the title registered nurse,
neither may she practise nursing for gain in any capacity
whatsoever. This would constitute a criminal offence.
6. The service rendered by the professional nurse must
relate to the welfare of the community. This must at all
times take precedence when decisions in regard to the
practice of the profession have to made. (This does not
mean that the public can exploit the professional prac
titioner). It must recognize the dignity and rights of
others.
7. A professional nurse is held accountable for her actions
both to the community and to her peer-group (the other
members of the profession). This of course also applies
to other categories of nurses.
8. The professional nursing group is an organized group in
the community with a common goal.
9. The members of the nursing profession show subcon
scious as well as conscious awareness of identity with
other members of the group. They are an “ in-group” .
10. There is a substantial level of uniformity in how the
members of the group view the final objective of their
role (e.g. nurse-clinicians, nurse-administrators, nurse-
teachers, nurse-researchers, all have one final end in
view for their service — better health care for the people
of their country and for others over the borders of their
country who might seek their care).
11. The norms and ethics of the group are developed by the
group.
12. The profession is subjectively recognized by its own
members and legally by Parliament because the public is
willing to accept the occupation as a profession. Be
cause of its importance to the community, the public
granted it recognition and status but at the same time
desired to control it. It recognized the status of the
profession by vesting this control in the profession itself.
The profession is also recognized by other professions.
13. There is an obvious sentiment that the professional nurse
belongs to an exclusive group which must meet the high
standards of practice. Only those who have complied
with the standards for admission are admitted to the
group.
14. The members of the profession have prescribed means
of admitting new members to the profession. Once the
member has been accepted into the group, she is ex
pected to observe the norms and ethics of the group and
to assume special responsibilities towards colleagues,
clients, patients, and the public at large.
15. As a return for this observance of the group norms, the
member may obtain a protected title, wear certain insig
nia and use certain letters after her name; all this ensures
a certain status.
16. The recognition of the group as a profession by the
community has resulted in the delegation of rights and
privileges to the group; the use of the services of the
group to the exclusion of others who wish to render the
service; official recognition as a separate service group;
requests for advice from the group; and awards of spe
cial status symbols, titles and honours.
17. The profession has a strong professional association to
organize and develop it; to act as the voice of the profes
sion; to ensure professional standards; to regularize the
approach to the problems of the practice of the profes
sion; to act as a watchdog over all matters pertaining to
the enabling legislation, regulations and administrative
implementatiop that affect nursing and through it the
public welfare. It has to advise on the systematising of
education and training, the rationalisation of selection of
recruits to the profession and must formulate the basis
and guidelines for the development within the profes
sion itself.
18. The profession is controlled by the profession itself
under delegated responsibility from Parliament by
means of the South African Nursing Council in respect
of the critical elements of professionalism, namely pre
scribing admission standards, education, prescribing
syllabi, approving and inspecting nursing schools, ex
amination of competence, registration and prescribing
the regulations relating to professional practice, and
disciplinary control.
These then are the criteria by which the nursing profession
has earned its professional recognition in South Africa. The
origins of South African professionalism in midwifery date
back to 1652 and to nursing to 1891. During the intervening
years the nursing and midwifery professions have grown to
full professional status. This is something that South African
nurses must cherish as a priceless heritage.
REFERENCES
1. Bernard, / & Thompson, L. (1966): Sociology - nurses and their patients in a
modern society Saint Louis: C.V. Mosby Co p. 11
2. Buick-Constable, Byron (1969): The professionalism spectre in International
Nursing Review V. 16: 2. pp 133-134
3. Carr-Saunders, A.M . & W ilson, P. A. (1964): 77i€professions London: Frank &
Cass pp 107-125
4. Darley, Ward (1961): The professions and professional people in Nursing
Forum Winter issue p83
5. Etzioni, A (1969): The sem i-professions-nurses, teachers, social workers New
York: Free Press
6. Henderson, V & Nite, G (1978): Principles and practice o f nursing New York:
MacMillan Publishing Co 6th Edition pp. 15-46
7. Millerson, G (1964): The qualifying associations New York: Routledge &
Kegan Paul p.212
8. M illerson, G (1964): The qualifying associations New York: Routledge &
Kegan Paul pp. 224 & 239
9. Searle, C (1967): Criteria fo r professionalism in N ursing in South Africa
Unpublished notes
10. Towle, Charlotte (1954): The learner in education for the professions Chicago:
University o f Chicago Press p.3
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