Midwifery is internationally recognised as a distinct profession, closely allied to nursing and medicine, and as such it requires to be specifically identified, and not subsumed into Nursing. This Bill regulates nursing and midwifery in South Africa. Although the majority of registered nurses in South Africa have also trained as midwives and can therefore be referred to as nurse midwives, comparatively few retain their currency in midwifery.

Support the titles of the "Nursing Bill" and the "South African Nursing Council"

"Accoucheur"

(Accredited) Nursing education institution

Learner nurse/midwife

Nursing agencies

"Accoucheur" is a very foreign term, and there is no profession that reflects this practice. (This would be consistent with the international designation.) The term midwifery is not gender based because it is translated "with woman" and does not refer to the practitioner as "wife" but rather to the function of the practitioner. All midwives (male and female) should have a practice which is "with woman", i.e. responsive and sensitive to the needs of women. This would then require the definition of "midwife" to omit reference to "female".

The definitions contains two definitions on ‘nursing education institutions’. All nursing education institutions have to be accredited by the SANC

The use of the term ‘learner’ is not supported.

It is noted that the definition of "nursing agency" has been included in the list of definitions as well as clauses 46(1) and 58(1)(j) referring to the regulations that the Minister may make on the conditions under which the business of a nursing agency may be carried on, while there is no clause in the Bill referring to the responsibility of the Council with regard to Nursing Agencies. It is taken that the intention of the Bill is to remove the nursing agencies from this Bill as the National Health Act makes reference to the inclusion of agencies and that the presence of these three statements on nursing agencies is an editorial oversight. If this is correct it is then assumed that clause 61(1) will apply when the Bill is promulgated into law in the case of nursing agencies currently registered with the SA Nursing Council, namely that any regulation that is not consistent with the new Act, will be repealed.

"midwifery". In order to be consistent with the format of the definition for "nurse", this should be amended.

The Bill refers to several aspects that have not been defined in this section.

This term should be deleted and the term midwife be adopted as a universal term.

Delete the definition ‘Accredited Nursing education institution’ and use only the ‘nursing education institution’ definition – this definition must be used throughout.

The term ‘student’ be retained in the Bill as the Higher Education Act (Act 101 of 1997) endorses the term "student" for any person registered at higher education institutions such as universities [section 1(xxviii)].

Delete all references to nursing agencies in the Bill to prevent duplication as the National Health Act (Act 61 of 2003) includes nursing agencies.

Delete a section in S46(1) "….practitioner or a director, manager or owner of an agency registered in terms of this Act and…."

Amend to read: ‘refers to a caring profession practiced by a person registered under section 31, which supports and assists the health care user and family, and in particular the mother and baby, to achieve and maintain optimum health during pregnancy, all stages of labour and the puerperium (omit italics), and the neonatal period.’

Add definitions on the following:

• Basic Nursing [S30(2)]
• community service [S40(1)] p20
• community service practitioner [S40(2)] p20
• Community health [S5(1)(a)]
• Comprehensive nursing [S30(1)]
• continuing professional development [S39]
• Elementary Nursing [S30(4)]
• Impairment as defined in 51(7) p25
• Mental health [S5(1)(a)]
• Occupational health [S5(1)(a)]
• Open shop [S56(7)] This is defined in S55(8) but as it is a definition it should surely be placed in chapter 1. This definition should be excluded in this Bill (see comment under S56)
• Primary health care [S5(1)(a)] This should reflect the philosophical fundamentals embodied in the Alma Ata Declaration and the principles that flow from this which touch each aspect of nursing and healthcare practice, and indeed is impacted by other sectors. It is problematic to refer to one type of nursing care, i.e. diagnosis and treatment of illness as primary health care, as this deflects from the wholistic approach to health which is important for the improved health of the nation. It is also consistent with nursing practice which concentrates on the full spectrum of health, and is not limited to illness (medically orientated) care. An alternative term would be far preferable.

S3(e) maintain professional conduct

S3(f) maintain liaison and communication re nursing standards

It is believed that in the interest of health and safety of both health care users and nurses, that the Council should develop regulations to ensure safe and healthy environments for patients and nurses to enable quality health care, e.g. minimum staffing norms for various clinical settings.

Research has indicated that the optimal workload for a nurse was found to be four patients. Increasing the workload to 6 patients makes it 14% more likely for patients to die within 30 days of admission and a workload of 8 patients versus 4 patients result in a 31% increase in mortality. This study and other studies further indicated that nurses with the highest number of patients per nurse were more than twice as likely to report burnout and were nearly twice as likely to report dissatisfaction with their job. Results from the study by Needleman & Buerhaus provided information consistent with other research regarding patient outcomes and nurse staffing. It revealed that strong and consistent relationships were found between hospital nurse staffing levels and five patient outcomes, namely urinary tract infections, shock, length of stay, upper gastrointestinal bleeding and pneumonia. JCAHO indicated that Staffing shortages was a factor in 1 of every 4 unexpected hospital deaths or injuries caused by errors. Low RN staffing levels and poor organizational climates have been found to put nurses at greater risk of needle stick injuries. The higher the percentage of RNs, the more satisfied patients were with nursing care, pain management, education and overall care.

Addition to current clause

This section needs to make reference to the evidence base for nursing and midwifery practice. In order to protect the interests of the public it is essential to promote the development of the profession. This requires an ongoing study of the developing evidence, and research into practice and education developments of the profession. Unfortunately this is not evident in this document and it is believed that this does therefore not serve the best interests of the public in terms of nursing and midwifery practice. This document seems to alienate the professions rather than embracing them as key partners in achieving the stated purpose.

Another provision should be added. Currently the lack of communication, poor communication, lack of infrastructure, inordinate delays in making decisions, are hampering the effective functioning of other nursing and midwifery institutions throughout the country and preventing the necessary transformations and innovations from being implemented.

This activity requires the establishment of a Task Team to investigate and make recommendations with regard to:

• nurse: health care user ratios
• numbers of nurses that have to be trained

Skill mix research needs to include the effects

" …. the ambit of this Act and any applicable law"

Add:

S4(c) conducting examinations

Use of the term "disciplinary"

4(1)(j) investigate and take action

2(h) Investigate complaints

This section needs to include a database that accurately reflects the current statistics in relation to professional human resources in terms of qualifications and currency of the practice. For example, it is irresponsible for someone who qualified as a psychiatric nurse 20 years ago and who has not practiced in the field to be expected to take on a psychiatric nursing responsibility simply because his/her registration reflects that s/he was once qualified to function in this area. The public deserve better than this. The current situation creates expectations in the public of the quality of service /care they should receive, yet they are unaware of how out of date or deskilled people are, having not worked in specific fields for a long period of time. This is also unfair on the nurses who are expected to deliver high quality, expert, up to date care across the entire health and illness spectrum.

The education standards are protected by this clause, which is important in view of the fact that Council has the responsibility of licensing nurses, although many of the institutions run their own examinations. There are examinations that only the Council is responsible for, for example the examinations for foreign nurses.

‘Disciplinary’ and ‘professional conduct’ are used interchangeably

This section is not clear on how the Council will be empowered to take action against non-accredited institutions. Council does not have any jurisdiction over them and it becomes a criminal offence for the criminal justice system to deal with. At the most an investigation can be done and reported to the SA Police Service as is currently done.

Council is currently not considering the plight of the nurse and midwife, especially the unacceptable conditions they are working under when complaints are investigated. Add additional information to the clause.

Private practitioners who work independently as nurse/midwife practitioners have an obligation to be registered as nurses/midwifes in terms of 31(1). It seems grossly unfair and discriminatory to expect them to pay an additional fee for yet another license - at the present time no such provisions exist for any other private health care practitioners. This determination appears to overlap with the Certificate of Need required by the National Health Act and is regarded as unconstitutional in terms of S22 of the Constitution of the RSA referring to Freedom of trade, occupation and profession, which indicates that although professions are regulated by law, every citizen has the right to practice their profession freely.

Database for health practitioners, including nurses has to be strengthened by providing information on the areas where nurses/midwives are practicing. Alternatively there should be a database on a national information system that could indicate where health care professionals are employed and the numbers employed.

Amend the clause to refer to "….relevant examinations"

Delete ‘disciplinary’ throughout the Bill and only use ‘professional conduct’. The purpose is not to be punitive, but rather a peer review process to model the correct behaviour amongst nurses.

Clarity and maybe rephrasing required.

Add:

"….nursing service, lack of resources, inadequate staffing or poor working conditions that compromise the quality of care."

5(1)(b) Composition

5(2) nomination and appointment

The smaller size Council will enable a more effective and streamline performance that will hopefully make the Council more productive. The concern, however, is that the work may become too much for the 25 members.

Composition of the Council does not include a midwife and students. The inclusion of students is especially important for the grooming of neophytes to the nursing profession. However, considering the size of the Council and the number of nurses who will be available for the working committees of the Council, it is believed that appointees should include persons with skills and expertise to ensure that the business of the Council progress.

The Bill is not clear on whether other components of the Council such as the community members and DoH member would/could be nurses.

The sole control of the Minister in the appointment of members of the Council strips the profession of its democracy, independence and autonomy and therefore put its whole self-preservation on the line and in the hands of a person, currently with no nursing background.

There should be fair elections.

It is believed that a bank of nursing expertise should be developed by the SANC to co-opt the appropriate expertise for the different working committees to assist the Council to perform its duties. Such cooption has to be regulated.

The Council should consist of at least 16 nurses.

Include skills of practicing midwife, management, combine community and primary health care and medical practitioner

The nursing/midwifery expertise must outnumber the other members of the Council.

Clear criteria must be made available to qualify the purpose and expertise of community members that will be appointed

At least half of the nurse members on the Council should be elected by the profession.

Should a nomination process become law, nomination should be clearly guided by regulation. Selection and appointment by the Minister should not happen in isolation. It is recommended that the selection process should be done in conjunction with a forum consisting of stakeholders (nursing groups, labour, community organisations).

6(f)(ii) uttering a forged document

S6(g) cumulative membership of Council

To preclude a person from membership who has been diagnosed with a mental illness or is a mental health care user is discriminatory and contrary to the provisions of Chapter 2 of the Constitution and section 10(1) of the Mental Health Care Bill (1/6/2002), and promotes stigmatizing such individuals. The Bill should be more specific about the functional capacity/incapacity of such a person as a Council member e.g. those diagnosed with psychotic or personality disorders, and substance abuse. Surely if any mental or physical condition for that matter impairs an individual’s ability to fulfil duties and responsibilities on the Council, membership must not be considered.

This seems to be strange wording – how can a document be ‘uttered’?

While it is appreciated that the need to limit some members serving for inordinately long periods of time, this clause seems to suggest that 10 years would be the limit in a professional lifetime. Certainly no more than 10 years at any one time should be supported, but there should be provision for someone to be eligible at a later date e.g. after a full term’s absence. The current provision could exclude special expertise that might not otherwise be available, and if the person is willing to serve, then there should be a mechanism to facilitate this.

Does this intend to mean of a ‘party’ political nature? As the wording currently stands, any civil society organisation, e.g. professional society, trade union, consumer pressure group, could be seen to be political in nature, and thus be excluded. However, the concept that office bearers of organisations cannot serve on the Council as well, is supported.

Clarify the statement to reflect the intention of the legislator more clearly and to reflect incapacity

Rephrase

Proposed that the cumulative be changed to consecutive.

Add "… in terms of section 5(2) and the category represented by the former member and every…."

This again reflects the autocracy and control of the Council by the Minster – the Council should elect the chairperson. The chair of the Council should be a nurse and should not be appointed by the Minister without consultation of the new Council.

Preferred option: that Council will elect chairperson.

Second choice: Add "…. after consultation with the new council". Also add this in clause (7)

Vice-chair and Treasurer to be elected by the members of the new Council

As it currently stands it is possible for the executive committee of eight (8) to have only three (3) professional nurses. In order to have effective regulation of the profession by the profession, the nurses should be more than other members

There should be at least 5 professional nurses / midwives on the executive committee

Replace the word "disciplinary" with "professional conduct"

Replace the word "may" with "must"

Outline the appeals process clearly similar to that described in S57

Consideration should be given to moving this section to Chapter 3 where other issues regarding Professional Conduct is discussed

Given that the Council is established to protect the public and fully controlled by the Minister as proposed by this Bill, it seems reasonable to expect that public funding would be made available to finance the activities of the Council. At present the funding is raised entirely from nurses and midwives in the form of license fees, and through other costs levied against nursing activities. While being a large professional group will serve to spread the cost, it also increases the volume of work undertaken by the Council in its everyday operational functioning. It is not reasonable to burden the most impoverished professional group with carrying the entire burden of financing the Council for the benefit of the public and not necessarily to the benefit of the professions.

Consideration must be given to the control of the Minister on the Council and its structures. The Bill appears to give all control to the Minister and therefore it is believed that the Minister should provide funding to maintain the Council and its activities.

Reference to an auxiliary midwife providing elementary nursing care is unclear and in the current draft scope of practice there is no mention of an auxiliary midwife.

It is not clear what sort of possibilities is envisaged in these sections, but these two statements form part and parcel of the HRH plan and inclusion is not supported.

Delete auxiliary midwife in this section, in the definitions and section 43(1)

S31(5) registration of practitioners

This clause must be reconsidered in the light of evidence provided by population demographics: rural vs. urban, disease profiles, global perspectives and professional imperatives. The proliferation of categories in the absence of evidence-based indicators may result in inappropriate categories and blurring of roles and scopes of practice of such categories. This cannot be done in isolation and must happen as part of a comprehensive HRH plan for the country. If such categories are decided upon in isolation, that this can become a quick fix to the detriment of appropriately qualified practitioners to provide quality care to the nation.

As it stands it denies registration to permanent residents of South Africa - this could be unconstitutional, but it certainly is not in the interest of the health service to deny the country the skills of people who are permanently residing in the country.

It is very difficult to provide proof of good character and good standing and it is not clear how and who would be appropriate to provide a certificate for such characteristics.

Research based indicators should be developed for comprehensive HRH planning of the country. This clause should be deleted from this Bill.

This clause may be unconstitutional and should be reconsidered.

33. Limited registration

S33(1)(b) refers to non-compliance with S31. Section 31 is very lengthy. It appears that S33(1)(b) specifically relate to S31(5).

It is not clear what "purpose of practice" in S33(1)(d) refers to. Would this be required of visiting international consultants / experts in certain fields of practice?

S33(1)(d) indicates that limited registration may be granted for the purpose of practice, research or education, and in S33(2) it states that this is limited to a period not exceeding 2 years. Two years may be insufficient particularly for higher education degrees which include significant research projects.

Clarify

Clarify

This period be given as 3 years or else that S33(2)(1a) be amended to state that such a period may be extended on the basis of satisfactory progress towards completing the work for which the limited registration is required

This section in effect excludes any foreign nurse or midwife who has undertaken an educational programme from having their qualification lodged with the Council. This can be problematic in terms of having this qualification recognised when they return to their home countries. Also nurses coming back to South Africa with foreign qualifications find it difficult to register additional qualifications.

Section 38 is very unclear to a reader who does not know what the intention is of the drafters of this bill. This could undermine the foundations of nursing and midwifery practice that is inculcated into the programmes offered by accredited NEIs. We need to have this clarified before this is taken further.

Generally this initiative is welcomed. However, there needs to be an appropriate infrastructure and financing in place to ensure that ALL nurses and midwives can afford, have access and are enabled to attend such professional development activities.

Nurses have to remain competent throughout their working lives and to achieve this there is a need for the development of assessment methods. The importance of an affordable and workable model cannot be overemphasized. Consultation with stakeholders should take place.

Section 40(2) states that such a person must be registered in the category "community service". There is no such category in S31.

While the philosophy and intention of community service is understood and supported, it is believed that it does not apply to nursing education and training for the following reasons:

• There must be careful consideration of what is a reasonable community service time commitment for people who have done far more hours of service (usually) in the public sector health services during their basic professional education, than many other health professionals. Occupational Therapists and Physiotherapists are required to do 1000 hours during their 4 year programmes, and Speech Therapists/Audiologists a mere 300 hours, yet nurses who have done 4-13 times more service as part of their learning, are required to give the same amount of time.
• All student nurses who have Department of Health funding sign a contract to work for 2 – 4 years (depending on the province) in the government sector on completion of their studies. It is only a very small percentage that does not receive funding during their training programme.
• Nurses and students are working in rural services and have been doing so for many years.
• Logistically the numbers of nurses who complete training and have to be placed as community service practitioners are big and will create a logistical nightmare, especially in provinces where there is not enough funded posts, accommodation and supervision to place students.

Add a category "Community service" practitioner and define these terms.

This section indicates that a prescribed fee must be paid for any nursing education programme. This is a situation where the legislation requires registration of programmes, the health system requires the educational programmes to meet the health service needs of the country, yet the service provider (the HEI) is required to carry the cost. Such costs could prevent the necessary education programmes being offered or limiting the training to the more lucrative and popular programmes, which might not address the health service needs.

The NEIs are already having to pay for accreditation visits.

It is believed that this provision must be removed. It would be preferable for a tendering system to be put in place and for the Department of Health to pay the prescribed fee, if indeed such a fee should be levied at all.

S44(1)

S44(1)(g) due unprofessional conduct

This is one way of ensuring that the register becomes one of currency of available professional nursing and midwifery professionals. Any move to ensure that the data on the register is accurate is to be welcomed. However, S44(1) refers to a continuous absence of more than 3 years. A number of nurses take the opportunity to undertake higher education studies abroad. In the case of doctoral study this is often 4 – 6 years during which time they might not be able to return to practice in South Africa. Anyone who has been absent for more than 3 years should be asked what the circumstances are of their absence, and if it is for study purposes as indicated, then they should have the option to remain on the council register.

Similarly one might ask questions of people who are on the register but do not intend to practice in the medium term, e.g. young people starting a family might take a break of 5 years. It would serve the information needs of the country better, to have a non -practicing register. This may link well to the provisions for continuing professional development, but these have not yet been made public.

This section appears to remove all practitioners found guilty of unprofessional conduct

Concerns has been expressed by stakeholders that this section may be abused as a tool to get rid of ‘difficult’ students at NEIs.

A non-practicing register or code should be created for those who do not wish to practice for a selected time.

Add "..depending to the penalty/sanction"

This sectioned is welcomed. It is important that the Council be empowered to act proactively. This clause will give it the power to do so. This was one of the recommendations made to the Truth and Reconciliation Commission on behalf of the profession. However, the problem remains in terms of the proceedings, namely who becomes the complainant(s) in the case

This is the area where DENOSA is experiencing the biggest problem with the Council – procedures are unfair, panel members are not well prepared/equipped to serve on such a peer review panel, e.g. continuously and aggressively cross questions the nurse appearing in front of the professional conduct committee.

This section does not comment on the composition of a professional inquiry panel or professional conduct committee. (Neither is this clear in S15.) Certain provisions must be respected in terms of the composition of the committee, namely ‘As far as professional conduct hearings are concerned, it is essential that the committee be comprised of people who have the necessary expertise to make a professional judgement. This means that a person appearing before such a committee should have a committee which is composed of peers in their area of specialty particularly when there are matters of the science of nursing or midwifery being considered, e.g. there should be intensive care nurses on a committee where there are issues relating to intensive care. …. Where there is a matter of science there must be appropriately qualified peers (with credibility in the field) on the committee.’

(Similarly in Section 51(1) and 51(6) – "Unfitness to practice due to impairment" - the composition of the committee should have peers if the concern relates to a matter of science.)

In Section 47 there is no mention of where such inquiries would be held. It would be financially impossible for many nurses or midwives to have to appear in person in a location such as Pretoria.

Indicates that the chairperson of the professional conduct committee may appoint assessors to advise the committee on matters of law, procedure or evidence when holding an enquiry.

• Such a person cannot be simultaneously in the prosecutorial role
• There should be a requirement for any member of a professional conduct committee to undergo training in weighing evidence, to ensure that the hearings are in fact treated with the same legal rigour and not based on personal opinion. The public and the profession deserve a rigorous process to ensure that all participants in such hearings are accorded the respect they deserve.’

It is strongly recommended that:

• a national panel of reviewers with a variety of expertise be trained (and updated annually) and co-opted on an ad hoc basis for hearings. There should be accountability and a regulated process.
• Nurses should form the bulk of the panel
• A lawyer should form part of the panel
• A nurse should chair the inquiry and ideally also have legal experience
• The Council may only within a certain time limit, start the inquiry and misconduct proceedings in order to ensure that the Council don’t come after 5 years to charge a person.
• Consistent awarding of penalties
• Alternatively outsourcing of the professional conduct hearings could be considered

The legal protocol is for hearings to take place where the alleged misdemeanour took place, so we believe that this principle should be embodied in the bill.

56. Special Provisions

S56(1) register persons to assess, diagnose, prescribe treatment, keep and supply medicine

S56(2) Council must issue certificate

S53 (3) The certificate referred to in S56(2) will be valid for 3 years

S56(4) Council may renew certificate

S56(5) Actions that may be performed by persons registered in terms of S56(1)

S56(6) authorization by DG of Health

S56(7) Nurses may not keep an open shop

S56(8) Definition of open shop

Section 56(1) relates to registering people to assess, diagnose, prescribe treatment, keep and supply medication for prescribed illnesses and health related conditions. In the course of their everyday work registered nurses and registered midwives (as defined under the 1978 Act) assess, diagnose and prescribe treatment, so it is unhelpful to have to register in addition to the basic registration. This also seems to be an unnecessary duplication of the same function contained in S34 (Registration of additional qualifications) where provision is made for the registration of all other additional qualifications, the detail of which is provided in regulations.

The relevance of these two sections is not clear in terms of the abovementioned or other basic or additional qualifications. In terms of S39 continuous professional development will be instituted which by implication will ensure that all nurses/midwives in future have to update their knowledge and skills in the area where they practice.

Alternatively, if sections (1) up to (4) refer to a process of licensing nurses/midwives to assess, diagnose and prescribe treatment, then section 56(6) becomes obsolete.

The inclusion of these is confusing as it repeats clause (6)(iii) and a section from the Medicines Control Act (101 of 1965). This seems to be an unnecessary repetition.

This section is almost an exact replica of S38A in the current Nursing Act which has not been helpful in facilitation of health service delivery and improving access to health services.

In terms of section (a) to (d) the access to health services are limited by providing such a specific list. There are organisations and NGO’s, e.g. hospices, which provide a valuable service to our people who do not have access to other health care services and practitioners, should have the authorisation to provide the services that are required. Comprehensive services by occupational health nurses can ensure maximum productivity at work by offering such a service without cost while still meeting the health care needs of the workers in those workplaces. For someone to have to take a day off work to engage a practitioner in one of the designated sites, is harmful to the economy and wasteful of time and finances for transport etc.

Authorisation by the DG of Health or delegate is contradictory to Section 22(A)(14)(b) of the Medicines and Related Substances Act (Act 101 of 1965, as amended) which indicates the following:

"Notwithstanding anything to the contrary contained in this section –

2. no nurse or person registered under the Health Professions Act, 1974, other than a medical practitioner or dentist, may prescribe a medicine or Schedules substance unless he or she has been authorized to do so by his or her professional council concerned."

This by no means indicates that all nurses and midwives should have authorisation to prescribe treatment.

In terms of section (i) to (iv) this clause is not helpful in facilitating service delivery in the health services for the following reasons:

• It only refers to physical assessment/physical illness or defects and does not make mention of mental illness. The trend is to move health care users out of mental care institutions into the community, but nurses who are responsible for community health care services are not empowered to care for these individuals in the communities where they work.
• Further it appears that the regulations under which registered midwives may carry and use certain medications have not been replaced hence there is a vacuum, potentially preventing women and newborns from obtaining potentially lifesaving treatment e.g. Oxytocin, Konakion, Penicillin eye drops. The inclusion of the regulation 47 in the General regulations (R510) to the Medicines Control Act does not provide the detail in terms of the medication mentioned in the previous regulation.
• Inclusion of family planning is not in line with what is happening in clinical practice where it is mostly nurses who provide these services - in particular promotion of family planning is an activity that should be a service common for all women in ANY service, even if they are being treated for Tuberculosis, Diabetes Mellitus or HIV/AIDS. This limitation works against the policy of increasing access to required health care.
• This section states that these specified activities may be carried out "if the services of a medical practitioner or pharmacist, as the circumstances may require, are not available". This is not helpful, for example, where the patient load is so high that even if there are medical practitioners present, they cannot handle the patient load without the inclusion of nurses with the relevant skills to assist with the diagnosis and prescribing treatment. This statement as it stands, also exploits the nurses and midwives and suggests that their attention can be diverted away from their necessary nursing and midwifery functions. This does not recognise their value to function at this level, and to be suitably remunerated. Further, a pregnant woman should not have to see a medical practitioner except in a very limited way, and so all midwives should be automatically be recognised for this level of practice.

This determination is included in the Medicines Control Act (101 of 1965) and should not be duplicated

Delete S56(1) & (2) as it is a duplication of S34 in Chapter 2 (unless the intention is as indicated in the next paragraph)

Clarity is required to indicate the intention of sections 56(1) to (4):

• If the intention is to "authorize" or license/certificate practitioners to assess, diagnose and prescribe treatment, then these sections should remain and section (6) should be deleted. The intention should then be clarified as such. Having successfully completed the course does not automatically provide these practitioners with authorization to assess, diagnose and prescribe treatment.
• If the intention is only to register an additional qualification, then sections (1) to (4) should be deleted

Delete clause 56(5) as these sections are included elsewhere in this Bill and other relevant legislation

It is recommended that S56(6) be deleted and replaced by a clause making provision for the Council to authorize nurses to assess, diagnose and prescribe treatment (depending on whether the first 4 sections are amended to fulfill this need function).

Authorization must reside with the Council to be implemented according to a regulation.

Propose removal of this clause

57. Appeal against decisions of Council

Additional information added. This should ensure credibility and competence to review such an appeal.

The location of such an appeal (if it involves the presence of the appellant) should be in a decentralised location.

S58(1)(a) suggests that there will be an election for some members of the council. This is not made clear in the preceding text of this bill.

Amongst the many documents that are required to flow from this legislation, there is no mention of the equivalent of the current "R387 Acts and Omissions", or "R2488 Conditions under which a registered midwife may carry out their profession". Presumably these will be covered in S58(1)(q).