Self-reported compliance with occupational health legislation among professional nurses in South Africa



K Michell, LC Rispel

School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Correspondence: Dr Karen Michell, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Private Bag 3, WITS 2050, South Africa. e-mail:

Karen Michell is a SASOHN honorary life member

Background: The 2015 Sustainable Development Goals emphasise universal health coverage, access to quality health services, and legislation as tools to reduce inequality between, and within, countries. However, there is dearth of research on compliance with occupational health (OH) legislation in low- and middle-income countries.

Objective: To determine occupational health practitioners’ (OHPs) self-reported compliance with key legal requirements for occupational health services (OHS) delivery as stated in South Africa’s Occupational Health and Safety Act (OHSA) and Mine Health and Safety Act (MHSA).

Methods: During 2014 and 2015, a cross-sectional study was conducted among professional nurses delivering OHS in South Africa. Participants completed a web-based questionnaire to establish self-reported compliance with selected aspects of OH legislation in South Africa. Binary logistic regression analysis was used to identify factors associated with compliance.

Results: An overall response rate of 36.8% (475 of 1 292) was obtained from occupational health nursing practitioners. Compliance with the OHSA was 94.6% for retention of medical records, 92.7% for obtaining informed consent to share medical records, 90.4% for timely notification of occupational diseases diagnosed, 86.3% for certification for fitness to work, and 85.3% for risk assessment in the clinical setting. Service assessment of OHS was significantly associated with compliance with the five OHSA criteria assessed (p = 0.00). Compliance with the MHSA was 99.1% for performance of medical surveillance by an occupational medical practitioner (OMP) registered with the Health Professions Council of South Africa (HPCSA), 95.6% for retention of medical records, 80.0% for annual reporting of employee health, and 44.4% and 44.3% for conducting of exit and other medical examinations by OMPs, respectively. The number of sites served by OHPs was significantly associated with compliance with medical examinations (p = 0.04); OMPs were less likely to comply when they serviced more than two sites (OR = 0.33; 95% CI 0.11-0.97).

Conclusion: The suboptimal self-reported compliance with existing OH legislation is of concern and suggests the need for regulatory enforcement in order to achieve 100% compliance.

Keywords: legislation, occupational health services, compliance, enforcement, inspection, standards.

The 2015 Sustainable Development Goals (SDGs) emphasise universal health coverage, access to quality health services, and legislation as tools to reduce inequality between, and within, countries,1 while the Istanbul 2011 Declaration on Safety and Health at Work underscores the provision of a healthy and safe working environment as a fundamental human right.2 In 2007, the World Health Organization (WHO) highlighted ‘major gaps between and within countries in the exposure of workers and local communities to occupational hazards and in their access to occupational health services’.3

Occupational health services (OHS) are defined as ‘services entrusted with essentially preventive functions and responsible for advising the employer, the workers and their representatives on the requirements for establishing and maintaining a safe and healthy working environment, which will facilitate optimal physical and mental health in relation to work and the adaptation of work to the capabilities of workers in light of their state of physical and mental health’.4 In this paper, we use a narrow definition of OHS, namely medical examinations, fitness to work assessments and medical surveillance activities provided by OHS providers, specifically doctors and professional nurses.

In recognition of the importance of workers’ health to overall economic development, key goals of the WHO’s 2008-2017 Global Plan of Action on Workers’ Health are to develop and implement policy instruments (e.g. legislation) on workers’ health, and to improve the performance of, and access to, OHS.3 This is because OHS contribute to workers’ health and wellbeing and the prevention or reduction of occupational diseases, injuries, disability and death.5-7 However, access to quality OHS remains inadequate, with estimates for access ranging from 5% in low- and middle-income countries (LMIC) to around 50% in industrialised countries.8

Legislation is seen as an important tool for achieving policy goals and, ultimately, achieving improvements in access to OHS and the health of workers.3 Compliance with legislation is important as it measures the degree to which laws, regulations and standards are followed, thus providing a measure of safety9 and quality of a service.10,11 However, the effectiveness of legislation depends on clear intention, implementation and enforcement of compliance,12,13 with appropriate incentives for conformance with standards14,15 or penalties for non-compliance.12,16

Governments use a range of regulatory tools to achieve compliance. These include deterrence-based tools such as inspections and audits, fines, administrative notices or orders, and prosecutions or cooperative tools such as tax incentives or voluntary disclosure.7,9,17 Nonetheless, research has shown that enforcement through inspections improves compliance and contributes to safer workplaces, 9,14,16,18 although to varying degrees, with specific, focused inspections having greatest impact.16 Baggs et al. demonstrated the positive effect of inspection where fixed site occupational health (OH) facilities inspected for compliance to local laws decreased injury insurance claims by 25%, compared to non-inspected sites and providers.18 In contrast, poor or no compliance with legislation or standards is associated with poor quality healthcare10,19 or suboptimal protection of workers in critical areas, such as hearing and respiratory conservation.20-22

In South Africa, the 1997 White Paper for the Transformation of the Health System emphasised the important role of OHS in light of the historical neglect of workers’ health in the country.23 The White Paper envisaged a new, integrated, coordinated legislative framework and the creation of a national health and safety agency for policymaking and standard-setting, with contributions by organised labour, business, government departments, and occupational health and safety specialists.23 However, these strategies have not been implemented due to a lack of resources and fragmented development of services.5

Hence, in 2017 the OHS legislative framework remained complex and fragmented. Two main laws govern OH, i.e. the Mine Health and Safety Act (MHSA) that governs mines and quarries,24 and the Occupational Health and Safety Act (OHSA) that governs all other sectors.25Different government departments are responsible for the enforcement of each law. OHS are provided by doctors and professional nurses (with four years of training) whose practice is governed by two professional councils 26,27 as well as the National Health Act.12,28 The OHSA and the MHSA legislate that certain OH activities (e.g. medical surveillance examinations and return to work assessments) are conducted by a professional with a specialised OH qualification.24,25 The MHSA is more prescriptive and stipulates that all fitness to work and exit medical examinations should be performed by an occupational medical practitioner (OMP).29

Furthermore, OHS are provided through various models of service delivery, by full-time or part-time practitioners who may be employed either directly by companies or through service providers.28 Although the labour inspectorate could investigate and enforce compliance with relevant legislation, scholars have pointed out that mechanisms to ensure OHS compliance in South Africa are insufficient or lacking,5 resulting in a largely self-regulated compliance system.30

There are several reasons for studying compliance: it serves as a proxy for policy implementation (in this case, OH legislation); it gives an indication of gaps or risks in OHS provision; and it may point to specific policy implementation strategies or the need for changes in existing legislation.

Although numerous stakeholders are involved in OHS, this paper focuses on self-reported compliance among occupational health nursing practitioners (OHNPs), using selected policy and regulatory criteria relevant to OHS delivery. This is in light of the importance of OHNPs as providers of direct service delivery to workers.


A cross-sectional study was conducted during 2014 and 2015 among doctors and nurses involved in OH service delivery in South Africa. Although doctors and nurses are required to be registered with the Health Professions Council of South Africa (HPCSA) and the South African Nursing Council (SANC), respectively, these professionals are not required to indicate whether or where they are practising. Hence, there is no reliable database of practising doctors or nurses in the OH sector. The professional societies, i.e. The South African Society of Occupational Medicine (SASOM) and the South African Society of Occupational Health Nursing Practitioners (SASOHN), are voluntary associations of doctors and nurses practising OH in South Africa. Both societies were approached for a list of all members registered in their databases. The SASOHN database of 1 292 members was made available to the principal researcher (KM) after signing a confidentiality and limitation of use agreement. The database included names of all persons who had ever been a member or had applied to join the organisation, but did not indicate which members were deceased, had emigrated or had ceased practising in OH. SASOM was not willing to supply its membership database but offered to send the questionnaire to the 791 members via email. Hence, all members on the SASOM and SASOHN databases were invited to participate in the study.

Box 1. Criteria selected to explore compliance with the OHS Act and the MHS Act

The self-administered questionnaire was web-based and included sections on socio-demographic characteristics and self-reported compliance with 10 selected OH criteria: five from the OHSA and five from the MHSA. These criteria, as listed in Box 1, were based on aspects of the legislation that were directly relevant to occupational healthcare and, more specifically, the functions of the occupational health practitioner (OHP). Participants were asked to indicate compliance with the OH legislation as ‘yes’, ‘no’ or ‘unsure’. The survey was pre-tested with five OHNPs with the same characteristics as the study population, and these individuals were excluded from the analysis. Following piloting of the tool, some questions were revised to improve clarity.

Data were collected and managed using REDCap (Research Electronic Data Capture), a secure, web-based application designed to support data capture for research studies31 and hosted at the University of the Witwatersrand in Johannesburg. Nurses were sent a message via short message service (SMS) by the principle researcher to notify them about the survey; the doctors received an e-mail via the SASOM national office. The SMS requested practitioners to verify their contact details and directed them to the online survey questionnaire. Participants could decline participation by answering ‘no’ in the consent section which recorded their response as complete and removed them from the reminder list. Participants had the ability to complete the survey on line, using the public link provided, or by using a personalised code sent to them in the SMS. Every week from 4 November 2014 to 20 January 2015, a reminder e-mail and SMS were sent to participants who had not completed the survey. Hence, OHNPs who did not respond to the initial request received a maximum of eight reminders.

Responses from the questionnaire were captured directly into REDCap and stored in a secure server. A code book was developed for the responses to facilitate analysis in Stata® 14. Frequency tabulations were performed to describe the socio-demographic characteristics of the participants. Cross-tabulations were done to explore associations of each of the factors with legal compliance, the main outcome of interest.

Bivariate logistic regression models were fitted where the outcome variables were the 10 criteria for compliance. These were retention of medical records for 40 years, obtaining informed consent for sharing of medical information, notification of occupational diseases, certification of fitness to work and risk assessment for the OHSA. For the MHSA, the factors were performance of medical surveillance by OMPs registered with the the HPCSA, retention of medical surveillance records for 40 years, production of annual occupational health medical reports for management, and performance of medical and exit medical examinations by medical officers.        

Explanatory variables considered for the bivariate modelling included: having a qualification in OH, academic level of the highest qualification, model of service delivery (either an employee of the company to which OHS are provided or employed through a service provider who offers OHS to companies on a for-profit basis), type of clinic, industry sector, number of sites serviced, and any form of assessment of the service. Variables found to be statistically significant at the 10% level were considered in the building of the final multivariable logistic regression model. Statistical results were considered significant at the 5% level.

Ethics approval was obtained from the University of the Witwatersrand’s Human Research Ethics Committee (clearance certificate no. M140442).

The response rate was 36.8% (n = 475/1 292) among nurses; it was much lower among doctors (n = 21/791; 2.7%), leading to their exclusion from the data analysis. Of the 475 nurses who responded, 88.6% answered the self-reported OH legal compliance questions.

The median age of OHNPs was 50 years, ranging from 27 to 76 years. Table 1 summarises the work-related characteristics of the nurses. The median of work experience was 10 years (<1 year to 50 years). Most practitioners (n = 417; 87.8%) had completed a post-basic qualification in occupational health nursing, with certificate, diploma and bachelor degree level accounting for the majority of these qualifications. Only 11 (3.1%) of OHNPs had completed a Masters or PhD degree. The majority of practitioners were employed in the private sector 380 (90.3%); 26 (6.2%) were employed in the public sector. Very few (n = 15; 3.6%) were employed in both the private and public sectors. The reported models of service delivery in OH were: employment through a corporate model, a direct employee of the company to which services were offered; and employment through an external service provider. The minority (n = 53; 12.9%) were self-employed, providing services on a contract basis.

Practitioners employed in a fixed site facility were in the majority (n = 357; 83.4%). More practitioners offered services through both mobile and fixed site facilities than through mobile facilities only, viz. 49 (12.0%) and 15 (4.7%), respectively. The majority of participants were from the manufacturing (n = 216; 51.9%), mining (n = 89; 22.7%) and consruction/ engineering (n = 80; 20.8%) industries. Most were employed at one site (n = 220; 52.3%); with 134 (31.8%) employed at three or more sites. The majority of respondents (n = 392; 93.2%) reported that some form of OHS assessment was conducted, ranging from self-assessments to external assessments for accreditation purposes. More than two thirds (n = 291; 69.2%) reported that they were governed by the OHSA, compared to those governed by both the MHSA and OHSA (n = 118; 27.9%), and the MHSA alone (n = 12; 2.9%).

Table 1. Work-related characteristics of participants (N = 475)

Compliance with legislated occupational health criteria
Table 2 shows self-reported compliance with the OHSA and the MHSA. No participants reported 100% compliance with any of the criteria. The proportions of self-reports of compliance ranged from 85.2% to 94.6% for the OHSA, and from 44.4% to 99.1% for the MHSA. For the OHSA, highest compliance was reported for retention of medical records for 40 years 
(n = 365; 94.6%), and obtaining informed consent from patients (n = 358; 92.8%). Lower compliance was recorded for certifying previously unfit workers as fit for work (86.3%), and conducting a risk assessment for exposure to hazardous biological agents (85.2%). For the MHSA, the highest compliance was recorded for registration of OMPs with the HPCSA (n = 114; 99.1%) and retention of medical records for the prescribed 40 years (n = 110; 95.7%). Lowest compliance was recorded for medical examinations (n = 51; 44.4 %) and exit medical examinations (n = 51; 44.4%) being conducted by an OMP. As shown in Table 2, a number of participants were unsure whether their services were achieving compliance with some of the criteria of both the OHSA and the MHSA.

Predictors of self-reported compliance
Tables 3 and 4 show the results of multivariable logistic regression analyses which only included variables that were significant (p < 0.1) in the bivariate analyses (results not shown). The final model considered the following variables as predictors of legal compliance: model of service delivery, method of service delivery (fixed site and/or mobile clinics), OH qualifications, number of sites served, and whether any form of service assessment had been undertaken.

Table 3 shows factors associated with self-reported compliance for each of the five OHSA criteria investigated. Assessment of the OHS was statistically significant for the five compliance criteria (p < 0.01): compliance was lower where no assessments were conducted. For all service delivery models, there was an 80% to 90% likelihood of achieving compliance where an assessment (ranging from self-assessments to external assessments for certification purposes) of the service had been conducted.

Table 4 shows the factors associated with self-reported compliance for the MHSA. Only one factor (number of sites served) was found to significantly influence self-reported compliance (p = 0.04). When compared to those servicing only one site, medical examinations were 33% less likely to be performed by an OMP where three or more sites were serviced. For both laws, self-reported compliance with the legislation was not associated with sector, years of experience, completion of a post-basic qualification in OH nursing, or the level of this qualification.

The provision of OHS adds value through improving quality and productivity in the workplace.12,32 In this study, OHNPs reported not achieving 100% compliance with any of the criteria selected from the OHSA and the MHSA. Legislation represents the crystallisation of policy objectives into an enforceable medium, with compliance representing the measure of how well stakeholders comply with these laws.13 The Department of Labour’s Chief Inspector has argued that compliance needs to be at 100%,32 and the Minister of Health has stated that quality of care is non-negotiable.33 Although our study did not measure the quality of OHS delivery or its outcomes, studies in non-occupational settings have found that poor compliance with existing standards contributed to poorer quality of care.11,34,35 The findings are also illustrative of the policy-implementation gaps that have been enunciated by health policy researchers.36-38

Although OHNPs reported compliance of at least 80% with eight of the 10 selected OH legislation criteria, for two of the 10 criteria, namely whether medical examinations and exit medical examinations were conducted by an OMP, reported compliance was only 44%. One explanation is that the professional nurses who responded to the survey did not know whether the medical examinations were conducted by an OMP. However, as OHNPs work closely with doctors, and play a major role in the recording of procedures, it is assumed they should know this. On the other hand, the finding suggests that the employers are in breach of the MHSA because the Act stipulates that all fitness to work and exit medical examinations should be performed by an OMP.29 The reported poor compliance with these legislative requirements could be due to the shortage of OMPs, as reported in other studies.5,39 

The Department of Mineral Resources (DMR) has a medical inspectorate that conducts general inspections on OHS governed by the MHSA. Although higher reported levels of compliance were anticipated, studies have shown that different types of inspections have varied impact,16,40 with the first inspection having the greatest impact.17 The Department of Labour (DoL) does not have a medical inspectorate, and the slightly higher compliance reported by participants governed by the OHSA may be due to a sampling and/or social desirability bias; practitioners who participated in the study might have believed they were compliant with the criteria being explored.

The only factor found to influence compliance with criteria for the MHSA was the number of clinics serviced by study participants. An OMP was less likely to perform the medical examination where three or more clinics were serviced, possibly due to the heavy workload of the OMP in numerous clinics. Another possible explanation for this contravention, as well as the failure to achieve 100% compliance with any criterion, may be the lack of government enforcement of existing OH legislation.30

The implementation of some form of OHS assessment was the only factor that influenced self-reported compliance with the OHSA across all five study criteria. This finding is supported by other studies where a system of inspection led to improved compliance.9,17,41,42 Enforcement has been shown to be an effective deterrent43 and this finding supports the opinion that enforcement, through effective and appropriate inspection of OHS endorsed by government structures (which is lacking for OHS), would improve compliance.40,44

Neither the achievement of an additional or higher OH qualification nor the model of service delivery was associated with higher levels of reported compliance. The delivery of OHS through mobile facilities and external service providers have been cited in other studies as reasons for poor compliance with regulations.20,45,46 However, these factors were not significant in this study, which may be a consequence of the low response rate.

While more research is needed to determine the reasons for poor compliance, strategies are urgently needed to overcome the shortage of OMPs, including offering incentives to OMPs to engage with services in the mining sector, and expanding the scope of practice of OHNPs to include medical examinations.

The implementation of OHS assessment was the only factor that influenced self-reported compliance with the all five OHSA criteria. These findings demonstrate a need to improve legal compliance, and provide support for enforcement of OHS inspection, in line with the ILO recommendations.4 The DoL and DMR need to know who provides OHS that are legislated by the OHSA and MHSA, respectively, in order to monitor and control legal compliance – a process hindered by the lack of a national database of OH service providers. Although the professional councils (HPCSA and SANC), as the registering authorities, could be expected to retain comprehensive databases of all OH professionals, this is not the case. The HPCSA does not require OMPs to register OH qualifications. The SANC only registers qualifications achieved and submitted by nurses for inclusion on the Register, and the Council is thus reliant on the nurses to complete this process. These concerns highlight the need to develop a national database of OHPs. At the time this paper was written, the DoL was addressing this concern through the development of a national database of all OH service providers.47 Based on current initiatives by the DoL, employers will, in future, be required to use a DoL-approved OH service provider when engaging OHPs to conduct activities legislated by the OHSA. The same process is recommended for the DMR which regulates the MHSA.

The nature of the DMR inspections should be investigated to evaluate and improve the impact that they have on compliance, given the varied nature of service delivery models in this study. As greater enforcement may increase compliance, the professional associations should ensure that the importance of legislative compliance is emphasised in continuing professional education of their members.  

The lack of 100% compliance with any one of the criteria under investigation in our study suggests the need for empirical studies on the quality of OHS delivery. In addition, further studies are needed to determine knowledge about, and practice of, OH legislation through direct observation. Research is also needed to verify and determine the reasons for the finding that the number of clinics serviced by an OMP was associated with poor compliance with the MSHA criteria.

Despite extensive efforts to encourage participation, the response rate was low. Restricted access to doctors meant the researchers were unable to explore compliance within this practitioner group and the low response rate from nurses prevents extrapolation to the general population. The databases of the voluntary professional societies were found to be outdated and did not represent all practising OHPs. Considering the low response rate and the lack of a national database, the results are not likely to be representative of OH legislative compliance. Nonetheless, this is one of the first studies to explore reported compliance with the OHSA and MHSA from an occupational healthcare perspective in South Africa, where there is a dearth of research into the delivery of OHS. We identified knowledge gaps that should be further investigated.

The purpose of OH legislation is to protect the health and safety of workers. Compliance with legislation, as a policy instrument, can improve performance of, and access to, OHS. Compliance with key OH legislation criteria was suboptimal among our study participants, indicating a need for policymakers to improve regulatory enforcement of OHS. OH service providers play a key role in service delivery, and practitioners should comply with existing legislation. Policymakers and professional associations should explore mechanisms of enhancing compliance with existing legislation, which will contribute to an overall improvement in the health and safety of workers. The professional societies and academic institutions could use the findings of this study when developing continuing professional development programmes aimed at improving the knowledge and skills of practitioners, to improve compliance which is used as a proxy for improved service delivery.

• There is suboptimal compliance with OH legislation among OH service providers.
• Improved legal compliance could be achieved through the enforcement of OHS assessments.
• Complete and up-to-date databases of recognised OH service providers are not readily available.

We acknowledge the assistance provided by Prof. Jonathan Levin, Head of the Epidemiology and Biostatistics Division, School of Public Health, University of Witwatersrand, for his assistance with the data analysis. This paper is based on findings from the principal researcher’s (KM) PhD study entitled ‘Experiences and perceptions of occupational health practitioners on the quality and governance of occupational health services in South Africa’.

The authors declare that this is their own work; all the sources used in this paper have been duly acknowledged and there are no conflicts of interest.

LR was the academic supervisor of KM’s PhD.

Conception and design of the study: KM, LR

Data acquisition: KM
Data analysis: KM
Interpretation of data: KM, LR
Drafting of paper: KM
Critical revision of paper: KM, LR

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