DOES A NURSING PRACTITIONER HAVE A DUTY TO WORK IN A CLINIC 
WITHOUT THE FUNDAMENTAL RESOURCE OF WATER? 

 
 
 
 
 
 
                                       Makhotso Merriam Ralehike 
 
 
 
 
 

 

Submitted to the Faculty of Health Sciences, University of the Witwatersrand, 

Johannesburg, in partial fulfilment of the requirements for the degree of Master 

of Science in Medicine in Bioethics and Health Law 

 

                                      Johannesburg, 2022. 

 

 



i 
 

 

Declaration 
 

I Makhotso Merriam Ralehike, student number 2261574 declare that this Research 

Report is my own, unaided work. It is being submitted for the Degree of Master of 

Science in Medicine in Bioethics and Health Law at the University of the 

Witwatersrand, Johannesburg. It has not been submitted before for any degree or 

examination at any other University. 

17th day of October, 2022 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



ii 
 

 

Dedication 
                                                

                                             In memory of my late mother 

                                               Mahlape Gladys Mpholo 

                                                          1956-2005 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



iii 
 

 

Abstract 
 

The purpose of this study is to explore the current situation where nursing 

practitioners find themselves working at the rural healthcare facilities where there is 

a lack of water as a fundamental resource necessary to render quality services. The 

ethical problem is a nurse’s obligation to care for patients in such a clinical setting 

and the risk of being exposed to infections, including SARS-Cov-2, which have the 

potential to harm human health and affect a nursing practitioner’s decision on 

whether to work in such a clinical facility or not. This study outlines the magnitude of 

the need of the South African nursing regulatory body to adopt a code of ethics that 

reflects the realities of the healthcare systems in rural health facilities in which 

nurses care for patients. 

I carried out a normative study, and the existing relevant legal and ethical literature 

was critically analysed. I employed my 8 (eight) years of experience working as a 

nursing practitioner in rural healthcare facilities, from which this research report topic 

grew. The moral argument was primarily based on relevant literature and laws, 

philosophical perspectives, where Kantian Deontology moral theory was analysed, 

and the bioethical principles of autonomy, beneficence, non-maleficence and justice. 

A conclusion is reached that current nursing guidelines and policies in place are not 

addressing the issue that nurses do not have a moral duty to practice in an under-

resourced health environment where the fundamental resource for hygiene and 

sanitation is lacking.  A revised approach and potentially legal revisions toward 

developing and justifying a new ethical and legal or regulatory framework are 

recommended.  

Keywords: Nursing practitioner, nursing duties, healthcare, water and fundamental 

resource. 

 

 

 

 



iv 
 

Acknowledgements 
 

I would like to thank Dr Mary O’Grady for her guidance, patience and enthusiasm 

throughout my research journey. I also would like to thank all the staff members at 

the Steve Biko Centre for Bioethics for their continuing support. I would like to thank 

my husband, Makgotla Simon Ralehike, my sons, Keorapetse and Reatile Ralehike, 

my father, Matsepe Joseph Mpholo, and my siblings for their support, and my 

colleagues for remaining convinced of my abilities from the beginning of this 

research. 

This research report has benefited from the input and support from Me Modiehi Mpeli 

(University of the Free State) and Mrs Ditsietsi Palesa Moalusi. Lastly, I would to 

thank the Democratic Nursing Organisation of South Africa (DENOSA) for financial 

funding in 2021. 

 

 



v 
 

Table of Contents 

Contents 
Declaration ............................................................................................................................................ i 

Dedication ............................................................................................................................................ ii 

Abstract ............................................................................................................................................... iii 

Acknowledgements .......................................................................................................................... iv 

Acronyms ........................................................................................................................................... vii 

Chapter 1 .............................................................................................................................................. 1 

1.1 Introductory Summary ...................................................................................................... 1 

1.2 Research Objectives ......................................................................................................... 2 

1.3 Background Literature Analysis and Critique ............................................................ 3 

1.4 Rationale for the Study ..................................................................................................... 7 

1.5 Research Methods Limitations ....................................................................................... 8 

1.6 Presentation of Arguments ............................................................................................. 8 

Chapter 2 .............................................................................................................................................. 9 

2.1 Introduction............................................................................................................................... 9 

2.2 Legal Obligation of the South African Government on the Lack of Water in 

Health Clinics .................................................................................................................................. 9 

2.2.1 National Health Act ........................................................................................................ 11 

2.2.2 Occupational Health and Safety Act ......................................................................... 12 

2.2.3 Other national legislation ............................................................................................. 12 

2.3 How Access to Clean Water is a Legal Right of the Nursing Practitioner at the 

Clinic ................................................................................................................................................ 13 

2.4 The Human Right to Water .................................................................................................. 14 

3.1 Introduction............................................................................................................................. 20 

3.2 Infection Prevention and Control Measures and High-Quality Service Delivery at 

Clinics ............................................................................................................................................. 20 

3.3 Disease Outbreaks (COVID-19 Pandemic) and Water (Hygiene and Cleanliness)

 .......................................................................................................................................................... 24 

Chapter 4 ............................................................................................................................................ 28 

4.1 Introduction............................................................................................................................. 28 

4.2 Nursing Practitioners’ Ethical Duties in the Context of Limited Fundamental 

Resources ...................................................................................................................................... 29 

4.3 Application of Philosophical Perspectives and Moral Theories ............................... 31 

4.3.1 Underlying principles and their application ............................................................ 31 

4.3.2 Kantian deontology moral theory application ........................................................ 39 

Chapter 5 ............................................................................................................................................ 45 



vi 
 

5.1 Conclusion .............................................................................................................................. 45 

5.2 Recommendations ................................................................................................................ 46 

List of References ............................................................................................................................ 48 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 



vii 
 

Acronyms 
 

ANA American Nurses Association 

ANHE             Alliance of Nurses for Healthy Environments 

CHWs             Community Healthcare Workers 

COVID-19       Coronavirus Disease of 2019 

DoH                 Department of Health 

DENOSA         Democratic Nursing Organisation of South Africa 

HAIs Healthcare-associated infections 

HPCSA             Health Professions Council of South Africa 

HREC               Human Research Ethics Committee 

ICESCR            International Covenant on Economic, Social and Cultural Rights 

ILO International Labour Organization 

NHA National Health Act 

OHSA Occupational Health and Safety Act 

PHC                 Primary Health Care 

PPE                  Positive Practice Environment 

SAHRC South African Human Rights Commission 

SANC               South African Nursing Council 

SARS-CoV-2    Severe Acute Respiratory Syndrome Coronavirus-2 

SDGs                Sustainable Development Goals  

UN                    United Nations 

UNICEF            United Nations Children’s Fund 

WASH               Water, Sanitation and Hygiene 

WHO                 World Health Organization 



viii 
 

WMA                 World Medical Association



1 
 

Chapter 1 

1.1 Introductory Summary    

This research report explores the resources that shape a nurse’s safe working 

environment and the costs of an unhealthy workplace when there is a lack water in 

clinics. It articulates the ethical principles underlying and supporting my thesis 

statement and defends my stance that a nursing practitioner does not have a duty to 

work in a clinic where the fundamental resource of clean, running water to provide 

quality health care services is unavailable. The lack of a potable water supply has a 

potential to harm human health, and it can affect a nursing practitioner’s decision on 

whether to work in such a clinical facility or not.  A lack of water supply in health 

facilities can result in poor nursing services, yet the duty and responsibility of a 

nursing practitioner is to ensure a positive patient outcome. This deficient clinical 

care situation introduces an ethical dilemma, which is due to unavailable 

professional and legal guidelines that provide an appropriate foundation to guide 

nursing practitioners who encounter a lack of resources necessary to render quality 

services.   

In this chapter, I will be looking at nurses working in a clinic where there is lack of the 

fundamental resource of water and giving a brief critical review of the relevant 

professional and legal guidelines on this issue and closely related problems. 

Safe and sufficient sanitation and hygiene is the fundamental key to prevent the 

spread of diseases in healthcare facilities, especially in rural clinics (Guo, Bowling, 

Bartram, et al., 2017). This study focuses on the lack of the fundamental resource of 

water in health clinics mainly in rural regions of South Africa, which poses a threat to 

the health of nursing practitioners and their patients in these clinical settings. This is 

an ongoing situation in some of the rural areas in South Africa, but it is not limited to 

rural areas. In 2021, in both Helen Joseph Hospital and Rahima Moosa Mother and 

Child Hospital in Johannesburg, which are large hospitals, there was no water for 

nearly a week (Botho, 2021; Mohamed, 2021).  Cleaners in the hospitals had to 

collect water with containers from an outside tap and mobile water tankers were 

used for staff to wash their hands (Mohamed, 2021). This incident did not just 

interrupt the health services in these hospitals, but it also compromised the general 

cleanliness and hygiene in wards where patients were nursed (Mohamed, 2021). In 



2 
 

Rahima Moosa Mother and Child Hospital, patients were instructed to discard used 

toilet paper in a red bag, instead of flushing it down the toilets, because the toilets 

were not working (Mohamed, 2021). This situation was an unhealthy working 

environment for both nursing practitioners and for patients’ care, especially during 

this time of the COVID-19 pandemic.  

The available professional and legal guidelines provided by the South African 

Nursing Council (SANC) do not provide a clear and fundamental guide to nursing 

practitioners on what ought to be done when there is a lack of the necessary 

resources in healthcare facilities, which are needed to guide the ethical decisions 

nursing practitioners are supposed to take.  

Water supply at the primary healthcare facilities is an essential element to prevent 

the spread of disease. Little research has been conducted regarding the clinics 

without running water especially in rural areas, where nurses render nursing services 

ranging from outpatients’ services to emergency transfers.  According to Guo, et al., 

less than 50% of rural healthcare facilities in South Africa, including the clinics, have 

access to consistent running water (2017). 

1.2 Research Objectives 

The overall objective of this research is to argue that nursing practitioners do not 

have a moral duty to work in a clinic where there is a lack of the fundamental 

resource of water to provide quality health care services.  

Primary Objective 

• The first objective is to describe the reasons why clean, running water is a 

necessity for health care provision and to articulate how the lack of clean, 

running water in a health facility prevents a nursing practitioner from providing 

quality nursing care, because lack of water hinders the quality of nursing 

services.  

Secondary Objectives 

• The second objective is to characterise the individual moral and legal rights of 

a nursing practitioner, to recognise and support the basic human rights of the 

nurses, as the concept of human rights provides the guide for how nurses 

ought to be treated as individuals.  



3 
 

• The third objective is to evaluate and enumerate the South African laws that 

support my argument that a nursing practitioner does not have a duty to work 

in a clinic where the basic health care necessity of clean, running water is 

unavailable, because the workplace has to be safe for the provision of nursing 

practices.  

• The fourth objective is to apply the ethical framework of principlism. My 

deontological argument is in defence of a nurse not having a duty to work in a 

clinic where the basic fundamental resource for health care provision, clean, 

running water, is unavailable. 

Principlism refers to the approach to moral arguments developed by philosophers 

Tom Beauchamp and James Childress and includes four principles of biomedical 

ethics (2013). The basic idea proposes that moral problems can be best approached 

using or applying one or more of these basic ethical principles, namely respect for 

autonomy, beneficence, non-maleficence and justice (Moodley, 2011).  According to 

Moodley, these principles are guiding actions which are used in evaluating moral 

problems (2011). 

1.3 Background Literature Analysis and Critique 

The majority of the health workforce in South Africa consists of nursing practitioners, 

and they play an important role in providing primary health care (PHC) services. 

Health care systems in this country are increasingly challenged. There is a wide 

increase of health needs and financial constraints, which restrict the services that 

have the potential to strengthen health sector infrastructure and the workforce 

(Baumann, 2012). The International Council of Nurses states that the health sector is 

faced with a global nursing workplace crisis, one marked by a critical shortage of 

water as a standard resource for a health facility to be fully operational and functional 

(Baumann, 2012). The reasons for a lack of water in health facilities, especially in 

clinics, are varied and complex, but key among them is poor infrastructure 

(Baumann, 2012). Lack of water creates an unhealthy work environment that 

weakens the performance of nursing practitioners, separates them from their specific 

work settings, and from the nursing profession itself. 

If the clinical setting does not support a nurse’s ability to provide excellent health 

care services because the facility lacks water, it will not promote the practice of 



4 
 

personal hygiene etiquette, such as frequent hand washing with soap and water, to 

prevent the spread of disease (Baumann, 2012; Howard, Bartram, Williams, et al., 

2020). The practice of hand washing is essential to overall cleanliness and 

preventing the spread of disease (Howard, Bartram, Williams, et al., 2020). Another 

component due to a lack of water that must be reviewed is that such a clinic situation 

affects a nursing practitioner’s human health and well-being. Daily consumption of 

sufficient, clean water is required to replenish body fluids and facilitate physiological 

processes of all human beings, including nursing practitioners (Howard, Bartram, 

Williams, et al., 2020).  

If the instruments and tools the nurse uses are not clean, the work environment will 

not promote positive nursing practice, nor will it be beneficial for patient outcomes 

(Howard, Bartram, Williams, et al., 2020). Thus, the deficient work environment will 

have a negative effect on nurses’ satisfaction with the work they do (Howard, 

Bartram, Williams, et al., 2020). In my view, this level of compromised health 

services also would be insufficient to ensure that enhanced personal hygiene of 

nursing practitioners could be practised under disease outbreak conditions, i.e., the 

COVID-19 pandemic. Based on my personal experience working on a COVID-19 

ward at Tshwaragano District Hospital in Kuruman, Northern Cape Province, as a 

professional nurse, the infection control measures are compromised, resulting in an 

unhealthy workplace and increased cases of COVID-19 infection amongst 

employees in the ward because of the water insufficiency needed for ward 

cleanliness and good health.  

Water is considered as a limited natural resource and a public good fundamental for 

life and health (World Health Organization and UNICEF, 2019). However, water 

scarcity remains a common condition of many communities in South Africa (World 

Health Organization and UNICEF, 2019). Water is a fundamental human need and 

has to be readily available and easily accessible in health institutions (World Health 

Organization and UNICEF, 2019). Nevertheless, due to some limitations, such as 

poor infrastructure of healthcare facilities at clinics like Penryn Local Clinic in John-

Taolo Gaetsewe local district municipality in Kuruman, Northern Cape Province, 

South Africa, nursing practitioners can find themselves compromising quality nursing 

care services due to water scarcity in the area, as there is no access to water due to 

inadequate infrastructure of the clinic. Penryn Clinic is now closed because there 



5 
 

was no running water in the taps, and nurses had to reserve or store water in the big 

drums for drinking and domestic use, including washing hands. The nurses had to 

use a pit toilet because there was no water in the facility. According to the South 

African Human Rights Commission (SAHRC), the human right to water is obligatory 

for leading a life in human dignity (2014).  

The lack of running water in a clinic facility dehumanises the human rights of nursing 

practitioners and limits their human dignity in ensuring and sustaining quality-nursing 

care (SAHRC, 2014). The human right to clean running water and sanitation is 

considered to be of utmost importance in health care facilities (SAHRC, 2014). 

Furthermore, the nature and scope of the existing healthcare system profile in South 

Africa does not allow nursing practitioners to practice in such an environment, as it 

does not meet the ethical standards required to render medical care of good quality, 

as stipulated in World Medical Association (WMA) Declaration of Lisbon on the 

Rights of the Patient (2005).  

A serious philosophical problem arises when the lack of water supply affects the 

clinics in rural areas, where a nursing practitioner is faced with an ethical dilemma of 

working in unfavourable conditions, yet s/he has a duty to provide care to the patient 

(WMA, 2005). In clinics where there is lack of potable water supply as a necessity to 

render health services, the nursing regulations in South Africa governing the nurses’ 

obligations in such circumstances are not clear as to what a nursing practitioner 

ought to do during a scarcity of water in the clinic.  

Healthcare service delivery occurs within a specific regulatory and contextual 

framework, guided by general national legislation and regulations, professional, 

ethical and legal contexts, the National Health Act, and specific health care 

regulations and policies (Muller, 2013). According to Muller, the professional 

practitioners involved in health care service delivery are regulated in accordance with 

the specific professional-ethical legislation of a particular profession, which in the 

case of nursing practitioners in South Africa is the Nursing Council (2013). 

The South African Nursing Council (SANC), as a regulatory body, authorised by the 

Nursing Act in Act 33, has developed the definition of the Nursing Scope of Practice, 

Professional Standards and Competencies (Nursing Act of 2005). The Nursing 



6 
 

Council (n.d.) claims that the obligation of the nursing practitioner is to use their 

judgement and skill in providing safe and competent patient care.  

Nursing practitioners are expected to be accountable and take responsibility for the 

decisions they make and the actions they take related to any aspect of the patient 

under their care (Searle, Human and Mogotlane, 2009). However, the Nursing 

Council does not define what exactly is it that a nurse ought to do in clinical activities 

where the fundamental resource as potable water is not available to carry out good 

quality care. These activities do occur in clinics where water is not available, 

especially in the rural villages of South Africa, and recently in the City of 

Johannesburg (Botho, 2021; Mohamed, 2021).  

Primary health care facilities are the grassroots level front line of re-engineering a 

referral system of health, which is a method used by South Africa’s Department of 

Health (DOH) to increase access to health services and improve the quality of health 

services in general (Soul City Institute, n.d.). In this referral system, it is often a 

nursing practitioner at the clinic, working independently in the absence of a medical 

officer, who is expected to ensure patients get their basic health needs met through 

nursing activities ranging from diagnosing, preventing and treating emergencies, and 

monitoring chronic and managing acute illnesses. In all of these cases, nursing 

practitioners must ensure quality health care, preventing diseases and infections 

according to Nursing Council ethics guidelines (SANC Ethics Guideline, 2013). 

In clinics, nurses often have nurse-patient relationships, which can go beyond what 

is called the social contract, as published in the ethical guidelines of the Health 

Professions Council of South Africa (HPCSA Guideline, Booklet 1, 2016). According 

to the Nursing Council’s ethical guidelines (2013), for any claims where the principles 

and values are overriding, or in conflict, the nurse must make use of an ethical 

committee: “It may be advisable wherever possible, to make some of the decisions 

within an ethical committee where diverse values, perceptions and views are taken 

into consideration by a collective. The more diverse the group in such an ethical 

committee, the more ethically and morally sound the decision will be…” (SANC 

Ethics Guideline, 2013). However, I find this guidance debatable since not all the 

health facilities have an ethical committee, and some dilemmas remain unresolved, 

especially when the health facility has no water supply, yet it must remain 



7 
 

operational to serve the health needs of that specific community. This situation has 

led to the rationale for my study and my research question. 

1.4 Rationale for the Study 

The rationale for the research is that in health facilities, there is a global nursing 

workplace crisis characterised by an intensifying shortage of resources, such as 

water in rural clinics, which nurses are faced with (Bell, 2005). This is an ongoing 

situation in some of the rural areas in South Africa, such as in the Free State, 

Northern Cape, and Eastern Cape Provinces, where water scarcity is a fundamental 

problem that nurses are facing (Molungisi, 2020). 

In the areas without clean, potable water, the lack of a water supply has a potential 

to harm human health and affect a nursing practitioner’s decision on whether to work 

in such a clinical facility or not. This ethical dilemma resulting from a lack of water 

supply in the health facility and poor nursing quality health services increases the 

duties and responsibilities of nursing practitioners. This clinical care situation is due 

to unavailable professional and legal guidelines to provide an appropriate foundation 

to guide nursing practitioners who encounter ethical dilemmas due to a lack of water 

to be able to render quality healthcare services. 

I found in my research that the available professional and legal guidelines provided 

by the SANC do not provide a clear and fundamental guide to nursing practitioners 

on what ought to be done when there is a lack of potable water in healthcare 

facilities. Such guidelines are needed to guide the ethical decisions nursing 

practitioners are supposed to take.  

I will argue that the Nursing Act 33 and the professional nursing guidelines should be 

changed to provide clearer directives on the duties of nursing practitioners when 

confronting ethical dilemmas in their working environment. The SANC, as a 

regulatory body, authorised by the Nursing Act in Act 33, has developed the 

definition of the Nursing Professional Standards and Competencies (Nursing Act of 

2005). The Nursing Council (n.d.) claims that the obligation of the nursing 

practitioner is to use their judgement and skill in providing safe and competent 

patient care. Guidance is needed on the duties of a nurse when the health facility 

lacks the basic necessity of clean, potable water, to enable a nurse to provide quality 

health care services. 



8 
 

1.5 Research Methods Limitations 

This research design was purely a normative study. It does not draw on new 

empirical research, but is based on the available literature and analysis of nurses 

practicing in an under-resourced health care environment, where the fundamental 

resource of water for hygiene and sanitation is lacking. My research explores the 

ethical implications of the lack of this fundamental environmental resource on 

nursing practice. 

No new data will be collected, and no study participants will be involved. However, 

some examples will be included based on my personal experiences working as a 

nursing practitioner to support my ethical stance. Bioethical and philosophical 

research methods will be used. I will evaluate the existing nursing guidelines and 

policies, employing normative methods in critiquing the existing guidance, with the 

aim of recommending a revised approach and potentially legal revisions toward 

developing and justifying a new ethical and legal or regulatory framework. 

1.6 Presentation of Arguments 

This report takes the form of three succeeding chapters (2, 3 and 4) discussing the 

ethical arguments emanating from my research and support for my answer to the 

main research question. My conclusion and recommendations will be presented in 

Chapter 5.  

The following Chapter 2 sets out to argue how access to clean water at the clinic is a 

legal right of the nursing practitioner. Since South African law gives priority to ensure 

the supply of water for personal and domestic use, the law guarantees nursing 

practitioners with water availability and sustainability for environmental hygiene, 

especially in health facilities (Kwesell, 2020). The following chapter contains findings 

relevant to my primary objective which is to describe the reasons why clean, running 

water is necessary for health care provision, and articulate how the lack of clean, 

running water in a health facility prevents a nursing practitioner from providing quality 

nursing care. 

 



9 
 

Chapter 2 

2.1 Introduction 

In the first part of this chapter, I will be discussing the legal obligation of the South 

African government to respond to the lack of water in health clinics. In the second 

part of this chapter, I will be discussing how access to water is a legal right of nurses 

at the clinics. Lastly, I will address the concept of water as a human right.  

Researchers have for years been demonstrating the importance of water in 

healthcare facilities (World Health Organisation and UNICEF, 2019). According to 

the WHO and UNICEF, “Globally, 26% of health facilities lack basic water 

services….and the situation is worsening in Eastern and Southern Africa” (2019). 

The study by Mmanga, Holm and Bella highlights that, compared to hospitals, 

services in rural areas, in clinics and in government health facilities are more likely to 

have gaps in water supply (2020).  

“Access to adequate clean water is a human right for all citizens, irrespective of their 

demographic origin” (WHO and UNICEF, 2019).  I argue in this chapter that a 

nursing practitioner does not have a moral duty to work in a clinic where there is a 

lack of the fundamental resource of water to provide quality health care services.  

This chapter supports the secondary objectives of my research, which characterise 

the individual moral and legal rights of a nursing practitioner. The first part of this 

chapter discusses the legal obligation of the South African government in regard to a 

lack of water in rural clinics. 

2.2 Legal Obligation of the South African Government on the Lack of Water in 

Health Clinics 

The Constitution of the Republic of South Africa, Act 108 of 1996 (the Constitution) is 

the highest law of the country (The Constitution and Public Health Policy, n.d.). 

Chapter 3 of the Constitution contains the Bill of Rights, which is binding on all 

legislative and executive organs of state at all levels of government such as national, 

provincial and local departments (Acutt and Hattingh, 2015). Furthermore, The 

Constitution of the Republic of South Africa, Act of 108 in Chapter 2, Section 24 (a) 

guarantees every South African citizen: “The right to an environment that is not 

harmful to their health or wellbeing” (Constitution Act 108 of 1996). According to the 

World Health Organization and UNICEF, “No one goes to a health facility to get 



10 
 

sick….yet hundreds of millions of people face an increased risk of infection by 

seeking care in health facilities that lack basic necessities, including water…” (2019). 

The WHO and UNICEF further state that “Not only does lack of water, sanitation and 

hygiene services in health care facilities compromise patient safety and dignity, but 

has a potential to exacerbate the spread of diseases and undermines efforts to 

improve health of patients” (WHO and UNICEF, 2019).  

The Constitution of the Republic of South Africa, Act of 108 in terms of Section 27 

(1)(b) of stipulates that “everyone has a right to have access to sufficient….water” 

(Constitution Act 108 of 1996). “Safe clean water is an individual human right which 

correlates precisely with public duty of civic authorities to provide clean, running 

water” (Schirrmacher and Johnson, 2016). Furthermore, Schirrmacher and Johnson 

argued that governments, not South Africa in particular, “have duty to assure that 

people have access to clean water” (2016). The responsibility for the provision of 

safe and clean water is outlined in the range of legislation and different sections of 

the Constitution, and as stated above, the Constitution of South Africa, Act of 108 in 

terms of Section 27 (1) (b) stipulates that: “everyone has a right to have access to 

sufficient….water” (Constitution Act 108 of 1996).  

The International Labour Organization (ILO) Article 12 of the Convention, adopted in 

2014, stated that workers must be supplied with drinking water: “The Committee 

requests the government to provide….or ensure that sufficient supply of wholesome 

drinking water is made available to workers” (International labour Organization, 

2017).  Wholesome drinking water in this context implies healthy drinking water 

(International Labour Organization, 2017). Further, the WHO and UNICEF stated:  

“Water is important for the patients and workers, as it enables them to remain 

hydrated, clean themselves, and also reduce risk of infection” (2019).    

The Constitution makes the provision that it grants South African citizens important 

and fundamental human rights in the chapter about the Bill of Rights, and it 

undertakes to protect these rights by various means (Acutt and Hattingh, 2015). The 

Constitution of South Africa, Act of 108 in terms of Section 7 (2) stipulates that: “The 

state is obliged to respect, protect, promote and implement all the provisions and 

requirements of the Bill of Rights” (Constitution Act 108 of 1996). 



11 
 

2.2.1 National Health Act 

The National Health Act (Act 61 of 2003) of South Africa provides a framework for 

the uniform health system that conforms to the requirements of the Constitution and 

the existing legislation that governs health services (Acutt and Hattingh, 2015). The 

National Health Act (NHA) in Act 61, Chapter 1 Section 2 (c) (ii) stipulates that the 

objective of this Act is to regulate national health and provide uniformity with regard 

to health services in South Africa by “Protecting, respecting, promoting and fulfilling 

the rights of the people of South Africa to an environment that is not harmful to their 

health or well-being” (National Health Act of 2003). In addition, Schedule 8 (1) of the 

National Health Act in Act 2003, Section 90(1A) addresses the infection prevention 

and control programmes and states that: “The health establishment must maintain 

an environment, which minimises the risk of disease outbreaks, the transmission of 

the infection to users, health care personnel and visitors” (National Health Act of 

2003). 

The WHO and UNICEF argued that: “No one goes to a health facility to get 

sick….yet hundreds of millions of people face an increased risk of infection by 

seeking care in health facilities that lack basic necessities, including water…” (2019 

). According to the WHO and UNICEF, “The provision of safe water and hygienic 

conditions is essential for preventing and for protecting human health during all 

infectious disease outbreaks, including SARS-CoV-2, the virus that causes a 

respiratory disease called coronavirus disease 19 (COVID-19)” (2020).        

Schirrmacher and Johnson argued that clean water is an individual right which 

correlates precisely with a public duty of civic authorities to provide clean water to 

people (2016). This claim is supported by the National Health Act in Act 61 which 

addresses the general functions of the national department in Chapter 3, Section 21 

(b) (ii) and states: “The director-general must, in accordance with national health 

policy, issue and promote adherence to norms and standards on health matters, 

including environmental conditions that constitute a health hazard” (National Health 

Act of 2003).  

In my opinion, the provision of a safe working environment for nursing practitioners in 

the clinical setting is not limited to general cleanliness of the clinic, but also the 

functional ablutions with hand washing facilities and access of water for any other 



12 
 

use (either clinical or personal use).Schedule 8 (2) (a) of NHA in Act 61, Section 

90(1A) addresses the infection prevention and control programmes and states that: 

“The health establishment must ensure that there are hand washing facilities in every 

service area” (National Health Act of 2003).       

2.2.2 Occupational Health and Safety Act 

South Africa’s Occupational Health and Safety Act (Act 85 of 1993) is considered as 

an essentially preventive act because it describes all the measures that should be 

taken to prevent disease as well as accidents (Acutt and Hattingh, 2015). According 

to Acutt and Hattingh, one of the main objectives of the Act is to ensure that working 

conditions are both healthy and safe for workers and community members that may 

be affected by the work activities (2015). In addition, the WHO and UNICEF state 

that: “The basic water services in health care facilities….is important to improve 

health outcomes, increase quality of care and protect health care workers” (2019). 

Again, the WHO and UNICEF state: “workers in health care facilities need sufficient 

quantities of safe water to provide health care services” (2019).  The Schedule 20 of 

NHA in Act 61 under Section 90(1A) stipulates that “the health establishment must 

comply with the requirements of Occupational Health and Safety Act 1993” (National 

Health Act of 2003).       

The Occupational Health and Safety Act in Act 85 addresses the general duties of 

the employers to their employees in Chapter 8, Section (1), which states: “every 

employer shall provide and maintain, as far as reasonably practicable, a working 

environment that is safe and without risk to the health of his employees” 

(Occupational Health and Safety Act of 1993). Schirrmacher and Johnson argued 

that, “Safe water must be provided by public authorities, regardless of whether those 

authorities are called clan, tribe or government” (2016).  

2.2.3 Other national legislation 

In the Water Service Act (Act 108 of 1997), one of the main objectives of the Act: “Is 

to provide for the right of access to basic water supply….necessary to secure 

sufficient water and an environment not harmful to human health or well-being” 

(Water Service Act 108 of 1997). This claim is also supported by the National 

Environmental Management Act (Act 59 of 2008), which outlines the purpose of this 

act generally as to: “Give effect to Section 24 of the Constitution in order to secure 



13 
 

an environment that is not harmful to health and wellbeing” (National Environmental 

Management Act 59 of 2008).   

The Occupational Health and Safety Act (Act 85 of 1993) Section 8 (1) of the Act 

stipulates the general duties of the employers to their employees, including that 

“every employer provide and maintain, as far as is reasonably practicable, a working 

environment that is safe and without health risks” (Occupational Health and Safety 

Act 85 of 1993). The National Infection Prevention and Control Strategic Framework 

developed by Department of Health states that: “Delivery of quality healthcare should 

take place in a hygienically clean, safe environment with an adequate supply of 

clean running water….for both patients and staff in order to reduce [infections]” 

(2020). In addition, the Department of Water and Sanitation in National Norms and 

Standards for Domestic water and Sanitation Services document No. 41100, states: 

“No clinic or health centre is allowed to function without potable water” (2017).       

In the preceding first part of this chapter, I discussed the legal obligations of the 

South African government to respond to the lack of water in health clinics. Now, in 

the second part of the chapter, I will discuss how access to clean water is a legal 

right of a nursing practitioner at a clinic. 

2.3 How Access to Clean Water is a Legal Right of the Nursing Practitioner at 

the Clinic 

In a healthcare setting, water is used for general consumption, general cleaning, 

handwashing for staff and patients (Mmanga, Holm and Bella, 2020). In this 

pandemic of COVID-19, water is used for dilution of chlorine solutions for surfaces 

and instrument disinfection (Mmanga, Holm and Bella, 2020). According to the WHO 

and UNICEF, “Ensuring evidence-based and consistently applied water, sanitation 

and hygiene (WASH) management practices in healthcare facilities will help prevent 

human-to-human transmission of pathogens including SARS-Cov-2, the virus that 

causes COVID-19” (2020). 

The WHO and UNICEF held a joint monitoring programme meeting in Geneva in 

2014, where they developed a global action plan for WASH (water, sanitation and 

hygiene) in health care facilities (Potgieter, Banda, Becker, et al., 2021). In the global 

action plan, the WHO and UNICEF state that by 2030, “Every healthcare facility in 

every setting must have safely managed, reliable water, sanitation and hygiene 



14 
 

facilities to meet staff and patient needs in order to provide quality, safe people 

centred care” (Potgieter, Banda, Becker, et al., 2021). 

However, several reports on a lack of water in clinics and poor hand hygiene 

practices and general cleanliness in healthcare facilities can result in numerous 

consequences, such as exposing nurses and patients to health care-associated 

infections (HAI). Most common types of HAI are surgical site infections in wounds, 

clinical sepsis, respiratory infections such as COVID-19, etc. (Potgieter, Banda, 

Becker, et al., 2021). I argue that if there is a provision of safe water and hygienic 

conditions, this will support the provision of good healthcare services by nurses in 

such a way that the patient’s health outcome would also improve.  

This claim is supported by the WHO and UNICEF, as stated earlier, that, “The basic 

water services in health care facilities….is important to improve health outcomes of 

patients, increase quality of care and protect health care workers” (2019).  Services 

such as wound dressings, cleaning of the surgical tools, certain surgical procedures 

need running water, and between patients, frequent and correct hand washing is one 

of the most important measures to prevent infection (Potgieter, Banda, Becker, et al., 

2021; National Infection Prevention and Control Strategic Framework, 2020).   

The WHO and UNICEF guideline definition for basic water services at the healthcare 

clinic states that the main water source must be an improved water source, located 

on the premises and the water should be available continuously ( 2019). In 2010, the 

United Nations General Assembly (UNGA) adopted the resolution that recognises 

physical accessibility of water, which states that: “everyone has the right to water 

and sanitation services that is physically accessible within, or in the immediate 

vicinity of the….workplace or health institution” (UN, 2015).  Access to water has 

been a right of a nursing practitioner in clinics, and this was directly supported by the 

South African Human Rights Commission (SAHRC) in 2014.  

A study by Potgieter et al. has shown that, “Intermittent or an unreliable water supply 

in the healthcare facilities is associated with high possibility of spread of disease and 

compromises the health of both the nurses and patients” (2021).  

2.4 The Human Right to Water 

Water is essential to human life (Vettel, 2009; Salman and Mclnerney-Lankford, 

2014). The argument which Vettel made to support this claim was that a person can 



15 
 

only live a few days without water, yet can live days or longer with only water as 

sustenance (2009). The study conducted by Vettel states that: “People have the right 

to the basic needs for life, and if everyone has a right to life, which makes water a 

human right” (2009). Salman and Mclnerney-Lankford supported the statement by 

giving the human right definition by Maurice Cranston: “The human right is a 

universal moral right, something which all men everywhere, at all times ought to 

have, something that no one may be deprived…something which is owed to every 

human being simply because he is human” (2014). The South African Human Rights 

Commission claimed that: “Water is the precondition of other human rights” (SAHRC, 

2014). 

Furthermore, Salman and Mclnerney-Lankford added that human rights are an 

entitlement due to people and their violation can never be justified (2014). Defining a 

human right is important because water is both a vital and a minimal need to 

everyone, and therefore essential to human life (Salman and Mclnerney-Lankford, 

2014).   

The WHO and UNICEF stated that: “Workers in health care facilities need sufficient 

water for drinking, hand hygiene….and variety of general and specialized medical 

uses which all require reliable supply of safe water” (2019).   

As mentioned above, Act 108 of the Constitution of the Republic of South Africa, 

Section 7 (2) states that: “The State is obliged to respect, protect, promote and fulfil 

all the rights in the Bill of Rights stipulated in the [Act]”. The United Nations (UN) 

International Covenant on Economic, Social and Cultural Rights (ICESCR), Article 

12, also provides brief guidance to the States regarding their obligation to fulfil the 

right to water and also showing respect to this right by protecting it (SAHRC, 2014). 

According to ICESCR General Comment No.15, Article 12, states that: “The right to 

water, like any human right, imposes three types of obligations on States parties: 

Obligations to respect, obligation to protect and obligation to fulfil” (2002). The right 

to water is recognised and given a priority by both the national and international law.   

Kwesell claimed that: “The human right to water is indispensable for leading a life in 

human dignity” (2020). According to the WHO, water is argued as a limited natural 

resource around the globe (WHO and UNICEF, 2019). The ICESCR General 

Comment No.15 also states: “Water is a limited natural resource and public good 



16 
 

fundamental for life and health” (2002). South Africa’s Constitution recognises water 

as a right to everyone in terms of Section 27 (1) (b) on Bill of Rights, where it claims 

that water is essential for a dignified life (1996).  

Nursing practitioners must have access to an adequate amount of clean, running 

water in the clinics (Kwesell, 2020). As water adequacy in the clinical setting is 

primarily a health good, which means water adequacy in a clinic should not depend 

on the social, economic or geographical context (Kwesell, 2020). In my opinion, the 

nurses in rural clinics should practice in the setting where accessibility of water is not 

a struggle to maintain basic health, with particular regard for themselves and the 

most vulnerable in the community they serve. Asamani, Ismaila, Aligsi, et al., 

claimed equal access to healthcare resources by all people as fairness (2021). 

According to Kwesell, the UN Committee on Economic, Social and Cultural Rights 

(CESCR), in General Comment 15 provided detailed guidance to the State that: “The 

right to water includes availability, quality and accessibility as interrelated and 

essential feature” (2020). The Committee also noted that with regard to water 

availability, “Everyone should have access to quantity of water needed to satisfy 

basic needs, which will vary depending on the context including health status… and 

work condition…” (Kwesell, 2020). This quote is relevant to the necessary availability 

of an adequate of water supply in a rural clinic for nurses because of nature of work 

they do, which involves the health and well-being of others, especially in this 

pandemic of COVID-19, where hands and general hygiene is important to curb the 

transmission of infection (WHO, 2020).  

The availability of clean water is one of the most important resources in healthcare 

facilities and will be increasingly critical for the future, as growing demand outstrips 

supplies (WHO, 2019). In my view, a water crisis would have a negative health 

impact on rendering high quality health services that have the capacity to help 

improve the health of the patients. 

In the article by Kwesell, it was argued that the Committee noted that: “Water, and 

associated facilities and services, must be within safe physical reach for everyone, 

without discrimination on any prohibited ground” (2020).   

As a professional nurse working in the rural village of Kuruman situated in Northern 

Cape Province in South Africa, I experienced a serious ethical dilemma in which as a 



17 
 

nursing practitioner, I had to render health services in unfavourable conditions, 

where the front-line village clinic in Penryn, Kuruman, had no water supply. Patients 

and staff in the clinic could use only pit latrines, with no water and soap for 

handwashing. Furthermore, the pit latrines were not safely emptied and had poor 

latrine-construction standards that were posing health risks to nurses and patients, 

such as the transmission of infections and a range of illnesses and diseases which 

were caused by poor hygiene.  

In addition, another local healthcare facility, Bankhara-Bodulong Clinic, in Kuruman, 

in Northern Cape, South Africa, was temporarily closed for service after “Six 

Community Health Workers (CHWs) and one professional nurse contracted COVID-

19 due to lack of water in the clinic to practice good hand hygiene and general clinic 

cleaning” (Hoo, 2021). “Some nurses had to be relocated to other facilities nearby 

because of this unfavourable working condition at the clinic” (Hoo, 2021). Asamani, 

Ismaila, Aligsi, et al., argued that each individual is deemed to be entitled to an equal 

share of the total healthcare expenditure (2021). In this instance, referring patients to 

other healthcare facilities could cost them more money for transportation to a more 

distant clinic, which they may not have. 

The lack of water is ongoing situation at Rahima Moosa Mother and Child Hospital in 

Johannesburg, where the unhygienic hospital conditions due to the lack of potable 

water is causing the deaths of some patients (children). The report by De Maayer 

claimed, “Children are dying and the horrendous conditions in our public hospitals 

are contributing to their deaths” (2022). Further, the author added, “….Come and see 

how hospital-acquired infections spread like wildfire through the neonatal ward 

because the taps are dry, and washing your hands while lifting a five-litre water 

container after examining each child is just not feasible” (De Maayer, 2022). 

In Mpumalanga Hospital, nurses and the patient’s family had to bring water from 

home to use for their personal hygiene and drinking, and patients had to use dirty 

linen repeatedly because of the lack of water at the healthcare facilities (Lefafa, 

2022).  

However, Scanlon, Cassar and Nemes argued that the right to water is recognised 

by some international instruments at various degrees, and amongst them is the 

action plan from the United Nations Water Conference, which was held in Mar del 



18 
 

Plata in 1977 (2004). The UN Water Conference recognised: “Water as a right, 

declaring that all people have the right to drinking water in qualities and quality equal 

to their basic needs” (Scanlon, Cassar and Nemes, 2004). In other words, the 

importance of clean drinking water in the clinic is also for keeping rehydrated, as 

mentioned earlier.  

A healthcare facility lacking or with inadequate water and poor hygiene is not just an 

environment ripe for transmission of diseases such as dysentery, hepatitis and 

coronavirus, but it also exposes nurses to preventable health risks. According to the 

World Health Organization, the new strain of severe acute respiratory syndrome 

coronavirus 2 (SARS-CoV-2) spread between people through poor hand hygiene 

practices and general hygiene practices, such as touching contaminated surfaces 

(2020). The study by the WHO suggested that to slow the spread of this 

transmissible disease, washing hands with clean water and soap and regularly 

disinfecting surfaces is required (2020). 

According to the WHO, human rights standards and international humanitarian law 

are two distinct, but complementary bodies of law, concerned with the protection of 

life, health and dignity (2019). 

Ersel claimed that: “The content of the right to water is generally defined as a right to 

access to water for sufficient cleanliness and good sanitation to meet the individual 

needs” (2015). I argue that it includes nursing practitioners in the healthcare 

facilities, such as rural clinics for the promotion of a clean workplace. In the article by 

Ersel, it was argued that, “Good hygiene practices, the provision of safe drinking 

water and the reduction of environment health risks are conditions that allow people 

to a healthy life.” (Ersel, 2015).    

The human right to water entails the important key aspects which I individually 

suggest are important: Firstly, the SAHRC claimed that: “Water services are an 

obligation not a charitable act” (2014), which means providing water services at the 

healthcare facilities should be seen as the obligation of the state and the right of 

each individual, including nursing practitioners.  

Secondly, the SAHRC claimed that: “Human rights are inter-related and all must be 

respected: No human right may be sacrificed to achieve another human right” 

(SAHRC, 2014). The Human Rights Commission noted that it is unacceptable to 



19 
 

justify a human rights violation by claiming to be fulfilling another (SAHRC, 2014). In 

my opinion, a right to access health services is important, and the standards at which 

nursing care services are served at the clinics that lack water should not be 

overlooked, because the quality of service is compromised.  

As mentioned earlier, the WHO and UNICEF claimed that, “Not only does lack of 

water, sanitation and hygiene services in health care facilities compromise patient 

safety and dignity, but has a potential to exacerbate the spread of diseases and 

undermines efforts to improve health of patients” (2019). Again, in my view, nursing 

practitioners’ right to work in a safe environment should not prompt a moral debate 

and must be formally and publicly acknowledged by the professional body as well as 

by national governance. As I discussed earlier, the South African legislations and law 

are in support for a “safe environment” for nurses in healthcare facilities.  

In conclusion, the first part of this chapter discussed the legal obligation of the South 

African government to respond to the lack of water in health clinics. I discussed 

South Africa’s Constitutional Bill of Rights, the National Health Act and what a “safe 

environment” entails that relates to water availability in clinics. The second part of 

this chapter discussed how access of water is a legal right of nurses in clinics. I also 

addressed and analysed the concept of the human right to water in application to my 

argument that nursing practitioners do not have a moral duty to work in clinics where 

there is a lack of water as a fundamental resource. This chapter discussed the legal 

obligation of the government to provide clean water, the related legal rights, and 

human rights.  

In the following chapter, I will review and discuss literature regarding how the lack of 

clean water in a clinic prevents a nurse from providing quality nursing care.   

 

 

 

 

 



20 
 

Chapter 3 

3.1 Introduction 

In this chapter, I will be arguing how a lack of potable water in a clinic prevents a 

nurse from providing quality nursing care. This chapter contains the findings relevant 

to my primary objective, which is to describe the reasons why clean, running water is 

necessary for health care provision and articulate how the lack of clean, running 

water in a clinic prevents a nursing practitioner from providing quality nursing care. 

According to the World Health Organization (WHO) and UNICEF, “An estimated 896 

million people use health care facilities with no water services….” (2019). The WHO 

and UNICEF further state that: “It is likely that many people are served by health 

care facilities lacking hand hygiene facilities…” (2019). It was also indicated by the 

WHO and UNICEF that, “Water, sanitation and hygiene services are likely to be 

available in hospitals than in other types of other health care facilities, and in urban 

areas than in rural areas” (WHO and UNICEF, 2019).  

In the first part of this chapter, I discuss why clean water is a necessity in a health 

care facility. 

3.2 Infection Prevention and Control Measures and High-Quality Service 

Delivery at Clinics 

Infection prevention and control is argued as the main component of safe and high-

quality service delivery at healthcare facilities such as clinics (Soul City Institute, 

n.d.). According to the South African Nursing Council (SANC), as the statutory body 

of nursing practitioners, “In all of cases that are seen in the primary health facilities, 

nursing practitioners must ensure quality health care, preventing diseases and 

infections” (SANC Ethics Guideline, 2013). Burhans and Alligood argued that quality 

nursing care is important to patient outcomes and safety (2010). In their study, they 

concluded that quality-nursing care meant meeting human needs of patients through 

caring as an essential foundation (Burhans and Alligood, 2010).  A safe health care 

environment is fundamental for safe health care delivery (Cronk, Guo, Folz, et al., 

2021) 

Nurses working in the facilities with access to clean, running water supply are most 

likely to have a good infection and prevention control measures in place, as 



21 
 

compared to those that lack water accessibility in their facilities.  The study report by 

Biniyam, Azeb, Tadesse, et al., supports the statement, “Health care workers 

working in department with continuous running water supply were 1.7 times more 

likely to have good infection prevention practices as compared with healthcare 

workers working in department without continuous running water” (2018). Related to 

the nature of the work nurses do, sometimes they are exposed to incidents such as 

being splashed by body fluids into their eyes, which needs clean running water to be 

able to clean up. In additional support, Biniyam et al. further argued that: “With an 

inadequate practice of infection prevention, the risk of healthcare workers acquiring 

infections through exposure to bloods, body fluids, etc., in healthcare facilities is 

substantial” (2018). 

Again, Biniyam et al. argued that, “Infection prevention practice is fundamental to 

quality of care and essential to protect healthcare workers, patients and community 

from tremendous risks” (2018). As mentioned in the previous chapter, Schedule 8 (1) 

of National Health Act in Act 2003, Section 90 (1A) addresses the infection 

prevention and control programmes, which stated that the healthcare facility should 

be an environment with minimal risks of infection or disease transmissions to 

healthcare workers and patients (National Health Act of 2003). The WHO claimed 

that: “Preventing harm to health workers, patients…due to health care-associated 

infections (HAIs) is fundamental to achieve safe quality care….” (2020). The study by 

Burhans and Alligood mentioned that the nurses are accountable for quality of care 

and systemic improvement of the nursing practice (2020). 

According to Biniyam et al., “Contracting an infection while in a healthcare setting 

challenges the basic idea that healthcare is meant to make people well” (2018). In 

addition, Biniyam et al. claimed that, “Globally, hundreds of millions of people are 

affected every year by avoidable infections in health care” (2018). The study by 

Cronk et al. indicated that a lack of essential conditions in health care facilities, which 

includes low availability of hygiene items such as soap, poor supply of water, 

unclean facilities and inadequate hygienic practices, contribute to an estimated 34-

fold higher mortality risk among patients due to sepsis ( 2021). 

The National Infection Prevention and Control Framework stated that: “Effective 

infection prevention and control [measures] are the cornerstone for combating 



22 
 

healthcare-associated infections (HAIs)….since they affect the safety of healthcare 

workers and patients” (2020). The United Nations Sustainable Development Goals 

(SDGs), which came into effect in 2016, under SDG 6 reinforced the need for a 

supply of clean water and good sanitation services in healthcare facilities (UN Global 

Sustainable Development Report, 2015). Taken from the UN report, the National 

Infection Prevention and Control Framework claimed that clean running water and 

sanitation services under SDG 6 are essential for safe and effective high-quality 

health service delivery in healthcare facilities (2020).  

In South Africa, the National Health Act of 2003 makes provision for the prescribing 

of norms and standards applicable to healthcare facilities (National Health Act 61 of 

2003).  The National Health Act, Act 2003 Section 8 (2) (a) of Norms and Standards 

Regulations stipulates: “A health establishment must ensure that there are hand 

washing facilities in every service area” (National Health Act 61 of 2003). Thus, there 

are infection prevention and control standards, which are applicable in healthcare 

facilities including clinics in South Africa. Unsafe healthcare environments are 

associated with death of both the mother and new-born child due to infections; 

according to the study by Cronk et al., “Unsafe healthcare environments are linked to 

maternal and neonatal morbidity, mortality….worldwide” (2021).  

The study by Cronk et al. further demonstrated that, “A safe health care environment 

lowers HAI rates and improves outcomes for mothers and babies” (2021). 

Implementation of creating a safe environment to improve the quality-of-care nurses 

give to patients in clinics includes adequate conditions for safe hygiene practices to 

reduce the potential for infection transmission between patients and nurses.  

According to Cronk et al., “To assist with the monitoring and implementation of a 

safe health care environment and clean birth practices in healthcare facilities, the 

World Health Organization identifies the ‘six cleans’ which are guidelines for 

reducing infection among mothers and neonates and represent important conditions 

for hygienic infant delivery” (2021). The nurses, who at times assist mothers to give 

birth to babies at the clinics, are expected to do so with clean hands, on a clean bed 

(birthing surface), and with a clean towels or linen to dry and wrap the babies and 

clean the perineum of the mother after birth (Cronk et al., 2021). In order to achieve 



23 
 

a reliable, safe and healthy standard of nursing care and the desired positive patient 

outcome, a clean water supply is needed in the clinics (Cronk et al., 2021).  

The hands are argued to be a prevalent mode of transmitting infection. Allegranzi 

and Pittet claimed that: “Healthcare workers’ hands are the most common vehicle for 

transmission of healthcare-associated pathogens from patients to patients and within 

the healthcare environment” (2009). Again, the unavailability of water to wash hands 

makes it very difficult for nurses to comply with hand hygiene practices, as in 

between caring for individual patients, they should clean their hands to prevent the 

possible transmission of disease. In support of the claim Allegranzi and Pittet stated, 

“Healthcare workers encounter difficulties in complying with hand hygiene practice 

due to lack of appropriate resources important to enable hand hygiene 

performance...” (2009).  

The National Infection Prevention and Control Framework stated that: “Availability of 

infection prevention and control materials such as those required for hand 

hygiene….must be available at the point of care” (The National Infection Prevention 

and Control Framework, 2020; WHO and UNICEF, 2015). As mentioned earlier, 

Moolasart et al. stated that for cleaning hands, water and soap is important (2021). 

In the report from the Global Meeting held in Geneva in 2015, the WHO and UNICEF 

recommended that: “Healthcare facilities should include availability of on-site safe, 

sufficient water…. for safe hygiene practices (e.g., handwashing), hygiene promotion 

to patients and caregivers…” (WHO and UNICEF, 2015).  

The WHO and UNICEF stated, “Improving hand hygiene in health care is one of the 

key areas of focus of the global WHO and UNICEF hand hygiene for all initiatives” 

(WHO, 2021). In addition, the WHO and UNICEF claimed that: “Healthcare 

workers….must be able to access hand hygiene through water supply availability 

from the source on the health facilities at the point of care, toilets and service areas, 

where protective clothing is put on or taken off…..etc.” (2021). The emphases on the 

importance of water availability and good infection prevention and control practices 

are high-impact opportunities to enhance essential environmental conditions that 

would improve the quality of care in healthcare facilities (Cronk et al., 2021). 

 



24 
 

3.3 Disease Outbreaks (COVID-19 Pandemic) and Water (Hygiene and 

Cleanliness) 

The National Infection Prevention and Control Framework stated that: “Current 

threats by epidemics such as Ebola…., pandemics like [COVID-19]….have become 

increasingly evident as an ongoing universal challenge to public health” (The 

National Infection Prevention and Control Framework, 2020). It further stated, “These 

challenges have been given priority for action on the global health agenda with 

patient safety and water in health care facilities” (The National Infection Prevention 

and Control Framework, 2020). As mentioned in the previous chapter, the National 

Infection Prevention and Control Framework argued that the: “Delivery of quality 

healthcare should take place in a hygienically clean, safe environment with adequate 

supply of clean running water….for both patients and staff in order to reduce 

HAIs….” (2020). 

According to The World Bank, “One of the most cost-effective strategies or 

measures for this pandemic preparedness, particularly in resource-constrained 

settings, is investing in core public health infrastructure which includes clean, running 

water and good sanitation systems” (2020). In my opinion, good general hygiene 

serves as a golden rule in healthcare settings, which is impossible to achieve without 

potable water. 

This clinical need is supported by the WHO, which noted that, “Good hygiene 

practices that are consistently applied in the public healthcare facilities including rural 

clinics serve as barriers to human-to-human transmission of the COVID-19 virus in 

communities, healthcare facilities….” (2020). The report by the WHO in response to 

COVID-19 pandemic recommended that: “One of the most cost-effective strategies 

for increasing pandemic preparedness, especially in resource-constrained settings, 

is investing in core public health infrastructure, including water….systems” (WHO, 

2020). 

The World Bank also stated that: “The availability of water, sanitation and hygiene 

services in the healthcare facilities are also critical during the recovery phase of a 

disease outbreak to mitigate secondary impacts on the community livelihoods and 

wellbeing” (2020). As mentioned in Chapter 2, during the COVID-19 pandemic, the 

water supply in healthcare facilities has played an essential role in hand washing, as 



25 
 

one of the measures to decrease the transmission of the disease between people 

(WHO, 2020). According to the World Bank, if public healthcare facilities [clinics] do 

not practice good hygiene protocols, secondary impacts can increase the risk of 

further spreading of disease including potential disease outbreaks such as the 

COVID-19 pandemic (2020).  

Furthermore, the World Bank claimed that, “The quality of healthcare services in the 

clinics where there is poor hygiene negatively impacts the wellbeing of those getting 

it” (2020). This was evident in a number of cases during the COVID-19 pandemic, 

when individuals [nurses] became infected with COVID-19, which resulted in 

healthcare facilities closing down temporarily. The empirical study results published 

by Sahashi, Endo, Sugimoto, et al., highlighted that: “After the outbreak of COVID-

19, a large number of healthcare workers (HCWs) became infected with SARS-CoV-

2 accounting for 4–11% of confirmed cases” (2021).  

In the WHO technical brief on hand hygiene and sanitation, the WHO claimed that: 

“During COVID-19 pandemic, frequent and proper hand hygiene is one of the most 

important measures that can be used to prevent the spread of the COVID-19 virus” 

(2020). According to the WHO, healthcare facilities should have a clean water supply 

to allow patients and nurses to clean their hands to prevent disease transmission 

(2020). Accordingly, the WHO stated that: “Healthcare facilities should enable more 

frequent and regular hand washing by having clean, running water in combination 

with other behavioural changes...” (2020). 

The World Bank also argued that beyond the human tragedy, the impact of the 

COVID-19 pandemic is anticipated to affect the most vulnerable communities, 

especially those who have no access to water, hygiene and sanitation services in 

place (2020). Improving the water and hygiene access in healthcare facilities may 

improve health outcomes of patients in low-and middle-income countries (Mmanga, 

Holm and Bella, 2020). According to Maipas, Panayiotides, Tsiodras, et al., “The 

social determinates of environmental health, such as lack of access to safe water, 

poor hygienic conditions….significantly interact with the ongoing pandemic as 

evident by the significant spread especially in rural areas” (2021). In support of this 

claim, as mentioned in the previous chapter, Bankhara-Bodulong Clinic around 

Kuruman, in Northern Cape Province, South Africa, was temporarily closed for 



26 
 

service, after six Community Health Workers (CHWs) and one professional nurse 

contracted COVID-19 due to the lack of water in the clinic to be able to practice good 

hand hygiene and general clinic cleaning (Hoo, 2021).  

According to the United Nations (UN), “COVID-19 will hit the world’s most vulnerable 

people the most, many of whom live in informal settlements and rural community 

settings” (2020). This impact could be because of inadequate provision of a water 

supply in the public places, including healthcare facilities (UN, 2020). Access to 

adequate supplies of water and soap for hand washing has been argued to be part 

of the standard precautions taken to prevent the transmission of infections (Mmanga 

et al., 2020). The empirical study results published in the Health Care Facilities 

Global Baseline Report in 2019 highlighted that, “One in four healthcare facilities 

especially in rural areas lacks basic water service, which affects more than 900 

million people” (WHO, 2020).  

As I argued in the previous chapter, during an infectious disease outbreak, health 

services should meet the minimum quality standards. Water should be available at 

the point of care and soap for hand hygiene to ensure that health services are not 

disrupted in the clinics (WHO, 2020). The WHO stated that, “The provision of clean, 

running water in healthcare clinics is mandatory” (2020). 

In conclusion, the rural village health clinics provide the first point of care for those in 

rural communities and require continuous access to adequate water (Mmanga et al., 

2020). Improving the quality of nursing care needs adequate environmental hygiene 

items such as soap, adequate environmental health infrastructure, i.e., a supply of 

clean water, and a clean environment, all of which are necessary for safe and 

hygienic patient care (Cronk et al., 2021) 

In the first part of this chapter, I discussed why clean water is a necessity in a health 

care facility. I showed how infection prevention and control in the context of poor 

hands hygiene due to a lack of water supply in a healthcare facility could 

compromise the quality of health services. Secondly, I briefly discussed the 

importance of water availability during the COVID-19 pandemic in relation to 

cleanliness and hygiene. The arguments demonstrated the need for a clean water 

supply in health care settings for the provision of quality nursing services.  



27 
 

Chapter 4 sets out the real moral duties and professional responsibilities of a nursing 

practitioner at a clinic.   I will be addressing and analysing the concept of the positive 

practice environment in application to basic ethical principles, namely beneficence, 

non-maleficence, autonomy, and justice, according to Beauchamp and Childress 

(2013). The following chapter contains findings relevant to my second objective, 

which is to characterise the individual moral and legal rights of a nursing practitioner, 

and my fourth objective, which is to apply the ethical framework of principlism in 

defence of my argument. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



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Chapter 4 

In the first part of this chapter, I will be addressing the duties and professional 

responsibilities of nursing practitioners working in a clinic where there is a lack of 

potable water, a fundamental resource. In the second part of this chapter, I will give 

a brief critical discussion on the philosophical perspective and moral theories, such 

as ethical principlism, utilitarianism and Kantian moral theory, in support of my 

thesis.  

4.1 Introduction 

The World Medical Association Declaration of Geneva under the International Code 

on Medical Ethics (Declaration of Geneva) detailed the ethical duties and obligations 

of [nursing practitioners] towards patients (Dhai and McQuoid-Mason, 2011). The 

Declaration of Geneva stated that the [nursing practitioner] has: “A general duty to 

always act in the best interest of the patient, always using their professional 

judgement….for the benefit of the patients” (Dhai and McQuoid-Mason, 2011). The 

improved patient’s outcome is always the nurse’s desire, and the research article 

written by Kieft, Brouwer, Francke, et al., argued that: “Improving patient care, 

patient safety…is by creating a good and healthy work environment for nurses” 

(2014). 

In the COVID-19 pandemic, nurses are faced with multiple ethical problems, which 

include the obligation to care for the patients and the risk for infection with COVID-19 

virus (Shaibu, et al., 2021).   Shaibu et al., argued that there should be a discussion 

about the tension between nurses’ duty to care in healthcare settings where there 

are limited resources in the context of the COVID-19 pandemic (2021). 

Again, in the context of the COVID-19 pandemic, there were measures which were 

implemented in healthcare facilities, such as good hands hygiene and general 

environmental cleanliness, to protect healthcare workers and patients (Shaibu et al., 

2021). Shaibu et al. argued: “The COVID-19 pandemic demanded implementation of 

rapid measures to collectively protect populations….” (2021). In addition, Shaibu et 

al. argued that the response to the COVID-19 virus has posed several ethical 

challenges for nurses, as they provide care, and they are also at risk of being 

exposed to the virus as a result of inadequate supply of water in the healthcare 



29 
 

facilities, and a poor working environment for nurses, such as poor hygienic clinical 

settings, etc. (2021).  

The first part of this chapter will discuss the ethical and professional aspects of the 

duty of care for nurses. 

4.2 Nursing Practitioners’ Ethical Duties in the Context of Limited Fundamental 

Resources 

Dowie claimed that the duty of care is: “A fundamental aspect of nursing, and many 

nurses consider this to be an important part of their professional duties as a nurse” 

(2017). According to the South African Nursing Council (SANC), a duty is defined as 

“An obligation to do or refrain from doing something” (SANC Guideline, 2016). 

Moreover, the SANC claimed that nurses are informed that they have a duty of care 

for their patients (Dowie, 2017). 

It was stated in the article by Shaibu et al. that in highly infectious disease outbreaks, 

nurses are likely to be exposed and get infected (2021). Again, nurses experience 

the ethical tensions between professionalism and the risk for contagion especially in 

a healthcare facility which lacks appropriate resources for their protection (Shaibu, et 

al., 2021). When nurses lack appropriate resources, such as potable water for 

personal hygiene and general environmental cleanliness to protect themselves from 

getting infection, they find themselves in a conflict between their professional 

responsibility to care for patients and fear of getting infected. This situation was 

supported by Shaibu et al., who argued that: “Healthcare workers reported conflicts 

between their responsibility of care for sick patients and the fear of infection….” 

(2021).   

Nurses are health professionals working with patients and have a duty to provide 

care and relieve suffering (Shaibu et al., 2021). Shaibu et al, claimed that: “this duty 

of care is consistent with the principle of beneficence” (2021). The principle of 

beneficence is defined as doing no harm (Rawlings, Brandt, Ferreres, et al., 2020). 

The challenge of being expected to render quality nursing care to patients in the 

healthcare facility where there is no adequate supply of a fundamental resource such 

as water exposes nurses to the ethical dilemmas of balancing harm with care and 

demanding a safe working environment for their health and wellbeing. Shaibu et al. 

further stated: “A review of nurses’ experiences of ethical dilemmas illustrated that 



30 
 

balancing harm of care was one of the most prevalent challenges confronting nurses 

in their nursing practice” (2021). This balancing creates a dilemma where nurses 

have to make an impossible decision between providing care while risking getting an 

infection (Shaibu et al., 2021). 

According to the SANC, “In carrying out his/her duty to patients, the nurse operates 

within the ethical rules governing the profession….” (SANC Guideline, 2016). A 

nursing practitioner has to ensure that s/he provides safe, adequate nursing services 

to the patients (SANC Guideline, 2016). An article by Fouche stated: “The intended 

outcome of nursing practitioners is to make practice environments more positive, 

healthy….in areas that affect safety of patients and health care personnel” (2011). 

The intentions of having those desired outcomes become impossible if the nursing 

service is compromised by the lack of essential resources such as water in the 

health care facility. When nurses are confronted with professional obligations without 

safeguards, they become vulnerable to contagious diseases such as COVID-19.  

Shaibu et al. stated: “Nurses have an innate duty to promote their health and safety” 

(2021). The principle of non-maleficence holds that there is an obligation not to inflict 

harm on others; it is closely associated with, “First do no harm” (Beauchamp and 

Childress, 2013). The principle of non-maleficence in this situation means that the 

dilemma for nurses is whether to prioritise patient care over care for themselves. 

In my opinion, nursing practitioners are faced with a significant challenge in some 

rural clinics in South Africa, especially because of the limited fundamental resources 

such as a clean water supply to render quality services to the patients. Such a 

compromised working environment in the rural clinics negatively affects the quality 

and standard of care the patients get at the clinic, i.e., a risk for infection exposure 

due to poor hygiene practises. This claim is supported by the article by Shaibu et al., 

which argued that: “Nurses must balance their obligations of beneficence and duty of 

care for patients with their rights and responsibilities while addressing the 

inadequacies of resources in the health systems in which they practice” (2021). In an 

ethical dilemma where nurses have to decide on providing nursing care while risking 

their health, the application of a philosophical perspective can be enough to give a 

clear-cut direction to how nurses ought to handle ethical and moral issues they are 

faced with (Shaibu et al., 2021). 



31 
 

The following discussion will therefore address the second part of the chapter, which 

is the application of a philosophical perceptive and Kantian moral theory to support 

my argument that nursing practitioners do not have a moral duty to work in a clinic 

where there is a lack of clean water. 

4.3 Application of Philosophical Perspectives and Moral Theories 

Generally, there are four fundamental ethical principles that guide health care 

delivery which were developed as guidance by Beauchamp and Childress (Rawlings 

et al., 2020; Beauchamp and Childress, 2013). They are: respect for autonomy, 

beneficence, non-maleficence and justice (Beauchamp and Childress, 2013). These 

principles are referred to as the principlism framework (Beauchamp and Childress, 

2013). Beauchamp and Childress stated that the choice of moral principles as a 

framework comes from the health professionals’ obligations and virtues that 

contextualise the commitment to provide medical care (2013). The study by Mathibe-

Neke claimed that the four ethical principles have equal status, with none having 

priority over the other unless it is applied in a specific context (2015). Principles are 

binding, unless they are in conflict with other obligations (Beauchamp and Childress, 

2013). In a situation where the norms are in conflict, the framework comes into play 

to find some sort of balancing or harmony, otherwise one norm will have to 

supersede the others (Beauchamp and Childress, 2013). 

According to Beauchamp and Childress, “The framework aims at producing benefits 

that can compensate for any harm that could be introduced in the process of healing, 

and again to enable equal access of health resources by all deserving individuals” 

(1995). The principles protect both the patient and the nursing practitioner from any 

harm in the process of nursing care, while at the same time; they protect their health 

and wellbeing from disease and possible health system failure.   

4.3.1 Underlying principles and their application 

According to Beauchamp and Childress, “The four principles of respect for 

autonomy, beneficence, non-maleficence and justice express common values and 

their underlying rules, and therefore define a set of norms shared by people devoted 

to morality” (2001). This statement means what is morally good must be common 

across all the individuals concerned in the nursing care, and in this case, it is the 

nursing practitioners and patients. Mpeli argued that: “Common morality is drawn 



32 
 

from universal norms shared by all people in all places, and it contains universally…. 

endorsed human rights and moral ideals that are esteemed in many cultures” (2018).   

In the nursing care context, respect for autonomy is respecting a patient’s choice: 

“Acknowledging the value and the decision-making rights of other autonomous 

persons” (Mpeli, 2018; Rawlings et al., 2020; Beauchamp and Childress, 2013). 

Beneficence refers to promoting the wellbeing of all patients under a nurse’s care, 

which means acting in the best interest of patients (Mpeli, 2018; Beauchamp and 

Childress, 2013). Non-maleficence is argued to do no harm to the patients, by acting 

to avoid harm (Mpeli, 2018; Beauchamp and Childress, 2013.).  Lastly, justice refers 

to treating others fairly, impartially, and equally: “Justice refers to fair practices and 

the appropriate distribution of benefits and burdens as determined by norms that 

structure the terms of social cooperation” (Mpeli, 2018). Rawlings et al. argued that 

these four basic principles are fundamental to deliver quality health care (2020). 

With reference to nursing care in the clinical setting where there is an inadequate 

supply of potable water to provide quality nursing care, the health of both the nurse 

and the patient is compromised by exposure to infections due to poor hygienic 

practices and the unclean environment. Respect for autonomy comes into play, 

which allows the patient to choose and be the advocate of their own healthcare, 

requesting nursing services that meet their health needs and quality standards 

(Mathibe-Neke, 2015). Rawlings et al. argued that, “A patient’s request for resources 

for care is still to be respected….” (2020).  

The basic ethical principle of respect for autonomy is affected by an unclean 

healthcare facility, as it involves health risks and possible harm to the patients and 

nurses (Code of Ethics for Healthcare Professionals, 2021). As previously cited, the 

health risks associated with no access to clean, running water in the healthcare 

facilities includes exposure to HAI due to poor hygiene practices. The Code of Ethics 

for Healthcare Professionals argued that professional and practice laws give 

emphasis to safe practice that supports the wellbeing of patients and respects their 

dignity (Code of Ethics for Healthcare Professionals, 2021). The patients have to be 

informed about the nature of the treatment they will receive, the expected benefits 

and the existing ranges of choices available in a healthcare facility with limited health 

resources, such as a lack of potable water supply (Code of Ethics for Healthcare 



33 
 

Professionals, 2021). Therefore, even though respect for the patient’s autonomy is 

supported by several healthcare guidelines and laws, they support a patient’s right to 

be served in a clean environment that promotes safe and high-quality nursing care 

for the improved patient outcome. The Nursing Council (n.d.) also claims that the 

obligation of the nursing practitioner is to use their judgement and skill in providing 

safe and competent patient care, in this instance a nursing practitioner can use 

his/her professional discretion/ professional autonomy.  

Dhai and McQuoid-Mason highlighted the World Medical Association Declaration of 

Madrid on Professional Autonomy and Self-Regulation (Declaration of Madrid), 

which emphases an ethical code for self-regulation and professional autonomy in the 

caring professions (2011). According to the Declaration of Madrid, it noted that: “The 

cornerstone of professional autonomy is that [nursing practitioners] are allowed to 

exercise their professional judgement unhindered by others” (Dhai and McQuoid-

Mason, 2011). The World Medical Association further believed that “The [nurse’s] 

autonomy helps to ensure quality care, thus it should not be compromised” (Dhai 

and McQuoid-Mason, 2011). The World Medical Association stated that something 

unique to the medical profession is that practitioners are allowed to be self-regulating 

and autonomous (Dhai and McQuoid-Mason, 2011). Dhai and McQuoid-Mason 

argued that it is common knowledge that in some countries, resource shortages 

make it almost impossible for practitioners to provide the standard of care they would 

ideally like to provide, but the Declaration of Madrid urges practitioners to do their 

best for their patients.        

The SANC stated that to enable the nurse to provide safe and adequate nursing 

care, the nursing practitioner has: “The right to a safe working environment which is 

adequately equipped with at least the minimum physical resources….” (2020.). Singh 

and Mathuray stated, “Safety and quality of the patient care is determined by the 

environment in which care is provided” (2015). The SANC furthermore argued that: 

“When care falls short of standards, due to lack of resources…. the nurse bears this 

responsibility” (2020). The SANC statement claimed that when a lack of resources 

affects the standard of care, it is the nurse’s fault, which means the nurse bears the 

responsibility for the substandard care. As previously mentioned, South African law 

has supported that it is the employer’s (the South African government in the case of 

public health clinics) responsibility for adequate clinic resources to provide the 



34 
 

standard of care expected of nurses (the employees) professionally and by their 

patients.  

South Africa’s Occupational Health and Safety Act in Act 85 addresses the general 

duties of the employers to their employees in Chapter 8, Section (1), which states: 

“Every employer shall provide and maintain, as far as reasonably practicable, a 

working environment that is safe and without risk to the health of his employees” 

(Occupational Health and Safety Act of 1993). This Act supports the premise that 

nurses have a moral duty to work in a healthcare facility which has an adequate 

supply of clean water for quality nursing care. Schirrmacher and Johnson argued 

that: “Safe water must be provided by public authorities, regardless of whether those 

authorities are called clan, tribe or government” (2016). 

The moral justification to refuse to work in the clinic where there is lack of potable 

water supply as a fundamental resource was supported by Muller, who argued that: 

“The nurse has a right to refuse to participate in activities that are not in the interest 

of the patient” (Muller, 2013). Yet, “Nursing practitioners have the duty to care for the 

patients under their care”, which presents an ethical dilemma if their ability to provide 

the necessary care is compromised by the lack of the fundamental resource of clean, 

running water (Muller, 2013). 

The duty of care is argued to be: “Consistent with the principle of beneficence” 

(Rawlings et al., 2020).  According to the WHO, “Preventing harm to patients, health 

workers and visitors due to infection in health care facilities is fundamental” (2020). 

Furthermore, the WHO stated that: “Strong, effective infection prevention and control 

programmes have ability to achieve quality care, protect all those providing care 

across the health system” (2020). Armstrong spelled out that the principles of 

autonomy and beneficence are moral obligations for nurses, aimed at benefiting the 

patient (2015). The role of nurses is to ensure quality care and patient safety (WHO, 

2020). In my opinion and that of the professional healthcare organizations already 

cited, the approach to a patient’s safety and the provision of a quality service is 

through nursing care that prevents and controls infections in the healthcare facilities. 

Nursing practitioners are expected to be accountable and take responsibility for the 

decisions they make and the actions they take related to any aspect of the patient 

under their care (Searle, Human and Mogotlane, 2009). When nursing practitioners 



35 
 

are expected to practice in accordance with the standards set for them by their 

professional body (SANC), they have rights and duties which are indisputable and 

which will permit them to practice in a manner that will ensure their wellbeing is safe 

and that of the public (Searle, Human and Mogotlane, 2009). 

In Chapter 2 of the Constitution of the Republic of South Africa, the Bill of Rights 

articulates the principles that are fundamental to the ethics of nursing (Singh and 

Mathuray, 2018). For example, Singh and Mathuray describe the ethical principle of 

beneficence as aligned to Section 27 (1) of the Constitution, which stated that 

everyone has the right to access sufficient services including clean, adequate water 

supply (2018). The South African Constitution, Section 27 (1) (b) stipulated that: 

“Everyone has a right to have access to sufficient….water” (Constitution Act 108 of 

1996).  Beneficence implies that a nursing practitioner should take an action to 

benefit the patient and facilitate their wellbeing.  

Moreover, Singh and Mathuray argued that Chapter 2 of the Constitution of South 

Africa ensures that the Bill of Rights and ethical principles respectively are adhered 

to in the health care facilities to fulfil their purpose of safeguarding the health and 

wellbeing of the health professionals and that of patients (2018). Singh and Mathuray 

warned that: “The Constitution and the rights entrenched therein serves as the 

backdrop for the ethical and legal practice for nurses….” (2018). 

Singh and Mathuray described the ethical principle of non-maleficence as reflected 

in the Constitution in Section 24(a), which stated that: “Everyone has the right to an 

environment that is not harmful to their health or well-being…” (2018). In support of 

this statement, a document by the South African non-governmental organization 

Section27 noted that the right to a safe working environment is necessary to prevent 

workers [nurses] from contracting occupational diseases (Section27, n.d.).  

South Africa’s National Health Act 61 of 2003 serves as a guideline to healthcare 

users, as well as to health institutions, concerning the rights and duties of healthcare 

providers [nursing practitioners] (NHA Act 61 of 2003). Singh and Mathuray argued 

that: “The Act promulgates the obligations imposed by the Constitution and other 

relevant health legislation including nursing care….rights and responsibilities of the 

healthcare provider” (2018). 



36 
 

South Africa’s Public Service and Administration has under Section 41 of the Public 

Service Act 103 of 1994 a regulation in Chapter 4 about employment matters (The 

Public Service Act 103 of 1994). In part 3 of Chapter 4, the Public Service Act 

addresses the working environment issues (The Public Service Act 103 of 1994).  

Schedule 53 of the Public Service Act (Act 103 of 1994) addressed health and safety 

and stated: “A head of department shall establish and maintain a safe and healthy 

work environment for employees of the department and a safe and healthy service 

delivery environment for members of the public” (The Public Service Act 103 of 

1994). 

In the ethical principle of justice, a nurse carries out nursing practices that ensure fair 

nursing care for the patients and fair share of health benefits to address their 

individual needs (Shaibu et al., 2021). Shaibu et al. spelled out that nurses contribute 

to the community’s health and well-being alongside other healthcare professionals 

by protecting the patients from a high risk of contagion of disease such as COVID-19 

(Shaibu et al., 2021). The healthcare facilities and the government have a duty to 

provide appropriate safe working conditions and infection prevention and control 

tools such as clean water and soap for hand washing, etc. (Shaibu et al., 2021). 

According to Shaibu et al., taking care of patients with an inadequate supply of water 

in the healthcare facilities makes nurses vulnerable to COVID-19 infection; therefore, 

the lack of the provision of water shifts the ethical dynamics that subject nurses to a 

greater professional obligation to care at the expense of their own health (2021).  

In South Africa, the SANC, which is the regulatory body of nurses, states: “To enable 

the nurse to provide safe, adequate nursing, he/she has the right to a safe 

environment which is compatible with efficient patient care….” (South African 

Nursing Council, n.d.). According to the WHO and UNICEF, “The reasons to improve 

water, sanitation and hygiene in health care facilities are mainly: higher quality care, 

less health care related infections, greater uptake of health service….” (2015).  

The report by WHO and UNICEF further stated that adequate water, sanitation, and 

hygiene are essential components of providing basic health services (2015). In 

addition, many health care facilities in low resource settings lack basic water, 

sanitation and hygiene services, compromising the ability to provide safe care and 

presenting serious health risks to those seeking treatment (WHO and UNICEF, 



37 
 

2015). Nurses’ capacity to protect their bodily integrity in the COVID-19 crisis 

becomes hindered when they work in the healthcare facilities which lack adequate 

resources, and this poses a serious public health concern (Shaibu et al., 2021). 

According to the WHO and UNICEF, “The provision of water, sanitation and hygiene 

in health care facilities serves to prevent infections and spread of disease, protect 

staff and patients, and uphold the dignity of vulnerable populations….” (2015).The 

justice principle in nursing refers to rendering nursing care that patients deserve and 

ensuring the fair distribution of available resources (Mathibe-Neke, 2015). In 

addition, the WHO and UNICEF stated: “The consequences of poor water, sanitation 

and hygiene services in health care facilities are numerous” (2015). 

Justice in nursing care refers to offering a quality nursing care that patients deserve 

and ensuring fair distribution of the fundamental resources in the healthcare facilities, 

irrespective of demographic region (Mathibe-Neke, 2015).  Mathibe-Neke further 

argued that: “Justice advocates respect for people’s rights and respect for morally 

acceptable laws” (2015).   

The SANC stated that: “The nurse has the right to a working environment which is 

free of threats and or interference” (South African Nursing Council, n.d.). Protecting 

nurses from a harmful working environment illustrates the fair distribution of rightfully 

expected benefits for nurses, which has been cited previously by numerous authors. 

A number of South Afr