Prof Siedine Coetzee on how nurse leadership can improve patient care

Speaker A: Foreigna Kutsia uh is a leading nursing researcher at AH Northwest University specializing in nursing leadership and improving South Africa's healthcare system. Her work focuses on creating better working environments for nurses, supporting their well being and improving patient safety and, and strengthening the quality of care. She also serves on the board of the Academy of Nursing of South Africa and she plays a key role in nurse lead and national program developing the next generation of nursing leaders. Prof. Sadina Kutzia, dst, uh, NRF Research Chair Nursing and Science at NWU thank you for joining us for this episode of what's Next. Your research suggests that the, the environment in which nurses work and particularly the quality of nursing leadership can have a profound effect on both nurses and patients. Are we focusing on the right problem or are we sometimes focusing on the symptoms rather than a problem we can actually change?

Speaker B: So if I can answer that, I think the best way is always to give an illustration and I think how we focus on nursing in South Africa is very much like putting a plaster on a broken leg. So um, we apply the plaster and think everything will get better from there, but we don't really look at the system failures in that. So um, I've been doing the research looking at nurse outcomes and patient outcomes and system outcomes over the past 10 years and it's globally recognized that the nurse practice environment is the single most important predictor of nurse outcomes and, and of patient outcomes. So when we're speaking about nurse outcomes, I just want you to understand that's like the health and well being of the nurse, her relationship with the work, her satisfaction with work, her productivity and effectiveness. So everything we need of a nurse is very much related to the practice environment. And we talk about patient outcomes, we're talking about how nurses perceive the quality of care and patient safety as well as patients. So we were in a fortunate position to be part of a consortium. So we collect the same data across South Africa that they do in Europe, the Americas, Asia. So it also gives us comparative data. And the SAR sheets enabled me to actually do some longitudinal studies. So at this point we've done two national studies and they have just started this year with the post Covid study. But in all those studies we found, just like the global recognized, um, stones, that the practice environment has the most effect when we're looking at nurse outcomes and patient outcomes. So when I, um, did the next application for Sochi or the next cycle, I wanted to understand the practice environment in itself is a lot of aspects to look at. If I had to focus for the next Five years on the one aspect of the practice environment that I consider or that the data is showing is the most important, then, um, that would be leadership. But I just really want to highlight what the practice environment of the nurse looks at. So it includes staffing and resource adequacy, it looks at collegial nurse doctor relations, looks at nursing foundations of quality of care. It looks at the nurse manageability, leadership and support of nurses, as well as nurse participation, hospital affairs. So whenever I present this data, uh, to the hospitals or to nurses in policy, they'll think, oh, it's definitely staffing and resource adequacy. Because that's something that was marked most negatively by nurses across South Africa. Private and public sector. They're both saying they're understaffed and under resourced. But if you actually look at nurse outcomes, will nurse manager ability about the most effect, um, while nurse participation, hospital fees have the most effect on patient outcomes? So that is why my focus is now on current and emerging nurse leaders to teach them to listen, respond to nurses in practice. Because that's what came out when we did a sub analysis that nurses really need leaders that listen and respond because we have sometimes nurses that listen and do nothing about it or that just jump the gun and don't listen to what the actual problem is. So we also want to teach them to have a voice only in their units, but in hospitals, provinces, the profession, our country. Yeah. And then I think we cannot look away from the fact that we have poor staffing and resources. So that's also something we really want to look at, um, is looking at retaining our staff. Because as I said, the plaster effect is let's just recruit new nurses, let's train new nurses, let's get more in the system. But if the system is fundamentally broken, if we don't have a practice environment that supports nurses, they'll keep leaving. So our focus, and that's also the global call, is to look at retaining nurses and that is looking at the practice environment.

Speaker A: Absolutely fascinating. So, um, just, just to clarify, um, the, the research that you've done, I'm assuming that it's been done in private and public health care, right? Um, yes. Um, and do you see, do you see massive differences in the quality of nursing care between the public and the private sector?

Speaker B: So there's always a significant difference between, um, the nurse outcomes in the private and the public sector. Private always scoring higher. Where there are similarities is with the ratios. So that looks similar across, um, South Africa, which means we are basing our staffing on historical data, but definitely if we look at practice environments, um, they also rated staffing and resources low in the private sector, but less so than the public sector. So you can always see statistically significant higher, um, or they'll say lower outcomes with nurses and the patient quality and safety in the public sector.

Speaker A: That's very, that's very interesting. Now your, your synopsis research looks at uh, nurse organizational, patient, healthcare system and outcomes together. So it's very, very detailed. What has this research taught you about the connection between the well being of a nurse and the safety and quality of care a patient receives? Because I imagine that if you have a nurse that's tired and exhausted and the well being is poor, it's going to affect the quality of care that you receive, that the patient receives. So I think the two go hand in hand. What have you seen?

Speaker B: Yeah, that's a very obvious, um, association, I think. M and I've learned with policymakers, they always want hard facts. So I think that's also the motivation to continue doing these surveys. So I think I want to paint out some hard facts of the data. So we're saying that three quarters of nurses experience mild to severe physical and mental symptoms. 3/4 Private and public. That's national data. Half of our nurses have high level burnout. The nurses are on majority obese and almost a fifth of them are hypertensive. A third are dissatisfied with their jobs. A quarter want to leave the profession altogether. So you can see a very negative loop happening. So the more unhealthy and dissatisfied I'm in the job, the more turnover I have, which leaves nurses that are remaining in practice with more pressure and the loop continues. So globally we have seen evidence in hospitals that have focused on the practice environment and that's the magnet hospitals. So they've really looked at the practice environment, staffing, resources, having good collegial relationships, having nurses at the policy table, decision making. And there they found that as soon as you create a positive practice environment, nurses are happy, they're healthier, they, they're engaged and then you automatically have better patient outcomes. And when you look at patient outcomes and saying there's less adverse events because think about it, there's enough staff, you're not going to have errors, you're not going to have as many falls, you're um, going to have less complaints because patients actually feel like they're getting holistic care, they have access to the nurse, they're not waiting for the bell to be answered and they're much more satisfied. And then it rolls down even further, you have better financial outcomes because if you're retaining staff, you're not having to train new staff all the time, you're not having being sued for certain adverse outcomes. And then you're also having better organizational outcomes because all of a sudden you are fully staffed all the time. And I mean that just has the financial impact of that and like just the management structures.

Speaker A: Wow. It's quite frightening. So you, you, you've said that the, the nursing uh, practice environment can change outcomes. Now what does a good uh, practice environment look like in a real South African hospital? And what changes for the patient when we get it right? And how do we get this right?

Speaker B: So I think what a lot of research we're trying to focus on now, I've got two students really focusing on if we try to apply magnet status in South Africa, what would that look like? Because there is a uh, contrast between a developing country and a developed country such as United States. So I think what I want to point out uh, is what our practice environment looks like in South Africa. And we're saying that um, more than half of the nurses in South Africa say the practice environment is poor. That's public and private sector. So 50% say absolutely, this is not a good practice environment to work in. Um, 70% say they're working with inadequate resources and equipment. That's across the board and over 80% with insufficient staff. So that is incredible statistics if you think of the practicing brand. So we know we do have to look at staffing and resources. Um, and then as soon as you don't have enough staff and resources, what's happening? I'm not getting to the nursing care that I'm actually paid for and qualified and trained to do. Um, so as soon as that's not happening, the patients are complaining which is telling me I'm not good enough with my job. I'm losing my job success, my job satisfaction. Um, and in addition to that we're finding that nurses are spending most of their day on non nursing tasks. So that is like recording notes, um, doing career, career work or moving, um, taking telephone calls, doing administrative tasks. So I think it's a refocus of how can we really loosen nurses hands to do the job they love. And I think that's something I want to highlight every time I do an interview is we find with our national studies that nurses are happy with their career choice, they love being nurses. So it's not about nurses are here and they're just doing it because there's a job they love being nurses. They're dissatisfaction lies with their job, and that's very often related to the practice environment. So I think as soon as we have more staffing and resources, they can actually get to the job they love, which will make patients more satisfied, which gives a positive loop. Again, you guys are great. You're doing a good job. What are nurses currently hearing? It takes forever for them to answer a call button. I never see my nurse. My medication was late, my pain medication was late. The other thing is, if we release nurses to really do what they're trained for, they're early watchdogs. So before there's a problem in the system, nurses are going to alert you. That's why, um, doing surveys with nurses is so important, because before the problem really arises in practice, they will be telling you, I'm starting to see there's an issue with this doctor, there's an issue with this recording system, but getting their voices to be heard is the problem. So I think really creating a platform where they can participate and where they can lead, and, yeah, getting enough staffing and resources.

Speaker A: At the end of the day, this all boils down to leadership, right? And if leadership is one of the areas where the research shows we can make a meaningful difference, how is nurse lead taking that evidence and really turning it into practical solutions nurse leaders can use in hospitals, in clinics, in healthcare facilities to make a real difference?

Speaker B: So I think, um, I just want to start with the nurse lead initiative I looked at because of the results of, if we had a focus on one aspect of the practice environment, it would have been to look at the leaders as well as to get nurses participating in hospital affairs. So I think it was also based on the fact we did a study looking at clinics, and you would have thought that the clinic with the most resources or in an urban area would have the best nurse outcomes. But we found it was actually one of the most rural clinics that had the best nurse outcomes. And when we explored that further, we found it was because of the nurse leader. She remembered their birthday. She was very accommodative with shifts. So that is something I'm bringing across to nurse leaders wherever I go is they kind of think they're the middleman. They don't really make a difference because they're just following orders. And then the staff doesn't always feel like they're that important, but for them to understand how important their link is. So that's something I'm really trying to empower nurse leaders is to understand as a unit manager, you make the most difference, not only nurse outcomes, but patient outcomes. Um, so how nurse lead also developed from there is we, um, did a pilot study in Northwest, and through that I got connected to the chief nursing officer at the National Department of Health. And I think here I really want to highlight how proud I am to be a South African. Um, I was recently in a Canadian conference and South Africa as a chief nursing officer, that's something you don't see in America. So it really shows that we have a voice up there to speak for leaders. Um, so with the chief nursing officer, they developed the national, um, Nursing Leadership Competency Framework along with academia and practice. And at the same time, my research would show that the practice environment shows that we need to focus on nurse leadership. So then it just happened as a connect and I reached out to the chief nursing officer and I told her about the pilot study we'd done in Northwest Province and the things we'd learned and would we be able to pilot that on a national level. So she was immediately on board. And we got together academics that are experts in the different competencies. So, uh, from the competency framework we developed specifically for South Africa, we found experts in policy, in communication, and she then looked for experts in practice, because I think that's where we often miss each other in many professions is what the theories are showing and what international evidence is showing is not always what can be applied in practice. So together we have developed a UM program or a curriculum which you will roll out next year in the central hospitals, and then just pilot really what works, what doesn't work, what competencies do nurses want to access and then make it nationally available. So I think the main purpose of Both myself and Dr. Matandela is really to make sure that every nurse knows they're a leader. So we didn't want to just access current leaders. We also wanted to access emerg emerging leaders. Because we talk about shining a light in your corner. Everyone has a sphere of influence, so everyone should lead from their corner. So I think that's what you're really trying to burst in nursing is you do have a voice. Everyone has a voice. Some of us have a louder voice or more of a voice, but you have a voice. So in that place, develop yourself as a leader, and through that you start changing the people around you and the practice environment.

Speaker A: Fantastic. So, so nurse lead brings the nwu, the National Department of Health, Nursing academics, and frontline nursing leaders together. Why is that collaboration so important if university research is going on to create change in the real Healthcare system rather than remain within academia, if you know what I mean.

Speaker B: Yeah, I think there's two parts to that. I think we are beyond the age of doing research for research sake. Resources uh, are limited. Um, and we want to make sure that we are addressing real world problems and making a real impact. So I think all like NRF and the nwo, we all looking at impact. What is the difference you're making with the limited resources we have? So at NWU there's a strong alignment with national research agenda, on the um, provincial research agenda. But beyond that I think we've come to a place where we really have wicked problems. So it's not something you can just look through with a single scope or a single view. We have to collaborate with multiple sectors and stakeholders and that is policy, practice, academia, education as well as other disciplines. So for instance, I work a lot with industrial engineers because it's just, it's system problems. So you need different perspectives, you need a systems thinking approach. So um, the other thing I think is that nurses currently make up about 56% of the human resources for health, yet we rarely see them at the decision making table. And I think it's a mindset that we need to change because our profession has been very much taking orders like a military environment, nursing, um, and that's why we're trying to focus on emerging leaders or the young nurses and emerging leaders and emerging nurse academics. Because I think really if you think about millennials and Gen Z, they are thought leaders and influencers and we need them desperately to change the status quo and give nurses a voice. But I think that goes hand in hand that they also need us to mentor them and guide them in the profession. So that's also the aspect we're really focusing is on the emerging nurse leaders and really about mentoring. I think so much we have um, they spoke about nurses eat their young. So I think we're also trying to change that in the environment of we are training the nurses that will look after us tomorrow. So how can we take hands? Because they really bring that aspect of influencing policy and the media. So we really want to take hands with emerging leaders and change the way the environment of nurses currently looks in media and in policy.

Speaker A: Brilliant. I mean the work you're doing is incredible and well done to you and your team. And if, if, if the work that you are doing through nursing and science and nurse uh, lead succeeds, what should be noticeably different five or ten years from now? Not only for, for the nurse walking into a hospital for a shift, but you know, for the patient who's waiting to be careful as well. So if we get this right, what can this profession look like five to ten years from now?

Speaker B: So I think the first thing I'll say, we'll have excellent nurse leaders on every sphere. So I'm passionate about nurses in practice. I'm also passionate about nurses in academia. Um, we want to see excellent nurse leaders in policy. We have a few, we want more. We will have enough nurses, we will have enough resources, and we'll have positive practice environments where nurses want to work. So how we will do this is training leaders that want to lead. Because currently a lot of what happens is the younger generation looks at our example and thinks, uh, ah, I'm not so sure I want to lead. But if we start changing our way of speaking about leadership and show them that you actually have a voice and you can change system areas, um, then we'll start having people that want to lead and actually bring their voice to the table and change things. Like, it's not okay that we don't have enough stuff. It's not okay that we don't have enough resources. We want them at the policy table and we want nurses making decisions for nurses. We want that to change where other policymakers decide what nurses must do. And then we have to implement something that really can't work in practice. Um, I also want to see that there's waiting lists at universities and colleges to train nurses, um, waiting lists, um, for work at hospitals. And it sounds far fetched, but Johnson Johnson a couple of years ago did a media campaign to say how wonderful it is to be a nurse. And they really saw that there was too much applications at universities and hospitals, had numerous applications to work there. So we really want to have nurses, uh, people want to be nurses, reach the younger generation to say, yes, this is something where I can change the health system. Because we do have a lot of voice, actually. We just need are not empowered always to use it. And I think I want to leave again the idea of that nurses choose to be nurses because they love the profession. So we can do anything with someone that's passionate for the profession. It's just to really empower them to know how to use that voice appropriately and also to mentor the young to walk in our step and to empower them to help lead and not kind of moving the system of, you know, I learned it the hard way, but actually to roll out the stone for younger generation to say, this is how you lead and this is how you can go further and in turn, they will also teach us, like, they are very quick to say, like, this is enough. I need the resources. I need the staffing. So I really see in five to ten years, um, intergenerational, multidisciplinary, and multisectoral collaboration with nurses really leading the profession.

Speaker A: Fantastic. Wow. That was quite inspirational. Professor Dina Kutzia, uh, the DST NRF research chain, Nursing Science at Northwest University, thank you very, very much for your time and for the chat. I mean, I. I've learned so much about nursing that we take for granted and that we've got lots of work to do still. And thank you very much for the incredible work that you and your team do. Thank you for your time.

Speaker B: Thank you so much for the opportunity.