A radical new approach to nurse staffing levels in hospitals, designed to put patient needs first, was launched today by Minister for Health Leo Varadkar and the Chief Nursing Officer Dr Siobhan O’Halloran.
The €2 million pilot project in three hospitals ranging in size from small-scale to large-scale will end the practice of calculating nurse staffing levels based on ward size, and instead allocate nurses according to the needs of the particular patients in that ward.
Minister Varadkar was joined by the Chief Nursing Officer Dr Siobhan O’Halloran and nursing union leaders to launch the first national Framework for safe nurse staffing and skill mix in acute hospitals. The Framework will now be piloted in three acute hospitals in general and specialist medical and surgical inpatient units. It’s also the first policy paper produced by the Office of the Chief Nursing Officer.
Minister Varadkar said: “This approach involves a significant change of emphasis in calculating the number and type of nurses for each ward. Instead of matching the number of nurses to the size of the ward, this pilot project will match nurses to the type and number of patients on the ward, and their particular needs. This should have an immediate impact on the safety and quality of care, and on the experience of patients.
“It also means big benefits for staff by improving their workload, and ensuring that wards are staffed more realistically. In the longer term it should produce a more positive working environment with less turnover of staff. It shows this Government’s genuine commitment to safe patient care.”
The €2 million allocated in funding will allow the project to be piloted later this year. The Interim Report with Recommendations published today sets out the Framework for the pilot, including a method to calculate a safe nurse staffing and skill mix for acute hospitals. In particular, it recommends replacing the ‘one size fits all’ approach with a range of factors when calculating safe nurse staffing and skill mix.
The ultimate goal is to stabilise the nursing workforce, raise care for patients, and make hospitals a healthier and more attractive work environment for staff.
The Framework identifies four core assumptions which should be used in calculating the number and type of nurses to be deployed on any given ward:
Individual patient need should be measured to identify the actual demand for nursing care through acuity and dependency measurement for example;
The skill mix within the nursing team as a whole in addition to the nursing hours required to meet patient need should be assessed to determine the optimum skill mix and number to provide safe, effective and efficient care;
Monitoring the ward and organisational culture are important indicators of effective leadership that can influence the ward and organisational climate and delivery of safe, effective and efficient care and staff experience;
The monitoring of patient outcomes of quality and safety including: patient experience, pressure ulcers and falls, along with day to day measurement of safety triggers such as nursing care left undone, can provide a mechanism for both the necessary immediate response and recognition of patient safety concerns in addition to their medium to longer term management across hospitals.
The Framework also recommends changes at organisational level to ensure continuous monitoring of staffing levels within hospitals and across hospital groups. It sets out an overarching nursing workforce governance structure, where ward to board and board to ward accountability for safe nurse staffing decisions is centre stage.
The Framework was drafted by a 17 member Steering Group. The Chair of the Steering Committee, Dr Siobhan O’Halloran, said ‘The way the Steering Group developed this work, was one of genuine partnership, through engagement at local level with clinical nurses. The richness of this approach has delivered a a patient focused way to determine nurse staffing that ensures the right balance for both patient and staff experience that is so vital and necessary in our services’.
The Way Forward
This Report sets out a brand new way to planning and organising nurse staffing. It details the way forward to driving the implementation of this new approach. It recommends testing the framework to assure its capability to deliver on its intended outcomes.
A pilot implementation group is being established to plan and co-ordinate the testing throughout 2016. This group will advise on the pilot sites to be selected for inclusion, which will include a selection of general and specialist medical and surgical wards across acute hospitals of various sizes.
On completion of the pilot, the Taskforce Steering Committee will prepare a Final Report and Recommendations.
Ends
Further Information
Office of the Chief Nursing Officer
In 2013, the Department of Health appointed Dr Siobhan O’Halloran as its first Chief Nursing Officer at Assistant Secretary level. This appointment will ensure that the role of nursing and midwifery is represented at the highest level in terms of policy making for the health service. The development of the Office of the Chief Nursing Officer (OCNO) continued with the appointment of three Deputy Chief Nursing Officers in 2014 as follows; Dr Philippa Ryan Withero, with specific responsibility for Clinical Governance and Practice; Dr AnneMarie Ryan, with specific responsibility for Nursing and Midwifery Policy and Legislation and; Ms. Susan Kent, with specific responsibility for Women’s Health, Child Health and Welfare and Primary Care Services. The purpose of these posts is to maximise the contribution of the nursing and midwifery professions by driving a culture of patient safety through the development of robust systems of accountability and responsibility.
Taskforce on staffing and Skill Mix for Nursing
The Programme for Government (2011-2016) contains commitments for radical reform and restructuring of the health services in Ireland. These include: the planned shift from acute hospital care to primary care; establishment of clinical care programmes; introduction of free GP care; establishment of hospital trusts in addition to financial reform to a “money follows the patient”/purchaser/provider system. There is a clear trend towards greater interdisciplinary integrated care underpinning these changes. The reforms collectively present diverse challenges and indeed opportunities for the nursing workforce.
There is a wide range of challenges associated with determining appropriate nurse staffing and skill mix levels in hospitals and community settings in Ireland. The subject of nurse staffing has been a topic of discussion for a number of years most notably since the publication of The Report of the Commission on Nursing (1998). Ensuring appropriate staffing and skill mix has been referenced in inquiries and investigations, demonstrated by research and is viewed by patients and their carers as a key element in influencing the quality of care.
Objective of the Taskforce
Deciding on an optimal number of nurses is not an easy task. There is a delicate balance to be struck to meet economic, efficiency and patient safety requirements. Achieving this requires that relevant expertise be applied to the decision making process. It was for this reason that Minister Reilly approved the establishment of a taskforce to develop a framework that will determine the staffing and skill mix requirements for the nursing workforce in a range of major specialities. The Taskforce began its work in September 2014. Phase I of the project focused on developing a staffing and skill mix framework related to general and specialist adult hospital medical and surgical care settings. Chaired by the CNO it has a partnership approach to its membership that includes representation from: HSE and Department of Health Acute Hospitals, HSE and Department of Health HR Division, HSE Director of Nursing and Midwifery Services, representatives from the National Clinical Programmes for Acute Medicine and Surgery, HSE Quality Improvement Division, the Irish Association of Directors of Nursing and Midwifery, Staff Associations INMO and SIPTU, and national and international experts in the topic.
In its work the Taskforce has engaged in a significant number of activities including: 20 Taskforce Steering Group meetings, 14 regional meetings, 9 presentations and discussion forums, a range of stakeholder briefings with 22 stakeholders including Hospital CEOs, HIQA, IMO, CORU, RCSI, DPER, Irish Patients Association, NMBI and many others.
The Taskforce also issued 6 newsletters out across the acute hospital system to keep services informed of developments.
Pilot Test
The pilot will test the logic of each of the above components and how the framework as a whole can be reliably applied into practice. A pilot planning and implementation group is being established to oversee the pilot test in a range of general and specialist medical and surgical wards across a range of acute hospitals of varying size.
The pilot will test;
1) Mechanisms for acuity and dependency measurement and nursing hours per patient day including the necessary ICT infrastructure to support these;
2) The framework safe staffing recommendations against the current staffing profile to determine the extent of the gap/overlap;
3) The extent to which the framework will impact on the stabilisation of the nursing workforce through conversion of agency/overtime;
4) The extent of the impact on patient safety and staff experience;
5) The requirements for future national rollout.
Members of the Steering Group
1. Dr Siobhan O ‘Halloran, Chief Nursing Officer Department of Health (Chairperson)
2. Dr Philippa Ryan Withero, Deputy Chief Nursing Officer, Department of Health
3. Professor P. Anne Scott, Professor of Nursing, Dublin City University. Executive Dean, Faculty of Education, Health and Community, Liverpool John Moores University, Liverpool, UK (from 1st August 2014).
4. Ms Joan Regan, Principal Officer, Acute Hospitals Department of Health
5. Ms Helen Byrne, Head of Planning and Performance, Acute Hospital, HSE
6. Ms. Sheila Mc Guinness, Irish Association of Directors of Nursing and Midwifery, Director of Nursing Beaumont Hospital
7. Mr John Delamere, Head of Corporate Employee Relations, HSE
8. Ms Gabrielle Jacob, Assistant Principal, Workforce Planning, Department of Health
9. Dr Michael Shannon, Director, Nursing and Midwifery Services, HSE
10. Dr Garry Courtney, Clinical Lead, National Clinical Programme for Acute Medicine, HSE
11. Mr Liam Doran, General Secretary, Irish Nurses and Midwives Organisation
12. Mr Kevin Figgis, Sector Organiser, Health Division, Services Industrial Professional and Technical Union (SIPTU)
13. Ms Margaret Gleeson, Director of Nursing Lead, National Clinical Programme for Acute Medicine, HSE
14. Ms Catherine Farrell, Programme Manager, National Clinical Programme for Orthopaedics (representing the national Clinical Programme for Surgery), HSE
15. Ms Avilene Casey, Irish Association of Directors of Nursing and Midwifery, National Director of Nursing, Quality Improvement Division and Office of the Nursing and Midwifery Services Director
16. Professor Jonathan Drennan, Professor of Healthcare Research, University of Southampton, UK
17. Ms Mary Wynne, Area Director, Office of the Nursing and Midwifery Services Director, HSE