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Interview - First among equals

Siobhan O’Halloran is the first chief nursing officer appointed at assistant secretary level in the DoH. She spoke with Alison Moore

Passion is a word that is thrown about all too cheaply these days but it is apt in the case of Dr Siobhan O’Halloran, the newly appointed chief nursing officer (CNO) in the Department of Health (DoH).

Exuding positivity and a ‘can-do’ attitude, she explains that while being a nurse was all she ever wanted to do she “never in a million years” dreamed that one day she would hold her current office.

Dr O’Halloran explains that the CNO’s role requires passion, courage, a strong sense of self, intellect, stamina and, most of all, to be ‘bilingual’ – that is they must speak and understand the language of nursing as well as the language of politics and know the “rules of the game”.

The CNO must know both worlds intimately and be able to explain one to the other.

“The CNO must be a leader for nurses and midwives, striving to realise goals on behalf of those professions, while also representing the broader public service, and dealing with the corporate responsibilities therein,” she said.

The primary responsibility of the role however, is to achieve national public health goals through nursing and midwifery. In short, public good is the end, the patient is central, and nursing and midwifery is the means. No small order here so.

Reform agenda
When WIN last spoke to Dr O’Halloran in late 2006, she was just settling in to her role as nursing services director at the HSE and she was palpably enthusiastic about health service reform. In the interim however, the economic crisis and years of austerity have put all frontline services under immense strain so I wondered if her outlook had changed?

“I’d still be extremely positive towards reform. Things have moved significantly. It’s true that the economic crisis, particularly in the last five years, has had an impact on the nursing resource but we have a new reform agenda, ‘Future Health’, which sets out the road map for reform for our health services between now and 2016.

“I would be extremely positive about the role that nurses can play in that reform, and, as a matter of fact, I would go far as to say that the reform can’t take place without nursing being at the centre of it,” she said.

“It was only 12 years ago that we launched the degree programme. We are seeing the outcomes now – people who have studied to graduate level are confident in articulating their views and I would hope that there is increased confidence across the profession, a confidence that this type of an educational background brings with it and positions us as equal members of multidisciplinary teams,” she said.

Dr O’Halloran believes that other professions within the health service have more respect for the modern nursing and midwifery workforce and suggests that the appointment of a CNO at assistant secretary level in the Department of Health illustrates that government places an “importance on the voice and role of nursing now, that maybe heretofore it didn’t”.

“The level of appointment sends a signal to the professionals within the health service and to the broader community that nursing now is first among equals,” she added.

Future of nursing
According to Dr O’Halloran, one of the most pressing issues on the agenda is how to maximise the nursing and midwifery resource that we have.

“The question is how can the health system accommodate an increasing demand while at the same time improving quality of services. If that is one of our core challenges, then a core question for us is to ask what roles we can assume into the future that will help to drive the reform and address the increasing demand for safe, high quality services.

“In answering those questions, I think that we have to deal with the whole issue of the nursing resource in terms of nursing ratios, the graduate nurse programme, skill mix and the expansion of nursing practice. We need to manage those four critical issues together in order to maximise the nursing resource and the economic investment in it. I don’t think we can deal with any one of those independently of the others,” said Dr O’Halloran.

In order to support this approach, it will be imperative to develop systems that gather quality-assured data. In order to better understand nursing and midwifery and their contribution to the health services, we need strong empirical data on which to base decisions.

“We have argued for many years around the OECD data and its relevance to Ireland but to make logical, evidence-based arguments both within the profession itself and by the profession into government we need that quality assured nursing data,” she said.

So how will such data be obtained? Dr O’Halloran explained that the new Nursing and Midwives Act allows for some interaction with the Register and the Nursing and Midwifery Board of Ireland.

“That is a phenomenally useful and robust data repository and is one of the ways we can start to address this issue,” she said.

The second element that will need to underpin how we look at nursing, to maximise resources, is clinical leadership. According to Dr O’Halloran, there are certain elements of reform coming on stream,not least the development of the hospital groups, that will need clinical leaders from within nursing and midwifery.

“There are going to be very serious, senior, nursing appointments within the hospital group structure. We need to make sure that leaders of the professions are prepared and confident enough to take up those positions and competently work within that team at that level,” she said.

Dr O’Halloran made special mention of the CNM/CMM2 needing more support.

“I think the CNM/CMM2 in Ireland has a particularly challenging role and we have to find ways of empowering and enabling them. Everything converges on this post at the moment, quality, patient safety, etc. I think that this is a real ‘pinch point’ in nursing structure and we need to work out how to best support them.

“If you look at what has happened over the past number of years, there are a lot of pieces that have been added on to nursing that now fall into the remit of the CNM/CMM2, so they have a huge amount of responsibility. They have limited control over their resources and that is something that we will have to deal with in the light of lessons learned from the Francis Report (Mid Staffordshire NHS Foundation Trust Public Inquiry) in the UK,” she said.

Dr O’Halloran described the graduate programme as a very welcome initiative that has the potential to retain Irish-educated nurses and midwives within the health system.

“We are reaping the reward of investment in nurse and midwife education by retaining this resource within the Irish health system. It is not unlike the type of schemes that have been run across all parts of Irish society through the years,” she told WIN.

According to Dr O’Halloran, there is significant interest in these programmes now and we are now retaining a significant proportion of graduates - something she stressed was not only important now but for the future.

Role expansion
Nursing and midwifery are now graduate professions and there are a significant number of advanced practitioners and clinical specialists within the professions and when you put those influences together, Dr O’Halloran believes that they point to the fact that the environment is ripe for nurses and midwives to expand their roles into other areas.

“If you are looking at expansion of role, the professional resource is finite, so if we are changing tasks around, if something is coming from medicine to nursing or midwifery, or from elsewhere, then we have to be able to shed some tasks as well. So some tasks move to healthcare assistants or other allied professionals or to other parts of the health system,” she explained.

The areas where this has been done successfully in the past include the introduction of nurse prescribing, nurse ordered x-rays and nurse-led discharge.

She explained that there is a “whole gamut” of other skills and tasks that can safely be undertaken by nurses but that these will vary on where they are working and what division of nursing they are working in, such as mental health, intellectual disability or the acute sector.

When nurse prescribing was introduced in 2007, a twin-track approach to make the legislation as empowering as possible while ensuring the system of prescribing was a safe as possible – by putting a regulatory framework in place – was pursued. According to Dr O’Halloran, this has proved to be very successful.

“There has been significant evaluation of prescribing and here in Ireland it would be considered to be very successful and there is nothing in the data that would suggest it is anything but high quality with patient safety at the very cornerstone of it,” she said.

Trolleys on wards
With the increasing pressure on frontline resources, staff in the acute sector are accordingly concerned about patient safety around areas such as nurse-patient ratios and policies that can stretch them such as the placing of trolleys on wards. On ratios, Dr O’Halloran said that she believed it was “dangerous to set minimums” as the temptation for management would be to only ever achieve base levels. Instead, she said that the dynamics, acuity and skill mix of individual workplaces must be taken into account in order to establish accurate ratios that maintain “patient safety as a cornerstone of the health system”.

When it comes to trolleys on wards, Dr O’Halloran stressed that there was a full capacity protocol (FCP) in place as part of the Special Delivery Unit’s approach to manage ED overcrowding and that all elements of the protocol much be followed to ensure that extra beds are on wards for the minimum time possible.

“ED overcrowding is actually a wholehospital problem and therefore our response to it must be a whole-hospital response. Part of the protocol is that in certain instances the patients will be moved on to the wards but the protocol also suggests that a de-escalation process is central to the management of patients as well. A number of different things, such as consultant rounds, patient discharge etc, need to kick in so that the crisis can be de-escalated,” she said.

Evolution of the profession
Dr O’Halloran identified key milestones that she believes illustrate that the nursing profession is becoming a mature, autonomous profession: The Report on the Commission on Nursing in 1998; the introduction of the nursing degree in 2002; the introduction of nurse prescribing in 2007; the passing of the Nurses and Midwives Act in 2011; and the appointment of a chief nurse officer at assistant secretary level in 2013.

“To me these are hallmarks of the increasing evolution of the profession of nursing in Ireland,” she said.

She explained that there were three pillars to the future of nursing and midwifery: the development of the hospital groups; the reform of primary care; and the transition to a system where the money follows the patient.

“The system will evolve in accordance with reform, not in isolation. As the system reforms, nursing will reform,” she said.

The critical challenge, according to Dr O’Halloran, will be to recognise the centrality of nursing and for the profession to take up that challenge and drive reform.

At the end of her term in office, Dr O’Halloran’s aims are that nursing and midwifery will be professions with a steadfast commitment to patient care, improved safety, quality and outcomes. She wants practice to encompass health promotion, disease prevention, co-ordination of care to cure and palliative care. She wants nurses and midwives to be confident and that, through their adaptive capacity, close proximity to patients, and scientific understanding of care, they will be in a position to drive health reform from the bedside to the boardroom.

The INMO looks forward to working with her to realise this vision.

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