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ADC - Safe staffing - How low can staffing go?

Launching the safe staffing campaign, Liam Doran said a systematic approach to staffing levels was urgently needed. Tara Horan reports

“HOW LOW can staffing go? There is no floor. Management in the health system has no notion of how low staffing can go in the care of patients. The only notion they have is how much money they can save by cutting frontline staff,” INMO general secretary Liam Doran told the ADC at the launch of the safe staffing campaign.

The INMO is demanding the introduction of a systematic approach to nursing and midwifery staffing. “If catastrophes and unnecessary deaths are to be avoided, the government must legislate for mandatory safe staffing ratios in Irish hospitals and other healthcare settings,” Mr Doran said. “It can’t just be left to chance, left to the ebb and flow of staff coming and going. We urgently need to apply science to nurse and midwife mandated staffing ratios.”

Speaking at the campaign launch INMO president Claire Mahon said: “This campaign, which is fully underpinned by international research, is targeted at creating and sustaining within our health service, an environment for patients where their care is always quality assured and delivered with dignity.

“The ratio of one nurse to look after four patients (1: 4) at times of high activity on medical/surgical wards will be a cornerstone of this campaign. The current reality of one nurse looking after more than eight patients on day shifts and more than 12 patients at night can’t continue. The research confirms the risks and dangers for patients associated with this high workload and the government cannot ignore this any longer.”

The core elements of the safe staffing campaign agreed at conference are outlined in the Table opposite.

The evidence
In 2012, the INMO undertook a comparative staffing survey that identified significant staff shortages on medical/ surgical wards in Ireland, when compared to the UK. In preparation for this campaign launch, the INMO undertook a second sample study, which confirmed that staffing levels in Ireland have fallen further in the past two years. In comparison to the UK, nurses in Ireland have to look after:

  • 1.8 more patients per nurse on early/ late shifts
  • Up to 5.2 more patients per nurse on night shifts.

The launch also saw the publication of Safe staffing: the evidence, a compilation of international research undertaken in recent years, which confirms the added value the presence of nurses and midwives brings to patient care and patient outcomes. All of this research confirms lower staffing is associated with:

  • Increased risk of mortality
  • Adverse events in poor care
  • Less effective and efficient care
  • Higher nurse fatigue and burn out.

Mr Doran said: “It applies science to what we are saying. It is scientifically proven that the presence of a registered nurse is an economic good in sufficient numbers. The RN4CAST study quantifies the increased risk to patients when the nurse to patient ratio is increased. It shows you have the risk of mortality and increased morbidity. These researchers have proven that nurse patient ratios and safe staffing levels are beneficial to everyone, including the health system as a whole. It is no longer just a staff side demand; it is now a demand underpinned by research that fully supports the benefits that accrue from having adequate numbers of RGNs and RMs in the workplace.

“The recruitment embargo is crude, it is merciless and it is immoral and it has to be lifted. We have inadequate numbers of nurses and midwives on wards and clinical areas. Hospital managers will tell you we are working with safe levels, regardless of what they are, but they haven’t a clue what ‘safe’ is. They’re only concerned about balancing their budget.

“Added to this is an inappropriate and unplanned skill mix with poorly defined roles and functions. There is also an inadequate number of support staff with people not being replaced. There is the pressure of the clinical nurse/midwife manager not being supernumerary but carrying a clinical caseload,” he said.

“The reality is that we have the perfect storm, which is being overseen by those who are totally blind. We have finances and meeting targets dominating completely over clinical management needs. ”

Core elements of INMO safe staffing campaign
  • The introduction of a nurse to patient ratio of one to four at busy times on acute medical and surgical wards, with one to seven at night
  • Staffing in all other areas to be determined by an agreed best practice dependency tool managed by a supernumerary ward nurse manager
  • In the case of midwifery, a ratio of one midwife to 29.5 births, which is internationally accepted as the necessary ratio in maternity services
  • In care of the elderly facilities, there should be a 60:40 skill mix – 60% registered nurses to 40% trained HCAs for high dependency patients (with other care environments having their staffing determined by an agreed dependency tool, managed by a supernumerary nurse manager)
  • Immediate commissioning of independent research to identify and measure ‘missed care’ in the community to determine appropriate staffing/skill mix levels, recognising the roles of public health nurses, community RGN/RMs, practice nurses, specialist nurses (ie. RNID) and trained HCAs

Why campaign?
“We can’t continue in the current environment, where management has no minimum standard, refuses to acknowledge risk and will continue to cut,” said Mr Doran.

The UK and Northern Ireland are responding positively to reports; they’re not doing everything but are moving in the right direction, according to Mr Doran. They are actively recruiting and ensuring that CNNs and CNMs are supernumerary.

“These are the things they are moving to in the wake of adverse difficulties, mid- Staffordshire and so on. Why not we? We need to learn lessons from other countries. We are only seeking what has been accepted in other jurisdictions.”

He pointed out that this was not done without a struggle in other countries, as outlined to delegates by Judith Kiedja, acting general secretary of the New South Wales Nursing and Midwifery Association, Australia (see page 26-27).

The INMO launched the campaign for more midwifery staff in March. The international recommended ratio is one midwife to 29.5 births. This is currently 1:26 in Northern Ireland.

“Does a mother-to-be in Newry have a right to better service than a mother-to-be in Drogheda? In some midwifery units in Ireland the ratio is 1:32 at best and at worst 1:55. The HSE has acknowledged that in our worst unit, Portlaoise, the ratio was actually 1:70 at times during this year. That is immoral. People who oversaw that should hang their heads in shame,” Mr Doran said.

“It shouldn’t be by luck, it should be by planned science that we have adequate staffing in the right place. There are international norms and that is what this campaign is about. There is no defence to that, no matter what measure of austerity we are in – because it causes harm to patients, harm to mothers, harm to newborns and no civilised society should stand over that.”

In response to Portlaoise, the HSE recently established a midwifery workforce group on which the INMO is represented by Elizabeth Adams, director of professional development.

“We’re clear on what we’re seeking from that group because the evidence is there. We don’t have a different kind of patient than the patients presenting in Australia, California or the UK. The patients presenting need the same type of staffing profile. We’re not going to re-invent the wheel – we just want management to accept international best practice,” said Mr Doran.

“The primary driver of the change in the past four years is research. The RN4CAST has got to be used as a turning point in every debate about the role of nurses and midwives in the provision of healthcare and the economic value that flows from them being there in adequate numbers.”

Mr Doran pointed to a number of reports carried out by the UK authorities such as the Francis report and the Keogh report.

“All of these have stated that cuts in nursing numbers harm patient care. They all had the courage to say that. We don’t have that courage here. We had a report after Portlaoise and the chief medical officer did everything to avoid saying staffing was a reason for the problems because that might cost money. He didn’t interview the midwives either when he decided it wasn’t staffing. In the UK they have had a more honest appraisal of their failings and that has led to reports being acted upon.”

Staff to patient ratios in the areas of care of older people and in community health are also of major concern.

“You don’t cut, slash and burn and pretend that you are providing safe care in care of the elderly services,” said Mr Doran. There needs to be a 60% to 40% skill mix of registered nurses to HCAs in highdependency care of older people units.

He said community based nursing is the big challenge: “All we hear is to get patients out of hospital and the invisible primary care service will step in and maintain your independence and so on. “

In the first phase of this campaign, the INMO Executive Council is commissioning independent research from UCD about missed care in the community.

“From that, we will quantify the skill mix in the community. We have got to trail-blaze on this because nobody in government, in authority, has a clue about what the staffing levels in the community are required to be, as we move out to chronic disease management and health education in the community,” Mr Doran said.

Next steps
“We have got to put this up in lights, put it in capital letters to anyone who pontificates about the health service. The cut, slash and burn merchants on radio and TV will all probably be in a private hospital if they ever need healthcare.

“We need a media campaign. We have to engage with other stakeholders and patient groups. We can’t stand alone on this; we have a message to tell and we have to tell it to others who care about our health service. We need to present facts to the government, the Oireachtas and every TD and senator – put it right under their nose.

“Let’s take them on full frontal on the issue of ‘we can’t afford it and you’ve got to be more efficient and effective’. Let’s prove that we are efficient, we are effective, but this is what you need to be safe in hospital. We’ve got to get political. This is something that has to be on the manifestoes of political parties going into the next general election.

“This campaign is about protecting patients, protecting practice and protecting your registration. Remember: safe staffing, equals safe care, equals safe patients and that’s what we all want.”

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