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ADC - Keynote speaker - From bedside to boardroom

As the first chief nurse of Ireland ever to address the INMO ADC, Siobhan O’Halloran set out the current challenges and priorities for nurses and midwives. Tara Horan reports

There is somewhat of a dichotomy in Siobhan O’Halloran’s role as chief nursing officer. On one hand she is a key part of the Department of Health’s management team at assistant secretary level, while on the other she is the nurse leader of this country. But far from finding this an impossible position to be in, Dr O’Halloran is embracing the challenge.

Addressing the INMO ADC, she said: “I cannot think of a job I would rather be doing than this, working with nurses and midwives to harness and to lead the biggest percentage of people in the most important part of our health service.”

She said it was her role to bring the voice of nurses and midwives through to government on what our health services should be shaped like and she was listening to the INMO and nurses and midwives on the ground. “I know that workloads are increasing, that you are principally concerned about safe staffing, that you’re concerned about access and wait times, and that you’re concerned about quality and safety.”

However, she stressed that nursing and midwifery do not exist in isolation but are part of a social, political, economic and technological world. “Ten years ago, we were on the brink of our nursing reforms. With the completion of the Commission on Nursing we had things like the National Council of Midwifery Planning and Development Unit, the advent of advanced practice and the appointment of advisers into the Department of Health.

“We thrived during that era but very quickly we were catapulted into a world of chaos here in Ireland as we greeted the economic austerity measures. I know these have had an impact on nurses and midwives practising in Ireland and I know that you are practising under very difficult conditions at the moment,” she said.

However, she has no panacea for all that is wrong in the health service. “The troika may have left our shores but we’re still not completely in control of our public purse. We’ve a continued downward pressure on health spending and a continued low tolerance of budget overruns. That is just where we are in Ireland at the moment,” she said pragmatically.

Reform programme
The government’s reform plan would fundamentally change the overall system of management and administration of the public service. “The public service is reforming in its entirety. We are reforming how we manage people, how we manage expenditure, how we’re organised and we’re reforming the political framework. It’s within that context of national reform that we are trying to reform health.”

Nursing and midwifery operate within the context of public service policy, she said. “Again this is just how it is. The framework that we are working in is the Programme for Government. The government has a programme taking us to 2016 and that’s one of the frames around which we must operate at the moment.

“We are working within the context of Future Health – our health reform programme, taking us into universal health. We are working within the context of the Haddington Road agreement and the Nurses and Midwives Act 2011. We need to work hard to commence the pieces of the Act needed to ensure that you have an appropriate and safe professional practice environment within which to work.”

She said she was committed to doing that and was working with the Nursing and Midwifery Board of Ireland with the aim of putting in place the legislation and bringing about initiatives like continuing competence.

“We’re on the journey to a single tier health system supported by universal health insurance, where access is based on need, not on income.”

She welcomed recent developments such as the publication of the framework for smaller hospitals, the announcement of the hospital groups, the appointment of one group director in the new hospital groups, the appointment of one chairperson of the hospital groups – Prof Geraldine McCarthy, who is a nurse. She confirmed that the Department was on the way to appointing the rest of the directors of the hospital groups.

She said that nursing and midwifery are intrinsically linked to the future of healthcare in Ireland. “Much of the answers to our health system’s problems can be found in that unique nexus that exists in the very special relationship of the nurse and the patient. By adding nursing and midwifery to health reform we will get increased quality. We will improve access and nurses and midwives can contribute to reducing the cost of the health services by making them more efficient and effective.

“The question is how can the health system accommodate an increase in demand while at the same time improve quality of healthcare and keep healthcare safe. If that’s the big question we’re asking ourselves in health, I think the big question we’re asking ourselves in nursing and midwifery is what roles can we assume to drive reform and address the increasing demand for safe, high quality and effective healthcare services? What roles can nurses and midwives assume, in leading from the bedside to the boardroom? These are roles like the appointment of a chief nurse at assistant secretary level, the appointment of executive directors of nursing and also about recognising the roles of critical grades.“

Reflecting on how much nursing and midwifery has changed, Dr O’Halloran said: “It’s extraordinary; we’ve moved into a technological age. Our graduates are growing up in this age. They’re not going to respond to supervision – what they respond to is inspiration. That is something we need to acknowledge.

“Look how far we have come in Ireland. We have moved to a graduate profession: 168 advanced practitioners, 660 nurse prescribers all that in the short period since I trained. It is important that we reflect on what we have done here in Ireland, acknowledge it and continue to be very proud of our professions and their contribution to healthcare. We are all leaders and we have a choice – do we try to predict the future and work around it or as a collective, do we invent it for ourselves? As a profession we must invent it for ourselves. We are the people that people have been waiting for. We’re it! There’s nobody coming over the hill with new ideas for us. It is up to us to decide how we move the professions forward.

“Timing is critical at the moment because there is a growing body of evidence that illustrates the relationship between nurses and nursing numbers and nursing workloads and patient outcomes. We’ve watched the literature on trips and falls, on patient safety and patient satisfaction and its relationship to nursing.”

She said this moved to a new plane with the recent publication of the RN4CAST study results in The Lancet which found that nurse staffing cuts to save money had an adverse affect on patient outcomes.

“What nursing brings to our health services is a steadfast commitment to patient care, improved safety, quality and outcomes. It brings with it clinicians who practise from health promotion, disease prevention co-ordination of care to cure and to palliative care when cure isn’t possible. And clinicians who are absolutely confident regardless of what happens, that through their adaptive capacity (advanced roles, prescribing and so on), through their close proximity to patients, through their scientific understanding of healthcare, can drive reform from the bedside to the boardroom. That is what our profession stands for.”

Key challenges
Dr O’Halloran said nursing and midwifery had three challenges coming up:

  • Collectively to create the future and to cultivate the next generation of nurses and midwives
  • A new style of leadership – values-based leadership which will give nurses and midwives the capacity to balance innovation with risk
  • Strategic resilience – rather than responding to a once-off crisis, nurses and midwives need to anticipate the challenges coming and to prepare for them. For example, universal health insurance is on the agenda and serious debate is needed on how nursing and midwifery will fit into the concept of UHI.

As chief nursing officer, Dr O’Halloran said her primary responsibility is to achieve national public health goals through nursing and midwifery. “Public good is the end, the patient is always central and nursing and midwifery is the means.”

Returning to the dual aspect of her role she said: “One part of the role is as a public service leader with corporate identity and responsibility. I am a member of the Department of Health management team that advises the secretary general and Minister for Health directly on health policy. I am a member of a management team and I contribute as a member of that team. I happen to be a nurse.

“On the other hand I am a nursing and midwifery leader who is an agent for transformation within the profession, given the positioning at the highest level of policy making. I believe that it is within the tension of those two roles that we together can set realisable goals for nursing and midwifery.

Immediate priorities
She identified three immediate priorities:

  • Better deployment of nursing and midwifery staff. One is the management of the nursing resource, the other is how we manage practice, another is skill mix and another is the graduate nurse programme. It is considering all of these together that we will get answers and new answers to the deployment of the nursing resource.
  • Continuing to build clinical leadership to prepare nurses for the most senior roles in our health services
  • To develop quality assured nursing data; to build on studies such as the RN4CAST to be able to present solid evidence in relation to nursing and midwifery when making cases for things to be different.

“As we work together to address these type of things, together we have the capacity to bridge the gap between access and coverage. The nursing and midwifery professions by vir tue of our numbers, our distribution and our proximity to patients are the only professions that have the capacity to bridge that gap.

“We are starting to change the reference point from which nursing has been judged. I know that as we continue to work together, the future of nursing and midwifery in Ireland is safe.”

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