Meeting with
Oireachtas Committee on Health
on
Comparative Survey of Nurse Staffing Levels in
Medical, Surgical, Care of the Elderly and
Admission & Assessment Units in
Ireland versus the UK.
Opening Statement
24 January 2013
Chairman and Members of the Committee
1.
Introduction
On behalf of the Irish Nurses and Midwives Organisation (INMO) I wish to
begin by expressing our appreciation to the Chairman, Mr. Jerry Buttimer TD,
and all members of the Oireachtas Health Committee, for agreeing to meet
with us to discuss the many issues arising from our comparative survey of
nurse staffing levels in medical, surgical, care of the elderly and admission
and assessment units in hospitals in Ireland versus the UK.
It is the sincerely held view of the INMO that this survey, carried out
independently by Dr. Keith Hurst, Independent Researcher and Analyst; and
Editor, International Journal of Healthcare Quality Assurance, a most
reputable expert in this area who has worked for the HSE and other major
health employers confirms that staffing levels, in this country, are now at a
critical and unsafe level.
The INMO in approaching this exercise is acutely aware that, when it comes
to health staffing, there are many variables, such as patient dependency and
acuity, physical layout of ward/unit, skill mix and grade mix and traditional
roles of key grades. These variables make it difficult, for any party, to be
absolute about what is safe, or unsafe, staffing levels. Notwithstanding these
caveats we sit before you today clearly of the view that this survey confirms
our worst fears that our staffing levels have reached unacceptable levels
which are now compromising patient care and the ability of registered nurses
to ensure safe care through safe practice.
Apart from the demand from our own members, to undertake this staffing
comparison, the INMO was also influenced by the Royal Commission Report
in relation to the standards of care in the Mid-Staffordshire Hospital Trust.
This Royal Commission found that between 2005 and 2009 there were
between 400 and 1,200 avoidable deaths due to poor care. In addition the
report found that nursing staff had submitted 1,722 incident reports, in relation
to poor staffing levels, which had not been acknowledged, or responded to, by
Trust senior management.
It is of serious concern, to the INMO, that a similar environment now exists,
here in Ireland, with regard to adherence to budgets, realisation of targets and
contraction of frontline staff which led to the very negative findings in MidStaffordshire. Our members are telling us, every day, that their documented
expressions of concern, with regard to patient care, are being ignored by
senior management due to their fixation on meeting budget targets and WTE
ceilings.
2.
The Survey
The comparative survey was undertaken, on a wholly independent basis, by
Dr. Keith Hurst and his team based in the United Kingdom. The survey
involved a detailed sampling of wards, in these four specialities, as follows:
Speciality
General Medicine
Surgery
Elderly Care
Admission & Assessment Units
No. of Wards Sampled
Ireland
UK
42
166
23
132
24
135
5
37
The difference in the number of wards sampled, per speciality, is explained by
reference to the overall size of the respective health services.
The methodology employed essentially involved the following:

the collection of data from a cross sample of medical/surgical/elderly care/
admission and assessment units/wards in hospitals of similar size and
complexity;

the analysis of this data with reference to the size of ward, grade/skill mix
and patient acuity; and

measurement, in comparative terms, of man hours per patient, staff per
occupied bed and the application of these measurements to a standard 25
bedded ward in both countries.
Appendix 1, to this opening statement, provides a one page summary of the
findings of this survey which confirms the following:
1.
Irish wards, without exception, are larger (in terms of bed numbers)
which, of itself, has significant nursing workload implications.
2.
The average 25 bedded Irish ward (as compared to their UK
counterpart) has fewer staff as follows:




surgical - 6 less;
medical - 3.5 less;
admission and assessment units - 13.5 less; and
elderly care - 3.25 less.
3.
The average roster on these wards would see clinical areas working
with between one and two less staff, at all times over the 24 hour cycle,
as compared to their UK counterpart.
4.
This staffing deficit is, according to the feedback and responses from
nurses in Ireland, negatively affecting patient care and increasing staff
burnout, absenteeism and overall fatigue.
In the appendix provided we have also sought to breakdown, in a tabulated
way, the staffing reality with reference to the following:
 staff per occupied bed;
 total care hours available on ward per week; and
 the resulting ward complement - 25 bedded ward.
In addition we have also detailed, again in a comparative sense, the
implications, for the ward, with regard to a sample daily roster regarding
staffing on mornings, afternoons and night shifts.
3.
Context
In bringing forward this comparative survey it is necessary, in order to provide
the proper context, to remind the Committee of the following:
1.
As a direct result of the public service recruitment moratorium the
number of nursing/midwifery posts, in the Irish public health service,
has reduced from 39,006, at the beginning of 2009 to 34,614 currently
(loss of 4,392 posts or 11.5%)1.
 this reduction has taken place in an uncontrolled manner and has
been particularly severe in the past 12 months due to the volume of
retirements which took place in the weeks leading up to 28th
February 20121;
 in the same period the public health service has reduced the
number of health service support staff (this would include ward
clerks, healthcare assistants and ward support staff) from 18,517 to
17,142 (loss of 1,375 posts or 7.5%)1;
 The contraction of numbers, within these grades, has further
depleted the number of ward based staff which, in turn, increases
workloads and negatively impacts upon the time for patient contact,
overall patient care and safe practice.
2.
During this same period, and primarily under the clinical care
programmes, the acuity and dependency of patients, in these wards,
has increased significantly for a number of reasons including:
 increased throughput as number of day procedures has increased
from 675,162 in 2009 to 804,274 in 20112;
 a decrease in the Average Length of Stay (ALOS) from 6.4 in 2009
to 5.8 at the end of 20121;
 an increase in occupancy rate from 89.3% in 2009 to 91.2% end
2012 (80% plus internationally recognised as overcrowding1; and
 the continuing closure of beds (acute and non-acute) with the result
that we now have 2,469 beds closed across the country (source
INMO bed count).
In addition to these specific measurable increases in productivity we
also have seen the introduction of specific targets, at hospital level,
including:
 no patient to wait longer than nine months for admission; and
 maximum of six hours waiting time, from presentation to either
admission or discharge, in emergency departments;
both of which, while welcome, have further increased the pressure
upon surgical/ medical/ admission and assessment units.
4.
Workforce Planning
The Number of Registered Nurses in Ireland - The Reality
In recent years successive Ministers, the Department of Health and the HSE
has consistently, and repeatedly, stated that Ireland is “rich” in the number of
nurses we have, per 1,000 of the population, when compared to fellow OECD
countries.
This is wholly incorrect, seriously misleading and not borne out by any serious
examination of the real manpower figures.
The first large scale study, towards workforce planning, was undertaken by
the Department of Health and Children and provided a comprehensive
approach to the issue of nursing/midwifery workforce planning inclusive of 118
recommendations3. This report identified, and corrected, one of the most
significant misconceptions in relation to our nursing and midwifery resource,
which suggested that Ireland had one of the highest ratios of practicing nurses
per 1,000 of the population at 16.5. The Department’s own text states that
this figure was significantly inflated and the actual figure was 10.8 per 1,000
population and 8.04 in the public health service. However this correction is
consistently ignored by the Department of Health when making public
comment.
Furthermore, in the context of the impact of the recruitment embargo,
summarised earlier, and the current population of Ireland, the INMO believes
a more relevant measure is that of employed nurses in the public/private
health service which is as follows:
Number of Nursing/Midwifery Posts - HSE
Number of Nurses/Midwives - Private Sector
Sub-Total
Minus Number of Midwives (public and private)
Total
Population
Nurse per 1,000
34,614
10,000
44,614
(2,200)
42,414
4,600,000
9.22
This falls within the average ratio found by the OECD. This, therefore, fails to
take into account the following:
 unique demography of the Irish population (percentage over 65 and
percentage under 5);
 reduced level of acute beds, per 1,000, resulting in high acuity,
dependency and overall turnover; and
 very high bed occupancy rate which, internationally, would be accepted as
ongoing overcrowding.
It should also be noted that, in Ireland, the undergraduate nurse/midwife,
when undertaking their rostered placement, is counted as 0.5 of a whole-time
post. This confirms their inclusion as an integral part of the qualified nursing
workforce despite the fact that they are not registered nurses/midwives. In
comparison the UK excludes all reference to undergraduate nurses/midwives,
undertaking clinical placements, when they calculate their nursing/midwifery
numbers.
This Registered Nurse Forecasting (RN4CAST) study funded by the
European Union also found that the Irish nurse per 1,000 population falls
within the average OECD ratio4. The RN4CAST studied features of hospital
environments impact on nurse recruitment, retention and patient outcomes in
approximately 500 general acute care hospitals in 12 European countries
(Belgium, England, Finland Germany, Greece, Ireland, Netherlands, Norway,
Poland, Spain Sweden and Switzerland). The study found that workforce
planning in the Irish health service and for nursing in particular, has been
limited due to poor information on public health workers and inadequate
availability of information on the supply and demand of health care workers in
the private and voluntary sectors. The RN4CAST found that the determination
of staffing levels on Irish wards (30 participating hospitals) was reported to be:










largely historical (n=24);
not based on a formal system (n=25);
variable across wards (n=23);
reviewed regularly in almost half the hospitals (n=14);
not determined by reference to benchmarks, in just over half of the
hospitals (n=17);
not set to match existing benchmarks (n=20);
not set to exceed existing benchmarks (n=28);
not matched to patient acuity or dependency (n=-21);
somewhat based on informal review of patient acuity (n=18);
not planned on a shift-by-shift basis using patient acuity/ dependency
(n=23)5.
The need for a comprehensive approach to strategic workforce planning for
the health service is becoming more evident. There are no set or
recommended nurse to patient ratios in Ireland and workload assessment
tools, staffing systems and workforce planning techniques are varied and lack
integration. The World Health Organization states that “the formulation of
national human resources for health (HRH) policies and strategies requires
evidence-based planning to rationalise decisions” 6.
5.
The Value of a Registered Nurse to Patient Outcome and Wellbeing
In every economic downturn, and particularly where cost containment is
required in health, nursing and midwifery staff are often seen as a target for
cost saving rather than being an essential part of the solution. The current
emphasis is on crisis management as opposed to a planned strategy of how
best to use existing valuable resources like nursing and midwifery.
Research studies across the world (as detailed in Appendix 2) over decades
have established a direct association between lower nurse staffing and:




higher mortality;
adverse events and poor care;
less effective and efficient care;
higher fatigue and burnout7.
Lower staffing associated with higher patient mortality has been identified in
numerous countries including USA, England, Switzerland, Belgium, China and
Taiwan. Poor nurse staffing practices is associated with increased incidence
of a range of poor patient outcomes including increased rates of pneumonia,
rates of urinary tract and surgical site infection and pressure ulcers. Lower
nurse staffing is associated with longer lengths of stay, as well as increased
rates of readmission to hospital after discharge. Both readmission and longer
lengths of stay increase healthcare costs.
Internationally, it has been demonstrated that poor staffing levels increase the risk of
burnout amongst nurses. This in turn, increases the risk of poorer patient care. This
has also been supported by the RN4CAST research across the 30 participating Irish
hospitals which find:
 77.6% of staff reporting there was insufficient staff to get all the required work
done;
 74.9% reporting there were inadequate numbers of registered nurses to provide
quality care;
 42% of nurses surveyed reported high levels of emotional exhaustion.
A number of research studies have also identified that increasing the number of staff
with lesser qualifications will not bring about the same care improvements as
increasing the number of registered nurses. Similarly, poorer care outcomes have
been associated with lower proportions of registered nurses in the staffing profile.
In the RN4CAST findings, in relation to grade mix (on the last shift), it found the
following:
Ireland
UK
Nurse
72%
70%
Support Staff
28%
30%
This further rebuffs the perception that Ireland is “rich” with nurses.
Conclusion
In this comparative survey, and associated research, the INMO has sought, through
the use of wholly independent sources, to outline the very serious staff shortages,
and deficits, which now exist in critical areas of our hospitals across the country.
The comparative study itself, has confirmed our worse fears as it has identified in
surgical, medical, care of the elderly and admission and assessment units our
staffing levels are significantly below that of the United Kingdom.
These staffing deficits are undoubtedly, at this stage, compromising both the quality
and quantity of care available to patients and the ability of registered nurses to
provide safe care through safe practice.
This situation continues to worsen due to the current application of the public service
recruitment moratorium and the policy, imposed by government, of further
contraction, of staffing in our health service, which, this year alone, demands a
further 2,500 (net) loss of posts. We would respectively suggest to the committee
that this cannot continue and this unmanaged approach, to staffing in the frontline,
must cease.
Arising from this study, and the compilation of related research, it is also possible to
state the following:
1.
Ireland does not have an over supply of nurses, compared to the OECD, and
the actual number of nurses employed falls in the average range.
2.
At 72% to 28% (registered nurse to support staff) our grade mix is very similar
to that which applies in the United Kingdom (70:30). However this fails to take
into account the fact that all of the support staff, included in this ratio in the
United Kingdom, have undertaken standard vocational type further education.
3.
It is a reality that staffing levels, in our wards, continue to vary, considerably,
and would appear to be based on historical factors rather than any qualitative
estimation of need or measure of patient acuity/ dependency - this cannot
continue and needs to be addressed as part of the ongoing reform and
reorganisation of our health service.
4.
Associated, academically proofed and wholly independent, research
continues to record the growing fears, of registered nurses, that patient care is
being compromised, on a regular basis, arising from this low staffing level and
that burn out and fatigue, resulting in absenteeism are now significant
problems for nurses.
5.
Every, and all, measures brought forward, to address this critical staffing
shortages, must ensure that adequate numbers of registered nurses, remain
in the clinical area, as international research shows patient outcomes are
improved and enhanced when the required level of registered nurse presence
is maintained.
It is the view of the INMO that the health service must fundamentally alter how it
determines, and maintains, adequate staffing levels, on wards, which ensure the
best outcome for patients and safe practice for registered nurses. In this context, and
having studied many other jurisdictions, it is our view that the best, and ultimately
most cost effective, way of doing this is to introduce Mandatory Nurse Patient Ratios.
It is therefore our request, of this committee, that once you have studied, examined
and analysed, this comparative study and related international research, you would
initiatie discussions, with all the relevant stakeholders, with regard to bringing
forward the required regulation which would introduce mandatory nurse patient
ratios. This would ensure consistent care standards and patient outcomes,
throughout our health system regardless of geography or any other factor. We
believe this reform is of greater relevance, and importance, than the constant
attention being given to the reform and reorganisation of management structures
while hospital wards and units are left understaffed and overworked.
May I close by thanking the Chair, Deputy Buttimer, and every member of the
Committee for affording us the opportunity, of this meeting this morning. Thank you
for your attention and we will now try to answer any questions or queries you have.
References
1.
Health Service Executive (2012) HSE Performance Report.
2.
Implementation Body PSA Second Progress Report.
3.
Department of Health and Children (2002). The Nursing and Midwifery
Resource Final Report of the Steering Group: Towards Workforce Planning.
Dublin: DOH
4.
Dublin City University (2012) RN4CAST – Workforce Planning for the Nursing
Profession: Current Perspectives and Recent Research Findings for Ireland.
Research Update No.3 of 3. Dublin: DCU
5.
Dublin City University (2012) RN4CAST – Nurse Survey Results for Ireland.
Research Update No.1 of 3. Dublin: DCU
6.
World Health Organization (2010). Models and Tools for Health Workforce
Planning and Projections. Human Resources for Health Observer, Issue No.3.
Geneva: WHO.
7.
Irish Nurses and Midwives Organisation (2013) Safe Staffing: The Evidence Key Facts from a Review of Published Research Findings. Dublin: INMO.