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Framework for setting safe nurse staffing levels launched in Ireland’s health service

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The Irish government has launched a new framework for establishing safe nurse staffing levels in hospitals.

The move follows a trial that found the tool resulted in better quality care and other benefits for patients and staff, including reductions in agency staff and increased job satisfaction.

“It will allow us to determine the appropriate number of nurses and healthcare assistants”

Simon Harris

The framework, which recommends an 80:20% ratio of nurses to healthcare assistants, provides guidance on calculating the appropriate number of staff based on the number and needs of patients.

Developed by a taskforce of experts, including nurses, it involves regular monitoring of patient and acuity alongside the use of professional judgement to determine optimal staffing levels, as well as gathering information on patient and staff welfare to check if staffing is correct.

Under the framework, nurses and others determine a patient safety “tipping point” for each ward, with information on “care left undone events” – known as Safety CLUEs – recorded daily to indicate the adequacy of nurse staffing on individual wards and across an organisation.

The framework emphasises the need to factor in turnover and planned and unplanned absences, while highlighting the importance of good leadership and support, stressing the need to ensure the senior ward staff remain “supervisory” on general and specialist medical and surgical wards.

It was tested on 16 wards across three hospital sites, with encouraging results that will be scrutinised by policymakers and nursing bodies in the UK.

“The implementation of the framework would lead to dramatic improvements”

Phil Ni Sheaghdha

The pilot found an uneven distribution of nurses and HCAs across the wards involved with some wards needing more nurses, changes to skills mix or more permanent support workers delivering one to one care.

However, the pilot also revealed fairly heavy reliance on one-to-one care and highlighted the need to manage this more effectively.

Wards that saw staffing changes generally saw a reduction in the need for one-to-one “specialling” ranging from 74 to 88%.

Meanwhile, wards trialling the approach saw numerous improvements including when it came to “nurse sensitive outcomes”, such as pressure ulcers and falls, and a 58% reduction in “care left undone” incidents.

There was also evidence the framework could reduce death rates, with wards that saw the biggest increases in staffing levels after following the guidance recording a significant reduction in mortality.

The trial found using the framework had led to shorter stays in hospital and increased patient satisfaction, while staff reported an increase in job satisfaction and were less likely to go off sick.

Meanwhile, it also led to dramatic and sustained reductions in the use of agency staff of up to 95% and related cost savings.

In wards that saw changes in staffing, there was an overall increase in the number of staff who said they intended to stay.

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Simon Harris

In launching the framework, Irish health minister Simon Harris said it “clearly works”. The next step was for the Health Service Executive – which is responsible for the provision of health and social care services in Ireland – was to develop a national implementation plan, he said.

“This framework sets out, for the first time in Ireland, the staffing requirements and skill mix needed in our hospital wards to achieve the best outcomes for patients,” said Mr Harris.

“It will allow us to determine the appropriate number of nurses and healthcare assistants required for each ward, based on the number of patients and their particular needs, rather than solely on the ward size,” he added.

The framework has been welcomed by the Irish Nurses and Midwives Organisation (INMO). But the union said the government would need to invest in the recruitment and retention of nurses – including looking at pay – in order to ensure it could be implemented across the country.

“The implementation of the framework would lead to dramatic improvements in patient outcomes and it would revitalise and re-energise nursing staff,” said INMO general secretary Phil Ni Sheaghdha, who called for it to be rolled out “without delay”.

However, she said it was clear current staffing levels in Ireland were “grossly inadequate” and action was needed to tackle this – especially when it came to pay.

“The provision of optimal care and hope to patients and the nurses who care for them is now a real possibility,” she said.

She added: “This requires real investment in attracting nurses to work in Ireland and retaining those that are leaving. Pay remains the single area not addressed.”

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