Press Release

Minister Harris publishes new plan to determine the number and type of nurses needed in each hospital ward around the country

Minister Harris publishes new plan to determine the number and type of nurses needed in each hospital ward around the country

Plan will change the way we staff wards, improving patient outcomes, reducing agency spend and increasing job satisfaction for staff
Minister for Health Simon Harris TD today (Monday) launched a new plan to determine the number and type of nurses needed in each hospital ward around the country. The plan puts the needs of patients at the centre of the process.

“A Framework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Care Settings in Adult Hospitals in Ireland” was launched in Dublin Castle today.

The Framework focuses on delivering positive patient outcomes and creating a healthier and more attractive work environment for staff.

Speaking at the launch, Minister Harris 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. 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.

“Piloting of this Framework has demonstrated significant benefits for both patients and staff. The Framework led to increased quality of care, decreased length of stay in hospital and increased satisfaction with the care received, while staff reported an increase in job satisfaction. There has also been a sustained decrease, up to 95%, in the use of agency staff. I’m pleased to say that a promising trend in relation to reduced mortality rates has also begun to emerge.

“This Framework clearly works so the next step now is for the HSE to develop a national implementation plan, beginning with incremental implementation across our hospitals. I look forward to the outcome of this process.”

The framework was developed based on international research, consultation with key stakeholders and was piloted in three hospital sites; Beaumont Hospital, Our Lady of Lourdes Hospital, Drogheda and St Colmcilles Hospital, Loughlinstown.

The framework is available on the Department of Health website.


Notes to the Editor


A Taskforce on Safe Nurse Staffing and Skill Mix was established in 2014 to develop a framework to support the determination of safe nurse staffing and skill mix ranges (whereby nurse staffing refers to the nursing team including both the nurse and healthcare assistant roles) in a range of major specialities. Phase I focused on general and specialist medical and surgical care settings in adult hospitals in Ireland.

The Framework on Safe Nurse Staffing and Skill Mix is based on four pillars which are as follows:

1) Patient Elements – this first pillar is underpinned by the belief and evidence that all patients are not the same and therefore their care needs are different. Thus the elements influencing the determination of safe nurse staffing and skill mix are those directly related to the patient. Consequently, to determine the right staffing and skill mix, requires the measurement of patient care needs systematically and consistently. Included in this pillar are: acuity and dependency measurements, one to one specialling and professional judgement.

2) Nurse Staffing- this second pillar is underpinned by the belief and the evidence that the size and skill mix of the nursing care team is important to delivering high-quality, safe care to patients (Aiken et al 2014, Kane et al 2007). The elements influencing the determination of nurse staffing and skill mix are those directly related to the nursing care team across general and specialist medical and surgical adult in-patient settings in acute hospitals. Included in this pillar are: staffing profiles, skill mix (nurse: healthcare assistant), recruitment, planned and unplanned absences and Tipping points.

3) Organisational Factors- this pillar is underpinned by the belief and the evidence that features of the organisational environment, such as the ward climate, organisational culture, ward/organisational care processes and, ward size and layout has a direct impact on the ability of the nursing team to deliver safe effective care (See evidence review report). The more positive the organisational culture and ward climate are, where staff are respected, supported, developed and listened to, the better the outcomes for both patients and staff (Kapinos et al 2012; West and Lyubovnikova 2013; West and Dawson 2012). Included in this pillar are: ward leadership and care processes and models of care.

4) Outcomes- this pillar is based on the belief and the evidence that the nurse staffing and skill mix resource has a direct impact on patient and staff outcomes (Aiken et al 2014; Aiken et al 2012; Duffield et al 2011; Griffiths et al 2014; Simon et al 2014 ). Therefore, monitoring staff and nurse sensitive patient outcomes is necessary to determine if the nurse staffing and skill mix resource is at a safe level and is capable of adequately meeting patients’ needs. Included in this pillar are: nurse sensitive Key Performance Indicators, staff and patient experiences and Care Left Undone Events.

The approach taken to the development of this framework has been underpinned by evidence, not only in its development but equally in testing its capability to deliver in practice.


Pilot results

A pilot of the framework was undertaken in six wards across three hospital sites of varying size (Model 4, Model 3 and Model 2), which was extended to ten further wards. This programme of research will continue to measure the impact of implementation on a longitudinal basis. The pilot showed that there was an uneven distribution of nurses and health care assistants across the wards involved. The pilot also showed that some wards required: (i) an uplift in nurse staffing; (ii) a change to skill mix arrangements to achieve an 80-20 range; and (iii) a change from a reliance on agency healthcare assistants to established posts for the delivery of one to one care.

In tandem with the pilot, a three year programme of research, in collaboration with the Health Research Board, has underpinned the evaluation of the impact and outcomes from the pilot.

The results of the pilot demonstrated benefits to patients, sustained financial efficiencies and staff. Results demonstrated by the pilot included:

· An increase in patient satisfaction concerning the care they received while in hospital

· Care Left Undone Events (these are care activities which had been necessary but left undone on their most recent shift) – There was a 58% decrease in Care Left Undone Events from pre intervention to post intervention
· Nurse Sensitive Outcomes (NSO’s), these are diagnoses which the patient acquires while in hospital such as hospital acquired pneumonia, pressure sores and/or falls. A number of patient outcomes sensitive to nursing care were measured through an analysis of data from the Hospital In-Patient Enquiry (HIPE) system. Initial analysis of this data show a nursing sensitive patient outcome (NSO) increase by 0.66% per day in Time 1(pre-implementation of the framework) but decreased by 0.88% in Time 2 (post implementation of the framework). This reduction in adverse events to date has both patient care and economic outcomes. The analysis showed that the odds of developing an NSO began to decline in Time 2. This data needs to be treated with caution as further data collection and analysis is on-going as part of the longitudinal programme of research. Each Nurse Sensitive Outcome represents an average cost of €2,397 (Health Pricing Office)
· Mortality Rates: In those wards that received the largest staffing uplift (Hospital 1) at pre-intervention, 2.5% of patients died during their stay in the pilot wards. Post intervention this reduced to 1.6%. Note that controls were utilised to account for patient and hospital type. This is a substantial reduction, however further work is required on the relationship between the improvement in mortality rates and improvements in nurse staffing that requires a much larger sample size over a longer period of time
· Decreased Length of Stay- there was an overall mean decrease in length of stay of 0.52 days, with one ward demonstrating a 3 day decrease post implementation of the framework
· Sustained decrease in agency/overtime use – One of the most significant results following implementation of the recommendations in the Framework was the reduction in agency usage on the majority of wards. In some cases there were substantial reductions with up to a 95% fall in the use of agency staff. It is of note that, in wards that did not receive changes in staffing but implemented the recommendations in the Framework, there was also a reduction in levels of agency use when both Time 1 and Time 2 of the study are compared. Another notable result was that, over the course of the pilot the reductions in the number of hours provided by agency have not only reduced, but have been sustained. This points to greater ward stability and the potential for longer lasting stabilisation of the workforce as the vast majority of care is now provided by ward based staff
· Decreased absenteeism-Overall absenteeism (sick absence, family, maternity, compassionate leave) decreased in the majority of wards. The majority of wards in Time 2 reported sickness absence rates below the national average of 5% (HSE 2016). However, there was some variability related to seasonal factors and further research is on-going in this area
· Decreases in one to one specialling- Pre intervention of the framework a relatively high proportion of hours was provided by one-to-one specialling. Overall, in the pilot wards that received targeted changes to staffing, the requirement for one-to-one specialling reduced substantially with percentage decreases ranging from approximately 74% to 88%. The identification of the relatively extensive use of one-to-one specialling prior to the introduction of the Framework, has resulted in the implementation of an initiative to actively manage the care of patients who require one-to-one care
· Economic Analysis – Overall, the monthly cost of implementing the required changes to staffing (€79,574) was less than the agency savings realised (€82,480). Therefore, in implementing the Framework to date, there was a net monthly saving (€2,905) across the six pilot wards.
· Skill Mix- in the pre-intervention phase, skill mix on the pilot wards varied with an average mix of 75:25 (nurse: healthcare assistant) recorded. In the post intervention phase the skill mix is noted as having achieved the 80:20 mix recommended by the framework
· Staff Outcomes – Overall, there were improvements in the following areas: staff perceptions of collegiality between doctors and nurses, leadership and support, nurse participation in hospital affairs and the ability to apply nursing foundations for the quality of care. In particular, in those wards that received alterations in staffing, there were significant increases in self reporting by nurses in the quality of care delivered to patients. Similarly an overall increase was reported in the number of staff intending to stay