Speech by Minister Harris at the All-Ireland CNOs’ Conference in Dublin Castle – Strengthening the sustainability of the Nursing and Midwifery Workforce — Delivering Results

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Minister O’Neill, ladies and gentlemen, I am delighted to join you here today. I want to thank our two hosts, Dr Siobhan O’Halloran and Professor Charlotte McArdle for inviting me to my first All-Ireland CNOs’ Conference.

Given the theme of today’s conference, I feel I have to make reference to a remarkable event this weekend when the Cork University Maternity Hospital and the eHealth Ireland team made Ireland’s first hospital-based Electronic Health Record live. Before five o’clock on Saturday afternoon, Ireland had its first four digital babies, each baby with a health record that can be shared throughout the care pathway, a record that can evolve over time, one that can truly deliver an integrated care experience. I caught up with the team on Sunday afternoon via video dial up so I could get a feel for how the staff were managing the delivery of this exciting change, and noticed a quote on the white board there, “Today is day one of the future – CUMH first in Ireland.” The pride of the team in what has been achieved is palpable, the excitement the staff have felt as they have driven this solution to implementation is extraordinary to see and again shows me the level of commitment that all health staff have to drive change and deliver a better health service. I’m looking forward to visiting the hospital, actually rather than virtually, in the near future and I of course acknowledge that there are also issues of concern at the hospital that I want to hear about first-hand.

Cross Border Initiatives/CNOs’ Collaboration

Today’s event is a wonderful way to highlight the great cross-border initiatives that that are providing services that best meet the needs of patients. Initiatives like the All Island Congenital Heart Disease Network, the cross-border service for County Donegal patients requiring Primary Percutaneous Coronary Intervention, and the new Radiotherapy Unit at Altnagelvin Area Hospital which will be officially opened next week.

This conference, though, is really about cross-border collaboration of a more personal kind, like that shown by our two Chief Nursing Officers, Siobhan and Charlotte. It is a testament to their leadership that they realised their shared vision of holding a conference that would celebrate nursing and midwifery while focussing on what can be achieved through cross-border collaboration. Today is a very tangible manifestation of collaboration between our two CNOs, but they have had several years of very fruitful engagement behind the scenes as well.

Sustainable nursing and midwifery workforce

This is the third year of the conference and it is growing in popularity.

I think it’s fair to say that the first time this conference was held, the foremost challenge for the health service was an economic one.

While the situation is improving, a challenge that remains for nursing and midwifery is the sustainability of the nursing and midwifery workforce. Our experiences over the last few years have taught us that we can no longer rely on the systems of the past to solve the problems of today and the future. But each challenge brings with it the opportunity to think afresh.

So I believe today’s conference is very topical, not only in highlighting the issues around nurse and midwifery staffing but, crucially, in finding ways to address those issues. This is not a difficult task when you have room full of the best brains from the north and south supported by a line-up of international experts!

CNO’s Office

I mentioned that fresh thinking is required to address the issue of workforce sustainability and in that context I’d like to talk about the CNO’s Office in my Department because it is to the forefront of fresh thinking when it comes to nursing and midwifery. This is all the more remarkable when you consider that 2015 was the first full-year of the Office’s existence.

For those of you who don’t know, Dr Siobhan O’Halloran, was appointed, in 2013, as the first CNO at Assistant Secretary level in my Department.

The aim of this appointment was to ensure that a nursing and midwifery perspective is brought to bear on the development of policy.

But, clearly, one person alone can’t effect change and collective wisdom delivers better results. It was in this spirit that Siobhan was joined by three Deputy CNOs, Dr Anne-Marie Ryan, Dr Philippa Ryan Withero and Susan Kent, all with their own areas of expertise and I’m delighted to say, all of whom are here today. The Deputy CNOs work in partnership with their civil service colleagues to develop policy and with this model, we clearly have the best of both worlds.

The CNO’s Office set out a very ambitious programme of work for 2015, 2016 and 2017 is set to continue that trend.

We talk a lot about challenges in the health services, and I’m sure you’re tired of the word, but I am convinced we can overcome anything if we have a clear idea about what we want to achieve, and what we need to do to achieve it.

Strategy for the CNO’s Office

It is for this reason that the CNO’s Office developed a three-year Strategy that was launched on the 3rd of February. The purpose of the Strategy is to ensure there is broad understanding, both internally and externally, of the role of the CNO’s Office and the link between the Office and overarching health policy.

The Strategy provides the necessary direction for the Office in supporting the nursing and midwifery professions and maximising their contribution to health policy.

The Strategy sets out the Vision, Mission and Values for the CNO’s Office. It also includes four strategic objectives, to be achieved by the end of 2017, which will optimise the roles of nurses and midwives and their contribution to the health service. Most importantly, the Strategy’s ultimate aim is to help ensure that health service users receive the best possible care.

Initiative on Nursing and Midwifery Values

I know that the professions of nursing and midwifery in Ireland have a long and distinguished history of providing a valuable contribution to the health of our society. I am aware of significant changes in the role of nurses and midwives over recent years.

Practices like medicinal product prescribing, administering I.V. antibiotics, and ordering diagnostics are all worthwhile activities and enhance the capacity of our services to respond to patient needs.

However, we must always remember the fact that at the core of nursing is caring and if we lose that we lose something very precious in our health services. We all know that when we meet a nurse or midwife who demonstrates the values we associate with good care that we feel better about the interaction and we remember it as a positive experience in our lives. The way you care for people stays with them, the comfort your care gives their families stays with them.

Recent health inquiry reports have made for uncomfortable reading. However, as nurses and midwives, I know that part of your response was to reflect on what it is that makes your professions’ unique and why it is that the public has so much respect for and trust in you as nurses and midwives. You also recognised that we can never be complacent and must always continue to improve.

It is for this reason that the CNO’s Office led an initiative on the core values that underpin nursing and midwifery practice, in partnership with the Office of the Nursing and Midwifery Services Director in the HSE, and the Nursing and Midwifery Board of Ireland.

The initiative was launched on the 3rd of February and its objective was to identify values that support behaviours associated with care, compassion, and competence and to ensure that they are reinforced in nursing and midwifery practice and culture across all settings.

A national consultation process asked nurses and midwives to identify, agree and commit to a set of core values that underpin their practice. This process identified Compassion, Care, and Commitment as the three core values. In June, I launched a position paper on the values that outlines a framework for supporting nurses and midwives to sustain and renew the values. The desired, and very important, outcome of this initiative is to help the nursing and midwifery professions to continue building a culture of safe patient care.

Patient Safety

Patient safety is fundamental to quality healthcare and the health system must be enabled to deliver safe care while balancing competing pressures in a dynamic and complex environment.

Healthcare systems are safer when they are open, honest, identify errors and opportunities for improvement, put in place systems to apply evidence and learning and that, most importantly, interact well with patients to learn from their experiences, both positive and negative, to ensure that their services continually improve.

Taking actions to mitigate the effect of harm or error is critical. Creating a culture of open disclosure and learning from the things that go wrong is the bedrock of making systems safer.

Nurses and midwives are central to providing and assuring a safe, high-quality service. Leadership, governance, clinical commitment and clinical effectiveness approaches are required to deliver safe quality care at national, regional and local level.

Later this week at the Patient Safety Conference, I will launch the National Patient Safety Office (NPSO) which will be located in my Department.

Improving safety and quality is dependent on the professionalism of our staff and the values that underpin this, values such as compassion, care and commitment. These imply a commitment to the development of competence, critical examination of practice, honesty and openness with patients and underpin making choices on care options.

The Maternity Strategy

Patient safety is also at the core of the National Maternity Strategy that was published this year. The Strategy demonstrates a new and enhanced focus on maternity care at both policy and service delivery level, and provides a roadmap for how we can improve services in the years ahead. Of note too is that, this month, HIQA will publish National Standards for Safer Better Maternity Services. The Standards will provide a framework for maternity service providers to ensure that they are meeting the needs of women, their babies and their partners, and that a consistent service is delivered across the country. I am confident that the Strategy, coupled with the new Standards, will provide the building blocks for a safer and better service.

Taskforce on Staffing and Skill Mix for Nursing

Behaviours associated with care, compassion and competence are hugely important for patient safety but so too is staffing. The CNO’s Office has approached this issue with characteristic innovation through the establishment of the Taskforce on Staffing and Skill Mix for Nursing whose first aim is to develop a framework to determine the safe staffing and skill mix requirements for the nursing workforce in general and specialist medical and surgical care settings.

I am aware that the CNO’s Office in Northern Ireland developed the framework ‘Delivering Care – Nurse Staffing in Northern Ireland’ and acknowledge the support of Professor McArdle and her team in helping to shape our approach to the issue of nurse staffing.

The Interim Report on the Framework was launched on the 1st of February. The framework is the first step on a journey towards radically changing how we approach the age old problem of staffing our hospitals.

It places the needs of the patient centre stage and recognises the relationship between nurse staffing arrangements and patient outcomes. Research and health inquiry reports provide valuable lessons. They point to the equal importance and impact of ensuring the right mix of skills and knowledge, strong clinical leadership and a healthy culture within a hospital.

This new approach is underpinned by evidence based on assessment of individual patient need, monitoring patient outcomes, measuring staff experience and ward climate, as well as assessing the required nursing hours per patient day.

The staffing infrastructure in a hospital is everybody’s concern. It is for this reason the decision making framework sets out a whole hospital approach designed to ensure ward to board and board to ward accountability.

I was pleased to see that the Framework sets out an evidence based approach aimed at stabilising the nursing resource, delivering positive benefits for patients, and making hospitals a healthier and more attractive work environment for staff.

There is a lot of merit in this approach and because of this funding of €2 million was secured to allow for the implementation of the framework on a pilot basis throughout this year. The pilot project is being carried out in three hospitals and will test the capability of the Framework components to deliver on their intended outcomes. It is intended that the findings of the pilot will be available in early 2017.

In addition, the learning gleaned from the first phase of the work of the Taskforce will be applied, this year, to the second phase that is focussed on staffing and skill mix in Emergency Department and plans are well advanced for this phase of the work due to commence in January.

While the work of the Taskforce is to be welcomed, as you can appreciate, the number of staff is only part of the solution. We must continue to ensure that the expertise of nurses and midwives is fully utilised to ensure that we get the best possible outcomes for health service users.

In this regard, the CNO’s Office has developed a paper proposing an evidenced-based policy model or pathway for a graduate, specialist and advanced nursing and midwifery workforce that is flexible, enabling and adaptive. This policy will facilitate a more responsive way of developing advanced and clinical nurse specialists across our services that will ensure we have a critical mass of these posts to better meet patient needs.

Furthermore, the Office has developed a policy on integrated community nursing and midwifery practice that will develop genuine integration between our hospitals and our community services. This policy reiterates the position of the primary health care team as the first point of contact for the population in the community setting, coupled with developing and re-engineering the current nursing and midwifery resources to optimise their impact in an integrated model of healthcare.

Nursing and Midwifery KPIs

Over the years, we have developed the nursing and midwifery professions and rightly so. Significant investment has been made and it’s important that we demonstrate its effects.

It is vital, therefore, that we measure the outcomes and impacts of nursing and midwifery initiatives on the health service user, who is central to everything. Nursing and Midwifery Key Performance Indicators or KPIs are central to this.

The CNO’s Office has developed a framework for national nursing and midwifery KPIs to ensure that their development, prioritisation, and endorsement is standardised. The framework will assist in demonstrating the impact of nursing and midwifery across key areas of our health services.

In a nutshell, these five initiatives aim to embed the values of nursing and midwifery, stabilise the nursing and midwifery resource, maximise nursing and midwifery outcomes and measure the impact of nursing and midwifery. They are fully integrated and, I believe once implemented, have the potential to revolutionise the delivery of nursing and midwifery services.

Recruitment and retention of nursing staff

Of course, the implementation of these initiatives requires an appropriate number of nurses and midwives and that means addressing the issue of recruitment and retention of nursing and midwifery staff. This issue is not only a priority for our health services but is an international issue.

Recruitment remains challenging given nursing shortages globally, intense competition at home and abroad, and the demand for Irish trained nurses and midwives.

There are many initiatives currently underway to improve staffing levels throughout the country. The HSE is offering permanent posts to 2016 degree programme graduates, and full time permanent contracts to those in temporary posts. The HSE is also focused on converting agency staffing to permanent posts. The HSE’s National Recruitment Service is actively operating rolling nursing recruitment campaigns. The campaigns encompass General, Mental Health, Intellectual Disability and Registered Children’s Nurses, and also Midwives. In addition, a relocation package of up to €1,500 is available to nurses who return from overseas.

A number of specific measures have also been taken in relation to pay that will support the recruitment and retention of Irish nursing and midwifery graduates. Measures to date include the first stage of pay restoration under the Lansdowne Road Agreement, additional pay in return for taking on some duties from doctors and an increase in the rate of pay for the student nursing placement to 70% of the first point of the staff nurse pay scale. Last month the Government approved restoration of incremental credit for all nurses in respect of the 36 week clinical placement undertaken by 4th year student nurses in the context of the 2017 Estimates.

This decision means that all nurses and midwives will receive incremental credit for the 36 week placement restored from 1 January 2017, restoration of the credit to 2016 and future graduates having been approved earlier this year. It is estimated that the inclusion of 2011 to 2015 graduates will benefit around 4,000 nurses who are currently working within the public health service and potentially another 3,000 who may wish to return to the public system in the future.

There has been an increase of almost 1,200 nurses employed in the public health service (34,336 to 35,534) from September 2014 to September 2016, numbers having fallen by almost 4,600 from 2007 to 2014. The total budget for the health service in 2017 is €14.6 billion, the highest budget ever allocated to the health service and this will allow for the recruitment of additional nursing staff to meet service needs. Given recognised difficulties in filling psychiatric nursing vacancies, an additional 60 undergraduate places have been put in place this autumn with a further 70 additional places to be provided next year.

Improvements in the Health Service

Recruitment and retention are just two of the challenges we face in delivering health services. Yes, there have been many challenges in recent years, for nurses, midwives and indeed all health service staff, but we need to acknowledge the great work that has been done.

This conference is incredibly important in celebrating nursing and midwifery and all of the good work that is being done on both sides of the border. It is also a great way to showcase the innovative approaches being taken to tackling the staffing issues in nursing and midwifery.

Sometimes, there is an unfair focus on the negative aspects of the health service, particularly in the media, and good news stories tend to be ignored.

That is why, since becoming Minister for Health earlier this year, I have embarked on a series of hospital visits to see for myself the work that is being done and meet staff on the frontline.

Progress is being made in delivering better outcomes for service users in a number of areas:

  • since 2004, life expectancy in Ireland has increased by two and a half years and is above the EU average;
  • between 2005 and 2014 mortality rates for all circulatory system diseases fell by 31.5%, for cancer by 7.9%, and for respiratory system diseases by 20%;
  • between 2004 and 2013, there has been a 40% reduction in the in-hospital mortality rate following admission with a heart attack;
  • between 2000 and 2013, the average length of stay in Irish hospitals decreased by 19%;

These improvements are impressive and demonstrate that the health service is changing for the better and becoming more responsive to the needs of service users.

Concluding remarks

I welcome the leadership and initiative by both Chief Nursing Officers in holding this conference today and taking the lead in developing ways to create a sustainable workforce.

I want to thank all of you for the positive difference you’ve made to many lives. I’ve seen first-hand the contribution nurses and midwives make to the health service and I’ve also seen the challenges you encounter.

But I believe that, based on what I’ve just said, there are many reasons to feel hopeful and, indeed, excited about the future direction of nursing and midwifery and your place in it.