Mr. Liam Doran:

On behalf of the Irish Nurses and Midwives Organisation - the INMO - I express our appreciation to the Chairman, Deputy Jerry Buttimer, and the members of the 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 the survey confirms that staffing levels in this country are at a critical and unsafe level. The survey was carried out independently by Dr. Keith Hurst, independent researcher and analyst and editor of the International Journal of Healthcare Quality Assurance and a most reputable expert in the area who has worked for the HSE and other major health employers. The INMO in approaching this exercise was acutely aware that there are many variables in health staffing including patient dependency and acuity, physical layout of wards and units, skill mix and grade mix and traditional roles of key grades. These variables make it difficult for any party to be absolutist as to what constitutes safe or unsafe staffing levels. Notwithstanding these caveats, we sit before the committee today clearly of the view that the survey confirms our worst fears that staffing levels have reached unacceptable levels which compromise patient care and the ability of registered nurses to ensure safe care through safe practice.

Apart from the demand from our own members, the INMO was influenced to undertake this staffing comparison by the Royal Commission report on standards of care in the Mid-Staffordshire Hospital Trust in the United Kingdom. The 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 on poor staffing levels which had not been acknowledged or responded to by the trust's senior management. It is of serious concern to the INMO that a similar environment now exists in Ireland with the same adherence to budgets, realisation of targets and contraction of frontline staff which led to negative findings in mid-Staffordshire. Our members tell us daily that their documented expressions of concern about patient care are being ignored by senior management due to a fixation with meeting budget targets and WTE ceilings.

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 the four specialties of general medicine, surgery, elderly care and admissions and assessment. The number of wards sampled in each specialty is set out in the table in the opening statement document circulated to members. 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 in the survey involved the collection of data from a cross-sample of medical, surgical, elderly care and admission and assessment units and, or, wards in hospitals of similar size and complexity; the analysis of this data with reference to the size of ward, grade and skill mix and patient acuity; the 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 the copy of my opening statement as circulated to members provides a single-page summary of the findings of this survey which confirms that Irish wards, without exception, are larger in terms of bed numbers which, of itself, has significant nursing workload implications. The summary also states that the average 25-bedded Irish ward as compared to its UK counterpart has fewer staff as follows; six fewer surgical ward or unit staff; 3.5 fewer medical ward or unit staff; 13.5 fewer admission and assessment units staff; and 3.25 fewer elderly care ward staff. The average roster on these wards sees clinical areas operating with between one and two fewer staff members at all times over a 24-hour cycle as compared to UK counterparts. According to the feedback and responses from nurses in Ireland, the staffing deficit is negatively affecting patient care and increasing staff burnout, absenteeism and overall fatigue. We also set out in the appendix a tabulated breakdown of the staffing reality with reference to staff per occupied bed; total care hours available on a ward per week and the resulting ward complement on a 25 bedded ward. In addition, we have also detailed in a comparative sense the implications for a ward by reference to a sample daily roster of staffing on mornings, afternoons and night shifts.

It is necessary to remind the committee of a number of matters in order to contextualise the comparative survey. As a direct result of the public service recruitment moratorium, the number of nursing and midwifery posts in the public health service has fallen from 39,006 at the beginning of 2009 to 34,614 currently. This is a loss of 4,392 posts or 11.5%. The reduction in posts has taken place in an uncontrolled manner and has been particularly severe over the past 12 months due to the volume of retirements which took place in the weeks leading up to 28 February 2012. In the same period, the public health service has reduced the number of health service support staff, including ward clerks, health care assistants and ward support staff, from 18,517 to 17,142. This is a loss of 1,375 posts or 7.5%. The contraction in numbers within these grades has further depleted the number of ward-based staff which, in turn, increases workloads and negatively impacts upon the time available for patient contact, overall patient care and safe practice. During the same period - primarily under the clinical care programmes - the acuity and dependency of patients in these wards increased significantly. The reasons for that are as follows. There has been increased throughput as the number of day procedures has increased from 675,162 in 2009 to 804,274 in 2011. There has been a decrease in the average length of stay from 6.4 in 2009 to 5.8 at the end of 2012 and an increase in the occupancy rate from 89.3% in 2009 to 91.2% at the end of 2012.

Bed occupancy of over 80% is internationally recognised as overcrowding. The continuing closure of beds, acute and non-acute means that we now have 2,469 beds closed throughout the country. The source for that information is our own bed count, not an external source. In addition to these specific measurable increases in productivity, we have also seen the introduction of specific targets at hospital level, including no patient waiting longer than nine months for admission and a maximum of six hours' waiting time, from presentation to either admission or discharge, in emergency departments. Both of these increases, while welcome, have further increased the pressure upon surgical, medical, admission and assessment units.

In recent years, successive Ministers, the Department of Health and the HSE have consistently and repeatedly stated that Ireland is "rich" in the number of nurses we have per 1,000 of the population when compared with fellow OECD countries. This is wholly incorrect, seriously misleading and not borne out by any serious examination of the real manpower figures.

In 2002 the Department of Health and Children undertook the first large-scale study for workforce planning which provided a comprehensive approach to the issue of nursing and midwifery workforce planning inclusive of 118 recommendations. 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 practising 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 of the population and 8.04 in the public health service. This correction, however, 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 and private health service which is as follows. The number of nursing and midwifery posts in the HSE is 34,614. The number of nurses and midwives in the private sector is approximately 10,000 which, minus the number of midwives in public and private hospitals, leaves 2,200, giving a total of 42,414 nurses employed for a population of 4.6 million. Therefore, the ratio of nurses per 1,000 of the population is 9.22. This falls within the average ratio found by the OECD and fails to take into account the following: the unique demography of the Irish population, that is, the percentage over 65 and percentage under five which places pressure on the hospital system; the reduced level of acute beds per 1,000, resulting in high acuity, dependency and overall turnover; and a very high bed occupancy rate which, internationally, would be accepted as ongoing overcrowding.

It should also be noted that, in Ireland, the undergraduate nurse or midwife, when undertaking a 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 and midwives. In comparison, the UK excludes all reference to undergraduate nurses and midwives undertaking clinical placements when they calculate their nursing and 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 ratio. The RN4CAST studied features of hospital environments which impact on nurse recruitment, retention and patient outcomes in approximately 500 general acute care hospitals in 12 European countries, as listed in the document submitted to the committee. 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 with 30 participating hospitals was reported to be largely historical for 24, not based on a formal system for 25, variable across wards in 23, reviewed regularly in almost half the hospitals - 14, not determined by reference to benchmarks in 17, not set to match existing benchmarks in 20, not set to exceed existing benchmarks in 28, not matched to patient acuity or dependency in 21, somewhat based on informal review of patient acuity in 18, and not planned on a shift-by-shift basis using patient acuity or dependency in 23. 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".

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. Over decades research studies across the world, as detailed in appendix 2 of our submission, have established a direct association between lower nurse staffing and higher mortality; adverse events and poor care; less effective and efficient care; and higher fatigue and burnout. Lower staffing associated with higher patient mortality has been identified in numerous countries, including the USA, England, Switzerland, Belgium, China and Taiwan. Poor nurse staffing practices are 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 health care costs.

Internationally, it has been demonstrated that poor staffing levels increase the risk of burnout among 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 found 77.6% of staff reporting that 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, and 42% of nurses surveyed reporting high levels of emotional exhaustion.

A number of research studies have also shown 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. The RN4CAST survey found in relation to grade mix of staff on the last shift that Ireland had a 72:28 ratio of nurses to support staff and the UK ratio is 70:30. This further rebuffs the perception that Ireland is "rich" in nurses.

In this comparative survey and associated research, the INMO has sought to outline, through the use of wholly independent sources, the very serious staff shortages and deficits which now exist in critical areas of our hospitals throughout the country. The comparative study itself has confirmed our worst fears as it has identified in surgical, medical, care of the elderly and admission and assessment units that our staffing levels are significantly below those 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 respectfully suggest to the committee that this cannot continue and this unmanaged approach to staffing on the front line must cease.

Arising from this study, and the compilation of related research, it is also possible to state the following. Ireland does not have an oversupply of nurses compared with the OECD, and the actual number of nurses employed falls within the average range. At a ratio of 72:28 of registered nurse to support staff, our grade mix is very similar to that which applies in the United Kingdom where it is 70:30.

However, this fails to take into account that all of the support staff, included in this ratio in the United Kingdom, have undertaken standard vocational-type further education. 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 or dependency. This cannot continue and needs to be addressed as part of the ongoing reform and reorganisation of our health service.

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 burnout and fatigue resulting in absenteeism are now significant problems for nurses. All measures brought forward to address this critical staffing shortage 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 that once the committee has studied, examined and analysed this comparative study and related international research, it would initiate discussions with all the relevant stakeholders on 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.

I thank the Chairman and members of the committee for affording us the opportunity of this meeting this morning. I thank them for their kind attention and we will now try to answer any questions or queries they have.