Summary

Clinical settings that are safely staffed lead to better outcomes, including reduced patient mortality, reduced staff turnover and burnout, and increased job satisfaction. However, calculating safe staffing levels is complex and needs to be based on patient need. Professor Drennan and his team have now implemented and tested safe nurse staffing frameworks for medical/surgical wards and emergency departments in Ireland. They have shown that their Frameworks result in significant improvements in patient outcome and staff wellbeing. They also save thousands of Euros per ward every month.

These Frameworks have now become national policy, and the Government has committed €25 million to implement them in every hospital in Ireland, meaning many thousands of patients every year will experience superior care and better health outcomes.

Research description

Medical wards and emergency departments with low levels of nursing staff result in higher rates of patient mortality and adverse events, higher levels of staff turnover and burnout, and increased costs to the health service. While there is evidence that higher levels of staffing are related to better patient and staff outcomes, calculating safe nurse staffing levels and the right skill-mix is complex, and needs to account for the high level of variation in patients’ needs.

Phase 1: Medical and surgical wards

Professor Drennan and his team, in conjunction with the Department of Health, sought to work out the optimum nursing levels needed to safely staff wards. Taking an evidence-based approach, they implemented a new Framework, consisting of range of measures that were initially tested in three hospitals prior to being rolled out nationally. These included:

• Determining safe staff levels, using a software system to calculate the nursing hours required by patients based on their needs, and adjusting levels accordingly.
• Ensuring the skill-mix on the ward (i.e. the ratio of registered nurses to healthcare assistants) was appropriate for the patients’ healthcare needs. This was based on the evidence that a higher proportion of registered nurses is associated with improved patient outcomes.
• Guaranteeing that the nurse in charge of the ward was 100% supervisory (i.e. that they did not take a patient caseload but were free to ensure that quality care was delivered). This was based on evidence that when the ward leader does not take a patient caseload, there are higher levels of patient and staff satisfaction and a reduction in adverse patient events.

The team gathered a variety of data before and after the Framework was put in place, enabling them to calculate the impact of these measures on patients, staff, and the wider organisation.

As a result of the Framework, patient adverse events, including mortality, decreased by 0.88%; and levels of missed care reduced from 75.6% of nurses reporting care left undone to just 31.8%. At an organisational level, there was a 95% reduction in the use of agency staff to provide nursing care, saving €2,905 per ward every month. The research also found that each adverse event experienced by patients cost, on average, €2,397.

Phase 2: Emergency departments

To assess the best way to staff emergency care settings, Professor Drennan and his team implemented and assessed a second Framework. Here, they took a unique approach, using routinely collected triage data and assigning a number of nursing hours to each patient according to their urgency.

This resulted in a 35% decrease in time to triage, a 52% decrease in the proportion of patients leaving without being seen, and a 17% decrease in waiting times. Job satisfaction among nurses increased from 54% to 80%, and staff perception that the quality of care was good or excellent increased from 52% to 66%. Levels of burnout also reduced. The Framework resulted in a 22% decrease in spend on agency nurses.

Research impact

Political impact

The research team presented their results to two ministers of health – Simon Harris TD and Stephen Donnelly TD. Both ministers launched the reports, which are published on the Department of Health website. The research team continues to work closely with the Department to develop an additional Framework focused on safe staffing for older persons’ settings.

The work of the research team has directly resulted in Minister for Health Stephen Donnelly committing €25 million in funding for 854 additional nursing posts to fully implement the Framework in all acute hospitals nationally. There have been several Dáil Éireann debates on the development and implementation of the Frameworks for Safe Nurse Staffing, with cross-party support for the initiative, and calls from TDs for further frameworks to be developed in community and long-term residential settings.

Based on the team’s research, the implementation and further development of safe staffing frameworks has also been recommended in the Covid-19 Nursing Homes Expert Panel: Final Report, the Sláintecare Action Plan 2022, the Report of the Expert Review Body on Nursing and Midwifery. The Health and Information and Quality Authority also supports the Framework, and recommends its rollout in inspections of emergency departments in Ireland.

The pilot programme demonstrated compelling evidence that having the correct nurse staffing levels and skill mix, based on patient need, has many positive impacts for patients, organisations and the staff themselves.

— Minister Stephen Donnelly TD

Health and economic impact

Evidently, implementing the Frameworks has resulted in a range of positive outcomes in medical/surgical wards and emergency departments. As described above, research by Professor Drennan and his team has shown that their approach to safe nursing staffing levels leads to tangible improvements in patient outcomes and nurse wellbeing, as well as reductions in healthcare expenditure.

Initially, the Frameworks were adopted in three hospitals and three emergency departments. However, this already significant impact has quickly expanded. The Frameworks are now in place in the majority of acute hospital wards and emergency departments in Ireland, meaning many thousands of patients every year will experience superior care and better health outcomes. Similarly, the research showed that the Frameworks save each ward, on average, €2,905 per month, and each adverse event avoided saves €2,397.

Aggregating the results of the research to the Irish acute hospital population (approximately 633,155 inpatients discharged annually) suggests the annual economic impact of adverse events associated with safe staffing is €91.3 million for the health service. Reducing these events by 20% would result in a saving of over €18 million per annum. In addition, a 22% reduction in spending on agency nursing nationally would save the HSE approximately €29 million per annum. These saving could be used to employ permanent staff.

With further Frameworks on the way, aimed at developing safe staffing protocols in long-term residential settings for older people and community care, the impact of this work will only increase.

Academic impact

There has been extensive international interest in the frameworks: the research team have been invited to the United Kingdom, Malta, Italy, Denmark and Sweden to present and discuss the model and the potential for trialing it within their health systems.