OECD nurse patient ratios do not give the full picture

Prof. Jonathan Drennan
Prof. Jonathan Drennan

The OECD figures for nurse patient ratios in Ireland did not portray the full picture of nursing work in Ireland, Prof. Jonathan Drennan, Professor of Nursing and Health Services Research, School of Nursing and Midwifery, University College, Cork, told the conference.

Prof. Jonathan Drennan
Prof. Jonathan Drennan

Speaking on “Safer nurse staffing: the right person in the right place at the right time, he said that if you just looked at OECD figures, Ireland, with 12.4 nurses per 1,000 population, had more nurses than most OECD states. However, this was not the full picture, as the Irish figures included nurses working in management and education and that made it difficult to get accurate figures of those working directly in clinical practice. In other countries, part of the registration process involved stating place of work – this did not happen in Ireland.

It had also to be remembered that the environment in which Irish nurses worked was very complex, because Ireland had one of the lowest number of beds per thousand population and one of the highest bed occupancy rates in the OECD. The number of beds in hospitals, patient acuity and dependency, support from other health professionals and patient turnover determined the kind of work which nurses carried out. A small number of beds, increasing patient acuity and dependency and high turnover meant nurses would be much busier.

Ireland had one of the lowest number of beds per thousand population and one of the highest bed occupancy rates in the OECD.

According to the OECD (2015) Ireland had 2.6 beds per thousand of the population, compared to 13.17 in Japan, 6.13 in France, 4.82 in Luxemburg and 4.35 in Finland.
The bed occupancy rate in Ireland was also very high. According to the OECD, we had a 94% bed occupancy rate, while the rate in Europe ranged from 68% in Slovenia to 84% in the United Kingdom, and 46% in the Netherlands.

“So nurses in Ireland are working clinical settings with high rates of patient turnover, which leads to increased nursing work. Therefore to accurately predict nursing numbers we need to have reliable data that includes patient dependency and acuity, patient turnover, bed occupancy, elective vs. acute admissions and educational level and skill-mix of the nursing workforce.”

Prof. Drennan said that the Francis report, into the Mid Staffordshire NHS Foundation Trust showed that over two years, the number of deaths was 27-45% higher than would be expected at a similar NHS trust.

The public inquiry found many causes, including inadequate nurse staffing, which led to these excess deaths. To make financial savings, changes were made in nurse staffing in the wards and skills mix diluted with nurses replaced by healthcare assistants.

Robert Francis (2013), in the Mid-Staff Report, highlighted a number of warning signs about poor care and leadership that were highlighted in the Trust.

In particular, he highlighted the findings of one internal investigation: ‘The investigation has found evidence of poor leadership and management and of poor nursing care … There is a strong view … that failings are due to the poor staffing levels and therefore excusable. The culture on the ward appears to allow for support of this view … Nobody at Directorate/Trust level appears to have taken responsibility for monitoring to ensure that basic nursing standards/patient care needs are met … There appears to be a lack of commitment at the highest level in the Trust to tackle these problems.’

A number of associations between nurse staffing, educational level and mortality have been identified in the literature. Prof. Drennan said that, for example, Aiken et al. in 2014 found that an increase in a nurse’s workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7%. It also found that every 10% increase in bachelor’s degree nurses was associated with a decrease in this likelihood by 7%.
Aiken et al. also showed that patients in hospitals in which 60% of nurses had bachelor’s degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients.

An increase in a nurse’s workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7%.

Prof. Drennan said research by his Department in UCC funded by the Department of Health and the Health Research Board was carried out to determine the number of nurses needed and the skill mix that should be on medical/surgical wards based on patient acuity and dependency.

“In this study we looked on a day-to-day basis at nurse staffing which previously was largely determined by legacy issues or professional judgement.

“One of the key recommendations of the Taskforce on Nurse Staffing and Skill-Mix published by the Department of Health in February 2016 was that making the role of the clinical nurse manager 100% supervisory, would result in better staff and patient outcomes as this role is essential in ensuring the provision of quality care.

“It said that given the evidence on the impact on the role of the ward leader on quality and staff retention, the reduction in the supervisory time of this role currently in the system was worthy of specific consideration.”

In particular, the research being undertaken in UCC is measuring the economics of nurse staffing and nurse sensitive outcomes associated with nurse staffing including measures such as length of stay, urinary tract infections, pressure ulcers, hospital-acquired pneumonia, shock or cardiac arrest, upper GI bleeding, hospital-acquired sepsis, deep venous thrombosis, CNS complications, wound infection, pulmonary failure, metabolic derangement, mortality and failure to rescue.

Prof. Drennan concluded by saying that future research would target the development and testing of effective staffing methods and the impact of leadership approaches on patient, nurse and organisational outcomes.

“High-quality care cannot be achieved without an empirical approach to safe nurse staffing and leadership,” he said.

They were now moving to research the relationship between nurse staffing and patient care in EDs and a wider number of medical and surgical settings.