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Ireland Proposes Promising Model for Nurse Staffing

Sofer, Dalia

AJN The American Journal of Nursing: July 2018 - Volume 118 - Issue 7 - p 15
doi: 10.1097/01.NAJ.0000541418.75229.9d
In the News

In pilot studies, the framework reduced adverse events and absenteeism.

Dalia Sofer



Ireland's Department of Health has published the final draft of a proposed framework for levels of nurse staffing and skill mix in acute care settings. Among other recommendations, the report, Framework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Care Settings in Adult Hospitals in Ireland, calls for a skill mix of 80% RNs to 20% health care assistants.

The proposal, developed by a task force over four years, was based on consultation with nurses and other stakeholders and on a review of the research literature on safe staffing practices. Shunning a “one-size-fits-all” approach for determining safe nurse staffing and skill mix, the final draft takes into account many influencing factors such as the changing dynamic of patients, nursing roles, and environmental conditions. It also allows for professional judgment in determining optimum staffing.

Besides the 80:20 ratio of RNs to health care assistants, recommendations include a clinical nurse manager in an exclusively supervisory role; timely recruitment to avoid gaps in staff replacement; identification of a specific “tipping point” on each hospital unit to mark the staffing level below which care becomes unsafe; and identifying, on a shift-by-shift basis, Safety CLUEs (Care Left Undone Events)—activities that could not be completed (for example, timely provision of medications; support for patients with toileting, eating, or washing needs; missed staff meal breaks; and delays in recording clinical events or updating care plans). The CLUE reports are to be monitored by a clinical nurse manager with the authority and defined institutional protocols to initiate appropriate response.

Pilot studies of the framework in three hospitals across Ireland yielded overwhelmingly positive results. These included reductions in adverse events, missed care, absenteeism (most units reported sickness absence rates below the national average of 5%), and use of agency nurses to augment staffing levels. In addition, nurses reported improved job satisfaction, noting greater collegiality between physicians and nurses, improved abilities in nurse managers, better leadership and support, and more opportunity for nurses to participate in hospital affairs and provide a high quality of care.

Early data on cost-effectiveness also are promising. The pilot studies measured fewer adverse patient events as a result of the framework, suggesting cost savings from better patient outcomes. And reduced use of agency nurses—as much as 95% in some settings—more than offset the cost of implementing the recommended staffing ratios.

The Irish Nurses and Midwives Organisation welcomed the new framework, which was released in April, and called for immediate government funding to implement it nationally. Access the full report at—Dalia Sofer

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