Episode Transcript
[00:00:06] Speaker A: Benvenute e benvenutia Podcast nursing La serie podcast realizzata ne lambito della settione nursing del Universita di Genova sono nemaria bagnasco cuesti pod caste suno dedicati etemi del dibatito scientifico e contemporaneo sul infirmieristica da removoce a infirmier italiane internazionali esperti e ricercatori percur un prendere le s fide di questo momento storico chiano nariaduta sul infirmiaristica.
[00:00:35] Speaker B: My name is Jonathan Drennan. I'm professor of Nursing at the School of Nursing, Midriffry and Health Systems at University College Dublin in Ireland. And today I'm going to be talking about the health workforce, particularly the nursing workforce, and looking at its current challenges and looking at what's going to happen in the future in relation to needs and demands of the nursing workforce across Europe. I'll be talking about Ireland and doing some comparisons with Italy as well. So if we look at the overview of the health workforce internationally, we now employ more healthcare professionals than ever before.
But despite this growth that is expected to be over the next decade, a shortfall in the number of healthcare professionals to provide care.
Approximately 10% of the total workforce are employed in health and social care and we look at some of the figures, that's approximately 15% of the total workforce in Nordic countries and the Netherlands. In Ireland, where I work, it's in and around 10 to 12% and in Italy it's gone from approximately 5% to 8% to 68% increase over the last number of years.
When we look at the nursing workforce in particular, one trend that is very obvious is that countries across and particularly the OECD countries have invested heavily increasing their nursing workforce over the last 20 years.
The OECD average is around about 10 nurses per thousand population, but this goes from a low of one to a high of about 20 nurses depending on the countries. In Ireland we've got slightly above we have above the OECD average at 12.7 nurses and in Italy it's approximately 6.2 to 7 per thousand. With Italy lower than the OECD average approximately.
And it has only seen a small growth in the last decade.
And as populations age, this workforce is expected to change in relation to it. So if we look at it as potential, as the populations age, the potential supply of labor in the economy is expected to decline.
So on average, if you look now, there's approximately four people of working age for every one person over 65 and older. But this rate is projected to halve from 4.2 in the last decade to 2.1 across OECD countries over the next 40 years.
And that, in effect, says there's going to be a lower labor market in relation to or fewer people available to enter the nursing and the midwifery professions and healthcare professionals overall.
To counter this, a number of countries are employing or recruiting large numbers of nursing graduates.
And there's huge variation. This can be as low as 8 nursing graduates per 100,000 population, seen in some countries, to a high of 115.7 nursing graduates per 100,000 population. As seen in Australia, Ireland has approximately 32, 33 nursing graduates per 100,000 population. And Italy is relatively low at 17.2. And I know a number of countries are looking at changing this. The OECD average is 42.8 per 100,000 graduates.
But looking at the numbers is not enough. We need to look at the context within which nurses work, and the number of hospital beds can determine nursing work, both within the hospital setting and in the community setting. And if we look at the EU average, the EU average, the 27 EU countries have on average around 4.7 beds per thousand population.
Ireland is lower than the average at 2.9. And Italy is also lower than the average at 3.1, slightly higher than in Ireland.
When you have fewer beds, you get greater demands in relation to emergency departments, you get greater demands in relation to community services and so on, because you've got fewer beds to admit patients. And when you have fewer beds in the hospital, you have higher levels of turnover, and this leads to higher bed occupancy rates. And we know with Italy having 3.1 beds per thousand population and Ireland 2.9, which is below, as I said, the OECD average of around 4.6.
What you do is you get high occupancy rates within hospitals. So in Italy, the bed occupancy rate around about 2020, 2021 was around 75%. In Ireland, that is as high as 90%. And what you get with high bed occupancy rates, you get increased nursing work, particularly at the point of and at the point of discharge, where there is a greater demand for nursing care as patients come in acutely well or you're preparing for patients for discharge. So better occupancy rates need to be taken into account when you're determining the size of the workforce that you need.
So as I said there will be an increasing demand for healthcare workers in the future, with their skills and roads changing, such as advanced nurse practitioners, advanced midwife practitioners, nurses working in the community, developing specialist community service, and so on.
These changes are partially due to the aging population, but also aligned to the growth of people who are living now with long term illnesses.
And this will lead to the reorganization and delivery of care and how we deliver care.
When we look at the aging population, we can see that in Ireland, for example, people aged 65 years and older account for approximately 13% of the population, but they require one third of healthcare activity.
And when you've got a population such as Italy, where There are approximately 19 to 20% of the population are older, that group will account for 50% of healthcare activity. So as populations age, the potential supply of labor in the economy or healthcare labor is expected to decline and the health workforce and the aging population.
So if we look that it's Projected by that 2050, across the EU, 30% of the population will be aged 65 years of age and older. But the work, the health and social care workforce will be approximately 15% of total employment. So we know as we age our career, our care needs increase.
And this results in us having to have a larger and a more diverse and skilled healthcare workforce to provide care.
So with this in mind, we need to questions we need to ask is what type of roles do we need in the future? And we know we need increasing specialist roles. We know we need to develop advanced nurse practitioners, advanced midwife practitioners. We know we need to develop our community nursing to a great extent.
And we know that getting the right numbers of nurses with the right skills in the right place at the right time is really, really important. For example, a paper by Linda Aiken and colleagues in 2014, their results showed this. They looked at discharge data for nearly half a million patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries and a survey of over 265,000 nurses.
And what they found is 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%.
And the education level was also found to be really important.
Every 10% increase in Bachelor's degree nurses, that's nurses who have an education at degree level, was associated with a decrease in mortality by the likelihood of 7%.
And there have been other papers that have shown there's a significant association between increased mortality and increased exposure to shifts in which staffing is below the target level and you get.
The association between increased mortality and high patient turnover was also significant. And we see high patient turnover happening more and more as there's more demands on beds.
In Ireland, we have developed frameworks for safe nurse staffing and skillnets which have become government policy.
And these have been implemented where measures are used to determine the staffing levels based on patient need. And we use nursing hours per patient day in medical surgical wards and nursing hours, patient presentation and emergency departments. And what we find is that when staffing levels are at the level that matches patient need, we get a number of better outcomes when we compare prior to the introduction of the recommendations in the framework and the introduction of SAFE staffing and post. So what we saw was we saw improvement within the clinical environment.
There was an increase in perceptions of staffing, resource adequacy and nurse manager leadership and support, improved, nurse participation in the affairs of the hospital improved and nurses were able to provide higher quality care.
We also saw a fall in the number of activities or care left undone events.
They reduced from prior to the introduction of SAFE staffing from approximately 2.5 per shift down to less than 1 per shift over time.
So this went from approximately 75% of shifts having at least one item undone down to just a little bit over 30% having one item undone. We also saw ratings improve prior to the introduction of SAFE staffing. For example, 4.5% of staff said that the quality of care over the previous six months had improved and this increased to 40.2% following the introduction.
A big European study has also been carried out called Magnet for Europe. And this looks at the work environment and how we can improve the work environment by implementing MAGNET principles in European hospitals.
And things that are shown to improve the environment are things like transformational leadership, structural empowerment, having exemplary professional practice and basing nursing care on the use of knowledge and using research in relation to empirical quality results.
And when we ask nurses what they want in relation to improving their well being and reducing burnout, the one thing that comes up at the top of the list are those organizational interventions that nurses find helps improve their working environment. So things like improving nurse staffing levels, reducing the burden of clinical documentation and ensuring that there's a systematic approach to determining staffing levels. The things that are least seen as helpful for reducing burnout and least successful in improving wellbeing are things like meditation and reflection and providing resilience training.
We're not saying these are not important, but what nurses find as the most important are those organizational rather than Individual level interventions that can change their well being and reduce the levels of burnout. And this is shown in other results that we took from nurses in 64 hospitals across Europe. So a sample size of over 6,500 and those who work in poor working environments. 28% of the staff within poor working environments met the level of having burnout and 38% intended to leave. However, when working environments are good or improve, what we see is that the percentage of experiencing burnout fall to 17%. So a reduction from 28 we see to 17% is and approximately 20% have an intention to leave.
So how can we improve workforce wellbeing? And the WHO has produced a very good report called Health and Care Workforce in Time to act. And they talk about retention and recruitment with predominance of retention.
So as the workforce ages, we need to be in a position where we can retain the workforce. And there are 10 actions that the WHO talks about strengthening the workforce.
We need to align education with population needs and health service requirement. So the education of nurses and midwives should be aligned to that in relation to the population and particularly the development of roles that would be able to provide care in the community, provide advanced nurse practitioners to provide specialized care. And in relation to ongoing education, continuing professional development is seen as a key factor in relation to it. So we need to equip the workforce with new knowledge and competencies, new skills.
We need to expand the use of digital tools that support the workforce and most importantly develop strategies that attract and retain health workers in all areas, but in particular those areas where it's difficult to recruit nursing staff.
And many of the magnet principles that I spoke about earlier will help with that.
The working conditions of nurses are extremely important and we need to be create work conditions that promote a healthy work life balance. And nurses themselves say that one of the main ways of doing this is to ensure that safe levels of staffing are available.
We need to protect the health and mental well being of the workforce. And this goes back to creating a healthy environment and promoting a healthy work life balance.
Leadership is extremely important and developing leaders both at ward level and at hospital level and community level. So those nurses and midwives that are going to lead in the future, we need to develop their capacity and to ensure that they have the skills that they can apply to workforce governance and planning.
We need to strengthen health information systems and data is the lifeblood of the research that we do in relation to showing that when we identify safe staffing levels, the change that makes both to staff and patient outcomes and we need to increase public involvement in workforce education, development and protection, and then optimize the healthcare funds we use through innovative workforce policies.
So what we can see overall in relation to the healthcare workforce is there's going to be an increasing demand for healthcare workers over the next 20 to 30 years, particularly as populations age and their needs become quite unique in relation to provision of care. We need to diversify roles not to be too hospital centric, although the hospital workforce will remain important, but we need to look at roles that will provide care in the community for the those patients to remain at home or as close to home as long as possible.
And we also need to develop further advanced nurse practitioner roles. In Ireland this has been very successful, but approximately 3 to 4% of the nursing workforce and midwifery workforce now in advanced practice roles emergency care, care of the older persons, care of patients with long term conditions such as in relation to rheumatology and so on. And these have been very successful in preventing hospitalizations but also ensuring those patients have access to a wide range of health care. We also need to introduce models of safe staffing that are based on evidence. We know from the evidence, as I said, that where you have a workforce that meets the needs of patients and is at the level of patient requirement, you get reduced mortality, reduced adverse events, high levels of patient satisfaction and much better patient outcomes. And these also impact on staff, such as reducing burnout, increasing job satisfaction and reducing intention to leave in that patient that staff will want to remain within the healthcare setting.
So there are challenges ahead, but research and evidence has been used within developments that will impact on the healthcare workforce. Using evidence to determine safe staffing levels and using evidence to show the impact that nurses have on patient outcomes. I hope you found the podcast helpful. I can be contacted at Jonathan drennancd ie if you have any queries or follow ups. Thank you.
[00:18:41] Speaker A: Podcast Nursing a frontal giornamento scientifico continuo sul infirmieristica italiane internazionale e promo vela cultura e la conoscenza del nursing una produzione uni geradio.
