Having worked as a health professional for almost 40 years, in Ireland and abroad, I am astounded by the rhetoric offered by politicians and health service administrators, year after year, as a response to an annual predictable health services challenge. What is most worrying about the official response is the helplessness, the lack of direction and solutions, and a tacit public acceptance of the problem.
The emergency department (ED) problem requires new services involving primary care and community care and secondary care including the public and private health sectors with a funded plan detailing buildings, bed capacity and staffing.
The first task is to make a clear factual statement about the appropriateness and capacity of the existing hospital structures and the allocated budget to deal with the trolley crises.
The shortage of doctors and nurses has been a constant in the narrative on the ED crises, with hospital bed closures being attributed to a lack of staff. The answer to the manpower problem is not just about the requirement for more healthcare staff, it is also about how staff and beds and managed. A number of areas must be addressed: staff recruitment and retention; staff deployment and staff management. Manpower plans for each ED must determine the level of understaffing that exists, with plans and funding to address the problem. Medical consultants must be available in all EDs, right around the clock, to support timely and effective decision-making about patient relocation.
Negative impact
There is irrefutable evidence that the ED medical and nursing roles, in normal circumstances, are categorised as very stressful roles, and the current environment has further had a negative impact on the work of staff. The environments in which doctors and nurses work are expected to manage patient care are Dickensian and the antithesis of the education they received and practice standards which they are accountable for, and expected to abide by, through statutory regulation of their professional roles.
Doctors are expected to execute indefensible decisions about patients progressing from a chair to a trolley to a bed in a corridor and, eventually, to a bed in a ward
Health professionals as patient advocates are expected to be responsible for executing indefensible decisions about ED patients progressing from a chair, to a trolley, to a bed in a corridor, and eventually to a bed in a ward. Such scenarios are alien to best practice and create a vulnerable environment for sick people and health professionals. Attracting staff to such health care environments is one of the major obstacles to be addressed.
The Health Service Executive must reverse the perceptions and image of the nursing and medical professions created in recent years. Workplace empowerment of nurses and doctors needs to be embraced by health services employers so as to create working conditions that promote work effectiveness, positive work attitudes and better staff satisfaction. It’s not just about recruitment – it is also about retention of nurses and doctors and this will require extraordinary measures aimed at incentivising staff as a means of stabilising the nursing and medical professions in Ireland. Addressing the staffing issue also requires a review of roles and skill mix, including medical staff, nursing staff and healthcare assistants, in fulfilling the work of the ED.
Shortage of beds
There is now agreement at all levels of decision-making about the shortage of hospital beds, with the latest official report committing to more than 2,000 beds. However some observers argue there is need for 9,000 new beds. If we replicate the current approach to bed management and the organisation of clinical services, we are unlikely to solve the problem.
For a patient, arriving in a hospital ED, with an expectation of a bed in that hospital, may be unrealistic in the future. Bed management, with a lack of hospital beds, requires lateral thinking about the use of beds. A national plan must focus in key areas including: as well as beds, an enhanced investment in step-down infrastructure; expansion and diversification of community nursing services to include highly-skilled advanced nurse practitioners in primary care, with decision-making powers, which will bring a new order to healthcare delivery; an expansion of day surgery to international best practice levels will ensure a functioning hospital not constipated by the trolley crises.
An examination, review and plan for the use of nursing-home beds should be configured with a clearly established position in relation to bed capacity and medical and nursing skills required in nursing homes, within the vicinity of each ED. Such an arrangement can ensure a bed and a more appropriate environment for some sick people on trolleys in the department.
Policymakers and health service employers must learn from the sequence of events of the last 10 years which has fragmented health service developments with no unifying direction.
Prof Seamus Cowman is head of the school of nursing and midwifery at the Royal College of Surgeons in Ireland