Advanced nurse and midwife practitioners' experience of interprofessional collaboration when implementing evidence-based practice into routine care: An interpretative phenomenological analysis.

AIM: To understand advanced nurse and midwife practitioners' experience of interprofessional collaboration in implementing evidence-based practice into routine care. DESIGN: A qualitative interpretative phenomenological analysis. METHODS: A purposeful sample of 10 Registered Advanced Nurse and Midwife Practitioners from a range of practice settings in the Republic of Ireland participated in semi-structured interviews over a 10-month timeframe. Interviews were transcribed verbatim and data were analysed using a multi-stage approach in line with guidance for interpretative phenomenological analysis. RESULTS: Six superordinate themes emerged: Understanding of advanced practice; 'Treated as an equal and as a "nurse"'; Nursing management support; 'A voice to implement anything new'; Confidence and Emotional intelligence. These factors impacted interprofessional relationships and the extent to which advanced practitioners could implement evidence-based practice. CONCLUSION: There is scope to improve advanced practitioners' ability to collaborate with the interprofessional team in implementing evidence-based practice into routine care. IMPACT AND IMPLICATIONS: The study findings demonstrate that enhancing understanding of the advanced practice role; increasing organizational support for advanced practitioners and augmenting specific practitioner skills and attributes will increase their ability to collaborate effectively and implement evidence-based practice. Supporting advanced practitioners in this important aspect of their role will positively influence health outcomes for patients. CONTRIBUTION TO THE WIDER GLOBAL CLINICAL COMMUNITY: As numbers of both nurse and midwife practitioners increase globally, this study provides timely evidence from a range of practice settings to guide the design of education programmes and policies governing advanced practice. Study recommendations have broad applicability to all healthcare professionals who are engaged in implementing evidence-based practice into routine care. REPORTING METHOD: Consolidated criteria for reporting qualitative research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Insider versus outsider workplace mistreatment and their impact on affective ill-being in healthcare professionals: Can personal resources act as buffers?

AIMS: Workplace stress can negatively impact healthcare providers' professionalism and quality of care. One source of workplace stress is the experience of workplace mistreatment. Drawing on the Job Demands-Resources theory, this study aimed to (a) investigate the impact of mistreatment frequency experienced by healthcare workers from insider sources (i.e. co-workers, supervisors) and outsider sources (i.e. patients, visitors) on affective ill-being and (b) the potential moderating role of trait resilience and trait self-efficacy, as personal resources, in the mistreatment-ill-being relationship. DESIGN: Lagged design. METHODS: We collected data from 153 Irish healthcare workers between January 2018 and June 2019 via three surveys, separated by 1-week intervals. Personal resources were measured at Time 1, frequency of mistreatment from the two sources was assessed at Time 2 and affective ill-being was assessed at Time 3. We used moderated regression analyses to evaluate the association of mistreatment frequency from the two sources and affective ill-being and the moderating effect of personal resources. RESULTS: Only insider mistreatment frequency was positively related to affective ill-being. Furthermore, the positive impact of insider mistreatment on affective ill-being was moderated by self-efficacy (but not by trait resilience). In contrast to our expectations, the relationship was stronger at high levels compared to low levels of self-efficacy. CONCLUSION: Mistreatment from co-workers and supervisors is linked to higher levels of affective ill-being. Additionally, healthcare workers with high self-efficacy were more vulnerable to the negative consequences of co-worker and supervisor mistreatment as it impacted their affective ill-being. IMPACT: These findings extend the literature on workplace mistreatment by integrating insider and outsider perpetrators of mistreatment and examining their differential impact on the employees' affective ill-being. It also highlights mistreatment from organizational insiders as a significant factor in the relationship between mistreatment and affective ill-being. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL COMMUNITY?: The findings underscore the detrimental impact of workplace mistreatment on the well-being of healthcare professionals. The study findings of higher frequency of insider mistreatment being associated with increased affective ill-being call for action, with line managers and supervisors being critical to achieving respective changes in healthcare workers' environment. The findings have implications for policymakers interested in developing a framework to support healthcare professionals in addressing workplace mistreatment, enabling them to effectively fulfil their role as care providers.

Clinical decision-making processes among graduate nurses, specialist nurses and nurse practitioners A collaborative international study.

AIM: To explore clinical decision-making by comparing the processes used by three groups of nurses in the emergency departments of three hospitals: in Norway, Finland and Ireland. BACKGROUND: Clinical decision-making in an emergency department environment is a complex process often occurring in times of crisis. It is an important aspect contributing to the quality of care. However, empirical research is limited regarding the decision-making process in different nursing roles. METHODS: In accordance with the consolidated criteria for reporting qualitative research, a qualitative and observational study was conducted to explore clinical decision-making by comparing the processes used by three groups of nurses in the emergency departments of three hospitals: in Norway, Finland and Ireland. Six Registered Nurses, six Nurse Specialists and six Nurse Practitioners were observed. A total of 40 hours of observation was made at each setting according to a structured observation guideline, followed by clarifying questions. The data material was analysed by means of a qualitative manifest and latent content analysis. RESULTS: Three themes arose: acting in accordance with routines, previous experience and intuition; considering patient experience; and facilitating new alternatives based on critical thinking. The Registered Nurses mainly used the first approach, the Nurse Specialists used the first and the second approaches, and the Nurse Practitioners used all three approaches. CONCLUSIONS: The results highlight the differences in decision-making processes between these groups. Nurse Practitioners were the only group that facilitated and evaluated new alternatives using their clinical autonomy, such as stepping up and making independent and collaborative decision-making. IMPLICATION: The results can be used in countries developing advanced practice nursing education and defining their scope of practice to inform stakeholders.

Nursing in rural, remote and isolated settings: a literature review.

INTRODUCTION: Public Health and Community Nurses provide the foundation of Ireland's community, school and home delivered nursing care in rural, remote and isolated settings in Ireland, yet there is limited research evidence on the roles, responsibilities and models of care provided by these nurses. METHODS: Research literature was searched using CINAHL, PubMED, Medline. Fifteen articles were subject to quality appraisal and included for review. Findings were analysed, thematised and compared. RESULTS: Emergent themes - (1) models of nursing care provision in rural, remote and isolated settings; (2) barriers and facilitating factors impacting the roles and responsibilities; (3) expanded scope of practice shaping responsibilities; and (4) providing an integrated approach to care. DISCUSSION: Nurses working in rural, remote and isolated settings including off-shore islands are frequently lone workers who act as liaison for care recipients and their families with other healthcare providers. They triage care, engage in home visits, provide emergency first response, engage in illness prevention and health maintenance support. Models of care delivery using a hub and spoke model, orbiting staff, or longer-term shared positions must be based on principles for assigning nurses in rural settings and off-shore islands. New technologies allow specialist care to be delivered remotely and acute professionals will integrate with nurses in maximising care in the community. Better health outcomes are driven by the use of: validated evidence-based decision-making tools; medicine protocols; and accessible, integrated and role-specific education. Planned and focused mentorship programmes support nurses who are lone workers and impact on retention challenges.

Assessing Operative Skill in the Competency-based Education Era: Lessons From the UK and Ireland.

INTRODUCTION: Decisions regarding the operative competence of surgical residents in the United Kingdom and Ireland are informed by operative workplace-based assessments (WBAs) and operative number targets for index procedures. This review seeks to outline the validity evidence of these assessment methods. METHODS: A review of the MEDLINE (Pubmed), EMBASE and Cochrane Library databases was undertaken in accordance with the Joanna Briggs Institute Protocol for Scoping Reviews (2020). Articles were included if they provided evidence of the validity of procedure-based assessments, direct observation of procedural skills, or indicative operative number targets. The educational impact of each article was evaluated using a modified Kirkpatrick model. RESULTS: Twenty-eight articles outlining validity evidence of WBAs and operative number targets were synthesised by narrative review. Five studies documented users' views on current assessment methods (Kirkpatrick level 1). Two articles recorded changes in attitudes towards current operative assessments (level 2a). Ten studies documented the ability of current assessments to record improvements in operative competence (level 2b). Ten studies measured a change in behaviour as a result of the introduction of these assessments (level 3). One article studied the ability of operative assessments to predict clinical outcomes (level 4b). CONCLUSIONS: Operative WBAs are reliable. Scores achieved correlate with both time spent in training and recorded operative experience. Trainers and residents have concerns regarding the subjectivity of these assessments and the opportunistic nature in which they are used. Operative number targets are not criterion-referenced, lack validity evidence, and may be set too low to ensure operative competence.

Implications for health system reform, workforce recovery and rebuilding in the context of the Great Recession and COVID-19: a case study of workforce trends in Ireland 2008-2021.

BACKGROUND: Workforce is a fundamental health systems building block, with unprecedented measures taken to meet extra demand and facilitate surge capacity during the COVID-19 pandemic, following a prolonged period of austerity. This case study examines trends in Ireland's publicly funded health service workforce, from the global financial crisis, through the Recovery period and into the COVID-19 pandemic, to understand resource allocation across community and acute settings. Specifically, this paper aims to uncover whether skill-mix and staff capacity are aligned with policy intent and the broader reform agenda to achieve universal access to integrated healthcare, in part, by shifting free care into primary and community settings. METHODS: Secondary analysis of anonymised aggregated national human resources data was conducted over a period of almost 14 years, from December 31st 2008 to August 31st 2021. Comparative analysis was conducted, by professional cadre, across three keys periods: 'Recession period' December 31st 2008-December 31st 2014; 'Recovery period' December 31st 2014-December 31st 2019; and the 'COVID-19 period' December 31st 2019-August 31st 2021. RESULTS: During the Recession period there was an overall decrease of 8.1% (n = 9333) between December 31st 2008 and December 31st 2014, while the Recovery period saw the overall staff levels rebound and increase by 15.2% (n = 16,789) between December 31st 2014 and December 31st 2019. These figures continued to grow, at an accelerated rate during the most recent COVID-19 period, increasing by a further 8.9% (n = 10,716) in under 2 years. However, a notable shift occurred in 2013, when the number of staff in acute services surpassed those employed in community services (n = 50,038 and 49,857, respectively). This gap accelerated during the Recovery and COVID-19 phase. By August 2021, there were 13,645 more whole-time equivalents in acute settings compared to community, a complete reverse of the 2008 situation. This was consistent across all cadres. Workforce absence trends indicate short-term spikes resulting from shocks while COVID-19 redeployment disproportionately impacted negatively on primary care and community services. CONCLUSIONS: This paper clearly demonstrates the prioritisation of staff recruitment within acute services-increasing needed capacity, without the same commitment to support government policy to shift care into primary and community settings. Concerted action including the permanent redistribution of personnel is required to ensure progressive and sustainable responses are learned from recent shocks.

Public health nursing education in Ireland and Norway: A comparative analysis.

BACKGROUND: Public health, primary health care, and nursing are founding principles of public health nursing. Thus, the underpinning curriculum needs to reflect these core principles. Public health nursing educators sought to delve deeper into curricula and training of public health nurse (PHNs) in Ireland and Norway OBJECTIVE: To compare PHNs' educational training in Ireland and Norway through a collaborative process DESIGN: This study used a descriptive comparative design SAMPLE: A panel of expert educators (the authors) compared national Public health nursing education strategies, guidelines, and curricula used to train PHN students RESULTS: Four core categories emerged from the analysis: general characteristics, theoretical and empirical knowledge base for PHNs practice, applying theory to clinical practice, and professional/ethical dimensions for practice. Results revealed more similarities than differences in both countries' educational models. The central difference related to the specialist role in Norway versus the generalist role in Ireland CONCLUSIONS: Workforce requirements drive the delivery of Public Health Nursing programs and educational curricula. However, it is imperative that educators evaluate their curricula in terms of fitness and practice, not just purpose.

COVID-19 and doctor emigration: the case of Ireland.

BACKGROUND: Since the 2008 recession, Ireland has experienced large-scale doctor emigration. This paper seeks to ascertain whether (and how) the COVID-19 pandemic might disrupt or reinforce existing patterns of doctor emigration. METHOD: This paper draws on qualitative interviews with 31 hospital doctors in Ireland, undertaken in June-July 2020. As the researchers were subject to a government mandated work-from-home order at that time, they utilised Twitter™ to contact potential respondents (snowball sampling); and conducted interviews via Zoom™ or telephone. FINDINGS: Two cohorts of doctors were identified; COVID Returners (N = 12) and COVID Would-be Emigrants (N = 19). COVID Returners are Irish-trained emigrant doctors who returned to Ireland in March 2020, just as global travel ground to a halt. They returned to be closer to home and in response to a pandemic-related recruitment call issued by the Irish government. COVID Would-be Emigrants are hospital doctors considering emigration. Some had experienced pandemic-related disruptions to their emigration plans as a result of travel restrictions and border closures. However, most of the drivers of emigration mentioned by respondents related to underlying problems in the Irish health system rather than to the pandemic, i.e. a culture of medical emigration, poor working conditions and the limited availability of posts in the Irish health system. DISCUSSION/CONCLUSION: This paper illustrates how the pandemic intensified and reinforced, rather than radically altered, the dynamics of doctor emigration from Ireland. Ireland must begin to prioritise doctor retention and return by developing a coherent policy response to the underlying drivers of doctor emigration.

Prioritization and management of calls from older people to GP out-of-hours services.

BACKGROUND: Urgent out-of-hours medical care is necessary to ensure people can remain living at home into older age. However, older people experience multiple barriers to using out-of-hours services including poor awareness about the general practitioner (GP) out-of-hours (GPOOH) service and how to access it. In particular, older people are reluctant users of GPOOH services because they expect either their symptoms will not be taken seriously or they will simply be referred to hospital accident and emergency services. The aim of this study was to examine if this expectation was borne out in the manner of GPOOH service provision. OBJECTIVE: The objective was to establish the urgency categorization and management of calls to GPOOH , for community dwelling older people in Ireland. METHODS: An 8-week sample of 770 calls, for people over 65 years, to a GPOOH service in Ireland, was analysed using Excel and Nvivo software. RESULTS: Urgency categorization of older people shows 40% of calls categorized as urgent. Recognition of the severity of symptoms, prompting calls to the GPOOH service, is also reflected in a quarter of callers receiving a home visit by the GP and referral of a third of calls to emergency services. The findings also show widespread reliance on another person to negotiate the GPOOH system, with a third party making 70% of calls on behalf of the older person seeking care. CONCLUSION: Older people are in urgent need of medical services when they contact GPOOH service, which plays an effective and patient-centred gatekeeping role, particularly directing the oldest old to the appropriate level of care outside GP office hours. The promotion of GPOOH services should be enhanced to ensure older people understand their role in supporting community living.

Teaching acute hospital staff and students about patient flow.

Good patient flow in an acute hospital is concerned with ensuring patients experience minimal delays throughout the hospital journey, from the emergency department to the wards, outpatients and to a suitable discharge destination. Good flow requires effective processes, staff buy-in and staff education. This study aimed to explore ways in which this topic is currently taught in an Irish acute hospital group. Participants were recruited to engage in semi-structured interviews about their experience of teaching patient flow. Following qualitative data analysis using a structured analysis guide, five main themes were identified: current methods, unstructured nature of teaching, frustration with frequency, dissemination of teaching/learning and opportunities for improvement. Recommendations from this study could be used to support a formalised approach to teaching this topic in the future. The use of the Teaching for Understanding framework and Universal Design for Learning principles are strongly advocated to support the development of a nationwide module, to structure the topics to be taught and provide guidance on how to effectively and efficiently teach this topic in Ireland.

The effect of breaches of the psychological contract on the job satisfaction and wellbeing of doctors in Ireland: a quantitative study.

BACKGROUND: Medicine is one of the most popular college degrees at both undergraduate and postgraduate level. Despite this, morale and wellbeing in doctors at all levels internationally is reportedly low. Long hours and stressful working environments have been implicated as the cause of this. The psychological contract is the implicit expectations and mutual obligations held between an employee and employer. Breaches in this contract can lead to strong negative emotional responses. This study will examine the psychological contract of non-consultant doctors and gain further insight into their job satisfaction and wellbeing. It aims to ascertain the effect of breaches of the psychological contract on their job satisfaction and wellbeing. METHODS: This is a quantitative study performed using a questionnaire on a closed online forum. Job satisfaction, wellbeing and breaches of the psychological contract were measured using pre-existing and pre-validated scales. Statistical analysis was performed to determine the effect of breaches of the psychological contract on job satisfaction and wellbeing. RESULTS: This study ascertained that training and career development were the most important areas of the psychological contract for non-consultant doctors and training and organizational support the most important breaches. It found, overall, positive levels of job satisfaction and wellbeing. A statistically significant relationship between breaches of the psychological contract and job satisfaction and wellbeing was found. CONCLUSION: This study provides an insight into the psychological contract of non-consultant doctors in Ireland. By doing so, it identifies areas for change which may improve their future job satisfaction and wellbeing.

The development of a framework of entrustable professional activities for the intern year in Ireland.

BACKGROUND: Entrustable Professional Activities (EPAs) are units of professional practice that capture essential competencies in which trainees must become proficient before undertaking them independently. EPAs provide supervisors with a solid justification for delegating an activity to trainees. This study aimed to develop and ensure face validity of a set of EPAs for junior doctors in the first year of clinical practice in the Republic of Ireland. METHODS: An iterative eight stage consensus building process was used to develop the set of EPAs. This process was based on international best practice recommendations for EPA development. A series of surveys and workshops with stakeholders was used to develop a framework of EPAs and associated competencies. An external stakeholder consultation survey was then conducted by the Irish Medical Council. The framework of EPAs was then benchmarked against the 13 core EPAs developed by the Association of American Medical Colleges (AAMC). RESULTS: A framework of seven EPAs, and associated competencies resulted from this study. These EPAs address all core activities that junior doctors should be readily entrusted with at the end of the intern year, which is the first year of clinical practice in the Republic of Ireland. Each EPA contains a series of defined competencies. The final EPAs were found to be comparable to the AAMC core EPAs for entering residency. CONCLUSIONS: A framework of EPAs for interns in Ireland that are appropriate for the intern year has been developed by key stakeholders. The implementation of the EPAs in practice is the next step, and is likely to result in an improved intern training process and increased patient safety.

Patient satisfaction with physician assistant/associate care: an international scoping review.

BACKGROUND: As the role of the physician assistant/associate grows globally, one question is: what is the level of patient satisfaction with PAs? Driven by legislative enactments to improve access to care, the PA has emerged as a ready and able medical professional to address workforce shortages. The aim of this study was to review the literature on patient satisfaction of PAs. OBJECTIVES: The basis for this review was to clarify working definitions, synthesize the evidence, and establish conceptual boundaries around the topic of patient satisfaction with PAs. The intent was to identify gaps in the literature and offer suggested undertakings for more clarification on the subject. METHODS: A scoping review was undertaken. Literature from 1968 to 2019 was searched and filtered for eligibility. Those that met criteria were categorized by date, method, geography, themes, and design. RESULTS: In total, there were 987 papers or reports that were identified through bibliography database searching. Additional articles found through snowball methodology-reviewing references (n = 11). Only English language articles emerged for analysis. From this effort, 25 articles surfaced from the filtering process for final inclusion. Most (72%) of the articles came from the United States of America, three from the United Kingdom, and one each from Ireland, the Netherlands, and New Zealand. Most articles were descriptive in nature. Some variations in methods emerged. CONCLUSION: PAs are operational in 15 nations; their acceptance appears successful and satisfaction with their care largely indistinguishable from physicians. Findings from this analysis highlight one theory that when patient's needs are met, satisfaction is high regardless of the medical provider. Areas for further research are identified.

Tracking the leavers: towards a better understanding of doctor migration from Ireland to Australia 2008-2018.

BACKGROUND: The recession of 2008 triggered large-scale emigration from Ireland. Australia emerged as a popular destination for Irish emigrants and for Irish-trained doctors. This paper illustrates the impact that such an external shock can have on the medical workforce and demonstrates how cross-national data sharing can assist the source country to better understand doctor emigration trends. METHOD: This study draws on Australian immigration, registration and census data to highlight doctor migration flows from Ireland to Australia, 2008-2018. FINDINGS: General population migration from Ireland to Australia increased following the 2008 recession, peaked between 2011 and 2013 before returning to pre-2008 levels by 2014, in line with the general economic recovery in Ireland. Doctor emigration from Ireland to Australia did not follow the same pattern, but rather increased in 2008 and increased year on year since 2014. In 2018, 326 Irish doctors obtained working visas for Australia. That doctor migration is out of sync with general economic conditions in Ireland and with wider migration patterns indicates that it is influenced by factors other than evolving economic conditions in Ireland, perhaps factors relating to the health system. DISCUSSION: Doctor emigration from Ireland to Australia has not decreased in line with improved economic conditions in Ireland, indicating that other factors are driving and sustaining doctor emigration. This paper considers some of these factors. Largescale doctor emigration has significant implications for the Irish health system; representing a brain drain of talent, generating a need for replacement migration and a high dependence on internationally trained doctors. This paper illustrates how source countries, such as Ireland, can use destination country data to inform an evidence-based policy response to doctor emigration.

The impacts of training pathways and experiences during intern year on doctor emigration from Ireland.

BACKGROUND: Emigration of domestically-trained health professionals is widespread, including in Ireland which has the highest rate of medical graduates in the OECD. Ireland's failure to retain graduates necessitates high levels of international recruitment. This study aimed to identify factors associated with recently graduated doctors' intention to migrate, focusing on their work experiences during the mandatory post-graduation year, their wellbeing, and their perceptions of postgraduate training in Ireland. METHODS: A baseline survey was administered online to all final year students in Ireland's six medical schools. A subsequent sweep surveyed those who consented to follow-up (n = 483) during the final month of first year of practice. RESULTS: Of the 232 respondents (48% response rate), 210 (94%) were Irish passport holders. Of these, only 36% intended to remain in Ireland after their internship, 57% intended to leave but return later, and 7% intended to leave permanently. A strong predictor of intention was study pathway: 60% of Graduate Entry Medicine (GEM) graduates and 25% of Direct Entry Medicine (DEM) graduates intended to remain in Ireland. Equal proportions intended to leave permanently (8% DEM, 6% GEM). Being a GEM graduate significantly reduced the likelihood of leaving to return (relative risk ratio (RRR) 0.20, 95% confidence interval (CI) (0.11-0.39), p < 0.001). When adjusted for study pathway, a negative experience as an intern increased the likelihood of leaving to return (RRR 1.16 CI (1.00-1.34), p = 0.043) and leaving permanently (1.54 (1.15-2.04), p = 0.003). Similarly, experience of callousness was associated with leaving to return (1.23 (1.03-1.46), p = 0.023) and leaving permanently (1.77 (1.24-2.53), p = 0.002), as was burnout with leaving permanently (1.57 (1.08-2.27), p = 0.017). Those planning to specialise in Medicine versus General Practice were more likely to leave and return (3.01 (1.09-8.34), p = 0.034). Those with negative perceptions of training in Ireland were more likely to leave and return (1.16 (1.01-1.34), p = 0.037); a positive perception reduced the likelihood of leaving permanently (0.50 (0.26-0.94), p = 0.032). CONCLUSIONS: Increasing GEM training places might improve Ireland's retention of domestically-trained doctors, reducing reliance on non-EU-trained doctors. However, improvements in the working experiences, perceptions of training, and protection of wellbeing are essential for retaining this highly sought-after and geographically mobile cohort.

'Everything was just getting worse and worse': deteriorating job quality as a driver of doctor emigration from Ireland.

BACKGROUND: Medicine is a high-status, high-skill occupation which has traditionally provided access to good quality jobs and relatively high salaries. In Ireland, historic underfunding combined with austerity-related cutbacks has negatively impacted job quality to the extent that hospital medical jobs have begun to resemble extreme jobs. Extreme jobs combine components of a good quality job-high pay, high job control, challenging demands, with those of a low-quality job-long working hours, heavy workloads. Deteriorating job quality and the normalisation of extreme working is driving doctor emigration from Ireland and deterring return. METHODS: Semi-structured qualitative interviews were conducted with 40 Irish emigrant doctors in Australia who had emigrated from Ireland since 2008. Interviews were held in July-August 2018. RESULTS: Respondents reflected on their experiences of working in the Irish health system, describing hospital workplaces that were understaffed, overstretched and within which extreme working had become normalised, particularly in relation to long working hours, fast working pace, doing more with less and fighting a climate of negativity. Drawing on Hirschman's work on exit, voice and loyalty (1970), the authors consider doctor emigration as exit and present respondent experiences of voice prior to emigration. Only 14/40 respondent emigrant doctors intend to return to work in Ireland. DISCUSSION: The deterioration in medical job quality and the normalisation of extreme working is a key driver of doctor emigration from Ireland, and deterring return. Irish trained hospital doctors emigrate to access good quality jobs in Australia and are increasingly likely to remain abroad once they have secured them. To improve doctor retention, health systems and employers must mitigate a gainst the emergence of extreme work in healthcare. Employee voice (about working conditions, about patient safety, etc.) should be encouraged and used to inform health system improvement and to mitigate exit.

Ageing in the nursing workforce - a global challenge in an Irish context.

BACKGROUND: The 2008 financial crisis exacerbated an already mounting workforce challenge faced by most health services in the western world, namely the recruitment and retention of qualified nurses. AIM: This paper examines two additional challenges of relevance to workforce planning in health care, an ageing nursing workforce and reliance upon migrant nurses to solve short-term workforce issues. METHODS: Using Ireland as a case exemplar of these issues, this paper argues that policy makers and service providers should seek not only to address the challenge of retaining trained newly qualified and younger nurses but also focus on supporting older nurses and migrant nurses to remain within the workforce. FINDINGS: The findings of this paper highlight the need for workforce planners, policy makers and service providers to take account of an ageing nursing workforce and reliance on foreign-trained nurses as a solution to short-term planning difficulties. CONCLUSION: Failure to address this need is likely to lead to significant workforce difficulties for health services into the future and undermine current efforts to increase the number and long-term retention of qualified nursing staff. IMPLICATIONS FOR NURSING POLICY: Policy makers and service providers should focus on the retention of trained older nurses as an important element of workforce planning.

Human Disease/Clinical Medical Sciences in Dentistry: Current state and future directions of undergraduate teaching in the UK and Ireland.

In March 2017, a group of teachers of human disease/clinical medical science (HD/CMSD) representing the majority of schools from around the UK and Republic of Ireland met to discuss the current state of teaching of human disease and also to discuss how the delivery of this theme might evolve to inform improved healthcare. This study outlines how the original teaching in medicine and surgery to dental undergraduate students has developed into the theme of HD/CMSD reflecting changing needs as well as guidance from the regulators, and how different dental schools have developed their approaches to reach their current state. Each school was also asked to share a strengths, weakness, opportunities and threats (SWOT) analysis of their programme and to outline how they thought their HD/CMSD programme may develop. The school representatives who coordinate the delivery and assessment of HD/CMSD in the undergraduate curriculum have extensive insight in this area and are well-placed to shape the HD/CMSD development for the future.

The impact of austerity on the health workforce and the achievement of human resources for health policies in Ireland (2008-2014).

BACKGROUND: The global economic crisis saw recessionary conditions in most EU countries. Ireland's severe recession produced pro-cyclical health spending cuts. Yet, human resources for health (HRH) are the most critical of inputs into a health system and an important economic driver. The aim of this article is to evaluate how the Irish health system coped with austerity in relation to HRH and whether austerity allowed and/or facilitated the implementation of HRH policy. METHODS: The authors employed a quantitative longitudinal trend analysis over the period 2008 to 2014 with Health Service Executive (HSE) staff database as the principal source. For the purpose of this study, heath service employment is defined as directly employed whole-time equivalent public service staffing in the HSE and other government agencies. The authors also examined the heath sector pay bill and sought to establish linkages between the main staff database and pay expenditure, as given in the HSE Annual Accounts and Financial Statements (AFS), and key HRH policies. RESULTS: The actual cut in total whole-time equivalent (WTE) of directly employed health services human resources over the period 2008 to 2014 was 8027 WTE, a reduction of 7.2% but substantially less than government claims. There was a degree of relative protection for frontline staffing decreasing by 2.9% between 2008 and 2014 and far less than the 18.5% reduction in other staff. Staff exempted from the general moratorium also increased by a combined 12.6%. Counter to stated policy, the decline in staffing of non-acute care was over double than in acute care. Further, the reduction in directly employed staff was to a great extent matched by a marked increase in agency spending. CONCLUSIONS: The cuts forced substantial HRH reductions and yet there was some success in pursuing policy goals, such as increasing the frontline workforce while reducing support staff and protection of some cadres. Nevertheless, other policies failed such as moving staff away from acute settings and the claimed financial savings were substantially offset by overtime payments and the need to hire more expensive agency workers. There was also substantial demotivation of staff as a consequence of the changes.

The consequences of Ireland's culture of medical migration.

BACKGROUND: In recent years, Ireland has experienced a large-scale, outward migration of doctors. This presents a challenge for national policy makers and workforce planners seeking to build a self-sufficient medical workforce that trains and retains enough doctors to meet demand. Although, traditionally, medical migration has been considered beneficial to the Irish health system, austerity has brought a greater level of uncertainty to the health system and, with it, a need to reappraise the professional culture of migration and its impact on the Irish health system. METHODS: This paper illustrates how a culture of migration informs career and migration plans. It draws on quantitative data-registration and migration data from source and destination countries-and qualitative data-in-depth interviews with 50 doctors who had undertaken postgraduate medical training in Ireland. RESULTS: Of 50 respondents, 42 highlighted the importance of migration. The culture of medical migration rests on two assumptions-that international training/experience is beneficial to all doctors and that those who emigrate will return to Ireland with additional skills and experience. This assumption of return is challenged by a new generation of doctors whose professional lives have been shaped by globalisation and by austerity. Global comparisons reveal the comparatively poor working conditions, training and career opportunities in Ireland and the relative attractiveness of a permanent career abroad. CONCLUSION: In light of these changes, there is a need to critically appraise the culture of medical migration to determine if and in what circumstances migration is appropriate to the needs of the Irish health system. The paper considers the need to reappraise the culture of medical migration and the widespread emigration that it promotes.