Irish Nurses and Midwives Organisation

Submissions to the Independent COVID-19 Evaluation on Long Term Residential Care (LTRC)

INMO Recommendations:

1. The Government must urgently advance the development of publicly led and delivered home care and support services to meet the growing needs of Ireland’s ageing population.
2. Fully implement the Framework for Safe Nurse Staffing and Skill Mix across all healthcare settings and ensure funding for phase 3 in long term care and community settings.
3. Enshrine safe nurse and midwife staffing levels in legislation through the Patient Safety (Licensing) Bill.
4. Despite repeated recommendations, safe staffing and collective bargaining rights remain unsecured. The introduction of robust underpinning legislation is now essential.
5. A review of the employment terms and conditions of nurses working in this sector must be undertaken as recommended by the COVID-19 Nursing Homes Expert Panel (2021), including the effective transposition of the EU Directive on Adequate Minimum Wages and its associated provisions to increase collective bargaining rates.
6. Nurse-led care based in long-term residential settings must be supported and funded by removing barriers, allowing nurses to work to their full scope, including advanced clinical interventions.
7. The substitution of registered nurses and midwives for cost-containment purposes must cease through the full implementation of the Framework for Safe Nurse Staffing and Skill Mix and the introduction of mandated nurse staffing levels in legislation, including through the Patient Safety (Licensing) Bill.
8. Implement a nationally coordinated IPC strategy across all long-term care settings, ensuring access to specialist IPC nursing expertise, formal integration with public health and acute services, and clear escalation and surge capacity pathways.
9. A national occupational health service, inclusive of all healthcare settings, must be developed and resourced to support the physical and mental health needs of nurses, midwives and other healthcare workers.
10. Future pandemic planning must explicitly recognise the disproportionate risk faced by patient facing nurses, midwives and other patient facing staff working in LTRC settings. Targeted protective measures should be built into occupational health strategies for high-risk healthcare roles.
11. All cases of healthcare acquired COVID-19 among HCWs must be subject to thorough investigation, with a clear focus on identifying causative factors and implementing preventative measures
12. In future public health emergencies, all derogation policies and related workforce practices must adhere to the precautionary principle and align fully with national public health guidance on isolation periods. Protecting nurses, midwives, and other healthcare workers must take precedence over operational convenience.
13. The HSE and other healthcare employers must install effective air infiltration systems as part of a long-term strategy to maintain high air quality standards for both residents and staff.
14. In line with the European Commission, the Government must formally classify COVID-19 as an occupational illness or injury.
15. Establishment of a permanent Occupational Illness Scheme for healthcare workers with Long COVID, in consultation with health sector trade unions and aligned with existing public service long term absence frameworks.

Introduction

The Irish Nurses and Midwives Organisation (INMO), representing the majority of nurses and midwives across Ireland in both the public and private sectors, welcomes the opportunity to contribute to the COVID-19 Evaluation in Long Term Residential Care (LTRC). This submission builds upon the comprehensive evidence and recommendations we prepared and submitted last year and the INMO wishes to emphasise that our previous submission remains relevant and should be considered in conjunction with these updated observations.

Model of Long Term Care

The INMO has consistently opposed the sustained expansion of privatised long-term residential care in Ireland. The current model, in which approximately 74% of nursing home beds are operated by private providers and an estimated 82% of the sector operates on a for-profit basis, represents a significant structural policy shift away from publicly governed care. In the view of the INMO, this over-reliance on market provision has weakened workforce stability, diluted governance and accountability, and contributed to systemic inequities in care standards.

The COVID-19 pandemic did not create these weaknesses; it merely exposed and intensified them. The fragmentation of LTRC, characterised by variable clinical governance and poor integration with acute services, created avoidable vulnerabilities.

The pandemic demonstrated that the private sector was unable to sustain its own operations during a crisis. The necessity of a large-scale Government intervention, in which the HSE and Department of Health provided clinical oversight, infection control expertise, large-scale PPE, and emergency staffing, confirms that the privatised model is fundamentally dependent on public sector stabilisation.

The growing involvement of corporate and international investment entities has intensified pressures to prioritise financial performance over evidence-based safe staffing. This “financialisaton” of care has resulted in inconsistent employment standards and a lack of integrated occupational health supports, directly impacting resident safety and staff protection.

The COVID-19 Nursing Homes Expert Panel (2020) explicitly reinforced these concerns, identifying profound deficits in workforce planning and governance. The Panel’s recommendation for greater alignment with the wider health and social care system substantiates the INMO’s position: the prevailing for-profit model is structurally flawed and lacks the resilience required to withstand public health emergencies.

The continued expansion of private provision risks entrenching a two-tier model of care, directly contradicts the core principles of Sláintecare. Sláintecare commits to ending the over-reliance on market mechanisms and expanding publicly provided nursing home and home care services. The pandemic has proven that these commitments must move beyond aspirational policy. They are now a fundamental necessity to ensure system resilience, equity, and patient safety.

Recommendations:

• Public services must operate and deliver long term care.

• The Government must urgently advance the development of publicly led and delivered home care and support services to meet the growing needs of Ireland’s ageing population.

Safe Nurse and Staffing

Persistent workforce planning failures, chronic staffing deficits, and a widening mismatch between demand and capacity have long undermined safe staffing levels in LTRC. These structural weaknesses significantly reduced system resilience and were sharply magnified during the COVID-19 pandemic, contributing to unsafe conditions for both residents and staff.

The staffing crisis in residential care remains one of the most urgent and unresolved challenges in the sector. Evidence of the scale of instability is clear. A 2023 PwC workforce report identified turnover rates of 38% among nurses and midwives and 54% among healthcare assistants in private and voluntary nursing homes, compared with 11% and 10% respectively in the HSE (PwC, 2023). These stark disparities demonstrate the destabilising effect of inferior pay, pension entitlements, and employment conditions in the private sector.

High turnover has driven increased reliance on agency staffing and international recruitment, with recruitment costs per bed rising by 59% since 2017 (PwC, 2023). However, this strategy has proven unsustainable. Many internationally recruited nurses and midwives transition to HSE employment within one year, reflecting the structural pull of better terms and conditions. This pattern illustrates a systemic failure to achieve workforce parity across State-funded care settings and reinforces the INMO’s longstanding position that safe staffing cannot be achieved without equal employment standards.

The COVID-19 pandemic exposed the serious risks associated with inadequate staffing in LTRC. Infection prevention and control requirements, including staff self-isolation during outbreaks, significantly reduced workforce availability. HIQA (2020) reported that some centres were left operating with minimal staffing, highlighting staffing levels as particularly unsafe at night. It also found that 21% of centres inspected during the pandemic were non-compliant with regulations on staffing levels and skill-mix.

The INMO maintains that addressing workforce shortages requires more than recruitment initiatives. It requires guaranteeing decent, lawful, and equitable working conditions across all care settings. Social dialogue and collective bargaining are essential mechanisms for stabilising the workforce, improving retention, and safeguarding resident safety. The European Commission (2024) has recognised the critical role of collective bargaining in strengthening healthcare workforce participation. Ireland must fully and effectively implement the EU Directive on Adequate Minimum Wages, including measures to increase collective bargaining coverage in the long-term care sector.

The Framework for Safe Nurse Staffing and Skill Mix has demonstrated measurable improvements in patient outcomes, reductions in adverse events, and enhanced staff retention where implemented. The evaluation of the Pilot Implementation of the Framework for Safe Nurse Staffing and Skill-Mix in Long-Term Residential Settings for Older People confirms the fundamental necessity for safe nurse staffing and skill mix and it must now be funded, legally underpinned and implemented across the LTRC setting.

Equally, safe staffing must therefore become a statutory requirement. The Patient Safety (Licensing) Bill presents a critical opportunity to enshrine safe nurse and midwife staffing levels in legislation. Legislative underpinning would strengthen regulatory enforcement, protect residents, enhance workforce retention, and reduce long-term system costs associated with adverse events and emergency responses.

Failure to legislate for safe staffing would represent a failure to internalise one of the clearest lessons of the pandemic.

Recommendation:

• Fully implement the Framework for Safe Nurse Staffing and Skill Mix across all healthcare settings and ensure funding for phase 3 in long term care and community settings.
• Enshrine safe nurse and midwife staffing levels in legislation through the Patient Safety (Licensing) Bill.
• A review of the employment terms and conditions of nurses working in this sector must be undertaken as recommended by the COVID-19 Nursing Homes Expert Panel (2021), including the effective transposition of the EU Directive on Adequate Minimum Wages and its associated provisions to increase collective bargaining rates.

Optimising the Role of the Nurse in LTRC Settings

As outlined in the INMO’s submission to the Expert Review Panel (2020), any sustainable model of long-term care must place nursing at its core and maximise the full contribution of the profession to care excellence. Clinical care in LTRC settings should be nurse-led. However, contrary to the strong international evidence linking registered nurse staffing to improved care outcomes, the substitution of registered nurses has been used within parts of the sector as a cost-saving measure. This practice undermines resident care safety and must cease.

Optimising the scope of nursing practice is essential in long-term care, where resident needs are increasingly complex. The effective implementation of task-sharing arrangements, including those agreed under the Haddington Road Agreement, supports timely intervention in the resident’s place of care and reduces unnecessary transfers to emergency departments. Treating residents in situ reduces morbidity, avoids hospital-associated complications, and alleviates pressure on ambulance and acute hospital services.

All nurses and midwives must be supported to practise to the full extent of their education and competence, including the provision of services such as intravenous antibiotics and IV fluid therapy within the nursing home setting. The temporary introduction of nurse-led pronouncement of death during the COVID-19 public health emergency demonstrated the system’s capacity to safely expand scope of practice when required. Although agreed in 2017, this measure had not been operationalised prior to the pandemic, reflecting persistent barriers to role optimisation.

The removal of local and national practice barriers is essential if nursing is to operate at full scope beyond COVID-19 (Rosa et al., 2020). Embedding advanced nursing practice within LTRC settings is not simply a workforce issue, it is a patient safety and system efficiency imperative.

Recommendations:

• Nurse-led care based in long-term residential settings must be supported and funded by removing barriers, allowing nurses to work to their full scope, including advanced clinical interventions.
• The substitution of registered nurses and midwives for cost-containment purposes must cease through the full implementation of the Framework for Safe Nurse Staffing and Skill Mix and the introduction of mandated nurse staffing levels in legislation, including through the Patient Safety (Licensing) Bill.

Infection Prevention and Control (IPC)

The COVID-19 pandemic exposed significant weaknesses in infection prevention and control (IPC) infrastructure within LTRC. While IPC is a practical, evidence-based framework designed to prevent avoidable infection and protect both residents and healthcare workers, the system entered the pandemic without the operational capacity required to respond to a public health emergency of this scale.

Preparedness in many residential settings, particularly within the predominantly private nursing home sector, was undermined by structural vulnerabilities. The absence of formalised integration with public health teams, coupled with limited on-site access to specialist IPC clinical expertise, contributed to the delayed implementation of protective measures and inconsistent outbreak management.

Regulatory standards were not sufficiently robust to withstand the pressures of a fast-moving pandemic. As observed by the Chief Inspector of Social Services early in the pandemic, existing nursing home regulations on IPC were “not commensurate with what is required to respond and manage a COVID-19 outbreak” (HIQA, 2020). This is a significant finding and reinforces the INMO’s longstanding concern that the sector lacked enforceable IPC capacity prior to the pandemic (INMO Submission to Expert Review Panel; Submission to the Special Committee on Covid-19 Response – Congregated Settings: Nursing Homes).

Although national and international guidance evolved rapidly as evidence emerged, the precautionary principle was not consistently applied in practice. Key preventive measures were introduced late or implemented inconsistently across settings. In a population characterised by advanced age, frailty and multimorbidity, such delays increased avoidable transmission risk.

Staffing pressures during outbreaks further compromised IPC practice. Reduced staffing levels required personnel to move between resident areas, increasing the potential for cross-transmission. This underscores a central lesson of the pandemic: IPC cannot function effectively without safe staffing levels, an appropriate skill mix, and contingency workforce planning.

System-level decisions in the early phase of the pandemic also placed additional strain on residential settings. Between January and May 2020, 4,073 patients were approved for transfer from acute hospitals to private nursing homes, including 1,680 transfers during March and April alone (Bowers, 2020). At a time of limited testing capacity and evolving knowledge regarding asymptomatic transmission, these transfers occurred within a system that lacked fully embedded IPC supports.

Further weakening IPC capacity were:

• Inconsistent interpretation and implementation of HSE guidance
• Shortages of personal protective equipment (PPE)
• Limited access to essential clinical resources such as oxygen and intravenous fluids
• Delays in staff and resident testing, and prolonged turnaround times for results
• Derogations permitting asymptomatic close contacts to attend work, later shown to pose significant transmission risk

Taken together, these factors demonstrate that IPC cannot rely on individual providers responding in isolation during a national emergency. A fragmented model of provision is incompatible with effective outbreak control.

An IPC strategy is required across all long-term care settings. Such a model must be supported by access to specialist IPC nursing expertise, formal operational integration with public health and acute hospital services and clear escalation and surge capacity pathways.

Recommendation:

• Implement a nationally coordinated IPC strategy across all long-term care settings, ensuring access to specialist IPC nursing expertise, formal integration with public health and acute services, and clear escalation and surge capacity pathways.

Physical and Psychological Impact on Nurses and Midwives

The COVID-19 pandemic placed an unprecedented burden on nurses working in the LTRC setting. INMO members worked tirelessly to deliver safe, high-quality care under extraordinarily challenging conditions. While nurses are accustomed to working under pressure, the pandemic’s demands were exceptional, affecting both physical and mental wellbeing.

Evidence from INMO Surveys

Surveys conducted by the INMO during the pandemic consistently highlighted the intense psychological strain experienced by nurses and midwives, particularly those working in LTRC settings. Respondents reported high levels of exhaustion, anxiety, and concern for both their own health and that of residents.

Key findings included:

Psychological Impact of COVID-19 Surveys	2020	2021
Has your experience of working during the COVID-19 caused you to consider leaving the profession?	Yes 58.40%	Yes 63.14%
Do you believe that your experience of COVID-19 has had a negative psychological impact on you?	Yes 86.93%	Yes 81.96%
I feel that my personal health has been put at risk	Strongly Agree or Agree 83.69%	Strongly Agree or Agree 83.53%

Qualitative responses illustrate the impact on nurses working in LTRC settings:

“Covid 19 has increased my anxiety levels especially before our residents n staff were vaccinated The day to worry n fear of our unit contracting the virus caused heightened anxiety ongoing since March 2020.”

“Extreme pressure from under staffing.”

“we had to fight to wear masks and be supplied with PPE we had to involve the unions. Many weeks we worked over our hours with no appreciation for it. We had annual leave cancelled. It was so stressful worrying about bringing Covid into our residents or home to our families. It’s been such a traumatic time.”

“I am feeling lonely and over stressed in this foreign country. Many nurses including me is unable to bring there family due to Covid restrictions.”

Independent studies support these findings. Brady et al. (2022) reported that nursing home staff experienced high levels of post-traumatic stress, mood disturbance, and moral injury during the pandemic. A follow-up study in 2023 confirmed persistently high prevalences of PTSD, depression, moral injury, and suicidal thinking, even as pandemic-related conditions were easing. The research also noted that concerns regarding infection control systems and job stress increased over time, highlighting worsening working conditions (Brady et al., 2022; 2023).

Protecting the mental health of HCWs was identified early in the pandemic as a global priority by the WHO, intrinsically linking patient outcomes to the wellbeing of nurses and midwives. This was strongly echoed by international and national nursing and midwifery bodies (ICN, 2021; WHO Europe, 2022; WISH, 2022). WHO Europe’s (2022) post-COVID workforce recommendations emphasised the need to “protect the health and mental well-being of the workforce.” This principle must underpin all efforts to support nurses and midwives across every healthcare setting, both now and into the future.

Similarly, the International Labour Organisation’s (ILO’s) Biological Hazards in the Working Environment Convention, 2025 (No. 192) has further underscored the equal importance of safeguarding both the mental and physical health of workers.

The pandemic demonstrates that the physical and psychological wellbeing of nurses and midwives is not optional. It is central to safe, effective care. LTRC and other high-risk settings require proactive, sustained measures to prevent burnout, stress-related illness, and workforce attrition.

Recommendation:

• A national occupational health service, inclusive of all healthcare settings, must be developed and resourced to support the physical and mental health needs of nurses, midwives and other healthcare workers.

High Healthcare Worker Infection Rates

Evidence from the Phase 1 Interim Report of the Prevalence of Antibodies to SARS-CoV-2 in Irish Healthcare Workers (Allen et al., 2021) highlighted that nurses, midwives, and healthcare assistants (HCAs) were at the greatest risk of exposure and infection. HPSC data further confirm this, showing that as of 29 June 2020, HCWs accounted for 31.9% of all confirmed COVID-19 cases nationally. Within this group, nurses, midwives, and HCAs comprised nearly 60% of healthcare worker infections.

These findings clearly demonstrate that HCWs in LTRC settings faced elevated occupational risk, particularly those in direct patient care roles.

Within the LTRC setting, HCWs experienced high rates of COVID-19 infection throughout the pandemic, reflecting both occupational exposure and systemic vulnerabilities. Again, nurses and healthcare assistants, in particular, faced unprecedented levels of infection during the first wave.

The Expert Review Panel noted a total of 1,892 confirmed cases among nursing home HCWs between March and June 2020, with infections surging in April, which accounted for approximately 77.7% of all cases (estimated 1,471 cases).

Similarly, by May 2020, 1,450 nursing home HCWs had contracted COVID-19 in facilities with identified clusters, compared with 613 HCWs infected in acute hospital clusters (Carswell and Wall, 2020). In June 2020, the Health Protection Surveillance Centre (HPSC) reported that 21.5% of all confirmed cases were associated with nursing homes (HPSC, 2020).

These figures highlight that HCWs in LTRC settings experienced particularly high exposure and infection rates during the first wave, reflecting both the vulnerability of the sector and the early challenges in outbreak control.

The INMO consistently raised concerns about healthcare-acquired infections throughout the pandemic. Our firm view remains that when a worker contracts an illness in the workplace, each case should be thoroughly investigated to determine how the infection occurred and what measures can be implemented to prevent recurrence.

Recommendation:

• Future pandemic planning must explicitly recognise the disproportionate risk faced by patient facing nurses, midwives and other patient facing staff working in LTRC settings. Targeted protective measures should be built into occupational health strategies for high-risk healthcare roles.
• All cases of healthcare acquired COVID-19 among HCWs must be subject to thorough investigation, with a clear focus on identifying causative factors and implementing preventative measures

Workplace Policies

A significant issue within the LTRC was staffing during the pandemic. While the nursing

and midwifery workforce demonstrated remarkable agility through widespread redeployment during the pandemic, nurses and midwives were assigned to many areas, including private residential care facilities.

It must be noted that redeployment was not always straightforward and came with challenges for staff. Such transitions often required rapid upskilling, further highlighting the dedication and professionalism of the workforce in the face of unprecedented pressures.

In terms of the LTRC setting, the INMO consistently advocated for equal treatment between public and private sector nurses regarding safety, PPE, and the Pandemic Recognition Payment, arguing that private nursing home staff deserved the same recognition. (Letter to Minister for Health re Section 38, 26th March 2020; Letter to Minister for Health re private nursing homes, 1st April 2020).

To prevent excessive staff redeployment during future pandemics and ensure high-quality care amid current and future rising demand, addressing nurse staffing shortages in LTRC facilities must be an urgent priority.

Recommendation:

• Fully fund and implement the Framework for Safe Nurse Staffing and Skill Mix in long term care and community settings.
• Enshrine safe nurse and midwife staffing levels in legislation through the Patient Safety (Licensing) Bill.
• A review of the employment terms and conditions of nurses working in this sector must be undertaken as recommended by the COVID-19 Nursing Homes Expert Panel (2021), including the effective transposition of the EU Directive on Adequate Minimum Wages and its associated provisions to increase collective bargaining rates.

Derogation

Throughout the COVID-19 pandemic, the INMO consistently challenged the Health Service Executive (HSE) derogation policies. These policies allowed asymptomatic healthcare workers (HCWs) who were close contacts to return to work at management’s discretion. The INMO’s opposition was rooted in the precautionary principle, arguing that the policy failed to account for emerging evidence on asymptomatic transmission. Retrospective data has since confirmed that these derogations were a serious error, facilitating the spread of the virus within clinical settings. The INMO was consistently critical of the HSE’s derogation policy and its subsequent revisions throughout the pandemic. (Submission to the Special Committee on Covid-19 Response: Infection Risk and Disease in Healthcare Workers; COVID-19 Testing and Surveillance for Healthcare Staff, July 2020).

The INMO consistently supported using the same 14-day isolation period for healthcare workers as outlined in public health guidelines for the general population. We opposed the discretionary shortening of isolation periods for close-contact HCWs, which the derogation policy allowed.

During the peak of the third wave, the HSE further amended the policy to exempt HCWs from the five-day self-isolation rule even when a household member tested positive. In response, the National Joint Council (NJC) formally opposed this revision, citing it as a primary factor in the reintroduction of the virus into hospitals and LTRC settings. (INMO, 2021; Opening Statement to the Joint Committee on Health Protection and Support for Frontline Healthcare Workers, 2021).

The consequences of these derogations were particularly acute in the LTRC sector. The Special Committee on COVID-19 Response later echoed the INMO’s concerns, noting that allowing close-contact staff to work while asymptomatic was a significant mistake in light of transmission data. It is the INMO’s firm view that these policies directly increased the infection risk for nurses and midwives, contributing to the disproportionately high incidence of COVID-19 among healthcare workers.

Recommendation:

• In future public health emergencies, all derogation policies and related workforce practices must adhere to the precautionary principle and align fully with national public health guidance on isolation periods. Protecting nurses, midwives, and other healthcare workers must take precedence over operational convenience.

Occupational Health Supports

The provision of occupational health support for nurses, midwives, and the broader healthcare workforce during the COVID-19 pandemic was deeply inadequate. Inconsistent communication regarding policy changes/updates exacerbated staff

stress and created a climate of clinical uncertainty. The INMO repeatedly highlighted these systemic failures before the Special Committee on the COVID-19 Response and the Joint Committee on Health (2021, 2023).

The ILO’s Biological Hazards in the Working Environment Convention, 2025 (No. 192) represents a major advance in international labour standards. It calls on Member States to ensure universal access to occupational health services, with specific emphasis on high-risk sectors such as health and social care. The Convention requires employers to adopt preventive and protective measures in collaboration with workers, and mandates that staff be adequately informed and trained about biological risks. Its accompanying recommendation offers practical guidance on risk assessments, outbreak response and the development of preparedness systems, all directly relevant to the Irish health service context.

Recommendation:

• A national occupational health service, inclusive of all healthcare settings, must be developed and resourced to support the physical and mental health needs of nurses, midwives and other healthcare workers.
• The Government must also take immediate steps to ratify ILO Convention No. 192 (2025) and incorporate its provisions into national policy, ensuring a robust, rights-based framework to protect the health, safety and dignity of all healthcare workers.

Environmental Factors: Air Quality and Workplace Safety

As COVID-19 is an airborne pathogen, maintaining high indoor air quality (IAQ) is a fundamental requirement for workplace safety. Throughout the pandemic, the INMO consistently rejected the HSE’s rationale for refusing to implement mechanical air filtration units across healthcare locations, including LTRC settings.

Despite the progression of the pandemic, CO2 monitoring remained inadequate. During winter months, natural ventilation was further compromised by the necessity of indoor heating, creating high-risk environments for airborne transmission (Ref: Correspondence to Chief Clinical Officer, 5 January 2022; Correspondence to National Director of Acute Hospitals, 9 July 2021).

In testimony to the Joint Committee on Health (2023), the INMO highlighted that virus transmission was frequently driven by inadequate staff facilities. Overcrowded changing rooms, poorly ventilated break rooms, and cramped administrative offices became significant vectors for infection. The failure to prioritise these “non-clinical” spaces in IPC strategies left nurses unnecessarily exposed.

While air filtration systems were prioritised and introduced in educational settings, they were not afforded the same priority in healthcare environments where confirmed COVID-19 cases were actively present.

The INMO welcomes the Health and Safety Authority’s (HSA) Code of Practice for Indoor Air Quality. A code of practice is only effective if matched by employer implementation. There must be appropriate investment in LTRC facilities that are designed to modern IPC standards, capable of withstanding future pandemics.

Recommendation:

• The HSE and other healthcare employers must install effective air infiltration systems as part of a long-term strategy to maintain high air quality standards for both residents and staff.

Recognition of COVID-19 as an Occupational Disease

To provide a sustainable future for the healthcare workforce, the State must establish a clear link between viral exposure and the work environment. The European Commission has formally acknowledged COVID-19 as an occupational disease, specifically citing the elevated risk faced by healthcare staff.

“Healthcare staff are recognised by the European Commission in that Covid 19 is an occupational disease.”1

The INMO strongly welcomed this recognition, viewing it as a critical step in acknowledging both the significant health risks faced by frontline workers and the essential contribution of those in health, social care, and other high-risk occupations during the pandemic.

Data from Eurostat (2024) reveals that Ireland is now an outlier within the European Union. While sixteen Member States formally recognise COVID-19 as an occupational disease, and a further eight recognise it as a workplace accident, Ireland remains in a small minority that offers no such legal classification. This refusal to align with European peers denies Irish nurses and midwives the protections and compensation afforded to their counterparts across the EU.

Recommendation:

• In line with the European Commission, the Government must formally classify COVID-19 as an occupational illness or injury.

Long Covid

The withdrawal of Special Leave with Pay (SLWP) and the subsequent limitations of the 2022 Temporary Scheme have created a “financial cliff-edge” for healthcare workers suffering from Long COVID. The current criteria for support are both arbitrary and unjust, frequently based on the date of infection rather than the severity of the illness or the occupational nature of the exposure.

The Labour Court Recommendation (June 2024) highlighted a critical legislative barrier. Because COVID-19 is not currently recognised as an occupational illness in this jurisdiction, the Court noted it lacked the authority to mandate a permanent occupational scheme. Consequently, workers face transitioning to standard sick leave by December 2025, a move that fails to recognise the unique circumstances of their infection and their service during a national emergency.

The distress and financial uncertainty faced by those with Long COVID must serve as a catalyst for reform. No HCW who becomes seriously ill in the course of their duty should be subjected to the stress of short-term extensions and expiring support schemes. To withstand future pandemics, we must have a permanent, rights-based framework in place that recognises the inherent risks of frontline clinical work.

Recommendation:

• The Government must recognise COVID-19 as an occupational illness or injury, as this is essential to removing the barriers identified by the Labour Court that currently prevent the establishment of a permanent Occupational Illness Scheme for healthcare workers with Long COVID. This scheme should be developed in full consultation with health sector unions and aligned with existing public service long term absence frameworks.

Impact on Long Term Residential Care Residents

Residents in LTRC settings experienced disproportionate impact during the pandemic. National data indicate that between March 2020 and April 2023, nearly 30% of all COVID-19 related deaths in Ireland occurred in residential institutions, including nursing homes, underscoring the sector’s vulnerability during the pandemic period. Research by Walsh, Connolly, and Wren (2023) found that two-thirds of all LTRC homes had at least one COVID-19 outbreak between March 2020 and March 2021, with 8,502 confirmed cases among residents and more than 2,100 resident deaths reported across outbreaks. This equated to a high case fatality rate among infected residents.

However, the epidemiological data only partly reflect the broader lived impact on residents’ wellbeing. Qualitative and mixed-methods research demonstrates that the pandemic’s indirect effects on residents’ social, emotional and psychological health were profound. Sweeney et al. (2022) found that the response to COVID-19 in residential care settings was experienced by many residents as a period marked by intense isolation, loss of connectedness, anxiety, fear and distress. Visiting suspensions and infection control measures severed family input to care, an essential source of emotional support and advocacy for residents, which participants linked to deterioration in physical health, rapid declines in mobility and psychosocial wellbeing. Residents frequently described a reduction in the level and quality of care provision, not only due to outbreak challenges, but also because of staffing pressures and operational constraints.

The experience of residents during the pandemic highlights the need for future pandemic responses to balance infection control with fundamental rights to social engagement and person-centred care, and to ensure that protective measures do not inadvertently undermine the dignity, wellbeing and holistic health of older people in long-term care.

Recommendation: Despite repeated recommendations, safe staffing and collective bargaining rights remain unsecured. The introduction of robust underpinning legislation is now essential.

References

Allen, N. et al. (2021) Prevalence of antibodies to SARS-CoV-2 in Irish healthcare workers: Phase 1 interim report, October 2020. Dublin: Health Protection Surveillance Centre. Available at:                                             https://www.hpsc.ie/a-

z/respiratory/coronavirus/novelcoronavirus/research/precise/PRECISE%20Study%20Phase

%201%20Interim%20Report%20January%202021.pdf (Accessed: 24 June 2025).

Bowers, F. (2020) Nursing homes have changed for the foreseeable future – HIQA. Available at: https://www.rte.ie/news/coronavirus/2020/0617/1147922-coronavirus-ireland/ (Accessed: 5 March 2025).

Brady, C., Fenton, C., Loughran, O., Hayes, B., Hennessy, M., Higgins, A., Leroi, I., Shanagher, D. and McLoughlin, D.M. (2022) ‘Nursing home staff mental health during the Covid-19 pandemic in the Republic of Ireland’, International Journal of Geriatric Psychiatry,

37(1). doi: 10.1002/gps.5648.

Brady, C., Shackleton, E., Fenton, C., Loughran, O., Hayes, B., Hennessy, M., Higgins, A., Leroi, I., Shanagher, D. and McLoughlin, D.M. (2023) ‘Worsening of mental health outcomes in nursing home staff during the COVID-19 pandemic in Ireland’, PLOS ONE, 18(9), e0291988. doi: 10.1371/journal.pone.0291988.

Eurostat (2024) Possibility of recognising COVID-19 as being of occupational origin at national level in EU, EFTA, candidate, and potential candidate countries: 2024 edition. Luxembourg: Publications          Office          of          the                              European    Union.  Available at: https://ec.europa.eu/eurostat/documents/7870049/20599277/KS-FT-24-006-EN-N.pdf (Accessed: 05 March 2026).

Health Information and Quality Authority (HIQA) (2020) The impact of COVID-19 on nursing homes in Ireland.      Dublin:    Health Information and Quality Authority. Available at: https://www.hiqa.ie/sites/default/files/2020-07/The-impact-of-COVID-19-on-nursing-homes-  in-Ireland_0.pdf (Accessed: 5 March 2025).

Health Protection Surveillance Centre (HPSC) (2020) Profile of COVID-19 cases in healthcare workers in Ireland: report prepared by HPSC on 29/06/2020. Dublin: HPSC.

International     Council    of    Nurses    (ICN)                        (2021)      COVID-19      update.                        Available  at: https://www.icn.ch/sites/default/files/inline-files/ICN%20COVID19%20update%20report%20FINAL.pdf (Accessed: 5 March 2026).

Irish Nurses and Midwives Organisation (2021) Healthcare workers must not be exempt from 5-day isolation rule – INMO, SIPTU, FÓRSA. Available at: https://www.inmo.ie/News-Campaigns/Details/healthcare-workers-must-not-be-exempt-from-5-day-isolation-rule-inmo-siptu-f211rsa (Accessed: 6 March 2025).

PwC (2023) Challenges for nursing homes in the provision of older persons care: private and voluntary nursing home sector. Dublin: PwC. Available at: https://nhi.ie/wp-content/uploads/2023/05/PWC-Nursing-Home-Industry-Report-Final.pdf (Accessed: 5 March 2025).

Rosa, W.E., Fitzgerald, M., Davis, S., Farley, J.E., Khanyola, J., Kwong, J., Moreland, P.J., Rogers, M., Sibanda, B. and Turale, S. (2020) ‘Leveraging nurse practitioner capacities to achieve global health for all: COVID-19 and beyond’, International Nursing Review, 67(4), pp. 554-559. doi: 10.1111/inr.12632.

Sweeney, M.R., Boilson, A., White, C., Nevin, M., Casey, B., Boylan, P. and Staines, A. (2022) ‘Experiences of residents, family members and staff in residential care settings for older people during COVID-19: a mixed methods study’, Journal of Nursing Management, 30(4),

pp. 872-882. doi: 10.1111/jonm.13574.

Wall, M. and Carswell, S. (2020) ‘More than 1,400 nursing home healthcare workers infected in outbreaks – HSE’, The Irish Times, 25 May. Available at: https://www.irishtimes.com/news/health/more-than-1-400-nursing-home-healthcare-workers-infected-in-outbreaks-hse-1.4261409 (Accessed: 5 March 2026).

Walsh, B., Connolly, S. and Wren, M.-A. (2023) ‘Covid-19 in the community and outbreaks in long-term residential care in Ireland’, Journal of Long-Term Care, 2023, pp. 23–32. doi: 10.31389/jltc.191.

World Health Organization Regional Office for Europe (2022) Health and care workforce in Europe: time to act. Copenhagen: WHO Regional Office for Europe. Available at: https://iris.who.int/handle/10665/362379 (Accessed: 5 March 2026).

World Innovation Summit for Health and World Health Organization (2022) Our duty of care: a global call to action to protect the mental health of health and care workers. Doha and Geneva: WISH / World Health Organization. Available at: https://www.who.int/publications/m/item/wish_report (Accessed: 5 March 2026).

INMO Submissions

1. Submission to the Special Committee on Covid-19 Response – Testing and Contact Tracing, 16 June 2020
2. Submission to the COVID-19 Nursing Homes Expert Panel Consultation Survey, 19 June 2020
3. Submission to the Special Committee on Covid-19 Response – Congregated Settings: Nursing Homes, 25 June 2020
4. Submission to the Special Committee on Covid-19 Response – Infection Risk and Disease in Healthcare Workers, 6 July 2020
5. Opening Statement to the Joint Committee on Health – Protection and Support for Frontline Healthcare Workers, 9 February 2021
6. Submission to the HSA’s Draft Code of Practice for Indoor Air Quality, 2 December 2022
7. Opening Statement to the Joint Committee on Health on The Welfare and Safety of Workers in the Public Health Service, 8 February 2023.

INMO Correspondence

1. Correspondence to National Director of Acute Hospitals, 9 July 2021.
2. Letter to Minister for Health re private nursing homes, 1st April 2020
3. Letter to Minister for Health re Section 38, 26th March 2020
4. Correspondence to Chief Clinical Officer, 5 January 2022