Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis

Effects of the Affordable Care Act Medicaid Expansion on the Distribution of New General Internists Across States

BACKGROUND

Some states expanded Medicaid under the Affordable Care Act, boosting their low-income residents' demand for health care, while other states opted not to expand.

OBJECTIVE

The objective of this study was to determine whether the Medicaid expansion influenced the states selected by physicians just completing graduate medical education for establishing their first practices.

RESEARCH DESIGN

Using 2009-2019 data from the American Medical Association Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following implementation of the expansion to where they located during the 5 years preceding implementation.

SUBJECTS

The sample consisted of 160,842 physicians in 8 specialty groups.

RESULTS

Thirty-three states and the District of Columbia expanded Medicaid by the end of the study period. Compared with preexpansion patterns, we found that physicians in one specialty group-general internal medicine-were increasingly likely to locate in expansion states with time after the expansion. The Medicaid expansion influenced the practice location choices of men and international medical graduates in general internal medicine; women and United States medical graduates did not alter their preexpansion location patterns. Simulations estimated that, between 2014 and 2019, nonexpansion states lost 310 general internists (95% confidence interval, 156-464) to expansion states.

CONCLUSIONS

The Medicaid expansion influenced the practice location choices of new general internists. States that opted not to expand Medicaid under the Affordable Care Act lost general internists to expansion states, potentially affecting access to care for all their residents irrespective of insurance coverage.

Nurses and Pharmaceutical Care: Interprofessional, Evidence-Based Working to Improve Patient Care and Outcomes

Pharmaceutical care necessitates significant efforts from patients, informal caregivers, the interprofessional team of health care professionals and health care system administrators. Collaboration, mutual respect and agreement amongst all stakeholders regarding responsibilities throughout the complex process of pharmaceutical care is needed before patients can take full advantage of modern medicine. Based on the literature and policy documents, in this position paper, we reflect on opportunities for integrated evidence-based pharmaceutical care to improve care quality and patient outcomes from a nursing perspective. Despite the consensus that interprofessional collaboration is essential, in clinical practice, research, education and policy-making challenges are often not addressed interprofessionally. This paper concludes with specific advises to move towards the implementation of more interprofessional, evidence-based pharmaceutical care.

Effect of integrated medical and nursing intervention model on quality of life and unhealthy emotion of patients with esophageal cancer undergoing radiotherapy

OBJECTIVE

To explore the application of integrated medical and nursing intervention model in radiotherapy for patients with esophageal cancer.

METHODS

A total of 78 patients with esophageal cancer undergoing radiotherapy were randomly divided into two groups: control group (n=39, receiving traditional separate medical and nursing management) and study group (n=39, receiving integrated medical and nursing intervention mode). Before and after intervention, the mental state, nutritional index, quality of life and self-efficacy were compared between the two groups, and the adverse reactions were recorded during radiotherapy.

RESULTS

Compared with those before intervention, the scores of hamilton anxiety rating scale (HAMA) and hamilton depression scale (HAMD) were lower in both groups when they were discharged from hospital, and the study group was lower than the control group (all P<0.05). The scores of comprehensive quality of life assessment questionnaire (GQOLI-74) and self-management efficacy scale (SUPPH) were increased in both groups, and the study group was higher than the control group (all P<0.05). After intervention for 3 weeks, the levels of Hb, TP and Alb in the two groups were higher than those before intervention, and the study group was higher than the control group (all P<0.05). During radiotherapy, the total incidence of adverse reactions in the study group was lower than that in the control group (P<0.05).

CONCLUSION

Integrated medical and nursing intervention can obviously relieve the unhealthy emotion and improve the nutritional status, quality of life and self-efficacy for patients with esophageal cancer undergoing radiotherapy.

A survey of physicians' appreciation and knowledge about airway safety measures in the wake of COVID-19 pandemic

Background and Aims:

The implementation of safety measures during airway management is a major concern to prevent COVID-19 transmission during pandemic. Various guidelines and advisories are in vogue to ensure safe practices. However, their success depends on the caregivers’ knowledge and understanding. This survey was conducted to assess the knowledge and safety concerns amongst physicians towards airway management in the background of COVID-19 pandemic.

Material and Methods:

A survey instrument of thirty questions covering three timelines of airway management viz. ‘before’, ‘during’ and ‘after’ airway intervention was created. The questionnaire was electronically mailed to the eligible physicians over a period of one month via a web-based platform and the responses were analyzed. The responses were depicted numerically as percentage. A multiple discriminant analysis was used to test the accuracy of responses after adjusting for common variables.

Results:

Out of 407 responses, 300 were eligible for analysis. The respondents with correct answers to questions with single correct response were 46%, 69% and 57.3%, along the three timelines and the respondents with more than 75% correct responses in questions with multiple correct responses were 49%, 58% and 31% along the same timelines. About 75% of the participants became aware of transmission through aerosols aftermath pandemic. About two-third of the participants had knowledge about the safety guidelines and recommendations. Majority of the respondents were aware of the safety measures ‘during airway intervention’.

Conclusion:

Our study found satisfactory knowledge and appreciable concern among the practicing physicians regarding airway safety measures in the wake of COVID-19 pandemic. However, more physicians were aware about the measures required to be adopted ‘during’ airway intervention. The survey highlights the need for a more focused training of the caregivers about safety measures ‘before’ and ‘after’ airway intervention.

Reducing the use of physical restraints in home care: development and feasibility testing of a multicomponent program to support the implementation of a guideline

BACKGROUND

A validated evidence-based guideline was developed to reduce physical restraint use in home care. However, the implementation of guidelines in home care is challenging. Therefore, this study aims to systematically develop and evaluate a multicomponent program for the implementation of the guideline for reducing the use of physical restraints in home care.

METHODS

Intervention Mapping was used to develop a multicomponent program. This method contains six steps. Each step comprises several tasks towards the design, implementation and evaluation of an intervention; which is theory and evidence informed, as well as practical. To ensure that the multicomponent program would support the implementation of the guideline in home care, a feasibility study of 8 months was organized in one primary care district in Flanders, Belgium. A concurrent triangulation mixed methods design was used to evaluate the multicomponent program consisting of a knowledge test, focus groups and an online survey.

RESULTS

The Social Cognitive Theory and the Theory of Planned Behavior are the foundations of the multicomponent program. Based on modeling, active learning, guided practice, belief selection and resistance to social pressure, eight practical applications were developed to operationalize these methods. The key components of the program are: the ambassadors for restraint-free home care (n = 15), the tutorials, the physical restraint checklist and the flyer. The results of the feasibility study show the necessity to select uniform terminology and definition for physical restraints, to involve all stakeholders from the beginning of the process, to take time for the implementation process, to select competent ambassadors and to collaborate with other home care providers.

CONCLUSIONS

The multicomponent program shows promising results. Prior to future use, further research needs to focus on the last two steps of Intervention Mapping (program implementation plan and developing an evaluation plan), to guide implementation on a larger scale and to formally evaluate the effectiveness of the multicomponent program.

Factors that impact on recruitment to randomised trials in health care: a qualitative evidence synthesis

BACKGROUND

Randomised trials (also referred to as 'randomised controlled trials' or 'trials') are the optimal way to minimise bias in evaluating the effects of competing treatments, therapies and innovations in health care. It is important to achieve the required sample size for a trial, otherwise trialists may not be able to draw conclusive results leading to research waste and raising ethical questions about trial participation. The reasons why potential participants may accept or decline participation are multifaceted. Yet, the evidence of effectiveness of interventions to improve recruitment to trials is not substantial and fails to recognise these individual decision-making processes. It is important to synthesise the experiences and perceptions of those invited to participate in randomised trials to better inform recruitment strategies.

OBJECTIVES

To explore potential trial participants' views and experiences of the recruitment process for participation. The specific objectives are to describe potential participants' perceptions and experiences of accepting or declining to participate in trials, to explore barriers and facilitators to trial participation, and to explore to what extent barriers and facilitators identified are addressed by strategies to improve recruitment evaluated in previous reviews of the effects of interventions including a Cochrane Methodology Review.

SEARCH METHODS

We searched the Cochrane Library, Medline, Embase, CINAHL, Epistemonikos, LILACS, PsycINFO, ORRCA, and grey literature sources. We ran the most recent set of searches for which the results were incorporated into the review in July 2017.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with an identifiable qualitative component) that explored potential trial participants' experiences and perceptions of being invited to participate in a trial. We excluded studies that focused only on recruiters' perspectives, and trials solely involving children under 18 years, or adults who were assessed as having impaired mental capacity.

DATA COLLECTION AND ANALYSIS

Five review authors independently assessed the titles, abstracts and full texts identified by the search. We used the CART (completeness, accuracy, relevance, timeliness) criteria to exclude studies that had limited focus on the phenomenon of interest. We used QSR NVivo to extract and manage the data. We assessed methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We used thematic synthesis to analyse and synthesise the evidence. This provided analytical themes and a conceptual model. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. Our findings were integrated with two previous intervention effectiveness reviews by juxtaposing the quantitative and qualitative findings in a matrix.

MAIN RESULTS

We included 29 studies (published in 30 papers) in our synthesis. Twenty-two key findings were produced under three broad themes (with six subthemes) to capture the experience of being invited to participate in a trial and making the decision whether to participate. Most of these findings had moderate to high confidence. We identified factors from the trial itself that influenced participation. These included how trial information was communicated, and elements of the trial such as the time commitment that might be considered burdensome. The second theme related to personal factors such as how other people can influence the individual's decision; and how a personal understanding of potential harms and benefits could impact on the decision. Finally, the potential benefits of participation were found to be key to the decision to participate, namely personal benefits such as access to new treatments, but also the chance to make a difference and help others. The conceptual model we developed presents the decision-making process as a gauge and the factors that influence whether the person will, or will not, take part.

AUTHORS' CONCLUSIONS

This qualitative evidence synthesis has provided comprehensive insight into the complexity of factors that influence a person's decision whether to participate in a trial. We developed key questions that trialists can ask when developing their recruitment strategy. In addition, our conceptual model emphasises the need for participant-centred approaches to recruitment. We demonstrated moderate to high level confidence in our findings, which in some way can be attributed to the large volume of highly relevant studies in this field. We recommend that these insights be used to direct or influence or underpin future recruitment strategies that are developed in a participant-driven way that ultimately improves trial conduct and reduces research waste.

A case study of a collaborative allied health and nursing crisis response

The COVID-19 pandemic was declared by the World Health Organization on 11 March 2020. The rapid spread of SARS-CoV-2 required an equally rapid response from health-care organizations to find innovative ways to utilize the existing workforce to care for people with COVID-19. Using an evaluative case study, a unique insight into the collaborative allied health and nursing professions' response to COVID-19 at a specialist cardiothoracic hospital in the United Kingdom is presented. The aim of the case study was to evaluate how an interprofessional workforce from the wider organization could be supported to work in critical care as part of a crisis response. In identifying the key enablers to setting up an interprofessional Essential Care Team and learning from the lived experiences of those involved, this case study has demonstrated that, in supported, interprofessional teams the wider organizational workforce can be facilitated to effectively and safely provide critical care services. The lessons learned from this study will support future pandemic responses and aid the identification of further opportunities for interprofessional learning and practice. Ultimately, the study highlights that by identifying and investing in the key enablers, health-care organizations can be better prepared to respond to a global crisis.

Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation

BACKGROUND

The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms.

OBJECTIVES

An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis.

DATA SOURCES

Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019.

PARTICIPANTS

Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes.

INTERVENTIONS

Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes.

RESULTS

Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000.

LIMITATIONS

Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points.

CONCLUSIONS

Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study).

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015025520.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.

Recruiters' perspectives of recruiting women during pregnancy and childbirth to clinical trials: A qualitative evidence synthesis

INTRODUCTION

Research on research is key to enhancing efficacy in trial methodology. Clinical trials involving women during pregnancy and childbirth are limited, with a paucity of data guiding evidence-based practice. Following a prioritisation exercise that highlighted the top-ten unanswered recruitment questions, this qualitative evidence synthesis was designed specifically to focus on the barriers and enablers for clinicians/healthcare professionals in helping conduct randomised trials within the context of recruitment during pregnancy and childbirth.

METHODS

The synthesis was undertaken using Thomas and Harden's three stage thematic synthesis method and reported following the ENTREQ guidelines. Using a pre-determined SPIDER strategy, we conducted a comprehensive search of databases; Pubmed, CINAHL, PsycINFO, EMBASE, and grey searches for records until January 2019. We included all reports of qualitative data on recruiter's experiences, perceptions, views of recruiting women during pregnancy and childbirth to clinical trials. Altogether 13,401 records were screened, resulting in 31 full-text reviews, of which five were eligible for inclusion. Quality was appraised using CASP. Data were extracted onto a specifically defined form. We used thematic synthesis to identify descriptive and analytical themes, and to interpret and generate theory. Confidence was assessed using GRADE-CERQual. The review protocol is publicly available (OSF https://osf.io/g4dt9/).

RESULTS

Five papers (representing four individual studies) from two different countries were included. All studies focused on the experiences of trial recruiters in the maternity setting. We identified four analytical themes; Recruitment through a clinician's lens, Recruiters judgement on acceptability, From protocol to recruiters lived experience, Framing recruitment in context. These were linked by an overarching theme combining beliefs and power.

CONCLUSION

The overarching theme combining beliefs and power links the experiences and perceptions of recruiters. This synthesis shows a gap between the trial design study protocol and the recruiter's lived experience. Strategies such as collaborative trial design, mitigating gatekeeping behaviours, and training may support recruiters in their endeavour.

Substitution of nurses for physicians in the hospital setting for patient, process of care, and economic outcomes

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

The main objective of the review is to examine the impact of substituting nurses for doctors in the hospital setting (hospital inpatient units and outpatient clinics) on patient outcomes, process of care outcomes, and economic outcomes.

The secondary objectives of this review are to assess whether the effects of nurse‐doctor substitution differ according to healthcare setting (low‐ and middle‐income countries versus high‐income countries), patient disease, patient type (inpatients versus outpatients), and mode of nursing practice (unsupervised versus delegated/under medical supervision).

Unlocking medical leadership’s potential: a multilevel virtuous circle?

Background and aimMedical leadership (ML) has been introduced in many countries, promising to support healthcare services improvement and help further system reform through effective leadership behaviours. Despite some evidence of its success, such lofty promises remain unfulfilled.

MethodCouched in extant international literature, this paper provides a conceptual framework to analyse ML’s potential in the context of healthcare’s complex, multifaceted setting.

ResultsWe identify four interrelated levels of analysis, or domains, that influence ML’s potential to transform healthcare delivery. These are the healthcare ecosystem domain, the professional domain, the organisational domain and the individual doctor domain. We discuss the tensions between the various actors working in and across these domains and argue that greater multilevel and multistakeholder collaborative working in healthcare is necessary to reprofessionalise and transform healthcare ecosystems.

Understanding factors influencing venous leg ulcer guideline implementation in Australian primary care

The aim of this study was to gain a better understanding of the venous leg ulcer (VLU) management in primary health care settings located in Melbourne metropolitan and rural Victoria, Australia. We explored health professionals' perspective on the use of the Australian and New Zealand Venous Leg Ulcer Clinical Practice Guideline (VLU CPG) to identify the main challenges of VLU CPG uptake in clinical practice. We conducted semi-structured interviews with 15 general practitioners (GPs) and 20 practice nurses (PNs), including two Aboriginal health nurses. The Theoretical Domains Framework guided data collection and analysis. Data were analysed using a theory-driven analysis. We found a lack of awareness of the VLU CPGs, which resulted in suboptimal knowledge and limited adherence to evidence-based recommendations. Environmental factors, such as busy nature of clinical environment and absence of handheld Doppler ultrasound, as well as social and professional identity factors, such as reliance on previous experience and colleague's advice, influenced the uptake of the VLU CPGs in primary care. Findings of this study will inform development of interventions to increase the uptake of the VLU CPG in primary care settings and to reduce the evidence-practice gap in VLU management by health professionals.

Factors that influence participation in physical activity for anxiety or depression: a synthesis of qualitative evidence

This is a protocol for a Cochrane Review (Qualitative). The objectives are as follows:

Main objective: To identify the factors that create barriers or facilitate physical activity for people with a diagnosis of anxiety or depression from the perspectives of service users, carers, service providers and practitioners to help inform the design and implementation of interventions that promote physical activity.

The overall aim of this review is to identify, appraise, and synthesise qualitative research evidence on the barriers and facilitators to engaging in physical activity in general lifestyle settings or as part of an intervention designed to increase physical activity for people with anxiety and depression. This will allow us to identify factors that create barriers and facilitators of physical activity in this population to inform the development, design, and implementation of future interventions. We will also integrate the findings from the QES with the two associated effectiveness reviews (Cooney 2014 ; Larun 2006 ). We will communicate our findings to public health commissioners and other stakeholders.

Qualitative Evidence Synthesis (QES) for Guidelines: Paper 3 - Using qualitative evidence syntheses to develop implementation considerations and inform implementation processes

BACKGROUND

This is the third in a series of three papers describing the use of qualitative evidence syntheses (QES) to inform the development of clinical and health systems guidelines. WHO has recognised the need to improve its guideline methodology to ensure that decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable to end users. In addition to the standard data on effectiveness, WHO guidelines increasingly use evidence derived from QES to provide information on acceptability and feasibility and to develop important implementation considerations.

METHODS

WHO convened a group drawn from the technical teams involved in formulating recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. As members of WHO guideline technical teams, our aim in this paper is to explore how we have used findings from QES to develop implementation considerations for these guidelines.

RESULTS

For each guideline, in addition to using systematic reviews of effectiveness, the technical teams used QES to gather evidence of the acceptability and feasibility of interventions and, in some cases, equity issues and the value people place on different outcomes. This evidence was synthesised using standardised processes. The teams then used the QES to identify implementation considerations combined with other sources of information and input from experts.

CONCLUSIONS

QES were useful sources of information for implementation considerations. However, several issues for further development remain, including whether researchers should use existing health systems frameworks when developing implementation considerations; whether researchers should take confidence in the evidence into account when developing implementation considerations; whether qualitative evidence that reveals implementation challenges should lead guideline panels to make conditional recommendations or only point to implementation considerations; and whether guideline users find it helpful to have challenges pointed out to them or whether they also need solutions. Finally, we need to explore how QES findings can be incorporated into derivative products to aid implementation.

Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis

BACKGROUND

Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles.

OBJECTIVES

(1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review.

SEARCH METHODS

We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed.

SELECTION CRITERIA

We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively.

DATA COLLECTION AND ANALYSIS

We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness.

MAIN RESULTS

We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses.

AUTHORS' CONCLUSIONS

Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.

Nurses as substitutes for doctors in primary care

BACKGROUND

Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005.

OBJECTIVES

Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:• patient outcomes;• processes of care; and• utilisation, including volume and cost.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'.

SELECTION CRITERIA

Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis.

MAIN RESULTS

For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):• Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).• Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).• Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low.

AUTHORS' CONCLUSIONS

This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse-led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors.

Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis

BACKGROUND

Lay health workers (LHWs) perform functions related to healthcare delivery, receive some level of training, but have no formal professional or paraprofessional certificate or tertiary education degree. They provide care for a range of issues, including maternal and child health. For LHW programmes to be effective, we need a better understanding of the factors that influence their success and sustainability. This review addresses these issues through a synthesis of qualitative evidence and was carried out alongside the Cochrane review of the effectiveness of LHWs for maternal and child health.

OBJECTIVES

The overall aim of the review is to explore factors affecting the implementation of LHW programmes for maternal and child health.

SEARCH METHODS

We searched MEDLINE, OvidSP (searched 21 December 2011); MEDLINE Ovid In-Process & Other Non-Indexed Citations, OvidSP (searched 21 December 2011); CINAHL, EBSCO (searched 21 December 2011); British Nursing Index and Archive, OvidSP (searched 13 May 2011). We searched reference lists of included studies, contacted experts in the field, and included studies that were carried out alongside the trials from the LHW effectiveness review.

SELECTION CRITERIA

Studies that used qualitative methods for data collection and analysis and that focused on the experiences and attitudes of stakeholders regarding LHW programmes for maternal or child health in a primary or community healthcare setting.

DATA COLLECTION AND ANALYSIS

We identified barriers and facilitators to LHW programme implementation using the framework thematic synthesis approach. Two review authors independently assessed study quality using a standard tool. We assessed the certainty of the review findings using the CerQual approach, an approach that we developed alongside this and related qualitative syntheses. We integrated our findings with the outcome measures included in the review of LHW programme effectiveness in a logic model. Finally, we identified hypotheses for subgroup analyses in future updates of the review of effectiveness.

MAIN RESULTS

We included 53 studies primarily describing the experiences of LHWs, programme recipients, and other health workers. LHWs in high income countries mainly offered promotion, counselling and support. In low and middle income countries, LHWs offered similar services but sometimes also distributed supplements, contraceptives and other products, and diagnosed and treated children with common childhood diseases. Some LHWs were trained to manage uncomplicated labour and to refer women with pregnancy or labour complications.Many of the findings were based on studies from multiple settings, but with some methodological limitations. These findings were assessed as being of moderate certainty. Some findings were based on one or two studies and had some methodological limitations. These were assessed have low certainty.Barriers and facilitators were mainly tied to programme acceptability, appropriateness and credibility; and health system constraints. Programme recipients were generally positive to the programmes, appreciating the LHWs' skills and the similarities they saw between themselves and the LHWs. However, some recipients were concerned about confidentiality when receiving home visits. Others saw LHW services as not relevant or not sufficient, particularly when LHWs only offered promotional services. LHWs and recipients emphasised the importance of trust, respect, kindness and empathy. However, LHWs sometimes found it difficult to manage emotional relationships and boundaries with recipients. Some LHWs feared blame if care was not successful. Others felt demotivated when their services were not appreciated. Support from health systems and community leaders could give LHWs credibility, at least if the health systems and community leaders had authority and respect. Active support from family members was also important.Health professionals often appreciated the LHWs' contributions in reducing their workload and for their communication skills and commitment. However, some health professionals thought that LHWs added to their workload and feared a loss of authority.LHWs were motivated by factors including altruism, social recognition, knowledge gain and career development. Some unsalaried LHWs wanted regular payment, while others were concerned that payment might threaten their social status or lead recipients to question their motives. Some salaried LHWs were dissatisfied with their pay levels. Others were frustrated when payment differed across regions or institutions. Some LHWs stated that they had few opportunities to voice complaints. LHWs described insufficient, poor quality, irrelevant and inflexible training programmes, calling for more training in counselling and communication and in topics outside their current role, including common health problems and domestic problems. LHWs and supervisors complained about supervisors' lack of skills, time and transportation. Some LHWs appreciated the opportunity to share experiences with fellow LHWs.In some studies, LHWs were traditional birth attendants who had received additional training. Some health professionals were concerned that these LHWs were over-confident about their ability to manage danger signs. LHWs and recipients pointed to other problems, including women's reluctance to be referred after bad experiences with health professionals, fear of caesarean sections, lack of transport, and cost. Some LHWs were reluctant to refer women on because of poor co-operation with health professionals.We organised these findings and the outcome measures included in the review of LHW programme effectiveness in a logic model. Here we proposed six chains of events where specific programme components lead to specific intermediate or long-term outcomes, and where specific moderators positively or negatively affect this process. We suggest how future updates of the LHW effectiveness review could explore whether the presence of these components influences programme success.

AUTHORS' CONCLUSIONS

Rather than being seen as a lesser trained health worker, LHWs may represent a different and sometimes preferred type of health worker. The close relationship between LHWs and recipients is a programme strength. However, programme planners must consider how to achieve the benefits of closeness while minimizing the potential drawbacks. Other important facilitators may include the development of services that recipients perceive as relevant; regular and visible support from the health system and the community; and appropriate training, supervision and incentives.