The role of governance in implementing task-shifting from physicians to nurses in advanced roles in Europe, U.S., Canada, New Zealand and Australia

From policy to practice: Rolling out the clinical nurse specialist role in Portugal

The specialization of Health Human Resources (HHR) is increasingly recognized as essential for addressing evolving healthcare demands. This paper presents a comprehensive policy framework for assisting with the implementation of Clinical Nurse Specialist (CNS) roles at the national or regional level, integrating key dimensions including barriers and enablers, regulation and governance, education and training requirements, career development, workforce planning, and economic analysis. The framework was applied to the implementation of CNS roles in Portugal, resulting in the issuance of a decree-law by the government. Our findings demonstrate that the economic analysis step was critical in addressing concerns from government authorities and health system funders regarding the potential budgetary impact of CNS implementation. By providing evidence-based projections of costs and benefits, the economic analysis facilitated smoother negotiations and consensus-building among stakeholders, including nursing unions. Furthermore, the integration of workforce planning ensured the alignment of educational capacity with workforce needs, thus avoiding potential implementation bottlenecks. The application of the framework also revealed important feedback relationships between its dimensions, highlighting the interdependent nature of the implementation process. This dynamic approach, which adapts to real-time feedback and stakeholder input, underscores the necessity of a holistic and iterative strategy for successful CNS role integration. The insights gained from the Portuguese case underscore the utility of this policy framework in guiding the implementation of advanced nursing roles in diverse healthcare contexts.

It's not the task, it's the shifting exploring physicians' and leaders' perspectives on task shifting in emergency departments in Norway

BACKGROUND

Task shifting is an approach where specific tasks are transferred, when convenient, from health workers with high qualifications to health workers with less training and lower qualifications. This approach is mainly used to utilize the available human resources for health. Tasks that are traditionally linked to the physician role have increasingly been transferred to registered nurses during the last decade. Knowledge regarding the experiences and reflections of physicians and their leaders related to giving up tasks or how such policies can best be implemented is limited. This study aimed to explore physicians' and their leaders' perspectives on task shifting, especially to registered nurses, in different Norwegian emergency departments.

METHODS

The study was carried out from June to October 2022. It had an explorative and descriptive qualitative design and an inductive approach, semi-structured interviews was used. The study involved ten physicians and leaders from three different regional hospitals in south-eastern Norway. Manifest and latent content analysis were used to analyse the data. The COREQ guidelines were applied in the study.

RESULTS

From the three categories 1) The rationale for task shifting, 2) Teambuilding and 3) Implementation of task shifting, with nine subcategories. One overall main theme emerged: It is not the task, it is the shifting - moving towards a person-centred culture.

CONCLUSIONS

The study indicates that developing a person-centred culture and fostering a team approach in emergency departments is more important than simply shifting tasks, as task shifting may lead to fragmented care and resistance from physicians. Hospital leaders must invest time and effort into organising teams and providing clear leadership to support the redesign of professional roles, recognising the cultural and traditional challenges involved. Policymakers should promote guideline development, team training programs, and cooperation methods to support a person-centred culture and effective task shifting in emergency departments.

Advanced practice nurse competencies to practice in emergency and critical care settings: A scoping review

AIM

Advanced Practice Nurses are expected to provide lifesaving care to patients with complex acute illnesses in emergency and critical care settings. However, little is known about their competencies and barriers to practice in emergency and critical care settings. This review investigated these nurses' competencies to practice.

METHODS

A scoping review was conducted in accordance with Arksey and O'Malley's framework. Extensive research searches were conducted using seven electronic databases: MEDLINE, CINAHL, Scopus, Web of Science, Ichushi Web, Mednar and GreyNet International. Definitions and explanations of Advanced Practice Nurse competencies were categorized into elements and grouped according to similarity.

RESULTS

The database searches identified 2,483 studies, and data were extracted for 23 studies. Analysed studies were published between 2000 and 2021 and conducted in eight countries. Seven competencies were identified: performing advanced practice nursing, acute patient care, diagnostic assessment, interdisciplinary collaboration and consultation, leadership and system management, documenting patient care and supporting patient and family decision-making.

CONCLUSION

This review identified competencies unique to Advanced Practice Nurses in emergency and critical care settings. Further research is required to facilitate understanding of the crucial roles of advanced care nurses among healthcare providers.

Designing and implementing an Advanced Nurse Practice in Critical Care programme from a university perspective within Northern Ireland

The number of advanced practice roles in healthcare is increasing in response to several factors such as changes in medical education, economic pressures, workforce shortages and the increasing complexity of health needs of the population. The Advanced Critical Care Practitioner Curriculum, developed by the Faculty of Intensive Care Medicine in the UK (United Kingdom), enables the development and delivery of a structured education programme which can contribute to addressing these challenges. This article outlines how one university designed and implemented this programme, the first of its kind in Northern Ireland.

International comparison of professional competency frameworks for nurses: a document analysis

BACKGROUND

Nursing competency frameworks describe the competencies; knowledge, skills and attitudes nurses should possess. Countries have their own framework. Knowledge of the content of professional competency frameworks in different countries can enhance the development of these frameworks and international collaborations.

OBJECTIVE

This study examines how competencies and task divisions are described in the current professional competency frameworks for registered nurses (RNs with a Bachelor's degree) in the Netherlands, Belgium, the United Kingdom (UK), Canada and the United States (US).

METHODS

Qualitative document analysis was conducted using the most recently published professional competency frameworks for registered nurses in the above-mentioned five countries.

RESULTS

All the competency frameworks distinguished categories of competencies. Three of the five frameworks explicitly mentioned the basis for the categorization: an adaptation of the CanMEDS model (Netherlands), European directives on the recognition of professional qualifications (Belgium) and an adapted inter-professional framework (US). Although there was variation in how competencies were grouped, we inductively identified ten generic competency domains: (1) Professional Attitude, (2) Clinical Care in Practice, (3) Communication and Collaboration, (4) Health Promotion and Prevention, (5) Organization and Planning of Care, (6) Leadership, (7) Quality and Safety of Care, (8) Training and (continuing) Education, (9) Technology and e-Health, (10) Support of Self-Management and Patient Empowerment. Country differences were found in some more specific competency descriptions. All frameworks described aspects related to the division of tasks between nurses on the one hand and physicians and other healthcare professionals on the other hand. However, these descriptions were rather limited and often imprecise.

CONCLUSIONS

Although ten generic domains could be identified when analysing and comparing the competency frameworks, there are country differences in the categorizations and the details of the competencies described in the frameworks. These differences and the limited attention paid to the division of tasks might lead to cross-country differences in nursing practice and barriers to the international labour mobility of Bachelor-educated RNs.

Advanced non-medical roles within surgery and their engagement with assistive health technologies

The role of the surgical care practitioner (SCP) is common in UK surgical centres. The SCP curriculum is robust and well developed in multiple specialties since it was first developed in 1989. The SCP role can often concentrate on technical skills, developing a skillset that is highly effective during traditional open surgical procedures. This skillset requires further investigation because technology-assisted surgeries are becoming more common, including the use of novel approaches to developing non-technical skills. To effectively develop this skillset, analysis of robust advanced practice frameworks is necessary, alongside clear alignment to the advanced practitioners' professional regulations. This article examines the interpretation of the advanced practice concept within technology-assisted surgeries, which is potentially guiding the evolution of advanced practice within operating theatres and improving patient care.

Factors that influence scope of practice of the five largest health care professions in Australia: a scoping review

INTRODUCTION

A well-functioning health system delivers quality services to all people when and where they need them. To help navigate the complex realm of patient care, it is essential that health care professions have a thorough understanding of their scope of practice. However, a lack of uniformity regarding scope of practice across the regulated health professions in Australia currently exists. This has led to ambiguity about what comprises scope of practice in some health care professions in the region.

OBJECTIVE

The objective of this review was to explore the literature on the factors that influence scope of practice of the five largest health care professions in Australia.

METHODS

This study employed scoping review methodology to document the current state of the literature on factors that influence scope of practice of the five largest health care professions in Australia. The search was conducted using the following databases: AMED (Allied and Complementary Medicine Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, EMBASE (Excerpta Medica Database), MANTIS (Manual, Alternative and Natural Therapy Index System), MEDLINE, PubMed, and SCOPUS. Additional data sources were searched from Google and ProQuest.

RESULTS

A total of 12 771 publications were identified from the literature search. Twenty-three documents fulfilled the inclusion criteria and were included in the final analysis. Eight factors were identified across three professions (nursing & midwifery, pharmacy and physiotherapy) that influenced scope of practice: education, competency, professional identity, role confusion, legislation and regulatory policies, organisational structures, financial factors, and professional and personal factors.

CONCLUSION

The results of this study will inform a range of stakeholders including the private and public arms of the healthcare system, educators, employers, funding bodies, policymakers and practitioners about the factors that influence scope of practice of health professions in Australia.

Exploring inter- and intra-organisational dynamics supporting task-shifting opportunities in AIDS service organisations: A qualitative study

Task-shifting of combination sexual health services from clinicians to community workers has been well-studied in low-resource settings, but lacks empirical examination as a response to service inequities in North American community-based AIDS service organisations (ASOs). This study adopts a qualitative exploratory approach to understanding how ASOs may support task-shifting for gay, bisexual and other men who have sex with men (GBMSM), drawing from interviews (n = 33) with clinicians and community workers in southern Ontario. Results include intra-organisational (including resource supports, development of community worker roles, providing task-shifting training, provider representation and inclusive service environment) and inter-organisational (including structure of engagement, streamlining referrals, development of effective partnerships, development of a formal organisational network and increasing awareness) dynamics which, when applied at an organisation level within ASOs, encourage successful and effective task-shifting. Related activities may be used to increase service quality and access for GBMSM. Considerations for application and management practice is provided.

Doctor Clerk Implementation in Rural Community Hospitals for Effective Task Shifting of Doctors: A Grounded Theory Approach

With the diversification of medical care and work reform, doctor clerks play a major role today and are recruited to mitigate the burden of doctors worldwide. Their recruitment can improve the working conditions of physicians, facilitate task shifting in rural community hospitals, improve patient care, and help address the lack of healthcare resources. This study used a qualitative method to investigate difficulties in the implementation of doctor clerks and ascertain the features of effective implementation by collecting ethnographic data through field notes and semi-structured interviews with workers. We observed and interviewed 4 doctor clerks, 10 physicians, 14 nurses, 2 pharmacists, 1 nutritionist, and 2 therapists for our study. We clarified the doctor clerk process in rural hospitals through four themes: initial challenge, balance between education and expansion, vision for work progression, and drive for quality of care. We further clarified effectiveness, difficulties, and enhancing factors in implementation. Doctor clerk recruitment and bridging of discrepancies among medical professionals can mitigate professional workloads and improve staff motivation, leading to better interprofessional collaboration and patient care.

A framework of the institutional policies and practice environments of nurse practitioner primary care models: A cross-case analysis

PURPOSE

The purpose of this article was to compare the implementation of distinct models of nurse practitioner (NP) integration into primary care offices.

DESIGN/METHODOLOGY

A multiple case study design of three NP primary care practice models allowed for in-depth exploration of the management processes supporting the utilization of NPs. At each site, semistructured qualitative interviews, document review, and site tours/observations were conducted and subject to cross-case analysis guided by the NP Primary Care Organizational Framework (NP-PCOF)-developed for this study based on existing theory.

RESULTS

Our case study sites represent three distinct NP primary care models. In the restricted practice model, NPs care for same-day/walk-in acute patients. NPs in the independent practice model have an independent panel of patients and interact collegially as independent coworkers. NPs in the comanagement model function on a team (a physician and two NPs), have a team office space, collectively care for a shared panel of patients, and can earn financial bonuses contingent upon meeting team quality metrics. Our cross-case analysis confirmed differences in physical space design, the relational structure of a workplace, and the capacity for innovation via NP compensation and performance metrics across different NP primary care models.

CONCLUSION

Our findings suggest that NP primary care models are supported by complex management systems and the NP-PCOF is a tool to help understand this complexity.

IMPLICATIONS

The NP-PCOF is a framework to understand the management systems that facilitate the utilization of NPs within primary care organizations.

Nationwide evaluation of the advanced clinical practitioner role in England: a cross-sectional survey

BACKGROUND AND STUDY OBJECTIVE

In response to growing pressures on healthcare systems, the advanced clinical practice (ACP) role has been implemented widely in the UK and internationally. In England, ACP is a level of practice applicable across various healthcare professions, who exercise a level of autonomy across four domains, referred to as the four pillars of practice (education, leadership, research and clinical practice). A national framework for ACP was established in 2017 to ensure consistency across the ACP role, however current ACP governance, education and support is yet to be evaluated. This study aimed to analyse data from a national survey of the ACP role to inform the development and improvement of policies relating to ACP in the National Health Service (NHS) in England.

DESIGN

A cross-sectional survey with free-text comments.

SETTING

The survey was distributed across primary and secondary levels of care to three distinct groups in England, including individual ACPs, NHS provider organisations and Trusts and primary care settings.

PARTICIPANTS

A total of 4365 surveys were returned, from ACP staff (n=4013), NHS provider organisations and Trusts (n=166) and primary care organisations (n=186).

RESULTS

Considerable variation was found in role titles, scope of practice, job descriptions and educational backgrounds of ACPs. Differing approaches to governance were noted, which led to inconsistent ACP frameworks in some organisations. A further challenge highlighted included committing time to work across the four pillars of advanced practice, particularly the research pillar. ACPs called for improvements in supervision and continuing professional development alongside further support in navigating career pathways.

CONCLUSIONS

A standardised approach may support ACP workforce development in England and enable ACPs to work across the four pillars of practice. Due to the wide uptake of ACP roles internationally, this study has relevance across professions for global healthcare workforce transformation.

Are advanced clinical practice roles in England's National Health Service a remedy for workforce problems? A qualitative study of senior staff perspectives

OBJECTIVE

A major issue facing all health systems is improving population health while at the same time responding to both growing patient numbers and needs and developing and retaining the health care workforce. One policy response to workforce shortages has been the development of advanced clinical practice roles. In the context of an English national policy promoting such roles in the health service, we explored senior managers' and senior clinicians' perceptions of factors at the organization level that support or inhibit the introduction of advanced clinical practice roles. The investigation was framed by theories of the diffusion of innovation and the system of professions.

METHODS

We conducted a qualitative interview study of 39 senior manager and clinicians in 19 National Health Service acute, community, mental health and ambulance organizations across a metropolitan area in 2019.

RESULTS

Small numbers of advanced clinical practice roles were reported, often in single services. Four main influences were identified in the development of advanced clinical practice roles: staff shortages (particularly of doctors in training grades) combined with rising patient demand, the desire to retain individual experienced staff, external commissioners or purchasers of services looking to shape services in line with national policy, and commissioner-funded new roles in new ambulatory care services and primary care. Three factors were reported as enabling the roles: finance for substantive posts, evidence of value of the posts, and structural support within the organization. Three factors were perceived as inhibiting developing the roles: confusion and lack of knowledge amongst clinicians and managers, the availability of finance for the roles, and a nervousness (sometimes resistance) to introducing the new roles.

CONCLUSIONS

While the national policy was to promote advanced clinical practice roles, the evidence suggested there was and would continue to be limited implementation at the operational level. Development scenarios that introduced new monies for such roles reduced some of the inhibiting factors. However, where the introduction of roles required funding to move from one part of a service to another, and potentially from one staff group to another, the growth of these roles was and is likely to be contested. In such scenarios, research and business evidence of relative advantage will be important, as too will be supporters in powerful positions. The paucity of publicly available evidence on the effectiveness of advanced clinical practice roles across the specialties and professions in different contexts requires urgent attention.

Perceptions and beliefs about the regulation of advanced nurse practitioners

BACKGROUND

The role of the advanced nurse practitioner (ANP) is not regulated in the UK, which has led to wide variation in the skills, competencies and academic qualifications of nurses using this title. Urgent treatment centres (UTCs) require a broad and experienced knowledge base to meet the demand of patients presenting with undifferentiated illnesses and injuries, which can be stressful and challenging.

AIM

To examine the perceptions and beliefs about ANP regulation, and to explore and discuss any ideas about proposed regulation.

METHOD

The author used interpretative phenomenological analysis to uncover valuable insights into the experiences of two ANPs working in an UTC, and their beliefs around regulation of the ANP role.

RESULTS

Both ANPs had different backgrounds and qualifications yet still had similar perceptions and beliefs regarding the regulation of ANPs. Five main themes were developed from the interview transcripts.

CONCLUSION

This study identified the need to consider the importance of ANPs' identity and the complex regulatory process required to standardise the role.

Skills, competencies, and policies for advanced practice critical care nursing in Europe: A scoping review

OBJECTIVES

Management of critically ill patients is changing due a rise in population age, comorbidity and complexity. To accommodate these changes, the demand is increasing for advanced practice nurses. More knowledge is needed regarding the role of advanced practice critical care nurses in European countries. The aim of the study was to review the literature describing skills and competencies required for advanced practice critical care nursing in Europe and to investigate related policy.

REVIEW METHOD

We performed a scoping review including papers published in 1992-2019 targeting policy and the intersection of advanced practice nursing (level of practice), critical care nursing (specialty area) and Europe (geographical origin).

DESIGN AND DATA SOURCES

Main sources of evidence were PubMed, EMBASE, PsycINFO, CINAHL, Cochrane Library, SweMed+, Scopus, ERIC and Social Sciences Citation Index. We also searched grey literature, webpages, reference lists and performed hand-search.

RESULTS

The search identified 11,478 papers/references of which 42 were included. Four levels of practice were identified with unclear boundaries: professional nurse, specialized nurse, advanced practice nurse and advanced critical care practitioner (nurse or other). Most skills and competencies described in the literature were generic to advanced practice and only few were area specific to critical care. Advanced practice critical care nurses were often unable to fulfil their role because education, supportive policy and legislation were lacking.

CONCLUSIONS

This scoping review informs the policy makers and the INACTIC study of existing advanced practice in critical care nursing in Europe. The advanced role in critical care nursing is characterized by inconsistency regarding policy, education, titles, roles, scope of practice, skills and competencies. Levels of practice and areas of specialization need to be clarified. Most skills and competencies identified were generic for advanced practice nursing and many were generic for any profession. Task-shifting from physician to nurse needs to be more clearly defined and patient outcomes described. Given the scarcity of papers in our target area, we believe it might be too early to conduct a systematic review at this time.

What impact do specialist and advanced-level nurses have on people living with heart failure compared to physician-led care? A literature review

BACKGROUND

The inclusion of specialist nurses in multi-disciplinary teams is the current gold standard for care of people with heart failure (HF) in the UK; however, they remain underutilised in practice. Though existing systematic reviews favourably compare advanced nursing roles to physician-led care, none has focused solely on HF.

AIM

To investigate the impact of specialist and advanced nurse-led care on the clinical outcomes, quality of life and satisfaction of people with HF compared to physician-led care.

METHODS

Literature review and narrative synthesis.

RESULTS

This review included 12 studies and categorised their measured outcomes into five domains: mortality; hospital admissions and length of stay; HF diagnosis and management; quality of life and patient satisfaction; and finally, self-assessment and self-care. Five studies appraised as medium or low risk of bias suggest the impact of specialist and advanced-level nurses on people with HF to be broadly equivalent to physicians regarding mortality, hospital admissions and length of stay, while superior in terms of self-assessment and self-care behaviours.

CONCLUSIONS

There were too few studies of sufficient methodological quality to draw definitive conclusions. However, no evidence was found to suggest that nurse-led services are any less effective or safe than physician-led services.

Clinical services in community pharmacies: a scoping review of policy and social implications

OBJECTIVES

Clinical services have allowed pharmacists to shift from product-oriented to patient-oriented services. However, the policy and social implications of clinical services in community pharmacies are not well described. The purpose of this scoping review was to identify these implications.

KEY FINDINGS

We searched Pubmed and Embase, from inception to March 2019, as well as grey literature for publications that discussed policy (e.g. pharmacy model and pharmacist status) or social (e.g. role of pharmacists and interprofessional collaboration) implications of clinical services. Publications had to address clinical services provided by pharmacists in community settings that target the global long-term care of patients. We extracted data related to the implications and classified them into themes thereafter. The search process identified 73 relevant publications, of which 13 were included in regard to policy implications and 60 relative to social implications. Two themes emerged from policy implications: implementation and characteristics of policies, and professional status. Pharmacists' independence from distribution, financial coverage of clinical services and innovative models of practice were addressed. Social implications involved three themes: roles and interprofessional collaboration, changes in practice and barriers and model of practices and services. Perceptions of pharmacists' skills, organisational barriers, time constraints, lack of self-confidence and cultural shifts required to implement clinical services were included in these themes.

SUMMARY

Our review demonstrates the changing role of community pharmacists in provision of clinical services within the healthcare system. The range of clinical services varies widely from one setting to another. The context of community pharmacy is not well suited to these changes in practice.

Advanced practice nurses' experiences and well-being: Baseline demographics from a cohort study

AIMS

To create a cohort of advanced practice nurses from across the UK and to report the initial questionnaire including demographics, work experiences and well-being.

BACKGROUND

In the UK, advanced nursing practice is not regulated. This has led to the concern that advanced nurses are working in very different ways with different levels of autonomy and support.

METHODS

Participants were recruited via university and Royal College of Nursing mailing lists, and social media adverts. They completed the initial questionnaire about their background and workplace, work experiences, credentialing and well-being.

RESULTS

A total of 143 nurses were recruited to the cohort and 86 completed the survey. Over 40 job titles were reported, across five pay bands. Job title was not correlated with pay band (p = .988). Participant well-being was not significantly different from the UK general population, but they reported high rates of work-related stress (44.2%) compared with the National Health Service national average (37.9%).

CONCLUSION

There is a wide disparity in pay, which is not reflected in title or setting. The high levels of work-related stress require further exploration.

IMPLICATIONS FOR NURSING MANAGEMENT

The range of experiences reported here should encourage managers to evaluate whether title, pay and support mechanisms for Advanced Practice Nurses in their organisations align with suggested national standards set by Royal Colleges and government departments.

Exploring the roles of advanced practice nurses in the care of patients following fragility hip fracture: A systematic review

AIM

This study aimed to explore the role and impact of advanced practice nurses (APNs) in care of patients following fragility hip fracture by systematically reviewing the available evidence.

REVIEW DESIGN

Systematic review.

DATA SOURCES

A search of the databases Ovid Medline, CINAHL, Embase, Emcare, Cochrane Library, and Google Scholar was conducted from January-February 2019.

METHOD

This systematic review adhered to The PRISMA Statement. Study selection was managed using the Covidence software platform and quality was assessed using JBI Critical appraisal tools. Studies included adults >18 years and described the role and impact of APNs in care of patients following fragility hip fracture on clinical and non-clinical outcomes.

RESULTS

There were 19 papers identified that met the inclusion/exclusion criteria. Quality was graded as moderate to low risk of bias. Six characteristics of APNs were identified: (1) coordination; (2) collaboration; (3) education; (4) assessment, investigation and treatment recommendations; (5) discharge planning, support and follow up; and (6) documentation. Overall mortality and LOS improved when characteristics of the APN role were present.

CONCLUSION

Key findings from this systematic review showed: (1) The APN title and role are not clearly defined, but characteristics of the APN role are evident; (2) characteristics of APNs promote the delivery of best practice hip fracture care and have a positive impact on mortality and LOS; and (3) innovative service delivery models involving APNs should be considered to address future projections of hip fracture rates and improve outcomes.

IMPACT

This systematic review provides evidence of the role characteristics of APNs in fragility hip fracture and the impact of the role on outcomes. Findings from this research could be used to develop service delivery models using APNs to care for patients following fragility hip fracture and to inform practice where APN roles may improve outcomes for other patient cohorts.

Drivers for emigration among healthcare professionals: Testing an analytical model in a primary healthcare setting

This paper aims to contribute to the discussion on health workforce migration, notably by testing an analytical model of the individual drivers for a professional to decide to emigrate. A large database was obtained from all primary health care units on mainland Portugal. A professional satisfaction survey was conducted and information on social-economic, labour and job satisfaction characteristics, including burnout, was obtained. Results showed that healthcare professionals who reported intention to emigrate are mostly male, young, not married, and more educated; they consider their income insufficient for their needs, and show higher levels of burnout at work and professional dissatisfaction. This profile is slightly different for GPs and nurses. The results obtained contribute to the discussion on what motivates primary health care professionals, including GPs and nurses, to emigrate. They also provide insight into the design of policy measures that may mitigate the intention of these healthcare professionals in general to emigrate.

Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up

BACKGROUND

The expanding roles and increasing importance of the nursing workforce in health services delivery in resource-limited settings is not adequately documented and sufficiently recognized in the current literature. Drawing upon the theme of 2020 as the International Year of the Nurse and the Midwife, we set out to describe how the role of nurses expanded tremendously in health facilities in Uganda during the era of anti-retroviral therapy (ART) scale-up that commenced in June 2004.

METHODS

We employed a mixed-methods sequential explanatory research design. Phase I entailed a cross-sectional health facility survey (n = 195) to assess the extent to which human resource management strategies (such as task shifting) were common. Phase II entailed a qualitative multiple case study of 16 (of the 195) health facilities for an in-depth understanding of the strategies adopted (e.g. nurse-centred HIV care). Descriptive analyses were performed in STATA (v 13) while qualitative data were analysed by thematic approach.

RESULTS

We found that nurses were the most represented cadre of health workers involved in the overall leadership of HIV clinics across Uganda. Most nurse-led HIV clinics were based in rural settings; however, this trend was fairly even across setting (rural/urban/peri-urban). While 181 (93%) health facilities allowed non-physician cadre to prescribe ART, a number of health facilities (n = 36) or 18% deliberately adopted nurse-led HIV care models. Nurses were empowered to be multi-skilled with a wide range of competencies across the HIV care continuum right from HIV testing to mainstream clinical HIV disease management. In several facilities, nursing cadre were the backbone of ART service delivery. A select number of facilities devised differentiated models of task shifting from physicians to nurses in which the latter handled patients who were stable on ART.

CONCLUSION

Overall, our study reveals a wide expansion in the scope-of-practice of nurses during ART scale-up in Uganda. Nurses were thrust in roles of HIV disease management that were traditionally the preserve of physicians. Our study underscores the importance of reforming regulatory frameworks governing nursing workforce scope of practice such as the need for developing a policy on task shifting which is currently lacking in Uganda.

Re-assessing the validity of the Moral Sensitivity Questionnaire (MSQ): Two new scales for moral deliberation and paternalism

RATIONALE, AIMS, AND OBJECTIVES

The current study and previous research have called the six-component model of Lützen's 30-item Moral Sensitivity Questionnaire (MSQ) into question. For this reason, we re-examined the construct validity of this instrument.

METHODS

In this cross-sectional study, which was based on a convenience sample of Dutch nurse practitioners (NPs) and physician assistants (PAs), we tested the validity of MSQ items using exploratory and confirmatory factor analyses (EFA and CFA, respectively).

RESULTS

The EFA revealed a two-component model, which was then tested as a target model with CFA and was found to have good model fit. Some items were correlated with two uncorrelated latent constructs, which we labelled as "paternalistic" and "deliberate" attitudes towards patients.

CONCLUSIONS

As in previous studies, the analyses in the current study, which was conducted among PAs and NPs, did not reveal six dimensions for the 30 items. Two new latent dimensions of moral sensitivity were psychometrically tested and confirmed. These two components relate to studies investigating ethical behaviour, and they can be used to describe the moral climate in healthcare organizations. The scales are indicators of the extent to which health professionals behave in a deliberate (sensitive) or paternalistic (insensitive) manner towards the opinions of patients within the context of medical decision-making.

Regulation of Advanced Critical Care Practitioners: Past, present and future

The role of Advanced Critical Care Practitioners was included in the Department of Health's recent consultation document on the regulation of Medical Associate Professions. This prompted the author, an Advanced Critical Care Practitioner, to examine the regulation of Advanced Critical Care Practitioners in the past, present and future. National competence frameworks have been developed. However, there continued to be criticism on the lack of regulation and title protection of Advanced Critical Care Practitioners. This article discusses the response of governing bodies to the consultation and its potential future implications for Advanced Critical Care Practitioners.

Advanced practice nurses' and general practitioners' first experiences with introducing the advanced practice nurse role to Swiss primary care: a qualitative study

BACKGROUND

Primary care is facing a multimorbid, ageing population and a lack of general practitioners (GPs), especially in rural areas. In many countries, advanced practice nurses (APNs) may be a potential solution for these challenges. Switzerland, however, is in the early stages of APN role development with a handful of pilot projects that are unresearched. Our aim was to explore the experiences of APNs and GPs involved in introducing the APN role to Swiss primary care.

METHODS

We organised two focus group discussions with APNs (n = 9) engaged in primary care across German-speaking Switzerland and individual interviews with APNs (n = 2) and GPs (n = 4) from two pilot projects in remote areas. Data analysis followed an exploratory hybrid approach of thematic analysis and was guided by the PEPPA Plus framework.

RESULTS

The analysis resulted in five main themes: The participants considered themselves pioneers developing a new model in primary care, seeking to shape and improve future health care ((1) pioneering spirit). Both nurses and doctors agreed on the additional value of the APN role, a role seen as having more time for and a different approach to patient care, bringing higher quality of care and flexibility to the practice ((2) added value from the APN role). Participants also emphasized the importance of asking for advice when unsure about diagnostic steps or appropriate treatment ((3) awareness of limited knowledge and skills). The main barriers identified included the impression that Swiss doctors have little knowledge about nurses in advanced roles ((4) GP's lack of knowledge regarding the APN role), and that further regulations will be important to foster role clarity and accountability ((5) political and legal obstacles in introducing the APN role).

CONCLUSIONS

The early phase of introducing APNs to Swiss primary care is characterised by heterogeneous, small-scale projects of pioneering GPs and APNs recognising the added value and limits of APNs despite a lack of governance and knowledge regarding the APN role among GPs. Experiences gained from ongoing projects provide elements of good practice for political discussions and regulations.

Perspectives of Quebec Primary Health Care Nurse Practitioners on Their Role and Challenges in Chronic Disease Management: A Qualitative Study

BACKGROUND

Primary health care nurse practitioners (PHCNPs) can play a key role in chronic disease management. However, little is known about the challenges they face.

PURPOSE

The study aimed to describe PHCNPs' perspectives on their role for patients with chronic health conditions, the barriers they face, and facilitating factors.

METHODS

A qualitative descriptive exploratory study was conducted with 24 PHCNPs in the Canadian province of Quebec.

RESULTS

PHCNPs believe that they are in an optimal position to address the needs of patients with chronic health conditions, especially in providing self-management support. However, PHCNPs reported feeling pressured to practice according to a biomedical model and to constantly defend their role in chronic disease management. They feel that they are frequently being diverted from their role to compensate for the lack of family doctors. PHCNPs made concrete recommendations to optimize their autonomous practice and quality of care: promoting strong interprofessional communication skills, genuine mentoring relationships between PHCNPs and partner physicians, managers upholding the full scope of PHCNPs' practice, and a more flexible legislative framework.

CONCLUSIONS

The original conception of PHCNPs as health professionals with unique characteristics is at stake. The factors that should be targeted to support the autonomy of PHCNPs were identified.

Evidence-informed policymaking: Modelling nurses' career pathway from registered nurse to advanced practice nurse

AIM

To formulate, validate, and disseminate policy, modelling nurses' career pathway from registered to advanced practice nurse.

METHOD

The evidence-informed policy and practice pathway framework was utilized. Multiple methods were used, including scoping review of literature, consultation of key informants, survey study, and expert group round-table discussions during 5-year project between 2013 and 2018.

RESULTS

Through (a) sourcing, (b) using, and (c) implementing the evidence, the expert group worked systematically to formulate a policy on a career pathway from registered to advanced practice nurse. The formulated career pathway includes three competence levels: registered nurse, specialized nurse, and advanced practice nurse, which includes the roles of nurse practitioner and clinical nurse specialist. In addition, validation and dissemination of the policy, as well as its effective implementation and the process of integrating it into practice, were examined.

CONCLUSION

Evidence-informed policymaking is an effective, interactive way to work collaboratively in achieving consensus and translating knowledge into practice. The formulated policy will contribute to the increased awareness, acknowledgement, and implementation of the registered nurses' traditional and new roles within health care environments. Implementing and integrating the policy in national health care policy, legislation, education, and organizations across the country is a work in progress.

Reasons for choosing or refusing care from a nurse practitioner: Results from a national population-based survey

AIM

To understand the public's willingness or lack thereof, to be seen and treated by a nurse practitioner (NP) as the first point of contact when accessing healthcare services.

DESIGN

This cross-sectional, population-based survey study used computer assisted telephone interviewing to elicit public opinions on the topic.

METHODS

Data were collected in July and August 2015 from calls randomly placed to Australian households. Survey questions were developed from previous surveys and pilot tested. Summative content analysis was used to analyse open-ended responses.

RESULTS

Most respondents were always, or in some situations, willing to receive care from a nurse practitioner. The main themes identified from those willing to be seen by a nurse practitioner in any situation were, (a) appropriately qualified nurse practitioners, (b) the knowledge and experience to refer on if necessary. Description of situations from those unwilling to be seen by a nurse practitioner related to concern about appropriate care in a life-threatening condition.

CONCLUSION

Respondents unwilling to consider any care from a nurse practitioner or care in an emergency situation, reveal a lack of understanding of their role in the wider healthcare team. As the number of nurse practitioners increase, professional groups and community awareness programmes should be focused on explaining and promoting their essential role.

IMPACT

This study addresses the increasing healthcare requirements of ageing populations through understanding acceptance by society to the provision of care from health professionals other than medical practitioners. Most respondents were willing to be seen by a nurse practitioner for all or most of their healthcare needs. Lack of understanding of their scope of practice and role in the wider healthcare team, particularly in emergency situations, was reflected in responses. Those who would refuse care from a NP were in the minority. Appropriateness and acceptability of the roles of health professionals to provide quality care collaboration need consideration by policy makers.

Enablers and Barriers to Registered Nurses Expanding Their Scope of Practice in Australia: A Cross-Sectional Study

A number of resources exist to assist registered nurses in Australia to determine their scope of practice; however, the ability of a professional nurse to expand his or her practice is highly context dependent. This article reports on barriers and enablers to expanding scope of practice, as identified by registered nurses across Australia. A cross-sectional survey administered online in 2016 returned 1,205 useable submissions. Results indicated that nurses wishing to expand their practice felt supported to do so by nursing colleagues and were aware of professional and regulatory documents relating to expanding scope of practice. Less support for this process was evident from other health professionals or employers. Respondents also indicated that they were motivated to expand their scope by professional satisfaction, potential for career advancement, and the desire to meet health service user's needs. The majority of respondents identified barriers to expanding scope of practice, including lack of remuneration and the absence of supportive guidelines. Respondents in the early stage of their careers were more likely to perceive organizational support for expanding their scope of practice. When required to expand their role, the majority of respondents indicated that they had undertaken additional training or accessed various resources to guide them in this process. Barriers to expanding nursing scope of practice can result in underutilization of the one of the greatest resources in the health care system. This article identifies a number of strategies that can facilitate role expansion to ensure that nursing continues to make a significant contribution to positive health service outcomes in Australia.

Innovative Models in Mental Health Delivery Systems: Task Sharing Care with Non-specialist Providers to Close the Mental Health Treatment Gap

PURPOSE OF REVIEW

Most people do not have access to adequate mental health care, and lack of skilled human resources is a major factor. We provide a narrative review of approaches to implementing task sharing-engaging non-specialist providers-to deliver mental health care.

RECENT FINDINGS

There is strong evidence both for the effectiveness of task sharing as a means of delivering care for a range of conditions across settings and for the effectiveness of non-specialist providers and health workers in delivering elements of culturally adapted psychosocial and psychological interventions for common and severe mental disorders. Key approaches to facilitate task sharing of care include balanced care, collaborative care, sustained training and supervision, use of trans-diagnostic interventions based on a dimensional approach to wellness and illness, and the use of emerging digital technologies. Non-specialist providers and health workers are well positioned to deliver evidence-based interventions for mental disorders, and a variety of delivery approaches can support, facilitate, and sustain this innovation. These approaches should be used, and evaluated, to increase access to mental health services.

Health workforce planning: which countries include nurse practitioners and physician assistants and to what effect?

BACKGROUND

An increasing number of countries are introducing new health professions, such as Nurse Practitioners (NPs) and Physician Assistants (PAs). There is however limited evidence, on whether these new professions are included in countries' workforce planning.

METHODS

A cross-country comparison of workforce planning methods. Countries with NPs and/or PAs were identified, workforce planning projections reviewed and differences in outcomes were analysed, based on a review of workforce planning models and a scoping review. Data on multi-professional (physicians/NPs/PAs) vs. physician-only models were extracted and compared descriptively. Analysis of policy implications was based on policy documents and grey literature.

RESULTS

Of eight countries with NPs/PAs, three (Canada, the Netherlands, United States) included these professions in their workforce planning. In Canada, NPs were partially included in Ontario's needs-based projection, yet only as one parameter to enhance efficiency. In the United States and the Netherlands, NPs/PAs were covered as one of several scenarios. Compared with physician-only models, multi-professional models resulted in lower physician manpower projections, primarily in primary care. A weakness of the multi-professional models was the accuracy of data on substitution. Impacts on policy were limited, except for the Netherlands.

CONCLUSIONS

Few countries have integrated NPs/PAs into workforce planning. Yet, those with multi-professional models reveal considerable differences in projected workforce outcomes. Countries should develop several scenarios with and without NPs/PAs to inform policy.

National mixed methods evaluation of the effects of removing legal barriers to full practice authority of Dutch nurse practitioners and physician assistants

OBJECTIVE

To evaluate the effects of granting legal full practice authority (FPA) to nurse practitioners (NP) and physician assistants (PA) regarding the performance of specified reserved medical procedures and to support governmental decision-making.

DESIGN

Nationwide mixed methods design with triangulation of quantitative (Pre-post test design) and qualitative data (expert interviews and focus groups).

METHODS

Surveys focused on the performance of the procedures (monthly number, authorisation mode, consultations and procedural time) and legal cross-compliance requirements (adherence with protocols, competence). Interviews focused on competence, knowledge, skills, responsibilities, routine behaviour, NP/PA role, acceptance, organisational structure, collaboration, consultation, NP/PA positioning, adherence with protocols and resources. Data collection took place between 2011 and 2015.

RESULTS

Quantitative data included 1251 NPs, 798 PAs and 504 physicians. Besides, expert interviews with 33 healthcare providers and 28 key stakeholders, and 5 focus groups (31 healthcare providers) were held.After obtaining FPA, the proportion of NPs and PAs performing reserved procedures increased from 77% to 85% and from 86% to 93%, respectively; the proportion of procedures performed on own authority increased from 63% to 76% for NPs and from 67% to 71% for PAs. The mean number of monthly contacts between NPs/PAs and physicians about procedures decreased (from 81 to 49 and from 107 to 54, respectively), as did the mean duration in minutes (from 9.9 to 8.6 and from 8.8 to 7.4, respectively). Utilisation of FPA was dependent on the setting, as scepticism of physicians and medical boards hampered full implementation. Legal cross-compliance requirements were mostly fulfilled.

CONCLUSIONS

Informal practice was legalised. The opportunities to independently perform catheterisations, injections, prescribing, punctures and small surgical procedures were highly used. Care processes were organised more efficiently, services were performed by the most appropriate healthcare provider and conditions were met. This led to the recommendation to continue with FPA.

Task shifting between physicians and nurses in acute care hospitals: cross-sectional study in nine countries

BACKGROUND

Countries vary in the extent to which reforms have been implemented expanding nurses' Scopes-of-Practice (SoP). There is limited cross-country research if and how reforms affect clinical practice, particularly in hospitals. This study analyses health professionals' perceptions of role change and of task shifting between the medical and nursing professions in nine European countries.

METHODS

Cross-sectional design with surveys completed by 1716 health professionals treating patients with breast cancer (BC) and acute myocardial infarction (AMI) in 161 hospitals across nine countries. Descriptive and bivariate analysis on self-reported staff role changes and levels of independence (with/without physician oversight) by two country groups, with major SoP reforms implemented between 2010 and 2015 (Netherlands, England, Scotland) and without (Czech Republic, Germany, Italy, Norway, Poland, Turkey). Participation in 'medical tasks' was identified using two methods, a data-driven and a conceptual approach. Individual task-related analyses were performed for the medical and nursing professions, and Advanced Practice Nurses/Specialist Nurses (APN/SN).

RESULTS

Health professionals from the Netherlands, England and Scotland more frequently reported changes to staff roles over this time period vs. the other six countries (BC 74.0% vs. 38.7%, p < .001; AMI 61.7% vs. 37.3%, p < .001), and higher independence in new roles (BC 58.6% vs. 24.0%, p < .001; AMI 48.9% vs. 29.2%, p < .001). A higher proportion of nurses and APN/SN from these three countries reported to undertake tasks related to BC diagnosis, therapy, prescribing of medicines and information to patients compared to the six countries. Similar cross-country differences existed for AMI on prescribing medications and follow-up care. Tasks related to diagnosis and therapy, however, remained largely within the medical profession's domain. Most tasks were reported to be performed by both professions rather than carried out by one profession only.

CONCLUSIONS

Higher levels of changes to staff roles and task shifting were reported in the Netherlands, England and Scotland, suggesting that professional boundaries have shifted, for instance on chemotherapy or prescribing medicines. For most tasks, however, a partial instead of full task shifting is practice.

Skill mix change between general practitioners, nurse practitioners, physician assistants and nurses in primary healthcare for older people: a qualitative study

Background

More and more older adults desire to and are enabled to grow old in their own home, regardless of their physical and mental capabilities. This change, together with the growing number of older adults, increases the demand for general practitioners (GPs). However, care for older people lacks prestige among medical students and few medical students are interested in a career in care for older people. Innovative solutions are needed to reduce the demand for GPs, to guarantee quality of healthcare and to contain costs. A solution might be found in skill mix change by introducing nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs). The aim of this study was to describe how skill mix change is organised in daily practice, what influences it and what the effects are of introducing NPs, PAs or RNs into primary healthcare for older people.

Methods

In total, 34 care providers working in primary healthcare in the Netherlands were interviewed: GPs (n = 9), NPs (n = 10), PAs (n = 5) and RNs (n = 10). Five focus groups and 14 individual interviews were conducted. Analysis consisted of open coding, creating categories and abstraction.

Results

In most cases, healthcare for older people was only a small part of the tasks of NPs, PAs and RNs; they did not solely focus on older people. The tasks they performed and their responsibilities in healthcare for older people differed between, as well as within, professions. Although the interviewees debated the usefulness of proactive structural screening on frailty in the older population, when implemented, it was also unclear who should perform the geriatric assessment. Interviewees considered NPs, PAs and RNs an added value, and it was stated that the role of the GP changed with the introduction of NPs, PAs or RNs.

Conclusions

The roles and responsibilities of NPs, PAs and RNs for the care of older people living at home are still not established. Nonetheless, these examples show the potential of these professionals. The establishment of a clear vision on primary healthcare for older people, including the organisation of proactive healthcare, is necessary to optimise the impact of skill mix change.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0746-1) contains supplementary material, which is available to authorized users.

The role of advanced geriatric nurses in Norway: A descriptive exploratory study

BACKGROUND

Care of older adults in the community is becoming increasingly complex. However, nursing staff often has insufficient knowledge and skills to adequately address the needs of frail older adults. There is therefore a need for nurses with advanced qualifications. To meet this need, advanced geriatric nursing has been introduced in Norway.

AIMS AND OBJECTIVES

This study aimed to describe the experiences of nurses with their new role as advanced geriatric nurses in care of older adults and to determine what strategies the nurses considered important in the development of their new role.

DESIGN

This study applied a descriptive, exploratory design.

METHODS

In-depth interviews were conducted with 21 nurses who had undergone an educational programme to become advanced geriatric nurses in Norway in 2016. Content analysis was used to analyse the data.

FINDINGS

The participants described a complex and extensive nursing role, which they related to a new understanding of the patients, relatives and the system in which they worked. This new gaze had developed based on a combination of their new knowledge, their skills, experiences and professional interests. The opportunities to use their role depended on their workplace conditions. They related to contextual challenges at their workplace in different ways to optimise the use of their new gaze.

CONCLUSIONS

Common for all participants was a broader and deeper understanding of the patient's health and life situation, which guided participants' actions. The key issue in developing the new role was developing effective strategies to foster role integration.

IMPLICATIONS FOR PRACTICE

Advanced geriatric nurses should collaborate with their managers to create a role that takes advantage of their knowledge and skills, as well as collaborate with colleagues to enhance understanding of utilisation of their role.

Development and regulation of advanced nurse practitioners in the UK and internationally

The NHS in the UK is under increasing pressure as a result of financial and recruitment issues, as well as an ageing population. Nursing has continued to adapt to this challenging time. Over the past few years, the advanced nurse practitioner (ANP) role has been implemented widely in primary and secondary care. However, the ANP role has lacked consistency in scope of practice, training and regulation. This article summarises the development of the ANP role in the UK and internationally, and issues relating to regulation. Globally, ANPs are regulated by one of three different bodies: nationally by central government or a professional body, or locally by employers. In the UK, the role is regulated by local procedures, relying on employers to make decisions about the scope and preparation for practice. Some of the challenges in the UK in relation to ANP regulation are discussed, including variations in scope, organisational constraints and lack of support. These challenges are exacerbated by a lack of role clarity, thereby indicating there is a need to improve regulation of ANPs. The Royal College of Nursing has responded to these challenges by introducing 'credentialing', a system for recording qualifications, skills and experience, but the uptake of this process is yet to be evaluated. Therefore, employers and ANPs should be aware of their collective responsibility for ensuring appropriate role regulation.

Professional groups driving change toward patient-centred care: interprofessional working in stroke rehabilitation in Denmark

BACKGROUND

Patient-centred care based on needs has been gaining momentum in health policy and the workforce. This creates new demand for interprofessional teams and redefining roles and tasks of professionals, yet little is known on how to implement new health policies more effectively. Our aim was to analyse the role and capacity of health professions in driving organisational change in interprofessional working and patient-centred care.

METHODS

A case study of the introduction of interprofessional, early discharge teams in stroke rehabilitation in Denmark was conducted with focus on day-to-day coordination of care tasks and the professional groups' interests and strategies. The study included 5 stroke teams and 17 interviews with different health professionals conducted in 2015.

RESULTS

Professional groups expressed highly positive professional interest in reorganised stroke rehabilitation concerning patients, professional practice and intersectoral relations; individual professional and collective interprofessional interests strongly coincided. The corresponding strategies were driven by a shared goal of providing needs-based care for patients. Individual professionals worked independently and on behalf of the team. There was also a degree of skills transfer as individual team members screened patients on behalf of other professional groups.

CONCLUSIONS

The study identified supportive factors and contexts of patient-centred care. This highlights capacity to improve health workforce governance through professional participation, which should be explored more systematically in a wider range of healthcare services.

Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: protocol for a realist evaluation case study

INTRODUCTION

In developed countries, substituting physicians with nurse practitioners, physician assistants and nurses (physician substitution) occurs in nursing homes as an answer to the challenges related to the ageing population and the shortage of staff, as well as to guarantee the quality of nursing home care. However, there is great diversity in how physician substitution in nursing homes is modelled and it is unknown how it can best contribute to the quality of healthcare. This study aims to gain insight into how physician substitution is modelled and whether it contributes to perceived quality of healthcare. Second, this study aims to provide insight into the elements of physician substitution that contribute to quality of healthcare.

METHODS AND ANALYSIS

This study will use a multiple-case study design that draws upon realist evaluation principles. The realist evaluation is based on four concepts for explaining and understanding interventions: context, mechanism, outcome and context-mechanism-outcome configuration. The following steps will be taken: (1) developing a theory, (2) conducting seven case studies, (3) analysing outcome patterns after each case and a cross-case analysis at the end and (4) revising the initial theory.

ETHICS AND DISSEMINATION

The research ethics committee of the region Arnhem Nijmegen in the Netherlands concluded that this study does not fall within the scope of the Dutch Medical Research Involving Human Subjects Act (WMO) (registration number 2015/1914). Before the start of the study, the Board of Directors of the nursing home organisations will be informed verbally and by letter and will also be asked for informed consent. In addition, all participants will be informed verbally and by letter and will be asked for informed consent. Findings will be disseminated by publication in a peer-reviewed journal, international and national conferences, national professional associations and policy partners in national government.

Nurse practitioners as primary care providers with their own patient panels and organizational structures: A cross-sectional study

BACKGROUND

Health care systems globally are facing challenges of meeting the growing demand for primary care services due to a shortage of primary care physicians. Policy makers and administrators are searching for solutions to increase the primary care capacity. The effective utilization of nurse practitioners (NPs) has been proposed as a solution. However, organizations utilize NPs in variable capacities. In some settings, NPs serve as primary care providers delivering ongoing continuous care to their patients, referred to as patient panels, whereas in other settings they deliver episodic care. Little is known about why organizations deploy NPs differently.

OBJECTIVES

Investigate the NP role in care delivery-primary care providers with the own patient panels or delivering episodic care-within their organizations and understand how work environments affect their role.

DESIGN

A cross-sectional survey design was used to collect data from primary care NPs.

SETTINGS

The study was conducted in one state in the United States (Massachusetts). Data from 163 primary care organizations was obtained, which employed between one to 12 NPs.

PARTICIPANTS

807 NPs recruited from the Massachusetts Provider Database received mail surveys; 314 completed and returned the survey, yielding a response rate of 40%.

METHODS

The survey contained measures of NP role in care delivery and work environment. NP role was measured by an item asking NPs to report if they deliver ongoing continuous care to their patient panel or if they do not have patient panel. The work environment was measured with the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). The multilevel Cox regression models investigated the influence of organization-level work environment on NP role in care delivery.

RESULTS

About 45% of NPs served as primary care providers with their own patient panel. Organization-level Independent Practice and Support subscale, an NP-PCOCQ subscale, had a significant positive effect on NP role (risk ratio=2.33; 95% CI: 1.06-5.13); with a one unit increase on this subscale, the incidence of the NPs serving as primary care providers with their own patient panel doubled.

CONCLUSIONS

NPs can help meet the increasing demand for primary care by taking responsibilities as primary care providers, and organizations can assign NPs their own patient panels. Supporting NP independent practice within organizations promotes NP role as primary care providers. Policy and organizational change focused on promoting NP work environments so NPs can practice as primary care providers can be an effective strategy to increase the primary care capacity.

Nurse-Performed Endoscopy: Implications for the Nursing Profession in Australia

Increasing demands for health care globally often lead to discussions about expanding the involvement of nurses in a range of nontraditional roles. Several countries have introduced nurse endoscopists as a means of easing the burden of demand for a range of endoscopic procedures. A shortage of medical staff in Australia combined with increasing demand for endoscopy led to the implementation of nurse endoscopists as a pilot program in the state of Queensland, where a nurse practitioner model was implemented, and Victoria, where an advanced practice model was used. This article will discuss the implementation of and responses from the nursing, medical, and policy community to nurse-performed endoscopy in this country. Regarding health policy, access to cancer screening may be improved by providing nurses with advanced training to safely perform endoscopy procedures. Moreover, issues of nurse credentialing and payment need to be considered appropriate to each country's health system model.

Regional health workforce monitoring as governance innovation: a German model to coordinate sectoral demand, skill mix and mobility

BACKGROUND

As health workforce policy is gaining momentum, data sources and monitoring systems have significantly improved in the European Union and internationally. Yet data remain poorly connected to policy-making and implementation and often do not adequately support integrated approaches. This brings the importance of governance and the need for innovation into play.

CASE

The present case study introduces a regional health workforce monitor in the German Federal State of Rhineland-Palatinate and seeks to explore the capacity of monitoring to innovate health workforce governance. The monitor applies an approach from the European Network on Regional Labour Market Monitoring to the health workforce. The novel aspect of this model is an integrated, procedural approach that promotes a 'learning system' of governance based on three interconnected pillars: mixed methods and bottom-up data collection, strong stakeholder involvement with complex communication tools and shared decision- and policy-making. Selected empirical examples illustrate the approach and the tools focusing on two aspects: the connection between sectoral, occupational and mobility data to analyse skill/qualification mixes and the supply-demand matches and the connection between monitoring and stakeholder-driven policy.

CONCLUSION

Regional health workforce monitoring can promote effective governance in high-income countries like Germany with overall high density of health workers but maldistribution of staff and skills. The regional stakeholder networks are cost-effective and easily accessible and might therefore be appealing also to low- and middle-income countries.

Descriptive, cross-country analysis of the nurse practitioner workforce in six countries: size, growth, physician substitution potential

OBJECTIVES

Many countries are facing provider shortages and imbalances in primary care or are projecting shortfalls for the future, triggered by the rise in chronic diseases and multimorbidity. In order to assess the potential of nurse practitioners (NPs) in expanding access, we analysed the size, annual growth (2005-2015) and the extent of advanced practice of NPs in 6 Organisation for Economic Cooperation and Development (OECD) countries.

DESIGN

Cross-country data analysis of national nursing registries, regulatory bodies, statistical offices data as well as OECD health workforce and population data, plus literature scoping review.

SETTING/PARTICIPANTS

NP and physician workforces in 6 OECD countries (Australia, Canada, Ireland, the Netherlands, New Zealand and USA).

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcomes were the absolute and relative number of NPs per 100 000 population compared with the nursing and physician workforces, the compound annual growth rates, annual and median percentage changes from 2005 to 2015 and a synthesis of the literature on the extent of advanced clinical practice measured by physician substitution effect.

RESULTS

The USA showed the highest absolute number of NPs and rate per population (40.5 per 100 000 population), followed by the Netherlands (12.6), Canada (9.8), Australia (4.4), and Ireland and New Zealand (3.1, respectively). Annual growth rates were high in all countries, ranging from annual compound rates of 6.1% in the USA to 27.8% in the Netherlands. Growth rates were between three and nine times higher compared with physicians. Finally, the empirical studies emanating from the literature scoping review suggested that NPs are able to provide 67-93% of all primary care services, yet, based on limited evidence.

CONCLUSIONS

NPs are a rapidly growing workforce with high levels of advanced practice potential in primary care. Workforce monitoring based on accurate data is critical to inform educational capacity and workforce planning.

Expanding clinical roles for nurses to realign the global health workforce with population needs: a commentary

Many countries, including Israel, face health workforce challenges to meet the needs of their citizens, as chronic conditions increase. Provider shortages and geographical maldistribution are common. Increasing the contribution of nurse practitioners and other advanced practice nursing roles through task-shifting and expansion of scope-of-practice can improve access to care and result in greater workforce efficiency. Israel and many other countries are introducing reforms to expand nurses' scope-of-practice. Recent international research offers three policy lessons for how countries just beginning to implement reforms could bypass policy barriers to implementation. First, there is substantial evidence on the equivalence in quality of care, patient safety and high consumer acceptance which should move policy debates from if to how to effectively implement new roles in practice. Second, regulatory and finance policies as well as accessible advanced education are essential to facilitate realignment of roles. Third, country experience suggests that advanced practice roles for nurses improve the attractiveness of nursing as a career thus contributing to solving nursing shortages rather than exacerbating them. Designing enabling policy environments and removing barriers will gain in relevance in the future as the demand for high-quality, patient-centered care is increasing.

Feasibility of improving child behavioral health using task-shifting to implement the 4Rs and 2Ss program for strengthening families in child welfare

Background

Children whose families are involved with child welfare services manifest disproportionately high levels of behavioral difficulties, which could be addressed in community-based organizations providing services to prevent out-of-home placement. Unfortunately, few evidence-based practices have been successfully implemented in child welfare settings, especially those originally delivered by mental health providers. Given that such settings typically employ caseworkers who lack prior mental health training, this is a significant barrier to implementation. Consequently, the overall aim of the current study is to test the feasibility of shifting a mental health intervention from specialized services to community-based organizations. It uses task-shifting and the Practical, Robust, Implementation, and Sustainability model (PRISM) to implement an evidence-based intervention to reduce child behavior difficulties, originally provided by mental health practitioners, so that it can be delivered by caseworkers providing placement prevention services to child welfare-involved families. Task-shifting involves (1) modifying the intervention for provision by non-mental health providers, (2) training non-mental health providers in the modified intervention, and (3) establishing regular supervision and monitoring by mental health specialists.

Methods/design

This study uses the 4Rs and 2Ss Program for Strengthening Families, a multiple family group service delivery model to reduce child behavior difficulties, as the example intervention. This intervention has had prior success with child welfare-involved families. The proposed study objectives are (1) to tailor the content, training, and supervision of the intervention for delivery by caseworkers serving child welfare-involved families and (2) to assess the feasibility and acceptability of the modified intervention. Mixed quantitative and qualitative methods will assess feasibility and acceptability from key stakeholders (caseworkers, supervisors, administrators, caregivers). In phase I, a collaborative advisory board will be convened (1) to modify the intervention to be delivered by caseworkers in placement prevention service settings and (2) to develop training and supervision protocols for caseworkers. In phase 2, the modified intervention will be pilot-tested for delivery by n = 4 caseworkers to n = 20 families receiving placement preventive services (where children manifest behavior problems). Mixed quantitative/qualitative methods will be used to assess feasibility and acceptability.

Discussion

This protocol will be of particular interest to agency administrators, program managers, and researchers interested in developing and testing cross-setting implementation guidelines for similar evidence-based practices.

Where health workforce governance research meets health services management

A deficit of one million healthcare workers forecasted in the European Union by 2020 turns the ‘universal truth’ that there is ‘no health without a workforce’ into the perhaps biggest challenge for future healthcare systems and services management. We argue that effective healthcare management needs systematic connections with health workforce macro- and meso-levels of governance. We seek to explore the overlaps and the benefits of closer connections using health workforce planning, recruitment and retention and the changes in the skills mix and competencies of the health workforce as three illustrative examples. Two major areas of management intervention are emerging: (1) changes in the composition of the skills and competencies in the health workforce guided by a needs-based services management approach rather than by professional interests and (2) changes in the management of workplace and career conditions. Furthermore, an integrated governance approach is needed that connects innovations at the organizational level of services management with health workforce policy and systems-based governance interventions.

Health workforce development in the European Union: A matrix for comparing trajectories of change in the professions

This article assesses professional development trajectories in top-, middle- and basic-level health workforce groups (doctors, nurses, care assistants) in different European Union countries using available international databases. Three theoretical strands (labour market, welfare state, and professions studies) were connected to explore ideal types and to develop a matrix for comparison. With a focus on larger EU-15 countries and four different types of healthcare systems, Germany, Italy, Sweden and the United Kingdom serve as empirical test cases. The analysis draws on selected indicators from public statistics/OECD data and micro-data from the EU Labour Force Survey. Five ideal typical trajectories of professional development were identified from the literature, which served as a matrix to compare developments in the three health workforce groups. The results reveal country-specific trajectories with uneven professional development and bring opportunities for policy interventions into view. First, there is a need for integrated health labour market monitoring systems to improve data on the skills mix of the health workforce. Second, a relevant number of health workers with fixed contracts and involuntary part-time reveals an important source for better recruitment and retention strategies. Third, a general trend towards increasing numbers while worsening working conditions was identified across our country cases. This trend hits care assistants, partly also nurses, the most. The research illustrates how public data sources may serve to create new knowledge and promote more sustainable health workforce policy.