The best person (or machine) for the job: Rethinking task shifting in healthcare

Physicians' responses to time pressure: Experimental evidence on treatment quality and documentation behaviour

BACKGROUND

In hospitals, decisions are often made under time pressure. There is, however, little evidence on how time pressure affects the quality of treatment and the documentation behaviour of physicians.

SETTING

We implemented a controlled laboratory experiment with a healthcare framing in which international medical students in the Czech Republic treated patients in the role of hospital physicians. We varied the presence of time pressure and a documentation task.

RESULTS

We observed worse treatment quality when individuals were faced with a combination of a documentation task and time pressure. In line with the concept of the speed-accuracy trade-off, we showed that quality changes are likely driven by less accuracy. Finally, we showed that while documentation quality was relatively high overall, time pressure significantly lowered the latter leading to a higher hypothetical profit loss for the hospital.

CONCLUSIONS

Our results suggest that policy reforms aimed at increasing staffing and promoting novel technologies that facilitate physicians' treatment decisions and support their documentation work in the hospital sector might be promising means of improving the treatment quality and reducing inefficiencies potentially caused by documentation errors.

A mixed methods protocol for an impact and implementation evaluation of the Pharmacy First Services for management of common conditions in England

OBJECTIVES

In response to high levels of demand for primary medical services in England, characterized by longer appointment waiting times and delayed referrals, the Government developed its National Health Service (NHS) Primary Care Recovery Plan. A key component of the plan is Pharmacy First (PF), which involves participating community pharmacies supplying prescription-only medicine after consultation with a pharmacist for seven common conditions: earache, uncomplicated urinary tract infections in women, sore throat, sinusitis, impetigo, shingles, and infected insect bites. The study aims to evaluate the implementation of the PF service and its impact on the volume of prescribing, case mix of General Practitioner consultations, accident and emergency department and other hospital use, equity of access, and cost for different groups of patients in different contexts, as well as its acceptability and fidelity.

METHODS

A 36-month, mixed methods evaluation with five elements, namely evidence synthesis, semi-structured interviews, focus groups, quantitative analysis of impacts before and after implementation (e.g. using interrupted time series analysis) using routine data, and an economic evaluation. Findings will be synthesized and interpreted using the Consolidated Framework for Implementation Research supplemented by Proctor's Implementation Outcomes Framework.

CONCLUSIONS

The evaluation should have service level, policy, professional, and research impact both in England and beyond. This includes generating evidence to show: whether PF contributes to improving primary healthcare access, assessing the quality of antimicrobial use, identifying the scope for refinements to PF, and, overall, informing better implementation of PF. The findings will also provide robust evidence to enable policymakers to determine how to enhance the role of community pharmacy in England in the future. Furthermore, the evaluation will develop a data dashboard, and the methods and codes used to interrogate it (though not the patient data), will be made publicly available that could support other similar evaluations in England and internationally.

Transforming healthcare through just, equitable and quality driven artificial intelligence solutions in South Asia

AI can transform healthcare in LMICs by improving access, reducing costs, and enhancing efficiency. However, challenges such as safety, bias, and the resource constraints need to be addressed. Further, collaboration across domains is essential to develop capacity, user-friendly tools, and training. Ethical considerations should be central to AI deployment. By emphasizing gender equity, fairness, and responsible design, LMICs can harness AI's power to enhance healthcare outcomes and advance equitable care.

The Future of the Health Professions: Navigating Shortages, Imbalances, and Automation

The healthcare sector is undergoing significant transformation driven by workforce shortages, role imbalances, and technological advances. Traditional health professions, characterised by advanced knowledge and self-regulation, face challenges from two key trends. First, there is a growing reliance on less-trained workers, such as nursing assistants and physician associates, to fill gaps, raising concerns about patient safety and the quality of care. While these roles can assist in simpler tasks, their expanded responsibilities-often exceeding their training-can lead to adverse outcomes, particularly in critical medical scenarios. Second, the rise of automation and artificial intelligence (AI) offers both opportunities and risks. While AI shows promise in reducing administrative burdens and aiding specialized tasks like image recognition, its limitations hinder its broader adoption, such as reinforcing biases and failing to reason diagnostically. This editorial argues that uncritical reliance on these developments risks compromising healthcare quality. It calls for evidence-based policymaking, robust oversight, and updated regulatory frameworks to ensure patient safety while adapting to these shifts. Getting the right balance between maintaining professional autonomy and integrating new roles and technologies is critical for building resilient healthcare systems capable of responding to future challenges.

Cardiovascular disease in the Americas: optimizing primary and secondary prevention of cardiovascular disease series: cardiovascular disease in the Americas

While, many interventions can prevent cardiovascular disease (CVD), and its resulting morbidity or mortality, these are used sub-optimally in most countries. Therefore, health systems need to develop new approaches to ensure that proven CVD therapies are delivered widely. In this review, we describe five impactful implementation strategies which include: (1) Task shifting, (2) Use of mobile-Health (mHealth) support and virtual access to care, (3) simplified diagnostic and management algorithms for the prevention of CVD, (4) improving the use of combinations of medicines (i.e., polypill), and (5) patient engagement and role of patient-nominated peer support (i.e., treatment supporters). Adapting and tailoring these strategies to the local context in different settings in various countries in the Americas and the Caribbean can reduce the morbidity and mortality of CVD substantially.

A contentious intervention to support the medical workforce: a case study of the policy of introducing physician associates in the United Kingdom

BACKGROUND

Health systems across Europe are facing a workforce crisis, with some experiencing severe shortages of doctors. In response, many are exploring greater task-sharing, across established professions, such as doctors, nurses, and pharmacists, with patients and carers, and with new occupational groups, in particular ones that can assist doctors and relieve their workload.

CASE PRESENTATION

In the early 2000s the United Kingdom created a new occupational role, that of physician assistant. They had a science degree and then underwent a 2-year postgraduate training course. The name soon changed, to physician associate, and the range of roles and responsibilities expanded greatly, although in a largely unregulated manner; by 2024, some were undertaking complex procedures or managing undifferentiated patients in primary care. Catalysed by some high-profile failings, this expansion has generated major concerns, over patient safety and consent, the scope of practice and preferential employment conditions of this group, the adverse consequences for medical training, and the additional medical workload involved in supervision. This has led to a widespread grassroots backlash by the medical profession, often challenging their leaders who had supported this idea. As a consequence, professional bodies that were initially in favour are now expressing serious concerns and it seems likely that the roles and responsibilities of physician associates (and related occupations) will be curtailed. We review published literature and official documentation about this policy to understand the drivers of its development, its benefits, and risks.

CONCLUSIONS

The experience in the UK offers cautionary lessons for other European countries contemplating similar ideas. It underscores the importance of maintaining trust with those affected by change, undertaking a detailed systems analysis with attention to risks of unintended consequences, agreeing clear role definitions, providing adequate regulatory oversight, and the need to avoid damaging training of future doctors. This case study highlights the need for a carefully thought-out approach that considers both the potential benefits and pitfalls of integrating new roles like physician associates into a healthcare system. The failure to do so has created a new occupational group with unrealistic expectations and has further demoralised an already unhappy medical profession.

Validation of the World Health Organization Rehabilitation Competency Framework: An illustration using physiotherapy

OBJECTIVE

The World Health Organization's Rehabilitation 2030 initiative represents a new strategic direction for the worldwide rehabilitation community and their Rehabilitation Competency Framework (RCF) was designed to describe the requirements of a rehabilitation workforce. This study aimed to identify and review global physiotherapy competencies and explore their congruence with the WHO-RCF.

DESIGN

A document review and thematic analysis were conducted on competency documents sourced from World Physiotherapy member countries.

METHODS

A three-pronged search strategy was used to identify physiotherapy competencies in all World Physiotherapy members that were listed on their website at the time of the study. All competency statements identified were sorted using the definitions of the five domains of the WHO-RCF. A desktop inductive thematic analysis of competencies was conducted to derive a conceptual framework for future competency framework development.

RESULTS

Two thousand and one competency statements were extracted from 20 documents, all accommodated within the WHO-RCF. From the dataset, a conceptual framework was developed consisting of 17 themes and 59 sub-themes across five domains. Technological competence, entrepreneurship and broader competencies to advance the social justice agenda were identified as gaps.

CONCLUSION

To promote homogeneity, it is recommended that all rehabilitation professionals utilise a similar methodology using the WHO-RCF to develop future frameworks that are contextually relevant. Competencies needed for change in support of equitable access and better health for all should be included.

Collaborative teaching among ultrasonographers, anesthesiologists, and vascular surgeons: its unique role in specialty training for vascular surgeons in developing countries

This study explored the unique role of collaborative teaching among ultrasonographers, anesthesiologists, and vascular surgeons in the training of vascular surgeons in developing countries. Using qualitative research methods, data were collected through in-depth interviews and observations to analyze the improvement in ultrasound operational skills and basic anesthesia skills among trainees, as well as their satisfaction with collaborative teaching. The results indicate that collaborative teaching significantly enhances trainees' professional skills and interdisciplinary collaboration abilities, gaining widespread recognition from trainees. This teaching model provides trainees with a comprehensive learning experience through interdisciplinary cooperation, hands-on practice, contributing to the cultivation of vascular surgeons with comprehensive qualities and professional competencies. This study offers new ideas and methods for the training of vascular surgeons in developing countries, holding significant implications for the development of medical education.

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.

Who Does What in Hand Osteoarthritis Care? A Qualitative Study of Boundary Work Between Rheumatologists and Occupational Therapists in Norway

Purpose

The pressure on professionals within the healthcare workforce is increasing due to staffing shortages, economic demands and changing care models. Through boundary work theories, our study explores how task-shifting in hand osteoarthritis (OA) care impacts the professional boundaries and division of labor between rheumatologists and occupational therapists (OTs) in Norwegian specialist healthcare.

Methodology

Seventeen semi-structured qualitative interviews were conducted at two hospitals in Norway. Participants included ten rheumatologists and five OTs. Data were analyzed using reflexive thematic analysis.

Results

The analysis resulted in three themes (1) Forms of responsibility and task transfers, (2) Circumventing the rules to ensure efficient practices and appropriate patient care, (3) Broadening and specializing; movement of professional demarcations. Overall, we found that medical tasks in hand OA care are increasingly delegated to, and adopted by, OTs, blurring the rheumatologist-OT boundary. Some of the task delegations skirted Norwegian legal boundaries, in efforts to streamline clinic operations. OTs expanded their scope of practice by adopting new tasks, whereas rheumatologist increased their specialist status by shedding unwanted tasks.

Conclusion

Task shifting between rheumatologists and OTs in hand OA care was characterized by boundary blurring activities. The results support a shift in hand OA management from rheumatologists to OTs.

Did the organization of primary care practices during the COVID-19 pandemic influence quality and safety? - an international survey

BACKGROUND

Changes in demographics with an older population, the illness panorama with increasing prevalence of non-communicable diseases, and the shift from hospital care to home-based care place demand on primary health care, which requires multiprofessional collaboration and team-based organization of work. The COVID-19 pandemic affected health care in various ways, such as heightened infection control measures, changing work practices, and increased workload.

OBJECTIVES

This study aimed to investigate the association between primary care practices' organization, and quality and safety changes during the COVID-19 pandemic.

DESIGN

Data were collected from 38 countries in a large online survey, the PRICOV-19 study. For this paper, the participating practices were categorized as "Only GPs", comprising practices with solely general practitioners (GPs) and/or GP trainees, without any other health care professionals (n = 1,544), and "Multiprofessional," comprising practices with at least one GP or GP trainee and one or more other health professionals (n = 3,936).

RESULTS

Both categories of practices improved in infection control routines when compared before and during the COVID-19 pandemic. A larger proportion of the multiprofessional practices changed their routines to protect vulnerable patients. Telephone triage was used in more "Multiprofessional" practices, whereas "Only GPs" were more likely to perform video consultations as an alternative to physical visits. Both types of practices reported that the time to review new guidelines and scientific literature decreased during the pandemic. However, both had more meetings to discuss directives than before the pandemic.

CONCLUSIONS

Multiprofessional teams were keener to introduce changes to the care organization to protect vulnerable patients. However, practices with only GPs were found to be more aligned with video consultations, perhaps reflecting the close patient-doctor relationship. In contrast, telephone triage was used more in multiprofessional teams.

Composition and influencing factors of professionals' capacity in public health emergency rescues: a qualitative study

Objective

To explore the composition and influencing factors of professionals' capacity in public health emergency rescues.

Methods

A descriptive qualitative design was used in this study. Medical workers, managers, and members of an emergency rescue team in Hangzhou, Zhejiang, were recruited for participation through a purposive sampling method. The data were collected using semi-structured interviews and analyzed using a conventional content analysis method.

Findings

A total of 2 themes and 13 sub-themes emerged from the analysis: ability composition (knowledge reserve, early warning assessment, information reporting, emergency response, self-protection, personal ability, coordination and cooperation, health education) and influencing factors (educational background, region, experience, hospital level, human resources, and financial investment).

Conclusion

These findings offer a basis for the construction of a related indicator system and provide a reference for relevant departments to further optimize their emergency education and training, strengthen their emergency drills, and improve their emergency rescue abilities. The findings indicate that it is necessary to pay attention to the construction of an emergency rescue team, adjust the ratio of personnel, improve their remuneration, and promote work enthusiasm to improve the emergency rescue ability of an organization.

Determinants of the optimal selection of vascular access devices: A systematic review underpinned by the COM-B behavioural model

BACKGROUND

Optimal selection of vascular access devices is based on multiple factors and is the first strategy to reduce vascular access device-related complications. This process is dependent on behavioural and human factors. The COM-B (Capability, Opportunity, Motivation, Behaviour) model was used as a theoretical framework to organize the findings of this systematic review.

METHODS/AIMS

To synthesize the evidence on determinants shaping the optimal selection of vascular access devices, using the COM-B behavioural model as the theoretical framework.

DESIGN

Systematic review of studies which explore decision-making at the time of selecting vascular access devices.

DATA SOURCES

The Medline, Web of Science, Scopus and EbscoHost databases were interrogated to extract manuscripts published up to 31 December 2021, in English or Spanish.

RESULTS

Among 16 studies included in the review, 8/16 (50%) focused on physical capability, 8/16 (50%) psychological capability, 15/16 (94%) physical opportunity, 12/16 (75%) social opportunity, 1/16 (6%) reflective motivation and 0/16 (0%) automatic motivation. This distribution represents a large gap in terms of interpersonal and motivational influences and cultural and social environments. Specialist teams (teams created for the insertion or maintenance of vascular access devices) are core for the optimal selection of vascular access devices (75% physical capability, 62% psychological capability, 80% physical opportunity and 100% social opportunity).

CONCLUSION

Specialist teams predominantly lead all actions undertaken towards the optimal selection of vascular access devices. These actions primarily centre on assessing opportunity and capability, often overlooking motivational influences and social environments.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

A more implementation-focused professional approach could decrease inequity among patients and complications associated with vascular access devices.

IMPACT

Optimal selection of vascular access devices is the primary strategy in mitigating complications associated with these devices. There is a significant disparity between interpersonal and motivational influences and the cultural and social environments. Furthermore, specialized teams play a pivotal role in facilitating the optimal selection of vascular access devices. The study can benefit institutions concerned about vascular access devices and their complications.

REPORTING METHOD

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution. WHAT DOES THIS ARTICLE CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Optimal selection of vascular devices remains a growing yet unresolved issue with costly clinical and patient experience impact. Interventions to improve the optimal selection of vascular devices have focused on training, education, algorithms and implementation of specialist vascular teams; alas, these approaches do not seem to have substantially addressed the problem. Specialist vascular teams should evolve and pivot towards leading the implementation of quality improvement interventions, optimizing resource use and enhancing their role.

Implementation of clinical assistants in a pediatric oncology department: An impact analysis

Bureaucratic and administrative tasks associated with health care provision have historically fallen on health care professionals, which is one among the factors contributing to low job satisfaction and lower productivity. Incorporating new professional roles that help to better respond to the needs of both patients and professionals can increase the quality and efficiency of service provision. This article aims to evaluate the impact of the clinical assistant's introduction in the Sant Joan de Déu Barcelona Children's Hospital's pediatric oncology department, in terms of (i) displacement of activity loads carried out by this new professional role and the consequent time freed up for physicians, (ii) physicians' satisfaction and (iii) efficiency of the new care model. This is an observational and retrospective study using administrative data based on the type of activity performed by clinical assistants and the measurement of the time freed up in favor of the physicians. The potential skill mix productivity increase, survey of physicians' satisfaction, and reduction in costs with the new model was analyzed. During the first year of its implementation in the pediatric oncology department, clinical assistants have performed 13,553 requests (69% of the total), representing a total saving of 266.83 hours or 6.67 workweeks of 40 hours. They performed 74% of outpatient surgical requests in the oncology department, 87% of day hospital requests and 54% of total requests in the outpatient consultations area. Physicians are overall satisfied with the new role and think they can use the time gained to do other things such as research or improving the quality of care. The role change allows reducing the cost per request by 56% in relation to the conventional model. In conclusion, the introduction of clinical assistants in the oncology department could be efficient to the extent that it displaces a significant part of the bureaucratic and administrative tasks previously performed by health care professionals and thus enables to reduce the cost of these processes. This delegation allows them to work more closely to the maximum of their competences and the physicians to have more time for higher added value clinical tasks and increase professional satisfaction.

Experiences and attitudes of task-shifting and task-sharing of physicians, nurses, and nursing assistants in hospitals: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to explore the experiences and attitudes of physicians, nurses, and nursing assistants regarding task-shifting and task-sharing in hospitals.

INTRODUCTION

Despite multiple health care professionals performing overlapping tasks, the need for effective task-shifting and task-sharing remains a concern. Understanding task-shifting and task-sharing experiences, as well as the attitudes of health care providers in hospitals, is essential for providing safe and patient-appropriate care with limited human resources.

INCLUSION CRITERIA

Qualitative studies that examine the experiences and attitudes of physicians, nurses, and nursing assistants in hospitals regarding task-shifting and task-sharing will be included. The review will include physicians, advanced practice nurses who are nurse practitioners or clinical nurse specialists, registered nurses, and nursing assistants. Midwives, pharmacists, occupational therapists, physical therapists, and students will be excluded.

METHODS

PubMed, MEDLINE, CINAHL, PsycINFO, Cochrane Database, and Web of Science will be searched as part of a 3-step search strategy. We will search for unpublished research and gray literature using Google Scholar and ProQuest Dissertations and Theses. Studies published in English or Japanese from the time each database was established to the present will be considered for inclusion. The methodological quality of all studies will be evaluated by screening against the inclusion criteria and by at least 2 critical evaluations using the standardized JBI checklist. Synthesized results will be pooled by meta-aggregation and published as a ConQual Summary of Findings.

REVIEW REGISTRATION

PROSPERO CRD42023409612.

Meeting the challenges of the 21st century: the fundamental importance of trust for transformation

BACKGROUND

This paper is one of a collection on challenges facing health systems in the future. One obvious challenge is how to transform to meet changing health needs and take advantage of emerging treatment opportunities. However, we argue that effective transformations are only possible if there is trust in the health system.

MAIN BODY

We focus on three of the many relationships that require trust in health systems, trust by patients and the public, by health workers, and by politicians. Unfortunately, we are seeing a concerning loss of trust in these relationships and, for too long, the importance of trust to health policymaking and health system functioning has been overlooked and under-valued. We contend that trust must be given the attention, time, and resources it warrants as an indispensable element of any health system and, in this paper, we review why trust is so important in health systems, how trust has been thought about by scholars from different disciplines, what we know about its place in health systems, and how we can give it greater prominence in research and policy.

CONCLUSION

Trust is essential if health systems are to meet the challenges of the 21st century but it is too often overlooked or, in some cases, undermined.

Gap analysis of diabetes-related foot disease management systems in Pacific Islands Countries and Territories

BACKGROUND

Pacific Island Countries and Territories (PICTs) are known to have high prevalence of Diabetes Mellitus and high incidence of diabetes-related foot disease. Diabetes-related foot disease can lead to lower limb amputation and is associated with poor outcomes, with increased morbidity and mortality. The purpose of this study was to gain a better understanding of diabetes-related foot disease management in selected countries in PICTs and to identify potential barriers in management of diabetes-related foot disease management in the region.

METHODS

A cross-sectional survey was sent to eleven hospitals across six selected PICTs. The survey instrument was designed to provide an overview of diabetes-related foot disease (number of admissions, and number of lower limb amputations over 12 months) and to identify clinical services available within each institution. Two open-ended questions (free text responses) were included in the instrument to explore initiatives that have helped to improve management and treatment of diabetes-related foot diseases, as well as obstacles that clinicians have encountered in management of diabetes-related foot disease. The survey was conducted over 6 weeks.

RESULTS

Seven hospitals across four countries provided responses. Number of admissions and amputations related to diabetes-related foot disease were only reported as an estimate by clinicians. Diabetes-related foot disease was managed primarily by general medicine physician, general surgeon and/or orthopaedic surgeon in the hospitals surveyed, as there were no subspecialty services in the region. Only one hospital had access to outpatient podiatry. Common themes identified around barriers faced in management of diabetes-related foot disease by clinicians were broadly centred around resource availability, awareness and education, and professional development.

CONCLUSION

Despite the high prevalence of diabetes-related foot disease within PICTs, there appears to be a lack of functional multi-disciplinary foot services (MDFs). To improve the outcomes for diabetes-related foot disease patients in the region, there is a need to establish functional MDFs and engage international stakeholders to provide ongoing supports in the form of education, mentoring, as well as physical resources.

Proposed task shifting integrated with telemedicine to address uncorrected refractive error in Kenya: Delphi study

BACKGROUND

Developing countries such as Kenya still experience challenges around human resource to deliver refractive error services. However, given the burden of uncorrected refractive error, adoption of innovative and cost effective approaches is desirable. Hence this study intended to develop a task shifting framework integrated with telemedicine to potentially scale refractive error services.

METHODS

This was an exploratory study conducted in four phases as follows: a scoping review of the scope of practice for ophthalmic workers in Kenya, an interview with key opinion leaders on the need for integration of public health approaches such as the vision corridors within the eye health ecosystem in Kenya and their knowledge on task shifting, and finally development and validation of a proposed task shifting framework through a Delphi technique. Purposive sampling was used to recruit key opinion leaders and data was collected via telephonic interviews. The qualitative data was analyzed thematically using NVivo Software, Version 11.

RESULTS

The scoping review showed that only optometrists, ophthalmologists and ophthalmic clinical officers are allowed to undertake refraction in Kenya. All of the key opinion leaders (100%) were aware of task shifting and agreed that it is suitable for adoption within the eye health ecosystem in Kenya. All of the key opinion leaders (100%) agreed that skills development for healthcare workers without prior training on eye health supervised by optometrists through telemedicine is desirable. Notwithstanding, all of the key opinion leaders (100%) agreed that integration of public health approaches such as the vision corridors across all levels of healthcare delivery channels and development of a self-assessment visual acuity tool is desirable. Finally all of the key opinion leaders (100%) agreed that task shifting is relevant for adoption within the eye health ecosystem in Kenya. The developed framework prioritized partnership, advocacy, skills development, establishment and equipping of refraction points. The proposed framework advocated for a telemedicine between professionals with conventional training and those with skills development.

CONCLUSION

Task shifting integrated with telemedicine could cost effectively scale refractive error service delivery. However, internal and external factors may hinder the success warranting the need for a multi-faceted interventions and a connection between planning and training to scale the uptake.

Hospital-Level COVID-19 Preparedness and Crisis Management in Czechia

Objectives: The COVID-19 pandemic exposed the inadequacy of pandemic preparedness mechanisms worldwide. This study gathered comprehensive data from Czech hospitals, identified possible weaknesses in important areas of crisis preparedness, and quantified changes performed to enhance crisis resilience of healthcare facilities. Methods: Drawing on literature review on pandemic preparedness and hospital crisis management and detailed interviews with hospital representatives, a questionnaire was designed and distributed by email among quality managers of all Czech hospitals. Statistical analysis of their responses was conducted using EZR software. Fisher's exact test and Kruskal-Wallis test, with post hoc testing, were used to assess statistical significance. Results: Achieving response rate of 31.9%, responses from 65 hospitals were analysed. New crisis management policies were necessary in 72.3% of responding hospitals. Furthermore, a majority of the respondents changes indicated the need for changes in policies on general pandemic, human resources and infrastructure and material preparedness. Conclusion: The COVID-19 crisis required significant alterations to previously established hospital crisis management protocols and establishment of new ones. The absence of a unified system for crisis preparedness was noted at hospital and national levels.

First contact physiotherapists: are they able to reduce the burden on rheumatology services? A critical review of the evidence base

First contact practitioners have emerged over recent years in response to growing pressures within the National Health Service (NHS) and are now central to primary care musculoskeletal (MSK) services. Within the MSK field, these allied health professionals can be from a range of disciplines, including physiotherapy, podiatry and osteopathy. Early referral to rheumatology is key to successful long-term management of many inflammatory MSK conditions, but presents challenges to overburdened services. Evidence supporting the recognition and referral of patients with rheumatological disorders by First Contact Practitioners is lacking; however, physiotherapists have been shown successfully to substitute the role of a doctor within the MSK field. This review investigates the value of First Contact Physiotherapists (FCPs) within primary care and their role in early recognition and referral of rheumatological MSK disorders in line with national guidance. FCPs best placed to fulfil the role of MSK champions, positively impacting the whole MSK pathway, with the potential to reduce the burden on rheumatology services. Planned rapid upscaling of FCPs over the next few years will support sustainability of MSK NHS services.

Boundary work in task-shifting practices - a qualitative study of reablement teams

BACKGROUND

Health services worldwide have provided incentives for establishing teams to accommodate complex health care tasks, enhance patient outcomes and organizational efficiency, and compensate for shortages of health care professionals. Parallel to and partly due to the increased focus on teamwork, task shifting has become a health policy. Task shifting involves new tasks and responsibilities, which may result in social negotiations about occupational boundaries.

OBJECTIVE

The aim of this study was to explore how the division of tasks, responsibilities, and roles in reablement practices can appear as boundary work between physiotherapists (PTs) and home trainers (HTs).

METHODS

The study drew on data from fieldwork with seven Norwegian reablement teams, including observations and individual interviews with PTs and HTs. We conducted thematic analysis informed by a theoretical framework on professional boundaries.

RESULTS

We identified two different practices, which we labeled as: i) "The engine and the assistant" and ii) "The symbiotic team." We drew on these practices and theory of boundary making and boundary blurring to interpret the results.

CONCLUSION

The findings indicate that boundary-making processes may generate asymmetric power relations that may constrain autonomous work and job satisfaction in teams, whereas boundary-blurring processes may promote collaborative practices that enhance holistic approaches and mutual learning on reablement teams.

Delegation of insulin administration to non-registered healthcare workers in community nursing teams: A qualitative study

AIMS

To explore stakeholder perspectives on the benefits and/or disadvantages of the delegation of insulin injections to healthcare support workers in community nursing services.

DESIGN

Qualitative case study.

METHODS

Interviews with stakeholders purposively sampled from three case sites in England. Data collection took place between October 2020 and July 2021. A reflexive thematic approach to analysis was adopted.

RESULTS

A total of 34 interviews were completed: patients and relatives (n = 7), healthcare support workers (n = 8), registered nurses (n = 10) and senior managers/clinicians (n = 9). Analysis resulted in three themes: (i) Acceptance and confidence, (ii) benefits and (iii) concerns and coping strategies. Delegation was accepted by stakeholders on condition that appropriate training, supervision and governance was in place. Continuing contact between patients and registered nurses, and regular contact between registered nurses and healthcare support workers was deemed essential for clinical safety. Services were reliant on the contribution of healthcare support workers providing insulin injections, particularly during the COVID-19 pandemic. Benefits for service and registered nurses included: flexible team working, increased service capacity and care continuity. Job satisfaction and career development was reported for healthcare support workers. Patients benefit from timely administration, and enhanced relationships with the nursing team. Concerns raised by all stakeholders included potential missed care, remuneration and task shifting.

CONCLUSION

Delegation of insulin injections is acceptable to stakeholders and has many benefits when managed effectively.

IMPACT

Demand for community nursing is increasing. Findings of this study suggest that delegation of insulin administration contributes to improving service capacity. Findings highlight the essential role played by key factors such as appropriate training, competency assessment and teamwork, in developing confidence in delegation among stakeholders. Understanding and supporting these factors can help ensure that practice develops in an acceptable, safe and beneficial way, and informs future development of delegation practice in community settings.

PATIENT OR PUBLIC CONTRIBUTION

A service user group was consulted during the design phase prior to grant application and provided comments on draft findings. Two people with diabetes were members of the project advisory group and contributed to the study design, development of interview questions, monitoring study progress and provided feedback on study findings.

Evaluating task shifting to the clinical technologist in Dutch healthcare: A mixed methods study

BACKGROUND

Expected rise in the demand for healthcare and a dropping supply of healthcare professionals, has generated an increased interest in the most effective deployment of healthcare professionals. Consequently, task shifting has become a common strategy to redistribute tasks between established professional groups, however, little is known about the effects of shifting tasks to emerging professional groups. The aim of this study was to evaluate a legal amendment to facilitate task shifting to an emerging profession in Dutch healthcare: Clinical Technologists (CTs). CTs were introduced and provided an Extended Scope of Practice (ESP) to perform nine 'reserved procedures' independently.

METHODS

A concurrent multi-phase mixed methods study was used to evaluate whether a legal amendment to facilitate task shifting to CTs was effective and efficient.

RESULTS

The results show that CTs use their ESP frequently to perform five categories of reserved procedures independently and suggest that the ESP increased the efficiency of care delivery for those procedures. Additionally, the findings highlight that task shifting was influenced by the setting in which CTs worked, time allotted to patient-contact as well as external factors (e.g., financing).

CONCLUSIONS

This study provides tentative lessons for policymakers on how task shifting to emerging professional groups can be improved. Providing a legal amendment to facilitate task shifting to CTs seems to be effective and efficient. However, it also poses multiple challenges. While established professional groups can face similar challenges, it is likely that these are exacerbated for emerging professional groups, particularly when shifting tasks occurs horizontally.

Perspectives on snakebite envenoming care needs across different sociocultural contexts and health systems: A comparative qualitative analysis among US and Brazilian health providers

With the advancements in therapeutics and available treatment options, almost all deaths and permanent disabilities from snakebite envenoming (SBE) are preventable. The challenge lies in implementing these evidence-based treatments and practices across different settings and populations. This study aims to compare data on provider perceptions of SBE care across health systems and cultural contexts to inform potential implementation science approaches. We hypothesize different health systems and cultural contexts will influence specific perceived needs to provide adequate snakebite care within central tenets of care delivery (e.g., cost, access, human resources). We previously conducted exploratory descriptive studies in the US and Brazil in order to understand the experience, knowledge, and perceptions of health professionals treating SBE. In the US, in-depth interviews were performed with emergency physicians from January 2020 to March 2020. In BR, focus group discussions were conducted with health professionals from community health centers at the end of June 2021. The focus group discussions (BR) were originally analyzed through an inductive thematic analysis approach. We conducted a secondary qualitative analysis in which this codebook was then applied to the interviews (US) in a deductive content analysis. The analysis concluded in August 2022. Brazil participants were physicians (n=5) or nurses (n=20) from three municipalities in the State of Amazonas with an average of three years of professional experience. US participants were emergency physicians (n=16) with an average of 15 years of professional experience. Four main themes emerged: 1) barriers to adequate care on the patient and/or community side and 2) on the health system side, 3) perceived considerations for how to address SBE, and 4) identified needs for improving care. There were 25 subthemes within the four themes. These subthemes were largely the same across the Brazil and US data, but the rationale and content within each shared subtheme varied significantly. For example, the subtheme "role of health professionals in improving care" extended across Brazil and the US. Brazil emphasized the need for task-shifting and -sharing amongst health care disciplines, whereas the US suggested specialized approaches geared toward increasing access to toxicologists and other referral resources. Despite similar core barriers to adequate snakebite envenoming care and factors to consider when trying to improve care delivery, health professionals in different health systems and sociocultural contexts identified different needs. Accounting for, and understanding, these differences is crucial to the success of initiatives intended to strengthen snakebite envenoming care. Implementation science efforts, with explicit health professional input, should be applied to develop new and/or adapt existing evidence-based treatments and practices for SBE.

Rehabilitation for Pediatric Stroke in Low and Middle Income Countries: A Focused Review

Rehabilitation for pediatric stroke survivors can maximize a child's potential through each developmental stage of life. Timely diagnosis and referral to a rehabilitation specialist may harness opportunities to maximize brain plasticity, to help children adapt and learn, and to participate in and enjoy daily life to their capability. The aim of this focused review is to explore current rehabilitation models and evidence-based interventions for pediatric stroke survivors in Low- and Middle- Income Countries (LMICs) and to provide recommendations for future research and focused areas of improvement.There are several published pediatric stroke guidelines from the American Heart Association (AHA), Canada, Australia, and the United Kingdom (UK) which provide specific recommendations for rehabilitation, although the suggested intervention and services vary. There are no current guidelines developed in or contextually adapted for LMICs, although the current pediatric stroke guidelines emphasize the need to develop interventions that fit the cultural and environmental contexts. The World Health Organization (WHO) Rehabilitation 2030 initiative acknowledges profound unmet rehabilitation needs around the world, especially in LMICs. According to the WHO, LMICs have less than ten skilled rehabilitation professionals per one million people. Enhancing the understanding of rehabilitation services in LMICs could lead to nationally supported workforce education initiatives targeted to expand the number of locally trained therapy providers. This could improve access to and delivery of quality rehabilitation interventions to pediatric stroke survivors in these settings.

Perceived barriers to the process of COVID-19 control among frontline healthcare workers in South Korea: a qualitative study

OBJECTIVE

This study aimed to explore barriers to disease control perceived by frontline healthcare workers (HCWs) working in community settings during the COVID-19 pandemic in South Korea.

DESIGN

A qualitative study was conducted using semistructured focus group interviews. All interviews were conducted in Korean on Zoom between October and November 2020, audio-recorded and transcribed for reflexive thematic analysis.

SETTING

All participants were working in Gyeonggi-do, the most populous province in South Korea. The province had the second-highest COVID-19 infection rates at the time of the interview.

PARTICIPANTS

Participants serving as HCWs in Gyeonggi Province were eligible to participate in the study. A total of 20 HCWs comprised of public health doctors and professional epidemiologists agreed to participate in the study.

RESULTS

Four themes were generated. Each theme described how these barriers affected a disease control process: (1) 'uncooperative public and unprepared community health centre' delayed the investigation of newly diagnosed COVID-19 cases; (2) 'uncoordinated disease control system' impeded the collection and analysis of digital data; (3) 'the gap between responsibilities and capabilities' hindered the classification of close and casual contacts; and (4) 'conflicts with persons who have different interests and priorities' hampered epidemiological decision-making.

CONCLUSIONS

Our study found that frontline HCWs experienced various challenges disrupting their work performance to control COVID-19. We provide several recommendations, such as providing HCWs with systematic interview skill training, strengthening patient information security systems, providing sufficient resources, securing a regular workforce, collecting the field experiences of HCWs, implementing task-shifting, and having regular stakeholder meetings. These strategies may promote work capacity among the frontline HCWs and subsequently strengthen emergency preparedness.

[Health workforce development in rheumatology : A mapping exercise and wake-up call for health policy]

BACKGROUND AND OBJECTIVE

Health workforce shortage in German rheumatology has been identified as a healthcare service and delivery problem. Health policy has increased staffing targets, yet effective intervention strategies are lacking. This research aimed to systematically map the rheumatology workforce to improve the evidence for interventions and explore possibilities for more effective health workforce management.

METHODS

The WHO National Health Workforce Accounts provided a conceptual framework for the mapping exercise. Four major sets of indicators were selected, comprising staffing levels, health labor market flows, composition and education/training. A comparison of age groups and time series was applied to explore trends. Public statistics and other secondary sources served our analysis using descriptive methodology.

RESULTS

In Germany there are 1076 physicians specialized in internal medical rheumatology. Absolute numbers have nearly doubled (91%) since 2000 but with a strong demographic bias. Between 2000 and 2019 numbers markedly increased in the group aged 50 years and older but only by 9% in the younger group under 50 years; since 2010 the group aged 40-50 years even faces a decrease. In 2019, the absolute numbers of rheumatologists in retirement age exceeded those aged 40 years and under. Since 2015 an expanding workforce trend has overall flattened but this was strongest in the hospital sector; the numbers in resident training did not show any relevant growth.

CONCLUSION

Health workforce trends reveal that an available number of rheumatologists cannot meet new health policy planning targets. There is a need for effective health workforce management, focusing on innovation in resident training, improved task delegation and gender equality.

Pandemics and Other Health Crises: A Special Report from a European Parliament Workshop

Once an emergency has passed, general attention typically returns to dealing with day-to-day system management, and the opportunity to learn from the crisis and improve is missed. Lessons from the coronavirus disease 2019 (COVID-19) crisis must be learned, and the necessary changes made at all levels, both in terms of improving collaboration and strengthening health systems. This special report provides the conclusion of a workshop held in the European Parliament (EP) in Brussels, Belgium. The event explored the modalities of response and preparation to the COVID-19 pandemic, and to health crises in general. The workshop considered actions at different levels: international organizations (global level), European Union (EU) Member States ([MS] national level), and health services (local level). It provided an opportunity to look back at several initiatives taken during the pandemic, and to draw inspiration from them.

Task shifting from general practitioners to practice assistants and nurses in primary care: a cross-sectional survey in 34 countries

Aim:

To describe variation in task shifting from GPs to practice assistants/nurses in 34 countries and to explain differences by analysing associations with characteristics of the GPs and their practices and features of the health care systems.

Background:

Redistribution of tasks and responsibilities in primary care are driven by changes in demand, such as the growing number of patients with chronic conditions, and workforce developments, including staff shortage. The need to manage an expanding range of services has led to adaptations in the skill-mix of primary care teams. These developments are hampered by barriers between professional domains.

Methods:

Data were collected between 2011 and 2013 through a cross-sectional survey among approximately 7,200 general practitioners (GPs) in 34 countries. Task shifting is measured through a composite score of GPs’ self-reported shifting of tasks. Independent variables at GP and practice level are as follows: innovativeness; part-time working; availability of staff; location and population of the practice. Country-level independent variables are as follows: demand for and supply of care, nurse prescribing, and professionalisation of practice assistants/nurses. Multilevel analysis is used to account for clustering of GPs in countries.

Findings:

Countries vary in the degree of task shifting. Regarding GP and practice characteristics, use of electronic health records and availability of support staff in the practice are positively associated with task shifting and GPs’ working hours negatively, in line with our hypotheses. Age of the GPs is, contrary to our hypothesis, positively related to task shifting. These variables explain 11% of the variance at GP level. Two country variables are related to task shifting: a lower percentage of practices without support staff in a country and nurse prescribing rights coincide with more task shifting. The percentage of practices without support staff has the strongest relationship, explaining 73% of the country variation.

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.

Integrating HIV and substance misuse services: a person-centred approach grounded in human rights

Integrating HIV-related care with treatment for substance use disorder provides an opportunity to better meet the needs of people living with these conditions. People with substance use disorder are rendered especially vulnerable by prevailing policies, structural inequalities, and stigmatisation. In this Series paper we analyse existing literature and empirical evidence from scoping reviews on integration designs for the treatment of HIV and substance use disorder, to understand barriers to and facilitators of care integration and to map ways forward. We discuss how approaches to integration address two core gaps in current models: a failure to consider human rights when incorporating the perspectives of people living with HIV and people who use drugs, and a failure to reflect critically on structural factors that determine risk, vulnerability, health-care seeking, and health equity. We argue that successful integration requires a person-centred approach, which is grounded in human rights, treats both concerns holistically, and reconnects with underlying social, economic, and political inequalities.

Reported Incidents Involving Non-medical Care Workers and Nursery Teachers in Hospitals in Japan: An Analysis of the Japan Council for Quality Health Care Nationwide Database

Objective

With the shortage of medical staff, the birth rate decline, and aging populations in some countries, task shifting from specific medical staff to non-medical care workers in hospitals has been implemented as a short-term solution. Incident reporting reduces preventable patient errors, improves the quality of healthcare services, and contributes to patient safety. However, research focused on the expanding roles of non-medical staff who provide direct care for patients is lacking. The present study aimed to bridge this gap by examining reported incidents involving non-medical care workers and nursery teachers in hospitals in Japan.

Methodology

A retrospective mixed-methods study was conducted using data published by the Japan Council for Quality Health Care. A total of 21,876 cases were reported between 2016 and 2020, and 97 out of 21,876 cases were analysed, after excluding incidents involving workers or staff other than care workers/nursery teachers. Descriptive statistics were used to examine the incidents, and textual data included in the incident reports were analysed by two registered nurses.

Results

The occupations of the people involved were care worker (n=80, 82.5%) and nursery teacher (n=17, 17.5%). There were two reports of worker injuries (n=2, 2.1%), which were excluded. A total of 95 cases were included in the final analysis to examine the effects on patients. Among the remaining 95 cases, there were five severe patient incidents (death, n=2, 2.1%; cerebral hemorrhage, n=3, 3.2%), and the most frequent incident was bone fracture (n=64, 67.4%). Some patients had cognitive impairment (n=29, 30.5%) and osteoporosis (n=25, 26.3%). We divided the factors related to incident occurrence into software (procedures and protocols), environment (wards and theaters), and liveware (people, including care workers, nursery teachers, and patients). Regarding the reasons for the incidents, the percentages for the three factors were as follows: education/training 34.7% (n=33), in software; patient state 4.1% (n=39), in environment; and neglect to observe 45.3% (n=43), in liveware.

Conclusion

Our study involved a secondary analysis of published data, and the sample size was small. However, incident reports from care workers and nursery teachers working in hospitals included serious errors. The role of non-medical care staff in hospitals is broad and diverse, and has been shifting from direct care for patients with mild illnesses to direct care for patients with severe illnesses. An efficient clinical environment that ensures quality of care and service is lacking. By focusing on patient safety outcomes, policymakers and hospital teams should consider adjusting the working environment.

Health system resilience and health workforce capacities: Comparing health system responses during the COVID-19 pandemic in six European countries

BACKGROUND

The health workforce is a key component of any health system and the present crisis offers a unique opportunity to better understand its specific contribution to health system resilience. The literature acknowledges the importance of the health workforce, but there is little systematic knowledge about how the health workforce matters across different countries.

AIMS

We aim to analyse the adaptive, absorptive and transformative capacities of the health workforce during the first wave of the COVID-19 pandemic in Europe (January-May/June 2020), and to assess how health systems prerequisites influence these capacities.

MATERIALS AND METHODS

We selected countries according to different types of health systems and pandemic burdens. The analysis is based on short, descriptive country case studies, using written secondary and primary sources and expert information.

RESULTS AND DISCUSSION

Our analysis shows that in our countries, the health workforce drew on a wide range of capacities during the first wave of the pandemic. However, health systems prerequisites seemed to have little influence on the health workforce's specific combinations of capacities.

CONCLUSION

This calls for a reconceptualisation of the institutional perquisites of health system resilience to fully grasp the health workforce contribution. Here, strengthening governance emerges as key to effective health system responses to the COVID-19 crisis, as it integrates health professions as frontline workers and collective actors.

Development of an innovative strategy to determine functioning attributed to health conditions in low-resource settings

Objectives

Rehabilitation is a health strategy that aims to reduce functioning problems. There is a lack of country-level data on the burden and type of functioning problems to inform service planning and management of patients' rehabilitation needs, particularly at primary care level in low-resource settings. Health researchers need an application that automates synthesis of data extracted from several peer-reviewed publications to determine the most prevalent functioning problems compared across several health states. This article describes the journey leading to the conceptualization and development of the Rehab4all application and compares the application's performance to a standard desktop program.

Methods

A descriptive case study approach was used to report on the following steps involved in the development of the web-based Rehab4all application: (i) preliminary literature review to assess the evidence gap of country-level data on functioning problems comparable across several health states; (ii) an initial attempt to perform data extraction and synthesis in Excel; (iii) design and development of Rehab4all; (iv) piloting of the Rehab4all application; and (v) implementation of application with input data from South Africa and Zimbabwe.

Results

The Rehab4all application offers a feasible solution for synthesizing data from several peer-reviewed publications to provide information on context-specific, priority functioning problems at country level through the integrated global International Classification of Functioning, Disability and Health Framework (ICF).

Conclusion

This bespoke innovation provides impetus for further development, profile comparison and shared information between countries to co-develop strategies which can strengthen rehabilitation service delivery.

Drawing light from the pandemic: Rethinking strategies for health policy and beyond

The COVID-19 pandemic is a catastrophe. It was also preventable. The potential impacts of a novel pathogen were foreseen and for decades scientists and commentators around the world warned of the threat. Most governments and global institutions failed to heed the warnings or to pay enough attention to risks emerging at the interface of human, animal, and environmental health. We were not ready for COVID-19, and people, economies, and governments around the world have suffered as a result. We must learn from these experiences now and implement transformational changes so that we can prevent future crises, and if and when emergencies do emerge, we can respond in more timely, robust and equitable ways, and minimize immediate and longer-term impacts.

In 2020–21 the Pan-European Commission on Health and Sustainable Development assessed the challenges posed by COVID-19 in the WHO European region and the lessons from the response. The Commissioners have addressed health in its entirety, analyzing the interactions between health and sustainable development and considering how other policy priorities can contribute to achieving both. The Commission's final report makes a series of policy recommendations that are evidence-informed and above all actionable. Adopting them would achieve seven key objectives and help build truly sustainable health systems and fairer societies.

Task shifting from general practitioners to practice assistants and nurses in primary care: a cross-sectional survey in 34 countries

AIM

To describe variation in task shifting from general practitioners (GPs) to practice assistants/nurses in 34 countries, and to explain differences by analysing associations with characteristics of the GPs, their practices and features of the health care systems.

BACKGROUND

Redistribution of tasks and responsibilities in primary care are driven by changes in demand for care, such as the growing number of patients with chronic conditions, and workforce developments, including staff shortage. The need to manage an expanding range of services has led to adaptations in the skill mix of primary care teams. However, these developments are hampered by barriers between professional domains, which can be rigid as a result of strict regulation, traditional attitudes and lack of trust.

METHODS

Data were collected between 2011 and 2013 through a cross-sectional survey among approximately 7200 GPs in 34 countries. The dependent variable 'task shifting' is measured through a composite score of GPs' self-reported shifting of tasks. Independent variables at GP and practice level are: innovativeness; part-time working; availability of staff; location and population of the practice. Country-level independent variables are: institutional development of primary care; demand for and supply of care; nurse prescribing as an indicator for professional boundaries; professionalisation of practice assistants/nurses (indicated by professional training, professional associations and journals). Multilevel analysis is used to account for the clustering of GPs in countries.

FINDINGS

Countries vary in the degree of task shifting by GPs. Regarding GP and practice characteristics, use of electronic health record applications (as an indicator for innovativeness) and age of the GPs are significantly related to task shifting. These variables explain only little variance at the level of GPs. Two country variables are positively related to task shifting: nurse prescribing and professionalisation of primary care nursing. Professionalisation has the strongest relationship, explaining 21% of the country variation.

Health workforce protection and preparedness during the COVID-19 pandemic: a tool for the rapid assessment of EU health systems

This article is dedicated to the WHO International Year of Health and Care Workers in 2021 in recognition of their commitment during the COVID-19 pandemic. The study aims to strengthen health workforce preparedness, protection and ultimately resilience during a pandemic. We argue for a health system approach and introduce a tool for rapid comparative assessment based on integrated multi-level governance. We draw on secondary sources and expert information, including material from Denmark, Germany, Portugal and Romania. The results reveal similar developments across countries: action has been taken to improve physical protection, digitalization and prioritization of healthcare worker vaccination, whereas social and mental health support programmes were weak or missing. Developments were more diverse in relation to occupational and organizational preparedness: some ad-hoc transformations of work routines and tasks were observed in all countries, yet skill-mix innovation and collaboration were strongest in Demark and weak in Portugal and Romania. Major governance gaps exist in relation to education and health integration, surveillance, social and mental health support programmes, gendered issues of health workforce capacity and integration of migrant healthcare workers (HCW). There is a need to step up efforts and make health systems more accountable to the needs of HCW during global public health emergencies.

Work situation of rheumatologists and residents in times of COVID-19 : Findings from a survey in Germany

Background and objective

The work situation is an important dimension of professional life and wellbeing, and a policy lever to strengthen recruitment and retention. This study aims to explore the work situation of physicians and residents in internal medical rheumatology, considering the impact of the coronavirus pandemic COVID-19.

Methods

A questionnaire-based online survey was conducted in early 2021 at the Hannover Medical School, supported by the German Society of Rheumatology. Target groups were all rheumatology physicians and residents in Germany. The main areas of investigation included work hours, task delegation, and collaboration; workload and mental health issues; discrimination and sexual harassment experiences; and the impact of COVID-19. Descriptive statistical analysis was performed for the standardized items and qualitative content analysis for the free-text information.

Results

The respondents (n = 101) expressed positive attitudes towards cooperation and task delegation to medical assistants, especially those specialized in rheumatology, while attitudes towards cooperation with GPs pointed to blockades. There was a strong mismatch between actual and desired work hours both in the group of women and in the group of men. 81% rated their workload as high or very high; every sixth rheumatologist has suffered from stress or burnout syndromes at least once in the past. Experiences of gender discrimination and sexual harassment/violence were frequently reported, mostly by women. COVID-19 was an amplifier of stress, with major stressors being digitalization and increased demand for communication and patient education.

Conclusion

There is an urgent need to improve the work situation of rheumatologists and reduce stress and mental health risks.

Supplementary Information

The online version of this article (10.1007/s00393-021-01081-5) includes the survey questionnaire in German.

Broadening the scope of task shifting in the organisation of healthcare

Task shifting in healthcare has mainly been initiated and studied as a way to react to/or mitigate workforce shortages. Here, we define task shifting as the structural redistribution of tasks, usually including responsibilities and competencies between different professions. As such, task shifting is commonly focused on highly specialised and trained professionals who hand-over specific, standardised tasks to professionals with lower levels of education. It is expected that this type of task shifting will lead to efficiency and cost savings to healthcare organisations. Yet, there are more benefits to task shifting, in particular its contribution to integrated patient-centred quality of care and a tailored system that meets the changing care demands in society. Hence the importance to broaden the scope of task shifting, its goals, manifestations and how task shifting plays a role in addressing both the strengths and weaknesses in the healthcare system. In this focus piece, trends and conditions for task shifting and its (un)anticipated effects are discussed. We argue that, only when designed to face specific complexities at the workplace and taking into account the balance between specialists and generalists, task shifting may substantially contribute to enhanced quality of care that meets the changing needs of society.

Use of lay vaccinators in animal vaccination programmes: A scoping review

BACKGROUND

The human resource gap in veterinary sectors, particularly in low-income countries, imposes limitations on the delivery of animal healthcare in hard-to-reach populations. Lay animal health workers have been deployed in these settings to fill the gap though there are mixed views about the benefits of doing this and whether they can deliver services safely. We mapped evidence on the nature and extent of roles assigned to lay animal vaccinators, and identified lessons useful for their future deployment.

METHODOLOGY/PRINCIPAL FINDINGS

Following the PRISMA Extension for Scoping Reviews guidelines, we searched seven bibliographic databases for articles published between 1980 and 2021, with the search terms lay OR community-based OR volunteer AND "animal health worker" OR vaccinator*, and applied an a priori exclusion criteria to select studies. From 30 identified studies, lay vaccinators were used by non-government developmental (n = 12, 40%), research (n = 10, 33%) and government (n = 5, 17%) programmes to vaccinate domestic animals. The main reason for using lay vaccinators was to provide access to animal vaccination in the absence of professional veterinarians (n = 12, 40%). Reported positive outcomes of programmes included increased flock and herd sizes and farmer knowledge of best practice (n = 13, 43%); decreased disease transmission, outbreaks and mortality (n = 11, 37%); higher vaccination coverage (10, 33%); non-inferior seroconversion and birth rates among vaccinated herds (n = 3, 10%). The most frequently reported facilitating factor of lay vaccinator programmes was community participation (n = 14, 47%), whilst opposition from professional veterinarians (n = 8, 27%), stakeholders seeking financial gains to detriment of programmes goals (n = 8, 27%) and programming issues (n = 8, 27%) were the most frequently reported barriers. No study reported on cost-effectiveness and we found no record from a low and middle-income country of lay vaccinator programmes being integrated into national veterinary services.

CONCLUSION

Although the majority of included studies reported more benefits and positive perceptions of lay vaccinator programmes than problems and challenges, regularization will ensure the programmes can be designed and implemented to meet the needs of all stakeholders.

Conceptual framework for task shifting and task sharing: an international Delphi study

BACKGROUND

Task shifting and sharing (TS/S) involves the redistribution of health tasks within workforces and communities. Conceptual frameworks lay out the key factors, constructs, and variables involved in a given phenomenon, as well as the relationships between those factors. Though TS/S is a leading strategy to address health worker shortages and improve access to services worldwide, a conceptual framework for this approach is lacking.

METHODS

We used an online Delphi process to engage an international panel of scholars with experience in knowledge synthesis concerning TS/S and develop a conceptual framework for TS/S. We invited 55 prospective panelists to participate in a series of questionnaires exploring the purpose of TS/S and the characteristics of contexts amenable to TS/S programmes. Panelist responses were analysed and integrated through an iterative process to achieve consensus on the elements included in the conceptual framework.

RESULTS

The panel achieved consensus concerning the included concepts after three Delphi rounds among 15 panelists. The COATS Framework (Concepts and Opportunities to Advance Task Shifting and Task Sharing) offers a refined definition of TS/S and a general purpose statement to guide TS/S programmes. COATS describes that opportunities for health system improvement arising from TS/S programmes depending on the implementation context, and enumerates eight necessary conditions and important considerations for implementing TS/S programmes.

CONCLUSION

The COATS Framework offers a conceptual model for TS/S programmes. The COATS Framework is comprehensive and adaptable, and can guide refinements in policy, programme development, evaluation, and research to improve TS/S globally.