Trends in private caregiving cost after implementing a comprehensive nursing service covered by national health insurance: Interrupted time series

BACKGROUND

The Korean government has implemented a comprehensive nursing care service system (CNS) to mitigate the stress faced by caregivers.

OBJECTIVE

This study aimed to assess trends in the estimated average costs of private caregiving and determine the difference in costs between those using CNS and those not using it.

DESIGN

A comparative interrupted time series analysis with a 2-year lag period verified total private caregiving cost trends; biannual differences in costs were evaluated based on using CNS.

PARTICIPANTS

The main unit of analysis was episode. We extracted a total of 6418 episodes of hospitalization in acute care settings that included the use of caregiving services (formal, informal caregiving and CNS).

METHODS

We conducted segmented regression to assess the impact of CNS on total private caregiving costs using data from 2012 to 2018, excluding the years 2015 and 2016 of the Korean Health Panel dataset.

RESULTS

We presented that the immediate mean difference in total private caregiving costs between CNS users and non-users was -444.7 USD two years after the implementation of the CNS policy (95 % CI -714.5 to -174.5, p-value 0.001). Among individuals living in rural areas, two years after the implementation of the CNS policy, there was a significant immediate mean cost difference of -476.9 USD in total private caregiving costs between CNS users and non-users (p-value 0.011). Similarly, for episodes with a Charlson Comorbidity Index (CCI) score of 0 to 1, there was a substantial immediate mean cost difference in total private caregiving costs between CNS users and non-users, amounting to -399.9 USD two years after the CNS policy (p-value 0.008).

CONCLUSIONS

This study evaluated the trend of total private caregiving costs between groups using and not using CNS. After two years of being covered by CNS health insurance, those who utilized CNS paid $433 less for their total private caregiving cost over a 6-month period, compared to those who did not use CNS. The adoption of CNS may be an effective system for relieving the financial burden on inpatients in need of private caregiving services.

TWEETABLE ABSTRACT

Korean Comprehensive Nursing Service reduces private caregiving costs.

Impact of home-visit nursing service use on costs in the last 3 months of life among older adults: A retrospective cohort study

INTRODUCTION

Considering Japan's aging society, the number of older individuals who die at home is expected to increase. In Japan, there are challenges in utilizing and promoting home-visit nursing services at the end of life for community-dwelling older adults. We examined the use of home-visit nursing services at the end of patients' lives and the recommended use patterns of this service (utilization, timing of initiation, and continuity) that contribute to reducing the medical care and long-term care costs (total costs) in the last 3 months of life.

DESIGN

This was a retrospective cohort study.

METHODS

We examined 33 municipalities in Japan, including depopulated areas. The analysis included 22,927 people aged 75 or older who died between September 2016 and September 2018. We used monthly medical care and long-term care insurance claims data. Participants were classified into five groups based on their history of home-visit nursing service use: (1) early initiation/continuous use, (2) early initiation/discontinued or fragment use, (3) not-early initiation/continuous use, (4) not-early initiation/fragment use, and (5) no use. Univariate and multivariate linear regression analyses were performed to examine the association between total costs in the last 3 months of life and patterns of home-visit nursing service use.

RESULTS

Overall, the median age was 85, and 12,217 participants were men (53.3%). In the last half year before death, 5424 (23.7%) older adults used home-visit nursing services. Multivariable linear regression analysis of the log10-transformed value of total costs revealed that compared with the no use group, the early initiation/continuous use group was estimated to have 0.88 times (95% confidence interval: 0.84, 0.93) the total costs in the last 3 months of life (p < 0.001).

CONCLUSION

Early initiation use of home-visit nursing services may contribute to reducing total costs in the last 3 months of life for Japanese people aged 75 years or older living at home as they approach the end of life.

CLINICAL RELEVANCE

When approaching the end of life, many older adults require daily life care and palliative care. Policymakers are strengthening end-of-life care for community-dwelling older adults in Japan. Although the current results do not demonstrate the effectiveness of home-visit nursing services, they provide a perspective from which to assess the use of home-visit nursing services and its impact on older adults. The findings can be helpful in considering how to provide nursing care in home-care settings for older adults who prefer to spend their final days at home.

Internet appointment has more advantages than traditional appointment in the nursing service of dry eye patients

Dry eye disease is one of the most common eye diseases. Clinical studies have found that meibomian gland expression can effectively improve the function of meibomian glands in patients with meibomian gland dysfunction. Compared with traditional appointments, Internet appointment has advantages in treating dry eye disease. A cross-sectional study was conducted to collect 300 patients with dry eye disease through an online questionnaire. Using Pearson chi-squared test, associations between the clinical parameters and appointment mode were analyzed. Spearman-rho test was executed to compare clinical data and appointment mode for correlation analysis and relationship between score of advantages of Internet booking (SOAIB), evaluation of the effectiveness of the Internet booking (EEIB), waiting in line for medical treatment (WMT). Univariate logistic regression analysis calculated the odds ratio (OR) of appointment mode for potential correlation factors. By using Pearson chi-squared test, SOAIB (P = .005), EEIB (P = .029) and WMT (P = .041) was significantly correlated with the appointment mode. Spearman correlation coefficient displayed that appointment mode was significantly correlated with EEIB (ρ = -0.126, P = .029) and WMT (ρ = 0.118, P = .041). Univariate logistic regression and concludes that EEIB (OR = 0.183, 95%CI: 0.033-1.004, P = .05), WMT (OR = 2.543, 95%CI: 1.013-6.384, P = .047) have a clear correlation with appointment mode. Spearman correlation coefficient displayed that SOAIB was significantly correlated with EEIB (ρ = -0.247, P < .001) and WMT (ρ = 0.157, P = .006). Internet appointment can effectively reduce the waiting time for dry eye disease treatment by meibomian gland expression. Effectiveness evaluation of Internet appointments is significantly higher than traditional appointments.

Nursing Services in the First Level of Care in Colombia. Analysis of the Offer 2002-2020

OBJECTIVES

This work sought to characterize the primary care nursing consultation services reported in the official systemsof health services records in Colombia between 2002 and 2020.

METHODS

This was a descriptive, cross-sectional, retrospective study. Node geographic analysis and descriptive statistics were performed for quantitative data from the Special Registry of Health Providers and the Ministry of Health and Social Protection.

RESULTS

The study identified 6079 nursing services of which 72% are outpatient, 95.05% are assigned to institutions providing health services, 99.75% are of low complexity, and 48.22% of the offer was created in the last five years. The nodes with the highest increase in the offer of services are Caribbean (n = 909) and Pacific (n = 499), while Amazon (n = 48) showed the lowest offer in the last five years.

CONCLUSIONS

Disparity is evident in the availability of services by region and node, in addition to a low liberal exercise to provide nursing care.

Sustaining a culture of safety and optimising patient outcomes while implementing zero harm programme: a 2-year project of the nursing services - SBAHC

This quality improvement report details how Sultan Bin Abdulaziz Humanitarian City (The City), the largest rehabilitation facility within Middle East with a capacity of 511 beds and more than 20 nursing in-patient units improved the quality and patient safety culture in nursing services after successfully adopting and implementing the zero harm programme.In healthcare settings, the idea of zero harm including zero incidents, zero injuries and injury-free are commonly used to highlight the importance of patient safety. Patient injuries and deaths resulting from hospital-acquired illnesses such as medication administration errors, falls, central line-associated bloodstream infections, hospital-acquired pressure injuries and catheter-associated urinary tract infection are largely preventable and grossly unacceptable occurrences. Achieving zero incidents of such critical measures can significantly impact treatment plan and enhance patient experience.The projects' purpose was to build a new culture of safety by implementing innovative strategy designed to protect patients from preventable harm while maintaining an extraordinary high standard of quality patient care. Additionally, the programme was established with the aim of instilling a sense of commitment to every nurse working in this organisation to anticipate potential harms and to be vigilant to prevent it before it reaches the patient.This document also describes a set of initiatives aimed at mitigating preventable incidents and ultimately achieving zero harm on our organisation. The result showed a significant increase by 95% between the percentage of nursing units that had 365 days of zero harm in 2020 and 2021. This improvement indicates that the concept of zero harm had been successfully inculcated among nursing units and had motivated nursing staff to uphold a higher culture of patient safety. Furthermore, by incorporating the Just Culture model into the electronic reporting system, the reporting rate of occurrences in the zero-harm programme was supported and sustained.

Nurses' perceptions of engaging in internet-based nursing services: A qualitative study based on three hospitals in China

AIM

In response to the ageing population and shortage of human resources for nursing care, China is piloting internet-based nursing services (nurses who provide this care are called online nurses). Nurses are the providers of this model, so it is important to understand their perceptions. We aim to explore nurses' perceptions of engaging in internet-based nursing services.

DESIGN

This study is descriptive qualitative research, so the data were analysed using a descriptive qualitative research method based on the theory of planned behaviour, using thematic analysis.

METHODS

With personal semi-structured interviews conducted by two Master of Science in Nursing with 18 online nurses and nine clinical nurses, terminated after information saturation.

RESULTS

Nurses' emotional attitudes towards internet-based nursing services were generally positive, but their behavioural intentions were negative. Social support, hospital organisational climate and family responsibilities had a statistically significant impact on nurses' behavioural decisions. Internet-based nursing services place higher demands on nurses' knowledge and skills, and nurses are most concerned with ensuring patient and nurse safety.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Charting new territory: medication administration records and transcribing in district nursing services

Community nurses are often requested to administer medicines. A medicines administration record (MAR) is usually used to demonstrate all medicines administered, withheld or declined. In Wales, district nursing teams have highlighted concerns about accessing MARs and have been seeking solutions, which includes transcription of medication, where an exact copy of previously prescribed medicines are made to enable their administration. To understand the types of medicines administered in district nursing teams and nurses' views on transcribing, an anonymised electronic survey was developed and shared with such teams across Wales. A total of 286 responses were received from Health Boards in Wales. The survey found 60% of nurses experienced difficulties in accessing MARs, particularly during the out of hours period. Overall, 77% of nurses supported transcribing as a possible solution. Further work is required to develop clear policies and training to support safe transcribing within district nursing services. This can be supported by providing access to the person's medical records.

Efficacy of long-term extended nursing services combined with atezolizumab in patients with bladder cancer after endoscopic bladder resection

BACKGROUND

Nursing has been reported to effectively ameliorate physical movement, significantly decrease postoperative complications, and markedly improve the quality of life in patients with bladder cancer after endoscopic bladder resection. Atezolizumab (ATZ) has been approved as effective therapy for patients with bladder cancer. This study was aimed to assess the efficacy of long-term extended nursing services combined with ATZ in patients with bladder cancer after endoscopic bladder resection.

METHODS

A total of one 126 patients diagnosed with bladder cancer underwent endoscopic bladder resection were recruited in this study. Patients were randomly allocated into the long-term conventional nursing plus atezolizumab (LTCN-ATZ) (n = 60) and long-term extended nursing services plus atezolizumab (LTENS-ATZ) groups (n = 66). The renal function, physical movement, postoperative complications, the quality of life, survival, and recurrence were examined in patients in LTCN-ATZ and LTENS-ATZ groups during 36-month follow up.

RESULTS

Data in the current study demonstrated that the renal function, quality of life, satisfaction anxiety and depression for LTENS-ATZ group was significantly improved compared with that of LTCN-ATZ group. The occurrence rate was significantly lower, and the length of hospital stay was shorter for LTENS-ATZ than that of LTCN-ATZ group. Outcomes demonstrated that LTENS-ATZ increased survival and decreased the occurrence compared to those patients in LTENS-ATZ group.

CONCLUSION

In conclusion, outcomes in this study indicate that LTENS-ATZ improves renal function, and quality of life and prognosis in patients with bladder cancer after endoscopic bladder resection.

Study on the application of the Internet + nursing service in family rehabilitation of common bone and joint diseases in the elderly

OBJECTIVE

To explore the feasibility of the Internet + nursing service mode in family rehabilitation of elderly patients with osteoarthritic diseases.

PATIENTS AND METHODS

The control group (n=50) received routine rehabilitation treatment procedures and discharge guidance. For the observation group (n=50), extended nursing rehabilitation service was conducted through the Internet + nursing service platform based on the routine treatment in the control group.

RESULTS

(1) The compliance with follow-up of the patients in the observation group was significantly higher than that in the control group; (2) The total satisfaction of patients in the observation group was significantly higher than that in the control group; (3) The VAS (1 month: 4.36±1.15 vs. 5.86±1.61, p<0.05; 3 months 4.36±1.15 vs. 5.86±1.61, p<0.05), SAS (1 month: 37.21±14.16 vs. 49.31±13.45, p<0.05; 3 months 26.73±8.25 vs. 40.33±9.50, p<0.05), SDS (1 month: 32.36±10.15 vs. 46.32±12.61, p<0.05; 3 months 27.11±8.08 vs. 40.62±11.40, p<0.05) and PSQI (1 month: 13.64 ± 1.13 vs. 16.31 ± 3.45, p<0.05; 3 months 11.54 ± 1.87 vs. 15.74 ± 1.36, p<0.05) scores in the observational group were significantly lower than that in control group at one month and three months after discharge. The ADL (1 month: 86.86 ± 4.13 vs. 74.33 ± 3.44, p<0.05; 3 months 90.34 ± 7.87 vs. 78.52 ± 6.36, p<0.05) scores in the observational group were significantly higher than that in control group at one month and three months after discharge.

CONCLUSIONS

The extended rehabilitation nursing management for family rehabilitation of elderly patients with osteoarthritic diseases through the Internet + nursing service is a family rehabilitation model suitable for elderly patients with osteoarthritic diseases in China and has positive significance in developing a diversified medical nursing model.

Effect of 1 + N Extended Nursing Service on Functional Recovery of Colostomy Patients

To many hospitals' management as well as to patients, the nursing service is one of the most important aspects. Many diseases like sugar, blood pressure, urine passage, and gas are a little bit dangerous to handle by patients themselves. The earlier stage models are unable to give good services to patients; therefore, an advanced JHE: Effect of 1 + N extended nursing service is necessary to crossover the above limitations. Colostomy and colorectal cancers are very dangerous syndromes thus, disease monitoring is so difficult. In this research work, an extended JHE: Effect of 1 + N extended nursing service modeling is discussed with experimental modeling. Apart from conventional nursing care provided by the observation group, it was given online training as well as service providing. Self-efficacy and self-care competence were assessed in both groups 6 months after the discharge. Quality of life and mental health were also assessed. Besides, their dimensional and total self-care ability scores, and the observation group's self-efficacy ratings were substantially higher than those of the control group (P 0.05) after the intervention. It was observed that the intervention group's 6-month adjustment to the stoma was statistically more favorable than the control group's (P 0.001), and only the intervention group showed a significantly major change (P 0.001) between their two evaluations. This proposed methodology can improve the accuracy rate by 93.23%, and succussive treatment rate of 92.14% had been attained.

Implementing digital technology during the pandemic: impact on stoma nursing services at a tertiary referral centre

The COVID-19 pandemic has been one of the greatest challenges to the NHS, creating turmoil in the public health workforce and for all of those who use its services. Its immediate impact was a rapid change in how care in the NHS is planned, delivered and accessed, with no concession for stoma care services. Investment in global resources detailing COVID-19 recovery plans and the steady increase in national data related to the transmission and treatment of the virus has allowed stoma care nurses to better understand the long-term effects of the pandemic and mitigate future risk to specialist nursing services. This article describes how this crisis has provided an opportunity to radically change systems and processes in stoma care through the use of digital technology to continue interaction with patients, communicate with the multidisciplinary team and collaborate with relatives or carers, and as a platform to enhance personal development, training and education.

Perception and Attitude of Health Care Personnel Regarding Integration of Nursing Education and Nursing Services for Patient Care at a Tertiary Care Center of Northern India

This study aims to assess the perception and attitude of health care personnel regarding integration of nursing education and nursing services. Using purposive and stratified random sampling technique, 92 medical faculty, 32 nursing faculty and 346 nursing officers were enrolled. A three-point Likert scale consisting of 15 items and six open ended questions was used to collect the data. Overall, the concept of integration of nursing education and nursing services at their institute was welcomed by 74.4% of health care personnel. Medical faculty (47.8%), nursing faculty (37.5%) and nursing officers (57.5%) scored the concept of integration as very good.

Have Elderly Individuals in Urban China Been Satisfied with Nursing Services during the COVID-19 Pandemic?

Based on the customer satisfaction index model, we constructed an elderly care service satisfaction model that includes 5 latent variables and 16 observed variables. To analyze the degree of satisfaction of elderly individuals in nursing homes, we used structural equation model (SEM) to test the nursing service elderly satisfaction model. With the help of AMOS 22.0 software, we analyzed the degree of model fit and the behavioral relationships between the variables that affect the path. We found that the satisfaction of Chinese urban elderly individuals in nursing homes is at a moderate level, which is lower than the quality expected by elderly individuals. The customer satisfaction index model can be applied to assess satisfaction with nursing services. Furthermore, perceived quality and value have a significant impact on satisfaction.

Determination of gaps in the spatial accessibility of nursing services for persons over the age of 65 with lowered self-sufficiency: Evidence from the Czech Republic

The subject of this research is one of the main preconditions for the provision of high-quality social care services for people over the age of 65 with lowered self-sufficiency. It involves the spatial accessibility of formally established nursing services examined in 76 districts of the Czech Republic. The aim of this article is to identify and evaluate the gaps in spatial accessibility of the selected residential and outpatient-clinic services at the level of districts in individual regions of the Czech Republic in 2018. A three-phase analysis was performed, including an ArcGIS network analysis, multi-criteria evaluation according to the TOPSIS method, and a correlation analysis encompassing the confidence interval gained via the Bootstrap method. Seven indicators were selected-recipients of the allowance for the care, capacity of residential and outpatient-clinic services, and four indicators of accessibility via individual and public transport within the set time intervals. The results show good availability of residential care (no gap) within 30 min. by individual and public transport in most districts (94%). However, day services centers do not have a space gap in only 28% of districts by individual transport, and 8% of districts by public transport. In the case of day care centers, 54% of districts by individual transport, and 29% of districts by public transport do not have a space gap. The results also show that the level of spatial availability of care (gaps) in the district is not related to the number of people aged 65+ with reduced self-sufficiency in the district. On the contrary, the correlation analysis shows that with the growing number of people aged 65+ with reduced self-sufficiency in the district, the capacity of residential and outpatient services increases and the gaps in spatial accessibility do not decrease.

Accreditation of nursing clinical services: Development of an appraisal tool

Aim

This study aimed to determine comprehensive and applicable indicators for assessing the quality of nursing clinical services.

Design

Methodological research.

Methods

The checklist was designed in three phases (conceptualization, item generation and item reduction). In the first phase, a qualitative study using conventional content analysis was performed to clarify the concept of accreditation of clinical nursing services. In the second phase, using the views of experts was obtained in phase 1 and then by a review of the literature, related items were extracted, and item pool was formed. In the last phase, validity and reliability of the checklist were examined.

Result

Based on three phases (Conceptualization, Item Generation and Item Reduction), the accreditation indicators of clinical nursing services were extracted in three dimensions including structure, process and outcome at two levels of organizational (including structural and outcome indicators) and individual performance appraisal (process indicators) in 19 main categories.

Does the mutual recognition agreement on nursing services accelerate nurse migration in member countries of the Association of Southeast Asian Nations?

Aim

To clarify the situations of nursing education and activity, its affecting factors and the nursing educators' views on nurse migration relating Mutual Recognition Agreement on Nursing Services in the Association of Southeast Asian Nations. Design: Descriptive qualitative research.

Methods

The individual semi-structured interviews with 11 nursing educators, analysed using thematic analysis.

Results

Nursing educators acknowledged that the change in nursing was mainly due to the creation and amendment of laws, acts and regulations regarding nursing and improvements in nursing education systems. Some of these improvements occurred by this mutual agreement. The conceptualization of the progress indicated an improvement in the quality of nursing. Nurse migration to the outside of Southeast Asian countries might be accelerated due to concurrent improvements in the quality of nursing. New trends among nurses working as caregivers in surrounding countries such as China, South Korea and Japan to deal with demographic ageing should be considered.

Is deployment of trained nurses to rural villages a remedy for the low skilled birth attendance in Ethiopia? A cluster randomized-controlled community trial

Background

Low coverage of Skilled Birth Attendance (SBA) is one of the major drivers of maternal mortality in many low- and middle-income countries (LMICs) including Ethiopia. We conducted a cluster-randomized controlled community trial to assess the effect of deploying trained community based nurses to rural communities on the uptake levels of SBA in Ethiopia.

Methods

A three-arm, parallel groups, cluster-randomized community trial was conducted to assess the effect of deploying trained community based reproductive health nurses (CORN) on the uptake of SBA services. A total of 282 villages were randomly selected and assigned to a control arm (n = 94) or 1 of 2 treatment arms (n = 94 each). The treatment groups differed by where these new service providers were deployed, a health post (HP) or health center (HC). Baseline and end line surveys were conducted to document and measure the effects of the intervention. Program impacts on SBA coverage were calculated using difference‐in‐difference (DID) analysis.

Results

After nine months of intervention, the coverage of SBA services increased significantly by 81.1% (from 24.61 to 44.59) in the HP based intervention arm, and by 122.9% (from 16.41 to 36.59) in the HC arm, respectively (p <0.01). Conversely, a small and non-significant (2%) decline in SBA coverage were observed in the control arm (P >0.05). The DID estimate indicated a net increase in SBA coverage of 21.32 and 20.52 percentage points (PP) across the HP and HC based intervention arms, respectively (p < 0.001).

Conclusions

Deployment of trained reproductive health nurses to rural communities in Ethiopia significantly improved utilization of SBA services. Therefore; in similar low income settings where coverage of SBA services is very low, deployment of trained community based nurses to grassroots level could potentiate rapid service uptake. Additional cost-effectiveness and validation studies at various setups are required, before scale-up of the innovation, however.

Trial registration

clinicaltrails.gov NCT02501252.

[It's either all or nothing: Utilization of care and relief services amongst people with dementia. A cohort study based on administrative data]

OBJECTIVE

Caregiving often is a demanding task for family caregivers of people with dementia. In order to provide relief for caregivers and stabilize informal care, care and relief services for people with dementia and their caregivers were established by the German long-term care insurance ("Pflegeversicherung"). It is unknown how many people with dementia have used the additional care and relief services over the time and which characteristics predict permanent utilization.

METHODS

The analysis is based on administrative data. 2,887 people with prevalent dementia were followed from 2012 to 2015. The data was analyzed descriptively and by logistic regression.

RESULTS

About a quarter of the observed people with dementia continuously used the additional care and relief services from 2012 to 2015. 22.8% used them since 2013, while nearly a quarter made no use whatsoever of the services during the observation period. The probability of using care and relief services is higher when using an outpatient nursing service in comparison to family care and when the care level has gone up in the year before use.

CONCLUSION

Permanent utilization of care and relief services seems to be based on need in most cases. It could also be a learning effect or supplier-induced when simultaneously using an outpatient nursing service. People who discontinued service use or never used it could provide further information in order to adjust the additional care and relief services program.

Internationally educated nurses in Canada: predictors of workforce integration

BACKGROUND

Global trends in migration accompanied with recent changes to the immigrant selection process may have influenced the demographic and human capital characteristics of internationally educated nurses (IENs) in Canada and in turn the assistance required to facilitate their workforce integration. This study aimed to describe the demographic and human capital profile of IENs in Canada, to explore recent changes to the profile, and to identify predictors of IENs' workforce integration.

METHODS

A cross-sectional, descriptive, correlational survey design was used. Eligible IENs were immigrants, registered and employed as regulated nurses in Canada. Data were collected in 2014 via online and paper questionnaires. Descriptive statistics were used to examine the data by year of immigration. Logistic regression modeling was employed to identify predictors of IENs' workforce integration measured as passing the licensure exam to acquire professional recertification and securing employment.

RESULTS

The sample consisted of 2280 IENs, representative of all Canadian provincial jurisdictions. Since changes to the immigrant selection process in 2002, the IEN population in Canada has become more racially diverse with greater numbers emigrating from developing countries. Recent arrivals (after 2002) had high levels of human capital (knowledge, professional experience, language proficiency). Some, but not all, benefited from the formal and informal assistance available to facilitate their workforce integration. Professional experience and help studying significantly predicted if IENs passed the licensure exam on their first attempt. Bridging program participation and assistance from social networks in Canada were significant predictors if IENs had difficulty securing employment.

CONCLUSIONS

Nurses will continue to migrate from a wide variety of countries throughout the world that have dissimilar nursing education and health systems. Thus, IENs are not a homogenous group, and a "one size fits all" model may not be effective for facilitating their professional recertification and employment in the destination country. Canada, as well as other countries, could consider using a case management approach to develop and tailor education and forms of assistance to meet the individual needs of IENs. Using technology to reach IENs who have not yet immigrated or have settled outside of urban centers are other potential strategies that may facilitate their timely entrance into the destination countries' nursing workforce.

Under Pressure: Nursing in a stressed, underfunded health service

Over the following pages, nurses, midwives and health care assistants describe how an underfunded health service undermines their ability to provide good care.

Designing services in partnership with patients

A variety of methods are available to encourage health professionals to listen to patients and relatives, but are not routinely used to improve the quality of services. Experience-based co-design enables staff and patients to design services and/or care pathways in partnership. This article explains how the approach works in practice, outlines its benefits and details the resources available to help health professionals use it to improve patients' experiences.