Contextually appropriate nurse staffing models: a realist review protocol

INTRODUCTION

Decisions about nurse staffing models are a concern for health systems globally due to workforce retention and well-being challenges. Nurse staffing models range from all Registered Nurse workforce to a mix of differentially educated nurses and aides (regulated and unregulated), such as Licensed Practical or Vocational Nurses and Health Care Aides. Systematic reviews have examined relationships between specific nurse staffing models and client, staff and health system outcomes (eg, mortality, adverse events, retention, healthcare costs), with inconclusive or contradictory results. No evidence has been synthesised and consolidated on how, why and under what contexts certain staffing models produce different outcomes. We aim to describe how we will (1) conduct a realist review to determine how nurse staffing models produce different client, staff and health system outcomes, in which contexts and through what mechanisms and (2) coproduce recommendations with decision-makers to guide future research and implementation of nurse staffing models.

METHODS AND ANALYSIS

Using an integrated knowledge translation approach with researchers and decision-makers as partners, we are conducting a three-phase realist review. In this protocol, we report on the final two phases of this realist review. We will use Citation tracking, tracing Lead authors, identifying Unpublished materials, Google Scholar searching, Theory tracking, ancestry searching for Early examples, and follow-up of Related projects (CLUSTER) searching, specifically designed for realist searches as the review progresses. We will search empirical evidence to test identified programme theories and engage stakeholders to contextualise findings, finalise programme theories document our search processes as per established realist review methods.

ETHICS AND DISSEMINATION

Ethical approval for this study was provided by the Health Research Ethics Board of the University of Alberta (Study ID Pro00100425). We will disseminate the findings through peer-reviewed publications, national and international conference presentations, regional briefing sessions, webinars and lay summary.

Organization of primary care

Strong primary care does not develop spontaneously but requires a well-developed organizational planning between levels of care. Primary care-oriented health systems are required to effectively tackle unmet health needs of the population, and efficient primary care organization (PCO) is crucial for this aim. Via strong primary care, health delivery, health outcomes, equity, and health security could be improved. There are several theoretical models on how primary care can be organized. In this position paper, the key aspects and benchmarks of PCO will be explored based on previously mentioned frameworks and domains. The aim of this position paper is to assist primary care providers, policymakers, and researchers by discussing the current context of PCO and providing guidance for implementation, development, and evaluation of it in a particular setting. The conceptual map of this paper consists of structural and process (PC service organization) domains and is adapted from frameworks described in literature and World Health Organization resources. Evidence we have gathered for this paper shows that for establishing a strong PCO, it is crucial to ensure accessible, continuous, person-centered, community-oriented, coordinated, and integrated primary care services provided by competent and socially accountable multiprofessional teams working in a setting where clear policy documents exist, adequate funding is available, and primary care is managed by dedicated units.

A whole-team approach to optimising general dental practice teamwork: development of the Skills Optimisation Self-Evaluation Toolkit (SOSET)

Introduction Studies across the health service reveal benefits of teamwork and barriers to its optimal use. Drawing upon the established Maturity Matrix Dentistry method, the Skills Optimisation Self-Evaluation Toolkit (SOSET) was developed to enable the whole dental team to critically review how they address skill-mix in delivery of patient-centred oral healthcare in their practice. This paper outlines the development of the SOSET and explores its usefulness to general dental practice teams.Methods Research literature and interview data from general dental practice teams were coded for high-level factors (positive and negative) influencing teamwork. We used this coding to identify skill-mix domains, and within each, define criteria. The SOSET process was refined following consultations with dental professionals and piloting.Results Eighty-four papers were coded and 38 dental team members were interviewed across six sites. The SOSET matrix was developed containing nine domains reflecting the use of skill-mix, each containing six development-level criteria. The domains addressed factors such as team beliefs on skill-mix and knowledge of team members' scope of practice, patient demand, the business case, staffing and training, and the practice premises. The process was piloted in 11 practices across South Wales, and feedback was received from 92 staff members. Results showed that the SOSET process was straightforward, that the whole team could contribute to discussion and that it would be used to improve practice. Following piloting, four domains were merged into two new domains, and the number of criteria within all domains was reduced and the wording simplified (seven domains, with four criteria each).Conclusion We used a systematic and rigorous process to develop the SOSET to support dental teams to progress their teamwork practices. Its usefulness was demonstrated in the pilot. The SOSET is now being offered to general dental practices across Wales.

Dental therapists in general dental practice. A literature review and case-study analysis to determine what works, why, how and in what circumstances

INTRODUCTION

In the United Kingdom, policy and guidance changes regarding the role of dental therapists (DTs) were implemented in recent years with a view to changing dental care to a more preventive-focussed, teamwork approach. However, success in the adoption of this model of working has been varied.

AIMS

Adopting a realist approach, our aim was, to examine the use of DTs in general dental practices in Wales, exploring what works, why, how and in what circumstances.

MATERIALS AND METHODS

The research comprised two stages. (a) A structured literature search, dual-coding papers for high-level factors describing the conditions or context(s) under which the mechanisms operated to produce outcomes. From this, we derived theories about how skill-mix operates in the general dental service. (b) Six case studies of general dental practices (three with a dental therapist/three without a dental therapist) employing a range of skill-mix models incorporating semi-structured interviews with all team members. We used the case studies/interviews to explore and refine the theories derived from the literature.

RESULTS

Eighty-four papers were coded. From this coding, we identified seven theories which reflected factors influencing general dental practices within three broad contexts: the dental practice as a business, as a healthcare provider and as a workplace. We tested these theories in interviews with 38 dental team members across the six care studies. As a result, we amended five of the theories.

CONCLUSION

Our analysis provides theory about outcomes that DTs may facilitate and the mechanisms that may assist the work of DTs within different contexts of general dental practice.

Assessment of public oral healthcare services in Curitiba, Brazil: a cross-sectional study using the Primary Care Assessment Tool (PCATool)

OBJECTIVES

To compare two different models of public oral health in primary care services, a so-called family health strategy (FHS), as opposed to non-FHS services designated as 'conventional' healthcare (CHC), regarding the presence and extent of the attributes of 'good' primary healthcare (PHC). The null hypothesis of this study is that the attributes do not differ between the FHS and CHC.

DESIGN

Cross-sectional.

SETTING

Public PHC services in Curitiba, the state capital of Paraná.

PARTICIPANTS

PHC users of the public oral health network (n=900) and dentists active in this municipal network (n=203).

PRIMARY AND SECONDARY OUTCOME MEASURES

The Primary Care Assessment Tool (PCATool)-Dentists and PCATool-Users were used to analyse the primary outcomes ('essential' attributes) and secondary outcomes ('derived' attributes) in the PHC.

RESULTS

Overall, the primary care services in oral health were well evaluated, both by users and by dentists, with mean scores ascribed to PHC attributes mostly above the cut-off point (6.6). The exception for users were affiliation (6.36; 95% CI 6.11 to 6.60) and accessibility (5.83; 95% CI 5.78 to 5.89); and for dentists the accessibility (5.80; 95% CI 5.63 to 5.96). When comparing FHS and CHC, there was a superiority of the FHS model, which reached a general mean score of 7.53 (95% CI 7.48 to 7.58) among users and 7.56 (95% CI 7.45 to 7.67) among dentists; on the other hand, the CHC general mean score was of 6.61 (95% CI 6.49 to 6.73) and 6.68 (95% CI 6.56 to 6.80) respectively for users and dentists.

CONCLUSIONS

The results reveal a reasonable level of attainment of PHC attributes in the services investigated. Nevertheless, public health managers should make efforts to reduce the difficulties faced by users in accessing dental care. The more positive results achieved by FHS services indicate that the provision of oral healthcare under this strategy should be expanded.

Interprofessional enhanced skills training in periodontology: a qualitative study of one London pilot

OBJECTIVES/AIMS:

Health Education England (HEE) London developed an innovative 2-year pilot educational and training initiative for enhancing skills in periodontology for dentists and dental hygienists/therapists in 2011. This study explores the perceptions and experiences of those involved in initiating, designing, delivering and participating in this interprofessional approach to training.

MATERIALS AND METHODS:

Semi-structured qualitative interviews were conducted with a purposive sample of key stakeholders including course participants (dentists and dental hygienists and/or therapists), education and training commissioners, and providers towards the end of the 2-year programme. Interviews, based on a topic guide informed by health services and policy literature, were audio-recorded and transcribed verbatim. Data were analysed based on framework methodology, using QSR NVivo 9 software to manage the data.

RESULTS:

Twenty-two people were interviewed. Although certain challenges were identified in designing, and teaching, a course bringing together different professional backgrounds and level of skills, the experiences of all key stakeholders were overwhelmingly positive relating to the concept. There was evidence of ‘creative interprofessional learning’, which led to ‘enhancing team working’, ‘enabling role recognition’ and ‘equipping participants for delivery of new models of care’. Recommendations emerged with regard to future training and wider health policy, and systems that will enable participants on future enhanced skills courses in periodontology to apply these skills in clinical practice.

CONCLUSION:

The interprofessional approach to enhanced skills training in periodontology represents an important creative innovation to build capacity within the oral health workforce. This qualitative study has provided a useful insight into the benefits and tensions of an interprofessional model of training from the perspectives of different groups of key stakeholders and suggests its application to other areas of dentistry.

Investments and costs of oral health care for Family Health Care

OBJECTIVE

To estimate the investments to implement and operational costs of a type I Oral Health Care Team in the Family Health Care Strategy.

METHODS

This is an economic assessment study, for analyzing the investments and operational costs of an oral health care team in the city of Salvador, BA, Northeastern Brazil. The amount worth of investments for its implementation was obtained by summing up the investments in civil projects and shared facilities, in equipments, furniture, and instruments. Regarding the operational costs, the 2009-2012 time series was analyzed and the month of December 2012 was adopted for assessing the monetary values in effect. The costs were classified as direct variable costs (consumables) and direct fixed costs (salaries, maintenance, equipment depreciation, instruments, furniture, and facilities), besides the indirect fixed costs (cleaning, security, energy, and water). The Ministry of Health’s share in funding was also calculated, and the factors that influence cost behavior were described.

RESULTS

The investment to implement a type I Oral Health Care Team was R$29,864.00 (US$15,236.76). The operational costs of a type I Oral Health Care Team were around R$95,434.00 (US$48,690.82) a year. The Ministry of Health’s financial incentives for investments accounted for 41.8% of the implementation investments, whereas the municipality contributed with a 59.2% share of the total. Regarding operational costs, the Ministry of Health contributed with 33.1% of the total, whereas the municipality, with 66.9%. Concerning the operational costs, the element of heaviest weight was salaries, which accounted for 84.7%.

CONCLUSIONS

Problems with the regularity in the supply of inputs and maintenance of equipment greatly influence the composition of costs, besides reducing the supply of services to the target population, which results in the service probably being inefficient. States are suggested to partake in funding, especially to cover the team’s operational cost.

Health workforce governance and oral health: Diversity and challenges in Europe

Throughout the life course, oral diseases are some of the most common non-communicable diseases globally, and in Europe. Human resources for oral health are fundamental to healthcare systems in general and dentistry is no exception. As political and healthcare systems change, so do forms of governance. The aim of this paper is to examine human resources for oral health in Europe, against a workforce governance framework, using England as a case study. The findings suggest that neo-liberalist philosophies are leading to multiple forms of soft governance at professional, system, organisational and individual levels, most notably in England, where there is no longer professional self-regulation. Benefits include professional regulation of a wider cadre of human resources for oral health, reorientation of care towards evidence-informed practice including prevention, and consideration of care pathways for patients. Across Europe there has been significant professional collaboration in relation to quality standards in the education of dentists, following transnational policies permitting freedom of movement of health professionals; however, the distribution of dentists is inequitable. Challenges include facilitating employment of graduates to serve the needs and demands of the population in certain countries, together with governance of workforce production and migration across Europe. Integrated trans-European approaches to monitoring mobility and governance are urgently required.

Dentists with enhanced skills (Special Interest) in Endodontics: gatekeepers views in London

BACKGROUND

Dentists with a special interest hold enhanced skills enabling them to treat cases of intermediate complexity. The aim of this study was to explore primary dental care practitioners' views of dentists with a special interest (DwSIs) in Endodontics in London, with reference to an educational and service initiative established by (the former) London Deanery in conjunction with the NHS.

METHODS

A cross-sectional postal survey of primary care dentists working across different models of care within London was conducted, with a target to achieve views of at least 5 % of London's dentists. The questionnaire instrument was informed by qualitative research and the dental literature and piloted prior to distribution; data were analysed using SPSS v19 and STATA v12.0.

RESULTS

Six per cent of London's primary care dentists (n = 243) responded to the survey; 53 % were male. Just over one third (37 %; n = 90) were aware of the DwSI service being provided. Most practitioners reported that having access to a DwSI in Endodontics would support the care of their patients (89 %; n = 215), would carry out more endodontic treatment in the NHS primary dental care if adequately reimbursed (93 %; n = 220), and had more time (76 %; n = 180). Female respondents appeared to be less confident in doing endodontic treatment (p = 0.001). More recently qualified respondents reported greater need for training/support for performing more endodontic treatment in the NHS primary dental care (p = 0.001), were more dissatisfied with access to endodontic service in the NHS primary dental care (p = 0.007) and more interested to train as a DwSI in endodontics (p = 0.001) compared with respondents having a greater number of years of clinical experience since qualification.

CONCLUSION

The findings lend support to the concept of developing dentists with enhanced skills as well as ensuring additional funding, time and support to facilitate more routine endodontics through the NHS primary care to meet patient needs. More recently qualified dentists working in London were more concerned regarding endodontic service access, expressed need for training/support for undertaking more endodontic treatment in the NHS primary dental care and a desire to train as a DwSI in endodontics.

Extending dental nurses' duties: a national survey investigating skill-mix in Scotland's child oral health improvement programme (Childsmile)

Background

Childsmile is Scotland’s national child oral health improvement programme. To support the delivery of prevention in general dental practice in keeping with clinical guidelines, Childsmile sought accreditation for extended duty training for dental nurses to deliver clinical preventive care. This approach has allowed extended duty dental nurses (EDDNs) to take on roles traditionally undertaken by general dental practitioners (GDPs). While skill-mix approaches have been found to work well in general medicine, they have not been formally evaluated in dentistry. Understanding the factors which influence nurses’ ability to fully deliver their extended roles is necessary to ensure nurses’ potential is reached and that children receive preventive care in line with clinical guidance in a cost-effective way. This paper investigates the supplementation of GDPs’ roles by EDDNs, in general dental practice across Scotland.

Methods

A cross-sectional postal survey aiming to reach all EDDNs practising in general dental practice in Scotland was undertaken. The survey measured nurses’: role satisfaction, perceived utility of training, frequency, and potential behavioural mediators of, preventive delivery. Frequencies, correlations and multi-variable linear regression were used to analyse the data.

Results

Seventy-three percent of practices responded with 174 eligible nurses returning questionnaires. Respondents reported a very high level of role satisfaction and the majority found their training helpful in preparing them for their extended role. While a high level of preventive delivery was reported, fluoride vanish (FV) was delivered less frequently than dietary advice (DA), or oral hygiene advice (OHA). Delivering FV more frequently was associated with higher role satisfaction (p < 0.001). Those nurses who had been practising longer reported delivering FV less frequently than those more recently qualified (p < 0.001). Perceived difficulty of delivering preventive care (skills) and motivation to do so were most strongly associated with frequency of delivery (p < 0.001 for delivery of FV, DA and OHA).

Conclusions

This study has provided insight into EDDNs’ experiences and demonstrates that with appropriate training and support, EDDNs can supplement GDPs’ roles in general dental practice in Scotland. However, some barriers to delivery were identified with delivery of FV showing scope for improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6831-14-137) contains supplementary material, which is available to authorized users.

Oral health in the context of primary care in Brazil

This article presents an integrative literature review that analyses the advances and challenges in oral health care of the Brazilian primary health care system, based on a political agenda that envisages re-organising the unified health system (SistemaÚnico de Saúde - SUS). It is presumed that the actions suggested by the Alma-Ata Conference of 1978 are still up-to-date and relevant when adapted to the situation in Brazil. Several studies and policies are reviewed, including works demonstrating the importance of primary care as an organising platform in an integrated health-care network, Brazil's strategy for reorganising the primary care network known as the Family Health Strategy, and the National Oral Health Policy. This review discusses results obtained over the last twenty years, with special attention paid to changes in oral health-care practices, as well as the funding of action programmes and assistance cover. The conclusion is that oral healthcare in the Brazilian primary health care system has advanced over the past decades; however, serious obstacles have been experienced, especially with regard to the guarantee of universal access to services and funding. The continuous efforts of public managers and society should focus on the goal of achieving universal coverage for all Brazilians.

Contemporary issues in the provision of restorative dentistry

This review highlights current issues in the provision of restorative dentistry both in primary and secondary care settings. Current challenges in the provision of restorative procedures are reviewed and methods in improving care and efficiency are proposed. Possible changes to the infrastructure and delivery of care are suggested in order to improve effectiveness and the patient pathway.