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Maier CB, Winkelmann J, Pfirter L, Williams GA. Skill-Mix Changes Targeting Health Promotion and Prevention Interventions and Effects on Outcomes in all Settings (Except Hospitals): Overview of Reviews. Int J Public Health 2023; 68:1605448. [PMID: 37228895 PMCID: PMC10203245 DOI: 10.3389/ijph.2023.1605448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 04/14/2023] [Indexed: 05/27/2023] Open
Abstract
Objectives: Skill-mix changes to step up health promotion and prevention are increasing, but there is limited evidence on their effects. Methods: Overview of reviews, based on a protocol. The search was carried out in six databases, screening was performed ensuring high interrater reliability. All countries, health professions and lay workers in all settings (except hospitals) were included, quality appraisals performed. Results: A total of 31 systematic reviews were included. Expanded roles performing outreach (e.g., home visits) had mostly positive effects on access and health outcomes, primarily for hard-to-reach groups. Task-shifting in colorectal or skin cancer screenings (performed by advanced practice nurses) were suggested effective; supporting roles (by community health workers) increased uptake in screenings, but based on limited evidence. Expanded roles of various professions focusing on lifestyle modification showed promising effects in most reviews, including weight, diet, smoking cessation and physical activity. Reviews on cost-effectiveness were based on limited evidence. Conclusion: Promising skill-mix changes included expanded roles providing lifestyle modifying interventions, task-shifting, and outreach roles for hard-to-reach groups, whereas evidence on costs was limited.
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Affiliation(s)
- Claudia Bettina Maier
- Department of Health Care Management, Faculty of Economics and Management, Technical University Berlin, Berlin, Germany
| | | | - Laura Pfirter
- Department of Health Care Management, Faculty of Economics and Management, Technical University Berlin, Berlin, Germany
| | - Gemma A. Williams
- European Observatory on Health Systems and Policies, London School of Economics and Political Science, London, United Kingdom
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Köppen J, Hartl K, Maier CB. Health workforce response to Covid-19: What pandemic preparedness planning and action at the federal and state levels in Germany?: Germany's health workforce responses to Covid-19. Int J Health Plann Manage 2021; 36:71-91. [PMID: 33735509 PMCID: PMC8250947 DOI: 10.1002/hpm.3146] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction The Covid‐19 pandemic has required countries to prepare their health workforce for a rapid increase of patients. This research aims to analyse the planning and health workforce policies in Germany, a country with a largely decentralised workforce governance mechanism. Methods Systematic search between 18 and 31 May 2020 at federal and 16 states on health workforce action and planning (websites of ministries of health, public health authorities), including pandemic preparedness plans and policies. The search followed World Health Organisation (WHO) Europe's health workforce guidance on Covid‐19. Content analysis was performed, informed by the themes of WHO. Results The pandemic preparedness plans consisted of no or limited information on how to expand and prepare the health workforce during pandemics. The 16 states varied considerably regarding implementing strategies to expand health workforce capacities. Only one state adopted a policy on task‐shifting despite a federal law on task‐shifting during pandemics. Conclusions Planning on the health workforce, its capacity and skill‐mix during pandemics was limited in the pandemic response plans. Actions during the peak of the pandemic varied considerably across states, were implemented ad hoc and with limited planning. Future action should focus on integrated planning and evaluation of workforce policies.
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Affiliation(s)
- Julia Köppen
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Kimberly Hartl
- Medical Department, Division of Gastroenterology and Hepatology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Max Delbrück Center for Molecular Medicine, Berlin Institute for Medical Systems Biology, Berlin, Germany
| | - Claudia B Maier
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
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Barnes E, Bullock A, Chestnutt IG, Cowpe J, Moons K, Warren W. Dental therapists in general dental practice. A literature review and case-study analysis to determine what works, why, how and in what circumstances. Eur J Dent Educ 2020; 24:109-120. [PMID: 31618492 DOI: 10.1111/eje.12474] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 10/08/2019] [Accepted: 10/14/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Emma Barnes
- Cardiff Unit for Research and Evaluation in Medical and Dental Education (CUREMeDE) Cardiff University, Cardiff, UK
| | - Alison Bullock
- Cardiff Unit for Research and Evaluation in Medical and Dental Education (CUREMeDE) Cardiff University, Cardiff, UK
| | - Ivor G Chestnutt
- College of Biomedical and Life Sciences, Cardiff University School of Dentistry, Cardiff, UK
| | - Jonathan Cowpe
- College of Biomedical and Life Sciences, Cardiff University School of Dentistry, Cardiff, UK
| | - Kirstie Moons
- The Dental Postgraduate Section, Health Education and Improvement Wales, Cardiff, UK
| | - Wendy Warren
- Aneurin Bevan University Health Board, Cardiff, UK
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Nelson PA, Bradley F, Martindale AM, McBride A, Hodgson D. Skill-mix change in general practice: a qualitative comparison of three 'new' non-medical roles in English primary care. Br J Gen Pract 2019; 69:e489-98. [PMID: 31160367 DOI: 10.3399/bjgp19X704117] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/20/2018] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND General practice is currently facing a significant workforce challenge. Changing the general practice skill mix by introducing new non-medical roles is recommended as one solution; the literature highlights that organisational and/or operational difficulties are associated with skill-mix changes. AIM To compare how three non-medical roles were being established in general practice, understand common implementation barriers, and identify measurable impacts or unintended consequences. DESIGN AND SETTING In-depth qualitative comparison of three role initiatives in general practices in one area of Greater Manchester, England; that is, advanced practitioner and physician associate training schemes, and a locally commissioned practice pharmacist service. METHOD Semi-structured interviews and focus groups with a purposive sample of stakeholders involved in the implementation of each role initiative were conducted. Template analysis enabled the production of pre-determined and researcher-generated codes, categories, and themes. RESULTS The final sample contained 38 stakeholders comprising training/service leads, role holders, and host practice staff. Three key themes captured participants' perspectives: purpose and place of new roles in general practice, involving unclear role definition and tension at professional boundaries; transition of new roles into general practice, involving risk management, closing training-practice gaps and managing expectations; and future of new roles in general practice, involving demonstrating impact and questions about sustainability. CONCLUSION This in-depth, in-context comparative study highlights that introducing new roles to general practice is not a simple process. Recognition of factors affecting the assimilation of roles may help to better align them with the goals of general practice and harness the commitment of individual practices to enable role sustainability.
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Havaei F, MacPhee M, Dahinten VS. The effect of nursing care delivery models on quality and safety outcomes of care: A cross-sectional survey study of medical-surgical nurses. J Adv Nurs 2019; 75:2144-2155. [PMID: 30883835 DOI: 10.1111/jan.13997] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/03/2019] [Accepted: 01/31/2019] [Indexed: 11/30/2022]
Abstract
AIMS This study examined the effect of two components of a model of nursing care delivery, the mode of nursing care delivery, and skill-mix on: (a) quality of nursing care; and (b) patient adverse events, after controlling for nurse demographics, work environment, and workload factors. DESIGN A cross-sectional exploratory correlational study that drew on secondary data was conducted. METHODS Survey data from 416 direct care registered nurses from medical-surgical settings across British Columbia were analysed using hierarchical multiple regression. Larger study data were collected in 2015. RESULTS Nurses working in a team-based mode reported a greater number of nursing tasks left undone compared with those working in a total patient care. Nurses working in a skill-mix with licensed practical nurses reported a higher frequency of patient adverse events compared with those working in a skill-mix without licensed practical nurses. At higher levels of acuity, nurses in a team-based mode reported a higher frequency of patient adverse events than did nurses in a total patient care. CONCLUSION Models of nursing care delivery components, mode and skill-mix, influenced quality and safety outcomes. Some of the team-based medical-surgical nurses in British Columbia are not functioning as effective teams. Team building strategies should be used to enhance collaboration among them. IMPACT Research into redesigning care delivery has typically focused on only one care delivery component at a time. The study findings could have implications for nurses and patients, nursing leadership and policymakers particularly in medical-surgical settings in British Columbia.
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Affiliation(s)
- Farinaz Havaei
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Maura MacPhee
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - V Susan Dahinten
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
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Hegney DG, Rees CS, Osseiran-Moisson R, Breen L, Eley R, Windsor C, Harvey C. Perceptions of nursing workloads and contributing factors, and their impact on implicit care rationing: A Queensland, Australia study. J Nurs Manag 2018; 27:371-380. [PMID: 30221436 DOI: 10.1111/jonm.12693] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 06/20/2018] [Accepted: 06/24/2018] [Indexed: 11/30/2022]
Abstract
AIMS To explore nurses' perceptions of factors affecting workloads and their impact on patient care. BACKGROUND Fiscal restraints and unpredictable patient illness trajectories challenge the provision of care. Cost containment affects the number of staff employed and the skill-mix for care provision. While organisations may acknowledge explicit rationing of care, implicit rationing takes place at the point of service as nurses are forced to make decisions about what care they can provide. METHOD A self-report cross sectional study was conducted using an on-line survey with 2,397 nurses in Queensland, Australia. RESULTS Twenty to forty per cent reported being unable to provide care in the time available; having insufficient staff; and an inadequate skill-mix. The respondents reported workload and skill-mix issues leading to implicit care rationing. Over 60% believed that the processes to address workload issues were inadequate. CONCLUSIONS Institutional influences on staffing levels and skill-mix are resulting in implicit care rationing. IMPLICATIONS FOR NURSE MANAGERS Adequate staffing should be based on patient acuity and the skill-mix required for safe care. Managers should be more assertive about adequate clinical workloads, involve staff in decision-making, and adopt a systematic planning approach. Failure to do so results in implicit care rationing impacting on patient safety.
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Affiliation(s)
- Desley Gail Hegney
- Research Division, Central Queensland University, Brisbane, Queensland, Australia.,School of Nursing and Midwifery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Clare Samantha Rees
- School of Psychology, Curtin University, Perth, Western Australia, Australia
| | - Rebecca Osseiran-Moisson
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Lauren Breen
- School of Psychology, Curtin University, Perth, Western Australia, Australia
| | - Robert Eley
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Carol Windsor
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Clare Harvey
- School of Nursing and Midwifery, Central Queensland University, Brisbane, Queensland, Australia
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Martínez-González NA, Djalali S, Tandjung R, Huber-Geismann F, Markun S, Wensing M, Rosemann T. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res 2014; 14:214. [PMID: 24884763 PMCID: PMC4065389 DOI: 10.1186/1472-6963-14-214] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 03/10/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND In many countries, substitution of physicians by nurses has become common due to the shortage of physicians and the need for high-quality, affordable care, especially for chronic and multi-morbid patients. We examined the evidence on the clinical effectiveness and care costs of physician-nurse substitution in primary care. METHODS We systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected and critically appraised published randomised controlled trials (RCTs) that compared nurse-led care with care by primary care physicians on patient satisfaction, Quality of Life (QoL), hospital admission, mortality and costs of healthcare. We assessed the individual study risk of bias, calculated the study-specific and pooled relative risks (RR) or standardised mean differences (SMD); and performed fixed-effects meta-analyses. RESULTS 24 RCTs (38,974 participants) and 2 economic studies met the inclusion criteria. Pooled analyses showed higher overall scores of patient satisfaction with nurse-led care (SMD 0.18, 95% CI 0.13 to 0.23), in RCTs of single contact or urgent care, short (less than 6 months) follow-up episodes and in small trials (N ≤ 200). Nurse-led care was effective at reducing the overall risk of hospital admission (RR 0.76, 95% CI 0.64 to 0.91), mortality (RR 0.89, 95% CI 0.84 to 0.96), in RCTs of on-going or non-urgent care, longer (at least 12 months) follow-up episodes and in larger (N > 200) RCTs. Higher quality RCTs (with better allocation concealment and less attrition) showed higher rates of hospital admissions and mortality with nurse-led care albeit less or not significant. The results seemed more consistent across nurse practitioners than with registered or licensed nurses. The effects of nurse-led care on QoL and costs were difficult to interpret due to heterogeneous outcome reporting, valuation of resources and the small number of studies. CONCLUSIONS The available evidence continues to be limited by the quality of the research considered. Nurse-led care seems to have a positive effect on patient satisfaction, hospital admission and mortality. This important finding should be confirmed and the determinants of this effect should be assessed in further, larger and more methodically rigorous research.
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Affiliation(s)
| | - Sima Djalali
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
| | - Ryan Tandjung
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
| | - Flore Huber-Geismann
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
| | - Stefan Markun
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
| | - Michel Wensing
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
- Scientific Institute for Quality in Healthcare, Radboud University Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, Netherlands
| | - Thomas Rosemann
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
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