Global health workforce strategies to address the COVID-19 pandemic: Learning lessons for the future

COVID-19 put unprecedented strain on the health and care workforce (HCWF). Yet, it also brought the HCWF to the forefront of the policy agenda and revealed many innovative solutions that can be built upon to overcome persistent workforce challenges. In this perspective, which draws on a Policy Brief prepared for the WHO Fifth Global Forum on Human Resources for Health, we present findings from a scoping review of global emergency workforce strategies implemented during the pandemic and consider what we can learn from them for the long-term sustainability of the HCWF. Our review shows that strategies to strengthen HCWF capacity during COVID-19 fell into three categories: (1) surging supply of health and care workers (HCWs); (2) optimizing the use of the workforce in terms of setting, skills and roles; and (3) providing HCWs with support and protection. While some initiatives were only short-term strategies, others have potential to be continued. COVID-19 demonstrated that changes to scope-of-practice and the introduction of team-based roles are possible and central to an effective, sustainable workforce. Additionally, the use of technology and digital tools increased rapidly during COVID-19 and can be built on to enhance access and efficiency. The pandemic also highlighted the importance of prioritizing the security, safety, and physical and mental health of workers, implementing measures that are gender and equity-focused, and ensuring the centrality of the worker perspective in efforts to improve HCWF retention. Flexibility of regulatory, financial, technical measures and quality assurance was critical in facilitating the implementation of HCWF strategies and needs to be continued. The lessons learned from COVID-19 can help countries strengthen the HCWF, health systems, and the health and well-being of all, now and in the future.

How Governor Directives Changed Health Workforce Flexibility in Response to the COVID-19 Pandemic

OBJECTIVES

In times of heightened population health needs, the health workforce must respond quickly and efficiently, especially at the state level. We examined state governors' executive orders related to 2 key health workforce flexibility issues, scope of practice (SOP) and licensing, in response to the COVID-19 pandemic.

METHODS

We conducted an in-depth document review of state governors' executive orders introduced in 2020 in all 50 states and the District of Columbia. We conducted a thematic content analysis of the executive order language using an inductive process and then categorized executive orders by profession (advanced practice registered nurses, physician assistants, and pharmacists) and degree of flexibility granted; for licensing, we indicated yes or no for easing or waiving cross-state regulatory barriers.

RESULTS

We identified executive orders in 36 states containing explicit directives addressing SOP or out-of-state licensing, with those in 20 states easing regulatory barriers pertaining to both workforce issues. Seventeen states issued executive orders expanding SOP for advanced practice nurses and physician assistants, most commonly by completely waiving physician practice agreements, while those in 9 states expanded pharmacist SOP. Executive orders in 31 states and the District of Columbia eased or waived out-of-state licensing regulatory barriers, usually for all health care professionals.

CONCLUSION

Governor directives issued through executive orders played an important role in expanding health workforce flexibility in the first year of the pandemic, especially in states with restrictive practice regulations prior to COVID-19. Future research should examine what effects these temporary flexibilities may have had on patient and practice outcomes or on permanent efforts to relax practice restrictions for health care professionals.

Variation in State Education Regulations for RNs

BACKGROUND

There is variation in nursing education quality, measured as first-time NCLEX (National Council Licensure Examination)-RN pass rates (FTPR), both across and within the United States. Current research examines program-level characteristics associated with performance.

METHOD

This study examines state-level policies and their relationship to FTPR (both associate and baccalaureate nursing degrees) to identify policies that enhance nursing program quality. Ordinary least squares regression analyses were conducted for state and program levels, and tests for interactions of variables were conducted between the two levels.

RESULTS

Accredited for-profit programs were associated with a 24% higher FTPR than nonaccredited for-profit programs. In addition, for-profit programs in more business-friendly states were associated with an 11.8% lower FTPR.

CONCLUSION

National standards for licensure pass rates, a mandate that all programs be accredited, and better enforcement could help improve the quality of RN programs nationwide. States with pro-business policies should be aware of the effect of their policies on the proliferation of for-profit schools. [J Nurs Educ. 2022;61(5):242-249.].

Advancing Social Mission Research: A Call to Action

Social mission efforts in health professions education are designed to advance health equity and address the health disparities of the society in which they exist. While there is growing evidence that social mission-related interventions are associated with intended outcomes such as practice in underserved communities, student diversity, and students graduating with skills and knowledge that prepare them to address societal needs, critical evidence gaps remain that limit the possibility of generalizing findings and using social mission strategically to advance health equity. At a time when COVID-19 has been laying bare health disparities related to systemic racism and maldistribution of resources, understanding how health professions training can produce the workforce needed to advance health equity becomes even more imperative. Yet, data and methods limitations are hindering progress in this critical research. The authors present an overview of the social mission research landscape; their review of the research led them to conclude that more rigorous research and data collection are needed to determine the link between social mission activities in health professions education and advances in health equity. To accelerate understanding of how health professions education and training can advance health equity, the authors propose a social mission research road map that includes (1) creating a social mission research community by consolidating stakeholders, (2) building a solid foundation for the research through development of a consensus-driven logic framework and research agenda, and (3) laying out the data and methodological needs that are imperative to strengthening the social mission evidence base and identifying opportunities to address these needs. Core to achieving these milestones is leadership from an organizing body that can serve as a hub for social mission research and engage stakeholder groups in building the evidence base for social mission strategies that will ultimately advance health equity.

The Use of Medical Scribes in Primary Care Settings: A Literature Synthesis

BACKGROUND

Clerical burdens have strained primary care providers already facing a shifting health care landscape and workforce shortages. These pressures may cause burnout and job dissatisfaction, with negative implications for patient care. Medical scribes, who perform real-time electronic health record documentation, have been posited as a solution to relieve clerical burdens, thus improving provider satisfaction and other outcomes.

OBJECTIVE

The purpose of this study is to identify and synthesize the published research on medical scribe utilization in primary care and safety net settings.

RESEARCH DESIGN

We conducted a review of the literature to identify outcomes studies published between 2010 and 2020 assessing medical scribe utilization in primary care settings. Searches were conducted in PubMed and supplemented by a review of the gray literature. Articles for inclusion were reviewed by the study authors and synthesized based on study characteristics, medical scribe tasks, and reported outcomes.

RESULTS

We identified 21 publications for inclusion, including 5 that examined scribes in health care safety net settings. Scribe utilization was consistently reported as being associated with improved productivity and efficiency, provider experience, and documentation quality. Findings for patient experience were mixed.

CONCLUSIONS

Published studies indicate scribe utilization in primary care may improve productivity, clinic and provider efficiencies, and provider experience without diminishing the patient experience. Further large-scale research is needed to validate the reliability of study findings and assess additional outcomes, including how scribes enhance providers' ability to advance health equity.

Yap regulates skeletal muscle fatty acid oxidation and adiposity in metabolic disease

Obesity is a major risk factor underlying the development of metabolic disease and a growing public health concern globally. Strategies to promote skeletal muscle metabolism can be effective to limit the progression of metabolic disease. Here, we demonstrate that the levels of the Hippo pathway transcriptional co-activator YAP are decreased in muscle biopsies from obese, insulin-resistant humans and mice. Targeted disruption of Yap in adult skeletal muscle resulted in incomplete oxidation of fatty acids and lipotoxicity. Integrated 'omics analysis from isolated adult muscle nuclei revealed that Yap regulates a transcriptional profile associated with metabolic substrate utilisation. In line with these findings, increasing Yap abundance in the striated muscle of obese (db/db) mice enhanced energy expenditure and attenuated adiposity. Our results demonstrate a vital role for Yap as a mediator of skeletal muscle metabolism. Strategies to enhance Yap activity in skeletal muscle warrant consideration as part of comprehensive approaches to treat metabolic disease.

1183Beta-Adrenoceptor activation increases cardiac galectin-3 levels via the hippo signaling pathway

Background

Galectin-3 (Gal-3) is a clinical biomarker for risk of cardiovascular disease and a disease mediator forming a therapeutic target. However, the mechanism(s) that regulate cardiac expression of Gal-3 remains unknown. Activation of the sympatho-β-adrenergic system is a hallmark of heart disease, but the relationship of βAR activation and cardiac content of Gal-3 remains unknown.

Purpose

To determine the role of βAR activation in regulating cardiac Gal-3 level and the responsible mechanism focusing on the Hippo signalling pathway.

Methods

Wild-type and Gal-3 gene deleted (Gal3-KO) mice were used. To test the role of the Hippo pathway, we used transgenic (TG) mouse strains with cardiac overexpression of mammalian-20-like sterile kinase 1 (Mst1, mammalian orthology of Drosophila Hippo kinase) either in wild-type form (TG-Mst1) or dominative-negative kinase dead mutant form (TG-dnMst1). Effects of β-antagonist (isoprenaline, ISO) and antagonists were determined. We measured phosphorylation (Ser127) of YAP as a transcription co-regulator acting as the main signal output of the Hippo pathway.

Results

In wild-type mice, treatment with ISO led to a time- and dose-dependent increase in cardiac expression of Gal-3 (Fig. A) accompanied by elevated circulating Gal-3 levels (Fig. B). ISO treatment stimulated cardiac expression of Mst1 and YAP hyper-phosphorylation (i.e. inactivation, Fig. C), indicating activation of the Hippo signalling. These effects of ISO were inhibited by β-blockers (propranolol, Prop; carvedilol, Carv; Fig. D,E). Relative to non-TG controls, ISO-induced expression of Gal-3 was inhibited by 75% in TG-dnMst1 mice (inactivated Mst1), but exaggerated by 7-fold in TG-Mst1 mice (activated Mst1). Mst1-TG mice had a 45-fold increase in Gal-3 content, YAP hyper-phosphorylation and enhanced pro-fibrotic signaling. In Mst1-TG mice, whilst blood Gal-3 level was unchanged, treatment with ISO (6 mg, 2 days) evoked a marked increase in cardiac and blood Gal-3 levels. Using rat cardiomyoblasts, we showed that ISO-mediated Mst1 expression and YAP phosphorylation were PKA-dependent and that siRNA-mediated YAP knockdown led to Gal-3 upregulation. The role of Gal-3 in mediating ISO-induced cardiomyopathy was examined by treating wild-type and Gal3-KO mice with ISO (30 mg/kg, 7 days). ISO-treated wild-type mice had 8-fold increase in cardiac Gal-3, ventricular dysfunction, fibrosis, hypertrophy and activated inflammatory or fibrotic signalling. All these changes, except hypertrophy, were abolished by Gal3-KO.

beta-AR regulates galectin-3

Conclusion

βAR stimulation increases cardiac expression of Gal-3 through activation of the Hippo signalling pathway. This is accompanied by elevated circulating Gal-3 level. βAR antagonists inhibited βAR-Mst1 (Hippo) signalling and cardiac Gal-3 expression, actions likely contributing to the overall efficacy of β-blockers.

Acknowledgement/Funding

NHMRC of Australia; Nature Science Fund of China

Anti-HLA alloantibodies of the IgA isotype in re-transplant candidates part II: Correlation with graft survival

We reported previously on the widespread occurrence of anti-HLA alloantibodies of the IgA isotype (anti-HLA IgA) in the sera of solid-organ re-transplantation (re-tx) candidates (Arnold et al., ). Specifically focussing on kidney re-tx patients, we now extended our earlier findings by examining the impact of the presence and donor specificity of anti-HLA IgA on graft survival. We observed frequent concurrence of anti-HLA IgA and anti-HLA IgG in 27% of our multicenter collective of 694 kidney re-tx patients. This subgroup displayed significantly reduced graft survival as evidenced by the median time to first dialysis after transplantation (TTD 77 months) compared to patients carrying either anti-HLA IgG or IgA (TTD 102 and 94 months, respectively). In addition, donor specificity of anti-HLA IgA had a significant negative impact on graft survival (TTD 74 months) in our study. Taken together, our data strongly indicate that presence of anti-HLA IgA, in particular in conjunction with anti-HLA-IgG, in sera of kidney re-tx patients is associated with negative transplantation outcome.

Successes and Challenges in School Meal Reform: Qualitative Insights From Food Service Directors

BACKGROUND

The Healthy, Hunger-Free Kids Act of 2010 (HHFKA) directed the US Department of Agriculture (USDA) to revise school meal standards to increase healthy food offerings. A critical stakeholder in the implementation of standards is Food Service Directors (FSDs). We sought to examine FSDs' perspectives on revised school meal standards to gain insight into successful implementation strategies.

METHODS

Semistructured interviews were conducted with FSDs (N = 9) from high schools that had achieved HealthierUS Schools Challenge: Smarter Lunchrooms (HUSSC: SL) status. Qualitative interview data were team coded in Atlas.ti v7 and analyzed with principles of constant comparative analysis.

RESULTS

FSDs reported overall positive perceptions of the revised school meal standards and its potential impacts, as well as improved fruit and vegetable consumption, despite initial challenges with plate waste, procurement of whole grain-rich products, and fast paced sodium targets. Implementation was described as complex, ongoing processes; with time and in-service trainings, student acceptance to these changes improved.

CONCLUSIONS

These findings are directly relevant to future reauthorization of the Child Nutrition Act and to revisions to the implementation time line for the federal school meal standards related to sodium, whole grains, and flavored milk. Insights into FSDs' strategies suggest that more time and targeted technical assistance at federal, state, and local levels is warranted.

Transfusion-transmitted CMV infection - current knowledge and future perspectives

Transmission of human cytomegalovirus (CMV) via transfusion (TT-CMV) may still occur and remains a challenge in the treatment of immunocompromised CMV-seronegative patients, e.g. after stem cell transplantation, and for low birthweight infants. Measures to reduce the risk of TT-CMV have been evaluated in clinical studies, including leucocyte depletion of cellular blood products and/or the selection of CMV-IgG-negative donations. Studies in large blood donor cohorts indicate that donations from newly CMV-IgG-positive donors should bear the highest risk for transmitting CMV infections because they contain the highest levels of CMV-DNA, and early CMV antibodies cannot neutralise CMV. Based on this knowledge, rational strategies to reduce the residual risk of TT-CMV using leucoreduced blood products could be designed. However, there is a lack of evidence that CMV is still transmitted by transfusion of leucoreduced units. In low birthweight infants, most (if not all) CMV infections are caused by breast milk feeding or congenital transmission rather than by transfusion of leucoreduced blood products. For other patients at risk, no definitive data exist about the relative importance of alternative transmission routes of CMV compared to blood transfusion. As a result, only the conduction of well-designed studies addressing strategies to prevent TT-CMV and the thorough examination of presumed cases of TT-CMV will achieve guidance for the best transfusion regimen in patients at risk.

16(th) IHIW: anti-HLA alloantibodies of the of IgA isotype in re-transplant candidates

In this multicentre study, sera from 803 retransplant candidates, including 775 kidney transplant recipients, were analysed with regard to the presence and specificity of anti-HLA alloantibodies of the IgA isotype using a modified microsphere-based platform. Of the kidney recipients, nearly one-third (n = 237, 31%) had IgA alloantibodies. Mostly, these antibodies were found in sera that also harboured IgG alloantibodies that could be found in a total of 572 (74%) of patients. Interestingly, IgA anti-HLA antibodies were preferentially targeting HLA class I antigens in contrast to those of the IgG isotype, which targeted mostly both HLA class I and II antigens. Donor specificity of the IgA alloantibodies could be established for over half of the 237 patients with IgA alloantibodies (n = 124, 52%). A further 58 patients had specificities against HLA-C or HLA-DP, for which no information regarding donor typing was available. In summary, these data showed in a large cohort of retransplant candidates that IgA alloantibodies occur in about one-third of patients, about half of these antibodies being donor specific.

The natural course of primary cytomegalovirus infection in blood donors

BACKGROUND AND OBJECTIVES

As cytomegalovirus (CMV) DNA is frequently detectable in the plasma of recently infected sero-positive blood donors, information concerning primary CMV infection is important for the identification of possibly infectious donors.

MATERIALS AND METHODS

Monitoring of 17 982 donors for CMV antibodies and DNA in plasma identified 14 subjects with ongoing primary CMV infection. Thirteen donors were interrogated for possible sources of infection and CMV-related symptoms, and monitored for CMV antigens, CMV DNA in plasma, leucocytes and urine, course of IgG and IgM antibodies as well as markers of systemic infection and parameters of organ function.

RESULTS

CMV antigens and DNA were detectable in peripheral blood for up to 54 and 269 days respectively. Clearance of CMV DNA from blood correlated with clearance of IgM antibodies, development of IgG antibodies against the membrane glycoprotein gB and development of high avidity IgG antibodies. Eighty-five percent of subjects with primary CMV infection, but even 69% of matched controls reported possibly CMV-related symptoms. Sixty-two and 23%, respectively, had contact with possible sources of infection. One donor developed a febrile illness accompanied by increased levels of CMV DNA in peripheral blood 2 to 3 weeks after seroconversion. In other donors, neither markers of systemic infection nor parameters of organ function correlated with the course of CMV DNA and antigens.

CONCLUSION

Potentially infectious donors can be identified by measuring CMV DNA, IgM antibodies or avidity of IgG antibodies. Alternatively, blood products donated during the first year after seroconversion should not be used for immunocompromised patients.

Origin and diversification of land plant CC-type glutaredoxins

Glutaredoxins (GRXs) are ubiquitous glutathione-dependent oxidoreductase enzymes implicated in redox homeostasis, particularly oxidative stress response. Three major classes of GRX genes exist, the CPYC, CGFS classes are present in all pro- and eukaryote species, whereas the CC-type class GRXs are specific to land plants. In the basal land plant Physcomitrella patens, only two CC-type GRXs are present, compared with 21 in Arabidopsis. In contrast, sizes of the CPYC and CGFS classes remained rather similar throughout plant evolution, raising the interesting question as to when the CC-type GRXs first originated and how and why they expanded during land plant evolution. Recent evidence suggests that CC-type GRXs may have been recruited during evolution into diverse plant-specific functions of flower development (ROXY1, ROXY2) and pathogenesis response (ROXY19/GRX480). In the present study, GRX genes from the genomes of a range of green algae and evolutionarily diverse land plant species were identified; Ostreococcus, Micromonas, Volvox, Selaginella, Vitis, Sorghum, and Brachypodium. Previously identified sequences from Chlamydomonas, Physcomitrella, Oryza, Arabidopsis, and Populus were integrated to generate a more comprehensive understanding of the forces behind the evolution of various GRX classes. The analysis indicates that the CC-type GRXs probably arose by diversification from the CPYC class, at a time coinciding with colonization of land by plants. This strong differential expansion of the CC-type class occurred exclusively in the angiosperms, mainly through paleopolyploidy duplication events shortly after the monocot–eudicot split, and more recently through multiple tandem duplications that occurred independently in five investigated angiosperm lineages. The presented data suggest that following duplications, subfunctionalization, and subsequent neofunctionalization likely facilitated the sequestration of land plant-specific CC-type GRXs into novel functions such as development and pathogenesis response.

Updated audit database for breast imaging/histopathology correlation

AIM

To develop, test and validate an audit database, evolved from a prior, peer-reviewed, audit tool for symptomatic multi-modality breast imaging services.

MATERIALS AND METHODS

The database is to cover all aspects of non-invasive breast imaging and recognize subspeciality inputs. When more than one imaging investigation is used for diagnosis, an overall breast imaging audit grade is to be introduced. Data derived from clinical studies has been input into the new database.

RESULTS

Results for mammography alone are virtually identical to those of the previous program. A slight increase in accuracy is suggested by using more investigations if the first investigation is not conclusive. More comprehensive reports can be issued.

CONCLUSION

The audit program can be used in the same context as the old audit. If mammography is the sole investigation, there is no change from the previous standards of a minimum mammography (ultrasound)/histopathology agreement of 70%, an equivocal rate of less than 15%, a false-positive rate of less than 7.5% and a false-negative rate of less than 6.5%. Although there is no statistical difference when more than one imaging investigation is used, there is some marginal improvement. It is suggested that initial audit standards for multi-imaging should be 75% for minimum agreement, a 10% maximum for an equivocal rate, a 5% maximum for false negative and an unchanged false positive rate of 7.5% maximum. These standards will be refined with experience. Due to the nature of the database, complex queries can be made including those about histopathological data. If widely used, the database will be a useful tool to audit the accuracy of symptomatic breast imaging services and types and frequencies of symptomatic breast disease, as seen in routine settings.

Methodological and analytical aspects of simple methods for measuring iodine in urine. Comparison with HPLC and Technicon Autoanalyzer II

This work describes an optimization of a simple photometric determination of iodine concentrations in urine using a modified ceric arsenite method with ammonium persulfate as oxidant. By means of this sensitive method iodine concentrations can be determined in very small specimens (50 microL). Urine samples (105) collected from a mixed population, were analyzed for urine iodine content by the optimized ammonium persulfate method, a Technicon Autoanalyzer II and a paired-ion-RP HPLC. We found that the precision of this optimized ammonium persulfate method yields inter assay CVs of <10% for urinary iodine concentrations >10 microg/dL. Recovery of [123I]iodide added to urine in vitro was 100.9 +/- 2.4%. The detection limit was 0.0029 microg iodine. There was a high correlation between all three methods (r > 0.94 in any case) and the interpretation of the results was consistent. We conclude that this simple, manual ammonium persulfate method is suitable for urinary iodine analysis and can be performed in any routine clinical laboratory.