Overview of Retention Strategies for Medical Doctors in Low- and Middle-Income Countries and Their Effectiveness: Protocol for a Scoping Review

BACKGROUND

The global shortage and maldistribution of health care workers, especially medical doctors, pose a significant threat to achieving the United Nations' sustainable development goal 3 of ensuring well-being and healthy lives for all. Low- and middle-income countries (LMICs) are disproportionately affected by this crisis, with a high rate of brain drain from rural to urban areas, as well as to high-income countries. Various retention strategies have been implemented in different settings and organizations. However, their effectiveness remains underexplored, particularly in LMICs.

OBJECTIVE

We aim to review the available retention strategies for medical doctors in LMICs and to determine the effectiveness of the various strategies. This review aims to compile relevant research findings on this issue to generate a thorough summary of all the retention strategies practiced in LMICs and, more importantly, to provide the current state of evidence of the effectiveness of these strategies in retaining medical doctors in countries with limited resources and high disease burden.

METHODS

The structured framework given by Arksey and O'Malley will serve as the basis for conducting this scoping review. A comprehensive search strategy will be conducted across 4 electronic databases (PubMed, EBSCOHost, Scopus, and ScienceDirect). A systematic approach following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines will be executed to search, screen, review, and extract data from studies that meet predefined inclusion criteria. Data encompassing bibliographical information, study location, retention strategies, influencing factors, and outcomes (effectiveness) will be obtained from the selected studies using standardized data extraction. Endnote and Microsoft Excel will be used for reference management and removal of duplicate studies. A narrative synthesis will be performed after categorizing and analyzing all the extracted data to identify recurrent themes.

RESULTS

This ongoing review will generate a comprehensive compilation of retention strategies implemented in LMICs to prevent brain drain among medical doctors. Data extraction is currently in progress, and completion is expected by early 2024. Themes regarding the types of strategies, influencing factors, and outcomes will be synthesized. The findings will highlight effective retention strategies, gaps, and challenges in implementation for the benefits of future research. By identifying common barriers and facilitators, this review will provide insights into enhancing the policies and initiatives for doctor retention in LMICs.

CONCLUSIONS

This scoping review explores the retention strategies practiced in LMICs and attempts to identify effective strategies from existing research. By evaluating the barriers and challenges that influence the effectiveness of these strategies, policymakers and health care leaders can strive to obtain balanced and optimal health human resources in their respective organizations and countries.

TRIAL REGISTRATION

Malaysian National Medical Research Register (NMRR) ID-23-01994-OGW; https://nmrr.gov.my/research-directory/ac4f5b88-8619-4b2b-b6c7-9abcef65fdcd.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52938.

The gender wage gap among health care workers across educational and occupational groups

Women perform 77% of health care jobs in the United States, but gender inequity within the health care sector harms women's compensation and advancement in health care jobs. Using data from 2003 to 2021 of the Annual Social and Economic Supplement of the Current Population Survey (CPS), we measured women's representation and the gender wage gap in health care jobs by educational level and occupational category. We found, descriptively, that women's representation in health care occupations has increased over time in occupations that require a master's or doctoral/professional degree (eg, physicians, therapists), while men's representation has increased slightly in nursing occupations (eg, registered nurses, LPNs/LVNs, aides, and assistants). The adjusted wage gap between women and men is the largest among workers in high-education health care (eg, physicians, advanced practitioners) but has decreased substantially over the last 20 years, while, descriptively, the gender wage gap has stagnated or grown larger in some lower education occupations. Our policy recommendations include gender equity reviews within health care organizations, prioritizing women managers, and realigning Medicare and Medicaid reimbursement policies to promote greater gender equity within and across health care occupations.

Earnings, job satisfaction, and turnover of nurse practitioners across employment settings

Nurse practitioners (NPs) are an important part of the health care workforce. However, little information is available on NP earnings, job satisfaction, or turnover. National survey data from 2018 offer a pre-COVID-19 baseline for ongoing NP workforce monitoring. We found evidence that NPs earned approximately $92 500 annually, ranging from $82 800 in long-term care to $95 600 in hospital settings. Wages increased with tenure in the workforce and varied considerably by geography. Approximately 1 in 5 NPs switched jobs annually, with some net in-flow to ambulatory settings. Both NPs who left their position or considered leaving reported better pay and benefits, burnout, management role, stressful work environment, career advancement, and inadequate staffing as the primary explanations. These findings were augmented by analysis of 2012-2022 Bureau of Labor Statistics data that illustrated substantial growth in the NP workforce. Improving NP job satisfaction has the direct benefit of supporting a critical and growing segment of the health workforce; it has the additional benefit of reducing job turnover and the associated costs, potentially increasing earnings for NPs. Policies that improve working conditions for NPs in different employment settings will not just increase immediate job satisfaction but also ideally strengthen the longer-term labor market to improve patient outcomes.

Transforming Medical Education to Provide Gender-Affirming Care for Transgender and Gender-Diverse Patients: A Policy Brief

Transgender and gender-diverse (TGD) patients experience a greater burden of health disparities compared with their heterosexual/cisgender counterparts. Some of the poorer health outcomes observed in these populations are known to be associated with the prevalence of implicit bias, bullying, emotional distress, alcoholism, drug abuse, intimate partner violence, sexually transmitted infections (eg, human immunodeficiency virus and human papilloma virus), and cancer. The TGD populations face unique barriers to receiving both routine and gender-affirming health care (acquiring hormones and gender-affirming surgeries). Additional barriers to implementing affirming care training for TGD patients are lack of expertise among medical education faculty and preceptors both in undergraduate and in graduate medical education programs. Drawing on a systematic review of the literature, we propose a policy brief aimed at raising awareness about gender-affirming care among education planners and policy makers in government and advisory bodies.

Local Area Hospice Capacity and Rural Disparities in Hospice Use among Older Adults with Metastatic Breast Cancer

Background: Little is known about how local area hospice capacity and staffing levels impact hospice use in urban versus rural areas. Objectives: To examine the association between local hospice capacity and staffing levels and hospice use in the context of rural disparities in hospice use, among a sample of patients with metastatic breast cancer. Design: A retrospective cohort study using Surveillance Epidemiology End-Results (SEER)-Medicare linked data 2000-2010, Medicare Provider of Service files, and Census 2000 U.S. Zip Code Tabulation Areas files. Setting: Use of Medicare-certified hospice programs among older adults with metastatic breast cancer residing in one of the SEER program cancer registries designated by National Cancer Institute in the United States. Measurements: Measurements of geographic access to hospices include urban/rural characteristics of patient residence and driving time from the nearest Medicare-certified hospice headquarter. Measurements of local-area hospice capacity and staffing levels include per capita number of Medicare-certified hospice programs and full-time employees among older adults within a predefined radius. Results: Among the study population (N = 5418), remote and suburban areas were negatively associated with hospice use. Lower hospice use in remote and suburban areas was associated with fewer per capita number of Medicare-certified hospice program employees in local areas ≥70-minute driving radius (p = 0.0042), while per capita number of Medicare-certified hospice programs in local areas showed no impact. Conclusion: For older patients with metastatic breast cancer, availability of hospice staff, rather than driving distance or the number of hospice agencies, may limit hospice use in remote and suburban areas.

Lessons From the Northeast COVID-19 Surge: Well-Being of the Health Care Workforce

The COVID-19 pandemic has had an unprecedented impact on the US health care system which was already experiencing higher levels of personal burnout among health care workers than the average US worker. Well-being efforts to support the workforce have become a critical countermeasure during the pandemic. This work was presented at the Thomas Jefferson University, College of Population Health Seminar Series: Clinical Lessons from the Northeast Surge, COVID-19: Spread the Science, not the Virus, held August 18, 2020. The entire series was held virtually from July 21 to September 29, 2020. The authors describe issues impacting health care workers during this early period of the pandemic with two examples of concrete strategies to approach well-being at the organizational level and lessons learned.

The effect of nursing home closure on local employment in the United States

OBJECTIVE

To estimate the effect of nursing home closure on local employment, overall, and by rurality.

DATA SOURCES AND STUDY SETTING

We obtained 2008-2018 county-level data from the Quarterly Workforce Indicators, Medicare Provider of Services, Area Health Resource, and Urban Influence Codes files. From 2008 to 2018, 878 counties experienced at least one nursing home closure, and 2055 counties did not experience a closure.

STUDY DESIGN

Using a difference-in-difference study design, we compare the changes of total employment, health sector employment and non-health sector employment over time between counties with and without a nursing home closure. We utilize the variation in the year and quarter of nursing home closures to estimate subsequent employment changes as well as employment trends before closure. We also account for contemporaneous events including nursing home entries and hospital entries and closures, and evaluate heterogeneity by rurality.

DATA EXTRACTION

We include data on nursing home closure from the Medicare Provider of Service file. Quarterly county-level employee counts were obtained from the Quarterly Workforce Indicators provided by the Census Bureau. County-level demographic data were obtained from the Area Health Resource Files. We use Urban Influence Codes from the Economic Research Service, Department of Agriculture, to classify metropolitan, micropolitan, and rural (noncore) counties.

PRINCIPAL FINDINGS

Health sector employment decreased by about 3.2%-4.1% (p < 0.01) in counties with a nursing home closure. The reduction was largest in rural counties (approximately 7.2%-9.4%, p < 0.01). The reduction in health sector employment persisted over time, particularly in rural counties. Overall, there was no discernable effect on non-health sector employment.

CONCLUSIONS

Nursing home closure is associated with a persistent decline in health sector employment, particularly in rural counties, suggesting a reduction in the health care workforce and in the ability to sustain health care services supply, particularly in rural areas.

Prepandemic Mental Health and Well-being: Differences Within the Health Care Workforce and the Need for Targeted Resources

BACKGROUND

Occupational stress and diminished well-being among health care workers were concerning even before the coronavirus disease 2019 pandemic exacerbated existing stressors and created new challenges for this workforce. Research on the mental health of health care workers has focused on physicians and nurses, with less attention to other occupations.

METHODS

To assess pre-coronavirus disease mental health and well-being among workers in multiple health care occupations, we used 2017 to 2019 data from the Behavioral Risk Factor Surveillance System.

RESULTS

Across the health care workforce, insufficient sleep (41.0%) and diagnosed depression (18.9%) were the most common conditions reported. Counselors had the highest prevalence of diagnosed depression. Health care support workers had elevated prevalences for most adverse health conditions.

CONCLUSIONS

Ensuring a robust health care workforce necessitates identifying and implementing effective occupation-specific prevention, intervention, and mitigation strategies that address organizational and personal conditions adversely affecting mental health.

Toward a Uniform Classification of Nurse Practitioner Scope of Practice Laws

Many states' scope of practice laws limits the ability of nurse practitioners to deliver care by requiring physician supervision of their practices and prescribing activities. A robust literature has evolved around examining the role of these scope of practice laws in various contexts, including labor market outcomes, health care access, health care prices, and the delivery of care for specific diseases. Unfortunately, these studies use different, and sometimes conflicting, measures of scope of practice laws, limiting their comparability and overall usefulness to policymakers and future researchers. We address this salient problem by providing a recommended coding of nurse practitioner scope of practice laws over a 24-year period based on actual statutory and regulatory language. Our classification of scope of practice laws solves an important problem within this growing literature and provides a solid legal foundation for researchers as they continue to investigate the effects of these laws.

The Affordable Care Act Medicaid Expansion, Social Disadvantage, and the Practice Location Choices of New General Internists

BACKGROUND

A recent study found that states that expanded Medicaid under the Affordable Care Act (ACA) gained new general internists who were establishing their first practices, whereas nonexpansion states lost them.

OBJECTIVE

The objective of this study was to examine the level of social disadvantage of the areas of expansion states that gained new physicians and the areas of nonexpansion states that lost them.

RESEARCH DESIGN

We used American Community Survey data to classify commuting zones as high, medium, or low social disadvantage. Using 2009-2019 data from the AMA Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following the expansion to where they located during the 5 years preceding the expansion.

SUBJECTS

A total of 32,102 new general internists.

RESULTS

Compared with preexpansion patterns, new general internists were more likely to locate in expansion states after the expansion, a finding that held for high, medium, and low disadvantage areas. We estimated that, between 2014 and 2019, nonexpansion states lost 371 new general internists (95% confidence interval, 203-540) to expansion states. However, 62.5% of the physicians lost by nonexpansion states were lost from high disadvantage areas even though these areas only accounted for 17.9% of the population of nonexpansion states.

CONCLUSIONS

States that opted not to expand Medicaid lost new general internists to expansion states. A highly disproportionate share of the physicians lost by nonexpansion states were lost from high disadvantage areas, potentially compromising access for all residents irrespective of insurance coverage.

Vertical Integration and Physician Practice Labor Composition

With the growth of vertical integration among physician practices (i.e., hospital-physician integration), there have been many studies of its effects on health care treatments and spending. It is unknown if integration shapes provider configurations, especially against the backdrop of increasing employment of nurse practitioners (NPs) and physician assistants (PAs) across specialties. Using a longitudinal panel of 144,289 practices (2008-2015), we examined the association of vertical integration with NP and PA employment. We find positive associations between vertical integration and newly employing NPs and PAs within physician practices; however, the relationships differ by practice specialty type as well as timing of vertical integration. Supplementary analyses offer supporting evidence for coinciding enhancements to practice productivity, diversification, and provider task allocation. Our results suggest that vertical integration may promote interdisciplinary provider configurations, which has the potential to improve care delivery efficiency.

Career Ladders for Medical Assistants in Primary Care Clinics

BACKGROUND

This study examines the use of career ladders for medical assistants (MAs) in primary care practices as a mechanism for increasing wages and career opportunity for MAs. A growing body of research on primary care suggests that successful expansion of support staff roles such as MAs may have positive organizational and quality of care outcomes, but little is known about worker outcomes.

OBJECTIVE

Evaluate the effectiveness of career ladders in improving wages and career opportunity among MAs.

DESIGN

We use a mixed-methods design to evaluate the impact of career ladders on MA job quality.

PARTICIPANTS

We draw on interview data collected from 115 key informants at four large health systems (ranging from 24 to 29 clinics each), and we analyze wage and employment data for MAs from primary care clinics in the four health systems in the sample.

APPROACH

We describe the MA career ladder context and infrastructure within primary care clinics and evaluate the rewards to MAs for participation in the career ladder programs.

KEY RESULTS

The expanded roles within career ladders for MAs focused on the following four clinical and educational areas: panel management and care coordination, EHR documentation support, supporting delivery of person-centered care, and supervision and training. The three primary components of the career ladder infrastructure were training and education for MAs and providers, credentialing and certification for MAs, and differentiated job levels for MAs. The use of career ladders in the four large health systems in our case study sample resulted in yearly income increases ranging from $3000 to $10,000 annually.

CONCLUSION

Investing in career ladders in primary care clinics can improve MA job quality while also potentially addressing issues of equity, efficiency, and quality in the health care sector.

Health Care Policy and Congenital Heart Disease: 2020 Focus on Our 2030 Future

The congenital heart care community faces a myriad of public health issues that act as barriers toward optimum patient outcomes. In this article, we attempt to define advocacy and policy initiatives meant to spotlight and potentially address these challenges. Issues are organized into the following 3 key facets of our community: patient population, health care delivery, and workforce. We discuss the social determinants of health and health care disparities that affect patients in the community that require the attention of policy makers. Furthermore, we highlight the many needs of the growing adults with congenital heart disease and those with comorbidities, highlighting concerns regarding the inequities in access to cardiac care and the need for multidisciplinary care. We also recognize the problems of transparency in outcomes reporting and the promising application of telehealth. Finally, we highlight the training of providers, measures of productivity, diversity in the workforce, and the importance of patient-family centered organizations in advocating for patients. Although all of these issues remain relevant to many subspecialties in medicine, this article attempts to illustrate the unique needs of this population and highlight ways in which to work together to address important opportunities for change in the cardiac care community and beyond. This article provides a framework for policy and advocacy efforts for the next decade.

Applying the Ottawa Charter to guide resilience-building programs for health care organizations

Resilience is situated at the core of the World Health Organization European policy framework for health and well-being and the United Nations Sustainable Development Goals. Resilience refers to how effectively a person, group, or system deals with and recovers from challenging situations. In this paper resilience refers to the capacity of a health care professional to manage complex issues and adapt to situations successfully. This brief paper provides explicit knowledge for strengthening personal resilience in health care using the Ottawa Charter framework as a guide. Developing a resilient health care workforce should address all five Ottawa Charter areas of action, should involve multiple stakeholders, and should incorporate resilience strategies into everyday health care activities. The paper presents recommendations for future programs designed to build a resilient workforce that can provide high quality care in a sustainable manner.

Effects of the Affordable Care Act Medicaid Expansion on the Distribution of New General Internists Across States

BACKGROUND

Some states expanded Medicaid under the Affordable Care Act, boosting their low-income residents' demand for health care, while other states opted not to expand.

OBJECTIVE

The objective of this study was to determine whether the Medicaid expansion influenced the states selected by physicians just completing graduate medical education for establishing their first practices.

RESEARCH DESIGN

Using 2009-2019 data from the American Medical Association Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following implementation of the expansion to where they located during the 5 years preceding implementation.

SUBJECTS

The sample consisted of 160,842 physicians in 8 specialty groups.

RESULTS

Thirty-three states and the District of Columbia expanded Medicaid by the end of the study period. Compared with preexpansion patterns, we found that physicians in one specialty group-general internal medicine-were increasingly likely to locate in expansion states with time after the expansion. The Medicaid expansion influenced the practice location choices of men and international medical graduates in general internal medicine; women and United States medical graduates did not alter their preexpansion location patterns. Simulations estimated that, between 2014 and 2019, nonexpansion states lost 310 general internists (95% confidence interval, 156-464) to expansion states.

CONCLUSIONS

The Medicaid expansion influenced the practice location choices of new general internists. States that opted not to expand Medicaid under the Affordable Care Act lost general internists to expansion states, potentially affecting access to care for all their residents irrespective of insurance coverage.

Realizing the vision of the Lancet Commission on Education of Health Professionals for the 21st Century: Transforming medical education through the Accelerating Change in Medical Education Consortium

In the last two decades, prompted by the anticipated arrival of the 21st Century and on the centenary of the publication of the Flexner Report, many in medical education called for change to address the expanding chasm between the requirements of the health care system and the educational systems producing the health care workforce. Calls were uniform. Curricular content was missing. There was a mismatch in where people trained and where they were needed to practice, legacy approaches to pedagogical methods that needed to be challenged, an imbalance in diversity of trainees, and a lack of research on educational outcomes, resulting in a workforce that was described as ill-equipped to provide health care in the current and future environment. The Lancet Commission on Education of Health Professionals for the 21st Century published a widely acclaimed report in 2010 that called for a complete and authoritative re-examination of health professional education. This paper describes the innovations of the American Medical Association Accelerating Change in Medical Education Consortium schools as they relate to the recommendations of the Lancet Commission. We outline the successes, challenges, and lessons learned in working to deeply reform medical education.

Factors contributing to the distress, concerns, and needs of UK Neuroscience health care workers during the COVID-19 pandemic

COVID-19 research from China suggests health care workers are at risk of distress, have specific concerns, and need support. It remains unknown whether findings are applicable to UK health care staff and whether psychological support based on generic approaches is effective. We administered an online survey at a leading neuroscience hospital in the UK to examine how individual staff characteristics contribute to distress, concerns, and interventions most valued during the COVID-19 pandemic. We found a high incidence of distress, particularly in females and staff with previous mental health history. Concerns fell into three factors: 'risk of infection', 'work challenges', and 'social change', and were affected by professional role and contact with COVID-19 patients. These three factors predicted distress. Psychological support and clear updates were deemed most useful, with specific needs affected by age, professional role, and contact with COVID-19 patients. This is the first documentation of a high incidence of psychological distress predicted by three types of concerns in health care workers of a neuroscience hospital. Distress, concerns, and interventions most valued were all affected by individual staff characteristics. These findings highlight the importance of providing stratified, one to one support interventions, tailored to professional group, and background, rather than more generic approaches. PRACTITIONER POINTS: The COVID-19 pandemic has resulted in a high incidence of psychological distress in UK health care staff. Distress, concerns, and interventions most valued are influenced by individual staff characteristics. Stratified, one-to-one support interventions, tailored to professional group, and background, rather than more generic approaches for stress reduction and resilience, are crucial.

Racial and Ethnic Diversity in the Nursing Workforce: A Focus on Maternity Care

Racial and ethnic inequities in health are a national crisis requiring engagement across a range of factors, including the health care workforce. Racial inequities in maternal and infant health are an increasing focus of attention in the wake of rising rates of maternal morbidity and mortality in the United States. Efforts to achieve racial equity in childbirth should include attention to the nurses who provide care before and during pregnancy, at childbirth, and postpartum.

Characteristics of Nursing Homes by COVID-19 Cases Among Staff: March to August 2020

Objective

To measure the association between nursing home (NH) characteristics and Coronavirus Disease 2019 (COVID-19) prevalence among NH staff.

Design

Retrospective cross-sectional study.

Setting and Participants

Centers for Disease Control and Prevention COVID-19 database for US NHs between March and August 2020, linked to NH facility characteristics (LTCFocus database) and local COVID-19 prevalence (USA Facts).

Methods

We estimated the associations between NH characteristics, local infection rates, and other regional characteristics and COVID-19 cases among NH staff (nursing staff, clinical staff, aides, and other facility personnel) measured per 100 beds, controlling for the hospital referral regions in which NHs were located to account for local infection control practices and other unobserved characteristics.

Results

Of the 11,858 NHs in our sample, 78.6% reported at least 1 staff case of COVID-19. After accounting for local COVID-19 prevalence, NHs in the highest quartile of confirmed resident cases (413.5 to 920.0 cases per 1000 residents) reported 18.9 more staff cases per 100 beds compared with NHs that had no resident cases. Large NHs (150 or more beds) reported 2.6 fewer staff cases per 100 beds compared with small NHs (<50 beds) and for-profit NHs reported 0.8 fewer staff cases per 100 beds compared with nonprofit NHs. Higher occupancy and more direct-care hours per day were associated with more staff cases (0.4 more cases per 100 beds for a 10% increase in occupancy, and 0.7 more cases per 100 beds for an increase in direct-care staffing of 1 hour per resident day, respectively). Estimates associated with resident demographics, payer mix, or regional socioeconomic characteristics were not statistically significant.

Conclusions and Implications

These findings highlight the urgent need to support facilities with emergency resources such as back-up staff and protocols to reduce resident density within the facility, which may help stem outbreaks.

Using Dental Health Care Personnel During a Crisis : COVID-19 Pandemic in the Bronx, New York

The first few months of the coronavirus disease 2019 (COVID-19) pandemic challenged health care facilities worldwide in many ways. Inpatient and intensive care unit (ICU) beds were at a premium, and personnel shortages occurred during the initial peak of the pandemic. New York State was the hardest hit of all US states, with a high concentration of cases in New York City and, in particular, Bronx County. The governor of New York and leadership of hospitals in New York City called upon all available personnel to provide support and patient care during this health care crisis. This case study highlights the efforts of Jacobi Medical Center, located in the northeast Bronx, from March 1 through May 31, 2020, and its use of nontraditional health care personnel, including Department of Dentistry/OMFS (Oral and Maxillofacial Surgery) staff members, to provide a wide range of health care services. Dental staff members including ancillary personnel, residents, and attendings were redeployed and functioned throughout the facility. Dental anesthesiology residents provided medical services in support of their colleagues in a step-down COVID-19-dedicated ICU, providing intubation, ventilator management, and critical and palliative care. (Step-down units provide an intermediate level of care between ICUs and the general medical-surgical wards.) Clear communication of an acute need, a well-articulated mission, creative use of personnel, and dedicated staff members were evident during this challenging time. Although not routinely called upon to provide support in the medical and surgical inpatient areas, dental staff members may provide additional health care personnel during times of need.

The Role of Care Navigators Working with People with Dementia and Their Caregivers

BACKGROUND

Care navigation is an approach to personalized care management and care coordination that can help overcome barriers to care. Care navigation has not been extensively studied in dementia, where health care workforce innovations are needed as a result of increasing disease prevalence and resulting costs to the health care system.

OBJECTIVE

To identify facilitators and barriers to care navigation in dementia and to assess dementia caregiver satisfaction with care navigation.

METHODS

Methods include qualitative research (interviews, focus groups, observations) with "Care Team Navigators" (CTNs) who were part of a dementia care navigation program, the Care Ecosystem, and a quantitative survey with caregivers about their experiences with CTNs. Transcripts were analyzed to identify themes within the data.

RESULTS

CTNs identified the following facilitators to care navigation in dementia: working closely with caregivers; providing emotional support; tailoring education and resources; and coordinating with a clinical team around issues ranging from clinical questions to financial and legal decision-making. The barriers CTNS identified included burn-out, the progressive nature of the disease; coordinating with primary care providers; and identifying resources for dyads who are low-income, do not speak English, or live in rural areas. Caregivers across both sites highly rated CTNs, though satisfaction was higher among those in Nebraska and Iowa.

CONCLUSIONS

Innovative approaches to care delivery in dementia are crucial. Care navigation offers a feasible model to train unlicensed people to deliver care as a way to deliver larger-scale support for the growing population of adults living with dementia and their caregivers.

Experiences of Patient-Centered Medical Home Staff Team Members Working in Interprofessional Training Environments

BACKGROUND

Evidence is growing that interprofessional team-based models benefit providers, trainees, and patients, but less is understood about the experiences of staff who work beside trainees learning these models.

OBJECTIVE

To understand the experiences of staff in five VA training clinics participating in an interprofessional team-based learning initiative.

DESIGN

Individual semi-structured interviews with staff were conducted during site visits, qualitatively coded, and analyzed for themes across sites and participant groups.

PARTICIPANTS

Patient-centered medical home (PCMH) staff members (n = 32; RNs, Clinical and Clerical Associates) in non-primary care provider (PCP) roles working on teams with trainees from medicine, nursing, pharmacy, and psychology.

APPROACH

Benefits and challenges of working in an interprofessional, academic clinic were coded by the primary author using a hybrid inductive/directed thematic analytic approach, with review and iterative theme development by the interprofessional author team.

KEY RESULTS

Efforts to improve interprofessional collaboration among trainees and providers, such as increased shared leadership, have positive spillover effects for PCMH staff members. These staff members perceive themselves playing an educational role for trainees that is not always acknowledged. Playing this role, learning from the "fresh" knowledge imparted by trainees, and contributing to the future of health care all bring satisfaction to staff members. Some constraints exist for full participation in the educational efforts of the clinic.

CONCLUSIONS

Increased recognition of and expanded support for PCMH staff members to participate in educational endeavors is essential as interprofessional training clinics grow.

Redesigning the Role of Medical Assistants in Primary Care: Challenges and Strategies During Implementation

Efforts to reform primary care increasingly focus on redesigning care in ways that utilize nonprovider staff such as medical assistants (MAs), but the implementation of MA role redesign efforts remains understudied in the U.S. health care literature. This article draws on rich, longitudinal case study data collected from four health care systems across the United States to examine critical challenges in the planning, implementation, and early sustainment of MA role redesign efforts in primary care. During the planning period, challenges included recruitment of highly trained MAs, compliance with organizational and state regulations regarding MA scope of practice, provision of consistent training across primary care clinics, and creation of career ladders that provided tiered compensation for MAs. During active implementation, challenges included provider training and preventing MA burnout. Strategies for addressing challenges in MA role redesign efforts are discussed, as well as early sustainment of program practices and organizational policies.

Does the DSW Practice Doctorate Provide Opportunities for Closing Gaps in Gerontology?

The 2019 annual conference of the Group for the Advancement of Doctoral Education in Social Work (GADE) highlighted the increasing role that the Doctor of Social Work (DSW) degree is playing in social work education. Over the past 15 years, social work has followed suit with a number of other health and helping professions (PsyD, DNP, DPT, etc.) by expanding access to practice doctorate programs for professionals who are interested in doctoral-level training, but primarily have interest to remain working in the field as practitioners, rather than become researchers. As more DSW programs have emerged, questions and concerns persist about the DSW, with most questions pertaining to the meaning of the degree for the overall field and the value of having an additional advanced practice degree in social work beyond the MSW degree. However, I urge readers of the Journal of Gerontological Social Work to consider the opportunities that the DSW may present for advancing gerontological education, research, and practice.

Should I stay or should I go now? The impact of "pull" factors on physician decisions to remain in a destination country

BACKGROUND

The recruitment and retention of a competent health care workforce is a worldwide problem. Globalization and increased mobility have provided skilled clinicians the freedom to offer their services in an interconnected global employment market, with multiple studies revealing a pattern of migration from low- and middle-income countries to high-income countries in North America, Western Europe, and more recently, the Middle East. The purpose of this study is to review the United Arab Emirates health care man power strategy and to assess the impact of pull factors on physician retention plans.

METHODS

The study employed a mixed-method comparative approach, comprising a comprehensive review of the literature on human resources for health issues and physician migration patterns, along with a cross sectional survey of expatriate physicians working in private and public sectors in the United Arab Emirates (UAE) between November 2018 and March 2019.

RESULTS

Of 479 physicians, 374 participated (79% response rate). Issues related to family and social life encouraged remaining in the UAE, including close proximity to extended family, social environment, and spouse's employment opportunities. The government's new policy to provide 10-year visas to health professionals was perceived as an important factor encouraging retention. Only 35% of respondents felt that their income was an important factor in deciding to remain in the UAE. Significant gender differences exist in physician migration decisions.

CONCLUSION

Factors influencing retention of the UAE's expatriate physician workforce are primarily lifestyle-related. Physicians also report positive perceptions of newly implemented visa policies.

Economic downturns and nurse attachment to federal employment

The impact of the financial crisis has been uneven-with differences across industries and occupations. Jobs linked to health care appear better insulated, with nurses specifically showing labor force gains during the recent recession. What is not known is how important public sector employment opportunities are for these national nursing trends. Observing the universe of nurses working for one of the largest (and publicly operated) health care employers, we show that worsening economic conditions lead to stronger job attachment. Relatedly, older nurses also seem more willing to delay retirement and instead transition to part-time positions during a downturn.

A Profile of Regulated Nurses Employed in Canadian Long-Term Care Facilities

ABSTRACTRegistered nurses (RNs) and licensed practical nurses (LPNs) provide the skilled component of nursing care in Canadian residential long-term care facilities, yet we know little about this important workforce. We surveyed 309 RNs and 448 LPNs from 91 nursing homes across Western Canada and report descriptively on their demographics and work and health-related outcomes. LPNs were significantly younger than RNs, worked more hours, and had less nursing experience. LPNs also experienced significantly more dementia-related responsive behaviours from residents compared to RNs. Younger LPNs and RNs reported significantly worse burnout (emotional exhaustion) and poorer mental health compared to older age groups. Significant differences in demographics and work- and health-related outcomes were also found within the LPN and RN samples by province, region, and owner-operator model. These findings can be used to inform important policy decisions and workplace planning to improve quality of work life for nurses in residential long-term care facilities.

Explaining primary care physicians' decision to quit patient-centered medical homes: Evidence from Quebec, Canada

OBJECTIVE

To examine the factors explaining primary care physicians' (PCPs) decision to leave patient-centered medical homes (PCMHs).

DATA SOURCES

Five-year longitudinal data on all the 906 PCPs who joined a PCMH in the Canadian province of Quebec, known there as a Family Medicine Group.

STUDY DESIGN

We use fixed-effects and random-effects logit models, with a variety of regression specifications and various subsamples. In addition to these models, we examine the robustness of our results using survival analysis, one lag in the regressions and focusing on a matched sample of quitters and stayers.

DATA COLLECTION/EXTRACTION METHODS

We extract information from Quebec's universal health insurer billing data on all the PCPs who joined a PCMH between 2003 and 2005, supplemented by information on their elderly and chronically ill patients.

PRINCIPAL FINDINGS

About 17 percent of PCPs leave PCMHs within 5 years of follow-up. Physicians' demographics have little influence. However, those with more complex patients and higher revenues are less likely to leave the medical homes. These findings are robust across a variety of specifications.

CONCLUSION

As expected, higher revenue favors retention. Importantly, our results suggest that PCMH may provide appropriate support to physicians dealing with complex patients.

Training Psychologists for Rural Practice: Exploring Opportunities and Constraints

PURPOSE

To examine trends in the psychologist workforce and training opportunities, including factors that may influence the decision of clinical psychologists to practice in rural settings.

METHODS

We use a mixed-methods approach to examine the psychologist workforce nationally and in North Carolina (NC), including (1) an analysis of the location of programs awarding doctoral degrees; (2) an analysis of the practice, demographic, and educational characteristics of the psychologist workforce; and (3) interviews with directors of doctoral programs in clinical psychology to understand where current graduates are getting jobs and why they may or may not be choosing to practice in rural communities.

FINDINGS

Fewer than 1% of programs and institutions awarding doctoral degrees in psychology in the United States are located in rural areas. In NC, approximately 80% of practicing psychologists have out-of-state degrees and about 80% of recent NC graduates are not currently licensed in the state. This juxtaposition undermines the utility of adding more in-state degree programs. While expansion of training programs within rural areas could help alleviate the shortages of mental health providers, adding new degree-granting programs alone will not necessarily increase supply. We discuss complementary recruitment and retention strategies, including greater incentives for rural training and practice as well as training in emerging technologies that don't require providers to be physically located in underserved areas, such as telemedicine.

CONCLUSIONS

Increasing the supply of psychologists practicing in rural areas will require a thoughtful, multipronged approach to training this critical part of the behavioral health workforce.

The reliability and validity of three-item screening measures for burnout: Evidence from group-employed health care practitioners in upstate New York

We investigate the psychometric validity and reliability of three-item screening measures for emotional exhaustion, depersonalization, and personal achievement comprising an abbreviated version of the Maslach Burnout Inventory®. Despite its utilization in multiple studies, the shortened instrument has not been sufficiently validated in diverse settings, populations, and organizational contexts. We examine its ability to assess burnout accruing from patient care practice in a rural, underserved area. Utilizing data from a cross-sectional survey of 308 rural-based medical professionals, we investigate how the three short-form subscales of the nine-item abbreviated inventory compare with their gold-standard parent subscales from the original 22-item human services scale in measuring corresponding dimensions of burnout. The findings provide significant evidence that the three-item measures are valid and reliable proxies for the long-form subscales. The short-form measures are highly correlated with the original subscales and display high convergent and discriminant validity. Each of the abbreviated subscales manifests the kind of high sensitivity with adequate specificity that one would expect to see in a good screening instrument. We conclude that the short-form measures can be utilized to rapidly screen human service professionals such as rural health care practitioners for symptoms of each of the three dimensions of burnout.

The Health Care Job Engine: Where Do They Come From and What Do They Say About Our Future?

Health care has been cited as a job engine for the U.S. economy. This study used the Current Population Survey to examine the sector and occupation shifts that underlie this growth trend. Health care has had a cyclical relationship with retail trade, leisure and hospitality, education, and professional services. The entering workforce has been increasingly taking on low-skilled occupations. The exiting workforce has not been necessarily retiring or going back to school, but appeared to be leaving without a job, with potentially more child care duties, and with high rates of disability and poverty levels. This study also found that the number of workers staying in health care has been slowly declining over time. As the United States moves toward team-based care, more attention should be paid to the needs of the lower skilled workers to reduce turnover and ensure delivery of quality care.

Utilizing Task Shifting to Increase Access to Maternal and Infant Health Interventions: A Case Study of Midwives for Haiti

The shortage of health workers worldwide has been identified as a barrier to achieving targeted health goals. Task shifting has been recommended by the World Health Organization to increase access to trained and skilled birth attendants. One example of task shifting is the use of cadres of health care workers, such as nurses and auxiliary nurse-midwives, who can successfully deliver skilled care to women and infants in low-resource areas where women would otherwise lack access to critical health interventions during the childbearing years. Midwives for Haiti is an organization demonstrating the use of task shifting in its education program for auxiliary midwives. Graduates of the Midwives for Haiti education program are employed and working with women in hospitals, birth centers, and clinics across Haiti. This article reviews the Midwives for Haiti education program and presents successes and challenges in task shifting as a strategy to increase access to skilled maternal and newborn care and to meet international health goals to reduce maternal and infant mortality in a low-resource country.

Diversifying the Midwifery Workforce: Inclusivity, Culturally Sensitive Bridging, and Innovation

Midwifery educators and regulators in Canada have begun to address diversity, equity, and inclusion in admission processes and program curricula. Populations served by midwives value internationally educated midwives from their countries of origin. The International Midwifery Pre-Registration Program at Ryerson University in Toronto, Ontario, provides assessment, midwifery workplace orientation, and accelerated education for internationally educated midwives on behalf of the regulatory College of Midwives of Ontario. Between 2003 and 2015, midwives from 41 countries participated in the bridging program, and 214 (80%) successfully completed the program and qualified for licensure. Of these 214 graduates, 100% passed the Canadian Midwifery Registration Examination and 193 (90%) were employed full time as midwives within 4 months of graduation. The program curriculum enables the integration of these midwives into health care workplaces utilizing innovative approaches to assessment and competency enhancement. Critical to the bridging process are simulation-based practices to develop effective psychomotor learning, virtual and real primary care community placements, and coaching in empathetic, client-centered communication. Cultural sensitivity is embedded into the multiple assessment and learning modalities, and addresses relevant barriers faced by immigrant midwives in the workplace. Findings from the 13 years of the program may be applicable to increase diversity in other North American midwifery settings. This article describes the process, content, outcomes, and findings of the program. Midwifery educators and regulators may consider the utility of these approaches for their settings.

Wage Growth for the Health Care Workforce: Projecting the Affordable Care Act Impact

OBJECTIVE

To predict changes in wage growth for health care workers based on projections of insurance enrollment from the Affordable Care Act (ACA).

DATA SOURCES

Enrollment data came from three large employers and a sampling of premiums from ehealthinsurance.com. Information on state Medicaid eligibility rules and costs were from the Kaiser Family Foundation. National predictions were based on the MEPS and Medicare Current Beneficiary surveys. Bureau of Labor Statistics data were used to estimate employment.

STUDY DESIGN

We projected health insurance enrollment by plan type using a health plan choice model. Using claims data, we measured the services demanded for each plan choice and year. Projections of labor demand were based on current output/input ratios. Changes in wages resulting from changes in labor demand from 2014 to 2021 were based on labor supply and demand elasticities.

PRINCIPAL FINDINGS

Expenditures required to retain and grow the health care workforce will increase substantially. Wages will increase most for professions with the greatest training requirements (physicians and registered nurses). The largest impact will be felt in 2015.

CONCLUSIONS

Projected wage increases for health care workers may drive substantial growth in insurance premiums and reduce the affordability of health insurance.

From triple to quadruple aim: care of the patient requires care of the provider

The Triple Aim-enhancing patient experience, improving population health, and reducing costs-is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.

Patient turnover and nursing employment in Massachusetts hospitals before and after health insurance reform: implications for the Patient Protection and Affordable Care Act

The Affordable Care Act is modeled after Massachusetts insurance reforms enacted in 2006. A linear mixed effect model examined trends in patient turnover and nurse employment in Massachusetts, New York, and California nonfederal hospitals from 2000 to 2011. The linear mixed effect analysis found that the rate of increase in hospital admissions was significantly higher in Massachusetts hospitals (p<.001) than that in California and New York (p=.007). The rate of change in registered nurses full-time equivalent hours per patient day was significantly less (p=.02) in Massachusetts than that in California and was not different from zero. The rate of change in admissions to registered nurses full-time equivalent hours per patient day was significantly greater in Massachusetts than California (p=.001) and New York (p<.01). Nurse staffing remained flat in Massachusetts, despite a significant increase in hospital admissions. The implications of the findings for nurse employment and hospital utilization following the implementation of national health insurance reform are discussed.

Factors influencing Ghanaian midwifery students' willingness to work in rural areas: a computerized survey

BACKGROUND

Lack of midwives in rural and remote areas of Ghana is a national concern as the country attempts to reach targets set by Millennium Development Goals to reduce maternal and child mortality by 2015.

OBJECTIVES

To understand factors influencing third-year Ghanaian midwifery students' willingness to work in rural areas.

SETTING

Two of the largest midwifery schools in Ghana.

PARTICIPANTS

Third-year midwifery students (n=238) about to graduate and enter the workforce.

METHODS

Based on focus group discussions with midwifery students, we refined a computerized survey to assess students' preferences for rural posting after graduation. We then administered this survey to midwifery students in Ghana. We used Pearson's chi-squared to compare the top reasons for choosing job location between those students likely and not likely to work in a rural area. Logistic regression models were used to calculate the odds ratios.

RESULTS

An opportunity to gain additional education was the most important factor for the midwifery students in deciding where they would eventually work (72%). Poor quality of clinical facilities (26%), poor quality of education for children (19%), and lack of social amenities (17%) were major deterrents to working in rural communities. For student midwives willing to work in rural areas the top reasons cited included to serve humanity (74%), and increased opportunities to gain clinical experience (62%). More experiences overall with rural communities resulted in greater odds of being willing to work in a rural area. Being born in a rural area (OR: 1.95, 95% CI: 0.736, 5.16) and living in a rural area after age 5 for one-year or more (OR: 1.52, CI: 0.857, 2.70). An exception to this was midwifery students who performed health work for six weeks or more in a rural area during training. These students were found to have 0.83 lower odds of willingness to work in a rural area (95% CI: 0.449, 1.55).

CONCLUSION

By better understanding the motivating factors for rural healthcare workers, specific policy interventions can be established to improve the distribution of midwives thereby decreasing the burden of maternal and infant mortality.

Public health and nursing: a natural partnership

The health of individuals occurs within the context of their environment and the other individuals they interact with in the communities they live in, work in and visit. Promoting the health of the public requires multiple strategies aimed at improving the environment, the health knowledge of groups and individuals, maintaining adequate food and water, and reducing the spread of disease. Many disciplines are needed to meet these goals, but the largest segment of the professional health work force required to meet these needs is nursing. Historically, nursing leaders in public health such as Florence Nightingale and Lillian Wald made significant inroads related to serious health issues because they were nurses. Today across the globe, nurses provide the key components of public health interventions including well baby care, health education, screening and immunization clinics, disaster management and emergency preparedness. With the growing nursing shortage in acute care settings, the brain drain of nurses from certain areas of the world, the shrinking public dollars for preventive health care, the nursing workforce needed to continue to provide these essential health care services is threatened. It is essential to put the spot light on nursing's role in public health with the hopes of attracting more public funds and more nurses to provide these essential services.