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1.  Health workforce skill mix and task shifting in low income countries: a review of recent evidence 
Health workforce needs-based shortages and skill mix imbalances are significant health workforce challenges. Task shifting, defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training, is a potential strategy to address these challenges. This study uses an economics perspective to review the skill mix literature to determine its strength of the evidence, identify gaps in the evidence, and to propose a research agenda.
Studies primarily from low-income countries published between 2006 and September 2010 were found using Google Scholar and PubMed. Keywords included terms such as skill mix, task shifting, assistant medical officer, assistant clinical officer, assistant nurse, assistant pharmacist, and community health worker. Thirty-one studies were selected to analyze, based on the strength of evidence.
First, the studies provide substantial evidence that task shifting is an important policy option to help alleviate workforce shortages and skill mix imbalances. For example, in Mozambique, surgically trained assistant medical officers, who were the key providers in district hospitals, produced similar patient outcomes at a significantly lower cost as compared to physician obstetricians and gynaecologists. Second, although task shifting is promising, it can present its own challenges. For example, a study analyzing task shifting in HIV/AIDS in sub-Saharan Africa noted quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance. Third, most task shifting studies compare the results of the new cadre with the traditional cadre. Studies also need to compare the new cadre's results to the results from the care that would have been provided--if any care at all--had task shifting not occurred.
Task shifting is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost. Future studies should examine the development of new professional cadres that evolve with technology and country-specific labour markets. To strengthen the evidence, skill mix changes need to be evaluated with a rigorous research design to estimate the effect on patient health outcomes, quality of care, and costs.
PMCID: PMC3027093  PMID: 21223546
2.  Effects of Physician-Nurse Substitution on Clinical Parameters: A Systematic Review and Meta-Analysis 
PLoS ONE  2014;9(2):e89181.
Physicians’ shortage in many countries and demands of high-quality and affordable care make physician-nurse substitution an appealing workforce strategy. The objective of this study is to conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the impact of physician-nurse substitution in primary care on clinical parameters.
We systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected peer-reviewed RCTs comparing physician-led care with nurse-led care on changes in clinical parameters. Study selection and data extraction were performed in duplicate by independent reviewers. We assessed the individual study risk of bias; calculated the study-specific and pooled relative risks (RR) or weighted mean differences (WMD); and performed fixed-effects meta-analyses.
11 RCTs (N = 30,247) were included; most were from Europe, generally small with higher risk of bias. In all studies, nurses provided care for complex conditions including HIV, hypertension, heart failure, cerebrovascular diseases, diabetes, asthma, Parkinson’s disease and incontinence. Meta-analyses showed greater reductions in systolic blood pressure (SBP) in favour of nurse-led care (WMD −4.27 mmHg, 95% CI −6.31 to −2.23) but no statistically significant differences between groups in the reduction of diastolic blood pressure (DBP) (WMD −1.48 mmHg, 95%CI −3.05 to −0.09), total cholesterol (TC) (WMD -0.08 mmol/l, 95%CI -0.22 to 0.07) or glycosylated haemoglobin (WMD 0.12%HbAc1, 95%CI -0.13 to 0.37). Of other 32 clinical parameters identified, less than a fifth favoured nurse-led care while 25 showed no significant differences between groups.
disease-specific interventions from a small selection of healthcare systems, insufficient quantity and quality of studies, many different parameters.
trained nurses appeared to be better than physicians at lowering SBP but similar at lowering DBP, TC or HbA1c. There is insufficient evidence that nurse-led care leads to better outcomes of other clinical parameters than physician-led care.
PMCID: PMC3933531  PMID: 24586577
3.  Use of a Multisource Feedback Tool to Develop Pharmacists in a Postgraduate Training Program 
Objectives. To evaluate use of a peer-assessment tool as a performance indicator for junior pharmacists in a formal postgraduate training program in London.
Methods. A 4-year retrospective analysis of data gathered using the pharmacy mini-PAT (peer-assessment tool) was undertaken. Assessments, including junior pharmacist self-evaluations, were conducted every 6 months. Overall performance and performance for clustered items were analyzed to determine changes. Assessments by healthcare professionals were then compared between professional groupings, which included pharmacists, physicians, and nurses.
Results. There was a significant improvement over time in both self-assessment scores and scores on assessments conducted by others using the mini-PAT. Junior pharmacists rated themselves significantly lower than did their assessors (p<0.001); pharmacist assessors rated the performance of junior pharmacists significantly lower than did other healthcare professionals (p<0.001). Validity, ease of use, and relevance of the pharmacy mini-PAT were demonstrated.
Conclusions. As part of a range of formative evaluations involving assessors from across various health professions, the mini-PAT is a valuable instrument for developing junior pharmacists. A cohort’s mini-PAT result provides a snapshot of his/her performance that can be used to identify key areas requiring further training.
PMCID: PMC3631727  PMID: 23610470
multisource feedback; peer assessment; performance assessment; work-based assessment
4.  Nursing resources 
Purpose of review
There is growing concern that changes in nurse workforce and hospital-restructuring interventions negatively impact on patient outcomes. This review focuses on the association between understaffing and health-care-associated infections.
Recent findings
There is a large number of studies showing that overcrowding, understaffing or a misbalance between workload and resources are important determinants of nosocomial infections and cross-transmission of microorganisms. Importantly, not only the number of staff but also the level of their training affects outcomes. The nurse workforce is ageing, mainly due to fewer individuals’ engaging in a nursing career. This phenomenon, combined with cost-driven downsizing, contributes to a nursing shortage, and this tendency is not expected to revert unless important system changes are implemented. The causal pathway between understaffing and infection is complex, and factors might include lack of time to comply with infection control recommendations, job dissatisfaction, job-related burnout, absenteeism and a high staff turnover.
The evidence that cost-driven downsizing and changes in staffing patterns causes harm to patients cannot be ignored, and should not be considered as an inevitable outcome. More research is needed to better define the optimal patient-to-nurse ratio in various hospital settings and to estimate the economical impact of the nursing shortage. All quality-improvement interventions should carefully take into account systems and processes to be successful, as the issue of staffing is essentially a structural problem.
PMCID: PMC2080680  PMID: 16894083
cross-transmission; nosocomial infection; nurse; understaffing; workload
5.  New investments in primary care in Australia 
There is a crisis in primary care health workforce shortages in Australia. Its government has attempted to fix this by role-substitution (replacing medical work with nursing instead). This was not completely successful. Obstacles included entrenched social roles (leading to doctors 'checking' their nurse role-substituted work) and structures (nurses subservient to doctors) - both exacerbated by primary care doctors' ageing demographic; doctors owning their own practices; doctors feeling themselves to have primary responsibility for the care delivered; and greater attraction towards independence that may have selected doctors into primary care in the first place.
Yet there is much to be optimistic about this social experiment. It was conducted, if not ideally, at least in an environment that the Australian government has enriched with capacity for research and evaluation.
PMCID: PMC3048490  PMID: 21329507
6.  Treat to Goal: Impact of Clinical Pharmacist Referral Service Primarily in Diabetes Management 
Hospital Pharmacy  2013;48(8):656-661.
To describe the impact of pharmacist services in a collaborative practice providing care to primarily Medicaid and indigent patients. The practice includes primary care physicians, nurses, a care navigator, and pharmacists. Pharmacy services are provided by pharmacists, including PGY-1 pharmacy residents and pharmacy students.
A retrospective chart review was conducted to perform a pre-post analysis on all patients referred to pharmacists within an adult medicine clinic. Patients were included if they were more than 18 years old; were referred for type 1 or 2 diabetes mellitus, hypertension, hyperlipidemia, or medication reconciliation; and were seen from August 2010 to March 2011. All charts were reviewed to assess pharmacist impact on adherence to standards of care including hemoglobin A1c; lipids; blood pressure; vaccination status; usage of aspirin, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins; and other criteria. Subgroup analysis was performed on diabetic patients who were not at goal at the time of referral to the pharmacy clinic.
Ninety-three charts were reviewed. In the overall group, rates of influenza and pneumococcal vaccination improved significantly, as did annual foot and eye exams in diabetics. Pharmacists significantly decreased A1c from 9.12% at baseline to 8.13% (P < .001), systolic blood pressure (SBP) from 142.6 to 133.5 mm Hg (P < .001), and low-density lipoprotein (LDL) from 143.6 to 103.2 mg/dL (P < .001) in diabetic patients who were not at goal at baseline.
Pharmacists were effective in improving surrogate outcomes for patients with diabetes and in assisting physicians to address all standards of care.
PMCID: PMC3847985  PMID: 24421536
diabetes mellitus; hyperlipidemias; pharmacists; pharmaceutical services; standard of care; vaccination
7.  Care Providers’ Satisfaction with Restructured Clinical Pharmacy Services in a Tertiary Care Teaching Hospital 
At the time this study was undertaken, clinical pharmacy services at the authors’ institution, a tertiary care teaching hospital, were largely reactive in nature, with patients and units receiving inconsistent coverage.
To develop an evidence-based model of proactive practice and to evaluate the satisfaction of pharmacists and other stakeholders after restructuring of clinical pharmacy services.
The literature was reviewed to determine a core set of pharmacist services associated with the greatest beneficial impact on patients’ health. On the basis of established staffing levels, the work schedule was modified, and pharmacists were assigned to a limited number of patient care teams to proactively and consistently provide these core services. Other patient care teams continued to receive reactive troubleshooting-based services, as directed by staff in the pharmacy dispensary. A satisfaction survey was distributed to all pharmacists, nurses, and physicians 18 months after the restructuring.
Of the 26 pharmacists who responded to the survey, all agreed or strongly agreed that the restructuring of services had improved job satisfaction and patient safety and that other health care professionals valued their contribution to patient care. Nurses and physicians from units where pharmacists had been assigned to provide proactive services perceived pharmacist services more favourably than those from units where pharmacist services were reactive. Pharmacists, nurses, and physicians all felt that proactive pharmacist services should be more widely available. Challenges reported by pharmacists included increased expectations for documentation and guilt about “cutting back” services where they had previously been provided.
Restructuring clinical pharmacy services in an evidence-based manner improved pharmacists’ satisfaction and created demand from other stakeholders to provide this level of service for all patients.
PMCID: PMC2858499  PMID: 22478965
clinical pharmacy; restructuring; tertiary care hospital; evidence-based; practice delivery; pharmacie clinique; restructuration; hôpital de soins tertiaires; données probantes; prestation de services
8.  An evidence-based health workforce model for primary and community care 
The delivery of best practice care can markedly improve clinical outcomes in patients with chronic disease. While the provision of a skilled, multidisciplinary team is pivotal to the delivery of best practice care, the occupational or skill mix required to deliver this care is unclear; it is also uncertain whether such a team would have the capacity to adequately address the complex needs of the clinic population. This is the role of needs-based health workforce planning. The objective of this article is to describe the development of an evidence-informed, needs-based health workforce model to support the delivery of best-practice interdisciplinary chronic disease management in the primary and community care setting using diabetes as a case exemplar.
Development of the workforce model was informed by a strategic review of the literature, critical appraisal of clinical practice guidelines, and a consensus elicitation technique using expert multidisciplinary clinical panels. Twenty-four distinct patient attributes that require unique clinical competencies for the management of diabetes in the primary care setting were identified. Patient attributes were grouped into four major themes and developed into a conceptual model: the Workforce Evidence-Based (WEB) planning model. The four levels of the WEB model are (1) promotion, prevention, and screening of the general or high-risk population; (2) type or stage of disease; (3) complications; and (4) threats to self-care capacity. Given the number of potential combinations of attributes, the model can account for literally millions of individual patient types, each with a distinct clinical team need, which can be used to estimate the total health workforce requirement.
The WEB model was developed in a way that is not only reflective of the diversity in the community and clinic populations but also parsimonious and clear to present and operationalize. A key feature of the model is the classification of subpopulations, which gives attention to the particular care needs of disadvantaged groups by incorporating threats to self-care capacity. The model can be used for clinical, health services, and health workforce planning.
PMCID: PMC3163196  PMID: 21819608
9.  Time for chronic disease care and management 
The Canadian Journal of Cardiology  2007;23(12):971-975.
To manage the future costs and quality of care, a health strategy must move beyond the individual, acute care model and address the care of older people with chronic, and often multiple, diseases. This strategy must address the issue of care gaps, ie, the differences between best care and usual care. It should also embrace broad partnerships in which providers may be a cross-disciplinary team of nurses, physicians and pharmacists; the patient partners may include all patients in the community with a disease or group of diseases; and the system managers should work with all to seek improved long-term care and share the governance of interventions and resources. This partnership is activated by repeated and widely communicated measurements of actual practices and outcomes, facilitating rapid knowledge gain and translation, including unmasking the invisible wait list of unmeasured care gaps. It drives continuous improvement in practices and outcomes. The time is right for such care models. There is increasing evidence of their clinical and financial benefits. There is a clear and immediate opportunity to evaluate them as part of a health strategy for effective chronic care in our aging society. Things can be better.
PMCID: PMC2651420  PMID: 17932573
Chronic care; Disease management; Knowledge translation; Measurement; Partnership
10.  Pharmacist provision of primary health care: a modified Delphi validation of pharmacists' competencies 
BMC Family Practice  2012;13:27.
Pharmacists have expanded their roles and responsibilities as a result of primary health care reform. There is currently no consensus on the core competencies for pharmacists working in these evolving practices. The aim of this study was to develop and validate competencies for pharmacists' effective performance in these roles, and in so doing, document the perceived contribution of pharmacists providing collaborative primary health care services.
Using a modified Delphi process including assessing perception of the frequency and criticality of performing tasks, we validated competencies important to primary health care pharmacists practising across Canada.
Ten key informants contributed to competency drafting; thirty-three expert pharmacists replied to a second round survey. The final primary health care pharmacist competencies consisted of 34 elements and 153 sub-elements organized in seven CanMeds-based domains. Highest importance rankings were allocated to the domains of care provider and professional, followed by communicator and collaborator, with the lower importance rankings relatively equally distributed across the manager, advocate and scholar domains.
Expert pharmacists working in primary health care estimated their most important responsibilities to be related to direct patient care. Competencies that underlie and are required for successful fulfillment of these patient care responsibilities, such as those related to communication, collaboration and professionalism were also highly ranked. These ranked competencies can be used to help pharmacists understand their potential roles in these evolving practices, to help other health care professionals learn about pharmacists' contributions to primary health care, to establish standards and performance indicators, and to prioritize supports and education to maximize effectiveness in this role.
PMCID: PMC3372430  PMID: 22455482
Primary health care; Pharmacy; Pharmacists; Competencies; Scope of practice
11.  Internationally trained pharmacists in Great Britain: what do registration data tell us about their recruitment? 
Internationally trained health professionals are an important part of the domestic workforce, but little is known about pharmacists who come to work in Great Britain. Recent changes in the registration routes onto the Register of Pharmacists of the Royal Pharmaceutical Society of Great Britain may have affected entries from overseas: reciprocal arrangements for pharmacists from Australia and New Zealand ended in June 2006; 10 new states joined the European Union in 2004 and a further two in 2007, allowing straightforward registration.
The aims of the paper are to extend our knowledge about the extent to which Great Britain is relying on the contribution of internationally trained pharmacists and to explore their routes of entry and demographic characteristics and compare them to those of pharmacists trained in Great Britain.
The August 2007 Register of Pharmacists provided the main data for analysis. Register extracts between 2002 and 2005 were also explored, allowing longitudinal comparison, and work pattern data from the 2005 Pharmacist Workforce Census were included.
In 2007, internationally trained pharmacists represented 8.8% of the 43 262 registered pharmacists domiciled in Great Britain. The majority (40.6%) had joined the Register from Europe; 33.6% and 25.8% joined via adjudication and reciprocal arrangements. Until this entry route ended for pharmacists from Australia and New Zealand in 2006, annual numbers of reciprocal pharmacists increased. European pharmacists are younger (mean age 31.7) than reciprocal (40.0) or adjudication pharmacists (43.0), and the percentage of women among European-trained pharmacists is much higher (68%) when compared with British-trained pharmacists (56%). While only 7.1% of pharmacists registered in Great Britain have a London address, this proportion is much higher for European (13.9%), adjudication (19.5%) and reciprocal pharmacists (28.9%). The latter are more likely to work in hospitals than in community pharmacies, and all groups of internationally trained pharmacist are more likely to work full-time than British-trained ones. Adjudication pharmacists appear to stay on the Register longer than their reciprocal and European colleagues.
Analysis of the Register of Pharmacists provides novel insights into the origins, composition and destinations of internationally trained pharmacists. They represent a notable proportion of the Register, indicating that British employers are relying on their contribution for the delivery of pharmacy services. With the increasing mobility of health care professionals across geographical borders, it will be important to undertake primary research to gain a better understanding of the expectations, plans and experiences of pharmacists entering from outside Great Britain.
PMCID: PMC2714492  PMID: 19555489
12.  The impact on nurses and nurse managers of introducing PEPFAR clinical services in urban government clinics in Uganda 
Improving provider performance is central to strengthening health services in developing countries. Because of critical shortages of physicians, many clinics in sub-Saharan Africa are led by nurses. In addition to clinical skills, nurse managers need practical managerial skills and adequate resources to ensure procurement of essential supplies, quality assurance implementation, and productive work environment. Giving nurses more autonomy in their work empowers them in the workplace and has shown to create positive influence on work attitudes and behaviors. The Infectious Disease Institute, an affiliate of Makerere University College of Health Science, in an effort to expand the needed HIV services in the Ugandan capital, established a community-university partnership with the Ministry of Health to implement an innovative model to build capacity in HIV service delivery. This paper evaluates the impact on the nurses from this innovative program to provide more health care in six nurse managed Kampala City Council (KCC) Clinics.
A mixed method approach was used. The descriptive study collected key informant interviews from the six nurse managers, and administered a questionnaire to 20 staff nurses between September and December 2009. Key themes were manually identified from the interviews, and the questionnaire data were analyzed using SPSS.
Introducing new HIV services into six KCC clinics was positive for the nurses. They identified the project as successful because of perceived improved environment, increase in useful in-service training, new competence to manage patients and staff, improved physical infrastructure, provision of more direct patient care, motivation to improve the clinic because the project acted on their suggestions, and involvement in role expansion. All of these helped empower the nurses, improving quality of care and increasing job satisfaction.
This community-university HIV innovative model was successful from the point of view of the nurses and nurse managers. This model shows promise in increasing effective, quality health service; HIV and other programs can build capacity and empower nurses and nurse managers to directly implement such services. It also demonstrates how MakCHS can be instrumental through partnerships in designing and testing effective strategies, building human health resources and improving Ugandan health outcomes.
PMCID: PMC3059480  PMID: 21411008
13.  Over the counter drugs. The future for self medication. 
BMJ : British Medical Journal  1996;312(7034):835-837.
The increasing trend towards deregulation of more medicines to over the counter status has implications for the primary health care team as well as for consumers and patients. Better information for patients could improve the safety of over the counter medicines, but better systems need to be devised for reporting adverse reactions. "Collaborative care" could bring financial benefits. Doctors, nurses, and pharmacists need to discuss how they will respond to self medication practices, and ways of rewarding pharmacists for advising patients need to be found. Improved communication between doctors and pharmacists and the involvement of nurses could bring health care professionals into a new and more constructive interaction with each other and with the patient--or the changes required could split the professions as they each try to keep control of medicines.
PMCID: PMC2350729  PMID: 8608296
14.  From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management 
Throughout the world, countries are experiencing shortages of health care workers. Policy-makers and system managers have developed a range of methods and initiatives to optimise the available workforce and achieve the right number and mix of personnel needed to provide high-quality care. Our literature review found that such initiatives often focus more on staff types than on staff members' skills and the effective use of those skills. Our review describes evidence about the benefits and pitfalls of current approaches to human resources optimisation in health care. We conclude that in order to use human resources most effectively, health care organisations must consider a more systemic approach - one that accounts for factors beyond narrowly defined human resources management practices and includes organisational and institutional conditions.
PMCID: PMC2813845  PMID: 20021682
15.  Pharmacist Interventions to Improve Cardiovascular Disease Risk Factors in Diabetes 
Diabetes Care  2012;35(12):2706-2717.
This systematic review and meta-analysis of randomized controlled trials (RCTs) assesses the effect of pharmacist care on cardiovascular disease (CVD) risk factors among outpatients with diabetes.
MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched. Pharmacist interventions were classified, and a meta-analysis of mean changes of blood pressure (BP), total cholesterol (TC), LDL cholesterol, HDL cholesterol, and BMI was performed using random-effects models.
The meta-analysis included 15 RCTs (9,111 outpatients) in which interventions were conducted exclusively by pharmacists in 8 studies and in collaboration with physicians, nurses, dietitians, or physical therapists in 7 studies. Pharmacist interventions included medication management, educational interventions, feedback to physicians, measurement of CVD risk factors, or patient-reminder systems. Compared with usual care, pharmacist care was associated with significant reductions for systolic BP (12 studies with 1,894 patients; −6.2 mmHg [95% CI −7.8 to −4.6]); diastolic BP (9 studies with 1,496 patients; −4.5 mmHg [−6.2 to −2.8]); TC (8 studies with 1,280 patients; −15.2 mg/dL [−24.7 to −5.7]); LDL cholesterol (9 studies with 8,084 patients; −11.7 mg/dL [−15.8 to −7.6]); and BMI (5 studies with 751 patients; −0.9 kg/m2 [−1.7 to −0.1]). Pharmacist care was not associated with a significant change in HDL cholesterol (6 studies with 826 patients; 0.2 mg/dL [−1.9 to 2.4]).
This meta-analysis supports pharmacist interventions—alone or in collaboration with other health care professionals—to improve major CVD risk factors among outpatients with diabetes.
PMCID: PMC3507563  PMID: 23173140
16.  Design of a trial to evaluate the impact of clinical pharmacists and community health promoters working with African-Americans and Latinos with Diabetes 
BMC Public Health  2012;12:891.
Given the increasing prevalence of diabetes and the lack of patients reaching recommended therapeutic goals, novel models of team-based care are emerging. These teams typically include a combination of physicians, nurses, case managers, pharmacists, and community-based peer health promoters (HPs). Recent evidence supports the role of pharmacists in diabetes management to improve glycemic control, as they offer expertise in medication management with the ability to collaboratively intensify therapy. However, few studies of pharmacy-based models of care have focused on low income, minority populations that are most in need of intervention. Alternatively, HP interventions have focused largely upon low income minority groups, addressing their unique psychosocial and environmental challenges in diabetes self-care. This study will evaluate the impact of HPs as a complement to pharmacist management in a randomized controlled trial.
The primary aim of this randomized trial is to evaluate the effectiveness of clinical pharmacists and HPs on diabetes behaviors (including healthy eating, physical activity, and medication adherence), hemoglobin A1c, blood pressure, and LDL-cholesterol levels. A total of 300 minority patients with uncontrolled diabetes from the University of Illinois Medical Center ambulatory network in Chicago will be randomized to either pharmacist management alone, or pharmacist management plus HP support. After one year, the pharmacist-only group will be intensified by the addition of HP support and maintenance will be assessed by phasing out HP support from the pharmacist plus HP group (crossover design). Outcomes will be evaluated at baseline, 6, 12, and 24 months. In addition, program and healthcare utilization data will be incorporated into cost and cost-effectiveness evaluations of pharmacist management with and without HP support.
The study will evaluate an innovative, integrated approach to chronic disease management in minorities with poorly controlled diabetes. The approach is comprised of clinic-based pharmacists and community-based health promoters collaborating together. They will target patient-level factors (e.g., lack of adherence to lifestyle modification and medications) and provider-level factors (e.g., clinical inertia) that contribute to poor clinical outcomes in diabetes. Importantly, the study design and analytic approach will help determine the differential and combined impact of adherence to lifestyle changes, medication, and intensification on clinical outcomes.
Trial registration identifier: NCT01498159
PMCID: PMC3571948  PMID: 23088168
(3–10): Diabetes mellitus/drug therapy; Patient compliance; Patient education; Pharmacists; Community health workers
17.  Social Network Analysis in Healthcare Settings: A Systematic Scoping Review 
PLoS ONE  2012;7(8):e41911.
Social network analysis (SNA) has been widely used across a range of disciplines but is most commonly applied to help improve the effectiveness and efficiency of decision making processes in commercial organisations. We are utilising SNA to inform the development and implementation of tailored behaviour-change interventions to improve the uptake of evidence into practice in the English National Health Service. To inform this work, we conducted a systematic scoping review to identify and evaluate the use of SNA as part of an intervention to support the implementation of change in healthcare settings.
Methods and Findings
We searched ten bibliographic databases to October 2011. We also searched reference lists, hand searched selected journals and websites, and contacted experts in the field. To be eligible for the review, studies had to describe and report the results of an SNA performed with healthcare professionals (e.g. doctors, nurses, pharmacists, radiographers etc.) and others involved in their professional social networks. We included 52 completed studies, reported in 62 publications. Almost all of the studies were limited to cross sectional descriptions of networks; only one involved using the results of the SNA as part of an intervention to change practice.
We found very little evidence for the potential of SNA being realised in healthcare settings. However, it seems unlikely that networks are less important in healthcare than other settings. Future research should seek to go beyond the merely descriptive to implement and evaluate SNA-based interventions.
PMCID: PMC3411695  PMID: 22870261
18.  Solving nursing shortages: a common priority 
Journal of clinical nursing  2008;17(24):3262-3268.
Aims and objectives
This paper provides a context for this special edition. It highlights the scale of the challenge of nursing shortages, but also makes the point that there is a policy agenda that provides workable solutions.
An overview of nurse:population ratios in different countries and regions of the world, highlighting considerable variations, with Africa and South East Asia having the lowest average ratios. The paper argues that the ‘shortage’ of nurses is not necessarily a shortage of individuals with nursing qualifications, it is a shortage of nurses willing to work in the present conditions. The causes of shortages are multi-faceted, and there is no single global measure of their extent and nature, there is growing evidence of the impact of relatively low staffing levels on health care delivery and outcomes. The main causes of nursing shortages are highlighted: inadequate workforce planning and allocation mechanisms, resource constrained undersupply of new staff, poor recruitment, retention and ‘return’ policies, and ineffective use of available nursing resources through inappropriate skill mix and utilisation, poor incentive structures and inadequate career support.
What now faces policy makers in Japan, Europe and other developed countries is a policy agenda with a core of common themes. First, themes related to addressing supply side issues: getting, keeping and keeping in touch with relatively scarce nurses. Second, themes related to dealing with demand side challenges. The paper concludes that the main challenge for policy makers is to develop a co-ordinated package of policies that provide a long term and sustainable solution.
Relevance to clinical practice
This paper highlights the impact that nursing shortages has on clinical practice and in health service delivery. It outlines scope for addressing shortage problems and therefore for providing a more positive staffing environment in which clinical practice can be delivered.
PMCID: PMC2858425  PMID: 19146584
nurses; nursing; workforce issues; workforce planning
19.  Stakeholder experiences with general practice pharmacist services: a qualitative study 
BMJ Open  2013;3(9):e003214.
To explore general practice staff, pharmacist and patient experiences with pharmacist services in Australian general practice clinics within the Pharmacists in Practice Study.
Qualitative study.
Two general practice clinics in Melbourne, Australia, in which pharmacists provided medication reviews, patient and staff education, medicines information and quality assurance services over a 6-month period.
Patients, practice staff and pharmacists.
Semi-structured telephone interviews with patients, focus groups with practice staff and semi-structured interviews and periodic narrative reports with practice pharmacists. Data were analysed thematically and theoretical frameworks used to explain the findings.
34 participants were recruited: 18 patients, 14 practice staff (9 general practitioners, 4 practice nurses, 1 practice manager) and 2 practice pharmacists. Five main themes emerged: environment; professional relationships and integration; pharmacist attributes; staff and patient benefits and logistical challenges. Participants reported that colocation and the interdisciplinary environment of general practice enabled better communication and collaboration compared to traditional community and consultant pharmacy services. Participants felt that pharmacists needed to possess certain attributes to ensure successful integration, including being personable and proactive. Attitudinal, professional and logistical barriers were identified but were able to be overcome. The findings were explained using D'Amour's structuration model of collaboration and Roger's diffusion of innovation theory.
This is the first qualitative study to explore the experiences of general practice staff, pharmacists and patients on their interactions within the Australian general practice environment. Participants were receptive of colocated pharmacist services, and various barriers and facilitators to integration were identified. Future research should investigate the feasibility and sustainability of general practice pharmacist roles.
PMCID: PMC3773653  PMID: 24030867
Primary Care; Qualitative Research; Health Services Administration & Management
20.  Is there a crisis in nursing retention in New South Wales? 
There is a severe shortage of nurses in Australia. Policy makers and researchers are especially concerned that retention levels of nurses in the health workforce have worsened over the last decade. There are also concerns that rapidly growing private sector hospitals are attracting qualified nurses away from the public sector. To date no systematic analysis of trends in nursing retention rates over time has been conducted due to the lack of consistent panel data.
A 1.4 percentage point improvement in retention has led to a 10% increase in the overall supply of nurses in NSW. There has also been a substantial aging of the workforce, due to greater retention and an increase in mature age entrants. The improvement in retention is found in all types of premises and is largest in nursing homes. There is a substantial amount of year to year movement in and out of the workforce and across premises. The shortage of nurses in public hospitals is due to a slowdown in entry rather than competition from the rapidly growing private sector hospitals.
Policy Implications
The finding of an improvement (rather than a worsening) in retention suggests that additional improvements may be difficult to achieve as further retention must involve individuals more and more dissatisfied with nursing relative to other opportunities. Hence policies targeting entry such as increased places in nursing programs and additional subsidies for training costs may be more effective in dealing with the workforce shortage. This is also the case for shortages in public sector hospitals as retention in nursing is found to be relatively high in this sector. However, the large amount of year to year movements across nursing jobs, especially among the younger nurses, also suggests that policies aimed at reducing job switches and increasing the number who return to nursing should also be pursued. More research is needed in understanding the relative importance of detailed working conditions and the problems associated with combining family responsibilities and nursing jobs.
PMCID: PMC2546412  PMID: 18681970
21.  Communications Training in Pharmacy Education, 1995-2010 
The role of the pharmacist as a “communicator” of information and advice between patients, other healthcare practitioners, and the community is recognized as a vital component of the responsibilities of a practicing pharmacist. Pharmacy education is changing to reflect this, although the difficulty is in designing a curriculum that is capable of equipping students with the necessary knowledge and skills, using activities that are effective in promoting communication competency. The objective of this review was to identify published, peer-reviewed articles concerning communication training in pharmacy education programs, and describe which communication skills the structured learning activities aimed to improve and how these learning activities were assessed. A systematic literature search was conducted and the articles found were analyzed and divided into categories based on specific communication skills taught and type of learning activity used. Oral interpersonal communication skills targeted at patients were the most common skill-type described, followed by clinical writing skills. Common teaching methods included simulated and standardized patient interactions and pharmacy practice experience courses. Most educational interventions were assessed by subjective measures. Many interventions were described as fragments, in isolation of other learning activities that took place in a course, which impedes complete analysis of study results. To succeed in communication training, integration between different learning activities and progression within pharmacy educations are important.
PMCID: PMC3602860  PMID: 23519011
communication; educational methods; learning outcomes; pharmacy education
22.  How evidence-based workforce planning in Australia is informing policy development in the retention and distribution of the health workforce 
Australia’s health workforce is facing significant challenges now and into the future. Health Workforce Australia (HWA) was established by the Council of Australian Governments as the national agency to progress health workforce reform to address the challenges of providing a skilled, innovative and flexible health workforce in Australia. HWA developed Australia’s first major, long-term national workforce projections for doctors, nurses and midwives over a planning horizon to 2025 (called Health Workforce 2025; HW 2025), which provided a national platform for developing policies to help ensure Australia’s health workforce meets the community’s needs.
A review of existing workforce planning methodologies, in concert with the project brief and an examination of data availability, identified that the best fit-for-purpose workforce planning methodology was the stock and flow model for estimating workforce supply and the utilisation method for estimating workforce demand. Scenario modelling was conducted to explore the implications of possible alternative futures, and to demonstrate the sensitivity of the model to various input parameters. Extensive consultation was conducted to test the methodology, data and assumptions used, and also influenced the scenarios selected for modelling. Additionally, a number of other key principles were adopted in developing HW 2025 to ensure the workforce projections were robust and able to be applied nationally.
The findings from HW 2025 highlighted that a ‘business as usual’ approach to Australia’s health workforce is not sustainable over the next 10 years, with a need for co-ordinated, long-term reforms by government, professions and the higher education and training sector for a sustainable and affordable health workforce. The main policy levers identified to achieve change were innovation and reform, immigration, training capacity and efficiency and workforce distribution.
While HW 2025 has provided a national platform for health workforce policy development, it is not a one-off project. It is an ongoing process where HWA will continue to develop and improve health workforce projections incorporating data and methodology improvements to support incremental health workforce changes.
PMCID: PMC3922608  PMID: 24490586
Workforce planning; Workforce projections
23.  Economic evaluation of task-shifting approaches to the dispensing of anti-retroviral therapy 
A scarcity of human resources for health has been identified as one of the primary constraints to the scale-up of the provision of Anti-Retroviral Treatment (ART). In South Africa there is a particularly severe lack of pharmacists. The study aims to compare two task-shifting approaches to the dispensing of ART: Indirectly Supervised Pharmacist’s Assistants (ISPA) and Nurse-based pharmaceutical care models against the standard of care which involves a pharmacist dispensing ART.
A cross-sectional mixed methods study design was used. Patient exit interviews, time and motion studies, expert interviews and staff costs were used to conduct a costing from the societal perspective. Six facilities were sampled in the Western Cape province of South Africa, and 230 patient interviews conducted.
The ISPA model was found to be the least costly task-shifting pharmaceutical model. However, patients preferred receiving medication from the nurse. This related to a fear of stigma and being identified by virtue of receiving ART at the pharmacy.
While these models are not mutually exclusive, and a variety of pharmaceutical care models will be necessary for scale up, it is useful to consider the impact of implementing these models on the provider, patient access to treatment and difficulties in implementation.
PMCID: PMC3473241  PMID: 22974373
Task-shifting; Pharmaceutical care models; Skills mix; Anti-retroviral therapy
24.  Physician and Pharmacist Collaboration: The University of Hawai‘i at Hilo College of Pharmacy - JABSOM Experience 
Hawaii Medical Journal  2010;69(6 Suppl 3):42-44.
The purpose of this article is to describe the experiential program created at the newly formed University of Hawai‘i at Hilo College of Pharmacy (UHH CoP). The Introductory Pharmacy Practice Experience (IPPE) rotations were developed to prepare student pharmacists for their final year of Advanced Pharmacy Practice Experience (APPE) rotations by improving clinical skills and patient interactions. In partnership with the John A. Burns School of Medicine (JABSOM) Department of Family Practice, physician and pharmacist teams collaborate to deliver patient care for chronic diseases and elevate educational opportunities provided by UHH CoP. Another goal of the experiential program is to determine whether the investment of pharmacist faculty and adjunct physician/nurse preceptors prepares students for the final year of APPE rotations. A survey was administered to non-faculty pharmacist preceptors who taught the third IPPE rotation during the summer of 2009. Twenty-nine surveys were received from six facilities on O‘ahu and the Big Island. Initial survey results revealed an overall rating average of 3.72 (Likert scale: 1-lowest to 5-highest), an average of 4.14 for professionalism, an average of 3.41 for overall clinical skills, and an average of 3.45 for overall readiness for experiential rotations. Average ratings when compared with fourth-year students from several mainland colleges ranged from 1.7 to 2.2 (1-worse than, 2-same, 3-better). This data demonstrates that UHH CoP is investing faculty and preceptor resources wisely to enhance the preparation of students for APPE rotations.
PMCID: PMC3123145  PMID: 20540001
25.  Effective in-service training design and delivery: evidence from an integrative literature review 
In-service training represents a significant financial investment for supporting continued competence of the health care workforce. An integrative review of the education and training literature was conducted to identify effective training approaches for health worker continuing professional education (CPE) and what evidence exists of outcomes derived from CPE.
A literature review was conducted from multiple databases including PubMed, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between May and June 2011. The initial review of titles and abstracts produced 244 results. Articles selected for analysis after two quality reviews consisted of systematic reviews, randomized controlled trials (RCTs) and programme evaluations published in peer-reviewed journals from 2000 to 2011 in the English language. The articles analysed included 37 systematic reviews and 32 RCTs. The research questions focused on the evidence supporting educational techniques, frequency, setting and media used to deliver instruction for continuing health professional education.
The evidence suggests the use of multiple techniques that allow for interaction and enable learners to process and apply information. Case-based learning, clinical simulations, practice and feedback are identified as effective educational techniques. Didactic techniques that involve passive instruction, such as reading or lecture, have been found to have little or no impact on learning outcomes. Repetitive interventions, rather than single interventions, were shown to be superior for learning outcomes. Settings similar to the workplace improved skill acquisition and performance. Computer-based learning can be equally or more effective than live instruction and more cost efficient if effective techniques are used. Effective techniques can lead to improvements in knowledge and skill outcomes and clinical practice behaviours, but there is less evidence directly linking CPE to improved clinical outcomes. Very limited quality data are available from low- to middle-income countries.
Educational techniques are critical to learning outcomes. Targeted, repetitive interventions can result in better learning outcomes. Setting should be selected to support relevant and realistic practice and increase efficiency. Media should be selected based on the potential to support effective educational techniques and efficiency of instruction. CPE can lead to improved learning outcomes if effective techniques are used. Limited data indicate that there may also be an effect on improving clinical practice behaviours. The research agenda calls for well-constructed evaluations of culturally appropriate combinations of technique, setting, frequency and media, developed for and tested among all levels of health workers in low- and middle-income countries.
PMCID: PMC3850724  PMID: 24083659
In-service training; Continuing professional education; Continuing medical education; Continuing professional development

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