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Background: Delegation of clinical tasks from physiotherapists to physiotherapy support workers is common yet varies considerably in musculoskeletal outpatient physiotherapy services, leading to variation in patient care. This study aimed to explore patients' preferences and estimate specific trade-offs patients are willing to make in treatment choices when treated in musculoskeletal outpatient physiotherapy services. Methods: A discrete choice experiment was conducted using an efficient design with 16 choice scenarios, divided into two blocks. Adult patients with musculoskeletal conditions recruited from a physiotherapy service completed a cross-sectional, online questionnaire. Choice data analyses were conducted using a multinomial logit model. The marginal rate of substitution for waiting time to first follow-up physiotherapy appointment and distance from the physiotherapy clinic was calculated and a probability model was built to estimate the probability of choosing between two distinct physiotherapy service options under different scenarios. Results: 382 patient questionnaires were completed; 302 participants were treated by physiotherapists and 80 by physiotherapists and support workers. There was a significant preference to be seen by a physiotherapist, have more follow-up treatments, to wait less time for the first follow-up appointment, to be seen one-to-one, to see the same clinician, to travel a shorter distance to get to the clinic and to go to clinics with ample parking. Participants treated by support workers did not have a significant preference to be seen by a physiotherapist and it was more likely that they would choose to be seen by a support worker for clinic scenarios where the characteristics of the physiotherapy service were as good or better. Conclusions: Findings highlight that patients treated by support workers are likely to choose to be treated by support workers again if the other service characteristics are as good or better compared to a service where treatment is provided only by physiotherapists. Findings have implications for the design of physiotherapy services to enhance patient experience when patients are treated by support workers. The findings will contribute to the development of "best practice" recommendations to guide physiotherapists in delegating clinical work to physiotherapy support workers for patients with musculoskeletal conditions. [ABSTRACT FROM AUTHOR]

Abstract Background Delegation of clinical tasks from physiotherapists to physiotherapy support workers is common yet varies considerably in musculoskeletal outpatient physiotherapy services, leading to variation in patient care. This study aimed to explore patients’ preferences and estimate specific trade-offs patients are willing to make in treatment choices when treated in musculoskeletal outpatient physiotherapy services. Methods A discrete choice experiment was conducted using an efficient design with 16 choice scenarios, divided into two blocks. Adult patients with musculoskeletal conditions recruited from a physiotherapy service completed a cross-sectional, online questionnaire. Choice data analyses were conducted using a multinomial logit model. The marginal rate of substitution for waiting time to first follow-up physiotherapy appointment and distance from the physiotherapy clinic was calculated and a probability model was built to estimate the probability of choosing between two distinct physiotherapy service options under different scenarios. Results 382 patient questionnaires were completed; 302 participants were treated by physiotherapists and 80 by physiotherapists and support workers. There was a significant preference to be seen by a physiotherapist, have more follow-up treatments, to wait less time for the first follow-up appointment, to be seen one-to-one, to see the same clinician, to travel a shorter distance to get to the clinic and to go to clinics with ample parking. Participants treated by support workers did not have a significant preference to be seen by a physiotherapist and it was more likely that they would choose to be seen by a support worker for clinic scenarios where the characteristics of the physiotherapy service were as good or better. Conclusions Findings highlight that patients treated by support workers are likely to choose to be treated by support workers again if the other service characteristics are as good or better compared to a service where treatment is provided only by physiotherapists. Findings have implications for the design of physiotherapy services to enhance patient experience when patients are treated by support workers. The findings will contribute to the development of “best practice” recommendations to guide physiotherapists in delegating clinical work to physiotherapy support workers for patients with musculoskeletal conditions.

Why you should read this article: • To refresh your knowledge of the nursing associate role and the reasons why it was introduced • To recognise the barriers and challenges in implementing the nursing associate role in general practice • To consider how the nursing associate role could be better supported and more widely accepted in general practice. Background: The nursing associate role was introduced to help reduce staff shortages in the NHS by bridging the gap between healthcare assistants and nurses. However, there is evidence that its implementation in general practice has been limited. Aim: To understand why, how and to what extent the nursing associate role has been implemented in general practice and what the barriers and enablers have been. Method: Semi-structured interviews and focus group discussions were conducted with a purposive sample of general practice staff in north east England. Template analysis based on a priori themes drawn from the literature was used to analyse the data. Findings: A total of 17 interviews and three focus group discussions were conducted with 29 GPs, managers, nurses, nursing associates, trainee nursing associates and healthcare assistants from five general practices. The barriers to the implementation of the new role included a lack of clarity about the place and purpose of nursing associates, a mismatch between nursing associate training and practices’ needs, tensions around professional boundaries, and challenges in developing a professional identity. Conclusion: In general practice settings, the role of nursing associate is not yet fulfilling its original purpose and it needs to be better supported, accepted and implemented. [ABSTRACT FROM AUTHOR]

In the UK the development of skill mix in radiography at the end of the 20th century formalised the assistant practitioner role, separating it from the support worker function. The key aim was to increase imaging capacity whilst enabling opportunities for career progression within both the support and radiography workforce. There has been limited examination of these support and assistive roles and this review aims to explore the current evidence. This scoping review used a systematic search strategy and interrogated MEDLINE, CINAHL, Scopus and Google Scholar. Primary research articles published in the English-language referring to studies conducted in the UK on assistant or support roles in radiography were sought. The sourced data was uploaded to a web-based review platform for screening. The literature search identified only 11 articles which met the search criteria, of which only one referred to the support worker role. Adopting a primarily qualitative approach the quality of the articles varied. Thematic analysis was undertaken using a priori themes role purpose, outcomes, aspirations and capacity building. There is limited research evidence of capacity generation with most presenting individual perspectives. Job satisfaction and career aspirations within the support and assistive workforce are evident but there is still confusion over scope of practice and supervision. The support and assistive workforce are a key part of the diagnostic imaging workforce but limited research evidence examining these roles has been published. Further research exploring the impact of skill mix changes across all levels and imaging professions is required. [ABSTRACT FROM AUTHOR]

To deal with the upcoming challenges and complexity of the nursing profession, it is deemed important to reflect on our current organization of care. However, before starting to rethink the organization of nursing care, an overview of important elements concerning nursing care organization, more specifically nursing models, is necessary. The aim of this study was to conduct a mapping review, accompanied by an evidence map to map the existing literature, to map the field of knowledge on a meta‐level and to identify current research gaps concerning nursing models in a hospital setting. Next to nursing models, two other organizational correlates seem to be of importance when looking at the organization of nursing care: nurse staffing and skill mix. Although it seems that in recent research, the theoretical focus on the organization of nursing care has been left behind, the increasingly complex healthcare environment might gain from the use of nursing theory, or in this case, care delivery models. As almost no fundamental studies have been done toward the combination of care delivery models, nurse staffing, and skill mix, those elements should be taken into account to fully capture the organization of nursing care in future research. [ABSTRACT FROM AUTHOR]

The success and safety of modern radiotherapy relies on accurate contouring. Understanding the time taken to complete radiotherapy contours is critical to informing workforce planning and, in the context of a workforce shortfall, advocating for investment in technology and multi-professional skills mix. We aimed to quantify the time taken to delineate target volumes for radical radiotherapy. The Royal College of Radiologists circulated two electronic surveys via email to all clinical oncology consultants in the UK. The individual case survey requested anonymous data regarding the next five patients contoured for radical radiotherapy. The second survey collected data on respondents' usual practice in radiotherapy contouring. The median time to contour one radiotherapy case was 85 minutes (IQR = 50–131 minutes). Marked variability between and within tumour sites was evident: paediatric cancers took the most time (median = 210 minutes, IQR = 87.5 minutes), followed by head and neck and gynaecological cancers (median = 120 minutes, IQR = 71 and 72.5 minutes respectively). Breast cancer contouring required the least time (median = 43 minutes, IQR = 60 minutes). Radiotherapy technique, inclusion of nodes and 4D CT planning were associated with longer contouring times. A non-medical professional was involved in contouring in 65% of cases, but clinical oncology consultants were involved in target volume delineation in 90% of cases, and OARs in 74%. Peer review took place in 46% of cases with 56% of consultants reporting no time for peer review in their job plan. Contouring for radical radiotherapy is complex and time-consuming, and despite increasing involvement of non-medical professionals, clinical oncology consultants remain the primary practitioners. Peer review practice is variable and time is often a limiting factor. Many factors influence the time required for contouring, and departments should take these factors and the need for peer-review into account when developing job plans. • Contouring for radical radiotherapy requires considerable consultant time. • Time needed for contouring varies considerably, and is affected by patient, tumour and treatment related factors. • As more advanced treatment techniques become more commonplace, complexity and time requirements are certain to increase. • Despite involvement of non-medical professionals, clinical oncology consultants remain the primary contouring practitioners. • Time constraints are a major factor limiting peer review practice. [ABSTRACT FROM AUTHOR]

Abstract Background Independent inquiries have identified that appropriate staffing in maternity units is key to enabling quality care and minimising harm, but optimal staffing levels can be difficult to achieve when there is a shortage of midwives. The services provided and how they are staffed (total staffing, skill-mix and deployment) have been changing, and the effects of workforce changes on care quality and outcomes have not been assessed. This study aims to explore the association between daily midwifery staffing levels and the rate of reported harmful incidents affecting mothers and babies. Methods We conducted a cross-sectional analysis of daily reports of clinical incidents in maternity inpatient areas matched with inpatient staffing levels for three maternity services in England, using data from April 2015 to February 2020. Incidents resulting in harm to mothers or babies was the primary outcome measure. Staffing levels were calculated from daily staffing rosters, quantified in Hours Per Patient Day (HPPD) for midwives and maternity assistants. Understaffing was defined as staffing below the mean for the service. A negative binomial hierarchical model was used to assess the relationship between exposure to low staffing and reported incidents involving harm. Results The sample covered 106,904 maternal admissions over 46 months. The rate of harmful incidents in each of the three services ranged from 2.1 to 3.0 per 100 admissions across the study period. Understaffing by registered midwives was associated with an 11% increase in harmful incidents (adjusted IRR 1.110, 95% CI 1.002,1.229). Understaffing by maternity assistants was not associated with an increase in harmful incidents (adjusted IRR 0.919, 95% 0.813,1.039). Analysis of specific types of incidents showed no statistically significant associations, but most of the point estimates were in the direction of increased incidents when services were understaffed. Conclusion When there is understaffing by registered midwives, more harmful incidents are reported but understaffing by maternity assistants is not associated with higher risk of harms. Adequate registered midwife staffing levels are crucial for maintaining safety. Changes in the profile of maternity service workforces need to be carefully scrutinised to prevent mothers and babies being put at risk of avoidable harm.

Bureaucratic and administrative tasks associated with health care provision have historically fallen on health care professionals, which is one among the factors contributing to low job satisfaction and lower productivity. Incorporating new professional roles that help to better respond to the needs of both patients and professionals can increase the quality and efficiency of service provision. This article aims to evaluate the impact of the clinical assistant's introduction in the Sant Joan de Deu Barcelona Children's Hospital's pediatric oncology department, in terms of (i) displacement of activity loads carried out by this new professional role and the consequent time freed up for physicians, (ii) physicians' satisfaction and (iii) efficiency of the new care model. This is an observational and retrospective study using administrative data based on the type of activity performed by clinical assistants and the measurement of the time freed up in favor of the physicians. The potential skill mix productivity increase, survey of physicians' satisfaction, and reduction in costs with the new model was analyzed. During the first year of its implementation in the pediatric oncology department, clinical assistants have performed 13,553 requests (69% of the total), representing a total saving of 266.83 hours or 6.67 workweeks of 40 hours. They performed 74% of outpatient surgical requests in the oncology department, 87% of day hospital requests and 54% of total requests in the outpatient consultations area. Physicians are overall satisfied with the new role and think they can use the time gained to do other things such as research or improving the quality of care. The role change allows reducing the cost per request by 56% in relation to the conventional model. In conclusion, the introduction of clinical assistants in the oncology department could be efficient to the extent that it displaces a significant part of the bureaucratic and administrative tasks previously performed by health care professionals and thus enables to reduce the cost of these processes. This delegation allows them to work more closely to the maximum of their competences and the physicians to have more time for higher added value clinical tasks and increase professional satisfaction. [ABSTRACT FROM AUTHOR]

Background: The Additional Roles Reimbursement Scheme (ARRS) was set up to recruit 26 000 additional staff into general practice by 2024, with the aim of increasing patient access to appointments. Despite the potential benefits of integrating ARRS practitioners into primary care, their implementation has not always been straightforward. Aim: To explore the challenges and enablers to implementation of the ARRS including its impact on primary and secondary care systems. Design and setting: Qualitative interview study with ARRS healthcare professionals and key professional stakeholders involved in staff education or scheme implementation across three integrated care systems in England. Method: Participants (n = 37) were interviewed using semi-structured individual or paired interviews. Interviews were audio-recorded and transcribed. Data were analysed using framework analysis until data saturation occurred. Results: Using framework analysis, 10 categories were identified. Three were categorised as successes: staff valued but their impact unclear; multiple and certain roles maximise impact; and training hub support. Seven were categorised as challenges: scheme inflexibility; creating a sustainable workforce with career progression; managing scope and expectations; navigating supervision and roadmap progression; infrastructure and integration challenges; ARRS roles impact on wider systems; and tensions and perspectives of existing staff. Conclusion: Most ARRS staff felt valued, but the scheme broadened expertise available in primary care rather than reducing GP burden, which was originally anticipated. Some PCNs, especially those in areas of high deprivation, found it difficult to meet the population's needs as a result of the scheme's inflexibility, potentially leading to greater health inequalities in primary care. Recommendations are proposed to optimise the effective implementation of the primary care workforce model. Further research is required to explore administrative role solutions, further understand the impact of health inequalities, and investigate the wellbeing of ARRS staff. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To recognise differences in adverse incident reporting between mental health and general healthcare settings • To appreciate the need to alter adverse incident reporting processes in mental health to consider workforce-related issues • To acknowledge the need for nurses to feel able to include workforce-related issues in adverse incident reports. While overall incident reporting in mental health settings has increased in recent years, so too has the frequency of self-harm and aggression towards patients and staff, which continue to be leading causes of adverse incidents. However, unlike adverse incident reporting in general hospitals, which focuses on factors such as suboptimal treatment or care, adverse incidents in mental health still focus on patients and their acts of self-harm or perceived aggression. Mental health adverse incident policy needs to change to emphasise that incidents occur when staff are unable to provide appropriate care, rather than simply when a patient becomes aggressive or engages in self-harm. However, this requires a shift in the values used to monitor adverse incidents so that patients’ self-harm or aggression is regarded partly as an outcome of inappropriate or omitted care, rather than solely a result of the patient’s actions. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study is to profile the contemporary advanced clinical practitioner (ACP) role through standardized document sets. Design: Documentary analysis of job descriptions (JDs), person specification and advertisements. Data Sources: England based jobs advertised on NHS jobs website from 22 January to 21 April 2021. Results: A toatal of 143 trainee and qualified ACP roles were identified. A wide range of sectors and specialities were represented from across all English regions. The most common roles were urgent care, emergency medicine and primary care. Most qualified roles were agenda for change band 8A, although this did vary across specialities. Many roles were restricted to a small number of professions, notably nursing, physiotherapy and paramedic. Inconsistent role titles were noted. A lack of understanding of regulation across different professions was noted. Conclusion: The ACP role has become an accepted across healthcare providers in England. Implementation remains varied across specialities and organizations. Eligibility criteria may relate to professional bias. Implications for the Profession and/or Patient Care: ACP roles are expanding but this may be at the detriment to advanced nursing posts. Inconsistency in role eligibility suggests some professional bias exists. Impact: This was scoping of ACP roles across England using job advertisements. ACP roles are common across sectors and specialities but eligibility varies. The research will have impact on those looking to recruit to ACP roles as well as those refining JDs. Reporting Method: No EQUATOR guideline exists for document analysis. Patient or Public Contribution: No Patient or Public Contribution. The research relates to organizational human resource information only. [ABSTRACT FROM AUTHOR]

Objectives Pharmacists' response to practice change tends to range from apprehension to excitement. It is unknown if these varying responses are related to differing personality traits. This study aimed to describe the personality traits of Australian pharmacists, pharmacist interns and pharmacy students and any potential associations with their career satisfaction and/or outlook. Methods Australian pharmacy students, pre-registration and registered pharmacists were eligible to participate in the cross-sectional online survey that consisted of participant demographics, personality traits (using a reliable validated instrument, the Big Five Inventory) and career outlook statements (three optimistic and three pessimistic statements). Data were analysed descriptively and using linear regression. Key findings The 546 respondents scored highly for agreeableness (4.0 ± 0.6) and conscientiousness (4.0 ± 0.6) and lowest in neuroticism (2.8 ± 0.8)). Pessimistic career outlook statements were predominantly neutral or disagreement, in contrast to the responses to the optimistic outlook statements that were predominantly neutral or agreement. Just over half (198 out of 368, 53%) of the registered pharmacists stated that they intended to practice in the profession for more than 10 years. For pharmacists, age had significant positive associations with the three optimistic career outlook statements and significant inverse relationships with three pessimistic career outlook statements. Neuroticism had significant inverse associations with optimistic statements and positive relationships with pessimistic statements. Conclusions All demographics tested was overall optimistic about the pharmacy profession with pharmacists scoring highly in agreeableness, conscientiousness and openness. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To understand the barriers and facilitators to integrating new non-medical practitioners in general practices • To recognise the challenges associated with integrating new non-medical practitioners in general practices • To acknowledge that sustainable models of transdisciplinary working are needed to ensure that the general practice workforce can deliver safe, effective and responsive patient care General practices in England face workforce challenges because of insufficient numbers of GPs and practice nurses, combined with an increase in demand for services. One solution is to integrate new non-medical practitioners – such as advanced nurse practitioners, paramedics, pharmacists, physician associates and physiotherapists – in the general practice team. The integration of some of these roles is incentivised by the Additional Roles Reimbursement Scheme launched in 2019 for five years. This article reports on and discusses the findings of a scoping review of the recent literature on the barriers and facilitators to the integration of new non-medical practitioners in general practices in England. The review found that the integration of new non-medical practitioners faces many challenges and that sustainable models of transdisciplinary working are needed. [ABSTRACT FROM AUTHOR]

The article reflects on the development of a band five nurse coordinators' competency pathway at the Sheffield Children's National Health Service (NHS) Foundation Trust hospital in England. It describes a mixed-methods approach involving qualitative and quantitative data collection to assess the effectiveness of competency pathway and simulation training. Data analysis presented reveals gender gap, length of nurses' experience and embedding of pathway in the trust, and training effectiveness.

Although the phenomenon of crowding in emergency departments (EDs) is not new, it remains a significant problem for patients, ED staff and the wider healthcare system. Crowding in EDs, which is also called overcrowding, has been widely explored in the literature, but there are relatively few studies of the subject from an emergency nurse perspective. This article reports the findings of a literature review that aimed to explore the effects of crowding on nurses working in EDs. Four key themes were identified from a synthesis of 16 articles included in the review: staffing and skill mix; inadequate care and the effect on nurses' well-being and stress levels; violence in the ED; and hospital metrics and patient flow. Further research is required to explore in more depth the effects of ED crowding on emergency nurses and to address the multiple factors that perpetuate the phenomenon., Competing Interests: None declared, (© 2024 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Aim: The purpose of this study was to examine the impact of nurse staffing on inpatient falls performance across a multi‐hospital system. Background: Evidence to support which staffing variables influence fall performance so that health care organizations can better allocate resources is lacking. Method: A descriptive study design was used to analyse the impact of nurse staffing and falls performance, with units dichotomized as either high or low performing based on national benchmarking data. The impact was evaluated using 10 nurse staffing variables. Results: A total of nine units were included (five high and four low performing). Higher performing units showed less use of sitters and travellers, had fewer overtime hours worked by nurses, and employed more expert‐level clinical nurses and combined nursing assistant/health unit coordinator positions, than lower performing units. Conclusion: Findings provide evidence of how staffing variables affect a unit's falls performance. While significant relationships were found, further evaluation is needed to explore the relationship of staffing variables and quality outcomes. Implications for Nursing Management: Nursing managers may consider trying to reduce use of sitters and travellers, and utilize innovative staffing models, such as using combined nursing assistant/health unit coordinator positions, to help improve their falls performance. [ABSTRACT FROM AUTHOR]

Background: Globally, nurses are increasingly employed post-retirement, with task-shifting to nurses with lower competencies, a lack of knowledge being a barrier, all of which could lead to medication errors. Aim: To describe the impact of nurses’ age, experience, training, and skill mix on the medication administration processes in long-term care facilities (LTCFs). Setting: Nurses (N=123) working in 28 LTCFs in the Western Cape province, South Africa. Methods: A quantitative non-experimental, cross-sectional descriptive design was used. The LTCFs were divided into funded (state-subsidised) and private (for profit) facilities using a stratified sampling method and each stratum thereafter randomised to obtain equal samples from each stratum. Self-administered questionnaires with close-ended statements were used, and statistical software (SPSS version 27) to perform descriptive and inferential analyses. Results: Respondents, (27%), had more than nine years of experience, with 15.8% aged 61-70 years; and 3.5% aged 71-80 years. Some were ‘very inexperienced’ in computer use (29.3%), 35% received medication training longer than five years ago, and n=28 nurses administered medication outside their scope of practice. The highest sources of job pressure were an increase in workloads (75.6%), being under stress (42.3%), and being overworked (39.0%). Conclusion: The aging nursing workforce, although experienced, found the job demands, paperwork, and technology barriers. Outdated training and delegating medication administration to lower categories of nurses can lead to medication errors. Contribution: This study’s findings can serve as a guideline for creating succession plans, recruiting procedures, development, and training of nurses, and improving clinical practices.

Radiographers have been undertaking reporting tasks since the 1980's with a wealth of evidence published to support this practice. Radiographers have since developed skills in reporting all body systems, from all referral sources across a range of modalities. Radiographer reporting is now considered established and demand for radiographers in this role is rising to meet service demand. Reporting radiographers work as part of multi-professional image reporting teams, it is unclear how the radiographer role is perceived as part of this model. The aim was to review peer-reviewed literature to evaluate how the role of the reporting radiographer is portrayed and how the relationship between the two imaging professions has developed. Language used to discuss the role of the reporting radiographer has changed over time. There is progress demonstrated from the practice of radiographer reporting being considered contentious or opposed to accepted and established. Recent publications focus on the importance utilising the skills of all multi-disciplinary team members in workforce structure. This features prominently when discussing future workforce design, such as with the Cancer workforce strategy and the development of the national standards for musculoskeletal reporting. Published literature has highlighted a move towards acceptance of the reporting radiographer role. Multi-disciplinary team working, utilising the skills of all imaging team members, is essential to the success and sustainability of the imaging workforce moving forwards. Reporting by radiographers is established and will be prominent in the reporting workforce as part of long-term workforce planning, considering skills mix to form effective and sustainable multidisciplinary reporting teams. [ABSTRACT FROM AUTHOR]

Aim: To identify and follow‐up on the transition towards differentiated nursing practice among bachelor trained and vocationally trained nurses in Dutch hospitals. Design: A multiphase general qualitative interview study. Methods: Fifty semi‐structured interviews with project managers in charge of introducing differentiated nursing practice to their hospital were conducted. Purposive sampling was used, and data were collected in 2017, 2019 and 2020. A meta‐analysis was conducted after independent primary thematic analysis of each data collection. Results: The introduction of differentiated nursing practice to Dutch hospitals was perceived as uncertain and ambiguous. Three themes were identified during the transition towards differentiated nursing practice: (1) call to action; (2) sitting and waiting; and (3) new beginnings and open ends. The change to differentiated nursing practice is not straightforward and these findings highlight the emerging awareness among project managers of the nature and complexity of the transition. During the study period, professionalization of the nursing profession was recognized as fundamental in hospital organizations. Conclusion: Nursing cannot be separated from differentiated nursing practice. Visible leadership is important at all organizational levels and nurses' opinions must be considered as nurses are essential to such changes in healthcare. Impact: Differentiated nursing practice based on nursing education allows nurses to make the best use of their experience, skills and competencies, and could promote the provision of effective and high‐quality patient care. However, in many cases, a nurse's practice role is based on their nursing licensure instead of their educational background. The change to differentiated nursing practice in hospitals is not straightforward and the nature and complexity of the transition needs to be acknowledged. Nurses have an important role in healthcare transformation and need to be active in developing and formulating rather than just implementing the changes. [ABSTRACT FROM AUTHOR]

Background: Globally, nurses are increasingly employed post-retirement, with task-shifting to nurses with lower competencies, a lack of knowledge being a barrier, all of which could lead to medication errors. Aim: To describe the impact of nurses' age, experience, training, and skill mix on the medication administration processes in long-term care facilities (LTCFs). Setting: Nurses (N=123) working in 28 LTCFs in the Western Cape province, South Africa. Methods: A quantitative non-experimental, cross-sectional descriptive design was used. The LTCFs were divided into funded (state-subsidised) and private (for profit) facilities using a stratified sampling method and each stratum thereafter randomised to obtain equal samples from each stratum. Self-administered questionnaires with close-ended statements were used, and statistical software (SPSS version 27) to perform descriptive and inferential analyses. Results: Respondents, (27%), had more than nine years of experience, with 15.8% aged 61- 70 years; and 3.5% aged 71-80 years. Some were 'very inexperienced' in computer use (29.3%), 35% received medication training longer than five years ago, and n=28 nurses administered medication outside their scope of practice. The highest sources of job pressure were an increase in workloads (75.6%), being under stress (42.3%), and being overworked (39.0%). Conclusion: The aging nursing workforce, although experienced, found the job demands, paperwork, and technology barriers. Outdated training and delegating medication administration to lower categories of nurses can lead to medication errors. Contribution: This study's findings can serve as a guideline for creating succession plans, recruiting procedures, development, and training of nurses, and improving clinical practices. [ABSTRACT FROM AUTHOR]

Aim: Integrated knowledge translation (IKT) is an increasingly recommended collaborative approach to minimize knowledge translation gap. Still, few studies have documented the impact of IKT to optimize knowledge uptake in healthcare settings. An IKT-based clinical algorithm (Algo) was deployed in Quebec (Canada) homecare services to support skill mix for selecting bathing equipment for community-dwelling adults. The objective of this study was to document the characteristics related to Algo's IKT process. Methods: A multiple-case study with a nested concurrent mixed design was conducted in provincial homecare services. Based on Knott and Wildavsky's seven-stage classification and the integrated- Promoting Action on Research Implementation in Health Services model, Innovation , Recipients , and Context , characteristics related to Algo's levels of utilization were documented. Quantitative (electronic questionnaire) and qualitative (semistructured interviews and focus groups) data were collected for each case (i.e. homecare service). Descriptive statistics and thematic analysis were performed to describe each case through a mixed methods matrix, for intra/intercase analyses. Results: Knowledge translation characteristics of five Algo's levels of utilization were documented: reception, cognition, reference, effort, and impact. Innovation characteristics (e.g. underlying knowledge) were found to facilitate its dissemination and its use. However, the Recipients (e.g. unclear mechanisms to implement change) and Context (e.g. organizational mandates nonaligned with skill mix) characteristics hampered its application through intermediate and advanced levels of utilization. Conclusion: The knowledge translation analysis of Algo allowed for documenting the IKT-based benefits in terms of utilization in healthcare settings. Although an IKT approach appears to be a strong facilitator for initiating the implementation process, additional characteristics should be considered for promoting and sustaining its use on local, organizational, and external levels of context. Facilitation strategies should document the administrative benefits related to Algo's utilization and contextualize it according to homecare services' characteristics. Key points * The IKT approach used for developing Algo facilitated the initiation of its application but seems insufficient in its actual form to support its implementation accordingly to contextual characteristics (e.g. policies). * Ulterior IKT initiatives should embrace additional stakeholders and contextual characteristics to better align the codevelopment of scientific knowledge with priorities and mandates of the healthcare system. [ABSTRACT FROM AUTHOR]

Objective: To examine how estimates of the association between nurse staffing and patient length of stay (LOS) change with data aggregation over varying time periods and settings, and statistical controls for unobserved heterogeneity. Data Sources/Study Setting: Longitudinal secondary data from October 2002 to September 2006 for 215 intensive care units and 438 general acute care units at 143 facilities in the Veterans Affairs (VA) health care system. Research Design: This retrospective observational study used unit-level panel data to analyze the association between nurse staffing and LOS. This association was measured over both a month-long and a year-long period, with and without fixed effects. Data Collection: We used VA administrative data to obtain patient data on the severity of illness and LOS, as well as labor hours and wages for each unit by month. Principal Findings: Overall, shorter LOS was associated with higher nurse staffing hours and lower proportions of hours provided by licensed professional nurses (LPNs), unlicensed personnel, and contract staff. Estimates of the association between nurse staffing and LOS changed in magnitude when aggregating data over years instead of months, in different settings, and when controlling for unobserved heterogeneity. Conclusions: Estimating the association between nurse staffing and LOS is contingent on the time period of analysis and specific methodology. In future studies, researchers should be aware of these differences when exploring nurse staffing and patient outcomes. [ABSTRACT FROM AUTHOR]

Abstract This commentary article addresses a critical issue facing Kenya and other Low- and Middle-Income Countries (LMIC): how to remedy deficits in hospitals’ nursing workforce. Would employing health care assistants (HCAs) provide a partial solution? This article first gives a brief introduction to the Kenyan context and then explores the development of workforce roles to support nurses in Europe to highlight the diversity of these roles. Our introduction pinpoints that pressures to maintain or restrict costs have led to a wide variety of formal and informal task shifting from nurses to some form of HCA in the EU with differences noted in issues of appropriate skill mix, training, accountability, and regulation of HCA. Next, we draw from a suite of recent studies in hospitals in Kenya which illustrate nursing practices in a highly pressurized context. The studies took place in neo-natal wards in Kenyan hospitals between 2015 and 2018 and in a system with no legal or regulatory basis for task shifting to HCAs. We proffer data on why and how nurses informally delegate tasks to others in the public sector and the decision-making processes of nurses and frame this evidence in the specific contextual conditions. In the conclusion, the paper aims to deepen the debates on developing human resources for health. We argue that despite the urgent pressures to address glaring workforce deficits in Kenya and other LMIC, caution needs to be exercised in implementing changes to nursing practices through the introduction of HCAs. The evidence from EU suggests that the rapid growth in the employment of HCA has created crucial issues which need addressing. These include clearly defining the scope of practice and developing the appropriate skill mix between nurses and HCAs to match the specific health system context. Moreover, we suggest efforts to develop and implement such roles should be carefully designed and rigorously evaluated to inform continuing policy development.

An important problem faced by many healthcare systems is the shortage of medical staff, and in particular doctors and nurses. Their number, competences and qualifications determine the level of availability and quality of medical services. Unfortunately, the demand for medical services is increasing, along with the progressive aging of the population, as well as the increase in the incidence of chronic diseases and frequent reforms of health systems. Employee costs related to healthcare are the most burdensome for the system; therefore, based on the available resources, it is necessary to create effective teams of sector employees. This results in rationalizing employment, or providing new medical and about medical competencies to new groups of professionals, which gives rise to the skill mix phenomenon. A well-prepared and implemented skill mix contributes to improving the quality of patient care, increased patient satisfaction and better clinical outcomes. In the process of mixing of competences, the roles that have been exercised so far are being changed. While some professionals are expanding their existing roles, other employees are required to accept some aspects of the previous roles. In Poland, in order to counteract such negative trends (the shortage of doctors), changes have been introduced to increase access to medical services (e.g., nurses and midwives being vested with the right to issue prescriptions and medical ordinances, paramedics – with the right to perform medical emergency services and provide healthcare services, and physiotherapists – with the right to conduct independent physiotherapeutic visits). A new profession of a medical coordinator has also been introduced. Med Pr. 2020;71(3):337–52

Purpose: Delegation of clinical tasks from physiotherapists to physiotherapy support workers varies considerably in musculoskeletal outpatient physiotherapy services leading to variation in patient care. This study aimed to develop consensus amongst physiotherapists, support workers and managers about what components should be included in a future framework to guide effective and safe delegation of clinical tasks to physiotherapy support workers in United Kingdom's National Health Service musculoskeletal outpatient physiotherapy services., Methods: A consensus study was carried out, using Nominal Group Technique. Seven physiotherapists, ten physiotherapy support workers and ten physiotherapy operational/clinical leads from 13 musculoskeletal physiotherapy services within United Kingdom's National Health Service were recruited through the Chartered Society of Physiotherapy's professional networks and social media. Three separate, role-specific consensus groups were convened, involving participants generating, discussing and rating on a Likert scale, components for inclusion in a future delegation framework., Results: 32 out of 38 generated items reached consensus of ≥70%, i.e. a mean of ≥4.9 on a 7-point Likert scale, across the three groups. Items were grouped under five main categories: 1) training/Continuous Professional Development for physiotherapists and support workers; 2) need for a clear delegation process; 3) competencies 4) defining the role of support workers and 5) safety net., Conclusion: Key stakeholder groups were able to reach consensus on five priority areas which will be developed into a best practice framework to standardise delegation and guide physiotherapists when delegating clinical tasks to support workers., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Community hospitals (CHs) could address the emerging complex care needs of patients. We investigated which characteristics of patients’ and CHs affect patient outcomes, in order to identify who could benefit the most from CH care and the best skill mix to deliver this care. Methods: We analysed all elderly patients discharged from the CHs of Emilia-Romagna, Italy. CH skill mix and care processes were collected with an ad hoc survey. The primary outcome was improvement in the Barthel index (BI) on discharge. Hierarchical regression analysis was performed to test the associations under study. Results: 53% of the patients had a BI improvement ≥10. After adjusting for the diverse case mix of the patients, no significant association was found between CH characteristics and BI improvement. Patient characteristics explained only a portion of the variability in CH performance. Discussion: Heterogeneity in case mix reflects the nature of CHs, which play context-specific roles as integrators between primary care services and hospitals. Residual variability in BI improvement rates across CHs might be attributed to aspects of care not detected in our survey. Conclusions: More research is needed to study the impact of CH skill mix and care processes on patient outcomes.

Aims: To examine the association between type of nursing staff and nursing-sensitive outcomes in long-term institutional care. Design: This systematic review included studies published in English, German, and Dutch between January 1997 and January 2020. Data sources: The databases Medline (PubMed), CINAHL, PsycINFO, Embase, and the Cochrane Library were searched. Original quantitative studies were included. Review methods: The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were followed. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used to critically appraise the reporting of the studies. Results: Fifteen articles were included. Of 33 quality of care outcomes, 21 were identified as nursing-sensitive outcomes of which 13 showed a significant association with nursing staff, specifically: Activities of daily living, aggressive behavior, bladder/bowel incontinence, contractures, expressive language skills, falls, infection (including vaccination), range of motion, pain, pressure ulcers, and weight loss. However, studies reported inconsistent results regarding the association among RNs, LPNs, CNAs, and HCAs and these nursing-sensitive outcomes, evidence shows that more RNs have a positive impact on nursing-sensitive outcomes. As to the evidence regarding the other type of nursing staff, especially HCA, findings regularly showed a negative association. Conclusion: Future research should be expanded with structure and process variables of which the mediating and moderating effect on nursing-sensitive outcomes is known. These may explain variances in quality of care and guide quality improvement initiatives. Researchers should consider fully applying Donabedian's structure-process-outcomes framework as it is a coherent entirety for quality assessment. Impact: This review provides an overview of quality of care outcomes that are responsive to nursing interventions in long-term institutional care. As the effects can be monitored and documented, quality assessment should focus on these nursing-sensitive outcomes. The inconclusive results make it difficult to provide recommendations on who should best perform which care. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to investigate multi-stakeholder perceptions of practicerelated facilitators to optimising the quality of Regulated Pharmacy Technician (RPT) integration into the community workforce in Ontario. Facilitators to incorporating technicians into the workflow and supporting their optimal scope of practice were explored. Methods: A qualitative exploratory study comprising a series of one-to-one interviews using a piloted, semi-structured interview guide was conducted with four community pharmacy stakeholder groups; pharmacists, RPTs, pharmacy assistants and pharmacy owners. Interviews were conducted until saturation of themes. Verbatim transcripts were coded inductively using the software, NVivo v12 (QSR International) and general inductive analysis identified key findings. Key findings: Twenty-seven interviews were conducted consisting of seven pharmacists, seven RPTs, eight assistants and five pharmacy owners working within community pharmacy and/or academia or hospital. All participants from every stakeholder group acknowledged that the promise of regulation of pharmacy technicians was unfulfilled in practice. Three major themes of practical significance were derived: (i) A viable business plan that incorporates RPT remuneration and ensures sustainability is a facilitator to fuller integration of RPTs, (ii) Planning the pharmacy workflow to support RPTs' and pharmacists' evolving scopes is a facilitator to RPT integration and (iii) Schedule planning to incorporate RPTs and appropriate staffing ratios in relation to prescription volume and pharmacy services allows for optimal utilisation of RPT skills and facilitates their integration. Conclusions: Achieving integration of RPTs into the business of a community pharmacy has educational, workplace and regulatory implications, requiring the effective engagement of all stakeholders in pharmacy. [ABSTRACT FROM AUTHOR]

Background: Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice. Methods: A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis. Results: Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses' invisible work; (2) nurses' roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses' (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients' needs to organizational capacity. Conclusions: Conducting small-change experiments, anchored by action and appraisal rather than by design, clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a 'two-way-window' in nursing role development, aligning policy initiatives with daily nursing practices. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To learn how a self-rostering system could improve the morale of staff • To develop ideas for implementing self-rostering in your ward • To understand how self-rostering could result in cost savings Staff morale is an important factor in maintaining and improving nurse recruitment and retention. Evidence suggests more flexible working patterns can improve nurses' work-life balance and subsequently their workplace satisfaction. This article describes a ward-based quality improvement project that introduced a self-rostering system that enabled nurses to select their own shifts for a given four-week roster period. The aim was to increase staff satisfaction and subsequently improve retention and recruitment. The article describes the project and discusses the positive outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background The physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management. Study design A descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated. Methods The patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system. Findings In total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care. Conclusions NPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.

Abstract Aims To identify nurse staffing groups in acute care facilities. Design This retrospective descriptive study used a configurational approach. Methods Data from a two‐month target period from January–March 2016 were collected for 40 facilities in four different hospitals in one of the largest regions of Quebec. Multiple factorial analysis and hierarchical ascendant classification were used to generate a limited number of nurse staffing groups. Results/Findings Four distinct nurse staffing groups emerged from this study. The least resourced model relied mainly on less qualified personnel and agency staff. The moderately resourced basic model was assessed as average across all staffing dimensions, but employed less overtime, relying mostly on auxiliary nurses. The moderately resourced professional group, also moderate in most variables, involved more overtime and fewer less qualified personnel. The most resourced group maximized highly qualified personnel and minimized instability in the nursing team. Conclusion This study covered multiple staffing groups with widely varying characteristics. Most groups entailed risks for quality of care at one or more levels. Few care units approached the theoretical staffing ideal.

The radiography profession is challenged by greater responsibilities and shortage of educated radiographers. Implementation of task shifting is one strategy to deal with the current situation in health care. The aim of this studiy was to evaluate radiographers' perception of assistant nurses and nurses carrying out tasks that traditionally were undertaken within the radiography profession in a Swedish context. An electronic questionnaire was distributed to radiographers at eleven hospitals in Sweden. The questionnaire included background questions and questions about radiographers' perception about task shifting to nurses and assistant nurses. The respondents rated their agreement level regarding task shifting on a five-point Likert scale. Data was statistically evaluated in SPSS using Mann Whitney U test. Sixty-five radiographers participated in the study. Most radiographers responded negatively to task shifting to nurses (72%) or assistant nurses (65%). Most radiographers disagree that nurses should perform mammography screening or work within interventional radiography, while the attitude towards nurses calculating glomerular filtration rate was more positive. A majority disagree regarding assistant nurses performing conventional radiographs, informing the patient about contrast media administration or inserting peripheral intravenous catheters, while there was a positive attitude towards assistant nurses preparing patients for examinations. The attitude towards task shifting was not influenced by age, however radiographers with less working experience were more positive to task shifting in general. A majority of the radiographers had a negative attitude towards task shifting to nurses and assistant nurses. The radiographers were more positive to hand over tasks related to patient care and administrative tasks than technical related tasks within the profession. Knowledge about radiographers' perception on task shifting within the profession is essential when planning and implementing strategies for task shifting in the clinical settings. [ABSTRACT FROM AUTHOR]

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Patient safety is an important outcome for nurses who provide patient care within an environment that may increase the incidence of errors or impose them to omit care; these errors mostly happen because of staff shortage. The purpose of this study is to identify the types and reasons of "missed nursing care" among Jordanian nurses, and to examine the relationships between "missed nursing care", staffing, intent to leave, and job satisfaction. A cross‐sectional descriptive design was used. A convenience sample of 300 nurses completed the Arabic version of MISSCARE which included items to measure types and reasons for "missed nursing care", staffing adequacy, job satisfaction, and intent to leave. The results of this study indicated that Labor resources were the most common cause of "missed nursing care". The results also showed that a low number of nurses per shift were associated with a high level of "missed nursing care". Nurse managers need to tackle staffing problems that may increase the rate of missed care and result in negative outcomes on the patients, nurses, as well as organizations. Nurse administrators could conduct evidence‐based staffing plans to manage nurse to patient ratio to decrease missed care and enhance satisfaction. [ABSTRACT FROM AUTHOR]

Introduction: Community hospitals (CHs) could address the emerging complex care needs of patients. We investigated which characteristics of patients' and CHs affect patient outcomes, in order to identify who could benefit the most from CH care and the best skill mix to deliver this care. Methods: We analysed all elderly patients discharged from the CHs of Emilia-Romagna, Italy. CH skill mix and care processes were collected with an ad hoc survey. The primary outcome was improvement in the Barthel index (BI) on discharge. Hierarchical regression analysis was performed to test the associations under study. Results: 53% of the patients had a BI improvement =10. After adjusting for the diverse case mix of the patients, no significant association was found between CH characteristics and BI improvement. Patient characteristics explained only a portion of the variability in CH performance. Discussion: Heterogeneity in case mix reflects the nature of CHs, which play contextspecific roles as integrators between primary care services and hospitals. Residual variability in BI improvement rates across CHs might be attributed to aspects of care not detected in our survey. Conclusions: More research is needed to study the impact of CH skill mix and care processes on patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry. Objectives: The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis. Design: A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study. Setting: The setting was NHS dental practices in North West England. Participants: A total of 217 low-risk patients in eight high-street dental practices participated. Interventions: The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm). Main outcome measure: The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists. Results: No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined. Limitations: The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate. Conclusions: Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value. Future work: Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation. Trial registration: Current Controlled Trials ISRCTN70032696. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Federal governance matters. Policy coordination allows the economic union to exercise monopsony power over migrants. Therefore the migration volumes under the policycompetition regime exceed those under the policy-coordination regime. With loose federal governance, competition over low-skilled migrants, who come with no capital, induces the individual member state to raise the provision of social benefit, so as to attract more migrants when starting from the coordination equilibrium. As a result, the social benefits in all other member States must also be raised to keep these migrants at their own economy. This amounts to excessively high income redistribution – a negative fiscal externality.

What is the impact of including an allied health assistant (AHA) role on physiotherapy service delivery in an acute respiratory service? A pragmatic pre-post design study examined physiotherapy services across two 3-month periods: current service delivery [P1] and current service delivery plus AHA [P2]. Clinical and non-clinical activity quantified as number, type and duration (per day) of all staff activity categorised for skill level (AHA, junior, senior). Physiotherapy service delivery increased in P2 compared to P1 (n = 4730 vs n = 3048). Physiotherapists undertook fewer respiratory (p < 0.001) and exercise treatments (p < 0.001) but increased reviews for inpatients (p < 0.001) and at multidisciplinary clinics in P2 (56% vs 76%, p < 0.01). The AHA accounted for 20% of all service provision. AHA activity comprised mainly non-direct clinical care including oversight of respiratory equipment use (e.g. supply, set-up, cleaning, loan audits) and other patient-related administrative tasks associated with delegation handovers, supervision and clinical documentation (72%), delegated supervision of established respiratory (5%) and exercise treatments (10%) and delegated exercise tests (3%). The AHA completed most of the exercise tests (n = 25). AHA non-direct clinical tasks included departmental management activities (11%). No adverse events were reported. AHA inclusion in an acute respiratory care service changed physiotherapy service provision. The AHA completed delegated routine clinical and non-clinical tasks. Physiotherapists increased clinic activity and annual reviews. Including an AHA role offers sustainable options for enhancing physiotherapy service provision in acute respiratory care. [ABSTRACT FROM AUTHOR]

Accessible summary: What is known on the subject?: Nursing skill mix research has primarily focused on medical and surgical patients.The association between nursing skill mix and clinical outcomes for psychiatric inpatients has not been adequately explored.No systematic reviews have been reported that have examined the association between the ratio of mental health to registered nurses and patient outcomes. What this paper adds to existing knowledge?: Our protocol sets out, in detail, the methods we intend to follow to ensure that this review is conducted and reported to the highest possible standards. What are the implications for practice?: The review will summarize evidence about safe staffing in mental health inpatient units internationally.The review will inform health policy and planning of health services. Aim: To assess the association between mental health nurse to comprehensive/general nurse ratio and relapse—determined by hospital admission—in adult psychiatric inpatients. Background information: There is considerable variation in psychiatric inpatient nursing skill mix internationally. In most countries, wards are typically staffed by a mix of mental health and comprehensive/general nurses. To date, there have been no systematic reviews that have examined the association between the ratio of mental health to registered nurses and patient outcomes. Method: We will systematically search five databases. Risk of bias will be determined using the Effective Public Health Practice Project Quality Assessment Tool. A meta‐analysis will be undertaken if there are at least two similar studies. Results: For included studies, we will produce table summarizing risk of bias and extracted data. If we are able to undertake a meta‐analysis, this will be reported as a forest plot. Discussion: This paper sets out a detailed plan for a systematic review of mental health nurse skill mix research. Implications for practice: High‐quality evidence about the association between nursing skill mix and patient outcomes is important to inform the planning of mental health services internationally. [ABSTRACT FROM AUTHOR]

This commentary article addresses a critical issue facing Kenya and other Low- and Middle-Income Countries (LMIC): how to remedy deficits in hospitals' nursing workforce. Would employing health care assistants (HCAs) provide a partial solution? This article first gives a brief introduction to the Kenyan context and then explores the development of workforce roles to support nurses in Europe to highlight the diversity of these roles. Our introduction pinpoints that pressures to maintain or restrict costs have led to a wide variety of formal and informal task shifting from nurses to some form of HCA in the EU with differences noted in issues of appropriate skill mix, training, accountability, and regulation of HCA. Next, we draw from a suite of recent studies in hospitals in Kenya which illustrate nursing practices in a highly pressurized context. The studies took place in neo-natal wards in Kenyan hospitals between 2015 and 2018 and in a system with no legal or regulatory basis for task shifting to HCAs. We proffer data on why and how nurses informally delegate tasks to others in the public sector and the decision-making processes of nurses and frame this evidence in the specific contextual conditions. In the conclusion, the paper aims to deepen the debates on developing human resources for health. We argue that despite the urgent pressures to address glaring workforce deficits in Kenya and other LMIC, caution needs to be exercised in implementing changes to nursing practices through the introduction of HCAs. The evidence from EU suggests that the rapid growth in the employment of HCA has created crucial issues which need addressing. These include clearly defining the scope of practice and developing the appropriate skill mix between nurses and HCAs to match the specific health system context. Moreover, we suggest efforts to develop and implement such roles should be carefully designed and rigorously evaluated to inform continuing policy development. [ABSTRACT FROM AUTHOR]

Several high-profile inquiries and reports, including the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, by Sir Robert Francis QC, have identified that nurse staffing is an essential factor in patient safety and patient mortality rates. Since the Francis report, several policies and initiatives aimed at ensuring safe staffing in the NHS have been developed alongside guidance and evidence-based safe staffing tools, while the Care Quality Commission has been tasked with ensuring compliance with these policies. In 2015, the National Institute for Health Research (NIHR) Policy Research Programme commissioned research to examine the extent to which safe staffing policies have translated into practice locally in the NHS. This article summarises and examines the main findings of this research and suggests that, although policies have raised the profile of nurse staffing, nursing shortages have impeded their implementation. [ABSTRACT FROM AUTHOR]

Context: The relative availability of clinicians as well as the types and training of health care providers have been associated with morbidity and mortality in non-athletic health care settings. Whether staffing variations are associated with injury incidence in collegiate athletes is unknown. Objective: To evaluate whether the institutional ratio of athletes to athletic trainers (patient load) or the ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers or both is associated with the incidence of injuries sustained by male ice hockey athletes at the school. Design: Descriptive epidemiology study. Setting: National Collegiate Athletic Association (NCAA) men's ice hockey teams. Patients or Other Participants: Collegiate men's ice hockey athletes. Main Outcome Measure(s): The NCAA Injury Surveillance Program collected data from collegiate men's ice hockey athletes. Staffing patterns were obtained through telephone interviews. Injury counts, injury rates per 1000 athlete-exposures, and injury rate ratios with 95% confidence intervals were calculated and compared between the following groups: (1) schools with high (versus low) patient load and (2) schools with high (versus low) ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers. Results: Both the patient load and relative number of staff athletic trainers were associated with variations in the incidences and types of diagnosed injuries in male ice hockey players. Specifically, fewer injuries were diagnosed by clinicians at institutions with high patient loads. The rates of injury overall and non-time-loss injuries were lower in the high patient-load group. Time-loss injury rates, severe injury rates, concussion rates, and overall rates of injury during competition were greater in the group with a higher proportion of staff athletic trainers, whereas non-time-loss injury rates were lower. Conclusions: In this study of collegiate men's ice hockey players, athlete health outcomes were directly related to the number and types of clinicians available. Future researchers should evaluate whether this finding extends beyond men's ice hockey. [ABSTRACT FROM AUTHOR]

AUTH Why you should read this article: • To understand how nursing presence can enhance emergency nurses' job satisfaction, staff retention and patient outcomes • To recognise the combined effects of fatigue, workplace bullying, moral distress and inadequate staffing levels on nursing presence and staff retention • To understand the various factors to consider when making safe staffing decisions in the emergency department The phrase 'cut the Gordian knot' describes a bold and direct solution to a complicated problem. Nursing presence has been defined as nurses' ability to pay attention to patients and make them feel that their needs have been considered. In the emergency department (ED), nursing presence can be adversely affected by factors such as fatigue, workplace bullying, moral distress and inadequate staffing levels, which could lead to suboptimal patient outcomes and compromise the goals of nursing. Nursing presence is also important for nurses' job satisfaction and therefore for staff retention. This article explores the combined effects of fatigue, workplace bullying, moral distress and inadequate staffing levels on emergency nurses. To cut the Gordian knot it also provides recommendations for mitigating these issues in EDs through safe staffing decisions that consider patient acuity and skill mix. [ABSTRACT FROM AUTHOR]

Aims: To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals. Design: A quantitative systematic review included studies published in English between January 2000 – September 2018. Data sources: Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix‐methods designs were included if the quantitative component met the criteria. Review methods: The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy‐five percent or more of studies with significant results found this association. Results: Sixty‐three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure‐to‐rescue; pneumonia; sepsis; urinary tract infection; mortality/30‐day mortality; pressure injury; infections and shock/cardiac arrest/heart failure. Conclusion: Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes. Impact: Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning. [ABSTRACT FROM AUTHOR]

Background: Southern Africa lacks resources necessary to combat presenting health challenges. This crisis will likely be remedied through the in‐country training of healthcare professionals, for example, in Namibia. Monitoring the workforce will be essential to inform planning in health services and training. A national pilot workforce survey in Namibia using a multi‐modal sampling approach aimed to test methodology for describing the pharmacy workforce and quantifying preferences towards further training. Methods: The survey tool included questions relating to socio‐demographics, professional and practice aspects. A conjoint analysis approach was utilised to quantify preferences around study programme, modality of study and cost. Key findings: Respondents (N = 135; ~20% response) represented a diverse range of individuals in various pharmacy sectors in Namibia. The majority of respondents reported female gender, private sector working, studying outside Namibia and societal group membership. Societal membership and pharmacy ownership – indicators of professional engagement – were associated with higher age; ownership was also associated with study outside Namibia and practice in community pharmacy. Regarding further study preferences, respondents placed more importance on study programme and modality over cost with the most preferred scenario being a 2‐year full‐time Masters programme in pharmaceutical industry/regulation by distance learning at the highest cost bracket. Conclusions: This national survey sampled the population of pharmacists in Namibia exploring the composition of the profession and preferences towards training. Further work will validate the findings and provide ongoing monitoring of the pharmacy workforce that can be expanded to other professional groups over a larger geographical area. [ABSTRACT FROM AUTHOR]