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In recent years, genetic (counseling) assistants have been integrated in the genetics workforce, such that one‐third of genetic counselors now report working with a genetic assistant. While several studies showed that adoption of the genetic assistant model leads to an increase in patient volume, the impact of this role substitution has not been studied quantitatively beyond the cancer genetics workforce. This study utilized 18 years of data from a publicly funded genetics clinic with multiple specialties and varying staff mix. Time series regression modeling was applied to describe the evolving impact of genetic assistants on genetic counselor and clinical geneticist productivity (measured as patient volume). The regression models suggest that the integration of genetic assistants led to a sustainable increase in genetic counselor patient volume, while clinical geneticist patient volume was unaffected. Importantly, the models also demonstrated an interaction between the number of genetic counselors and genetic assistants, whereby the impact of adding a genetic counselor was greater as more genetic assistants were employed in the clinic, and vice versa. The main regression model was used to create "ClinMix: A Genetics Staff Mix Planning Tool," an Excel application that allows users to explore how different staffing plans could affect patient volume, by applying the parameters estimated from this data or their own. We hope this report and the ClinMix tool can be employed by the genetics workforce to advocate for further implementation and evaluation of genetic assistant positions. Adoption of the genetic assistant model may provide clinics the support needed to meet increasing service delivery demands and subsequently foster genetic counselor practice at "top of scope." [ABSTRACT FROM AUTHOR]

This paper is devoted to the observation of preschoolers’ free play with different types of materials for pretend play. It is shown that role substitution varies in play with different materials. When children played with play costumes (role markers), many of them renamed themselves; however, the roles were similar in character and strictly related to the proposed costumes. Also, children rarely performed their role through actions. Playing with character toys turned out to be gender specific. Boys rarely played a role, preferring a director's position. Girls’ play was of different levels of complexity, their roles were complementary to their toys and original in character. When children played with toys that imitate real objects (cups, swords, irons and so on), they were less likely to rename themselves, the roles were rather similar; however, almost all children acted from inside their roles. The most balanced environment for pretend play was the one with open-ended materials: many children renamed themselves, and the roles were original (in fact, originality was the highest with this type of materials), many children performed the role through play actions (this was especially true for older preschoolers). The exception were 6-year-old children who, despite renaming themselves, did not perform any play actions in this environment.

This paper is a part of the research devoted to observing free play with different role-playing materials in preschool children.Here we describe the results of our observations of preschoolers’ play with toy characters (dolls, figures, soft toys, etc.).It was found that there are significant gender differences in this type of play: boys either do not play at all or play in the director’s position; at the same time, if they take on a role, they tend to ignore toy characters.As it is shown, the number of role-playing names is quite high in the children’s play with toy characters.This may reflect the specific function of this type of material in play.Among the prevailing play topics are family, home, pets, everyday life and motives of care and attention in general.Age analysis showed that the number of children with roles increases at 6 years, while at 5 years — when play is at its peak – role substitution in playing with toy characters is rather ignored by children.

This paper is part of a larger research focused on observations of preschool children in free make-believe play with different objects. This paper presents the outcomes of observations of children’s play with toys that imitate real objects (cups, swords, irons and so on).The dynamics of play activity in different age groups (3, 4, 5 and 6 years) is shown. In the two younger groups, role renaming is extremely rare and is accompanied by play actions, while children do not change their appearance in accordance with the role. From the age of 5, the number of renaming increases sharply: two-thirds of children call themselves some kind of a role name, many dress up, and the vast majority plays a role. At 6 years, there is a slight decline in the number of children with role renaming and a slight increase in the number of children who change their appearance as compared to 5-year-olds.In the environment with toys imitating real objects, the role emerges in response to toys, which significantly differs from how the role appears in the environment with open-ended materials. The paper describes the roles that were employed in the play with toys.

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.

Background: Previous systematic reviews have found that nurses and pharmacists can provide equivalent, or higher, quality of care for some tasks performed by GPs in primary care. There is a lack of economic evidence for this substitution.Aim: To explore the costs and outcomes of role substitution between GPs and nurses, pharmacists, and allied health professionals in primary care.Design and Setting: A systematic review of economic evaluations exploring role substitution of allied health professionals in primary care was conducted. Role substitution was defined as 'the substitution of work that was previously completed by a GP in the past and is now completed by a nurse or allied health professional'.Method: The following databases were searched: Ovid MEDLINE, CINAHL, Cochrane Library, National Institute for Health and Care Excellence (NICE), and the Centre for Reviews and Dissemination. The review followed guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).Results: Six economic evaluations were identified. There was some limited evidence that nurse-led care for common minor health problems was cost-effective compared with GP care, and that nurse-led interventions for chronic fatigue syndrome and pharmacy-led services for the medicines management of coronary heart disease and chronic pain were not. In South Korea, community health practitioners delivered primary care services for half the cost of physicians. The review did not identify studies for other allied health professionals such as physiotherapists and occupational therapists.Conclusion: There is limited economic evidence for role substitution in primary care; more economic evaluations are needed. [ABSTRACT FROM AUTHOR]

Background: Maximising health gain for a given level and mix of resources is an ethical imperative for health-service planners. Approximately half of all patients who attend a regular NHS dental check-up do not require any further treatment, whereas many in the population do not regularly attend. Thus, the most expensive resource (the dentist) is seeing healthy patients at a time when many of those with disease do not access care. Role substitution in NHS dentistry, where other members of the dental team undertake the clinical tasks previously provided by dentists, has the potential to increase efficiency and the capacity to care and lower costs. However, no studies have empirically investigated the efficiency of NHS dental provision that makes use of role substitution. Research questions: This programme of research sought to address three research questions: (1) what is the efficiency of NHS dental teams that make use of role substitution?; (2) what are the barriers to, and facilitators of, role substitution in NHS dental practices?; and (3) how do incentives in the remuneration systems influence the organisation of these inputs and production of outputs in the NHS? Design: Data envelopment analysis was used to develop a productive efficiency frontier for participating NHS practices, which were then compared on a relative basis, after controlling for patient and practice characteristics. External validity was tested using stochastic frontier modelling, while semistructured interviews explored the views of participating dental teams and their patients to role substitution. Setting: NHS ‘high-street’ general dental practices. Participants: 121 practices across the north of England. Interventions: No active interventions were undertaken. Main outcome measures: Relative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients. Results: The utilisation of non-dentist roles in NHS practices was relatively low, the most common role type being the dental hygienist. Increasing the number of non-dentist team members reduced efficiency. However, it was not possible to determine the relative efficiency of individual team members, as the NHS contracts only with dentists. Financial incentives in the NHS dental contract and the views of practice principals (i.e. senior staff members) were equally important. Bespoke payment and referral systems were required to make role substitution economically viable. Many non-dentist team members were not being used to their full scope of practice and constraints on their ability to prescribe reduced efficiency further. Many non-dentist team members experienced a precarious existence, commonly being employed at multiple practices. Patients had a low level of awareness of the different non-dentist roles in a dental team. Many exhibited an inherent trust in the professional ‘system’, but prior experience of role substitution was important for social acceptability. Conclusions: Better alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical. Study limitations: Output data collected did not reflect the quality of care provided by the dental team and the input data were self-reported. Future work: Further work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Volunteer role identity has long been of interest to social scientists seeking to understand volunteer commitment and the psychological consequences of volunteering. The study reported here tests the theory that predicts that people identify more strongly with the volunteer role as compensation for the absence of other productive roles. Using a sample (n = 572) of Dutch volunteers over the age of 50, we find a strong association between age and volunteer role identity. For older volunteers, the volunteer role is a more important part of who they are. We find that retirement plays an important role in this. The retirement effect, in turn, is accounted for by the extra time retirees invest in the role, signaling a compensation strategy. We find a similar substitution effect for the unemployed/disabled, but not for widowhood. The study makes a contribution by situating the explanation of volunteer role identity within a life-course framework. [ABSTRACT FROM AUTHOR]

Background: Broadening the range of services provided through community pharmacy increases workloads for pharmacists that could be alleviated by reconfiguring roles within the pharmacy team.Objectives: To examine pharmacists' and pharmacy technicians (PTs)' perceptions of how safe it would be for support staff to undertake a range of pharmacy activities during a pharmacist's absence. Views on supervision, support staff roles, competency and responsibility were also sought.Methods: Informed by nominal group discussions, a questionnaire was developed and distributed to a random sample of 1500 pharmacists and 1500 PTs registered in England. Whilst focused on community pharmacy practice, hospital pharmacy respondents were included, as more advanced skill mix models may provide valuable insights. Respondents were asked to rank a list of 22 pharmacy activities in terms of perceived risk and safety of these activities being performed by support staff during a pharmacist's absence. Descriptive and comparative statistic analyses were conducted.Results: Six-hundred-and-forty-two pharmacists (43.2%) and 854 PTs (57.3%) responded; the majority worked in community pharmacy. Dependent on agreement levels with perceived safety, from community pharmacists and PTs, and hospital pharmacists and PTs, the 22 activities were grouped into 'safe' (n = 7), 'borderline' (n = 9) and 'unsafe' (n = 6). Activities such as assembly and labeling were considered 'safe,' clinical activities were considered 'unsafe.' There were clear differences between pharmacists and PTs, and sectors (community pharmacy vs. hospital). Community pharmacists were most cautious (particularly mobile and portfolio pharmacists) about which activities they felt support staff could safely perform; PTs in both sectors felt significantly more confident performing particularly technical activities than pharmacists.Conclusion: This paper presents novel empirical evidence informing the categorization of pharmacy activities into 'safe,' 'borderline' or 'unsafe.' 'Borderline' activities will deserve particular attention, especially where they are part of processes, e.g. dispensing. This categorization could help inform reconfiguration of skill mix in community pharmacy and thus make an important contribution to the rebalancing medicines legislation agenda and pharmacist supervision. [ABSTRACT FROM AUTHOR]

Introduction The Emergency Nurse Practitioner (ENP) role has become established over the last two decades within emergency care. This role has developed to meet the rising demands of healthcare, combat the continuing medical workforce shortfall and address targets around healthcare delivery within emergency care. The ENP role has been widely evaluated in terms of patient satisfaction, safety and outcome. To date there is no published literature exploring what drives senior nurses to undertake this role which involves additional clinical responsibility and educational preparation for no increase in pay. Aim This research seeks to explore how Emergency Nurse Practitioners view their role within the Emergency Department and Emergency Care Team. Methods A qualitative approach was utilised in order to gain greater in-depth understanding of ENPs' perspectives. A purposive sample of eight ENPs was chosen and semi-structured interviews were digitally recorded. The transcribed interviews were subjected to thematic analysis to look for any recurrent themes. Findings Following analysis of the data, four main themes emerged with a total of eight sub themes. • Inter-professional working – Within the ED and outside the ED, with nurses and team culture. • Role development – Expanding the role, the future of the role. • Education – The role of education, the barriers. • Motivation The findings suggested that whilst the role had been accepted amongst doctors within the ED, there was still a lack of understanding of the role outside the ED and conflict still existed amongst junior nurses. ENPs were motivated to undertake the role in order to gain greater job satisfaction. The findings also highlighted the concerns regarding financial remuneration for the role, lack of standardisation of the role and educational preparation. Conclusion The study concludes that education has a key role in the development and acceptance of the role and that ENPs are disappointed with the lack of financial remuneration for the role. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Complex and chronic disease is placing significant pressure on hospital outpatient departments. Novel ways of delivering care have been developed recently and are often described as 'triage' services. This paper reviews the literature pertaining to definitions and descriptions of orthopaedic/musculoskeletal triage processes, in order to provide information on 'best practice' to assist health care facilities. Method A comprehensive open-ended search was conducted using electronic databases to identify studies describing models of triage clinics for patients with a musculoskeletal/orthopaedic complaint, who have been referred to hospital outpatient clinics for a surgical consultation. Studies were critically appraised using the McMaster quality appraisal tool and ranked using the National Health and Medical Research Council hierarchy of evidence. A thematic analysis of the definitions, processes and procedures of triage described within the literature was undertaken. Results 1930 studies were identified and 45 were included in the review (including diagnostic and evaluative research). The hierarchy of evidence ranged from I to IV; however, the majority were at low levels of evidence and scored poorly on the critical appraisal tool. Three broad themes of triage were identified: presence of a referral, configuration of the triage (who, how and where) and the aim of triage. However, there were significant inconsistencies across these themes. Conclusions This systematic review highlighted the need for standardization of the definition of triage, the procedures of assessment and management and measures of outcome used in orthopaedic/musculoskeletal triage to ensure best-practice processes, procedures and outcomes for triage clinics. [ABSTRACT FROM AUTHOR]

Pharmacists now offer increasing levels and ranges of clinical, diagnostic and public health services, which may require a pharmacist to be absent from the pharmacy premises. Currently, in the UK, many pharmacy activities legally require the direct supervision and physical presence of the pharmacist. This study aimed to explore the potential for changes to supervision, allowing pharmacist absence, and greater utilisation of pharmacy support staff. Four nominal group discussions were conducted in May 2012 with community pharmacists ( CPs), community pharmacy support staff, hospital pharmacists and hospital pharmacy support staff, involving 21 participants. Participants were asked to generate pharmacy activities, which they felt could/could not be safely performed by support staff in the absence of a pharmacist, followed by a discussion of these items and voting using an agreement scale. A written record of the items generated and voting scores was made and the group discussion elements were audio-recorded, transcribed verbatim and analysed thematically. The selling of general sales list medicines, assembly of prescriptions and provision of public health services received a high level of agreement between groups, as activities that could be performed. There was greater disagreement about the safety of support staff selling pharmacy medicines and handing out checked and bagged prescription items to patients. Group discussion revealed some of the main challenges to supervision changes, including CPs' perceptions about their presence being critical to patient safety, reluctance to relinquish control, concerns about knowing and trusting the competencies of support staff, and reluctance by support staff to take greater professional responsibility. The findings of this study aim to inform a future consultation on changes to pharmacy supervision in the UK. The empowerment of pharmacy technicians as a professional group may be key to any future change; this may require clarity of their professional responsibilities, enhanced career progression and appropriate remuneration to match greater responsibility. [ABSTRACT FROM AUTHOR]

hoskins r. (2011) Interprofessional working or role substitution? A discussion of the emerging roles in emergency care. Journal of Advanced Nursing 68(6), 1894-1903. Abstract Aims. This article presents a discussion of emerging non-medical roles in emergency care against the current policy context and the issues of role substitution and interprofessional working. Background. Non-medical roles in emergency care have grown internationally in response to an increasing demand for emergency care services and to address the growing importance of the quality healthcare agenda. The blurring of role boundaries between professional groups has become more common. Data sources. Searches were made of three electronic databases; CINAHL, Medline and EMBASE. The literature relating to interprofessional healthcare roles, and new roles in emergency care was searched from 1980 to 2010 and underpinned the discussion. Discussion. A theoretical framework that has emerged from the literature is that task, role substitution and interprofessional working lie on a spectrum and evolving non-medical roles can be plotted on the spectrum, usually starting at one end of the spectrum under task substitution and then potentially moving in time towards true interprofessional working. Conclusions. There is still a great deal of progress to be made until non-medical roles in emergency care can truly be encompassed under the umbrella of interprofessional working and that a more robust critical mass of evidence is required to substantiate the theory that interprofessional working within teams contributes to effective, cost-effective care and better patient outcomes. Relevance to clinical practice. It is essential to understand the underlying motivation, policy context and key drivers for the development of new nursing and non-medical roles. This allows services to be established successfully, by understanding and addressing the key predicable barriers to implementation and change. [ABSTRACT FROM AUTHOR]

zwijnenberg n.c. & bours g.j.j.w. (2012) Nurse practitioners and physician assistants in Dutch hospitals: their role, extent of substitution and facilitators and barriers experienced in the reallocation of tasks. Journal of Advanced Nursing 68(6), 1235-1246. Abstract Aims. This paper is a report of a study exploring the role of nurse practitioners and physician assistants, the extent of substitution and the barriers and facilitators experienced by them as a consequence of substitution in public hospitals. Background. Nurse practitioners and physician assistants are emerging worldwide. However, despite the large amount of evidence showing the added value of these professionals, little evidence is available concerning the role, extent of substitution and facilitators and barriers experienced by them as a consequence of substitution. Methods. Interviews were conducted and a questionnaire was completed by 43 nurse practitioners and 13 physician assistants employed in public hospitals in the south of the Netherlands in 2007. Results. Nurse practitioners and physician assistants performed a broad spectrum of tasks, but differed significantly in the time spent and the kind of tasks performed. Nurse practitioners spent 25% (10·4 hours; sd = 5·5) and physician assistants 40% (18·7 hours; sd = 7·6) of their time on medical procedures. They both also performed new tasks or tasks for which there previously was insufficient capacity. Many of them experienced policy/organizational, legal, financial or facility problems in the reallocation of tasks. Conclusion. Nurse practitioners and physician assistants have wide ranging but different responsibilities in public hospitals. By performing medical procedures and new tasks or tasks for which there was not enough capacity, they function as substitutes and supplements for doctors. However, barriers are affecting the extent of substitution. The challenge ahead is to remove the barriers experienced by nurse practitioners and physician assistants. [ABSTRACT FROM AUTHOR]

Scand J Caring Sci; 2011; 25; 303-310 To explore experiences and attitudes of nurse specialists in primary care regarding their role in care for patients with urinary incontinence (UI), thereby identifying facilitators and barriers for wider implementation. Currently, primary care for patients with UI lacks sufficient adherence to existing guidelines on UI and is far from optimal. Studies in various countries show that involving nurse specialists may offer a solution to the inadequate care for UI. As qualitative studies on experiences of nurses with this type of intervention are lacking, we performed this study with a qualitative approach and data collection method within the course of a randomized controlled trial (RCT). A focus group study was conducted in 2007 with six nurse specialists who were trained in caring for patients with UI in our pragmatic RCT. The focus group interview was audio-taped and transcribed verbatim. The data were analysed using qualitative content analysis to identify themes. To understand obstacles and incentives for change, we relied on an existing 'implementation model'. Nurse specialists feel competent to provide advice and information, to offer possible solutions and to give attention and guidance to the process of care of people with UI. They feel appreciated by patients and feel they offer an added value to the usual care of general practitioners (GPs). Nurses sometimes notice that GPs lack interest in UI. Personal contact with the GPs, availability of enough time, adequate equipment and financial resources are important preconditions for effective nurse specialist care. Nurse specialists value continuous education and feedback in daily care for patients with UI. Trained nurse specialists appeared to feel competent and satisfied to support GPs in care for patients with UI. They feel highly appreciated by both patients and GPs. [ABSTRACT FROM AUTHOR]

The article presents abstracts on nursing topics which include the role of routine medication administration in preventing medical errors in hospital setting, the socioeconomic value of nursing and midwifery and a review of the experiences of adult ventilator-dependent patients.