Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis

Item does not contain fulltextBACKGROUND: Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles. OBJECTIVES: (1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review. SEARCH METHODS: We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed. SELECTION CRITERIA: We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively. DATA COLLECTION AND ANALYSIS: We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness. MAIN RESULTS: We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced thei

Prevalence of and reasons for women’s, family members’, and health professionals’ preferences for cesarean section in Iran: a mixed-methods systematic review

Abstract: Background: Cesarean section (CS) rates have been increasing globally. Iran has one of the highest CS rates in the world (47.9%). This review was conducted to assess the prevalence of and reasons for women’s, family members’, and health professionals’ preferences for CS in Iran. Methods and findings: In this mixed-methods systematic review, we searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, Google scholar; as well as Iranian scientific databases including SID, and Magiran from 1 January 1990 to 8th October 2019. Primary quantitative, qualitative, and mixed-methods studies that had been conducted in Iran with Persian or English languages were included. Meta-analysis of quantitative studies was conducted by extracting data from 65 cross-sectional, longitudinal, and baseline measurements of interventional studies. For meta-synthesis, we used 26 qualitative studies with designs such as ethnography, phenomenology, case studies, and grounded theory. The Review Manager Version 5.3 and the Comprehensive Meta-Analysis (CMA) software were used for meta-analysis and meta-regression analysis. Results showed that 5.46% of nulliparous women (95% CI 5.38–5.50%; χ2 = 1117.39; df = 28 [p < 0.00001]; I2 = 97%) preferred a CS mode of delivery. Results of subgroup analysis based on the time of pregnancy showed that proportions of preference for CS reported by women were 5.94% (95% CI 5.86–5.99%) in early and middle pregnancy, and 3.81% (95% CI 3.74–3.83%), in late pregnancy. The heterogeneity was high in this review. Most women were pregnant, regardless of their parity; the risk level of participants were unknown, and some Persian publications were appraised as low in quality. A combined inductive and deductive approach was used to synthesis the qualitative data, and CERQual was used to assess confidence in the findings. Meta-synthesis generated 10 emerging themes and three final themes: ‘Women’s factors’, ‘Health professional factors’, andex ‘Health organization, facility, or system factors’. Conclusion: Despite low preference for CS among women, CS rates are still so high. This implies the role of factors beyond the individual will. We identified a multiple individual, health facility, and health system factors which affected the preference for CS in Iran. Numerous attempts were made in recent years to design, test and implement interventions to decrease unnecessary CS in Iran, such as mother-friendly hospitals, standard protocols for labor and birth, preparation classes for women, midwives, and gynaecologists, and workshops for specialists and midwives through the “health sector evolution policy”. Although these programs were effective, high rates of CS persist and more efforts are needed to optimize the use of CS

Stress, Anxiety, and Depression Levels Among Healthcare Staff During the COVID-19 Epidemic

Introduction: In the Coronavirus Disease 2019 (COVID-19) pandemic, medical staff Are  in direct contact with the patients and experience high work pressure. Direct contact with the patients could create some psychological problems in this group. Thus, the prevalence of such problems must be investigated in them. The present study aimed to determine the level of stress, anxiety, and depression among the healthcare staff in Zanjan City, Iran, during the COVID-19 epidemic. Methods: This descriptive study has a cross-sectional design. The Sample of the study population consisted of 535 Staff healthcare members of Vali-e-Asr Hospital in Zanjan City, Iran. A sample of 200 of medical staff was randomly selected to participate in the present study. The required data were collected using the electronic version of Depression, Anxiety, Stress Scale (DASS) tool. Descriptive statistics, as well as the inferential statistics (the Pearson correlation coefficient, Spearman correlation coefficient, Phi, and Cramer’s correlation tests), were used to analyze the obtained data in SPSS. Results: The mean age of the study participants was 40.60 years. The mean values of depression, anxiety, and stress in study samples were 6.27, 5.38, and 8.41, respectively. There was a significant relation between gender and variables of depression, anxiety, and stress. There was also an inverse relationship between stress and variables of educational level and age (P<0/05). Conclusion: We found that our sample reported a normal degree of Depression, anxiety, and stress. The extent of stress induced by direct contact with patients was higher in female employees. Furthermore, with the increase in the education and age of the employees, their stress level decreased

The impact of general health and social support on health promoting lifestyle in the first year postpartum: the structural equation modelling

Background and aim: Postpartum is a critical period for mothers which often leads to neglect of their own health. Mothers’ new responsibilities may affect their health promoting lifestyle (HPL). The aim of this study was to determine the impact of both general health and social support on health-promoting lifestyle. Methods: A cross-sectional survey was conducted on 310 women who gave birth over a one-year period in Zanjan (Iran), 2016. A proportionate stratified random sampling technique was used to select respondents from each stratum. Health-promoting lifestyle was assessed using the health-promoting lifestyle profile II (HPLP II) scale. A structure equation model (SEM) was used to determine the relationship between observed and latent variables. Data were analysed using SPSS version 22 and LISREL 8.5 software. Results: The age of 42.6% of the participants was more than 30 years and 40.3% of them had an academic education. The mean score of the health-promoting lifestyle was 131.28 (15.37). The structural equation model fitted well with RMSEA =0.07, CFI=0.92, and GFI=0.94. Among the latent factors, general health, with a factor load of -0.68, had greater impact on health-promoting lifestyle than social support. Moreover, there was a significant correlation (-0.63) between general health and perceived social support in the postpartum period. Conclusion: health-promoting lifestyle was not at appropriate levels among women in the first year after delivery. These findings suggest that strengthening general health and social support would improve a health- promoting lifestyle in Iranian postpartum women

The role of perceived barrier in the postpartum women's health promoting lifestyle: A partial mediator between self-efficacy and health promoting lifestyle

Introduction: In recent decades, the focuses of health studies were mostly in middle-aged women, and few studies have investigated the lifestyle of women after delivery. The aim of this study was to determine the effects of both self-efficacy and perceived barriers on Iranian women health-promoting lifestyle (HPL) in the first 1 year after childbirth. Materials and Methods: Using a cross-sectional design, 310 women at first-year postpartum were surveyed in Zanjan (Iran) in 2016. The proportionate stratified random sampling method was carried out to select a participant. HPL has assessed with HPL profile II questionnaire. Self-efficacy was assessed using self-rated abilities for health practices scale. Perceived barriers were assessed by Barriers to Health-promoting Activities for Disabled Person scale. A meditational model was used to examine whether perceived barriers mediates between perceived self-efficacy and HPL. Results: The participants mean age was 29.82 (5.1) years, 53.9% were primiparous, and most of them were homemakers (82.9%). The mean total score of HPL was 2.50 (0.29). The relationship between HPL and self-efficacy was mediated by perceived barriers partially. Discussion: Self-efficacy, not only promotes women's HPL but also indirectly affect the women's lifestyle by reducing perceived barriers

A conceptual model for empowering faculty members of third-generation universities of medical sciences

الملخص: أهداف البحث: يجب أن تكون جامعات الجيل الثالث قادرة على أن تكون مستقلة وأن تعد طلابها لتلبية احتياجات المجتمع ودخول سوق العمل. في الواقع، الأداء المتوقع منهم هو تطبيق البحث في المجتمع. على الرغم من الدور الحاسم للموظفين وخاصة أعضاء هيئة التدريس في التحرك نحو جامعات الجيل الثالث، فضلا عن ضرورة تمكين الموظفين، إلا أنه تم إجراء عدد قليل من الدراسات حول تمكين أعضاء هيئة التدريس (أعضاء هيئة التدريس). هدفت هذه الدراسة إلى تصميم نموذج تصوري لتمكين أعضاء هيئة التدريس في جامعات العلوم الطبية وتسهيل الانتقال إلى جامعات الجيل الثالث. طرق البحث: تم اعتماد منهج النظرية المتجذرة لإجراء هذه الدراسة النوعية. تم اختيار ما مجموعه 11 من أعضاء هيئة التدريس من ذوي الخبرة في ريادة الأعمال كعينة باستخدام أخذ العينات الهادف. تم جمع البيانات باستخدام المقابلات شبه المنظمة، وتم إدخال البيانات التي تم الحصول عليها في برنامج حاسوبي مصمم للبيانات النوعية والمختلطة بمساعدة الكمبيوتر. النتائج: تم تلخيص المفاهيم المحددة في عملية الترميز وتصنيفها إلى خمس مجموعات وسبع فئات رئيسية. تم تصميم النموذج التصوري بعد ذلك بمجموعة من العوامل السببية (بما في ذلك هيكل نظام التعليم، والتوظيف، والتدريب، والاستثمار)، وعوامل الهيكل والسياق (بما في ذلك الهيكل والعلاقة)، والعوامل المتداخلة (بما في ذلك أنظمة الترقية والترتيب في الجامعات ونقص من الثقة المتبادلة بين الصناعة والجامعة)، فئة أساسية (خصائص أعضاء هيئة التدريس الأكفاء)، والنتيجة (جامعة الجيل الثالث). أخيرا، تم تطوير النموذج التصوري لتمكين أعضاء هيئة التدريس في جامعات الجيل الثالث من العلوم الطبية. الاستنتاجات: بناء على النموذج التصوري المصمم، فإن أهم قضية في التوجه نحو جامعات الجيل الثالث هي ''خصائص أعضاء هيئة التدريس القادرين''. تساعد النتائج الحالية صانعي السياسات على فهم العوامل الرئيسية التي تؤثر على تمكين أعضاء هيئة التدريس بشكل أفضل. Abstract: Background and objectives: Despite the crucial role of university staff and especially faculty members in moving towards third-generation universities, as well as the necessity of staff empowerment, only a handful of studies have been carried out on staff (especially faculty member) empowerment. This study designed a conceptual model for empowering faculty members of universities of medical sciences and facilitating transition to third-generation universities. Methods: The grounded theory approach was adopted to conduct this qualitative study. A total of 11 faculty members with entrepreneurial experience were selected as the sample using purposive sampling. The data were collected using semi-structured interviews, and the obtained data were entered into qualitative software (MAXQDA 10) for analysis. Results: The concepts identified in the coding process were summarized and classified into five groups and seven main categories. Then the conceptual model was designed with a set of causal factors (including structure of the education system, recruitment, training, and investment), structure and context factors (including structure and relationship), intervening factors (including promotion and ranking systems in universities and lack of mutual trust between industry and university), a core category (characteristics of capable faculty members), and an outcome (third-generation university). Finally, the conceptual model was developed to empower faculty members of third-generation universities of medical sciences. Conclusions: Based on the designed conceptual model, the most important issue in moving towards third-generation universities is “characteristics of capable faculty members.” The present findings will help policy makers better understand the major factors affecting faculty member empowerment