Claudia B. Maier

Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care

Objectives To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care. Design Cross-sectional patient discharge data, hospital characteristics and nurse and patient survey data were merged and analysed using generalised estimating equations (GEE) and logistic regression models. Setting Adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland. Participants Survey data were collected from 13 077 nurses in 243 hospitals, and 18 828 patients in 182 of the same hospitals in the six countries. Discharge data were obtained for 275 519 surgical patients in 188 of these hospitals. Main outcome measures Patient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction. Results Richer nurse skill mix (eg, every 10-point increase in the percentage of professional nurses among all nursing personnel) was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80<OR<0.93), after adjusting for patient and hospital factors. Each 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death. In our hospital sample, there were an average of six caregivers for every 25 patients, four of whom were professional nurses. Substituting one nurse assistant for a professional nurse for every 25 patients is associated with a 21% increase in the odds of dying. Conclusions A bedside care workforce with a greater proportion of professional nurses is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding nursing associates and other categories of assistive nursing personnel without professional nurse qualifications may contribute to preventable deaths, erode quality and safety of hospital care and contribute to hospital nurse shortages.

Mobility of health professionals pre and post 2004 and 2007 EU enlargements: Evidence from the EU project PROMeTHEUS

BACKGROUND EU enlargement has facilitated the mobility of EU citizens, including health professionals, from the 2004 and 2007 EU accession states. Fears have been raised about a mass exodus of health professionals and the consequences for the operation of health systems. However, to date a systematic analysis of the EU enlargements effects on the mobility of health professionals has been lacking. The aim of this article is to shed light on the changes in the scale of movement, trends and directions of flows pre and post 2004 and 2007 EU enlargements. METHODS The study follows a pan-European secondary data analysis to (i) quantitatively and (ii) qualitatively analyse mobility before and after the EU enlargement. (i) The secondary data analysis covers 34 countries (including all EU Member States). (ii) Data were triangulated with the findings of 17 country case studies to qualitatively assess the effects of enlargement on health workforce mobility. RESULTS The stock of health professionals from the new (EU-12) into the old EU Member States (EU-15) have increased following EU accession. The stock of medical doctors from the EU-12 in the EU-15 countries has more than doubled between 2003 and 2007. The available data suggest the same trend for dentists. The extremely limited data for nurses show that the stock of nurses has, in contrast, only slightly increased. However, while no reliable data is available evidence suggests that the number of undocumented or self-employed migrant nurses in the home-care sector has significantly increased. Health professionals trained in the EU-12 are becoming increasingly important in providing sufficient health care in some destination countries and regions facing staff shortages. CONCLUSION A mass exodus of health professionals has not taken place after the 2004 and 2007 EU enlargements. The estimated annual outflows from the EU-12 countries have rarely exceeded 3% of the domestic workforce. This is partly due to labour market restrictions in the destination countries, but also to improvements in salaries and working conditions in some source countries. The overall mobility of health professionals is hence relatively moderate and in line with the overall movement of citizens within the EU. However, for some countries even losing small numbers of health professionals can have impacts in underserved regions.

The role of governance in implementing task-shifting from physicians to nurses in advanced roles in Europe, U.S., Canada, New Zealand and Australia

Task-shifting from physicians to nurses is increasing worldwide; however, research on how it is governed is scarce. This international study assessed task-shifting governance models and implications on practice, based on a literature scoping review; and a survey with 93 country experts in 39 countries (response rate: 85.3%). Governance was assessed by several indicators, regulation of titles, scope of practice, prescriptive authority, and registration policies. This policy analysis focused on eleven countries with task-shifting at the Advanced Practice Nursing/Nurse Practitioner (APN/NP) level. Governance models ranged from national, decentralized to no regulation, but at the discretion of employers and settings. In countries with national or decentralized regulation, restrictive scope of practice laws were shown as barrier, up-to-date laws as enablers to advanced practice. Countries with decentralized regulation resulted in uneven levels of practice. In countries leaving governance to individual settings, practice variations existed, moreover data availability and role clarity was limited. Policy options include periodic reviews to ensure laws are up to date, minimum harmonization in decentralized contexts, harmonized educational and practice-level requirements to reduce practice variation and ensure quality. From a European Union (EU) perspective, regulation is preferred over non-regulation as a first step toward the recognition of qualifications in countries with similar levels of advanced practice. Countries early on in the process need to be aware that different governance models can influence practice.

Effects of Regulation and Payment Policies on Nurse Practitioners’ Clinical Practices:

Increasing patient demand following health care reform has led to concerns about provider shortages, particularly in primary care and for Medicaid patients. Nurse practitioners (NPs) represent a potential solution to meeting demand. However, varying state scope of practice regulations and Medicaid reimbursement rates may limit efficient distribution of NPs. Using a national sample of 252,657 ambulatory practices, we examined the effect of state policies on NP employment in primary care and practice Medicaid acceptance. NPs had 13% higher odds of working in primary care in states with full scope of practice; those odds increased to 20% if the state also reimbursed NPs at 100% of the physician Medicaid fee-for-service rate. Furthermore, in states with 100% Medicaid reimbursement, practices with NPs had 23% higher odds of accepting Medicaid than practices without NPs. Removing scope of practice restrictions and increasing Medicaid reimbursement may increase NP participation in primary care and practice Medicaid acceptance.

Descriptive, cross-country analysis of the nurse practitioner workforce in six countries: size, growth, physician substitution potential

Objectives Many countries are facing provider shortages and imbalances in primary care or are projecting shortfalls for the future, triggered by the rise in chronic diseases and multimorbidity. In order to assess the potential of nurse practitioners (NPs) in expanding access, we analysed the size, annual growth (2005–2015) and the extent of advanced practice of NPs in 6 Organisation for Economic Cooperation and Development (OECD) countries. Design Cross-country data analysis of national nursing registries, regulatory bodies, statistical offices data as well as OECD health workforce and population data, plus literature scoping review. Setting/participants NP and physician workforces in 6 OECD countries (Australia, Canada, Ireland, the Netherlands, New Zealand and USA). Primary and secondary outcome measures The main outcomes were the absolute and relative number of NPs per 100 000 population compared with the nursing and physician workforces, the compound annual growth rates, annual and median percentage changes from 2005 to 2015 and a synthesis of the literature on the extent of advanced clinical practice measured by physician substitution effect. Results The USA showed the highest absolute number of NPs and rate per population (40.5 per 100 000 population), followed by the Netherlands (12.6), Canada (9.8), Australia (4.4), and Ireland and New Zealand (3.1, respectively). Annual growth rates were high in all countries, ranging from annual compound rates of 6.1% in the USA to 27.8% in the Netherlands. Growth rates were between three and nine times higher compared with physicians. Finally, the empirical studies emanating from the literature scoping review suggested that NPs are able to provide 67–93% of all primary care services, yet, based on limited evidence. Conclusions NPs are a rapidly growing workforce with high levels of advanced practice potential in primary care. Workforce monitoring based on accurate data is critical to inform educational capacity and workforce planning.

Expanding clinical roles for nurses to realign the global health workforce with population needs: a commentary.

Many countries, including Israel, face health workforce challenges to meet the needs of their citizens, as chronic conditions increase. Provider shortages and geographical maldistribution are common. Increasing the contribution of nurse practitioners and other advanced practice nursing roles through task-shifting and expansion of scope-of-practice can improve access to care and result in greater workforce efficiency. Israel and many other countries are introducing reforms to expand nurses’ scope-of-practice. Recent international research offers three policy lessons for how countries just beginning to implement reforms could bypass policy barriers to implementation. First, there is substantial evidence on the equivalence in quality of care, patient safety and high consumer acceptance which should move policy debates from if to how to effectively implement new roles in practice. Second, regulatory and finance policies as well as accessible advanced education are essential to facilitate realignment of roles. Third, country experience suggests that advanced practice roles for nurses improve the attractiveness of nursing as a career thus contributing to solving nursing shortages rather than exacerbating them. Designing enabling policy environments and removing barriers will gain in relevance in the future as the demand for high-quality, patient-centered care is increasing.

A call for action to establish a research agenda for building a future health workforce in Europe

The importance of a sustainable health workforce is increasingly recognised. However, the building of a future health workforce that is responsive to diverse population needs and demographic and economic change remains insufficiently understood. There is a compelling argument to be made for a comprehensive research agenda to address the questions. With a focus on Europe and taking a health systems approach, we introduce an agenda linked to the ‘Health Workforce Research’ section of the European Public Health Association. Six major objectives for health workforce policy were identified: (1) to develop frameworks that align health systems/governance and health workforce policy/planning, (2) to explore the effects of changing skill mixes and competencies across sectors and occupational groups, (3) to map how education and health workforce governance can be better integrated, (4) to analyse the impact of health workforce mobility on health systems, (5) to optimise the use of international/EU, national and regional health workforce data and monitoring and (6) to build capacity for policy implementation. This article highlights critical knowledge gaps that currently hamper the opportunities of effectively responding to these challenges and advising policy-makers in different health systems. Closing these knowledge gaps is therefore an important step towards future health workforce governance and policy implementation. There is an urgent need for building health workforce research as an independent, interdisciplinary and multi-professional field. This requires dedicated research funding, new academic education programmes, comparative methodology and knowledge transfer and leadership that can help countries to build a people-centred health workforce.

Nurses in expanded roles to strengthen community-based health promotion and chronic care: policy implications from an international perspective; A commentary

Chronic conditions and health inequalities are increasing worldwide. Against this backdrop, several countries, including Israel, have expanded the roles of nurses as one measure to strengthen the primary care workforce. In Israel, community nurses work in expanded roles with increased responsibilities for patients with chronic conditions. They also work increasingly in the field of health promotion and disease prevention. Common barriers to role change in Israel are mirrored by other countries. Barriers include legal and financial restrictions, resistance by professional associations, inflexible labor markets and lack of resources. Policies should be revisited and aligned across education, financing and labor markets, to enable nurses to practice in the expanded roles. Financial incentives can accelerate the uptake of new, expanded roles so that all patients including vulnerable population groups, benefit from equitable and patient-centered service delivery in the communities.