The development of the new assistant practitioner role in the English National Health Service: a critical realist perspective.

Adopting a critical realist perspective, this article examines the emergence of a relatively new non-professional healthcare role, the assistant practitioner (AP). The role is presented as a malleable construct cascading through and sensitive to structure-agency interaction at different levels of NHS England: the sector, organisation and department. At the core of the analysis is the permissiveness of structures established at the respective levels of the NHS, facilitating or restricting agency as the role progresses through the healthcare system. A permissive regulatory framework at the sector level is reflected in the different choices made by two case study NHS acute hospital trusts, in their engagement with the AP role. These different choices have consequences for how the AP impacts at the departmental level.

[Preferences of general practitioners in metropolitan France with regard to the delegation of medico-administrative tasks to secretaries assisting medico-social workers: Study in conjoint analysis]. / Préférences des médecins généralistes libéraux en France métropolitaine quant à la délégation des tâches médico-administratives aux secrétaires assistant(e)s médico-social(e)s : étude en analyse conjointe.

BACKGROUND: A general practitioner's office is an economic unit where task delegation is an essential component in improving the quality and performance of work. AIM: To classify the preferences of general practitioners regarding the delegation of medical-administrative tasks to assistant medical-social secretaries. METHOD: Conjoint analysis was applied to a random sample of 175 general practitioners working in metropolitan France. Ten scenarios were constructed based on seven attributes: training for medical secretaries, logistical support during the consultation, delegation of management planning, medical records, accounting, maintenance, and taking initiative on the telephone. A factorial design was used to reduce the number of scenarios. Physicians' socio-demographic variables were collected. RESULTS: One hundred and three physicians responded and the analysis included 90 respondents respecting the transitivity of preferences hypothesis. Perceived difficulty was scored 2.8 out of 5. The high rates of respondents (59%; 95% CI [51.7-66.3]) and transitivity (87.5%; 95% CI [81.1-93.9]) showed physicians' interest in this topic. Delegation of tasks concerning management planning (OR=2.91; 95% CI [2.40-13.52]) and medical records (OR=1.88; 95% CI [1.56-2.27]) were the two most important attributes for physicians. The only variable for which the choice of a secretary was not taken into account was logistical support. CONCLUSION: This is a first study examining the choices of general practitioners concerning the delegation of tasks to assistants. These findings are helpful to better understand the determinants of practitioners' choices in delegating certain tasks or not. They reveal doctors' desire to limit their ancillary tasks in order to favor better use of time for "medical" tasks. They also expose interest for training medical secretaries and widening their field of competence, suggesting the emergence of a new professional occupation that could be called "medical assistant".

Barriers and Facilitators to Expanding Roles of Medical Assistants in Patient-Centered Medical Homes (PCMHs).

BACKGROUND: Many primary care practices participating in patient-centered medical home (PCMH) transformation initiatives are expanding the work roles of their medical assistants (MAs). Little is known about attitudes of MAs or barriers and facilitators to these role changes. METHODS: Secondary data analysis of qualitative cross-case comparison study of 15 New Jersey primary care practices participating in a PCMH project during 2012 to 2013. Observation field notes and in-depth and key informant interviews (with physicians, office managers, staff and care coordinators) were iteratively analyzed using grounded theory. RESULTS: MA roles and responsibilities changed from a mostly reactive role, completing tasks dependent on physician orders during the patient visit and facilitating patient flow through the office, to a more proactive one, conducting previsit planning, engaging in the overall care for patients, and assisting with population management. MAs differed in their attitudes about increased responsibilities, with some welcoming the opportunity to take on expanded roles, others resenting their increased responsibilities, and some expressing insufficient understanding regarding why new tasks and procedures were being implemented. Major barriers to MA role shifts included 1) insufficient understanding of the PCMH concept, 2) lack of time for added responsibilities, 3) additional workload without additional compensation, 4) disparate levels of medical knowledge and training, 5) reluctance of clinicians to delegate tasks, 6) uncertainty in making new workflow changes routine, 7) staff turnover, and 8) change fatigue. MAs were more positive about their role shifts when they 1) understood how their responsibilities fit within broader PCMH practice transformation goals; 2) received formal training in new tasks; 3) had detailed protocols and standing orders; 4) initiated role changes with small, achievable goals; 5) had open communication with clinicians and practice leaders; and 5) received additional compensation or paths to career advancement. CONCLUSIONS: Practice leaders need to be conscious of obstacles when they increase expectations of MAs, and they must be willing to invest time and resources into developing their MA workforce. An environment that allows open dialog with MAs and rewards and compensation that recognizes their increased efforts will help make expansion of MA roles occur more smoothly and efficiently.

Task Delegation and Burnout Trade-offs Among Primary Care Providers and Nurses in Veterans Affairs Patient Aligned Care Teams (VA PACTs).

PURPOSE: Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, (1) the extent to which delegation occurs within multidisciplinary teams, (2) factors associated with greater delegation, and (3) whether delegation is associated with burnout are all unknown. METHODS: We performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in Department of VA primary care clinics, 4 years into the VA's patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks; paired nurses reported how much they were relied on to complete the same tasks. A composite score of task delegation/reliance was developed by taking the average of the responses to the 15 questions. We performed multivariable regression to explore predictors of task delegation and burnout. RESULTS: Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported being relied on (PCP mean ± standard deviation composite delegation score, 2.97± 0.64 [range, 1-4]; nurse composite reliance score, 3.26 ± 0.50 [range, 1-4]). Approximately 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout (odds ratio [OR], 0.62 per unit of delegation; 95% confidence interval [CI], 0.49-0.78), whereas nurses who reported being relied on more reported more burnout (OR, 1.83 per unit of reliance; 95% CI, 1.33-2.5). CONCLUSIONS: Task delegation was associated with less burnout for PCPs, whereas task reliance was associated with greater burnout for nurses. Strategies to improve work life in primary care by increasing PCP task delegation must consider the impact on nurses.

The Role of School Nurses, Challenges, and Reactions to Delegation Legislation: A Qualitative Approach.

Passage of new laws, national standards regarding delegation, and the recommendation for at least one full-time nurse in every school have provided more visibility to the role of school nurses. Recent legislative amendments in Kentucky presented an opportunity to examine how the role of the school nurse is changing. Aims were to describe the (1) role of school nurses in Kentucky, (2) impact of school nurses, (3) challenges faced by school nurses, and (4) impact of budget cuts and legislation. Three focus groups were conducted. School nurses faced challenges of limited time and resources, communication barriers, and multiple documentation requirements. Nurses' greatest impacts were their availability, recognition of psychosocial problems and health concerns, and connection with resources. Nurses had not yet encountered many changes due to new legislation that expanded delegation of diabetes-related tasks to unlicensed school personnel, but some had concerns about possible negative effects while others expressed support.

Overview of the uptake and implementation of non-medical prescribing in Wales: a national survey.

OBJECTIVES: To identify (1) the non-medical healthcare professionals in Wales qualified to prescribe medicines (including job title, employer, where the prescribing qualification is used, care setting and service provided); (2) the mode of prescribing used by these healthcare professionals, the frequency with which medicines are prescribed and the different ways in which the prescribing qualification is used; and (3) the safety and clinical governance systems within which these healthcare professionals practise. DESIGN: National questionnaire survey. SETTING: All three National Health Service (NHS) Trusts and seven Health Boards (HB) in Wales. PARTICIPANTS: Non-medical prescribers. RESULTS: 379 (63%) participants responded to the survey. Most of these prescribers (41.1%) were specialist nurses who work in a variety of healthcare settings (primarily in secondary care) within each HB/NHS Trust, and regularly use independent prescribing to prescribe for a broad range of conditions. Nearly a quarter of the sample (22%) reported that prior to undertaking the prescribing programme, they had completed master's level specialist training and 65.5% had 5 years qualified experience. Over half (55.8%) reported that there were plans to increase non-medical prescriber numbers within the team in which they worked. Only 7.1% reported they did not prescribe and the median number of items prescribed per week was between 21 and 30. Nearly all (87.8%) of the sample reported that they perceived prescribing to have ensured better use of their skills and 91.5% indicated that they believed it had improved the quality of care they were able to provide. CONCLUSION: Non-medical prescribing has been implemented across the whole of Wales; however, its uptake within HBs and NHS Trusts has been inconsistent, and it has not been considered across all services, particularly those in primary care. Opportunities therefore exist to share learning across organisations.

Registered nurses' perceptions regarding nurse-led antiretroviral therapy initiation in Hhohho region, Swaziland.

BACKGROUND: Swaziland has the highest HIV prevalence globally. It faces a critical shortage of health workers for addressing the HIV pandemic. To curb this human resource challenge, Swaziland adopted a nurse-driven model for antiretroviral therapy delivery in line with the recommendations of the World Health Organization on task shifting. OBJECTIVE: The study explored the perceptions of registered nurses on the nurse-led antiretroviral therapy initiation programme in the Hhohho region of Swaziland (NARTIS). DESIGN: The study utilized a phenomenological design, specifically a phenomenographic design. SETTING: The study was conducted in ten health facilities in the Hhohho region of Swaziland. These facilities comprised eight clinics, a hospital and a health centre. PARTICIPANTS: These were registered nurses, trained and certified in the nurse-led antiretroviral therapy initiation programme. The nurses also had experience of working in a nurse-led antiretroviral therapy initiation programme. Eighteen (18) nurses were purposively selected and recruited to participate in the study. METHODS: Data were collected through open and deep individual interviews guided by a semi-structured interview schedule. The audio-recorded interviews were transcribed and analysed thematically using Sjöström and Dahlgren's approach to data analysis. RESULTS: Three major themes emerged from the study data: nurses' emotional reactions to the implementation of the NARTIS programme, and influences and overcoming barriers to the programme. CONCLUSIONS: The study findings have generated insights into this program which is useful for the provision of care to people living with HIV/AIDS in Swaziland. But nurses need support to ensure effective implementation. IMPLICATION FOR NURSING AND HEALTH POLICY: The study findings have implications for both the practice of the NARTIS programme and health policy development. The development of a health policy that alleviates the barriers to the NARTIS programme can enhance nurses' role and make care provision to people living with HIV/AIDS more effective.

[Delegation of Medical Treatment to Non-physician Health Care Professionals: The Medical Care Structure agneszwei in Brandenburg - A Qualitative Acceptance Analysis]. / Delegation ärztlicher Leistungen an nichtärztliche Fachkräfte: Der Versorgungsansatz agneszwei in Brandenburg ­ eine qualitative Akzeptanzanalyse.

Backround: To address the increasing shortage of primary care physicians in rural regions, pilot model projects were tested, where general practitioners delegate certain physician tasks including house calls to qualified physician assistants. Evaluations show a high level of acceptance among participating physicians, medical assistants and patients. This study aims to measure the quality of cooperation among professionals participating in an outpatient health care delegation structure agneszwei with a focus on case management in Brandenburg. Methods: We conducted 10 qualitative semi-structured expert interviews among 6 physicians and 4 physician's assistants. Results: Physicians and physicians' assistants reported the cooperative action to be successful and as an advantage for patients. The precondition for successful cooperation is that non-physician health care professionals strictly respect the governance of the General Practitioners. Physicians report that the delegation of certain medical tasks reduces their everyday workload. Physician assistants derive professional satisfaction from the confidential relationship they have with the patients. All physician assistants are in favor of medical tasks being delegated to them in regular medical outpatient care, while most physicians are skeptical or reluctant despite their reported positive experience. Conclusion: Despite the high level of acceptance of delegating some medical tasks to physician assistants, the negotiation process of introducing cooperative working structures in the outpatient health care system is still at the beginning.

An Exploratory Descriptive Study on Task Shifting in East Africa.

The purpose of this study was to explore the perceptions of nurse leaders in Ethiopia, Kenya, Tanzania, and Uganda who have taken on expanded roles through task shifting. Understanding how nurses perceive task shifting directs education and training to more effectively meet population health needs in their communities. Participants were nurse leaders in countries with complex health care systems and few resources. Participants identified conflicting roles and expectations that were not consistent with their role preparation or scope of practice.

Delegation: a solution to the workload problem? Observations and interviews with community pharmacists in England.

OBJECTIVE: This study aims to describe how pharmacists utilise and perceive delegation in the community setting. METHOD: Non-participant observations and semi-structured interviews with a convenience sample of community pharmacists working in Kent between July and October 2011. Content analysis was undertaken to determine key themes and the point of theme saturation informed sample size. Findings from observations were also compared against those from interviews. KEY FINDINGS: Observations and interviews were undertaken with 11 pharmacists. Observations showed that delegation occurred in four different forms: assumed, active, partial and reverse. It was also employed to varying extents within the different pharmacies. Interviews revealed mixed views on delegation. Some pharmacists presented positive attitudes towards delegation while others were concerned about maintaining accountability for delegated tasks, particularly in terms of accuracy checking of dispensed medication. Other pharmacists noted the ability to delegate was not a skill they found inherently easy. Comparison of observation and interview data highlighted discrepancies between tasks pharmacists perceived they delegated and what they actually delegated. CONCLUSIONS: Effective delegation can potentially promote better management of workload to provide pharmacists with additional time to spend on cognitive pharmaceutical services. To do this, pharmacists' reluctance to delegate must be addressed. Lack of insight into own practice might be helped by self-reflection and feedback from staff. Also, a greater understanding of legal accountability in the context of delegation needs to be achieved. Finally, delegation is not just dependent on pharmacists, but also on support staff; ensuring staff are empowered and equipped to take on delegated roles is essential.

[An evidence-based healthcare system and the role of the healthcare professions]. / Ein evidenzbasiertes Gesundheitssystem: die Rolle der Gesundheitsfachberufe.

An evidence-based healthcare system necessitates a new role allocation and new role definitions of the players. By means of professional delegation, physician-nurse substitution and adoption of new professional functions, which so far have not been part of their professional profiles, nurses, midwives and allied health professionals will adopt a broad spectrum of new responsibilities. At present, nurses, midwives and allied health professionals lack basic scientific competencies and opportunities to acquire skills in evidence-based practice. A reliable link between evidence-generating sciences in nursing, midwifery and allied health professions and clinical practice is missing. In the future, an increase of academically qualified health professionals and a new skills mix within each profession might promote active and effective participation in an evidence-based healthcare system. (As supplied by author).

[Involvement of healthcare assistants in nursing procedures]. / La collaboration de l'aide-soignante aux actes de l'infirmière.

Healthcare assistants are authorised to perform nursing procedures in accordance with regulated conditions. They do not perform their functions autonomously but carry out their actions within the framework of the nurse's responsibilities.

Maternity support workers and safety in maternity care in England.

Errors in health care may lead to poor outcomes or even death. In maternity care the issue is more acute as most women and babies are healthy--and mistakes can have devastating effects. In the last 20 years 'patient' safety in maternity care has received significant attention in terms of both policy and research. With few exceptions, the resultant publications have been aimed at health service managers or registered health professionals. However a substantial section of the workforce now consists of support workers who may receive minimal training. This article aims to serve as a reminder that everyone is responsible for the safety of maternity care, and the learning needs of unregistered care staff require attention to strengthen safety defences.

[Evaluating the deployment of VERAHs in family doctor-centred health care in Baden-Wuerttemberg]. / Evaluation des VERAH-Einsatzes in der Hausarztzentrierten Versorgung in Baden-Württemberg.

BACKGROUND: The contract covering family doctor-centred health care (HzV) in Baden-Wuerttemberg supports and remunerates the deployment of specially trained health care assistants (VERAHs). It is as yet unknown to what extent VERAHs are actually deployed in HzV, what the focus of their work is, what changes and shifts in responsibility have resulted in the practice team, and whether they have relieved the burden on family doctors. METHOD: A full survey of all VERAHs in HzV practices in Baden-Wuerttemberg was conducted using a questionnaire (response rate over 32 %, N = 294). The questions aimed to gather information on how often and where VERAHs were deployed and on observed changes in their fields of responsibility. The family doctors employing VERAHs also received a questionnaire containing questions related to the changes observed, and additional questions on the delegation of responsibilities to VERAHs. RESULTS: To an increasing extent, VERAHs take on responsibilities that directly involve the patient, such as home visits agreed on with the doctor, vaccination and drug management, wound management and case management. Thus they take on tasks traditionally reserved for doctors. Both family doctors and VERAHs said that patient health care has improved and that the use of VERAHs helps doctors save time. CONCLUSIONS: The deployment of VERAHs in family doctor-centred health care leads to the redistribution of responsibilities in the practice and thus relieves physician burden. Chronically ill patients benefit from continuous care and an additional contact person. Health care assistants benefit from new career options.

Delegation and beyond: what happens when things go wrong?

Both midwives and maternity support workers can be confused about who is liable if a task is delegated and something goes wrong. With proper understanding of roles and a knowledge of which tasks can and can't be delegated, however, the midwife should be protected, particularly as in practice the NHS body will have vicarious liability in the event of any claim. Clinical negligence training identifies the risks and responsibilities involved--and, leaving aside issues of delegation, training should also instil common sense safeguards against incurring criminal liability, which is independent from any professional or civil sanction.