Health workforce data needed to minimize inequities associated with health-worker migration.

A persistent challenge with health-worker migration is the inequities it creates. To minimize these inequities, systems of global governance of health-worker migration have arisen which include various global codes of practice, agreements and reporting requirements. Reporting that is rigorous, open and transparent, and subject to scrutiny from the public, researchers, civil society organizations and other interested stakeholders, is important. One element of these codes and agreements with perhaps the greatest potential to deal with the impact of health-worker migration is more robust planning of the health workforce to address the goal of self-sufficiency. Open platforms for data sharing enable engagement of the public and stakeholders with data on the distribution and national origin of health workers, and reveal policy strengths and weaknesses related to health-workforce planning. We explore recent policies directed at reducing the inequities from health-worker migration. While many of the examples used focus on nurses and doctors, the issues discussed are relevant to all cadres of internationally trained health workers.

La migration des professionnels de la santé constitue un problème persistant en raison des inégalités qu'elle engendre. Pour y remédier, des systèmes de gouvernance mondiale axés sur la migration des professionnels de la santé ont vu le jour. Ces systèmes comprennent différents codes de pratique, accords et exigences mondiaux en matière d'établissement de rapports. Il est essentiel que ces rapports soient rigoureux, ouverts et transparents et qu'ils fassent l'objet d'un examen minutieux de la part du public, des chercheurs, des organisations de la société civile et d'autres parties prenantes intéressées. L'un des éléments de ces codes de pratiques et accords qui induit peut-être le plus grand potentiel pour faire face à l'impact de la migration des professionnels de la santé est une planification plus soutenue des professionnels de la santé afin d'atteindre l'objectif d'autosuffisance. Des plateformes ouvertes de partage de données permettent au public et aux parties prenantes d'accéder aux données sur la répartition et l'origine nationale des professionnels de la santé et révèlent les forces et faiblesses des politiques liées à la planification du personnel de santé. Dans cette étude, nous explorons les politiques récentes visant à réduire les inégalités liées à la migration des professionnels de la santé. Bien que de nombreux exemples utilisés se concentrent sur le personnel infirmier et les médecins, les questions abordées concernent également tous les supérieurs des professionnels de la santé formés à l'étranger.

Uno de los desafíos persistentes de la migración de los profesionales sanitarios son las desigualdades que genera. Para minimizar estas desigualdades, han surgido sistemas de gobernanza mundial de la migración de los profesionales sanitarios que incluyen diversos códigos de prácticas, acuerdos y requisitos de presentación de informes a escala mundial. Es importante que los informes sean detallados, abiertos y transparentes, y que estén sujetos al escrutinio del público, los investigadores, las organizaciones de la sociedad civil y otras partes interesadas. Uno de los elementos de estos códigos y acuerdos con mayor potencial para hacer frente al impacto de la migración de los profesionales sanitarios es una planificación más sólida del personal sanitario para alcanzar el objetivo de la autosuficiencia. Las plataformas abiertas para el intercambio de datos permiten la participación del público y las partes interesadas con datos sobre la distribución y el origen nacional de los profesionales sanitarios y revelan las fortalezas y debilidades de las políticas relacionadas con la planificación del personal sanitario. Exploramos las políticas recientes dirigidas a reducir las desigualdades derivadas de la migración de los profesionales sanitarios. Aunque muchos de los ejemplos utilizados se centran en el personal de enfermería y los médicos, los temas tratados son relevantes para todos los tipos de profesionales sanitarios con formación internacional.

Complexities of health and care worker migration pathways and corresponding international reporting requirements.

The increasing complexity of the migration pathways of health and care workers is a critical consideration in the reporting requirements of international agreements designed to address their impacts. There are inherent challenges across these different agreements including reporting functions that are misaligned across different data collection tools, variable capacity of country respondents, and a lack of transparency or accountability in the reporting process. Moreover, reporting processes often neglect to recognize the broader intersectional gendered and racialized political economy of health and care worker migration. We argue for a more coordinated approach to the various international reporting requirements and processes that involve building capacity within countries to report on their domestic situation in response to these codes and conventions, and internationally to make such reporting result in more than simply the sum of their responses, but to reflect cross-national and transnational interactions and relationships. These strategies would better enable policy interventions along migration pathways that would more accurately recognize the growing complexity of health worker migration leading to more effective responses to mitigate its negative effects for migrants, source, destination, and transit countries. While recognizing the multiple layers of complexity, we nevertheless reaffirm the fact that countries still have an ethical responsibility to undertake health workforce planning in their countries that does not overly rely on the recruitment of migrant health and care workers.

Teaming up for long-term care: Recognizing all long-term care staff contribute to quality care.

When looking to promising international approaches to improve quality care in long-term care, it is necessary to avoid cherry-picking specific dimensions ignoring the integrated nature of what makes these approaches promising in the first place. In looking at promising Scandinavian or Green House models, attention is often paid to the size of facility. This often overlooks the importance of higher level of staffing, mix, and compensation of direct care staff and the integration of dietary, laundry, and housekeeping staff to care teams. Other overlooked considerations include recognition of family and friends and policies supporting care continuity.

The pathway from mental health, leaves of absence, and return to work of health professionals: Gender and leadership matter.

Health professions are ranked among the most stressful occupations and have a much higher likelihood of absenteeism from work. In this article, we present findings from four health professional case studies in our Healthy Professional Worker partnership, involving surveys with 1,860 respondents and 163 interviews with nurses, physicians, midwives, and dentists conducted between December 2020 and April 2021. We found that the pathway from mental health experiences through to the decision to take a leave of absence and return to work differed between the health professions and that both gender and leadership matter greatly. There is a need to de-stigmatize mental health issues and encourage greater awareness and support from supervisors and colleagues. Leadership can play an important role in mitigating mental health issues, and as such investment in both leadership training and mentorship are important first steps in acting upon our research findings.

Leadership for quality in long-term care.

Leadership in long-term care is a burgeoning field of research, particularly that which is focused on enabling point of care staff to provide high-quality and responsive healthcare. In this article, we focus on the relatively important role that leadership plays in enabling the conditions for high-quality long-term care. Our methodological approach involved a rapid in-depth ethnography undertaken by an interdisciplinary team across eight public and non-profit long-term care homes in Canada, where we conducted over 1,000 hours of observations and 275 formal and informal interviews with managers, staff, residents, family members and volunteers. Guiding our analysis post hoc is the LEADS in a Caring Environment framework. We mapped key promising leadership practices identified by our analysis and discuss how these can inform the development of leadership standards across staff and management in long-term care.

Mapping the peer-reviewed literature on accommodating nurses' return to work after leaves of absence for mental health issues: a scoping review.

BACKGROUND: The complexity of nursing practice increases the risk of nurses suffering from mental health issues, such as substance use disorders, anxiety, burnout, depression, and posttraumatic stress disorder (PTSD). These mental health issues can potentially lead to nurses taking leaves of absence and may require accommodations for their return to work. The purpose of this review was to map key themes in the peer-reviewed literature about accommodations for nurses' return to work following leaves of absence for mental health issues. METHODS: A six-step methodological framework for scoping reviews was used to summarize the amount, types, sources, and distribution of the literature. The academic literature was searched through nine electronic databases. Electronic charts were used to extract code and collate the data. Findings were derived inductively and summarized thematically and numerically. RESULTS: Academic literature is scarce regarding interventions for nurses' return to work following leaves of absence for mental health issues, and most focused on substance use concerns. Search of the peer-reviewed literature yielded only six records. The records were primarily quantitative studies (n = 4, 68%), published between 1997 and 2018, and originated in the United States (n = 6, 100%). The qualitative thematic findings addressed three major themes: alternative to discipline programs (ADPs), peer support, and return to work policies, procedures, and practices. CONCLUSIONS: While the literature supports alternative to discipline programs as a primary accommodation supporting return to work of nurses, more on the effectiveness of such programs is required. Empirical evidence is necessary to develop, maintain, and refine much needed return to work accommodations for nurses after leaves of absence for mental health issues.

Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia.

PURPOSE: Providing care in alternative (non-office) locations and outside office hours are important elements of access and comprehensiveness of primary care. We examined the trends in and determinants of the services provided in a cohort of primary care physicians in British Columbia, Canada. METHODS: We used physician-level payments for all primary care physicians practicing in British Columbia from 2006-2007 through 2011-2012. We examined the association between physician demographics and practice characteristics and payment for care in alternative locations and after hours across rural, urban, and metropolitan areas using longitudinal mixed-effects models. RESULTS: The proportion of physicians who provided care in alternative locations and after hours declined significantly during the period, in rural, urban, and metropolitan practices. Declines ranged from 5% for long-term care facility visits to 22% for after-hours care. Female physicians, and those in the oldest age category, had lower odds of providing care at alternative locations and for urgent after-hours care. Compared with those practicing in metropolitan centers, physicians working in rural areas had significantly higher odds of providing care both in alternative locations and after hours. CONCLUSION: Care provided in non-office locations and after office hours declined significantly during the study period. Jurisdictions where providing these services are not mandated, and where similar workforce demographic shifts are occurring, may experience similar accessibility challenges.

Is attending birth dying out? Trends in obstetric care provision among primary care physicians in British Columbia.

OBJECTIVE: To examine trends in and sociodemographic predictors of the provision of obstetric care within the primary care context among physicians in British Columbia (BC). DESIGN: Population-based, longitudinal cohort study using administrative data. SETTING: British Columbia. PARTICIPANTS: All primary care physicians practising in BC between 2005-2006 and 2011-2012. MAIN OUTCOME MEASURES: Fee-for-service payment records were used to identify the provision of prenatal and postnatal care and deliveries. The proportions of physicians who attended deliveries and who included any obstetric care provision in their practices were examined over time using longitudinal mixed-effects log-linear models. RESULTS: The proportion of physicians attending deliveries or providing any obstetric care declined significantly over the study period (deliveries: odds ratio [OR] of 0.92, 95% CI 0.89-0.95; obstetric care: OR = 0.92, 95% CI 0.89-0.95), and obstetric care provision accounted for a smaller proportion of overall practice activity (OR = 0.96, 95% CI 0.94-0.99). Female physicians had higher odds of including obstetric care in their practices (OR = 1.46, 95% CI 1.27-1.69), and by 2011-2012 had significantly higher odds of attending deliveries (OR = 1.22, 95% CI 1.05-1.38). Older physicians and those located in metropolitan centres were less likely to provide obstetric care or attend deliveries. CONCLUSION: The provision of obstetric care by primary care physicians in BC declined over this period, suggesting the possibility of a growing access issue, particularly in rural and remote communities where family physicians are often the sole providers of obstetric services.

"This policy sucks and it's stupid:" Mapping maternity care for First Nations women on reserves in Manitoba, Canada.

First Nations women who live on rural and remote reserves in Canada leave their communities between 36 and 38 weeks gestational age to receive labor and birthing services in large urban centers. The process and administrative details of this process are undocumented despite decades of relocation as a routine component of maternity care. Using data from 32 semistructured interviews and information from peer-reviewed literature, grey literature, and public documents, I constructed a descriptive map and a visual representation of the policy. I present new and detailed information about Canada's health policy as well as recommendations to address the health care gaps identified.

The implications of the feminization of the primary care physician workforce on service supply: a systematic review.

There is a widespread perception that the increasing proportion of female physicians in most developed countries is contributing to a primary care service shortage because females work less and provide less patient care compared with their male counterparts. There has, however, been no comprehensive investigation of the effects of primary care physician (PCP) workforce feminization on service supply. We undertook a systematic review to examine the current evidence that quantifies the effect of feminization on time spent working, intensity and scope of work, and practice characteristics. We searched Medline, Embase, and Web of Science from 1991 to 2013 using variations of the terms 'primary care', 'women', 'manpower', and 'supply and distribution'; screened the abstracts of all articles; and entered those meeting our inclusion criteria into a data abstraction tool. Original research comparing male to female PCPs on measures of years of practice, time spent working, intensity of work, scope of work, or practice characteristics was included. We screened 1,271 unique abstracts and selected 74 studies for full-text review. Of these, 34 met the inclusion criteria. Years of practice, hours of work, intensity of work, scope of work, and practice characteristics featured in 12%, 53%, 42%, 50%, and 21% of studies respectively. Female PCPs self-report fewer hours of work than male PCPs, have fewer patient encounters, and deliver fewer services, but spend longer with their patients during a contact and deal with more separate presenting problems in one visit. They write fewer prescriptions but refer to diagnostic services and specialist physicians more often. The studies included in this review suggest that the feminization of the workforce is likely to have a small negative impact on the availability of primary health care services, and that the drivers of observed differences between male and female PCPs are complex and nuanced. The true scale of the impact of these findings on future effective physician supply is difficult to determine with currently available evidence, given that few studies looked at trends over time, and results from those that did are inconsistent. Additional research examining gender differences in practice patterns and scope of work is warranted.

Global evidence of gender equity in academic health research: a scoping review.

OBJECTIVES: To chart the global literature on gender equity in academic health research. DESIGN: Scoping review. PARTICIPANTS: Quantitative studies were eligible if they examined gender equity within academic institutions including health researchers. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes related to equity across gender and other social identities in academia: (1) faculty workforce: representation of all genders in university/faculty departments, academic rank or position and salary; (2) service: teaching obligations and administrative/non-teaching activities; (3) recruitment and hiring data: number of applicants by gender, interviews and new hires for various rank; (4) promotion: opportunities for promotion and time to progress through academic ranks; (5) academic leadership: type of leadership positions, opportunities for leadership promotion or training, opportunities to supervise/mentor and support for leadership bids; (6) scholarly output or productivity: number/type of publications and presentations, position of authorship, number/value of grants or awards and intellectual property ownership; (7) contextual factors of universities; (8) infrastructure; (9) knowledge and technology translation activities; (10) availability of maternity/paternity/parental/family leave; (11) collaboration activities/opportunities for collaboration; (12) qualitative considerations: perceptions around promotion, finances and support. RESULTS: Literature search yielded 94 798 citations; 4753 full-text articles were screened, and 562 studies were included. Most studies originated from North America (462/562, 82.2%). Few studies (27/562, 4.8%) reported race and fewer reported sex/gender (which were used interchangeably in most studies) other than male/female (11/562, 2.0%). Only one study provided data on religion. No other PROGRESS-PLUS variables were reported. A total of 2996 outcomes were reported, with most studies examining academic output (371/562, 66.0%). CONCLUSIONS: Reviewed literature suggest a lack in analytic approaches that consider genders beyond the binary categories of man and woman, additional social identities (race, religion, social capital and disability) and an intersectionality lens examining the interconnection of multiple social identities in understanding discrimination and disadvantage. All of these are necessary to tailor strategies that promote gender equity. TRIAL REGISTRATION NUMBER: Open Science Framework: https://osf.io/8wk7e/.

Canada's evacuation policy for pregnant First Nations women: Resignation, resilience, and resistance.

BACKGROUND: Aboriginal peoples in Canada are comprised of First Nations, Métis, and Inuit. Health care services for First Nations who live on rural and remote reserves are mostly provided by the Government of Canada through the federal department, Health Canada. One Health Canada policy, the evacuation policy, requires all First Nations women living on rural and remote reserves to leave their communities between 36 and 38 weeks gestational age and travel to urban centres to await labour and birth. Although there are a few First Nations communities in Canada that have re-established community birthing and Aboriginal midwifery is growing, most First Nations communities are still reliant on the evacuation policy for labour and birthing services. In one Canadian province, Manitoba, First Nations women are evacuated to The Pas, Thompson, or Winnipeg but most - including all women with high-risk pregnancies - go to Winnipeg. AIM: To contribute scholarship that describes First Nations women's and community members' experiences and perspectives of Health Canada's evacuation policy in Manitoba. METHODS: Applying intersectional theory to data collected through 12 semi-structured interviews with seven women and five community members (four females, one male) in Manitoba who had experienced the evacuation policy. The data were analyzed thematically, which revealed three themes: resignation, resilience, and resistance. FINDINGS: The theme of resignation was epitomized by the quote, "Nobody has a choice." The ability to withstand and endure the evacuation policy despite poor or absent communication and loneliness informed of resilience. Resistance was demonstrated by women who questioned the necessity and requirement of evacuation for labour and birth. In one instance, resistance took the form of a planned homebirth with Aboriginal registered midwives. CONCLUSION: There is a pressing need to improve the maternity care services that First Nations women receive when they are evacuated out of their communities, particularly when understood from the specific legal and constitutional position of First Nations women in Manitoba.

Networks as systems.

Purpose The purpose of this paper is to present a case study of the World Health Organization's Global Healthcare Workforce Alliance (GHWA). Based on a commissioned evaluation of GHWA, it applies network theory and key concepts from systems thinking to explore network emergence, effectiveness, and evolution to over a ten-year period. The research was designed to provide high-level strategic guidance for further evolution of global governance in human resources for health (HRH). Design/methodology/approach Methods included a review of published literature on HRH governance and current practice in the field and an in-depth case study whose main data sources were relevant GHWA background documents and key informant interviews with GHWA leaders, staff, and stakeholders. Sampling was purposive and at a senior level, focusing on board members, executive directors, funders, and academics. Data were analyzed thematically with reference to systems theory and Shiffman's theory of network development. Findings Five key lessons emerged: effective management and leadership are critical; networks need to balance "tight" and "loose" approaches to their structure and processes; an active communication strategy is key to create and maintain support; the goals, priorities, and membership must be carefully focused; and the network needs to support shared measurement of progress on agreed-upon goals. Shiffman's middle-range network theory is a useful tool when guided by the principles of complex systems that illuminate dynamic situations and shifting interests as global alliances evolve. Research limitations/implications This study was implemented at the end of the ten-year funding cycle. A more continuous evaluation throughout the term would have provided richer understanding of issues. Experience and perspectives at the country level were not assessed. Practical implications Design and management of large, complex networks requires ongoing attention to key issues like leadership, and flexible structures and processes to accommodate the dynamic reality of these networks. Originality/value This case study builds on growing interest in the role of networks to foster large-scale change. The particular value rests on the longitudinal perspective on the evolution of a large, complex global network, and the use of theory to guide understanding.

In British Columbia, The Supply Of Primary Care Physicians Grew, But Their Rate Of Clinical Activity Declined.

Reports of a primary care shortage are ubiquitous in Canada and the United States. We used a population-based, retrospective cohort study to examine the extent to which the feminization and aging of the primary care physician workforce and secular trends may contribute to changes in the availability of primary care services. We used billing data for all primary care physicians in British Columbia for the period 2005-12. We used multivariate linear mixed-effects models to study physician remuneration and activity levels. We found limited change in per physician remuneration over the study period. However, numbers of patient contacts and practice sizes (numbers of unique patients) declined by 14 percent and 10 percent, respectively. Although the feminization of the workforce-and, to a lesser extent, its aging-contributed to this decline, the primary driver appears to be a broad trend toward reduced clinical activity over time. To the extent that similar trends are occurring in the United States, the implications of our study for the availability of primary care services beyond Canada are potentially significant.

Results of implementation of a hospital-based strategy to reduce cesarean delivery among low-risk women in Canada.

OBJECTIVE: To assess the cesarean delivery (CD) rate among low-risk pregnancies before and after implementation of a hospital-based program in Canada. METHODS: A prospective before-and-after study was conducted to assess the effects of the CARE (CAesarean REduction) strategy, which was developed and implemented at Markham Stouffville Hospital, Toronto, ON, Canada, in 2010 to reduce CD among low-risk women. Hospital records were reviewed to identify changes in the proportions of CD performed during 12 months (April 2009-March 2010) before implementation of the CARE strategy versus 12 months after implementation (April 2012-March 2013) at Markham Stouffville Hospital and 36 hospitals of the same level in the same province. RESULTS: At the intervention hospital, 30.3% (964/3181) of women underwent CD in 2009-2010, compared with 26.4% (803/3045) in 2012-2013 (difference -3.9%, P<0.001). By contrast, no significant difference was recorded in control hospitals (28.1% [23 694/84 361] vs 28.2% [23 683/83 895]; difference 0.1%, P=0.5157). CONCLUSION: Implementation of the CARE strategy reduced rates of CD among the target population.

Acculturation and nutritional health of immigrants in Canada: a scoping review.

Although recent immigrants to Canada are healthier than Canadian born (i.e., the Healthy Immigrant Effect), they experience a deterioration in their health status which is partly due to transitions in dietary habits. Since pathways to these transitions are under-documented, this scoping review aims to identify knowledge gaps and research priorities related to immigrant nutritional health. A total of 49 articles were retrieved and reviewed using electronic databases and a stakeholder consultation was undertaken to consolidate findings. Overall, research tends to confirm the Healthy Immigrant Effect and suggests that significant knowledge gaps in nutritional health persist, thereby creating a barrier to the advancement of health promotion and the achievement of maximum health equity. Five research priorities were identified including (1) risks and benefits associated with traditional/ethnic foods; (2) access and outreach to immigrants; (3) mechanisms and coping strategies for food security; (4) mechanisms of food choice in immigrant families; and (5) health promotion strategies that work for immigrant populations.

Comparing approaches to integrating refugee and asylum-seeking healthcare professionals in Canada and the UK.

In this paper, we examine barriers to the integration of refugee doctors and nurses in Canada and the United Kingdom. Key obstacles impeding the integration of internationally trained health professionals are well documented, but less attention has been paid to the integration of refugee health professionals, particularly in Canada. Based on documentary analysis and semi-structured interviews with 46 Canadian and 34 UK stakeholders, our research shows that there are no simple solutions to mitigating the core obstacles that prohibit the professional integration of refugee doctors and nurses into host countries. The targeted approach adopted in parts of the UK does provide some promising practices for Canada, which has yet to develop policies and initiatives specific to health professional refugees. This study is intended to contribute to our understanding of how immigration and health human resources policies have shaped the economic integration of refugee healthcare professionals in the UK and Canada in distinct ways.

The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis.

OBJECTIVE: To estimate the lost investment of domestically educated doctors migrating from sub-Saharan African countries to Australia, Canada, the United Kingdom, and the United States. DESIGN: Human capital cost analysis using publicly accessible data. SETTINGS: Sub-Saharan African countries. PARTICIPANTS: Nine sub-Saharan African countries with an HIV prevalence of 5% or greater or with more than one million people with HIV/AIDS and with at least one medical school (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), and data available on the number of doctors practising in destination countries. MAIN OUTCOME MEASURES: The financial cost of educating a doctor (through primary, secondary, and medical school), assuming that migration occurred after graduation, using current country specific interest rates for savings converted to US dollars; cost according to the number of source country doctors currently working in the destination countries; and savings to destination countries of receiving trained doctors. RESULTS: In the nine source countries the estimated government subsidised cost of a doctor's education ranged from $21,000 (£13,000; €15,000) in Uganda to $58,700 in South Africa. The overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn (95% confidence interval 2.13bn to 2.21bn), with costs for each country ranging from $2.16m (1.55m to 2.78m) for Malawi to $1.41bn (1.38bn to 1.44bn) for South Africa. The ratio of the estimated compounded lost investment over gross domestic product showed that Zimbabwe and South Africa had the largest losses. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m). CONCLUSIONS: Among sub-Saharan African countries most affected by HIV/AIDS, lost investment from the emigration of doctors is considerable. Destination countries should consider investing in measurable training for source countries and strengthening of their health systems.

Canadian family physicians and complementary/alternative medicine: the role of practice setting, medical training, and province of practice.

The present study sheds some light on how and why Canadian family physicians offer complementary and alternative medicine (CAM) services to their patients. Our results suggest that organizational settings discourage physicians from offering CAM, while solo clinics are most conducive. Physicians trained in French-language medical schools are less likely than their English-language trained colleagues to offer CAM services, and those in British Columbia are the most likely to do so. Provincial differences do not appear to be related to the presence or absence of "negative proof" legislation that is considered to facilitate CAM provision by physicians.