Gestão compartilhada: potencialidades do fortalecimento da integração ensino- serviço no âmbito hospitalar / Shared management: potential for strengthening teaching-service integration in the hospital environment

Objetivo: relatar a experiência acerca da gestão compartilhada e as potencialidades da integração ensino-serviço no âmbito hospitalar. Método: Trata-se de um estudo qualitativo, do tipo relato de experiência, vivenciado por uma enfermeira educadora no período de setembro de 2022 a junho de 2023 por meio de atividades de educação permanente realizadas por meio da integração ensino-serviço. Resultados: Por meio das atividades que foram realizadas pelos estudantes em conjunto com os profissionais, pode-se evidenciar melhor adesão dos colabores aos treinamentos realizados pelo setor de educação permanente, podendo ser clarificado através dos indicadores de desempenho do setor, tendo uma maior aceitação dos profissionais por categoria. Conclusão: A constata que a integração ensino-serviço tem provocado reflexão dos processos de trabalho, por meio de espaços de discussão, de troca de saberes e experiências, tem favorecido uma gestão compartilhada pautada na significância, no respeito aos atores sociais e nas pluralidades.(AU)

Objective: to report the experience about shared management and the potential of teaching-service integration in the hospital setting. Method: This is a qualitative study, of the experience report type, experienced by a nurse educator in the period from September 2022 to June 2023 through permanent education activities carried out through teaching-service integration. Results: Through the activities that were carried out by the students together with the professionals, it can be evidenced a better adherence of the collaborators to the training carried out by the permanent education sector, which can be clarified through the sector's performance indicators, having a greater acceptance of professionals by category. Conclusion: It was found that the teaching-service integration has provoked reflection of work processes, through spaces for discussion, exchange of knowledge and experiences, has favored a shared management based on significance, respect for social actors and pluralities.(AU)

Objetivo: relatar la experiencia sobre la gestión compartida y el potencial de la integración enseñanza-servicio en el ámbito hospitalario. Método: Se trata de un estudio cualitativo, de tipo relato de experiencia, vivenciado por una enfermera educadora en el período de septiembre de 2022 a junio de 2023 a través de actividades de educación permanente realizadas por medio de la integración enseñanza-servicio. Resultados: A través de las actividades que fueron realizadas por los estudiantes en conjunto con los profesionales, se puede evidenciar una mejor adherencia de los colaboradores a la formación realizada por el sector de educación permanente, lo que puede ser esclarecido a través de los indicadores de desempeño del sector, teniendo una mayor aceptación de los profesionales por categoría. Conclusión: Se constató que la integración enseñanza-servicio ha provocado la reflexión sobre los procesos de trabajo, a través de espacios de discusión, intercambio de conocimientos y experiencias, ha favorecido una gestión compartida basada en la significatividad, el respeto a los actores sociales y a las pluralidades.(AU)

Processos de reflexividade dos psicólogos do esporte e coaches: um estudo fenomenológico / Reflexivity processes of sport psychologists and coaches: a phenomenological study / Procesos de reflexividad de psicólogos del deporte y coaches: un estudio fenomenológico

O objetivo desta pesquisa é identificar e compreender fenomenologicamente, por meio de relato de Psicólogos de Esporte (PE) e de Coaches, em sua vivência prática, como ocorrem os processos reflexivos em sua atuação, conforme apreendidos a partir de relatos de experiências. O método de investigação escolhido foi a fenomenologia, pois oferece os recursos necessários para tal mergulho junto à experiência reflexiva. A amostra intencional foi delineada por PE e Coaches (profissionais de Educação Física que recorrem ao Coaching) em atividade em esportes de alto rendimento, que tenham atuado ou estejam atuando em modalidades esportivas coletivas e/ou individuais. Realizaram-se nove entrevistas (cinco com PE, quatro com Coaches). O acesso ao objeto desse estudo se deu por meio de entrevistas em profundidade e semiestruturadas, orientadas pela escuta suspensiva. As questões disparadoras foram formuladas com base no Procedimento Estruturado de Reflexão adaptado. Para análise das entrevistas, realizou-se uma síntese de cada relato, seguindo-se de cruzamento intencional. Como resultados, percebeu-se que PE e Coaches trazem algumas similaridades no que se refere aos modos de refletir sobre sua prática. No entanto, as experiências que eles fazem desses processos reflexivos é que podem tomar rumos distintos. Os(as) PE amparam-se na regulamentação da profissão e resguardam-se em seus apontamentos, trazendo suas experiências e reflexões sobre os processos vividos. Os(as) Coaches trazem em suas explanações um trabalho coerente, organizado e compatível com o método do Coaching. Problematizar os processos reflexivos desses profissionais permite diferenciar qualitativa e eticamente suas atuações, possibilitando o fomento multiprofissional no esporte.(AU)

The aim of this study consists in phenomenologically identifying and understanding, by the report of Sport Psychologists (SP) and coaches, in their practical experience, how would be the reflexive processes that take place in their performance, as learned from reports of their experiences. The research method chosen was phenomenology, since it offers the necessary resources for such a dive along with the reflective experience. The intentional sample was outlined by SP and coaches (Physical Education professionals who use coaching) active in high performance sports, who have or are working in collective and/or individual sports. Nine interviews were conducted (five with SP, four with coaches). Access to the object of this study took place by in-depth and semi-structured interviews, guided by suspensive listening. The triggering questions were formulated based on the adapted Structured Reflection Procedure. For the analysis of the interviews, a synthesis of each report was carried out, followed by the intentional crossing. As results, it was noticed that SP and coaches bring some similarities regarding the ways of reflecting on their practice. However, their experiences of these reflective processes are that they can take different directions. The SP are based on the regulation of the profession and guard themselves in their notes, bringing their experiences and reflections on the processes experienced. Coaches bring in their explanations a coherent, organized, and compatible work with the coaching method. Problematizing the reflective processes of these professionals allows to differentiate their actuation qualitatively and ethically, making the multiprofessional phenomenon in sport possible.(AU)

El objetivo de este estudio consiste en identificar y comprender fenomenológicamente, a partir de la experiencia práctica de psicólogos del deporte (PD) y coaches, cómo serían los procesos reflexivos que se llevan a cabo en su rendimiento, tal y como se desprende de los informes de experiencias. El método de investigación elegido fue la fenomenología, ya que ofrece los recursos necesarios junto con la experiencia. La muestra intencional fue delineada por PD y coaches (profesionales de la educación física que utilizan el coaching) activos en deportes de alto rendimiento, que tienen o están trabajando en deportes colectivos e/o individuales. Se realizaron nueve entrevistas (cinco con PD, cuatro con coaches). El acceso al objeto de este estudio fue entrevistas en profundidad y semiestructuradas, guiadas por escuchas suspensivas. Las preguntas se formularon desde el procedimiento de reflexión estructurado adaptado. Para el análisis de las entrevistas, se hizo una síntesis de cada informe, seguida del cruce intencional. Como resultados, se notó que los PD y coaches tienen algunas similitudes con respecto a las formas de reflexionar sobre su práctica. Sin embargo, las experiencias que hacen de estos procesos pueden tomar diferentes direcciones. Los(las) PD se basan en la regulación de la profesión y se protegen en sus notas, aportando sus experiencias y reflexiones sobre los procesos vividos. Los(las) coaches plantean en sus explicaciones un trabajo coherente, organizado y compatible con el método de Coaching. Problematizar los procesos reflexivos de estos profesionales permite diferenciar sus acciones de manera cualitativa y ética, además de posibilitar la promoción multiprofesional en el deporte.(AU)

Gaps in Practice Management Skills After Training: A Qualitative Needs Assessment of Early Career Surgeons.

PURPOSE: Shifts in American healthcare delivery mechanisms pose significant hurdles to new physicians. Surgeons are particularly susceptible to these changes, but surgical residency educational efforts primarily focus on technical and clinical training to the exclusion of business and management practices. This study conducted a needs assessment of perceived gaps in practice management skills among early career surgeons to guide future training curricula. METHODS: This study was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify early career (<5 years following fellowship completion) surgeons across the United States. A semi-structured interview guide was created from interviews with surgical administrators and physician administrative curricula. Transcripts were de-identified and analyzed using a constructivist grounded theory approach. RESULTS: Ten surgeons from 6 specialties and 6 institutions were interviewed along with 3 surgeon administrators. Three major domains of need were identified: (1) fundamentals of procedural coding, clinical billing, & compliance, (2) finding/building a practice, and (3) navigating organizational challenges. First, surgeons thought trainees would benefit from a better understanding of reimbursement schema and the basics of health policy. They also thought that more exposure to malpractice litigation, especially for handling case review or expert witness requests, would be helpful for discerning how to handle such issues early in their career. In addition, early career surgeons expressed a desire to have dedicated mentorship time, a primer on evaluating job offers with simulated contract negotiation, and guidance regarding administrative roles. Finally, surgeons requested training in change management techniques, care pathway construction, and the basics of staffing decisions. CONCLUSIONS: There are significant practice management gaps in surgical training which may be amenable to targeted educational efforts during a residency or fellowship program. Future research will test the generalizability of these findings as well as build curricula that adequately meet these needs.

Practice Management Strategies for Imaging Facilities Facing an Acute Iodinated Contrast Media Shortage.

An unanticipated but severe shortage in iodinated contrast media (ICM) is currently affecting imaging practices across the globe and is expected to persist through at least the end of June 2022. This supply shock may lead health care systems to experience an acute imaging crisis, given that many affected facilities have contrast agent supplies that are anticipated to last only a week or two under normal operating conditions. To maximize the opportunity to continue to provide optimal care for patients with emergent or life-threatening imaging indications and thereby minimize the overall impact on patient care, practice leaders will need to quickly assess their contrast material inventories, prioritize examination indications, and reduce their expected short-term usage of ICM. This Clinical Perspective reviews ICM conservation techniques that the Yale School of Medicine has deployed or is considering deploying, depending on the severity and length of the supply shortage.

Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons.

BACKGROUND: A survey was conducted at the 2021 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) to evaluate current practice management strategies among AAHKS members. METHODS: An application was used by AAHKS members to answer both multiple-choice and yes or no questions. Specific questions were asked regarding the impact of COVID-19 pandemic on practice patterns. RESULTS: There was a dramatic acceleration in same day total joint arthroplasty with 85% of AAHKS members performing same day total joint arthroplasty. More AAHKS members remain in private practice (46%) than other practice types, whereas fee for service (34%) and relative value units (26%) are the major form of compensation. At the present time, 93% of practices are experiencing staffing shortages, and these shortages are having an impact on surgical volume. CONCLUSION: This survey elucidates the current practice patterns of AAHKS members. The pandemic has had a significant impact on some aspects of practice activity. Future surveys need to monitor changes in practice patterns over time.

Relación entre habilidades investigativas y gestión en salud en enfermeras de la Red de Salud Arequipa-Caylloma / Relationship between Research Skills and Health Management in Nurses from Arequipa-Caylloma Health Network

Introducción: Es necesario que las enfermeras tengan habilidades investigativas para resolver problemas y necesidades en la gestión de salud. Objetivo: Identificar la relación existente entre las habilidades investigativas y la gestión en salud en las enfermeras de la Red de Salud Arequipa-Caylloma. Métodos: Estudio descriptivo correlacional, de corte transversal, en la Red Arequipa - Caylloma en Arequipa, Perú durante el año 2017. El universo de estudio quedó constituido por 153 profesionales de enfermería, con la aplicación de la fórmula de población finita para variable cualitativa, mediante muestreo aleatorio simple se obtuvo una muestra de 90 enfermeras. Las variables de estudio fueron habilidades investigativas y Gestión de salud en enfermería. Para obtener la información la investigadora utilizó dos cuestionarios. Para el análisis distribuciones de frecuencias absolutas y porcentajes, para la asociación de variables el χ² con una significación de p < 0.05. Resultados: Predominaron las enfermeras con nivel regular de habilidades investigativas (47,77 por ciento) y de gestión en salud (45,55 por ciento), con el estadístico no paramétrico el χ² se encontró asociación significativa (p = 0,001) entre las variables habilidades investigativas y la gestión de salud. Conclusión: Aunque predominaron los niveles regulares de gestión y de habilidades investigativas en enfermeras de la Red de Salud Arequipa Caylloma, se encontró relación significativa entre las variables habilidades investigativas y la gestión en salud(AU)

Introduction: It is necessary for nurses to have research skills to solve problems and needs in health management. Objective: To identify the relationship between research skills and health management in nurses from Arequipa-Caylloma Health Network. Methods: Descriptive, correlational and cross-sectional study carried out, during the year 2017, with the Arequipa-Caylloma Network in Arequipa, Peru. The study universe was made up of 153 nursing professionals, with the application of the finite population formula for qualitative variable. By simple random sampling, a sample of ninety nurses was obtained. The study variables were research skills and nursing health management. To obtain the information, the researcher used two questionnaires. For the analysis of absolute frequency distributions and percentages, as well as for the association of variables, the chi-square test was used, with a significance level of P < 0.05. Results: Nurses with a regular level of investigative skills (47.77 percent) and health management skills (45.55 percent) predominated. The nonparametric statistic chi-square test permitted to find a significant association (P = 0.001) between the variables of investigative skills and health management. Conclusion: Although regular levels of management and research skills predominated in nurses from Arequipa-Caylloma Health Network, a significant relationship was found between the variables of research skills and health management(AU)

Psychological and professional impact of COVID-19 lockdown on French dermatologists: Data from a large survey.

AIM: To evaluate the extent to which COVID-19-related lockdown affected dermatologists. METHODS: An anonymous online survey was proposed to all French dermatologists and dermatology residents to assess the impact of COVID-19 lockdown on their professional activity, their level of stress and their psychological state, as well as their coping strategies. RESULTS: Exactly 800 dermatologists completed the survey. The respondents noted changes in behaviour in their professional and personal environment. The number of cancelled or rescheduled appointments was very high, with a huge financial impact for private practitioners. Stigmatisation was also reported. Anxiety and a feeling of increased stress were very frequent. Increased substance use was also reported. CONCLUSION: The impact of the COVID-19 pandemic and lockdown was significant for French dermatologists, with risks to their own health, profound changes in their practice, and financial and psychological impact, but also the development of new consultation and evaluation strategies to improve their work-life balance.

Overcoming Overuse Part 4: Small Business Survival.

SUMMARY: The challenge of overuse raises important questions for those in the business of musculoskeletal health care. What is the right number of physical therapy visits for a given condition? Can a practice provide "less" but still be profitable? In this, the editorial on overcoming overuse of musculoskeletal health care, we consider the economic drivers of overuse in the private sector. We propose actions that could support small business leaders to overcome overuse and build profitable, high-quality services. J Orthop Sports Phys Ther 2021;51(1):1-4. doi:10.2519/jospt.2021.0101.

Billing, coding, and practice management: a primer for today's reproductive medicine professional.

Despite years of recognition that many physicians are woefully unprepared to face challenges regarding the business of medicine, marginal progress has been made. In this piece, we aim to provide the contemporary reproductive medicine physician with an understanding of billing, coding, and, most importantly, cost containment for a typical fertility practice. It is critical for modern practices to not forego hard-earned revenue to insurance companies or not be aware of critical rules and regulations. While running a successful fertility practice requires good medical care, a profitable practice is necessary for overall long-term success. This article provides a brief history of medical insurance and billing, explains the process of updating billing codes, and reviews the revenue cycle, cost containment, and contract negotiations with insurance companies.

The Society for Vascular Surgery Alternative Payment Model Task Force report on opportunities for value-based reimbursement in care for patients with peripheral artery disease.

The Society for Vascular Surgery Alternative Payment Model (APM) Taskforce document explores the drivers and implications for developing objective value-based reimbursement plans for the care of patients with peripheral arterial disease (PAD). The APM is a payment approach that highlights high-quality and cost-efficient care and is a financially incentivized pathway for participation in the Quality Payment Program, which aims to replace the traditional fee-for-service payment method. At present, the participation of vascular specialists in APMs is hampered owing to the absence of dedicated models. The increasing prevalence of PAD diagnosis, technological advances in therapeutic devices, and the increasing cost of care of the affected patients have financial consequences on care delivery models and population health. The document summarizes the existing measurement methods of cost, care processes, and outcomes using payor data, patient-reported outcomes, and registry participation. The document also evaluates the existing challenges in the evaluation of PAD care, including intervention overuse, treatment disparities, varied clinical presentations, and the effects of multiple comorbid conditions on the cost potentially attributable to the vascular interventionalist. Medicare reimbursement data analysis also confirmed the prolonged need for additional healthcare services after vascular interventions. The Society for Vascular Surgery proposes that a PAD APM should provide patients with comprehensive care using a longitudinal approach with integration of multiple key medical and surgical services. It should maintain appropriate access to diagnostic and therapeutic advancements and eliminate unnecessary interventions. It should also decrease the variability in care but must also consider the varying complexity of the presenting PAD conditions. Enhanced quality of care and physician innovation should be rewarded. In addition, provisions should be present within an APM for high-risk patients who carry the risk of exclusion from care because of the naturally associated high costs. Although the document demonstrates clear opportunities for quality improvement and cost savings in PAD care, continued PAD APM development requires the assessment of more granular data for accurate risk adjustment, in addition to largescale testing before public release. Collaboration between payors and physician specialty societies remains key.

Basics of practice management: managing many for the care of one.

In today's changing health care landscape, it has become necessary that providers have a fundamental understanding of practice management as pertinent to the care they provide. The reproductive endocrinology and infertility (REI) practice is a uniquely complex setting with many component parts, necessitating frequent assessment and collaboration to provide safe, quality, and cost-effective care. In this review, we aim to describe the basics of medical practice management, divided into six sections: practice models; operations; patient safety; patient experience; employee recruitment; development, and satisfaction; and technology. These topics will be presented with a focus on the application of these principles to the REI practice.

Processo gerencial em centro cirúrgico sob a ótica de enfermeiros / Proceso de gestión en el quirófano bajo la óptica de enfermeros / Management process in surgicenters from the perspective of nurses

Resumo Objetivo: Descrever o processo gerencial realizado por enfermeiros em centro cirúrgico. Métodos: Estudo descritivo e exploratório, de abordagem qualitativa, realizado com 10 enfermeiros do centro cirúrgico de um hospital universitário. Os dados coletados no período de setembro a outubro de 2019 por meio de entrevistas individuais semiestruturadas foram analisados com auxílio do software IRaMuTeQ e submetidos à análise temática indutiva. Resultados: A análise de similitude demonstra o protagonismo da equipe de enfermagem do centro cirúrgico e sua relação direta com o cuidado do paciente, enquanto a atuação do enfermeiro se caracteriza por ações predominantemente gerenciais relacionadas à organização do trabalho. Por meio da análise temática indutiva, foram elencadas três categorias relacionadas ao processo gerencial em centro cirúrgico: gestão de pessoas, gestão de recursos materiais e gestão do cuidado. Conclusão: Os achados indicaram que o processo gerencial em centro cirúrgico, segundo os enfermeiros, envolve a necessidade de aprimoramento das competências, bem como do conhecimento das ferramentas gerenciais para a gestão de pessoas, para o gerenciamento de recursos materiais e para a gestão do cuidado.

Resumen Objetivo: Describir el proceso de gestión realizado por enfermeros en el quirófano. Métodos: Estudio descriptivo y exploratorio, de enfoque cualitativo, realizado con 10 enfermeros del quirófano de un hospital universitario. Los datos recopilados durante el período de septiembre a octubre de 2019, mediante entrevistas individuales semiestructuradas, fueron analizados con ayuda del software IRaMuTeQ y sometidos al análisis temático inductivo. Resultados: El análisis de similitudes demuestra el protagonismo del equipo de enfermería del quirófano y su relación directa con el cuidado del paciente, y la actuación del enfermero se caracteriza por acciones predominantemente de gestión relacionadas con la organización del trabajo. Mediante el análisis temático inductivo, se enumeraron tres categorías relacionadas con el proceso de gestión en el quirófano: gestión de personas, gestión de recursos materiales y gestión del cuidado. Conclusión: Los resultados indicaron que el proceso de gestión en el quirófano, según los enfermeros, comprende la necesidad de mejora de las competencias, así como del conocimiento de las herramientas de gestión para la administración de personas, de recursos materiales y del cuidado.

Abstract Objective: To describe the management process performed by nurses in surgicenters. Methods: This is a descriptive, exploratory and qualitative study conducted with 10 nurses in a surgicenters of a university hospital. The data collected from September to October 2019 through semi-structured individual interviews were analyzed with the aid of the IRaMuTeQ software and submitted to inductive thematic analysis. Results: Similarity analysis demonstrates the role of the nursing team in the surgicenters and their direct relationship with patient care, while the role of nurses is characterized by predominantly management actions related to work organization. Through inductive thematic analysis, three categories related to the management process in surgicenters were listed: people management, material resource management and care management. Conclusion: The findings indicated that the management process in surgicenters, according to nurses, involves the need to improve skills, as well as knowledge of tools for managing people, for managing material resources and care.

Escopo de prática de médicos em atenção primária em saúde no Brasil / Scope of practice of doctors in primary health care in Brazil

O escopo de prática de profissionais da Atenção Primária em Saúde (APS) e seus determinantes têm sido objeto de estudos em diversos países que buscam maneiras inovadoras para responder aos cenários de escassez e má distribuição de profissionais, principalmente de médicos. Recentemente, o escopo de prática também entrou na pauta de planejadores de Recursos Humanos em Saúde (RHS) no Brasil. Entretanto, estudos nesta temática no país ainda são escassos. A presente tese tem por objetivo investigar o escopo de prática de médicos que atuam na APS no Brasil. Adicionalmente, realizar uma revisão de estratégias de flexibilização da regulação e dos escopos de prática de profissionais de saúde que vêm sendo adotadas e recomendados internacionalmente, considerando o cenário atual da pandemia da COVID-19. Foram elaborados três estudos no âmbito desta tese. No Estudo 1, foram analisados dados de um estudo exploratório, de corte transversal, por meio de um survey on-line, com 2.277 médicos da APS, para identificar diferenças no escopo de prática de médicos que atuam nesse nível de atenção e levantar os principais fatores associados à expansão da prática em áreas rurais e urbanas no Brasil. Diferenças em relação às atividades e procedimentos realizados pelos médicos por localidade foram investigados pelos testes Kruskal-Wallist/Dunn's Post Hoc e Qui-quadrado. Os fatores associados a um escopo de prática ampliado foram avaliados por meio de regressão linear com inferência via método bootstrap. No Estudo 2, com o objetivo de delinear o perfil do médico no Brasil, considerando os determinantes e a abrangência do escopo de prática, foram analisados dados de um segundo estudo exploratório, de corte transversal, com 830 médicos de diferentes níveis de atenção. O método utilizado foi o Grade of Membership (GoM), a partir do qual foram gerados quatro perfis de médicos, considerando o grupo da especialidade de atuação, a abrangência do escopo e os determinantes: 1) aspectos pessoais; 2) formação; 3) localidade de atuação. No Estudo 3, foi realizada uma revisão de escopo (scoping review) com o objetivo de identificar as principais estratégias internacionais relacionadas a medidas de flexibilização de regulação das práticas de profissionais de saúde que vêm sendo adotadas e/ou recomendadas no contexto da pandemia da COVID-19. No Estudo 1, independentemente da localização, os resultados revelaram que médicos da APS estão praticando aquém de suas competências. Médicos rurais, no entanto, declararam realizar uma média maior de procedimentos e ações de saúde em comparação com seus pares em municípios intermediários e urbanos. Considerando a amostra geral, as variáveis relacionadas a um escopo de prática ampliado incluíram sexo masculino, trabalhar em municípios rurais, participar de programas de educação permanente e consultar protocolos clínicos, livros e artigos. No Estudo 2, os resultados sugerem que a abrangência do escopo de prática pode ser analisada por meio de quatro perfis de médicos. Os perfis 1 e 2 apresentaram maior probabilidade de um escopo de prática mais abrangente e possuem similaridades, como atuar em especialidades da APS, em Unidades Básicas de Saúde (UBS), em áreas descritas como rurais, inseguras/violentas e urbanas com escassez de médicos. Os médicos dos perfis 3 e 4 possuem em escopo de prática menos abrangente, em especial os do perfil 4. Ambos os grupos são de médicos brasileiros, que possuem Registro de Qualificação da Especialidade (RQE) e têm maior probabilidade de atuarem em áreas urbanas sem escassez ou dificuldade de fixar médicos. No Estudo 3, a revisão incluiu 36 documentos. As seguintes estratégias foram identificadas: 1) ampliação de escopo de prática de profissionais de saúde; 2) transferência de funções e atividades de uma categoria profissional para outra (task-shifting); 3) autorização para faturamento e atendimento via telemedicina; 4) licenciamento e recrutamento de profissionais não ativos; 5) recrutamento de profissionais de outras regiões/Estados; 6) mudanças na formação e oferta de treinamento. Os três estudos evidenciam que há variações importantes na prática de profissionais, que devem ser analisadas de forma mais aprofundada. O reconhecimento dessas diferenças pode ser relevante para determinar a competência, a formação e os recursos necessários para a prática de médicos em diferentes localidades em busca de uma melhora na qualidade e acesso a serviços de saúde. O Estudo 3 revela que muitos países estão experimentando novas maneiras de potencializar sua força de trabalho em saúde durante a pandemia. Talvez uma das estratégias mais importantes em resposta a situações de escassez de profissionais tem sido a flexibilidade e a disposição para adaptar, ampliar e redistribuir as atividades da prática de profissionais de saúde. A revisão evidencia a importância em se realizarem reformas na regulação da prática de profissionais, buscando otimizar a força de trabalho em saúde existente, para que esta possa atender de forma rápida as necessidades de saúde da população.

The scope of practice of Primary Health Care (PHC) professionals and its determinants has been the subject of studies in several countries that seeks innovative ways to respond to scenarios of shortage and poor distribution of professionals, especially physicians. Recently, the scope of practice has also entered the agenda of Health Human Resource (HRH) planners in Brazil. However, the number of studies on this topic in the country is still low. The present thesis aims to investigate the scope of practice of PHC physicians in Brazil and its main determinants. In addition, carry out a literature review on strategies of reducing barriers of health professionals' scope of practice regulations that have been recommended and/or implemented internationally, considering the current scenario of the COVID-19 pandemic. We developed three studies within this thesis. In Study 1, we analyzed data from an exploratory cross-sectional study, through an online survey, with 2.277 PHC physicians to identify differences in primary care physicians' scope of practice and to raise the main factors associated with expanded practice in rural and urban areas of Brazil. Differences regarding activities and procedures performed by physicians per location were verified by Kruskal-Wallis/Dunn's Post Hoc and Chi-square tests. Multivariate linear regression analyses were done using the bootstrap technique to identify the main factors associated with an expanded scope of practice. Study 2 aimed to define the profile of physicians in Brazil, considering their scope of practice and its determinants; we used data of a cross-sectional study, with 830 physicians of different levels of care. We used the method Grade of Membership (GoM). Four physicians' profiles were gendered, considering medical specialty, the scope of practice, and the following determinants: i: personal factors, ii. education, and iii practice location. In Study 3 we carried out a scoping review to identify the main international strategies to reduce practice barriers of health professionals' regulations that have been recommended and/or implemented in the context of the COVID-19 pandemic. In Study 1 regardless of the location, the results showed that primary care physicians are practicing below their competencies. Rural physicians performed a higher number of procedures and activities compared with their peers from intermediate and urban municipalities. Within the overall sample, the variables related to a broader scope of practice included: male gender, working in rural municipalities, participating in training and continuing education programs, and consulting clinical protocols, articles, and books. In Study 2 the results suggest that the scope of practice can be analyzed through four physicians' profiles. Profile 1 and 2 were more likely to have a broader scope of practice and showed similarities concerning working o PHC facilities and specialties, in areas described as rural, unsafe/violent, and urban with a shortage of physicians. Physicians of profiles 3 and 4 have a less comprehensive scope of practice, especially those in profile 4. Both groups are Brazilian physicians who have the Qualification of Specialty Registration and are more likely to work in urban areas without physician shortage. In Study 3 the scoping review included 36 documents. The following strategies were identified: 1) enhancing health professionals' scope of practice; 2) task-shifting from one professional category to another; 3) authorization and billing of telemedicine; 4) licensing and recruitment of non-active professionals; 5) changes in education and provision of targeted training. The three studies show that there are important variants in professionals' practice, which must be analyzed in more depth. The recognition of these differences can be relevant to determine the competencies, training, and recourses required for physicians practicing in different locations, seeking to improve the quality and access of health care services. Study 3 reveals that many countries are experimenting with new ways to enhance their health workforce during the pandemic. Perhaps one of the most important strategies in response to scenarios of professional's shortage and quickly meeting the needs of the population, has been the flexibility and willingness to adapt, expand and redistribute activities of health professionals. The review highlights the importance of carrying out reforms in the professional scope of practice regulations, to optimize the available health workforce, to quickly meet the health needs of the population.

Exploring views and experiences of how infections are detected and managed in practice by nurses, care workers and manager's in nursing homes in England and Sweden: a survey protocol.

INTRODUCTION: In order to avoid unnecessary hospital admission and associated complications, there is an urgent need to improve the early detection of infection in nursing home residents. Monitoring signs and symptoms with checklists or aids called decision support tools may help nursing home staff to detect infection in residents, particularly during the current COVID-19 pandemic.We plan to conduct a survey exploring views and experiences of how infections are detected and managed in practice by nurses, care workers and managers in nursing homes in England and Sweden. METHODS AND ANALYSIS: An international cross-sectional descriptive survey, using a pretested questionnaire, will be used to explore nurses, care workers and managers views and experiences of how infections are detected and managed in practice in nursing homes. Data will be analysed descriptively and univariate associations between personal and organisational factors explored. This will help identify important factors related to awareness, knowledge, attitudes, belief and skills likely to affect future implementation of a decision support tool for the early detection of infection in nursing home residents. ETHICS AND DISSEMINATION: This study was approved using the self-certification process at the University of Surrey and Linköping University ethics committee (Approval 2018/514-32) in 2018. Study findings will be disseminated through community/stakeholder/service user engagement events in each country, publication in academic peer-reviewed journals and conference presentations. A LAY summary will be provided to participants who indicate they would like to receive this information.This is the first stage of a plan of work to revise and evaluate the Early Detection of Infection Scale (EDIS) tool and its effect on managing infections and reducing unplanned hospital admissions in nursing home residents. Implementation of the EDIS tool may have important implications for the healthcare economy; this will be explored in cost-benefit analyses as the work progresses.