Making doctors stay: Rethinking doctor retention policy in a contracted-out primary healthcare setting in urban Bangladesh.

BACKGROUND: "Contracting Out" is a popular strategy to expand coverage and utilization of health services. Bangladesh began contracting out primary healthcare services to NGOs in urban areas through the Urban Primary Health Care Project (UPHCP) in 1998. Over the three phases of this project, retention of trained and skilled human resources, especially doctors, proved to be an intractable challenge. This paper highlights the issues influencing doctor's retention both in managerial as well as service provision level in the contracted-out setting. METHODOLOGY: In this qualitative study, 42 Key Informant Interviews were undertaken with individuals involved with UPHCP in various levels including relevant ministries, project personnel representing the City Corporations and municipalities, NGO managers and doctors. Verbatim transcripts were coded in ATLAS.ti and analyzed using the thematic analysis. Document review was done for data triangulation. RESULTS: The most cited problem was a low salary structure in contrast to public sector pay scale followed by a dearth of other financial incentives such as performance-based incentives, provident funds and gratuities. Lack of career ladder, for those in both managerial and service delivery roles, was also identified as a factor hindering staff retention. Other disincentives included inadequate opportunities for training to improve clinical skills, ineffective staffing arrangements, security issues during night shifts, abuse from community members in the context of critical patient management, and lack of job security after project completion. CONCLUSIONS: An adequate, efficient and dedicated health workforce is a pre-requisite for quality service provision and patient utilization of these services. Improved career development opportunities, the provision of salaries and incentives, and a safer working environment are necessary actions to retain and motivate those serving in managerial and service delivery positions in contracting out arrangements.

The Effect of Supervision Waivers on Practice: A Survey of Massachusetts Nurse Practitioners During the COVID-19 Pandemic.

BACKGROUND: While optimal utilization of the nurse practitioner (NP) workforce is an increasingly popular proposal to alleviate the growing primary care shortage, federal, state, and organizational scope of practice policies inhibit NPs from practicing to the full extent of their license and training. In March of 2020, NP state-specific supervisory requirements were temporarily waived to meet the demands of the coronavirus disease 2019 (COVID-19) pandemic in Massachusetts. OBJECTIVE: The objective of this study was to examine the impact of temporarily waived state practice restrictions on NP perception of care delivery during the initial surge of the COVID-19 pandemic in Massachusetts. RESEARCH DESIGN: Mixed methods descriptive analysis of a web-based survey of Massachusetts NPs (N=391), conducted in May and June 2020. RESULTS: The vast majority (75%) of NPs believed the temporary removal of practice restriction did not perceptibly improve clinical work. Psychiatric mental health NPs were significantly more likely than other NP specialties to believe the waiver improved clinical work (odds ratio=6.68, P=0.001). NPs that experienced an increase in working hours during the pandemic surge were also more likely to report a positive effect of the waiver (odds ratio=2.56, P=0.000). CONCLUSIONS: Temporary removal of state-level practice barriers alone is not sufficient to achieve immediate full scope of practice for NPs. The successful implementation of modernized scope of practice laws may require a collective effort to revise organizational and payer policies accordingly.

Is Hospital Nurse Staffing Legislation in the Public's Interest?: An Observational Study in New York State.

BACKGROUND: The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown. OBJECTIVES: To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs). RESEARCH DESIGN: Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data. SUBJECTS: A total of 417,861 Medicare medical and surgical patients. MEASURES: Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios. RESULTS: Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions. CONCLUSIONS: Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.

The Potential Impact of COVID-19 on H-2A Agricultural Workers.

The disproportionate impact of COVID-19 on farmworker communities has been well documented by the media. The virus overlays existing health disparities among farmworkers, but the population is not homogenous. One group of workers that may be even more vulnerable to the transmission of COVID-19 is the H-2A temporary worker population, because they have less control over their physical environments than domestic farmworkers, who may obtain their own housing and transportation. The H-2A program was recently altered at the federal level to ensure a steady flow of essential workers that can protect the nation's food supply during a crisis. Yet, in spite of increasing numbers of COVID-19 cases in states with significant H-2A worker populations, the federal rule that temporarily expanded the H-2A program did not address needs to protect workers' health. Although the CDC has developed recommendations for the agricultural industry to safeguard against COVID-19, most health and safety regulation for farmworkers are left to state and local agencies that may lack knowledge or resources to effectively address the needs of a specialized growing workforce such as H-2A workers. More research is needed on the disparate health and safety needs of H-2A workers to assess how policy can be tailored to reduce the transmission of the COVID-19 virus among the population.

Improvement Plan of Nurse Staffing Standards in Korea.

PURPOSE: This study compares the expected nurse-to-patient ratio, penalties for violating these regulations, and the laws enacted in the medical and nursing fields in Korea and advanced countries like Germany, Australia, the United States, and Japan. METHODS: This study deployed an integrative review method and used search terms such as "nursing law," "nurse ratio," "nurse," "nurse staffing," "health," and "staffing" to find articles published in English, Korean, German, or Japanese through Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, the Westlaw (International Materials-Jurisdiction) site, US government and state sites (federal parliament, National Conference of State Legislatures), and Google Scholar. RESULTS: Compared with medical laws in other advanced countries, Korean laws are quite crude and its nurse-to-patient ratio does not reflect patients' status. Korea also lacks strict penalties for nurse staffing ratio violations. CONCLUSION: Korea requires a strong regulatory apparatus for nurse staffing in health-care organizations to improve the quality of its health-care services and patient safety.

Infection preventionist staffing in nursing homes.

Infection preventionist (IP) staffing in nursing homes (NHs) is now required as part of new federal regulations. In this study, we examined IP staffing changes from 2014 to 2018 and found relatively few changes over time. IP staffing in NHs remains low but does vary between for profit and non-profit facilities.

The Impact of Title VII Dental Workforce Programs on Dentists' Practice Location: A Difference-in-Differences Analysis.

PURPOSE: To examine the potential impact of Health Resources and Services Administration (HRSA) funding (predoctoral [PD] and postdoctoral [PDD] programs) on dentists' practice location in the United States. METHOD: The authors linked 2011-2015 data from HRSA's Electronic Handbooks to 2015 data from the American Dental Association Masterfile, dental health professional shortage areas, and rural-urban commuting area codes. They examined the associations between PD and PDD funding and dentists' practice location between 2004 and 2015 using a difference-in-differences analysis and multiple logistic regressions, adjusting for covariates. RESULTS: From 2004 to 2015, 21.2% (1,588/7,506) of dentists graduated from institutions receiving PD funding and 26.8% (2,014/7,506) graduated from institutions receiving PDD funding. Among dentists graduating from institutions receiving PDD funding, after adjusting for covariates, those graduating between 2011 and 2015 were more likely to practice in a rural area than those graduating between 2004 and 2010 (odds ratio [OR] = 1.98; 95% confidence interval [CI] = 1.04-3.76). The difference-in-differences approach showed that PD and PDD funding significantly increased the odds that a dentist would practice in a rural area (respectively, OR = 2.70; 95% CI = 1.31-5.79/OR = 2.84; 95% CI = 1.40-5.77). CONCLUSIONS: HRSA oral health training program funding had a positive effect on dentists choosing to practice in a rural area. By increasing the number of dentists practicing in rural communities, HRSA is improving access to, and the delivery of, oral health care services to underserved and vulnerable rural populations.

The Scope of Midwifery Practice Regulations and the Availability of the Certified Nurse-Midwifery and Certified Midwifery Workforce, 2012-2016.

INTRODUCTION: Studies have linked midwifery practice laws to the availability of midwives but have generally not related workforce data to potential demand for reproductive health services. We examined state regulatory structure for midwives and its relationship to midwifery distribution and vital statistics data at the state and county level. METHODS: Midwifery distribution data came from the Area Health Resources Files, distribution of women of reproductive age came from the US Census, and birth statistics came from US Natality Files from 2012 to 2016. Midwifery regulations were drawn from American College of Nurse-Midwives Annual Reports. We used bivariate analysis to examine the relationship between state midwifery practice regulations and the number of midwives available in states and counties to potentially meet women's health care needs. RESULTS: Twenty states and the District of Columbia had autonomous practice regulatory frameworks, whereas 24 states had collaborative practice regulatory frameworks during the years between 2012 and 2016. Six states changed regulations during that period. In 2016, the number of midwife-attended births per number of midwives in a state was not related to the regulatory framework. However, states with autonomous frameworks had 2.2 times as many midwives per women of reproductive age (P < .0001) and 2.3 times as many midwives per total births when compared with states with collaborative statutory frameworks (P < .0001). At the county level, 70.1% of US counties had no midwife. Of those states with autonomous practice, only 59.7% of counties had no midwives, compared with 74.1% in states with collaborative models (P < .0001). DISCUSSION: Midwives have the potential to help address the shortage of maternity and reproductive health service providers. Our research suggests that increasing the number of states with autonomous regulatory frameworks can be one way to expand access to care for women in the United States.

Is individual placement and support an "active" labor market policy?

OBJECTIVE: The aim of this study was to propose individual placement and support (IPS) as an important component of modern labor market policies and as a paradigm to be considered while drafting and adopting them. BACKGROUND: Modern European labor market policies, termed activation policies, aim to support a personal commitment to seek employment by linking welfare benefits to active engagement in job search. METHOD: In this essay, the authors describe European "activation policies," outline labor market regulations in Italy in the last 3 decades, and analyze core components of IPS in the light of labor policies. FINDINGS: IPS, which provides individual psychological and practical support, has become a highly successful method for helping people with mental disorders to reach competitive employment in Italy. It has been effective in many countries, regardless of local employment conditions and market regulations. Its effectiveness may be greater in places with weaker employment protection legislation and integration efforts and less generous disability benefits, as is the case in Italy. Conclusions and Implications for Policies: Labor market policies should carefully balance financial benefits, integration efforts, and individual support. They should include IPS for people with mental disorders. Modified versions of IPS may also be beneficial to nonpsychiatric unemployed populations. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Historical perspective on physical employment standards.

BACKGROUND: When one thinks of jobs with physical employment standards, the first thoughts typically center around firefighting, law enforcement, and military jobs. However, there are 100s of arduous jobs that exist in the public and private sectors that range from moderately demanding to strenuous. The Bureau of Labor Statistics reported that 28% of the workforce in the United States performs physically demanding jobs that involve construction, machinery installation and repair, public safety, and other professions. OBJECTIVE: This paper provides a historical perspective of physical employment standards for hiring workers into these arduous jobs, how we arrived at our current knowledge base, and the challenges faced today when determining and implementing physical employment standards. METHOD: This narrative review draws on evidence from 62 published sources. RESULTS: This paper focuses on the need for a multidisciplinary approach to identifying job requirements, the professions (e.g., medical, psychology, physiology) that underpin the methodologies, and the knowledge used by current researchers. Descriptions of test and cut score development, legal issues, and challenges for the future also are highlighted.

Gig Workers.

Occupational health nurses can ensure that gig workers are aware of health and safety requirements, receive appropriate training for the job, and use appropriate personal protective equipment.

The Implications of the Current Visa System for Foreign Medical Graduates During and After Graduate Medical Education Training.

The current and projected deficit in the physician workforce in the US is a challenge for primary care and specialty medical settings. Foreign medical graduates (FMGs) represent an important component of the US graduate medical education (GME) training pathway and can help to address the US physician workforce deficit. Availability of FMGs is particularly important to the internal medicine community, as recent data demonstrate that internal medicine is the specialty with the highest number of FMGs. System-based and logistical inefficiencies in the current US visa system represent significant obstacles to FMG trainees and have important psychological, emotional, and logistical consequences to FMG engagement and participation in US GME training and in the post-training workforce. In this article, we review the contemporary structure, process, and challenges of obtaining a visa for GME training. The H1B and J1 visa programs are compared and contrasted, with an emphasis on logistical specifics for FMG GME trainees and training programs. The process of and options for J1 visa waivers are reviewed. These considerations are specifically reviewed in the context of recent policy decisions by the Trump administration, with emphasis on the effects of these decisions on FMGs in medical training and practice.

Professional Boundaries in Corrections.

Boundary violations occurring in corrections settings require special attention. There is a unique relationship between officers and inmates, governed by policies and procedures as well as ethics in general (e.g., the lack of ability for a person in a controlled environment to consent to a relationship due to power imbalance). Recent high-profile cases between corrections officers and inmates demonstrate the complexities inherent in these relationships. We examine several recent cases and offer analysis of the factors leading to these dangerous encounters. We discuss how a special relationship develops between a corrections employee and an inmate and how that can lead to blackmail, the introduction of contraband to the prison, or other illegal activity. It is easy to state that one should not engage in sexual encounters, but it is harder to discuss and identify feelings that develop in correctional settings, such as transference and counter-transference feelings in a therapeutic relationship. Lessons of professionalism from the doctor-patient relationship parallel the relationships between officers and inmates.

[Methodology for determining workforce in health nephrologic unit in ITALY. Update of lows].

Nephrology continues to be in transition. While rates of kidney diseases and injury continue to rise, changes in the general health care system and the delivery of kidney care make it unclear how increases in need will be translated into demand for nephrologists. The changes in the delivery system also raise questions as to the future roles and career paths for nephrologists. There a major interrelated workforce issues to be watched closely : how many nephrologists are needed ? The supply of nephrologists does not reflect the distribution of patients with kidney diseases or the activity and job description related to end stage renal disease (ESRD) patients. Looking forward, more needs to be done to systematically measure need and access, and to identify clinical areas and activity of high need for nephrologists. This review examines the laws that govern the measure of work and the needs of personnel of the Italian state and in particular in health care. Therefore, once the method is accepted and established, it will be possible communicate those findings to policy makers and fellows and to involve the politicians.