Characteristics of medical deserts and approaches to mitigate them: a scoping review.

INTRODUCTION: Medical deserts are increasingly considered problematic and many countries employ a multitude of actions and initiatives to achieve a better distribution of the health workforce (HWF). This study systematically maps research and provides an overview of the definitions/characteristics of medical deserts. It also identifies contributing factors and approaches to mitigate medical deserts. METHODS: Embase, MEDLINE, CINAHL, Web of Science Core Collection, Google Scholar and The Cochrane Library were searched from inception to May 2021. Studies reporting primary research on definitions, characteristics, contributing factors and approaches to mitigate medical deserts were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies. RESULTS: Two-hundred and forty studies were included (49% Australia/New Zealand, 43% North America, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=160), characteristics (n=71), contributing/associated factors (n=113), and approaches to mitigate medical deserts (n=94). Most medical deserts were defined by the density of the population in an area. Contributing/associated factors consisted in sociodemographic/characteristics of HWF (n=70), work-related factors (n=43) and lifestyle conditions (n=34). Approaches focused on training adapted to the scope of rural practice (n=79), HWF distribution (n=3), support and infrastructure (n=6) and innovative models of care (n=7). DISCUSSION: Our study provides the first scoping review on definitions, characteristics, contributing/associated factors and approaches to mitigate medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate medical deserts.

Characteristics of Medical Deserts and Approaches to Mitigate Their Health Workforce Issues: A Scoping Review of Empirical Studies in Western Countries.

BACKGROUND: Medical deserts are considered a problematic issue for many Western countries which try to employ multitude of policies and initiatives to achieve a better distribution of their health workforce (HWF). The aim of this study was to systematically map research and provide an overview of definitions, characteristics, contributing factors and approaches to mitigate medical deserts within the European Union (EU)-funded project "ROUTE-HWF" (a Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies). METHODS: We performed a scoping review to identify knowledge clusters/research gaps in the field of medical deserts focusing on HWF issues. Six databases were searched till June 2021. Studies reporting primary research from Western countries on definitions, characteristics, contributing factors, and approaches were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies according to the four defined outcomes. RESULTS: Two-hundred and forty studies were included (n=116, 48% Australia/New Zealand; n=105, 44% North America; n=20, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=171, 71%), characteristics (n=95, 40%), contributing factors (n=112, 47%), and approaches to mitigate medical deserts (n=87, 36%). Most medical deserts were defined by the density of the population in an area. Contributing factors to HWF issues in medical deserts consisted in work-related (n=55, 23%) and lifestyle-related factors (n=33, 14%) of the HWF as well as sociodemographic characteristics (n=79, 33%). Approaches to mitigate them focused on training adapted to the scope of rural practice (n=67, 28%), HWF distribution (n=3, 1%), support/infrastructure (n=8, 3%) and innovative models of care (n=7, 3%). CONCLUSION: Our study provides the first scoping review that presents and categorizes definitions, characteristics, contributing factors, and approaches to mitigate HWF issues in medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate the impact of factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate HWF issues.

The influence of the down- and upscaling of activities in long-term care facilities during the COVID-19 visitor ban on caregivers' exhaustion and ability to provide care and support: A questionnaire study.

In the Netherlands, a national visitor-ban was in place in LTCFs during the first outbreak of COVID-19 in 2020. Meaningful activities were cancelled or downscaled, while others were performed more often. It is known that a lack of activities has several negative effects on residents, while the impact on caregivers remains largely unexplored. Here we investigate the influence of the down- and upscaling of activities on caregivers' physical and emotional exhaustion and their perceived ability to provide care and support. Downscaling of activities for residents, in particular watching television and musical activities, had a negative impact on caregivers' emotional exhaustion. The downscaling of watching television increased caregivers 'physical exhaustion. Furthermore, the downscaling of both activities had a negative impact on caregivers' perceived ability to provide ADL care and emotional support. This study triggers the need for more knowledge about the function of meaningful activities for residents, from a LTCF caregivers' perspective.

Behavioural, psychiatric and psychosocial factors associated with aggressive behaviour in adults with intellectual disabilities: A systematic review and narrative analysis.

BACKGROUND: Aggressive behaviour is prevalent in people with intellectual disabilities. To understand the aetiology, it is important to recognize factors associated with the behaviour. METHOD: A systematic review was conducted and included studies published between January 2002 and April 2017 on the association of behavioural, psychiatric and psychosocial factors with aggressive behaviour in adults with intellectual disabilities. RESULTS: Thirty-eight studies were included that presented associations with 11 behavioural, psychiatric and psychosocial factors. Conflicting evidence was found on the association of these factors with aggressive behaviour. CONCLUSIONS: The aetiology of aggressive behaviour is specific for a certain person in a certain context and may be multifactorial. Additional research is required to identify contributing factors, to understand causal relationships and to increase knowledge on possible interaction effects of different factors.

Challenging behaviours: Views and preferences of people with intellectual disabilities.

BACKGROUND: Challenging behaviour is a common problem among people with ID and in services for people with ID. This paper aims to provide an overview of the views and preferences of people with ID on challenging behaviour. METHOD: Semi-structured interviews were conducted with thirteen adults with mild to moderate ID and seven proxies (family or close associates of adults with ID who were unable to communicate and/or with severe or profound ID) in the Netherlands. The interviews were audio-recorded, transcribed and analysed thematically. RESULTS: People with ID and (a history of) challenging behaviour have clear views and preferences on factors related to challenging behaviour, assessments, non-pharmacological and pharmacological interventions and health professionals' approach. CONCLUSIONS: The identified views and preferences of people with ID are not always in accordance with current procedures and treatments for challenging behaviour and should be included in future care processes and research.

Healthcare assistants in EU Member States: An overview.

With many European countries facing health workforce shortages, especially in nursing, and an increasing demand for healthcare, the importance of healthcare assistants (HCAs) in modern healthcare systems is expected to grow. Yet HCAs' knowledge, skills, competences and education are largely unexplored. The study 'Support for the definition of core competences for healthcare assistants' (CC4HCA, 2015-2016) aimed to further the knowledge on HCAs across Europe. This paper presents an overview of the position of healthcare assistants in 27 EU Member States (MSs) and reflects on the emerging country differences. It is shown that most learning outcomes for HCAs across Europe are defined in terms of knowledge and skills, often at a basic instead of more specialized level, and much less so in terms of competences. While there are many differences between MSs, there also appears to be a common, core set of knowledge and skills-related learning outcomes which almost all HCAs across Europe possess. Country differences can to a large extent be explained by the regulatory and educational frameworks in which HCAs operate, influencing their current and future position in the healthcare system. Further investments should be made to explore a common understanding of HCAs, in order to feed discussions at policy and organisational levels, while simultaneously investments in the development and implementation of context-specific HCA workforce policies are needed.

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

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

The Joint Action on Health Workforce Planning and Forecasting: Results of a European programme to improve health workforce policies.

Health workforce (HWF) planning and forecasting is faced with a number of challenges, most notably a lack of consistent terminology, a lack of data, limited model-, demand-based- and future-based planning, and limited inter-country collaboration. The Joint Action on Health Workforce Planning and Forecasting (JAHWF, 2013-2016) aimed to move forward on the HWF planning process and support countries in tackling the key challenges facing the HWF and HWF planning. This paper synthesizes and discusses the results of the JAHWF. It is shown that the JAHWF has provided important steps towards improved HWF planning and forecasting across Europe, among others through the creation of a minimum data set for HWF planning and the 'Handbook on Health Workforce Planning Methodologies across EU countries'. At the same time, the context-sensitivity of HWF planning was repeatedly noticeable in the application of the tools through pilot- and feasibility studies. Further investments should be made by all actors involved to support and stimulate countries in their HWF efforts, among others by implementing the tools developed by the JAHWF in diverse national and regional contexts. Simultaneously, investments should be made in evaluation to build a more robust evidence base for HWF planning methods.

How can structured cooperation between countries address health workforce challenges related to highly specialized health care? Improving access to services through voluntary cooperation in the EU

This policy brief draws on the experience of different cross-border collaborations in highly specialized health care in order to address health workforce challenges that countries face. It identifies the factors that can enable or block structured cooperation and describes the institutional framework in place. It also examines the policy implications for supporting structured cooperation in the European Union. It was written to inform discussions under the Maltese presidency of the European Union in 2017.

Recruitment and retention of health professionals across Europe: A literature review and multiple case study research.

Many European countries are faced with health workforce shortages and the need to develop effective recruitment and retention (R&R) strategies. Yet comparative studies on R&R in Europe are scarce. This paper provides an overview of the measures in place to improve the R&R of health professionals across Europe and offers further insight into the evidence base for R&R; the interaction between policy and organisational levels in driving R&R outcomes; the facilitators and barriers throughout these process; and good practices in the R&R of health professionals across Europe. The study adopted a multi-method approach combining an extensive literature review and multiple-case study research. 64 publications were included in the review and 34 R&R interventions from 20 European countries were included in the multiple-case study. We found a consistent lack of evidence about the effectiveness of R&R interventions. Most interventions are not explicitly part of a coherent package of measures but they tend to involve multiple actors from policy and organisational levels, sometimes in complex configurations. A list of good practices for R&R interventions was identified, including context-sensitivity when implementing and transferring interventions to different organisations and countries. While single R&R interventions on their own have little impact, bundles of interventions are more effective. Interventions backed by political and executive commitment benefit from a strong support base and involvement of relevant stakeholders.

Changes in nurses' views and practices concerning nurse prescribing between 2006 and 2012: results from two national surveys.

AIMS: To assess changes in the prescribing practices and views about nurse prescribing of Registered Nurses in the Netherlands between 2006 and 2012. BACKGROUND: Considering the developments that took place in the Netherlands between 2006 and 2012, such as increased opportunities for nurse prescribing education and stricter control of nurses' prescribing practices, this study examines the extent to which nurses' prescribing practices and views have changed in the intervening years. In both years, nurses were not legally allowed to prescribe. DESIGN: Survey study. METHODS: Surveys were conducted in 2006 and 2012. Questionnaires were sent to a national sample of nurses. The questionnaires addressed nurses' views on nurse prescribing and the extent to which nurse prescribing took place in the respondents' work setting. RESULTS: There were 386 and 644 respondents to the 2006 and 2012 surveys respectively. The proportion of nurses who said that they felt adequately equipped to prescribe medicines remained constant around 12%. Insufficient knowledge to prescribe remained the most important reason for feelings of inadequacy. More than a quarter of the nurses in both surveys stated that nurses in their team sometimes write prescriptions. There were few changes in views on the consequences of nurse prescribing for nurses' practice. CONCLUSION: Overall, nurses' support for nurse prescribing remained stable at a fairly cautious level, while the number of nurses feeling inadequately equipped to prescribe remained high. As nurse prescribing is expected to improve the quality and continuity of care, this should be taken into account in policy expectations.

The effects of nurse prescribing: a systematic review.

BACKGROUND: In 2008, we conducted a systematic review on the effects of nurse prescribing using studies with a comparative design. In view of the growing number of countries that are introducing nurse prescribing and the fact that several studies into nurse prescribing have been conducted recently, there is a need for an updated review to reassess the available information on the effects of nurse prescribing when compared to physician prescribing. OBJECTIVE: To identify, appraise and synthesise the evidence on the effects of nurse prescribing when compared to physician prescribing on the quantity and types of medication prescribed and on patient outcomes. DESIGN: A systematic review. DATA SOURCES: In addition to the previous review, which covered the literature up to 2005, 11 literature databases and four websites were searched for relevant studies from January 2006 up to January 2012 without limitations as to language or country. Moreover, full-text copies of all studies included in the previous review were reviewed. REVIEW METHODS: A three-stage inclusion process, consisting of an initial sifting, checking full-text papers for inclusion criteria and methodological assessment, was performed independently by two reviewers. Data on effects were synthesised using narrative and tabular methods. RESULTS: Thirty-five studies met the inclusion criteria. All but five studies had a high risk of bias. Nurses prescribe in comparable ways to physicians. They prescribe for equal numbers of patients and prescribe comparable types and doses of medicines. Studies comparing the total amount of medication prescribed by nurses and doctors show mixed results. There appear to be few differences between nurses and physicians in patient health outcomes: clinical parameters were the same or better for treatment by nurses, perceived quality of care was similar or better and patients treated by nurses were just as satisfied or more satisfied. CONCLUSIONS: The effects of nurse prescribing on medication and patient outcomes seem positive when compared to physician prescribing. However, conclusions must remain tentative due to methodological weaknesses in this body of research. More randomised controlled designs in the field of nurse prescribing are required for definitive conclusions about the effects of nurse prescribing.

Neutral to positive views on the consequences of nurse prescribing: Results of a national survey among registered nurses, nurse specialists and physicians.

BACKGROUND: Over the last two decades, the number of countries where nurses are legally permitted to prescribe medication has grown considerably. A lack of peer support and/or objections by physicians can act as factors hampering nurse prescribing. Earlier research suggests that physicians are generally less supportive and more concerned about nurse prescribing than nurses are. However, direct comparisons between doctors' and nurses' views are scarce and are often based on small sample sizes. OBJECTIVES: To gain insight into the views of Dutch registered nurses (RNs), nurse specialists (with a master's in Advanced Nursing Practice) and physicians on the consequences of nurse prescribing. DESIGN: Survey study. PARTICIPANTS: Survey questionnaires were sent to national samples of RNs, nurse specialists and physicians. METHODS: The questionnaire addressed, among others, respondents' general views on the consequences of nurse prescribing for the quality of care, the nursing and medical professions, and the relationship between the medical and nursing professions. RESULTS: The net response rate was 66.0% for RNs (n=617), 28.3% for nurse specialists (n=375) and 33.7% for physicians (n=265). It was found that all groups agreed that nurse prescribing benefits nurses' daily practice and the nursing profession. There were few concerns about negative consequences for physicians' practice and the medical profession. Nurse specialists gave significantly (P<0.05) more positive scores on most items than RNs and physicians. We found relatively little difference in views between RNs and physicians. It was only on issues surrounding the quality of care and patient safety that doctors showed more concerns, albeit mild, than RNs and nurse specialists. CONCLUSIONS: RNs, nurse specialists and physicians generally hold neutral to moderately positive views on nurse prescribing. This is beneficial for the implementation and potential success of nurse prescribing in practice, as a lack of peer support and/or objections from physicians can be a hampering factor. However, concerns about the consequences of nurse prescribing for the quality of care and patient safety remain a point for attention, especially among physicians.

Knowledge claims, jurisdictional control and professional status: the case of nurse prescribing.

Over the past decades, professional boundaries in health care have come under pressure, and the expansion of prescriptive authority to include nurses touches on issues of professional domains and interprofessional competition. Knowledge claims play an important role in achieving jurisdictional control. Knowledge can take on multiple forms, ranging from indeterminate to technical (I/T ratio) and from everyday to exclusive knowledge. To investigate the interrelatedness of jurisdiction, knowledge claims and professional status, we examine which knowledge claims were made by the medical and nursing professions in the Netherlands to secure or obtain, respectively, jurisdictional control over prescribing, and which form this knowledge took. The study is based on thirteen semi-structured stakeholder interviews and an extensive document analysis. We found that the nursing profession in its knowledge claims strongly emphasized the technicality and everyday knowledge character of the prescribing task, by asserting that nurses were already prescribing medicines, albeit on an illegal basis. Their second claim focused on the indeterminate knowledge skills of nurses and stated that nurse prescribing would do justice to nurses' skills and expertise. This is a strong claim in a quest for (higher) professional status. Results showed that the medical profession initially proclaimed that prescribing should be reserved for doctors as it is a task requiring medical knowledge, i.e. indeterminate knowledge. Gradually, however, the medical profession adjusted its claims and tried to reduce nurse prescribing to a task almost exclusively based on technicality knowledge, among others by stating that nurses could prescribe in routine cases, which would generate little professional status. By investigating the form that professional knowledge claims took, this study was able to show the interconnectedness of jurisdictional control, knowledge claims and professional status. Knowledge claims are not mere rhetoric, but actively influence the everyday realities of professional status, interprofessional competition and jurisdictional division between professions.

Nurse prescribing of medicines in Western European and Anglo-Saxon countries: a survey on forces, conditions and jurisdictional control.

BACKGROUND: The number of Western European and Anglo-Saxon countries where nurses are legally allowed to prescribe medicines is growing. As the prescribing of medicines has traditionally been the task of the medical profession, nurse prescribing is changing the relationship between the medical and nursing professions. OBJECTIVES: To gain more insight into the forces that led to the introduction of nurse prescribing of medicines in Western European and Anglo-Saxon countries, as well as into the legal, educational and organizational conditions under which nurses prescribe in these countries. Moreover, this study sought to determine which consequences nurse prescribing has for the division of jurisdictional control over prescribing between the nursing and medical professions. DESIGN: International survey. PARTICIPANTS: An email survey was sent to 60 stakeholders of professional nursing or medical associations or government bodies, at national, state or provincial level across ten Western European and Anglo-Saxon countries, namely Australia, Canada, Finland, Ireland, the Netherlands, New Zealand, Spain, Sweden, the United Kingdom and the United States of America. METHODS: The survey addressed the reasons for the introduction of nurse prescribing and the conditions under which nurses are or will be prescribing medicines. RESULTS: The response rate was 65% (n=39). It was shown that a diversity of forces led to the introduction of nurse prescribing, and respondents from nursing and medical associations and government bodies cited different forces as being important for the introduction of nurse prescribing. Representatives of nurses' associations oftentimes emphasized the medication needs of patients living in remote geographical areas, while representatives of medical associations more often pointed to workforce shortages within the health care service. The conditions under which nurses prescribe medicines vary considerably, from countries where nurses prescribe independently to countries in which prescribing by nurses is only allowed under strict conditions and the supervision of physicians. CONCLUSIONS: Citing different forces as being important in the introduction of nurse prescribing can be conceived as a professional 'problem construction' in order to gain jurisdiction over the prescribing task. In most countries, nurses prescribe in a subordinate position and the jurisdiction over prescribing remains predominantly with the medical profession.

Nurse prescribing of medicines in Western European and Anglo-Saxon countries: a systematic review of the literature.

BACKGROUND: A growing number of countries are introducing some form of nurse prescribing. However, international reviews concerning nurse prescribing are scarce and lack a systematic and theoretical approach. The aim of this review was twofold: firstly, to gain insight into the scientific and professional literature describing the extent to and the ways in which nurse prescribing has been realised or is being introduced in Western European and Anglo-Saxon countries; secondly, to identify possible mechanisms underlying the introduction and organisation of nurse prescribing on the basis of Abbott's theory on the division of professional labor. METHODS: A comprehensive search of six literature databases and seven websites was performed without any limitation as to date of publication, language or country. Additionally, experts in the field of nurse prescribing were consulted. A three stage inclusion process, consisting of initial sifting, more detailed selection and checking full-text publications, was performed independently by pairs of reviewers. Data were synthesized using narrative and tabular methods. RESULTS: One hundred and twenty-four publications met the inclusion criteria. So far, seven Western European and Anglo-Saxon countries have implemented nurse prescribing of medicines, viz., Australia, Canada, Ireland, New Zealand, Sweden, the UK and the USA. The Netherlands and Spain are in the process of introducing nurse prescribing. A diversity of external and internal forces has led to the introduction of nurse prescribing internationally. The legal, educational and organizational conditions under which nurses prescribe medicines vary considerably between countries; from situations where nurses prescribe independently to situations in which prescribing by nurses is only allowed under strict conditions and supervision of physicians. CONCLUSIONS: Differences between countries are reflected in the jurisdictional settlements between the nursing and medical professions concerning prescribing. In some countries, nurses share (full) jurisdiction with the medical profession, whereas in other countries nurses prescribe in a subordinate position. In most countries the jurisdiction over prescribing remains predominantly with the medical profession. There seems to be a mechanism linking the jurisdictional settlements between professions with the forces that led to the introduction of nurse prescribing. Forces focussing on efficiency appear to lead to more extensive prescribing rights.