Changes In Skill Mix Research Articles

Developing the future research agenda for the health and social care workforce in the United Kingdom: Findings from a national forum for policymakers and researchers.

There is a gap between healthcare workforce research and decision-making in policy and practice. This matters more than ever given the urgent staffing crisis. As a national research network, we held the first ever United Kingdom (UK) forum on healthcare workforce evidence in March 2023. This paper summarises outputs of the event including an emerging UK healthcare workforce agenda and actions to build research capacity and bridge the gap between academics and decisionmakers. The forum brought together over 80 clinical and system leaders, policymakers and regulators with workforce researchers. Fifteen sessions convened by leading experts combined knowledge exchange with deliberative dialogue over 2days. Topics ranged from workforce analytics, forecasting, international migration to interprofessional working. In the small groups that were convened, important gaps were identified in both the existing research body and uptake of evidence already available. There had not been enough high quality evaluations of recent workforce initiatives implemented at pace, from virtual wards to e-rostering. The pandemic had accelerated many changes in skillmix and professional roles with little learning from other countries and systems. Existing research was often small-scale or focused on individual, rather than organisational solutions in areas such as staff wellbeing. In terms of existing research, managers were often unaware of accepted high quality evidence in areas like the relationship between registered nurse staffing levels and patient outcomes. More work is needed to engage new disciplines from labour economics and occupational health to academic human resources and to strengthen the emerging diverse community of healthcare workforce researchers.

The patient experience of skill mix changes in primary care: an in-depth study of patient 'work' when accessing primary care.

This paper presents insights into patient experiences of changes in workforce composition due to increasing deployment in general practice of practitioners from a number of different professional disciplines (skill mix). We explore these experiences via the concept of 'patient illness work'; how a patient's capacity for action is linked to the work arising from healthcare. We conducted four focus group interviews with Patient Participation Group members across participating English general practitioner practices. Thematic analysis and a theoretical lens of illness work were used to explore patients' attempts to understand and navigate new structures, roles and ways to access healthcare. Participants' lack of knowledge about incoming practitioners constrained their agency in accessing primary care. They reported both increased and burdensome illness work as they were given responsibility for navigating and understanding new systems of access while simultaneously understanding new practitioner roles. While skill mix changes were not resisted by patients, they were keen to improve their agency in capacity to access, by being better informed about newer practitioners to accept and trust them. Some patients require support to navigate change, especially where new systems demand specific capacities such as technological skills and adaptation to unfamiliar practitioners.

Skill-Mix Changes Targeting Health Promotion and Prevention Interventions and Effects on Outcomes in all Settings (Except Hospitals): Overview of Reviews.

Objectives: Skill-mix changes to step up health promotion and prevention are increasing, but there is limited evidence on their effects. Methods: Overview of reviews, based on a protocol. The search was carried out in six databases, screening was performed ensuring high interrater reliability. All countries, health professions and lay workers in all settings (except hospitals) were included, quality appraisals performed. Results: A total of 31 systematic reviews were included. Expanded roles performing outreach (e.g., home visits) had mostly positive effects on access and health outcomes, primarily for hard-to-reach groups. Task-shifting in colorectal or skin cancer screenings (performed by advanced practice nurses) were suggested effective; supporting roles (by community health workers) increased uptake in screenings, but based on limited evidence. Expanded roles of various professions focusing on lifestyle modification showed promising effects in most reviews, including weight, diet, smoking cessation and physical activity. Reviews on cost-effectiveness were based on limited evidence. Conclusion: Promising skill-mix changes included expanded roles providing lifestyle modifying interventions, task-shifting, and outreach roles for hard-to-reach groups, whereas evidence on costs was limited.

Overview of innovative skill-mix changes in nursing across Europe

Abstract Background Many countries in Europe and worldwide have implemented new professional for nurses or are in the process of implementation, yet, an overview of the evidence on skill-mix changes has been missing. This study has analysed skill-mix innovations in nursing, evidence on outcomes and lessons for implementation. Methods An overview of systematic reviews, following a protocol plus country case studies, as part of an international study. The literature search was performed in six databases, with search terms covering skill-mix whereby the nursing profession played a key role. Screening was performed by three researchers after high interrater reliability rates were achieved. Analyses were performed for the nursing professions, a typology of skill-mix changes (task-shifting and role expansion) and evidence on outcomes. Results A total of 42 systematic reviews were identified on nurses working in new roles. The roles varied considerably, ranging from nurse prescribing to advanced practice nursing and nurse-led clinics. Nurse-led chronic care programmes were frequently identified, with overall positive outcomes on several health outcomes, e.g., for patients with diabetes or cardiovascular diseases. Nurses were also working in advanced roles in health promotion and prevention, e.g., performing screening programmes, showing equivalent quality of care compared with doctors if adequately trained. Several skill-mix models to enhance care coordination and integration were identified, suggesting that when tailored to the needs of specific population groups, particularly for vulnerable groups, may improve health outcomes or access to services. Conclusions The roles of nurses are increasingly diversifying and expanding internationally. Sharing country experiences on how to effectively educate the workforce to be prepared for these new roles and ensure smooth integration is critical.

7.L. Workshop: New roles and innovative skill-mix in nursing across Europe: trends and lessons for implementation

Abstract Many countries in Europe are changing the roles and skill-mix of their nursing workforce. A sufficient and well-skilled nursing workforce has shown to be key for population health, most recently demonstrated during the Covid-19 pandemic. An increasing number of countries have introduced Master-level education for nurses to work in advanced practice nursing (APN) roles. These changes in the educational systems have implications on patients, clinical practice, teams and health systems. Moreover, many countries are re-orienting their health services from hospital to primary health care and prevention, driving new roles for nurses. The relevance of high-quality education and upskilling has been exemplified during the Covid-19 pandemic, where nurses had to quickly adapt to new treatment and caregiving situations in challenging work environments. Objectives of the workshop. This workshop will provide an overview of research and policy developments in Europe, drawing on recent research. First, an overview of innovative skill-mix changes in nursing will be presented and evidence on health outcomes, based on a study from the European Observatory on Health Systems and Policies. Second, research from Germany in five innovator hospitals will be presented, a country which is still at an early stage with integrating nurses in advanced roles. The panel discussion will address innovations in APN research, practice and policy lessons in Europe and with in-depth insights from four countries (Netherlands, Finland, Switzerland, Germany). In the Netherlands, the policy instrument “experimental law” has led to full practice authority for Nurse Practitioners, its impact on practice as well as barriers and enablers will be addressed. In Finland, the focus will be on recent evidence on the expanded role of nurse prescribers, the policy process and early evidence on impacts for nurses and patients. In Switzerland, the lack of regulation and reimbursement schemes restrict advanced practice, whereas drivers comprise changes in population needs, education (master and doctoral level) and reduced workforce availability. Developments at the national and cantonal level and the evaluation of innovative care models with APNs will be presented using case examples and recent research (e.g. university hospitals, primary care). The panelists will discuss implications for research, policy and nursing management, also taking into account the Covid-19 pandemic and other unexpected “health shocks” which have shown to impact considerably on nurses’ roles in practice. Lessons will be shared on strategies for a well-qualified and -resourced nursing workforce integrated in systems. The format is ‘regular workshop’ with two presentations and a panel discussion with experts from four countries. Key messages • Multiple innovative nursing skill-mix model exist, with promising outcomes for individuals and population groups if nurses are well trained and equipped. • Implementation of APN roles requires enabling policy contexts, sufficient funding, clinical leadership, teams that are open to innovations, and strong nurses that take on APN roles.

Skill-mix change and outcomes in primary care: Longitudinal analysis of general practices in England 2015–2019

BackgroundIncreasing the employment of staff with new clinical roles in primary care has been proposed as a solution to the shortages of GPs and nurses. However, evidence of the impacts this has on practice outcomes is limited. We examine how outcomes changed following changes in skill-mix in general practices in England. MethodsWe obtained annual data on staff in 6,296 English general practices between 2015 and 2019 and grouped professionals into four categories: GPs, Nurses, Health Professionals, and Healthcare Associate Professionals. We linked 10 indicators of quality of care covering the dimensions of accessibility, clinical effectiveness, user experiences and health system costs. We used both fixed-effect and first-differences regressions to model changes in staff composition and outcomes, adjusting for practice and population factors. ResultsEmployment increased over time for all four staff groups, with largest increases for Healthcare Professionals (from 0.04 FTE per practice in 2015 to 0.28 in 2019) and smallest for Nurses who experienced a 3.5 percent growth. Increases in numbers of GPs and Nurses were positively associated with changes in practice activity and outcomes. The introduction of new roles was negatively associated with patient satisfaction: a one FTE increase in Health Professionals was associated with decreases of 0.126 [-0.175, −0.078] and 0.116 [-0.161, −0.071] standard deviations in overall patient satisfaction and satisfaction with making an appointment. Pharmacists improved medicine prescribing outcomes. All staff categories were associated with higher health system costs. There was little evidence of direct complementarity or substitution between different staff groups. ConclusionsIntroduction of new roles to support GPs does not have straightforward effects on quality or patient satisfaction. Problems can arise from the complex adaptation required to adjust practice organisation and from the novelty of these roles to patients. These findings suggest caution over the implementation of policies encouraging more employment of different professionals in primary care.

Scale, scope and impact of skill mix change in primary care in England: a mixed-methods study

Background General practices have had difficulty recruiting and retaining enough general practitioners to keep up with increasing demand for primary health care in recent years. Proposals to increase workforce capacity include a policy-driven strategy to employ additional numbers and a wider range of health professionals. Objectives Our objective was to conduct a comprehensive study of the scale, scope and impact of changing patterns of practitioner employment in general practice in England. This included an analysis of employment trends, motivations behind employment decisions, staff and patient experiences, and how skill mix changes are associated with outcome measures and costs. Design NHS Digital workforce data (2015–19) were used to analyse employment changes and to look at their association with outcomes data, such as the General Practitioner Patient Survey, General Practitioner Worklife Survey, prescribing data, Hospital Episode Statistics, Quality and Outcomes Framework and NHS payments to practices. A practice manager survey (August–December 2019) explored factors motivating general practices’ employment decisions. An in-depth case study of five general practices in England (August–December 2019) examined how a broader range of practitioners is experienced by practice staff and patients. Results We found a 2.84% increase in reported full-time equivalent per 1000 patients across all practitioners during the study period. The full-time equivalent of general practitioner partners decreased, while the full-time equivalent of salaried general practitioners, advanced nurse practitioners, clinical pharmacists, physiotherapists, physician associates and paramedics increased. General practitioners and practice managers reported different motivating factors regarding skill mix employment. General practitioners saw skill mix employment as a strategy to cope with a general practitioner shortage, whereas managers prioritised potential cost-efficiencies. Case studies demonstrated the importance of matching patients’ problems with practitioners’ competencies and ensuring flexibility for practitioners to obtain advice when perfect matching was not achieved. Senior clinicians provided additional support and had supervisory and other responsibilities, and analysis of the General Practitioner Worklife Survey data suggested that general practitioners’ job satisfaction may not increase with skill mix changes. Patients lacked information about newer practitioners, but felt reassured by the accessibility of expert advice. However, General Practitioner Patient Survey data indicated that higher patient satisfaction was associated with a higher general practitioner full-time equivalent. Quality and Outcomes Framework achievement was higher when more practitioners were employed (i.e. full-time equivalent per 1000 patients). Higher clinical pharmacist full-time equivalents per 1000 patients were associated with higher quality and lower cost prescribing. Associations between skill mix and hospital activity were mixed. Our analysis of payments to practices and prescribing costs suggested that NHS expenditure may not decrease with increasing skill mix employment. Limitations These findings may reflect turbulence during a period of rapid skill mix change in general practice. The current policy of employing staff through primary care networks is likely to accelerate workforce change and generate additional challenges. Conclusions Skill mix implementation is challenging because of the inherent complexity of general practice caseloads; it is associated with a mix of positive and negative outcome measures. Future work Findings from this study will inform future funding applications for projects that seek to examine the nature and impact of evolving multiprofessional teams in primary care. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 9. See the NIHR Journals Library website for further project information.

The Rising Value of Time and the Origin of Urban Gentrification

In recent decades, gentrification has transformed American central city neighborhoods. I estimate a spatial equilibrium model to show that the rising value of high-skilled workers’ time contributes to the gentrification of American central cities. I show that the increasing value of time raises the cost of commuting and exogenously increases the demand for central locations by high-skilled workers. While change in the value of time has a modest direct effect on gentrification of central cities, the effect is substantially magnified by endogenous amenity change driven by the changes in local skill mix. (JEL J22, J24, R21, R23)

Mobilizing human resources

The COVID-19 pandemic has confronted health systems with extraordinary changes in demand for health services, which magnified underlying disparities in the health workforce. Initial health workforce capacities were critical, as health systems only have two options to increase workforce level: increasing capacity among the existing workforce or mobilising/recruiting additional personnel. Workforce capacity became a limiting factor in an effective pandemic response, particularly in countries with acute workforce shortages. Countries in Europe have pursued various strategies to rapidly surge the numbers of health workers and using their existing human resources differently, including by introducing or expanding on alternative and flexible approaches such as task shifting and other skill-mix changes. The pressure to provide services across the continuum of care, from prevention and vaccination to specialist and inpatient care, led several countries to re-evaluate the distribution of tasks among the health workforce. In the best cases, multidisciplinary team-based staffing models combined the skills of multiple health professionals, enabling provision of the right care at the right time. This presentation will provide an overview of strategies to increase capacity for surges in human resources requirements, as well as supporting measures that help recognise the key role of health workers in the pandemic response. A brief overview of key metrics to assess resilience in the area of human resources will also be provided.

Using Cost Evidence for Price Setting: Experience from a Large National Public Insurance Scheme of India

Background: In 2018, the Government of India launched Ayushman Bharat – Pradhan Mantri Jan Aarogya Yojana (AB - PMJAY), a large tax-funded health insurance scheme. Provider payment rates for the AB-PMJAY health benefit packages (HBPs) were determined through consultative process and review of existing publicly financed health insurance (PFHI) schemes. In this paper, we present findings of the Costing of Health Services in India (CHSI) study and the process of price revision in 2019. Methods: Reference costs were generated from first phase of CHSI study which sampled 11 tertiary public hospitals from 11 Indian states. Economic costs were estimated using mixed (top-down & bottom-up) micro-costing methods. Based on stakeholder consultations, the cost of HBPs were analysed with different combinations of fixed and variable costs. The HBP cost was compared with AB-PMJAY prices of 2018 and 2019 and the budgetary impact was estimated. Finding: Only 13% of the HBPs in 2018, were close to (± 10%) to the actual cost of providing care. More than one-third (42%) of the HBPs had price less than 50% of the cost. After revision of prices in 2019, the latter decreased to 20%. The evidence-informed revision of HBP prices is estimated to increase claims amount by 200 million (0·7%). Interpretation: Strategic purchasing and price-setting of HBPs require creation of systems of evidence generation on the cost of providing services. Further, research is recommended to develop a cost-function for unit cost estimation with changes in time, region, prices, skill-mix and other factors. Funding Department of Health Research. Funding Statement: The study is funded by Department of Health Research (DHR), Ministry of Health & Family Welfare, Government of India. Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: The present study was approved by the Institutional Ethics Committee (IEC) vide letter no. PGI/IEC/2018/00125A and Institutional Collaborative Committee (ICC) vide letter no. 79/30-Edu-13/111273 of Postgraduate Institute of Medical Education & Research, Chandigarh, India.

Opportunities for, and implications of, skill mix changes in health care pathways: Pay, productivity and practice variations in a needs-based planning framework.

Health workforce planning is traditionally based on demographically-driven 'silo-based' models in which future requirements for particular health professions are determined by applying estimates of the future population to the existing population-based level of workforce supply. Estimates of future workforce requirements are focused on, and constrained by population size and requirements increase monotonically. Key failures of existing models include (1) lack of integration between planning the health care workforce, health care services and health care funding and (2) lack of integration between planning different health care inputs and the potential for substitution between inputs. Hence planning models fail to incorporate emerging developments in healthcare delivery and workforce change. We present an integrated needs-based framework for health workforce planning and apply the framework using data from nine European countries to explore the workforce and financial implications of re-configuring the delivery of care through changes in the allocation of treatment tasks between health care professions (skill mix). We show that cost consequences depend not only on pay differences. Instead, workforce planning in rapidly changing workforce environments must consider and incorporate between-provider group differences in productivity (the number of patients that are served per fixed period of time) and practice style (the number and mix of tasks used in providing care to the same type of patient).

An international perspective on organisational strategies to foster skill-mix changes in healthcare

Abstract Background The implementation of skill-mix innovations in healthcare organisations is a complex process which many factors affect, positively or negatively. Facilitators are factors which stimulate or expand skill-mix change, whereas barriers are factors that limit or restrict skill-mix change. This study provides an overview of the most common facilitators and barriers. Methods An overview of systematic reviews was conducted as part of a larger project studying skill-mix innovations. 20 reviews on organisational-level factors related to the implementation of skill-mix innovations were included. The evidence from the reviews was supplemented with country case studies. Results Organisational factors, such as physical proximity of services involved in the skill-mix or well-functioning information systems, are often discussed in the literature on skill-mix implementation at organisational level. The same applies to individual factors, such as required knowledge levels or (lack of) trust. Process factors and characteristics of the skill-mix intervention seem to play a less important role, even though coaching and support for professionals seem to facilitate the implementation process. The institutional environment mainly seems to have a hampering effect, especially related to a lack of financing, reimbursement issues or perceived fears of liability. Often, the implementation of skill-mix interventions at organisational level is approached by focusing on specific facilitators and barriers, yet little attention is paid to structural approaches. Conclusions There is no single appropriate strategy for implementing skill-innovations that will fit all organisations. Managers must adopt an optimal strategy when implementing skill-mix, usually involving a combination of approaches best suited to local factors, to their specific organisational context and to the individuals involved.

A quantitative systematic review of the association between nurse skill mix and nursing-sensitive patient outcomes in the acute care setting.

AimsTo examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.DesignA quantitative systematic review included studies published in English between January 2000 – September 2018.Data sourcesCochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix‐methods designs were included if the quantitative component met the criteria.Review methodsThe Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy‐five percent or more of studies with significant results found this association.ResultsSixty‐three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure‐to‐rescue; pneumonia; sepsis; urinary tract infection; mortality/30‐day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.ConclusionNursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.ImpactSkill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.

Hospital nurse-staffing models and patient- and staff-related outcomes.

Nurses comprise the largest component of the health workforce worldwide and numerous models of workforce allocation and profile have been implemented. These include changes in skill mix, grade mix or qualification mix, staff-allocation models, staffing levels, nursing shifts, or nurses' work patterns. This is the first update of our review published in 2011. The purpose of this review was to explore the effect of hospital nurse-staffing models on patient and staff-related outcomes in the hospital setting, specifically to identify which staffing model(s) are associated with: 1) better outcomes for patients, 2) better staff-related outcomes, and, 3) the impact of staffing model(s) on cost outcomes. CENTRAL, MEDLINE, Embase, two other databases and two trials registers were searched on 22 March 2018 together with reference checking, citation searching and contact with study authors to identify additional studies. We included randomised trials, non-randomised trials, controlled before-after studies and interrupted-time-series or repeated-measures studies of interventions relating to hospital nurse-staffing models. Participants were patients and nursing staff working in hospital settings. We included any objective reported measure of patient-, staff-related, or economic outcome. The most important outcomes included in this review were: nursing-staff turnover, patient mortality, patient readmissions, patient attendances at the emergency department (ED), length of stay, patients with pressure ulcers, and costs. We worked independently in pairs to extract data from each potentially relevant study and to assess risk of bias and the certainty of the evidence. We included 19 studies, 17 of which were included in the analysis and eight of which we identified for this update. We identified four types of interventions relating to hospital nurse-staffing models:- introduction of advanced or specialist nurses to the nursing workforce;- introduction of nursing assistive personnel to the hospital workforce;- primary nursing; and- staffing models.The studies were conducted in the USA, the Netherlands, UK, Australia, and Canada and included patients with cancer, asthma, diabetes and chronic illness, on medical, acute care, intensive care and long-stay psychiatric units. The risk of bias across studies was high, with limitations mainly related to blinding of patients and personnel, allocation concealment, sequence generation, and blinding of outcome assessment.The addition of advanced or specialist nurses to hospital nurse staffing may lead to little or no difference in patient mortality (3 studies, 1358 participants). It is uncertain whether this intervention reduces patient readmissions (7 studies, 2995 participants), patient attendances at the ED (6 studies, 2274 participants), length of stay (3 studies, 907 participants), number of patients with pressure ulcers (1 study, 753 participants), or costs (3 studies, 617 participants), as we assessed the evidence for these outcomes as being of very low certainty. It is uncertain whether adding nursing assistive personnel to the hospital workforce reduces costs (1 study, 6769 participants), as we assessed the evidence for this outcome to be of very low certainty. It is uncertain whether primary nursing (3 studies, > 464 participants) or staffing models (1 study, 647 participants) reduces nursing-staff turnover, or if primary nursing (2 studies, > 138 participants) reduces costs, as we assessed the evidence for these outcomes to be of very low certainty. The findings of this review should be treated with caution due to the limited amount and quality of the published research that was included. We have most confidence in our finding that the introduction of advanced or specialist nurses may lead to little or no difference in one patient outcome (i.e. mortality) with greater uncertainty about other patient outcomes (i.e. readmissions, ED attendance, length of stay and pressure ulcer rates). The evidence is of insufficient certainty to draw conclusions about the effectiveness of other types of interventions, including new nurse-staffing models and introduction of nursing assistive personnel, on patient, staff and cost outcomes. Although it has been seven years since the original review was published, the certainty of the evidence about hospital nurse staffing still remains very low.

Overview of systematic reviews: outcomes of health workforce skill-mix changes in ambulatory care

Overview of systematic reviews: outcomes of health workforce skill-mix changes in ambulatory care

Overview of systematic reviews: outcomes of health workforce skill-mix changes in ambulatory care

Overview of systematic reviews: outcomes of health workforce skill-mix changes in ambulatory care

Ensuring safe, sustainable and productive staffing.

Sam Foster, Chief Nurse, Oxford University Hospitals, considers the impact of the staffing crisis and guidance produced for the National Quality Board around changes in staffing and skill mix.

The Rising Value of Time and the Origin of Urban Gentrification

In the past decades, gentrification has transformed American central city neighborhoods. In this paper, I estimate a spatial equilibrium model to show that the rising value of high-skilled workers' time contributes to the gentrification of American central cities. I show that the increasing value of time raises the cost of commuting and exogenously increases the demand for central locations by high-skilled workers. While change in value of time has a modest direct effect on gentrification of the central cities, the effect is substantially magnified by endogenous amenity improvement driven by the changes in local skill mix.

What are the motivating and hindering factors for health professionals to undertake new roles in hospitals? A study among physicians, nurses and managers looking at breast cancer and acute myocardial infarction care in nine countries

BackgroundMany European countries experience health workforce skill-mix changes due to population ageing, multimorbidity and medical technology. Yet, there is limited cross-country research in hospitals. MethodsCross-sectional, observational study on staff role changes and contributing factors in nine European countries. Survey of physicians, nurses and managers (n = 1524) in 112 hospitals treating patients with breast cancer or acute myocardial infarction. Group differences were analysed across country clusters (skill-mix reform countries [England, Scotland and the Netherlands] versus no reform countries [Czech Republic, Germany, Italy, Norway, Poland and Turkey]) and stratified by physicians, nurses and managers, using Chi-squared, Mann-Whitney U and Kruskal Wallis tests. ResultsNurses in countries with major skill-mix reforms reported more frequently being motivated to undertake a new role (66.5%) and having the opportunity to do so (52.4%), compared to nurses in countries with no reforms (39.2%; 24.8%; p < .001 each). Physicians and nurses considered intrinsic motivating factors (personal satisfaction, use of qualifications) more motivating than extrinsic factors (salary, career opportunities). Reported barriers were workforce shortages, facilitators were professional and management support. Managers’ recruitment decisions on choice of staff were mainly influenced by skills, competences and experience of staff. ConclusionManagers need to know the motivational factors of their employees and enabling versus hindering factors within their organisations to govern change effectively.

Learning from the introduction of ‘skill-mix’ changes in general practice: a qualitative process evaluation

Background‘Skill-mix’ change (changing mix of staff roles or introducing new ways of working) is increasingly promoted to relieve pressure in general practice teams. As part of a primary care workforce strategy, one locality in Greater Manchester is seeking to integrate three ‘non-medical’ roles – Advanced Practitioners (APs), Physician Associates (PAs) and Clinical Pharmacists (CPs) – to work alongside practice staff.AimA qualitative process evaluation studied the integration of these roles to: establish the aims and priorities of the new services; understand and compare the ways in which the roles are being established with identification of measurable impacts and unintended consequences.MethodA rapid scoping review of the primary care skill-mix literature was conducted to inform the evaluation. Purposive and ‘snowball’ sampling enabled semi-structured interviews (12) and focus groups (2) to be conducted with 27 key individuals (workforce/training leads for the new services; APs/PAs/CPs; GPs/practice managers), before being transcribed, anonymised and analysed thematically with a combination of a priori and grounded codes. Analysis of relevant service/training plans supplemented interview/focus group data.ResultsA number of organisational and operational factors affecting implementation success in early adopter sites were identified including: the intended scope and function of new roles with corresponding implications for measuring impacts; leadership/active management of workforce changes; appropriate training and education; inter-professional tensions; regulatory provisions, and sustainability.ConclusionThere is variation in how the three skill-mix initiatives are being implemented in early adopter sites, with implications for success. Key considerations for introducing skill-mix changes in general practice are being identified.