Task Sharing and Task Shifting in Nursing and Midwifery Practice: Implications for Policy Development Project. Presenter: Mmule Magama (DNP)

Transcription

1 Task Sharing and Task Shifting in Nursing and Midwifery Practice: Implications for Policy Development Project Presenter: Mmule Magama (DNP) 1

2 No disclosures. 2

3 PROJECT ASSIGNMENTS * Funding: Centres for Disease Control and Prevention - Botswana * Project managers: Mrs K Modisaeman, Ministry of Health & the Botswana African Regulatory Collaborative (ARC) team * External project manager: Dr Maureen Kelley, Emory University, USA * Project consultant: Ms Jill Iliffe (Commonwealth Nurses and Midwives Federation) * Researchers: University of Botswana School of Nursing - Dr. Mabel Magowe (PI) - Dr. Kefalotse Dithole & - Dr. Mmule Magama 3

4 BACKGROUND 4

5 BOTSWANA 5

6 Ministry of Health 6

7 Global Health Workforce Shortage Shortage of health workers Estimated shortfall of 7.2 million health workers Estimated demand increasing to 12.9 million by 2035 if no interventions are made (WHO, 2013). Impact of Man Power Shortages * Increase in childhood infections * Increase in maternal and neonatal mortality * Poor access to health care services 7

8 Workforce Issues in Botswana Issues: * Doctor nurse ratios per 1,000 population is 1.94 : 9.81 respectively (2 doctors for every 10 nurses) * Tasks from other health cadres are shifted or shared with nurses & Midwifes (note that all midwifes are nurses) Innovations to ease the health workforce shortages in Botswana: * increase in the number of Health training institutions * Increased number of nurses and midwives trained annually * Establishment of the medical schools (UB and DDT College) * Upgrading of all health care diploma programs to degree (Nursing and Midwifery Council of Botswana, 2011; Magowe, Seboni and Rapinyana, 2015). 8

9 Purpose of the Study * Guide the development of a task-sharing policy * Identify opportunities for task sharing and task shifting for nurses and midwives 9

10 Objectives * Explore the Experiences of Nurses, Midwives and Stake Holders in Regard to task sharing and task shifting - Identify commonly shared tasks among health care providers - Determine perceived effects of task sharing and task shifting on the scope of practice - Identify barriers associated with task sharing and task shifting - Determine guiding principles for task shifting and task sharing - Solicit stake holder ideas for task sharing and task shifting policy 10

11 METHODS & PROCEDURES 11

12 Design * Descriptive cross sectional study that triangulated quantitative and qualitative face to face interview methods (Exploratory sequential mixed design) 12

13 Sampling & Sample Size Sample Sampling Technique Sample Size DHMT s Systematic sampling 10 Health Facilities Purposive sampling 22 Nurses Purposive sampling 491 Key Informants Officers holding key policy positions 12 13

14 Study Tools * Nurses: Self administered Questionnaire with 5 sections - 13 items - demographics - 19 items existence of tasks shared/shifted - 5 items - HIV & AIDS - 53 items tasks likely to be shared - 14 items - principles important for task sharing policy 14

15 Study Tools * Stake Holders: Interview guide exploring: - Understanding of task sharing & task shifting - Tasks shared b/ cadres - Principles to consider - Benefits, barriers, solutions and impact on the scope of practice 15

16 Procedures 1. Training of nurse managers 16

17 Procedures 2. Training of Officers - Data Entry * Training of two persons on data entry; a qualified statistician, and an officer qualified in data management and electronic digitization of data. 17

18 Procedures 3. Planning, organizing, scheduling and a wide consultation with selected DHMT authorities, health care experts & stake holders 18

19 Procedure 4. Pilot Testing * Piloted on 30 nurses at Bamalete Lutheran Hospital * selected because of its proximity to the research team and the similarities it shares with other hospitals * The objective was to ensure that the data collection methods and instruments were practical, comprehensive feasible and acceptable to typical respondents * Tools modified accordingly as suggested by respondents 19

20 Data Collection Nurses Mining Hospital 20

21 Data Collection 21

22 Data Analysis * Quantitative Data - digitized and uploaded into an excel spread sheet and then transferred into SPSS version 23 - descriptive statistics * Qualitative data - audio-recording - transcription - coding - content analyzed and summarized using key themes 22

23 RERSULTS - Demographics 23

24 Distribution of respondents by health district 24

25 Distribution of respondents by facility (n=488) Type of facility Frequency (Respondents) Percentage % Health post Clinic without maternity Clinic with maternity Primary hospital District hospital Referral Hospital Private Hospital Mission Hospital Total

26 Years of Work Years working as nurse Frequency Percentage % 1-5 years years years years years years years Total

27 Respondents by Age 27

28 Results - Quantitative Data 28

29 Sharing of Tasks (Nurses, doctors, Pharmacists and laboratory scientists) * 95% of respondents shared tasks amongst themselves often; the rest rarely or never share tasks * 49% shared tasks with non-nursing staff, the rest rarely or never share tasks with non-nursing staff * 21% of respondents shared tasks with doctors * 25% of tasks were found to be shared between nurses, midwives and doctors * Only 2 tasks were primarily carried out by nurses (nebulizing and requisition of supplies and equipment) 29

30 Examples of Tasks Shared * Assessment of a pregnant mother * Venue puncture * Administration of fluids * Ordering and administering drugs * Suturing of wounds * Catheterization * Nasogastric tubing * Respiratory suctioning * Male circumcision * Collection of blood specimens * Removal of foreign bodies (ear & eye) * Cardio pulmonary resuscitation * In-service training 30

31 Task Sharing & Shifting In HIV * All HIV activities listed were performed by nurses and midwives; commonly shared activities were: - routine screening and testing - screening for risk or exposure - pre and post-test counselling - counseling (infant feeding, positive results, Family planning, STI s) - dispensing - cervical cancer screening - Interpretation of CD4/VL, haematology and chemistry results Less than 10% of respondents performed tubal ligation, vasectomy, anaesthesia, and VMMC 31

32 Supervision * 90% (N= 412) of respondents worked in the same location as their supervisors * 67% had adequate and constant supervision * 54 % seek assistance only when they have a problem 32

33 Autonomy, Responsibility & Support * 86% of respondents worked autonomously & independently * 70% assumed a full responsibility of tasks shifted to them * 88% had not shifted tasks to anyone * 78% said tasks they perform are not included in their job descriptions * 63% were supported for performing the task by government, institution or policy, the rest had no support 33

34 RQ : Principles Considered Extremely Important in Task Sharing / Task Shifting a) Consultation b) Fair distribution of responsibilities and workload c) Review of job description d) Research to justify shifting of tasks e) Recognition and incentives f) Supportive legislation and policy g) Availability of resources h) Adequate education and training 34

35 Results Qualitative Data 35

36 Key Informants Respondents Organization Ministry of Health Greater Gaborone DHMT UNAIDS ACHAP WHO Gender distribution Respondents Principal Health Officer, SRH, Public Health Chief Health Officer, Laboratory Services, Clinical Services Director Health Inspectorate Deputy Permanent Secretary Clinical Services Acting Director Health Policy Development Monitoring and Evaluation Pharmacist Referral Hospital Pharmacy Technician Psychologist Medical Doctor Country Representative Country Representative Country Representative 8 males and 4 females 36

37 1. Understanding Meaning clearly understood, objective meant to: - fulfill common goal - increase access of care Task sharing is when nurses share tasks with other health care cadre when there is shortage of manpower. 37

38 Importance & Considerations 2. Importance - perceived to be inevitable - Should be decided case-by-case - Should consider all professionals involved 3. Circumstances Under which Task Sharing/Shifting should Occur - Shortage of staff (doctors, pharmacies etc.) - rural-urban disparity in human resources (allocation disparities) - Emergency situations, disasters or epidemics - Expansion of access to health care - Outreach programs - Provision of service to underserved populations, mostly in remote areas 38

39 Need for Health System Planning * Caution: task sharing and task shifting should not be a long term solutions for long standing human resource management problems * However, respondents could not explain targets to be set, time frames or transition plans for short-term solution * Emphasis was on the need to correct the system in order to solve immediate health workforce shortages 39

40 Tasks to be Shared Among Nurses and Other Health Cadres * Consultation, assessment and medication prescription * Dispensing of medications * Provision of Sexual and reproductive health services * Prescription and issuing of contraceptives * HIV and AIDS treatment; refilling patient prescriptions for antiretroviral therapy; or initiating therapy for uncomplicated cases * HIV testing and counseling * community education 40

41 Need for Incentives and Recognition * Recognition and incentives for those taking additional responsibility when tasks are shifted or shared. * I think tasks that are shifted or shared calls for recognition of those who perform them, not necessarily in terms of money but other non-monetary incentives could be used, said one respondent 41

42 Benefits of Task Sharing and Task Shifting * Professional development * Intrinsic motivation when one learns new skills * Contribution to the community * Enhancement of team work * Increase access and equity of service delivery * Cost savings 42

43 Barriers to Task Sharing and Task Shifting * lack of resources and delays in dispatching equipment and supplies * Possibility of dumping tasks on one cadre (nurses) this would overwhelm and overwork these professionals especially if correct measures such as supervision, coaching, monitoring, evaluation and follow-up are not in place. * Lack of guidelines and legal tools * Poor quality of services related to lack of training, no-supportive environment and lack of incentives * Erosion of profession integrity * Friction and inter-professional conflicts among health care providers regarding lack of professional boundaries. * Some officers may feel indispensable, some may feel threatened by the loss of professional territory. One respondent suggested changing the title General Nurse as that title gives the impression that nurses are generalists or jack of all trades who should do everything. 43

44 Discourse About Shifting and Sharing of Tasks Despite the preference for task sharing over task shifting, respondents concluded that task sharing/task shifting: * contravenes professional rules and regulations * prevents institutions from being accredited because the right health professionals may not be in place to meet accreditation requirements * may not enable provision of holistic care * Allows unprofessional and unlawful practices in which health professionals consult and dispense at the same time, this does not permit checks and balances According one respondent, failure to abide to pharmaceutical regulations could be detrimental to the lives of patients 44

45 Discourse Respondents Statements * One respondent said: Botswana is a developing country and this must be explored critically because the country may never train enough of other cadres for a very long time and it may not be cost effective to place them in very small settlements where they attend very few patients. 45

46 Discourse Respondents Statements * Another respondent said, There are gaps when nurses run the dispensaries, things are not done properly. In dispensaries where nurses are in charge, a lot of drug management problems exist; this includes stock management and cold chain management as well as drug wastage. I believe everybody should be allowed to practice what they have been trained for. Even though availing drugs to patients is accomplished when nurses dispense; there is need to recognize that pharmacy is not only dishing out drugs. There are a host of activities that pharmacists perform. We also evaluate what doctors and other practitioners have ordered, and we have observed some limitations in regard to prescription and dispensing. 46

47 Discourse Respondents Statements * Another respondent said, Task sharing is good of course, but it is not in-line with the policies of pharmacy, hence accreditation becomes a problem. For instance, a dispensary is to be run by a pharmacist and that is not happening in Botswana; in our case, a pharmacist is currently an overseer and the dispensary is headed by pharmacy technician and this is not allowed according to professional requirements. Even though task sharing is a welcome move, it tends to ignore some of the requirements of the profession and that is why our pharmacy has not been accredited by COSASA. There are gaps when nurses run the dispensaries, things are not done properly. * 47

48 Discourse Respondents Statements * One respondent was concerned about the need for health professionals to have a system where they can counter check each other, saying, Shortage of staff is a common rationale for sharing or shifting tasks. In these cases, nurses run a station and sometimes do everything alone. It is not allowed for a consulting officer to dispense because this is detrimental to the lives of patients. There is no way one can correct the mistakes they have done during consultation. 48

49 Principles and or Recommendations * Establish legal framework to protect all health care professionals involved. * Maintain professional boundaries * Collaborate and consult with other health care professionals affected by tasks that are to be shared or shifted * Involve regulatory and professional bodies to enforce quality standards * Seek acceptance by the cadres involved to release and/or assume responsibility for new tasks * Develop or review existing legal tools, such as Acts, regulations, policies, guidelines and standards to protect professionals and to ensuring quality of services and safety of patients * Select task sharing as opposed to task shifting 49

50 Principles and or Recommendations * Nurses who share tasks must have expertise in the task being shared * National policy and curriculum content should provide direction for the tasks to be shared * Develop short term and long term training with an emphasis on proper attainment of higher qualifications. * Follow-up, coach, mentor, supervise, monitor, and evaluate tasks shared and shifted. * Recognize and provide incentives for additional tasks * Provide long term solutions to human resource gaps * Define targets, timeframes and transition plans 50

51 CONCLUSION Respondents prefer task sharing rather than task shifting * Sharing and shifting of tasks to and with the nursing professionals is a common trend * A considerable number of tasks are shared between nurses and other health professionals, especially doctors * Most Nurses and midwifes perform and assume responsibility of shared or shifted tasks independently, autonomously and with minimum supervision or support * Most tasks are shifted to nurses whereas other professionals do not assume nursing duties * Considerations need to be made when developing a task sharing policy * Participation of the professional bodies affected and their acceptance is essential * The need for develop a legal framework is essential to protect involved partners and patients * There is evidence of discomfort that cause or are likely to cause friction and conflicts between nurses and other health professionals. While nurses do not wish to assume duties from other professionals; other professionals reject transfer of their tasks to nurses * There is a strong feeling that the Health care system should change in an attempt to address issues of man power shortages in a more professional manner 51

52 References Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams, G., S., Bloom, L.R., Fathima, S., Feigl, A.B., Gaziano, T., Mowafi, M., Pandya, A., Prettner, K., Rosenberg, L., Seligman, B., Stein, A.Z. and Weinstein, C., (2011). The global burden of noncommunicable diseases Geneva: World Economic Forum. Magowe, Seboni and Rapinyana (2015). Expected roles of nurses and midwives in Botswana: Unpublished research report. Nursing and Midwifery Council of Botswana (2011). Task Analysis Report Chen, L., Evans, T., Anand, S., Boufford, J, I., Brown, H., Showdhury, M., Cueto, M., Dare, L., Dussault G., Elzinga, G., Fee, E., Habte. D., Hanvoravongchai, P., Jacobs, M., Kurowski, C., Michael, S., Pablos- Mendez, A., Sewankambo, N., & Solimano, G., (2004). Human Resources for Health: Overcoming the Crisis. Lancet. 2004:364: World Health Organization (2013). Global health workforce shortage to reach 12.9 million in coming decades. Available at World Health Organization, (2006). The World Health Report Working together for health Geneva, World Health organization. WHO Library Cataloguing-in-Publication Data ISBN World Health Organization (2006). Taking stock: health worker shortages and response to AIDS. Available at 52