Abstract
Background: Countries globally face a growing health human resource crisis in primary care. Task shifting and skill mix are two inter-related strategies that have been implemented to alleviate the health human resource crisis. Both interventions involve changing or expanding clinical roles, ultimately optimizing the current workforce. This realist synthesis of a systematic review aims to understand how and why task shifting and skill mix interventions are effective in primary care, with a focus on high-income countries.
Methods: A realist review is a theory-driven interpretive approach to studying complex interventions. The guiding research question is “what works for whom, in what circumstances, in what respects and how?” For our realist review, the research question was: “What are the contextual factors, mechanisms, and outcomes of task shifting and skill mix implementation in primary care settings?”
Pawson summarizes five steps of a realist review: 1) an initial program theory was developed; 2) a search strategy was developed and searched for the evidence; 3) documents were screened, selected, and appraised; 4) data was extracted and organized into tables; 5) data was then analyzed and synthesized into a Context-Mechanism-Outcome (CMO) configuration, refining the initial program theory.
RAMESES guidelines for realist reviews were followed. All titles and abstracts were double-reviewed. We excluded any articles that met our inclusion criteria but did not yield any data toward CMO configurations.
Results: Our initial program theory was: “When there is a health workforce shortage (Context), Task Shifting and Skill Mix interventions can be implemented (Mechanism), in order to improve patient journeys and outcomes, clinician outcomes, and health systems outcomes (Outcome).” Using this theory to guide our systematic review, we implemented a search strategy combining terms for primary care and task shifting and skill mix in seven health sciences and nursing databases. Our search yielded a total 1783 articles. All titles and abstracts were screened and included articles were extracted and coded into CMO configurations.
37 papers are synthesized in our results. Studies varied in geography from the Netherlands to the USA, Germany, and Australia. Almost all papers involved changes to physician roles and scope of practice and the majority of these papers discussed moving work to nurses (registered nurses and nurse practitioners) or pharmacists.
In revising our initial program theory, we expanded the one to multiple in order to include the three typologies of skill mix (task shifting, adding new tasks/roles, and introducing or changing teamwork), each of which had a different mechanism. We found evidence that perceptions of worker competence, patient acceptance and satisfaction, and patient altruism were aspects that mediated the task shifting and skill mix interventions. We also found little discussion in the literature regarding facilitation of teamwork, whether this was formal training and education or informal. Teamwork plays an important role in mediating task shifting and skill mix intervention outcomes.
Conclusion: Our realist review highlights the difficulty of tackling health human resource challenges in primary care. This study is the first of its kind and offers international insights for health human resource planning and development.