Description of the condition
The majority of countries are facing a chronic shortage and maldistribution of health workers (WHO 2008). This is a key barrier to the achievement of Millennium Development Goals 4, 5 and 6 (WHO 2004). For example, it is acknowledged that human resource shortages in public health care systems play an important role in unsatisfactory health outcomes such as higher maternal mortality rates (Anand 2004; WHO 2008). The problem of human resources shortages is particularly challenging in low- and middle-income countries (LMICs) in sub-Saharan Africa, and in parts of Asia and the Americas. At the same time, the demand for health care is rising. Meeting the Millennium Development Goals of improving maternal and child health, and combating specific diseases (including HIV/AIDS, malaria and tuberculosis (TB)) that are major challenges in LMICs, requires strengthening health systems and equipping them with effective and efficient health service delivery strategies, as well as increasing the coverage and reach of the effective services that are already in place (WHO 2008).
Governments across the world are using a number of approaches to address this problem. One key approach is the moving of tasks from more specialised or highly-trained to less specialised or less highly-trained health workers, for instance by transferring certain tasks from doctors to nurses or midwives. This is sometimes referred to as 'task shifting'; or 'optimising'. By re-organising the health workforce in this way, policy makers hope to make more efficient use of the human resources already available (WHO 2008; WHO 2012). Doctor-nurse substitution may contribute to addressing doctor shortages and reducing physician workload and human resource costs. Anand and Bärnighausen's (Anand 2004) analysis of data from 198 countries suggests that substitution strategies may offer an opportunity for achieving Millennium Development Goals 4, 5 or 6 in LMICs.
Description of the intervention
Substitution is a process of delegation whereby specific tasks are moved, when feasible, to less highly trained health workers (WHO 2004). The aim of this process is to use more efficiently existing workforce resources in the health sector. This approach can be used to provide a range of health services.
Substitution is not a new strategy. For example, high-income countries such as Australia, the United Kingdom (UK) and the United States of America have extended nurses' roles to include the prescription of routine medications (Cutliffe 2002; Hobson 2010; Stenner 2010). Also, a number of LMICs such as Ethiopia, Haiti, Malawi, Mozambique, Namibia, Rwanda, Uganda and Zambia are currently implementing this strategy to address the chronic shortage of health workers, particularly in the context of generalized HIV epidemics (Assan 2008; Koenig 2004;Morris 2009).
A recent overview of systematic reviews considered the evidence for policy options for human resources, such as substitution or shifting tasks between different types of health workers, and assessed the effectiveness of these strategies in LMICs (Chopra 2008). Results showed that evidence from LMICs is sparse, and the studies are less rigorous than those from high income settings. The authors concluded that more reviews on the effects of policy options to improve human resources in such countries are needed. In addition, a systematic review of substitution (task shifting) strategies for HIV care in Africa noted that the most commonly used intervention was the delegation of tasks from doctors to nurses and other non-physician clinicians (Callaghan 2010). This review concluded that the delegation of tasks to nurses offered cost-effective care to more patients than a physician-centred model, and others have reached similar conclusions (Colvin 2010; WHO 2008).
How the intervention might work
The Cochrane Library includes a review exploring the effectiveness of the substitution of general practitioners (family doctors) by nurses in primary care (Laurant 2004a). This review focused on patient outcomes including morbidity, satisfaction with care, quality of life, care processes (e.g., patient compliance, adherence to guidelines), use of resources (including length of consultations, prescriptions, test ordering) and economic variables. The review concluded that nurse-led care was as effective as doctor-led care and associated with higher levels of patient satisfaction and compliance, longer consultations and higher rates of laboratory tests. This review is currently being updated, and its findings are also supported by more recent studies investigating the impact on patient outcomes of nurses or nurse midwives working as substitutes for primary care doctors (Keleher 2009; Sibbald 2004).
By substituting doctors by nurses, nurses take on roles that were previously performed by doctors. The nature of the contribution that nurses substituting for doctors provide in clinical practice is complex and depends on the setting and the roles assigned to nurses, or accepted by them. Different arguments can be put forward to explain why the substitution strategies are employed:
Substitution may reduce the cost of providing health care (as nurses are usually paid less than doctors), and hence may be more affordable for the health systems and users of care.
Substitution may improve access to care as nurses may provide more coverage; nurses may be available in settings where access to doctors is limited; and doctors may use their free-up time for provision of other services
Substitution may even improve quality of care in certain areas, as some clinical tasks, for example patient education, may be better delivered by nurses
Substitution may also result in better retention of the nursing workforce via providing new clinical career pathways for experienced and educated nurses, further addressing nursing workforce shortages.
These potential relationships between the implementation of substitution strategies and health system objectives, however, are not straightforward and might vary based on the setting and the organisation of care. The complexity of nurse-doctor substitution, its interactions with the contextual factors in each setting as well as the limited effectiveness evidence available, has meant that it is difficult to explain why and how the intervention works, or does not work, in different settings. For example, a randomised trial showed that, at least in the short run, adding nurses to general practice teams did not reduce general practitioners' workload (Laurant 2004b). This trial suggested that nurse practitioners acted as supplements, rather than substitutes, for health care provided by general practitioners. This finding highlights the need to examine how these initiatives are implemented and what factors may explain their effects.
As noted above, one main reason that policy makers may consider substituting doctors with nurses is the expectation that using nurses may reduce costs. Evidence on this is not clear cut (Dierick-van Daele 2009; Hollinghurst 2006; Liu 2012). The Laurant review suggests that longer consultations in nurse–led care may decrease the cost savings of using nurses instead of doctors (Laurant 2004a). However, the exact effect on health service costs was unclear. In addition, Hollinghurst et al. (Hollinghurst 2006) conclude that the costs of employing nurses in primary care are likely to be similar to employing salaried primary care doctors. The way in which the providers (including doctors and nurses) organise their work might also affect the cost-effectiveness of substitution (Liu 2012). In addition, substitution might improve cost-effectiveness of care or address equity concerns (for instance, via improving access to those most in need and most likely to benefit from care) without incurring cost savings. Furthermore, the long term cost-effectiveness of a service might differ from short term outcomes, while the former is more difficult to assess.
In 2010, Rashid (Rashid 2010) conducted an integrative qualitative review exploring the benefits and limitations of the recent expansion of clinical roles among nurses working in general practice in the UK. The focus of the study was to establish whether the findings of a previous Cochrane review (Laurant 2004a) were still relevant in the light of recent expansion of nurses’ clinical roles in the UK general practice setting. In this study they integrated qualitative evidence with evidence on the effectiveness of nurse-doctor substitution in primary care. The study followed a limited approach that only considered qualitative studies conducted in the UK. The author clustered the findings of this review under three themes: the impact on patients, on nurse competence and on National Health Service policy. According to the findings, patients generally thought that all general practice nurses would be able to deal with simple conditions, but preferred to consult with a general practitioner if they thought it necessary. Indeed, there were concerns about nurses’ knowledge base, particularly in diagnostics and therapeutics, and their levels of training and competence in roles formerly undertaken by general practitioners. The review concluded that studies in this key area of health care policy are limited.
As most of this limited evidence is from high-income settings, it is not clear to what extent these findings regarding how nurse-doctor substitution works would apply to LMICs.
Why it is important to do this review
The last few years have seen a strong development in systematic review methodology for integrating and interpreting data from multiple qualitative studies, including within the Cochrane Collaboration (Noyes 2009). The Cochrane Qualitative Research Methods Group has identified around 500 such reviews, although very few of these are of direct relevance to policy makers making health workforce decisions in LMICs. It has been argued that in all countries, including resource poor countries, evidence informed decision making is essential (Chinnock 2005; Garner 1998; Oxman 2010). Policy makers need different types of evidence when choosing appropriate strategies. This includes reliable evidence about local context; but also global research evidence about the effectiveness of different strategies, and about potential barriers and facilitators to their implementation and success.
While the Cochrane intervention review on nurse-doctor substitution concluded that the effectiveness of nurse-doctor substitution initiatives was promising, the results of the included trials were heterogeneous (Laurant 2004a). This finding is not unexpected given the complexity and variability of these types of interventions. In addition, the level of organisation and support used on these trial interventions may have been higher than in real-life settings. If these types of interventions are to be successfully implemented, we need a proper understanding of the factors that may influence their implementation, success and sustainability. Such factors may include the values and preferences of stakeholders and the feasibility and applicability of the intervention for particular settings and health care systems.
There is a growing acknowledgement of the contribution that qualitative research can make to exploring and addressing these questions. As with systematic reviews of effectiveness, reviews of qualitative evidence should be carried out in a systematic and transparent way. By pairing and integrating systematic reviews of effectiveness data with syntheses of qualitative evidence, it will be possible to develop more comprehensive insights and understanding about relevant questions of interest in these topic areas. At least one published Cochrane review has previously prompted a parallel review of qualitative evidence. The Cochrane review of directly observed therapy (DOT) versus self-administered treatment for adherence to TB treatment showed that DOT, despite its widespread use, does not achieve better outcomes than self-administered treatment (Volmink 2007). Two parallel reviews (Munro 2007; Noyes 2007), searched for qualitative studies on factors explaining non-adherence to TB treatment so as to shed light on the Cochrane review results. Together, these reviews were not only able to provide compelling evidence regarding the intervention’s lack of effect, but also insights that could explain this lack of effect and inform policy and the design of more appropriate interventions (Garner 2007).
Pairing and integrating reviews of effect with reviews of qualitative evidence is equally relevant in the field of health worker interventions, and a body of relevant qualitative research exists. A synthesis of qualitative evidence can help in identifying barriers and facilitators to the success of substitution interventions, including the attitudes and experience of the health workers themselves; but also those of other stakeholders (Harden 2004; Thomas 2008). The previous review on this issue conducted by Rashid 2010 is limited to UK studies only and covered a specific period of time (2004-2009). The review also does not appear to link qualitative studies with effectiveness studies.
Undertaking this qualitative review is particularly relevant now as the existing Cochrane review on nurse-doctor substitution is currently being updated (Laurant 2004a). The review is also one of a series of reviews of qualitative research that aim to inform the World Health Organization's "Recommendations for Optimizing Health Worker Roles to Improve Access to key Maternal and Newborn Health Interventions through Task Shifting" (OPTIMIZEMNH) (WHO 2012).