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Global role shifting and health care

In times of global economic austerity, governments and healthcare systems look for more cost-effective ways to deliver the same, or increased, levels of health care for less. ‘Task shifting’ is fast becoming a byword for reassigning delivery of healthcare interventions and services from more expensive to less expensive cadres of staff. ‘Task shifting’ is also considered an essential component to delivering the Millennium Development Goals by 2015 (Save the Children Fund 2011).

Although ‘task shifting’ feels like an inappropriate term to describe the redistribution and assignment of professional roles, there is growing evidence that ‘task shifting’ to a less highly trained and paid cadre of staff can be equally as effective. In a Cochrane review on doctor to nurse substitution, which is currently being updated, Laurant et al. (2004) found that nurses in mainly developed countries could provide care with similar outcomes to doctors. In another Cochrane review Lewin et al. (2010), found that lay health workers provided promising benefits in promoting immunization uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared with usual care. For other health issues, evidence was insufficient to draw conclusions about the effects of lay health workers.

An additional series of qualitative syntheses on the barriers and facilitators to optimizing implementation of task shifting are currently being undertaken to complement existing quantitative systematic reviews of effectiveness (WHO Alliance 2011). Common to all of these reviews, however, is a lack of clarity on the roles and level of training and practice of nurses to, or from whom a ‘task’ is being shifted. A higher level of consistency and clarity about nursing and advanced nursing roles is urgently needed in published studies to support interpretation of evidence in systematic reviews, and practice development generally.

In this issue of the JAN, Lowe et al. (2011) report a long overdue discussion of published literature in their article Time to clarify – the value of advanced practice nursing roles in health care’. The discussion is based on a search of relevant literature published between 1995–2010. The authors eloquently articulate the lack of clarity regarding roles and the proliferation of roles across international boundaries. Lowe et al. conclude that:

  •  clarity around what each of the advanced nursing roles offer is paramount to take advantage of this opportunity to improve healthcare delivery and
  •  It is difficult to provide evidence of efficiency and cost effectiveness without clarity and consistency of roles.

These findings echo the challenges encountered by review authors in synthesizing and interpreting evidence on ‘task shifting’, nursing roles and outcomes of care. The key message is that international nursing regulators need to standardize and clarify roles and definitions, and authors of primary research studies need guidance on the essential elements of nursing roles to report, such as level and type of training and competencies, local registration and regulatory frameworks, specified tasks, roles and responsibilities, and proximity of the nurse to supervision and, as appropriate, medical support. Lowe et al. argue that this type of clarity is required so that standardized measures can be used to establish efficiency, cost effectiveness and realization of patient outcomes. Evidence synthesis funders and authors would welcome this much needed clarity and support the call by Lowe et al. for international nursing regulators to urgently work together to resolve the differences in nursing role definitions and functions.

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