Moriah Ellen

Background: Nurse practitioners (NPs)—nurses with advanced training who can provide and prescribe care—are increasingly prevalent internationally. The growth of NPs can be attributed to physician shortages, growing demand for health services, and the professionalization of nursing. Ensuring efficacious integration of NPs into the health system is critical for maximizing their impact on patient and system outcomes. Nonetheless, there is a dearth of information on practical policy interventions facilitating the successful integration of NPs. Effective policy interventions should capture the perspectives of actors at all levels of the health system—ie, national and organizational levels. This study aimed to delineate a taxonomy of policy interventions for integrating NPs into health systems. This paper presents a taxonomy developed among gerontology NPs in Israel. Methods: This qualitative descriptive study used multiple perspective, one-to-one interviews with four professional groups—national policy-makers, organizational administrators, NPs, and physicians. Data were analyzed using deductive content analysis. Analysis accounted for diverging and converging patterns between professional groups. Results: There were 58 participants across the four professional groups. The national-level domain interventions include marketing, workforce development, professional licensure and regulation, financial incentives, stakeholder cooperation, education and training programs, and national-level research. Organizational domain interventions included organizational guidelines, infrastructure development and resource allocation, interprofessional leadership engagement, and organizational messaging. Unit- and care-team domain interventions included interprofessional experience and exposure, team communication, and mentorship. Conclusion: The taxonomy’s trichotomy of three health system level domains describes the relationship between national and organizational policy interventions. Adopting these interventions may result in an improved response to provider shortages. Policies insufficiently addressing role clarity and workforce retention resulted in poor integration and a failure to efficaciously combat workforce shortages. Future work will expand the focus of this preliminary taxonomy by further development and testing with international participants.

Background: Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders’ perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation. Methods: In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis. Results: Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors’ work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct "organizational incentives" suggested that current pay-for-performance incentives function as a "double-edged sword," increasing family doctors’ motivation to excel while creating pressures to "game the system" among some physicians. When considering the CFIR construct "reflecting and evaluating," policy-makers perceived the online evaluation application – which provides daily reports on family doctors’ work – to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the "network and communication" construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs. Conclusion: The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital–community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.

In their study of manifestations of policy support organizations (PSOs), Al Sabahi et al found that PSOs are united in their goal to support evidence-informed policy-making (EIPM), albeit with differing approaches. Their article is an important contribution to the body of research on evidence utilization and implementation. The unprecedented evidence climate presented by coronavirus disease 2019 (COVID-19) provides a unique window to motivate EIPM implementation. Research such as Al Sabahi and colleagues must prompt a dialogue regarding how best to address some of the current shortcomings in the field of EIPM. Monitoring and evaluation of best practices in EIPM is scarce. EIPM uptake is unsatisfactory, and the scientific community needs to ask itself why that is and what can be done. And, we should strive to develop a gradient that discerns between the convenient and the essential so countries can evaluate and pursue the policies to best address their greatest pain points through evidence.