|Year : 2020 | Volume
| Issue : 1 | Page : 4-10
Nurses role in cardiovascular risk assessment and communication: Indian nurses perspective
Kavita Kavita1, Jarnail Singh Thakur2, Rajesh Vijayvergiya3, Sandhya Ghai1
1 National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2 Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India
3 Department of Cardiology, PGIMER, Chandigarh, India
|Date of Submission||02-Aug-2019|
|Date of Decision||06-Sep-2019|
|Date of Acceptance||10-Mar-2020|
|Date of Web Publication||31-Mar-2020|
Dr. Kavita Kavita
B-2 Mittal Paradise Apartments, Shivalik City, Sector 127, Greater Mohali, Kharar, Punjab
Source of Support: None, Conflict of Interest: None
Background: Internationally, the implementation of cardiovascular disease (CVD) prevention programs by nurse practitioners is being encouraged. Evidence suggests the effectiveness of nurse-led clinics for the primary and secondary prevention of CVDs. However, in India, nurses are underutilized for this task. The present study was undertaken to check the feasibility of task shifting of CVD risk assessment and management by nurses and have concluded that given appropriate training, nurses can do this task. However, to facilitate the implementation of these tasks by nurses at the larger level, barriers need to be identified and lifted. Hence, the experiences of nurses who participated in the study were assessed.
Methodology: Qualitative approach was adopted to explore the experiences of nurses who participated in the study to determine the potential barriers and facilitators to implementing CV risk assessment and management using the World Health Organization/International Society of Hypertension (WHO/ISH) charts as routine practice by nurses. In-depth interviews were conducted with the help of the topic guide. These interviews were transcribed verbatim for analysis. A total of six in-depth interviews were conducted. No new themes emerged after the first four interviews.
Results: A total of six nurses participated in the study. All the nurses were female, with the mean age of 38 ± 9.2 years. The analysis resulted in seven key themes which are crucial to the nurses involvement in CVD risk assessment and management. The themes are (1) Use of WHO/ISH charts in routine nursing practice, (2) Lack of contact with patients, (3) Time, (4) Lack of appraisal and Performance-based appraisal, (5) Increasing the scope of task shifting, (6) Infrastructure, (7) Training facilities for nurses, (8) Team member support.
Conclusion: The study concludes that despite the challenges and barriers participating nurses expressed their willingness to do the task of CVD risk assessment and management. Appropriate training and continuous feedback from the higher health-care professional is essential for the successful implementation of CVD risk assessment and communication as routine practice by nurses. The availability of adequate workforce and time were the key concerns raised by participating nurses.
Keywords: Cardiovascular risk assessment, nurse practitioners, risk communication, World Health Organization/International Society of Hypertension charts
|How to cite this article:|
Kavita K, Thakur JS, Vijayvergiya R, Ghai S. Nurses role in cardiovascular risk assessment and communication: Indian nurses perspective. Int J Non-Commun Dis 2020;5:4-10
|How to cite this URL:|
Kavita K, Thakur JS, Vijayvergiya R, Ghai S. Nurses role in cardiovascular risk assessment and communication: Indian nurses perspective. Int J Non-Commun Dis [serial online] 2020 [cited 2020 Jun 5];5:4-10. Available from: http://www.ijncd.org/text.asp?2020/5/1/4/281665
| Introduction|| |
Cardiovascular diseases (CVDs) account for high morbidity and mortality among all noncommunicable diseases (NCDs) globally. As per the Global burden of disease study, 2015 estimates NCDs constituted the highest attributable disability-adjusted life years (DALYs). Among different NCD cause groups, attributable DALYs for cardiovascular and circulatory diseases were as high as 85.3% (84.0–86.6).
In the developing countries, including India the proportion of CVDs among all NCDs is higher. Among CVDs, Coronary artery disease and stroke are the most prevalent forms and constitute majority of cardiovascular mortality (83%) in India., Coronary artery disease in India occurs at a younger age and affects the more productive section of society. The prevalence of coronary artery disease has increased approximately seven times (from 2% to 14%) in urban and four times (1.7% to 7.4%) in rural India over the past four to five decades.
The burden of NCDs is rising to the epidemic proportions substantiating the need to take urgent measures to control the same. Evidence suggests that CVDs can be prevented with appropriate primary and secondary prevention strategies. Many countries have witnessed a decline in NCD risk factors due to major public health interventions/programs.,,,,, However, implementing prevention program in developing countries, including India, is challenging because of scarce health workforce. Among the various resources required, the availability of human resources is vital for executing the prevention program. There is a shortage of human resources for health (HRH) in India as the health workforce density is less than the WHO norm of 2.5 workers/1000 population. Employing task-shifting in one among the various solutions available to address deficit HRH. Task shifting refers to the development and deployment of non-physician health-care providers, ranging from community health workers to mid-level health workers, for example, nurse practitioners. It can be one of the immediate and most sustainable solutions for implementing CVD prevention programs.
A framework for implementation and sustainability of prevention programs, including CVD risk assessment and management by nurse practitioners, is well documented in the developed countries. Evidence suggests that nurse-led services are effective in primary and secondary CVD prevention. Nurse practitioner role in the management of CVDs is well established in the Western world with their involvement for chronic disease management in both dependent and independent (nurse-led clinics) roles.,,,,, Nurses can play a key role in managing the risks for coronary artery disease in a low-resource setting. The individualized care provided by nurses is cost-effective and relevant to a society that has high demands for risk intervention. However, in India, the nurses role in CVD risk assessment and management is limited and not well established. Hence, the present study was undertaken and concluded that task shifting of CVD risk assessment and communication to nurses is feasible and effective.
However, to facilitate the implementation of these tasks by nurses at a larger level, barriers need to be identified and lifted. Hence, the qualitative approach was adopted to explore the perspective of Indian nurses regarding their role in CVD risk assessment and communication and also perceived barriers in introducing risk prediction charting as routine nursing practice.
| Methodology|| |
The qualitative research approach was adopted to explore the experiences of nurses to determine the potential barriers and facilitators to implementing CV risk assessment and management as routine practice by nurses. Nurses chosen in the study were those who had participated in task shifting of CVD risk assessment and management for primary and secondary prevention of CVDs in a tertiary health-care institute. Full description of the study protocol is published elsewhere. In-depth interviews were conducted with the help of the topic guide. In-depth topic guide was prepared to ensure that all relevant topics were discussed, and the validity was established by giving it to experts. It included open-ended questions to explore the nurses' perceptions. These interviews were audio-recorded, and each interview took around 40–50 minutes. These interviews were transcribed verbatim for the analysis. A total of six in-depth interviews were conducted with nurses purposely sampled. No new themes emerged after the first four interviews. Written informed consent was obtained from the participants. Ethical approval of the study was obtained from the Institute Ethics Committee of Post Graduate Institute of Medical education and research, Chandigarh. Written informed consent was obtained from participants.
Audio recorded interviews were transcribed verbatim for the analysis. Two researchers coded the data, and the coding discrepancies were discussed till the time of consensus. After analyzing four interviews, no new codes or themes emerged, and conceptual saturation was reached. The remaining two interviews were used to confirm the analysis
| Results|| |
A total of six nurses participated in the study. All the nurses were female. Two nurses were graduate (B. Sc) in nursing, whereas rest were qualified up to diploma in general nursing and midwifery. The mean age of nurses was 38 ± 9.2 years. The analysis resulted in seven key themes which are crucial to the nurses involvement in CVD risk assessment and management. The themes are: (1) Use of the World Health Organization/International Society of Hypertension (WHO/ISH) charts in routine nursing practice, (2) Lack of contact with patients, (3) Time, (4) Lack of appraisal and Performance-based appraisal, (5) Increasing the scope of task shifting, (6) Infrastructure, (7) Training facilities for nurses, and (8) Team member support.
Adequacy of training
The training which was given to participating nurses in the study was seen by all the nurses as useful in enhancing their knowledge and skills in CVD risk assessment and management. They verbalized that the content of training was adequate. In addition, they said that although they were aware of some facts, after the training, they learned how to comprehensively present information to the patients.
Nurse 2........ Some of the tips like abdominal girth above 90 cm increase the risk were not known to me and I came to know only after the training.
Participation in the study also encouraged nurses in adopting healthy lifestyle themselves. They assessed their own risk also. Some nurses said that after training, they incorporated the changes in their own life, which helped them in lifestyle modification. They also said that if they will practice healthy lifestyle then only they can ask patients to do so.
Nurse 3........ I am benefited in my personal life also as I have reduced the salt content in my diet, charts helped me to know the risk.
Nurse 4.....I am able to gain knowledge about my CVD risk with the help of risk prediction charts.
They said that the information given in training should also be periodically updated as per the newer evidence.
Nurse 2....... I really enjoyed your training program. Although it was complete but needs to be periodically updated as per the new studies.
Theme 1. Use of World Health Organization/International Society of Hypertension charts in routine nursing practice
Nurses in the present study have demonstrated that they can do cardiovascular risk assessment and risk communication using WHO/ISH risk prediction charts among patients visiting different outpatient departments (OPDs) of a tertiary health-care setting. However, to continue this practice, it is important that it should be incorporated into their routine nursing practice. Opinions of the participating nurses were asked regarding the routine use of risk prediction charts by them.
Almost all the nurses verbalized that nurses can undertake this task of CVD risk assessment and management as any other routine charting by nurses. None of the nurses in the study found the use of the WHO/ISH risk prediction chart as difficult. They felt confident in using these charts. In addition, they also said that the charts can also be used for indoor patients and suggested that risk can be assessed at the time of admission itself. They also mentioned that training of all the nurses would be required before assigning them this task in routine practice.
Nurse 1........ If the nurses want they can do this charting also as they do TPR charting or intake output charting..........I can confidently use these charts, it is easy and convenient.......quickly we can assess the clients risk for the next ten years.
Nurse 3......... All the nurses can be trained; it is not a difficult task...... If we train the nurses and educate them about CVD risk they will definitely do this assessment.................. Like we do other routine charting of intake output, etc., these charts should also be made compulsory for nurses.
Nurses also mentioned that risk prediction charts are also helpful in communicating the risk. All the nurses said that they were not aware of the risk prediction charts before the study.
Nurse 3........ Did not know about charts and was not aware of how to detect the risk.....
One nurse mentioned that she has already started the risk assessment in routine day practice.
Nurse 1......have started in daily routine for every patient who has high BP......tell them about the importance of dietary modification, exercise and daily walk.
They verbalized that shortage of staff can also act as a barrier in implementation of CVD risk assessment and management as a routine.
Nurse 1.......... If only one staff on duty and many patients then will face difficulty.
Theme 2. Lack of contact with patients
Although all the nurses wanted to practice CVD risk assessment and communication in their OPDs. However, some of the limitations, they said for using these charts as a routine practice for all patients in OPDs is that all patients visiting OPDs are not coming in contact with nurses, so the opportunity of assessing risk is missed. Nurses said that after registration, they visit the concerned doctor and visit nurses only in case they have been prescribed an injection or for any inquiry, etc.
Nurse 4...... Nurses do not come in contact with all the patients in the OPD, only those patients for whom injection is due visit me rest leave after visiting a doctor. Out of 100 patients, only 20-30 come in contact with me.
Nurse 6........ As the patients do follow-up with physician, there should be follow-up with nurses also...... Patients visit doctors and leave.
In spite of these problems, nurses showed their willingness to do this task. They also mentioned about their as well as patient satisfaction with the task.
Nurse 3........ Could do in this study and think we can sustain it further..... Every nurses can do this task
Nurse 6...... Patients were satisfied, but I also felt satisfied as I was able to do something for them.
Theme 3. Time
Some nurses said that availability of time is the main determining factor for carrying out opportunistic screening of CVD risk assessment and management.
A key concern nurses raised was the shortage of time in implementing opportunistic screening of CVDs. Some nurses verbalized that due to a shortage of staff, sometimes only one nurse is there in OPD that can make the task difficult.
Nurse 4......... Feels time constraint.. Risk assessment and management takes around 30–40 minutes, minimum of 30 minutes.... so it becomes difficult if I am alone in OPD.....
Theme 4. Lack of appraisal and performance-based appraisal
Most of the nurses verbalized the lack of recognition for doing good work. They emphasized on the need of appraisal to keep up their motivation.
Nurse 4.... No mechanism exists for giving recognition for doing good work....... like in corporate offices the best worker of the week or month is chosen and rewarded... there should be something for us also.....
Nurses also verbalized performance should be the basis for promotion
Nurse 3..........time to time exams should be there for promotion like.......... hospital where Nurses have classes for ECG and ventilator etc.... exam is there and certificate is given after clearing the exam.
Theme 5. Increasing the scope of task shifting
The present study scope of task shifting was limited to CVD risk assessment and communication by nurses. One nurse emphasized on the need to increase the scope of task shifting. She verbalized the limitation of risk communication without the authority to prescribe medication. She said that it is very difficult to communicate with patients without the authority to give certain medications. She mentioned that one patient asks her about that whether he can give sorbitrate in case somebody has heart attack or not.
However due to a lack of authority to prescribe medication, she could not give appropriate response. She was also concerned that the patient often loses trust in such scenarios, which may limit the uptake of healthy behaviors suggested by a nurse.
Nurses suggested that certain protocols can be made for nurses which can be used by nurses for prescribing some important drugs in an emergency.
Nurse 2.......... patient was asking if someone gets a heart attack– can we give sorbitrate to the patient.......we are not given so much of power to tell them whether they can take it or not......... In emergency nurses should be trained to give medicines.
Theme 6. Infrastructure
There is a wide use of information and communication technology to support patient care worldwide. Chronic diseases like CVDs require care, which is long term and continuous. The use of communication technology like the utilization of mobile phones can play a significant role in the care of patients with chronic conditions. In the present study, telephonic reminders were used for reinforcing risk reduction strategies and improving medication adherence. However, almost all the nurses said that they had problem in doing telephonic follow-ups. Lack of time and nonavailability of official phone was one among the several reasons for difficulty in doing follow-ups. They also feared that their personal mobile number can be misused by patients or making calls at odd hours.
Nurse 2.......by using our own phone for the telephonic phone up we can also get unnecessary calls from patients at odd hours which are not related to the topic.
Nurses also suggested a solution to the problem. One nurse verbalized the help of telephone department can be taken. She said that there can be a centralized area with the availability of official phone from where the follow-ups can be done. Since time was also one of the constraints, another nurse suggested that one nurse can be posted only for doing telephonic follow-ups or they should be given some stipulated time within the duty hours for making reminder calls to patients.
Nurse 3........ Provide one exclusive phone number at the counter or reception for follow-ups will help........ follow-up rate will increase.
Theme 7. Training facilities for nurses
Best patient care by nurses can only be provided if they have up to date knowledge and skills. Training programs provide the opportunity to expand knowledge and skills. Periodic in-service and continuing education program plays a key role in enhancing the performance of nurses in providing quality patient care. It also keeps up their motivation, improves performance, and provides satisfaction Nurses in the study also feel the importance of continuing in-service education. Most of them realize that specialization in their area of work as well as skill updates should be there for nurses. Participating nurses also verbalized that there are very few or none opportunity for nurses to attend in-service education program and expressed the need for the same. Most of them said that in the last 5–10 years they had only attended the training program for the present study. They also said that even if they get some opportunity to attend, the permission to attend is not granted because of the shortage of staff.
Nurse 2........... We do not get much of in-service education opportunities....... since 2010 I am working in cardiology I did not get any inservice education, I only got training from you............opportunity of specialization in the area of work should be provided...............
Nurse 4......... Inservice education is there but did not get opportunity either due to non suitability of timings or did not get permission from administration due to staff shortage in the OPD..... we face these problems for attending in-service education programs.
Theme 8. Team member support
Nurses in the study also believe that they will receive support from the health team members in this task of CVD risk assessment and management. They also believe that it will reduce the workload of doctors.
Nurse 2............ Workload of doctors will decrease...... when doctors are examining the patients in the OPD they can send them to us as they don't have time to explain everything to the patients.........
Nurses in the study also believe that if nurses start doing this task it will raise the profile of nurses and will give them due recognition among team members.
Nurse 3...........this study will help a lot in raising the profile of nurses.....nurses will get recognition and their knowledge and qualification will increase.
| Discussion|| |
Globally, the human resource deficit in healthcare is pervasive. India like many other low- and middle-income countries faces the shortage of health workforce. The major contributing factors of the health workforce crisis is brain drain, i.e., migration of doctors and nurses from developing countries to the developed world. Underproduction of health workers is another important factor. Since independence, concerted efforts have been taken to meet the deficit health workforce in India. However, shortage exists in all the categories of health workforce at different levels. Considering the high burden of NCDs combined with a continued shortage of HRH, task shifting is a priority
In this study, we explored the nurses' perception of barriers in implementing CVD risk assessment as a routine practice for nurses. Nurses included for this qualitative analysis were those who participated in task shifting study where the nurses were trained in CVD risk assessment and communication, which concluded that task shifting was effective for primary and secondary prevention of CVDs. However, for the optimum utilization of nurses in CVD risk assessment and communication and to continue it in routine practice barriers need to be identified and addressed. Hence, the qualitative approach was adopted to assess the perception and barriers of participating nurses for incorporating this into the routine practice by nurses.
Analysis of in-depth interview revealed that nurses working in a tertiary health care hospital were willing to do the task of CVD risk assessment and management. However, there is a need to train the nurses in this task, and it should also be incorporated in their job description. Although there is limited evidence from India regarding the utilization of nurses' in the task of CVD risk assessment and communication, the findings are consistent with many studies from the Western countries where the nurses are trained in this task and are willingly and effectively are carrying out as a part of their job description.
Nurses in the study also verbalised the need of continuous training and organizational support for the task shifting of CVD risk assessment and communication by them. The findings are similar to the study by Feiring and Lie where participants emphasized the need of structural training as an essential implementation enabler of task shifting.
Deficit of HRH is pervasive and exists across all cadres, including nursing. According to the National sample survey organization estimates Nurse and midwives density was 2.3/10,000 population as compared to the total health worker density of 8/10,000 population. It was also identified as a barrier by the participating nurses. Availability of adequate workforce and time is also a key concern raised by nurses by participating nurses. They verbalized that shortage of the staff makes the task difficult.
Human resource and infrastructural issues identify in this study are similar to many other task-shifting initiatives.
Availability of time was also one of the key concerns raised by nurses in this study, which is similar to the study by Iwelunmor et al. where time was felt as a constraint for carrying out task shifting in hypertension.
Nurses in the present study also feel satisfied and also believed that this task would raise the profile of nurses. The findings are similar to a study (TAASH) in Ghana which included the task shifting for hypertension control. In this study, nurses enjoyed seeing the positive effects of the program and improvement in patient health. Nurses involvement in TAASH program also contrasted their previous role where the whole responsibility of the management of hypertension was with the physician.
However as a routine practice patients visit nurses only if they are prescribed any injection or dressing, etc. Hence, there is a need to establish a system by which patients visiting OPDs should also visit a nurse in the OPD. All the nurses who participated in the study found the use of WHO/ISH risk prediction charts easy and feel confident to use these charts in a routine nursing practice. Although the physicians' perception was not undertaken in the study, nurses believe that it will decrease the workload of doctors.
| Conclusion|| |
Study concludes that despite the challenges and barriers participating nurses expressed their willingness to do the task of CVD risk assessment and management. However for successfully carrying out the task of CVD risk assessment and communication for all patients visiting the OPDs of a tertiary health-care setting certain barriers like provision of adequate manpower and infrastructure should be there. To keep up the motivation of nurses, there should be proper appraisal mechanism and periodic in service education program. Appropriate training and continuous feedback from the higher health-care professional is essential for the successful implementation of CVD risk assessment and communication as a routine practice by nurses.
We would like to thank the participants of the study. We acknowledge the contribution of Dr Tarun Narang, Assistant Professor, PGIMER, Chandigarh for helping us with editing of the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1545-602.
Shah B, Mathur P. Surveillance of cardiovascular disease risk factors in India: The need and scope. Indian J Med Res 2010;132:634-42.
] [Full text]
Patel V, Chatterji S, Chisholm D, Ebrahim S, Gopalakrishna G, Mathers C, et al
. Chronic diseases and injuries in India. Lancet 2011;377:413-28.
Iyengar SS, Gupta R, Ravi S, Thangam S, Alexander T, Manjunath CN, et al
. Premature coronary artery disease in India: Coronary artery disease in the young (CADY) registry. Indian Heart J 2017;69:211-6.
Prabhakaran D, Jeemon P, Roy A. Cardiovascular diseases in India: Current epidemiology and future directions. Circulation 2016;133:1605-20.
Shroufi A, Chowdhury R, Anchala R, Stevens S, Blanco P, Han T, et al
. Cost effective interventions for the prevention of cardiovascular disease in low and middle income countries: A systematic review. BMC Public Health 2013;13:285.
Puska P. The North Karelia Project: 30 years successfully preventing chronic diseases Diabet Voice 2008;53:26-9.
Winkleby MA, Taylor CB, Jatulis D, Fortmann SP. The long-term effects of a cardiovascular disease prevention trial: The Stanford Five-City Project. Am J Public Health 1996;86:1773-9.
Lando HA, Pechacek TF, Pirie PL, Murray DM, Mittelmark MB, Lichtenstein E, et al
. Changes in adult cigarette smoking in the Minnesota Heart Health Program. Am J Public Health 1995;85:201-8.
Thakur JS, Pala S, Sharma Y, Jain S, Kumari S, Kumar R. Integrated non-communicable disease control program in a Northern part of India: Lessons from a demonstration project in low resource setting of a developing country. CVD Prev Control 2010;4:193-9.
Mendis S. Cardiovascular risk assessment and management in developing countries. Vasc Health Risk Manag 2005;1:15-8.
Samb B, Desai N, Nishtar S, Mendis S, Bekedam H, Wright A, et al
. Prevention and management of chronic disease: A litmus test for health-systems strengthening in low-income and middle-income countries. Lancet 2010;376:1785-97.
Planning Commission of India: High Level Expert Group Report on Universal Health Coverage for India, New Delhi; October, 2011.
Horsburgh M, Smith FG, Yallop J. Nursing initiatives inprimary care: An approach to risk reduction forcardiovascular disease and diabetes. N
Z Fam Physician 2008;35:176-82.
Tiessen AH, Smit AJ, Broer J, Groenier KH, van der Meer K. Randomized controlled trial on cardiovascular risk management by practice nurses supported by self-monitoring in primary care. BMC Fam Pract 2012;13:90.
Primdahl J, Ferreira RJ, Garcia-Diaz S, Ndosi M, Palmer D, van Eijk-Hustings Y. Nurses' role in cardiovascular risk assessment and management in people with inflammatory arthritis: A European perspective. Musculoskeletal Care 2016;14:133-51.
Voogdt-Pruis HR, Beusmans GH, Gorgels AP, Kester AD, Van Ree JW. Effectiveness of nurse-delivered cardiovascular risk management in primary care: A randomised trial. Br J Gen Pract 2010;60:40-6.
Woodward A, Wallymahmed M, Wilding J, Gill G. Successful cardiovascular risk reduction in type 2 diabetes by nurse-led care using an open clinical algorithm. Diabet Med 2006;23:780-7.
Clark CE, Smith LF, Taylor RS, Campbell JL. Nurse led interventions to improve control of blood pressure in people with hypertension: Systematic review and meta-analysis. BMJ 2010;341:c3995.
Al-Mallah MH, Farah I, Al-Madani W, Bdeir B, Al Habib S, Bigelow ML, et al
. The impact of nurse-led clinics on the mortality and morbidity of patients with cardiovascular diseases: A systematic review and meta-analysis. J Cardiovasc Nurs 2016;31:89-95.
Lanuza DM, Davidson PM, Dunbar SB, Hughes S, De Geest S. Preparing nurses for leadership roles in cardiovascular disease prevention. J Cardiovasc Nurs 2011;26:S56-63.
Kavita K, Thakur JS, Vijayvergiya R, Ghai S. Rationale and design of cardiovascular diseases (CVD) risk assessment and communication by nurses for primary and secondary prevention of CVDs in India. Nurs Midwifery Res J 2018;14:62-9.
Terry B, Bisanzo M, McNamara M, Dreifuss B, Chamberlain S, Nelson SW, et al
. Task shifting: Meeting the human resources needs for acute and emergency care in Africa. Afr J Emerg Med 2012;2:182-7. Available from: http://dx.doi.org/10.1016/j.afjem. 2012.06.005.
[Last accessed on 2012 Nov 18].
Nandan D, Nair KS, Datta U. Human resources for public health in India –issues and challenges. Health Popul Perspect Issues 2007;30:230-42.
Feiring E, Lie AE. Factors perceived to influence implementation of task shifting in highly specialised healthcare: A theory-based qualitative approach. BMC Health Serv Res 2018;18:899.
Rao KD, Bhatnagar A, Berman P. India health beat. In: La Forgia J, Rao KD, editors. India's Health Workforce: Size, Composition and Distribution. Vol. 1. New Delhi: World Bank, New Delhi and Public Health Foundation of India; 2009. p. 3.
Colvin CJ, de Heer J, Winterton L, Mellenkamp M, Glenton C, Noyes J, et al
. A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services. Midwifery 2013;29:1211-21.
Davies NE, Homfray M, Venables EC. Nurse and manager perceptions of nurse initiated and managed antiretroviral therapy (NIMART) implementation in South Africa: A qualitative study. BMJ Open 2013;3:e003840.
Iwelunmor J, Gyamfi J, Plange-Rhule J, Blackstone S, Quakyi NK, Ntim M, et al
. Exploring stakeholders' perceptions of a task-shifting strategy for hypertension control in Ghana: A qualitative study. BMC Public Health 2017;17:216.