Mário Amorim Lopes

Abstract
Aims: The aims of this paper are to explore the role of cross-disciplinary knowledge exchange and integration in advancing the science of unfinished nursing care and to offer preliminary guidance for theory development activities for this growing international community of scholars. Background: Unfinished nursing care, also known as missed care or rationed care is a highly prevalent problem with negative consequences for patients, nurses and healthcare organizations around the world. It presents as a ‘wicked’ sustainability problem resulting from structural obstacles to effective resource allocation that have been resistant to conventional solutions. Research activity related to this problem is on the rise internationally but is hindered by inconsistencies in conceptualizations of the problem and lack of robust theory development around the phenomenon. A unified conceptual framework is needed to focus scholarly activities and facilitate advancement of a robust science of unfinished nursing care. Design: Discussion paper. Data Sources: This discussion paper is based on our own experiences in international and interdisciplinary research partnerships related to unfinished nursing care. These experiences are placed in the context of both classic and current literature related to the evolution of scientific knowledge. Implications for Nursing: The problem of unfinished nursing care crosses multiple scientific disciplines. It is imperative that the community of scholars interested in solving this wicked problem engage in meaningful cross-disciplinary knowledge integration and move towards transdisciplinarity. Conclusion: Metatheorizing guided by structuration theory should be considered as a strategy to promote transdiciplinarity around the problem of unfinished nursing care. © 2019 John Wiley & Sons Ltd

Abstract
Medical training is an intricate and long process, which is compulsory to medical practice and often lasts up to twelve years for some specialties. Health stakeholders recognise that an adequate planning is crucial for health systems to deliver necessary care services. However, proper planning needs to account for complexity related with the setting of medical school vacancies and of residency programs, which are highly influenced by multiple stakeholders with diverse perspectives and views, as well as by the specificities of medical training. Aiming at building comprehensive models with a potential to assist health decision-makers, this article develops a multi-methodological framework to assist the planning of medical training under such a complex environment. It combines the structuring of the objectives and specificities of the medical training problem with a Soft Systems Methodology through the CATWOE (Customer, Actor, Transformation, Weltanschauung, Owner, Environment) approach, and the formulation of a Mixed Integer Linear Programming model that considers all relevant aspects. Considering the specificities of countries based on a National Health Service structure, a multi-objective planning model emerges, informing on how many vacancies should be opened/closed per year in medical schools and in each specialty. This model aims at (i) minimizing imbalances between medical demand and supply; (ii) minimizing costs; and (iii) maximizing equity across medical specialties. A case study in Portugal is explored so as to illustrate the applicability of the proposed multi-methodology, showing the relevance of proper structuring for planning models having the potential to inform health decision-makers and planners in practice. © 2018 Elsevier B.V.

Abstract
Physician emigration can either function as an escape valve to help the health labour market clear from a supply surplus, or aggravate the problem further in case of a shortage. Either way, policy-makers should be particularly aware and devise policies to minimize the occurrence of an imbalance in the physician workforce, which may require physician retention policies if barriers to entry and other market rigidities can not be removed. To this purpose we have developed an agent-based computational economics model to analyse physician emigration, and have used it to study the impact of potential short- and long-term retention policies. As a real case study we have calibrated it with data from Portugal, which features a very particular health system with many rigidities. Results show that all policies are capable of increasing the workforce size, but not all reduce emigration. Also, the effect of return migration is non-negligible, and may substantially offset the impact on the workforce size. Furthermore, the welfare impact of the policies varies considerably. Whether policies to retain physicians should be enacted or whether policy makers should let physicians go will depend on the type of imbalance present in the health system. © 2018, Springer Science+Business Media, LLC, part of Springer Nature.

Abstract

Abstract
Starting in the 50s, healthcare workforce planning became a major concern for researchers and policy makers, since an imbalance of health professionals may create a serious insufficiency in the health system, and eventually lead to avoidable patient deaths. As such, methodologies and techniques have evolved significantly throughout the years, and simulation, in particular system dynamics, has been used broadly. However, tools such as stochastic agent-based simulation offer additional advantages for conducting forecasts, making it straightforward to incorporate microeconomic foundations and behavior rules into the agents. Surprisingly, we found no application of agent-based simulation to healthcare workforce planning above the hospital level. In this paper we develop a stochastic agent-based simulation model to forecast the supply of physicians and apply it to the Portuguese physician workforce. Moreover, we study the effect of variability in key input parameters using Monte Carlo simulation, concluding that small deviations in emigration or dropout rates may originate disparate forecasts. We also present different scenarios reflecting opposing policy directions and quantify their effect using the model. Finally, we perform an analysis of the impact of existing demographic projections on the demand for healthcare services. Results suggest that despite a declining population there may not be enough physicians to deliver all the care an ageing population may require. Such conclusion challenges anecdotal evidence of a surplus of physicians, supported mainly by the observation that Portugal has more physicians than the EU average. © 2016 Springer Science+Business Media New York