Task shifting [Neurosurgery Wiki]

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====== Task shifting ======

Task Shifting in Neurosurgery is a timely and insightful resource with practical examples and global relevance. However, its scientific [[rigor]] is uneven, and its findings should be interpreted cautiously. The document is best viewed as a foundational guide for policy discussions and future research, rather than a source of definitive clinical evidence.

===== Task Shifting vs. Task Sharing =====

These two concepts are often used in global health and surgical workforce planning, but they have distinct meanings, especially in neurosurgery.

^ Concept        ^ **Task Shifting**                                                                                     ^ **Task Sharing**                                                                                         ^
| **Definition** | Delegating tasks **from highly specialized providers** to **less-specialized health workers**         | Distributing tasks **among health workers** to **collaborate and jointly manage care**                   |
| **Ownership**  | Tasks are **transferred** entirely to another provider                                                | Tasks are **shared** among team members, often with **ongoing oversight and collaboration**              |
| **Typical Use**| When specialists are **not available**, especially in **low-resource settings**                       | To **enhance teamwork and efficiency**, even in well-staffed systems                                     |
| **Training**   | Requires **upskilling** less-specialized workers to take over responsibilities                        | Requires **collaborative training** and defined protocols                                                |
| **Supervision**| Often limited or indirect supervision                                                                 | Involves **active supervision, feedback, and communication**                                             |
| **Goal**       | Expand **access** to services in areas with workforce shortages                                       | Improve **quality, safety, and continuity** of care through teamwork                                     |
| **Risk**       | Potential for **de-skilling** if not properly managed                                                 | Promotes **capacity building** and role optimization                                                     |

==== Neurosurgical Example ====
  * **Task Shifting** → A general surgeon performs emergency burr holes in a rural hospital without a neurosurgeon.
  * **Task Sharing** → A neurosurgeon, anesthetist, and ICU nurse jointly manage perioperative care in a trauma center, with shared responsibilities and active communication.

==== Summary ====
> *Task shifting* focuses on **delegation to bridge gaps**, often due to workforce shortages.  
> *Task sharing* emphasizes **collaborative care**, enhancing quality through team-based practice.


===== Task Shifting in Neurosurgery =====

**Definition**:  
[[Task]] shifting in neurosurgery refers to the **intentional delegation of specific neurosurgical or perioperative tasks** from board-certified neurosurgeons to other trained health professionals, such as general surgeons, medical officers, or physician assistants—to **expand access to neurosurgical care**, especially in resource-limited settings.

==== Context and Applications ====
Task shifting is particularly relevant in **low- and middle-income countries (LMICs)** or rural areas where neurosurgeons are scarce.

^ Task                       ^ Shifted to                  ^ Example Use Case                                ^
| Emergency burr holes       | General surgeons             | Remote hospital without neurosurgical service   |
| Postoperative monitoring   | ICU nurses, residents        | ICP control, wound care                        |
| Spine trauma stabilization | Orthopedic surgeons          | Initial stabilization in trauma units          |
| Image-based triage         | Medical officers             | Using telemedicine or decision algorithms      |
| First surgical assistance  | Surgical techs, trainees     | Under neurosurgeon supervision                 |

==== Benefits ====
  * Increased access to emergency and essential neurosurgical care.
  * Reduced treatment delays in underserved regions.
  * Optimization of limited specialist workforce.

==== Challenges ====
  * Requires strict **protocols**, **training**, and **supervision**.
  * **Patient safety** and quality control must be prioritized.
  * Risk of **de-professionalization** if applied without safeguards.

==== Global Perspective ====
The **World Federation of Neurosurgical Societies (WFNS)** and global health entities support task shifting as a **temporary strategy** to address workforce shortages, provided that it is part of a **long-term capacity-building plan**.

===== Descriptive Case Study / Narrative Program Reports =====

Task shifting (training nonphysician surgical providers) and 2-tiered systems (fast-track certification of general surgeons to perform basic neurosurgical procedures) may serve some of the immediate need, but these options will not sustain the development of a comprehensive neurosurgical footprint. Ultimately, long-term solutions to the need for neurosurgical care in Tanzania can only be fulfilled by local government investment in capacity building (infrastructure and neurosurgical training), and the commitment of Tanzanians trained in neurosurgery. With this task in mind, Tanzania developed an independent neurosurgery training program in Dar es Salaam. While significant progress has been made, several training deficiencies remain. To address these deficiencies, the Muhimbili Orthopedic Institute (MOI) Division of Neurosurgery and the University of Colorado School of Medicine Department of Neurosurgery set up a Memorandum of Understanding in 2016. This relationship was developed with the perspective of a "collaboration of equals." Through this collaboration, faculty members and trainees from both institutions have the opportunity to participate in international exchange, join in collaborative research, experience the culture and friendship of a new country, and share scholarship through presentations and teaching. Ultimately, through this international partnership, mutual improvement in the care of the neurosurgical patient will develop, bringing programs like MOI out of isolation and obscurity. From Dar es Salaam, a center of excellence is developing to train neurosurgeons who can go well equipped throughout Tanzania to improve the care of the neurosurgical patient everywhere. The authors encourage further such exchanges to be developed between partnership training programs throughout the world, improving the scholarship, subspecialization, and teaching expertise of partner programs throughout the world
((Ormond DR, Kahamba J, Lillehei KO, Rutabasibwa N. Overcoming barriers to neurosurgical training in Tanzania: international exchange, curriculum development, and novel methods of resource utilization and subspecialty development. Neurosurg Focus. 2018 Oct;45(4):E6. doi: 10.3171/2018.7.FOCUS18239. PMID: 30269594.))


===== Retrospective Observational Comparative Studies =====

A Retrospective Observational Comparative Study aimed to investigate the role of nurse practitioners (NPs) in neurovascular interventions and evaluate the validity of task shifting in our institute.

Methods: Medical records from 684 neurovascular intervention cases from 2020 to 2023 were retrospectively reviewed, and the tasks performed by NPs were investigated. Additionally, the procedure times between cases in which NPs acted as the first assistant alongside a physician (NP + physician group) and those in which 2 physicians performed the procedure (physician + physician group) were compared.

Results: The main tasks performed by NPs included preoperative checks, assistance during the procedure, postoperative care, the initial handling of complications, and inputting orders. No significant differences in procedure times were found between the NP + physician and physician + physician groups.

Conclusion: NPs showed potential for task shifting in perioperative neurovascular interventions, particularly in assisting, providing care, inputting orders, and initially handling complications. However, further discussions and improvements are needed regarding task shifting in emergency cases and work arrangements for NPs
((Katayama T, Komatsu F, Okubo M, Kihara K, Sasaki K, Tanaka R, Hasebe A, Tanabe J, Haraguchi K, Yamada Y, Nakahara I, Kato Y. Task Shifting by Nurse Practitioner in Neuroendovascular Therapy. J Neuroendovasc Ther. 2025;19(1):2024-0082. doi: 10.5797/jnet.oa.2024-0082. Epub 2025 Apr 25. PMID: 40309717; PMCID: PMC12040601))



This study is a useful preliminary step in evaluating task shifting in neurovascular interventions, demonstrating workflow efficiency with NP involvement. However, its retrospective design, limited outcome metrics, and lack of safety data prevent it from being definitive. Future research should include multicenter, prospective trials that assess clinical outcomes, safety profiles, and patient perspectives.
===== Descriptive Observational Studies =====
The National Hospital Organization Nagasaki Medical Center serves as the main hub for eight remote island hospitals(RIHs)in Nagasaki Prefecture, Japan. The shortage of stroke physicians, which has led to overwork, is a major concern. Several "task-shifting" systems were adopted to avoid physician burnout. First, the emergency department established a hotline system for receiving emergency calls regarding a stroke, and which managed initial care until the stroke physicians arrived(called the Nagasaki Medical Center stroke hotline system: N-SHOT)in 2014. The rt-PA administration rate increased from 3.3% in the Pre-N-SHOT group to 6.7% in the N-SHOT group. Second, the 'isolated islands stroke hotline system(I-SHOT)', with which physicians in RIHs participate in cooperation with N-SHOT, was started in 2017. After I-SHOT was introduced, the number of patients treated with the drip and ship method using teleradiology and 24-h helicopter transportation increased from 20(2010-2016)to 29 cases in 2017-2018. Additionally, new information and communication technology(ICT)using smart devices was introduced into the teleradiology system for task support. Third, on behalf of stroke physicians, nurse practitioners(NP)helped bedridden patients who had been delivered from RIHs and who had received acute treatment, and returned to their islands by helicopter or airplane as transitions of care. N-SHOT is smoothly operated by each hospital department without reducing the quality of the stroke hotline. It has contributed to an increase in rt-PA and mechanical thrombectomy cases; I-SHOT has had the same effect. Task-shifting and task support with N- & I-SHOT, the smooth transfer system by NP, and the new ICT are considered to be useful for reducing the overall burden of stroke physicians
((Hiu T, Otsuka H, Nakamichi C, Honda K, Gon C, Yamasaki K, Matsuo A, Kawahara I, Iwanaga H, Tokuda M, Itoh T, Moritsuka T, Kutsuna F, Ueno M, Ono T, Haraguchi W, Ushijima R, Tsutsumi K. [Task-shifting Carried out by an Emergency Department's Stroke Hotline and Medical Care Support Conducted by Nurse Practitioners]. No Shinkei Geka. 2020 Sep;48(9):781-792. Japanese. doi: 10.11477/mf.1436204274. PMID: 32938806.))
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This is a valuable, real-world demonstration of how integrated task-shifting and task-sharing interventions can improve access and alleviate workforce pressure in acute stroke care. While the reported benefits are compelling, the lack of rigorous statistical analysis, safety data, and clinical outcome measures limits the evidence level. Nonetheless, this case study offers a scalable and transferable model for other regions facing similar healthcare delivery challenges.

===== Surveys =====

A survey investigated perceptions of neurosurgical TS/S to elucidate whether it is a permissible temporary solution to the global workforce deficit.

Methods: The survey was distributed to a convenience sample of individuals providing neurosurgical care. A digital survey link was distributed through electronic mailing lists of continental neurosurgical societies and various collectives, conference announcements, and social media platforms (July 2018-January 2019). Data were analyzed by descriptive statistics and univariate regression of Likert Scale scores.

Results: Survey respondents represented 105 of 194 World Health Organization member countries (54.1%; 391 respondents, 162 from high-income countries and 229 from low- and middle-income countries [LMICs]). The most agreed-upon statement was that task sharing is preferred to task shifting. There was broad consensus that both task shifting and task sharing should require competency-based evaluation, standardized training endorsed by governing organizations, and maintenance of certification. When perspectives were stratified by income class, LMICs were significantly more likely to agree that task shifting is professionally disruptive to traditional training, task sharing should be a priority where human resources are scarce, and to call for additional TS/S regulation, such as certification and formal consultation with a neurosurgeon (in person or electronic/telemedicine).

 Both LMIC and high-income countries agreed that task sharing should be prioritized over task shifting and that additional recommendations and regulations could enhance care. These data invite future discussions on policy and training programs
((Robertson FC, Esene IN, Kolias AG, Khan T, Rosseau G, Gormley WB, Park KB, Broekman MLD; Global Neurosurgery Survey Collaborators. Global Perspectives on Task Shifting and Task Sharing in Neurosurgery. World Neurosurg X. 2019 Sep 9;6:100060. doi: 10.1016/j.wnsx.2019.100060. PMID: 32309801; PMCID: PMC7154229.)).
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This study effectively maps the global sentiment toward task shifting and task sharing in neurosurgery. While limited by sampling and lack of qualitative depth, it provides a solid foundation for policy advocacy and future research.

Recommendation: Future studies should incorporate mixed methods (qualitative + quantitative) and involve a broader spectrum of healthcare providers. Policymakers and neurosurgical societies should use this data to develop structured, supervised TS/S pathways rather than allow informal task migration by necessity.

===== References =====