Aurizki Et Al - 2022

Received: 13 March 2021 Revised: 26 January 2022 Accepted: 20 February 2022
DOI: 10.1111/ijn.13046
REVIEW
Nurse-led task-shifting strategies to substitute for mental

health specialists in primary care: A systematic review
Gading Ekapuja Aurizki RN, MSc, Lecturer, Student1,2 | Ian Wilson RMN, MSc, Lecturer3
1
Faculty of Nursing, Universitas Airlangga,
Surabaya, East Java, Indonesia Abstract
2
Advanced Leadership for Professional Aim: The study aimed to synthesize evidence comparing task-shifting interventions
Practice (Nursing) Programme, The University
led by general practice nurses and mental health specialists in improving mental
of Manchester, Manchester, UK
3
Division of Nursing, Midwifery and Social health outcomes of adults in primary care.
Work, School of Health Sciences, The Design: This study used a systematic review of randomized controlled trials.
University of Manchester, Manchester, UK
Data Sources: Articles from the databases CINAHL, MEDLINE, APA PsycInfo,
Correspondence PubMed, EMBASE, Cochrane EBM Reviews, Web of Science Core Collection, and
Gading Ekapuja Aurizki. Faculty of Nursing,
Universitas Airlangga, Campus C MERR, ProQuest Dissertation and Thesis published between 2000 and 2020 were included.
Surabaya, East Java, 60115, Indonesia. Review Methods: The review was arranged based on the Cochrane Collaboration
Email: [email protected]
guidelines and reported using the Preferred Reporting Items for Systematic Reviews
Funding information and Meta-Analyses (PRISMA).
University of Manchester
Results: Twelve articles met the eligibility criteria. Eight studies revealed that nurse-
led intervention was significantly superior to its comparator. The review identified
three major themes: training and supervision, single and collaborative care and psy-
chosocial treatments.
Conclusion: Nurses could be temporarily employed to provide mental health services
in the absence of mental health specialists as long as appropriate training and super-
vision was provided. This finding should be interpreted with caution due to the high
risk of bias in the studies reviewed and the limited generalisability of their findings.
KEYWORDS
mental health, nurses, primary care, roles, task-sharing, task-shifting
Summary statement
What is already known about this topic?
• The shortage of psychiatrists and other mental health professionals has been caus-
ing treatment gaps in mental health care, not only in developing countries but also
in developed countries.
• Task-shifting or task-sharing is one of the most promising strategies in addressing
the treatment gap, but the involvement of nurses in this strategy is barely studied.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. International Journal of Nursing Practice published by John Wiley & Sons Australia, Ltd.
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2 of 15 AURIZKI AND WILSON
What this paper adds?
• This paper explores the effect of task-shifting and task-sharing interventions led
by general practice nurses for adults with mental disorders in primary care and
found that nurses could deliver psychosocial interventions normally delivered by
mental health specialists with at least the same quality provided they received
proper training and supervision.
• This paper presented a theoretical framework of task-shifting.
The implications of this paper:
• In the absence of mental health services in primary care, general practice nurses
could be temporarily employed to fill the vacancies.
• However, appropriate training and supervision are required before the programme
is started to make sure that the nurses are adequately prepared to undertake the
new roles in practice.
• The implementation of task-shifting and task-sharing requires a well-planned and
gradual implementation strategy to avoid burnout and workplace-related distress
in the target health workers.
1 | I N T RO DU CT I O N interchangeably with task-sharing, but the latter term is implemented

in more collaborative ways (Orkin et al., 2021). Despite the differences,
The shortage of psychiatrists and other mental health professionals the basic idea of both approaches is to utilize the available NSHWs to
has been causing treatment gaps in mental health care, not only in provide mental health-care services in the absence of mental health
developing countries but also developed countries (Bruckner specialists. For convenience purpose, this article uses ‘task-shifting’ to
et al., 2011; Butryn et al., 2017). This problem becomes a global con- refer to both approaches, unless otherwise specified.
cern as mental disorders are among the leading factors for the global Many articles have discussed the task-shifting strategy; mental
burden of disease (Hay et al., 2017). Many people with mental health health is the sixth most discussed cluster in task-shifting research
problems, particularly mood and anxiety disorders, did not get proper (Benton et al., 2020). Between 2013 and 2020, 11 systematic reviews
treatments they need (Thornicroft, 2007). The treatment gap reached discussed the implementation of task-shifting in mental health context
63% in high-income countries and even higher in upper-middle- (Dham et al., 2017; Ekers et al., 2013; Galvin & Byansi, 2020; Halcomb
income (78%) and lower-middle-income countries (86.3%) (Alonso et al., 2018; Ho et al., 2016; Hoeft et al., 2018; Padmanathan & De
et al., 2018; Evans-Lacko et al., 2018). Silva, 2013; Shahmalak et al., 2019; van Ginneken et al., 2013; van
Despite the shortage, the conventional model of mental health- Straten et al., 2015; Verhey et al., 2020). These reviews have various
care deliveries (i.e. one-to-one treatment session, at a health-care concerns in terms of settings, mental disorders, treatment providers
facility and by a highly qualified provider) is still widely implemented involved, methodologies included and interventions provided. How-
(Kazdin, 2017; Patel et al., 2011). This model is insufficient to reach ever, only two systematic reviews focused on nurses as the leading
more people to get treated as most mental health specialists are usu- providers of task-shifting (Ekers et al., 2013; Halcomb et al., 2018).
ally concentrated in urban areas, and many people are unable to go to One review summarized mental health interventions led by general
health-care facilities due to various reasons (Kazdin, 2017). There are practice nurses, hereinafter referred to as the nurses, in primary care
some strategies proposed to address this issue, namely, increasing the without sufficiently exploring the task-shifting outcomes (Halcomb
production of mental health professionals, developing psychosocial et al., 2018). Meanwhile, the other review focused on one aspect of
interventions, utilizing innovative technological platform and involving task-sharing but was not comprehensive enough to cover the task-
nonspecialist health workers (NSHWs) (Kazdin, 2017; Patel shifting counterpart (Ekers et al., 2013).
et al., 2010; Rebello et al., 2014). The involvement of NSHWs in men- The involvement of nurses in task-shifting interventions is argu-
tal health-care delivery, often called as task-shifting or task-sharing, is ably underestimated. Some authors did not recognize their profes-
arguably the most prominent strategy. sional roles and often misleadingly generalized them as community
Task-shifting, by definition, is ‘a process whereby specific tasks are health workers (Afolabi et al., 2019; Gureje et al., 2019; Ola &
moved, where appropriate, to health workers with shorter training and Atilola, 2019). Moreover, some reviews did not distinguish the role of
fewer qualifications’ (p.7) (WHO, 2008). Task-shifting is often used the nurses from doctors and social workers and referred to all of them
AURIZKI AND WILSON 3 of 15
as NSHWs (van Ginneken et al., 2013; Verhey et al., 2020). Accord- collaborative and stepped care, training and supervision, trans-
ingly, a systematic review that focuses on the involvement of nurses diagnostic or staged interventions, and digital innovations (Patel et al.,
in substituting mental health specialists is needed to complete the 2018; Raviola et al., 2019).
body of evidence regarding task-shifting research.
2.3.3 | Comparisons
2 | REVIEW METHODS
This review specified the task-shifting comparison between nurses
2.1 | Aims who have little experience or no formal qualification in mental health
field and mental health specialists (e.g. psychiatrist, psychologist or
This review aimed to synthesize evidence concerning task-shifting mental health/psychiatric nurse) or general practitioners (GPs). The
interventions led by general practice nurses compared with usual or studies must involve at least one intervention arm provided by nurses
specialist care in improving the mental health outcomes of adult and at least one comparison arm provided by mental health specialists
patients in primary care. or GPs.
2.2 | Design 2.3.4 | Outcomes
This study used a systematic review design guided by the Cochrane The included studies should report at least one mental health out-
Handbook guidelines (Higgins et al., 2019) and reported using the Pre- come with a valid instrument. Studies that did not report the mental
ferred Reporting Items for Systematic Reviews and Meta-Analyses health outcome or used unclear instrument were excluded.
(PRISMA) statement (Moher et al., 2009). The first author conducted
the literature search and analysis, while the second author reviewed
the abstracts of the final studies included and did not express any dis- 2.3.5 | Study design
agreement regarding the eligibility criteria.
This review only included studies using a randomized controlled trial
(RCT) design published between 2000 and 2020 with accessible full-
2.3 | Eligibility criteria text in English. Any non-randomized study or publication before 2000
or where the full-text was not available or reported in any language
The eligibility criteria were determined based on the PICOS format, other than English was deemed ineligible.
namely Participants and Places, Intervention, Comparisons, Outcomes
and Study design, as follows:
2.4 | Literature search strategy
2.3.1 | Participants and places The reviewers generated the articles from eight databases between
2 and 3 July 2020, namely, CINAHL, EMBASE, MEDLINE, APA Psy-
This review included studies where the participants were primarily cInfo, Cochrane Database of Systematic Reviews and Web of Science
diagnosed with mental health problems. However, studies focused on Core Collection, as well as Proquest Dissertation and Thesis for grey
alcohol and substance use or neurological disorders were excluded. literature. Additional articles were searched through reference list
The participants must be adults, 18 years old or above. Regarding the tracking. The search terms were determined based on four concepts:
settings, the review included only studies conducted in primary care primary health care, nurse-led task-shifting, mental disorder and RCT.
or community settings and excluded studies conducted in hospitals The Boolean search formulation and detailed search terms of these
and hospital-based outpatient clinics. To avoid distraction from concepts are described in supporting information S1.
physical-based usual care, this review excluded studies which limited
the participants only to those who have physical-related conditions
such as pregnant women, postpartum mothers and patients with 2.5 | Study selection
chronic illnesses or disabilities.
Initial searching obtained 4548 articles. Additional articles were gener-
ated through reference lists searching and grey literature, totalling
2.3.2 | Intervention 88 articles. A total of 1850 articles remained following the removal of
duplicates. The title and abstract screening excluded 1555 and
The studies must involve various task-shifting interventions, among 228 articles, respectively, leaving 67 remaining articles for full-text
others, employing NSHWs in mental health interventions, screening. From these, 12 articles met the eligibility criteria, 55 articles
were excluded because the studies focused on mental health nurse 2.6 | Data extraction and analysis
specialists (n = 29), on participants with chronic or physical com-
orbidities (n = 10), the comparisons were lay health workers or not Data were extracted and inputted to Covidence (https://app.
specified (n = 6), the nurses shared the same role with other health covidence.org/). As the studies included have a high degree of het-
workers (n = 3), the studies focused on the differences between the erogeneity, including various intervention durations and outcome
interventions instead of the providers (n = 3), the settings were in measurements (see Appendix Table A1), statistical synthesis or
hospitals or outpatient clinics (n = 2), the team members were not meta-analysis of data was not appropriate. Therefore, this
specified (n = 1) and no treatment arm was provided by nurses review used thematic analysis to summarize the most important
(n = 1). The PRISMA flow diagram summarizes the study selection issues and themes found in the body of literature (Mays
process (see Figure 1). et al., 2005).
FIGURE 1 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram
2.7 | Quality appraisal 3.2 | Outcomes
This review used the Cochrane tool for assessing the risk of There are three types of outcomes reported in the included studies:
bias (RoB) in randomized trials (Sterne et al., 2019), mental health (n = 12), patient satisfaction (n = 5) and cost-
which consists of five domains: randomization process, effectiveness (n = 1).
deviations from intended interventions, missing outcome data,
measurement of the outcome and the selection of the
reported result. The results of RoB assesments were summarized 3.2.1 | Mental health
in Table 1.
Most studies (n = 8) suggested that nurse-led interventions were sig-
nificantly superior to the comparators in improving the participant
3 | RESULTS mental health outcomes. In Aragonès et al. (2012), the mul-
ticomponent care led by a nurse was significantly more effective than
3.1 | Study characteristics usual care delivered by a GP in improving depression severity at 3 and
6 months (both p = 0.009). The response and remission rates were
The studies included a total of 3755 participants randomized into significantly higher in the nurse-led group at 3-, 6- and 12-month
the treatment groups. Most participants were female (n = 2527; follow-ups (p < 0.05). In Casañas et al. (2012), the remission rates
67.3%). All but one study was conducted in high-income countries were also significantly higher in the nurse-led group at 3 (p = 0.005),
(n = 11; 91.6%). Overall, the studies were carried out in 159 6 and 9 months (both p = 0.014). Ejeby et al. (2014) revealed that
centres, 70 of which were located in urban areas (44.0%). Eleven multimodal interventions delivered by a nurse had a higher mean
studies (91.6%) involved patients with depression, four of which improvement on SF-36 Mental Health than cognitive behaviour ther-
were specified as major or chronic depression. Only one study apy (CBT) delivered by a psychologist (p = 0.02) and usual care by GP
focused on severe mental illness: bipolar or schizophrenia spectrum (p = 0.001) at 2 weeks and 12 months.
disorders. The baseline duration of interventions across the studies Fortney et al.'s (2013) telemedicine group led by a nurse had sig-
spanned from 1 week to 12 months. The characteristics of the nificantly higher mean improvement, response and remission rates of
12 included studies, and the outcome measurements were described Hopkins Symptom Checklist-20 (HSCL-20) than practice-based group
in Table 2. in 6-, 12- and 18-month follow-ups (p < 0.001). In Hunkeler
TABLE 1 The Cochrane risk of bias

Study R D Mi Me S Overall risk of bias
assessment
Aragonès et al. (2012)* + ? ? + + Some concerns
Buszewicz et al. (2016) + ? ? ? + Some concerns
Casañas et al. (2012)* + + + + High
Dobscha et al. (2006) ? ? + + High
Ejeby et al. (2014)* + ? ? + High
Fortney et al. (2013)* ? ? + + High
Hunkeler et al. (2000)* + High
Malakouti et al. (2015)* ? + High
Mynors-Wallis et al. (2000) + + High
Rost et al. (2001)* ? ? + + High
Rost et al. (2002)* ? + + ? + Some concerns
Zimmermann et al. (2016) + + High
Low risk of bias 5 2 4 6 9 0
Some concerns 5 3 6 2 0 3
High risk of bias 2 7 2 4 3 9
Note: R, bias arising from the randomization process; D, bias due to deviations from intended
interventions; Mi, bias due to missing outcome data; Me, bias in measurement of the outcome; S, bias in
selection of the reported result; O, overall risk of bias; +, low risk of bias; ?, some concerns; , high risk
of bias.
*p < 0.05.
TABLE 2 The characteristics of the included studies and risk of bias assessment
6 of 15
Country Risk of
Study (centres) Baseline participants Treatment arms and the providers Main findings bias
Aragonès Spain (20 388 people with depression (79.3% female) 1) Multicomponent programme led by nurse Multicomponent care led by a nurse was more Some
et al. (2012)* centres) case manager, in collaboration with GP and effective than usual care led by a GP in concerns
psychiatrist practices (shared consultation). improving depression severity at 3 and
Duration: 1 week after inclusion then 6 months (both p = 0.009). Besides, the
monthly until remission. response and resmission were significantly
2) Usual care by GP higher in the nurse-led arm.
Buszewicz UK (42 centres) 558 people with chronic depression (74.9% 1) Proactive care led by nurse case manager, The BDI-II outcome of patients in proactive Some
et al. (2016) female) in collaboration with GP (shared care group led by nurse and usual care concerns
consultation). Duration: 10 appointments group led by GP was not statistically
offered after 1 month, 2 months, and every different (p = 0.125).
3 months for 2 years.
2) Usual care by GP
Casañas Spain (12 231 people with Major depression (89.2% 1) Psychoeducational interventions by two Psychoeducational interventions by nurses High
et al. (2012)* centres) female) nurses. Duration: 12 weeks. could produce higher remission rate of BDI
2) Usual care by GP and nurse than the usual care at 3- (p = 0.005), 6- and
9-month (both p = 0.014) follow-ups.
Dobscha USA (5 centres) 375 people with depression (6.9% female) 1) Depression decision support team led by The HSCL-20 score at 12 months was not High
et al. (2006) nurse care manager, in collaboration with a significantly different in depression decision
psychiatrist (shared consultation). Duration: support and usual care groups (p = 0.49),
1–3 weeks. but the nurse-led group had greater
2) Usual care by GP plus nurses and/or satisfaction (p = 0.002), improved care
physician assistant process (p = 0.003) and follow-up action
(p < 0.001).
Ejeby et al. (2014)* Sweden (1 245 people with common mental disorders 1) Multimodal intervention (MMI) by nurse. MMI led by nurses produced a higher mean High
centre) (80.8% female) Duration: 6 weeks. improvement on SF-36 Mental Health than
2) Cognitive behavioural therapy (CBT) by CBT led by psychologist (p = 0.02) and
psychologist. Duration: 12 weeks. usual care led by GP (p = 0.001) at 2-week
2) Usual care by GP and 12-month follow-ups.
Fortney USA (5 centres) 364 people with depression (81.6% female) 1) Collaborative telemedicine team led by The telemedicine group led by a nurse had High
et al. (2013)* nurse care manager, in collaboration to significantly higher mean improvement,
pharmacist, psychologist or psychiatrist response and remission rates of HSCL-20
(stepped care referral). Duration: than practice-based group in 6-, 12- and
12 months. 18-months follow-ups (p < 0.001).
2) Practice-based intervention by nurse or GP.
Duration: 12 months.
Hunkeler USA (2 centres) 302 people with major depressive disorder or 1) Telehealth intervention led by nurse, in The ≥50% improvement of depression was High
et al. (2000)* dysthymia (45.7% female) collaboration with GP (shared consultation) significantly higher in nurse telehealth group
plus peer support. Duration: 4 months. compared with usual care at 6 weeks
2) Usual care by GP (p = 0.01) and 6 months (p = 0.003).
AURIZKI AND WILSON
TABLE 2 (Continued)
Country Risk of
Study (centres) Baseline participants Treatment arms and the providers Main findings bias
AURIZKI AND WILSON
Malakouti Iran (4 centres) 176 people with severe mental illness (36.4% 1) Home visits led by nurse, in collaboration The Young Mania Rating Scale in nurse-led High
et al. (2015)* female) with a psychiatrist (referral and counter- home visits was significantly lower than in
referral). Duration: every 2 weeks in the the GP-led home visits and usual care
first 3 months and then once every month (p = 0.03).
until 12 months.
2) Home visits led by GP. Duration: Every
2 weeks in the first 3 months and then once
every month until 12 months.
2) Usual care by referral to a psychiatrist
Mynors-Wallis UK (24 centres) 151 people with major depression (76.8% 1) Problem-solving therapy led by nurse. Despite the improvements of BDI or HDRS in High
et al. (2000) female) Duration: 12 weeks. all treatment groups, the differences among
2) Problem-solving therapy led by GP. groups were not significant (all p > 0.1).
Duration: 12 weeks.
3) Medication
4) Combination of medication and problem-
solving therapy
Rost et al. (2001)* USA (12 479 people with depression (83.9% female) 1) Collaborative care led by nurse, involving The nurse-led collaborative care significantly High
centres) GP and administrative staff (collaboration improved the mCES-D score compared with
nonhierarchical). Duration: baseline the usual care (p = 0.04).
6 months and continuing intervention from
7 to 24 months.
2) Usual care by GP, plus nurse and
administrative staff
Rost et al. (2002)* USA (12 211 people with depression (83.9% female) 1) Nurse care manager, added to GP practice The nurse-led enhanced care showed Some
centres) (shared consultation), supported by office increased remission (i.e. mCES-D score <16) concerns
staff. Duration: 3 months. compared with usual care across times
2) Usual care by GP (p = 0.02).
Zimmermann Germany (20 325 people with anxiety, depression, somatic 1) Nurse-led self-management therapy, in The self-management therapy led by nurses High
et al. (2016) centres) symptoms (66.8% female) collaboration with GP (shared consultation). significantly improved the patients' self-
Duration: 12 months. efficacy compared with the the control
2) Usual care by GP group (p = 0.004), but the PHQ-D
outcomes were not significantly different
between groups (p > 0.05).
Abbreviations: BDI, Beck Depression Inventory; CBT, cognitive behaviour therapy; GP, general practitioner; HDRS, Hamilton Depression Rating Scale; mCES-D, modified Centre for Epidemiological Studies
Depression; PHQ-D, Patient Health Questionnaire-Depression.
*p < 0.05.
7 of 15
et al. (2000), the response rates were significantly higher in the nurse 3.3 | Thematic findings
telehealth group compared with usual care at 6 weeks (p = 0.01) and
6 months (p = 0.003). However, based on the Beck Depression Inven- This review has synthesized 10 components of task-shifting interven-
tory (BDI), the difference of response rates between the groups was tions and grouped into three major themes: training and supervision,
not significant at 6 weeks (p = 0.28) but was significant at 6 months single and collaborative care and the implementation of psychosocial
(p = 0.05). The Young Mania Rating Scale in Malakouti et al.'s (2015) treatment delivery (Table 3). The theoretical framework of the inter-
nurse-led home visits was significantly lower than in the GP-led home vention components is described in Figure 2. The complex task-
visits and usual care (p = 0.03). In Rost et al. (2001), the improvement shifting intervention includes in-service supports through training and
of modified Centre for Epidemiological Studies Depression (mCES-D) supervision, two types of treatment providers and some kinds of psy-
scores in the nurse-led intervention group was statistically signifi- chosocial treatments, as well as the outcomes of mental health status,
cantly higher than usual care (p = 0.04). Meanwhile, Rost patient satisfaction and cost-effectiveness.
et al.'s (2002) nurse-led enhanced care showed an increased remission
compared with usual care across times (p = 0.02).
In four studies, the nurse-led intervention groups were not sta- 3.3.1 | Training and supervision
tistically significantly different from the comparators. Buszewicz
et al. (2016) revealed that the BDI-II between the treatment groups All studies involved training for the treatment provider in at least one
was not statistically different (p = 0.125). In Dobscha et al. (2006), treatment arm; six studies provided training for all treatment arms.
the HSCL-20 score at 12 months was not significantly different in The training duration varies, from one-point training provided in a
both groups (p = 0.49). Mynors-Wallis et al. (2000) concluded that couple of hours or days less than a week (n = 7) (Aragonès
there were improvements in BDI or Hamilton Depression Rating et al., 2012; Buszewicz et al., 2016; Casañas et al., 2012; Dobscha
Scale (HDRS) scores in all treatment groups, but the differences et al., 2006; Fortney et al., 2013; Hunkeler et al., 2000; Malakouti
among groups were not significant (all p > 0.1). Meanwhile, in et al., 2015) to serial training with additional coordination sessions
Zimmermann et al. (2016), the improvement of self-efficacy in (Rost et al., 2001, 2002). Two studies did not disclose the duration but
nurse-led intervention groups was more significant than the control specified the training names: multimodal intervention (Ejeby
group (p = 0.004), but the Patient Health Questionnaire-Depression et al., 2014) and problem-solving therapy training (Mynors-Wallis
(PHQ-D) outcomes were not significantly different between groups et al., 2000). In one study, the nurses were sent to local primary care
(p > 0.05). centres to directly learn about mental health service (Zimmermann
et al., 2016).
Furthermore, six studies provided regular supervision to the
3.2.2 | Patient satisfaction treating nurses, with two of these studies also providing additional
supervision to the GPs. In Buszewicz et al. (2016), the nurses received
Five studies assessed patient satisfaction. Two studies used validated a quality assurance visit from a Medical Research Council GP and reg-
instruments, that is, the Consumer Assessment of Healthcare Pro- ular telephone contact from a team of two GPs and one psychologist.
viders and Systems (CAHPS) (Fortney et al., 2013) and the eight-item Clinical supervision was also undertaken in Fortney et al. (2013) and
version of Attkisson and Zwick's Client Questionnaire Satisfaction Hunkeler et al. (2000), mostly by telephone; in Malakouti et al. (2015),
(CQS-8) (Malakouti et al., 2015). Three studies asked each participant the supervision was provided by the principal investigator. In two
about their satisfaction with 5-point Likert scale response (Dobscha studies, the supervisors were experts in the respective therapies: the
et al., 2006; Hunkeler et al., 2000; Rost et al., 2001). All studies originator of multimodal intervention (Ejeby et al., 2014) and an expe-
claimed patient satisfaction in the nurse-led group were significantly rienced problem-solving therapist (Mynors-Wallis et al., 2000).
higher than in the comparison group. However, Fortney et al.'s (2013)
satisfaction claim was based on significance at 0.10 level (p = 0.08),
different than the common 0.05 level. 3.3.2 | Single and collaborative care
In three studies, the intervention arm was led by a single-

3.2.3 | Cost-effectiveness unidisciplinary provider, only a nurse. Each patient in two studies
received treatment from one nurse (Ejeby et al., 2014; Mynors-Wallis
Only one study from Iran examined the cost-effectiveness (Malakouti et al., 2000), while in one study, the patient was treated by two
et al., 2015). A cost-utility analysis was used. The study found that the nurses (Casañas et al., 2012). All these studies compared the nurse-
costs per-Quality-Adjusted Life Year (QALY) gained for GP-led and led with the GP-led intervention. In Casañas et al. (2012), the com-
nurse-led groups compared with the control group were 5,740,807 parison arm included a nurse as the GP's companion. Meanwhile,
and 5,048,459 Iranian Rial (IRR), respectively. The nurse-led group's Mynors-Wallis et al. (2000) compared the nurse-led problem-solving
cost was lower by 692,348 IRR (12%), but the significance difference therapy with three comparators: problem-solving therapy by doctors,
between groups was not analysed by the authors. fluvoxamine medication and the combination of both. In nine studies,
TABLE 3 The themes generated from the analysis
Implementation
Themes In-service supports Treatm. provider Psychosocial treatment delivery

Complex Emotional Cognitive and
intervention Collaborative- Single or and social behavioural
AURIZKI AND WILSON
Study components Training Supervision multidisciplinary unidisciplinary Education supports changes

Aragonès et al. (2012)* ● ● ● ●
Buszewicz et al. (2016) ● ● ● ● ●
Casañas et al. (2012)* ● ● ● ● ●
Dobscha et al. (2006) ● ● ●
Ejeby et al. (2014)* ● ● ● ● ● ●
Fortney et al. (2013)* ● ● ● ● ●
Hunkeler et al. (2000)* ● ● ● ●
Malakouti et al. (2015)* ● ● ● ●
Mynors-Wallis et al. (2000) ● ● ● ●
Rost et al. (2001)* ● ● ●
Rost et al. (2002)* ● ●
Zimmermann et al. (2016) ● ● ●
Total 12 6 9 3 7 4 7
*p < 0.05.
TABLE 3 (Continued)
Implementation
Themes Psychosocial treatment delivery Outcomes

Relaxation Treatment Mental health Patient Cost-
Study techniques adherence Monitoring improvement satisfaction effectiveness
Aragonès et al. (2012)* ● ● ●
Buszewicz et al. (2016) ● ● ●
Casañas et al. (2012)* ● ●
Dobscha et al. (2006) ● ● ● ●
Ejeby et al. (2014)* ● ●
Fortney et al. (2013)* ● ● ●
Hunkeler et al. (2000)* ● ● ● ●
Malakouti et al. (2015)* ● ● ● ●
Mynors-Wallis et al. (2000) ● ●
Rost et al. (2001)* ● ●
Rost et al. (2002)* ● ● ●
Zimmermann et al. (2016) ●
Total 2 6 7 12 5 1
9 of 15
*p < 0.05.
FIGURE 2 Mental health task-shifting and task-sharing theoretical framework
the nurse actively collaborated with multidisciplinary providers, et al., 2000); the relaxation techniques were breathing technique
mainly GP and psychiatrist. Of which, two were exclusively between (Casañas et al., 2012) and physical training and yoga (Ejeby
nurse and GP (Buszewicz et al., 2016; Zimmermann et al., 2016). In et al., 2014). Regular monitoring was undertaken in seven studies
five studies, the nurse worked collaboratively with GP and another (Aragonès et al., 2012; Buszewicz et al., 2016; Dobscha et al., 2006;
provider, for example, psychiatrist (Aragonès et al., 2012; Fortney Fortney et al., 2013; Hunkeler et al., 2000; Malakouti et al., 2015;
et al., 2013), psychologist, pharmacist (Fortney et al., 2013), peer sup- Rost et al., 2002), in which the nurses made contact with the
port volunteer (Hunkeler et al., 2000) or health administrator (Rost patients and assessed their conditions, including their symptoms,
et al., 2001, 2002). Two studies showed that the nurse had an exclu- medication, mood and social circumstances.
sive collaboration with a psychiatrist (Dobscha et al., 2006; Malakouti
et al., 2015).
Six studies conducted collaboration through shared consultation, 4 | DI SCU SSION
in which the nurse case/care manager closely worked and consulted
with the other health professionals about the patient's condition 4.1 | Non-inferiority interpretation
(Aragonès et al., 2012; Buszewicz et al., 2016; Dobscha et al., 2006;
Hunkeler et al., 2000; Rost et al., 2002; Zimmermann et al., 2016). The majority of nurse-led task-shifting interventions significantly
Two studies involved referral or counter-referral from the nurses to improved mental health symptoms in adults with mental health prob-
the other providers (Fortney et al., 2013; Malakouti et al., 2015). lems. This result indicates that the nurses can provide mental health
Meanwhile, in one study, the nurse and the other providers (GP and intervention normally delivered by GPs, psychiatrists or psychologists.
administrative staff) worked as a team with distinctive and non- Although few studies indicated that the nurse-led arm was not supe-
hierarchical roles (Rost et al., 2001). rior to the comparator, the outcome demonstrated significant
improvement. These studies suggested that the mental health out-
comes between nurses and other providers, for example, GPs, psychi-
3.3.3 | Psychosocial treatments atrists and psychologists, were not significantly different. This result
means that substituting or redistributing mental health interventions
The studies indicated that nurses had a role as a psychosocial treat- to nurses did not decrease the quality of care. Some systematic
ment provider. The treatments consisted of several components, reviews concerning various health issues indicated that interventions
namely, psychoeducation (n = 7), emotional and social supports shifted to or shared with nurses were comparable with interventions
(n = 4), cognitive and behavioural change supports (n = 7), relaxa- delivered by health providers with higher qualifications. These inter-
tion techniques (n = 2) and treatment adherence supports (n = 6). ventions could reduce the treatment cost and address health-care
Most cognitive and behavioural changes were delivered through workforce shortage without compromising patient health outcomes
self-management therapy (Aragonès et al., 2012; Fortney (Callaghan et al., 2010; Lassi et al., 2013; Martínez-González
et al., 2013; Zimmermann et al., 2016) or problem-solving therapy et al., 2015; Mdege et al., 2013; Ogedegbe et al., 2014; Penazzato
(Buszewicz et al., 2016; Casañas et al., 2012; Mynors-Wallis et al., 2014).
Decreased quality is an expected expense for interventions 4.3 | Review limitations

shifted to or shared with the less qualified providers. Accordingly,
many studies demonstrated what we call ‘noninferiority interpreta- Despite the positive results found in most evidence, the effect esti-
tion’, which means that the ‘target’ provider (i.e. to which the tasks mates of the studies should be interpreted carefully. First, the inter-
are shifted or shared) does not necessarily have to be superior to the nal validity in most studies was ambiguous due to the high RoB. The
‘original’ provider (i.e. from which the tasks originally come) to call an nature of psychosocial interventions means that some biases cannot
intervention successful and worthy of being implemented. Therefore, be avoided. For instance, it is impossible to blind both the partici-
it only requires the target health providers to be at least not worse pants and treatment providers, making them aware of the treatment
than the original as the purpose of task-shifting research corresponds allocation as the interventions were delivered face-to-face. Second,
with the noninferiority trial rationale, that is, to find the ‘good substi- the external validity was limited because almost all studies were
tute’ of medical or health treatment (Mauri & D'Agostino, 2017). conducted in European and North American high-income countries.
This means that Asian, African, Oceanian and South American
regions as well as the low- and middle-income countries were still
4.2 | Complex intervention underrepresented.
Furthermore, this systematic review did not register and pub-
Shifting and sharing mental health-care delivery to the nurses requires lish a prespecified protocol before the review starts due to time
the involvement of several independent and interdependent compo- constraint and limited resources. The review only included
nents; accordingly, this intervention can be considered as a complex studies written in English. There is a possibility that studies written
intervention (Campbell et al., 2000). The review has synthesized in languages other than English may meet the inclusion and
10 components of the complex intervention, which were grouped into exclusion criteria. However, these studies may not be adequately
three major themes: in-service supports, treatment provider and psy- screened due to the reviewer's language barrier. Finally, none of
chosocial treatment delivery. These themes build up the conceptual the studies included were explicitly claimed as task-shifting/sharing
framework of task-shifting complex interventions involving the nurses research. The eligibility criteria were based on health providers
in mental health context (see Figure 2). involvement which may resemble a task-shifting situation. This
The nurse-delivered task-shifting intervention usually started methodological choice potentially undermines the internal validity
with the provision of training and supervision to the nurses to whom of the review.
the tasks are being shifted or shared. These supports are usually pro-
vided preceding the services, though some sessions can be conducted
during the services, particularly the supervisions. These two compo- 5 | CONC LU SIONS
nents are intended to enhance the nurse capabilities in undertaking
some competencies that are beyond their basic qualification. Regard- The practical implication of this study is that the government could
less of the purpose and delivery method, some evidence concerning employ nurses to deliver mental health interventions in the absence
various health issues showed that training and supervision are the of mental health services in primary care due to the shortage of men-
inevitable parts of task-shifting that have many benefits (Federspiel tal health specialists. However, it should be noted that appropriate
et al., 2018; Hoeft et al., 2018; Raviola et al., 2019). Despite the bene- training and supervision are required before the nurses are ready to
fits, most evidence revealed that training and supervision did not undertake the new roles in practice. Expanding the nurses' scope of
directly improve patient clinical outcomes. Both are supporting com- practice may require regulatory changes to ensure that substituting
ponents which improve the providers' capabilities but do not have an mental health interventions to nurses are addressed by the laws
indirect effect on patient outcomes. (Benton et al., 2020). Besides, the task-shifting and task-sharing inter-
As mentioned before, there are differences between task-shifting ventions require a well-planned and gradual implementation strategy;
and task-sharing. The involvement of single-provider or collaboration an outright implementation may instantly overcome the treatment
can distinguish whether an intervention is shifted or shared, respec- gap, but it could induce burnout and workplace-related distress
tively (Orkin et al., 2021). In this review, collaborative care studies (Padmanathan & De Silva, 2013).
outnumbered single-provider care studies, nine compared with three There is an agenda that can be developed in further studies: first,
studies, respectively. Task-sharing intervention was more frequently to compare the effect of task-shifting and task-sharing interventions,
studied than task-shifting. However, this review was unable to deter- as well as to identify which approach is more recommended in a par-
mine which approach producing better results as the percentage of ticular context; second, to calculate the cost-effectiveness of the
studies with significant results is the same (66.7%). Moreover, the nurse-led task-shifting interventions; and third, to identify the impact
evidence that directly compares task-shifting and task-sharing are still of technology on task-shifting implementation.
limited. When discussed separately, both task-shifting and
task-sharing have considerable benefits. However, evidence-based AC KNOW LEDG EME NT S
collaborative care for depression and anxiety was not widely studied; We thank Dr. Tim Bradshaw for the guidance and feedbacks during
therefore, its broader applicability requires further scrutiny. the manuscript writing. GEA postgraduate study at The University of
Manchester was fully funded by the Indonesia Endowment Fund for evaluation of complex interventions to improve health. British Medical
Education—Lembaga Pengelola Dana Pendidikan (LPDP), from the Journal, 321(7262), 694–696. https://doi.org/10.1136/bmj.321.
7262.694
Government of Indonesia. The funder had no role in the study design,
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APPENDIX A
TABLE A1 Various mental health outcomes measurements
Study PHQ-9 SF-12 SF-36 BDI (II) WSAS EQ-5D EQ-VAS CIDI HSCL-20
Aragonès et al. (2012) ● ●
Buszewicz et al. (2016) ● ● ● ●
Casañas et al. (2012) ●a ●
Dobscha et al. (2006) ● ● ●
Ejeby et al. (2014) ●
Fortney et al. (2013) ● ●b
Hunkeler et al. (2000) ● ●b
Malakouti et al. (2015)
Mynors-Wallis et al. (2000) ●
Rost et al. (2001)
Rost et al. (2002) ●
Zimmermann et al. (2016) ● ●
Total 3x 3x 3x 4x 1x 2x 1x 1x 2x
Abbreviations: BDI (II), Beck Depression Inventory (Version II); CIDI, WHO Composite International Diagnostic Interview; CPRS, Comprehensive
Psychopathological EQ-5D, 5-item EuroQOL Depression; Rating Scale; EQ-VAS, EuroQOL Visual Analogue Scale; GHQ-28, 28-item General Health
Questionnaire (GHQ-28); GSES, General Self-Efficacy Scale; HDRS, Hamilton Depression Rating Scale; HSCL-20, 20-item Hopkins Symptom Checklist;
mCES-D, modified version of Centre for Epidemiologic Studies—Depression Scale; PHQ-9, 9-item Patient Health Questionnaire; QALYs, Quality-Adjusted
Life Years; SF-12, 12-item Short Form Survey; SF-36, 36-item Short Form Survey; WSAS, Work and Social Activity Scale.
a
Remission.
b
Response.
TABLE A1 (Continued)
Study CPRS mCES-D GSES GHQ-28 HDRS Antidepressant use QALYs Satisfaction Others
Aragonès et al. (2012)
Buszewicz et al. (2016) ●
Casañas et al. (2012)
Dobscha et al. (2006) ● ●
Ejeby et al. (2014) ● ●
Fortney et al. (2013) ● ●
Hunkeler et al. (2000) ●b ●
Malakouti et al. (2015) ● ● ● ●
Mynors-Wallis et al. (2000) ● ●
Rost et al. (2001) ●b ●
Rost et al. (2002) ●a
Zimmermann et al. (2016) ●
Total 1x 2x 1x 1x 2x 2x 1x 5x NA
Abbreviations: BDI (II), Beck Depression Inventory (Version II); CIDI, WHO Composite International Diagnostic Interview; CPRS, Comprehensive
Psychopathological EQ-5D, 5-item EuroQOL Depression; Rating Scale; EQ-VAS, EuroQOL Visual Analogue Scale; GHQ-28, 28-item General Health
Questionnaire (GHQ-28); GSES, General Self-Efficacy Scale; HDRS, Hamilton Depression Rating Scale; HSCL-20, 20-item Hopkins Symptom Checklist;
mCES-D, modified version of Centre for Epidemiologic Studies—Depression Scale; PHQ-9, 9-item Patient Health Questionnaire; QALYs, Quality-Adjusted
Life Years; SF-12, 12-item Short Form Survey; SF-36, 36-item Short Form Survey; WSAS, Work and Social Activity Scale.
a
Remission.
b
Response.

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Received: 13 March 2021 Revised: 26 January 2022 Accepted: 20 February 2022

Nurse-led task-shifting strategies to substitute for mental

Int J Nurs Pract. 2022;28:e13046. wileyonlinelibrary.com/journal/ijn 1 of 15

What this paper adds?

1 | I N T RO DU CT I O N interchangeably with task-sharing, but the latter term is implemented

2.2 | Design 2.3.4 | Outcomes

2.7 | Quality appraisal 3.2 | Outcomes

TABLE 1 The Cochrane risk of bias

In three studies, the intervention arm was led by a single-

Themes In-service supports Treatm. provider Psychosocial treatment delivery

Study components Training Supervision multidisciplinary unidisciplinary Education supports changes

Themes Psychosocial treatment delivery Outcomes

FIGURE 2 Mental health task-shifting and task-sharing theoretical framework

Decreased quality is an expected expense for interventions 4.3 | Review limitations

TABLE A1 Various mental health outcomes measurements

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