The knowledge synthesis method used for this study was scoping review and it was based on the framework outlined by Arksey and O’Malley[14, 15] including recommendations made by Levac et al. (2010) with additional recommendations outlined by Joanna Briggs Institute (JBI) manual for evidence synthesis [16–18]. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was used[19]. The review included the following six key phases: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) Analysis of the evidence and Presentation of the results and (6) Summarizing the evidence in relation to the purpose of the review, making conclusions and noting any implications of the finding.
A detailed priori review protocol was developed before undertaking the scoping review to pre-define the objectives, methods and reporting of the review that showed transparency of the process. This protocol has been registered at Open Science Framework ( https://osf.io/kybsc/). The protocol had detail criteria that the reviewers used to include and exclude sources of evidence, to identify what data were relevant, and how the data were extracted and presented. The protocol provided plan for the scoping review and was important in limiting the occurrence of reporting bias.
Research question
This review was guided by the research question, what are the limitations, challenges and advantages of implementing WISN method of health workforce planning at health facility?
Identifying relevant studies or search strategy
A Comprehensive three stage search strategy was conducted in order to identify both published and unpublished (gray or difficult to locate literature) primary sources of evidence, as well as reviews. The first step was an initial limited search of PubMed and Google Scholar databases relevant to WISN method of health work force planning. This initial search was then followed by analysis of the text words contained in the title and abstract of retrieved papers, and index terms used to describe the articles. A second search was undertaken using all identified keywords and the index terms across all included databases. Thirdly, the reference list of identified reports and articles were searched for additional sources.
The databases searched were PubMed, Scopus, Web of Science, EBSCOHost, CINHAL, Global index medicus and Google scholar. A sample of the search strategy used for PubMed database was shown (see Additional file 1), which was then modified as appropriate for the other databases. To ensure that relevant papers were not unduly excluded or missed, there was no restriction on country of origin but year of publication was starting on 1998, and there was a restriction to papers published in only the English language. Also, forward, and backward citation search of highly cited papers were manually conducted. An evidence-based guideline for Peer review of Electronic Search Strategies (PRESS) was used [20], the search strategy was developed for each database and followed by both reviewers. The search was last updated on 3 May 2022.
Inclusion and exclusion criteria
An Inclusion and exclusion criteria was clearly stated based on the title, research question, Population, Concept and Context (PCC) frame work of the scoping review (Table 1).
Table 1
Inclusion and exclusion criteria
Inclusion criteria | Exclusion criteria |
1. Participants were health care workers who were serving at health care settings. 2. Papers were included if they reported the use of Workload indicators of staffing need (WISN) method for health worker planning. 3. Papers were included if they reported in English language. 4. Papers were included if the full text article were freely accessible. 5. A health care setting for this study includes; hospitals, health centers, clinics and other related governmental health care settings. 6. Studies conducted in any country. 7. All types of literature including preprints and case studies that employ all types of methodologies, such as qualitative, quantitative, mixed methods. | 1. Health care workers who were not serving at health care settings were excluded 2. Papers reported with WISN method use other than health care settings were excluded. 3. Papers reported the use of WISN method at health care settings owned by privates |
Study selection
After discarding duplicate items, the process of screening was conducted in two levels. Level one was based on titles and abstracts of the paper. Papers with titles and abstracts that provided insufficient information to decide at this stage were passed to the next stage. In the second level, papers that have passed from the screening level were downloaded and evaluated against the inclusion criteria. All selected articles from this stage were saved in a separate folder for further assessment and synthesis. Papers that were excluded based on the full-text assessment against the inclusion and exclusion criteria were justified with the reasons. The entire screening and selection process was undertaken independently by two authors. The authors finally compared their results. There were no major discrepancies, minor discrepancies resolved based on consensus of the two authors.
Charting the Data
The extraction of data for a scoping review is referred to as ‘charting the results’. Available evidences were logically and descriptively summarized in line with the objectives of the review. A charting table was developed to record characteristics of the included studies and the key information relevant to the review question. Articles that met the inclusion criteria were critically reviewed using a data extraction matrix adapted from the CHARMS checklist[21] and the Joana Briggs Institute Reviewer’s Manual for Scoping Reviews[18]. The following items from each eligible article were extracted and charted: First Author/year, country of study done, participants, context, study methods, key findings and conclusion. Data extraction was conducted initially independently and finally together by GDA and YKG using the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI)[22]. The results of the search and the study inclusion process were reported and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)[19, 23].
Analysis and Presentation of the Evidence
Based on Centre for Reviews and Dissemination (CRD’s) guidance on systematic reviews[24], descriptive analysis and narrative synthesis of the findings were conducted and presented, taking into account the volume and quality of studies as well as the critical modeling considerations made in the application of WISN to health workforce planning. The evidence presented was congruence with the review objectives. The data was presented graphically, diagrammatically and in chart or tabular form as it was found appropriate.
Findings from the literature review on workload indicators of staffing need (WISN) method for health workforce planning at health facility
Electronic database searches generated 239,804 results. Of which 239,244 were removed as duplicates. Of the remaining items, 176 were excluded based on title/abstract screening, leaving 80 full-text articles to be further reviewed. Of these, 53 articles were deemed ineligible because they did not evaluate WISN implementation (n = 40), were irretrievable (n = 12), was not in English (n = 1), resulting in a total of 27 eligible articles that were included in this scoping review. A PRISMA diagram showed the details in Fig. 1.
Characteristics of Included Articles
The study settings range from clinics to referral hospitals and the participants were mainly health professionals working at health facilities (see Additional file 2).
More than 83% of the included articles were published in the year between 2019 and 2022 (Fig. 2).
Countries with more than one article were Brazil and India. All studies used cross sectional study with quantitative retrospective data of the previous year but four studies incorporate qualitative parts (observational data, focus group discussion and Delphi method) (see Additional file 3).
The workload pressure ranges from high to none. Health worker categories with high workload pressure were physicians, midwives and consultation clinicians, and categories with low workload pressure were radiology installation staffs. The countries with significant workforce shortage based on included studies were; Iraq, India and Kenya while Indonesia had surplus of health workforce. Countries with distribution and task shifting problems were Philippines, Brazil, and Papua New Guinea (see Additional file 4).
Implications, Challenges And Limitations Of Using Wisn Method During Workforce Planning
Implications of WISN method during workforce planning
A workload indicator of staffing need (WISN) is a human resource management tool that has significance advantage to different stakeholders over the previous planning modalities. Human resource planners use WISN for evidence based estimation of health work force[27]. Health authorities can use WISN model to adjust or develop new staffing norms and objectively inform their demand to academic institutions. Academic institutions restructure their plan to adjust the supply based on health authorities WISN result [25]. Civil society organizations can use WISN to advocate and hold the government accountable for health service quality and guarantee [26]. Researchers and policy makers consider recommendation to policy change based on WISN result of health facilities. WISN strengthens primary health care team by clearly assigning job description for each cadre of the health facility [29]. The health facilities use WISN to assess the surge capacity and resulting disaster preparedness [35]; to understand the level of workload pressure, the cause of shortage or surplus and reassign staff or change facility status[31, 33].
Monitoring and evaluating bodies can use WISN to reveal time spent by health professionals on health service activities, additional activities and support activates [36]. WISN is an important complement to enhance national health work force account (NHWA) data quality [37], and ensure equity in distribution of cadres among health facilities [41]. During monitoring and evaluation of health system, WISN can be used to enhance human resources for health investment[44]; to update current sanctioning norms [42]; to decide what activities and tasks of a cadre should shift to other cadre [41]; to effectively and efficiently manage health workforce[46]; to observe details in the work process that were not perceived as a source of work overload [48].
More importantly, WISN is used to improve the health sector headaches that are data quality improvement, health service quality improvement, staff satisfaction and patient satisfaction by ensuring scope of practice matches with the training received by specific cadres, and assuring that those skills are being used at recommended workload to deliver quality health service[47].
Challenges of using WISN method of health workforce planning
Health workforce planning using WISN method has challenges too. Main challenges identified with this scoping review were grouped as data availability and quality issues[27, 28, 40, 43] (lack of properly documented health service performance data, poor quality health service activity data and several data sources for single information), activity standard issues[33, 38, 43] (multi-tasking nature of non-clinical staff which has detrimental effect on task performance, activity standards cannot be adopted or adapted from one country to another as the context varies from one country to another country, wide spread task shifting and unavailability of standard workload for some health worker categories ) and technical issues [40, 43](The technical task forces need training in each step of the WISN method, WISN method needs laborious data entry and setting activity standards need detail activity).
Limitations of WISN method during health workforce planning
WISN method of health workforce planning has some limitations according to the reviewed articles. The limitations include use of last year health service performance data to forecast this year staffing requirement, no clear consideration of frequent service interruption during workload analysis, differences in the severity of illness for which patients sought consultation time was not considered, activity standards did not consider individual professional variations in performing an activity, sudden surge of patients was not assumed, lack of standards for certain activities, on-call time workers were not considered and weekend and holiday workers were not considered during workload calculation [25, 26, 30, 34, 35, 38, 42, 50].