Health care staff responses to disinvestment-A systematic search and qualitative thematic synthesis

BACKGROUND: Health care services must deliver high-quality, evidence-based care that represents sound value. Disinvestment is the process of withdrawing resources from any existing health care practices that deliver low gain for their cost and reallocating these toward practices that are more effective, efficient, and cost-effective, thus benefiting patients and the community. PURPOSE: This is the first review to examine the responses of health care staff to disinvestment and investigate the factors that increase the likelihood of these staff accepting disinvestment or reallocation of resources from the health services they provide. METHODS: We conducted a systematic search of five electronic databases using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) framework. A critical appraisal process of the quality of the included studies was performed by two authors. We undertook a thematic synthesis of the qualitative data to develop an overarching narrative. RESULTS: Twelve studies were identified for synthesis and all found that the disinvestment process was challenging and controversial for those health care staff involved. Negative staff reactions to disinvestment identified were anxiety, disempowerment, distrust, and feelings of being dismissed and disrespected. Engagement with disinvestment was observed when staff were invited to participate in a process they considered transparent and in the best interests of the community. PRACTICE RECOMMENDATIONS: Health care staff have a strong professional identity associated with autonomy in their decision making in the provision of health care services. Disinvestment from a service that health care staff can usually choose to provide threatens this identity. Engaging clinical champions to lead change, using rigorous patient outcome data, and transparent decision-making processes may assist health care staff to embrace a new identity as innovators and accept disinvestment in low-value health care.