This study explored the perspectives of stakeholders on the implementation of mental health task-shifting in Indonesia with three key themes emerging: task-shifting feasibility and acceptability, shared task implementation, and nurses’ role enhancement issues.
Theme 1: Task-shifting feasibility and acceptability
It was recognised that a number of aspects should be considered when implementing task-shifting. The first of these is a legal framework. The WHO has emphasised that task-shifting should be supported by appropriate health legislation and administrative regulation that enables checks and balances and ensures the safety of both patients and health workers involved . Otherwise, task-shifting implementation can induce jurisdictional debates on nurses’ scope of practice . In Indonesia, at least two laws have covered task-shifting topics: Health Workers and Nursing Laws. These laws grant permission to nurses and health workers to provide medical services in certain limited contexts in the absence of medical personnel. The implementation should consider the providers’ competence and authorisation from the regional government [29, 30]. Indonesia’s laws have generally regulated the task-shifting standards, including the requirements that must be fulfilled upon implementation. Technical guidelines, however, are still needed to make sure the task-shifting is implemented smoothly and sustainably.
The requirements set by the laws are also in line with the other aspects covered in this theme, namely appropriate contexts in which task-shifting is urgently needed, in-service training to enhance the providers’ competence, and acceptability from stakeholders. These aspects correspond with task-shifting implementation criteria recommended by a systematic review and an international Delphi study involving participants from the United States, South Africa, United Kingdom, Nigeria, India, and Australia, among others, trained health providers, existing health human resources shortage or inaccessibility, important health issues, and socially acceptable interventions [33, 49]. These requirements are needed to maintain quality and ensure effective and efficient implementation.
Regarding acceptability, stakeholders in this study had different attitudes on task-shifting. One stakeholder opposed task-shifting, given that they believed mental health services should be conducted collaboratively in accordance with each profession’s competence. Meanwhile, others supported the implementation citing that task-shifting is needed to make sure no one is left behind. This finding corresponds with some evidence from some countries in Africa and South Asia finding that stakeholders generally have various attitudes on task-shifting, either positive, negative, neutral, or even skeptical [33, 50]. Opposing views can be barriers to task-shifting implementation, particularly if they come from policymakers.
Theme 2: Shared Task Implementation
Despite different views on task-shifting, participants in this study had similar perceptions about the collaborative nature of mental health services. This supports the use of so-called ‘task-sharing’, a term that is closely linked with task-shifting. Although both terms similarly involve redistribution of duties among health workers, task-shifting gives more emphasis on task delegation or transfer, while task-sharing focuses on the involvement of providers with different qualifications to complete the tasks . An Indonesian-based grounded theory coined the term ‘connecting care’ to describe collaborative mental health service models that involve multiple stakeholders . Therefore, we consider that task-sharing is generally more acceptable for most stakeholders in Indonesia compared to task-shifting.
Task-sharing is implemented based on the intertwined and complementary roles of mental health workers through some approaches, e.g., collaborative and coordinated care; staged and referral services; and communication technology utilisation. These approaches are supported by a literature review as evidence-based components that facilitate task-sharing . Usually implemented within a system involving various care components, from specialist services to self-care, these approaches also correspond with the WHO pyramid framework designed to provide optimal mental health services [53, 54]. Furthermore, communication technology, such as phone calls or Whatsapp, plays a pivotal role in mediating collaboration and care delivery. A systematic review identified technology as a strategy to leverage the scope of mental health services . Another study focusing on developing medical devices for task-shifting for health professionals in Ethiopia, Ghana, and Uganda revealed devices should be easy to use, safe, and effective, especially for target users, i.e., less specialised health workers . Technology utilisation can improve agility and responsiveness of mental health services and allows task-shifting to be demanded.
Themes 3: Nurses’ role enhancement issues
Task-shifting (and task-sharing) require nurses’ roles to be enhanced. However, this study found that the enhancement process faced numerous barriers. First, nurses had administrative and other task responsibilities, such as finance, medical record maintenance, nutrition, health promotion, and environmental health. Primary care nurses may not be able to provide optimum services if they are burdened with too many administrative tasks . Second, nurse delegation procedures were unstandardised. Delegations that do not follow any protocol or standard can raise accountability problems and be detrimental to nurses . In Indonesia’s context, nurses carrying out medical actions without written delegation can be considered a criminal case . Therefore, nurses’ role enhancement should be supported by policies to reduce unnecessary burdens and develop standardised delegation protocols.
Third, participants raised serious concerns about nurses’ abilities in undertaking medical tasks and which tasks could be performed independently by nurses. These concerns were associated with the duration of training and scope of practice, particularly on diagnostics and therapeutics, which are considered insufficient to take on medical roles [59, 60]. Fourth, there is potential resistance from the medical profession regarding task-shifting implementation. Doctors were concerned that nurses would take their authority and threaten their jobs . Therefore, doctors preferred nurses to carry out only non-medical tasks .
Fifth, nurses’ role enhancements were found to be hindered by unequal training distribution. In-service training determines task-shifting feasibility [31, 62, 63] and can improve the knowledge, skills, and confidence of non-specialist health workers to deliver mental health interventions . However, training and supervision for mental health task-shifting were generally seen to be lacking in terms of duration and frequency . Policymakers should provide regular training and supervision for nurses to improve their abilities in delivering mental health services.
Sixth, supports from national-level stakeholders was perceived by participants to be lacking. In general, the participation of nurses in the policy-making process is also still very limited . Therefore, nurses need to be encouraged to be more involved in the policy-making process, both at clinical, local, and national levels. Compared to the medical profession, nurses were particularly seen to be lacking representation in policymaking institutions.
Strength and limitations
This is the first qualitative study to explore task-shifting and task-sharing in Indonesia involving stakeholders from national to clinical levels and could be a reference for the development of the emerging approaches in Indonesia and other settings, especially low-and-middle income countries where mental health services are not widely available in primary care.
Besides those strengths, this study has several limitations. Multi-leveled participants involved made it difficult to find commonalities in their answers, especially among national-level participants. This situation was inevitable as these participants had different backgrounds, positions, and organisations with their respective roles and proximity to task-shifting and task-sharing issues. Data from primary care nurses was saturated after the third participant and interviews were stopped at the fifth. For other participants, the investigators did not wait until the data was saturated and stopped data collection after all invitees were interviewed, unless they were unavailable or not responding.
Although some stakeholders have medical backgrounds, official representatives from medical professional organisations could not be recruited in the given research period, particularly from the Indonesian Psychiatric Association, so this study could not capture their opinions. Besides, invitations were addressed to the organisation and position instead of the person. The organisation appointed their representatives, which made the investigators could not control the personal representations such as gender and professional background.
The investigators planned to involve clinicians from some regions to capture different perspectives. However, due to implementation of COVID-19 restrictions, only primary care nurses from Bali Province could be interviewed. Therefore, this study cannot capture clinical situations in broader contexts to enrich the data as mental health services in each region are likely to be different. The findings are limited to the Indonesian context that has specific circumstances regarding the availability of mental health services and the supporting systems. Implementation in other countries requires careful examination.
The three-month gap became an obstacle as it significantly changed the research plan set by the investigators. It also delayed the data collection, analysis and manuscript writing. As the funder had a strict reporting deadline to adhere, the investigators cannot sent the transcript and research findings to all participants to get appropriate member checking.