It’s not the task, it’s the shifting: Exploring physicians’ and leaders’ perspectives on task shifting in emergency departments in Norway

The framework of Person-Centred Practice (PCP) was developed by McCance & McCormack (2023). The authors argue that a person-centred culture can be viewed as the outcome of PCP underpinned by shared values, person-centred language, and behaviour. The PCP framework highlights both macro and micro levels in the framework, thus both system and persons, emphasizing the five pillars of the framework: 1) working with the person’s beliefs and values, 2) engaging authentically, 3) sharing decision making, 4) being sympathetically present, and 5) working holistically [24]. To promote and aim for a person-centred culture, it is important to explore values and beliefs of the persons working and practicing within the culture. The practice environment within this framework also encompasses elements such as power sharing, appropriate skill mix, shared decision-making systems and supportive organisational systems [22]. Knowledge regarding this topic linked to task shifting is scarce. Access to healthcare professional and economic factors are the driving forces to look at new ways to utilise different areas of competencies, for example among nurses and physicians and the organisation of healthcare services. Thereby, bringing forward the concept of task shifting and raising the question of how to achieve the most sustainable utilisation and organisation of healthcare professionals’ competence for effective healthcare services.

This is a qualitative study using an exploratory, descriptive and inductive approach. This approach is suitable for the exploratory phase of research, when exploring task shifting. The descriptive design is suitable for gaining an in-depth and detailed view of the task shifting as a phenomenon and the inductive reasoning underlines the openness in the interviews, then moving further to broader generalisation of phenomena of interest; task shifting [25, 26]. The Consolidated Criteria for Reporting Qualitative research (COREQ) checklist [27] was applied in the study (Supplementary file 1).

The setting for this study was three regional hospitals in South-Eastern Norway offering acute healthcare services to a population of approximately 900,000 people. In Norway, an emergency department is an in-hospital facility that is staffed 24 h a day, 7 days a week and provides unscheduled outpatient services to patients whose condition requires immediate care. In Norway, emergency departments provide universal access to emergency care regardless of the patients’ financial situation. There is always availability of highly specialised healthcare personnel, as well as modern medical equipment and technology supporting the diagnosis and treatment of acute conditions.

A purposeful snowball sampling strategy was used to recruit the participants in this study; this recruitment stategy is appropriate when participants are selected based on their characteristics, knowledge, experiences or other specific criteria [25]. The principles of snowball recruitment process were applied to purposively identify persons with first hand knowledge or experience from task shifting in the emergency department at different hospital trusts. Ten participants were therefore recruited during the data collection period.

Individual semi-structured interviews were conducted at three different emergency department from June until October 2022. The first author, conducted all ten interviews using an interview guide developed for this study (Supplementary file 2). The development of the interview guide was based on two previous studies aiming to: 1) investigate development of a training program for nurse-led ultrasound guided femoral nerve block [28], and 2) test the nurse-led procedures up to the standard of care [29]. The experience from these two studies showed that despite the registered nurses learned and managed well the ultrasound guided femoral nerve blocks, the implementation of nurse-led ultrasound guided femoral nerve block did not occur.

The interview guide explored three main topics: 1) the participants’ overall views regarding task shifting as a means of action in healthcare services; 2) the advantages and disadvantages of transferring tasks traditionally linked to the physician’s role to registered nurses; and 3) important factors to take into consideration regarding possible implementations of shifting tasks from physicians to registered nurses in emergency departments. The interview guide was piloted with the first participant in this study and since the data provided considerable insight and knowledge related to the aim of the study, the interview was included in the overall data material, and no revisions were needed regarding the interview guide.

Each interview started with an open-ended question: Can you please tell me about your overall views regarding task shifting as a means of action in the healthcare services? The participants were encouraged to speak as freely as possible and asked follow-up questions such as: You just mentioned … could you please explain more? Individual viewpoints and experiences were verified against other participants’ responses to obtain a rich picture of the experiences [25]. At the end of the interview, a short summary was provided and a final question was asked to give the participant an opportunity to present additional information. The interviews took place in a private, quiet workplace setting in line with the participants’ preferences. The interviews lasted between 30 and 74 min (mean 37 min) and were audio recorded with the permission of the participants. When ten interviews were conducted, a consensus decision was made by the first and last author that data saturation seemed to be reached, as no new perspectives on the main themes in the interview guide were presented in the interviews.

The interviews were analysed using manifest and latent content analysis, following the approach described by Graneheim and Lundman [30]. Initially, the interviews were conducted, recorded and transcribed verbatim by the first author (ES). Thereafter, all authors familiarized themselves with the transcriptions to gain a comprehensive understanding of the participants’ experiences.

Subsequently, the data were divided into meaningful units, which were condensed and coded. Theses codes were collaboratively discussed and labelled by the first and last authors (ES and KS) and were subsequently compared and grouped into subcategories and, later, categories. Consistent with Graneheim and Lundman [30], the initial phase of the analysis focused on the manifest content, encompassing explicit or surface-level descriptions present in the data. This phase involved a back-and-forth process with a constant critical perspective when identifying and categorising descriptions evident within the texts, as illustrated in Table 1. In the subsequent phase, we turned our attention towards comprehending the deeper, underlying meaning conveyed by the data. This entailed reflecting on the identified categories and subcategories to uncover broader themes and implicit messages inherent in the texts. This process was supported by asking, ‘What are the texts really communicating?

The first steps of the data analysis also involved the exploration of the manifest content in a back-and-forth process with a constant critical perspective during the analysis, as illustrated in Fig. 1. Finally, in the latent part of the analysis, we reflected on the categories and codes and asked ourselves what the texts were talking about, and an overall theme emerged that identified the underlying meaning of the data from a global view of the coded categories [30].

To enhance credibility during the process of analysing the data, the first and last authors analysed the data separately, but with ongoing discussion about the emerging subcategories and the categories. The data analysis involved therefore the process of moving back and forth between different phases of the content analysis. When interpretations between the two authors differed, the researchers explored the possible sources of the difference and returned to the text to reach consensus about the interpretation of the data. To aim for reliability in the interpretation, the preliminary findings were presented for the whole research team and one external expert and critically discussed in a one-day workshop. This discussion of the preliminary finding led to adjustments of and changes to subcategories and renaming of categories, and the overall theme.

The content analysis revealed three main categories: 1) rationale for task shifting, 2) team approach for task-shifting and implementation of task shifting, 3) resulting in the overall theme: It is not the task, it is the shifting – moving towards a person-centred culture. Figure 1 illustrates the theme, categories, and subcategories. In the following text, the categories and subcategories are presented leading up to a summary of the results, outlining the overall theme of the data analysis.

This category represents the rationale for tasks shifting from a physician to a registered nurse. Three subcategories constitute this category: finding the low-hanging fruit, understanding the responsibility and building competence and confidence in new tasks.

This category signifies the findings on how the participants experiences with task shifting often being linked to motivation for experienced registered nurses to stay, team approach to sustainability, and empowerment within a team.

The participants described the challenges of implementing task shifting between physicians and registered nurses in emergency departments and possible solutions. Their responses can be divided into three subcategories: first, they shared their perspectives on the change in roles of the professions involved; second, they emphasized the importance of recognizing leadership and rules; and finally they acknowledge that change takes time.

The study findings suggest that an important starting point for implementing task shifting should be to identify appropriate tasks to transfer. This is in line with the EU report highlighting the importance of avoiding inappropriate task shifting, which can lead to increased workloads and fragmentation of care [4]. Furthermore, the process of task shifting includes more than focusing on “just the task”; it also involves clarifying why a task is being transferred [8]. As an example, existing tools for stakeholders planning and implementing task shifting appear to take a more holistic approach, taking all the different aspects of task shifting into consideration [8].

This study identifies different aspects of task shifting processes: a) The instrumental aspect involves tasks like performing a femoral nerve block, b) Professional competence is foundational for understanding task complexity, and c) Personal capability, such as bravery and resilience, is essential for taking on tasks. Mastering a task involves understanding its complexity and taking responsibility. It also hinges on an individual’s professional competency, which is tied to their capability – their ability to perform effectively [31]. Capability goes beyond competency in that it requires a relational understanding of context and critical analysis of the situation to allow for the flexible application of knowledge and deciding who is the right person for the task [31]. Therefore, a more holistic understanding of task shifting includes the development of professional competency among registered nurses, also referred to as professional empowerment [32].

Studies indicate that authentic leadership and structural empowerment significantly influence experienced registered nurses’ perceptions of interprofessional collaboration, and several studies have identified that managing responsibility is a major barrier to task shifting among registered nurses [4, 13, 19, 32]. It is therefore paramount for leaders across healthcare settings to understand what encourages registered nurses to take over a task and what challenges and facilitating factors they encounter when doing so [31]. This understanding helps leaders to develop organisational commitment among healthcare professionals [31].

The development of organisational commitment involves developing a person-centred culture highlighting concepts such as success and personal and professional growth [24]. The main obstacles for leaders when trying to cultivate a person-centred culture in acute care environments stem from the various cultural aspects within the organisation [22]. These include the organisational culture, the culture of learning and the culture of care [33]. Emergency departments are known for the high amount of stress and unpredictable working days [34].

The study findings highlight the value and importance of working and learning as a team in the process of shifting tasks. This is in line with findings from an Indonesian study investigating stakeholders’ perspectives on task shifting in mental health care, which underlined the value of sharing and collaboration [35]. Creating an environment and culture that enables teamwork, creativity, adaptability and innovation is a powerful strategy in when it comes to building teams and person-centred cultures [34], referred to as shared decision-making systems [36]. Implementing shared decision-making teams consisting of registered nurses and physicians can contribute to more sustainable task shifting processes. Shared decision-making teams can support the instrumental, personal, and professional aspects of task shifting, thereby establishing a more person-centred culture in the context of care.

The PCP framework emphasises the value and importance of working and learning as a team in the process of shifting tasks. This approach encourages collective leadership with the main goal of providing high-quality care in emergency departments.

The participants in the study shared their concerns about task shifting leading to fragmentation in patient care when the responsibility for tasks was divided among multiple health care professionals. At worst, this could lead to adverse patient outcomes, such as extended hospital stay, increased risk of readmission to hospital, and increased mortality [37]. A Swedish study found that the provision of care in the emergency department exhibits fragmentation, with nursing care often viewed as an extension of medical practice and registered nurses sometimes undervaluing their unique nursing role [38]. While medical goals remain clearly delineated, nursing goals lack distinct boundaries [39]. The establishment of strong interdisciplinary teams with clear role boundaries tailored to specific care contexts can help prevent fragmentation of care [4, 39].

Closely connected to perspectives on the fragmentation of care is the aspect of managing the responsibility for the task shifting. One of the findings in the study was perspectives on whether registered nurses had the confidence to manage the responsibility that came with task shifting. Furthermore, the participants expressed taking responsibility was more closed linked to the physician role as a matter of tradition and through medical education. The perspective of crossing the line between medicine and nursing in relation to task shifting has been addressed in previous studies [40], which have suggested focussing on teambuilding rather than on transferring specific tasks [41]. One recent study highlighted teamwork as one of the most important factors for quality of care, noting that a lack of teamwork can contribute to burnout among physicians and adverse events [42]. This supports the importance of building a resilient team when implementing task shifting both to prevent fragmentation of patient care and to help registered nurses manage the responsibility of providing treatment. In this way, organisations facilitate a team approach to build trust and psychological safety, which allow registered nurses to practice responsibility with support from physicians [4]. The findings in this study suggested an understanding of “task sharing” within the team approach that did not necessarily entail shifting responsibility for a task entirely but rather sharing the task within the team. Leaders should facilitate team relationships, considering in particular the need to build competence over time and bolster registered nurses’ ability to take full responsibility for tasks traditionally performed by physicians [43].

By highlighting the task sharing approach within interdisciplinary teams, conflicts can be avoided and physicians’ professional identity can be preserved. Professional identity is achieved in stages over time, during which the characteristics, values and norms of the medical profession are internalized, resulting in an individual thinking, acting and feeling like a doctor [44]. Shifting a task from one profession to another will most likely transform the status of both the person taking over the task and the one giving it away [40].

The PCP framework emphasizes power sharing and having an appropriate skill mix. It also promotes shared decision-making systems and a team approach to task sharing. This framework encourages collective leadership with the goal of providing high-quality care in emergency departments. These aspects might be more important than specific tasks, such as who injects nerve blocks or signs x-ray requisitions, this might also be more significant than who initiates the next step of treatment. Registered nurses working in interprofessional teams have reported greater well-being and less risk of burnout [9, 34], which is the one of the most urgent issues facing healthcare today [45, 46].

It is most common to transfer traditional physician tasks to registered nurses, primarily because the latter form the largest group of healthcare professionals. Their extensive capabilities and widespread availability across nearly every healthcare facility make them essential contributors to the delivery of quality care [47]. Our study highlights that the tension that exists in task shifting is not a result of the specific task so much as the shifting process. Therefore, it is necessary to identify what benefits patients in terms of quality of care and which healthcare professionals are capable of learning and taking responsibility for new tasks. However, taking over tasks that physicians perceive as high-status might lead to a change in status for registered nurses. The alteration in status due to task redistribution is not solely a concern for the relationship between physicians and registered nurses, but also for relationships among registered nurses themselves. A qualitative Norwegian study reported instances of envy and fears of change in status [19]. The study underscores the significance of managing negative emotions in the workplace and building a team-centric culture [19]. Challenges resulting from factors related to hierarchy are shaped by context and cultural factors [48], which also shape patient safety culture, and will differ from one country to another, and even from one hospital to another in the same country. This highlights complexities in the workplace, and the culture that call for different ways of implementing task shifting, as well as an assessment of the organisational system [4, 19]. The PCP framework supports empowering all healthcare professionals, regardless of their hierarcical position to contribute to patient safety and care. It is therefore imperative that leaders understand both the workplace culture and the driving factors within their organisation if they are to work against many of the deeply engrained structural and social norms that prevail [49].

Registered nurses’ workload must be acknowledged in any discussion of task shifting [50]. It is important to reconsider the need for transferring traditional physician tasks to registered nurses if this leads more work overload. Shifting tasks from registered nurses to other health care workers, such as registered nurse assistants or health secretaries, must also be considered. As a result, team building in relation to task shifting can involve physicians, registered nurses and registered nurse assistants. The findings in the study highlights the importance that leaders acknowledge leaders to acknowledge the complexities of task shifting and allow sufficient time to adjust when changing professional boundaries. The absence of time was perceived as a barrier created by hospital leaders and politicians due to years of focus on efficiency and cost savings rather than on quality of care. Previous studies have reported lack of organisational support as a barrier for task shifting [40, 51, 52]. By focusing on establishing and empowering interdisciplinary teams, leaders can support the emergence of a more person-centred care culture in emergency departments.

A key strength of our study is that we believe it to be the first to explore task shifting from the perspective of hospital physicians and leaders in the emergency department setting in high-income countries. A limitation of the study is the choice to explore only the perspectives of physicians and leaders. The perspectives of other healthcare professionals such as registered nurses, while equally important, are not within the scope of this study.

Several measures have been taken to ensure trustworthiness and transparency, such as member checking [53]. First, the first and last authors cooperated closely throughout the analysis process and held a workshop with experts and co-researchers with the goal of avoiding bias [54]. Second, the research team members have different perspectives due to their various professional competences and research backgrounds. This mix of competencies and perspectives helped the team avoid unidimensional interpretation of findings, thereby improving trustworthiness.

Another strength is the inclusion of thick descriptions in the form of verbatim quotations in the manuscript. These descriptions contribute to the transparency and credibility of the interpretation of latent content by helping to uncover the researcher’s thinking during data analysis and how that thinking influences the creation and application of codes [55].

Having a registered nurse and physician who had worked in hospitals for several years on the research team was important to critically discuss the findings. It was, however, a possible limitation that their pre-understandings might have influenced their interpretation of task shifting between physicians and registered nurse [56]. However, two additional members of our research team (despite their limited familiarity with task shifting and lack of experience in emergency departments) brought extensive expertise from analogous environments, as well as in data analysis, coding and critical thinking. Their ability to analyse critically from a fresh perspective enhances the credibility of our analysis, and strengthens the trustworthiness of our results.

Finally, the first author is a registered nurse and some of the participants were fellow workers, previous leaders and colleagues. This could be considered a strength as it presented a unique opportunity to have easy access to informants and it meant that trust was already established. However, the researcher had to be careful and reflect on the impact of their preconceptions on the validity of the findings because of their previous knowledge of the participants. Furthermore, because the participants were physicians and leaders, power relations had the potential to be challenging due to the fact that the registered nurse–physician relationship is known to be influenced by the power of authority, social status, gender and other factors [57]. The first author therefore discussed their feelings and immediate experiences from the interviews with the co-authors to avoid interpretations based on the first author’s relationship with the participants.