Background
The concept of task shifting is an important development within primary care systems in industrialized countries. International experiences have shown that, besides physicians, other non-physician health professionals, e.g., nurse practitioners or registered nurses, support the medical care of patients [
1,
2]. However, the degree of task shifting differs substantially among countries. A systematic review has revealed that the evidence from good quality studies concerning task shifting from physicians to nurses is very limited [
3]. Different political and legal frameworks in the respective countries are responsible for task shifting from physicians to non-physicians. In comparison with countries such as Canada, New Zealand and the Netherlands, Germany appears to be less advanced in adopting task shifting [
1].
The shifting of medical tasks to non-physician healthcare staff has been allowed in Germany since 2008. One of these medical tasks is the delegation of home visits to non-physician staff, which is completely legal [
4]. Therefore, in Germany, different delegation projects have been initiated, such as VERAH (health care assistants in family practices) and AGnES (general practitioner (GP)-supporting, community-based, e-health-assisted, systematic intervention) [
5,
6]. The AGnES project has been well evaluated and has been implemented in two federal states (Mecklenburg-Vorpommern and Brandenburg). This concept is based on GP support in the context of home visits [
7]. An economic evaluation of the AGnES-practice assistants has revealed a decrease in home visits performed by GPs [
5]. Hence, it can be assumed that GPs have more time for other activities within their practices. Moreover, most GPs participating in previous studies have agreed that task shifting saves the physicians’ time and relieves them of some of their workload, especially that concerning home visits [
6,
8].
Therefore, task shifting as a transfer of clinical tasks from a physician to another health care staff member is crucial for health care teams consisting of physicians and non-physicians [
2]. Moreover, high-performing team-based care could be associated with the redistribution of tasks in addition to the shifting of tasks from clinicians to non-clinicians [
9].
In Germany, a country where task shifting is in an emerging phase, the perceptions of the GPs regarding the benefits and concerns of task shifting have been unknown. The German Medical Association has provided a list of different tasks that can be delegated from physician to non-physician staff [
10], but the experiences and attitudes from the physicians’ perspectives and the aspects that might support a positive attitude towards task shifting have not been well evaluated. Therefore, the aim of the current study was to evaluate the experiences and attitudes towards the concept of task shifting and to identify predictors of a positive attitude towards task shifting from the perspective of GPs.
Discussion
Our results present an initial overview of experiences and attitudes towards the concept of task shifting from the perspective of GPs in a country beginning to change its attitudes towards task shifting. Our sample consisted of GPs with long work experience, nearly half of whom had positive attitudes towards shifting of tasks. In contrast to our non-responder sample, the participating GPs were younger and included a lower percentage of women. The concept of task shifting from the perspective of GPs was related to different important benefits but also to some concerns. The respondents strongly agreed that qualified staff and adequate payments for the staff are needed. As described in recent literature, the main barrier for high-performing team-based care, including task shifting, is the lack of an adequate remuneration of the work performed by non-clinical staff [
9]. As our results demonstrated, GPs mainly delegated tasks that could be summarized under the term standardized procedures, such as recording electrocardiograms and measuring blood glucose, whereas fewer of the GPs delegated tasks that required communicative competence in terms of counselling, such as advisory activities. It could be assumed that GPs do not feel confident towards their staff concerning the performance of tasks that require communicative competence. It could also be assumed that there is a certain lack of awareness among the GPs regarding the tasks that can be delegated to their staff.
An important concern regarding the concept of task shifting, from the perspective of GPs, is that there is uncertainty regarding responsibilities and legal situations. A study on the extent of task shifting in 39 countries has shown that Germany is among a group of countries with no official legal regulations for task shifting from physicians to nurses in primary care [
1]. Notwithstanding the above, as our results demonstrated, the proportion of different tasks that were currently delegated in our sample was very high. GPs strongly agreed that task shifting can lead directly to time savings and thus provide an opportunity to offer health care to more patients. These advantages of task shifting are comparable to findings in other studies [
6,
8]. These findings have been complemented by an economic evaluation of the AGnES project and have shown that home visits performed by practice assistants result in time saving for GPs [
5], thus allowing GPs to offer health care to more patients.
Therefore, it is necessary to invest in a well-performing primary care team performing different roles and comprising qualified staff. Changes in primary care are pending. The limited career development of practice staff has often been described [
2,
9]. However, with the concept of task shifting, it is possible to appreciate the work of practice staff with new responsibilities that should be defined precisely. Multidisciplinary teams with different occupational backgrounds will be integral parts of primary care teams in order to meet the requirements of health care in the future and to reduce occupational stress and increase physicians’ job satisfaction. Different studies on job satisfaction have shown that GPs are often less satisfied with their working hours but are highly satisfied with their teams [
16,
17]. As our results demonstrated, a positive attitude towards task shifting is associated with increases in job satisfaction and qualified staff members. Moreover, a recently published study has shown that task shifting to practice staff can lead to staff being more motivated and satisfied [
18].
Our study provides an important contribution regarding the experiences and attitudes towards the concept of task shifting from the perspective of GPs in a country where the attitude towards task shifting is changing. The list of delegated tasks was developed from a literature review concerning the current state of the concept of task shifting in the German health system and within the international context. All participating GPs from the present study came from one federal state in Germany. Therefore, the findings are tentative, and it is not possible to determine cause-and-effect relationships. The strength of the study is that we included a non-responder analysis. Only GPs were involved in this study; non-physician staff, such as practice assistants, were not asked about their experiences with delegated tasks. The participation of GPs in this study was voluntary; therefore, a potential selection bias is likely. The questionnaire was sent to only GPs in a pilot trial but was not validated. Moreover, no power calculation was performed. Finally, this was a cross-sectional study; thus, we must be cautious about deriving causal links from these findings.
Conclusions
German GPs are beginning to delegate tasks to non-physicians and should extend delegated tasks to their practice staff. As our study shows, GPs mainly delegated tasks that are standardized procedures. There is a willingness to expand the roles of non-clinical practice staff, but this willingness is dependent on legal requirements, adequate payment and the availability of qualified staff. There is a need for continuing professional development in primary care teams, especially for non-clinical practice staff.
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