In October 2018, we conducted 60-minute interviews with five GPs. The participants had a median of 7 years [range 2-27 years] of experience as GPs and they varied in other baseline characteristics (Table 1). All interviews were conducted as planned. By the last interview, no new knowledge emerged. After the analysis, data saturation was discussed and agreed upon between RHK, CAA, and AR. Three GPs refused to participate because of high workload in their practices. There were no drop-outs.
The GPs all described having experiences with delegating assignments and patientcare to nurses and other staff working under their supervision. While some GPs were eager to delegate, others were more reluctant to delegate tasks. Some GPs also described having many patients with LBP but none of the GPs were currently delegating care of this patient group to their staff. Through the analytical process, the following main themes derived: General practice organisation; delegation to clinical staff members; GP/patient relationship; exercise instruction; Clinical pathway for patients; and external support. Subthemes within each theme are illustrated in Figure 1.
General practice organisation
All GPs had experience with delegating tasks to their clinic staff, but it varied which tasks the GPs delegated and to which types of clinical staff members. The GPs described how they typically delegated tasks to relieve the pressure on themselves, and how a generally increasing work load in general practice with e.g. the outsourcing/relocation/transference of healthcare from secondary care to general practice had increased the need for delegating tasks to the clinic staff. However, because of the tasks that had already been delegated to the clinics’ staff and the balance between these, their readiness for taking on new tasks were affected:
‘right now I would think that there is a longer waiting time for our nurses, than for ourselves (…) right now we are holding back on giving them tasks’ (E)
Even though the GPs would like to delegate more tasks to their staff, economic concerns and the physical space in the clinic could limit the expansion of staff.
All the GPs described having experiences with patients with LBP. The patients were typically seen by the GP for ‘emergency sessions’ when the symptoms appeared and the GPs rarely scheduled follow-up sessions. However, several patients returned to the general practice after having completed treatments with the physiotherapist. Some of the GPs described how patients with LBP have a strong presence in the clinical everyday life:
‘it’s an incredible amount of people, and they have an immensely strong presence in our work day (…) in comparison to so many other conditions (…) but low back pain really has volume’ (B)
Meanwhile, others did not experience that patients with LBP constituted a group of patients to be sufficiently large to necessitate a change in the current management strategy:
‘it (…) is [not] at the top of the list of things I would think, I could delegate to the nurse (…) because it does not take up enough time, even though we see some, you know, we see the problem regularly, but they do not go through long courses of treatment most of them (…) I cannot see that it would change much’ (D)
The GPs described how it is difficult to manage a sufficient back examination within the time frame they have in general practices, and how conversations about LBP often demand extensive explanation to the patient. One of the GPs described how delegating treatment of LBP to the clinic staff would be a new way of involving the staff that is not straight forward, as it involves complex problems. On the other hand, the GP also described how the patient often needed a more pedagogical than medical effort.
Delegating to clinical staff members
The GPs described how the tasks they delegate to the clinic staff depend on the staff’s professional and individual competencies. Most commonly, GPs delegated tasks to nurses and some also delegated to care assistants. One of the doctors also had a medicine student employed.
The GPs explained how the tasks and patient population had to be clearly defined, stable and uncomplicated in order for it to be possible to delegable. There also had to be a certain volume in order for the staff to gain experience with the task.
‘there has to be a homogeneity to the patient group, and there has to be some volume of patients to be suited for delegation’ (B)
One of the doctors described how delegating a task to the clinic staff required proper training of the staff, and required that they had supporting tools e.g., flow charts clearly defining patient course of treatment as well as ‘red flags’ that entails physician involvement. Furthermore, the GPs explained that delegating task required trust and confidence in the clinical staff and their abilities to acknowledge the limits of their own competencies. Some GPs had scheduled appointments for supervision with their clinic staff, meanwhile all performed ad hoc supervision.
The GPs described how delegating a task required training of the clinical staff in the form of theoretical teaching and supervised consultations. The GPs had developed and defined this training themselves and described this training as an investment. Consequently, one of the GPs mentioned how it should not be for temporary staff i.e. medicine students:
‘Training takes time and resources (…) it should be for the permanent staff’ (C)
The doctors primarily had experience with delegating tasks to the nurses. One of the doctors described how especially the nurses were suited for taking on independent tasks because of their extended education in comparison to other staff groups:
‘we choose two nurses because we believe that they have an education (…) that makes them able to handle these things’ (E)
The GPs described how the nurses were good at following set procedures and at knowing their own limitations, but they also described weaknesses in the nurses’ basic training. Several GPs stated that nurses were not trained to diagnose:
‘I might fear (…) that we still would risk… losing some, but also risk over-diagnosis (…) I think the nurses have more of a tendency to do that than the rest of us’ (A)
Some GPs consequently questioned if the nurses would be able to manage the first diagnostic consultation with the patient and thereby performing triage, while others could see the nurse as a medical officer in advance of a consultation with a doctor. Several GPs could imagine the nurse conducting follow-up consultations including information and guidance:
‘[it] could provide the patient with a coordinator, who could offer (…) the individual patient some more opportunities for contact than I am able to. [The patient] gets worried (…) so I could see the nurses having competencies, which would be good for accommodating that (…) as some of the patients have a need for more frequent consultation, which I am not able to offer them’ (B)
The GPs did however describe that it would require extensive training of the clinical staff members before delegating the treatment of LBP.
The doctors described how delegating tasks to the clinic staff had consequences for their knowledge of the patients and consequently the continuity and doctor-patient relationship.
‘it [also] may harm the continuity, you do get a little out of touch (…) because you hand over [the patients], and then it is suddenly [the nurse] who knows them the best’ (D)
One GP described how the knowledge of the patients’ history and the complete medical overview are prerequisites for diagnostics in many of the patients’ cases.
Some GPs described how delegating tasks and patients to the clinic staff affected the tasks they were left with. One of the doctors mentioned how the delegation of the simple tasks to the clinic staff members entailed that the doctors were treating all the complex problems:
‘now we have moved the easy stuff (…) and then it is replaced with something which is more complex. That is always the risk’ (A)
Another GP experienced great satisfaction in seeing patients with LBP and performing manipulation. This GP was reluctant to hand over these patients to a clinical staff member.
GPs described how exercise instruction was part of the treatment for patients with LBP. However, the short timeframe for the GP’s consultation compromised the delivery of exercise instructions. The GPs who instructed in exercises, did this very quickly and often by recommending websites with exercise programs.
‘I partly use different web resources (…) with good instruction videos (…) generally I stick to (…) I do not have half an hour like the physios do, so I give one to three exercises max (…) because I do not have the time’ (B)
GPs explained how instructing the patients on exercises were within the physiotherapists’ remit and that they often referred patients to them. They also said that they both refer patients to physiotherapists for complete low back examinations and assessments as well as exercises/training. Several of the GPs described how they often instructed patients in a few exercises, which the patient could use while they were waiting for an appointment with a physiotherapist. One of the GPs explained that patients would restrict from doing exercises if they were not properly instructed.
Other GPs preferred not to step into the physiotherapists’ area of expertise. Partly because physiotherapists traditionally perform exercise instruction and partly because physiotherapists are more skilled for this tasks and had the necessary setting.
‘I do not [think] that it is our job (…) I [think] the physiotherapists can do it better (…) that what we would do, would be a light setup (…) when you go to a physiotherapist, (…) they have some training equipment’ (A)
The interviewed GP thought that physiotherapists employed in general practices could help with the diagnostics:
‘If there were to be a physiotherapist here, (…) then it should be for diagnostics and not for treatment’ (A)
However, the GP’s did not think that they had enough patients for hiring a physiotherapist in their clinic, but that a physiotherapist would be suitable in a large practice with a large patient base.
Clinical pathway for patients
Even though the GPs described that they frequently consulted patients with LBP, they rarely scheduled new appointments and thereby creating a predetermined LBP treatment course in general practice.
‘I don’t see particularly many patients with LBP in what I would call predetermined treatment courses’ (A)
The GPs described how they let the patients transfer to treatment by the physiotherapist but gave the patients the opportunity of returning to the clinic on their own initiative:
‘[we] agree to talk at a later time. I do not give them a new time for an appointment (…) we have such easy access here (…) so I would say “well, let’s talk in a couple of weeks’, or “we should see each other again if it is not better by then’ (…) if they are in the process of a good successful treatment with the physiotherapist, I don’t necessarily need to see them again after 14 days’ (A)
If the GPs scheduled a new appointment for a follow-up, it was mostly given as a precaution for the patient and not necessarily as a planned clinical pathway:
‘I would offer him or her a new control session 14 days after, because then they sort of get a feeling of (…) them having some safety net, that they can come back’ (C)
The GPs believed that involving clinical staff members could enable systematic treatment course for LBP. This could improve the treatment of patients:
‘it would be motivating for patients, and that they are able to come back and talk about ‘well, I did not quite understand the thing he showed me’ or ‘it hurts when I do it’ (…) it is definitely possible to imagine that it would be helpful that they see a nurse who would be able to do a follow up’ (C)
Several of the GPs did however think that it was important to consider how this should be organised in terms of the division of work between the GP and the clinical staff member:
‘our collective agreement with the public health care providers, is not suited for patients first [having] ten minutes with the [nurse] and then ten minutes with me’ (B)
GPs said that delegation could potential cause confusion when patients were to see different health care professionals in the same house. Furthermore, delegation of work could lead to too much repetition of tasks.
‘you would definitely have to be aware that if you divide it too much, what the risks are for both the patients’ sake and in terms of duplication of work’ (A)
The GPs described how they usually introduced a training program and support tools for the staff prior to delegating tasks. These were developed by the GPs or adapted from clinical guidelines. The GPs also described how they previously had used formalised courses for practice staff. As the GPs considered delegating treatment of LBP to staff members a larger task, they called for help and support from outside the clinic e.g. in the form of clinical guidelines:
‘It would be highly relevant to have a proper guideline from the national society for general practitioners’ (B)
One of the GPs described how the challenge could be addressed by courses for the clinical staff and a proper plan for how tasks are delegated:
‘you could solve that challenge by letting an employee in the regional quality unit for general practice arrange a course for clinic staff members and make a model for implementation’ (C)
Another GP said that courses for clinical staff members could strengthen the overall knowledge in the practice:
‘we [also] learn from our nurses (…) it could also be them who took a course and came back and taught us how you (…) divided management of LBP into different things and then moved forward, and in that manner I actually also think that you would reach most possible general practices if it was the staff you reach out to’ (E)
Several GPs expected their future work to entail managing more patients with LBP as a part of a negotiation of collective agreements with the national health care providers. However, GPs were uncertain to which extend and they described lacking structure and alignment in this area:
‘what you (…) could have use of, and that might be in the program for course of treatment (…), that is (…) a structured stratification of what non-specific LBP is. Who should be sent to secondary sector, on which indication should they be sent, when should we talk to the back surgeons (…) so that it would be easy for the staff to know when they should knock on the door (…) that I would (…) like to see schematically’ (B)
‘it is a help with things like a flowchart and that it is set up in a schematic manner’ (E)
Generally, GPs were interested in enhancing their knowledge about LBP:
‘We only know what we know, you know we have to handle a lot of different tasks, it would be really good for all of us to be upgraded in this field’ (B)