Op0259-HPR Who Does What? Task-Shifting, Circumventions and Role Re-Configurations in Hand Osteoarthritis Care: A Qualitative Study of Rheumatologists and Occupational Therapists in Norway

Background: Professional boundaries within the healthcare workforce are facing new pressures due to staffing shortages, economic demands and changing care models. To address this, global trends emphasise allied health professional-led care, involving delegation of tasks and responsibilities from physicians to other health professionals, often called task-shifting[1]. Objectives: To explore how task-shifting in hand OA care impacts the division of labour and professional role boundaries between rheumatologists (RTs) and occupational therapists (OTs) in Norwegian specialist healthcare. Methods: The current qualitative study is nested within a larger project investigating task-shifting between RTs and OTs in hand-OA care where OTs conduct initial patient consultations[2]. Individual semi-structured interviews were conducted in-person, digitally and by telephone, with RTs and OTs at Hospital A and B. They were audio-recorded and transcribed verbatim. Reflexive thematic analysis[3] was employed to analyse the data, and conducted in NVivo. Results: In total, 15 participants were interviewed; 10 rheumatologists and 5 OTs. The majority of participants were female (n= 13), between 30 and 65 years of age, and had over 20 years of experience working within the field of rheumatology. Interviews lasted on average 90 minutes, (range: 45-120 minutes). The analysis resulted in 3 themes: (1)Forms of responsibility and task transfers: OTs are taking on a growing number of medical tasks alongside their core OT-related tasks due to vertical task delegation from RTs. For example, OTs describe increasing engagement in differential diagnostic work, reporting that they have become more meticulous in their consultations. They also described making referrals to injection clinics; a task traditionally associated with medical doctors. They made these referrals without consulting a rheumatologist first. (2)Circumventing the rules to ensure efficient practices and appropriate patient care: OTs made diagnostic imaging referrals (x-rays). In Norway, medical radiation is strictly regulated and only a few professional groups are legally allowed to refer patients for diagnostic imaging; OTs not being one of them. Moreover, they describe using RTs signatures to authorise the referrals. Similarly, they used RTs signatures to complete applications for orthopaedic assistive devices. They described these workarounds as efforts to streamline and expedite clinic operations benefiting both OTs, rheumatologists and patients. (3)Movement of professional demarcations: Task shifting blurred the boundaries between RTs and OTs, subsequently impacting their professional role boundaries. OTs went through a process of diversification, where they broadened their professional boundaries as a result of gaining tasks and responsibilities outside their traditional scope of practice. RTs narrowed their scope of practice by relinquishing unwanted tasks to OTs and subsequently underwent a process of specialisation, retaining tasks only they could perform. Conclusion: Medical tasks that traditionally belong within the jurisdiction of RTs in hand OA care are increasingly delegated to, and adopted by, OTs. The absence of formalised task shifting procedures inadvertently encourages health professionals to engage in rule-circumventing workarounds. As a product of vertical delegation, the OT role underwent a process of diversification, whereas the RT role underwent a process of specialisation. REFERENCES: [1] van Schalkwyk MC, Bourek A, Kringos DS, Siciliani L, Barry MM, De Maeseneer J, McKee M. The best person (or machine) for the job: Rethinking task shifting in healthcare. Health Policy. 2020;124(12):1379-86. [2] Kjeken I, Bergsmark K, Haugen IK, Hennig T, Hermann-Eriksen M, Hornburg VT, et al. Task shifting in the care for patients with hand osteoarthritis. Protocol for a randomized controlled non-inferiority trial. BMC Musculoskeletal Disorders. 2021;22(1):1-11. [3] Braun V, Clarke V. Thematic Analysis: A Practical Guide: SAGE Publications; 2021. Acknowledgements: The authors would like to thank all the participants for their time and insights. The overall project is funded by the Research Council of Norway (Grant 300823/H40). Disclosure of Interests: None declared.