Abstract
Background
Skill mix in primary care is increasing, but introducing new roles to general practice is challenging. Concerns have been raised that the skill mix may add to the general practitioners' (GPs') workload. This study examined whether the skill mix was associated with GPs' working hours, time used on management, and burnout.
Methods
In total, 1659 GPs working in 1045 practices completed a survey assessing working hours, time spent on management and administration, and burnout. Burnout was assessed by the Maslach Burnout Inventory (MBI). A composite score of quartile points was calculated for the three subscales of the MBI, and a score ≥9 was categorized as a high level of burnout. Skill mix was measured as the number of nurses, secretaries, and other healthcare professionals (OHCPs) per GP in practice. OHCPs constituted a broad staff category comprising, among others, physiotherapists, midwives, pharmacists, and psychologists. Associations were investigated by generalized linear models for binary outcomes.
Results
Employment of nurses was associated with a lower probability of burnout, whereas employment of OHCPs was associated with a higher probability of burnout. The latter was found only in partnership GPs, where employment of OHCPs was also associated with an increased number of hours used on management. Skill mix was unrelated to the number of working hours per week.
Conclusions
Task-shifting from GPs to nurses might unburden GPs exposed to high workload, but the results suggest caution when it comes to employing OHCPs in primary care, although causality cannot be determined. Studies with experimental designs are needed to clarify causal mechanisms.
Keywords: burnout, professional, general practitioners, health personnel, nurses, organization and administration, primary health care
Key messages.
This study examined whether skill mix is related to GP burnout and working hours.
Employment of nurses was associated with a lower probability of burnout.
Using other healthcare professionals was linked to higher burnout risk.
Skill mix was unrelated to the number of working hours per week.
Future studies should use longitudinal or quasi-experiemental designs.
Introduction
Family medicine plays an important role as the first point of contact when patients experience health concerns. The demand for general practice appointments is increasing, driven by factors such as an aging population, rising levels of frailty, and more complex patient needs [1]. At the same time, a shortage of general practitioners (GPs) has created a mismatch between demand and capacity, leading to a crisis in primary care services across many European countries [2, 3]. Burnout among GPs has become a serious global concern [4], making it crucial to structure primary care in ways that support optimal working conditions for GPs. To enhance patient access to primary care and increase primary care resilience, the primary care workforce is undergoing transformation, with an increasing reliance on skill mix approaches [2].
Skill mix in general practice has been conceptualized as the mix of different types of healthcare professionals (HCPs) in a clinical setting [2, 5], including nurses, pharmacists, physiotherapists, midwives, and mental health support workers [6].
The integration of diverse HCPs in primary care is driven by two key motivations: (i) the need for innovative service models to address complex patient health needs and (ii) the necessity of substituting GPs with other HCPs to alleviate workload pressures [5]. Studies have shown that skill mix is more commonly implemented in practices serving higher proportions of elderly patients and those in socioeconomically deprived areas [7]. These findings suggest that skill mix may serve both as a strategy to improve care for complex patients and as a response to GP shortages, which tend to be more pronounced in disadvantaged areas, a phenomenon previously described as the “inverse care law” [8].
Evidence suggests that introducing new roles to general practice is not a simple task and that implementing skill mix requires active management to prevent inefficiencies and duplication of work [2]. This could suggest that skill mix has the potential to inadvertently contribute to the escalation of GP workload. If skill mix results in higher GP workload, it could increase the risk of burnout and premature workforce attrition, thereby exacerbating the primary care workforce crisis [1, 6].
On this background, the aim of the present study was to examine whether skill mix in primary care was associated with working hours per week, hours per week used on administration and management, and burnout among GPs.
Methods
Setting
The Danish healthcare system is tax-funded, and 98% of Danish citizens are listed with a specific general practice, which they must consult for medical advice. Danish GPs act as gatekeepers to the specialized healthcare system. GPs in Denmark work as independent contractors for the public health service, and they are remunerated through a mixture of fee-for-service (approx. 75%) and capitation (approx. 25%). Most Danish general practices are either partnership practices (approx. 75%) or single-handed practices (approx. 25%). Each practice has a unique provider number used for remuneration of service fees. In a partnership practice, the GPs share the same provider number.
Study population
The study population consisted of practice owners of single-handed or partnership practices (excluding locums and trainees) participating in a national survey on their working conditions and mental well-being.
Data collection
The vast majority of Danish GPs are self-employed private practitioners who work under a contract with the Danish regions. All practicing GPs are organized in the Organization of General Practitioners in Denmark (PLO). In April 2023, all Danish GPs listed with a valid email address at PLO received an email with a link to an electronically administered questionnaire. The survey was announced one week before in a PLO newsletter. Nonrespondents received a reminder after two weeks and again after one week. The link to the questionnaire was personal and contained a unique serial number. The research group collected the survey data and transferred the data to Statistics Denmark [9]. PLO provided data on GPs' sex, age, and provider number, which was anonymized prior to analysis. Among the GPs invited to participate in the survey, the number of GPs sharing the same provider number was registered. This information identified single-handed practices and number of GPs working in each partnership practice.
Explanatory variable
Skill mix served as the explanatory variable and included nurses, medical secretaries, and a diverse staff group.
Nurses and medical secretaries: In the questionnaire, general practitioners (GPs) provided information on the number of nurses and medical secretaries employed in their practice. Response options were: “0”, “1”, “2”, “3”, “4”, “5 or more”, or “don’t know”.
Other healthcare professionals (OHCPS): GPs reported the number of staff in each of the following seven HCP roles: community care workers, midwives, physiotherapists, laboratory technicians, pharmacists, pharmacologists, and psychologists. Response options were: “0”, “1”, “2”, “3”, “4”, “5 or more”, or “don’t know”. Due to the low numbers reported for some of the individual HCP categories, they were combined into a single aggregated HCP category.
The response option “don’t know” was only used once and this response was recoded as “none.” The number of employed nurses, medical secretaries, and OHCPs was divided by number of GPs in the practice (i.e. GPs registered on the same provider number at PLO) to obtain a ratio of employed nurses, medical secretaries, and OHCPs per GP in the practice.
Outcome variables
We included three outcome variables reported by the GPs in the questionnaire:
Working hours per week: Respondents were asked to report the average total number of working hours per week in their role as general practitioners (GPs). This included time spent in practice, overtime, working from home, attending congresses, teaching students and colleagues, participating in research, reading professional literature, and performing administrative or managerial tasks. Weekly working hours were grouped into four: ≤40 hours, 41–45 hours, 46–50 hours, and >51 hours per week. For analysis purposes, working more than 45 hours per week was classified as having a “high number of working hours.”
Hours per week used on administration and management: Respondents were asked to report the number of hours per week they typically used on administration, management, and meetings in practice. The response categories were “less than 1 hour”, “approx. 1 to 2 hours”, “approx. 3 to 4 hours”, and “more than 4 hours”. The response categories were dichotomized for analysis, collapsing the two first and the two last response categories.
Burnout: Burnout was measured by the 22-item Maslach Burnout Inventory (MBI)—Human Services Survey, which consists of three subscales corresponding to three burnout dimensions: emotional exhaustion (9 items), depersonalization (5 items), and personal accomplishment (8 items) [10]. It is recommended that the three subscales of the MBI-HSS are not combined to form a single burnout scale. Thus, to handle burnout as a multidimensional construct, we categorized each subscale according to quartiles of the subscale sum scores (reversed score for personal accomplishment), and one point was assigned for subscale scores in the first quartile, whereas two, three, or four points were assigned for scores in the second, third, and fourth quartiles. The quartile points were added up, and the composite score was categorized into two groups: 3–8 points (low/middle composite burnout score) and 9–12 points (high composite burnout score). This scoring procedure has been used in previous studies [11, 12]. The English version of the MBI-HSS was translated into Danish and culturally adapted in accordance with the WHO guidelines [13].
Statistical methods
Sex and age of participants in the final study sample were compared to the background population of Danish GPs using chi2 test for categorical data. To assess the psychometric properties of the MBI in our study sample, we examined internal consistency reliability using Cronbach's alpha for the total scale and subscales. In addition, we evaluated floor and ceiling effects, defined as the proportion of participants scoring at the minimum or maximum possible score, respectively. Floor or ceiling effects were considered present if more than 15% of participants achieved the lowest or highest score. Associations between skill mix, a high number of working hours per week, a high number of hours per week used on administration, management and meetings in practice, and a high composite burnout score were investigated by generalized linear models for binary outcomes, estimating prevalence ratio (PR) with 95% confidence intervals for categories of skill mix use. Associations for employed nurses, medical secretaries, and OHCPs per GP in the practice were tested individually. When GPs sharing the same provider number disagreed on the number of HCPs employed, the number was excluded from the relevant analysis. Analyses were adjusted for the influence of sex, age, and clusters of GPs working in the same practice. A P-value of ≤0.05 was considered statistically significant. Analyses were performed with Stata v.18.
Patient and public involvement
GP representatives were involved in refining the questionnaire survey. Due to data protection restrictions, we could not involve GPs in other areas than study design. The results of the study will be disseminated to GPs at national conferences and to the public through social media and podcasts. No patients were involved in the study.
Results
The electronic link to the survey was sent to 3420 GPs, and responses from 1659 GPs in 1045 practices were included in the analyses (response rate = 49%). Comparisons of participants in the final sample with GPs in the background population revealed that women were more frequent among responders (64%) than in the total population (59%) (chi2 = 9.12, P = 0.003) whereas GPs older than 65 years were less frequent among responders (4%) than in the total population (8%) (chi2 = 30.00, P < 0.001).
The MBI demonstrated good internal consistency in our sample, with Cronbach's α values of 0.93 for the total scale and 0.79–0.93 across subscales. No significant floor or ceiling effects were observed: 0.00–3.13% of participants scored at the minimum and 0.06–0.12% at the maximum, both below the 15% threshold.
Characteristics of the included GPs are shown in Table 1. Eighty percent worked in partnership practices, and 604 GPs (36.4%) had a high composite burnout score. The use of skill mix is shown in Table 2. Note that the share of practices that did not use skill mix was higher among single-handed practices than among partnership practices.
Table 1.
Characteristics of the included 1659 general practitioners from 1045 practices.
| Characteristics | Number (%) |
|---|---|
| Sex | |
| Females | 1060 (63.9) |
| Males | 599 (36.1) |
| Age groups in years | |
| 40 or younger | 121 (7.3) |
| 41–50 | 721 (43.5) |
| 51–60 | 582 (35.1) |
| 61–65 | 171 (10.3) |
| 66 or older | 64 (3.9) |
| Type of practice | |
| Single-handed | 329 (19.8) |
| Partnership | 1330 (80.2) |
| Working hours per week | |
| ≤40 | 562 (33.9) |
| 41–45 | 453 (27.3) |
| 46–50 | 408 (24.6) |
| ≥51 | 236 (14.2) |
| Hours used on administration, management and meetings in practice per week | |
| Less than 1 hour | 373 (22.5) |
| Approx. 1–2 hours | 885 (53.4) |
| Approx. 3–4 hours | 300 (18.1) |
| More than 4 hours | 101 (6.1) |
| Composite burnout score | |
| 3–4 (low) | 372 (22.4) |
| 5–6 (low) | 351 (21.2) |
| 7–8 (low) | 332 (20.0) |
| 9–10 (high) | 352 (21.2) |
| 11–12 (high) | 252 (15.2) |
Table 2.
Use of skill mix in 1045 single-handed and partnership practices.
| All practices N (%) 1045 (100.0) |
Single-handed practices N (%) 329 (31.5) |
Partnership practices N (%) 716 (68.5) |
|
|---|---|---|---|
| Healthcare professionals per GP in practice | |||
| Nurses | |||
| 0 | 138 (13.2) | 89 (27.1) | 49 (6.8) |
| >0–1 | 694 (66.4) | 146 (44.4) | 548 (76.5) |
| >1 | 178 (17.0) | 94 (28.6) | 84 (11.7) |
| Practices with disagreement | 35 (3.3) | — | 35 (4.9) |
| Medical secretaries | |||
| 0 | 283 (27.1) | 137 (41.6) | 146 (20.4) |
| >0–1 | 604 (57.8) | 149 (45.3) | 455 (63.5) |
| >1 | 68 (6.5) | 43 (13.1) | 25 (3.5) |
| Practices with disagreement | 90 (8.6) | — | 90 (12.6) |
| Other healthcare professionalsa | |||
| 0 | 522 (50.0) | 214 (65.1) | 308 (43.0) |
| >0–1 | 375 (35.9) | 76 (23.1) | 299 (41.8) |
| >1 | 58 (5.6) | 39 (11.9) | 19 (2.7) |
| Practices with disagreement | 90 (8.6) | — | 90 (12.6) |
aCommunity care workers, midwives, physiotherapists, laboratory technicians, pharmacists, pharmacologists, and psychologists.
Among GPs working in either single-handed or partnership practices, use of skill mix was not linked to longer weekly working hours (Tables 3 and 4). Employing more OHCPs in the practices did not decrease the proportion of GPs working more than 45 hours per week.
Table 3.
Single-handed practices: associations between skill mix and working hours per week, hours per week used on administration, management and meetings in practice, and burnout (N = 329).
| High number of working hours per week (>45) | High number of hours per week (≥3) used on administration, management and meetings in practice | A high composite burnout score | ||||
|---|---|---|---|---|---|---|
| N in highest group of working hours/total N (%) | Prevalence ratio PRadja (95% CI) | N using a high number of hours on administration/total N (%) | Prevalence ratio PRadja (95% CI) | N with high composite burnout score/total N (%) | Prevalence ratio PRadja (95% CI) | |
| Number of nurses per GP | ||||||
| 0 | 45/89 (50.6) | 1.00 | 9/89 (10.1) | 1.00 | 40/89 (44.9) | 1.00 |
| >0–1 | 76/146 (52.1) | 1.03 (0.80–1.34) | 28/146 (19.2) | 1.69 (0.84–3.40) | 47/146 (32.2) | 0.69 (0.50–0.96) |
| >1 | 59/94 (62.8) | 1.25 (0.96–1.62) | 23/94 (24.5) | 2.07 (1.01–4.25) | 27/94 (28.7) | 0.62 (0.42–0.92) |
| Number of secretaries per GP | ||||||
| 0 | 69/137 (50.4) | 1.00 | 24/137 (17.5) | 1.00 | 55/137 (40.2) | 1.00 |
| >0–1 | 84/149 (56.4) | 1.12 (0.90–1.40) | 26/149 (17.5) | 0.94 (0.57–1.55) | 47/149 (31.5) | 0.78 (0.57–1.07) |
| >1 | 27/43 (62.8) | 1.25 (0.94–1.66) | 10/43 (23.3) | 1.19 (0-62–2.28) | 12/43 (27.9) | 0.69 (0.41–1.17) |
| Number of OHCPsb per GP | ||||||
| 0 | 117/214 (54.7) | 1.00 | 33/214 (15.4) | 1.00 | 68/214 (31.8) | 1.00 |
| >0–1 | 42/76 (55.3) | 1.01 (0.80–1.28) | 16/76 (21.1) | 1.20 (0.70–2.05) | 31/76 (40.8) | 1.25 (0.89–1.76) |
| >1 | 21/39 (53.9) | 0.98 (0.72–1.36) | 11/39 (28.2) | 1.43 (0.78–2.62) | 15/39 (38.4) | 1.16 (0.74–1.82) |
aAdjusted for age and sex of GP and clusters of GPs in partnership practices. bOther healthcare professionals: Community care workers, midwives, physiotherapists, laboratory technicians, pharmacists, pharmacologists, and psychologists. Bold indicates statistical significance, P < .05.
Table 4.
Partnership practices: associations between skill mix and working hours per week, hours per week used on administration, management and meetings in practice, and burnout (N = 1330).
| High number of working hours per week (>45) | High number of hours per week (≥3) used on administration, management and meetings in practice | A high composite burnout score | ||||
|---|---|---|---|---|---|---|
| N in the highest group of working hours/total N (%) | Prevalence ratio PRadja (95% CI) | N using a high number of hours on administration/total N (%) | Prevalence ratio PRadja (95% CI) | N with high composite burnout score/total N (%) | Prevalence ratio PRadja (95% CI) | |
| Number of nurses per GP | ||||||
| 0 | 28/70 (40.0) | 1.00 | 22/70 (31.4) | 1.00 | 35/70 (50.0) | 1.00 |
| >0–1 | 347/1041 (33.3) | 0.83 (0.61–1.15) | 243/1041 (23.3) | 0.73 (0.50–1.07) | 384/1041 (36.9) | 0.72 (0.55–0.92) |
| >1 | 54/131 (41.2) | 1.02 (0.71–1.47) | 45/131 (34.4) | 1.10 (0.72–1.68) | 41/131 (31.3) | 0.65 (0.46–0.90) |
| Number of secretaries per GP | ||||||
| 0 | 76/253 (30.0) | 1.00 | 70/253 (27.7) | 1.00 | 84/253 (33.2) | 1.00 |
| >0–1 | 288/797 (36.1) | 1.18 (0.94–1.47) | 202/797 (25.4) | 0.91 (0.69–1.19) | 306/797 (38.4) | 1.16 (0.93–1.39) |
| >1 | 15/35 (42.9) | 1.29 (0.84–1.96) | 11/35 (31.4) | 1.09 (0.61–1.94) | 17/35 (48.6) | 1.48 (0.99–2.21) |
| Number of OHCPs b per GP | ||||||
| 0 | 177/533 (33.2) | 1.00 | 136/533 (25.5) | 1.00 | 185/533 (34.7) | 1.00 |
| >0–1 | 182/530 (34.3) | 1.05 (0.87–1.26) | 139/530 (26.3) | 1.02 (0.82–1.28) | 201/530 (37.9) | 1.07 (0.90–1.27) |
| >1 | 7/27 (25.9) | 0.81 (0.45–1.45) | 14/27 (51.9) | 2.04 (1.35–3.09) | 14/27 (51.9) | 1.55 (1.11–2.17) |
aAdjusted for age and sex of GP and clusters of GPs in partnership practices. bOther healthcare professionals: Community care workers, midwives, physiotherapists, laboratory technicians, pharmacists, pharmacologists, and psychologists. Bold indicates statistical significance, P < .05.
For single-handed GPs, employing more than one nurse compared to not employing a nurse doubled the propensity of using a high number of working hours on administration (PR = 2.07, 95% CI = 1.01–4.25) (Table 3). For partnership GPs, employing more than one OHCP per GP compared to employing no OHCPs, doubled the propensity of using a high number of working hours on administration (PR = 2.04, 95% CI = 1.35–3.09) (Table 4).
Employing nurses was associated with a decreased probability of a high composite burnout score for both single-handed and partnership GPs. GPs in both types of practices almost halved their probability of a high composite burnout score when employing more than one nurse per GP in practice (PRsingle-handed GPs = 0.62, 95% CI = 0.42–0.92; PRpartnership GPs = 0.65, 95% CI = 0.46–0.90) (Tables 3 and 4). For partnership practices, employment of more than one OHCP per GP was associated with increased probability of high composite burnout score compared to employing no OHCPs (PR = 1.55, 95% CI = 1.11–2.17) (Table 4).
Discussion
Summary of primary findings
Our study showed that GPs employing nurses had a lower probability of burnout, and partnership GPs employing more than one OHCP per GP had a higher probability of burnout compared to GPs employing no nurses and no OHCPs, respectively. Partnership GPs employing more than one OHCP per GP used more working hours on administration, management and meetings in practice compared to partnership GPs employing no OHCPs. The same was found in single-handed GPs employing more than one nurse per GP compared to single-handed GPs employing no nurses. Despite that the skill mix was associated with a high number of working hours used on administration, management and meetings, the skill mix was not associated with GPs' number of total working hours per week.
Strengths and limitations
This study benefited from the use of a national register for the identification of GPs, which enabled accurate estimation of staff-to-GP ratios within practices. Although the overall response rate was satisfactory, the final sample size was reduced due to the exclusion of GPs from partnership practices where discrepancies existed regarding the number of employed staff. This exclusion may have reduced the statistical power of the analyses.
To enhance data validity, only partnership practices with internal agreement on staff numbers were included, allowing for internal cross-validation of responses. To facilitate survey completion and reduce respondent burden, participants were presented with a predefined list of staff categories and asked to report the number of employed staff irrespective of weekly working hours. We did not collect data on full-time equivalents, which would have improved the validity of the skill-mix. Counting staff per GP without accounting for their working hours may conceal the actual support capacity and distort associations with GP workload or burnout. Moreover, the predefined list of staff categories was not exhaustive.
HCPs were combined into a single aggregated HCP category (OHCPs), which may have complicated the interpretation of results. Unfortunately, a disaggregated analysis was not possible due to low numbers of many staff categories.
The cross-sectional design of the study limits causal interpretation. The associations may reflect reverse causality, for example, satisfied GPs may hire nurses, while burned-out GPs recruit more OHCPs. A third factor, such as shortages of both GPs and nurses [14], could also explain the findings: GP shortages increase burnout risk, and when nurses are scarce, other HCPs are employed instead.
Finally, the study included only practice owners, reflecting the Danish context, and the sample contained more women and fewer participants from the oldest age group compared to the background population of GPs, which may have reduced the generalizability of results.
Comparison with existing literature
The finding that use of skill mix was not associated with a high number of working hours per week in GPs working in neither single-handed practices nor partnership practices corresponds to previous research suggesting that employment of non-physician staff has a limited impact on GPs' average hours worked per week [6, 15]. Meanwhile, in single-handed practices and in partnership practices, it was suggested that the use of skill mix was associated with a high number of hours per week used on administration, management and meetings in practice. This indicates that the use of skill mix is linked to a shift in how GPs allocate their working hours, with a larger portion devoted to administrative and managerial tasks. This finding is consistent with previous research showing that management challenges frequently stem from the complex adjustments needed to reorganize practices around new roles, as well as the significant oversight GPs must provide to individuals who are often unfamiliar with the primary care setting [16].
Previous research from the UK has shown a non-significant association between a high number of employed HCPs and low job satisfaction [6, 15]. Similarly, our results reported an association between a high number of employed HCPs and increased risk of burnout in GPs working in partnership practices. This relationship may be due to the substantial supervision GPs often need to provide while HCPs adapt to the primary care setting [16], and a survey of primary care professionals found that only 26% of HCPs are entrusted with advanced responsibilities, such as managing and caring for complex patients [17]. Furthermore, the involvement of a large number of HCPs in primary care settings has been linked to lower patient satisfaction, highlighting the need for GPs to clarify and justify these new roles to patients [6, 16].
Contrary to previous studies reporting no significant link between nurse staffing levels and job satisfaction [6, 15], our findings indicate that a higher number of employed nurses is associated with reduced burnout risk. Unlike UK studies that included various nurse categories, our analysis focused solely on fully qualified nurses.
The observed reduction in physicians' risk of burnout when nurses are employed may be attributable to the nurses' ability to deliver high-quality, and in some cases superior, clinical outcomes when taking care of patients with complex health needs in primary care settings [18–20]. Patient experiences of skill mix in primary care obtained through focus group interviews revealed that patients quickly developed a trusting relationship with nurses who, in comparison with GPs, often provided longer consultations and considered the patient as “a whole” rather than dealing with one ailment [21]. The ability to confidently delegate a substantial proportion of consultations and follow-ups with patients suffering from chronic conditions to a practitioner nurse seems to represent a clear reduction in workload for general practitioners and contributes to high levels of job satisfaction.
Implications for research and practice
As new staff groups are incorporated into primary care teams, patients have at times expressed skepticism toward these roles. Further, GPs have raised concerns that diminished continuity of care may undermine job satisfaction and elevate the risk of burnout [22]. Continuity of care is described as one of the cornerstones of primary care [23, 24]. Our results suggest that employing nurses in primary care is not detrimental to GP job satisfaction. Future research should explore whether perceived continuity of care is maintained when nurses are added to the team, from both provider and patient perspectives [25]. Although greater team involvement may reduce relational continuity, defined as the ongoing personal relationship between patient and GP [26], continuity of care also includes informational and managerial continuity. These dimensions encompass the transfer of relevant patient information and the coordinated management of care across providers [26]. When these dimensions of continuity function effectively at the practice level, they may create a shared “collective memory” within the team and support a cohesive, collaborative care process beyond individual encounters.
Conversely, employing OHCPs in primary care may either increase the risk of GP burnout or reflect a strategy adopted by GPs already burdened by a high workload. The association between employment of OHCPs and increased probability of burnout was found only for GPs employing more than one OHCP per GP in practice. It could be hypothesized that when the number of OHCPs exceeds the number of GPs, this reflects that OHCPs are employed as substitutes for GPs, which supposedly would be more likely in areas with GP and nurse shortages and high risk of burnout a priori.
Since the study is cross-sectional and does not cover the mechanisms responsible for the observed association between a high number of OHCPs and increased risk of burnout, more research is needed concerning the quality of care, practice activity, and health system costs. Moreover, further research-based guidance is needed on how to effectively integrate HCPs into the primary care setting. This would help to ensure that the development of a balanced staffing model aligned with patient and system needs is not left solely to the judgment of individual practices.
Conclusions
The purpose of this study was to examine whether the use of skill mix was associated with working hours and risk of burnout in general practice. Working hours were not associated with skill mix, but the findings suggest they may be reallocated toward administrative and managerial tasks in practices with more nurses. A high number of OHCPs was associated with increased risk of burnout, and a high number of nurses was associated with decreased risk of burnout. Associations were stronger for GPs in partnership practices who also used more skill mix than single-handed GPs. Although causality cannot be determined, the results are suggestive that task-shifting from GPs to nurses could unburden the GP. Although the employment of OHCPs was not associated with increased workload regarding working hours, it was still associated with increased risk of burnout, suggesting that HCPs are employed by the GPs when working conditions are considered burdensome. Future studies should examine whether the strength of the associations is affected by whether obtained in underserved or affluent areas. Moreover, future studies using longitudinal or quasi-experimental designs will be essential.
Contributor Information
Anette Fischer Pedersen, Research Unit for General Practice, Bartholins Allé 2, Aarhus C 8000, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus N 8200, Denmark.
Peter Vedsted, Research Unit for General Practice, Bartholins Allé 2, Aarhus C 8000, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus N 8200, Denmark; Medical Diagnostic Centre, University Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1, Silkeborg 8600, Denmark.
Author contributions
Anette Fischer Pedersen (Conceptualization, Formal analysis, Writing—original draft, Writing—review & editing) and Peter Vedsted (Conceptualization, Data curation, Writing—review & editing)
Funding
The Danish Organization of General Practitioners has supported the survey. The organisation has not been involved in the analysis of data or the preparation of the manuscript.
Ethics approval
According to Danish law, the study needed no approval from the National Committee on Health Research Ethics as no biomedical intervention was included.
Data availability
Data are stored at Statistics Denmark, Copenhagen, and the access to the research data is restricted in accordance with the general data protection regulations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are stored at Statistics Denmark, Copenhagen, and the access to the research data is restricted in accordance with the general data protection regulations.