Task delegation in emerging chronic diseases: Long COVID care as a paradigm - a cross-sectional study

Abstract

Background

Emerging chronic diseases like Long COVID challenge traditional care models, creating therapeutic voids that nurses spontaneously fill through informal task delegation. This study examines nursing roles delegated in Long COVID care and identifies implications for nursing administration.

Methods

A cross-sectional study was conducted among 362 nurses in France’s Rhône-Alpes region (December 2023-March 2024). An online questionnaire assessed Long COVID care roles and delegation patterns.

Results

Among participants, 39.8% (95% CI: 34.8–44.9%) had cared for Long COVID patients. Primary delegated roles included psychological support (86.8%, 95% CI: 80.0-91.8%), proximity care (72.9%), screening/detection (42.4%, 95% CI: 34.2–50.9%), and therapeutic education (70.8%). Nurses performing screening roles were significantly more likely to also perform coordination activities (OR = 3.87, 95% CI: 1.92–7.80, p < 0.001) and therapeutic education (OR = 5.63, 95% CI: 2.37–13.36, p < 0.001). Private practice nurses demonstrated significantly greater task appropriation. Despite the quasi-total absence of specific training (1.4%), 80.4% (95% CI: 73.1–86.3%) of nurses with Long COVID care experience declare themselves ready to formally assume coordination responsibilities for Long COVID patient pathways.

Conclusions

Nurses spontaneously appropriate medical roles when confronting emerging diseases. Nursing administration must formalize this informal delegation through structured training and policy frameworks to optimize chronic disease management. The screening role assumed by nurses represents a significant evolution in diagnostic responsibilities distribution, requiring recognition and structured support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-04249-5.

Background

Contemporary epidemiological evolution is characterized by the emergence of new complex chronic pathologies that challenge traditional medical care models. Long COVID, a post-infectious syndrome affecting 10–20% of SARS-CoV-2 infected patients according to the World Health Organization, constitutes a paradigmatic example of these emerging chronic diseases [1, 2].

These new pathologies share common characteristics: fluctuating and multisystemic symptomatology, diagnostic uncertainty, absence of standardized treatments, and the necessity for prolonged follow-up [3, 4]. Faced with these challenges, healthcare systems must rethink care organization, particularly through task delegation to non-physicians’ healthcare professionals.

Task delegation, or “task shifting,” defined as the rational transfer of certain traditionally medical functions to other qualified healthcare professionals, emerges as an adaptation strategy facing the growing complexity of health needs [5, 6]. This approach, initially developed to address medical shortages in certain regions according to WHO recommendations in the context of AIDS disease [7], finds new relevance in managing emerging chronic diseases.

However, beyond formalized delegation through health policies, there exists a phenomenon of informal delegation that merits particular attention. Informal delegation is operationally defined in this study as nurses performing roles traditionally reserved for physicians (particularly screening/detection activities) without formal institutional protocols or specific training for these expanded responsibilities [8–10].

This informal delegation is particularly illustrated in screening functions, traditionally medical but spontaneously taken on by nurses in response to failures in the early detection system. Long COVID screening, characterized by fluctuating and multisystemic symptomatology requiring continuous clinical vigilance, exemplifies this spontaneous appropriation of diagnostic responsibilities by frontline professionals. Unlike formal delegation, which relies on established protocols and structured training, informal delegation stems from practical necessity and contextual adaptation by field professionals.

Nurses, through their clinical competencies, proximity to patients, and adaptability, appear as natural candidates to assume these new responsibilities [11]. In France, although their code of ethics and competencies already allow them to actively participate in clinical data collection, screening, health education, and care coordination [12], there is no regulatory framework in the case of crisis situation.

Despite growing documentation of task shifting in established chronic diseases, the spontaneous emergence of nursing roles in novel pathological contexts remains poorly characterized. The mechanisms by which nurses adapt their practice to fill therapeutic voids created by emerging diseases, and the factors influencing this adaptation, have not been systematically examined. This study aimed to characterize the informal delegation of tasks to nurses caring for patients with Long COVID and to examine the factors that influence this spontaneous appropriation of new roles.

Methods

Study design and population

A cross-sectional study using a descriptive-analytical design was conducted between December 2023 and March 2024. The source population consisted of registered nurses (RNs) enrolled in the nurses’ order in the Rhône-Alpes region. This region was chosen for its diversity of practice (urban/rural, private/salaried) representative of task delegation challenges in French territory.

Inclusion criteria

Registered nurses enrolled in French Nursing Order, currently practicing in Rhône-Alpes region and willing to participate voluntarily.

Exclusion criteria

Nursing students not yet registered, retired nurses no longer in active practice, nurses practicing exclusively outside Rhône-Alpes.

Data collection

A convenience sampling approach was used. Invitations to participate were distributed via the URPS nurses’ mailing list (approximately 7,500 nurses) and DAC networks. An initial mailing was sent out in February 2024, followed by two reminders in March and April 2024. The final sample of 362 nurses represents a response rate of approximately 4.8%.

Data were collected using an online self-administered questionnaire developed specifically for this study on the Lime Survey platform. The questionnaire was designed to capture informal task delegation patterns in Long COVID care, as no existing validated instrument addressed this specific phenomenon. An English translation of the complete questionnaire framework is provided as supplementary material (Additional file 1). The development process involved three phases:

• literature review of task delegation frameworks,

• expert consultation with 5 nursing professionals (3 clinical specialists, 1 academic, 1 administrator) reviewing content validity.

• pilot testing with 10 nurses assessing comprehensibility and completion time (mean: 12 min). Based on feedback, 2 questions reworded, and 1 redundant item removed.

The questionnaire employed multiple response formats adapted to each construct being measured. It was constructed according to a task delegation approach and collected: the participants’ sociodemographic characteristics (age, gender, practice setting), their practice setting (determining factor in delegation), the roles exercised with Long COVID patients, notably screening/detection activities defined as early identification of persistent symptoms and diagnostic orientation of patients, their willingness to assume coordination responsibilities and their perception of training needs to assume these new tasks. Attitudes, perceptions, and willingness measures (Sections D, E, G, H, I) were assessed using four-point Likert scales ranging from “Completely disagree” to “Completely agree”. The four-point format was deliberately chosen to eliminate the neutral midpoint option, thereby encouraging respondents to take definitive positions.

The main outcome measure in this study is informal task delegation. Most of the roles identified in this study are included in the French nursing competency framework [12]. However, the detection/screening role, which can be equated with early diagnosis, is a role reserved exclusively for physicians in France. Performing this role outside of a regulatory framework may be considered as informal task delegation.

Data analysis

We performed descriptive statistics. Analyses focused on identifying task delegation patterns. Univariate logistic regression analyses were performed. Dependent variable: screening/detection role adoption (yes/no) among nurses with Long COVID care experience (N = 144). Independent variables: practice setting, other role adoptions (coordination, therapeutic education, psychological support, proximity care), gender, years of experience. We did not perform multivariate analysis due to sample size limitations relative to number of potential predictors, which could lead to overfitting. All analyses were performed using Stata version 18. We selected this software for its robust handling of categorical data analysis and logistic regression analysis. Missing data were handled by pairwise deletion, with the actual number N specified for each analysis.

Results

Sample characteristics and delegation context

The study included 362 nurses, predominantly women (87.2%) with an average of 20.5 ± 7.8 years of experience. The predominance of private practice nurses (90.9%) is significant as this practice mode favors autonomy and appropriation of new tasks. Among them, 39.8% (N = 144) had already been confronted with the necessity of caring for Long COVID patients, a situation revealing the de facto delegation that occurs (Table 1).

Table 1.

Participant characteristics (N = 362)

Characteristics	N (%)
Gender
Female	314 (87.2)
Male	46 (12.8)
Age Groups
< 30 years	30 (8.3)
30–39 years	115 (31.8)
40–49 years	120 (33.1)
≥ 50 years	97 (26.8)
Years of nursing experience (mean ± SD)	20.5 ± 7.8 years
Practice Setting
Private practice	329 (90.9)
Salaried	33 (9.1)
Long COVID Care Experience
Cared for Long COVID patients	144 (39.8)
Never cared for Long COVID patients	218 (60.2)
Training Background
Received specific Long COVID training	2 (1.4)
No specific Long COVID training	142 (98.6)

Mapping of delegated tasks

The analysis of roles exercised reveals a de facto delegation structured around multiple domains. Among the 144 nurses who cared for Long COVID patients, psychological support was the most prevalent role (86.8%, 95% CI: 80.0-91.8%), representing a substitution for often inaccessible psychiatric follow-up. Proximity care (72.9%, 95% CI: 64.9–79.8%) compensates for insufficient close medical monitoring. Therapeutic education (70.8%, 95% CI: 62.7–78.0%) replaces medical information consultations. Screening/detection (42.4%, 95% CI: 34.2–50.9%) constitutes a particularly significant delegated diagnostic function: nurses spontaneously develop skills in identifying persistent Long COVID symptoms, thus compensating for diagnostic delays and difficulties in accessing specialized consultations. Coordination activities were assumed by 55.6% (95% CI: 47.2–63.7%) of nurses providing Long COVID care (Table 2).

Table 2.

Roles adopted by nurses in Long COVID care (N = 144) ᵃ

Role category	N (%)	Educational implications
Psychological Support	125 (86.8)	Advanced therapeutic communication, crisis intervention
Proximity Care	105 (72.9)	Chronic disease monitoring, symptom assessment
Therapeutic Education	102 (70.8)	Patient education methodologies, health behaviour change
Prevention	99 (68.8)	Public health principles, risk communication
Coordination	80 (55.6)	Care pathway development, interprofessional collaboration
Screening/Detection	61 (42.4)	Clinical assessment skills, diagnostic reasoning
Consultation	43 (29.9)	Advanced clinical judgment, scope of practice boundaries
Clinical Research	18 (12.5)	Research methodology, evidence-based practice

ᵃ Multiple responses possible

The appropriation of the screening role by 42.4% (95% CI: 34.2–50.9%) of nurses who cared for Long COVID patients deserves analysis. This function, traditionally medical, proves particularly suited to nursing skills in clinical surveillance and symptom evaluation. In the context of Long COVID, where the complexity and variability of symptoms make medical diagnosis difficult, nurses develop field expertise based on longitudinal observation and relational proximity with patients.

Factors associated with screening role adoption

Among the 144 nurses who cared for Long COVID patients, 61 (42.4%) adopted screening/detection roles. Logistic regression analysis revealed that nurses who assumed screening roles were significantly more likely to also perform coordination activities (OR = 3.87, 95% CI: 1.92–7.80, p < 0.001) and therapeutic education (OR = 5.63, 95% CI: 2.37–13.36, p < 0.001). Practice setting (private vs. salaried) and demographic characteristics showed no significant association with screening role adoption (Table 3).

Table 3.

Factors associated with screening role adoption among Long COVID care providers (N = 144)

Variable	Screening role N = 61 (%)	No screening role N = 83 (%)	Odds ratio (95% CI)	p-value
Practice Type
Private practice	57 (93.4)	71 (85.5)	2.41 (0.73–7.94)	0.152
Salaried	4 (6.6)	12 (14.5)	Reference	--
Associated Roles
Coordination role	45 (73.8)	35 (42.2)	3.87 (1.92–7.80)	< 0.001
Therapeutic education	54 (88.5)	48 (57.8)	5.63 (2.37–13.36)	< 0.001
Demographics
Female	53 (86.9)	67 (80.7)	1.60 (0.61–4.21)	0.337
Years of experience (mean ± SD)	19.1 ± 10.8	19.9 ± 11.2	0.99 (0.97–1.02) b	0.654

^b Per year increase

Willingness for formalized delegation

Despite the quasi-total absence of specific training (1.4%), 80.4% (95% CI: 73.1–86.3%) of nurses with Long COVID care experience among those who responded to this question (N = 138, 6 missing responses) declare themselves ready to formally assume coordination responsibilities for Long COVID patient pathways, revealing strong acceptance of task delegation among experienced nurses. Identified barriers among non-ready nurses include feeling of incompetence and lack of resources, underscoring necessary conditions for successful delegation (Table 4).

Table 4.

Willingness and barriers to formal task delegation (N = 138)

Variable	N (%)
Willingness to Assume Formal Coordination Responsibilities
Ready to coordinate Long COVID patient pathways	111/138 (80.4)
Not ready or uncertain about coordination	27/138 (19.6)
Barriers to Coordination c
Feeling of insufficient competence	15/27 (55.6)
Lack of institutional resources	8/27 (29.6)
Time contraints	12/27 (44.4)
Practice Setting and coordination Readiness
Private practice nurses ready to coordinate	103/123 (83.7)
Salaried nurses ready to coordinate	8/15(53.3)

^c Among those not ready for coordination (N = 27)

Discussion

Informal task delegation as adaptive response to emerging chronic diseases

This study reveals a phenomenon of spontaneous adaptation by nurses facing traditional care system failures in managing emerging chronic diseases. Long COVID, through its complexity and novelty, created a therapeutic void that nurses spontaneously invested, perfectly illustrating the concept of informal task delegation.

This informal delegation presents distinctive characteristics documented in our study. First, contextual reactivity occurs where new role appropriation directly responds to patients’ uncovered needs. The predominance of psychological support role (86.8%) testifies to necessary substitution facing insufficient psychiatric care for Long COVID patients [13]. This reactivity fits within the “role expansion” concept described by Kleinpell et al., [14] where professionals naturally extend their competencies to meet patient needs.

Second, the absence of prior institutional framework distinguishes informal from formal delegation. Our results show that 39.8% of the entire sample developed and played at least one role in the care pathway of Long COVID patients, yet 98.6% of those with Long COVID care experience did not receive any specific training on this disease. This situation illustrates the “tacit delegation” concept described by Dubois et al., [15] where delegation occurs through practical necessity rather than institutional planning.

Third, there is dependence on individual initiatives. Analysis reveals strong inter-individual variability in role appropriation, particularly marked between private practice and employed nurses. This variability characterizes informal delegation, which largely depends on personal initiative and practice context, unlike formal delegation aiming at practice uniformity [8].

Finally, experiential learning processes emerge where skill acquisition occurs “in the field” through direct clinical experience, as identified in David Kolb’s Experiential Learning Theory [16]. This explains the willingness of nurses to coordinate pathways despite absence of structured training.

Screening as a paradigm of informal diagnostic delegation and role bundling

The screening role assumed by 42.4% of nurses who cared for Long COVID patients illustrates a major evolution in the distribution of diagnostic responsibilities. This spontaneous appropriation is explained by several convergent factors: the nature of Long COVID, with its protean and evolving manifestations, requires continuous clinical surveillance that the traditional medical system struggles to provide. Nurses, through their temporal and relational proximity with patients, become privileged observers of symptom evolution. This screening delegation fits into a logic of healthcare system efficiency. Rather than waiting for often delayed medical consultations, nurses develop early warning and diagnostic orientation skills, thus optimizing care pathways [17]. This evolution questions traditional boundaries between nursing surveillance and medical diagnosis, suggesting the emergence of an interprofessional zone where skills complement rather than substitute for each other.

The clustering of screening with coordination and education roles suggests that informal delegation follows a pattern of comprehensive care appropriation rather than isolated skill development. This role bundling [18] phenomenon indicates that in France, nurses in private practice are more likely to assume complementary responsibilities, creating integrated care models that transcend traditional professional boundaries. The strong associations found between screening adoption and both coordination (OR = 3.87) and therapeutic education (OR = 5.63) support this concept of synergistic role expansion.

Informal delegation across the Long COVID care pathway

The distribution of roles revealed in Table 2 reflects nurses’ spontaneous positioning throughout the entire Long COVID care pathway, creating a comprehensive care continuum managed informally by nursing professionals. This pattern suggests that nurses do not simply assume isolated tasks but rather orchestrate integrated care sequences that span from early detection to long-term management, consistent with our previous study [19].

In the detection phase, screening activities (42.4%) and consultation roles (29.9%) position nurses as the first point of contact for patients with persistent symptoms, effectively creating alternative access pathways when traditional medical routes are saturated or delayed. The assessment and stabilization phase sees nurses providing proximity care (72.9%) and psychological support (86.8%), addressing both the clinical monitoring needs and the significant emotional burden that characterizes Long COVID patients’ experiences.

This care pathway integration demonstrates that informal task delegation in emerging chronic diseases extends beyond simple role substitution to encompass the creation of parallel, nurse-led care systems.

Private practice status as informal delegation catalyst

The association between private practice status and delegated task appropriation reveals the importance of professional autonomy in the informal delegation process. This observation is consistent with Maier and Aiken’s theoretical model [6] identifying professional autonomy as a major determinant of successful task shifting.

Private practice nurses, less constrained by institutional protocols and organizational hierarchies, more easily develop adaptive roles facing emerging needs. This organizational flexibility constitutes an “enabling factor” of informal delegation according to Martinez-Gonzalez et al.‘s classification [5]. Three mechanisms explain this facilitation: first, decision-making autonomy. Private practice allows direct decision-making facing patient needs, without need for hierarchical validation. This autonomy favors personal initiative, an essential component of informal delegation as self-leading healthcare professionals take initiative and responsibility, using self-influencing strategies to improve their motivation and ability to respond to patient needs [20]. Second, relational proximity, where care continuity in private practice creates a privileged therapeutic relationship facilitating identification of uncovered needs and encouraging professional role extension [21]. Third, temporal flexibility, as work time organization in private practice allows adaptation to chronic patients’ specific needs, unlike institutional temporal constraints limiting practice innovation [22]. This situation illustrates the informal delegation paradox in health systems: the more structured and protocolized the practice framework, the less informal delegation can develop, even though it responds to real needs uncovered by formal organization [23].

Implications for nursing administration

From informal to formal delegation: administrative challenges: The marked willingness of nurses to assume coordination responsibilities despite absence of training reveals an informal delegation potential already operational but not institutionally recognized. This situation illustrates the informal delegation paradox: it is both necessary for system functioning and invisible to policy makers.

Transition mechanisms from informal to formal: Literature identifies several stages in informal delegation formalization [24, 25]. The recognition phase involves identification of existing informal practices and their added value. Our study fits within this phase by documenting roles spontaneously developed by nurses. The validation phase encompasses evaluation of effectiveness and safety of these informal practices. Positive reported results suggest de facto effectiveness of this informal delegation. The structuring phase includes development of training, protocols, and adapted regulatory frameworks.

Administrative recommendations: Based on study findings, nursing administration should consider several key areas. Training program development should focus on creating continuing education programs specifically targeting emerging chronic diseases to structure existing informal delegation. Policy framework adaptation involves developing organizational policies recognizing expanded nursing roles while maintaining accountability frameworks. Resource allocation requires establishing dedicated support structures and resources to sustain nurses in these expanded responsibilities. Performance measurement necessitates implementing metrics to evaluate outcomes of both informal and formalized task delegation initiatives.

Study limitations

This study presents some limitations that warrant careful consideration in interpreting findings. The response rate of 4.8% represents a limitation that introduces potential selection bias. This low rate, although consistent with online surveys, could affect the generalisation of the results.

First, nurses who chose to respond may be more engaged with Long COVID issues or have direct experience with affected patients, potentially overestimating the prevalence of informal delegation practices in the broader nursing population. This could explain the finding that 39.8% of respondents had cared for Long COVID patients.

Second, the predominantly private practice composition (90.9%) likely reflects both greater survey engagement among autonomous practitioners and more effective dissemination through URPS professional networks. This over-representation limits direct generalization to institutional settings where organizational constraints, hierarchical structures, and formal protocols may substantially modify informal delegation patterns. However, this finding provides valuable insights into contexts where professional autonomy enables informal delegation to emerge naturally.

In sections containing Likert scale questions, we calculated Cronbach’s alpha coefficients but did not present them. In some cases, they were low. This is consistent with the literature [26, 27], as our questionnaire was designed for descriptive study purposes and not as a psychometric scale.

Despite these limitations, several factors support the value of our findings. The large absolute sample size (N = 362) enables detection of meaningful associations, as evidenced by the strong odds ratios identified (e.g., OR = 3.87 for coordination among nurses performing screening). The consistency of role clustering patterns and the theoretical coherence of findings with established task delegation frameworks suggest we have captured genuine phenomena rather than artifacts of sampling. Moreover, the exploratory nature of this first systematic documentation of informal delegation in emerging chronic diseases means these findings provide important preliminary evidence to guide more rigorous future investigations using probability sampling or mixed methods approaches.

The absence of formal psychometric validation including internal consistency testing reflects the questionnaire’s design as a descriptive behavioral survey rather than a psychometric scale. While this limits use of the instrument for measuring change in intervention studies, it is methodologically appropriate for the present exploratory aim of documenting delegation patterns.

Conclusions

This study demonstrates the existence of structured and functional informal task delegation that nurses spontaneously develop when facing emerging chronic diseases. Long COVID, as a paradigm of these new pathologies, reveals natural adaptive mechanisms of the care system and confirms nurses’ potential in this evolution.

For nursing administration, the primary practical implication is clear: formal recognition and structured support of these informally developed competencies through dedicated training programs and regulatory frameworks is essential. Specific actions required include: developing nursing screening protocols for Long COVID, combined appropriate education, legitimizing demonstrated clinical expertise.

This transition from informal to formal delegation requires immediate action to maintain care quality and professional accountability as emerging chronic diseases continue to challenge traditional care models.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

OLK, JG, and BB drafted the project and the study design. CD and BB managed the statistics aspects. EBN, MN and BB coordinated the writing of the manuscript at all stages. OLK, MN and LR supervised data collection. All authors contributed to the design of the manuscript, read, and approved final version of the manuscript before submission.

Funding

This study is part of the SPACO + project, which has received funding from ANRS - Agence Nationale de la Recherche / Emerging Infectious Diseases. (Grant number: ANRS283). The funders were not involved in the design of the study, the collection and analysis of the data, the decision to publish or the preparation of the manuscript.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study received approval from the ethics committee of Saint-Étienne University Hospital under reference IRBN1282023/CHUSTE and was conducted in full accordance with the principles of the Declaration of Helsinki. All participants provided informed consent for participation through their completion of the online questionnaire.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.