Nurses' roles in emerging chronic disease management: task delegation in Long COVID care as a paradigm - A cross-sectional study

Nurses' roles in emerging chronic disease management: task delegation in Long COVID care as a paradigm - A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Nurses' roles in emerging chronic disease management: task delegation in Long COVID care as a paradigm - A cross-sectional study Odette Linda Kamdem, Caroline Dupre, Jessica Guyot, Louise Ruiz, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7375791/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Jan, 2026 Read the published version in BMC Nursing → Version 1 posted 11 You are reading this latest preprint version 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% had cared for Long COVID patients. Primary delegated roles included psychological support (82.6%), proximity care (64.6%), screening/detection (44.4%), and therapeutic education (42.4%). Private practice nurses demonstrated significantly greater task appropriation. Despite the quasi-total absence of specific training (1.4%), 80.4% 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. Task delegation nursing administration Long COVID care coordination role expansion chronic disease management 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. This informal delegation may be defined as the spontaneous appropriation by non-physician healthcare professionals of roles and responsibilities traditionally medical, in response to health needs inadequately covered by the existing system ( 8 – 10 ). Thus, the informal task delegation could particularly be 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. The hypothesis of this research is that when facing emerging chronic diseases, nurses spontaneously develop substitution and complementary roles to traditional medical care, following a logic of informal but necessary task delegation. This informal delegation, defined as the unplanned appropriation of responsibilities facing emerging health needs, constitutes an organizational adaptation mechanism documented in the literature ( 13 , 14 ). It is distinguished from formal delegation by its reactive character, absence of prior institutional framework, and dependence on individual professional initiatives ( 15 ). This study therefore aims to characterize this informal delegation through the Long COVID example and examine factors influencing this spontaneous appropriation of new roles. Methods Study design and population A cross-sectional descriptive study 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. Data collection 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. The development process involved literature review of task delegation frameworks, expert consultation with nursing professionals, and pilot testing to ensure content validity and comprehensibility. An English translation of the complete questionnaire framework is provided as supplementary material (Additional file 1). Nurses were solicited by email via the Regional Union of Liberal Health Professionals (URPS nurses) and Coordination Support Devices (DAC). A reminder was sent on February 1, 2024. The questionnaire, constructed according to a task delegation approach, collected: Participants' sociodemographic characteristics (age, gender, practice setting) Their practice setting (determining factor in delegation) 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. Their perception of training needs to assume these new tasks. 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. Logistic regression analyses were performed to investigate the relationship between informal task delegation (Screening/detection) and the different characteristics of the participants. The analyses were carried out with the Stata v18 software. 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%), representing a substitution for often inaccessible psychiatric follow-up. Proximity care (72.9%) compensates for insufficient close medical monitoring. Therapeutic education (70.8%) replaces medical information consultations. Screening/detection (42.4%) 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% 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 Among nurses who had cared for Long COVID patients ; multiple responses possible The appropriation of the screening role by 42.4% of nurses who cared for Long COVID patients deserves particular 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% of nurses with Long COVID care experience 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 = 144) 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 several distinctive characteristics documented in our study. The first characteristic is contextual reactivity, 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( 16 ). This reactivity fits within the "role expansion" concept described by Kleinpell et al., ( 17 ) where professionals naturally extend their competencies to meet patient needs. The second characteristic involves the absence of prior institutional framework. Unlike formal delegation relying on established protocols ( 5 ), 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. However, we observe that 98.6% of those who have 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., ( 18 ) where delegation occurs through practical necessity rather than institutional planning. A third distinctive feature is the 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, there is an experiential learning process where skill acquisition occurs "in the field" through direct clinical experience. This process, is identified in the light of David Kolb's Experiential Learning Theory ( 19 ) and 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 ( 20 ). Finally, 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 ( 21 ) 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( 22 ) 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 significant 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: Decision-making autonomy represents the first mechanism. 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 ( 20 ). The second mechanism involves relational proximity, where care continuity in private practice creates a privileged therapeutic relationship facilitating identification of uncovered needs and encouraging professional role extension ( 23 ). The third mechanism is temporal flexibility, as work time organization in private practice allows adaptation to chronic patients' specific needs, unlike institutional temporal constraints limiting practice innovation ( 14 ). 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 ( 24 ). 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 classic 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 ( 25 , 26 ). 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 certain limitations inherent to informal delegation exploration. The over-representation of private practice nurses (90.9%) limits direct generalization to institutional settings but provides valuable insights into contexts where informal delegation naturally emerges. This finding could have international transferability as private practice autonomy patterns are consistent across healthcare systems globally. Self-reporting may induce social desirability bias, particularly when describing unofficially recognized practices. However, this methodological innovation in quantifying informal delegation. 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. The transition from informal to formal requires a training-regulation-organization triptych that recognizes and structures these innovative practices, particularly in the screening domain where nursing skills in clinical evaluation find a particularly relevant application, while preserving their adaptive capacity. For nursing care administration, this study particularly highlights the need to recognize and supervise screening skills developed informally by nurses. The development of nursing screening protocols, combined with appropriate training, could optimize early detection of emerging chronic diseases while valorizing the field expertise of professionals. 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. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors' 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. Acknowledgements The authors thank the Regional Union of Liberal Health Professionals (URPS nurses) and Coordination Support Devices (DAC) for their assistance in participant recruitment. We also thank all the participants of this study and Pr. Franck CHAUVIN (Director of PRESAGE Institute). References WHO. WHO Coronavirus (COVID-19). Dashboard [Internet]. 2023 [cité 9 août 2023]. Disponible sur: https://covid19.who.int Cárdaba-García RM, Durantez-Fernández C, Pérez LP, Barba-Pérez MÁ, Olea E. What Do We Know Today about Long COVID? Nursing Care for a New Clinical Syndrome. Int J Environ Res Public Health 15 juill. 2022;19(14):8642. Davis HE, McCorkell L, Vogel JM, Topol EJ. 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Supplementary Files 20250825studyQuestionnaire.docx Cite Share Download PDF Status: Published Journal Publication published 02 Jan, 2026 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 15 Oct, 2025 Reviews received at journal 15 Oct, 2025 Reviewers agreed at journal 05 Oct, 2025 Reviews received at journal 23 Sep, 2025 Reviewers agreed at journal 23 Sep, 2025 Reviewers agreed at journal 08 Sep, 2025 Reviewers invited by journal 03 Sep, 2025 Editor assigned by journal 03 Sep, 2025 Editor invited by journal 26 Aug, 2025 Submission checks completed at journal 25 Aug, 2025 First submitted to journal 25 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7375791","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":511766265,"identity":"39eecda3-7de7-42f4-ba60-ce979eb54631","order_by":0,"name":"Odette Linda Kamdem","email":"","orcid":"","institution":"INSERM, SAINBIOSE, University Jean Monnet, U1059","correspondingAuthor":false,"prefix":"","firstName":"Odette","middleName":"Linda","lastName":"Kamdem","suffix":""},{"id":511766266,"identity":"ad17dde2-82d7-4480-bf59-40a20308eb51","order_by":1,"name":"Caroline Dupre","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Saint-Etienne","correspondingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"","lastName":"Dupre","suffix":""},{"id":511766269,"identity":"14401b88-532a-4082-8035-9cac0d8d4395","order_by":2,"name":"Jessica Guyot","email":"","orcid":"","institution":"INSERM, SAINBIOSE, University Jean Monnet, U1059","correspondingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"","lastName":"Guyot","suffix":""},{"id":511766271,"identity":"e00a2a93-cd66-4bf5-87bf-ee2c611defe2","order_by":3,"name":"Louise Ruiz","email":"","orcid":"","institution":"URPS nurses’AURA","correspondingAuthor":false,"prefix":"","firstName":"Louise","middleName":"","lastName":"Ruiz","suffix":""},{"id":511766273,"identity":"96811022-02f9-4e03-9199-4eac9395b2aa","order_by":4,"name":"Mabrouk Nekaa","email":"","orcid":"","institution":"Lumière University Lyon 2","correspondingAuthor":false,"prefix":"","firstName":"Mabrouk","middleName":"","lastName":"Nekaa","suffix":""},{"id":511766274,"identity":"8e8a4c96-9a78-496e-9218-933be2bf1428","order_by":5,"name":"Elisabeth Botelho-Nevers","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Saint-Etienne","correspondingAuthor":false,"prefix":"","firstName":"Elisabeth","middleName":"","lastName":"Botelho-Nevers","suffix":""},{"id":511766275,"identity":"ce9cbb86-8d82-45c2-a233-e926208b93e5","order_by":6,"name":"Bienvenu Bongue","email":"data:image/png;base64,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","orcid":"","institution":"INSERM, SAINBIOSE, University Jean Monnet, U1059","correspondingAuthor":true,"prefix":"","firstName":"Bienvenu","middleName":"","lastName":"Bongue","suffix":""}],"badges":[],"createdAt":"2025-08-14 16:38:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7375791/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7375791/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-025-04249-5","type":"published","date":"2026-01-02T15:57:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":99545426,"identity":"fd00f4ec-dcae-4714-b2ef-cc5442e1f8d9","added_by":"auto","created_at":"2026-01-05 16:07:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1091196,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7375791/v1/eec0369a-7440-43a6-983c-1048ec9a5b29.pdf"},{"id":90980512,"identity":"a8fcc492-85a2-4bab-ba69-ca7e2303b455","added_by":"auto","created_at":"2025-09-10 09:21:39","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":28613,"visible":true,"origin":"","legend":"","description":"","filename":"20250825studyQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-7375791/v1/f899bfd0c6e5f5e7ed7e930a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eNurses' roles in emerging chronic disease management: task delegation in Long COVID care as a paradigm - A cross-sectional study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eContemporary 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\u0026ndash;20% of SARS-CoV-2 infected patients according to the World Health Organization, constitutes a paradigmatic example of these emerging chronic diseases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese new pathologies share common characteristics: fluctuating and multisystemic symptomatology, diagnostic uncertainty, absence of standardized treatments, and the necessity for prolonged follow-up (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Faced with these challenges, healthcare systems must rethink care organization, particularly through task delegation to non-physicians\u0026rsquo; healthcare professionals.\u003c/p\u003e\u003cp\u003eTask 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 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This approach, initially developed to address medical shortages in certain regions according to WHO recommendations in the context of AIDS disease (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), finds new relevance in managing emerging chronic diseases.\u003c/p\u003e\u003cp\u003eHowever, beyond formalized delegation through health policies, there exists a phenomenon of informal delegation that merits particular attention. This informal delegation may be defined as the spontaneous appropriation by non-physician healthcare professionals of roles and responsibilities traditionally medical, in response to health needs inadequately covered by the existing system (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Thus, the informal task delegation could particularly be 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.\u003c/p\u003e\u003cp\u003eNurses, through their clinical competencies, proximity to patients, and adaptability, appear as natural candidates to assume these new responsibilities (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). 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 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), there is no regulatory framework in the case of crisis situation.\u003c/p\u003e\u003cp\u003eThe hypothesis of this research is that when facing emerging chronic diseases, nurses spontaneously develop substitution and complementary roles to traditional medical care, following a logic of informal but necessary task delegation. This informal delegation, defined as the unplanned appropriation of responsibilities facing emerging health needs, constitutes an organizational adaptation mechanism documented in the literature (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It is distinguished from formal delegation by its reactive character, absence of prior institutional framework, and dependence on individual professional initiatives (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This study therefore aims to characterize this informal delegation through the Long COVID example and examine factors influencing this spontaneous appropriation of new roles.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and population\u003c/h2\u003e\u003cp\u003eA cross-sectional descriptive study was conducted between December 2023 and March 2024. The source population consisted of registered nurses (RNs) enrolled in the nurses' order in the Rh\u0026ocirc;ne-Alpes region. This region was chosen for its diversity of practice (urban/rural, private/salaried) representative of task delegation challenges in French territory.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData 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. The development process involved literature review of task delegation frameworks, expert consultation with nursing professionals, and pilot testing to ensure content validity and comprehensibility. An English translation of the complete questionnaire framework is provided as supplementary material (Additional file 1). Nurses were solicited by email via the Regional Union of Liberal Health Professionals (URPS nurses) and Coordination Support Devices (DAC). A reminder was sent on February 1, 2024.\u003c/p\u003e\u003cp\u003eThe questionnaire, constructed according to a task delegation approach, collected:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eParticipants' sociodemographic characteristics (age, gender, practice setting)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTheir practice setting (determining factor in delegation)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eRoles exercised with Long Covid patients, notably screening/detection activities defined as early identification of persistent symptoms and diagnostic orientation of patients.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTheir willingness to assume coordination responsibilities.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTheir perception of training needs to assume these new tasks.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe 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 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). 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.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eWe performed descriptive statistics. Analyses focused on identifying task delegation patterns. Logistic regression analyses were performed to investigate the relationship between informal task delegation (Screening/detection) and the different characteristics of the participants. The analyses were carried out with the Stata v18 software.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eSample characteristics and delegation context\u003c/h2\u003e\u003cp\u003eThe study included 362 nurses, predominantly women (87.2%) with an average of 20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;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\u0026thinsp;=\u0026thinsp;144) had already been confronted with the necessity of caring for Long Covid patients, a situation revealing the de facto delegation that occurs (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Characteristics (N\u0026thinsp;=\u0026thinsp;362)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e314 (87.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e46 (12.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge Groups\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30 (8.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;39 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e115 (31.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;49 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e120 (33.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;50 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e97 (26.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eYears of nursing experience\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePractice Setting\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e329 (90.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSalaried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33 (9.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLong COVID Care Experience\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCared for Long COVID patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e144 (39.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNever cared for Long COVID patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e218 (60.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTraining Background\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReceived specific Long COVID training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (1.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo specific Long COVID training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e142 (98.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eMapping of delegated tasks\u003c/h2\u003e\u003cp\u003eThe 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%), representing a substitution for often inaccessible psychiatric follow-up. Proximity care (72.9%) compensates for insufficient close medical monitoring. Therapeutic education (70.8%) replaces medical information consultations. Screening/detection (42.4%) 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% of nurses providing Long COVID care (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRoles Adopted by Nurses in Long COVID Care (N\u0026thinsp;=\u0026thinsp;144) ᵃ\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRole Category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEducational Implications\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e125 (86.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdvanced therapeutic communication, crisis intervention\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProximity Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e105 (72.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChronic disease monitoring, symptom assessment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTherapeutic Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e102 (70.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatient education methodologies, health behaviour change\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e99 (68.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePublic health principles, risk communication\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoordination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80 (55.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCare pathway development, interprofessional collaboration\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScreening/Detection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61 (42.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eClinical assessment skills, diagnostic reasoning\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConsultation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43 (29.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdvanced clinical judgment, scope of practice boundaries\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical Research\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eResearch methodology, evidence-based practice\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eᵃ Among nurses who had cared for Long COVID patients ; multiple responses possible\u003c/p\u003e\u003cp\u003eThe appropriation of the screening role by 42.4% of nurses who cared for Long COVID patients deserves particular 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.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFactors associated with screening role adoption.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAmong 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\u0026thinsp;=\u0026thinsp;3.87, 95% CI: 1.92\u0026ndash;7.80, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and therapeutic education (OR\u0026thinsp;=\u0026thinsp;5.63, 95% CI: 2.37\u0026ndash;13.36, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Practice setting (private vs. salaried) and demographic characteristics showed no significant association with screening role adoption (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors Associated with Screening Role Adoption among Long COVID Care Providers (N\u0026thinsp;=\u0026thinsp;144)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eScreening Role\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;61 (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo Screening Role\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;83 (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOdds Ratio\u003c/p\u003e\u003cp\u003e(95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePractice Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e57 (93.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71 (85.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.41 (0.73\u0026ndash;7.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.152\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSalaried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (6.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12 (14.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAssociated Roles\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoordination role\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45 (73.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35 (42.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.87 (1.92\u0026ndash;7.80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTherapeutic education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e54 (88.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48 (57.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.63 (2.37\u0026ndash;13.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDemographics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e53 (86.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67 (80.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.60 (0.61\u0026ndash;4.21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.337\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYears of experience (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.99 (0.97\u0026ndash;1.02) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.654\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003eb\u003c/sup\u003e Per year increase\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eWillingness for formalized delegation\u003c/h3\u003e\n\u003cp\u003eDespite the quasi-total absence of specific training (1.4%), 80.4% of nurses with Long COVID care experience 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\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eWillingness and Barriers to Formal Task Delegation (N\u0026thinsp;=\u0026thinsp;144)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWillingness to Assume Formal Coordination Responsibilities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReady to coordinate Long COVID patient pathways\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e111/138 (80.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot ready or uncertain about coordination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27/138 (19.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBarriers to Coordination\u003c/b\u003e \u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeeling of insufficient competence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15/27 (55.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLack of institutional resources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8/27 (29.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime contraints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12/27 (44.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePractice Setting and coordination Readiness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate practice nurses ready to coordinate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e103/123 (83.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSalaried nurses ready to coordinate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8/15(53.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003ec\u003c/sup\u003e Among those not ready for coordination (N\u0026thinsp;=\u0026thinsp;27)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eInformal task delegation as adaptive response to emerging chronic diseases\u003c/h2\u003e\u003cp\u003eThis 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.\u003c/p\u003e\u003cp\u003eThis informal delegation presents several distinctive characteristics documented in our study. The first characteristic is contextual reactivity, 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(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This reactivity fits within the \"role expansion\" concept described by Kleinpell et al., (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) where professionals naturally extend their competencies to meet patient needs.\u003c/p\u003e\u003cp\u003eThe second characteristic involves the absence of prior institutional framework. Unlike formal delegation relying on established protocols (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), 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. However, we observe that 98.6% of those who have 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., (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) where delegation occurs through practical necessity rather than institutional planning.\u003c/p\u003e\u003cp\u003eA third distinctive feature is the 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 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFinally, there is an experiential learning process where skill acquisition occurs \"in the field\" through direct clinical experience. This process, is identified in the light of David Kolb's Experiential Learning Theory (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and explains the willingness of nurses to coordinate pathways despite absence of structured training.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eScreening as a paradigm of informal diagnostic delegation and role bundling\u003c/h2\u003e\u003cp\u003eThe 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 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Finally, 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.\u003c/p\u003e\u003cp\u003eThe 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 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) 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\u0026thinsp;=\u0026thinsp;3.87) and therapeutic education (OR\u0026thinsp;=\u0026thinsp;5.63) support this concept of synergistic role expansion.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eInformal delegation across the Long COVID care pathway\u003c/h2\u003e\u003cp\u003eThe distribution of roles revealed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e 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(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eIn 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.\u003c/p\u003e\u003cp\u003eThis 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.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePrivate practice status as informal delegation catalyst\u003c/h2\u003e\u003cp\u003eThe significant 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 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) identifying professional autonomy as a major determinant of successful task shifting.\u003c/p\u003e\u003cp\u003ePrivate 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 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThree mechanisms explain this facilitation: Decision-making autonomy represents the first mechanism. 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 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The second mechanism involves relational proximity, where care continuity in private practice creates a privileged therapeutic relationship facilitating identification of uncovered needs and encouraging professional role extension (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The third mechanism is temporal flexibility, as work time organization in private practice allows adaptation to chronic patients' specific needs, unlike institutional temporal constraints limiting practice innovation (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis 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 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eImplications for nursing administration\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003eFrom informal to formal delegation: administrative challenges\u003c/h2\u003e\u003cp\u003eThe 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 classic informal delegation paradox: it is both necessary for system functioning and invisible to policy makers.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eTransition mechanisms from informal to formal\u003c/h2\u003e\u003cp\u003eLiterature identifies several stages in informal delegation formalization (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). 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.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eAdministrative recommendations\u003c/h2\u003e\u003cp\u003eBased 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.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStudy limitations\u003c/h2\u003e\u003cp\u003eThis study presents certain limitations inherent to informal delegation exploration. The over-representation of private practice nurses (90.9%) limits direct generalization to institutional settings but provides valuable insights into contexts where informal delegation naturally emerges. This finding could have international transferability as private practice autonomy patterns are consistent across healthcare systems globally. Self-reporting may induce social desirability bias, particularly when describing unofficially recognized practices. However, this methodological innovation in quantifying informal delegation.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis 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. The transition from informal to formal requires a training-regulation-organization triptych that recognizes and structures these innovative practices, particularly in the screening domain where nursing skills in clinical evaluation find a particularly relevant application, while preserving their adaptive capacity. For nursing care administration, this study particularly highlights the need to recognize and supervise screening skills developed informally by nurses. The development of nursing screening protocols, combined with appropriate training, could optimize early detection of emerging chronic diseases while valorizing the field expertise of professionals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received approval from the ethics committee of Saint-\u0026Eacute;tienne 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOLK, JG, and BB drafted the project and the study design. \u0026nbsp;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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the Regional Union of Liberal Health Professionals (URPS nurses) and Coordination Support Devices (DAC) for their assistance in participant recruitment. We also thank all the participants of this study and Pr. Franck CHAUVIN (Director of PRESAGE Institute).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. WHO Coronavirus (COVID-19). Dashboard [Internet]. 2023 [cit\u0026eacute; 9 ao\u0026ucirc;t 2023]. 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J Prof Nurs Off J Am Assoc Coll Nurs. 2013;29(6):338\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Task delegation, nursing administration, Long COVID, care coordination, role expansion, chronic disease management","lastPublishedDoi":"10.21203/rs.3.rs-7375791/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7375791/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEmerging 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted among 362 nurses in France's Rh\u0026ocirc;ne-Alpes region (December 2023-March 2024). An online questionnaire assessed Long COVID care roles and delegation patterns.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong participants, 39.8% had cared for Long COVID patients. Primary delegated roles included psychological support (82.6%), proximity care (64.6%), screening/detection (44.4%), and therapeutic education (42.4%). Private practice nurses demonstrated significantly greater task appropriation. Despite the quasi-total absence of specific training (1.4%), 80.4% of nurses with Long COVID care experience declare themselves ready to formally assume coordination responsibilities for Long COVID patient pathways.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eNurses 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.\u003c/p\u003e","manuscriptTitle":"Nurses' roles in emerging chronic disease management: task delegation in Long COVID care as a paradigm - A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-10 09:21:34","doi":"10.21203/rs.3.rs-7375791/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-15T11:09:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-15T09:31:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81806395915109666407370148199347384958","date":"2025-10-05T22:42:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-23T21:33:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168420338325480196214281650788056700526","date":"2025-09-23T21:01:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204305127442576118544689651106947002585","date":"2025-09-08T08:07:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-04T01:25:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-04T01:21:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-26T12:02:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-25T14:33:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-08-25T14:30:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"30ed8290-d654-4e4b-b72f-1f21ed03a6e6","owner":[],"postedDate":"September 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:03:39+00:00","versionOfRecord":{"articleIdentity":"rs-7375791","link":"https://doi.org/10.1186/s12912-025-04249-5","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2026-01-02 15:57:18","publishedOnDateReadable":"January 2nd, 2026"},"versionCreatedAt":"2025-09-10 09:21:34","video":"","vorDoi":"10.1186/s12912-025-04249-5","vorDoiUrl":"https://doi.org/10.1186/s12912-025-04249-5","workflowStages":[]},"version":"v1","identity":"rs-7375791","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7375791","identity":"rs-7375791","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}