Development of an evidence-based framework to guide delegation of clinical tasks to physiotherapy support workers in musculoskeletal outpatient physiotherapy services

Delegation of clinical tasks to physiotherapy support workers (PSWs) is a key strategy in musculoskeletal (MSK) outpatient physiotherapy services to meet rising demand and optimise workforce use. However, delegation practices remain inconsistent, due to variability in training, role definition, supervision and patient communication. This paper presents the final phase of a mixed-methods research program. In this phase, findings from earlier phases were triangulated to inform the development of a practical, evidence-based framework to support safe and consistent delegation in MSK outpatient physiotherapy services. This final phase of the research program used a triangulation approach to integrate findings from three earlier phases: (1) a focused ethnography of real-world delegation practices; (2) a consensus study using nominal group technique to identify best practice components of a delegation framework; and (3) a discrete choice experiment capturing patient preferences. Triangulation followed Farmer et al.’s convergence coding matrix to assess agreement, partial agreement, silence, or dissonance across data sources. A component was included if supported by at least two phases. Triangulation revealed strong convergence across professional and patient perspectives. Seven core components were identified for inclusion in the final framework: (1) training and development, (2) a clear delegation process, (3) defined roles, (4) a supportive team culture, (5) embedded safety mechanisms, (6) patient awareness and communication, and (7) implementation and evaluation strategies. The framework was developed with input from a clinical advisory group and public contributors to ensure relevance and applicability to real-world practice. This final phase of the research program synthesised diverse findings to produce a framework for improving delegation to PSWs in MSK physiotherapy services. The framework offers structured, practical guidance to support consistent delegation in clinical teams. The principles may be transferable to other healthcare settings. Further research should explore implementation and evaluate impact in routine practice.