The medical and nursing literature on collaborative staffing patterns has generally focused on the integration of nurse practitioners into the delivery of primary care services.25,36-38 Because of their advanced practice status, we classify nurse practitioners as primary care clinicians and do not include them in our discussion of patient care staff. When we use the term “nurse” we are referring to registered nurses (RNs) and licensed practical nurses (LPNs), and do not differentiate between 2-, 3-, or 4-year nursing graduates with RN licensure. A review of preparatory programs for nursing roles reveals that American associate degree, diploma, and baccalaureate nursing programs have not emphasized outpatient office-based care roles for nurses Table 1.39,40 Yet primary care practices employ large numbers of nonphysician patient care staff including professional and practical nurses to manage the day-to-day services required to provide care. These staff members are often generically called “nurses” by patients and those in office settings, but this is not always the case. Many auxiliary clinical staff are certified medical assistants (CMA), medical assistants (MA), and even radiology technicians (RTs) who have been cross-trained to perform patient care roles.
We explored the professional and practical nursing and auxiliary patient care staffing patterns of 18 community-based Midwestern family practices and describe the different roles patient care staff members assume in practice. We examine the education, training, and licensure of nursing and auxiliary staff and compare these with the roles these individuals play in patient care activities. The results have important implications for the design of efficient office staffing patterns that match human resources with service delivery goals and for the future education of nursing, mid-level professional, and auxiliary personnel.
Methods
The data used for this analysis were collected as part of the Prevention and Competing Demands in Primary Care study, a multimethod comparative case study that examined the organizational and clinical structures and process of 18 community-based family practices. Each practice was studied using extensive direct observation of office systems and of clinical encounters by field researchers who spent 4 weeks or more in each practice. Individual depth interviews with each clinician, many of the practice staff, and members of the community were used to obtain their perspectives of the practice. Details of the sampling and data collection are available elsewhere in this issue.41
This analysis was performed by a multidisciplinary team that had been involved in the analysis of the larger project. Team members began this analysis by independently reading and re-reading details of the contributions made by clinical support staff, both in the practice and in the patient encounters. Each team member independently made notes detailing important tasks and roles that staff performed. Afterward, team members met to compare and contrast their findings. This discussion led to the identification of staffing patterns that became our codebook. After establishing the codebook, team members met on several occasions to again methodically review staffing data on each practice. During these sessions, they constructed a large table with a column for each staffing pattern in the codebook and a row for each practice. In each of the table cells, they recorded whether the practice exhibited the staffing pattern characteristic. After the completion of this step and the attendant discussion, overall themes emerged.
Results
Details of the patient care staff in each of the 18 practices are presented in Table 2. Four practices had a solo physician, each with at least one physician assistant (PA) or nurse practitioner (NP); 6 practices had 2 physicians; 7 practices included 3 physicians; and another had 8 physicians. Ten of the 18 practices employed RNs, with 4 of these having both RNs and LPNs. Another 5 practices had LPNs but no RNs, leaving only 3 practices without either. These 3 employed CMAs as their most highly trained patient care staff. Rounding out the patient care staff in the 18 practices were combinations of CMAs, MAs, RTs, and on-the-job-trained assistants. The overall majority of practices used non-nursing personnel as the predominate patient care staff. The staff-to-clinician ratio ranged from a low of 0.5 to a high of 3.3. These figures have been corrected to indicate staff and physician full-time equivalents, since a number of staff members filled only part-time positions.
A key observation that emerged from the data was that the term “nurse” referred to any individual who performed clinical duties related to caring for patients in the practice. All practices employed varied combinations of patient care staff including RNs, LPNs, CMAs, both trained and untrained MAs, and even RTs who had been cross-trained to perform patient care duties. Typical duties ranged from simple tasks of moving patients in and out of examination rooms and taking vital signs to assisting with procedures and treatments and patient teaching Table 3. The generalized tasks of the “nurse”, however, belied the diversity of staffing roles and functions that characterized each individual practice. Approximately half of the practices (55%, 10 of 18) employed RNs, and 45% (8 of 18) did not. To analyze these data, we separated practices that hired RNs from those that did not, then compared and contrasted them.