The results of this study indicate that physician and administrative values and goals shape the expectations of staff roles, but these values and expectations are more focused on economics than on larger patient care issues. In reviewing practice documents of vision, values, and goals (where they existed), only 2 affiliated health system practices had strategic matching of staff to the goals of the practice. Instead of looking critically at clinical goals and then matching staff available with those goals, most of practices tried to get by with the minimum educational preparation and number of staff—the values seemed tied to economic returns. Although we do not discount the importance of economics in organizational planning for effective primary care practice, other considerations such as expanding the practice’s ability to provide additional services and staff development opportunities for promotion of staff leadership may have even wider implications in the delivery of primary care services. Without challenges and appropriate development opportunities, staff may become disinterested and bored in their work. With encouragement and in-service training opportunities, nonprofessional staff can develop into excellent service providers as some of the staff we studied proved.
Until recently there has been little exploration of how physicians and others providing primary services to patients could collaborate more effectively with nursing and clinical support patient care staff in the day to day delivery of services. Our findings imply that either staffing patterns need to change to improve and enhance the skill mix of staff or administrative expectations of staff need to better correspond to training backgrounds if such collaboration is to succeed between primary care staff and nursing and auxiliary staff. Practices may be making sound economic decisions by hiring minimally trained staff; however, these hiring and staffing patterns fly in the face of recommendations emerging from other sources,43,44 including a 4-part series of articles looking at the dimensions of ambulatory nursing role and staffing patterns in Nursing Economics.45-48 Recent work takes an intensive look at the role of nurses in ambulatory settings that delineates key components and describes the staffing pilot projects and outcomes at the Group Health Cooperative of Puget Sound.49,50 These studies argue that until there is an alignment of reimbursement with practice goals and corresponding staffing patterns, practices are unlikely to deliver the quality of care that patients deserve.
At the same time, practices do not seem to be taking into account the legal scope of nursing activities or encouraging their nurses to practice up to their levels of education. Also, nursing education, which is often focused on inpatient roles and responsibilities, needs to better address the task of preparing nurses for roles in ambulatory settings, particularly in practices. With physicians pressed with so many acute and chronic care needs, opportunities for teamwork abound, and registered nurses can fill in many of the gaps in primary care.
Limitations
Our study has a number of limitations. One of the most serious is that only 18 practices in a single state were studied, which limits the generalizability of the findings. We also did not link staffing characteristics to outcome measures or explicitly include patient perceptions of staff. Although these limitations are significant, we think the study has important implications for thinking about the configuration of staffing patterns.
Conclusion
Training and qualifications of staff alone do not tell the whole story about staffing patterns in family practices. These patterns are as varied as the practices themselves. Many opportunities exist for practices to engage their nursing and clinical support staff to enhance the quality of clinical services delivered and to provide opportunities for continual staff growth and development. It is clear that staff are malleable and can adapt to varied roles. Also, nursing and clinical support staff can potentially take greater leadership responsibility for patient care, which appears to be important for the creation of high-functioning primary care teams, regardless of staff titles and level of formal training.
Acknowledgments
The data used in our paper came from a study supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776). A Family Practice Research Center Grant from the American Academy of Family Physicians supported the analyses. We are grateful to the physicians, staff, and patients from the 18 practices, without whose participation our study would not have been possible. We also wish to thank dedicated work of Connie Gibbs and Jen Rouse, who spent countless hours collecting data and Mary McAndrews, who transcribed hundreds of taped interviews and dictated field notes. We would also like to thank Kurt C. Stange, MD, PhD, for reviewing earlier drafts of this manuscript. Dr Crabtree is associated with the Center for Research in Family Practice and Primary Care, Cleveland, New Brunswick, Allentown, and San Antonio.