OBJECTIVES: Collaborative models that involve office staff in the delivery of health care services offer promise for enhancing primary care practice; however, very little is known about current staffing patterns in practice. Our study describes patient care staff patterns and roles in community-based family practices.
STUDY DESIGN: We used a multimethod comparative case study design that included detailed descriptive field notes of the office environment of 18 family practices and of 1637 clinical encounters, as well as depth interviews of practice staff and physicians. Systematic analysis of these data provided detailed descriptions of patient care staff patterns and functions.
POPULATION: We included physicians and staff in 18 community-based Nebraska family practices.
RESULTS: Practices are staffed with a range of clinical personnel including registered nurses, licensed practical nurses, certified medical assistants, radiology technicians, and trained and untrained medical assistants. Each of these has specific educational preparation that potentially qualifies them for different patient care roles; however, staff roles were determined primarily by local needs and physician expectations rather than by education, training, or licensure. Staffing patterns varied greatly, with the majority of practices employing at least one registered nurse (10 of 18), licensed practical nurse (5), or both (4). Still, the overall majority of practices used non-nursing personnel as the predominate patient care staff. Patient care staff-to-clinician ratios ranged from a low of 0.5 to a high of 3.3.
CONCLUSIONS: Many recent recommendations about collaborative models of clinical care seem problematic when put into a context of the findings of current staffing patterns and use of personnel in family practices. Staff members often fulfill roles independent of training. Staff leadership is also potentially important for designing effective collaborative care models; however, we found leadership only occurred with the approval of clinic authorities. These practical issues are rarely addressed in normative recommendations about system change and intervention. Our findings indicate that there are considerable opportunities for practices to better use nursing and other patient care staff in the delivery of clinical services. Developing a collaborative practice model should include formalizing expectations of staff to reflect training and experience, and explicitly configuring staff to meet the needs, values, and goals of a practice.
KEY POINTS FOR CLINICIANS
- Family practices employ a wide range of nursing and non-nursing staff, but the responsibilities given to patient care staff are often not tied to professional training.
- Collaborative care models that are recommended for enhancing quality of care require physicians and administrators to hire staff trained to meet clinical goals and not just economic goals.
- Nursing and other support staff can assume greater leadership responsibilities when encouraged by physicians and administrators.
Primary care clinicians are being asked to deliver better-quality services with fewer resources. The literature has many examples of shortfalls in key physician services in primary care settings, including the delivery of preventive,1-7 chronic disease,8-15 and mental health services.16-19 The Institute of Medicine of the National Academy of Sciences, recognizing the importance of systems in the delivery of high-quality health care, has called for new emphasis on health care teams as a way to reduce medical error and improve quality of care.20 Collaborative team models have been proposed as a means to achieve a higher-quality level of clinical services.20-24 Are physicians maximizing the human resources they have in their offices by fully involving clinical staff in the delivery of preventive care? Who are the clinical staff in physician offices, what is their training, and what roles are they being asked to play?
Integrated systems of care, where physicians, nurses, and other professional and nonprofessional care-givers deliver services, have promoted the theoretical notion of greater interdisciplinary collaboration in the practice setting.20-25 At the same time, organizations such as the Medical Group Management Association have suggested optimal patient care staff-to-physician ratios for outpatient primary care practices. Their recommendations are based on surveys conducted in large group practices. However, the extent to which actual staffing patterns accommodate the diversity of practices is not well understood. Even less understood is the link between the idea of better systems of collaboration in patient care and the practical decisions that are made in determining the composition of clinical support staff. Also, assumptions about roles played by office staff underlie all staffing recommendations. Yet, competitive health care market forces may have forced many practices to seek less expensive help to provide patient care.26-31 This could result in many traditional nursing roles being performed by non-nursing patient care staff whose task training is too limited in scope to enhance and contribute flexibly to recommendations for collaborative care.30-35