Patient Care Staffing Patterns and Roles in Community-Based Family Practices

Hiring Practices Related to Patient Care Staff

Nursing and other patient care staff roles appeared to be influenced by a number of complex factors embedded in the context of the practice situation that transcended staff educational background and training. Key factors influencing the hiring of patient care staff were the expectations and vision of physicians and administrators, and these were further influenced by economics and labor pool availability. Who was hired for patient care staff positions did not necessarily depend on the prospective employee’s clinical training but was determined by expectations of the practice leadership who tended to hire a “person” rather than a “position.” Explicit practice goals about staffing did not appear to be considered in these decisions, and the larger system ramifications were not recognized. Two examples illustrate differences in hiring practices, one where physicians set expectations about who to hire, and another where administrators (health systems) set those expectations.

Example 1. Suburban Family Practice is a 3-physician practice that was established by a hospital health system in an affluent suburban area of a large city. Health system management determined which types of staff to hire and decided not to hire RN staff, because they thought nurses were overqualified for the work they envisioned in the office setting. Management hired bright nonprofessional office managers whom they trained to teach unskilled staff members how to do tasks (using protocols and checklists) that are required in the delivery of patient services during encounters. Patient care staff were also trained using written scripts to learn how to communicate with patients both in the office and on the telephone. Training included attention to being pleasant and friendly, and to calling the patient by name. Overall, patients seemed pleased with the quality of care given by staff that fieldworkers reported to be pleasant but basic.

Example 2. Rural Community Family Practice is a rural 2-physician practice that employs 2 physician assistants. Unlike most practices in the sample, the patient care staff consisted of 2 full-time RNs, a part-time RN, and another on-call RN. Additional patient care staff included a full-time and a part-time MA and a part-time LPN. One of the full-time RNs worked as the head nurse for the practice. The office had a separate business manager. The 2 physicians were each paired with RNs, while one of the PAs was paired with a MA and the other with a LPN. The office personnel were cross-trained to help each other and did so effectively and cheerfully. Everyone’s attitude supported a universally held desire to see the practice run efficiently, and a team spirit was noticeable, making for a pleasant working environment. The practice philosophy, values, and goals appeared to flow from one physician’s selfless mission-driven patient care focus, and he hired staff willing to go the extra mile with him, putting patients first. Despite having RNs on the staff, they did fairly basic tasks such as counseling and patient education and not collaborative patient care.

In general we found that the leadership philosophy of physicians and administrators as in the examples was very important in the configuring of staff patterns, but it was not the only factor that influenced hiring practices. Other factors such as geography and economics were also influential but not always as might be expected, leading us to consider the importance of access to trained personnel. The Midwestern area of the study is predominately rural with one medium-sized and several smaller cities and towns. Colleges that prepare various types of nursing and technical personnel are clustered predominantly in the eastern section of the study area with a few educational facilities scattered through the middle east-west corridor of the region.

Although one might anticipate that rural practices have less access to hiring trained staff than more urban practices where colleges and technical schools graduate prepared personnel, this was not always the case. In some cases, staff members told of having left their small communities to obtain training elsewhere and later returned. Other factors such as practice economics played a role. One community with a 3-physician practice was able to recruit 2 RNs and a LPN, as well as other assistants, but the practice was in competition with the community hospital and nursing home in hiring and retaining its trained staff. Another 3-physician rural community practice found that trained staff were simply unavailable. The lead physician in this practice stated that he simply had to train staff himself. Yet, economics was a significant factor in hiring practices, as illustrated by the first example of the health system practice. We found that some health systems constrained the hiring of well-trained and more costly staff, while other health systems did hire RNs but used them more as managers than for patient care. If practices did not always hire on the basis of training but rather were influenced by geography and economics, what were the resulting roles that nurses and other patient care staff played?