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

Patient Care Staff Roles

Roles and responsibilities of patient care staff found in the practices are listed in Table 3. The roles patient care staff assumed in these primary care practices were not determined by education, training, or even by licensure as outlined in Table 1.Cross-training for patient care staff was encouraged by many practices. As an example, in practices where RN and LPN staff were simultaneously employed treatments, procedures, immunizations, and injections were often part of both of their responsibilities. In practices where RN and LPN staff were not employed, however, other less-skilled staff members were trained to assist with these tasks.

We found distinctions in roles between professional nursing staff and lesser-trained staff in some but not all practices, with most practices cross-training staff with different backgrounds to perform basic tasks. Although not common, distinctions were identified in the realm of patient management, particularly regarding the need to use independent judgment and the potential for leadership allowed by physicians and administrators. These differences are highlighted by the following 2 examples.

Example 3. Rural Group Practice is a high-volume rural multispecialty practice where registered nurses triaged patients using their judgment as to which patients should be seen and which handled using the telephone. RNs also did considerable patient education in addition to all the other duties they performed. One RN in particular did all cardiac rehabilitation and dietary patient education. Physicians and nurses worked in pairs, with physicians giving nurses considerable autonomy in managing patients. A sense of camaraderie between the physicians and nurses was evident in the working environment. One physician in this practice recognized the leadership potential of his nurse colleague and encouraged her continued education.

Example 4. Downtown Family Practice was an inner-city solo physician practice and was part of a health system where the physician brought the staff, including a CMA and an MA, with him from a previous practice. The physician saw approximately 30 to 35 patients a day in a practice with 2 examination rooms. Patient care staff members felt under stress trying to keep up with the physician’s pace and often became short-tempered managing telephone inquiries and moving patients in and out of examining rooms. Although the physician was extraordinarily patient centered, the staff did not express the same commitment to serving patients and at times exhibited discomfort or uncertainty going beyond limited patient care duties. The clinician assumed many “nursing” roles himself that were performed by other patient care staff in other practices; in fact, it was not uncommon for him to clean the examination room between patients.

Differences in attitude about the patient care staffing role and level of judgment are apparent in these 2 examples, as is the difference in staff capacity to assume a higher level of care. Nurses in the third example were willing and able to assume much more of a patient management role than staff in the fourth example, who were simply task oriented. As quality of care takes on more importance in team-oriented systems of care, these differences in training and capacity would seem to assume greater importance.

Leadership capacity differences among staff were marked and tied to professional training in the latter 2 examples. However, patient care staffing leadership was not tied to professional training in every practice situation. In 6 of the 10 practices with RNs, the nurse exerted little or no clinical leadership. Instead, leadership seemed to be related to the degree to which there were personal or professional connections to the population served and the degree to which an individual’s initiative was supported by practice authorities. We generally saw more leadership among professional and nonprofessional staff in rural areas where individuals knew the patients and were a part of the community. In one case, a CMA in a practice without any professional nurses exerted considerable leadership and had one of the more extensive roles of all staff members studied. Also, leadership seemed dependent on the blessing of the physician or administrative leaders within the practices. Since staff members were employees who are lower in the hierarchy of a practice, the encouragement of authorities was important for sustained leadership to emerge.

Discussion

We found that practices employ a wide range and different mixtures of professional nursing and non-nursing staff. Although patient care staff roles vary widely, they are not necessarily tied to professional training or particular skill sets. This appears to be due in part to physician and/or practice administration values and goals directly affecting the types of staff hired and the roles they ultimately assume. These findings have important implications and are of interest because of the recent articles in the medical, nursing, and management literature on the need to develop collaborative care models in primary care.^20,42