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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.
- 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
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.
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?
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
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.
1. Wright PJ, Fortinsky RH, Covinsky KE, Anderson PA, Landefeld CS. Delivery of preventive services to older black patients using neighborhood health centers. J Am Geriatr Soc 2000;48:124-30.
2. Solberg LI, Kottke TE, Brekke ML. Will primary care clinics organize themselves to improve the delivery of preventive services? A randomized controlled trial. Prev Med 1998;27:623-31.
3. Solberg LI, Kottke TE, Conn SA, Brekke ML, Calomeni CA, Conboy KS. Delivering clinical preventive services is a systems problem. Ann Behav Med 1997;19:271-78.
4. Hulscher ME, Wensing M, Grol RP, van der Weijden T, van Weel C. Interventions to improve the delivery of preventive services in primary care. Am J Public Health 1999;89:737-46.
5. Coleman T, Wilson A. Factors associated with the provision of anti-smoking advice by general practitioners. Br J Gen Pract 1999;49:557-58.
6. Aita VA, Crabtree B. Historical reflections on current preventive practice. Prev Med 2000;30:5-16.
7. Zyzanski SJ, Stange KC, Langa D, Flocke SA. Trade-offs in high-volume primary care practice. J Fam Pract 1998;46:397-402.
8. Aubert RE, Herman WH, Waters J, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: a randomized, controlled trial. Ann Intern Med 1998;129:605-12.
9. Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998;339:1957-63.
10. Christiansen SC, Martin SB, Schleicher NC, Koziol JA, Mathews KP, Zuraw BL. Current prevalence of asthma-related symptoms in San Diego’s predominantly Hispanic inner-city children. J Asthma 1996;33:17-26.
11. Glasgow RE, Boles SM, Calder D, Dreyer L, Bagdade J. Diabetes care practices in primary care: results from two samples and three measurement sets. Diabetes Educ 1999;25:755-63.
12. Glasgow RE, Strycker LA. Preventive care practices for diabetes management in two primary care samples. Am J Prev Med 2000;19:9-14.
13. Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties: results from the medical outcomes study. JAMA 1995;274:1436-44.
14. McAlister FA, Teo KK, Lewanczuk RZ, Wells G, Montague TJ. Contemporary practice patterns in the management of newly diagnosed hypertension. CMAJ 1997;157:23-30.
15. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag Care Q 1996;4:12-25.
16. deGruy F. Mental health care in the primary care setting. In: Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.
17. Feldman EL, Jaffe A, Galambos N, Robbins A, Kelly RB, Froom J. Clinical practice guidelines on depression: awareness, attitudes, and content knowledge among family physicians in New York. Arch Fam Med 1998;7:58-62.
18. Goldman LS, Nielsen NH, Champion HC. Awareness, diagnosis, and treatment of depression. J Gen Intern Med 1999;14:569-80.
19. McQuaid JR, Stein MB, Laffaye C, McCahill ME. Depression in a primary care clinic: the prevalence and impact of an unrecognized disorder. J Affect Disord 1999;55:1-10.
20. Berwick DM, Donaldson MS. Crossing the chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
21. Campbell JD, Mauksch HO, Neikirk HJ, Hosokawa MC. Collaborative practice and provider styles of delivering health care. Soc Sci Med 1990;30:1359-65.
22. Patel VL, Cytryn KN, Shortliffe EH, Safran C. The collaborative health care team: the role of individual and group expertise. Teach Learn Med 2000;12:117-32.
23. Sommers LS, Marton KI, Barbaccia JC, Randolph J. Physician, nurse, and social worker collaboration in primary care for chronically ill seniors. Arch Intern Med 2000;160:1825-33.
24. Hall EK, McHugh M. Family practice health care: making collaborative practice a reality. N HC Perspect Comm 1995;16:270-75.
25. Atkin K, Lunt N. Negotiating the role of the practice nurse in general practice. J Adv Nurs 1996;24:498-505.
26. Kany K. Combating staffing problems. Am J Nurs 1999;99:68.-
27. Gallagher RK, Kany KA, Rowell PA, Peterson C. ANA’s nurse staffing principles. Am J Nurs 1999;99:50.-
28. Huber DG, Blegen MA, McCloskey JC. Use of nursing assistants: staff nurse opinions. Nurs Manage 1994;25:64-68.
29. McLaughlin FE, Thomas SA, Barter M. Changes related to care delivery patterns. J Nurs Adm 1995;25:35-46.
30. Huston C. Unlicensed assistive personnel: a solution to dwindling health care resources or the precursor to the apocalypse of registered nursing? Nurs Outlook 1996;44:67-73.
31. Krapohl G, Larson E. The impact of unlicensed assistive personnel on nursing care delivery. Nurs Econ 1996;14:99-122.
32. Keepnews D. Does APRN:MD=UAP:RN? (advanced practice registered nurses, unlicensed assistive personnel). Am Nurse 1997;29:7-9.
33. Barter M, Furmidge M. Unlicensed assistive personnel: issues relating to delegation and supervision. J Nurs Adm 1994;24:36-40.
34. Ahmed DS. ‘It’s not my job’: unlicensed assistive personnel should help with tasks, not patient assessment. Am J Nurs 2000;100:25.-
35. Cronenwett LR. The use of unlicensed assistive personnel: when to support, oppose, or be neutral. J Nurs Adm 1995;25:11-12.
36. Flanagan L. Family practice spectrum: Family physicians and nurse practitioners - a perfect team. Fam Pract Manage 1998;5:60-63.
37. Lee E, O’Neal S. A mobile clinic experience: nurse practitioners providing care to a rural population. J Pediatric Health Care 1994;8:12-17.
38. Stein L. Health care delivery to farm-workers in the southwest: an innovative nursing clinic. J Am Acad Nurse Practitioners 1993;5:119-24.
39. Palmer NS. Moving student clinical experiences into primary care settings. Nurse Educator 1995;20:12-14.
40. Bryan C. Practice nursing: a study of the role. Nurs Stand 1995;9:25-29.
41. Crabtree BF, Miller WL, Stange KC. Understanding practice from the ground up. J Fam Pract 2001;50:881-87.
42. Institute for Healthcare Improvement. Idealized design of clinical office practice (IDCOP). www.ihi.org/idealized/idcop/background.asp; 2001.
43. Mastal P. New signposts and directions: Indicators of quality in ambulatory nursing care. Nurs Econ 1999;17:103-04.
44. Schim SM, Thornburg P, Kravutske ME. Time, task, and talents in ambulatory care nursing. J Nurs Adm 2001;31:311-15.
45. Hackbarth D, Hass S, Kavanagh J, Valesses F. Dimensions of the staff nurse role in ambulatory care. Part I: methodology and analysis of data on current staff nurse practice. Nurs Econ 1995;13:89-98.
46. Hass S, Hackbarth D, Kavanagh J, Valesses F. Dimensions of the staff nurse role in ambulatory care. Part II: comparison of role dimensions in four ambulatory settings. Nurs Econ 1995;13:152-65.
47. Hass S, Hackbarth D. Dimensions of the staff nurse role in ambulatory care. Part III: using research data to design new models of nursing care delivery. Nurs Econ 1995;13:230-41.
48. Hass S, Hackbarth D. Dimensions of the staff nurse role in ambulatory care. Part IV: developing nursing intensity measures, standards, clinical ladders, and QI programs. Nurs Econ. 1995;13:285-94.
49. Schroeder CA, Trehearne B, Ward D. Expanded role of nursing in ambulatory managed care. Part I: literature, role development, and justification. Nurs Econ 2000;18:14-19.
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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.
- 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
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.
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?
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
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.
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.
- 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
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.
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?
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
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.
1. Wright PJ, Fortinsky RH, Covinsky KE, Anderson PA, Landefeld CS. Delivery of preventive services to older black patients using neighborhood health centers. J Am Geriatr Soc 2000;48:124-30.
2. Solberg LI, Kottke TE, Brekke ML. Will primary care clinics organize themselves to improve the delivery of preventive services? A randomized controlled trial. Prev Med 1998;27:623-31.
3. Solberg LI, Kottke TE, Conn SA, Brekke ML, Calomeni CA, Conboy KS. Delivering clinical preventive services is a systems problem. Ann Behav Med 1997;19:271-78.
4. Hulscher ME, Wensing M, Grol RP, van der Weijden T, van Weel C. Interventions to improve the delivery of preventive services in primary care. Am J Public Health 1999;89:737-46.
5. Coleman T, Wilson A. Factors associated with the provision of anti-smoking advice by general practitioners. Br J Gen Pract 1999;49:557-58.
6. Aita VA, Crabtree B. Historical reflections on current preventive practice. Prev Med 2000;30:5-16.
7. Zyzanski SJ, Stange KC, Langa D, Flocke SA. Trade-offs in high-volume primary care practice. J Fam Pract 1998;46:397-402.
8. Aubert RE, Herman WH, Waters J, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: a randomized, controlled trial. Ann Intern Med 1998;129:605-12.
9. Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998;339:1957-63.
10. Christiansen SC, Martin SB, Schleicher NC, Koziol JA, Mathews KP, Zuraw BL. Current prevalence of asthma-related symptoms in San Diego’s predominantly Hispanic inner-city children. J Asthma 1996;33:17-26.
11. Glasgow RE, Boles SM, Calder D, Dreyer L, Bagdade J. Diabetes care practices in primary care: results from two samples and three measurement sets. Diabetes Educ 1999;25:755-63.
12. Glasgow RE, Strycker LA. Preventive care practices for diabetes management in two primary care samples. Am J Prev Med 2000;19:9-14.
13. Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties: results from the medical outcomes study. JAMA 1995;274:1436-44.
14. McAlister FA, Teo KK, Lewanczuk RZ, Wells G, Montague TJ. Contemporary practice patterns in the management of newly diagnosed hypertension. CMAJ 1997;157:23-30.
15. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag Care Q 1996;4:12-25.
16. deGruy F. Mental health care in the primary care setting. In: Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.
17. Feldman EL, Jaffe A, Galambos N, Robbins A, Kelly RB, Froom J. Clinical practice guidelines on depression: awareness, attitudes, and content knowledge among family physicians in New York. Arch Fam Med 1998;7:58-62.
18. Goldman LS, Nielsen NH, Champion HC. Awareness, diagnosis, and treatment of depression. J Gen Intern Med 1999;14:569-80.
19. McQuaid JR, Stein MB, Laffaye C, McCahill ME. Depression in a primary care clinic: the prevalence and impact of an unrecognized disorder. J Affect Disord 1999;55:1-10.
20. Berwick DM, Donaldson MS. Crossing the chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
21. Campbell JD, Mauksch HO, Neikirk HJ, Hosokawa MC. Collaborative practice and provider styles of delivering health care. Soc Sci Med 1990;30:1359-65.
22. Patel VL, Cytryn KN, Shortliffe EH, Safran C. The collaborative health care team: the role of individual and group expertise. Teach Learn Med 2000;12:117-32.
23. Sommers LS, Marton KI, Barbaccia JC, Randolph J. Physician, nurse, and social worker collaboration in primary care for chronically ill seniors. Arch Intern Med 2000;160:1825-33.
24. Hall EK, McHugh M. Family practice health care: making collaborative practice a reality. N HC Perspect Comm 1995;16:270-75.
25. Atkin K, Lunt N. Negotiating the role of the practice nurse in general practice. J Adv Nurs 1996;24:498-505.
26. Kany K. Combating staffing problems. Am J Nurs 1999;99:68.-
27. Gallagher RK, Kany KA, Rowell PA, Peterson C. ANA’s nurse staffing principles. Am J Nurs 1999;99:50.-
28. Huber DG, Blegen MA, McCloskey JC. Use of nursing assistants: staff nurse opinions. Nurs Manage 1994;25:64-68.
29. McLaughlin FE, Thomas SA, Barter M. Changes related to care delivery patterns. J Nurs Adm 1995;25:35-46.
30. Huston C. Unlicensed assistive personnel: a solution to dwindling health care resources or the precursor to the apocalypse of registered nursing? Nurs Outlook 1996;44:67-73.
31. Krapohl G, Larson E. The impact of unlicensed assistive personnel on nursing care delivery. Nurs Econ 1996;14:99-122.
32. Keepnews D. Does APRN:MD=UAP:RN? (advanced practice registered nurses, unlicensed assistive personnel). Am Nurse 1997;29:7-9.
33. Barter M, Furmidge M. Unlicensed assistive personnel: issues relating to delegation and supervision. J Nurs Adm 1994;24:36-40.
34. Ahmed DS. ‘It’s not my job’: unlicensed assistive personnel should help with tasks, not patient assessment. Am J Nurs 2000;100:25.-
35. Cronenwett LR. The use of unlicensed assistive personnel: when to support, oppose, or be neutral. J Nurs Adm 1995;25:11-12.
36. Flanagan L. Family practice spectrum: Family physicians and nurse practitioners - a perfect team. Fam Pract Manage 1998;5:60-63.
37. Lee E, O’Neal S. A mobile clinic experience: nurse practitioners providing care to a rural population. J Pediatric Health Care 1994;8:12-17.
38. Stein L. Health care delivery to farm-workers in the southwest: an innovative nursing clinic. J Am Acad Nurse Practitioners 1993;5:119-24.
39. Palmer NS. Moving student clinical experiences into primary care settings. Nurse Educator 1995;20:12-14.
40. Bryan C. Practice nursing: a study of the role. Nurs Stand 1995;9:25-29.
41. Crabtree BF, Miller WL, Stange KC. Understanding practice from the ground up. J Fam Pract 2001;50:881-87.
42. Institute for Healthcare Improvement. Idealized design of clinical office practice (IDCOP). www.ihi.org/idealized/idcop/background.asp; 2001.
43. Mastal P. New signposts and directions: Indicators of quality in ambulatory nursing care. Nurs Econ 1999;17:103-04.
44. Schim SM, Thornburg P, Kravutske ME. Time, task, and talents in ambulatory care nursing. J Nurs Adm 2001;31:311-15.
45. Hackbarth D, Hass S, Kavanagh J, Valesses F. Dimensions of the staff nurse role in ambulatory care. Part I: methodology and analysis of data on current staff nurse practice. Nurs Econ 1995;13:89-98.
46. Hass S, Hackbarth D, Kavanagh J, Valesses F. Dimensions of the staff nurse role in ambulatory care. Part II: comparison of role dimensions in four ambulatory settings. Nurs Econ 1995;13:152-65.
47. Hass S, Hackbarth D. Dimensions of the staff nurse role in ambulatory care. Part III: using research data to design new models of nursing care delivery. Nurs Econ 1995;13:230-41.
48. Hass S, Hackbarth D. Dimensions of the staff nurse role in ambulatory care. Part IV: developing nursing intensity measures, standards, clinical ladders, and QI programs. Nurs Econ. 1995;13:285-94.
49. Schroeder CA, Trehearne B, Ward D. Expanded role of nursing in ambulatory managed care. Part I: literature, role development, and justification. Nurs Econ 2000;18:14-19.
50. Schroeder CA, Trehearne B, Ward D. Expanded role of nursing in ambulatory managed care. Part II: impact on outcomes of costs, quality, provider and patient satisfaction. Nurs Econ 2000;18:71-78.
1. Wright PJ, Fortinsky RH, Covinsky KE, Anderson PA, Landefeld CS. Delivery of preventive services to older black patients using neighborhood health centers. J Am Geriatr Soc 2000;48:124-30.
2. Solberg LI, Kottke TE, Brekke ML. Will primary care clinics organize themselves to improve the delivery of preventive services? A randomized controlled trial. Prev Med 1998;27:623-31.
3. Solberg LI, Kottke TE, Conn SA, Brekke ML, Calomeni CA, Conboy KS. Delivering clinical preventive services is a systems problem. Ann Behav Med 1997;19:271-78.
4. Hulscher ME, Wensing M, Grol RP, van der Weijden T, van Weel C. Interventions to improve the delivery of preventive services in primary care. Am J Public Health 1999;89:737-46.
5. Coleman T, Wilson A. Factors associated with the provision of anti-smoking advice by general practitioners. Br J Gen Pract 1999;49:557-58.
6. Aita VA, Crabtree B. Historical reflections on current preventive practice. Prev Med 2000;30:5-16.
7. Zyzanski SJ, Stange KC, Langa D, Flocke SA. Trade-offs in high-volume primary care practice. J Fam Pract 1998;46:397-402.
8. Aubert RE, Herman WH, Waters J, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: a randomized, controlled trial. Ann Intern Med 1998;129:605-12.
9. Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998;339:1957-63.
10. Christiansen SC, Martin SB, Schleicher NC, Koziol JA, Mathews KP, Zuraw BL. Current prevalence of asthma-related symptoms in San Diego’s predominantly Hispanic inner-city children. J Asthma 1996;33:17-26.
11. Glasgow RE, Boles SM, Calder D, Dreyer L, Bagdade J. Diabetes care practices in primary care: results from two samples and three measurement sets. Diabetes Educ 1999;25:755-63.
12. Glasgow RE, Strycker LA. Preventive care practices for diabetes management in two primary care samples. Am J Prev Med 2000;19:9-14.
13. Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties: results from the medical outcomes study. JAMA 1995;274:1436-44.
14. McAlister FA, Teo KK, Lewanczuk RZ, Wells G, Montague TJ. Contemporary practice patterns in the management of newly diagnosed hypertension. CMAJ 1997;157:23-30.
15. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag Care Q 1996;4:12-25.
16. deGruy F. Mental health care in the primary care setting. In: Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.
17. Feldman EL, Jaffe A, Galambos N, Robbins A, Kelly RB, Froom J. Clinical practice guidelines on depression: awareness, attitudes, and content knowledge among family physicians in New York. Arch Fam Med 1998;7:58-62.
18. Goldman LS, Nielsen NH, Champion HC. Awareness, diagnosis, and treatment of depression. J Gen Intern Med 1999;14:569-80.
19. McQuaid JR, Stein MB, Laffaye C, McCahill ME. Depression in a primary care clinic: the prevalence and impact of an unrecognized disorder. J Affect Disord 1999;55:1-10.
20. Berwick DM, Donaldson MS. Crossing the chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
21. Campbell JD, Mauksch HO, Neikirk HJ, Hosokawa MC. Collaborative practice and provider styles of delivering health care. Soc Sci Med 1990;30:1359-65.
22. Patel VL, Cytryn KN, Shortliffe EH, Safran C. The collaborative health care team: the role of individual and group expertise. Teach Learn Med 2000;12:117-32.
23. Sommers LS, Marton KI, Barbaccia JC, Randolph J. Physician, nurse, and social worker collaboration in primary care for chronically ill seniors. Arch Intern Med 2000;160:1825-33.
24. Hall EK, McHugh M. Family practice health care: making collaborative practice a reality. N HC Perspect Comm 1995;16:270-75.
25. Atkin K, Lunt N. Negotiating the role of the practice nurse in general practice. J Adv Nurs 1996;24:498-505.
26. Kany K. Combating staffing problems. Am J Nurs 1999;99:68.-
27. Gallagher RK, Kany KA, Rowell PA, Peterson C. ANA’s nurse staffing principles. Am J Nurs 1999;99:50.-
28. Huber DG, Blegen MA, McCloskey JC. Use of nursing assistants: staff nurse opinions. Nurs Manage 1994;25:64-68.
29. McLaughlin FE, Thomas SA, Barter M. Changes related to care delivery patterns. J Nurs Adm 1995;25:35-46.
30. Huston C. Unlicensed assistive personnel: a solution to dwindling health care resources or the precursor to the apocalypse of registered nursing? Nurs Outlook 1996;44:67-73.
31. Krapohl G, Larson E. The impact of unlicensed assistive personnel on nursing care delivery. Nurs Econ 1996;14:99-122.
32. Keepnews D. Does APRN:MD=UAP:RN? (advanced practice registered nurses, unlicensed assistive personnel). Am Nurse 1997;29:7-9.
33. Barter M, Furmidge M. Unlicensed assistive personnel: issues relating to delegation and supervision. J Nurs Adm 1994;24:36-40.
34. Ahmed DS. ‘It’s not my job’: unlicensed assistive personnel should help with tasks, not patient assessment. Am J Nurs 2000;100:25.-
35. Cronenwett LR. The use of unlicensed assistive personnel: when to support, oppose, or be neutral. J Nurs Adm 1995;25:11-12.
36. Flanagan L. Family practice spectrum: Family physicians and nurse practitioners - a perfect team. Fam Pract Manage 1998;5:60-63.
37. Lee E, O’Neal S. A mobile clinic experience: nurse practitioners providing care to a rural population. J Pediatric Health Care 1994;8:12-17.
38. Stein L. Health care delivery to farm-workers in the southwest: an innovative nursing clinic. J Am Acad Nurse Practitioners 1993;5:119-24.
39. Palmer NS. Moving student clinical experiences into primary care settings. Nurse Educator 1995;20:12-14.
40. Bryan C. Practice nursing: a study of the role. Nurs Stand 1995;9:25-29.
41. Crabtree BF, Miller WL, Stange KC. Understanding practice from the ground up. J Fam Pract 2001;50:881-87.
42. Institute for Healthcare Improvement. Idealized design of clinical office practice (IDCOP). www.ihi.org/idealized/idcop/background.asp; 2001.
43. Mastal P. New signposts and directions: Indicators of quality in ambulatory nursing care. Nurs Econ 1999;17:103-04.
44. Schim SM, Thornburg P, Kravutske ME. Time, task, and talents in ambulatory care nursing. J Nurs Adm 2001;31:311-15.
45. Hackbarth D, Hass S, Kavanagh J, Valesses F. Dimensions of the staff nurse role in ambulatory care. Part I: methodology and analysis of data on current staff nurse practice. Nurs Econ 1995;13:89-98.
46. Hass S, Hackbarth D, Kavanagh J, Valesses F. Dimensions of the staff nurse role in ambulatory care. Part II: comparison of role dimensions in four ambulatory settings. Nurs Econ 1995;13:152-65.
47. Hass S, Hackbarth D. Dimensions of the staff nurse role in ambulatory care. Part III: using research data to design new models of nursing care delivery. Nurs Econ 1995;13:230-41.
48. Hass S, Hackbarth D. Dimensions of the staff nurse role in ambulatory care. Part IV: developing nursing intensity measures, standards, clinical ladders, and QI programs. Nurs Econ. 1995;13:285-94.
49. Schroeder CA, Trehearne B, Ward D. Expanded role of nursing in ambulatory managed care. Part I: literature, role development, and justification. Nurs Econ 2000;18:14-19.
50. Schroeder CA, Trehearne B, Ward D. Expanded role of nursing in ambulatory managed care. Part II: impact on outcomes of costs, quality, provider and patient satisfaction. Nurs Econ 2000;18:71-78.