Subsequently, we present how general practice teams organize working procedures related mainly to the issuing of medical prescriptions and blood sampling. We also describe which work-related stressors and resources emerge during these processes according to the relevant psychosocial demands. Although we aimed to present specific examples for each of the psychosocial demands included, it becomes evident that many of the quotations could also be categorized into other subsections highlighting the complexity of the working procedures described.
Work content and task
Responsibilities for the issuing of prescriptions as well as for blood sampling are largely determined by legal regulations and required training. In comparison to GPs who are responsible for all the procedures, the responsibilities of the practice staff are limited. All PAs need to be able to prepare prescriptions and take blood from patients, whereas trainees need to be supervised and other employees (eg, administrative staff) may support the medical staff, but should not execute tasks requiring medical training:
Quotation (Q) 1: observation protocol, group practice:
The observer asks if everyone can work in the laboratory. A PA replies ‘only the three PAs’ […]. Two other colleagues are trainees and one person is an administrative assistant who should not and cannot work in the lab.
Two aspects became evident during the preparation of medical prescriptions: (1) the specific responsibilities of the GPs, and (2) the teamwork required to complete the task. Prescriptions can be issued or reissued directly as a result of the consultation with the GP, or they may be reissued without an appointment. Frequently, the latter occurs during consultation hours when patients ask for a renewal of prescriptions by telephone, email or directly at the registration desk. Before the prescription can be handed to the patient, the GP is required by law to check and sign the prescription. Hence, the GPs can either complete the entire tasks by themselves or delegate the preparation and handing over of the prescription to the patient to the team. Although each practice observed had slightly different ways of handling prescriptions, staff was always involved in the administrative part highlighting the division of this task through delegation and the dependency of the practice team on the GP to complete the whole procedure:
Q2, observation protocol, single practice:
A PA returns to her work station where a waiting patient requests a prescription. The PA immediately begins to prepare and print off the prescription. The patient is asked to wait in the waiting area until the prescription has been signed [by the doctor].
The practice staff (and the patients) had to wait frequently for the doctors to sign prescriptions. Due to the high work intensity observed in all practices, the practice team usually turned to another task (eg, patient registration, answering the phone) which was interrupted when the prescription was signed and had to be handed over to the patient. This example also highlights that staff are constantly meeting the needs of patients, colleagues or superiors.
Compared to the process of issuing prescriptions, PAs carried out both administrative and medical procedures during the process of blood sampling. The blood sampling procedure usually comprised a prior consultation of the patient with the GP who orders a specific blood test. Subsequently, the doctors can either complete the whole procedure by themselves or delegate particular tasks to a PA, including the preparation of the necessary administrative and medical equipment, the collection of the blood, and the preparation of the blood sample for the transport to an external laboratory usually undertaken by a laboratory transport service. Some tests (eg, blood sugar) were carried out directly in the practices whereas the comprehensive analysis of blood samples was completed by an external laboratory. Usually the PAs could execute their part of the procedure without any further consultation of the GP until the results from the laboratory arrived. The GP then communicates the results to the patient and the final documentation can be delegated to the practice team. Compared to handling prescriptions, the PAs had a larger scope of action during the process of blood sampling including preparatory as well as executing tasks, more influence on the sequence of the work (eg, the preparation of the equipment was usually undertaken the day before), and the probability of completing one task at a time was greater.
Organization of work
As noted previously, how work is organized is partly determined by legal regulations and recommendations as well as by the management preferences of the GPs and arrangements negotiated within the team. The subsequent example also highlights the importance of acknowledging the broader organizational context including an assessment of whether work content and task fit the training or abilities of the staff:
Q3, interview, single practice:
We used to work with ladies who have retired. For them it was a nightmare to work with the computer. Or we used to have somebody […] who was almost deaf. She said: ‘I can do anything, but I can’t answer the phone.’ Ok, here I have to show consideration. But I have to have worked at another work station to appreciate the work of the others and to understand - we do that in team meetings when we have time - which part do I play in the whole system? And if I do not play my part which processes are interrupted or blocked?
An interruption is a temporary suspension of the current activity which is to be continued at a later time [42]. Across all practices we observed high levels of work intensity. Interruptions through colleagues and patients were part of many work processes although not always consciously perceived as being particularly stressful:
Q4, focus group discussion, single practice:
“Interviewee (I)1: But I used to experience this when I was by myself at the front [desk]. […], telephone, everybody wants to pick up something, this and that. […] but if this is already stress, […], no, […].
I2: Yes, because you have that [incomplete task] in the back of your mind. Hopefully, I do not forget anything […].
I3: Yeah, that is stressing you out, I think so, that is stressful, isn’t it? So, hopefully I haven’t forgotten anything. Register something, prepare a bill, this and that.”
Subsequently, a PA describes an approach to deal with interruptions:
Q5, focus group discussion, group practice:
Especially at the reception desk, you cannot finish a thing, you really have to put your notepad next to you and write stuff down, bullet points, because otherwise you’ll forget stuff. Of course, this shouldn’t happen, so everything should be written down immediately and if possible one thing should be completed before the next thing.
On the one hand, interruptions due to incoming calls or inquiries from patients were likely to be put on hold till the previous task could be completed:
Q6, focus group discussion, single practice:
“I1: We try to be aware of everything. So, if somebody interrupts us at the registration desk while we are working on something else and another patient comes and says ‘I'd just like to …’, [we say:] ‘Just a moment, we'll finish this first, because otherwise we'll lose track and then we can [...] continue with you’. […].
I2: Exactly. […]
I1: […] everybody has to queue […].
I2: Everything is being taken care off one after another.
I1: Exactly, exactly.
I2: So that one thing can be finished.
I1: Yes.“
Although interruptions could frequently not be avoided, there was some scope for prioritization which increased the likelihood to complete one task before the next. Prioritization was particularly relevant at the reception desk, the center of activities and interruptions during consultation hours:
Q7, observation protocol, group practice:
Meanwhile [on top of all of the other things happening] the phone rings, which is ignored by the trainee saying ‘this has to wait’.
On the other hand, interruptions from colleagues or superiors were frequently taken for granted:
Q8, focus group discussion, group practice:
“Interviewer: […] I got the impression there are a lot of feedback loops and inquiries [between you and your colleagues], […].
I1: Yes, I don’t even notice it, it just happens, doesn’t it? We just talk it over.”
Q9, focus group discussion, group practice:
Interviewer: […]. During the observations I got the impression that you are exposed to many interruptions over the course of one particular task.
I2: Yes.Interviewer: How do you feel about that?I2: That’s right. Yes, that’s right. Even if you always do the same thing, you can finish a lot of things, but it depends on whether [one doctor] appears from a consulting room or [another doctor] appears from [another consulting room], if you want to make a phone call, of course you have to interrupt this and finish it later. That’s right. That happens every day.”
The procedure of blood sampling is an example of mostly “doing the same thing”. Usually, blood sampling took place during early consultation hours in a specifically equipped laboratory undertaken by one PA assigned to that task, sometimes for the entire week. As the process of blood sampling was largely prepared and executed by the PAs, we observed interruptions more frequently during the issuing of prescriptions where the practice team is more dependent on the GPs to complete the procedure. The handling of prescriptions was taken care of at various work stations throughout the practice by doctors as well as the team (eg, registration desk, consultation room, back office). On the one hand doctors sometimes requested to reduce interruptions during consultation hours:
Q10, interview, group practice:
“I'm calling a patient, […]. At that moment one of the staff dashes forward and hands a prescription to me. [...] And here I am bossy and say: ‘Dear people, please arrange work in a way that the consultation hours with the patients run smoothly and thoroughly; therefore, I do not want any heckling, for example, no telephone calls.’“
On the other hand, we also observed that prescriptions were signed by GPs during ongoing treatments of patients. This may result in spending more time and energy on the task due to the interruption. For the PAs, however, this is an opportunity to complete their task quickly and hand the signed prescription to a waiting patient:
Q11, observation protocol, single practice
„While [the doctor] is treating the patient, a PA knocks at the door and enters with a prescription for [the doctor] to sign. While the [doctor] is typing something at the computer, the PA is standing behind [the doctor]. She has to wait a moment until the doctor finishes typing and turns towards her taking the prescription to sign, handing it to the PA. The PA takes the prescription and leaves. [The doctor] and [the] PA have not spoken a word to each other.”
In some of the practices observed, there were particular areas for prescriptions to be signed (eg, trays, shelf space), some of which were in the immediate vicinity of the consulting rooms. The doctors were able to finish an appointment or a series of consultations before signing documents such as prescriptions stored in designated trays. Doctors were thus able to control their flow of work, and interruptions in the consulting room were reduced.
Working environment
The previous example highlights the interrelation between work organization and working environment, the latter including, for example, the spatial design of the waiting area, the treatment and consultation rooms and the associated work stations including any equipment.
During consultation hours, the registration desk was the most exposed work station, the center of various activities including, for example, short consultations between physicians, the PAs and administrative staff, the registration of patients, handling of prescriptions, arrangements of appointments, and the dealing with a multitude of phone calls:
Q12, observation protocol, group practice
„Today, the registration desk and the waiting area appear to be busier [than yesterday]. In the registration area, trainee 1 and 2 are making phone calls at the same time, one of the PAs is talking to patients or to a doctor, the waiting room is full, and the patients seated in front of the laboratory talk to each other. From time to time, an alarm clock rings in the lab - something needs to be checked […]. Returning to the registration desk, doctor A notices the list of registered patients and asks the PA: ‘Am I too fast?’ The PA replies: ‘No, that's fine, there are more [patients] listed on the next page.’ Doctor A mentions to doctor B that the consulting hours in the evening should not finish too late, […]. Now, the waiting room is completely packed, and three patients have to stand. Again, I notice that only a few patients say ‘hello or good day’ at the registration desk, but usually mention their concern immediately. PA 1 is always friendly and mostly replies ‘What can I do for you?’ PA 2 appears at the registration desk […], she is wearing surgical gloves, looks around and I ask whether she had time to talk about her tasks in the laboratory. She replies that she has to take care of an electrocardiogram first and leaves the registration area.”
In some of the practices, the registration area was designed in such a way that a multitude of tasks could be carried out at the same time. In other practices, however, the design of the working environment aimed at the separation of tasks. For example, there were workplaces at the registration desk not equipped with a telephone. There were also practices where separate workplaces were set up in a back-office area to handle, for example, administrative tasks or to take telephone calls. Similar to working in the laboratory, patient contact in these areas was limited, interruptions occurred less frequently, the parallel processing of several tasks was less likely, and the noise level was lower. At the same time, the staff working at the registration desk did not have to deal with particular administrative tasks (eg, scanning of laboratory results) or were relieved of taking phone calls reducing the noise level during consultation hours considerably. Overall, noise levels at the registration desk were, however, not mentioned by practice staff without direct inquiry from the observers.
Another factor discussed was the concern with the feeling of the staff of being under constant observation. Working at the registration desk, all personnel was continuously exposed to inquiries from patients, colleagues or superiors, and micro breaks were important to relax the body and the mind:
Q13, observation protocol, group practice
[The employee mentions to the observer] that she is “on display” at her work station. The patients can watch her continuously and she has to be on the spot all of the time. Therefore, she occasionally has to leave [her work station] for a short time to see something else and take a breath.
Working in the laboratory, the privacy of the PAs was more protected because the perceived social control through third parties (eg, patients or superiors) did occur less frequently or not at all as the PA was responsible only for one patient at a time.
The working environment also includes the availability and functioning of technical equipment at different work stations, such as computers, printers and work specific software (eg, lab management software). For example, the advantage of investing in several printers at different work stations facilitates smooth working processes, particularly evident in the laboratory environment. All but one of the laboratories visited were equipped with a computer, whereas a printer was available in only one lab. This printer, however, could not be used to print the required forms used in the lab:
Q14, observation protocol, group practice
"The PA tells [the observer] that she has to go [from the laboratory] to the front desk because she needs to use another printer. [The observer] follows the PA to the registration. Here, the PA puts [the required] form into an old printing device. […]. Subsequently, [the observer] follows the PA back to the lab. […]. The PA explains that patient data had to be printed on a particular form, and the printer in the lab can’t do that."
Furthermore, appropriate software can facilitate laboratory processes including information on particular blood tests or medical prescriptions when staff can access patient data directly in the lab. For example, we observed that PAs checked current medication plans directly at the laboratory computer before choosing appropriate equipment to take blood from patients taking drugs affecting clotting time. This was possible if electronic patient records were available which we observed only in some of the practices.
The laboratories were usually equipped with all utensils necessary to take blood samples (eg, surgical gloves, antiseptics, used needle containers or disinfectants); nevertheless, we observed that hygiene regulations were implemented to varying degrees of consistency in several practices:
Q15, observation protocol, group practice
[The PA] goes to the sink, takes some disinfectant into her right hand to rub a little on her hands. Shortly afterwards, she takes paper towels and wipes her hands again. [The observer] wonders whether this was the entire procedure of hand disinfection. In any case, this did not comply with the hand hygiene protocol poster displayed at the wall […]. Furthermore, neither did she use surgical gloves during the blood sampling nor has she disinfected or washed her hands between different patients.
As our project did not intend to evaluate workplace hygiene, the implementation of hygiene regulations was not discussed further in any of the interviews or focus group discussions. Only during one observation, did one of the staff mention that hand hygiene gives the patient a sense of security whereas self-protection was not mentioned at all. As we wanted the staff to discuss factors related to occupational stress as openly as possible, we aimed to avoid any criticism related to hygiene regulations.
Spatial design, missing or faulty equipment resulted in additional work for staff, particularly evident in the laboratories and at the registration desk. The availability of additional printers and appropriate software in the lab could facilitate work processes, avoid additional noise or work at the registration desk; from an economical point of view, however, providing additional equipment also creates additional costs.
Social relations
Whereas some of the GPs emphasized their special and long-term relationships with patients, the PAs participating in the focus group discussions highlighted particularly the value of mutual support and team work that we observed across all practice teams:
Q16, focus group discussion, group practice
"I1: Well, there are really days when you see, for example, that [there is a lot of work to do] in the lab. […]. The person who has [less to do] supports the person in the lab. […]. Yes, there are really situations like that. Anyhow. […], you just go and help.
I2: "We always support each other, no matter what."
Across all practices observed, there were several work stations at the registration desk where PAs could work simultaneously, facilitating mutual support, but also increasing the likelihood of interrupting each other. In the laboratory, work stations were more isolated which sometimes complicated direct communication and support. We observed, however, that PAs took particular effort and care to support each other during busy laboratory hours which also included communication across different work stations and rooms, and additional support from staff designated to different work stations than the lab:
Q17, Observation protocol, group practice
"[After trying twice] the PAs stops the blood sampling and informs the patient that she will get a colleague. The patient says that this is not necessary. The PA insists and says that she only tries twice [to puncture a vein]. […]. She leaves the laboratory and after a short time returns with a colleague who […] grabs a pair of surgical gloves from one of the two boxes, and sits down at the table [to continue with the procedure].“
Over the course of the field work, all practice teams highlighted the dependency on each team member to deal with the work intensity and ensure the quality of patient care. It was also discussed that insufficient team work can result into a serious burden for both individual team members as well as for the entire staff.