The place of receptionists in access to primary care: Challenges in the space between community and consultation

Patient aggression towards receptionists in general practice: a systematic review

OBJECTIVE

General practice receptionists provide an essential function in the healthcare system but routinely encounter acts of incivility and aggression from patients, including hostility, abuse and violence. This study was conducted to summarise what is known about patient-initiated aggression towards general practice receptionists, including impacts on reception staff and existing mitigation strategies.

DESIGN

Systematic review with convergent integrated synthesis.

ELIGIBILITY CRITERIA

Studies published at any time in English that examine patient aggression experiences of reception staff in primary care settings.

INFORMATION SOURCES

Searches of five major databases were performed (CINAHL Complete, Scopus, PubMed, Healthcare Administration Database and Google Scholar) to August 2022.

RESULTS

Twenty studies of various designs were included, ranging from the late 1970s to 2022 and originating from five OECD countries. Twelve were assessed as high quality using a validated checklist. Reviewed articles represented 4107 participants; 21.5% were general practice receptionists. All studies reported that displays of aggression towards receptionists by patients were a frequent and routine occurrence in general practice, particularly verbal abuse such as shouting, cursing, accusations of malicious behaviour and use of racist, ablest and sexist insults. Although infrequent, physical violence was widely reported. Inefficient appointment scheduling systems, delayed access to doctors and prescription denial appeared common precipitators. Receptionists adapted their behaviour and demeanour to placate and please patients to avoid escalation of patient frustrations at the cost of their own well-being and clinic productivity. Training in patient aggression management increased receptionist confidence and appeared to decrease negative sequalae. Coordinated support for general practice reception staff who had experienced patient aggression was generally lacking, with a small proportion receiving professional counselling.

CONCLUSIONS

Patient aggression towards reception staff is a serious workplace safety concern for general practices and negatively affects healthcare sector function more broadly. Receptionists in general practice deserve evidence-based measures to improve their working conditions and well-being for their own benefit and that of the community.

REGISTRATION

Pre-registered in Open Science Framework (osf.io/42p85).

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study

BACKGROUND

Type 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system - the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging, and this hampers outcomes for T2D care. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types.

METHODS

Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices.

RESULTS

The ACIC scores of the fee-for-service practices - containing 97% of Belgian patients - only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks.

CONCLUSIONS

Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.

Seating in Doctors' Waiting Rooms: Has COVID-19 Changed Our Choices?

OBJECTIVE

This study investigates preference for five different seating arrangements (e.g., rows, clusters) in a doctor's office waiting room, whether these reduce stress and improve judgments of medical care, and how such choices may have changed over the pandemic (2013 vs. 2021).

BACKGROUND

What is called the doctor's office layout, with chairs lining the perimeter of the waiting room, is criticized by designers, yet little empirical evidence exists to support that assessment.

METHOD

Data collected in 2013 and 2021 used sketches of five different seating arrangements; people saw just one of these. The study examined the effect of time and seating arrangement on anxiety, need for privacy, situational awareness, evaluation of the environment, and perception of the doctor.

RESULTS

There was no significant impact of the seating arrangement on any of the dependent variables, but ratings were higher for situational awareness, need for privacy, evaluation of the environment, and aspects related to the physician in 2021. In addition, seating preferences favored end, not middle seats, and chair selections with the chair back to a wall.

CONCLUSION

In this study, no evidence exists that the doctor's office layout is less preferred than four other seating arrangements, but seat choice shows people prefer end seats (not middle seats) across arrangements. The doctor's office layout may offer a supportive familiarity to people; also, given the percentage of people who visit the doctor unaccompanied, layouts designed to encourage social interaction may not always be appropriate.

Teledermatology to reduce face-to-face appointments in general practice during the COVID-19 pandemic: a quality improvement project

Teledermatology is an important subspecialty of telemedicine that continues to evolve with advances in telecommunication and mobile phone technology. A 19-week primary care quality improvement project collected baseline data and tested three change ideas, using the Model for Improvement method, with primary and secondary aims: to increase the weekly percentage of remote dermatological consultations with supporting images that were successfully concluded remotely to greater than 80% and to reduce the weekly percentage of dermatological face-to-face consultations to less than 50%. We hypothesised that by improving the quality of patient images and the confidence of reception staff in triaging skin complaints, there would be a decrease in the weekly number of face-to-face dermatological appointments, thereby decreasing the risk of COVID-19 transmission within the practice and community. Two change ideas focused on supporting patients to improve image quality by introducing ‘4 Key Instructions’ and a patient information leaflet (PIL). The third focused on increasing reception staff confidence in triaging skin complaints by introducing a triage pathway guidance tool. A total of 253 dermatological consultations were analysed: 170 of these were telephone consultations with 308 supporting images. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to an increase in completed remote consultation. Our primary outcome measure was achieved. Our secondary outcome measure suggested that in the absence of high-quality images, it might not be possible to reduce dermatological face-to-face consultations much below 50% in primary care. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to the increase in remote consultation. The implications of these findings for the theory of change are discussed.

The Unrecognized Role of VA Call Center and Primary Care Clerical Staff in Assisting Patients with Obtaining Needed Care

BACKGROUND

VA clerks, or medical support assistants (MSAs), are a critical part of patients' primary care (PC) experiences and are often the first points of contact between Veterans and the healthcare system. Despite the important role they might play in assisting Veterans with accessing care, research is lacking on the specific tasks they perform and what training and preparation they receive to perform their roles.

OBJECTIVE

Our primary aim in this study was to document MSA perceptions of their roles, the tasks they undertake helping Veterans with accessing healthcare, and additional training they may need to optimally perform their role.

DESIGN

Thematic analysis of semi-structured qualitative interviews with VA call center and PC MSAs (n=29) collected as part of in-person site visits from August to October 2019.

PARTICIPANTS

MSAs at administrative call centers and primary care clinics in one large VA regional network representing 8 healthcare systems serving nearly 1.5 million Veterans.

KEY RESULTS

We identified three key findings from the interviews: (1) MSAs perform tasks in addition to scheduling that help Veterans obtain needed care; (2) MSAs may not be fully prepared for their roles as first points of contact; and (3) low status and lack of recognition of the important and complex tasks performed by MSAs contribute to high turnover.

CONCLUSIONS

As healthcare systems continue expanding virtual access, the roles of administrative call center and PC MSAs as first points of contact will be increasingly important for shaping patient experiences. Our research suggests that MSAs may need better training and preparation for the roles they perform assisting Veterans with accessing care, coupled with an intentional approach by healthcare systems to address MSAs' concerns about recognition/compensation. Future research should explore the potential for enhanced MSA customer service training to improve the Veteran patient experience.

"Old friend and powerful cadre": Doctor-patient relationships and multi-dimensional therapeutic landscapes in China's primary hospitals

A positive doctor-patient relationship is believed to play a key role in the healing process in clinics. While challenges to the doctor-patient relationship are a global concern, complex social contexts which introduce familial collectivism and totalitarian bureaucracy to maintain a doctor's authority have complicated doctor-patient relationships in China. This study delineates a multi-dimensional therapeutic landscape of hospitals in China, focusing on the doctor-patient relationship performances used to improve patients' healing experiences. Based on fieldwork in two primary hospitals in Eastern China, we find that primary hospitals in China are not only professional spaces, but hybrids of professional and non-professional spaces. In these spaces, both professional and other discourses in various forms of social-environmental engagement affect therapeutic experiences. Varying time and space in hospitals allow doctors to construct multi-dimensional therapeutic landscapes vis-a-vis patients to secure patients' compliance with their recommendations, and thus improve health outcomes. We argue that these dimensions may also cause negative therapeutic experience such as unnecessary health care. This study contributes to the literature on therapeutic landscapes of health care by providing a critical view on the construction of multi-dimensional therapeutic hospital landscapes. Furthermore, it links the critical health geographies literature with China's broader social context to explicate the cultural and social transformation of health care spaces in contemporary China. Findings from this study inform both theoretical and empirical debates regarding therapeutic landscapes of health care by embedding the professional spaces of health care into broader geographical discourses. This calls for health professionals to reflect on ethical concerns in multi-dimensional health care landscapes.

Young peoples' perspectives about care in a youth-friendly general practice

INTRODUCTION Youth health outcomes are poor in New Zealand and have a life-long impact on individuals, whānau (family) and society. Little is known about how young people view their experiences of general practice care despite it being the most common place to access health care. AIM This study sought to explore young peoples' experiences of care in a selected, youth-friendly general practice. METHODS In-depth individual interviews with six young people. RESULTS Four themes were identified from young peoples' narratives in relation to their experiences of general practice care: going to the doctor is not easy for a young person; the attributes of staff make all the difference; specific youth-friendly consultation practices help young people; and a youth-friendly physical environment can help young people access services and feel safe. DISCUSSION Even though the study general practice had explicitly instituted youth-friendly initiatives, including offering no-charge consultations and specialist staff members, young people still described considerable barriers to attendance. Many barriers are practice-based and could be modified by staff training, provision of further youth care staff roles and consideration of environmental changes. Other barriers such as waiving prescription costs need government funding.

Exclusion and hospitality: the subtle dynamics of stigma in healthcare access for people emerging from alcohol and other drug treatment

This article explores the role of drug use-related stigma in constraining access to healthcare services. Drawing on interviews with 20 people conducted shortly after leaving an Australian alcohol and other drug withdrawal management unit, the article explores their willingness and ability to access primary care, hospital and further services. It finds repeated descriptions of feeling ignored and shamed during efforts to access care, with some descriptions relating to subtle signs of disapproval or condemnation, and others to being ignored or dismissed. Some accounts additionally emphasise unwelcoming atmospheres, and exclusion by omission of signals of welcome and encouragement. The article goes on to consider, for the first time in this field, contemporary notions of welcome and hospitality as outlined within the cosmopolitanism tradition, asking whether they offer insights into how healthcare may become more accessible for people who regularly experience stigmatisation. In concluding, the article considers the need to think further about forms of exclusion that occur when social and individual histories of stigma are not institutionally recognised, and measures to counter these histories are not actively adopted.

Frequent attenders' experiences of encounters with healthcare personnel: A systematic review of qualitative studies

Rather than measure demographic factors such as socioeconomics, the aim of this study was to examine the lived experience of frequent attenders by synthesizing findings on their encounters with healthcare personnel. The Scopus, CINAHL, PsycARTICLES, and PubMed (Medline) databases were searched in May 2020 in order to screen studies by title and abstract (n = 1794) and full-text (n = 20). Findings from the included studies (n = 6) were then pooled using meta-aggregation, yielding the following results: difficulties in resolving frequent attenders' situations may create "service circles," frustrating patients with their situation; frequent attenders' own expertise regarding their condition should be recognized and valued alongside that of healthcare professionals when performing collaborative care; a lack of empathy and disparagement may make frequent attenders feel misunderstood and unappreciated; frequent attenders should be recognized as individuals by taking their circumstances into account and providing support accordingly. Frequent attenders' experiences demonstrate the importance of shared decision-making, continuity of care, and acknowledging these patients' individual circumstances. Identifying the variety of frequent attenders' service needs by synthesizing their experiences is a practical way of organizing patient-centered healthcare services.

A quantitative assessment of the parameters of the role of receptionists in modern primary care using the work design framework

BACKGROUND

Amidst increased pressures on General Practice across England, the receptionist continues to fulfil key administrative and clinically related tasks. The need for more robust support for these key personnel to ensure they stay focussed and motivated is apparent, however, to be effective a more systematic understanding of the parameters of their work is required. Here we present a valuable insight into the tasks they fulfil, their relationship with colleagues and their organisation and their attitudes and behaviour at work collectively defined as their 'work design'.

METHODS

Our aim was to quantitatively assess the various characteristics of receptionists in primary care in England using the validated Work Design Questionnaire (WDQ) a 21 point validated questionnaire, divided into four categories: task, knowledge and social characteristics and work context with a series of sub-categories within each, disseminated online and as a postal questionnaire to 100 practices nationally.

RESULTS

Seventy participants completed the WDQ, 54 online and 16 using the postal questionnaire with the response rate for the latter being 3.1%. The WDQ suggested receptionists experience high levels of task variety, task significance and of information processing and knowledge demands, confirming the high cognitive load placed on receptionists by performing numerous yet significant tasks. Perhaps in relation to these substantial responsibilities a reliance on colleagues for support and feedback to help negotiate this workload was reported.

CONCLUSION

The evidence of our survey suggests that the role of modern GP receptionists requires an array of skills to accommodate various administrative, communicative, problem solving, and decision-making duties. There are ways in which the role might be better supported for example devising ways to separate complex tasks to avoid the errors involved with high cognitive load, providing informal feedback, and perhaps most importantly developing training programmes.

Permeable boundaries? Patient perspectives on space and time in general practice waiting rooms

This paper considers an under-examined space in primary health care - the reception area/waiting room. This space can be challenging to negotiate, particularly for those who experience social marginalisation. We begin by situating the significance of the 'entry into the health care setting' in the patient journey in terms of time as well as space. Through an analysis of interview and focus group data gathered in a New Zealand study, we highlight ways that patients view these spaces as firmly bounded and confronting. In reflecting on the data, we then identify the potential for these spaces to be more permeable. We conclude that this spatio-temporal context need not be one of constraint. Rather, there are ways in which the boundaries of this space can be potentially enabling to those required to pause in the process of enacting patienthood.

The Effect of Robot Attentional Behaviors on User Perceptions and Behaviors in a Simulated Health Care Interaction: Randomized Controlled Trial

Background

For robots to be effectively used in health applications, they need to display appropriate social behaviors. A fundamental requirement in all social interactions is the ability to engage, maintain, and demonstrate attention. Attentional behaviors include leaning forward, self-disclosure, and changes in voice pitch.

Objective

This study aimed to examine the effect of robot attentional behaviors on user perceptions and behaviors in a simulated health care interaction.

Methods

A parallel randomized controlled trial with a 1:1:1:1 allocation ratio was conducted. We randomized participants to 1 of 4 experimental conditions before engaging in a scripted face-to-face interaction with a fully automated medical receptionist robot. Experimental conditions included a self-disclosure condition, voice pitch change condition, forward lean condition, and neutral condition. Participants completed paper-based postinteraction measures relating to engagement, perceived robot attention, and perceived robot empathy. We video recorded interactions and coded for participant attentional behaviors.

Results

A total of 181 participants were recruited from the University of Auckland. Participants who interacted with the robot in the forward lean and self-disclosure conditions found the robot to be significantly more stimulating than those who interacted with the robot in the voice pitch or neutral conditions (P=.03). Participants in the forward lean, self-disclosure, and neutral conditions found the robot to be significantly more interesting than those in the voice pitch condition (P<.001). Participants in the forward lean and self-disclosure conditions spent significantly more time looking at the robot than participants in the neutral condition (P<.001). Significantly, more participants in the self-disclosure condition laughed during the interaction (P=.01), whereas significantly more participants in the forward lean condition leant toward the robot during the interaction (P<.001).

Conclusions

The use of self-disclosure and forward lean by a health care robot can increase human engagement and attentional behaviors. Voice pitch changes did not increase attention or engagement. The small effects with regard to participant perceptions are potentially because of the limitations in self-report measures or a lack of comparison for most participants who had never interacted with a robot before. Further research could explore the use of self-disclosure and forward lean using a within-subjects design and in real health care settings.

Organisational strategies and practices to improve care using patient experience data in acute NHS hospital trusts: an ethnographic study

Background

Although NHS organisations have access to a wealth of patient experience data in various formats (e.g. surveys, complaints and compliments, patient stories and online feedback), not enough attention has been paid to understanding how patient experience data translate into improvements in the quality of care.

Objectives

The main aim was to explore and enhance the organisational strategies and practices through which patient experience data are collected, interpreted and translated into quality improvements in acute NHS hospital trusts in England. The secondary aim was to understand and optimise the involvement and responsibilities of nurses in senior managerial and front-line roles with respect to such data.

Design

The study comprised two phases. Phase 1 consisted of an actor–network theory-informed ethnographic study of the ‘journeys’ of patient experience data in five acute NHS hospital trusts, particularly in cancer and dementia services. Phase 2 comprised a series of Joint Interpretive Forums (one cross-site and one at each trust) bringing together different stakeholders (e.g. members of staff, national policy-makers, patient/carer representatives) to distil generalisable principles to optimise the use of patient experience data.

Setting

Five purposively sampled acute NHS hospital trusts in England.

Results

The analysis points to five key themes: (1) each type of data takes multiple forms and can generate improvements in care at different stages in its complex ‘journey’ through an organisation; (2) where patient experience data participate in interactions (with human and/or non-human actors) characterised by the qualities of autonomy (to act/trigger action), authority (to ensure that action is seen as legitimate) and contextualisation (to act meaningfully in a given situation), quality improvements can take place in response to the data; (3) nurses largely have ultimate responsibility for the way in which data are collected, interpreted and used to improve care, but other professionals also have important roles that could be explored further; (4) formalised quality improvement can confer authority to patient experience data work, but the data also lead to action for improvement in ways that are not formally identified as quality improvement; (5) sense-making exercises with study participants can support organisational learning.

Limitations

Patient experience data practices at trusts performing ‘worse than others’ on the Care Quality Commission scores were not examined. Although attention was paid to the views of patients and carers, the study focused largely on organisational processes and practices. Finally, the processes and practices around other types of data were not examined, such as patient safety and clinical outcomes data, or how these interact with patient experience data.

Conclusions

NHS organisations may find it useful to identify the local roles and processes that bring about autonomy, authority and contextualisation in patient experience data work. The composition and expertise of patient experience teams could better complement the largely invisible nursing work that currently accounts for a large part of the translation of data into care improvements.

Future work

To date, future work has not been planned.

Study registration

NIHR 188882.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Improving Nonclinical and Clinical-Support Services: Lessons From Oncology

Nonclinical and clinical-support personnel serve patients on the front lines of care. Their service interactions have a powerful influence on how patients perceive their entire care experience, including the all-important interactions with clinical staff. Ignoring this reality means squandering opportunities to start patients out on the right foot at each care visit. Medical practices can improve the overall care they provide by focusing on nonclinical and clinical-support services in 5 crucial ways: (1) creating strong first impressions at every care visit by prioritizing superb front-desk service; (2) thoroughly vetting prospective hires to ensure that their values and demeanor align with the organization's; (3) preparing hired staff to deliver excellent service with a commitment to ongoing training and education at all staff levels; (4) minimizing needless delays in service delivery that can overburden patients and their families in profound ways; and (5) prioritizing the services that patients consider to be most important. We show how cancer care illustrates these principles, which are relevant across medical contexts. Without nonclinical and clinical-support staff who set the right tone for care at every service touchpoint, even the best clinical services cannot be truly optimal.

Owner and veterinary surgeon perspectives on the roles of veterinary nurses and receptionists in relation to small animal preventive healthcare consultations in the United Kingdom

Veterinary receptionists and veterinary nurses rarely feature in published practice-based research, yet are integral to small animal veterinary practice in the UK. The aim of this study was to investigate the perspectives of UK-based owners and veterinary surgeons about veterinary nurses and receptionists in relation to their role in preventive healthcare. Semistructured telephone interviews were conducted with 15 dog and cat owners and 14 veterinary surgeons. Interview transcripts were thematically analysed. Reception staff were identified as having a range of important roles, from rapport building to providing healthcare information and advice. The perceived importance of those roles appeared to differ between owners and veterinary surgeons. Veterinary nurses were described as performing a diversity of roles in relation to preventive healthcare, both in the reception area and in the consulting room. Many owners, and some veterinary surgeons, expressed uncertainty about the remit and status of veterinary nurses in relation to providing veterinary advice. This study identifies for the first time the degree of responsibility for preventive healthcare given to veterinary receptionists and veterinary nurses in UK small animal practices. Further work is needed involving reception and nursing staff to fully appreciate and define their roles in small animal practice.

Receptionists' role in new approaches to consultations in primary care: a focused ethnographic study

Background

The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments.

Aim

The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care.

Design and setting

The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016.

Method

Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation.

Results

Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists’ involvement in implementation and planning for the introduction of alternative approaches to face-to-face consultations was minimal, despite the expectation that they would be involved in delivery.

Conclusion

A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations.

Experiences of General Practitioners and Practice Support Staff Using a Health and Lifestyle Screening App in Primary Health Care: Implementation Case Study

Background

Technology-based screening of young people for mental health disorders and health compromising behaviors in general practice increases the disclosure of sensitive health issues and improves patient-centered care. However, few studies investigate how general practitioners (GPs) and practice support staff (receptionists and practice managers) integrate screening technology into their routine work, including the problems that arise and how the staff surmount them.

Objective

The aim of this study was to investigate the implementation of a health and lifestyle screening app, Check Up GP, for young people aged 14 to 25 years attending an Australian general practice.

Methods

We conducted an in-depth implementation case study of Check Up GP in one general practice clinic, with methodology informed by action research. Semistructured interviews and focus groups were conducted with GPs and support staff at the end of the implementation period. Data were thematically analyzed and mapped to normalization process theory constructs. We also analyzed the number of times we supported staff, the location where young people completed Check Up GP, and whether they felt they had sufficient privacy and received a text messaging (short message service, SMS) link at the time of taking their appointment.

Results

A total of 4 GPs and 10 support staff at the clinic participated in the study, with all except 3 receptionists participating in the final interviews and focus groups. During the 2-month implementation period, the technology and administration of Check Up GP was iterated through 4 major quality improvement cycles in response to the needs of the staff. This resulted in a reduction in the average time taken to complete Check Up GP from 14 min to 10 min, improved SMS text messaging for young people, and a more consistent description of the app by receptionists to young people. In the first weeks of implementation, researchers needed to regularly support staff with the app’s administration; however, this support decreased over time, even as usage rose slightly. The majority of young people (73/87, 84%) completed Check Up GP in the waiting room, with less than half (35/80, 44%) having received an SMS from the clinic with a link to the tool. Participating staff valued Check Up GP, particularly its facilitation of youth-friendly practice. However, there was at first a lack of organizational systems and capacity to implement the app and also initially a reliance on researchers to facilitate the process.

Conclusions

The implementation of a screening app in the dynamic and time-restricted general practice setting presents a range of technical and administrative challenges. Successful implementation of a screening app is possible but requires adequate time and intensive facilitation. More resources, external to staff, are needed to drive and support sustainable technology innovation and implementation in general practice settings.

Measuring doctor appointment availability in Northland general practice

INTRODUCTION Primary care access is associated with improved patient outcomes. Availability of appointments in general practice is one measure of access. Northland's demographics and high ambulatory sensitive hospitalisation rates may indicate constrained appointment availability. Our study aims were to determine appointment availability and establish the feasibility of measuring appointment availability through an automated process. METHODS An automated electronic query was created, run through a third party software programme that interrogated Northland general practice patient management systems. The time to third next available appointment (TNAA) was calculated for each general practitioner (GP) and a mean calculated for each practice and across the region. A research assistant telephone request for an urgent GP appointment captured the time to the urgent appointment and type of urgent appointment used to fit patients in. Regression analysis was used to determine the relationships between deprivation, patients per GP, and the use of walk-in clinics. RESULTS The mean TNAA was 2.5 days. 12% of practices offered walk-in clinics. There was a significant relationship between TNAA and increasing number of walk-in clinics. CONCLUSION The TNAA of 2.5 days indicates the possibility that routine appointments are constrained in Northland. However, TNAA may not give a reliable measure of urgent appointment availability and the measure needs to be interpreted by taking into account practice characteristics. Walk-in clinics, although increasing the availability of urgent appointments, may lead to more pressure on routine appointments. Using an electronic query is a feasible way to measure routine GP appointment availability.

Placing care: embodying architecture in hospital clinics for immigrant and refugee patients

This article is part of a hospital ethnography that investigates healthcare architecture as an aspect of an increasingly large, complex, and urgent global health issue: caring for refugees and other immigrants. It argues that hospitals are nodes in transnational social networks of immigrant and refugee patients that form assemblages of human and non-human objects. These assemblages co-produce place-specific hospital care in different hospital spaces. Place-specific tensions and power dynamics arise when refugees and immigrants come into contact with these biomedical spaces. The argument is developed by analysing waiting rooms and exam rooms in two outpatient clinics in one US hospital. The article draws its analysis from 9 months of fieldwork in 2012 that included following 69 adult immigrant and refugee patients and observing their encounters with interpreters and clinic staff. Its inclusion of a transnational dimension for understanding place-specific hospital care adds conceptual and empirical depth to the study of how place matters in 21st century hospitals.

Diabetes affects everything: Type 2 diabetes self-management among Spanish-speaking hispanic immigrants

This article is a report of qualitative findings of a mixed-methods study of the relationships among knowledge, self-efficacy, health promoting behaviors, and type 2 diabetes mellitus (T2DM) self-management among limited-english-proficient recent Hispanic immigrants, a population with increased incidence of T2DM and barriers to successful T2DM management. Semi-structured interviews were conducted with 30 participants, and physiological and demographic data also were collected. The participants generally attributed developing the disease to strong emotions and viewed T2DM as a serious disease. Although a majority understood the importance of exercise and diet in T2DM self-management, other aspects such as medication adherence were not well-understood. Obstacles to effective T2DM self-management were negative interactions and communications with health care providers and other personnel, cultural stigma related to the disease, financial constraints, immigration status, and the complexity of the disease. Suggested interventions to improve the care and self-management of this at-risk population are discussed.

From paperwork to parenting: experiences of professional staff in student support

CONTEXT

For academic staff, responding to student concerns is an important responsibility. Professional staff, or non-academic staff who do administrative work in medical schools, are often the first to be approached by students, yet there is little research on how they manage student issues. Informed by the conceptual framework of emotional labour, we examined the experiences of professional staff, aiming to identify theoretical and practical insights for improving the provision of student support. We examined the scope of support provided, the impact of providing this support on staff and how these impacts can be managed.

METHODS

Professional staff at two medical schools were invited to participate in semi-structured qualitative interviews. Interviews were transcribed and independently analysed for emergent themes. Data analysis continued with purposive sampling for maximum variation until thematic saturation was reached. Findings were returned to participants in writing and via oral presentations for member checking and refinement.

RESULTS

Twenty-two female staff from clinical, teaching and commercial backgrounds at nine urban and rural teaching sites were interviewed. Participants described providing support for diverse concerns, from routine requests to life-threatening emergencies. Four major themes emerged: firstly, all described roles consistent with emotional labour. Secondly, student support was regarded as informal work, and not well recognised or defined. Consequently, many drew upon their personal orientation to provide support. Finally, we identified both positive and negative personal impacts, including ongoing distress after critical events.

CONCLUSIONS

Professional staff perform a range of student support work, leading to emotional, personal and work impacts. In turn, they need support, recognition and training in this essential but under-recognised role. Emotional labour offers a conceptual framework for understanding the gendered nature and impact of this work and how it may be managed. We suggest practical strategies for promoting positive and preventing negative effects on staff from supporting medical students.

Taking data seriously: the value of actor-network theory in rethinking patient experience data

Hospitals are awash with patient experience data, much of it collected with the ostensible purpose of improving the quality of patient care. However, there has been comparatively little consideration of the nature and capacities of data itself. Using insights from actor-network theory, we propose that paying attention to patient experience data as having agency in particular hospital interactions allows us to better trace how and in what circumstances data lead (or fail to lead) to quality improvement.

Three modes of power operation: Understanding doctor-patient conflicts in China's hospital therapeutic landscapes

Doctor-patient conflicts in contemporary China are increasing in numbers and severity. This health geographic study shows how hospitals as a type of therapeutic landscape can shape doctor-patient relationships. First, the comprehensive nature of therapeutic landscapes with an emphasis on power operation within symbolic environments is provided as a framework for this study. Second, the results from participant observation and interviews with patients and doctors previously involved in conflicts are reported from Internal Medicine and Surgery Departments, within four hospitals in Anhui Province, Eastern China. The study finds that the spatial and temporal arrangements of spaces, the inside decorations and the different modes of discourses can build or ruin harmonious doctor-patient relations. The research concludes that adaptations to current hospital therapeutic landscapes can improve trust between patients and doctors, resulting in fewer conflicts and better health outcomes in China.

Calling the GP surgery: patient burden, patient satisfaction, and implications for training

BACKGROUND

Good communication is central to the effectiveness of GP service provision, as well as to patient satisfaction with surgeries, but very little is known about the actual communication that occurs between patients and surgeries.

AIM

This study was carried out to examine, for the first time, how receptionists interact with patients on the telephone, to identify features of communication associated with efficacy and patient satisfaction.

DESIGN AND SETTING

A qualitative conversation analysis of incoming patient telephone calls, recorded 'for training purposes', in three English GP surgeries.

METHOD

Data were analysed qualitatively to identify effective communication, then coded to establish the relative prevalence of communication types across each surgery.

RESULTS

Analysis identified a burden on patients to drive calls forward and achieve service. 'Patient burden' occurred when receptionists failed to offer alternatives to patients whose initial requests could not be met, or to summarise relevant next actions (for example, appointment, call-back, or other query) at the end of calls. Coding revealed that 'patient burden' frequency differed across the services. Increased 'patient burden' was associated with decreased satisfaction on published satisfaction survey scores.

CONCLUSION

Patients in some practices have to push for effective service when calling GP surgeries. Conversation analysis specifies what constitutes (in)effective communication. Findings can then underpin receptionist training and improve patient experience and satisfaction.

Patient burden during appointment-making telephone calls to GP practices

OBJECTIVE

This study addresses, for the first time, the effectiveness of receptionists handling incoming calls from patients to access General Practice services.

METHODS

It is a large-scale qualitative study of three services in the UK. Using conversation analysis, we identified the issue of 'patient burden', which we defined based on the trouble patients display pursuing service. We quantified instances of 'patient burden' using a coding scheme.

RESULTS

We demonstrate how 'patient burden' unfolds in two phases of the telephone calls: (i) following an initial rejection of a patient's request; and (ii) following a receptionist's initiation of call closing. Our quantitative analysis shows that the three GP services differ in the frequency of 'patient burden' and reveals a correlation between the proportion of 'patient burden' and independent national satisfaction scores for these surgeries.

CONCLUSION

Unlike post-hoc surveys, our analysis of live calls identifies the communicative practices which may constitute patient (dis)satisfaction.

PRACTICE IMPLICATIONS

Through establishing what receptionists handle well or less well in encounters with patients, we propose ways of improving such encounters through training or other forms of intervention.

The Critical Role of Clerks in the Patient-Centered Medical Home

Research evaluating the effectiveness, function, and implementation of patient-centered medical homes (PCMHs) has found major socioprofessional transformations and contributions of primary care physicians and, to a lesser degree, nurses. Our longitudinal ethnographic research with teams implementing PCMH in Veterans Health Administration (VHA) primary care identifies the important but largely underutilized contributions of clerks to PCMH outcomes. Although the relationship of high-performing clerical staff to patient satisfaction is widely acknowledged, PCMH can be further enhanced by enabling clerks to use administrative tasks as conduits for investing in long-term personalized relationships with patients that foster trust in the PCMH and the broader health care organization. Such relationships are engendered through the care-coordination activities clerks perform, which may be bolstered by organizational investment in clerks as skilled health care team members.

The care work of general practice receptionists

Abstract INTRODUCTION The care work of general practice receptionists has received limited research attention, despite receptionists position at the beginning of patients’ journeys in many health care systems. We examine receptionists’ perceptions of their work and the opportunities and constraints they experience in caring for patients while providing administrative support to practices. METHODS Data were collected in focus group interviews with 32 receptionists from urban and rural general practices in the Auckland and Northland regions of New Zealand. We employed tools from inductive thematic analysis and Straussian grounded theory in interpreting the data. FINDINGS We found that the way receptionists identified with a caring role strongly challenged the pejorative view of them in public discourse. Receptionists provide care in two key ways: for the practice and for patients. The juggling they do between the demands of the practice and of patients creates considerable work tensions that are often invisible to other staff members. CONCLUSION Receptionists have a critical role as the first step in the patient care pathway, bridging health care system and community. For general practice to be patient-centred and improve accessibility for the most vulnerable, the care work of receptionists must be considered core. KEYWORDS Receptionists; general practice; care; New Zealand

Migrant encounters in the clinic: Bureaucratic, biomedical, and community influences on patient interactions with front-line workers

Ethnographic research on the clinical encounter has focused almost exclusively on what happens in exam rooms-particularly patient-provider interactions-leaving much to be understood about other actors within the clinic. As part of a larger ethnographic study examining the impact of colonialism, transnational migration, discrimination, and gender relations on Chuukese migrant women's reproductive and sexual health outcomes in Guam, I conducted eight months of participant observation in three publicly funded health clinics, 24 interviews with health care workers, and 15 life-history interviews with Chuukese women between September 2012 and February 2014. Findings demonstrated differential treatment of Chuukese patients by front-line workers (FLWs), who engaged in "boundary work" with these patients. Further, care varied by clinic space and the actors in that space. This differential treatment and variation in care impacted Chuukese women's access to and experiences with health care in Guam. Utilizing the concept of "deservingness," this analysis unpacks how FLWs, like Lipsky's "street-level bureaucrats," are influenced by bureaucratic, biomedical, and community hierarchies, all contributing to differential patient treatment. This study concludes by calling for more integrated analyses of clinical environments which utilize Lipsky's concept to include community narratives of "deservingness" and incorporate the influence of clinic and community stratification.