Psychosocial demands and resources for working time organization in GP practices. Results from a team-based ethnographic study in Germany

We will give an overview over different models describing how GPs organized consultation hours. Then we will present how overall working time is organized in GP practices and how specific aspects such as breaks, sick leave and vacations are organised. All results will be illustrated by quotes from the observation protocols, interviews and focus group discussions (Tables 2, 3, 4 and 5). The selected quotes were linguistically revised and then translated from German into English by the authors. As we focused on the overall content of the data collected, no significant loss of meaning was expected due to the translation.

Table 2 Organization of consultation hoursTable 3 Organizing overall working timeTable 4 Organizing breaks in daily routinesTable 5 Organizing predictable and unpredictable absence of staffOrganization of consultation hours

The working hours of the GPs and the PrAs both comprised working time during the opening hours of the practice and working time behind closed practice doors. GPs in single and in group practices alike had long consultations hours, but it remained unclear whether there was a difference between the number of patients treated per GP in single practices compared to group practices. In group practices, physicians organised their overall working hours and their preferred consultation hours among themselves in order to ensure long practice opening hours without necessarily stretching their individual working hours [Table 2, Quote 1].

The practices observed used two different models to organize consultation hours: appointment scheduling and walk-in consultation hours. Appointment systems are characterised by patients booking specific appointments in advance and being treated in the order of appointments organized by the PrAs. Walk-in consultation hours are characterised by patients coming spontaneously to the practice and either waiting or coming back later that day to be seen by the GPs. The respective approach was usually determined by the GPs and carried out by the PrAs working at the registration desk. Several practices used hybrid models, e.g. when most parts of the GPs consultation hours were structured along appointments and a specific time frame per day was reserved to treat walk-in patients, or when most parts of the GPs consultation hours were organized as a walk-in system, but specific patients received appointments. In the hybrid models, some GPs had a higher frequency of patients during the walk-in hours, meaning more patient contacts and less time per patient [Table 2, Quote 2]. Furthermore, neither the PrAs nor the GPs would know in advance how many patients would come by and for which reasons.

Appointment scheduling reduced the number of patient contacts; hence, GPs had more time per patient, especially for those with complex diseases and situations, and the possibility to plan the order of cases (e.g. not 5 intense cases in a row). In both models, patients were seen as a ‘plannable unplannable factor’. Practice staff and GPs saw walk-in systems as a means to deal with unplannable patients in the sense of patients who became spontaneously sick or patients who were assumed to or had proven to not hold appointments. Appointment systems on the other hand offered more predictability, but still it was not certain whether additional patients would eventually show up during consultation hours.

Organizing overall working time

GPs saw the ‘unplannable’ as an integral part of their daily routine during consultation hours [Table 3, Quote 3]. They reported that they had to carry out different tasks and roles simultaneously during this time of their working day. For example, when a spontaneous need for action emerged, such as practice staff sickness notifications or technical disruptions, GPs had to switch between different roles during consultation hours which could lead to perceived psychological stress for the GPs and within the practice team, e.g. when the GP’s self-perceived situational role was “just doctor” while the PrAs needed another situational role [Table 3, Quote 4]. The GPs regarded administrative tasks such as the writing of expert reports or accounting as impossible to be carried out during practice opening hours. For this reason, they planned these tasks to be accomplished outside the opening/consultation hours, i.e. mostly in the evening or sometimes during the weekend. This was rather phrased as additional working hours than as part of the regular working hours [Table 3, Quote 5]. Altogether, GPs highlighted their extended working week and expressed a high workload and few rest periods [Table 3, Quote 6].

In contrast to the diverse tasks of GPs besides consultation hours, PrAs usually had no work-related tasks to manage after leaving the practice. It was reported that PrAs would be contacted occasionally after working hours for practice-related questions (e.g. management of deliveries, administrative tasks). The PrAs expressed satisfaction with the flexibility of different working time models and the GPs’ overall willingness to adjust working time models and hours to the needs of the PrAs. This was discussed in the interviews and focus groups mostly in the context of compatibility of work and (child) care. Yet, when it came to day-to-day organization of working time, our observations and the interviews/focus groups showed that the organization of daily finishing time was the other side of the coin. One GP addressed three available options: (1) the GP makes sure that the finishing times match the needs of the PrAs, (2) the GP looks for PrAs who match the finishing times of the practice, (3) the finishing times and the needs of the PrAs collide and the PrAs are exposed to pressure [Table 3, Quote 7].

Some GPs saw appointment systems as a means to ensure predictability through plannable finishing times. As the organization of the appointments was delegated to the PrAs, this was meant to also provide the latter with a scope for action [Table 3, Quote 8]. In contrast, the walk-in hours were difficult to plan. Here, the immediate treatment of patients was favoured over predictable working times for PrAs and the GPs themselves. As a result, the working times could become barely plannable, which was problematized by PrAs with regards to taking (lunch) breaks and finishing time [Table 3, Quote 9 and 10]. Solutions were sought partly in the workplace when GPs and PrAs planned rosters in a way that employees with children could leave on time or at least earlier. Other solutions had to be sought by the respective PrAs in their private lives, e.g. when private plans were rescheduled spontaneously or private networks helped out with childcare.

Organizing breaks in daily routines

Breaks are required by law to provide rest and recovery. It is the GP’s task as employer to enable breaks in terms of spatial as well as temporal dimensions. Paridon et al. [40] distinguish between micro-breaks (< 1 min), mini breaks (1-5 min), short breaks (5-10 min) and longer breaks (> 10 min). The GPs considered the practice staff self-responsible to organize at least most of their breaks if not all of them [Table 4, Quote 11]. We observed absence of micro and mini breaks at workplaces with high patient contacts, such as the registration desk. There, the PrAs rarely took micro breaks, e.g. for drinking, or mini breaks, e.g. for using the toilet [Table 4, Quote 12]. The PrAs connected this not only to a high workload, but also to the workplace design, as they were exposed to the gazes of patients at the desks and felt the urge to be visibly at work. We observed in several practices that GPs and PrAs made use of break rooms as a place for short breaks and longer breaks. The design of break rooms ranged from a small tea kitchen for one person to larger rooms with facilities for several people. The larger rooms usually held several functions: They were break rooms, but also had either a workstation integrated, or were used as storage space for materials [Table 4, Quote 13]. One GP pointed out that the break rooms were not only a room for individual recreation but also for maintaining social relationships among colleagues beyond working routines [Table 4, Quote 14].

Our data indicate that the behaviour of the GPs had to some extent an impact on the PrAs’ behaviour. We observed that some GPs took no breaks during consultation hours. This was also addressed by the PrAs in one focus group discussion [Table 4, Quote 15]. In the same practice, a PrA stated that practice staff would often prepare documents during their lunch break. We observed the GP in the same practice taking at least short breaks. In one practice, the lunch breaks were taken outside the practice by both GPs and PrAs.

Organizing predictable and unpredictable absence of staff

A further dimension of working time organization was the predictable and unpredictable absence of staff. Vacations go along with plannable absence of staff. We found different forms of collective and individual regulations for vacations in the practices observed. In this context, it was of utmost relevance whether one or several GPs worked in a practice. In single practices, the individual vacations of the GP automatically led to collective vacations of the whole practice team as the practice closed completely. In group practices, this was rather the result of a choice made by the practice owners: some chose for simultaneous vacations of all GPs and thus collective vacations and a closed practice. Others chose for individual vacations of the GPs and a practice that remained open with a reduced patient volume. Independent from these regulations, (additional) individual vacations were possible for PrAs across all practices. GPs in all practices delegated individual vacation planning to the practice staff under the condition that practice work would run smoothly and without conflicts [Table 5, Quote 16]. GPs showed willingness to support PrAs in their individual vacation planning, e.g. by adjusting the patient volume during vacation periods [Table 5, Quote 17]. The practice staff described mutual social support when planning individual vacations [Table 5, Quote 18].

In contrast to vacations, sick leaves of GPs or PrAs occur expectedly, but unpredictably. Overall, sick leaves were rather addressed with regards to the PrAs, while sick leaves of GPs were hardly discussed and was observed in one group practice only. A GP attributed this to the traditionally strong work ethics among GPs [Table 5, Quote 19]. Some GPs chose to handle sick leave of staff spontaneously. In these cases, tasks, rosters and patients were re-organized the day a staff member became sick. Either the GPs organized this themselves [Table 5, Quote 20] or delegated the task to the PrAs [Table 5, Quote 21]. Some PrAs explained that an organization of sick leave through the PrAs was beneficial for the organization of work as they had a more complete overview of the tasks at hand and the availability of PrAs [Table 5, Quote 22]. At the same time, a GP of the same practice criticized the described procedure of the PrAs if it was not authorized by the GP. From the GP’s point of view, the ultimate authority over decision-making on work re-organisations belonged to the GP. Consequently, conflict might arise when decisions were made by the PrAs without approval by the GP [Table 3, Quote 4].

Some GPs took preventive measures and thus planned the unpredictable absence of staff. One GP emphasized their responsibility for the planning of the staffing ratio as a precautionary measure to avoid spontaneous shortages due to illness [Table 5, Quote 23]. In a different practice, an on-call roster of the practice staff was drawn up for the entire year by a GP in cooperation with a staff member. Thus, little organizational effort was supposed to be required in case of sick leaves and possible stress due to short-term planning or insufficient staffing was supposed to be prevented [Table 5, Quote 24]. As the quote indicates, such an approach was also the result of a learning process, meaning that systems are constantly reworked and improved. In one of the group practices observed, the mutual substitution of the GPs for each other was contractually regulated. According to the contract, the GPs would cover each other’s absence for 6 weeks and then split the revenues.

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