Research

The effect of general practice team composition and climate on staff and patient experiences: a systematic review

Ruth Abrams, Bridget Jones, John Campbell, Simon de Lusignan, Stephen Peckham and Heather Gage
BJGP Open 2024; 8 (1): BJGPO.2023.0111. DOI: https://doi.org/10.3399/BJGPO.2023.0111

Abstract

Background Recent policy initiatives seeking to address the workforce crisis in general practice have promoted greater multidisciplinarity. Evidence is lacking on how changes in staffing and the relational climate in practice teams affect the experiences of staff and patients.

Aim To synthesise evidence on how the composition of the practice workforce and team climate affect staff job satisfaction and burnout, and the processes and quality of care for patients.

Design & setting A systematic literature review of international evidence.

Method Four different searches were carried out using MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science. Evidence from English language articles from 2012–2022 was identified, with no restriction on study design. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and data were synthesised thematically.

Results In total, 11 studies in primary healthcare settings were included, 10 from US integrated healthcare systems, one from Canada. Findings indicated that when teams are understaffed and work environments are stressful, patient care and staff wellbeing suffer. However, a good relational climate can buffer against burnout and protect patient care quality in situations of high workload. Good team dynamics and stable team membership are important for patient care coordination and job satisfaction. Female physicians are at greater risk of burnout.

Conclusion Evidence regarding team composition and team climate in relation to staff and patient outcomes in general practice remains limited. Challenges exist when drawing conclusions across different team compositions and definitions of team climate. Further research is needed to explore the conditions that generate a ‘good’ climate.

How this fits in

The review findings are relevant to the current workforce pressures in general practice. They demonstrate that how well a practice team works together affects staff wellbeing and patient care. A good relational team climate can mitigate against the adverse effects on staff and patients of high workloads. Implications for general practice are explored.

Introduction

Even before the global COVID-19 pandemic in 2020, general practice in the UK was facing a workforce crisis.1 The number of full-time equivalent (FTE) GPs was falling while workloads were increasing owing to population ageing and increased prevalence of long-term conditions.2,3 Policy initiatives have included the introduction of new roles into general practice,4,5 but evidence is lacking on what team composition works best for staff and patients. The environment in which employees interact on a daily basis (team climate), however, also affects care delivery,6,7 staff wellbeing, and job satisfaction.8,9 As independent contractors, general practices make their own staffing decisions and manage their own teams. To inform organisational decision making, we conducted a systematic review to identify evidence on how team composition and team climate in general practice affect outcomes for staff and patients.

Method

Conceptual framework

Guided by a conceptual framework (Figure 1), this review asked: how 1) the composition, and 2) the climate of a general practice team impacts on the outcomes for a) its staff, and b) its patients.

Figure 1.
Figure 1. Conceptual framework

For the purposes of this review, we define a general practice team as involving ≥2 types of staff, including non-clinical managerial and administrative staff.10 Team composition reflects structure, including all professions, grades, age, and sex of staff.11 Team climate refers to the relational processes of teamworking, including shared perceptions of organisational policies, practices, and procedures, along with psychosocial aspects such as trust.11 Although influenced by the underlying organisational culture,12 team climate is generally considered something that is more easily manipulated by team leaders to promote productivity.13 Team climate has been equated with team functioning.14 Culture is a deeper and more engrained concept, reflecting an organisations’ norms of behaviour, beliefs, and values.15 A range of outcomes for staff and patients arising from differences or changes in team composition and team climate were of interest, including staff job satisfaction, wellbeing, stress or burnout, and quality of care for patients.

Search strategy

A four-stage iterative search was carried out between December 2021 and March 2022. Search results were uploaded into Rayyan software16 for screening and quality assessment (Table 1). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for reporting transparency for systematic reviews were followed.17

View this table:
Table 1. Summary of review methodology

Results

The four searches yielded 11 011 records after de-duplication. Based on title and abstract screening, 50 records were selected for full-text screening, 39 of which were excluded because they did not explore the relationship between team composition or climate and the outcomes of interest. This resulted in 11 records for full inclusion (Figure 2 provides an integrated PRISMA covering all searches. Independent PRISMAs for each separate search can be found in Supplementary Figures S1–S4 and include exclusion reasons).

Figure 2.
Figure 2. Integrated PRISMA diagram

Document characteristics

Of the 11 included studies, 10 came from the US.18–27 The remaining study was from Canada.28 All studies were empirical and used multivariate regression modelling to assess the association between composition and/or climate variables and outcomes for patients and/or staff. Data were gathered by surveys and/or from administrative data; one mixed-methods design used surveys and qualitative interviews.25 Of the 10 US studies, five were conducted in the Veterans Health Administration (VHA);29–33 three were set in other integrated healthcare systems — the Mayo clinic18,19 and Harvard academic collaborative;25 two were surveys of family physicians — one national,20 the other in San Francisco, US.26 Full data extraction tables are in Supplementary Table S2.

Thematic summary

Studies were mapped to research questions (see Supplementary Figure S5). An overview of included articles and the measures or definitions used is in Supplementary Table S1; details of the quality assessment are in Supplementary Table S3. A summary of key findings is in Table 2.

View this table:
Table 2. Summary of findings

Team composition and team climate

The impact of team composition was explored in four studies. Composition was represented by the proportion of the total primary healthcare team FTE provided by physicians,18,19 team size and profession,20 and the physician sex balance.28 Only one study explicitly referred to team climate.24 Another examined the effect of team culture, defined as ‘team functioning’ and measured using an adapted version of the Team Climate Inventory, illustrating the lack of clarity around what distinguishes the concepts of climate and culture.26 Team climate was indirectly implicated in several other studies through related concepts, such as team effectiveness, efficiency, and dynamics, each measured in a variety of ways; for example, communication, shared understanding, participatory decision making, and staffing stability (because of its impact on working relationships). Staff insufficiency and stressful workloads were central to several articles and linked by authors to the negative effect this has on interactions and relational work environments.21–24,27 Hence, staffing levels were treated as ‘climate-related’ variables in the analysis.

Outcomes for staff

Six studies reported the association between team composition or climate and outcomes for staff, with five of these six reporting effects on emotional exhaustion or burnout19–22,26 and the other reporting effects on clinical job satisfaction.25 Associations are summarised in Table 2. Lower emotional exhaustion for all types of clinicians was associated with having a higher proportion of the total team FTE being a physician.19 Female clinicians were associated with a higher likelihood of burnout.20 Inadequate staffing21,22 and adverse work environments20,21 were associated with more emotional exhaustion. Perceived teamwork efficiency,20 participatory decision making,21 stability in team structure,21,22,26 and a better team ‘culture’ (measured by the Team Climate Inventory) were associated with less emotional exhaustion. Good team dynamics was strongly associated with clinician work satisfaction.25

Outcomes for patients

Patient outcomes were explored in six studies, summarised in Table 2. Two focused on clinical effectiveness proxied by mortality27 and avoidance of unnecessary hospitalisations or emergency department visits.18,27 The other four focused on various care quality measures.23–25,28 Hospital admissions and accident and emergency visits were not associated with physician time within a care team but were predicted by greater panel complexity and fewer years in practice (less clinical acumen and lower risk tolerance). Emergency department visits were, however, lower in patient panels led by physicians than in those of physician assistants or nurse practitioners.18

A positive association was identified between team dynamics and patient care coordination, with the latter positively affecting clinician work satisfaction.25 Quality of care (influenza vaccination rates, continuity with the same practitioner, time in consultations, and patient-reported satisfaction) was worse in teams with staffing below VHA-recommended levels. However, additional staff above recommendations did not add extra benefit.23,24 A favourable relational climate mitigated the adverse effect of high workload on quality of care.24 Similarly, better team functioning, rather than staff sufficiency, was associated with lower hospital admissions.27

Further detail on factors affecting outcomes for staff and patients are in Supplementary Tables S4a–S4d.

Discussion

Summary

A central finding is that staff burnout is higher and the quality of care for patients is worse when teams are understaffed and work environments are stressful. Physicians reported higher emotional exhaustion than other clinical and non-clinical staff. One study reported less burnout when physicians accounted for a higher proportion of the whole-team FTE. Higher rates of burnout were associated with female clinicians. While having sufficient staff to afford time to patients has a beneficial effect on quality of care, additional staff may eventually have diminishing returns, which were attributed to coordination problems and ‘social loafing’, a term for reduced staff motivation.23

A stable team structure is important for effective team functioning, but less so than having a cohesive team that works well together. Indeed, a good relational climate may act as a buffer against burnout where workloads are high. Staff job satisfaction is associated with a good team dynamic and that also appears to improve patient care coordination. Varied factors were associated with lower hospital utilisation, including more years of clinical experience, less patient comorbidity, and better team functioning.

Strengths and limitations

Despite a comprehensive search and an iterative process to widen the scope, a relatively small number of articles were identified. Searches were restricted to 10 years because the healthcare delivery landscape is constantly changing, and studies published earlier may no longer be relevant. Even so, data in two studies were from 2006.23,24 We also acknowledge that limiting the search to only English language articles may preclude the inclusion of valuable evidence from other countries.

Evidence from all but one study comes from the US. American provider organisations operate in a competitive environment, keep detailed patient data on service utilisation for billing, and routinely gather feedback from staff and patients to monitor their market positions, which facilitates research. Although the US studies were set in integrated healthcare systems that operate in ways similar to those of other advanced countries, including gatekeeping and rostering, context and organisation may differ such that the findings may not be directly transferable to other countries. In particular, different interpretations of what constitutes a primary healthcare team may be important. As described by articles in this review, primary healthcare practitioners in the US work with a dedicated nurse (or medical assistant) and clerk, in a small ‘teamlet’ within a primary care centre with several other ‘teamlets’. This differs from larger UK practices, where staff groupings are defined by roles. Physician-reported descriptions of teams in one study in the review revealed >800 different team compositions, indicating the challenges for researchers of analysing how staff combinations affect outcomes. The study condensed the multiple configurations to three groups (family practitioner plus one, or two, or three other roles) removing scope for nuanced interpretation.20

All included studies used quantitative methods (regression modelling), but cross-sectional data limited the analyses to measures of association rather than causal inference. Although the number of included studies was small, each had large sample sizes (hundreds of staff and thousands of patients). Response rates to surveys were generally >50%, except for two studies using the same dataset,21,22 and validated instruments (or adaptations) were used to measure climate-related variables in most studies.21,24–27

A narrative synthesis was necessitated by lack of consistency in the measurement of outcomes (for example, three different measures of burnout) and choice of predictor variables. There was a lack of clarity around the concept of team climate; definitions of what constitutes optimal team functioning or dynamics were varied. One study referred to team culture while measuring it using the Team Climate Inventory,26 others explored climate-related factors without labelling them as such. Where authors used variables reflecting relational teamworking, they were interpreted in the analysis as climate-related, but misinterpretations could have occurred. Workload was treated as climate-related because of its impact on how team members interact.24 Studies on climate that were relevant to the review could have been screened out because they used alternative terminology. Culture was outside of the review scope because of differences from climate in conceptualisation.7

Comparison with existing literature

Since this review was conducted, two new studies have analysed national general practice workforce data in England. Use of locum (temporary) GPs was found to be higher in rural and single GP practices and was associated with inadequate performance ratings at Care Quality Commission inspections.29 The second study found the composition of the clinical workforce associated with various population, professional, and system outcomes in differing ways.30,31 While additional GPs was associated with higher satisfaction for the GPs themselves and for patients, increasing staff in other clinical roles had the opposite effect. More clinical staff was associated with better practice performance in the Quality and Outcomes Framework (QOF), but also with more hospital activity, a finding that aligns with those of a US study in the current review.27

In line with articles in the review, there is consensus that strong leadership, shared goals, good communication, and participatory decision making contribute to a favourable team climate and improve functioning.12,14,32–36 While micro-level team composition and functioning are identified as important,37 existing context also matters in the development of models for primary healthcare delivery and determining optimal panel sizes.28,38,39 Larger teams have been associated with worse scores on the Team Climate Inventory14 but not consistently so.12 Similarly, larger patient panels do not necessarily mean worse quality of care.40

Implications for research and practice

Consistent with other studies,41–44 evidence from this review shows that in US integrated care systems in which primary healthcare practitioners (usually a physician but could be a physician’s assistant or nurse practitioner) have assigned ‘panels’ of patients, continuity of care (seeing the same practitioner) and care coordination were associated with better outcomes for staff and patients.23,25,28 In the NHS, concerns have been raised that combined practice lists, a so-called ‘collusion of anonymity’, result in higher utilisation and costs, increased mortality, and reduced patient satisfaction.45 Research is required to explore the impact of patient rostering on outcomes for patients and work satisfaction for staff, as well as the resource implications.

Studies based in the VHA report evidence-based guidelines for core primary healthcare teams regarding practitioner-to-patient ratios (900–1200 patients per physician or physicians associate or nurse practitioner, adjusted for case mix). The findings indicated patients benefit from spare capacity in a team (relative to guidelines) and diminishing returns from added staff above recommended levels.23,24 UK general practices make their own resourcing decisions, constrained by formula-driven practice payments that are intended to create an equitable allocation. However, the current average of 2600 patients per GP is regarded as unmanageable and has prompted the generation of guidelines for safe working.46,47 Investigation of optimal team sizes and economies of scale, with proposals for staff-to-patient ratios and associated incremental costs, is needed to inform decision making.39,48,49 With the trend for practices to increase in size, new organisational structures involving micro-teams have been suggested as a means to benefit from improved continuity of care.44

Studies in the review confirmed the adverse effects on staff wellbeing of insufficient staff, excessive workloads, and pressured work environments.50,51 These features have characterised British general practice in recent years owing to recruitment and retention problems and increased part-time working.3,52,53 Patient satisfaction is also at an historic low owing to access problems.54 Evidence from the review supports the mitigating impact of a good team climate on the adverse effects of high workload.24 However, more clarity is required on what ‘good’ looks like, the factors that create it, and how these are generated. Articles in the review variously indicate the importance of goals, leadership, and inclusivity for promoting productive interactions. Research is now needed to identify a clear conceptualisation of team climate specific to a healthcare context, which will inform the development of interventions to improve working environments.

There was little evidence from the review to inform the current policy of introducing additional roles into general practice to address staff shortages. Further research is required to explore whether having adequate staff per se or a greater variety of roles is the more effective at reducing work pressure and improving patient experiences,31 and how part-time staff affiliations in practices affects team climate. Similarly, studies in the review do not directly inform the post-pandemic debate about how use of remote consultation methods affects the quality of care,45 although they provide consistent evidence of the importance to patients of good access and a personalised approach. They also indicate that allowing patients more time with practitioners improves quality of care and patient satisfaction,24 which supports recent recommendations for increasing the length of consultations in general practice,55 with consultation lengths in the UK currently being the briefest in Europe.56

Finally, the increasing numbers of females becoming GPs also requires consideration. The present review, and another,57 have suggested that females may be at greater risk of emotional exhaustion,19,20 and that their higher rates of part-time working may adversely affect access and continuity of care for patients.28 While the new wellbeing QOF indicator is intended to reduce GP burnout, it places a significant onus on individual practices and individuals themselves.58 Policies and guidance are urgently needed to support local initiatives.59 In particular, how the working environment affects females and their ability to achieve wellbeing, job satisfaction, and deliver patient care now requires further research.

Notes

Funding

This project is funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research Programme (project number: 17/08/34). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Ethical approval

Ethical approval was not required for this systematic review.

Provenance

Freely submitted; externally peer reviewed.

Acknowledgements

We thank Vittoria Lutje for supporting the literature search, and Simon Bailey, Rebecca Cassidy, Rupa Chilvers, Catherine Marchand, Karen Spilsbury, and Suzanne Richards (members of the GP Teams project) for contributing to the evolution of the work. We are grateful to a panel of service users, led by Phelim Brady, that provided the lay person perspective on the work, and for advice from the project’s panel of professionals and commissioners.

Competing interests

RA is a member of the BJGP Editorial Board. She had no involvement in the peer review process or decision on this manuscript.

  • Received June 15, 2023.
  • Revision received August 22, 2023.
  • Accepted September 1, 2023.

This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)

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BJGP Open
Vol. 8, Issue 1
April 2024
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The effect of general practice team composition and climate on staff and patient experiences: a systematic review
Ruth Abrams, Bridget Jones, John Campbell, Simon de Lusignan, Stephen Peckham, Heather Gage
BJGP Open 2024; 8 (1): BJGPO.2023.0111. DOI: 10.3399/BJGPO.2023.0111
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Intended for Healthcare Professionals
 
 

British Journal of General Practice