The care work of general practice receptionists

General practice is the main entry portal to health care in New Zealand. For patients, contact is through general practice receptionists (‘receptionists’), who are the people at the beginning of their health care pathway. This position affords receptionists substantial influence on patients’ experience of health care.

Current discussions of primary care teams fail to acknowledge receptionists’ contribution to patient care.¹ With their focus firmly on clinical aspects of primary care, the non-clinical (or pre-clinical) aspects of care have often been ignored. The work of receptionists remains hidden. Yet, from patients’ perspectives, and especially patients with high health and social needs, receptionists may be important in helping them feel at ease; something indirectly demonstrated in Canadian hospital settings² and in New Zealand general practice.^3,4

Receptionists are often framed negatively in the literature as gatekeepers,⁵ sometimes attracting pejorative stereotyping.⁶ Research has highlighted negative patient perceptions and experiences of receptionists, including the view that receptionists’ focus on routine activity can lead to their being considered ‘cold’.⁷ They have also been identified as making judgements about patients when deciding how to prioritise appointment-making.⁸

However receptionists do much more than make appointments. As well as administration, they engage in clinical activities for which they are untrained, such as triage.^9,10 It has been questioned whether receptionists sometimes act as de facto nurses, lowering costs to the practice. This function has been identified as a potential legal risk to practices⁹ as well as to receptionists.¹¹

Receptionists may have considerable informal power to influence patients’ access to clinical care⁶ yet it is unclear how much power receptionists really have in general practices. There is evidence that receptionists are torn between their duties towards patients and practices^12,13 and of feeling the need to ‘protect’ the practice staff and policies.¹⁴ We explore these tensions in the general practice receptionist role in New Zealand. Like Hammond and colleagues,¹⁴ we argue that the work of receptionists cannot be understood in isolation from their work context.

We present findings from the initial phase of a study about of reception processes in New Zealand general practice. Our objective for this phase was to explore how receptionists viewed and experienced their roles, particularly with regard to people with high health and social needs.

To conceptualise how receptionists describe their roles and responsibilities, we applied a critical public health lens,¹⁵ drawing on a social constructivist interpretive approach.¹⁶ This theoretical framework enabled interpretation of individual receptionists’ experiences together with other receptionists, but also within the social context of general practice as a system.

After institutional ethics approval, receptionists were invited to participate in a single focus group interview with peers from other practices. In keeping with the requirements of ethical approval, indirect recruitment was undertaken through general practice managers in one of three primary health organisations (PHOs). Two PHOs were in the Auckland region (population ~1.5 million), and one was in Whangarei, the regional centre in Northland (population ~75 000). Study details were presented at routine PHO-led meetings for practice managers, who were then invited to discuss the study with their reception staff. Managers were given employer information and consent forms for themselves and practice owners. Employer consent was obtained before contacting potential receptionist participants. Permanently employed part-time or full-time receptionists were eligible to participate.

The sample comprised 32 receptionists from 15 practices in Auckland and 12 practices in Whangarei (and vicinity). Participants’ work settings were diverse in terms of number of doctors in their practices and practice location. While most practices were located in urban areas (particularly west and central Auckland, and Whangarei), a small proportion were from rural practices. All participants were women, five identified as Māori, and nearly half worked part-time. Their duration of experience as general practice receptionists ranged from one to 22 years.

A pilot study found that receptionists were not accustomed to reflecting on their roles. Therefore, focus group interviews were chosen to encourage discussion, and held over 12 months from August 2013. Participants from the same practice were allocated to different groups, when possible. Participants were offered the option of attending a Māori focus group, which was conducted following Māori cultural processes. Six groups comprised five or six receptionists.

The two Māori focus groups had three and two participants in Whangarei and Auckland respectively. These focus groups were facilitated by a Māori researcher, accompanied by the first author. Findings from these focus groups were distinctive, but as participant numbers were small they will be examined in a separate report with data from the Māori participants in later phases of the study.

The interview process involved distributing statements to participants to provoke discussion, a method described by Kitzinger.^19,20 Sample statements included:

• My role, as receptionist, is very important to patients

• Receptionists have a lot of control over their workload and work tasks

• Some patients make it hard for me to do my job.

In acknowledgment of participation, each focus group concluded with kai (food) and participants were given a voucher as koha (gift). Interviews were digitally audio-recorded, and transcribed verbatim.

A ‘thematic analysis’ approach was undertaken.¹⁷ Codes were devised for patterned ideas within and across interview transcripts, to extract themes from the data. The coding approach drew on the tools of grounded theory, open and axial coding¹⁸ to develop a broad understanding of receptionists’ work.

PN and IC analysed all data, doing independent inductive coding of each transcript and preliminary open coding across transcripts. Coding was then reviewed together and collaborative axial coding was undertaken to develop preliminary themes. These themes were validated through a participant feedback process. Findings were summarised and participant feedback was sought via a postal survey (20/31 (65%) responded). As a final step in analysis, interpretation was triangulated by involving the second author in finalising key themes.

Participants described their work as multi-faceted, without clear boundaries, and involving competing demands. While participants spoke passionately about their roles, they varied as to whether they saw themselves as ‘the glue’ holding a practice together, or a general ‘dog’s body’, expected to do anything and everything at times, or both. They consistently described their roles as two types of work. We discuss these categories thematically in terms of care for the practice, and for patients. We then present a third theme: the barriers receptionists face in delivering care.

When invited to talk about their jobs, participants first discussed their role as administrators. Administration is the aspect of their role most often referred to in the research literature. They did not consider this work peripheral to the clinical work of the practice. Rather, they saw themselves as keeping everyone on track – clinicians and patients alike – to keep the practice running smoothly on a day-to-day basis.

It’s the management, isn’t it, management of the whole day. Management of the doctors’ time, nurses’ time, patients’ time and having that, trying to just, so we have a smooth running of the day. (P23)

Their administrative tasks include many activities, categorised in Box 1. There were stories of multi-tasking, due to being constantly ‘on-call’ to the phones, patients arriving, and the requests of colleagues.

Many receptionists described having insufficient control over their work. They need to constantly reprioritise in response to interruptions from both patients and clinical staff, exacerbated by their location at the public workspace of the front desk. They might be busy enrolling a new patient, but if someone arrives acutely unwell and needs to be seen urgently, or they are asked to call an ambulance, they have to stop and change tack. They operate in the present, as illustrated in Box 2. (For further discussion of the administrative role, see Neuwelt et al.²⁰)

The way receptionists identified with a caring role challenges the pejorative view of them in public discourse. For some receptionists, care included developing relationships with patients so that when they contact or visit the practice they feel comfortable from the outset. Patient care also included carrying out routine administrative tasks with respect for patients and responding to urgent patient needs beyond their job descriptions.

Some more experienced receptionists spoke of patients with affection, describing long-standing relationships. For example, they told of patients phoning and expressing delight at hearing the voice of their ‘favourite’ receptionist. Some patients phone often, seeking reassurance or clarification about their concerns – care work that may be unrecognised by other members of the practice team. The interaction in Box 3 is illustrative.

Many said that their ‘care work’ gives them the most personal satisfaction in the job, yet constant demand for completion of administrative tasks can limit their ability to demonstrate care towards, and deliver care to, people. Many participants commented on the difficulty of maintaining a smile when there are so many competing demands (see Box 4).

Participants explained that they often have to carry out health care tasks that more appropriately lie within a nurse’s domain. While they routinely refer patients to nurses for clinical triage, many described responding to patients’ needs at times when nurses were unavailable. The following story from a rural practice is illustrative:

… one Saturday morning I arrived …. the next thing this man arrived with his wife, this patient, she looked really poorly. I had no doc, I had no nurse, I’d just opened, see. So I got them in, got them into theatre and the next thing I had the doctor arrive but no, the nurse still hadn’t arrived, so the doctor said, ‘Right, can you do this for me?’ And so, yeah, you can end up getting asked to do anything in our practice. (P30)

While participants appeared well aware of the non-clinical nature of their explicit role, they frequently spoke of having to work beyond their comfort zones and ‘scope of practice’ (see Box 5). Due to their location at the front of the practice, they described feeling in a more difficult position than clinicians ‘out back’.

Participants appeared to think that being a good receptionist (or being perceived as good by others) is an impossible task. They felt their patient care work was taken for granted by both patients and clinical colleagues. P29 discussed this point in detail, finishing with the statement, ‘And so you really have to be focused, totally focused on the front desk and find the balance between getting your work done and being a good receptionist with customer service and it’s very, very difficult to do.’ P26 supported this idea, stating ‘Sometimes your work has to go to the side so that you can look after your patients. Your work’s piling up but…’ When patients needed specific care, participants prioritised this over their administrative work.

Aspects of their role limit receptionists’ ability to deliver care. ‘Debt collecting’ was the most problematic in this regard. In New Zealand, general practice care is only partially government-subsidised. Every focus group discussion included some deliberation on participants’ discomfort when seeking payment from patients, as follows:

And it makes it harder, and also having to ask people to pay before they see the doctor because they’ve got such a large debt. Being a debt collector I think is probably one of the hardest things at reception to do. (P28)

Participants expressed the burden of responsibility they feel around handling patient payment and observed that it can undermine their relationships with people seeking care.

… your practice is a business as well, so it’s very important to be getting all that money in that’s due so you can basically keep your doors open and staff paid. So that’s quite a responsibility. It’s a very heavy responsibility actually, ‘cause not everybody likes you, no matter how nice. (P20)

Along with handling payments, receptionists also said that their availability to everyone in the practice challenges their ability to be empathic:

And your empathy has to be a bit balanced that you, because you’re in a role where it’s really busy and demands are, not only the patient demands but there could be demands from the doctor and from the nurse, and you’ve got to spread yourself across. (P25)

Box 6 demonstrates how competing demands from patients and clinicians can undermine receptionist care of highly vulnerable patients. While clinicians might argue that receptionists are not qualified to ‘counsel’ suicidal patients, participants described times that patients shared information that they would not disclose to clinical staff. They considered that some patients feel safer with them, as they are ‘on their level’.

In some focus groups, participants joked about the multitasking women do in their personal lives that is mirrored in their receptionist role. Many participants saw themselves as trying to make life easier for others, both patients and doctors, despite the conflicts between demands from each. Many expressed that both parties lacked understanding of the many facets of their role, and that they feel undervalued by clinical colleagues:

I think we [have] to take in patients’ issues, doctors’ moods…nurses’ moods. We do understand where they’re coming from, we do know they’re busy at the back of the scenes, we do know they’re busy with medical, however we would appreciate if they can value that our work is as important, because we might have a difficult patient that wants, or needs medical attention now and you have to go interrupt them and … it will be appreciated if they can understand that from us. We won’t just go and waste their time. (P21)

In contrast, other receptionists described ways that they feel respected and cared for in their general practices. For example, one GP would regularly come and thank them, before leaving work for the day. Focus group participants noted contrasts between their respective working environments with some surprise and concern.

As the public face of the practice, receptionists described being the target of patient frustration with tensions between what patients want and what the practice delivers. In every focus group participants spoke of verbal abuse from occasional patients frustrated by waiting times, unavailable prescriptions, or debt issues. One participant wrote on her feedback survey that receptionists are the ‘first point of attack…We get all the frustration and by the time the patient gets to the doctor or nurse, most of the frustration has been released and the patient is more relaxed.’ Patient frustration or anger often remains unseen by the nurses and doctors.

While there was no explicit discussion among participants about a need for better working conditions, they identified factors that help them manage the role:

• working alongside at least one other receptionist;

• having regular breaks away from the front desk;

• having other staff members (manager, nurse) help at the front desk during very busy times;

• having non-urgent secretarial tasks (such as scanning notes) and debt collection handled away from the front desk.

These ‘supportive factors’ were aspirational and for each participant only some of these factors existed in her current work environment. Participants most often mentioned wishing to be thanked regularly, especially by nurses and doctors, for their contribution to the team.

While participants did not explicitly state they would benefit from regular opportunities to engage with other receptionists about their work, many expressed gratitude for the opportunity to share observations with each other during the focus group interviews. They noted that while GPs, nurses, and practice managers meet with their peers regularly for ongoing education and support, they have no equivalent opportunities.

Receptionists have many, and often conflicting, responsibilities. Their role is complex, especially since the patients who they encounter are usually sick, and many have further vulnerabilities of high economic and social need. Receptionists receive limited training to deal with their full role. Being responsive to patients and clinicians while carrying out complicated administrative tasks in a (sometimes frantically) busy public workspace creates tensions for receptionists: simultaneously juggling multiple roles (e.g. administrator, waiting room manager); and addressing the care needs of patients within the limitations of their practice. Many experience the requests for help by nurses and GPs as ‘demands’ that demonstrate a lack of understanding, even by colleagues, of the many hats receptionists wear. Their location at the front of the practice means that receptionists are well placed to witness the gaps between what patients need and ask for, and what the practice is able to provide. Most have little power over their working conditions or practice processes.

Potentially our most important finding is that while some work is administration (e.g. billing and photocopying), the less visible work of receptionists is ‘being caring’ (e.g. providing reassurance to anxious or distressed patients). We contend that in undertaking this ‘care work’, receptionists are an important, under-recognised member of the primary care team. Much of their labour constitutes both administration and care; for example, appointment-making, collecting patients’ payment, and triage. Each of these tasks requires a high degree of responsiveness to both patients and clinicians.

This ‘care work’ undertaken by receptionists is performed in a relatively public and ‘front stage’ setting. This work is largely invisible to the wider practice team, given their physical location in practices. Yet, as has been identified in previous research, this work may be central to their role from patients’ perspectives.^3,4,21 Further, if patients experience vulnerability due to poverty or stigma, the caring attitude of receptionists might well determine whether or not they cross the practice threshold.

Beyond caring roles and consistent with previous research^9,10 we have highlighted the clinical role (triage) that general practice receptionists play. As unregistered members of the health workforce, receptionists are neither trained for clinical tasks nor, arguably, reimbursed at an appropriate level given this default responsibility. While not an explicit focus of this study, receptionists’ clinical role is worthy of further exploration.

Receptionists occupy an explicitly service-oriented role; service to both practice and patient. In offering care while juggling administrative tasks, receptionists are frequently the recipients of emotive interchanges. The work of trying to make life easier for both clinicians and patients amounts to an emotional labour, which warrants further exploration.

In summary, receptionists have relationships with patients that can sometimes span years and generations; relationships that both patients and receptionists identify as ‘care’. This ‘care work’ may be particularly important to people who are already socially marginalised (even before seeking health care), such as patients experiencing serious mental health issues; a question asked in the next phase of this research. In this way, receptionists perform the role of bridging medical practice and the outside world.¹⁴

Receptionist selection and training is unlikely to resolve tensions inherent in the role. Rather, we suggest a structural problem exists: receptionists’ care work being undervalued. Through this undervaluing, receptionists are disempowered in practices and hence have limited agency to change their working conditions. As Thomson and colleagues²² argue with respect to schools, “this is congruent with leadership and management practice which does not ‘see’ the office as a site in which high level skills of any kind are paramount” (pg. 143).

As shown in a UK study,²¹ patients want individualised, personal care that is reflected throughout their encounter with general practice. As the first point of contact, receptionists are key to establishing and sustaining patient comfort. If they are well-chosen for the role, and well-supported, receptionists can positively influence health care accessibility. For general practice care to be patient-centred, the diverse work of receptionists must be considered core.

Although this study does not represent the views of all general practice receptionists in New Zealand, it nonetheless offers insights into the experiences and contributions of under-recognised members of the health workforce. Receptionists have often untapped knowledge and expertise about patients and practice systems. Unlike others in practices, they work within the sight and earshot of patients. They deserve a high level of support. Enhanced recognition of the receptionist role, along with further exploration of the hierarchical nature of general practice as a system of care, holds great potential to enhance the preclinical aspects of patient care pathways.

No competing interests identified.