Clinical Risk Management: The Role of the Medical Receptionist

1. Elizabeth PattersonRN, BSc, MHSc (Nurs), PhD, MRCNA Senior Lecturer, Deputy Head, School of Nursing, Griffith University Kim ForresterRN, BA, LLB, LLM (Adv), PhD, MRCNA Senior Lecturer, School of Medicine, Griffith University Kay PriceRN, BN, MN, PhD, MRCNA Senior Lecturer, School of Nursing & Midwifery, University of South Australia Desley HegneyRN, BA (Hons), PhD, FCN (NSW), FRCNA Director, Centre for Rural & Remote Area Health, University of Southern Queensland, University of Queensland & Queensland Health Clinical Risk Management: The Role of the Medical Receptionist Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

2. Study Design • Case study of one Division of General Practice in South-east Queensland. • Conducted in two stages: 1. Phone and postal survey of principal GPs and PNs (included tasks undertaken by receptionists) 2. In-depth interviews with GPs, PNs and receptionists Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

3. Stage 1 Survey Results • 60% of practices did not employ a currently licensed nurse (cost, lack of need). • 50% of medical receptionists (MRs) involved (to greater or lesser degree) in patient assessment, monitoring and therapy. • 21% of the GPs who employed nurses, and 36% of those who did not, believed that MRs could be trained to undertake any required ‘nursing’ activities in the practice. Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

4. Stage 2 Methods • 7 MRs, 7 PNs and 5 GPs interviewed to further explore the role of MRs in clinical activities. • Purposeful sampling from GP survey responses to explore context of no/little/much involvement. • Interview transcripts analysed for both commonality and uniqueness Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

5. Findings • Cost identified as major obstacle to employing a nurse: Thisclinicis run as a family business (MR is principal GP's sister-in-law), so my heart and soul goes into it. I will do anything to save X money; he teaches me what a nurse would do because it's so expensive to employ nurses especially with penalty rates and all. (MR-6) … if you can train a receptionist to adequately do what you want them to do it saves you thousands of dollars a year paying someone registered to do it…and with the GP being so poor I guess you’ve got to try and make the most of it. (GP-1) Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

6. Diversity within and between practices in extent to which MRs engage in clinical activities. In practices with 4 or more MRs, each role tended to be specific rather than general: One might be out the back getting patient files out ready, one will be downloading pathology results from the computer and sorting X-rays into the relevant doctor’s boxes, one will be sterilising instruments and tidying up the waiting area and the other two will be on the front desk answering phones and dealing with patients as they come and go… one of the receptionists was a nursing sister and she does the lasers, about 16 a day, and the dressings. (MR-4) Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

7. MRS described a range of involvement in clinical activities: Whether it’s chest pain, whether they are bleeding, where they are bleeding from, have a look to see how deep the wound is. I just try to assess what the problem is, whether it’s burns or whatever…. (MR-7) I dolots of counselling with people on the phone that ring up upset; people saying that they are about to kill themselves or somebody's died, or you know, just different things, can't cope any more, something wrong with their children. Then I will try and calm them down and talk to them because I've had kids of my own as well, and been through all the things with kids trying to kill themselves and all that. I've got more life experience than formal, you know, practical rather than theory; plus the doctor's taught me a lot.(MR-5) Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

8. MRs ‘chat’ to patients while undertaking ‘routine tasks’ like laser application: We had a young girl and she had been going to another practice and coming here as well. She was a very bad asthmatic, and she was on two lots of different medication. And, because I take asthma medication myself, I said ‘ooh I don't know, I don't think that’s right’. I said, ‘look, I think you should ask the doctor’. So the next time she came I said to her, ‘look, you know I did mention it to the doctor and he is here now so would you like to see him?’ And we fitted her in to see the doctor. He couldn't believe it, she was on two lots of steroids and she had put on something like a stone and a half in weight. Couldn't have done her heart a lot of good either I wouldn't imagine. (MR-4) Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

9. MRs know that some patients think they are nurses: I think they assume that you are a nurse or have nursing background or something to be a medical receptionist. A lot of them have that idea.”(MR-2) MRs’ view of their future role: I see that being more of a nurse…I mean you could do it in two or three nights, you could learn to take blood and give needles and it only takes two days to get a medical first aid certificate...probably they will do a lot more nursing I think…It’s a lot cheaper to employ a receptionist. She gets a minimum wage of $13-$15 an hour, possibly up to 16 something dollars depending on her duties, but a nurse is a lot more. (MR-6) Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

10. Implications for Risk Management Identification of potential liability: • Is there a duty of care? • What conduct would amount to a breach? • Who is liable? Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

11. Common Law: Standard of Care Rogers v Whitaker (1992) 175 CLR 479: “The law imposed on the medical practitioner a duty to exercise reasonable care and skill in the provision of professional advice and treatment…The standard of reasonable care and skill required by that duty was that of the ordinary skilled person exercising and professing to have that special skill”. Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

12. Alexander v Heise & Anor [ 2001] NSWCA 422 New South Wales Court of Appeal held: The doctor’s receptionist had a duty to make an assessment of a patient's condition, make a determination of the urgency of the condition based on the assessment and schedule an appointment with the doctor accordingly. Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

13. Legislation: Section 50 of the Civil Liability (Personal Responsibility) Act 2002 (NSW) …precludes a professional from incurring liability in negligence arising from the provision “of a professional service if it is established that the professional acted in a manner that (at the time the service was provided) was widely accepted in Australia by peer professional opinion as competent professional practice…peer professional opinion cannot be relied on for the purposes of this section if the court considers that the opinion is irrational Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

14. Civil Liability Act 2003 (Qld) The person does not breach a duty to take precautions against the risk of harm unless: The risk was foreseeable…; The risk was not insignificant; and In the circumstances, a reasonable person in the position of the person would have taken the precautions. Take into account – the probability of the harm occurring, the likely seriousness of the harm, the burden of taking the precautions, and the social utility to the activity Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

15. Issues for Determination • Whether the level of skill of the receptionist was such that the risk of injury to the patient was foreseeable and significant such that a reasonable person would have taken precautions against the occurrence of such a risk? • Whether the receptionist acted in a manner that was widely accepted in Australia by peer professional opinion as competent professional practice? • Whether the receptionist was “held out” as competent to undertake particular activities? • Was the delegation of the tasks “reasonable”? Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing

16. Liability • Vicarious liability • Non delegable duty of care • Personal accountability Research Centre for Clinical Practice Innovation (RCCPI) and School of Nursing