Take your seats: culture and staff relationships in GP practices

I recently attended an event which brought together six Health Foundation project teams that had been involved in kidney care issues. Our project aimed to improve the management of Chronic Kidney Disease (CKD) within primary care, working to build knowledge and understanding among primary care staff, including how best to facilitate self management. Whilst preparing my presentation, I reflected on our project team's training sessions for primary care practitioners.

The sessions had two primary purposes: emphasising how to facilitate self management in people who have mild-to-moderate kidney problems, and more formal content on how to improve kidney disease management in primary care. The sessions were delivered at the practices by a nurse and a patient, and were attended by a range of clinicians including GPs, practice nurses, healthcare assistants and practice managers.

Following much musing over many months, I realised that I had been struck by the culture of each practice – it could be very varied and at times unexpected, but of course, unique. Indeed, one aspect of the culture seemed to manifest most starkly in an unusual way: in the layout of the training venue and the subsequent positioning of individuals in the seats. To explain…

When we arrived at the venue, some practices had laid out rows of seats which were dutifully filled by their staff in a stereotypical hierarchy (GPs in the front row, healthcare assistants at the back). Others had laid out the chairs in a semi-circle, others had helpfully asked us beforehand how we might like the chairs arranged (the sessions were on self-management after all!). What intrigued me was that the seating arrangements often reflected the way in which practice staff interacted with each other in a clinical setting and, in some way, mirrored how much the self management theme was accepted by clinicians and facilitated with patients.

The extent to which the training on self management facilitation was accepted was variable. Some practitioners voted with their feet, leaving the room after citing urgent business. Others were a study in non-verbal communication (crossed arms and stifled yawns), yet others were engaging, open and challenging. A minority clearly had difficulty in accepting that patients could teach them a thing or two about how to conduct a consultation. Many others welcomed the opportunity and openly commended the benefits of hearing first hand how best to facilitate self care.

As a team, we pondered these issues as the sessions progressed and attempted to learn from each experience. To give an example, we were concerned at the small minority who left the room after the clinical aspects of the session had been presented and just before the discussion on self management facilitation started. To overcome this, we changed the order of the sessions so that the self management aspects were presented at the start, with the clinical aspects following.

But are the issues of staff interaction just peculiar to primary care? I don’t think so, but maybe the special relationship between employer and employee in GP practices has something to do with it. I observed many times practice nurses who seemed to require ‘permission’ before taking any initiative, especially concerning changes/improvements in clinical practice. Indeed, my observations have shown that the ‘doctor-nurse game’ (Stein 1967) may still be alive and well, even if Stein himself said, in 1990, that it was no longer being played.

So if you want to begin to understand the culture of an organisation, ask for a few seats to be arranged for a teaching session and observe the way in which the seats are filled by the attendees – you may learn more from this than you think! 

Nicola is an independent renal nursing consultant and Editor of the Journal of Renal Care.