Quotes Illustrating Main Themes and Subthemes Within the Job Demand–Control (–Support) Model Framework
| Main theme | Subtheme | Illustrative quote |
|---|---|---|
| Demand | ||
| Staffing shortage (N = 12) | COVID as catalyst (N = 4) | Max panel for a full-timer is 1900 so I'm way, way over panelized but I've been. I've been at the stage of my career and it's not for anything else but I answer my phone calls, do my work and please patients that there's more people come and want me. So it's been a problem that way and another… I'm going to mention this because it's an effect of COVID-19. Five local primary care docs were at or near the time of retiring, did retire and droves of patients… “Somebody couldn't stand it so bad they left. (5 – Physician) |
| Pull extra weight (N = 4) | We're short two other MAs and one more is going to be leaving to go back to school. Now, mind you, we only have about eight to start, so we're going to be down half of our staff. That puts pressures on it. Most of the problem here is not COVID, most of the problem here is the software limiting our ability to see patients and the stress that we're putting on the staff. (34 – Physician) | |
| Patient behaviors and mental health (N = 14) | Challenging behaviors (N = 7) | Sometimes there will be one person that just absolutely steamrolls you, and that's what we're dealing with. Patients are cursing at the staff, not only on the telephone but in person at the front desk. Insulting them, insulting their habitus. You know, “You're a F-A-T person and you're stupid.” Like, this is not okay. I'm getting involved much more frequently and having to set boundaries for people. We have had to discharge patients for behavior. Those are the struggles. (3 – Office Manager) |
| Heightened stress and anxiety (N = 5) | I think in the beginning, people were anxious and upset and worried about one thing. And I really thought it would kind of wane over time, but I think people are still worried about different things. (7 – Nurse) | |
| Unchanged metrics (N = 3) | Quiet pressure to do more (N = 2) | Oh yeah it was bad. Any given day, we were working 10 to 12 hours a day and still feeling like we're not doing enough because your numbers are low. Right, because nobody wants to come in. Nobody wants to get their physical and all that will wait until next year. So, your numbers are low. So, admin in a sense is scolding you that you need to do new patients, your annual numbers need to be up. And you're, “What do you want me to do?” So, it's stressful. It was very stressful…I felt even though they acknowledged COVID-19 was an issue and it was across the board. It's almost, and I don't know if it was admin saying, basically, they didn't care or the payers, the insurance companies saying that it doesn't matter. We're still holding you accountable and it's a pandemic… (27 – Office Manager) |
| Competing ongoing system changes (N = 9) | Launching new EHR (N = 9) | And then of course throw Epic on top of it. Going live on Epic was a challenge. Yeah. Beginning of March. It's a huge undertaking. That's another whole … I wish they … well, they did. They did a survey on that too, because I think the go live launch just became more frustrating. We're already in it. We were already in a frustrating crunch of trying to deal with COVID. And do you bring them in or was it just an upper respiratory infection or sneaking patients in the back door because other people don't want to be exposed, and, oh and by the way, we're going to launch this whole new system and give you minimal at the elbow support. (9 – Receptionist) |
| Telehealth (N = 12) | Return to mostly in-person (N = 10) | I think there are a subset of patients who still like having that option of doing a follow-up from a telehealth standpoint. Especially, I think people who sometimes they have limited access to a car or to public transportation or their work schedule was really busy, or they have young children or they're a caretaker for someone older, too. I think those, they've asked to have telehealth visits as an option, but I think when given the option, if they can come in, they like to be seen in person. (4 – Physician) |
| Infection fears and PPE (N = 10) | Infection concerns and PPE use/fatigue (N = 7) | Better. We still have people who are a little nervous about the whole situation. We're still wearing the mask and the face shields. I'm looking forward to taking the face shields off. That's probably excessive, I think, but Jefferson's still telling us to wear them, so I keep it on. (2 – Physician) |
| Control | ||
| Working from home (N = 14) | Working from home and workload (N = 14) | The one good thing about not being in the office 5 days a week is because the work never ends when you're here. What's supposed to be an 8-hour day is a 10-, 11-hour day. At least when I'm home, I can stop. (11 – Nurse practitioner) For me personally, being back in the office 2 days a week has done wonders for my mood and productivity and ability to focus and delineate my various life roles. So that's been great. Before that had sort of waxed and waned in terms of periods of really intense burnout. (26 – Behavioral Health Consultant) |
| Decision latitude (N = 5) | Selected times for decision latitude (N = 5) | So, I think that at times in primary care can feel like things are always being asked of you and things that have to be done like right now or yesterday. It can be overwhelming. (4 – Physician) |
| Participation in decisions at the practice level (N = 9) | Opportunities for participation (N = 8) | So, we're very open with communication in here. We hold no bars. Because I feel like the more open and honest you are with your staff, the more open and honest they are with you. So, if they don't think something is going to work or whatever, they're more free, feel comfortable in telling you it's not going to work. You know what I mean? They're not going to be like, “Uh…” So whenever we are thinking about changing anything, we're saying, “Hey guys, what y'all think about this?” And they're like, “No, this won't work for this doctor.” (25 – Office Manager) |
| Participation in decisions at the organization level (N = 8) | Low level of participation (N = 7) | The leadership, more so. They don't really know what's going on in the offices, so they dictate policy that doesn't work in the office setting. So, because they're so far removed from it. Some of the corporate leadership, they've been out of office for 20 years. (25 – Office Manager) |
| Support | ||
| Practice-level support (N = 13) | High support (N = 13) | I think as our offices go, we've always been very collaborative and support each other pretty well. That's not too much of a question. We have a pretty good core team that we lean on each other. (21– Physician) COVID actually caused a sense of togetherness [and] unity, honestly” (7 – Nurse) |
| Low support (N = 1) | So no, I don't know that we were supportive, but I don't know that we were … For me personally, did the head of Jefferson walk through here and say thank you? Were the bigger people that were working from home coming out to the practices and saying, “We're here with you?” You're really not. You're, no offense, at your dining room table. You're at home in your kitchen, so to speak. So that's where it got frustrating. Or the snow days, when they're making decisions of whether or not to close offices because of snow. Well, yeah. It's easy for you to say stay open. You don't have to go anywhere because you got yourself all set up on remote when COVID hit. So, in that sense, it was, for the winter, it was frustrating. (9 – Reception) | |
| Organization-level support (N = 13) | Perspective-taking (N = 4) | “Some of them are so overworked that things that they say they'll do they forget about because they've got way too many things to do when it just falls off the radar. And I understand that. Cases like with staffing, it's not that they're not trying. It's just that they can't get it done.” (5 – Physician) |
| Low support (N = 9) | There's just such a disconnect. It's just almost like there's just no understanding of what we're really doing on the ground, you know? Big organizational talk without a real connection to what's going on and what we're doing and what works for us, and our practices are all unique. And so you just kind of get used to that sometimes when you work for… I've worked for healthcare… large health healthcare organizations for 10 years, so I'm familiar with sort of what can get lost from the top to the bottom. And so no, it's been pretty awful from that standpoint, I would say. (24 – Behavioral Health Consultant) | |
Abbreviations: EHR, electronic health record; PPE; personal protective equipment.