Patient care, integration and collaboration of physician associates in multiprofessional teams: A mixed methods study

Abstract Aims The aim of the study was to explore the physician associate role in patient care, integration and collaboration with team members, within the hospital setting. Design Convergent mixed methods case study design. Methods Questionnaires with some open‐ended questions and semi‐structured interviews were analysed with descriptive statistics and thematic analysis. Results Participants included 12 physician associates, 31 health professionals and 14 patients/relatives. Physician associates provide effective, safe and, importantly, continuity of care and patients received patient‐centred care. Integration into teams was variable, and there was a lack of knowledge about the physician associate role amongst staff and patients. Views towards physician associates were mostly positive, but support for physician associates differed across the three hospitals. Conclusion This study further consolidates the role of physician associates to multiprofessional teams and patient care and emphasises the importance of providing support to individuals and teams when integrating new professions. Interprofessional learning throughout healthcare careers can develop interprofessional working within multiprofessional teams. Impact Leaders in healthcare will see that clarity about the role of physician associates must be given to staff members and patients. Employers and team members will see the need to properly integrate new professions and team members within the workplace and to enhance professional identities. The research will also impact on educational establishments to provide more interprofessional training. Patient and Public Involvement There is no patient and public involvement.


| INTRODUC TI ON
The global shortage of medical and nursing workforce lead to the development of several new roles, for example nursing associates, advanced nurse practitioners and physician associates (PAs)-a strategic move to solve an ever-increasing challenge and care need (WHO, 2016). The PA role is generally accepted by other healthcare professionals (Halter et al., 2018), and their contributions to multiprofessional teams are recognised. Patients are mainly satisfied with the care they receive from PAs (Hooker et al., 2019). PAs are viewed as approachable, informative and patients trust them . However, confusion about the PA role is prevalent amongst staff and patients, which can lead to patient dissatisfaction Halter et al., 2018;Taylor et al., 2019) and poor integration into MDTs (Roberts et al., 2019).
In a recent survey of qualified and student PAs, although 80% were satisfied and enjoyed their work, almost 20% said they were despondent in their role and 30% felt excessive work pressure (Ritsema, 2018). It may be lack of clarity around roles that is challenging for new professions (Roberts et al., 2019).

| Background
PAs were first introduced in North America in the 1960 s to address medical shortages in primary care (Mittman et al., 2002). Since 2018, other countries have incorporated the PA role into their healthcare systems where they work in a variety of clinical contexts (Rick & Ballweg, 2017). In the Netherlands, research looking into the PA role have highlighted the need to understand how this new profession compares to and complements medical doctors to ensure optimal care delivery (Timmermans et al., 2016). PAs have been practising in the United Kingdom (UK) for 10 years, but only since 2018 in the region, which was the focus of this study. Here, we extend the current evidence of PAs contribution to care within the hospital setting, their integration into teams and their collaboration with team members and patients. Our study focused on hospitals in a rural location, where PAs have been recently employed, thus providing further understanding of introduction of PAs into acute hospital settings.

| Aim
To explore the PA role in the care of patients, their integration into teams, and their collaboration with team members and patients, within the hospital setting.

| Research team and reflexivity
The lead author (SHW) and SL were the researchers with most input into the study. Both researchers are female and hold PhDs. SL is a world advocate for interprofessional development and training, with over 30 years' experience. SHW has over 10 years in qualitative research and had no knowledge of the PA role prior to the research, therefore was cognisant to potential bias of doctor versus PA in the workforce.
One team member (AG) is director of PA training, another member (JR) is a PA, and RB is an experienced researcher who began the study.
A rapport was developed with participants before interview, when the lead researcher (SHW) explained the reasons for the research, their interest and possible assumptions about the PA role in health care.

| Study design
A mixed method convergent parallel (Creswell, 2011) case study design (Yin, 2009) was chosen. The study was informed by a pragmatic realist approach to understand how people perform within their work system (Robson, 2002).

| Setting
Three NHS acute hospitals in a rural area of the UK where PAs have been employed since 2018. The hospitals have a bed capacity ranging between 500 and 1200 and employ between 3000 and 6000 staff members.

| Participant selection
All PAs (20) working in the three hospitals at the start of this study were invited by email to take part. Staff who were working with them as part of the multiprofessional team also received an email invitation. Twenty-five patients, or relatives of patients who had been treated by each PA in the three hospitals, were approached by senior ward staff and over a one-week period.

| Data collection
The lead author (SHW) visited senior clinical collaborators in each hospital to ask them to recruit PAs, staff working with PAs and patients treated by PAs. All data were collected in 2020.

| Questionnaires
Questionnaires were designed on topics for each participant group (Table 1), included open-ended questions and an invitation to take part in the interview.

| Interviews
Participants who agreed to be interviewed (PAs = 6, staff = 15, patients/relatives = 6) were purposively selected to include diversity within the sample. Volunteers who were not selected received a letter to inform and thank them for their interest in the study. All interviewees gave informed consent prior to interview.
Semi-structured interviews were designed for each participant group, (Table 1).
Each interview was conducted by telephone, lasted between 15 and 45 minutes and were captured on a digital recorder. Interviews were transcribed verbatim, anonymised and returned to participants for member checking. Two staff and one PA made minor changes to their transcripts. Patients who were interviewed received £20 as 'thank you'.

| Ethical considerations
Ethical approval was gained from the NHS, using the Integrated Research. Application System, application number REDACTED.
Approval was granted on condition that a senior clinical collaborator in each hospital would recruit participants.

| Data analysis
Closed questions in the questionnaire were aggregated for descriptive analyses of each participant group. Open-ended questions and interviews were thematically and iteratively analysed following the steps outlined by Braun and Clarke (2006). Preliminary themes were identified across the PAs, staff and patient data sets to address the research questions. Case study analyses were conducted to examine any differences in PA treatment and employment at the three hospitals.

| Validity and reliability
Questionnaires and interview topics were drawn from previous research, and formal pre-study discussions with clinicians, trainers, Qualitative data were analysed by SHW and independently checked by SL. Two PAs, who were not interviewed, discussed, and helped to refine the preliminary themes with the researchers. In addition, case study design allowed comparison across cases (Yin, 2009).
Thirteen patients and one relative (hospitals 1 and 2) returned questionnaires. Five patients and one carer were female, three patients were male, and five did not report their gender.
Questionnaire responses for PAs, clinicians and patients are presented in Tables 3-5. Four PAs, seven clinicians, four patients and one relative across the three hospitals were interviewed. Synthesised findings are presented using our research enquiries as headings.

| The perceived contribution of PAs to patient care
Findings from both questionnaire and interviews showed that PAs provided patient-centred care and their interactions with patients were valued. PAs were seen to make positive contributions to the patient experience and were mostly thought to give safe patient care, but some staff were concerned about the clinical supervision of PAs.
Patients agreed or strongly agreed that they had confidence in PAs providing safe care, and that they would be happy to be treated by PAs in the future (Table 5). Patients, particularly in hospitals 2 and 3, welcomed the person-centred care of PAs, who explained everything clearly in layman terms and supported them during their healthcare journey. Despite the concerns, PAs and consultants had identified departments and roles where they could work to improve patient care.
PAs termed this as 'forging a role', due to the lack of professional structure for PAs within the interprofessional team. One example of this, was the development of a new role that co-ordinated discharge of mothers and babies (hospital 1).

| The perceived role of PAs within the multiprofessional team
The PA role was seen as varied, and findings demonstrate that they conduct numerous day-to-day procedures. In addition, PAs were also seen to improve multiprofessional practice by learning clinical procedures that are regularly needed in a department that they could manage independently. This was something some staff viewed positively.
[PAs] have independent flexible cystoscopy lists, which would have been something that previously my grade would have done, but it is easier to train the PAs once and they stay for much longer than the length of the surgical trainee rotation.
[Mid-grade doctor ID:3, hospital 1] PAs felt that as generalist clinicians, they could learn different skills and therefore contribute to various departments, but the downside of this flexibility would be loss of continuity of care, as highlighted by one PA.
I can go where I am needed, but at the same time it's a bit difficult for continuity both for myself and also for the patients as well.
[PA ID:1, hospital 2] Apart from not being regulated, some staff were concerned about less distinction of clinical roles if PAs were given more powers and whether all PAs would fit into the multiprofessional team.

| The perceived integration of PAs into existing teams and hospitals
Overall, perceptions of integration and attitudes were good, but there were several variations between hospital 1 compared with hospitals 2 and 3. Comparing the analyses of the three hospitals revealed notable differences in the attitudes towards employment, training and appraisal of PAs.
The lack of clarity of the PA role and how it fits into the wider multiprofessional team appeared to be due to little guidance being provided to staff and patients before the PAs were introduced to the teams. When PAs were first introduced to the location, there was strong opposition from some doctors who instead had preferred to take on more medical students.
Nobody has ever explained to me why, genuinely why they [PAs] are necessary other than sort of 'we're hoping to plug some gaps on the cheap'.
[Consultant ID:1, hospital 1] In addition, the variability of the PA work led some staff, particularly in hospital 1, to ask for more clarity around the PA role within the team so that they can contribute to care more effectively. PAs who did not have appraisals felt isolated, did not have contact with other PAs, and seemed unaware of support available to them.
By contrast, PAs working in hospitals 3 and 2 were also offered mentorship to help guide them through general matters, such as signing up for training. These hospitals (2 and 3) had recently appointed a senior member of staff to ensure PAs were properly managed and trained.
[The consultant] sorts out the appraisals and we have met a few times throughout the year to make sure that I am achieving the things that I want to achieve.
[PA ID:1 hospital 2] During member validation, PAs in hospitals 2 and 3 said that there were monthly meetings and social media support. In addition, there were opportunities to connect with PA ambassadors who were introduced by Health Education England to help raise awareness of the PA role and to liaise with education, sustainability and transformation teams.
Apart from gaining regulation, with the associated benefits including an enhanced clarity of the PA role, staff also noted the tradeoff between working regular hours versus career progression. Some staff members felt that the lack of career progression may reduce attraction of the PA role and others were critical of the development of PAs in the NHS.
I'm sure we are going to end up with a two-tier system where you know, if you can pay you can see a doctor and if you can't, you will probably see a PA you know.
[Consultant ID:1, hospital 1] Findings suggest that hospitals 2 and 3 work to a strategic plan for employment of PAs in and across departments with staff shortages, whereas the hospital 1 functions more at departmental level.
[PA] posts in the hospital are not being funded by, at senior level so they have to be employed on the basis of individual departments, which obviously makes it a lot more challenging trying to get them into the workplace.
[Consultant ID:5, hospital 1] PAs in all hospitals noted that the hospital systems were not set up to differentiate what PAs could or could not order (e.g. ultrasoundnon-ionising vs. X-ray-ionising).
Regardless of varied practices across the three hospitals, findings showed that PAs felt positive about their role. All PAs felt they were valued and trusted team members. Overall, PAs presented positive attitudes about the variety of work they did and enjoyed being part of the team.
I think we are all part of a big team and I think everyone appreciates that which is nice.

| DISCUSS ION
This study contributes to existing evidence showing the key contribution to Physician Associates (PAs) to the multiprofessional team and patient care. The study shows that the integration of PAs into hospital teams is variable and that there is a general lack of knowledge about the PA role amongst staff and patients. PAs in this study report that they are largely satisfied in their role but that they would welcome further support. Most staff embrace PAs as part of the team, but negative attitudes to this relatively new profession exist, something that the PAs are aware of, which highlights the need for a wider systems approach to support integration of PAs and more widely recognition of their valued contribution to patient care.
Indeed, patients in this study are predominately satisfied with the care they received from the PAs and state that it is especially due to PAs communicating appropriately and providing patientcentred continuous care, which has been shown by others to be key to patients' experience Hooker et al., 2019;Taylor et al., 2019). The negative findings amongst staff revealed in hospital 1, may be a result of PAs not having as clearly specified roles in this hospital. This is a reminder about the importance of clarity around integration of roles (Roberts et al., 2019) and interprofessional practice.
A recent review found that interprofessional practice improved quality of care, but factors such as teamwork, leadership, organisational structure, communications and culture, moderate its effectiveness (Pomare et al., 2020 Understanding the importance of clarifying roles and promoting positive attitudes towards different professions within the multiprofessional team can be achieved by offering purposeful interprofessional learning (IPL) opportunities (Hawkes et al., 2013).
IPL can emphasise the need for teamwork, collaboration, coordination and networking in the curricula, from the beginning of healthcare professionals' education and throughout their careers the practice setting, to enhance interprofessional collaborative practice and good patient care (Eddy et al., 2016;Hawkes et al., 2013;Xyrichis et al., 2018 Looking at the strengths of this study, the mixed methods approach provided opportunities to triangulate findings and assess contextual differences between hospitals. The bottom-up approach ensured discovery of new findings, which is important when there is a scarcity of research (Crouch & McKenzie, 2006).
While validation by participants and practicing PAs who were not part of the study provided trustworthiness to the findings. Taking a pragmatic realist approach, provided participant perceptions of the work system from a range of settings, thus capturing a broad range of viewpoints.

| Limitations
Having senior clinical collaborators in charge of recruitment may explain the low number of participants. For example, the lack of responses from patients treated at hospital 3, may be due to ward staff not having sufficient time to approach staff and patients to ask if they were able to participate. Other limitations for the study include low numbers of PAs working in the location. Also, those participating were mostly female, which may have influenced the findings and thus the generalisability to a sample that were more gender balanced.

| CON CLUS ION
This study provides a pragmatic realist insight into PA contribution to patient care in a location where they have worked since 2018.
Findings indicate that this relatively new profession could help address the global shortage of medical and nursing workforce. With that in mind, and taking findings of this study into account, it is important that hospitals and educational providers help support the integration of PAs. By clarifying the PA role to staff and patients, supporting teams to work together and investing in training opportunities for all is likely to benefit everyone. PAs will require formal and informal support, particularly during the initial transition into existing teams and the hospital itself, but this study has emphasised the need of the whole team to be supported for this integration to be successful. The study shows that a pro-active approach by senior leaders and managers can help shape a culture where everyone feels valued and thus prevent development of negative attitudes. In order to further promote positive attitudes towards PAs and increase understanding of roles, opportunities for interprofessional learning throughout education and training can further improve how team members best work together to provide optimal healthcare for people as part of a system that is in much need for the kind of support PAs can offer.

AUTH O R CO NTR I B UTI O N S
RB and SL designed the study. SHW collected all the data. SHW and SL, analysed and interpreted the data, and drafted the manuscript with the contribution of AG and JR. All authors have revised the manuscript critically and approved the final version.

ACK N O WLE D G E M ENTS
This study originated from a conference held by the Centre for Interprofessional Practice (CIPP) in 2018. We are grateful to all the stakeholders who helped to shape the study and this manuscript, especially Julie Houghton who provided a thorough review. The authors would like to thank the patients, relatives and staff who kindly gave time to participate in this study.

FU N D I N G I N FO R M ATI O N
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors have no competing interests to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request due to privacy/ethical restrictions.

E TH I C S S TATEM ENT
Ethical approval was gained from the NHS, using the Integrated Research Application System, application number 263045. Approval was granted on condition the a senior clinical collaborator in each hospital would recruit participants.