Introducing physician associates to hospital patients: Development and feasibility testing of a patient experience‐based intervention

Abstract Background Physician associates (PAs) are one of many new mid‐level health practitioner roles being introduced worldwide. They are a recent innovation in English hospitals. Patient confusion with novel mid‐level practitioner titles and roles is well documented, alongside evidence of a positive association between patients’ ability to identify practitioners and patient satisfaction. No prior research developed an intervention to introduce PAs or any other new practitioner role to hospital patients. Objective To develop, with patient and public involvement and engagement (PPIE), an intervention for introducing the PA role to hospital patients, and to test feasibility. Methods Intervention development was underpinned by an experience‐based co‐design approach. Workshop participants generated ideas for introducing PAs, subsequently explored in semi‐structured interviews with hospital patients (n = 13). Interview findings were used by participants in a second workshop to design the intervention. Feasibility of the intervention was assessed in relation to its acceptability and efficacy using semi‐structured interviews with hospital patients (n = 20) and PAs (n = 3). Results The intervention developed was a patient information leaflet. It was considered feasible to use in the hospital setting, helpful to patients in understanding the PA role and acceptable to both patients and PAs. The intervention was also appreciated by patients for providing reassurance of care and support. Conclusions An experience‐based co‐design approach enabled development of an intervention tailored to patients’ experiential preferences. Positive evidence of feasibility and utility is encouraging, supporting future larger‐scale testing. Patient and public contribution PPIE representatives were involved in the study design, intervention development and data interpretation.


| INTRODUC TI ON
Health-care systems worldwide are developing new health professional roles delivered by mid-level practitioners 1,2 to help address the quadruple aim of improving population health, patient experience and staff work environments, and containing costs. 3 While some new roles such as nurse practitioners incorporate existing health-care professionals, others are relatively novel professional groups such as physician assistants, known as physician associates (PAs) in the United Kingdom. PAs have a fifty-year history in the United States (US) but are a recent introduction in many more countries globally. 4,5 In England, PAs have been introduced into the National Health Service (NHS) as postgraduate, medically trained professionals undertaking medical histories, physical examinations, diagnosis and treatment within their scope of practice, under doctor supervision in medical/surgical teams. 4,6 Although small numbers of PAs currently work in NHS acute hospitals in England, the numbers will increase substantially from 2020 onwards as a result of government funding for PA education. 7 Patient confusion with new mid-level practitioner titles and roles has been well documented, [8][9][10][11] alongside evidence that the novel terminology can be difficult to interpret and is sometimes misleading. 8,10 Existing studies in England report poor recognition and comprehension of the PA role among hospital patients. 12,13 They are often confused by the title; its meaning is not immediately obvious and needs explanation. Furthermore, patients can mistakenly perceive PAs to be doctors and express concerns when made aware of the misconception. To prevent confusion, explanatory patient information about the role was considered necessary and beneficial. 13 A study in the Netherlands, where the role is also unfamiliar, similarly identified that hospital staff thought patients were unaware whether they had seen a PA or doctor. 14 Moreover, a US study undertaken over 30 years after the introduction of PAs found that emergency department inpatients needed better information about the role; patient confusion as to provider identity was reportedly associated with often covert physician substitution. 15 There is also evidence of the potential for patients' trust and confidence in the PA to be affected by lack of transparency, 13 with possible adverse implications for the PA-patient relationship. 16 Some studies have shown a positive association between hospital patients' ability to identify clinicians involved in their care, and patient-clinician communication and patient experience and satisfaction. [17][18][19] Explanatory theories suggest reduced psychological stress experienced by the hospitalized patients. 20,21 Evidence is inconclusive that interventions such as facecards, and use of whiteboards can improve clinician identification and understanding of roles among inpatients. 22,23 However, these interventions were conceived by hospital staff or researchers and not with patients. Patient and public involvement and engagement (PPIE) in health-care service improvement studies has been shown to develop interventions that are more appropriate and responsive to patients' needs, [24][25][26] and positively influence quality outcome data. 27,28

| Study design
The study was undertaken in two phases: (1) intervention development and (2) feasibility testing (Figure 1), informed by interpretive methodology. 29,30 The strength of the methodology was that it allowed for focus on exploration and understanding of participants' preferences

| Phase two: Feasibility testing
Feasibility of the intervention, a PIL, was assessed in relation to its acceptability and its efficacy in being helpful or otherwise for hospital patients in understanding the PA role. 39 We used evidence-based guidance for evaluating PILs to support data analysis and interpretation. 40 Semi-structured interviews were undertaken face-to-face with PA and patient participants. PA participants were asked to use the intervention for each inpatient they attended routinely over a three-week period. Three PAs participated and consented to be interviewed; one PA withdrew from the study after phase one due to work pressures. Eligibility criteria for patients were the same as for the semi-structured patient interviews in phase one, with the additional specification that patients had received the intervention. The same patient sampling, recruitment and consent procedures were also followed. Patient participant interviews took place one-three days after they had received the intervention. Twenty-four patients and patient representatives were introduced to the researcher and 20 (83%) consented to participate in a single interview. Four patients withdrew prior to consenting due to ill-health.  43 An initial framework was developed from the codes and categories after scrutiny and discussion with the principal investigator (VMD), who had read a sub-sample of transcripts. Together the researchers asked questions of the data to assist identification of category properties. Verbatim patient responses were then entered onto a spreadsheet with the coding framework. This process was undertaken independently by FT supplemented by collaborative discussion with VMD to reach consensus and confirm categories.
In the second workshop, data analysis was undertaken in situ by FT together with the participants, drawing together their ideas and opinions for the intervention design.

| Phase two: Feasibility testing
The patient and PA interview data sets were initially analysed separately using thematic analysis (FT). 42 The analysis was informed by the study topic guide and evidence-based guidance for evaluating PILs. 40 Data were broken down using line-by-line coding and codes clustered manually to identify preliminary categories based on issues and themes. These were scrutinized and discussed with VMD who read transcripts from a sub-sample of interviews from each data set.
Two separate frameworks were developed from the analyses, one for the patient data and one for the PA data, together with codebooks, and used to structure verbatim responses onto spreadsheets.
The codes and themes included in each of the frameworks were refined and elaborated collectively with data collection from further interviews. As sequential analysis progressed, significant data were compressed to adhere around key analytic themes. Where data did not fit existing themes, new ones were developed or existing ones modified, until all data were coded by theme. A further stage of synthesis was undertaken (FT, VMD) to describe and interpret findings, looking for triangulation of themes, patterns and plausible explanations across the two data sets, before confirmation of themes. Additionally, some participants mentioned that a hand-held information leaflet was more person-focused and convenient to read than accessing information from a poster.

I haven't been out of my bed for two weeks so unless
it's somewhere in my view it's no good to me…a leaflet you can read as right in front of you.
(Participant 9, male, orthopaedic) Some participants mentioned the perceived need for a leaflet to be made available in translated form for patients whose first language was not English. Others suggested a leaflet had the advantage that if unable to be read by a patient, it could be given to a family member who was able to read the information.
The intervention designed by participants in the second workshop was a two-sided, hand-size, card information leaflet with black wording on a yellow background (Figure 2), to be given to patients Feedback in response to an intervention prototype circulated to participants after the workshop showed the prototype to be in concordance with their proposals.

| Phase two: Feasibility testing
Sixteen patients and four patient representatives participated in interviews ( Table 1). The patients interviewed were aged between 24 and 85 years. English was a second language for five participants.
Three PAs were interviewed. The themes and sub-themes extracted from analysis of the interview data sets are summarized in Table 2 and described in turn.

Leaflet read when personally appropriate
Few patient participants reported reading the leaflet when it was given to them. Most participants described delayed use; putting the leaflet aside and reading it at a later, personally appropriate time.
Some mentioned looking at the leaflet when feeling less medicated and more alert, or less in pain, others when there were fewer staff encounters and they could give it attention. One female participant reported being handed the leaflet before surgery and not reading the information until afterwards when less anxious and preoccupied.
Another female participant, whose first language was not English, described keeping the leaflet until her sister visited, and together they could read and discuss the content.
Although only one participant expressed criticism of when they received the leaflet, several participants suggested more suitable timing. There were marked differences, however, in their recommendations; some participants proposed the leaflet be provided at

PAs adapted how they used intervention
Each PA participant had their own way of using the intervention, adjusting how and when they introduced themselves and the leaflet to suit their personal style and work context. One participant preferred to complete routine patient interactions such as taking bloods and return later with the leaflet. Another participant reported introducing themselves at the start of the encounter, but not handing over the leaflet until the end alongside verbally outlining key aspects of their role. For one participant, introduction of the leaflet was initially thought discordant with the mood and tempo they liked to maintain in patient encounters, particularly since the information was unrequested. They described trying several different approaches before finding one they felt comfortable using.
Participants also reported employing a patient-typology targeted approach. For example, one participant said they preferred not to use the intervention with patients who appeared very anxious or who had just been given bad news.
Some initial apprehension about using the intervention was expressed by all participants, particularly in relation to how patients would respond. However, use of the intervention was reported to become easier with practice and on not experiencing rejection.
It, kind of, becomes easier to give out. Whereas at the beginning you're a bit anxious like will they want it, will they avoid taking it, will they think why am I giving it to them?

| Size and format liked
Plaudits were expressed by many patient participants for the leaf- Diverse opinions were expressed about the leaflet's bright yellow colour, although it was consistently viewed as eye-catching and attention-grabbing. The most critical comments on the leaflet design were made with reference to its credibility and trustworthiness, since it lacked a hospital name or logo.
PA participants reported mostly favourable opinions on the size and format, although one participant felt a smaller-size leaflet would be more portable, particularly when wearing scrubs. While the leaflet's colour was generally liked for being conspicuous, one participant reported confusion because it was the same colour as patients' warfarin anticoagulant booklets.

Acceptability of intervention
While frequently described as novel and unexpected, the intervention prompted generally favourable reactions from patient participants. They recounted feeling better informed about who was providing their care which was thought beneficial and reassuring. Something at the bottom of the leaflet that says, "for more information please ask me".
(PA 3) The intervention was considered a novel and surprising approach to information provision in the hospital context by many patient participants. Although the PA participants described different ways that they introduced themselves and the information leaflet to patients, the variant used did not appear to influence the response of patient participants. It was the personal introduction of the leaflet by PAs that was generally welcomed and seemed important in encouraging patient use of the leaflet. This is in line with evidence-based recommendations for introducing information leaflets to patients;

| D ISCUSS I ON
hand-delivered and personalized by the clinician. 40 Leaflets on their own have been found to have limited effect, but combined oral and written information can enhance patient engagement. 45 Our findings revealed appreciation of the intervention not only for the information provided, but because it generated reassurance of care and support. The anticipated benefits of accessing information from the PA about their personal care and treatment were attractive to several participants. These responses are congruent with findings from the literature indicating that patients receive insufficient personal information from their doctors during hospital ward rounds. 46 The psychological benefits of patient information in the hospital context are also recognized in terms of helping patients know what to expect, thereby reducing uncertainty and anxiety. 20,21 While patient participants generally welcomed the intervention, PA participants described initial apprehension about introducing it into routine patient encounters. They anticipated some rejection of the offer of information. Clinicians' underestimation of the amount of information that patients need and want has been recognized in the literature. 47,48 Our study also identified that it would be beneficial to clarify in the leaflet how the PA might be contacted, allowing patients to access additional information if wanted. Patient participants felt this would make the intervention more patient-centred and enable communication of tailored and personalized treatment information. Existing evidence shows that patient leaflets providing easy to understand proactive information can invite and encourage patient participation in their care. 49 Our study finding also reflects the patient empowerment discourse identified by Dixon-Woods, 50 where patients use information as a resource aiding illness management. After consideration of these findings, the Patient Research Expert Group, the lead PA and the study researchers agreed that the patient leaflet should be revised to include the phrase, 'For more information, please ask me.'

| Strengths and limitations
A strength of the study was the use of an experience-based co-design approach 34 which supported development of an intervention tailored to patients' experiential preferences. The use of visual and written ideas for introducing PAs has shown some promise as a methodology to elicit and explore patient preferences prior to intervention design. Facilitation of the workshops enabled a patient-centred focus. Workshop participants themselves reported the co-design process as unpredictable and characterized by creative disagreement, but nonetheless rewarding. Incorporation in data analysis of guidance from the literature on evaluating PILs 40 provides evidencebased understanding of feasibility of the designed intervention.
There are limitations to the study. Workshop participants were not involved in all decision-making meetings, identified as a problem in other intervention development studies incorporating PPIE. 51 Some meetings between the PA participants and a study researcher took place outside the workshops due to clinician time-constraints, challenging the intended more equitable power-sharing.
While we endeavoured to employ purposive qualitative patient samples to provide diversity, the use of PAs as gatekeepers may have resulted in selection bias and recruitment of convenience samples. Our study was also based on small numbers of participants recruited from one hospital study site. Nevertheless, while the findings cannot be easily generalized, they do offer insights for potential further testing.

ACK N OWLED G EM ENTS
The authors would like to thank all patients, patient representatives, PAs and hospital staff whose involvement made this study possible. In addition, we thank members of the Patient Research Expert Group, Centre for Public Engagement, Kingston University and St George's University of London.

CO N FLI C T O F I NTE R E S T
The authors declare no conflicts of interest.