Contribution of physician assistants/associates to secondary care: a systematic review

Development of the nursing associate professional identity: A longitudinal qualitative study

AIM

The aim of this study was to understand the factors that contribute to the development of the nursing associate professional identity.

DESIGN

A 3-year longitudinal qualitative study of trainee nursing associates.

METHODS

Trainee nursing associates in England were interviewed remotely annually in February 2020, March 2021 and March 2022. They also provided diary entries. Data were anonymised, transcribed and analysed thematically.

RESULTS

Nursing associate professional identity was developed through: increased knowledge, skills and responsibility; and self-perceptions of identity alongside responses to the role by colleagues. Tensions arose when the scope of practice expected by organisations differed from that expected by the nursing associates. Frustrations occurred when nursing associates were perceived as substitutes for Registered Nurses in the context of nursing workforce shortages.

CONCLUSION

Nursing associates in this study clearly valued their new knowledge, skills and responsibility, enabling them to provide enhanced patient care. Increased clarity of role boundaries is necessary in enhancing the professional identity of nursing associates and reducing inter-professional tensions arising from role ambiguity within health and social care organisations.

IMPLICATIONS FOR THE PROFESSION

National guidance and employers should provide clarity on the boundaries of the nursing associate role which will strengthen their professional identity and mitigate role ambiguity within health and social care organisations.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research has been used to guide reporting.

PATIENT OF PUBLIC CONTRIBUTION

A patient and public involvement group was consulted during the initial study design stage.

IMPACT

This study aimed to understand the factors which contribute to the development of a nursing associate professional identity. Nursing associate professional identity is developed through increased knowledge, skills and responsibility, and the perceptions of identity by participants themselves and their colleagues. The findings should inform the implementation of initiatives to clarify nursing associate role boundaries and the development of similar roles internationally.

A survey exploring factors affecting employment of physician associates in Ireland

BACKGROUND

In the Republic of Ireland, the employment of physician associates (PAs) is growing. Following a pilot project in a hospital setting, PAs are now employed across primary and secondary care in public and private sectors. Most of the Irish PA graduates are working in hospital settings.

AIMS

The aim of the study was to explore factors which supported or inhibited the employment of PAs in Irish hospital settings and the perceived supports or challenges for potential employers in recruiting PAs.

METHODS

An online survey gathered data via human resources departments of public and private hospitals, with a 25% response rate.

RESULTS

Similar to previous studies, the barriers included the lack of recognition and regulation of the role and the small number of PAs to fill available posts. Enablers, which influenced the employment of PAs, included improving workflow, continuity of care and helping to address junior doctors' working hours.

CONCLUSIONS

Our data suggests that there is a keen interest and willingness to employ PAs and there is great potential to expand the role in Irish healthcare. However, there are some key issues around funding and recognition to be addressed at government level for this profession to highlight its worth.

The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study

BACKGROUND

Many countries are looking for ways to increase nurse practitioner (NP) and physician assistant/associate (PA) deployment. Countries are seeking to tackle the pressing issues of increasing healthcare demand, healthcare costs, and medical doctor shortages. This article provides insights into the potential impact of various policy measures on NP/PA workforce development in the Netherlands.

METHODS

We applied a multimethod approach study using three methods: 1) a review of government policies, 2) surveys on NP/PA workforce characteristics, and 3) surveys on intake in NP/PA training programs.

RESULTS

Until 2012, the annual intake into NP and PA training programs was comparable to the number of subsidized training places. In 2012, a 131% increase in intake coincided with extending the legal scope of practice of NPs and PAs and substantially increasing subsidized NP/PA training places. However, in 2013, the intake of NP and PA trainees decreased by 23% and 24%, respectively. The intake decreased in hospitals, (nursing) home care, and mental healthcare, coinciding with fiscal austerity in these sectors. We found that other policies, such as legal acknowledgment, reimbursement, and funding platforms and research, do not consistently coincide with NP/PA training and employment trends. The ratios of NPs and PAs to medical doctors increased substantially in all healthcare sectors from 3.5 and 1.0 per 100 full-time equivalents in medical doctors in 2012 to 11.0 and 3.9 in 2022, respectively. For NPs, the ratios vary between 2.5 per 100 full-time equivalents in medical doctors in primary care and 41.9 in mental healthcare. PA-medical doctor ratios range from 1.6 per 100 full-time equivalents in medical doctors in primary care to 5.8 in hospital care.

CONCLUSIONS

This study reveals that specific policies coincided with NP and PA workforce growth. Sudden and severe fiscal austerity coincided with declining NP/PA training intake. Furthermore, governmental training subsidies coincided and were likely associated with NP/PA workforce growth. Other policy measures did not consistently coincide with trends in intake in NP/PA training or employment. The role of extending the scope of practice remains to be determined. The skill mix is shifting toward an increasing share of medical care provided by NPs and PAs in all healthcare sectors.

Development of a Physician Assistant Orientation Program in a Pediatric Emergency Department

INTRODUCTION

The role of physician assistants (PAs) in the care of emergency department (ED) patients has been expanding in recent years. However, little is known about how PAs are prepared to practice in pediatric emergency medicine (PEM), and there is no published literature on how to train PAs in independently managing low-acuity visits in the pediatric emergency department (PED).

METHODS

We created a preorientation, orientation, and postorientation program for PAs who are onboarding in the PED at a large, free-standing pediatric acute care hospital. We implemented an evaluation system that assessed readiness for independent practice based on number and type of patients seen as well as supervising physicians' feedback.

RESULTS

On average, PAs took care of 877 patients over the course of their first year of employment at the hospital before achieving readiness for independent practice. Most PAs were deemed ready to see low-acuity patients without direct supervision by PEM attendings during their third or fourth quarter of employment.

DISCUSSION

The successful implementation of a 12-month curriculum and individualized feedback allowed our PED to prepare PAs for independent management of the low-acuity PED patient.

An Advanced Practice Provider Guide to Peripheral Nerve Stimulation

Objective

To describe the team approach of an interventional pain management practice, with particular emphasis on advanced practice providers (APPs), in the selection, education, care, and management of peripheral nerve stimulation (PNS) patients.

Materials and Methods

We devised an APP guide to PNS based on an in-depth search of multiple databases for studies on neuromodulation, pain management, and APPs.

Results

Of 65 articles captured in the search strategy, three articles were pertinent to the topic of APP involvement in neuromodulation. More specifically, only one of the three publications on neuromodulation discussed APP involvement in PNS. This single publication was from 1995 and focused on electrical stimulation of the trigeminal ganglion using a permanent percutaneously placed electrode.

Conclusion

PNS is growing in clinical indication and use for both acute and chronic pain conditions. With the increasing need for APPs in both general and specialty medicine, it is imperative that APPs are well educated on PNS. Here, we have outlined ways in which APPs can optimize the care of PNS patients and how the skillset of the APP in a PNS practice can potentially improve patient outcomes.

What do cardiac surgical assistants in the Kingdom of Saudi Arabia think about their job? A cross-sectional survey of job and work characteristics

Concerns about job design of the cardiac surgical assistant workforce such as role autonomy and job dissatisfaction have been outlined in the literature, although scant empirical research has examined these concerns from the perspective of cardiac surgical assistants themselves. This study surveyed the job design of cardiac surgical assistants in the Kingdom of Saudi Arabia using Morgeson and Humphrey's Work Design Questionnaire. All scalable items within the questionnaire were reported as satisfactory except for 'autonomy', 'task identity', 'feedback from the job', 'job complexity', 'social support', 'feedback from others', 'ergonomic' and 'work condition'. The results provide insight into aspects of cardiac surgical assistants' role characteristics and contribute to the body of knowledge about their organisational psychology. Given the growth of cardiothoracic operations, the role of the surgical care assistant needs to be further developed to address the job design issues raised.

Sociodemographic and work-related factors influencing long working hours among cardiovascular surgeons in Japan: a cross-sectional study

The maximum limit on overtime working hours for physicians will be applied from 2024. To explore sociodemographic and work-related factors influencing overtime work among cardiovascular surgeons (CS) in Japan. This cross-sectional study included 607 CS who responded to an online survey. Working hours were categorized into ≤60 hours, 60-79 hours, and ≥80 hours per week according to Japan Ministry of Health, Labour and Welfare. Adjusted odds ratios (aOR) were calculated using a multinomial analysis with stepwise reduction after adjustment for potential confounders. Compared to ≤60 hours, significant factors related to 60-79 hours and ≥80 hours per week were age groups of 30s to 50s versus 60s (aOR: 7.48-3.22 and 23.64-4.87), management with cardiovascular drugs (aOR: 1.87 and 5.80), and postoperative wound management (aOR: 0.47 and 0.16), respectively. Significantly related informed consent for surgery (aOR: 3.29) was seen in 60-79 hours. Contrarily, CS who worked for ≥80 hours took on-duty 5 times or more per month (aOR: 3.89), performed night or holiday calls 20 times or more per month (aOR: 2.26), and attended the intensive care unit (aOR: 3.12). These findings suggest that younger, and some non-surgical work-related factors could influence long working hours among CS.

A physician associate-led clinic for people with severe mental illness in the United Kingdom

OBJECTIVE

To evaluate an enhanced physical health clinic led by physician associates (PAs) for patients with severe mental illness.

METHODS

A guidance and data collection tool was developed to support and document the outcomes of the PA-led enhanced physical health clinic.

RESULTS

The clinic led to diagnoses of diabetes, hyperlipidemia, and hematologic abnormalities. One patient was started on metformin, two patients started a prediabetes program with their general practitioner, one patient started simvastatin, one patient switched from cigarettes to e-cigarettes, and one patient switched from olanzapine to aripiprazole because of metabolic adverse reactions. Three patients intended to contact the National Health Service for cancer screening for which they were eligible but they had not taken up.

CONCLUSIONS

PAs can be integrated into a community mental health multidisciplinary team and support the physical health of people with severe mental illness. Mental health trusts should consider roles for PAs in their workforce planning.

How we adapted the T&O inpatient service during the COVID-19 pandemic with physician associates to support the orthopaedic team

INTRODUCTION

In March 2020, due to the COVID-19 pandemic, there were increasing demands on medical and intensive care departments in the UK. Medical staff from surgical departments were redeployed. The aim of this study was to determine whether the department was able to maintain standards with the use of the physician associate / medical doctor (PA/MD) model of care.

METHODS

A mix of questionnaires and audit data was collected prospectively and compared with pre-COVID and the general surgical team which did not have PAs.

RESULTS

Sixty-five per cent of responses indicated an improvement compared with pre-COVID conditions and 35% indicated care was the same. The electronic discharge notification audit showed an 89% completion rate for orthopaedics compared with 73% for general surgery. Venous thromboembolism assessment compliance was better compared with general surgery.

CONCLUSION

Overall, the study supports the hypothesis that a PA/MD model of care is non-inferior to a MD-only model of care and was effective.

How Does the Presence of a Surgical Trainee Impact Patient Outcomes in Lumbar Fusion Surgery?

BACKGROUND

While the impact of trainee involvement in other surgical fields is well established, there is a paucity of literature assessing this relationship in orthopaedic spine surgery. The goal of this study was to further elucidate this relationship.

METHODS

A retrospective cohort study was initiated on patients undergoing 1-3 level lumbar spine fusion at a single academic center. Operative reports from cases were examined, and patients were divided into 2 groups depending on whether a fellow or resident (F/R) or a physician's assistant (PA) was used as the primary assist. Patients with less than 1-year follow-up were excluded. Multiple linear regression was used to assess change in each patient-reported outcome, and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission.

RESULTS

One hundred and seventy-two patients were included in the F/R group compared with 178 patients in the PA group. No differences existed between groups for total surgery time, length of stay, 30- or 90-day readmissions, infection, or revision rates. No differences existed between groups in terms of patient-reported outcomes preoperatively or postoperatively. In addition, presence of a surgical trainee was not a significant predictor of patient outcomes or rates of infection, overall revision, or 30- and 90-day readmission rates.

CONCLUSIONS

The results of this study indicate the presence of an orthopaedic spine F/R does not increase complication rates and does not affect short-term patient-reported outcomes in lumbar decompression and fusion surgery.

LEVEL OF EVIDENCE

3.

Advanced Practice Providers in Plastic Surgery

BACKGROUND

The aims of this article are to examine the scope of practice differences between physician assistant and nurse practitioner providers, to identify financial cost and benefits, and to posit the impact of physician extenders on plastic surgery practices.

METHODS

A review of the literature was performed using the PubMed database. Key words included "plastic surgery AND physician extender AND cost," "plastic surgery AND physician assistant AND cost," and "plastic surgery AND nurse practitioner AND cost." Secondarily, a search was performed for plastic surgery-related specialties of maxillofacial surgery, orthopedic surgery, and otolaryngology. Inclusion criteria consisted of any study design measuring the financial benefits associated with integrating physician extenders.

RESULTS

The PubMed search yielded 91 articles. Eight articles were ultimately included, of which four (plastic, maxillofacial, and orthopedic) discussed the impact of physician assistants and four (orthopedic and otolaryngology) discussed the impact of nurse practitioners. All eight studies demonstrated that integration of physician assistants and nurse practitioners into practices was associated with a net financial gain even after taking into account their overall costs, along with other outcomes such as productivity or time involvement.

CONCLUSIONS

As the number of physician extenders continues to grow, especially in subspecialties, plastic surgeons should be aware of their roles and the potentially positive impact of these providers, their respective training, and their quantifiable financial impact toward a plastic surgery practice. Both physician assistants and nurse practitioners appear to have a positive effect on costs in plastic surgery and plastic surgery-related practices.

Building the evidence base-10 years of PA research in England

This article describes the 10-year journey of a research group helping to build the research evidence base for physician assistants (PAs), known as physician associates in the United Kingdom, in the National Health Service in England. It draws out some key issues that may be of interest to those developing PA research programs in different specialties and different countries. PA research also can help healthcare policy makers address growing demand, issues of quality, and cost.

Physician Assistants and Nurse Practitioners in Primary Care Plus: A Systematic Review

Introduction

Shifting specialist care from the hospital to primary care/community care (also called primary care plus) is proposed as one option to reduce the increasing healthcare costs, improve quality of care and accessibility. The aim of this systematic review was to get insight in primary care plus provided by physician assistants or nurse practitioners.

Methods

Scientific databases and reference list were searched. Hits were screened on title/abstract and full text. Studies published between 1990-2018 with any study design were included. Risk of bias assessment was performed using QualSyst tool.

Results

Search resulted in 5.848 hits, 15 studies were included. Studies investigated nurse practitioners only. Primary care plus was at least equally effective as hospital care (patient-related outcomes). The number of admission/referral rates was significantly reduced in favor of primary care plus. Barriers to implement primary care plus included obtaining equipment, structural funding, direct access to patient-data. Facilitators included multidisciplinary collaboration, medical specialist support, protocols.

Conclusions and Discussion

Quality of care within primary care plus delivered by nurse practitioners appears to be guaranteed, at patient-level and professional-level, with better access to healthcare and fewer referrals to hospital. Most studies were of restricted methodological quality. Findings should be interpreted with caution.

Analysing synthesis of evidence in a systematic review in health professions education: observations on struggling beyond Kirkpatrick

Background: Systematic reviews in health professions education may well under-report struggles to synthesize disparate evidence that defies standard quantitative approaches. This paper reports further process analysis in a previously reported systematic review about mobile devices on clinical placements.Objective: For a troublesome systematic review: (1) Analyse further the distribution and reliability of classifying the evidence to Maxwell quality dimensions (beyond 'Does it work?') and their overlap with Kirkpatrick K-levels. (2) Analyse how the abstracts represented those dimensions of the evidence-base. (3) Reflect on difficulties in synthesis and merits of Maxwell dimensions.Design: Following integrative synthesis of 45 K2-K4 primary studies (by combined content-thematic analysis in the pragmatism paradigm): (1) Hierarchical cluster analysis explored overlap between Maxwell dimensions and K-levels. Independent and consensus-coding to Maxwell dimensions compared (using: percentages; kappa; McNemar hypothesis-testing) pre- vs post-discussion and (2) article abstract vs main body. (3) Narrative summary captured process difficulties and merits.Results: (1) The largest cluster (five-cluster dendrogram) was acceptability-accessibility-K1-appropriateness-K3, with K1 and K4 widely separated. For article main bodies, independent coding agreed most for appropriateness (good; adjusted kappa = 0.78). Evidence increased significantly pre-post-discussion about acceptability (p = 0.008; 31/45→39/45), accessibility, and equity-ethics-professionalism. (2) Abstracts suggested efficiency significantly less than main bodies evidenced: 31.1% vs 44.4%, p = 0.031. 3) Challenges and merits emerged for before, during, and after the review.Conclusions: There should be more systematic reporting of process analysis about difficulties synthesizing suboptimal evidence-bases. In this example, Maxwell dimensions were a useful framework beyond K-levels for classifying and synthesizing the evidence-base.

The role of PAs in providing mental health care

The prevalence of psychiatric and substance use disorders in the United States is rising and of growing concern. Because such behavioral conditions are widespread, one approach is to collaborate with various medical professionals to help offset this demand. To address this issue, the frequency and types of mental health conditions encountered by physician assistants (PAs) were assessed. The National Commission on the Certification of Physician Assistants Practice Analysis was examined for the types of mental health conditions encountered across the spectrum of medical and surgical practices. The findings reveal that, in 2015, at least 62% of PAs saw and evaluated mental health conditions and behavioral disorders at least weekly in their settings. These patient diagnoses were seen with variability based on the specialty of the PA. The highest percentage of cases reported by PAs were in psychiatry, followed by general internal medicine, emergency medicine, family medicine, and hospital medicine. With the profession projected to grow, recruiting, retaining, and integrating more PAs into mental health care is a suggested strategy for addressing national provider shortages.

Comparing physician associates and foundation year two doctors-in-training undertaking emergency medicine consultations in England: a mixed-methods study of processes and outcomes

OBJECTIVES

To compare the contribution of physician associates to the processes and outcomes of emergency medicine consultations with that of foundation year two doctors-in-training.

DESIGN

Mixed-methods study: retrospective chart review using 4 months' anonymised clinical record data of all patients seen by physician associates or foundation year two doctors-in-training in 2016; review of a subsample of 40 records for clinical adequacy; semi-structured interviews with staff and patients; observations of physician associates.

SETTING

Three emergency departments in England.

PARTICIPANTS

The records of 8816 patients attended by 6 physician associates and 40 foundation year two doctors-in-training; of these n=3197 had the primary outcome recorded (n=1129 physician associates, n=2068 doctor); 14 clinicians and managers and 6 patients or relatives for interview; 5 physician associates for observation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was unplanned re-attendance at the same emergency department within 7 days.

SECONDARY OUTCOMES

consultation processes, clinical adequacy of care, and staff and patient experience.

RESULTS

Re-attendances within 7 days (n=194 (6.1%)) showed no difference between physician associates and foundation year two doctors-in-training (OR 0.87, 95% CI 0.61 to 1.24, p=0.437). If seen by a physician associate, patients were more likely receive an X-ray investigation (OR 2.10, 95% CI 1.72 to 4.24), p<0.001), after adjustment for patient characteristics, triage severity of condition and statistically significant clinician intraclass correlation. Clinical reviewers found almost all patients' charts clinically adequate. Physician associates were evaluated as assessing patients in a similar way to foundation year two doctors-in-training and providing continuity in the team. Patients were positive about the care they had received from a physician associate, but had poor understanding of the role.

CONCLUSIONS

Physician associates in emergency departments in England treated patients with a range of conditions safely, and at a similar level to foundation year two doctors-in-training, providing clinical operational efficiencies.

The Effect of an Orthopaedic Surgeon's Attire on Patient Perceptions of Surgeon Traits and Identity: A Cross-Sectional Survey

In orthopaedic surgery, limited research is available addressing how attire, including white coats (WC) and feminine attire such as skirts, affects patient perceptions. It is unknown how surgeon appearance is associated with identification as a surgeon and perception of clinical skills, nor whether this differs between male and female surgeons.

Evaluation of an advanced practice provider emergency department critical care step-down unit

OBJECTIVE

In response to concerns about patient care and safety, our urban, tertiary care, Level 1 trauma center adult emergency department (ED) created an advanced practice provider-staffed critical care step-down unit (CCSU). We conducted a comprehensive evaluation of the CCSU's impact on patient care, safety, and ED operations.

METHODS

We compared ED length of stay, return visits to the ED within 72 hours, billing code assignments (current procedural terminology evaluation and management [CPT E&M] codes), and quality of electronic health record documentation per QNOTE for the 2 years after the CCSU was initiated (CCSU period) versus before its initiation (pre-CCSU period).

RESULTS

There were 31,418 critical care ED patient visits in the pre-CCSU period and 33,396 in the CCSU period. Median ED length of stay did not change overall between the CCSU versus pre-CCSU period (∆1 [95% confidence interval (CI) = -2.4, 4.4] minutes), but decreased for patients who remained in the critical care suites (∆-4 [95% CI = -7.8, -0.2] minutes). 72-hour return ED visits also did not change overall (∆0% [95% CI = -0.1, 0]), but decreased for patients who remained in the critical care suites (∆0.4% [95% CI = -0.05, -0.4]). CPT E&M billing increased for highest-level visits (99,291: ∆1.3% [95% CI= 0.5, 2.0]). Quality of electronic health record documentation as measured by QNOTE also improved (∆11.5% [95% CI = 4.9, 18.1]).

CONCLUSION

This ED's CCSU performance metrics indicate at least moderate improvement in ED length of stay, 72-hour return visits, critical care patient billing, and electronic health record documentation. EDs elsewhere can consider implementation of this advanced practice provider-staffed solution to improvement in critical care in ED.

Initial Evaluation by a Non-Surgeon Provider Does Not Delay the Surgical Care of Pediatric Forearm and Elbow Trauma in a Walk-In Orthopaedic Clinic

Introduction

Walk-in and after-hours clinics are being increasingly utilized in orthopedics and are especially beneficial for patients with simple sprains, fractures, or overuse injuries that might otherwise require an emergency room visit. To meet the increased patient load, additional staffing often is required, which might include a family medicine physician, nurse practitioner, or physician assistant. Few studies have evaluated the performance of these non-surgeon providers in an orthopedic clinical setting. This study compared the time to definitive care of pediatric patients with forearm and elbow injuries between non-surgeon providers in a walk-in clinic, orthopedic surgeons in a walk-in clinic, and a pediatric orthopedic surgeon in a regular clinic.

Methods

Children who had closed reduction and fixation of an elbow or forearm injury from January 2010 to December 2017 were identified. The patients were divided into groups: patients initially evaluated in a walk-in clinic by a non-surgeon provider; patients initially evaluated in a walk-in clinic by an orthopedic surgeon; and patients initially seen by a fellowship-trained, pediatric orthopedic surgeon in a regular clinic (control group). Neither type of provider (non-surgeon or surgeon) in the walk-in clinics definitively treated any injury but rather transferred care of the patient to a pediatric orthopedic surgeon. The number of clinic visits until surgery, the number of providers seen, the days before evaluation by a pediatric orthopedic surgeon, and the number of days before definitive surgical treatment were documented.

Results

Of the 162 patients identified, 36 (22%) were initially seen by an orthopedic surgeon and 62 (38%) by a non-surgeon provider in a walk-in clinic. The remaining 64 (40%) (control group) were initially seen in a regular office visit by a pediatric orthopedic surgeon. There were no significant differences noted for patients treated by orthopedic surgeon and non-surgeon providers in days before a referral visit to the pediatric orthopedic surgeon (3.7 vs. 3.9, respectively; p = 0.63) or days to surgery for definitive treatment (5.2 vs. 4.8, respectively; p = 0.62). The average number of providers seen (1.58 vs. 1.63, respectively; p = 0.69) and average number of clinic visits before surgery (2.08 vs. 2.06, respectively; p = 0.76) also were similar when comparing the two groups. The control group had significantly fewer days from evaluation to surgical treatment than the surgeon walk-in group (3.3 days vs. 5.2 days, p < 0.05) and the non-surgeon walk-in group (3.3 days vs. 4.8 days, p < 0.05).

Conclusion

There was no difference in the number of days to transfer patient care to a pediatric orthopedic surgeon between non-surgeon providers and orthopedic surgeons in the walk-in clinic. However, there was a one-day delay reaching definitive treatment when initial evaluation occurred in a walk-in clinic, regardless of whether the patient was initially seen by a surgeon or non-surgeon, when compared to an initial evaluation by a pediatric orthopedic surgeon.

Two decades on - cardiothoracic surgical care practitioners in the UK: a narrative review

Background

The role of Surgical Care Practitioner (SCP) was first introduced by the NHS in the field of cardiothoracic surgery more than two decades ago to overcome the chronic shortage of junior doctors, and subsequently evolved into other surgical specialties. This review aims to provide evidence on the current situation of SCPs’ clinical outcomes within their surgical extended role, with an emphasis on the cardiothoracic surgical field.

Method

A systematic search of PubMed, Scopus, Embase via Ovid, Web of Science and TRIP was conducted with no time restriction to explore the evidence on SCPs. All included articles were reviewed by three researchers using the selection criteria, and a narrative synthesis was undertaken.

Findings

Ten out of the 38 studies identified were selected for inclusion. Only one study specifically investigated cardiothoracic SCPs. Three themes were identified: (1) clinical outcomes (six studies), (2) workforce impact (two studies) and (3) colleagues’ opinions (two studies). All studies demonstrated that SCPs provided safe practice, added value and were of benefit to workforce environments and surgical teams.

Conclusion

Although the current literature provides assurances that the presence of SCPs within surgical teams is beneficial in terms of their clinical outcomes, their impact on the workforce and colleagues’ opinions, a significant gap was identified around the SCPs’ role within their surgical extended role, specifically in cardiac surgery. Thus, prospective clinical research is required to evaluate SCPs’ clinical impact.

Forging a new identity: a qualitative study exploring the experiences of UK-based physician associate students

OBJECTIVE

To explore student physician associates' (PAs) experiences of clinical training to ascertain the process of their occupational identity formation.

SETTING

The role of the PA is relatively new within the UK. There has been a rapid expansion in training places driven by National Health Service (NHS) workforce shortages, with the Department of Health recently announcing plans for the General Medical Council to statutorily regulate PAs. Given such recent changes and the relative newness of their role, PAs are currently establishing their occupational identity. Within adjacent fields, robust identity development improves well-being and career success. Thus, there are implications for recruitment, retention and workplace performance. This qualitative study analyses the views of student PAs to ascertain the process of PA occupational identity formation through the use of one-to-one semistructured interviews. A constructivist grounded theory approach to data analysis was taken. Research was informed by communities of practice and socialisation theory.

PARTICIPANTS

A theoretical sample of 19 PA students from two UK medical schools offering postgraduate PA studies courses.

RESULTS

A conceptual model detailing student PA identity formation is proposed. Factors facilitating identity formation include clinical exposure and continuity. Barriers to identity formation include ignorance and negativity regarding the PA role. Difficulties navigating identity formation and lacking support resulted in identity dissonance.

CONCLUSIONS

Although similarities exist between PA and medical student identity formation, unique challenges exist for student PAs. These include navigating a new role and poor access to PA role models. Given this, PA students are turning to medicine for their identity. Educators must provide support for student PA identity development in line with this work's recommendations. Such support is likely to improve the job satisfaction and retention of PAs within the UK NHS.

Palliative and end of life care in prisons: a mixed-methods rapid review of the literature from 2014-2018

OBJECTIVES

To explore current practice in relation to palliative and end of life care in prisons, and to make recommendations for its future provision.

DESIGN

A rapid literature review of studies using qualitative, quantitative and mixed-methods, with a narrative synthesis of results.

DATA SOURCES

Six databases searched between January 2014 to December 2018: ASSIA, CINAHL, Embase, MEDLINE, National Criminal Justice Reference Service Abstracts and Scopus.

ELIGIBILITY CRITERIA

Primary research articles reporting qualitative or quantitative findings about palliative and end of life care in prisons, published in peer-reviewed, English language journals between January 2014 to December 2018.

PARTICIPANTS

Prisoners, prisoners' families, prison healthcare staff and other prison staff.

DATA EXTRACTION/SYNTHESIS

Data extracted included: citation, design, aim, setting, sample/population, methods and key findings. Data were analysed thematically then subject to a narrative synthesis in order to answer the research questions.

QUALITY APPRAISAL

Two researchers independently appraised articles using the Qualsyst tool, by Kmet et al (2004). Aggregate summary quality scores are included with findings. Articles were not excluded based on quality appraisal.

RESULTS

23 articles were included (16 qualitative, 6 quantitative, 1 mixed methods). Top three findings (by prevalence) were: fostering relationships with people both inside and outside of prison is important to prisoners with palliative and end of life care needs, inmate hospice volunteers are able to build and maintain close relationships with the prisoners they care for and the conflicting priorities of care and custody can have a negative impact on the delivery of palliative and end of life care in prisons.

CONCLUSIONS

The key findings are: relationships are important to prisoners at the end of life, inmate hospice volunteers can build close bonds with the prisoners in their care and the prison environment and regime conflicts with best practices in palliative and end of life care. Directions for future research are also identified.

PROSPERO REGISTRATION NUMBER

PROSPERO ID: CRD42019118737. Registered January 2019.

An activity analysis of Dutch hospital-based physician assistants and nurse practitioners

BACKGROUND

The physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management.

STUDY DESIGN

A descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated.

METHODS

The patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system.

FINDINGS

In total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care.

CONCLUSIONS

NPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.

The role of physician associates in secondary care: the PA-SCER mixed-methods study

Background

Increasing demand for hospital services and staff shortages has led NHS organisations to review workforce configurations. One solution has been to employ physician associates (PAs). PAs are trained over 2 years at postgraduate level to work to a supervising doctor. Little is currently known about the roles and impact of PAs working in hospitals in England.

Objectives

(1) To investigate the factors influencing the adoption and deployment of PAs within medical and surgical teams in secondary care and (2) to explore the contribution of PAs, including their impact on patient experiences, organisation of services, working practices, professional relationships and service costs, in acute hospital care.

Methods

This was a mixed-methods, multiphase study. It comprised a systematic review, a policy review, national surveys of medical directors and PAs, case studies within six hospitals utilising PAs in England and a pragmatic retrospective record review of patients in emergency departments (EDs) attended by PAs and Foundation Year 2 (FY2) doctors.

Results

The surveys found that a small but growing number of hospitals employed PAs. From the case study element, it was found that medical and surgical teams mainly used PAs to provide continuity to the inpatient wards. Their continuous presence contributed to smoothing patient flow, accessibility for patients and nurses in communicating with doctors and releasing doctors’ (of all grades) time for more complex patients and for attending to patients in clinic and theatre settings. PAs undertook significant amounts of ward-based clinical administration related to patients’ care. The lack of authority to prescribe or order ionising radiation restricted the extent to which PAs assisted with the doctors’ workloads, although the extent of limitation varied between teams. A few consultants in high-dependency specialties considered that junior doctors fitted their team better. PAs were reported to be safe, as was also identified from the review of ED patient records. A comparison of a random sample of patient records in the ED found no difference in the rate of unplanned return for the same problem between those seen by PAs and those seen by FY2 doctors (odds ratio 1.33, 95% confidence interval 0.69 to 2.57;p = 0.40). In the ED, PAs were also valued for the continuity they brought and, as elsewhere, their input in inducting doctors in training into local clinical and hospital processes. Patients were positive about the care PAs provided, although they were not able to identify what or who a PA was; they simply saw them as part of the medical or surgical team looking after them. Although the inclusion of PAs was thought to reduce the need for more expensive locum junior doctors, the use of PAs was primarily discussed in terms of their contribution to patient safety and patient experience in contrast to utilising temporary staff.

Limitations

PAs work within medical and surgical teams, such that their specific impact cannot be distinguished from that of the whole team.

Conclusions

PAs can provide a flexible advanced clinical practitioner addition to the secondary care workforce without drawing from existing professions. However, their utility in the hospital setting is unlikely to be fully realised without the appropriate level of regulation and attendant authority to prescribe medicines and order ionising radiation within their scope of practice.

Future research

Comparative investigation is required of patient experience, outcomes and service costs in single, secondary care specialties with and without PAs and in comparison with other types of advanced clinical practitioners.

Study registration

The systematic review component of this study is registered as PROSPERO CRD42016032895.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

What is the contribution of physician associates in hospital care in England? A mixed methods, multiple case study

OBJECTIVES

To investigate the deployment of physician associates (PAs); the factors supporting and inhibiting their employment and their contribution and impact on patients' experience and outcomes and the organisation of services.

DESIGN

Mixed methods within a case study design, using interviews, observations, work diaries and documentary analysis.

SETTING

Six acute care hospitals in three regions of England in 2016-2017.

PARTICIPANTS

43 PAs, 77 other health professionals, 28 managers, 28 patients and relatives.

RESULTS

A key influencing factor supporting the employment of PAs in all settings was a shortage of doctors. PAs were found to be acceptable, appropriate and safe members of the medical/surgical teams by the majority of doctors, managers and nurses. They were mainly deployed to undertake inpatient ward work in the medical/surgical team during core weekday hours. They were reported to positively contribute to: continuity within their medical/surgical team, patient experience and flow, inducting new junior doctors, supporting the medical/surgical teams' workload, which released doctors for more complex patients and their training. The lack of regulation and attendant lack of authority to prescribe was seen as a problem in many but not all specialties. The contribution of PAs to productivity and patient outcomes was not quantifiable separately from other members of the team and wider service organisation. Patients and relatives described PAs positively but most did not understand who and what a PA was, often mistaking them for doctors.

CONCLUSIONS

This study offers new insights concerning the deployment and contribution of PAs in medical and surgical specialties in English hospitals. PAs provided a flexible addition to the secondary care workforce without drawing from existing professions. Their utility in the hospital setting is unlikely to be completely realised without the appropriate level of regulation and authority to prescribe medicines and order ionising radiation within their scope of practice.