Twenty-eight nurses, working in roles including staff nurse, ward manager, clinical nurse specialist and matron, were interviewed about their experiences of working with PAs. They worked in a range of adult and paediatric medical and surgical specialties as well as emergency medicine. The data are presented under the following themes: the work undertaken by the PAs, the contribution made by the PAs and challenges associated with PAs. The identifiers for quotations describe any type of staff nurse as ‘nurse’ and all others as ‘senior nurse’.
The work undertaken by the physician associates
Nurses described the kind of work that PAs were undertaking in their specialties, which included both patient-facing and non-patient-facing work. As part of the medical team, they were described as participating in ward rounds and communicating with patients and relatives. The reviewing of patients was a frequently mentioned task that PAs undertook, and one nurse described how their PA was supervised through this:
I came to understand when they see a patient and assess the patient. After that they come to see the doctor or whoever the consultant is and discuss it. Like junior doctors, student doctors, to discuss the plan.
The PAs were also reported to undertake procedures including taking blood, cannulation and more advanced procedures including central lines and removing drains. In terms of non-patient-facing tasks, PAs were following up and checking blood test results, attending multidisciplinary team meetings, liaising between specialties, and writing the bulk of discharge summaries:
The TTOs [to-take-out medicines], it’s very important and I’m feeling so sorry for them because most of the times the doctors don’t do the TTOs they are the ones who’s doing the TTOs.
Although the PAs were seen as undertaking medical roles, many nurses commented on the overlap between the work carried out by PAs and themselves:
We help each other so at times for example if the patient needs blood. So, if the nurse can’t do bloods the PA will go and she will do, but for example if I’m working and if I’m free or if I’m, if, if the PAs are busy I’m more than happy to go and bleed them. So, doesn’t need to be just the nurse or the doctor or the PA, so who’s free will go and do it.
Although she works within the medical team, she does take on some of the nursing roles as well as the doctor’s roles. When we fill out the checklists for patients that require further care, nursing home care, residential care, she helps us complete those checklists and also with our audits, our cannula care audits.
We turn now to the nurses’ views on the contribution of the PAs.
The contribution of the physician associates
All of the nurses who were interviewed had positive things to say about their experience of working with PAs. This included general statements, such as:
They are very useful; I am pleased when they’re working.
I think they’re really good, a really good asset to have as a member of the team and as a trust I would say that they’re fantastic to have around.
Some examples of the interaction observed between PAs and nurses are provided in Box 7.
This was an observation on a ward in a surgical specialty. Over the course of two different time periods I observed nurses regularly interacting with the PA in different ways. During the ward round a nurse asked the PA whether a patient’s blood had been taken (although in this instance the PA did not know). Nurses frequently came to the PA asking them to do jobs including update a patient’s notes as they were going to be discharged, to do a sick note for a patient, updating a patient’s record who had already been discharged, clarification as to whether a PA needed an outpatient appointment with a specific consultant or just a general one. The PA also received patient information from nurses for the medical team, such as when another department had phoned the ward to let them know that the phosphate levels of a patient who had arrived there were low. The PA also gave instructions to the nursing team; for example, a nurse came to the PA with urine she had collected, and the PA asked her to send it off to check for an infection.
The nurses also gave more detailed comments on the specific ways in which the PAs had made a positive contribution. These are interlinked themes:
- the provision of stability and continuity in the medical team
- ease of access for nurses to the medical team for escalation of concerns about deteriorating patients
- detailed knowledge of patients
- bridging medicine and nursing
- relieving the workload
- enhanced the patient experience.
We now elaborate on these.
The most widely described benefits provided by PAs related to their provision of continuity and stability in the setting in which they were working. This was depicted in a number of ways. First, the majority of PAs were not on a rotational programme, unlike their junior doctor colleagues. This permanency meant that the PAs were recognised as having extensive knowledge of the workings of the particular setting/specialty/team, which made them a useful source of information for all of the health-care professionals with whom they were working.
We are the staff that are consistent, as are the PAs. So, you do get a certain level of knowledge and expertise and that, sometimes you’re like, oh thank goodness, there are other people that, you know, because it’s knowing that it isn’t just knowledge of injuries and patients in that sense. It’s knowledge of processes and the computer systems and the referral.
The nurses reported that the PAs were predominantly working in a ward setting, unlike doctors who had other commitments (e.g. in outpatient clinics and operating theatres). The PAs largely remained on the wards they were attached to. This made them an accessible medical presence for nurses, which was important if they had concerns about patients.
The doctor went away on a cardiac arrest call, or to revive a patient, but there is somebody else on the unit who is more capable, like a doctor level, or they could kind of, if there’s any immediate concerns that we have they can come and take over and do it and nurses feel like there’s somebody around to help them.
Nurses also frequently described using PAs as a means of contacting the doctors (Box 8).
During the observations I saw the nurses use the PAs as a source of knowledge about medical/surgical teams and also as an intermediary. For example, a nurse asked PA what the number was for the [specialty] team bleep. Another nurse wanted to make contact with a certain doctor and asked the PA if they were around the wards. The PA knew that doctor was not on the wards and then tried to contact the doctor using their mobile phone rather than the hospital phone or bleep.
The nurses reported that, in particular, they valued using the PAs as the first step in the escalation process for concerns about deteriorating patients, as illustrated in this quotation and in our observation (Box 9):
If we need any form of escalation, getting in touch with doctors, we can also get in touch with the PAs, the PAs chase the doctors, so their role is quite significant as well . . . to get things going so patients are not left for long hours waiting for a doctor because doctors are doing other things, doctors are in theatres. They’re like the middle person who get things done between both sides, nurses and doctors.
During this part of the observation on a unit with very-high-dependency patients the PA was the sole member of the medical team present. During this time a nurse came and asked the PA to check on one of her patients, whom she thought might be having a seizure. The PA proceeded to assess the patient, asking the nurse questions, checking pupil dilation and the patient’s temperature. After letting the nurse know that the PA believed the patient was fine the PA asked the nurse to run an ECG [electrocardiogram] on the patient and to check their electrolytes.
The nurses considered that because PAs were present on a daily basis, usually on weekdays and during daytime hours, they also knew the patients and their histories very well:
Because they’re there on a daily basis, so they will know the day-to-day goings on of the patients. So they’re there Monday to Friday, well, the consultant will be in theatre all the time, but the PAs are supposed to stay on the ward, so if there’s anybody unwell, they should know about it . . . if the patient’s had an X-ray, an ultrasound, they should be able to say ‘This is the X-ray, do you want it?’ and get the consultant to review it and say that they’re happy with it.
Some of the nurses described forming close relationships with PAs who remained working in their specialty for a number of years and the trust that built up over time:
I’ve actually found them really good because with the junior doctor rotation, they have rotation every 6 months and with a PA they are, they’ve become like a you know member of the team in regard to that they’re long-standing . . . and you know you can build a more you know good relationship with them kind of thing . . . So, the last PA we had I think she was here for about 3 years before she left.
As well as linking the nursing and medical teams, as described previously, PAs were frequently described as an intermediary between the two. The reasons offered for this included PAs being more approachable and less intimidating:
I quite like them in the sense that you always have this like nurse/doctor thing and they’re not really either if that makes sense so, it’s sort of, not a neutral party that’s not quite the right word, but they’re not a nurse or a doctor.
And it’s quite nice to have them there to ask, ‘cause you wouldn’t, like, bleep the SHO to be like ‘Can you just give me your opinion?’. But if they’re [the PAs] on the ward it’s quite nice to have them there, like every problem you had kind of went through her so that was, like, quite nice.
As well as bridging between the two professions, the PAs were viewed as a benefit in that they relieved some of the work of the nurses, particularly in relation to the induction of new doctors in training:
Before new doctors come in the nurse in charge would take that responsibility of going through, like inducting them . . . but here the responsibility, if there’s a PA around they will do that job and they will induct so that pressure was taken off us and I think we found it very, professionally very useful and we thought oh gosh, this is good.
Many nurses commented that they felt that the PAs they worked with had a positive impact on patient experience. The nurses reported that the constant presence of the PAs on the wards meant that they were a familiar face within the medical team, someone whom patients and their families could easily approach:
[PA 1 first name] and [PA 2 first name] especially are so friendly, like they go over and they’re chatting, and, like, I think the patients feel more like they will discuss things with them more than maybe the consultant . . . Yeah, but I think definitely like they help the patients along.
The nurses described the PAs as being very proactive, and appreciated by patients, in communicating the detail of the medical plans and updates of test results. Many nurses spoke positively of PAs’ communication styles, contrasting them with doctors, in explaining medical terminology:
I think PAs tend to have a different approach, a little bit more of a down-to-earth approach, explain things a little bit better and use terminology that people you know understand and things like that.
Invaluable with relatives. If you’ve got one team leave and the next team starts, there’s somebody that’s always there constant, really great if we need a relative spoken to, she’s really willing to go and do that.
Most of the nurses did not think that patients understood who and what PAs were:
I wouldn’t particularly say the patients would know that’s a PA. I think they very much I think call them doctors because they see them as part of the ward round and things like that.
I think most of the patients, like, love them and I don’t they’re any, I don’t think they consider them any different to doctors either.
Although nurses did not elaborate on the specifics of the cost of employing PAs, many of the senior nurses did speculate that from a trust point of view employing PAs must be cost-effective, as they saw them undertaking the work of the doctors:
And I suppose from a trust point of view it’s cost as well because they’re seeing . . . yeah the cost must be, because they see as much as doctors if not more.
We turn now to consider the reported challenges in working with PAs.
Perceived challenges of working with physician associates
Although nurses described the positives that PAs contributed to the service, having PAs as part of the medical team also had some perceived limitations. These were the inability of the PAs to prescribe medicines, lack of clarity over the PA role and impact on nursing roles.
Inability to prescribe
The inability of PAs to prescribe was seen as the biggest drawback to their role by those nurses who were interviewed. This was often mentioned alongside their inability to request ionising radiation, due to the current lack of professional regulation; however, prescribing medication was the issue that was most commonly discussed. The degree to which PAs’ inability to prescribe had an impact varied. The fact that PAs were required to consult a doctor for prescriptions was seen as a step that created a time delay in patient care and flow through the system:
But that’s probably one downside, is that they can’t prescribe, because then things would go even more smoothly and quicker, that they could do the things and prescribe at the same time, and they could assess a patient and prescribe what that patient needed, rather than having to wait for a doctor to be available to prescribe certain medications or fluids, or a blood transfusion or whatever.
On some ward settings with a continuous doctor presence, this delay was viewed as a mild inconvenience with minimal impact, as there was usually a doctor around to ask for a prescription quickly (Box 10).
In this observation there was an instance where both the PA and the junior doctor were present, and the nurse went straight to the doctor to ask for a prescription, and then proceeded to ask the PA to document a patient’s consent for a blood transfusion, suggesting that the nurse knew the limitations of the PA role in relation to prescribing.
The nurses described other elements in their services that mitigated for the PAs’ inability to prescribe. These were elements such as the presence of a ward pharmacist who could prescribe, working in a specialty in which prescription of common types of medication was routinely made for all patients on admission, and the presence of other members of staff, such as nurse practitioners, who could order ionising radiation. We also observed workarounds to these issues in a few settings (Box 11).
This was an observation in which a PA was working in a clinic with specialty-trained nurse practitioners. Several of the patients in the clinic required X-rays and a nurse left their access card in the computer so that the PA could order X-rays using that. The PA was unable to do so using their own access card.
In emergency and urgent care settings, nurses pointed out that PAs were less efficient in a team than nurse practitioners who could prescribe and order ionising radiation:
So I think it’s a really good pathway for a patient to be seen by a PA it’s just a shame that it takes a little bit longer with that review by that doctor again. Whereas with a nurse practitioner, no doctor needs to see them [the patient] unless we want them to or feel that they need to. Whereas PAs they can’t because if they need anything it needs to go through somebody else.
In some high-acuity settings, however, there was a feeling that being unable to prescribe had a greater impact. Some nurses questioned the appropriateness of using PAs ‘out of hours’ when there were fewer doctors around, or in settings with fewer doctors when a doctor may be preoccupied with a seriously ill patient:
Because you need a prescription every 5 minutes sometimes, prescribe this, prescribe that, lots of medication, and then it’s not easy, you can’t just write it now, going online, it isn’t easy.
Nursing staff were not opposed to PAs being able to prescribe and many expressed surprise that they were not able to. After working with PAs, many nurses felt that PAs had demonstrated that they were working at a level and in a way that would allow them to prescribe at least the more routine medications. Comparisons were also made with advanced nurses who can prescribe and the implications for the PA role and career owing to PAs being unable to prescribe:
They can’t prescribe, they can’t do X-rays and they have to go through several different people maybe to get what they want. It’s not brilliant for a patient pathway and it’s not brilliant for them either really because it’s not fair when they’re more than capable, they know what they’re sending to X-ray, they know the implication of drugs, they know what drugs to give, but they can’t write it down on a piece of paper, so it just seems, it’s sad really that it hasn’t come about yet.
A further challenge of working with PAs related to the lack of clarity about the role, described next.
Lack of clarity on the physician associate role
Some nurses reported a view of a lack of clarity about the PA role, which had been particularly problematic on their introduction into a service. This had also been compounded by issues such as senior levels of grading, which the nurses had resented. The nurses who were interviewed who had experienced this reported that attitudes had changed over time through working with the PAs. However, they noted that there was still a lack of understanding of the role among new nursing staff:
I’m not sure if there’s any negative. I think it’s just, maybe the negative is from staff who maybe don’t understand it. But I think generally people are receptive of their role because unless they tell you that they’re a PA, most times you don’t know, you just figure that they’re a FY1 [Foundation Year 1 doctor].
Most of the nurses considered that there had been very little introduction for nurses to the new role. Most of them described working it out for themselves by seeing what the PAs did:
He was introduced ‘oh this is [PA name], this is our physician associate’. OK, what does that actually mean? I didn’t really understand, you know, was he a doctor, was he not? Did he have a clinical background? And really, we’ve never really kind of sat down and chatted about it, I’ve kind of learnt a little bit more on the job about the role.
I didn’t know at first and so I was thinking, ‘What are they?’. I thought they were doctors. I even went up to [PA name] and said ‘[PA name], can you prescribe me this?’. But she was saying ‘I cannot do that’. Just not a formal introduction to say that this is a PA and this is what their role is. So, you go along and work with them and that’s the only time you realise their limitations.
In some instances, nurses described introductions not being made and gave reports of nurses working with PAs sometimes for periods of months, mistaking their identity for a doctor if they were not told otherwise:
I think I worked with them for a few months before I actually knew who they were, what they did, or what, like, I didn’t understand the role at all, because it was just something I’d never seen before, and yeah, I just assumed they were all junior doctors.
Physician associates themselves were often reported as the key educators on their role:
I came to the ward and they said ‘I’m a physician associate’, I said, ‘OK what do you do?’ and they explained their roles.
The lack of clarity and understanding among the nursing staff meant that some of the senior nurses felt that this was an issue that they had a responsibility to help address. Several senior nurses described feeling responsible for junior nursing staff who might not understand the role yet and the implications of the PAs not being regulated. Examples were given of having to explain that the PA could not direct registered nurses to administer medicines in ways not yet prescribed by a doctor. Other examples were given that seemed to be a mixture of legal requirements and hospital regulations:
You have to because if you’ve got a junior nurse they might just allow that person to give that drug and actually we’ve had a few instances where drugs have been removed from like, controlled drugs like morphine removed out of the controlled drug cupboard by a doctor and a PA and actually it has to be two nurses sign out this medicine so then we have to say ‘guys, these are things you have to look out for’ because actually, if that went missing we’d really have to justify what’s happened.
In one setting, the senior nurses were requesting the development of written guidance on what the PAs role was and which procedures they were authorised to undertake so that it would be clear to new nursing staff. The role of the PA was also thought by some to have an impact on the nurses; this is discussed next.
Impact on the nurses’ role
Two of the nurses described the way in which the introduction of the PA role affected their role as nurses. The first was in changing the interaction between the ward nurses and the medical team and the second was a more direct impact on a nurse practitioner role. The first nurse suggested that the ward nurses had less interaction with the medical team following the introduction of the PAs. The PAs, being ward based, provided information that nurses might have provided previously, for example on ward rounds, or followed the consultant-led ward round by communicating the decisions to the nurses subsequently. In one nurse’s view, previously a nurse would have been part of the ward round. The second example was from a clinic setting, in which a nurse practitioner reported that her work was changed by the presence of a PA. The following quotation reflects the ambiguity and overlap of roles there can be in patient care:
When the PAs come in, the doctors automatically gravitate towards letting them see the patient over me. And maybe because as a nurse practitioner, and especially because I’m new and my role is new in this clinic, I think too that, you know like, I don’t sort of blame them because I think they would . . . they do have that much more knowledge base. However, they wouldn’t have a nursing input but then the nursing input could be substituted with any other nurse.
Summary
This section has provided an analysis of the views of nurses, which were predominantly positive, of the contribution of the PAs to the service and to care of patients. Nurses particularly commented on the stability the PAs brought to medical teams and their continual presence in ward settings. Nurses were able to describe the ways in PAs enhanced the communications between the medical team and the patients and relatives. From the ward nursing team perspective, they identified that the PAs enhanced their access to the medical team in situations when a patient’s condition was deteriorating and of concern. Although PAs were described in mainly positive terms, the limitations to their practice, particularly the inability to prescribe, restricted their utility in some settings – especially those with high-dependency inpatients, those needing frequent prescriptions or in urgent care settings in which many patients could usually be seen by someone working at clinical practitioner level. Many commented on a general lack of clarity as to the PAs’ role and that understanding it seemed to be dependent on working with them. Most of the nurses considered that patients also did not understand who this new addition to the medical team was.