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Table 2 Summary table of themes from cross-case analysis

From: Understanding health professional role integration in complex adaptive systems: a multiple-case study of physician assistants in Ontario, Canada

1. Contribution to Ontario Health Care Settings
• Idea of a versatile, flexible, responsive, accessible health care provider that models collaborative, interprofessional care (stemming from foundation of core professional competencies)(+)
• Focus on person-centered care – nature of the role allows for time, education and advocacy on behalf of patients(+)
• Patient navigator – navigates community resources, hospital resources, other services, etc. (+)
• Increase access to care – allows for increased patient volume, decreased wait times, same day appointments, faster consults, timely discharges (+); Fill gaps/bridging gaps in the health care system(+)
• Significant impact on improving continuity of care (+)
• Leadership & support – mentorship of learners, support residents, interest in research opportunities, quality improvement initiatives, other committee work, etc. (+/−)
• Cost of the role; organizational role (+/−)
2. Developing Role Awareness & Role Clarity
• Presence of a PA advocate or champion (+)
• Challenge of working as an unregulated health care provider (lack of regulation); understanding of delegation, controlled acts and use of medical directives (+/−); Knowing when to seek help, knowing what you don’t know(+)
• Trajectory of role development: how PA or role was initially introduced; PA transition to practice; PA establishing role and functioning effectively (learning curve) (+/−)
• Access to resources/supports (administrative, physical space, CPD funding/time) (+/−)
• Navigating role and work environments amongst residents (especially in academic centres); how PA role is introduced to a learner, i.e. medical students, residents, etc. (+/−)
• Heavy reliance on PA to deliver services; role evolution (+/−)
• Organizational support; level of autonomy; influence of patient satisfaction (+/−)
• Incentives (financial, time, support) to provide administrative, teaching or mentorship to medical students, residents, or PA learners (−)
• Other healthcare professions not understanding role, not accepting orders, interprofessional relationships(−)
• Concept of “caregiver creep”: PAs don’t have an individual or MD-associated billing number, blood results ordered by the PA go back to the physician provider rather than the PA, even if the PA has been regularly seeing patient. Leaves providers feeling as though they have lost their role as care provider (−)
• Lack of evaluation processes (performance, patient flow, productivity)(−)
3. Supervisory Relationship Dynamics
• Nature of supervisory relationship allows PA to learn from a variety of practitioners – PA is exposed to variety of practice styles, personalities, bed-side manner, medical expertise, other consulting services, etc. (PA can adapt their own practice style by observing others, determine what works best for their own setting/clinical environment – echoed across settings where multiple supervising physicians are part of daily practice)(+)
• Role of trust and mutual respect, defining entrustment, presence of PA frees up physician for other patients/cases (+)
• Mutual support/resource: PA develops skill set that extends Physician services, or PA becomes the procedure or content expert due to frequency of exposure and clinical experience (+)
• Mutual learning curves: PA orientation to clinical setting, procedures, physician preferences; Physician orientation to working with a PA (+/−); Physician experience, PA background (training, specialty interest) (+/−)
• Feeling alone, lack of supervisory oversight (−)
• Physician knowledge of oversight and liability (−)
4. System Variability and Sustainability
• Potential disconnect being the physician supervisor +/− employer that has implications on sustainability of role, vulnerability of PA role, and PAs ability to negotiate for equal/more pay (+/−)
• Navigating an unknown future; need to appropriately shift resources (+/−)
• Variable remuneration for additional responsibilities (i.e. teaching, mentorship, QI initiatives, research)(+/−)
• Inconsistent funding models, funding sources, salaries, benefit packages, and hourly rates; Lack of clarity around funding sources, streams, and opportunities (−)
• Poor responsiveness to cost of living standards, stagnant salaries(−)
• Concerns about “gaming the system”; double billing (−)
• Lack of PA specific management or advocacy for contract negotiations and role sustainability (−)
  1. Impact on Role Optimization (+ or -)
  2. (−) Factor or process negatively impacts role optimization (is a challenge or barrier)
  3. (+) Factor or process positively impacts role optimization (facilitates or supports role optimization)
  4. (+/−) Factor is neutral, or in some circumstances, it can act as a barrier; in other settings, it is a facilitator