cultural competence. Recruitment from overseas would still require an induction and settlement process to understand the unique challenges of the New Zealand health context, and particularly Māori health and their unique position as tangata whenua. Clarity of the work environment, including limitations on prescribing rights and more consistent orientation at sites would also be helpful for supporting integration. Considerations for development the physician assistant role in New Zealand If the PA is to develop into a ‘homegrown’ role, feedback from the sites suggests that the following issues will need to be considered: Workforce need and key areas of development Regulation and medico-legal issues Professional development Training base Advocacy and networking These are discussed in more detail in the full report. We acknowledge that this is an area of much contention, in particular the implications of the PA role for the development of existing professions. When reviewing the findings from this evaluation it is important to consider the strengths and limitations of the design. The evaluation presented here presents a comprehensive evaluation design that draws on multiple data sources to identify the perspectives and experiences of the PAs, doctors, nurses, managers, business owners, administrators and patients. Unlike previous evaluations, the strength of the evaluation design is also further bolstered through the integration of this evidence with the findings from the existing administrative and service data. When assessing the quality of mixed methods designs it is also important to review the individual data collection methods and procedures. The specific strengths and limitations of each data set are discussed in Section 12. We also acknowledge that the evaluation was designed to provide insight into the PA role at a specific sample of sites across New Zealand. The evaluation was not designed to explore aspects of regulation, establishing training programmes or other steps that might be considered for a longer term approach to integrating the role. In this respect, the evaluation offers insights and considerations that warrant further exploration by HWNZ, the Advisory Group and the wider sector in light of any policy decisions or development of the role.
This section uses the multiple data sets collected during the evaluation to address the evaluation questions. Specifically, this section draws on the interview data, the patient and staff survey to identify how PAs have integrated with practice activities and service models. There was some substantial variation in the level of preparedness of host organisations for the PAs arrival. For example, the two Tokoroa PAs arrived without local representatives of either the practice or host organisation being aware that they were in New Zealand, and no accommodation was ready. In contrast, all of the other settings had accommodation and transport organised for the arrival of the PAs. In Gore, all relevant staff were informed of what the PA role was, and how the role would fit into the medical community. They put an article in the local paper welcoming the PA to the town and explaining what the role was. An orientation for the PAs was facilitated by Gore Health and supported by Health Workforce New Zealand. The orientation introduced the PAs to the New Zealand medical system, including ACC and WINZ. However, not all of the PAs arrived in time to access to this more formal orientation process. A more consistent approach to orientation at each site would have supported the integration of all of the PAs. Following the orientation, HWNZ also supported regular face-to-face opportunities for training and support for the PAs. These meetings provided a highly valued opportunity for the PAs to connect with and support one another. In terms of training needs however, some of the PAs would have liked more opportunities to attend professional development opportunities targeted at doctors and nurses. Two of the PAs felt that this would have also supported their integration and connection with the wider sector. During the first set of site visits, most of the PAs felt relatively settled. They felt that they were fitting into their new communities and making friends. In the second set of site visits in September 2014, three of the PAs were planning to return to the United States. One PA was unsure if they would stay, and three were committed to remaining in New Zealand. Suggestions from PAs for future settlement processes (if required) were:
3: Source Measures Data Domain Gore Tokoroa Radius sites Patient Management System Number of patients seen Patient experience and outcomes Wait times (time till patient is seen by a medical practitioner) Patient volumes seen and time spent in emergency department Repeat visits to PA Patients referred to GP by PA (measured by patients seeing GP and PA in one day) Workforce impact PA contacting or referring to Medical Officer Average patients per hour Clinical Outcomes Clinical notes/ Patient Management System Prescriptions recommended Clinical outcomes Labs ordered (blood, x-ray, etc) ACC vs Medical Triage codes, presentation codes, and diagnosis code data dependent data dependent Volumes of next day re-presentations Referrals to other specialists Management/ Administration data Number of patients enrolled Workforce and financial impact Number of FTEs Hours worked (including other staff at the sites) Direct costs of PA Financial impact Indirect costs of PA (e.g. impact on supervising GPs) Locum costs Practice reimbursements Stakeholder Interviews Perceptions of the unique role/contribution of the PA PA integration and development and Contextual contributors Feedback on patients' response and acceptance of the PA Patient experience and impact