Graduation Date

Spring 5-4-2019

Document Type


Degree Name

Doctor of Philosophy (PhD)


Medical Sciences Interdepartmental Area

First Advisor

Barbara J. Jackson, Ph.D.

Second Advisor

Laura Bilek, Ph.D.

Third Advisor

Kendra Schmid, Ph.D.

Fourth Advisor

Dejun Su, Ph.D.


Introduction: The Physician Associate (PA) profession was brought from the United States (where it is called the "Physician Assistant" profession) to the United Kingdom (UK) approximately 15 years ago. Universities have begun to train PAs and these graduates are now starting work in the British National Health Service (NHS) in both primary and secondary care. The number of PAs graduating from PA programs and beginning to work in secondary care will increase substantially over the next few years. No research has been conducted on barriers and facilitators to the integration of a UK-trained PA onto a secondary service.

Methods: A grounded theory qualitative study design was employed. PAs who were educated in the UK and who had been employed as the first PA on their secondary care service were recruited to join the study. These PAs approached their supervising doctors to participate in the study. The PA and the doctor on each team were interviewed separately using a semi-structured interview guide. Nine PAs and eight doctors were interviewed. Data were coded using standard qualitative research methods and evaluated through Karl Weick’s sensemaking framework.

Results: Coding of data revealed nine barriers and ten facilitators to the integration of a UK-trained PA onto a secondary care service in the NHS. These barriers and facilitators were grouped into coherent themes, three groups of barriers and three groups of facilitators. The three barrier themes were: lack of understanding of the PA role inhibits the development of the PA role, having no champion or a champion of limited effectiveness inhibits the use of PAs in the hospital trust, and regulatory issues contribute to lack of role clarity. The three facilitator themes were: PA involvement in role development facilitates the smooth integration of a PA onto a secondary care service, an effective champion helps define and develop the PA role, and principled behavior allows the PA role to develop safely and effectively. Theoretical analysis reveals that a clear role for PAs is the essential facilitator and an unclear role for PAs is the primary barrier to the integration of PAs onto secondary care services in the NHS.

Discussion: As the number of PAs employed in the NHS grows substantially, PAs need a medical role distinct from that of junior doctors that is developed with input from the PAs themselves and they need strong champions to advocate for PAs within the hospital trust and within the NHS. PAs and doctors both need to engage in principled behavior to allow the PAs to practice safely and effectively. Lack of a legal framework for PA practice limits the development of the profession. Doctors and PAs alike engaged in sensemaking to come to a more thorough understanding of their experiences with a healthcare role new to the NHS.