Nurses condemns “flawed” evaluation of physician assistant trial

12 June 2012

Rolling out the physician assistant role based on the “sweeping conclusions” of a flawed evaluation of a flawed trial was not wise or safe, says a damning critique by nurses’ organisation NZNO.

The New Zealand Nurses Organisation have just released their very critical review of the Health Workforce New Zealand-funded trial of the physician assistant (PA) role at Middlemore Hospital and of the trial evaluation report by an Australian consultancy firm.

The critique says the trial’s final evaluation report was "methodologically flawed, factually incorrect in places, deficient in data sources, and demonstrates both poor understanding of the health workforce context in Aotearoa, and faulty logic in the sweeping conclusions it draws”. “As such it would be neither wise nor safe to act on its recommendations,” it adds.

But despite this and the “strong reservations” of nursing and medical stakeholder groups, HWNZ “prematurely planned” a further rollout of the new advanced practice role based on a “flawed evaluation of a limited demonstration”.

Brenda Wraight, HWNZ director, defended its PA demonstration process as providing “valuable learning” for the next phase but the decision to go ahead and plan a further PA demonstration in the primary care sector was also based on “international evidence” and local demand for the role. She added that in the US that both the advanced practice roles of nurse practitioner and PA had found their place.

Wraight did acknowledge that NZNO had drawn attention to “factual errors” in the evaluation report, including those relating to prescribing, and the errata would soon be published on the HWNZ site.

The NZNO critique said the trial of the two US-trained physician assistants had design deficiencies including it evaluating the performance of a day shift surgical team with PAs added as extra team members against a 24-hour surgical team with no added staff.

Geoff Annals said NZNO had welcomed the arrival of HWNZ as a central health workforce planning agency but it had been “disappointed to the point of disenchantment” with how well HWNZ had been “filling that brief”. “The physician assistant pilot is probably its worst demonstration (of that) to date.”

He called for HWNZ to “get back on track”, improve its engagement with stakeholders like itself and for the analysis and design of its workforce innovation trials to be based on robust evidence. Also for barriers that stop current health professionals, like nurse practitioners, practising to their full scope be removed before the country started introducing new roles.

Professor Jenny Carryer, executive director of the College of Nurses, commended NZNO for their critique and said what it revealed was “deeply disquieting”.

“Given the seriousness of impending workforce challenges it is of concern that, on the basis of this report, innovation would appear to be strongly agenda-driven rather than evidence-based,” Carryer said. She said of particular concern was the evident ability to fast track changes to facilitate the PA role compared to the “snail-like pace of attention” to barriers to nursing workforce development.

Wraight said in response to Annal’s comments that HWNZ’s aim was always to work closely with the sector in all that it did and engaging with organisations like NZNO was a “key part of that”.

She said HWNZ’s approach was to hold demonstrations of roles “proven elsewhere”, like the PA trial, and these were not randomised controlled trials or pilot studies but “assessment of workforce changes in specific settings”. She said evaluations of first phase demonstrations like the Middlemore PA demonstration and the diabetes nurse prescribing and nurse first surgical assistant demonstrations were used to inform “next steps”.

Wraight said discussions with providers keen to develop demonstration sites to “inform their long term strategy regarding PAs” had lead to the primary care demonstration.

It is understood that the primary health PA demonstration will probably involve at least three US-trained physician assistants working under the supervision of GPs in the Midlands Health Network region, and is likely to be underway before the end of the year.

The NZNO critique said if that a “genuine” primary health PA pilot was to be held that it was essential that HWNZ looked at the costs of establishing and maintaining a PA training programme, did a comparison of role descriptions and patient management between the PA and the primary health nurse practitioner role and also looked at the impact on the practice nursing role.