The number of practicing physician assistants (PAs) continues to increase at a staggering rate. A 36% increase was documented between 2010 and 2015 and projections predict a 37% employment growth rate between 2016 and 2026.1,2 As the profession and demand for PAs grow, the need for competent, educated, and efficient PA leaders also is likely to rise. The PA Administrators, Managers, and Supervisors (PAAMS) group on the AAPA Huddle (a professional online forum for AAPA members) reports more than 300 self-identified PA administrative leaders across the country. More than 130 PAs attended the American Academy of PAs' (AAPA's) executive leadership conference in 2018, a growth of more than 10% from 2015.3 Clearly, PAs are successfully filling the societal need for broader access to healthcare and are increasingly being asked to participate in and to lead a variety of healthcare teams.
PAs and NPs contribute significantly to the provision of healthcare services. They are poised to support best practices and often are leaders in team-delivered healthcare models. Brush and colleagues state that PAs and NPs broaden the scope and quality of care and should be considered assets to healthcare teams in cardiology.4 They also suggest that PAs and NPs be team leaders in certain areas, putting less focus on attending physicians as team leads.4 As recognized by Beresford, some healthcare systems have capitalized on this very suggestion by appointing hospital medicine PAs and NPs to serve in key leadership positions, including leading physician members.5
In response to the expanding need for PA leaders, the AAPA developed the Center for Healthcare Leadership and Management, a forum dedicated to providing leadership and professional development training for PAs and team optimization strategies for PA employers. A concurrent uptick in the number of PAs assuming leadership and administrative responsibilities implies the need for focused training in leadership skills, business acumen, and healthcare management. However, professional development carries costs, and mechanisms and allocations for supporting the continued growth and development of PAs seem limited. Of the more than 6,000 PAs who participated in the 2016 AAPA salary report, only 25.2% indicated their employers provided reimbursement for all continuing medical education (CME) expenses; and only 16.2% of employers reimbursed travel.6 Only 7.1% of employers provided reimbursement for professional development leadership programs. Despite the ostensible value of professional development to PA clinicians and employers, some PAs are left to bear the financial cost.7–11 For example, 11.2% of respondents to the 2016 salary survey indicated they received no funding at all for required CME-related activities.6 Professional education and training opportunities are purported to have positive effects on the recruitment and retention of healthcare personnel.7,9-11 Professional development is thought to have a direct effect on job satisfaction and productivity.8 Although the literature suggests professional development is an “effective mechanism for improving human resource outcomes” of healthcare providers (principally nurses), little documented evidence shows that similar benefits transfer to PAs, and it is unclear how offering professional development benefits may influence other measurable factors such as leadership perceptions, committee involvement, and satisfaction of PA professionals in the healthcare enterprise.11 This study sought to answer the question, “How strong are the correlations between the amount of professional development benefits offered by employers and self-perceptions of leadership potential, committee involvement, and career satisfaction among PAs?”
The population of interest in this study was PA professionals who completed both the 2015 AAPA National Survey and the 2016 AAPA Salary Survey. The study was granted exempt status by the Rush University institutional review board. Pertinent data were paired by the AAPA for each respondent who completed both surveys in order to perform a retrospective data analysis exploring the associations between four variables: professional development benefits, self-perceived leadership potential, committee involvement, and career satisfaction.
Derivation of study variables
The values for the four study variables were derived from a number of survey items as outlined in Table 1. No additional prospective data were collected. For the purpose of data interpretation, the professional development benefits variable was assumed to be stable and static, meaning that despite being reported on 1 year later, the data were treated as if they were reported simultaneously with the 2015 National Survey data.
The extent to which an employer covered fees, memberships, and expenses across multiple categories (for example, travel, CME, or technology) was used to approximate the scope of professional development benefits received by a PA. The highest attainable score (100%) meant that the employer had covered every fee, membership, and expense related to professional development, in full, across the 11 variables of interest (Table 1). A score of less than 100% indicated the minimum proportion of categories that were either covered in full, were partially covered, or a combination of the two. A leadership potential score was derived by aggregating responses from five items that captured participants' perceptions of their leadership status, influence, and abilities (Table 1). The survey items addressing self-perceived leadership potential were specifically related to quality/practice improvement in ones' primary clinical practice setting. The original 5-point Likert scale responses were recoded into 3-point scales (-1 = disagree; 0 = neutral; +1 = agree) to streamline data analysis and interpretation. The mean score computed across all five items represented the PA's leadership potential score, or the extent to which the PA perceived himself or herself to possess the qualities of a leader. Participants' involvement with committees was measured by tallying the number of different committees they indicated they participated in (see committee variables in Table 1). Aggregated responses from four items were used to measure career satisfaction. These survey items targeted perceptions of current and future morale related to the PA profession, whether the person would recommend becoming a PA to others (pa_recommend variable), and whether the person would still elect to become a PA if given the choice to do it all over again (agree_pa variable) (Table 1). Positive career satisfaction scores were indicative of satisfied PAs and negative composite scores represented dissatisfaction.
The provided data were analyzed using the statistical software SPSS version 22. Descriptive statistics of demographic information and the four aggregated study variables were reported to provide context for interpreting the analyzed data. Bivariate correlations (either a Pearson r correlation or Kendall tau-b) were used, depending on the nature of the data, to determine associations between the four variables of interest (professional development benefits, self-perceived leadership potential, committee involvement, and career satisfaction). Alpha was set to 0.05 for determining the level of statistical significance.
The AAPA provided 8,052 responses in the form of a merged dataset comprising data from two national surveys. After optimizing the dataset by removing participants with missing data, responses from 3,128 participants (representing 38.8% of the original dataset) were deemed eligible for analysis. Of the PAs analyzed, demographic information was available for only 33% (1,036 of 3,128) of survey respondents. Of the PAs who reported their demographics, 68% (705 of 1,036) identified as female, 4% (40 of 1,019) indicated their ethnicity was Hispanic or Latino, and white race was the most dominantly reported (90%; 916 of 1,015), followed by Asian (4%; 38 of 1,015). More than half of respondents were under age 40 years (57%; 571 of 1,006) and 99% (1,011 of 1,023) classified their primary role as clinical. Fifteen percent (152 of 1,023) also classified their role as education-related.
Descriptive statistics of study variables
In the context of the 11 targeted benefits, PAs reported that on average, employers covered a minimum of 51.2% of fees, memberships, or expenses related to professional development. Regarding PAs' perceptions of their leadership qualities, 72.8% (2,278 of 3,128) tended to agree they had the authority to lead, had the skills necessary to lead, and/or could influence certain parties. Across the five related leadership items, 12.3% of respondents (385 of 3,128) were collectively neutral and the remaining 14.9% (465 of 3,128) did not perceived themselves to possess leadership traits or have leadership experience. Twenty-seven percent of respondents (847 of 3,128) cited involvement in one or more of the 15 committee types available for selection on the survey. The remaining 73% (2,280 of 3,128) cited no involvement in a committee. Of the PAs involved in at least one committee, 51.7% (438 of 847) indicated involvement with only one type of committee. Lastly, 82.9% (2,593 of 3,128) of PAs were highly satisfied with their careers as indicated by purely positive perceptions across four items related to career satisfaction. Only 0.77% (24 of 3,128) of respondents reported dissatisfaction across all four related items.
Associations between explored variables
Table 2 summarizes the major research findings. Bivariate correlations were conducted to understand how strongly professional development benefits and one's self-awareness of leadership potential were associated with the number of committees in which PAs were involved. Despite the hypothesis that better professional development benefits may advance a PA intraprofessional status (through national networking, for example) and inadvertently encourage PAs to become involved in a diverse range of local and national committees, the proportion of professional development benefits provided by employers was not associated with the number of committees in which PAs were involved (P = .478). However, the extent to which PAs perceived themselves to possess leadership qualities was weakly correlated with committee involvement (P < .001; CC = 0.245).
In a separate analysis, the proportion of professional development benefits offered was not associated with perceived leadership potential (P = .721). No association between benefits and leadership perceptions was identified (P = .880) after isolating professional development benefits related specifically to leadership development and professional networking (for example, AAPA conference fee and travel expenses; excluding professional development fund dedicated for CME).
Of the investigated factors, only leadership perceptions was found to be weakly and positively associated with career satisfaction (P < .001; CC = 0.059). The proportion of professional development fees, memberships, and expenses covered by employers had no bearing on PAs' career satisfaction (P = .438). Likewise, the number of committees a PA was involved with had no correlation to career satisfaction (P = .321).
One aim of this study was to determine whether noticeable value is gained (in terms of enhanced leadership perceptions, increased committee involvement, and heightened career satisfaction) by having PA employers offer a wealth of professional development benefits. Although expanding professional development offerings so that PAs can garner the skills necessary for securing leadership and management positions is logical and laudable, this effort would be futile in the absence of evidence demonstrating a clear need or potential effect. Based on the presented findings, this work contends that no observable value appears to be added. Despite the common belief that CME dollars positively correlate to increased career satisfaction, this study found that the level of professional development benefits offered had no bearing on how satisfied PAs were with their careers. A recent and related qualitative study by Price and Reichert suggested that opportunities alone for professional development were enough to positively influence the job satisfaction of mid- and late-career nurses.12 They comment that “The opportunities for ongoing professional development and career progression opportunities not only were identified as demonstrating respect for mid- to late-career nurses' expertise and organizational commitment, but also were recognized as key elements in optimizing patient care, enhancing work environments, and retaining experienced nurses.”12
Kantsiper and colleagues previously noted that professional development was a key factor in the job satisfaction of hospitalist physicians.13 The nuanced differences between professional development opportunities and covered professional development reimbursements likely explains the divergence in findings between the present and previous works. Additionally, in the present study, participants were asked to report on professional development benefits and career satisfaction in isolation of one another. Although healthcare providers may perceive a close association between benefits offered and career satisfaction when directly prompted, our study suggests that extrinsic professional development benefits alone are not closely linked to enhancing PA satisfaction. If monetary professional development benefits were an associated factor, then those who were offered better benefits would have been more satisfied with their careers as a whole. This simply was not the case.
In a smaller but related study of 259 social workers who practiced in mental health agencies, organizational conditions (including the extent of opportunities for professional development) were found to be strong predictors of job satisfaction.14 Participation in professional development activities is likely associated with job satisfaction due to the intrinsic edifying reward that typically accompanies developmental opportunities. This notion explains why our analysis did not reveal a significant association between career satisfaction and the level at which professional development fees and expenses were reimbursed. Simply put, the benefits of perceived intrinsic rewards can far outweigh the disadvantages of extrinsic impediments (like cost); and as such, the perceived usefulness of gaining valuable employees through professional development can manifest in the form of increased career satisfaction. That being said, the determinants of career satisfaction among PAs are likely to be more strongly influenced by internal motivating factors than by fiscal rewards and benefits.
Another aim of this research was to directly assess the association between perceived leadership potential and job satisfaction. Upon analyzing the data, we found that an increase in the number of self-perceived leadership attributes was positively and significantly correlated with career satisfaction. The link between PAs' leadership perceptions and career satisfaction likely is a natural byproduct of psychologic empowerment, which involves a sense of control, awareness of one's environment, and community involvement.15 In general, when employees perceive their work and actions to hold meaning and when they perceive an ability to influence change, this psychologic empowerment positively influences career satisfaction.16–20
LIMITATIONS AND FUTURE DIRECTIONS
As PAs continue to assume more roles and responsibilities, the need for PA leadership at both a clinical and administrative level is anticipated to rise. Collecting data on PA leaders and those interested in assuming future leadership roles could provide employers with targeted information about the leadership development needs of PAs. More than half of the PAs surveyed indicated that they possessed the ability to lead quality improvement projects. Note, however, that no Likert-scale questions probed perceptions on the management of PAs, the oversight of other healthcare professionals, or the various administrative responsibilities in which PAs may engage. Moreover, survey data in general often are subject to selection bias. From the data collected, it was difficult to identify if a PA was actually in a true leadership position. As such, more refined survey questions probing PAs on the topic of leadership are needed to glean additional insights. This recommendation would likely entail modifying the AAPA surveys to better capture the current PA workforce, not only clinically but administratively and professionally. For example, future survey items might include questions concerning various PA titles, clinical and administrative job responsibilities, and the categories of healthcare providers PAs are responsible for managing. Other related questions could focus on gauging the amount of protected time PAs receive for their administrative responsibilities. It may also be useful to know the extent to which PAs are taking advantage of available clinical and/or professional leadership development opportunities. Lastly, because data were acquired from PAs with predominately clinical responsibilities, the findings of this work may not be fully representative of other PA populations, such as PA educators.
Overall, the scope of professional development benefits offered by employers appears to have no association with PAs' self-awareness of leadership potential, involvement in committees, or career satisfaction. Irrespective of the various levels of benefits received, PAs were equally satisfied with their careers. Per this research, it appears that tenets associated with psychologic empowerment, such as the role of self-perceived leadership potential, have a greater positive association with career satisfaction than those of acquired extrinsic benefits.
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