Figure 4 summarises the reasons for not working with PAs. Thirty ICUs were familiar with PAs but did not actually work with them. Their considerations for not working with PAs: no need for PAs because there is no shortage in residents (n=11); no need for working with residents or PAs (n=11); too expensive (n=2); time investment is too great (n=1); ICU care is too complex for PAs (n=2); have not considered it yet (n=3). Not all respondents who did not implement PAs stated a reason.

Survey among PAs
Of the 55 PAs working on Dutch ICUs, 43 responded to the survey (78%). Eleven of these PAs are still in training. The previous job of most PAs was ICU nurse (n=41, 95%), one was a physiotherapist and one was an anaesthesist nurse. The mean age of the group was 44 (IQR 12) years. The median time of employment was six years (IQR 7). The PAs are predominantly employed in larger hospitals with the minimum number of beds being 10 (median 15.5 beds). These hospitals implemented a mean of 2.0 (IQR 2) FTE PAs. The main reason for working with PAs was providing continuity of care (n=42, 95%) and high quality of care (n=28, 65%). Other reasons were providing career opportunities for ICU nurses (n=25, 58%) and alleviating the workload of the intensivists (n=14, 33%).

Communication of PAs as assessed by intensivists
Three out of the 23 intensivists who reported on communication of the PA thought that their communication with patients was as good as that of the intensivist (13%). Six intensivists reported they considered the communication of the PA less proficient than both resident and intensivist (26%) and 13 intensivists considered the communication of the PA less proficient than the intensivist but more proficient than residents (57%). One intensivist considered the communication of the PA more proficient than both resident and intensivist.

Regarding communication with other attending physicians, one intensivist considered communication with PAs to be equal to intensivists, nine intensivists considered it less proficient than the intensivist and resident (39%) and 13 intensivists considered it less than the intensivist but better than a resident (57%).

Communication assessed by PAs
All 32 certified PAs felt that their communication toward patients and family was adequate. Eighteen respondents felt that their communication with patients was equal in quality compared with residents and intensivists (56%). Twelve respondents felt that they communicated less proficiently than the intensivist but more adequately than the resident (38%) and two PAs graded themselves better in communication than both intensivist and resident (6%).

Eleven of the certified PAs felt that their communication towards the attending physicians was as good as the communication of the intensivists themselves (34%). Twenty felt that their communication was less effective than intensivists but more effective than residents (63%) and one felt that the communication of the PA was more proficient than both intensivist and resident (3%).

Shifts and other tasks assessed by intensivists
Of the 20 ICUs with certified PAs, the PAs did not work night shifts in five ICUs (25%). In eight of the ICUs the PA did not participate in the rapid response team (40%). All 20 ICUs reported that PAs performed low-complex tasks such as arterial catheter placement or treatment of the uncomplicated postoperative patient. Twelve (60%) reported that the PAs performed medium-complex tasks such as placement of central venous catheters or supervising electrical cardioversion performed by residents. Four of the 20 ICUs (20%) reported that PAs performed high-complex tasks such as consultation in the emergency department or unsupervised treatment of unstable patients.

Shifts and other tasks assessed by PAs
All 32 certified PAs responded to have supervision assignments and responsibilities, 26 supervised inexperienced residents (81%) and 20 supervised invasive procedures (63%). Twentynine (81%) PAs reported they participated in evening, night and weekend shifts.

Interventions assessed by intensivists
All 20 ICUs reported that certified PAs inserted arterial lines (100%). Eighteen of the 20 ICUs (80%) reported that PAs inserted central venous catheters and performed electrical cardioversions unsupervised. Seventeen ICUs (75%) reported that the PA performed complex intra-hospital transport. Intubations performed by PAs were reported in 12 of the 20 ICUs (60%).

Interventions assessed by PAs
All of the certified PAs reported inserting both arterial catheters and central venous catheters. Twenty-five of the 32 certified PAs reported performing intubations (78%), 28 reported performing electrical cardioversion and intra-hospital transportation with mechanically ventilated patients (88%) and 14 reported inserting thoracostomy tubes (44%). Twenty-seven PAs experienced a shift of the performance of invasive procedures from residents towards PAs (84%).

Employment and international cooperation
Seven intensivists expected the PA to stay on the same ICU for more than 10 years, six of them expected them to stay for five to ten years and one ICU expected them to stay two to five years. Seventeen ICUs want to expand the number of PAs. Moreover, 17 ICUs think that international cooperation would benefit the implementation and expansion of the profession. Eight ICUs do not think that international cooperation would benefit the integration of the PAs on Dutch ICUs.

Thirty-one out of 32 of the responding certified PAs think they would benefit from a more ICU-centred training or acute care training after their graduation to PA. Of the 32 certified PAs, three of them felt that they continuously had to live up to expectations and three PAs felt they were limited in their performance because their expertise was underestimated. One PA would have liked to expand research activities but did not have the opportunity to do so.

Discussion
The results of this Dutch survey provide a general overview about the use of PAs in the ICUs in the Netherlands. It shows that PAs are predominantly working in high-volume ICUs. Of the Dutch ICUs, 42% are considering or have already implemented PAs to improve the quality and continuity of care. When the smaller ICUs with only intensivists and without additional personnel are excluded, up to 58% have implemented PAs in their ICUs, either on top of existing formation or by replacing some of the residents by PAs. Next to quality and continuity of care, also career opportunities for employees is considered an argument to implement PAs.

When focusing on the specific tasks of the PA, such as communication or procedures, not much has been reported in the literature about evaluation of communication of acute care PAs. One study described perceptions of nurses, PAs and physicians regarding each other’s communication. PAs communicated adequately, which is in line with the results from our survey.[2] Three intensivists thought that the communication skills were equal between PAs and intensivists. Intensivists also agreed that the communication skills of the PA were better than those of the residents. However, PAs tend to assess their skills on patient and attending physician communication better than intensivists do. Intensivists and PAs both reported that PAs were able to perform the most common procedures. More difficult procedures such as insertion of central venous catheters or intubation but also participation in a rapid response team are not always undertaken by PAs, although there is evidence that these procedures can safely be performed by other care providers than intensivists.[3-9] Moreover, the legal foundations in the Netherlands allow them to do so.[10]

The majority of ICU’s do not yet work with PAs (58% vs 42%). The main reported reason is a policy decision, mainly in the smaller ICUs, to employ only intensivists and no other physicians or non-physician care providers. This budget containment is in contrast with a recent review about the cost-effectiveness of the PA and discusses financial and quality advantages.[11] If residents are readily available, there is also no incentive to explore the profession of the PA. Of the ICUs, 10% presume that quality issues will arise when employing PAs, although they did not actually use PAs. ICUs which do implement PAs, however, do not recognise these quality issues. These two contrasting opinions may partly be explained by misconceptions about the capabilities of PAs, possibly amplified by the time it takes to train a PA.

Alongside this Dutch survey, a European survey was distributed (unpublished results) which returned very limited results and showed that most European countries are unacquainted with this profession. This confirms the finding in the literature that the profession of PAs working in critical care has matured significantly in only a few countries: the United States of America, the Netherlands, Australia and the United Kingdom.[12]

This study has strengths and weaknesses. The high response rate from the Dutch survey together with agreement with the limited available literature and the accordance between intensivists and PAs, provides credibility and paints the picture of a relatively unknown profession with diverse potential. However, a weakness of every survey is the number of unanswered questions when zooming in on opinions of respondents. This may reflect unfamiliarity with the PA or differences in understanding and interpretation of the questions. In addition, the survey is not a validated questionnaire which implies that the questions might be multi-interpretable. Therefore, an acquiescence bias could be present: although the answers did provide negative answers and the survey was distributed by the NVIC and not by an individual person, bias could have been introduced because of the tendency to answer questions positively to avoid conflict. Furthermore, because some questions could be answered with more than one item, the response order effect could play a role. The number of questions with multiple items was, however, limited.

International cooperation will be helpful to expand acquaintance with PAs and to improve general awareness. Also, in the Netherlands, qualitative research into this profession will generate evidence which will standardise implementation and possibly convince the critics that PAs are a respected additional workforce in the critical care setting.

Conclusion
We have shown that familiarity of working with PAs in the critical care setting is increasing but not extensive in Dutch ICUs. In ICUs which have implemented PAs both intensivists and PAs are satisfied about their performance. PAs perform most tasks that are usually done by residents. Presumptions about the profession are barriers to the implementation of PAs.

Disclosures
All authors declare no conflict of interest. No funding or financial support was received.