title: Role expansion on interprofessional primary care teams: Barriers of role self-efficacy among clinical associates.
abstract: BACKGROUND
  Interprofessional team-based models of primary care that expand the role of clinical associates (CAs) are increasingly adopted in primary care practices. In this study we query team members of a newly implemented patient centered medical home (PCMH) to identify facilitators and barriers of occupational role self-efficacy, a belief of possessing the capacity to execute their new team based role effectively.
  
  
  METHODS
  79 key informants, members of primary care teams at six Veterans Health Administration (VA) clinics, were interviewed to assess their experiences with implementing expanded roles for CAs. All sites had implemented Patient Aligned Care Teams, the VA's version of PCMH.
  
  
  RESULTS
  Three themes that produced the self-efficacy necessary for successful role expansion of CAs were identified: (1) role training (2) time and resources for roles and (3) cross-disciplinary role agreement. Sub-themes emerged around role challenges. Training sub themes included incomplete or limited training, inconsistencies in trainings within a site, and not receiving training with team members. Insufficient resources sub-themes included limited time for expanded tasks, inadequate space, low staffing, and poor task mix. Cross-disciplinary agreement failed to occur specifically when there was insufficient coordination between medicine and nursing leadership about staff roles, poor primary care provider (PCPs) knowledge of the boundaries of staff roles, and lack of synchronicity between staff roles and what PCPs would like staff roles to include.
  
  
  CONCLUSIONS
  These identified themes have implications for healthcare professionals working in interprofessional teams in a variety of settings and indicate the need for interdisciplinary leadership based solutions.
  
  
  CONCLUSIONS
  Clarifying the factors that impact self-efficacy for the role expansion of PACT staff can inform strategies for role transformation for enhanced primary care delivery.
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Healthcare System, United States. Electronic address: karleen.giannitrapani@va.gov.
authors.forename: Karleen F
authors.initials: KF
authors.lastname: Giannitrapani
authors.affiliation: Ceders-Sinai Medical Center, United States.
authors.forename: Lynn
authors.initials: L
authors.lastname: Soban
authors.affiliation: Center for the Study of Healthcare Innovation, Implementation and Policy, VA, United States; Greater Los Angeles Healthcare System, University of California Los Angeles, United States.
authors.forename: Alison B
authors.initials: AB
authors.lastname: Hamilton
authors.affiliation: University of California Berkeley, United States.
authors.forename: Hector
authors.initials: H
authors.lastname: Rodriguez
authors.affiliation: Center for the Study of Healthcare Innovation, Implementation and Policy, VA, United States; Greater Los Angeles Healthcare System, United States.
authors.forename: Alexis
authors.initials: A
authors.lastname: Huynh
authors.affiliation: Center for the Study of Healthcare Innovation, Implementation and Policy, VA, United States; Greater Los Angeles Healthcare System, University of California Los Angeles, United States.
authors.forename: Susan
authors.initials: S
authors.lastname: Stockdale
authors.affiliation: Center for the Study of Healthcare Innovation, Implementation and Policy, VA, United States; Greater Los Angeles Healthcare System, University of California Los Angeles, United States.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Yano
authors.affiliation: Center for the Study of Healthcare Innovation, Implementation and Policy, VA, United States; Greater Los Angeles Healthcare System, University of California Los Angeles, Rand Corporation, United States.
authors.forename: Lisa V
authors.initials: LV
authors.lastname: Rubenstein
mesh_terms: D006787:Hospitals, Veterans; D006801:Humans; D007407:Interviews as Topic; D007857:Leadership; D024802:Nurse's Role; D010348:Patient Care Team / Q000458:organization & administration*; D018802:Patient-Centered Care / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration*; D036301:Qualitative Research; D011785:Quality Assurance, Health Care; D020377:Self Efficacy; D014481:United States
keywords: Interprofessional teams; Patient-centered medical home; Qualitative research; Veterans