Empowering effects of further professional education for medical assistants in Switzerland: Experiences and critical aspects for further research and interventions / Empowernde Effekte beruflicher Weiterbildung für Medizinische Praxisassistentinnen und -assistenten in der Schweiz: Erfahrungen und kritische Aspekte für weiterführende Forschung und Interventionen

This study used an exploratory qualitative research design with semi-structured individual interviews. The interview data were subjected to a content-structuring analysis using a hybrid deductive-inductive categorizing method (Braun & Clarke, 2013; Byrne, 2022; Kuckartz, 2016, 2018) that was based on a theoretical framework of empowerment, combining Kanter's (1993, 1979) and Spreitzer's (1995) empowerment theories. Figure 1 illustrates the theoretical framework.

Figure 1:

Kanter's theory of structural empowerment and Spreitzer's psychological empowerment in the workplace and empowered work behaviors & attitudes

Kanter (1979, 1993) states that access to structural factors, such as information, resources, support, and opportunities, empowers employees to perform their jobs purposefully and provides structural means for their growth and development. The availability of appropriate structural means has an effect on the employees and their experience of empowerment, which affects psychological experiences accordingly (Ning et al., 2009; Schermuly, 2015; Spence Laschinger et al., 2010; Sun, 2016).

Spreitzer (1995) developed and validated a multidimensional measure of individuals' psychological empowerment in the workplace and described four psychological cognitions: meaning, competence, self-determination, and impact, which influence the perception of individuals' work roles. Motivating or hindering cognitions can be considered a response to available structural means, resulting in empowered work outcomes, such as satisfaction, commitment, effectiveness, and innovation (1995, p. 1448). Systematically structuring the data based on Kanter's structural factors and Spreitzer's psychological cognitions enabled the identification of emerging themes of empowerment. The evaluation of emerging themes enabled the identification of critical aspects of workplace empowerment.

The present analysis is further inspired by a previous study by Travers et al. (2020) which explores “the relationship between organizational empowerment[,] structural components and feelings of psychological empowerment among hospital frontline workers” (2020, p. 1). We applied their theoretical model (Figure 1) to identify themes of structural factors influencing psychological empowerment and to detect critical aspects of the emerging themes of SMA empowerment.

Eligibility criteria for interview participation included completion of the Federal Diploma of Higher Education and an interest in sharing experiences regarding further education and new roles. No other criteria were specified. Convenience and snowball sampling were used to recruit participants (Braun & Clarke, 2013); a call for interview participation was posted online on the project website (University of Lucerne & Interface Politikstudien Forschung Beratung AG, 2025) and shared twice through the newsletters of the Swiss Association of Medical Practice Professionals.

Ten female participants gave written informed consent and were interviewed, with an average age of 36.8 years (standard deviation (SD) ± 7.1 years), and with an average of 12.6 years of work experience in the medical field (SD ± 8.8 years). Four SMAs held a clinical degree, five held a lead degree, and one held both. Most had already worked in their new roles for at least half a year, or for several years before graduation. Work settings varied widely (outpatient and inpatient settings), and all participants held multiple roles, including lead or clinical responsibilities as well as additional MPA responsibilities. More detailed characteristics of the participants can be found in the supplementary Appendix A.1.

An interview guide with open questions was developed (supplementary Appendix A.2). The questions were formulated based on a theoretical empowerment approach (Kanter, 1979, 1993; Spreitzer, 1995), and followed a problem- and theme-centered method suggested by Froschauer and Lueger (2020). The interview guide included probing questions to clarify ambiguities and obtain more detailed explanations, and followed the interview phases outlined in Ritchie et al. (2014; Froschauer & Lueger, 2020). The interviews were transcribed and coded using F4transkript and F4analyse (F4, 2020), and subsequently anonymized. The transcription rules (supplementary Appendix A.3) were created in the interest of a pragmatic, intelligent verbatim transcription, and were edited for readability and clarity (Bailey, 2008).

In advance, a codebook (supplementary Appendix A.4.1) detailing inclusion and exclusion criteria for deductive codes, aligned with the theoretical framework, was developed. At the same time, a code matrix with sample quotations was created for comparative purposes (supplementary Appendix A.4.2). Additional inductive subcodes were generated if needed and included in the codebook. Once the coding process was complete, the most meaningful quotations were extracted into a separate collection, structured according to the theoretical framework. This collection allowed us to identify emerging themes of empowerment in a first step (supplementary Appendix A.5) and, in a second step, to evaluate these themes and identify critical aspects of them. To ensure confirmability and transparency, the critical aspects of the emerging themes were illustrated with appropriate quotations (supplementary Appendix A.6).

To ensure coder reliability and consistency, the data were coded and re-coded multiple times with iterative refinement of the codebook. Subsequently, an independent coder performed a systematic code check to assess the accuracy and consistency of the analytical framework, codes, coding criteria, and coded quotations, thereby supporting reflective subjectivity.

The content of the SMA education modules was rated as “okay” (SMA2,49), “great” (SMA4,23; SMA7,113), or “on a good path” (SMA6,61) by the participants. However, they also expressed disappointment regarding the depth of knowledge content and considered some content of the modules to be more of a “general overview” (SMA4,23), “quite superficial” (SMA9,3), “not profound” (SMA9,15), “a sloppy training” (SMA5,9) and training program that is not quite “well-founded” (SMA1,44). More specific feedback described the content as “far from everyday practice” (SMA1,9) and called for more “practice-oriented inputs” (SMA2,7) to strengthen practical competencies, noting that “[o]ne learns a massive amount of theory, but not the practical part” (SMA5,15).

Referring to the added value of the knowledge content, they felt that the content of the modules supported their educational needs; they could “refer to it very often” (SMA1,9), “benefit a lot” (SMA8,19), or were able to “reflect” (SMA2,47) the knowledge they acquired in their daily work. In some modules, they “really learned a lot” (SMA10,13) and gave them confidence (ibid.); “Some [modules] were certainly very informative, some just a little less” (ibid.).

Participants requested various additions to the content and more in-depth information on several topics, namely in the fields of personnel management and legal knowledge (SMA4,45-47; SMA5,5) such as “staff appraisals” (SMA5,9), “conflict management” (SMA2,7; SMA8,39), and “change management” (SMA8,39), or new topics in clinical consulting such as “nutrition” (SMA7,69) and “mobility” (SMA7,101), more advanced information for SMAs in inpatient settings (SMA2,47) or advanced courses (SMA3,79; SMA6,61; SMA10,69) as well as personality courses on “resilience” (SMA5,51) and questions as to “how to negotiate […] with a physician” (SMA5,26). Another point both LSMAs and CSMAs raised regarding educational content was the extent to which the CCM modules were helpful to LSMAs (SMA3,9; SMA5,51; SMA7,29). One participant, for instance, stated the following: “What I really wouldn't need in the lead role are Chronic Care one and two” (SMA8,39).

Almost all participants expressed concerns about the federal examination procedure and the involvement of experts and case study assignment: “But I find it [the federal examination] in parts also a bit questionable - how it is assessed. The whole federal examination itself is, I think, still rather a lottery at the moment” (SMA8,25). Others stated that the quality of the final federal examination “does not work very well” (SMA4,23), that the examination procedure is a “matter of luck” (SMA3,25; SMA5,63), and a “big question mark” (SMA1,37), and that the “level [of the federal examination] is not very high” (SMA1,3). Accordingly, participants expressed a wish to “take a closer look” at the federal examination procedure (SMA1,37) or revise it (SMA5,51).

Most SMAs associated salary with “appreciation” (SMA2,35; SMA3,59) and viewed it as “an important component” (SMA5,26). One SMA reported that she felt working without a proper salary was like an “exploitation” (SMA2,33).

The consequence for her was that she did not stay there. Another SMA similarly stated: if the salary is not right, “one just leaves” (SMA1,11). However, salary was not the only thing that mattered, as they explained: “I don't remain there [at my workplace] for the pay. I am there because of other qualities” (SMA9,23); or “the level of satisfaction and my free time […] are more important” (SMA5,26).

Participants reported that not having enough staff and time for their tasks was “frustrating” (SMA5,39) and made them “dissatisfied” (SMA5,39). Most participants had taken on dual roles, such as lead and clinical roles, or a combination with their day-to-day MPA role. SMAs saw this dual role as a “challenge” (SMA3,39) or a “balancing act” (SMA5,19) and described the situation as follows: “But then again one has a guilty conscience that the others have to take over certain tasks from one” (SMA10,31). Staff shortages and dual roles also affected work outcomes. For example, regarding the clinical position, participants reported a “shortage of time for consultations” (SMA10,19), and, regarding the lead position, stated that “the staff management suffers” (SMA5,19), “the management [role] remains in the background” (SMA5,39), and that they felt “dissatisfied because one sees you can't keep up” (SMA5,39). The dual role was thus seen as “[…] difficult, though, when you have a leading position. And besides that, one should […] still have time for the patients as SMA specialized in clinical direction. Yes, sometimes time is scarce. I don't do justice to one or the other” (SMA3,5). In contrast, having time for patients was associated with positive outcomes for patients: “Most of them react very positively, simply because someone really has time to explain everything to them in detail” (SMA7,15); “they highly appreciate that” (SMA9,13).

The almost complete lack of billing options for services and consultations delivered by SMAs was seen as “the biggest obstacle” (SMA7,7) for working independently. One participant highlighted the following: “Until TARDOC [the new medical tariff structure] is in place, physicians will likely be less willing to do these types of consultations [delivered by SMAs]” (SMA5,7). Only when TARDOC becomes operational, SMAs will be able to “further expand” (SMA7,93) and as this statement points out: “One would have to have a service position in TARMED which is afterward also cost-effective for the practice [...]. It needs to make his [the physician's] work easier. He can take care of the patient in other ways. [...] And I support him [...] by being allowed to care for the patient and to bill additionally” (SMA9,53).

Exchange and networking with colleagues, team members, and quality circles were mainly evaluated as “good” (SMA7,83; SMA9,5) and were related to experiencing “acceptance” (SMA3,67). Participants consistently connected their professional exchanges positively with the possibility of addressing questions and insecurities (SMA4,91; SMA5,17; SMA10.65; SMA8,53).

Support from professional organizations (SVA, odamed), patient organizations, education providers, and pharmaceutical companies was associated with receiving information and professional advice, such as newsletters, continuing education offers, and other knowledge content (SMA,4,91; SMA6,53; SMA7,87; SMA9,35; SMA10,49). The participants suggested that more support from professional associations, for instance a “platform where you can exchange ideas” (SME3,71) or “tips and tricks [roughly translated to: useful hints]” (SMA2,41), would be beneficial.

For one participant, getting good support from superiors meant being able to share “insecurities and also fears” (SMA3,73) and feel “encouraged” (ibid.). Another reported the following: “In terms of responsibility, I don't feel more pressure […] and I don't have to be afraid that I'm doing something wrong now, because I still have the physicians in the background” (SMA10,27). However, one participant reported a negative experience with a physician who did not provide support. She stated about a former employer: “He found my service, my experience, my knowledge great but, eventually, pay me as an SMA was not worth it” (SMA6,5).

Regarding the autonomy of SMAs, the participants emphasized that it is important to know “where their responsibilities end” (SMA7,45) and “that one also does not overestimate oneself” (ibid.), because “the decision, when it comes to the patient, still has to be made by the physician” (SMA3,41), “he must take responsibility for all this” (SMA10,35) and, “in the end, the responsibility lies with the physician because we [SMAs] are not physicians” (SMA7,45). Therefore, “exchange” (SMA7,45), “feedback” (SMA9,29), and “consulting” (SMA10,35) with the physicians are seen as important. Also relevant is the question as to whether the employer “backs the [SMA]” (SMA9,15), as well as the ability of superiors “to hand over” (SMA2,23; SMA6,29; SMA7,13) responsibilities. Consequently, the support and autonomy that was delegated were experienced differently. One SMA had to act “in great agreement” (SMA2,39) with her superiors and “struggle[d] for autonomy” (ibid.), whereas others assumed many responsibilities and carried out tasks independently (SMA1,17; SMA5,7).

The degree of independence and reluctance physicians showed in delegating tasks or handing over responsibilities was often associated with statements about the levels of “trust” (SMA2,23; SMA3,41; SMA7,61; SMA8,95), “acceptance” (SMA4,65), or “knowledge” about the new profession (SMA2,23; SMA5,55) of superiors. Depending on the extent to which SMAs were supported by physicians, they described that this allowed them to provide a “relief” (SMA1,21; SMA2,23; SMA5,13) to the physician and thus contribute to work outcomes. As one stated aptly: “I have the feeling that the superiors' trust in this further education or this training program is not there yet. [...] I mean the physicians in the medical practices. They have not yet trusted in SMAs: “Okay, they can provide relief; they can support me. “ [...] I sometimes have the feeling that handing [tasks] over is difficult, simply because it [the new specialization] is still so unknown” (SMA2,23).

The participants connected the opportunity to complete the training and graduate with a Federal Diploma of Higher Education with the opportunity to have a recognition at the “tertiary level” (SMA3,31; SMA8,23), to get “away from the dead-end” (SMA8,115), to “be in a different position” (SMA6,3) and to “increase the chances […] [to] get in better in other places” (SMA4,31). However, several critical comments were raised about the training program. One participant stated that “the overall training is relatively expensive, very time-consuming” (SMA1,3), and that she “wouldn't be less advanced without the training program” (ibid.). Another highlighted that even after graduating from SMAs, “again face a dead end” (SMA8,115). Additionally, one participant stated: “It would be an upgrade if the salary were right. Because a simple upgrade with this title does not improve anything.” (SMA9,51). This view was also echoed by another participant, “They have to pay you more” (SMA5,28), while others specified that higher salaries would need to be justified by taking on additional responsibilities (SMA8,75; SMA10,39).

Participants connected the opportunity to take on new responsibilities to the expectation that they would be able to make their own decisions. For instance, one mentioned: “I also want to tell the ropes” (SMA6,21), and others said: “You have the perspective afterward, for example, to be able to lead a team as well” (SMA2,21) or “that I simply may do more myself” (SMA7,5). However, the new role they enter after completing the program still relies heavily on “learning by doing” (SMA5,17). As one participant put it: “With this training program, one has a small ‘backpack,’ but it still has to be filled” (SMA9,33).

The opportunity to perform the SMA role was described several times as “fun” (SMA4,15; SMA7,93; SMA9,31). One described her experience as “really enjoyable, and it suited […] [her] very much” (SMA2,3). Performing the role was seen as an opportunity to “steadily grow into it” (SMA10,84) and to learn something new with every consultation (SMA7,35). Another SMA stated: “So, I'm still of the opinion that you don't learn certain things until you really work on them” (SMA8,39). Participants valued being appreciated as a sparring partner and being asked for advice: “Ones work more closely with the physician. And they appreciate it very much and inquire something where they know that maybe I still might provide advice” (SMA10,27). LSMAs saw themselves as “troubleshooter” (SMA1,19), making sure “that the team works” (ibid.), and that the company would eventually be “cost-effective” (SMA9,55) with their contribution. CSMAs saw their role as providing relief for physicians in patient care and management, “where ones can take things from the physicians” (SMA8,115) and “save time” (SMA8,115) because the physicians then have “a lot more time to talk to the patients, not about their medication intake, but about their diagnosis” (SMA9,31). In addition, CSMAs emphasized their relationships with patients and their contributions to patient well-being: “It is simply a different relationship that one builds with people” (SMA10,86). Patients were described as more likely to confide in them about their health and lifestyle habits, such as drinking “a bottle of coke every once in a while. [Confiding] in me the barrier is a bit lower” (SMA9,13). Moreover, the success of the counseling sessions was described as follows: “[…] you can simply talk about something or just listen for half an hour, half an hour, where you haven't done anything at all really, and they already feel ten times better” (SMA10,84). Some SMAs were concerned about future job opportunities, especially the LSMAs. They raised the question as to “[h] ow many leading [SMAs] are needed” (SMA1,11). It was also noted that it is “difficult when they just come out [of the program] and don't have a job in sight and have the degree, but don't earn more” (SMA8,75). It might be because “right now they [the labor market] are looking for more clinical SMAs than lead SMAs” (SMA5,59) and “so many do not find a lead position” (SMA8,115). Some participants feel that the clinical direction offers more chances and provides a brighter future (SMA3,5) and that “many, many more [clinical SMAs] are needed for the patients” (SMA5,59). “I see a lot more potential in the clinical direction because of all the patient care and support where one can take things from the physicians. [This] is extremely valuable and certainly a great potential for what will happen in healthcare in the future” (SMA8,115).

When asked about whether they would have quit the MPA field if this opportunity regarding further education had not been available, half of the participants stated that they probably would have (SMA3; SMA5,11; SMA6,21; SMA8,41; SMA9). Nonetheless, further education has provided them the opportunity to acquire a “basic framework” or “foundation” (SMA5,17, SMA6,23). One SMA stated: “I would recommend this further education to many MPAs [...] just because of the knowledge that you get” (SMA2,49).

Affected psychological cognitions due to information: Having access to appropriate information and going through the federal examination affected their sense of competence and meaning. Participants reported being partially satisfied with the content of the available further education modules and that it provided know-how for their work (competence), but they also expected more and questioned the depth, scope, and practical benefit of certain knowledge content in the curriculum. Several parts of the final federal examination procedure were criticized, especially the quality of the examinations and the performance of the examiners; this did not make much sense to them compared to what they had learned (meaning). Both the quality and content of the curriculum and procedure of the federal examination [1] were thus a first critical aspect in the domain of the structural factor information.

Affected psychological cognitions due to resources: Receiving a proper salary was described as a resource of appreciation, giving the participants a sense of meaning. Although most SMAs were satisfied with their current salaries, they indicated a need for proactive negotiations for a salary increase. Other limited resources, such as staff and time, affected their sense of meaning in their new role, leaving participants dissatisfied; it also affected their sense of self-determination and their sense of having an impact on their work outcomes because they could not meet the work requirements. These challenges, arising from staff shortages and time management in their dual role [2], were a second critical aspect within the structural factor resources domain. However, having enough time with patients gave them a positive sense of making a difference in their patients' well-being and contributed to their job satisfaction.

Before the introduction of the new medical tariff structure (TARDOC) in January 2026, its unavailability as a resource for expanded billing options influenced decisions about whether certain services were offered, which in turn negatively affected the psychological cognitions of self-determination and impact on daily work outcomes, as well as cost-effectiveness. The unavailability of more billing options for SMA services [3] is therefore a third critical aspect in the domain of the structural factor resource.

Affected psychological cognitions due to support: Experiencing support from colleagues, team members, quality circles, professional associations, organizations, education providers, and companies mainly positively affected participants' sense of meaning and enhanced their competencies by enabling them to address questions and access information.

Support and trust from superiors affected feelings of recognition and, thus, a sense of meaning. Furthermore, the amount of self-determination they felt was influenced by how much responsibility they took on themselves or how much was handed over. Some statements suggested that a reluctance to hand over tasks and responsibilities may be related to a lack of knowledge or shared understanding of the SMA role. Consequently, this affected participants' sense of impact on work outcomes, such as providing relief to physicians. Knowledge about the new profession and a shared understanding of the new SMA role [4] with the associated trust and reluctance to delegate tasks that impacted the supervisor's support can thus be seen as a fourth critical aspect of the emerging themes of empowerment in the workplace.

Affected psychological cognitions due to opportunity: Having the opportunity to pursue further education and gain a tertiary degree, receiving a better salary, and feeling appreciated affected participants' sense of meaning and incentivized them to remain in their professional field. Pursuing further education provided most of the SMAs with basic further knowledge, increasing their sense of competence, raising their expectations for lead positions, and being more independent, which affected their sense of self-determination.

The opportunity to perform the SMA role provided satisfaction and enjoyment at work and affected the participants' sense of meaning, while their work experience with new responsibilities enhanced their competence. Additionally, their daily work enabled them to have an impact on daily work outcomes, provide relief for physicians, and influence patients' well-being. Being able to influence work outcomes was closely related to the level and quality of support they received from superiors.

However, concerns about future job opportunities for LSMAs or CSMAs were also raised, the feeling of having a choice in future job opportunities affected their sense of self-determination. Some participants saw no more need for LSMAs, but great potential for CSMAs. Concerns about future job opportunities for LSMAs or CSMAs [5] are thus a fifth critical aspect of the emerging themes of empowerment. Overall, these results corroborate evidence that workplace empowerment enhances psychological empowerment (Ning et al., 2009; Sarmiento et al., 2004; Spence Laschinger et al., 2001, 2010; Suhermin, 2019; Sun, 2016; Travers et al., 2020). In this context, quantitative approaches could be further used to investigate the extent to which structural factors influence psychological empowerment regarding job satisfaction (Ning et al., 2009; Sarmiento et al., 2004; Suhermin, 2019) or job retention (Biason, 2020; Lee, 2021; Lu et al., 2019).

The quality and content of the curriculum and procedure of the federal examination [1] were seen critically and affected participants negatively. Several studies have emphasized the importance of well-designed education programs and flexible curricula to empower MAs with expanded roles in terms of skill development, workplace engagement, and career ladders (Chapman et al., 2015; Chapman & Blash, 2017; Dill et al., 2019, 2021; Ferrante et al., 2018; Figueroa Gray et al., 2021; Fraher et al., 2021). Evaluating the educational content, curriculum, and private education providers, as well as the federal examination procedure, in collaboration with the SMAs, may provide insights into the concerns that were voiced and facilitate a refinement of the program's educational content and curriculum.

Time management in a dual role was reported as challenging, especially when there were staff shortages [2]. Studies have reported that expanded roles of MAs add more value to the work scope and give opportunity to remain engaged in their professional field, but also confirmed that MAs with expanded roles often encounter challenges with regard to their dual and flexible roles (Chapman & Blash, 2017; Ferrante et al., 2018; Taché & Hill-Sakurai, 2010). It is recommended that this fact be recognized and compensated financially (Ferrante et al., 2018). In addition, clarifying and defining roles and team structure could enable value- and team-oriented cooperation that leads to better work outcomes and greater job satisfaction (Ladden et al., 2013; Sheridan et al., 2018). Clear job descriptions and providing training can support the process of role shifts in PC (Dill et al., 2019). Role definition and a clear division of tasks are needed; therefore, further exploration is needed. An in-depth study from the subproject “Health2040” on facilitators and barriers of task-shifting between health professionals is currently underway in Switzerland for this purpose (University of Lucerne & Interface Politikstudien Forschung Beratung AG, 2025).

The unavailability of more billing options for SMA services [3] hindered broad, cost-effective CCM service delivery. It is assumed that diabetes consultations and pilot programs might be cost-effective in Switzerland (Ansorg et al., 2022; Frei et al., 2010; Mueller, 2022; Steurer-Stey, n.d.). This is due to the fact that the former medical tariff structure (TARMED) only included a single line for diabetes consultations of SMAs (Federal Office of Public Health, 2023). The new medical tariff structure (TARDOC), which was introduced in January 2026, includes more billing options (Federal Council, 2022b). The implementation of the TARDOC structure may therefore lead to enhanced CCM consultations carried out by SMAs and provide relief for PC physicians. The expanded services will make SMAs' professional experiences more diverse and attractive. However, further research is needed to evaluate the cost-effectiveness and performance of CCM services with the now expanded billing options in TARDOC.

The knowledge about the new profession and a shared understanding of the new SMA role [4] were reported to influence physicians' levels of trust and reluctance to delegate tasks. This was also confirmed by the study of Ferrante et al, (2018) on barriers and facilitators to expanded roles, which observed that clinicians only hesitantly trusted MAs with expanded roles and that this level of trust influenced their willingness to delegate tasks and hand over responsibilities. Other studies on expanded roles for MAs in the United States (Elder et al., 2014; Figueroa Gray et al., 2021; Fraher et al., 2021; Ladden et al., 2013; Sheridan et al., 2018) and on interprofessional collaboration in PC in Switzerland (Gysin et al., 2019; Josi et al., 2020) reported that open communication, building a shared understanding, and knowing and clarifying expanded roles are essential prerequisites for enabling team-based, interprofessional collaboration and task-shifting. These findings suggest that the SMAs' roles can be further empowered by promoting and raising awareness of the SMA profession and by clarifying tasks and roles.

Future job opportunities for LSMAs and CSMAs [5] turned out to be relevant for SMAs' future career prospects and to plan their career. Previous studies recommended that future research should closely examine expanded roles, responsibilities, and demands for different career perspectives and preferences, particularly with respect to professional distinctions and various fields of providers and settings (Dill et al., 2019, 2021; Fraher et al., 2021; Vilendrer et al., 2022). The needs and requirements of the transforming system in PC and other settings, as well as the specific demand for CSMAs and LSMAs, should be explored in more detail. A needs assessment regarding LSMA and CSMA specializations could inform a process that focuses on the question of how further education could be refined according to the specializations in different healthcare settings.

This study offers explorative insights into the empowerment of SMAs by their further education and new role, and complements the results of the report by the Swiss Federal Council (Federal Council, 2022a). The theoretical framework of empowerment that is drawn on allows for the systematic structuring of SMAs' statements, the identification of emerging themes, and the detection of critical aspects of those themes.

Limitations need to be considered, however. For one, this study's sampling method impacts the interpretation of the results, as a selection bias may play a role. The participants were found via convenience and snowball sampling in the German-speaking part of Switzerland, participated voluntarily, and were highly motivated professionally. Most had experience with supportive superiors. Secondly, while perspectives from PC settings and hospital out- and inpatient settings were captured, perspectives of graduate SMAs from smaller practices, e.g., with only one physician, need to be included in future research. Finally, it must be considered that healthcare settings are undergoing transformation, with new interprofessional collaborations and new fields in which SMAs are already involved and will be in the future. Although thematic convergence – regarding both positive and negative experiences – was observed across different settings, specializations, and ages of the ten participants, the sample size remains limited to achieve complete data saturation, given the diversity of the healthcare settings in Switzerland's various language regions. Further research on different healthcare settings, expected transformations, and professional diversification is recommended (Vilendrer et al., 2022). Ongoing changes across various healthcare settings should be reflected in accordance with the LSMA and CSMA specializations in further education.