Nursing workforce in surgery and trauma care delivery: A global call to action

This article is part of a series that describes efforts to improve global trauma care in Latin America. The first article in the series—“Using global surgical indicators to improve trauma care in Latin America”—was published in the April issue of the Bulletin.* In this article, the authors look at how improving nursing workforce can improve the availability of trauma care in low- and middle-income countries (LMICs). As in the other articles in this series, the authors describe efforts in Latin America that support the World Health Assembly (WHA) Resolution 68.15.

The need for interprofessional care

In the last 15 years, significant work has been conducted to quantify the global health care workforce burden. The World Health Report (WHR), a November 2006 expert assessment of shortfalls in global health care workforce, described the global health care workforce crisis and its massive effect in 57 countries and on 1 billion people, indicating that there is a global deficit of “2.4 million doctors, nurses, and midwives.”¹ An additional 4.3 million health care workers were needed to fulfill the Millennium Development Goals established by the United Nations in 2000, which include eight anti-poverty targets in the identified countries outlined in the WHR. The report also documented variances in geographical workforce density ranging from 2.3 in Africa, to 4.3 in Southeast Asia, to as high as 24.8 in the U.S. (numbers per thousand population). In fact, countries with fewer than 2.3 skilled health care workers per 1,000 population were observed to have poor primary health care intervention coverage.¹

The document, Working Together for Health, indicates that maximizing the capacity of the existing health care workforce is a key mechanism in decreasing the global health care burden.¹ In alignment with comprehensive literature highlighting the benefits of systems-based interprofessional health care approaches to patient care, Working Together for Health highlights the need to enhance current healthcare member teamwork, with noted emphasis on the teamwork core skills sets of communication and leadership as a key mechanism in overcoming health care shortfalls.^2-3 These concepts are consistent with the conclusions of various U.S. health care organizations that are documenting that teamwork—a critical component of interprofessional surgical teams—mitigates medical error and can be linked directly to improved patient outcomes and patient safety.^4-7

The Agency for Healthcare Research and Quality (AHRQ) and The Joint Commission indicate that low expectations, poor communication and teamwork, and authority gradients can inhibit effective teamwork in health care environments, and remain key underlying reasons for underdeveloped health care safety cultures.^6-7 AHRQ further indicates that hierarchical structures, such as those potentially related to gender or professional differences on a health care team, are well-documented obstacles to teamwork and patient safety.⁶

Nursing workforce disparities

Regional differences, as well as disparities in training, qualifications, gender, and profession, emphasize the imbalances in health care provider workforce shortage around the globe. Although almost two-thirds of all health care workers are women, data accentuates that women nurses are often underutilized and relegated to bed-making and other nonclinical tasks.^8-11 These differences, combined with variances in employment credentialing requirements, and barriers that inhibit standardization of the trauma nursing specialty paradigm among LMICs can have a negative effect on care and management of the injured patient (see Table 1).¹²

Table 1. Summary of Barriers that inhibit translation of trauma nursing specialty among LMICs

Regional disparities affecting health care workforce Differences in health care training Nonstandardized nursing education curriculums Minimal leadership training for nursing personnel Gender barriers, professional barriers, and clinical underutilization Lack of trauma nursing specialists Lack of clarity in trauma nurse specialty Scarcity in literature regarding workforce capacity shortfalls, systems strengthening roles, and nursing advanced degree requirements specific to trauma Under-designation of trauma programs/systems Underdevelopment of grassroots performance improvement structure and processes Early stages of surgery-championed policy (such as LCoGS trauma/surgical nursing workforce density indicator)

According to the Center for Projects Developments study published in 2013, Colombia had 7,872 medical specialists, 1,471 surgeons, 1,977 anesthesiologists, and 1,008 specialists in trauma and orthopaedics.¹³ Colombia’s workforce density numbers were 1.5 for physicians and 0.8 for nurses per 1,000 population.¹ The National Association of Nurses in Colombia (ANEC) states Colombia had 44,520 registered nurses from 1997 to 2015, of which 93 percent were women (see Table 2 for other supporting data).¹⁴ However, in the 72 nursing graduate programs offered in Colombia, nursing curricula are not designed to prepare nurses for advanced roles in trauma nursing leadership, surgical systems enhancement, or interprofessional team-based care paradigms.¹⁵

Table 2. Age distribution of Health care professionals with Nursing Training in Colombia

Age group	Women	Men	Total	Women (percent)	Men (percent)
16–20	2	0	2	~0%	~0%
21–25	2,362	263	2,625	~10	~1
26–30	8,018	958	8,976	~34	~4
31–35	6,130	878	7,008	~26	~4
36–40	2,026	366	2,392	~9	~2
41–45	1,080	158	1,238	~5	~1
46–50	694	67	761	~3	~0
51–55	416	31	447	~2	~0
56–60	174	20	194	~1	~0
= or > 61	40	10	50	~0	~0
Total	20,942	2,751	23,693	90%	12%

Source: Ortiz LC, Cubides H, Restrepo DA. Labour Characterization of Health Human Talent in Colombia: Approach from Quotation Base Wages to the General System and Social Security of Health. Ministry of Health and Protection: Social Management of Human Talent Development in the Republic of Colombia, 2012.

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Brazil, the largest and most populous country in Latin America, offers free universal health coverage to all of its 207 million residents.¹⁶ According to the Federal Councils of Nursing and Medicine, the provider-to-patient ratio per 10,000 population is 22.9 for nurses and 21.4 for physicians, whereas the ratios for surgeons and anesthesiologists are 10.8 and 8.8 per 100,000 population, respectively, with maldistribution of health care professionals to the southeast region overall.^17,18 Qualifying and quantifying the surgery and trauma nurse specialty in Brazil’s health system (see Table 3) has proven difficult, as a higher level of education or training to work in specialty areas is neither mandated nor easily assessed.

Table 3. Brazilian nursing in numbers

		Population	Nursing auxiliaries	Nursing technicians	Nurses	Nurses/ inhabitants	Nurses/ 100,000
North	Rondônia	1,787,279	2,970	8,975	3,309	0.0019	185.14
	Acre	816,687	672	4,613	2,050	0.0025	251.01
	Amazonas	4,001,667	3,364	27,326	8,731	0.0022	218.18
	Roraima	514,229	1,397	4,522	1,394	0.0027	271.09
	Pará	8,272,724	8,326	41,391	10,537	0.0013	127.37
	Amapá	782,295	911	8,937	1,748	0.0022	223.45
	Tocantins	1,532,902	1,030	10,751	4,712	0.0031	307.39
	TOTAL	17,707,783	18,670	106,515	32,481	0.0018	183.43
Northeast	Maranhão	6,954,036	4,214	32,773	12,090	0.0017	173.86
	Piauí	3,212,180	5,832	17,119	8,471	0.0026	263.71
	Ceará	8,963,663	14,250	33,747	17,474	0.0019	194.94
	Rio Grande do Norte	3,474,998	6,226	18,259	7,931	0.0023	228.23
	Paraíba	3,999,415	4,185	20,547	11,223	0.0028	280.62
	Pernambuco	9,410,336	13,015	55,794	20,443	0.0022	217.24
	Alagoas	3,358,963	5,606	11,398	5,608	0.0017	166.96
	Sergipe	2,265,779	6,811	8,767	4,360	0.0019	192.43
	Bahia	15,276,566	14,860	70,334	32,465	0.0021	212.52
	TOTAL	56,915,936	74,999	268,738	120,065	0.0021	210.95
Southeast	Minas Gerais	20,997,560	23,947	103,872	45,542	0.0022	216.89
	Espírito Santo	3,973,697	4,164	23,895	8,069	0.0020	203.06
	Rio de Janeiro	16,635,996	51,350	148,805	49,604	0.0030	298.17
	São Paulo	44,749,699	192,374	183,090	118,853	0.0027	265.60
	TOTAL	86,356,952	271,835	459,662	222,068	0.0026	257.15
South	Paraná	11,242,720	24,687	44,094	23,074	0.0021	205.24
	Santa Catarina	6,910,553	6,902	34,556	13,200	0.0019	191.01
	Rio Grande do Sul	11,286,500	15,207	81,903	23,476	0.0021	208.00
	TOTAL	29,439,773	46,796	160,553	59,750	0.0020	202.96
Midwest	Mato Grosso do Sul	2,682,386	3,576	12,042	5,995	0.0022	223.50
	Mato Grosso	3,305,531	2,783	15,228	7,935	0.0024	240.05
	Goiás	6,695,855	5,265	33,762	13,977	0.0021	208.74
	Distrito Federal	2,977,216	3,351	31,731	12,101	0.0041	406.45
	TOTAL	15,660,988	14,975	92,763	40,008	0.0026	255.46
Brasil		206,081,432	427,275	1,088,231	474,372	0.0023	230.19

Sources:

Brazilian Institute of Geography and Statistics. Estimates of the resident population in Brazil and Federative Units with reference date on July 1, 2016. Available at ww2.ibge.gov.br/home/estatistica/populacao/estimativa2016/estimativa_tcu.shtm. Accessed August 30, 2016.

Federal Council of Nursing. Nursing in numbers. Available at: www.cofen.gov.br/enfermagem-em-numeros. Accessed August 21, 2017.

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Much like Latin America, regional maldistribution in total health care workforce is addressed in the literature from other areas of the world, as well. For example, a 2009 survey in India estimated health care density in urban areas at 42 health workers per 10,000 population and 11.8 per 10,000 population in rural areas.¹⁹ This imbalance was even more exaggerated when levels of qualification and training are considered: physicians, 13.3 urban/3.3 rural; nurses and midwives, 15.9 urban/4.1 rural per 10,000 population.¹⁹ Similarly, geographic areas that the World Bank has not classified as a LMIC—such as Puerto Rico, an unincorporated area of the U.S.—faced the same financial challenges and lack of human and material resources as those countries that the World Bank does classify as low-income.²⁰ Here, health care provider-to-patient ratio was affected when international migration occurred, increasing the impact of nursing shortages and specialty gaps on the island.²⁰ This type of shifting in the nursing workforce stemming from international migration, as well as a lack of global standardization in nursing education, licensure, and regulation, affects the quality of care and organizational performance globally.²¹ This drives regional disparities in care and nursing competencies.^22-23 When specialty specific disparities exist as in the example of the trauma nursing specialty, middle- and high-income countries also experience challenges in health care delivery.²⁴

Importance of nurses in surgical and trauma care delivery

Nursing has the largest workforce of any health care profession and, therefore, may be a solution to providing emergency and essential surgical care globally.^22-23 The International Council of Nurses recognized the critical nature and positive health care impact provided through nursing in its report, Nurses: A Force for Change: Improving Health Systems’ Resilience.²⁵

The Lancet Commission on Global Surgery (LCoGS) put forth recommendations for implementation and evaluation of national surgical systems by proposing six core indicators to target the magnitude of the surgery and trauma burden by the year 2030.²⁶ Specifically, the LCoGS indicated that there is a need for global surgical workforce expansion to 20−40 surgery, anesthesia, and obstetrician physician specialists (SAOs) per 100,000 population by the year 2030. Although SAO roles are clearly delineated, nursing was more broadly categorized within the larger category of “allied health professionals,” and a “surgery and/or trauma nursing specialty” workforce density indicator was not delineated. However, this may require an adjustment because surgeons are unable to safely, consistently, and repeatedly execute surgical care delivery without nursing specialty professionals in surgery disciplines that are represented by the SAO density.

Since 2015, Rutgers Global Surgery has partnered with Rutgers School of Nursing, the Panamerican Trauma Society (PTS) nursing leadership, and select nursing professionals from Latin America to develop a support system for the role of nursing leadership in surgery and trauma nursing specialization. The academic interprofessional support system intends to empower and enhance interprofessional injury care in LMICs through education, training, networking, and team implementation for defining trauma nursing workforce and expansion of the specialty  (see Table 4).

Table 4. 2016 and 2017 Nursing Symposia and workshop aims

Effectively promote nursing roles in: Trauma program leadership Performance improvement Data management Systems strengthening Modeling of interprofessional team-based care Provide interprofessional forums for sharing global perspectives on existent barriers Enhance understanding of nursing perspectives on respective trauma hospital and program landscapes in LMICs

When we combine the LCoGS report and these symposia/workshop goals, the aim of improving surgical care delivery through maximizing the capability of existing workforce through improved nursing education, teamwork, and leadership begins to take shape in the international settings mentioned previously. Surgery and trauma nursing leadership could allow for an interprofessional establishment and continued development of data registry, performance improvement, and quality assurance initiatives, and be critical to decreasing perioperative mortality rates and increasing the total number of surgical interventions (LCoGS surgical care delivery indicators 3 and 4; see Table 5). To achieve LCoGS national surgery/trauma qualification and quantification of LCoGS surgery care delivery indicators and World Development Indicator targets by 2030, nursing leadership and task-sharing in these systems administrative roles may prove to be pivotal.

Table 5. LCoGS core indicators and associated trauma program/system element

Category	LCoGS indicator	Description	Proposed trauma program/ system element focus
Preparedness	1	The geographic accessibility of surgical facilities	Prehospital system and integration with hospital registry
	2*	The density of specialist surgical providers	Acute care surgeon/fellowships; trauma program manager
Delivery	3*	The number of surgical procedures provided per 100,000 population	Trauma and emergent/essential hospital/societal registries
	4	30-day perioperative mortality rates	Trauma and emergent/essential hospital/societal registries, formal trauma performance improvement and patient safety, and trauma morbidity/mortality review process
Impact	5*	The risk of impoverishing expenditure when surgery is required	Future work—ministries of health/education/finance and trauma/acute care surgery divisional business administration
	6*	The risk of catastrophic expenditure when surgery is required	Future work—ministries of health/education/finance and trauma/acute care surgery divisional business administration

*World development indicators

Promoting the role of the trauma nurse

Globally, there is documented confusion about the role, importance, and the conceptual application of the trauma nurse specialty.¹² The role of the trauma program manager (TPM), a nursing leadership position required for trauma center designation in North America, evolved as a result of inputs from the Society for Trauma Nurses and the American College of Surgeons (ACS) Committee on Trauma. Crouch and colleagues explained how a trauma nurse coordinator role in one country held 17 titles, and Walter and Curtis explained global variance between the context, scope, and impact of trauma practice.^12,27 Barleycorn and colleagues discussed the differences in trauma training and education within LMICs, stating, “trauma education should be differentiated for newly qualified nurses and those with experience,” and “advanced-level training should focus on teamwork, trauma nurse leadership, and crisis-management skills.”²⁴

Promotion of nursing leadership skills within every stage of the trauma program may foster intrapersonal and interpersonal consistency in various trauma nursing specialty roles, enable systems workload task sharing, promulgate interprofessional care, increase cost-effectiveness, and diversify the talents of existing human capital. Nursing leadership and collaboration with surgeons within surgery/trauma program process improvement (PI) activities is a process that improves surgery care delivery by identifying preventable or potentially preventable complications and participating in loop closure after collaborative nurse and surgeon identification of opportunities for improvement. However, there is no evidence to suggest this occurs on a regular basis, or with interprofessional participation, in the LMICs. PI directorship is an example of a leadership responsibility that a TPM could fulfill in an international application of the TPM role. As the TPM oversees the trauma program in its entirety, unit or departmental trauma nurse managers can distribute capacity in order to prioritize growth of other components of the trauma program (for example, injury prevention, trauma registry, trauma education, and so on). Another trauma nurse specialist role includes the PI coordinator, who may fulfill a PI leadership role, that allows off-loading from the TPM during the early stages of TPM leadership. However, the underdevelopment of affordable and quality education/training that could promote this simple paradigm in the LMICs seemingly perpetuates professional and gender disparities in surgery and trauma workforce leadership.

Call for action

To meet the metrics set forth within the 2030 LCoGS document, the present generation of nurses must be systemically educated, trained, and empowered in leadership positions around the world. A focused engagement of an interprofessional workforce may stimulate systems enhancement and assist in addressing the global surgical burden.

Surgical care is in a period of marked transition. The burden imposed by professional, economic, social, and surgery’s gender culture barriers exacerbates global surgical care deficits. The need to transition from a traditional hierarchical to a team-based interprofessional care model is evident.⁴ The transition in Latin America requires collaborative interprofessional and multinational action between advocacy groups such as the ACS and the PTS, and linkage to national surgical societies in LMICs. For this type of evolution to be successful, an earnest evaluation of any individual and organizational gender and professional-based gaps must be conducted together and transparently.

The extension of qualified nursing specialty roles into hospital, national, societal, and ministerial leadership positions will require formal policy development and action. The authors advocate for the delineation of a specific nursing specialty workforce density alongside the physicians’ specialist SAO indicator. The modification of SAO to include nursing specialists will aid in achieving the intent specified within Working Together for Health and be instrumental in crossing professional and gender chasms to properly align surgical care delivery and successful national surgical planning in LMICs that achieves the WHA Resolution 68.15.

Acknowledgements

The authors would like to thank the following individuals for their contributions to this article and the work described in it: Jorge Esteban Foianini, MD, FACS, secretary-treasurer, Panamerican Trauma Society; Jasmine Garces-King, DNP, RN, CCRN, TCRN, ACNP-BC, trauma program director, Orange Regional Medical Center, Middletown, NY; chair, leadership committee, Society of Trauma Nurses; and course director, trauma nursing course, Panamerican Trauma Society; Allissa Gerdes, MPH, global surgery program coordinator, Rutgers Robert Wood Johnson Medical School (RWJMS) acute care surgery division, New Brunswick, NJ; Vicente H. Gracias, MD, FACS, senior vice-chancellor, clinical affairs, Rutgers Biomedical Health Sciences, president and chair of Rutgers Health Group; and professor of surgery, Rutgers University RWJMS; John G. Meara, MD, DMD, MBA, FACS, director, Program in Global Surgery and Social Change, Harvard Medical School; chair, department of plastic and oral surgery, Boston Children’s Hospital; and co-chair, The Lancet Commission on Global Surgery; Edgar Rodas, MD, FACS, associate professor of surgery, division of acute care surgery, Virginia Commonwealth University School of Medicine, Richmond; member of the Panamerican Trauma Society Trauma Systems Committee; and co-chair of the Panamerican Trauma Systems Committee’s Indicators Working Group; and Yuly Andrea Santa Mejia, Enf. Esp., nurse specialist in adult critical care, La Universidad de Antioquia; and an emergency nurse, Hospital San Vicente Fundación, Medellin, Colombia.

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*Peck G, Saluja S, Blitzer DN, et al. Using global surgical indicators to improve trauma care in Latin America. Bull Am Coll Surg. 2017;102(4):11-16.

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