The Daily Dose • Monday, April 17, 2023

Where are Anesthesia Healthcare Workers? Strained but Still Out and About

Adaora M. Chima, MBBS, MPH

Healthcare worker shortages are a growing problem on a global scale. Anesthesia care delivery has not escaped this phenomenon, a dilemma that was the focus of a panel session, “The Anesthesia Workforce: Who’s Doing the Work?” that closed out the IARS 2023 Annual Meeting on Sunday, April 16.

This session was co-sponsored by the World Federation of Societies of Anesthesiologists (WFSA).

Moderator and first speaker Tyler Law, MD, Assistant Professor and Member of the Leadership Committee of the Center for Health Equity in Surgery and Anesthesia at University of California, San Francisco, introduced the audience to WFSA’s workforce survey which was disseminated in 2021 to update data from a similar survey in 2015. The goal was to collect more granular data including demographics, level of training and clinical specialty practice, relevant information for advocacy and evaluation of the impact of educational and recruitment interventions. Inclusion criteria and anesthesia roles were defined and stratified in order to capture all cadres of anesthesia personnel in participating sites. With the aid of WHO regional leaders, national and regional anesthesia organizations, including the International Federation of Nurse Anesthetists and their member associations, data was obtained from 148 countries, 76% of WHO target nations. Critical features of the survey methodology included the use of specific definitions, accessible live updates of obtained data, which encouraged more participation, validation of data source, which wasn’t always possible, and flexibility in project timeline.

Similar to the previous survey, the data showed a global distribution of 10.4 anesthesia providers/100,000 people, 7.6 of which are physician anesthesiologists (PA) and 2.8 nonphysician anesthesia providers (NPA). These numbers are more concentrated in countries with a higher per capita income, and sub-Saharan Africa had the lowest numbers. Generally, the number of anesthesia providers has increased but at a much slower pace than the population. An increase in physician providers per population was evident except in high income countries. In those locations, nonphysician providers were predominantly responsible for the increase in available personnel by both population and per capita. Demographic differences captured include a 77% female NPAP workforce in HICs compared to less than 40% in low- or middle-income countries (LMICs). There were also varied definitions of nonphysician providers and different training systems available and expected of both NPAs and PAs, sometimes within the same country. Constraints to the data collection included reliability of sources, duplication of data and inability due to the impact of COVID-19 on the process.

Fred Bulamba, MD, Physician Anesthesiologist at Busitema University, Uganda and a member of the WFSA Scientific Committee, shared his vantage point from his experience starting an anesthesia training program in Uganda with his presentation titled, “Bringing Some Sense to African Anesthesia Training Models.”

Sharing his survey findings regarding available anesthesia training pathways, based on data obtained from a survey of anesthesia stakeholders in Africa, he described the presence of 30 different pathways across the continent, 8 of which are geared towards physicians. The structure and duration of training programs varied for both PA and NPA cohorts, with an approximate mean of 48 and 24 months respectively. The credentialing and licensing process was also inconsistent across countries and geographic zones. The clinical roles/titles vary depending on these processes and are also influenced by cultural and historical perceptions of these roles. Despite the variability in training structure and infrastructure, the goal is consistent across the spectrum, to be able to perform anesthesia-related tasks independently, although some level of supervision is expected for the nonphysician anesthesia providers. This informational study is currently being prepared for publication.

Dr. Bulamba attributed the heterogeneity in training structure to differing national health priorities, availability of human and economic resources, and existing health systems. This elicited an interactive discussion about the existence of similar variations in higher income locations and whether homogeneity was an important and relevant goal for which to aspire. Challenges to anesthesia training in Africa include quality assurance, stakeholder acceptance, limited training resources, employment opportunities and brain migration. Collaborative training initiatives amongst African nations have resulted in regional training and certification bodies of which the West African College of Surgeons (which includes anesthesia) is an example. Open access sources on anesthesia such as OpenAnesthesia® have been very helpful to training programs. He concluded by challenging the audience to consider offering time and expertise to support anesthesia training programs in Africa, and offer more training and fellowship opportunities to interested clinicians from LMICs. Opportunities that support these efforts include Fund A Colleague’s Education (FACE), the UCSF HEAL Initiative or participating in WFSA activities.

Jackie Rowles, DNP, MBA, MA, CRNA, ANP-BC, President of International Federation of Nurse Anesthetists (IFNA) and Director, Advanced Pain Management Fellowship and Associate Professor of Professional Practice at Texas Christian University, presented a global perspective of the nurse anesthesia workforce based on WFSA survey findings. Historically, nurse anesthetists can be traced to ~170 years ago when religious nuns tended to trauma victims in battle and subsequently trained nurses to provide care during surgical procedures. This evolved from a hands-on training and apprenticeship in a time of need to formal training. An expansion in the scope of nurses in anesthesia and current training models required advanced training prior to commencing anesthesia training and practice. The WFSA survey responses revealed varying educational models and scopes of practice, strongly influenced by local practice regulations as well as the reception of the medical community. In some key responses, the results of the survey were widely divergent from the 2015 data, this is attributed to an improved data collection process this time. Rowles described residual resistance to NPA licensing from the medical community in some geographic locations that could benefit from increased anesthesia personnel. She called for increased communication and collaboration amongst all cadres of anesthesia providers, to advance the common goal of safe perioperative patient care.

This panel session underscored the prevailing healthcare worker shortage, which is heightened in resource-limited settings. It explored current global anesthesia provider distribution, examples of initiatives to improve training and recruitment, and challenged anesthesia providers to seek opportunities to improve access to quality anesthesia delivery by supporting training programs in resource-constrained locations.