As discussed in the previous sections, the benefits of APPs in ACS have been widely studied and published and are supported by national surgical organizations.23 What is critically important is the ‘how to’ create effective care models. To fully optimize integration of APPs into the multidisciplinary team, healthcare systems must be intentional in creating infrastructure to support this endeavor. Investing in professional development and constructing strategies to use APPs to enhance education for all learners as well as improve patient care will lead to excellent clinical outcomes and satisfaction by all members of the care team.24 Box 1 summarizes recommendations to consider when integrating APPs into ACS teams.
Box 1
Recommendations for integrating advanced practice providers (APPs) into your acute care surgery team
Recruitment, orientation, and training need to be intentional and well-coordinated.
Create an organizational chart for the Department of Surgery that includes how APPs fit into the overarching structure. This should include an APP leadership reporting structure and performance evaluation that includes feedback from both clinical and operational leadership.
Set expectations and create workflows to maximize knowledge base and skill set for the multidisciplinary team.
Educate all members of the care team to each other’s roles and responsibilities.
Create forums for APP advocacy and professional development.
Establish pathways for routine feedback from the interprofessional team to ensure the care model continues to be optimal.23 35
The remainder of this section addresses two common concepts that are imperative in integrating APPs in any clinical practice, namely, promoting autonomy and ensuring retention.
Autonomy
Ensuring APP autonomy in ACS teams is critical. In a review of 30 studies across three counties, Schirle et al25 found that Advanced Practice Registered Nurse autonomy is associated with increased job satisfaction, increased clinical productivity, and better teamwork and is also associated with less job strain and decreased intent to leave their current position. Integrating APPs into traditionally resident-run teams is challenging if a collaborative environment and mutual respect are absent. Depending on the support structure of the clinical team, APPs should be given their own designated panel of patients for whom they formulate plans. They can solicit assistance from the chief resident when necessary and lend their expertise to junior residents when appropriate. Per the Society of Trauma Nursing and Eastern Association for the Surgery of Trauma position paper, APPs are ‘leader(s),…master(s) of clinical practice guidelines, and resource(s) to other team members’.23 The longer APPs are integrated into a service, the more time they have to demonstrate their value and expertise to the residents, allowing a culture of collaboration and trust to grow. It is within these first few years of integration and ‘growing pains’ that protecting APP autonomy is particularly important.
Opportunities for APP autonomy may extend beyond simply having one’s own patient load. At the Medical College of Wisconsin, trauma APPs run a comprehensive multidisciplinary Trauma Quality of Life clinic and have a proven record of improving follow-up rates to ensure patients are recovering successfully.26 27 Although not yet described in the literature, there are APPs leading massive transfusion teams and other clinical specialty teams around the country as well.
In addition to state-level variations for scope of practice, hospital credentialing and privileging processes play an equally important role in defining the APP scope of practice. Even when APPs are licensed for full practice by state law, institutional bylaws or credentialing pathways may limit autonomy or delay full implementation of privileges. Aligning hospital credentialing with full licensure of practice for APPs is, therefore, critical. Standardizing this process by engaging physician, nursing, and administrative leaders early in credentialing discussions helps reduce barriers and ensures APPs can practice at the top of their license. Many institutions have found success through dedicated Advanced Practice Committees that review and expand APP privileges as services evolve and partner with physician credentialing to formalize the process.25 28
Retention
Turnover and strategies to retain healthcare employees have garnered greater attention during the last few years. Medicare data from 2010 to 2021 was reviewed to track APP turnover and noted that, cumulatively, 14.4% changed practices during their first year and 29.8% by their third year; however, turnover in hospital-based specialties outpaced that of medical specialties, with 43% of APPs changing practices by year three.29 In 2020, SullivanCotter published estimates of US$85,832 to US$114,919 that are lost when an APP position turns over.30 One may surmise that the hours and schedule faced by an emergency-based inpatient surgical service can influence an APP’s willingness to stay long term. The growing costs associated with recruitment and training, not to mention the time required and the effect on patient outcomes, compel leaders to identify opportunities for retaining team members.
First, it is helpful to identify those at risk for turnover and what drives this decision. SullivanCotter identified several reasons for attrition, including compensation; absence of an APP leadership structure; unclear job descriptions; and minimal, if any, administrative time.30 Other researchers distil these indicators into job satisfaction, reflecting a myriad of issues from staffing, function, leadership, and compensation.31
Compensation for APPs continues to increase. A large national survey found median total cash compensation rose by 10% to 13% over a 3-year period among surgical, medical, and hospital-based APPs.32 According to the American Academy of Physician Assistants 2025 salary report, median yearly compensation for physician assistants in trauma surgery was US$137,000.33 It is well recognized, anecdotally, that weekend, holiday, night shift, and extended‐hour coverage (which are frequent in ACS practice) are among risk factors for attrition and may prompt migration to other surgical services. Perceived benefits for specialties like colorectal and thoracic surgery may include lower call burden and weekend demands, as yearly salary was similar to trauma at US$136,000 and US$146,000, respectively.33 Intuitively, as a part of retention planning, ACS programs should explicitly evaluate how shift patterns and compensation differentials compare with other surgical services.
Several strategies exist to promote retention with varying results. Retention bonuses reward new hires for passing a tenure date but also set a date for when they can leave the organization. Retention bonuses should be used intentionally as they are often not the best long-term strategy.34 More effective approaches require deep organizational commitment and cultural shifts. Applying meaningful coaching to team members and cultivating a genuine sense of continuous learning helps.34 It is essential to invest in APPs’ professional development. Ensuring fair compensation and time for administrative responsibilities in addition to having a model for professional advancement will also strengthen retention efforts.
Effective coaching impacts other areas beyond retention and improves an organization’s performance. Moreover, addressing the drivers of turnover, such as an absent APP leadership structure or not using APPs to their fullest potential, mitigates turnover when APPs are able to maximize their full potential. Focusing on the culture and elevating APPs is a prudent initial step in retaining these essential healthcare providers.
