Neonatal Nurse Practitioners (NNPs) are an integral part of the NICU team. The NNP role has changed over the past forty plus years. This paper will outline the history and development of the NNP role, current challenges, standards of practice and conclude with my expectations for the role of NNP.
History of the NNP Role
It can be argued that the first advanced practice nurses were the nurse midwives and the nurse anesthetists in the late nineteenth and early twentieth century (Johnson, 2002). It wasn’t until the 1960s however that the role of the advanced practice nurse officially began when the University of Colorado offered a four-month certificate program for pediatric nurse practitioner (PNP). The family nurse practitioner program was developed in the 1970s to help meet primary care demands. The first NICU was also established on October 15, 1960, at Yale-New Haven Hospital and subsequently many more were established in major teaching hospitals (Johnson, 2002).
These NICUs were managed by interns and residents who were completing their pediatric residency under the supervision of a neonatologist. Through the 1970s more NICUs emerged and most areas adopted a perinatal regionalization model (Johnson, 2002). As demand for NICU expertise grew, the rotation hours for pediatric residents in the NICU continued to be reduced. This left a gap in care to be filled by neonatal nurse practitioners.
In 1973, a commission funded by the March of Dimes developed guidelines for the development of a neonatal nurse clinician (NNC) position (Johnson, 2002). The NNC differed from the clinical nurse specialist (CNS) who had a master’s degree. The four to nine-month NNC/NNP education programs were mostly unregulated, hospital-based certificate programs. Doctors, nurses, and hospitals also could not reach a consensus regarding the role of NNC/NNPs role. Therefore, their utilization was decided by the institutions that trained them. At this time there were at least 3 NNP practice models being used: the level III academic setting, the transport role, and the level II community hospital(Honeyfield, 2009).
In the 1980s, NNP educational programs moved to universities and became incorporated in masters programs. In 1983, the first NNP conference met to address the expansion of the NNP role, educational criteria, the confusing titles (NNC vs NNP), and the range of practice models (Honeyfield, 2009). This conference eventually led to the founding of the National Association of Neonatal Nursing (NANN). NNP certification started in 1983 and was administered by the National Certification Corporation (NCC)(Johnson, 2002).
The demand for NNPs continued during the 1990s with health care reform and managed care (Johnson, 2002). At this time, some states started requiring master’s degrees. NNPs gained privileges in hospitals and were allowed to perform procedures and patient management but they were also required to have physician supervisors. Additionally, NNPs along with other advanced practice nurses lobbied and were able to obtain prescriptive authority in many states. However, demand for NNPs has exceeded supply and some institutions started looking at alternative providers including physician assistants, hospitalists and pediatricians (Honeyfield, 2009).
Current challenges literature review
To determine the history and current issues of the NNP role, a search for articles was completed using the databases accessible through the University of Cincinnati library. The key terms used in searching these databases included the following: NNP, history of the neonatal nurse practitioner, NNP roles and responsibilities, NNP scope of practice, NICU and advanced practice nursing. Articles specifically regarding the history of the NNP role were older. Otherwise, the search was further narrowed to only include articles less than five years old, published in English, peer-reviewed and have the full text available online.
As NNP education has transitioned into graduate nursing programs, NNP practice has become more research-based, and more studies of NNP practice outcomes are now appearing in the literature. NNPs provide consistent, quality care in the NICU; however, with the shift of patient care from residents to NNPs, there now are concerns about NNP workload and fatigue. This problem is exasperated with a continued shortage of NNPs.
With the decline of resident participation in the NICU, NNPs are now more involved in the inpatient and outpatient setting. Their responsibilities include attending high-risk births, managing NICU patients, and performing more advanced procedures. Studies have now shown that there has been no decrease in quality of care and some instances an improvement (Dye & Wells, 2017). Studies were also conducted comparing NICUs managed by all NNPs with physician managed NICUs. The results of these studies showed comparable or better patient outcomes to control groups (Dye & Wells, 2017).
With increased utilization of NNPs, now the focus of concern has shifted to NNP staffing shortages, workloads, and fatigue. There are limited evidence-based standards for NNP patient workloads. There are practice standards that recommend the number of patients that bedside nurses and resident/fellow physicians can manage, but there are no guidelines for the NNP workload (Jaeger, Acree-Hamann, Zurmehly, Buck, & Patrick, 2016). Fatigue and job dissatisfaction have become a concern also, therefore, the National Association of Neonatal Nurse Practitioners recommended an NNP caseload of 6–10 for experienced NNP with adjustments to caseloads if there are other factors such as high patient acuity(‘NANNP,’ 2014).
Forty-three percent of the NNPs surveyed worked more than 40 hours per week, and 47% of NNPs in level IV NICUs reported that their actual hours worked exceeded scheduled hours (Dye & Wells, 2017). Jaeger et al. reported that more than half of NNPs who practiced in level IV NICUs also reported their patient loads were unsafe. NNP workforce shortages and shift work affect not only patient care but the health of the provider. To reduce fatigue, Keels (2016) recommended educating NNPs on sleep physiology and optimizing the home environment to achieve 7-9 hours of sleep. At work, NNPs need to work together with hospitals to develop staffing strategies that eliminate shifts of more than 12 hours and allow for at least 48 hours before rotating from night to a day shift (Keels, 2016).
Another concern for the NNP role is the shortage of new graduates into the workforce as well as the retirement or loss of current NNPs. It is estimated that the NNP shortage will continue for at least the next ten years (Schell et al., 2016). Researchers have analyzed the impact of improving the certification examination passing rate, increasing the number of master’s programs, and reducing the number of workforce losses to improve the NNP workforce (Schell et al., 2016).
They suggested improving exam pass rates by better preparing NNP candidates in their graduate programs on how to take the exam. There has also been a decrease in the number of NNP educational programs. To increase interest and enrollment, schools need to be innovative in the way they recruit. Current NNPs and neonatologists can also be involved in the recruiting of new NNP students and as preceptors and role models. Higher salaries may also be required to attract experienced RNs to pursue a graduate level of education.
Finally, changes have to be made to keep current NNPs in the workplace. The current rate of attrition annually is 1.5% (Schell et al., 2016). With these policy changes, the authors predicted a reduction in the forecasted shortage to 4 years.
Current NNP standards for practice (licensure, accreditation, certification, and examination)
NNPs are registered nurses who have completed a master’s degree and an advanced training program specializing in neonatology. They are considered acute care nurse practitioners and can practice in the NICU setting, in neonatal transport, in level 2 nurseries and in follow up or high-risk clinics. NNPs collaborate with or under the supervision of a physician, usually a neonatologist. However, there are states that allow NNPs to practice independently. Requirements for an NNP, as stated in the NANN position statement, include graduating from an accredited graduate-level, neonatal population-specific program, passing and maintaining national certification.
The national certification serves as the basis for the neonatal scope of practice and continued competency. Finally, those who have not met these requirements, and, are practicing in the NICU, are practicing outside their scope of practice (‘NANNP,’ 2014). In Ohio, to obtain an APRN license, the applicant must be a registered nurse and submit documentation to the board that he/she has earned a master’s or doctoral degree majoring in a nursing specialty that qualifies the applicant to take the certification examination.
Before starting practice, an APRN needs to establish a standard care arrangement (SCA) with each physician they will be collaborating with. A hospital can hire a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner as an employee and negotiate standard care arrangements on behalf of the employee (Ohio Board of Nursing, 2019).
My expectations in this role
As a NICU nurse, I very much enjoyed not only taking care of the fragile infants that made up our patient populations but interacting and educating their parents. Three years ago, I left the NICU to join the Vascular Access Team as a PICC nurse. This not only added to my skill set but exposed me to other units and different patient populations. I had been considering getting my master’s for a few years but other commitments, time constraints and the daunting thought of reentering school kept me from it.
When I was finally ready to take the plunge, I wanted to specialize in neonatology. I hope that I can take the experience and expertise that I have gained in the past eleven years to the next level. My goal is to work in a level 3 or 4 NICU, but I also would like to volunteer for community organizations like Cradle Cincinnati or the March of Dimes. Doing the research for this paper has opened my eyes to some of the challenges facing NNPs today. I hope I can contribute to solving these problems and inspire other nurses to follow in my footsteps.
The NNP role has evolved over the past forty years. Educational requirements have steadily increased from continuing education/certificate programs to masters and doctoral degrees. NNPs have become a key component in the quality of care received in the NICU. Increasing workloads, fatigue and a decreasing workforce are current and future challenges that need to be addressed for the NNP role to be successful in the future.
- [bookmark: R434927175162847I667773]Advanced Practice Registered Nurse: Role, Preparation, and Scope of Practice. (2014). Retrieved from http://nann.org/uploads/Membership/NANNP_Pubs/APRN_Role_Preparation_position_statement_FINAL.pdf
- [bookmark: R435203523111458I667773]Dye, E., & Wells, N. (2017). Subjective and Objective Measurement of Neonatal Nurse Practitioner Workload. Advances in Neonatal Care, 17(4), E3–E12. http://dx.doi.org/10.1097/ANC.0000000000000353
- [bookmark: R435199351528588I667773]Honeyfield, M. E. (2009). Neonatal Nurse Practitioners: Past, Present, and Future. Advances in Neonatal Care, 9(3), 125-128. http://dx.doi.org/10.1097/ANC.0b013e3181a8369f
- [bookmark: R434929226971412I667773]Jaeger, C. B., Acree-Hamann, C., Zurmehly, J., Buck, J., & Patrick, T. (2016). Assessment of Neonatal Nurse Practitioner Workload in a Level IV Neonatal Intensive Care Unit: Satisfaction. Newborn and Infant Nursing Reviews, 16(3), 138-148. Retrieved from https://doi.org/10.1053/j.nainr.2016.07.007
- [bookmark: R435197836444792I667773]Johnson, P. J. (2002). The History of the Neonatal Nurse Practitioner: Reflections from “Under the Looking Glass”. Neonatal Network, 21(5), 51-60. Retrieved from http://connect.springerpub.com/content/sgrnn/21/5/51.full.pdf
- [bookmark: R435204119620370I667773]Keels, E. L. (2016). Neonatal Nurse and Neonatal Nurse Practitioner Fatigue. Newborn and Infant Nursing Reviews, 16(3), 168-172. http://dx.doi.org/10.1053/j.nainr.2016.07.008
- [bookmark: R434926397789699I667773]Ohio Board of Nursing. (2019). http://www.nursing.ohio.gov/Practice-APRN.htm
- [bookmark: R435204312646991I667773]Schell, G. J., Lavieri, M. S., Jankovic, F., Li, X., Toriello, A., Martyn, K. K., & Freed, G. L. (2016). Strategic modeling of the neonatal nurse practitioner workforce. Nursing Outlook, 64(4), 385-394. http://dx.doi.org/10.1016/j.outlook.2016.03.007