The NNP
Workforce
Erin L. Keels MS, APRN, NNP-BC
NNP Program Manager
Nationwide Children’s Hospital
Columbus, Ohio
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Disclosures
• No conflict of interest
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Objectives
• Describe current legislative and policy
recommendations impacting the practice of the NNP
• Discuss the current professional recommendations
impacting the practice of the NNP
• List at least three items to consider for improving his
or her professional practice
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We’ve Come A Long Way, Baby
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1960: First NICU
1975: Neonatology --Pediatric Subspecialty
1970s: NNP role developed
1970s- proliferation of certification programs
1970-1990s: increase in utilization of NNPs
1983: NCC offers NNP Certification Exam
1980- 2000s: Studies: Care equivalent to/exceeds
medical resident
• 1984 NANN founded
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1990s: Certificate programs absorbed into graduate
2001: ANN founded
2003, 2009: Neonatal APRN role endorsed by AAP
2009- 2012: NANN/P Position Papers:
– Requirements for Advanced Neonatal Nursing Practice in
Neonatal Intensive Care Units
– Standard for Maintaining the Competence of Neonatal Nurse
Practitioners
– The Doctor of Nursing Practice Degree
– Impact of Fatigue
– NNP Workforce
• 2011: 4725 certified NNPs in US
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Supply vs Demand issues for NNP
Patient Protection and Affordable Care Act
(ACA):
http://www.whitehouse.gov/healthreform
– “Obamacare”
– Signed into law 2010
– Goals
• Decrease number of uninsured Americans
• Reduce overall cost of healthcare
Approximately 30 million more patients are expected to enter
the healthcare system through 2019.
Shortage of primary care physicians is expected to surpass
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52,000 by 2025
Patient Protection and Affordable Care Act
(ACA):
- State Based Insurance Exchanges
• Medicaid eligibility, enrollment and state budgets
-State Practice Laws
• NPA revised, full scope of APRN practice
• Pushback expected
– Truth in Advertising
• Neutral provider language
• Who can be called DOCTOR?
– Patient Safety and Public Health
• Transparency, Access
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The Future of Nursing Institute of Medicine
Recommendations (2010)
http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-ofNursing/Future%20of%20Nursing%202010%20Recommendations.pdf
1. Remove scope of practice barriers
2. Expand opportunities for nurses to lead collaborative
improvement efforts
3. Implement nurse residency programs
4. Increase the number of nurses with a baccalaureate degree to
80% by 2020
5. Double the number of nurses with a doctorate by 2020
6. Ensure that nurses engage in life long learning
7. Prepare and enable nurses to lead change and advance health
8. Build an infrastructure for the collection and analysis of
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interprofessional health care workforce data
Other Factors
• March of Dimes:
– Rates of prematurity in the United States continue to
outpace other countries
• Medical House Staff
– Decreased hands-on clinical experience availability to
provide patient care for pediatric residents in the NICU.
– Shifting the patient care workload onto other providers:
Neonatal Attendings and Fellows, Physician Assistants and
NNPs (Freed, 2012).
• A recent survey conducted of children’s hospitals (Freed,2012):
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– Planned to hire more hospitalists; PAs; hire more NNPs.
NNP Shortage Contributing Factors:
– Decreased enrollment in NNP programs
– Loss of workers to retirement and decreased hours
– NNP programs closing
– Poor/limited access to preceptors
– Financial burden of higher education and the
struggle to work while attending school
– Reasons RNs may not want to pursue NNP role:
• Workload
• Salary
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• Work schedule
Our Challenge
• Establish/maintain adequate numbers of NNPs
– Recruitment, retention
• Ensure competency, quality and safety
– Education, certification, licensure, OPPE
• Contribute to body of knowledge and research
– Professional role
• Articulate contribution and importance of role
– Sustainability of role, billing/reimbursement
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The APRN Consensus Work Group and the National
Council of State Boards of Nursing APRN Advisory
Committee (2008):
• APRN licensure, accreditation, certification and
education must be effectively aligned to meet
healthcare needs in a safe and effective manner in
order increase access and improve outcomes.
• States independently license and define scope of
APRN practice; no uniform standard; creates barriers
to access
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The APRN Consensus Work Group
• National Model of APRN Regulation:
– Standardizes foundations of licensure,
accreditation, certification, and educations
– Establishes independent practitioner role
– Aim for full implementation 2015
• Improve state to state reciprocity and patient access
• Ensure quality and safety of APRN practice
• Provide guidance for those involved with APRN
education, licensure, accreditation, certification,
regulation and employers.
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APRN Consensus Model
https://www.ncsbn.org/2276.htm
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APRN Consensus Model Toolkit
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L. A. C. E.
• Licensure
– Standardize foundations of licensure through state
BONs:
• Require national certification
• Ban temporary licenses
• Ensure education and certification are congruent with
license
• Independent practitioners
• Utilize APRN advisory councils
• Grandfather currently practicing APRNs
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L. A. C. E.
• Accreditation:
– Sets requirements for accreditation of education
programs
• Certification:
– Sets requirements for national certification exams
that are psychometrically and legally sound
– Certification must be congruent with education
– Competence assessed through professional
organizations
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L. A.C. E.
• Education:
– Across the lifespan
– Graduate programs accredited nationally
– Graduates prepared to sit for national
certification
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Where is Your State?
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Go to the NCSBN website
See where your State is with implementation
Contact your State Board of Nursing
Get involved
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NANN NNP Workforce Survey Report
(2011)
National Certification Corporation (NCC) database
4725 certified NNPs in the US.
679 (14%) NNPs responded to survey
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NNP Workforce Survey Results
• Wide and unbalanced geographical distribution of
NNPs
• 25% work 24 hour shifts, and two-thirds are not
guaranteed downtime.
• The majority of respondents are very satisfied with
their career.
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NNP Workforce Survey Results
• Lack of knowledge regarding billing procedures
• The supply of NNPs may not be distributed according
to need
• Studies are needed to examine the demand for NNPs
and the roles of other clinicians in the NICU
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NNP Workforce Survey Report
Recommendations
• Implementation of the APRN Consensus Model
• Development of Collaborative Practice Models
• Enhance visibility of NNPs
• Establish safe & appropriate workloads and work
hours
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Increase knowledge of billing practices
NANN NNP Workforce Position Paper (2012)
http://www.nann.org/uploads/NNP_Workforce_Position_Statement_01.22.13_FINAL.pdf
PURPOSE:
• Define the NNP contribution to the neonatal workforce
environment
• Propose a framework and factors to consider in assessing
workload
EVIDENCE:
• Institute of Medicine (IOM) report (2010)
• American Nurses Association Principals of Nurse Staffing
(2012)
• ACGME Guidelines (2010)
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The Many Roles of the NNP
• Leadership role
– Transformational
• Clinical Care
– EBP, Quality Improvement, Bench to Bedside
– Patient and Family
• Diverse Work Settings
– Community/academic, urban/rural
• Interprofessional Collaboration
– Multidisciplinary, multidepartmental
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The Many Roles of the NNP
• Educator: families, staff, peers, interdisciplinary team
• Preceptor: student NNPs, new NNP staff, RN, other professionals
• Mentor: RN, NNP, Fellows, Resident, New Faculty, other
professionals
• Advocate: patients/families, clinical and professional practice
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Safety and Quality of Care
National Organization of Nurse Practitioner Faculty
Competencies (2012)
Scientific Foundation Leadership
Quality
Practice Inquiry
Technology and Information Literacy
Policy
Health Delivery System
Ethics
Independent
Practice
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Safety and Quality of Care
National Association of Neonatal Nurse
Practitioners NNP Competencies (2011)
Management of Patient
Health/Illness Status
The Nurse Practitioner-Patient Relationship
The Teaching/Coaching Function
Professional Role
Managing and Negotiating Health Care Delivery
Systems
Monitoring and Ensuring the Quality of Health Care
Practice
Culturally
Sensitive Care
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2013
• NANNP revising NNP education standards
and competencies
• Improve alignment with NONPF and IOM
statement
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Safety and Quality of Care
The Joint Commission: Ongoing Professional
Performance Evaluation (OPPE)
-Organizations must:
Review performance data for all practitioners with
privileges on an ongoing basis
Take steps to improve performance in timely basis.
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Safety and Quality of Care
The Joint Commission Focused
Professional Practice Evaluation (FPPE)
Targeted, focused monitoring of competency associated
with the exercise of clinical privileges:
-New privileges: all initial (new) privileges
-Quality of Care Concern: specific questions/ concerns
regarding a currently privileged Practitioner’s clinical competence,
and/or professional behavior, and/or the ability to safely perform
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any
privilege.
Examples of Evidence
– Delivery logs
– Procedure logs
– Consult logs
– Prescriptive
practice audits
– Code review
– Chart reviews
-Documentation reviews
Delivery room
Sedation
Procedures
-Adverse drug events
-Serious safety events
-Complaints/compliments
-Hours worked
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Challenges
• Develop individual and group NNP-specific
outcomes metrics
• Institution- specific, state, national
• Novice to expert continuum
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Billing and Reimbursement
• Many Do NOT bill
• Education and training needed
• NANN hopes to develop webinars and/or
workshops in the future
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NNP Caseload
Given the multifaceted role, challenges and
attributes of the NNP, what is a reasonable
case load??
What evidence exists?
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ANA Principles of Staffing
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Level of Care, census, patient acuity
Procedures performed
Worked hours per patient day
Continuity of care,
readmissions/deliveries/discharges
• Consultations/transports
• Quality of work environment/EBP/Technology
• Communication and teamwork
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Additional Factors to Consider
• NNP Level of competence and experience
• Novice to expert
• Body of evidence related to fatigue and
impact on safety & quality
• Level of patient acuity
• Site specific workload issues
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NNP Workforce Paper Recommendations:
•Personal and professional accountability for
mental acumen and physical fitness to manage
flexible, acute situations for multiple neonatal
patients
•Caseloads:
– Consistent with level of acuity & NNP capability
–Flexible- taking into account additional NNP
responsibilities
• Mentoring, deliveries, procedures etc.
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NNP Workforce Paper Recommendations:
• Advanced Beginner
– 6 patients
• Competent to Expert
– 10 patients when activity is high
• Proficient and Expert
– >10 when activity and acuity decreased
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NANNP Preceptorship Module
http://www.nann.org/uploads/NNP_Workforce_Position_Statement_01.22.13_FINAL.pdf
Approaches to Teaching Adult Learners
Role Transition
Guidance for Preceptors
Guidance for Learners
Clinical Supervision in the Acute Care Setting
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Case Scenarios in Precepting
The Impact of Advanced Practice Nurses’
Shift Length and Fatigue on Patient Safety
(2011)
http://www.nann.org/uploads/files/Fatigue_and_APRNs.pdf
Standards in shift work?
Job satisfaction did not vary with shift length in 2011 survey.
The highest patient load was associated with night shift or 24hour shifts
Most common NNP shift length was 24 hours, followed by 12-,
10-, and 8-hour shifts, respectively
No
data exist for optimal NNP shift length
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Shift Length and Safety
ACGME Decreased resident duty hours in 2003 and again in
2011
IOM published nursing recommendations, guidelines for patient
safety in 2004
Landrigan and colleagues(2004) and Lockley and
colleagues (2004)
Reduced incidences of attentional failures and serious
medical errors among interns working shorter shift lengths
compared with those interns working a traditional schedule with
extended
shift lengths.
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Impact on Shift Length and Safety
Johnson, 2011:
Residents who worked more than 24 hours had a 16%
higher risk of having a motor vehicle accident post-call.
Buus-Frank, 2005; Lockley et al., 2007;
LoSasso,2011:
Task performance, after approximately 17 hours of
wakefulness, is comparable to that seen in people with
blood alcohol levels of 0.05 or who are under the influence
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No Differences?
• Studies performed after the decrease in ACGME
hours:
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No evidence of prolonged hospital stays
No changes in mortality, morbidities
No differences in hospital readmission rates
No changes in failure to rescue
AMS who worked 24-hour shifts had little sleep debt, which
was attributed to their ability to nap while on duty
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Differences Detected
• Nursing Research findings:
– Increased nursing errors when working longer than 12.5
hours
– Relationship between nurse hours worked and patient
mortality
– Relationship between nurse hours worked, sleep duration
and drowsy driving
• Fatigue Research:
– Delayed processing of information, diminished memory
– Delayed reaction time, impaired efficiency
– Lapses in vigilance, inappropriate responses
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Position Papers
• Resident Duty Hours: Enhancing Sleep, Supervision,
and Safety (IOM, 2008):
Factors that increase risk of harm to patients:
-prolonged wakefulness
-shifts longer than 16 consecutive hours
-variability of shifts
-volume and acuity of patient load
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Position Papers
• The Joint Commission Sentinel Event Alert, December
2011:
– Acknowledge the research to date linking extended-duration
worked shifts, fatigue, and impaired performance and safety.
• American Nurses Association 2006:
– recommend shift length for nurses of no more than 12 hours
in a 24-hour period or 60 hours in a 7-day period
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State Law
• New York State Office of the Professions
http://www.nysna.org/practice/mot/intro.htm
– Nurses who voluntarily work more than 16 hours must be
able to demonstrate competence to fulfill professional duties.
– Working beyond 16 hours will be considered as a factor in
determining willful disregard for patient safety and could
result in charges of unprofessional conduct
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NANN Recommendations: Education
• Awareness that fatigue may result in altered clinical
performance, increased potential for errors, which may
impact safety
• Recognize signs of fatigue and be willing to institute
appropriate interventions
• Educational programs
– dangers of fatigue, the causes of sleepiness on the job,
importance of sleep, proper sleep hygiene
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Recommendations: Fatigue Management
• Fatigue-related risks should be alleviated by researchbased strategies:
– Good sleep habits and routines on non/working days and
nights
– To avoid chronic sleep deprivation (8 hours/day)
– Disruption of the circadian rhythm should be reduced
– Sleep in the afternoon before working overnight
– NNPs who are more than 40 years of age should be aware
that they are at increased risk
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Recommendations: Fatigue Management
• Opportunities for rest should be incorporated:
– Strategic naps of 10–60 minutes
• Use caffeine cautiously
• NNPs should assume personal responsibility:
– Avoid excessive fatigue whenever possible
– Use fatigue-mitigating strategies.
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Recommendations: Systems Management
• NNPs, Employers and Institutions should collaborate
to design systems to prevent errors associated with
fatigue.
• Optimize scheduling patterns:
- Maximum shift length of 24 hours regardless of work setting
and patient acuity
- Develop a relief-call system to provide coverage for NNPs
who feel impaired by fatigue
- Provision for a period of protected sleep time following 16
consecutive hours of working.
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Recommendations: Systems Management
• Team-based care models
– Appropriate workload distribution
– Use of information and documentation systems.
• Employers and institutions should educate all
careproviders:
– The responsibility to be adequately rested and fit to deliver
optimal patientcare
– The effects of fatigue and sleep deprivation
– Strategies to mitigate fatigue and maintain alertness
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NANN Recommendations
• Maximum shift length should be 24 hours,
regardless of work setting and patient acuity
• A period of protected sleep time should be
provided following 16 consecutive hours of
working
• The maximum number of working hours per
week should be 60 hours
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In Summary
• The need for neonatal intensive/special care continues
• Neonatal Healthcare providers are greatly needed
• IOM Statement: recommendations to enhance nursing
contribution to healthcare
• APRN Consensus statement: align states in same licensure,
accreditation, certification and education standards for APRNsto enhance access for patients
• The demand for NNPs continues to outpace supply
• The role of the NNP is valued, variable and complex
• Standards, policies and recommendations : address
safety/quality, workload, fatigue, precepting/mentoring
challenges for NNPs
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Erin’s Recommendations
• Implementation of the APRN Consensus Model:
– Know what state your State is in
– Legislative advocacy- get involved!!
• Development of Collaborative Practice Models
– Engage in interprofessional collaborative practice,education
• Enhance visibility of NNPs
– Evidence Based Care
– Articulate the role and contribution of the NNP to outcomes
– Publish! Present!
– Consider the DNP
– Grow more NNPs- mentor RNs and junior NNPs, precept
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Erin’s Recommendations
• Establish safe & appropriate workloads and work hours
– Review, consider the workforce position paper, fatigue paper
– Personal accountability
– Establish quality metrics and benchmark your practice
• Increase knowledge of billing practices
– Educate yourself
– Advocate for billing and reimbursement at your institution
• Enjoy your profession
– Daily meaningful work
– Life long impact
– Pass it on
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References
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APRN Consensus Work Group and the National Council of state Boards of Nursing APRN
Advisory Committee. Consensus Model for APRN Regulation: Licensure, Accreditation,
Certification and Education. APRN Joint Dialogue Group Report July 7, 2008. Retrieved 9/26/12
from www.ncsbn.org.
Committee on Fetus and Newborn. Advanced Practice in Neonatal Nursing. Pediatrics 2003;
111(6): 1453-1454.
Committee on Fetus and Newborn. Advanced Practice in Neonatal Nursing. Pediatrics 2009;
123 (6): 1606-1607.
Freed G, Dunham K, Lamarand C, Martyn K and the AAP Researc h Advisory Committee.
Neonatal Nurse Practitioners: Distribution, Roles and Scope of Practice. Pediatrics 2010; 126
(5): 856-860
Freed G, Dunham L, Moran L, and Spera L. Resident Work Hour Changes in Children’s
Hospitals: Impact on Staffing Patterns and Workforce Needs. Pediatrics 2012; 130 (4): 700-704
Fry, M. Literature Review of the Impact of Nurse Practitioners in Critical Care Services. Nursing
in Critical Care 2011; 16(2): 58-66.
IOM Report: The Future of Nursing: Leading Change, Advancing Health. 2010
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References
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Lerman S, Eskin E, Flower D, George E, Gerson B, Hartenbaum M, Hursh S, Morre-Ede M.
Fatigue Risk Management in the Workplace. JOEM, Feb 2012; 54(2): 231-258.
National Association of Neonatal Nurse Practitioners (2012). The Impact of Advanced Practice
Nurses’ Shift Length and Fatigue on Patient Safety. Retrieved 9/26/12 from www.nann.org .
National Association of Neonatal Nurse Practitioners (2012). Neonatal Nurse Practitioner
Workforce. Retreived 9/26/12 from www.nann.org
National Association of Neonatal Nurse Practitioners (2009). Requirements for Advanced
Neonatal Nursing Practice in Neonatal Intensive Care Units. Retrieved 9/26/12 from
www.nann.org.
National Association of Neonatal Nurse Practitioners (2010). Standard for Maintaining the
Competence of Neonatal Nurse Practitioners. Retrieved 9/26/12 from www.nann.org
Newhouse R, Stanik-Hutt J, White K, Johantgen M, Bass E, Zangaro G, Wilson R, Fountain L,
Steinwachs D, Heindel L, Weiner J. Advanced Practice Nurse Outcomes 1990–2008: A
Systematic Review. Nurs Econ. 2011;29(5):230-250.
Timoney P, Sansoucie D. Neonatal Nurse Practitioner Workforce Survey Executive Summary.
Advances in Neonatal Care 2012; 12 (3): 176-178.
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Questions
• Erin.Keels@Nationwidechildrens.org
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