1. The NNP Workforce Erin L. Keels MS, APRN, NNP-BC NNP Program Manager
Nationwide Children’s Hospital
Columbus, Ohio

2. Disclosures
No conflict of interest

3. 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

4. We’ve Come A Long Way, Baby
1960: First NICU
1975: Neonatology --Pediatric Subspecialty
1970s: NNP role developed
1970s- proliferation of certification programs
s: increase in utilization of NNPs
1983: NCC offers NNP Certification Exam
s: Studies: Care equivalent to/exceeds medical resident
1984 NANN founded

5. 1990s: Certificate programs absorbed into graduate 2001: ANN founded
2003, 2009: Neonatal APRN role endorsed by AAP
: 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
Supply vs Demand issues for NNP

6. Patient Protection and Affordable Care Act (ACA): http://www
“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 52,000 by 2025

7. 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

8. The Future of Nursing Institute of Medicine Recommendations (2010)
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 interprofessional health care workforce data

9. Other Factors March of Dimes: Medical House Staff
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):
Planned to hire more hospitalists; PAs; hire more NNPs.
According to the March of Dimes, the rates of prematurity continue to outpace those of other countries. Additionally, Hospitals continue to establish or increase their neonatal beds

10. 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
Work schedule

11. 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

12. 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

13. 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.

14. APRN Consensus Model https://www.ncsbn.org/2276.htm

15. APRN Consensus Model Toolkit

16. 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

17. L. A. C. E. Accreditation: Certification:
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

18. L. A.C. E. Education: Across the lifespan
Graduate programs accredited nationally
Graduates prepared to sit for national certification

19. Where is Your State? Go to the NCSBN website
See where your State is with implementation
Contact your State Board of Nursing
Get involved

20. NANN NNP Workforce Survey Report (2011)
National Certification Corporation (NCC) database
4725 certified NNPs in the US.
679 (14%) NNPs responded to survey

21. 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.

22. 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

23. 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
Increase knowledge of billing practices

24. NANN NNP Workforce Position Paper (2012) http://www. nann
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)

25. 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

26. 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

27. 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

28. 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

29. 2013 NANNP revising NNP education standards and competencies
Improve alignment with NONPF and IOM statement

30. 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.
-Examples:
periodic chart review 
direct observation 
monitoring of diagnostic and treatment techniques 
discussion with other individuals involved in the care of each patient

31. 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 any privilege.

32. 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

33. Challenges Develop individual and group NNP-specific outcomes metrics
Institution- specific, state, national
Novice to expert continuum

34. Billing and Reimbursement
Many Do NOT bill
Education and training needed
NANN hopes to develop webinars and/or
workshops in the future

35. NNP Caseload
Given the multifaceted role, challenges and attributes of the NNP, what is a reasonable case load?? What evidence exists?

36. ANA Principles of Staffing
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

37. 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

38. 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.

39. 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

40. NANNP Preceptorship Module http://www. nann
Approaches to Teaching Adult Learners Role Transition Guidance for Preceptors Guidance for Learners Clinical Supervision in the Acute Care Setting Case Scenarios in Precepting

41. The Impact of Advanced Practice Nurses’ Shift Length and Fatigue on Patient Safety (2011)
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 24-hour 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

42. 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.
ACGME Responded to evidence in the literature suggesting a potential threat to patient safety and resident quality of life and health related to excessive duty hours.

43. 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

44. No Differences? Studies performed after the decrease in ACGME hours:
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

45. Differences Detected Nursing Research findings: Fatigue Research:
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

46. Position Papers -prolonged wakefulness
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

47. 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

48. State Law New York State Office of the Professions
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

49. 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
Education programs: should include the issues of sleep physiology and sleep inertia (grogginess upon awakening), personal and professional performance limitations, and identification of fatigue and fatigue mitigating strategies.

50. Recommendations: Fatigue Management
Fatigue-related risks should be alleviated by research-based 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

51. 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.

52. 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.

53. 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

54. 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

55. 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 APRNs- to 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

56. 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

57. 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

58. References
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, Retrieved 9/26/12 from
Committee on Fetus and Newborn. Advanced Practice in Neonatal Nursing. Pediatrics 2003; 111(6):
Committee on Fetus and Newborn. Advanced Practice in Neonatal Nursing. Pediatrics 2009; 123 (6):
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):
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):
Fry, M. Literature Review of the Impact of Nurse Practitioners in Critical Care Services. Nursing in Critical Care 2011; 16(2):
IOM Report: The Future of Nursing: Leading Change, Advancing Health. 2010

59. References
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):
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 .
National Association of Neonatal Nurse Practitioners (2012). Neonatal Nurse Practitioner Workforce. Retreived 9/26/12 from
National Association of Neonatal Nurse Practitioners (2009). Requirements for Advanced Neonatal Nursing Practice in Neonatal Intensive Care Units. Retrieved 9/26/12 from
National Association of Neonatal Nurse Practitioners (2010). Standard for Maintaining the Competence of Neonatal Nurse Practitioners. Retrieved 9/26/12 from
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):
Timoney P, Sansoucie D. Neonatal Nurse Practitioner Workforce Survey Executive Summary. Advances in Neonatal Care 2012; 12 (3):

60. Questions