3ObjectivesDescribe current legislative and policy recommendations impacting the practice of the NNPDiscuss the current professional recommendations impacting the practice of the NNPList at least three items to consider for improving his or her professional practice
4We’ve Come A Long Way, Baby 1960: First NICU1975: Neonatology --Pediatric Subspecialty1970s: NNP role developed1970s- proliferation of certification programss: increase in utilization of NNPs1983: NCC offers NNP Certification Exams: Studies: Care equivalent to/exceeds medical resident1984 NANN founded
51990s: 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 UnitsStandard for Maintaining the Competence of Neonatal Nurse PractitionersThe Doctor of Nursing Practice DegreeImpact of FatigueNNP Workforce2011: 4725 certified NNPs in USSupply vs Demand issues for NNP
6Patient Protection and Affordable Care Act (ACA): http://www “Obamacare”Signed into law 2010GoalsDecrease number of uninsured AmericansReduce overall cost of healthcareApproximately 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
7Patient Protection and Affordable Care Act (ACA): - State Based Insurance ExchangesMedicaid eligibility, enrollment and state budgets-State Practice LawsNPA revised, full scope of APRN practicePushback expectedTruth in AdvertisingNeutral provider languageWho can be called DOCTOR?Patient Safety and Public HealthTransparency, Access
8The Future of Nursing Institute of Medicine Recommendations (2010) 1. Remove scope of practice barriers2. Expand opportunities for nurses to lead collaborative improvement efforts3. Implement nurse residency programs4. Increase the number of nurses with a baccalaureate degree to 80% by 20205. Double the number of nurses with a doctorate by 20206. Ensure that nurses engage in life long learning7. Prepare and enable nurses to lead change and advance health8. Build an infrastructure for the collection and analysis of interprofessional health care workforce data
9Other Factors March of Dimes: Medical House Staff Rates of prematurity in the United States continue to outpace other countriesMedical House StaffDecreased 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
10NNP Shortage Contributing Factors: Decreased enrollment in NNP programsLoss of workers to retirement and decreased hoursNNP programs closingPoor/limited access to preceptorsFinancial burden of higher education and the struggle to work while attending schoolReasons RNs may not want to pursue NNP role:WorkloadSalaryWork schedule
11Our Challenge Establish/maintain adequate numbers of NNPs Recruitment, retentionEnsure competency, quality and safetyEducation, certification, licensure, OPPEContribute to body of knowledge and researchProfessional roleArticulate contribution and importance of roleSustainability of role, billing/reimbursement
12The 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
13The APRN Consensus Work Group National Model of APRN Regulation:Standardizes foundations of licensure, accreditation, certification, and educationsEstablishes independent practitioner roleAim for full implementation 2015Improve state to state reciprocity and patient accessEnsure quality and safety of APRN practiceProvide guidance for those involved with APRN education, licensure, accreditation, certification, regulation and employers.
14APRN Consensus Model https://www.ncsbn.org/2276.htm
16L. A. C. E.LicensureStandardize foundations of licensure through state BONs:Require national certificationBan temporary licensesEnsure education and certification are congruent with licenseIndependent practitionersUtilize APRN advisory councilsGrandfather currently practicing APRNs
17L. A. C. E. Accreditation: Certification: Sets requirements for accreditation of education programsCertification:Sets requirements for national certification exams that are psychometrically and legally soundCertification must be congruent with educationCompetence assessed through professional organizations
18L. A.C. E. Education: Across the lifespan Graduate programs accredited nationallyGraduates prepared to sit for national certification
19Where is Your State? Go to the NCSBN website See where your State is with implementationContact your State Board of NursingGet involved
20NANN NNP Workforce Survey Report (2011) National Certification Corporation (NCC) database4725 certified NNPs in the US.679 (14%) NNPs responded to survey
21NNP Workforce Survey Results Wide and unbalanced geographical distribution of NNPs25% work 24 hour shifts, and two-thirds are not guaranteed downtime.The majority of respondents are very satisfied with their career.
22NNP Workforce Survey Results Lack of knowledge regarding billing proceduresThe supply of NNPs may not be distributed according to needStudies are needed to examine the demand for NNPs and the roles of other clinicians in the NICU
23NNP Workforce Survey Report Recommendations Implementation of the APRN Consensus ModelDevelopment of Collaborative Practice ModelsEnhance visibility of NNPsEstablish safe & appropriate workloads and work hoursIncrease knowledge of billing practices
24NANN NNP Workforce Position Paper (2012) http://www. nann PURPOSE:Define the NNP contribution to the neonatal workforce environmentPropose a framework and factors to consider in assessing workloadEVIDENCE:Institute of Medicine (IOM) report (2010)American Nurses Association Principals of Nurse Staffing (2012)ACGME Guidelines (2010)
25The Many Roles of the NNP Leadership roleTransformationalClinical CareEBP, Quality Improvement, Bench to BedsidePatient and FamilyDiverse Work SettingsCommunity/academic, urban/ruralInterprofessional CollaborationMultidisciplinary, multidepartmental
26The Many Roles of the NNP Educator: families, staff, peers, interdisciplinary teamPreceptor: student NNPs, new NNP staff, RN, other professionalsMentor: RN, NNP, Fellows, Resident, New Faculty, other professionalsAdvocate: patients/families, clinical and professional practice
27Safety 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
28Safety and Quality of Care National Association of Neonatal Nurse Practitioners NNP Competencies (2011)Management of PatientHealth/Illness StatusThe Nurse Practitioner-Patient RelationshipThe Teaching/Coaching FunctionProfessional RoleManaging and Negotiating Health Care Delivery SystemsMonitoring and Ensuring the Quality of Health Care PracticeCulturally Sensitive Care
292013 NANNP revising NNP education standards and competencies Improve alignment with NONPF and IOM statement
30Safety 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 basisTake 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
31Safety 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.
32Examples of Evidence Delivery logs Procedure logs Consult logs Prescriptive practice auditsCode reviewChart reviews-Documentation reviewsDelivery roomSedationProcedures-Adverse drug events-Serious safety events-Complaints/compliments-Hours worked
33Challenges Develop individual and group NNP-specific outcomes metrics Institution- specific, state, nationalNovice to expert continuum
34Billing and Reimbursement Many Do NOT billEducation and training neededNANN hopes to develop webinars and/orworkshops in the future
35NNP CaseloadGiven the multifaceted role, challenges and attributes of the NNP, what is a reasonable case load?? What evidence exists?
36ANA Principles of Staffing Level of Care, census, patient acuityProcedures performedWorked hours per patient dayContinuity of care, readmissions/deliveries/dischargesConsultations/transportsQuality of work environment/EBP/TechnologyCommunication and teamwork
37Additional Factors to Consider NNP Level of competence and experienceNovice to expertBody of evidence related to fatigue and impact on safety & qualityLevel of patient acuitySite specific workload issues
38NNP Workforce Paper Recommendations: Personal and professional accountability for mental acumen and physical fitness to manage flexible, acute situations for multiple neonatal patientsCaseloads:Consistent with level of acuity & NNP capabilityFlexible- taking into account additional NNP responsibilitiesMentoring, deliveries, procedures etc.
39NNP Workforce Paper Recommendations: Advanced Beginner6 patientsCompetent to Expert10 patients when activity is highProficient and Expert>10 when activity and acuity decreased
40NANNP 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
41The 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 shiftsMost common NNP shift length was 24 hours, followed by 12-, 10-, and 8-hour shifts, respectivelyNo data exist for optimal NNP shift length
42Shift Length and Safety ACGME Decreased resident duty hours in 2003 and again in 2011IOM published nursing recommendations, guidelines for patient safety in 2004Landrigan 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.
43Impact 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
44No Differences? Studies performed after the decrease in ACGME hours: No evidence of prolonged hospital staysNo changes in mortality, morbiditiesNo differences in hospital readmission ratesNo changes in failure to rescueAMS who worked 24-hour shifts had little sleep debt, which was attributed to their ability to nap while on duty
45Differences Detected Nursing Research findings: Fatigue Research: Increased nursing errors when working longer than 12.5 hoursRelationship between nurse hours worked and patient mortalityRelationship between nurse hours worked, sleep duration and drowsy drivingFatigue Research:Delayed processing of information, diminished memoryDelayed reaction time, impaired efficiencyLapses in vigilance, inappropriate responses
46Position 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
47Position PapersThe 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
48State 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
49NANN Recommendations: Education Awareness that fatigue may result in altered clinical performance, increased potential for errors, which may impact safetyRecognize signs of fatigue and be willing to institute appropriate interventionsEducational programsdangers of fatigue, the causes of sleepiness on the job, importance of sleep, proper sleep hygieneEducation 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.
50Recommendations: Fatigue Management Fatigue-related risks should be alleviated by research-based strategies:Good sleep habits and routines on non/working days and nightsTo avoid chronic sleep deprivation (8 hours/day)Disruption of the circadian rhythm should be reducedSleep in the afternoon before working overnightNNPs who are more than 40 years of age should be aware that they are at increased risk
51Recommendations: Fatigue Management Opportunities for rest should be incorporated:Strategic naps of 10–60 minutesUse caffeine cautiouslyNNPs should assume personal responsibility:Avoid excessive fatigue whenever possibleUse fatigue-mitigating strategies.
52Recommendations: 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.
53Recommendations: Systems Management Team-based care modelsAppropriate workload distributionUse of information and documentation systems.Employers and institutions should educate all careproviders:The responsibility to be adequately rested and fit to deliver optimal patientcareThe effects of fatigue and sleep deprivationStrategies to mitigate fatigue and maintain alertness
54NANN RecommendationsMaximum shift length should be 24 hours, regardless of work setting and patient acuityA period of protected sleep time should be provided following 16 consecutive hours of workingThe maximum number of working hours per week should be 60 hours
55In Summary The need for neonatal intensive/special care continues Neonatal Healthcare providers are greatly neededIOM Statement: recommendations to enhance nursing contribution to healthcareAPRN Consensus statement: align states in same licensure, accreditation, certification and education standards for APRNs- to enhance access for patientsThe demand for NNPs continues to outpace supplyThe role of the NNP is valued, variable and complexStandards, policies and recommendations : address safety/quality, workload, fatigue, precepting/mentoring challenges for NNPs
56Erin’s Recommendations Implementation of the APRN Consensus Model:Know what state your State is inLegislative advocacy- get involved!!Development of Collaborative Practice ModelsEngage in interprofessional collaborative practice,educationEnhance visibility of NNPsEvidence Based CareArticulate the role and contribution of the NNP to outcomesPublish! Present!Consider the DNPGrow more NNPs- mentor RNs and junior NNPs, precept
57Erin’s Recommendations Establish safe & appropriate workloads and work hoursReview, consider the workforce position paper, fatigue paperPersonal accountabilityEstablish quality metrics and benchmark your practiceIncrease knowledge of billing practicesEducate yourselfAdvocate for billing and reimbursement at your institutionEnjoy your professionDaily meaningful workLife long impactPass it on
58ReferencesAPRN 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 fromCommittee 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
59ReferencesLerman 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 fromNational Association of Neonatal Nurse Practitioners (2009). Requirements for Advanced Neonatal Nursing Practice in Neonatal Intensive Care Units. Retrieved 9/26/12 fromNational Association of Neonatal Nurse Practitioners (2010). Standard for Maintaining the Competence of Neonatal Nurse Practitioners. Retrieved 9/26/12 fromNewhouse 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):