FANNP 25TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW

GS1 History of the NNP Role Patricia J. Johnson, DNP, MPH, NNP Neonatal Nurse Practitioner Coordinator Maricopa Integrated Health System, Phoenix, AZ The speaker has signed a disclosure form and indicated she has no significant financial interest or relationship with the companies or the manufacturer(s) of any commercial product and/or service that will be discussed as part of this presentation.

Session Summary This presentation will provide a review of the evolution of the NNP role from the 1970s to present. Where did we come from, why and how and where are we prepared to go?

Session Objectives Upon completion of this presentation, the participant will be able to:  identify social and professional stimuli leading to development of the neonatal advance practice nurse role;  recognize barriers to neonatal advance practice nursing over the past four decades;  list the patient care benefits of NNP practice introduction into neonatal care;  identify the issues impacting NNP future.

References American Academy of Pediatrics Historical Archives Advisory Committee (2001). Committee Report: American Pediatrics: Milestones at the millennium. Pediatrics, 107(6): 1482-1491. Cusson, R.M. & Viggiano, N.M. (2002). Transition to the neonatal nurse practitioner role: Making the change from the side to the head of the bed. Neonatal Network, 21(2): 21-28. Farah, A.L., Bieda, A. & Shiao, S.P.K. (1996). The History of the neonatal nurse practitioner in the United States. Neonatal Network, 15(5): 11-21. Federal Trade Commission (2014). Competition and regulation of advanced practice nurses. Available from http://www.nacns.org/docs/FTC140307aprnpolicy.pdf Honeyfield, M.E. (2009). Neonatal nurse practitioners: Past, present, and future. Advances in Neonatal Care, 9(3): 125-128 Institute of Medicine (2001 Mar). Crossing the quality chasm: A new health system for the 21st Century. Washington, DC: The National Academies Press. Institute of Medicine (2011 Jan). Future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Johnson, P.J. (2002). History of the neonatal nurse practitioner: Reflections from under the looking glass. Neonatal Network, 21(5): 51-59.

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FANNP 25TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW

NANN (2014). The future of neonatal advanced practice registered nurse practice. Available from http://www.nannp.org/uploads/files/Future_of_APRNs_white_paper_FINAL.pdf

Session Outline See presentation handout on the following pages.

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FANNP 25TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW

Ground Breaking Changes  Open the Door for NNP

History of the  Neonatal Nurse Practitioner Patricia Johnson, DNP, RN, NNP Presented for FANNP October 14, 2014

• 1920s: Hospitals developed facilities for care of  premature newborns – Nursing regarded as primary caretaker for children • 1940s: Mortality rate of premature recognized as  major public health issue  • 1950s: Improved survival of preterm infants with  technical advancements including incubator • 1960s: Feminist movement took off with nurses  identifying with the feminist cause

Ground Breaking Changes  Open the Door for NNP • 1960s: Decade of social awareness – Baby boomers enter child bearing age – Medicare and Medicaid enacted for vulnerable  – 1962 NICHD created to address disparities in  health outcomes and health care of mothers and  children • Maternal mortality 83 to 37/100,000 LB • Infant mortality 30/1000 LB and neonatal 25/1000 LB • 68% preterm with ND handicaps as LBW rising

Ground Breaking Changes  Open the Door for NNP • 1961: Critical nursing shortage • 1964: Nurse Training Act provided millions of $ for  loans,  grants and fund advanced training of nurses • 1965: End of Vietnam War brought skilled medics  1965: End of Vietnam War brought skilled medics home  – Start of PA program in Durham, NC

• 1965: Birth of NP movement  – PNP program in CO

• 1964 Amendment to Hill Burton Act of 1946, funded  construction and upgrade facilities

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Ground Breaking Changes  Open the Door for NNP CNA  (1887) and CNM (1925) introduced in US 1965 PNP founded by Loretta Ford U of CO 1970 FNP founded by Mary Breckinridge 970 FNP founded by Mary reckinridge 1964 Nurse Training Act funding NP education  by mid 1970s • 1970 NICU contributing to reduced NB  mortality

• • • •

Ground Breaking Changes  Open the Door for NNP • 1974: Pediatric residency changed from 1 + 2 yr   to 3 full years in Pediatrics – Included 9 months in NICU to 3 yrs PEDIATRICS – Pediatric Residency Review Board recommended  Pediatric Residency Review Board recommended reduction of time in inpatient specialty services and  promoted increased time in general Pediatrics  & OP – Result was reduction in work force for patient  management in NICU

• 1975: American Board of Pediatrics developed  the Sub‐Specialty of NPM and 375 were boarded

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FANNP 25TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW

Ground Breaking Changes  Open the Door for NNP • • • •

1971‐73: Blue Ribbon Commission proposes ANP  1973: Johnson pilots the NNP/NNC role in UT 1974: Slovis and Commerci report use of NNP 1974: Several 4‐9 month CE NNP programs commence – CO CE program 1974 CO CE 1974 – AZ CE program 1974

• • • •

1975: Guidelines for Education NC in Neonatal published 1976: Johnson implements NNP team in St. Paul, MN Late 1970s more NNP programs commence 1982: NNCPS established to search for organizational home  for neonatal APNs

Ground Breaking Changes  Open the Door for NNP • • • • • • •

Early Barriers to NNP Role  Implementation • Inter‐professional isolation • Variable educational preparation – Mix of medicine, nursing content  – Hospital based, university based

• Problems with identity, authority & autonomy • Underutilization d l – – – – –

Educator roles Follow up clinic Transport nurses Procedure nurses Limited to level 1 and or Level 2 patients

• Title ambiguity  • Lack of organized nursing and medicine support • Distrust of non‐medical provider alternatives

2001:  IOM Crossing the Quality Chasm 2008:  Consensus Document (LACE) 2010:  Accountability Care Act (ACA) 2011:  IOM Future of Nursing’ 2013:  Governors Report 2014:  Federal Trade Commission Report 2014:  AAP Endorsement of NNP Scope

Neonatal APN Titles • • • • • • • • •

Neonatal Nurse Practitioner (NNP) Neonatal Nurse Clinician (NNC) Neonatal Critical Care Nurse Practitioner (NCCNP) M t Maternal Child Nurse Practitioner (MCNP) l Child N P titi (MCNP) Pediatric Nurse Practitioner (PNP) Pediatric Nurse Associate (PNA) Advanced Practice Registered Nurse (APRN) Clinical Nurse Specialist (CNS) Doctor in Nursing Practice (DNP or DrNP)

Early NNP Education

NNP Role Definition

• 4‐9 month CE program usually hospital based • Applicants with NICU experience • Most programs provided hospital based  Most programs provided hospital based “internship” • Moved to University based CE by 1980s • Received university credits (non‐matriculated)  by 1990 • Transitioned to Masters programs mid 1990

• 1989: NANN accepted the title of NNP • 1992: Reaffirmed position on NNP • Role Defined: Manages a caseload of neonatal patients with 

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consultation, collaboration, and general supervision from a  consultation collaboration and general supervision from a physician. Utilizing the extensive knowledge of pathophysiology,  pharmacology, and physiology, the NNP exercises independent  judgment in the assessment, diagnosis and initiation of certain  delegated medical processes and procedures. Additionally  involved in education, consultation and research at various levels. 

• Role definition adopted by the AAP CFN 1991‐ 1992

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FANNP 25TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW

Certification • 1983: First NAACOG Certification test for NNP • 1991: NAACOG Certification Corp became NCC – Required minimum education: 24 months (2000hr) of  NICU nursing practice or NCC NICU certification NICU nursing practice or NCC NICU certification,  completion of educational program (minimum 1  yr)with standard NNP curriculum per NCC leading to  certificate or graduate nursing degree. Program 1/3  didactic and 2/3 clinical

• 1995: NANN recommend graduate degree by  2000.

Acceptance Improved by Late 1990s • During 1996‐1999, the American Academy of Pediatrics  carried out a study of pediatric subspecialty education  and practice called the "Future of Pediatric Education  II." Some of the findings for neonatology are  summarized below: summarized below:  • Over one‐third of neonatologists practice in a medical  school setting, while over one fourth are in a specialty  group practice. Nearly two thirds of neonatologists  agree that the most efficient model for providing  clinical care is a neonatologist providing hands‐on  clinical care side‐by‐side with NNPs [neonatal nurse  practitioners].

Farah, Bieda, Shiao, 1996

NNP at Turn of 21st Century • Overcame history of variable regard • NNPs were found in most Level III and many Level  II nurseries • Considered essential for adequate coverage Considered essential for adequate coverage – Vacancies increased annually – Salaries began to increase • Supply and demand prevailed • More education programs • More educational support from hospitals – ? Indentured servitude? 

What is the NNP Profession Facing • • • • • •

Aging workforce Stagnate growth Smallest sub group of APRN Residual CE graduates Many MS graduates DNP graduates  – MS to DNP benefit from additional content – BSN to DNP have limited clinical preparation – NCC certified but challenges with privileging

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Progression to DNP • 2004 AACN recommend DNP • Programs lack uniformity & standardization  – – – –

Admission qualifications Clinical requirements q Limit mobility Lack of qualified faculty

• NCC provides certification of minimum  knowledge  • Hospitals translate NCC certification as  competence

Current Regard for NNPs • Professional midlevel alternative providers • Integral to neonatal healthcare team at all  levels of care • Interstate variability in scope of practice • Demonstrated credibility and continuity • DNP may confound multidisciplinary  acceptance • Major resistance from AMA and State  Legislatures

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FANNP 25TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW

NNP Successes • Important force in transforming EBP in NICU • Model for acute care APN • Leaders in transforming the culture in NICU – Evidenced‐based practice – Family centered care – Nurturing and compassionate approach to total  care for ELBW and critical newborns – Parenteral care experts

• Desired service element at all levels

Current Measures of Success • NNP left alone without Neonatologist • NNP allowed to admit without Neonatologist • NNP allowed to bill for services Elena Bosque Seattle, Washington

• Need to maintain and demonstrate: Patient  centered, timely, efficient, effective, essential  and safe  IOM, 2001

Future of NNP • Expectations of Pediatrician alternative failed • Movement to physician group vs. hospital  employment • Need for universal competence measure  df i l (value metrics) • Need for ongoing research to validate  credibility and continuity contribution

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