the nnp workforce

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The NNP Workforce

Erin L. Keels MS, APRN, NNP-BCNNP Program Manager

Nationwide Children’s HospitalColumbus, 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• 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• Supply vs Demand issues for NNP

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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 52,000 by 2025

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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-of-Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf

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

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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):

– Planned to hire more hospitalists; PAs; hire more NNPs.

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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

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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 Modelhttps://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?• 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

• Increase knowledge of billing practices

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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 CareNational Organization of Nurse Practitioner Faculty

Competencies (2012) Scientific Foundation Leadership Quality Practice Inquiry Technology and Information LiteracyPolicy Health Delivery SystemEthics 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 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

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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 basisTake 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 any privilege.

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Examples of Evidence– Delivery logs– Procedure logs– Consult logs – Prescriptive

practice audits– Code review– Chart reviews

-Documentation reviewsDelivery roomSedationProcedures

-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 CaseloadGiven 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• 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 Modulehttp://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

Case Scenarios in Precepting

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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 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

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Shift Length and SafetyACGME 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: – 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 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

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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 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

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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• 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• 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