1. Witt, Catherine L.

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This month as part of our review of the past 25 years of the National Association of Neonatal Nurses, Mary Ellen Honeyfield, MS, NNP-BC, looks at the neonatal nurse practitioner (NNP) role. Ms Honeyfield looks at the history of the NNP role and how it developed, and then spends some time on where we are now and what the future might hold.


A crystal ball might be helpful here, if only we had one. There are a number of issues facing NNPs in the future that cause us great anxiety, with the shortage of NNPs being of primary concern. The impact of the doctorate of nursing practice is as yet unknown.1,2 There is a lack of adequate numbers of NNPs graduating from NNP programs.3 There is difficulty in recruiting nurses to the NNP role.4 There are other providers being used in places that cannot obtain enough NNPs.3,5 Perhaps the most distressing issue is that despite the fact that the demand for NNPs continues to increase and far outpace the supply, we find ourselves repeatedly having to justify our service and our cost to nursing and hospital administrations or to physician employers. We have to defend our role to legislators and to physician groups who would like to regulate or limit the practice of nurse practitioners and other advanced practice nurses. And, if you have ever tried to explain the role to families, including your own, you know how difficult it can be to describe what we do on any given day.


In the face of these issues, it is easy to become discouraged and pessimistic. Yet, I believe there are answers to these problems and that the NNP role can continue to grow and thrive. Neonatal nurse practitioners offer value to nursing and to the units they work in that has not been duplicated by any other group.


It has been repeatedly demonstrated that NNPs provide safe, cost-effective care to neonatal patients.5,6 As the number of residents decreases in academic centers, NNPs have increased their workload and the number of babies cared for.7 In addition, community hospitals have recognized the value of having NNPs available as first responders to the delivery room, the nursery, and their emergency services. Neonatal nurse practitioners have cared for increasing numbers of babies with no documentation of untoward outcomes.


In places with inadequate numbers of NNPs, other providers such as pediatricians, hospitalists, physician's assistants, and nurse practitioners from other specialties such as pediatrics or acute care have been used to fill the gaps. There remains a lack of research to show that physician's assistants or nurse practitioners from other specialties provide the same level of care as an NNP. This substitution of other providers also assumes that the only role of the NNP is daily patient management. In most hospitals, NNPs do many things in addition to patient care. Neonatal nurse practitioners teach the neonatal resuscitation program (NRP). We teach the STABLE program. We go on outreach and teach classes for new graduates in nursing orientation. We conduct research, go on transport, mentor new nurses, and participate in quality improvement projects. We serve as preceptors for NNP students. We teach and supervise residents. We teach certification review courses. We participate in our national association, we write articles for publication, and we teach in graduate programs. We do much of this extra work in addition to clinical responsibilities. Our staff nurse colleagues do many of these things as well, but can the same be said for the physician's assistants and hospitalists that are working in place of NNPs in some institutions?


A colleague of mine was told recently that NNPs make too much money and that the hospital could hire a physician in her place for the same salary. That may be true, but with all due respect for my physician colleagues, I don't think the hospital would get the same expanded level of service to nursing that the NNP can provide. The bottom line is that NNPs are nurses first and foremost. We have an affiliation with and an obligation to nursing that other disciplines do not. For many of us, the opportunity to participate in all these aspects of nursing-patient care, education, research, and service-is what we find most fulfilling about our roles. Our job now is to market this value-not only to those paying our salary, but also to those we hope to recruit to fill these workplace shortages.


How do we do this? First, we have to make sure we get credit for the work that we do. Often we toil away at teaching NRP, participating in committees, or doing research, and no one really pays attention. We have to keep educating administrators and others about the time we spend and how we improve patient care and staff education and turnover.


Second, we cannot make our job look so miserable that no one wants to do it and no one thinks we are fun to be around. It is easy to become a martyr and overdo it. We have to care for ourselves if we are going to take care of anyone else. A pilot study looking at NICU staff nurses and at their desire to become NNPs indicated that the majority of nurses are not interested in the NNP role.4 As the author points out, we cannot correct the shortage of NNPs if the role continues to be perceived in a negative light. This also requires that we be diligent in policing ourselves and our relationships with our other team members.


Third, we must continue to work on how we educate new NNPs and how we help them transition to the role of the NNP. We are growing and mentoring nurses who will take on a very multifaceted role, and that requires time, patience, and empathy. Nurses who were experts at bedside care find that reverting to the novice role is difficult, and lots of attention and support are required to help them make that transition.8


As Ms Honeyfield points out in her article, the issue of supply and demand will continue to be with us for a while. It takes time and money to educate new NNPs, and it appears likely that supply will not keep up with demand for a while. However, we cannot allow the supply issue to make us obsolete. We have to continue to be involved in issues of education and competency of providers, regulation of practice, and recruitment of new students. We have to continue to demonstrate our value to nursing and to the families we serve. We provide a service that cannot be duplicated by any other group. Now we just have to make sure everybody knows it.




1. Bellflower B, Carter MA. Primer on the practice doctorate for neonatal nurse practitioners. Adv Neonatal Care. 2006;6:323-332. [Context Link]


2. Cusson RM, Buss-Frank ME, Flanagan VA, Miller S, Zukowsky Z, Rasmussen L. A survey of the current neonatal nurse practitioner workforce. J Perinatol. 2008;28:830-836. [Context Link]


3. Cusson RM. State of the science of NNP education 2008. Adv Neonatal Care. 2008;8:255. [Context Link]


4. Rasmussen LB, Vargo LE, Reavey DA, Hunter KS. Pilot survey of NICU nurses' interest in the neonatal nurse practitioner role. Adv Neonatal Care. 2005;5:28-38. [Context Link]


5 Bissinger RL, Allred CA, Arford PH, Bellig LL. A cost-effectiveness analysis of neonatal nurse practitioners. Nurs Econ. 1997;15:92-99. [Context Link]


6. Karlowicz MG, McMurray JL. Comparison of neonatal nurse practitioners' and pediatric residents' care of extremely low-birth-weight infants. Arch Pediatr Adolesc Med. 2000;154:1123-1126. [Context Link]


7. Juretschke LJ. New standards for resident duty hours and the potential impact on the neonatal nurse practitioner role. Adv Neonatal Care. 2003;3:159-161. [Context Link]


8. Cusson RM, Viggiano NM. Transition to the neonatal nurse practitioner role: making the change from the side to the head of the bed. Neonatal Netw. 2002;21(2):21-28. [Context Link]