Development and evolution of neonatal nursing specialty care

Neonatal Nurse Practitioner

Historical Background. Neonatal refers to the first six weeks after birth (Jones 2004, Nursing 2000). Neonatology or neonatal care is, thus, the medical specialty in taking care of newborns, sick and premature babies. Neonatal nurses specialize in helping these babies survive and successfully live through the first 28 days of life. This kind of care requires the artful combination of high-tech and "high-touch" skills from these nurses. It has been available in specialized nurseries and intensive care units for infants since the 60s and has been evolving. It will be recalled that the late U.S. President John F. Kennedy's son, Patrick Bouvier Kennedy, was born prematurely and underdeveloped in 1963. If the current level of neonatal were available at that time, the baby should have survived. Modern neonatal care enables prematurely born infants with as little as 22 or 23 weeks out of the normal 40 to survive (Jones, Nursing). The reported sudden death or relapse of an infant in1978 drew heightened attention to the coping needs of parents as significant stressors. This and other stressors, such as conflict about life and death, emphasized the involvement of neonatal nurses in the care of critically ill or dying infants (Engler 2004). Technological advances account for the increased capability of neonatal care to save the lives of premature infants. Statistics revealed that there are roughly 40,000 low birth weight infants born yearly in the U.S. Typical neonatal intensive care units or NICUs no longer consider most of these infants critically ill and beyond help. Most of them are doing well in most of these NICUs, the rest of these babies treated for hyperbilirunemia, a condition leading to jaundice, or for infections or recovering from surgery (Jones 2004).

The need for nurses to specialize on neonatal care in the 70s created that specialty, which combined high technology and high touch in order to help problem infants to survive (Jones 2004). Under the regionalization plan in the 80s, premature or very ill newborns would be transferred to the nearest center for this kind of care. This transport included the assessment of the infant's condition, stabilization, and the provision of continuous high-level care. The neonatal nurse was an integral member of the transport team and the role of the transport nurse evolved from it (Jones).

A neonatal staff nurse works at a level I, II or III nursery (Jones 2004). Level I nursery is for healthy newborns. Mothers and their babies at present often share the same room because they stay only briefly in hospitals. Level II nursery is an intermediate or special care nursery for premature or ill babies. These babies may need supplemental oxygen, intravenous treatment, specialized feedings, or more time to mature before they are discharged from the hospital. And Level III is a neonatal intensive care unit or NICU for newborns in the first six weeks of life who cannot be treated at either Level I or II nursery. Babies at the NICU may be too small for their age, premature, or ill but full-term infants who need high-technology care. This care may require ventilators, special equipment, incubators, or surgery. NICUs are generally found in large general hospitals or in specialized children's hospitals. Neonatal nurse practitioners directly provide that care needed by these infants (Jones).

Components of the Neonatal Nurse Practitioner

These role components in a typical hospital include practice, educator, consultancy and role modeling through professional growth and development (Creech 2005). The neonatal nurse practitioner or NNP extends direct neonatal patient care, works with six neonatalogists, attends all in-house high-risk deliveries, and provides resuscitation and stabilization management of all high-risk neonatal transports. She uses the case management model of care in her practice, manages a certain case load average on a monthly basis, manages the tiny baby population, works with advanced technology, takes charge of these special infants from admission to discharge, collaborates with the attending physician in implementing the plan o care, performs different invasive procedures, participates in family discussions, focuses on family communication and coordination, maintains an internal neonatal database, provides orientation and formal educational programs on neonatal service, and participates in fund-generating fund projects or activities (Creech).

Research Findings on the Development of the Role of NPNs recent study on the perceptions of NPNs and other nurses managing critically ill or dying infants in NICUs showed that they were comfortable with their role and involvement with the infants' family in this difficult time (Engler 2004). These NPNs perceived and placed greater weight on the family's need of them than the expectation of their peers or the administrative personnel. Those who spent more years at NICUs expressed greater capability in handling the situation, although most of them had no adequate training or preparation in bereavement or end-of-life care. Most of the respondents considered caring for the dying infant, the actual death, and cultural differences as influential or determining factors in their involvement with the infant's family. The findings, therefore, emphasized the importance of providing education and training to these nurses on bereavement or end-of-life care and cultural competence in nursing curricula (Engler).

Parents of critically ill or dying infants needed and wanted compassionate support from their infants' caregiver during very painful or stressful time (Engler 2004). The respondents filled that need by allowing the family members to hold the dying infant; by participating in grief conferences with the family and other caregivers; and by sitting and listening to family members' outpour of grief. This time of deep grief was also stressful for the NNP. She may need to discuss difficult topics, like autopsy and organ donation, with the family. The NNP at Level 3 NICU was more comfortable caring for critically ill and/or dying infants and their families than those without the policy or experience. And language or cultural barrier also significantly affected the level of the NNP's involvement with the patient's family. She needed to learn their language to explain how to use a certain device or equipment, how the infant looked like, and what her name was. Over and above, providing this care was done on a daily basis as something both necessary and desirable. This act of giving of the self was what gave the family a voice in its infant's care and where the NNP asserted great impact (Engler).

Professional Organization of NNPs

The National Organization of Neonatal Nurses or NANN is the organization of NNPs and the professional voice that shapes their practice (2006). Its vision is to improve the lives of all newborns, infants, and their families through excellence in neonatal nursing practice, education, research and professional development. It is guided by a Code of Ethics in making this contribution. Its fundamental principles bind members to recognize the worth, dignity and rights of patients and their family; use knowledge and skills for the advancement of human welfare and respect for individual differences; assume their primary responsibility towards the patient's well-being; recognize family autonomy and its right to accurate, complete and understandable information for decision-making; respect the patient's rights to privacy and confidentiality; maintain professional integrity in resolving conflicts; serve with competency and accountability; and assume responsibility for their own professional advancement (NNAN).

Impact of Health Promotion and Disease Prevention on the Role of NNPs

Technological advances have been immensely enabling. Through them, healthcare professionals have been able to offer new treatment alternatives in addition or to supplement traditional ones (Kopala 2004). These technologies and wonder medicines have saved the lives of tiny babies and extended the lives of people with chronic illnesses. They have reduced prolonging life or postponing death to an option. Increased genetic and reproductive alternatives have also become available. Health care costs are, however, high and some resources are scarce. As a result, ethical issues and conflicts develop. Patients, their families and the health care community tend to have divergent views. They likewise often have conflicting beliefs on health and illness and views on what is right or wrong. The nurse's experience of ethical dilemmas and moral distress are proportionate to of the patient and/or the family. The nurse, the patient or surrogate decision-maker and family struggle to discover what can be done to prevent, improve or cure a particular medical condition according to a common belief of what "ought" to be. Supports can come from sources, such as ethics consultants and committees, nurse ethicists, pastoral care providers and institutional review boards. As a consequence, the Joint Commission for Accreditation of Healthcare Organizations requires agencies seeking accreditation to come up with a mechanism to address ethical issues in patient care of these kinds. Ethics committees and ethics consultants fulfill this requirement. Institutional or medical ethics committees in many hospitals have been educating, providing case consultations, and making recommendations since the 80s. Many such committees have been involved in policy development, such as through a nurse ethicist or nursing ethics committee assisting practitioners in handling these ethical issues. Nursing and medical schools have also recognized the importance of knowledge and skills for future practitioners and incorporated the introduction and development of these knowledge and skills in their curricula (Kopala).

Technological advances in the last decade have substantially decreased neonatal mortality rate, yet 19,000 newborns continue to die in the U.S. each year (Engler 2004). The registered or advanced practice neonatal nurse practitioner is often involved with the patient's family decisions in difficult or end-of-life times, such as withdrawing mechanical ventilation and the likelihood of the infant's death. Her support is most crucial at times like these. She can and should take advantage of the opportunity to form a relationship of trust with the family, which is vital to the optimal care she provides. Central to this care is her recognition of the importance of the loss of the infant. From this awareness, she can develop or initiate additional interventions in this time of grief, such as organized telephone follow-ups and forming support groups for the grieving family (Engler).

Schools or institutions establish their own requirements for neonatal nurse practitioners (Jones 2004). Most of them assess the nurse's ability to administer medications, do math calculations, start and maintain intravenous lines, conduct cardiopulmonary resuscitation, and perform corollary skills. These skills include suctioning, gavage feedings, and ventilator care. Some hospitals or medical centers hire NNPs after graduation from an accredited school and after passing the state board of nursing exams for licensure. The type and length of nursing experience also vary from one institution to another. In the current shortage of NNPs, the scarcity of qualified nurses is a deciding factor to most hospitals and medical centers. For their part, individual states or certifying bodies impose continuing education requirements on NNPs. There are no schools actually specializing in neonatal nursing. A nurse who aspires to be an NNP must obtain a master's degree in neonatal nursing, but the most common way is to work at any of the three nursery levels. A Nursing graduate should first acquire experience as a registered nurse in a NICU and then go to graduate school to become an NNP or clinical nurse specialist in order to qualify to work as an NNP (Jones).

The current shortage in nurses virtually insures nursing applicants of jobs in neonatal nursing (Jones 2004). The general downsizing conducted a few years ago reduced the volume of nursing pursing advanced practice education. This drove aspirants to positions in neonatal nursing. The average NNPs is also middle-aged and, thus, likely to move to less stressful nursing areas and positions. Most nurse practitioners with no experience receive a starting annual salary of between $30,000 and $40,000. Experienced NNPs receive higher salaries. A full-time nurse receives a percentage of health care benefits remitted by her employer. She gets two weeks vacation, a life insurance, a retirement plan, and tuition reimbursements for continuing education. An NNP can also aspire for advancement. Most hospitals offer more employment opportunities to NNPs with a master's or doctoral education. An NNP or clinical nurse specialist can expect higher job availability, responsibility and compensation. High-risk clinics for neonatal intensive care or home follow-up care also employ NNPs (Jones).

With almost 40,000 low-birth-weight babies born in the U.S. every year, there is clearly a growing market for NNPs (Jones 2004). The Workforce Report of the American Nurses Association and the Association of Nurse Executives in 1998 projected the shortage of acute care neonatal nurses to continue into the next decade. Neonatal nurse practitioners are privileged to work with newborns and experience the marvel of birth each day. It may not be as pleasant for NNPs working at NICUs because of occasional deaths of seriously ill or premature infants. But, on the whole, neonatal nursing is said to be one of the most rewarding nursing specialties available to qualified and willing nurses today (Jones).