TECHNICAL REPORT

Neonatal Provider WorkforceErin L. Keels, DNP, APRN-CNP, NNP-BC,a,b Jay P. Goldsmith, MD, FAAP,c COMMITTEE ON FETUS AND NEWBORN

abstractThis technical report reviews education, training, competency requirements,and scopes of practice of the different neonatal care providers who work tomeet the special needs of neonatal patients and their families in the NICU.Additionally, this report examines the current workforce issues of NICUproviders, offers suggestions for establishing and monitoring quality andsafety of care, and suggests potential solutions to the NICU provider workforceshortages now and in the future.

To meet the critical and complex health needs of preterm neonates andneonates who are ill in the NICU, collaborative teams of health careproviders work to render timely, safe, effective, efficient, and evidence-based care.1 Many NICU provider teams include neonatologists, advancedpractice registered nurses (APRNs), physician assistants (PAs), pediatrichospitalists, neonatal fellows, and pediatric residents.1 In collaboration,these providers work together to consistently provide high-quality carethroughout the neonatal hospitalization.

Training and licensure are different for the various NICU provider groups.Most APRNs and PAs working in NICUs have completed master’s ordoctoral degree programs that require the acquisition of certain cognitiveabilities and technical skills aimed at producing safe and effective patientcare.2,3 Neonatal nurse practitioners (NNPs) and pediatric nursepractitioners (PNPs) are registered nurses with advanced education andtraining to enable them to care for neonatal, infant, and pediatric patients,respectively, as APRNs.4 PAs are educated as medical generalists inprograms that include pediatric and adult medicine.5 After graduatingfrom a master’s- or doctoral-level academic program and achievingnational certification and state licensure, APRNs and PAs typicallycomplete medical staff credentialing and a period of orientation to theprovider role in the NICU on the basis of demonstrated skill sets andcompetencies. Pediatric hospitalists are physicians who have completeda graduate medical school program as well as a pediatric residencyprogram that requires proficiency and skills in all areas of pediatrics,including neonatal medicine.6 A minimum number of months in thenewborn nursery and NICU settings are required as part of any

aNational Association of Neonatal Nurses, Chicago, Illinois; bNationwideChildren’s Hospital, Columbus, Ohio; and cDepartment of Pediatrics,Tulane University, New Orleans, Louisiana

Technical reports from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, technical reports from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

On behalf of the Committee on Fetus and Newborn, Drs Keels andGoldsmith conducted a thorough literature review, synthesizedcurrently available information, authored and edited the manuscript,and approved the final manuscript as submitted.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

DOI: https://doi.org/10.1542/peds.2019-3147

Address correspondence to Erin L. Keels, DNP, APRN-CNP, NNP-BC.E-mail: Erin.keels@nationwidechildrens.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have nofinancial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated theyhave no potential conflicts of interest to disclose.

To cite: Keels EL, Goldsmith JP, AAP COMMITTEE ON FETUSAND NEWBORN. Neonatal Provider Workforce. Pediatrics.2019;144(6):e20193147

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Accreditation Council for GraduateMedical Education (ACGME)–certifiedpediatrics residency program.7 Aftercompletion of residency, pediatrichospitalists must maintain a medicallicense and medical staffcredentialing for their specific scopeof practice. Neonatal fellows arephysicians who have also completedgraduate medical school as well asa pediatric residency program andare currently completing advancedsubspecialty training in neonatology.8

Pediatric residents are physiciantrainees who have completedgraduate medical school but have notyet completed their pediatricresidency program.7 These physiciantrainees may have received differentamounts of training, experience, andtechnical instruction in neonatalintensive care.9

The continued revision of pediatricresident duty hours prescribed by theACGME has resulted in lessavailability of the pediatric residentworkforce to care for patients in theNICU.10,11 This trend has furtherreduced training time and skillacquisition of these trainees and hasshifted much of the work of providingcare in many NICUs onto otherproviders, such as pediatrichospitalists, NNPs, and PAs.11

Concurrently, there appears to bea growing national workforceshortage of NNPs and insufficientnumbers of PAs and pediatrichospitalists practicing in neonatalintensive care to fill the gap,challenging many neonatal programs’abilities to adequately staff theirNICUs with providers.2,11,12 Thischallenge has caused some programsto consider using various providers indifferent roles across NICU settings.11

Further guidance from nationalprofessional organizations and othergroups may be useful regarding theuse of these various provider types.

This technical report reviewseducation, training, competencyrequirements, and scopes of practiceof the different neonatal care

providers who work to meet thespecialized needs of neonatal patientsand their families in the NICU.Additionally, this report examines thecurrent workforce issues of the NICUproviders, offers suggestions forestablishing and monitoring qualityand safety of care, and suggestspotential solutions to the NICUprovider workforce shortages nowand in the future.

TEAM-BASED COLLABORATIVE CARE

In 2010, the Best Practices InnovationCollaborative of the Institute ofMedicine (IOM) Roundtable on Valueand Science-Driven Health Caredefined team-based, collaborativecare as the delivery of health servicesto individuals, families, and/orcommunities by at least 2 healthproviders who work collaborativelywith patients to accomplish sharedgoals and achieve coordinated, high-quality care.13 Collaboration, from theLatin term meaning “working” orlaboring together, requires effectiveleadership, skillful communication,and sharing of information in anenvironment in which help can besought and obtained freely andeasily.14 This often requires skills andpractice in crew resourcemanagement, performance review,communication, and simulation.

NICU provider team compositionvaries widely across the United Statesand, in addition to the neonatologist,may include pediatric hospitalists,NNPs, PNPs, PAs, neonatal fellows,and medical, APRN, and PA trainees.1

The knowledge base, scope ofpractice, and skill sets for each type ofprovider will vary on the basis offormal education, certification and/orlicensure, clinical experience, medicalstaff privileging, state practice laws,and job descriptions. However,a certain basic set of behavioralcompetencies, cognitive abilities, andtechnical skills is necessary for allneonatal providers to practice in thespecialized and high-risk setting of

the NICU. The ACGME providesdirection on the development ofcompetencies, skills, and abilities forpediatric residents and neonatalfellows,7,8 which is largely beyond thescope of this article. However, it maybe helpful to understand theeducational preparation,competencies, scope of practice, andworkforce issues of the pediatrichospitalists, APRNs, and PAs whowork in the NICU to develop sharedbasic competencies for all neonatalproviders.

Pediatric Physician Hospitalists

Pediatric hospitalists are physicianswhose primary professional focus isthe general medical care of pediatricpatients who are hospitalized.Pediatric hospitalist activities includepatient care, teaching, qualityimprovement, research, andleadership related to hospitalcare.15,16 Clinical responsibilities andpractice sites of pediatric hospitalistsvary significantly and may includegeneral inpatient pediatric care,emergency department care,perioperative surgical and medicalsubspecialty care, delivery roomservices, newborn nursery care, andNICU coverage.15,16 Somepediatricians pursue long-termcareers in hospital medicine in thehospitalist role and have gainedvaluable experience and clinicalexpertise in the field. Others may behired to work as a hospitalist fora discreet amount of time, duringwhich they can gain additionalclinical experience before enteringa general practice or a subspecialtyfellowship.

The Section on Hospital Medicine wasestablished within the AmericanAcademy of Pediatrics (AAP) in1998.6 Within the Section on HospitalMedicine is the Neonatal HospitalistsSubcommittee, which focuses on thecare of newborn infants who arehospitalized. Formal pediatrichospitalist fellowship trainingprograms are offered in growing

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numbers of academic centers acrossthe United States.17 The field ofpediatric hospital medicine (PHM)will be an American Board ofPediatrics (ABP)–certifiedsubspecialty starting in 2019.18

Some pediatric hospitalists workingin the NICU environment may begraduates of PHM fellowshipprograms and may have additionaltraining in the care of children whoare hospitalized. Other pediatriciansworking in the hospitalist role arepediatric residency graduates andwill have varying levels of NICUexperience, depending on theirtraining program and subsequentyears of clinical experience. The 6ACGME core competencies forresidents include patient care,medical knowledge, professionalism,interpersonal and communicationskills, practice-based learning andimprovement, and systems-basedlearning.19 The competencies areaimed at trainees in a particularspecialty (ie, pediatrics). Aftergraduation from a pediatric residencyprogram, successful boardcertification by the ABP validatesfoundational knowledge in pediatriccare.20 Individual state licensuregrants authority to practice asa physician, and behavioral andprocedural competencies for theneonatal and pediatric populationsare confirmed through organizationalcredentialing and periodic review.21

In 2010, core competencies forpediatric hospitalist programs weredeveloped in an effort to standardizeand improve inpatient trainingprograms.22 These core competenciesinclude common clinical diagnosesand conditions, core skills, specializedclinical services (including newborncare and delivery room management),and health care systems to supportand advance child health.22 Thesecore competencies are continuallybeing updated and revised. Inaddition, the Neonatal HospitalistSubcommittee of the AAP Section onHospital Medicine is helping to

develop and review goals andobjectives related to delivery roommanagement and common neonatalconditions for PHM fellowshipcurriculum as well as for the PHMsubspecialty board certificationexamination.18

As PHM programs, fellowships, andsubspecialty board certificationbecome more formally establishedand grow in popularity, there willlikely be an increasing workforce ofpediatric hospitalists in the future.Many pediatric hospitalists possessthe expertise necessary to care fornewborn infants who are hospitalizedand may become more commonlyused in the nursery and NICUsettings.

APRNs

APRNs are registered nurses whohave gained additional education,training, certification, and licensure topractice as providers.23 The 4 APRNroles are certified nurse practitioners(NPs), clinical nurse specialists,certified nurse midwives, andcertified registered nurseanesthetists.23 National certificationexaminations are required for each ofthese categories of advanced practicenursing within 1 of 6 population foci:adult-gerontology, family and/oracross the life span, pediatrics,psychiatric-mental health,neonatology, or women’s health. Inaddition, the populations of adult-gerontology and pediatrics includesseparate certifications in either acutecare or primary care.23 State-specificnurse practice acts regulate APRNlicensure, certification, and educationrequirements.23 To decreasevariability among states, theConsensus Model for APRNRegulation was introduced in 2008 tohelp define and standardize theserequirements.23 Although progresshas been noted, variation amongstates continues to exist, most notablyrelated to physician oversight ofpractice. Some states require formalagreements between the APRN and

physician(s) related to supervised orcollaborative practice, and otherstates have independent APRNpractices.23,24

Commonly, APRNs in neonatal careinclude the neonatal clinical nursespecialist to direct care, education,and continuous improvement inoutcomes for a population of patientsand the NNP to provide care toindividuals or populations ofpatients.25 In some settings, theprimary care–certified pediatricnurse practitioner (PC PNP) and/orthe acute care–certified pediatricnurse practitioner (AC PNP) mayprovide care for various populationswithin the neonatal service line orNICU within their respective scopesof practice, such as a neonatal follow-up clinic visit for PNPs certified inprimary care or inpatient NICU careof older infants with chronicconditions, such asbronchopulmonary dysplasia orcongenital heart lesions, for PNPscertified in acute care.26

Per the Consensus Model for APRNRegulation, the APRN scope ofpractice is defined as the culminationof the formal graduate- or doctoral-level education and boardcertification in one or more of thepopulation foci previously mentionedand is then further delineated byvariable state practice rules andorganizational bylaws and policies.23

General competencies for all NPs aredeveloped by the NationalOrganization of Nurse PractitionerFaculties (NONPF) and includescientific foundations, leadership,quality, practice inquiry, technologyand informatics literacy, policy, healthcare delivery systems, ethics, andindependent practice.4,27 APRNprofessional organizations, such asthe National Association of NeonatalNurses (NANN), use the NONPFrecommendations to developcompetencies for the specific NPpractice populations to guideeducation standards and clinicalpractice.28,29

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NNPs

NNPs are APRNs educated at thegraduate or doctoral level and arenationally board certified to care forhigh-risk neonates across the carecontinuum, from preterm and termbirth to the age of 2 years.25,28,29 NNPacademic graduate training programsfollow the Education Standards andCurriculum Guidelines for NeonatalNurse Practitioner Programs.29 Inaddition to didactic instruction, NNPgraduate students acquire supervisedclinical preceptorship hours indelivery rooms; in level II, level III,and level IV NICUs; and in follow-upand well-infant programs.29 Theclinical preceptorship experiencesinclude a wide variety of neonatalpopulations and disease processes aswell as opportunities to buildexpertise in communication,collaboration, transitions of care, andfamily-centered care strategies.29

After graduation, successful nationalboard certification by the NationalCertification Corporation validatesfoundational knowledge competencyin neonatal care.23,30 Individual statelicensure grants authority to practiceas an APRN, and behavioral andprocedural competencies areconfirmed through organizationalcredentialing and periodic review.1

The NANN has developed a processfor initial and ongoing neonatalcompetency maintenance andrecommends that each NNP becomeand remain technically competent inendotracheal intubation, umbilicalline insertion, needle-chestthoracentesis, and arterial punctureat a minimum.31 NNPs maintain theircertification in 3-year cycles witha core-competency knowledgeassessment and targeted continuingeducation based on theirassessments.25

Care to high-risk infants by NNPs hasbeen found to be safe, of high quality,and cost-effective.32–36 Accordingly,the role of the NNP in the care ofhigh-risk neonatal patients has been

endorsed by the AAP37 and in theGuidelines for Perinatal Care.1 Tomonitor the quality of individuals andteams of NNPs, the NANN hasdeveloped a policy withrecommendations on NNP-relatedquality metrics associated withneonatal care.38

Currently, the demand for NNPsoutpaces the supply, and a nationalNNP workforce shortage exists fora variety of reasons.39 In a 2016workforce survey, there were 5433certified NNPs in the United States.40

Of the 1100 survey respondents, theaverage age was 49 years, 72%worked at least 35 hours per week,and more than half reported that theyregularly worked more than theirscheduled hours because of staffingvacancies.40 The shortage of NNPs isfelt at the bedside, where NNPs mayhave higher-than-recommendedworkloads, creating frustration andburnout, which may further challengerecruitment and retentionendeavors.39,41 In a 2014 workforcesurvey, 5% of respondents planned toretire by the year 2020.39 At lastcount, 35 academic programs acrossthe United States reported graduating240 NNP students each year,42

although that number has increasedto more than 300 recently (S. Bellini,DNP, APRN, NNP-BC, CNE, personalcommunication, 2017), which isapproximately 1.6% of all newlygraduated NPs entering theworkforce in the United States.43

Strategic modeling of the current NNPworkforce predicts that the shortagemay last for up to 10 years unlessinnovative recruitment and retentionstrategies are used to deal with thisissue.41

PNPs

PNPs provide care to children fromlate preterm and term birth throughadulthood.43,44 Through formalgraduate or doctoral training, PNPsbecome nationally certified in acutecare, primary care, or both.43 AC PNPtraining programs are focused on the

care of the child with acutelychanging and/or unstable physiologyand include advanced physiology andpharmacology of the infant, child, oradolescent and neonatal content ontopics such as congenital heartlesions, chronic lung disease, andsepsis.4 PC PNP training programs arefocused on comprehensive, chronic,and continuous care; transitions incare; wellness; and prevention.4

Typical PC PNP neonatal curriculumincludes immunizations,breastfeeding, and commonchildhood diseases.4 Invasiveneonatal procedures are not part ofthe scope of practice for PC PNPs.Moreover, none of the AC PNP or PCPNP competencies, recommendedcurricula from the NONPF, or nationalPNP certification examinationguidelines include content related tofetal or preterm infant physiology,pathophysiology, or management ofhigh-risk preterm infants.4 However,AC PNP national certificationexamination content does includecompetencies related to ventilatormanagement, noninvasive positive-pressure ventilation, enteral andparenteral nutrition, diagnosticimaging, and laboratory testinterpretation.4 The management ofhigh-risk deliveries and preterminfants who are critically ill and/orhave low birth weight is not includedin the national competencies for PNPsby the NONPF.4 However, because theConsensus Model for APRNRegulation has not been fully adoptedand/or implemented in every state,inconsistent state nursing regulationsand variable practices in individualorganizations exist.24

Currently, there are approximately18 000 certified PNPs in the UnitedStates, which represents 0.6% of allNPs.43 A PNP workforce shortageexists for reasons similar to the NNPworkforce shortage, includinga limited number of academicprograms, faculty shortages, lowenrollment, and difficulties withsecuring clinical sites and

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preceptors.45,46 Strategic modelingpredicts that the shortage couldcontinue for 13 years unlessinnovative strategies for recruitmentand retention are implemented.47

PAs

PAs are nationally certified, state-licensed medical professionals whopractice medicine on health careteams.48,49 Medical education at thegraduate level prepares PAs to takemedical histories, perform physicalexaminations, order and interpretresults of laboratory tests, diagnoseillnesses, develop and managetreatment plans, prescribemedications, and assist in surgery.PA programs include didacticcontent across the life span andclinical hours in a variety of settings,leading to a foundation in generalmedical knowledge.49,50 Programsaverage 27 months in length andinclude 2000 hours of clinicalrotations.50

Before beginning to practice, PA-program graduates must passa national certification examinationadministered by the NationalCommission on Certification ofPhysician Assistants (NCCPA) andobtain a state license.50 PAs mustrecertify every 10 years and completeat least 100 hours of continuingmedical education (CME) every2 years.50 Neither recertification norCME requirements are specific toneonatal care.

PAs prepare to practice inneonatology either by receivingfurther specialized education in theclinical workplace or throughhospital-based postgraduateprograms,51 allowing each hospital-based program to develop its owncurricula and competencies to meetthe needs of the organization. Othercenters may not have formal PApostgraduate training programs;instead, newly hired PAs who do nothave neonatal experience receiveadditional training in the clinical

setting of unspecified scope andlength of time.

The PA scope of practice isdetermined by education andexperience, variable state laws thatinclude degree of physicianoversight, policies of employers andfacilities, and the needs ofpatients.50,52 PAs practice in everysetting and specialty. Of 123 000practicing PAs, approximately 4%(approximately 2400) practice inpediatrics.53 An estimated 500 PAswork in neonatal-perinatal orpediatric critical care medicine, andthe rest work in various pediatricsubspecialties.53

Studies have revealed that PAsprovide safe, high-quality, cost-effective care to infants. Thesestudies demonstrate that PAs providecare that is equal in quality to that ofother neonatal and pediatricproviders and complement thework of attending and residentphysicians.32,54–56 PAs are importantmembers of the NICU provider team,as described the Guidelines forPerinatal Care.1

The PA workforce has experiencedrobust growth over recent years.Overall employment of PAs isprojected to grow 37% from 2016 to2026, much faster than the averagefor all occupations, creating potentialfor PAs to help fill the need forneonatal providers.57–59 The NationalCenter for Health Workforce Analysispredicts that PAs in pediatricsubspecialties will experience growthof 185% between 2010 and 2025.60

Growth in the overall number of PAsand strategies to recruit PAs toneonatology may help increaseoverall numbers of neonatalproviders.

COMPETENCY, SAFETY, AND PATIENTOUTCOMES

Typically, health care providersacquire competence througheducation and training that beginsduring preclinical care settings and

continues over a continuum oftime, leading to the emergence ofexpertise from novice to expert.61,62

In the IOM publication HealthProfessions Education: A Bridgeto Quality, essential skills for allhealth care professionals’education and preparation areidentified to provide the foundationon which other specialty orpopulation-based competencies arefurther delineated to meet the goalsof safe, effective, efficient, patient-centered, timely, and equitablehealth care.63,64

In addition to the IOM competencies,the ABP (adopted by the ACGME),national PA organizations (theNCCPA, the Accreditation ReviewCommission on Education for thePhysician Assistant, the AmericanAcademy of Physician Assistants[AAPA], and the Physician AssistantEducation Association), and theNONPF have each developedsome neonatal competencies toguide the provision of safeand effective care.4,19,22,27,50,63,65

Simplistically, these corecompetencies can be organizedinto 3 broad categories:knowledge-based, procedural, andbehavioral competencies. Theorganizations and their corecompetencies are summarized inTable 1.

Knowledge-Based Competency

Neonatal-perinatal medicine andNNP board certificationexaminations validate knowledge-based competencies specificallyfocused on the care of the pretermand high-risk neonate.30,67 Otherproviders working in the NICU havevariable amounts of neonatalknowledge gained during theiracademic programs, clinicalexperiences, and past professionalpractices. It is important for all NICUproviders to have a basic knowledgebase and understanding of fetal andneonatal physiology, typical neonatalconditions and diseases, skills in

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physical examination and healthassessment, and pharmacology. Thisknowledge can be obtained duringa formal academic program, duringan employment orientation period,and throughout the provider’scareer through clinical experienceand CME. These knowledge-basedcompetencies enable providers toeffectively perform comprehensivephysical examinations and takemedical histories, develop plans forinitial care and stabilization, andorder laboratory tests, radiologicstudies, medications, andtreatments for infants with acuteand chronic illnesses.30,67 Skills indischarge planning (which includemedication reconciliation andmanagement), in assessment ofongoing needs for nutrition anddurable medical equipment, inmaking appropriate referrals, and in

educating and preparing parents fortheir infant’s discharge, includinghealth promotion and disease-prevention activities, are alsoimportant attributes for all NICUproviders.1,68

Procedural Competency

The ACGME Neonatal FellowshipProgram requirements providegeneral guidance on proceduralcompetencies for trainees, whichincludes general principles of criticalcare and neonatal resuscitation,venous and arterial access,evacuation of air leaks, endotrachealintubation, preparation fortransport, ventilator support,continuous monitoring, andtemperature control.8 Use of didacticinstruction, simulation, andsupervised performance is

recommended to establish basiccompetencies.8

Likewise, the National Association ofNeonatal Nurse Practitioners(NANNP), a subsidiary of the NANNthat is focused on issues specific toneonatal APRNs, has delineated thenecessary procedural competencyfor both practicing and studentNNPs.28,29 Neonatal procedures aretaught in classrooms and/orsimulation laboratories and areperformed in the clinical settingunder the supervision andmentorship of a competentpreceptor.29 Documentation of initialcompetency is required.29 Nationalcertification for AC PNPs requirescompetency in pediatric critical care,including mechanical ventilation,continuous monitoring, and invasiveprocedures.4 In some programs, PA

TABLE 1 Core Competencies by Organization

Professional Organization Core Competencies

AAP Section on Hospital Medicine22 Common clinical diagnoses and conditionsCore skillsSpecialized clinical servicesHealth care systems: supporting and advancingchild health

ABP and ACGME19,66 Patient careMedical knowledgeProfessionalismInterpersonal and communication skillsPractice-based learning and improvementSystems-based learning

IOM (now the National Academy of Medicine)63 Provision of patient-centered careInterdisciplinary teamworkEmployment of evidence-based practiceApplication of quality improvement strategiesUse of informatics

NONPF4,27 Scientific foundationsLeadershipQualityPractice inquiryTechnology and informatics literacyPolicyHealth care delivery systemsEthicsIndependent practice

NCCPA, Accreditation Review Commission on Education for the Physician Assistant, AAPA, Physician AssistantEducation Association50,65

Medical knowledge

Interpersonal and communication skillsPatient careProfessionalismPractice-based learning and improvementSystems-based practice

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students may be exposed to neonatalprocedures during their formalacademic program and clinicalrotations. Other avenues for PAs tobecome proficient in neonatologyinclude hospital-based postgraduateneonatal training programs andcourses69 and additional training inthe clinical setting as an employedPA. The definition of proceduralcompetency is elusive and is notsatisfied by the completion of anarbitrary number of proceduresalone but includes ongoinginstruction and/or feedback,simulation, and practice.70 Therecommendation for NNPs from theNANNP is no less than 3performances of each procedure tobe documented annually.28 If theNNP does not meet theserequirements, other provisions canbe made to ensure competency.28

National recommendations forprocedural review for NNPs includelogged procedures as well aspractice laboratories, proctoredsimulation, and review of policy andprocedural guidelines.Documentation of procedures arekept by each NNP, including whatprocedures were performed,success rates, and complications.Data obtained from the logs are

a necessary component for qualityimprovement purposes.28,38

In consideration of the basicknowledge and proceduralexperience of NICU provider roles, wepresent in Table 2 procedures thatare required and those that arerecommended for hospitalists, NNPs,AC PNPs, and PAs in the NICU. Use ofa quality improvement approach maybe helpful to establish initialcompetence and confidence.71 Formalinstruction and simulation can becompleted, along with directsupervision by a credentialed andcompetent provider for initialprocedural attempts, on patients inthe NICU. Initial and ongoingcompetency can be documentedthrough the use of procedure logs,observation, and/or proctoredsimulations and policy and procedurereviews.72–74

Behavioral Competency

The ABP, ACGME, various nationalPA organizations, and the NONPFprovide guidance on behavioralcompetency in areas such aspracticed-based learning and qualityimprovement, self-assessment,interpersonal and communicationskills, professionalism, and systems-

based practice.3–5,7,8,16,19,20,67 Theseemphasize independent andinterprofessional practice; analyticskills for evaluating and providingevidence-based, patient-centeredcare; and advanced knowledge ofhealth care delivery systems and arein accordance with the IOMrecommendations for healthprofessions education.63,64 Ata minimum, NICU providers must beable to make complex decisionsthrough analytical thinking andpractice inquiry, communicate andcollaborate with neonatologists andother health care providers, use andanalyze information technology,develop effective teamwork andquality improvement skills, usepatient- and family-centered carepractices, and incorporate evidence-based practice, safety, andknowledge of hospital and unitpolicy to promote the delivery ofhigh-quality, safe, and cost-effectivecare to neonates.4,8 Behavioralcompetencies are developed throughstructured education, mentorship,experience, and feedback, which mayinclude individual coaching, teamdebriefings, simulations, and root-cause analysis exercises, and can bepart of all providers’ developmentalprocess in training and throughouttheir careers.8,29 Periodicassessment of behavioralcompetencies can be conducted andincluded in initial and ongoingperformance evaluations.63

Initial and Ongoing NeonatalCompetency Acquisition andMaintenance

The Guidelines for Perinatal Care,Eighth Edition recommends thatprocedures are established for theinitial granting and subsequentmaintenance of privileges, ensuringthat the proper professionalcredentials are in place for eachNICU provider.1 Each institution isresponsible to ensure that theneonatal provider, whetherphysician, APRN, or PA, has theformal education, experience, and

TABLE 2 Essential Neonatal Procedures

Required neonatal procedures for all neonatal providersNeonatal resuscitation, according to the American Heart Association and AAP Neonatal Resuscitation

ProgramManagement of airway: positive-pressure ventilation with bag or mask, nasal continuous positive

airway pressure, and endotracheal intubationUmbilical line insertionNeedle-chest thoracentesis

Other procedures that may be recommended depending on the practice site (NICU-designated level) andpatient populationChest tube placementArterial blood gas samplingPeripheral arterial line insertionLumbar puncturePeripherally inserted central cathetersSuprapubic bladder tapsExchange transfusionVentricular reservoir tapsIntraosseous cannulation and infusionAbdominal paracentesisPericardiocentesis or pericardial tap

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board certification to function withinthe requested scope of clinical andprofessional privileges. Thecredentialing process is bestdeveloped through a collaborativeeffort between nursingadministration and the medical staffgoverning body by using guidancefrom national bodies regarding thecore competencies.1 Hospitalsaccredited by The Joint Commissionrequire physician and nonphysicianhealth care providers, includingAPRNs and PAs, to obtain privilegesto practice through a process ofmedical staff credentialing.75

Diagnostic and therapeutic servicesallowed by state and federal law maybe further restricted by the hospitaland/or medical staff.21,75 Proceduralprivileges may be limited byprofessional degree, experience, orlack of ability to demonstrateappropriate training or competenceto a credentialing body.21,75

Once an individual is credentialed,plans for initial and periodic reviewsof safety and quality care can bedeveloped, for individuals to maintainrequested privileges, througha practice such as the focusedprofessional practice evaluation andongoing professional practiceevaluation processes for thoseorganizations accredited by The JointCommission.76,77

POTENTIAL STRATEGIES TO ADDRESSWORKFORCE SHORTAGE OF NEONATALPROVIDERS

Strategies to address providerworkforce shortages in the NICU caninclude attempting to reduce theworkload (ie, reduce the number ofpatients admitted to the NICU and/or shorten the length of stay) and/orincrease the number of providers. Inaddition to declining birth rates inthe United States,78 new carestrategies may potentially change theacuity and locations where newborninfants receive their care and, overtime, may lead to a redistributionand change the workloads of the

NICU provider workforce. Theseemerging care strategies includelimiting elective cesarean deliveriesto 39 weeks’ gestation orgreater79,80; treating infants withneonatal abstinence syndromeoutside of the NICU81; reducing theneed for antibiotic administrationand, therefore, length of hospital stayfor mothers with intraamnioticinflammation or infection82;reducing NICU admissions fortreatment of hypoglycemia withintravenous glucose administrationby using dextrose or glucose gel83;and reducing length of NICU staythrough quality improvementstrategies, such as decreasing theincidence of central line–associatedbloodstream infections.84

Strategies to increase the NICUprovider workforce have mostly beenconcentrated on increasing the use ofpediatric hospitalists, NNPs, andPAs.11,15,39–41,45–47 Workforcesurveys conducted by the NANNPhave delineated the existing andfuture NNP workforce needs.39,40 Theauthors noted that education,recruitment, and retention of NNPswere key areas of focus to increasesupply.39,40

Education for NNPs has evolved over5 decades from certificate programs,to bachelor’s and master’s degrees innursing, to the doctorate of nursingpractice degree, which could slowthe NNP pipeline further.85,86

Barriers to obtaining this educationare lack of higher degree (ie,doctorate of nursing) programs,funding of faculty, access topreceptors, and federal and stateregulations.87 Regulations posed bythe US Department of Educationrelated to long-distance learninghave had an effect on NNP educationand have contributed to a drop inenrollment in states withsignificantly restrictiverequirements.87 Collaborationamong educational institutions maybe a strategy to overcome restrictiveregulations and minimize costs and

faculty needs.39 Locally, neonatalprograms and hospitals can increaseefforts to recruit more neonatalnurses within the workplace topursue higher education as an NNPand offer tuition reimbursement orscholarships to assist with thefinancial burden.88 This strategycapitalizes on the professionalexpertise of neonatal nurses,facilitating success and easing thetransition into the APRN role. Ashortage of university nursingfaculty is another limitation ofenrollment in academic programs.The NANNP has led a strategy tosupport NNP programs to prepareexpert NNP clinicians to becomeeducators in clinical faculties. Itis hoped that this effort toincrease faculty will enable anincrease in the student cohort sizeand consequently increase thenumbers of newly graduated NNPs inthe workforce.39

Recruitment of NNPs is vital to theNICU provider workforce. PracticingNNPs should contribute torecruitment efforts by serving asclinical preceptors for NNPstudents.25 Mentoring programs fornovice NNPs have been shown to bevaluable recruitment tools for NNPpractices and hospitals. Offeringlonger orientation or residencyprograms is attractive to newgraduates as well.

Retention of NNPs in the workforceis another important aspect ofmaintaining the NNP supply. With anaging workforce, any additionalreduction in manpower fromburnout and early retirement willcompound the workforce deficit andincrease demand. The scope ofresponsibility for NNPs includes theNICU provider role along with otherroles, such as transport NNP,educator, delivery roomresuscitation, cross-coverage forphysician housestaff, and well-infantconsultations, etc.25 Adequatestaffing ratios are required tobalance the needs of the unit with

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safe and effective care to neonates.39

Consideration of patient load andacuity will help reduce burnout andincrease job satisfaction.39 Inhospitals that maintain 24-hourwork shifts, ensuring downtime forNNPs is critical to safe andcompetent care.39 Other strategiesmay include creating shorter shiftlengths and devising creativescheduling techniques to offer betterwork-life balance in an attempt toincrease longevity of the NNProle.39,40

AC PNPs, acting within their scopeof practice, can be used as NICUproviders for term and olderinfants, such as those with surgicalconditions and chronic medicalconditions. PC PNPs, workingwithin their scope of practice, couldbe used to perform well-newbornand other types of consultations,discharge education, carecoordination, andneurodevelopmental follow-up.This team-based collaborativemodel capitalizes on the uniqueskill sets of each provider. However,the PNP workforce pipeline suffersfrom many of the same or similarissues as the NNP pipeline, and it islikely that applying some of theabove recruitment and retentionstrategies may help.45–47

Additionally, some PNPs mayconsider achieving additionalcertification as an NNP througha post–master’s certificationacademic program.

Efforts to increase the PA workforcein the NICU have included theaddition of postgraduate trainingprograms,69 and more hospitals arehiring PAs and providing onboardingfor those without specific NICUexperience. As the total population ofPAs continues to increase, offeringoptional rotations through the NICUduring student coursework andclinical rotations, creating morepostgraduate training opportunitiesin neonatology for PAs, andformalizing neonatal PA orientation

programs may increase the numbersof these providers in neonatology.Reynolds and Bricker51 note that PAs“represent a historicallyunderutilized resource to resolveneonatology’s workforce issues.”

Pediatric hospitalists havecompleted a formal pediatricsresidency program and are licensedphysicians who can be used as NICUproviders within their scope ofpractice. Hospitalists can currentlyachieve board certification throughthe ABP in the field of generalpediatrics20 and, if eligible, may alsosoon be able to obtain boardcertification in PHM.18 The AAPSection on Hospital Medicine and itsNeonatal Hospitalists Subcommitteeare developing and reviewingcontent on delivery room care andcommon neonatal conditions forPHM fellowship programs and forthe PHM board certificationprocess.18 Recruitment and retentionof pediatric hospitalists who arefocused on newborn care and workas providers in the NICU may behelpful to the overall NICU providerworkforce. The scope ofresponsibility for pediatric andneonatal hospitalists may includeclinical responsibilities for deliveryroom resuscitation, transport, cross-coverage for housestaff, well-newborn consultation and care, andthe care of selected newborn infantsin the intermediate and intensivecare nurseries.6,15 In addition, manypediatric hospitalists also serve aseducators, researchers, and leadersof committees and qualityimprovement activities.6,15 Adequatestaffing ratios are important to thepractice environment and arerequired to balance the needs of theunit with safe and effective care toneonates. Consideration of patientload, acuity, and need for academicand professional development willhelp reduce burnout and increaselongevity and job satisfactionof pediatric and neonatalhospitalists.

In addition to the pipeline,recruitment, and retention strategiesmentioned previously, efforts shouldalso be focused on effective use andquality-outcomes metrics of allneonatal providers to improveeffectiveness and efficiency issuesand to improve the quality of caredelivered to the neonate who ishospitalized.

SUMMARY AND CONCLUSIONS

• The NICU provider workforceconsists of a variety ofprofessionals in varied stages oftheir careers with a wide range ofdegrees, training, experience, skills,and competencies.

• Increasing collaboration ofneonatologists with other NICUproviders (pediatric hospitalists,APRNs, and PAs) and physiciantrainees will be necessary to meetthe needs of the NICU populationgoing forward.

• The skill level, experience, andcompetency of neonatologyphysician trainees (residents andfellows) and NICU providers (PAs,pediatric hospitalists, and PNPs)can be variable, although thetraining model for NNPs is welldeveloped and may serveas a model for other NICUproviders.

• All neonatal providers shouldpossess a basic set of knowledge,procedural, and behavioral-basedcompetencies to provide safe andeffective care.

• It is the responsibility of themedical and nursing leadership ofthe NICU, with the assistance of thehospital credentialing committee,to develop and periodically reviewcompetency criteria for all NICUproviders.

• Competency criteria, such as thosedeveloped by the AAP, ACGME,AAPA, and NONPF, can help guidethe development and evaluation ofNICU providers to provide high-quality, safe, and cost-effective

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care to the high-risk NICUpopulation.

• Strategies to increase the overallNICU provider workforce should beevaluated and thoughtfullyemployed at the national and statelevels to remove barriers toeducation, training, and practice.

• Ultimately, the attendingneonatologist is responsible for thecare given by NICU providers underhis or her supervision and/orcollaboration. He or she should beinvolved in the development andperiodic review of competencycriteria and should ensure thatmalpractice liability protection, ofthe institution or obtainedpersonally, covers adverse eventsthat may involve members of theneonatal care team.

LEAD AUTHORS

Erin L. Keels, DNP, APRN-CNP, NNP-BCJay P. Goldsmith, MD, FAAP

COMMITTEE ON FETUS AND NEWBORN,2018–2019

James J. Cummings, MD, FAAP, ChairpersonIra S. Adams-Chapman, MD, FAAPSusan Wright Aucott, MD, FAAPJay P. Goldsmith, MD, FAAPIvan L. Hand, MD, FAAPSandra E. Juul, MD, PhD, FAAPBrenda Bradley Poindexter, MD, MS, FAAPKaren Marie Puopolo, MD, PhD, FAAPDan L. Stewart, MD, FAAPWanda D. Barfield, MD, MPH, FAAP, RADM,USPHS

LIAISONS

Yasser El-Sayed, MD – American College ofObstetricians and GynecologistsErin L. Keels, DNP, APRN, NNP-BC – NationalAssociation of Neonatal NursesMeredith Mowitz, MD, MS, FAAP – AAPSection on Neonatal-Perinatal MedicineMichael Ryan Narvey, MD, FAAP – CanadianPediatric SocietyTonse N.K. Raju, MD, DCH, FAAP – NationalInstitutes of HealthKasper S. Wang, MD, FACS, FAAP – Section onSurgery

STAFF

Jim Couto, MA

ABBREVIATIONS

AAP: American Academy ofPediatrics

AAPA: American Academy ofPhysician Assistants

ABP: American Board of PediatricsACGME: Accreditation Council for

Graduate MedicalEducation

AC PNP: acute care–certifiedpediatric nursepractitioner

APRN: advanced practiceregistered nurse

CME: continuing medicaleducation

IOM: Institute of MedicineNANN: National Association of

Neonatal NursesNANNP: National Association of

Neonatal NursePractitioners

NCCPA: National Commission onCertification of PhysicianAssistants

NNP: neonatal nurse practitionerNONPF: National Organization of

Nurse PractitionerFaculties

NP: nurse practitionerPA: physician assistantPC PNP: primary care–certified

pediatric nursepractitioner

PHM: pediatric hospital medicinePNP: pediatric nurse practitioner

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