Role and Scope of Practice for the Neonatal Nurse Practitioner (NNP)
Author: Sheron Wagner, DNP, MSN, APRN, NNP-BC
Editor: Elizabeth Moran, MSN, RN, CPNP-PC
Neonates, in the traditional sense, include infants whose age range from birth through 2 months and in the hospital setting are typically identified as those patients in the neonatal intensive care unit (NICU) to provide quality care for this vulnerable and high-risk population, many NICUs across the country rely heavily on Neonatal Nurse Practitioners (NNPs) as part of their multidisciplinary healthcare teams. The NNP participates in a wide range of complex patient care activities in different settings that include academic settings, faculty in NNP programs, community-based hospitals, transport, and many other aspects of patient care. In fact, NNPs role and scope has evolved over several decades and has been bolstered by the ever-changing healthcare system.
The NNP is a Master’s prepared Advanced Practice Registered Nurse (APRN), who has completed formal education in an accredited graduate neonatal program. The NNP must successfully obtain board certification through the National Certification Corporation (NCC) and must maintain competency through clinical experience, continuing education, and recertification. According to the 2013 National Association of Neonatal Nurses position statement, nurse practitioners and clinical nurse specialists (CNS) who practice in neonatal intensive care units (NICUs), but who were not formally educated in the neonatal population, are practicing outside of their scope of practice. NNP education focuses on attaining theoretical and scientific knowledge, as well as a collection of advanced clinical skills. Advanced health assessment skills, critical decision-making abilities, diagnostic reasoning, and advanced clinical competencies are all also crucial skills for the NNP to obtain. In addition, the nature of the practice of the NNP is multifaceted and includes integration of research, education, practice, and management with a high degree of professional autonomy both independently and/or in collaboration with the neonatologist, as appropriate. As such, NNP practice is geared at health promotion and disease prevention and their holistic approach to patient care makes NNPs a well-respected part of the clinical team.
Scope of Practice
NNPs’ scope of practice includes a range of privileges, allowable by the certification and licensure held, and further determined by the individual facilities where employed. Responsibilities and duties may also be decided in conjunction with the neonatologist. In addition, the scope of practice is further determined by the needs of the patients and can include billing for services, such as specialized procedures, central line insertion, circumcisions, and high-risk delivery attendance.
Each state has Nurse Practice Acts that define the scope of practice. For example, some states limit the NNP’s authority to prescribe controlled substances and require the neonatologist to cosign. Other states do not have such limitations and the NNP can prescribe controlled substances but all should possess an accompanying DEA certificate. NNPs practice in a broader scope than that of a neonatal registered Nurse because they have advanced training, and can also obtain additional certifications by way of education in specialized areas of interest.
Standards of Practice
Standards of practice refer to the clinical practice of patient care. Whereas the scope of practice defines what an individual is able to do, standards of practice determine how it is done. The NNP must adhere to the standards of practice set forth by the organization in which he or she is employed. Standard of practice revolves around routine components of patient care and can include patient assessment, diagnosis, plan of care development, intervention, and evaluation. The NNP possessed these routine skills and are adept at holistic care delivery.
The NNP typically works under the direction of a neonatologist, but they assume complete responsibility for their patients and can make medical decisions to diagnose and treat various conditions, as well as perform procedures. Experienced NNPs are at times the sole provider on duty in many healthcare facilities across the country and must be competent and capable of handling medical emergencies. To that end; new graduate NNPs should ask careful questions while interviewing to gauge their level of support while new.
Furthermore, the level and setting of the NICU often determine whether or not the NNP can or cannot be the sole provider in the house. For example, Level I NICU typically admits healthy normal, term newborns and thus the NNP role may be more autonomous, but the scope of practice is more limited. Level II NICUs care for sick and premature babies that require a higher level of care, including mechanical ventilation and other invasive therapies, and do not require a neonatologist to be present at all times. Level III NICUs have more critically ill neonates and require an expanded level of care, and thus in most instances, a neonatologist must be present in house twenty-four hours, seven days a week. Level IV NICUs, which see and treat the sickest neonates, must of course also have a neonatologist present at all times.
NNPs are a highly specialized advanced practice role and are an integral part of the healthcare delivery team, functioning autonomously in many areas of clinical practice. NNPs care for sick and premature babies in the NICU, respond to high-risk deliveries and provide education and support to staff nurses, parents, and families regarding neonatal care. NNPs can diagnose and treat patients with varied disease processes and provide ongoing comprehensive disease management. They are engaged in direct and indirect patient care in acute settings, academic roles, research, health policy and practice, population health, push forward quality improvement initiatives and are instrumental in ensuring clinical practice is evidence-based. The motivation to become an NNP is often the idea of being able to practice autonomously. Increased clinical skills and knowledge base, in turn, improves NNP job satisfaction by means of being a respected part of the multidisciplinary team.
Despite their autonomous and versatile role, the demand for Neonatal Nurse Practitioners has historically far outweighed the supply. NNP programs across the country have limited space to accept new students and there is a shortage of NNP faculty within academic institutions. The nature of the NNP role is multifaceted and collaborative, and as a result, the shortage of NNPs has a direct impact on patient care delivery. As NICUs expand their bed counts, the gap of being able to provide NNP coverage grows.
The NNP role has a long history and boasts an impressive legacy of pioneers that have changed the face of healthcare. In the face of this supply and demand mismatch, we are all now tasked with helping to first recruit potential candidates into NNP programs and provide them with mentoring and guidance as they carve their paths to become successful graduates. All NNPs in clinical settings have a responsibility to serve as preceptors and nurture NNP students to help them fully realize their potential in becoming a highly respected and regarded member of the healthcare team. In addition, evidence-based care of the critically ill neonate is continually evolving, and NNPs must continually document their competence to assure the public that the NNP is consistently delivering safe, high-quality care and is both an influential, and necessary, part of the healthcare delivery team (NANN position statement # 3062, 2015).
National Association of Neonatal Nurses. (2013). Advanced Practice Registered Nurse: Role, Preparation, and Scope of Practice [position statement]. Austin, TX: Author. Retrieved from: http://nann.org/uploads/Membership/NANNP_Pubs/APRN_Role_Preparation_position_statement_FINAL.pdf
National Association of Neonatal Nurses. (2015). Standard of Maintaining the Competence of Neonatal Nurse Practitioners [position statement]. Austin, TX: Author. Retrieved from: http://nann.org/uploads/Membership/NANNP_Pubs/Standard_for_Maintaining_the_Competence_of_NNPs-FINAL.pdf
Sheron A. Wagner is a Neonatal Nurse Practitioner in Dallas, TX. She has over 35 years of nursing experience and over 10 years of NNP experience. Sheron is a published author in numerous articles, as well as in a first edition nursing text. She is heavily involved in research and quality improvement (QI) projects, mostly surrounding respiratory management of preterm neonates and in simulation. Current QI projects include evaluating reducing morbidity and mortality in preterm neonates—specifically in regards to management around respiratory and mechanical ventilator use, teaching skills by way of simulation to NNPs and physicians, and improving onboarding for new NNPs at her organization, just to name a few. Sheron has presented some of her work at international conferences. She is also clinical faculty for NNP students at UTMB at Galveston, TX. When she is not working, she spends time with her children and grandchildren. You can reach Sheron at Sheron.Wagner@phhs.org