PEDIATRICS Vol. 119 No. 2 February 2007, pp. 361-369 (doi:10.1542/10.1542/peds.2006-1084)
SPECIAL ARTICLE |
Nonphysician Clinicians in the Neonatal Intensive Care Unit: Meeting the Needs of Our Smallest Patients
a Division of Neonatology
b Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky
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ABSTRACT |
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 TOP ABSTRACT DEFINITIONSHISTORICAL PERSPECTIVES ON NPCsMODELS FOR TRAINING NNPs...THE ROLE OF NPCs...PA RESIDENCY PROGRAM IN...PATHWAY TO A PROGRAMCONCLUSIONSREFERENCES |
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Regional variations in the distribution of neonatal physicians and dependence on housestaff with restricted work hours have created workforce shortages in many NICUs. Although neonatal nurse practitioners assist in the delivery of high-quality care, availability of these providers may be inadequate in certain regions. Physician assistants represent a historically underutilized resource to resolve neonatology's workforce issues. We have developed a postgraduate training program for physician assistants in neonatology that we hope will improve local and regional workforce shortages. In this article we discuss the history of neonatal nurse practitioners and physician assistants in newborn care and outline the program that we developed. We further discuss some of the barriers we had to overcome in developing this program. Our program can serve as a model for other neonatology programs to adequately prepare physician assistants for a career in the NICU.
Key Words: neonatal nurse practitioner • physician assistant • alternative health care providers • neonatal intensive care
Abbreviations: NPC—nonphysician clinician • NP—nurse practitioner • NNP—neonatal nurse practitioner • PA—physician assistant • AAP—American Academy of Pediatrics • ARC-PA—Accreditation Review Commission on Education for the Physician Assistant • AMA—American Medical Association • NPA—neonatal physician assistant
More preterm infants with long hospital stays have put increasing pressure on the neonatology workforce. Although certain commentaries have identified what some consider an overabundance of neonatology physicians,1–3 regional variation in supply and the demands on physicians' time have resulted in a situation in which it is increasingly difficult to provide optimal care. Therefore, neonatologists have become increasingly dependent on residents and nonphysician clinicians (NPCs) such as neonatal nurse practitioners (NNPs). However, some institutions find it difficult to hire and/or retain these professionals. Physician assistants (PAs) are an underutilized resource that may be available to fill continued workforce gaps.
NPCs have been an important part of health care delivery in many cultures throughout history.4 NPCs are a heterogeneous group of health care providers, traditionally including nurse practitioners (NPs), clinical nurse specialists, certified nurse midwives, and PAs. Other groups included in discussions of NPCs are chiropractors, acupuncturists, and naturopaths. The NP and PA professions began in the mid-1960s (the same time as modern neonatology, incidentally) in an effort to meet the need for more access to primary care services. Over the past 40 years, NPs have become common in the NICU, with rigorous educational requirements and licensure standards specific to their area of practice. The role of PAs in primary care and surgical specialties has been well established. However, their role in most areas of subspecialty care has not yet become widely accepted, particularly in the NICU.
In this article we describe the history of NNPs and PAs in neonatology, identify the roles NPCs play in the delivery of neonatal care, and discuss the efforts of our program to create PAs with the technical skills and knowledge required for a career in the NICU.
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DEFINITIONS |
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TOPABSTRACTDEFINITIONSHISTORICAL PERSPECTIVES ON NPCsMODELS FOR TRAINING NNPs...THE ROLE OF NPCs...PA RESIDENCY PROGRAM IN...PATHWAY TO A PROGRAMCONCLUSIONSREFERENCES |
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Much discussion about the name for the generic group of advanced-practice nurses and fast-tracked medical professionals has occurred. In this article, "nonphysician clinician" (NPC) will be used to describe these health care providers. Although we acknowledge that this title actually describes what these providers are not, it is in keeping with past statements issued by the American Academy of Pediatrics (AAP).
An NP is a registered nurse with advanced academic and clinical experience that enables her (traditionally) or him to diagnose and manage most common and many chronic illnesses either independently or as part of a health care team. A registered nurse should have extensive clinical experience before applying to an NP program. A preceptorship under the supervision of a physician or an experienced NP and instruction in nursing theory are key components of most NP programs. NPs are educated through programs that grant either a certificate or a Master's degree. As of 2003, nearly all programs required Master's level training.5 A national certification examination is administered, and continuing education is required. Scope of practice varies by state. In medically underserved areas, NPs may provide care that is usually offered only by physicians. In most states, NPs have some prescribing authority.
PAs are licensed to practice medicine with physician supervision. They are trained in educational programs accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The mean length of PA programs is 26 months. PA students complete >2000 hours of supervised clinical practice before graduation. Many PA programs are moving to Master's level education. PAs conduct physical examinations, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and, in virtually all states, can write at least some prescriptions. Within the physician-PA relationship, PAs exercise autonomy in medical decision-making and provide a broad range of diagnostic and therapeutic services, as well as educational, research, and administrative duties. The national PA professional organization is content to continue the physician-PA relationship in its current supervisory form.
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HISTORICAL PERSPECTIVES ON NPCs |
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TOPABSTRACTDEFINITIONSHISTORICAL PERSPECTIVES ON NPCsMODELS FOR TRAINING NNPs...THE ROLE OF NPCs...PA RESIDENCY PROGRAM IN...PATHWAY TO A PROGRAMCONCLUSIONSREFERENCES |
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In the early 1960s it became clear that to meet the growing needs of the American health care system, more primary care providers needed to be trained. Congress created the National Institute of Child Health and Human Development in 1962 to address disparities in health outcomes and health care among mothers and children. However, training new doctors takes time and money. Dr Charles Hudson spoke to the American Medical Association (AMA) in 1961 about a new group of health care providers and suggested that military corpsmen could be trained in the technical aspects of medicine but take little or no part in diagnosis or prescribing drugs.4 By 1965, 2 new pathways were created to meet the primary care workforce needs: the NP and PA routes. Over the past 40 years, the realization of new workforce issues and a desire for professional growth have forced expansion of NPC roles beyond primary care and into subspecialty and hospital-based practice. Table 1 includes a list of events in the history of both the NNP and PA professions.
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The first advanced-practice nurse training program began in 1965 at the University of Colorado. Drs Loretta Ford and Henry Silver are credited with being the founders of the NP movement.6 However, publications by Dr Ford and others have identified the Western Interstate Commission on Higher Education as the major impetus for the creation of the modern NP movement.7,8 The initial goals of the program were to provide (1) primary care in underserved areas, (2) more health maintenance and prevention of illness for more people for less cost, and (3) a newer, more responsible role for nurses by expanding their existing skills to include capabilities in health appraisal.9,10 The traditional nursing characteristics (humanistic caring, comforting, nurturing, and supporting) were to be maintained and improved by the addition of equal status with other health care providers, collaborative and complementary relationships with physicians, and achievement of professional autonomy.6
In 1975, the American Nurses Association published a report from a March of Dimes Blue Ribbon Commission, Guidelines for Short-term Continuing Education Programs for the Nurse Clinician in Intensive Maternal-Fetal Care.11 This document served as the NNP training standard for nearly 20 years.12 During the 1990s, new standards were adopted for the education and practice of NNPs.13,14 Current standards are available from the National Association of Neonatal Nurses.15
NPs have been found to be acceptable, credible, and cost-effective alternatives to traditional physician care in both the outpatient and inpatient settings.16,17 In 1979, an early study of the NNP role found the quality of care delivered by the NNP to be comparable or superior to that of pediatric interns.18 Other studies have compared NNPs to higher-level residents and physicians and found results similar to those from the earlier study.14
In 1992, there were 253 training programs for NPs in 119 institutions. By 1995, this number had increased to 527 tracks in 202 institutions.19 In 1982, there were 29 neonatology-specific NP programs; this grew to 36 in 1996.20 In 2000, there were 102829 NPs in practice.5 By 2005, this number was expected to exceed 115000.21
The PA profession was born in the same economic and health care milieu as the NP movement. Dr Eugene Stead envisioned a way to meet the primary care needs of rural North Carolina with "midlevel generalists." His initial attempt was a collaborative effort with Thelma Ingles, RN, to expand nursing roles in generalist health care delivery. On 3 occasions, the National League of Nursing opposed the program, citing that delegating medical tasks to nurses was inappropriate.22 This is paradoxical, given the fact that the NP program at the University of Colorado was developing at the same time. Dr Stead continued his work via another collaborative effort. This time, with Dr Herbert Saltzman, he was able to obtain funding for an NPC training program. In 1965, 4 Navy corpsmen began a 2-year program that was considered the forerunner to the modern PA model.
A 9-month graduate program for PAs in neonatology was established in 1981 at the University of Southern California Medical Center.23,24 It remained active until the mid-1990s, when, because of budget cuts at the state level, it was discontinued (G.A. Halterman, III, PA, MS, JD, verbal communication, 2006). In 1986, a survey of PAs who graduated from that program found that, on average, these PAs spent 
22% of their time in level 1 nurseries, 53% of their time in level 2 nurseries, and 25% of their time in level 3 nurseries.25 Thirty-three percent also worked in follow-up clinics. These PAs performed tasks covering the entire spectrum of newborn care, from well-infant care to virtually every procedure required in the NICU. Patient loads varied from 3 to 60 depending on acuity. One third of the respondents participated in research. Nearly all the respondents had a role in the education of medical students and residents, PA students, nursing staff, and respiratory therapists.25
In 1997, there were nearly 29000 PAs in the United States. In 2002, that number had grown to >44000.26 Now (in 2006) there are 135 accredited PA training programs, and it is estimated that there are 58665 practicing PAs.27 Postgraduate training for PAs is optional. There is no accreditation process for PA residency programs. However, the ARC-PA is implementing an optional accreditation program to begin in 2007. The Association of Postgraduate PA Programs lists 32 member organizations.
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MODELS FOR TRAINING NNPs AND PAs |
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TOPABSTRACTDEFINITIONSHISTORICAL PERSPECTIVES ON NPCsMODELS FOR TRAINING NNPs...THE ROLE OF NPCs...PA RESIDENCY PROGRAM IN...PATHWAY TO A PROGRAMCONCLUSIONSREFERENCES |
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NPs and PAs perform similar roles in many areas of health care. However, each profession points to differences in philosophy to separate itself from the other. It is said that NPs are trained in the "nursing" model, and PA education is based on the "medical" model. In the NICU, it would seem that these differences have been reduced, if not eliminated. NNPs are taught to become proficient at diagnosis, treatment, and technical skills. PAs in the current NICU environment are exposed to "family-centered care," with more emphasis on the patient-parent-family unit rather than traditional disease diagnosis and treatment. In institutions that employ both types of NPCs, an understanding of what makes these professionals similar, instead of focusing on differences, may help integrate individuals into a team that is better able to deliver high-quality health care.
Nearly all published definitions of an NP begin with the phrase, "an NP is a registered nurse who... ." NP training, therefore, is based on a "nursing" model. Florence Nightingale was the first nursing theorist. She proposed basic tenets of nursing practice. Nurses were to "make astute observations of the sick and their environment, record observations and develop knowledge about factors that promoted healing."28 She saw the role of the nurse as putting the patient "in the best condition for nature to act on him."29 She saw nursing and medical knowledge as distinct disciplines. Over time, nursing theory has moved from grand, abstract constructs to more problem-focused, concrete concepts. However, the goals of nursing have remained the same. The focus of nursing is on the patient's response to illness and health and the mechanisms that allow nurses to empower patients to ensure better outcomes. Nursing theory views the patient as part of a larger system30 and the nurse as an equal part of the health care team, not subordinate to or assisting the doctor.
PAs are trained in the so-called medical model; that is to say, there is an intensive didactic lecture series consisting of traditional health science topics31 followed by hands-on clinical experience, similar to medical school curricula. The clinical experiences are in generalist fields, in keeping with the original intent of increasing access to primary care providers. The goal of PA education is to prepare the student academically and clinically to provide health care services under the direction and supervision of a doctor of medicine or osteopathy. Postgraduate training is optional.
Many aspects of the training that NPs and PAs receive are similar. In fact, in some institutions, there are combined NP/PA lectures and coursework. These similarities are even more pronounced in the NICU, with some neonatal PAs (NPAs) being trained by senior NNPs.32
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THE ROLE OF NPCs IN THE NICU |
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TOPABSTRACTDEFINITIONSHISTORICAL PERSPECTIVES ON NPCsMODELS FOR TRAINING NNPs...THE ROLE OF NPCs...PA RESIDENCY PROGRAM IN...PATHWAY TO A PROGRAMCONCLUSIONSREFERENCES |
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In 1993, as a result of downsizing of residencies, pediatric residents were withdrawn from the NICU at the Albert Einstein College of Medicine-Montfiore Medical Center in the Bronx, NY, and replaced with NPCs. The transition occurred over 18 months with minimal impact on hospital revenue and no effect on the quality of care.32 Results of a 1995 survey showed that >60% of teaching hospitals had experience with either replacing housestaff or augmenting the residency programs with NPCs.33
In February 2003, the AAP issued a policy statement on the scope of practice of NPCs.34 They recommend that pediatric care be delivered with a team approach. The team leader should be a physician, preferably a pediatrician. The American Academy of Physician Assistants has made it a policy of the organization that PAs should practice under the supervision of a physician who is responsible for the care of the patient. Professional organizations representing NPs, on the other hand, have continued to push for increasing autonomy for their constituents. The AAP supports the supervisory role for the physician-PA relationship and a collaborative relationship between physicians and NPs. The AAP does not support independent practice for NPCs.
It is obvious that training permanent NICU personnel is a good idea. When few pediatric residents are interested in neonatology, and those that feel they have a calling to the field have increasing limitations put on their exposure to the NICU, "It makes more sense from a public policy perspective to encourage the use of such persons [NPCs] who will be available for an entire career, as opposed to residents who work for only 3 years before going to the already existing surplus of practicing physicians."35
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PA RESIDENCY PROGRAM IN NEONATOLOGY |
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TOPABSTRACTDEFINITIONSHISTORICAL PERSPECTIVES ON NPCsMODELS FOR TRAINING NNPs...THE ROLE OF NPCs...PA RESIDENCY PROGRAM IN...PATHWAY TO A PROGRAMCONCLUSIONSREFERENCES |
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At the University of Kentucky, as with most academic institutions, the limitation of resident work hours combined with the increasing demands on physicians' time and a growing number of patients in the NICU have led to a relative workforce shortage in the NICU. We initially attempted to meet our personnel needs by expanding NNP coverage. However, we have been unable to recruit and/or retain enough qualified individuals to provide complete ("24/7") coverage of the NICU. The university has a flourishing PA training program that, up to this point, had been an untapped resource for the NICU.
Realizing that PA training is in general primary care practice, it was obvious that any PA we would hire for the NICU would not have the knowledge base or skills required for competent practice in the NICU. Therefore, a probationary period, or residency, would have to be developed to give these individuals neonatal experience. We developed a 1-year curriculum of clinical experience combined with didactic lectures. Essentially, we attempt to cover the entire clinical component of a neonatology fellowship in 1 year instead of 3 years, which is the current standard for physicians.
The clinical curriculum consists of 8 months of hands-on training in the NICU, 1 month in the newborn nursery, 1 month of high-risk obstetrics, and three 2-week electives on other services. Specific goals were developed for each rotation. In general, the focus of the NICU months is to gain experience and knowledge in patient management and technical skills. Experience in the newborn nursery gives the PA resident more opportunity to examine normal newborns and, thus, be able to recognize abnormal findings. The goals of the obstetric and elective rotations are for the resident to learn how these services interact with neonatology, how what happens on these services affects the patient in the NICU, and how what happens in the NICU affects the other services.
The PA resident takes in-house calls during the residency. They are on-call with a resident and an attending physician. Initially, the pediatric residents provided an excellent resource for the PA. As the PAs gained more experience, they soon began serving as a resource for the pediatric residents. The on-call schedule is necessary because it provides the PA resident with a greater opportunity to learn the skills required for a career in the NICU.
The didactic curriculum consists of the lectures that are usually arranged for the neonatology fellowship program. Because of the volume of material that must be covered, additional lecture time for the PA residents is also arranged. These lectures are on disease-specific or clinically oriented topics that follow an outline that was developed by combining several study guides for neonatology fellowship. Research topics are not included in the curriculum, but accommodations can be made if a particular resident is so inclined. The PA residents also attend regional or national clinical conferences.
Training needs of the PA residents are met through bedside teaching rounds and small didactic sessions during clinical rotations (which do not require additional commitments from the faculty), the regular didactic lectures designed for the fellowship program (also, not requiring additional commitments from the faculty), and PA resident-specific sessions usually requiring 1 extra hour per week divided among the faculty.
Graduates of the PA residency program will command salaries similar to NNPs. At the discretion of the institution, they may be able to bill for some services that would offset some of the cost of their employment.
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PATHWAY TO A PROGRAM |
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TOPABSTRACTDEFINITIONSHISTORICAL PERSPECTIVES ON NPCsMODELS FOR TRAINING NNPs...THE ROLE OF NPCs...PA RESIDENCY PROGRAM IN...PATHWAY TO A PROGRAMCONCLUSIONSREFERENCES |
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When a new training program is considered, there are going to be barriers to acceptance. Some barriers are inherent to trying anything new, and some are specific to an institution. To start our program, we had to deal with these issues and others.
At the program level, a curriculum had to be developed. Selection of a text book and scheduling lectures had to occur. The faculty had to be convinced of the value and feasibility of a new training program for PAs. The economic cost of the program had to be considered. PA resident salaries and benefits had to be provided. There were costs associated with printing brochures, advertising, and recruiting. Money for conferences and travel expenses was found. We had to determine if the PA resident would be billing for services in the NICU. Ultimately, we decided not to do so. Although human resources views the PA resident as a fully trained PA, in the NICU they are considered residents and in training.
We are considering ways to make the program economically independent. One possible method is finding other NICUs that would be willing to sponsor a PA resident in exchange for a commitment of some number of years of employment after residency.
At the institution level, the Committee on Graduate Medical Education had to be convinced that the new program would not interfere with the accredited residency programs of the university. This was certainly a valid concern, and we did not want to interfere with the optimal training of pediatric residents. In the end, it was clear that our 50-plus-bed NICU is big enough and busy enough to provide a thorough educational experience for both PAs and pediatric residents. Furthermore, the PA, starting the program with a meager knowledge base for neonatology, would provide the pediatric resident with another opportunity to hone teaching skills, improving the residency experience for both. Eventually, the PA residents gain more clinical experience than even the senior pediatric residents and can provide an additional resource for the pediatrician in training. Procedure logs have been maintained for the PA residents, similar to pediatric residents, to ensure proficiency and document any impact on the pediatric residents' opportunities to perform procedures. Our PA residents make up 10% to 30% of the NICU team (depending on the number of residents or NNPs that are working at the time) and are performing just over 10% of the procedures. They are gaining proficiency and experience without adversely affecting the pediatric residency. Another issue at the institutional level is the fact that the PA residents are seen by human resources as full employees, although they are technically in training. Therefore, they had to go through the credentialing process as with any other employee.
At the state level, the PA residents had to receive their state licenses before starting work. Again, this is an issue of being seen as full employees, unlike the pediatric residents, who are not licensed during the initial part of their training.
At the national level, there is currently no accreditation process for PA residency training. The ARC-PA is developing standards to be implemented in an optional accreditation process to begin in 2007. We joined the Association of Postgraduate PA Programs as part of our program development.
Also, at the national level, some view PA residency training as antithetical to the PA profession. Currently, PAs enjoy a great deal of lateral mobility within the medical profession. There is fear that postgraduate training will limit this mobility. Obviously, we disagree with this assessment. It is more likely that residency training will enhance the PA profession, giving those individuals who seek it additional competence and confidence in areas both inside and outside of the specialty in which their postgraduate training occurred.
Ignorance about PAs in general can be a major barrier to acceptance. The postgraduate training program for PAs in neonatology at the University of Kentucky was the first postgraduate program for PAs at the university. It was the second formal training program for PAs in neonatology in history and, when it started, was the only such program in existence. NICU personnel are accustomed to dealing with NNPs and often knew certain NNPs before and during their training. Few neonatologists and NICU nurses have ever interacted with PAs. Personnel may be unaware of the PAs' training and potential for growth in the NICU environment. Likewise, the state medical board, which oversees PA practice, does not have a definition for PA residents and views them as any other PA in practice. We have had to address these issues with our program. In England, where NPC programs are relatively new, many authors, program directors, and participants are dealing with similar issues for both PAs and NPs.36–40 These were the same issues encountered by the previous NPA training program >25 years ago. They had encountered the lack of a definition of PA residents to be a problem at the institution and at the state and national levels. Gaining acceptance from persons who had not worked with PAs previously was also an issue (G.A. Halterman, III, PA, MS, JD, verbal communication, 2006).
As part of our quality improvement process for the PA program, we administered an anonymous questionnaire to pediatric residents. Twenty-five of the respondents stated that they had worked with a PA resident in the NICU in the last year. Results of the questionnaire are summarized on Table 2. In addition, in the 1 year the program has been in place, only 4 pediatric residents stated that procedures he or she expected to do were given to PA residents. Because of the anonymous nature of the survey, we cannot identify the exact procedure or resident. However, given the volume of patients in our NICU, it is highly likely that these residents performed or will perform the missed procedures at some other time during their pediatric residency. Results from this small survey suggest that our PA program is having an immediate positive impact on the residency training in our NICU. Pediatric residents' opinions of the NPA residents are similar to their opinions of the NNPs. Additional evaluations are planned as more residents and nurses work with the PA residents.
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CONCLUSIONS |
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TOPABSTRACTDEFINITIONSHISTORICAL PERSPECTIVES ON NPCsMODELS FOR TRAINING NNPs...THE ROLE OF NPCs...PA RESIDENCY PROGRAM IN...PATHWAY TO A PROGRAMCONCLUSIONSREFERENCES |
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The future of the NPA is very promising. As the number of preterm infants continues to grow and resident work hours are scaled back, many institutions will continue to find gaps in their workforces. NPAs can be trained quickly and relatively inexpensively to fill those gaps. Postgraduate training in neonatology will obviously prepare a PA for a career in the NICU. In addition, the PAs who receive formal NICU training will be better prepared for other areas of pediatric general practice and subspecialty care. For example, a PA working in pediatric surgery, who has 1 year of neonatal nutrition, fluid, and ventilator management, would be a tremendous asset to the surgery program. NPA graduates in other areas of pediatrics will be more comfortable with newborn patients and have unique perspectives on their patients' conditions. It is unlikely that NNPs would choose such a career path.
Regional variations in personnel and limited resident work hours will continue to cause local workforce shortages in the NICU. The PA represents a mostly untapped resource to resolve these workforce issues. After appropriate training, the NPA will be able to provide high-quality medical care, under the supervision of the attending physician. We envision an era in which the NNP-NPA relationship will be seen, as with other NP-PA relationships, as "interchangeable but not identical."41 Neonatology training will also help those PAs who wish to practice in other areas of pediatrics or pediatric subspecialties by making them more comfortable meeting the needs of our smallest patients.
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FOOTNOTES |
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Accepted Sep 29, 2006.
Address correspondence to Eric W. Reynolds, MD, Department of Pediatrics, Division of Neonatology, University of Kentucky College of Medicine, 800 Rose St, MS 477, Lexington, KY 40536. E-mail: ereyn2{at}uky.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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