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The NNP Workforce

The NNP Workforce. Erin L. Keels MS, APRN, NNP-BC NNP Program Manager Nationwide Children’s Hospital Columbus, Ohio . Disclosures. No conflict of interest. Objectives. Describe current legislative and policy recommendations impacting the practice of the NNP

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The NNP Workforce

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  1. The NNP Workforce Erin L. Keels MS, APRN, NNP-BC NNP Program Manager Nationwide Children’s Hospital Columbus, Ohio

  2. Disclosures • No conflict of interest

  3. Objectives • Describe current legislative and policy recommendations impacting the practice of the NNP • Discuss the current professional recommendations impacting the practice of the NNP • List at least three items to consider for improving his or her professional practice

  4. We’ve Come A Long Way, Baby • 1960: First NICU • 1975: Neonatology --Pediatric Subspecialty • 1970s: NNP role developed • 1970s- proliferation of certification programs • 1970-1990s: increase in utilization of NNPs • 1983: NCC offers NNP Certification Exam • 1980- 2000s: Studies: Care equivalent to/exceeds medical resident • 1984 NANN founded

  5. 1990s: Certificate programs absorbed into graduate • 2001: ANN founded • 2003, 2009: Neonatal APRN role endorsed by AAP • 2009- 2012: NANN/P Position Papers: • Requirements for Advanced Neonatal Nursing Practice in Neonatal Intensive Care Units • Standard for Maintaining the Competence of Neonatal Nurse Practitioners • The Doctor of Nursing Practice Degree • Impact of Fatigue • NNP Workforce • 2011: 4725 certified NNPs in US • Supply vs Demand issues for NNP

  6. Patient Protection and Affordable Care Act (ACA):http://www.whitehouse.gov/healthreform • “Obamacare” • Signed into law 2010 • Goals • Decrease number of uninsured Americans • Reduce overall cost of healthcare Approximately 30 million more patients are expected to enter the healthcare system through 2019. Shortage of primary care physicians is expected to surpass 52,000 by 2025

  7. Patient Protection and Affordable Care Act (ACA): - State Based Insurance Exchanges • Medicaid eligibility, enrollment and state budgets -State Practice Laws • NPA revised, full scope of APRN practice • Pushback expected • Truth in Advertising • Neutral provider language • Who can be called DOCTOR? • Patient Safety and Public Health • Transparency, Access

  8. The Future of Nursing Institute of Medicine Recommendations (2010) http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf 1. Remove scope of practice barriers 2. Expand opportunities for nurses to leadcollaborative improvement efforts 3. Implement nurse residency programs 4. Increase the number of nurses with a baccalaureate degree to 80% by 2020 5. Double the number of nurses with a doctorate by 2020 6. Ensure that nurses engage in life long learning 7. Prepare and enable nurses to lead change and advance health 8. Build an infrastructure for the collection and analysis of interprofessional health care workforce data

  9. Other Factors • March of Dimes: • Rates of prematurity in the United States continue to outpace other countries • Medical House Staff • Decreased hands-on clinical experience availability to provide patient care for pediatric residents in the NICU. • Shifting the patient care workload onto other providers: Neonatal Attendings and Fellows, Physician Assistants and NNPs (Freed, 2012). • A recent survey conducted of children’s hospitals (Freed,2012): • Planned to hire more hospitalists; PAs; hire more NNPs.

  10. NNP Shortage Contributing Factors: • Decreased enrollment in NNP programs • Loss of workers to retirement and decreased hours • NNP programs closing • Poor/limited access to preceptors • Financial burden of higher education and the struggle to work while attending school • Reasons RNs may not want to pursue NNP role: • Workload • Salary • Work schedule

  11. Our Challenge • Establish/maintain adequate numbers of NNPs • Recruitment, retention • Ensure competency, quality and safety • Education, certification, licensure, OPPE • Contribute to body of knowledge and research • Professional role • Articulate contribution and importance of role • Sustainability of role, billing/reimbursement

  12. The APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee (2008): • APRN licensure, accreditation, certification and education must be effectively aligned to meet healthcare needs in a safe and effective manner in order increase access and improve outcomes. • States independently license and define scope of APRN practice; no uniform standard; creates barriers to access

  13. The APRN Consensus Work Group • National Model of APRN Regulation: • Standardizes foundations of licensure, accreditation, certification, and educations • Establishes independent practitioner role • Aim for full implementation 2015 • Improve state to state reciprocity and patient access • Ensure quality and safety of APRN practice • Provide guidance for those involved with APRN education, licensure, accreditation, certification, regulation and employers.

  14. APRN Consensus Modelhttps://www.ncsbn.org/2276.htm

  15. APRN Consensus Model Toolkit

  16. L. A. C. E. • Licensure • Standardize foundations of licensure through state BONs: • Require national certification • Ban temporary licenses • Ensure education and certification are congruent with license • Independent practitioners • Utilize APRN advisory councils • Grandfather currently practicing APRNs

  17. L. A. C. E. • Accreditation: • Sets requirements for accreditation of education programs • Certification: • Sets requirements for national certification exams that are psychometrically and legally sound • Certification must be congruent with education • Competence assessed through professional organizations

  18. L. A.C. E. • Education: • Across the lifespan • Graduate programs accredited nationally • Graduates prepared to sit for national certification

  19. Where is Your State? • Go to the NCSBN website • See where your State is with implementation • Contact your State Board of Nursing • Get involved

  20. NANN NNP Workforce Survey Report (2011) National Certification Corporation (NCC) database 4725 certified NNPs in the US. 679 (14%) NNPs responded to survey

  21. NNP Workforce Survey Results • Wide and unbalanced geographical distribution of NNPs • 25% work 24 hour shifts, and two-thirds are not guaranteed downtime. • The majority of respondents are very satisfied with their career.

  22. NNP Workforce Survey Results • Lack of knowledge regarding billing procedures • The supply of NNPs may not be distributed according to need • Studies are needed to examine the demand for NNPs and the roles of other clinicians in the NICU

  23. NNP Workforce Survey Report Recommendations • Implementation of the APRN Consensus Model • Development of Collaborative Practice Models • Enhance visibility of NNPs • Establish safe & appropriate workloads and work hours • Increase knowledge of billing practices

  24. NANN NNP Workforce Position Paper (2012) http://www.nann.org/uploads/NNP_Workforce_Position_Statement_01.22.13_FINAL.pdf PURPOSE: • Define the NNP contribution to the neonatal workforce environment • Propose a framework and factors to consider in assessing workload EVIDENCE: • Institute of Medicine (IOM) report (2010) • American Nurses Association Principals of Nurse Staffing (2012) • ACGME Guidelines (2010)

  25. The Many Roles of the NNP • Leadership role • Transformational • Clinical Care • EBP, Quality Improvement, Bench to Bedside • Patient and Family • Diverse Work Settings • Community/academic, urban/rural • Interprofessional Collaboration • Multidisciplinary, multidepartmental

  26. The Many Roles of the NNP • Educator: families, staff, peers, interdisciplinary team • Preceptor:student NNPs, new NNP staff, RN, other professionals • Mentor: RN, NNP, Fellows, Resident, New Faculty, other professionals • Advocate: patients/families, clinical and professional practice

  27. Safety and Quality of Care National Organization of Nurse Practitioner Faculty Competencies (2012) Scientific Foundation Leadership Quality Practice Inquiry Technology and Information Literacy Policy Health Delivery System Ethics Independent Practice

  28. Safety and Quality of Care National Association of Neonatal Nurse Practitioners NNP Competencies (2011) Management of Patient Health/Illness Status The Nurse Practitioner-Patient Relationship The Teaching/Coaching Function Professional Role Managing and Negotiating Health Care Delivery Systems Monitoring and Ensuring the Quality of Health Care Practice Culturally Sensitive Care

  29. 2013 • NANNP revising NNP education standards and competencies • Improve alignment with NONPF and IOM statement

  30. Safety and Quality of Care The Joint Commission: Ongoing Professional Performance Evaluation (OPPE) -Organizations must: Review performance data for all practitioners with privileges on an ongoing basis Take steps to improve performance in timely basis.

  31. Safety and Quality of Care The Joint Commission Focused Professional Practice Evaluation (FPPE) Targeted, focused monitoring of competency associated with the exercise of clinical privileges: -New privileges: all initial (new) privileges -Quality of Care Concern: specific questions/ concerns regarding a currently privileged Practitioner’s clinical competence, and/or professional behavior, and/or the ability to safely perform any privilege.

  32. Examples of Evidence • Delivery logs • Procedure logs • Consult logs • Prescriptive practice audits • Code review • Chart reviews • -Documentation reviews • Delivery room • Sedation • Procedures • -Adverse drug events • -Serious safety events • -Complaints/compliments • -Hours worked

  33. Challenges • Develop individual and group NNP-specific outcomes metrics • Institution- specific, state, national • Novice to expert continuum

  34. Billing and Reimbursement • Many Do NOT bill • Education and training needed • NANN hopes to develop webinars and/or workshops in the future

  35. NNP Caseload Given the multifaceted role, challenges and attributes of the NNP, what is a reasonable case load?? What evidence exists?

  36. ANA Principles of Staffing • Level of Care, census, patient acuity • Procedures performed • Worked hours per patient day • Continuity of care, readmissions/deliveries/discharges • Consultations/transports • Quality of work environment/EBP/Technology • Communication and teamwork

  37. Additional Factors to Consider • NNP Level of competence and experience • Novice to expert • Body of evidence related to fatigue and impact on safety & quality • Level of patient acuity • Site specific workload issues

  38. NNP Workforce Paper Recommendations: • Personal and professional accountability for mental acumen and physical fitness to manage flexible, acute situations for multiple neonatal patients • Caseloads: • Consistent with level of acuity & NNP capability • Flexible- taking into account additional NNP responsibilities • Mentoring, deliveries, procedures etc.

  39. NNP Workforce Paper Recommendations: • Advanced Beginner • 6 patients • Competent to Expert • 10 patients when activity is high • Proficient and Expert • >10 when activity and acuity decreased

  40. NANNP Preceptorship Modulehttp://www.nann.org/uploads/NNP_Workforce_Position_Statement_01.22.13_FINAL.pdf Approaches to Teaching Adult Learners Role Transition Guidance for Preceptors Guidance for Learners Clinical Supervision in the Acute Care Setting Case Scenarios in Precepting

  41. The Impact of Advanced Practice Nurses’ Shift Length and Fatigue on Patient Safety (2011)http://www.nann.org/uploads/files/Fatigue_and_APRNs.pdf Standards in shift work? Job satisfaction did not vary with shift length in 2011 survey. The highest patient load was associated with night shift or 24-hour shifts Most common NNP shift length was 24 hours, followed by 12-, 10-, and 8-hour shifts, respectively No data exist for optimal NNP shift length

  42. Shift Length and Safety ACGME Decreased resident duty hours in 2003 and again in 2011 IOM published nursing recommendations, guidelines for patient safety in 2004 Landrigan and colleagues(2004) and Lockley and colleagues (2004) Reduced incidences of attentional failures and serious medical errors among interns working shorter shift lengths compared with those interns working a traditional schedule with extended shift lengths.

  43. Impact on Shift Length and Safety Johnson, 2011: Residents who worked more than 24 hours had a 16% higher risk of having a motor vehicle accident post-call. Buus-Frank, 2005; Lockley et al., 2007; LoSasso,2011: Task performance, after approximately 17 hours of wakefulness, is comparable to that seen in people with blood alcohol levels of 0.05 or who are under the influence

  44. No Differences? • Studies performed after the decrease in ACGME hours: • No evidence of prolonged hospital stays • No changes in mortality, morbidities • No differences in hospital readmission rates • No changes in failure to rescue • AMS who worked 24-hour shifts had little sleep debt, which was attributed to their ability to nap while on duty

  45. Differences Detected • Nursing Research findings: • Increased nursing errors when working longer than 12.5 hours • Relationship between nurse hours worked and patient mortality • Relationship between nurse hours worked, sleep duration and drowsy driving • Fatigue Research: • Delayed processing of information, diminished memory • Delayed reaction time, impaired efficiency • Lapses in vigilance, inappropriate responses

  46. Position Papers • Resident Duty Hours: Enhancing Sleep, Supervision, and Safety (IOM, 2008): Factors that increase risk of harm to patients: -prolonged wakefulness -shifts longer than 16 consecutive hours -variability of shifts -volume and acuity of patient load

  47. Position Papers • The Joint Commission Sentinel Event Alert, December 2011: • Acknowledge the research to date linking extended-duration worked shifts, fatigue, and impaired performance and safety. • American Nurses Association 2006: • recommend shift length for nurses of no more than 12 hours in a 24-hour period or 60 hours in a 7-day period

  48. State Law • New York State Office of the Professions http://www.nysna.org/practice/mot/intro.htm • Nurses who voluntarily work more than 16 hours must be able to demonstrate competence to fulfill professional duties. • Working beyond 16 hours will be considered as a factor in determining willful disregard for patient safety and could result in charges of unprofessional conduct

  49. NANN Recommendations: Education • Awareness that fatigue may result in altered clinical performance, increased potential for errors, which may impact safety • Recognize signs of fatigue and be willing to institute appropriate interventions • Educational programs • dangers of fatigue, the causes of sleepiness on the job, importance of sleep, proper sleep hygiene

  50. Recommendations: Fatigue Management • Fatigue-related risks should be alleviated by research-based strategies: • Good sleep habits and routines on non/working days and nights • To avoid chronic sleep deprivation (8 hours/day) • Disruption of the circadian rhythm should be reduced • Sleep in the afternoon before working overnight • NNPs who are more than 40 years of age should be aware that they are at increased risk

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