DOI: 10.1542/peds.2006-1084 2007

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DOI: 10.1542/peds.2006-1084 2007

  1. 1. Nonphysician Clinicians in the Neonatal Intensive Care Unit: Meeting the Needs of Our Smallest Patients Eric W. Reynolds and J. Timothy Bricker Pediatrics 2007;119;361-369 DOI: 10.1542/peds.2006-1084 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/119/2/361 PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2007 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from www.pediatrics.org by on August 13, 2010
  2. 2. SPECIAL ARTICLE Nonphysician Clinicians in the Neonatal Intensive Care Unit: Meeting the Needs of Our Smallest Patients Eric W. Reynolds, MDa,b, J. Timothy Bricker, MDb a Division of Neonatology, bDepartment of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky The authors have indicated they have no financial relationships relevant to this article to disclose. ABSTRACT Regional variations in the distribution of neonatal physicians and dependence on housestaff with restricted work hours have created workforce shortages in many www.pediatrics.org/cgi/doi/10.1542/ NICUs. Although neonatal nurse practitioners assist in the delivery of high-quality peds.2006-1084 care, availability of these providers may be inadequate in certain regions. Physician doi:10.1542/peds.2006-1084 assistants represent a historically underutilized resource to resolve neonatology’s Key Words workforce issues. We have developed a postgraduate training program for physi- neonatal nurse practitioner, physician cian assistants in neonatology that we hope will improve local and regional assistant, alternative health care providers, neonatal intensive care workforce shortages. In this article we discuss the history of neonatal nurse Abbreviations practitioners and physician assistants in newborn care and outline the program NPC—nonphysician clinician that we developed. We further discuss some of the barriers we had to overcome in NP—nurse practitioner NNP—neonatal nurse practitioner developing this program. Our program can serve as a model for other neonatology PA—physician assistant programs to adequately prepare physician assistants for a career in the NICU. AAP—American Academy of Pediatrics ARC-PA—Accreditation Review Commission on Education for the Physician Assistant AMA—American Medical Association NPA—neonatal physician assistant Accepted for publication 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@uky.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2007 by the American Academy of Pediatrics PEDIATRICS Volume 119, Number 2, February 2007 361 Downloaded from www.pediatrics.org by on August 13, 2010
  3. 3. M ORE PRETERM INFANTS with long hospital stays have put increasing pressure on the neonatology workforce. Although certain commentaries have identi- tificate or a Master’s degree. As of 2003, nearly all pro- grams required Master’s level training.5 A national cer- tification examination is administered, and continuing fied what some consider an overabundance of neonatol- education is required. Scope of practice varies by state. ogy physicians,1–3 regional variation in supply and the In medically underserved areas, NPs may provide care demands on physicians’ time have resulted in a situation that is usually offered only by physicians. In most states, in which it is increasingly difficult to provide optimal NPs have some prescribing authority. care. Therefore, neonatologists have become increas- PAs are licensed to practice medicine with physician ingly dependent on residents and nonphysician clini- supervision. They are trained in educational programs cians (NPCs) such as neonatal nurse practitioners accredited by the Accreditation Review Commission on (NNPs). However, some institutions find it difficult to Education for the Physician Assistant (ARC-PA). The hire and/or retain these professionals. Physician assis- mean length of PA programs is 26 months. PA students tants (PAs) are an underutilized resource that may be complete 2000 hours of supervised clinical practice available to fill continued workforce gaps. before graduation. Many PA programs are moving to NPCs have been an important part of health care Master’s level education. PAs conduct physical exami- delivery in many cultures throughout history.4 NPCs are nations, diagnose and treat illnesses, order and interpret a heterogeneous group of health care providers, tradi- tests, counsel on preventive health care, assist in sur- tionally including nurse practitioners (NPs), clinical gery, and, in virtually all states, can write at least some nurse specialists, certified nurse midwives, and PAs. prescriptions. Within the physician-PA relationship, PAs Other groups included in discussions of NPCs are chiro- exercise autonomy in medical decision-making and pro- practors, acupuncturists, and naturopaths. The NP and vide a broad range of diagnostic and therapeutic services, PA professions began in the mid-1960s (the same time as as well as educational, research, and administrative du- modern neonatology, incidentally) in an effort to meet ties. The national PA professional organization is content the need for more access to primary care services. Over to continue the physician-PA relationship in its current the past 40 years, NPs have become common in the supervisory form. NICU, with rigorous educational requirements and li- censure standards specific to their area of practice. The HISTORICAL PERSPECTIVES ON NPCs role of PAs in primary care and surgical specialties has In the early 1960s it became clear that to meet the been well established. However, their role in most areas growing needs of the American health care system, more of subspecialty care has not yet become widely accepted, primary care providers needed to be trained. Congress particularly in the NICU. created the National Institute of Child Health and Hu- In this article we describe the history of NNPs and PAs man Development in 1962 to address disparities in in neonatology, identify the roles NPCs play in the de- health outcomes and health care among mothers and livery of neonatal care, and discuss the efforts of our children. However, training new doctors takes time and program to create PAs with the technical skills and money. Dr Charles Hudson spoke to the American Med- knowledge required for a career in the NICU. ical Association (AMA) in 1961 about a new group of health care providers and suggested that military corps- DEFINITIONS men could be trained in the technical aspects of medi- Much discussion about the name for the generic group cine but take little or no part in diagnosis or prescribing of advanced-practice nurses and fast-tracked medical drugs.4 By 1965, 2 new pathways were created to meet professionals has occurred. In this article, “nonphysician the primary care workforce needs: the NP and PA routes. clinician” (NPC) will be used to describe these health Over the past 40 years, the realization of new workforce care providers. Although we acknowledge that this title issues and a desire for professional growth have forced actually describes what these providers are not, it is in expansion of NPC roles beyond primary care and into keeping with past statements issued by the American subspecialty and hospital-based practice. Table 1 in- Academy of Pediatrics (AAP). cludes a list of events in the history of both the NNP and An NP is a registered nurse with advanced academic PA professions. and clinical experience that enables her (traditionally) or The first advanced-practice nurse training program him to diagnose and manage most common and many began in 1965 at the University of Colorado. Drs Loretta chronic illnesses either independently or as part of a Ford and Henry Silver are credited with being the health care team. A registered nurse should have exten- founders of the NP movement.6 However, publications sive clinical experience before applying to an NP pro- by Dr Ford and others have identified the Western In- gram. A preceptorship under the supervision of a phy- terstate Commission on Higher Education as the major sician or an experienced NP and instruction in nursing impetus for the creation of the modern NP movement.7,8 theory are key components of most NP programs. NPs The initial goals of the program were to provide (1) are educated through programs that grant either a cer- primary care in underserved areas, (2) more health 362 REYNOLDS, BRICKER Downloaded from www.pediatrics.org by on August 13, 2010
  4. 4. TABLE 1 Timeline of Important Events in the History of NNP and PA Professions NNPs PAs History Historic NPCs: midwives, feldshers (Germany and Russia), officiers de sante (France), barefoot doctors (China), and other minimally trained medical providers4 Early 1960s First attempt to expand nursing role in primary care at Duke University by Dr Eugene Stead and Thelma Ingles, RN, fails to win national accreditation because of resistance from the National League of Nursing22 1961 Dr Charles Hudson addresses the AMA about training military corpsmen for technical aspects of medical care but not diagnosis or prescribing4 1962 National Institutes of Child Health and Human Development forms 1964 Nurse Training Act: includes loans to nursing students, grants to develop and improve teaching programs in diploma schools and for advanced nursing training in administration, academic and clinical specialties Hill-Burton Act is amended to provide federal assistance to construct and upgrade nursing facilities 1965 First NP Program at University of Colorado founded by Drs Ford and Silver6 Drs Stead and Saltzman form first PA program at Duke University22 1968 PA programs at Bowman-Gray University and Alderson-Broadus College4 1969 MEDEX program at University of Washington4 1970 Hill-Burton Act is amended again to provide more federal assistance to construct and upgrade nursing facilities Frontier Nursing Service is instituted in Kentucky by Mary Breckinridge42 Health Manpower Act: provides funding for PA training programs AMA recognizes PA profession4 1971 AMA Committee on Allied Health Education and Accreditation develop guidelines for PA training programs. American Academy of Physician Assistants and Association of PA Programs are established43 First postgraduate training program for PAs started at Montefiore Hospital in New York in Department of Surgery44 1973 First advanced-practice neonatal nurse program at the University of Utah under Dr August Jung12 First use of term “neonatal nurse practitioner”45 University of Arizona program for NNPs fails to win March of Dimes funding because the term “practitioner” blurs the line between medical and nursing practice12 1974 University of Wisconsin program for “Neonatal Nurse Clinicians” funded by the March of Dimes March of Dimes Blue Ribbon Commission to examine the issue of formal educational standards for NNPs12 American Nurses Association Congress of Nurse Practitioners AAP issues first statement on scope of practice of PNPs46 1975 Guidelines for Short-term Continuing Education Programs for the Nurse Clinician in National Commission on Certification of Physician Assistants is Intensive Maternal-Fetal Care11 is published founded43 Physician Assistant National Certification Exam included in certification process for PAs43 1977 Rural Health Clinic Act: authorizes Medicare and Medicaid payments to NPs, PAs, and certified nurse midwives; limits independent practice to underserved areas PA students in newborn nursery at University of South Carolina25 1979 Patricia Johnson study finds quality of care delivered by NNPs to be comparable Full-time PA position in the intermediate care nursery established or superior to pediatric interns18 at the University of South Carolina25 1980s to First postgraduate program for PAs in neonatology at the early University of Southern California; state funding withdrawn in 1990s mid-1990s and program discontinued (G. A. Halterman, III, PA, MS, JD, verbal communication, 2006)23,24 1982 First Neonatal Nurse Clinician Practitioner Specialist meeting12 1983 First certification examination for NNPs 1984 Neonatal Nurse Clinician Practitioner Specialist affiliates with the National Association of Neonatal Nurses 1990s New education standards for NNPs13,14 1992 AAP adopts National Association of Neonatal Nurses titles and job descriptions for NNPs 1993 Housestaff at Montefiore Hospital is replaced with NPCs in the NICU32 1997 Balanced Budget Act: expands Medicare payments to NPCs at non–hospital sites and payments from CHAMPUS, FEHP, other federal programs, and most state Medicaid programs 1999 AAP statement on the role of NPs and PAs in the care of hospitalized children is published47 PEDIATRICS Volume 119, Number 2, February 2007 363 Downloaded from www.pediatrics.org by on August 13, 2010
  5. 5. TABLE 1 Continued NNPs PAs 2003 AAP Committee on the Fetus and Newborn statement on advanced-practice nursing is published48 AAP Committee on Pediatric Workforce statement on scope of practice is published34 Present and NPCs expand role and become essential to many, if not all, levels of health care future Studies of quality of care delivered by NPCs NPCs replace housestaff in some institutions PA postgraduate residency in neonatology at the University of Kentucky maintenance and prevention of illness for more people effort. This time, with Dr Herbert Saltzman, he was able for less cost, and (3) a newer, more responsible role for to obtain funding for an NPC training program. In 1965, nurses by expanding their existing skills to include ca- 4 Navy corpsmen began a 2-year program that was pabilities in health appraisal.9,10 The traditional nursing considered the forerunner to the modern PA model. characteristics (humanistic caring, comforting, nurtur- A 9-month graduate program for PAs in neonatology ing, and supporting) were to be maintained and im- was established in 1981 at the University of Southern proved by the addition of equal status with other health California Medical Center.23,24 It remained active until care providers, collaborative and complementary rela- the mid-1990s, when, because of budget cuts at the state tionships with physicians, and achievement of profes- level, it was discontinued (G. A. Halterman, III, PA, MS, sional autonomy.6 JD, verbal communication, 2006). In 1986, a survey of In 1975, the American Nurses Association published a PAs who graduated from that program found that, on report from a March of Dimes Blue Ribbon Commission, average, these PAs spent 22% of their time in level 1 Guidelines for Short-term Continuing Education Programs for nurseries, 53% of their time in level 2 nurseries, and the Nurse Clinician in Intensive Maternal-Fetal Care.11 This 25% of their time in level 3 nurseries.25 Thirty-three document served as the NNP training standard for nearly percent also worked in follow-up clinics. These PAs per- 20 years.12 During the 1990s, new standards were formed tasks covering the entire spectrum of newborn adopted for the education and practice of NNPs.13,14 Cur- care, from well-infant care to virtually every procedure rent standards are available from the National Associa- required in the NICU. Patient loads varied from 3 to 60 tion of Neonatal Nurses.15 depending on acuity. One third of the respondents par- NPs have been found to be acceptable, credible, and ticipated in research. Nearly all the respondents had a cost-effective alternatives to traditional physician care in role in the education of medical students and residents, both the outpatient and inpatient settings.16,17 In 1979, PA students, nursing staff, and respiratory therapists.25 an early study of the NNP role found the quality of care In 1997, there were nearly 29 000 PAs in the United delivered by the NNP to be comparable or superior to States. In 2002, that number had grown to 44 000.26 that of pediatric interns.18 Other studies have compared Now (in 2006) there are 135 accredited PA training NNPs to higher-level residents and physicians and found programs, and it is estimated that there are 58 665 prac- results similar to those from the earlier study.14 ticing PAs.27 Postgraduate training for PAs is optional. In 1992, there were 253 training programs for NPs in There is no accreditation process for PA residency pro- 119 institutions. By 1995, this number had increased to grams. However, the ARC-PA is implementing an op- 527 tracks in 202 institutions.19 In 1982, there were 29 tional accreditation program to begin in 2007. The As- neonatology-specific NP programs; this grew to 36 in sociation of Postgraduate PA Programs lists 32 member 1996.20 In 2000, there were 102 829 NPs in practice.5 By organizations. 2005, this number was expected to exceed 115 000.21 The PA profession was born in the same economic MODELS FOR TRAINING NNPs AND PAs and health care milieu as the NP movement. Dr Eugene NPs and PAs perform similar roles in many areas of Stead envisioned a way to meet the primary care needs health care. However, each profession points to differ- of rural North Carolina with “midlevel generalists.” His ences in philosophy to separate itself from the other. It is initial attempt was a collaborative effort with Thelma said that NPs are trained in the “nursing” model, and PA Ingles, RN, to expand nursing roles in generalist health education is based on the “medical” model. In the NICU, care delivery. On 3 occasions, the National League of it would seem that these differences have been reduced, Nursing opposed the program, citing that delegating if not eliminated. NNPs are taught to become proficient medical tasks to nurses was inappropriate.22 This is par- at diagnosis, treatment, and technical skills. PAs in the adoxical, given the fact that the NP program at the current NICU environment are exposed to “family-cen- University of Colorado was developing at the same time. tered care,” with more emphasis on the patient-parent- Dr Stead continued his work via another collaborative family unit rather than traditional disease diagnosis and 364 REYNOLDS, BRICKER Downloaded from www.pediatrics.org by on August 13, 2010
  6. 6. treatment. In institutions that employ both types of team leader should be a physician, preferably a pediatri- NPCs, an understanding of what makes these profession- cian. The American Academy of Physician Assistants has als similar, instead of focusing on differences, may help made it a policy of the organization that PAs should integrate individuals into a team that is better able to practice under the supervision of a physician who is deliver high-quality health care. responsible for the care of the patient. Professional or- Nearly all published definitions of an NP begin with ganizations representing NPs, on the other hand, have the phrase, “an NP is a registered nurse who. . . .” NP continued to push for increasing autonomy for their training, therefore, is based on a “nursing” model. Flo- constituents. The AAP supports the supervisory role for rence Nightingale was the first nursing theorist. She the physician-PA relationship and a collaborative rela- proposed basic tenets of nursing practice. Nurses were to tionship between physicians and NPs. The AAP does not “make astute observations of the sick and their environ- support independent practice for NPCs. ment, record observations and develop knowledge about It is obvious that training permanent NICU personnel factors that promoted healing.”28 She saw the role of the is a good idea. When few pediatric residents are inter- nurse as putting the patient “in the best condition for ested in neonatology, and those that feel they have a nature to act on him.”29 She saw nursing and medical calling to the field have increasing limitations put on knowledge as distinct disciplines. Over time, nursing their exposure to the NICU, “It makes more sense from theory has moved from grand, abstract constructs to a public policy perspective to encourage the use of such more problem-focused, concrete concepts. However, the persons [NPCs] who will be available for an entire ca- goals of nursing have remained the same. The focus of reer, as opposed to residents who work for only 3 years nursing is on the patient’s response to illness and health before going to the already existing surplus of practicing and the mechanisms that allow nurses to empower pa- physicians.”35 tients to ensure better outcomes. Nursing theory views the patient as part of a larger system30 and the nurse as PA RESIDENCY PROGRAM IN NEONATOLOGY an equal part of the health care team, not subordinate to At the University of Kentucky, as with most academic or assisting the doctor. institutions, the limitation of resident work hours com- PAs are trained in the so-called medical model; that is bined with the increasing demands on physicians’ time to say, there is an intensive didactic lecture series con- and a growing number of patients in the NICU have led sisting of traditional health science topics31 followed by to a relative workforce shortage in the NICU. We initially hands-on clinical experience, similar to medical school attempted to meet our personnel needs by expanding curricula. The clinical experiences are in generalist fields, NNP coverage. However, we have been unable to recruit in keeping with the original intent of increasing access to and/or retain enough qualified individuals to provide primary care providers. The goal of PA education is to complete (“24/7”) coverage of the NICU. The university prepare the student academically and clinically to pro- has a flourishing PA training program that, up to this vide health care services under the direction and super- point, had been an untapped resource for the NICU. vision of a doctor of medicine or osteopathy. Postgrad- Realizing that PA training is in general primary care uate training is optional. practice, it was obvious that any PA we would hire for Many aspects of the training that NPs and PAs receive the NICU would not have the knowledge base or skills are similar. In fact, in some institutions, there are com- required for competent practice in the NICU. Therefore, bined NP/PA lectures and coursework. These similarities a probationary period, or residency, would have to be are even more pronounced in the NICU, with some developed to give these individuals neonatal experience. neonatal PAs (NPAs) being trained by senior NNPs.32 We developed a 1-year curriculum of clinical experience combined with didactic lectures. Essentially, we attempt THE ROLE OF NPCs IN THE NICU to cover the entire clinical component of a neonatology In 1993, as a result of downsizing of residencies, pediat- fellowship in 1 year instead of 3 years, which is the ric residents were withdrawn from the NICU at the current standard for physicians. Albert Einstein College of Medicine-Montfiore Medical The clinical curriculum consists of 8 months of Center in the Bronx, NY, and replaced with NPCs. The hands-on training in the NICU, 1 month in the newborn transition occurred over 18 months with minimal impact nursery, 1 month of high-risk obstetrics, and three on hospital revenue and no effect on the quality of 2-week electives on other services. Specific goals were care.32 Results of a 1995 survey showed that 60% of developed for each rotation. In general, the focus of the teaching hospitals had experience with either replacing NICU months is to gain experience and knowledge in housestaff or augmenting the residency programs with patient management and technical skills. Experience in NPCs.33 the newborn nursery gives the PA resident more oppor- In February 2003, the AAP issued a policy statement tunity to examine normal newborns and, thus, be able to on the scope of practice of NPCs.34 They recommend that recognize abnormal findings. The goals of the obstetric pediatric care be delivered with a team approach. The and elective rotations are for the resident to learn how PEDIATRICS Volume 119, Number 2, February 2007 365 Downloaded from www.pediatrics.org by on August 13, 2010
  7. 7. these services interact with neonatology, how what hap- We are considering ways to make the program eco- pens on these services affects the patient in the NICU, nomically independent. One possible method is finding and how what happens in the NICU affects the other other NICUs that would be willing to sponsor a PA services. resident in exchange for a commitment of some number The PA resident takes in-house calls during the resi- of years of employment after residency. dency. They are on-call with a resident and an attending At the institution level, the Committee on Graduate physician. Initially, the pediatric residents provided an Medical Education had to be convinced that the new excellent resource for the PA. As the PAs gained more program would not interfere with the accredited resi- experience, they soon began serving as a resource for the dency programs of the university. This was certainly a pediatric residents. The on-call schedule is necessary valid concern, and we did not want to interfere with the because it provides the PA resident with a greater op- optimal training of pediatric residents. In the end, it was portunity to learn the skills required for a career in the clear that our 50-plus-bed NICU is big enough and busy NICU. enough to provide a thorough educational experience The didactic curriculum consists of the lectures that for both PAs and pediatric residents. Furthermore, the are usually arranged for the neonatology fellowship pro- PA, starting the program with a meager knowledge base gram. Because of the volume of material that must be for neonatology, would provide the pediatric resident covered, additional lecture time for the PA residents is with another opportunity to hone teaching skills, im- also arranged. These lectures are on disease-specific or proving the residency experience for both. Eventually, clinically oriented topics that follow an outline that was the PA residents gain more clinical experience than even developed by combining several study guides for neona- the senior pediatric residents and can provide an addi- tology fellowship. Research topics are not included in tional resource for the pediatrician in training. Proce- the curriculum, but accommodations can be made if a dure logs have been maintained for the PA residents, particular resident is so inclined. The PA residents also similar to pediatric residents, to ensure proficiency and attend regional or national clinical conferences. document any impact on the pediatric residents’ oppor- Training needs of the PA residents are met through tunities to perform procedures. Our PA residents make bedside teaching rounds and small didactic sessions dur- up 10% to 30% of the NICU team (depending on the ing clinical rotations (which do not require additional number of residents or NNPs that are working at the commitments from the faculty), the regular didactic lec- time) and are performing just over 10% of the proce- tures designed for the fellowship program (also, not dures. They are gaining proficiency and experience requiring additional commitments from the faculty), and without adversely affecting the pediatric residency. An- PA resident-specific sessions usually requiring 1 extra other issue at the institutional level is the fact that the PA hour per week divided among the faculty. residents are seen by human resources as full employees, Graduates of the PA residency program will com- although they are technically in training. Therefore, mand salaries similar to NNPs. At the discretion of the they had to go through the credentialing process as with institution, they may be able to bill for some services that any other employee. would offset some of the cost of their employment. At the state level, the PA residents had to receive their state licenses before starting work. Again, this is an issue PATHWAY TO A PROGRAM of being seen as full employees, unlike the pediatric When a new training program is considered, there are residents, who are not licensed during the initial part of going to be barriers to acceptance. Some barriers are their training. inherent to trying anything new, and some are specific At the national level, there is currently no accredita- to an institution. To start our program, we had to deal tion process for PA residency training. The ARC-PA is with these issues and others. developing standards to be implemented in an optional At the program level, a curriculum had to be devel- accreditation process to begin in 2007. We joined the oped. Selection of a text book and scheduling lectures Association of Postgraduate PA Programs as part of our had to occur. The faculty had to be convinced of the program development. value and feasibility of a new training program for PAs. Also, at the national level, some view PA residency The economic cost of the program had to be considered. training as antithetical to the PA profession. Currently, PA resident salaries and benefits had to be provided. PAs enjoy a great deal of lateral mobility within the There were costs associated with printing brochures, medical profession. There is fear that postgraduate train- advertising, and recruiting. Money for conferences and ing will limit this mobility. Obviously, we disagree with travel expenses was found. We had to determine if the this assessment. It is more likely that residency training PA resident would be billing for services in the NICU. will enhance the PA profession, giving those individuals Ultimately, we decided not to do so. Although human who seek it additional competence and confidence in resources views the PA resident as a fully trained PA, in areas both inside and outside of the specialty in which the NICU they are considered residents and in training. their postgraduate training occurred. 366 REYNOLDS, BRICKER Downloaded from www.pediatrics.org by on August 13, 2010
  8. 8. Ignorance about PAs in general can be a major barrier TABLE 2 Results of Questionnaire Survey Administered to Pediatric to acceptance. The postgraduate training program for Residents to Assess the Impact of the PA Residency PAs in neonatology at the University of Kentucky was Program on Pediatric Residency the first postgraduate program for PAs at the university. n It was the second formal training program for PAs in Respondents who had worked with PA residents 25 neonatology in history and, when it started, was the Overall impression of the PA resident only such program in existence. NICU personnel are Completely favorable 15 accustomed to dealing with NNPs and often knew cer- Mostly favorable 6 Neutral 3 tain NNPs before and during their training. Few neona- Mostly negative 0 tologists and NICU nurses have ever interacted with PAs. Completely negative 0 Personnel may be unaware of the PAs’ training and Overall impression of the NNP potential for growth in the NICU environment. Like- Completely favorable 13 wise, the state medical board, which oversees PA prac- Mostly favorable 10 Neutral 1 tice, does not have a definition for PA residents and Mostly negative 0 views them as any other PA in practice. We have had to Completely negative 0 address these issues with our program. In England, Agree or disagree with the following statements where NPC programs are relatively new, many authors, I served as a valuable teaching resource for the PA resident program directors, and participants are dealing with sim- Agree 15 Disagree 7 ilar issues for both PAs and NPs.36–40 These were the same Blank 3 issues encountered by the previous NPA training pro- I served as a valuable teaching resource for the NNP gram 25 years ago. They had encountered the lack of a Agree 2 definition of PA residents to be a problem at the institu- Disagree 20 tion and at the state and national levels. Gaining accep- Blank 3 The PA resident served as a valuable teaching resource for me tance from persons who had not worked with PAs pre- Agree 16 viously was also an issue (G. A. Halterman, III, PA, MS, Disagree 7 JD, verbal communication, 2006). Blank 2 As part of our quality improvement process for the PA The NNP served as a valuable teaching resource for me program, we administered an anonymous questionnaire Agree 21 Disagree 2 to pediatric residents. Twenty-five of the respondents Blank 2 stated that they had worked with a PA resident in the At what level will the PA resident function after graduation? NICU in the last year. Results of the questionnaire are Intern 24 summarized on Table 2. In addition, in the 1 year the Senior resident 21 program has been in place, only 4 pediatric residents Neonatal fellow 6 NNP 12 stated that procedures he or she expected to do were Attending physician 0 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 pared for other areas of pediatric general practice and will perform the missed procedures at some other time subspecialty care. For example, a PA working in pediat- during their pediatric residency. Results from this small ric surgery, who has 1 year of neonatal nutrition, fluid, survey suggest that our PA program is having an imme- and ventilator management, would be a tremendous diate positive impact on the residency training in our asset to the surgery program. NPA graduates in other NICU. Pediatric residents’ opinions of the NPA residents areas of pediatrics will be more comfortable with new- are similar to their opinions of the NNPs. Additional born patients and have unique perspectives on their evaluations are planned as more residents and nurses patients’ conditions. It is unlikely that NNPs would work with the PA residents. choose such a career path. Regional variations in personnel and limited resident CONCLUSIONS work hours will continue to cause local workforce short- The future of the NPA is very promising. As the number ages in the NICU. The PA represents a mostly untapped of preterm infants continues to grow and resident work resource to resolve these workforce issues. After appro- hours are scaled back, many institutions will continue to priate training, the NPA will be able to provide high- find gaps in their workforces. NPAs can be trained quality medical care, under the supervision of the at- quickly and relatively inexpensively to fill those gaps. tending physician. We envision an era in which the Postgraduate training in neonatology will obviously pre- NNP-NPA relationship will be seen, as with other NP-PA pare a PA for a career in the NICU. In addition, the PAs relationships, as “interchangeable but not identical.”41 who receive formal NICU training will be better pre- Neonatology training will also help those PAs who wish PEDIATRICS Volume 119, Number 2, February 2007 367 Downloaded from www.pediatrics.org by on August 13, 2010
  9. 9. to practice in other areas of pediatrics or pediatric sub- neonatal intensive care unit: a time to review, revise and specialties by making them more comfortable meeting reconfirm. Am J Perinatol. 1996;13:127–129 21. Cooper RA. Health care workforce for the twenty-first century: the needs of our smallest patients. the impact of nonphysician clinicians. Annu Rev Med. 2001;52: 51– 61 22. Fisher DW, Horowitz SM. The physician assistant: profile of a new health profession. In: Bliss A, Cohen E, eds. The New REFERENCES Health Professionals: Nurse Practitioners and Physician Assistants. 1. Hall RT. Neonatal manpower needs: the writing’s on the Germantown, MD: Aspen System Corporation; 1977 wall—we should read it and heed it. J Perinatol. 1997;17: 23. Hodgeman JE, Edwards N, Halterman G. Utilization of physi- 423– 424 cian assistants on a large newborn service [abstract]. Pediatr 2. Goodman DC, Fischer ES, Little GA, Stukel TA, Chang C. 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  10. 10. About us: purpose & mission. Available at: www.nccpa.net/ ical model, and two case studies in historical time. Can Bull Med AboutUs.aspx. Accessed November 17, 2006 Hist. 2004;21:411– 429 44. Rosen R. The Montefiore Medical Center experience. In: 47. American Academy of Pediatrics, Committee on Hospital Care. Zarlock S, Harbert K, eds. Physician Assistants: Their Present and The role of the nurse practitioner and physician assistant in the Future Models of Utilization. New York, NY: Praeger; 1986 care of hospitalized children. Pediatrics. 1999;103:1050 –1052 45. Slovis TL, Comerci GD. The neonatal nurse practitioner. Am J 48. American Academy of Pediatrics, Committee on the Fetus and Dis Child. 1974;128:310 –314 the Newborn. Advanced practice in neonatal nursing. Pediat- 46. D’Antonio P, Fairman J. Organizing practice: nursing, the med- rics. 2003;111:1453–1454 IMPLANTS AND SCIENCE “It took 14 years, but science finally trumped politics Friday, with the Food and Drug Administration’s lifting of its longstanding ban on silicone-gel breast implants. Women will at last be allowed to make their own decisions about cosmetic surgery. This is especially welcome news for mastectomy patients. The FDA removed them from the market in 1992 during the reign of Commissioner David Kessler, a politically ambitious bureaucrat who was courting support from the left. The agency cited health concerns that have long since been debunked, and silicone-gel breast implants have since been at the heart of one of the trial bar’s biggest scams. Class-action lawsuits raked in billions of dollars and drove implant makers out of the business. Dow Corning went into bankruptcy. Throughout it all, the trial bar was abetted by a gullible press, only too happy to ignore the science and play up sensationalist stories of supposed ‘victims.’ Meanwhile, as we reported in editorials at the time, study after study showed no linkage between silicone breast implants and cancer, lupus, the skin-hardening disease scleroderma or other serious illness. As far back as 1994, doctors at the Mayo Clinic found ‘no association between breast implants and the connective-tissue disease and other disorders’ that they studied. In 1999, the Institute of Medicine found no systemic health problems caused by implants. In 2003, an FDA advisory panel advised that the ban be removed.” New York Times. November 21, 2006 Noted by JFL, MD PEDIATRICS Volume 119, Number 2, February 2007 369 Downloaded from www.pediatrics.org by on August 13, 2010
  11. 11. Nonphysician Clinicians in the Neonatal Intensive Care Unit: Meeting the Needs of Our Smallest Patients Eric W. Reynolds and J. Timothy Bricker Pediatrics 2007;119;361-369 DOI: 10.1542/peds.2006-1084 Updated Information including high-resolution figures, can be found at: & Services http://www.pediatrics.org/cgi/content/full/119/2/361 References This article cites 34 articles, 9 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/119/2/361#BIBL Citations This article has been cited by 1 HighWire-hosted articles: http://www.pediatrics.org/cgi/content/full/119/2/361#otherarticle s Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Premature & Newborn http://www.pediatrics.org/cgi/collection/premature_and_newbor n Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtml Reprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml Downloaded from www.pediatrics.org by on August 13, 2010

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