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NICU team: Technical report addresses workforce issues to ensure effective care :

November 18, 2019

Providers who work in neonatal intensive care units (NICUs) need to demonstrate a basic set of behavioral competencies, cognitive abilities and technical skills to practice in this specialized, high-risk setting, according to a new AAP technical report.

The report, Neonatal Provider Workforce, reviews the training, education, competency requirements and scopes of practice for NICU providers. In addition, it offers suggestions for establishing and monitoring quality and safety of care and addresses potential solutions for workforce shortages.

The report, from the Committee on Fetus and Newborn (COFN), is available at and will be published in the December issue of Pediatrics.

“The major point of the technical report is that we should have some base of credentialing and training to have people working independently in a NICU,” said Jay P. Goldsmith, M.D., FAAP, a lead author and COFN member. “The neonatologist is the head of the ship, but he or she may have a hospitalist, nurse practitioners, physician assistants and other people who are working on that team. And we want them to have a certain commonality of basic educational and technical abilities.”

A table lists procedures that hospitalists, neonatal nurse practitioners (NNPs), acute care pediatric nurse practitioners (PNPs) and physician assistants (PAs) should be able to perform in the NICU. To meet future needs, increasing collaboration will be required of neonatologists and other NICU providers and physician trainees, the report noted.

Workforce concerns

The report points out a concern that pediatric residents are becoming less able to care for NICU patients, citing the continued revision of pediatric resident duty hours prescribed by the Accreditation Council for Graduate Medical Education. Training time has been reduced, with little chance for pediatric residents to master technical procedures like intubation and placement of catheters, Dr. Goldsmith said. As a result, many graduating residents are unable to perform these procedures.

At the same time, there is a shortage of NNPs and an insufficient number of PAs, PNPs and pediatric hospitalists working in NICUs.

A 2016 workforce survey found that the average age of NNPs was 49, and more than half of them regularly work more than their scheduled hours due to staffing vacancies. The shortage is predicted to last up to 10 years unless, the report warns, “innovative recruitment and retention strategies are used to deal with this issue.”

Likewise, PNPs are in short supply due to limited academic programs, faculty shortages, low enrollment and difficulty securing clinical sites and preceptors. This shortage is predicted to continue for the next 13 years.

Despite the shortages of NICU personnel in certain geographic areas, changes in NICUs have resulted in some improvements, said Dr. Goldsmith. More babies are able to be treated outside of NICUs for conditions like narcotic withdrawal, hypoglycemia and potential infections.

Review of competency

Medical and nursing leadership in the NICU, along with the hospital credentialing committee, must develop and periodically review competency criteria for all NICU providers, according to the report. Competency criteria developed by groups such as the AAP, Accreditation Council for Graduate Medical Education, American Academy of Physician Assistants and National Organization of Neonatal Nurse Practitioners can guide the development and evaluation of NICU providers to help ensure safe, quality and cost-effective care of infants in this high-risk environment.

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