Advanced Practice in Neonatal Nursing

The American Academy of Pediatrics (AAP) endorses the role of the advanced practice registered nurse (APRN) and the current training and credentialing process developed by the National Association of Neonatal Nurses.^1,2  These guidelines were specifically designed to educate APRNs at the graduate level to manage critically ill and convalescing infants. These guidelines and standards include requirements for the completion of a graduate-level education program of study and supervised practice beyond the level of basic nursing. This preparation includes the attainment of a master's degree in the neonatal nursing specialty. The neonatal nurse practitioner (NNP) curriculum must have included a minimum of 200 neonatal-specific didactic hours plus a minimum of 600 directly supervised hours with critically ill neonates/infants in level II and III NICUs.^1–5  Currently credentialed NNPs who have graduated from non–master's degree programs or certificate programs should be allowed to maintain their practice and be encouraged to complete a formal graduate education.⁶  The AAP supports the documented competency of the master's degree–prepared APRN for entry into practice as an NNP. Some APRNs may wish to pursue the highest level of educational preparation in nursing, either the doctor of philosophy (PhD) or the doctor of nurse practice (DNP). However, the AAP does not consider such a degree to be necessary for clinical practice.

Included in the category of neonatal APRNs are the following^1,2 :

• Neonatal clinical nurse specialist (NCNS): a registered nurse with a master's degree who, through study and supervised practice at the graduate level, has become expert in the theory and practice of neonatal nursing. The NCNS is responsible for fostering continuous quality improvement in neonatal nursing care and developing and educating staff. The NCNS models expert nursing practice and applies and promotes evidence-based nursing practice.

• NNP: a registered nurse with clinical expertise in neonatal nursing who has obtained a master's degree with supervised clinical experience in the management of newborn infants and their families. The NNP manages patients in collaboration with a physician, usually a pediatrician or neonatologist. Using the acquired knowledge of pathophysiology, pharmacology, and physiology, the NNP may exercise independent judgment in the assessment, diagnosis, and management of infants and in the performance of certain procedures. The NNP may also be responsible for education of staff, research, and developing standards of nursing care.^6,7 

The spectrum of duties performed by the neonatal APRN will vary among institutions and may be governed by state regulations. Each of these roles currently requires advanced education and a master's degree. Nationally recognized certification examinations and requirements for maintenance education exist for each category.⁸  Credentialing for practice is currently governed by individual states. Inpatient care privileges are granted by the individual institution. Each institution needs to develop a procedure for the initial granting and subsequent maintenance of privileges, ensuring that the proper professional credentials are in place. That procedure is best developed by the collaborative efforts of the nursing administration and the medical staff.

1. Medical care by the APRN for patients receiving level III newborn intensive care is provided in collaboration with, or under the supervision of, a physician, usually a neonatologist.

2. Medical care by the APRN for patients receiving level I and II care is provided in collaboration with, or under the supervision of, a physician with special interest and experience in neonatal medicine, usually a pediatrician or neonatologist.

3. Determination of whether the APRN practices in collaboration with, or under the supervision of, a physician should be determined in accordance with the board of nursing regulations in the state in which the APRN is practicing.⁸ 

4. The APRN should be certified by a nationally recognized organization and should maintain that certification.

5. The APRN should maintain clinical expertise and knowledge of current therapy by participating in continuing education and other scholarly activities as recommended by the National Certification Corporation.⁹ 

6. The APRN should comply with hospital policy regarding credentialing and recredentialing.¹⁰ 

Ann R. Stark, MD, Chairperson

David H. Adamkin, MD

Jill E. Baley, MD

Vinod K. Bhutani, MD

Waldemar A. Carlo, MD

Praveen Kumar, MD

Richard A. Polin, MD

Rosemarie C. Tan, MD, PhD

Kristi L. Watterberg, MD

Daniel G. Batton, MD

Edward F. Bell, MD

Susan E. Denson, MD

Gilbert I. Martin, MD

Ann L. Jefferies, MD

Canadian Paediatric Society

Sarah J. Kilpatrick, MD, PhD

American College of Obstetricians and Gynecologists

Tonse N. K. Raju, MD, DCH

National Institutes of Health

Capt. Wanda D. Barfield, MD, MPH

Centers for Disease Control and Prevention

^*Carol Wallman, RN, MS, NNP-BC

National Association of Neonatal Nurses and Association of Women's Health, Obstetric and Neonatal Nurses

Keith J. Barrington, MB, ChB

Canadian Paediatric Society

Gary D. V. Hankins, MD

American College of Obstetricians and Gynecologists

Kay M. Tomashek, MD, MPH

Centers for Disease Control and Prevention

Kasper S. Wang, MD

Jim Couto, MA

[email protected]