The responsibility of nurses in the care of high-risk infants has evolved over the past 35 years. The neonatal nurse of the past was concerned with maintaining temperatures, feeding lethargic premature infants, and protecting vulnerable patients from infections and other environmental hazards which the infants were not yet equipped to face. Now in the 1980s the neonatal nurse must add additional duties to these responsibilities. The knowledge explosion of the 1960s and 1970s contributed to an increased volume of neonatal theory and additional biotechnology which increased the nurse's scope of practice. The need for advanced levels of function by nurses in NICUs has resulted in the development of a variety of nursing roles and educational programs across the country to meet these needs.
EVOLUTION OF AN EXPANDED ROLE
Expanded nursing roles have been in operation since the late 1960s as nurses developed primary care roles in ambulatory settings. This move toward greater autonomy and independence in nursing was a result of a number of variables. The women's movement of the 1970s allowed nurses to comfortably demand more voice in the care of their patients. Also, society's health care needs were too vast for the numbers of physicians available to provide care to the public. Nurses, because of their medical knowledge base and experience within the health care system, were seen as an appropriate resource to develop into a group of health care providers to extend the services of physicians.
The American Nurses' Association Congress for Nursing Practice in 1974 delineated the nurse clinician role as an expanded role in which "well-developed competencies in utilizing a broad range of cues" were required for "prescribing and implementing both direct and indirect nursing care and for articulating nursing therapies with other nursing therapies."1 Because some of these functions were traditionally performed by physicians, role reorientation and collaboration between nurses and physicians was seen as essential for a safe and smooth transition of responsibility.2
The American Academy of Pediatrics has recommended the utilization of neo natal nurse clinicians (N NC) in the NICU.3 This endorsement of the role was based on their concern about extensive experience in an NICU for the pediatric house officer who would not need major exposure to neonatology to function in general pediatric practice. There also was concern about the emerging problem of providing patient care in NICUs with dwindling house staff.
Based on the American Nurses' Association guidelines developed by nursing and medical leaders, a role definition of the neonatal nurse clinician emerged. The scope of practice included participation in the identification, planning and implementation of care for high-risk neonates and their families in cooperation and consultation with other health team members. Specific functions such as securing a history, physical examination, and technical procedures requiring immediate intervention were specified as a part of the neonatal nurse clinician's responsibilities.2
From these guidelines educational programs were developed to produce graduates capable of functioning in the role. Content from the natural social sciences as well as nursing process, advanced biotechnology, and interdisciplinary team function were suggested. This provided the graduate with knowledge in neonatal physiology, pathophysiology, genetics, embryology, family dynamics, neonatal examination, radiology, technological monitoring, infant development, role reorientation, etc. Planned clinical experience was designated as an important component of the learning experience providing a transition from theory to practice.2
Initially most of these educational programs were eight- to nine-month certificate programs arising from schools of continuing education or from medical center bases. These programs focused heavily on the development of specific clinical expertise and were taught by physicians and nurses functioning in the practice area. Eventually some of these programs have drifted into graduate nursing education to focus on the broader areas of advanced nursing practice in neonatology. It is likely that both education levels are necessary. The short-term programs provide numbers of clinically-prepared nurse clinicians who can swiftly fill the present vacuum. This void is due to the demand in existing NICUs for neonatal nurse clinicians before many individuals were prepared to move into the role. The graduate level programs can complement the certificate programs by adding leadership skills and research sophistication as well as additional clinical depth to the role.
EVALUATION OF THE FUNCTIONING ROLE
Currently, a significant number of hospitals are employing neonatal nurse clinicians under that title or in the title of neonatal nurse practitioner. Due to concerns about conformity and utilization of the role, studies have been carried out to evaluate its status in the NICU. Harper, Little, and Sia4 found that approximately 57% of the nation's level III units employ neonatal nurse clinicians. These clinicians, independently within institutional protocols, carried out many of the procedures and responsibilities previously delegated to physicians. They also learned that a significant percentage of the NICUs studied delegated some of these same procedures to staff nurses and/ or head nurses who may have been trained to carry out these activities by seminars, in-house training, or other education experiences.
There was strong interest voiced by the neonatologists participating in their study for the continued preparation and employment of neonatal nurse clinicians. This interest is most likely based upon their own staffing needs as well as satisfaction with the role.
A second study to evaluate the neonatal clinician role was developed by New York H ospitai -Cornell Medical Center staff to review utilization and deployment of the clinician in other NICUs. There have been neonatal nurse clinicians trained and employed at that institution since 19775 and it was deemed appropriate to carry out this study as the hospital looked at plans for the future of the educational program and established role.
A random sample of 21 hospitals employing neonatal nurse clinicians was surveyed regarding the following issues: educational preparation of the clinicians, departmental and unit deployment, scheduling, supervision, salary, and clinical responsibilities. Certain general information about unit size, physician number, and number of clinicians was also asked to assist in developing the picture of the clinician's job in each institution. Seventeen of the 22 questionnaires were returned.
The results of the questionnaire gave the following picture:
Characteristics of the Units Surveyed
The size of unit ranged from 18 to 60 beds with an average unit capacity of 37 beds. Physician number ranged from two to 14, with no correlation seen between bed size and number of doctors.
Characteristics of the Clinicians
The clinicians fro m 12 of the 17 hospitals were prepared in certificate programs only. The other hospitals hired clinicians with combinations of masters and certificate preparation. There was a range of one to I I clinicians employed in any one NICU with an average number of five clinicians. There was also no correlation between number of clinicians and size of NICU.
TIME UTILIZATION BY NEONATAL NURSE CLINICIANS IN NYH STUDY
Unit and Institutional Deployment
Eighty-two percent of the group studied fit the clinician into one of their nursing departments, ie, pediatric nursing. The remaining percent deployed the clinicians within pediatric medicine. In the NICU the clinicians were found either within the physician team (59%) or within a separate nurse clinician team (41%). There seemed to be a correlation between number of clinicians and team deployment. At least six, if not more, clinicians must be available within a team to provide 24-hour coverage.
The majority (82%) worked 37.5- to 40-hour work weeks, with the rest working as many as 60 hours per week which included on-call. A combination of eight, ten and 12-hour shifts were utilized by some NlCUs (41%) while others (35%) depended upon ten-hour shifts exclusively. The remaining group (23%) scheduled their clinicians to work eight-hour shifts. The disparity in scheduling patterns may be related to the small numbers of clinicians available for coverage as well as the use of traditional physician scheduling for the new related nursing role.
Salaries for neonatal nurse clinicians ranged between S 17,500 and $30,000 depending upon experience, education, and hours worked. The majority (58%) were paid in the range of $20,000 to $24,499. Because of the difference in standard of living throughout the country, this average could be considerably better or just comparable to an average nurse's salary depending upon the clinician's geographic location.
Supervision of the clinicians was carried out jointly by nursing and medicine by a portion of the NlCUs (41%). The rest of the units split evenly with half utilizing medical supervision and half using nursing supervision.
The evaluation of clinical responsibilities showed conformity of the role from hospital to hospital (Table). The primary responsibility of the nurse clinician seemed to be patient management, which included admission of the patient, physical examination, assisting in development of a medical plan of care, and work rounds with the team. Technical skills such as chest tube insertion, umbilical catheterization and venipuncture were an integral part of the role as also shown in the Harper et al4 study. However, as shown on the table a much smaller portion of the clinician's time was spent on the multitude of technical operations which constitute the picture of intensive neonatal care. This is most likely due to the delegation of many of these skills to the bedside nurse.
Parent teaching and counseling was seen by most respondents as a part of the role, but not a major portion of it. From the author's experience as an educator for this role, many nurses attracted to the expanded role get most of their satisfaction from medical-technical course content and some seem less interested in family theory. Also, the responsibility for major family counseling and education in their NICUs may fall in the hands of other nurses or health professionals. Transport, inservice education, outreach education and supervision were of minimal importance to the role. Some hospitals may have separate specialized nursing roles for these activities, therefore, only involving their clinicians on a voluntary basis. Also, in some hospitals, there is a separate utilization of neonatal nurse clinicians solely for transport.6
A CURRENT CONCEPTUALIZATION OF THE NEONATAL NURSE CLINICIAN ROLE
The general picture emerging from these studies is that clinicians are employed in many NICUs primarily for the purpose of patient management with technical skills and parent responsibilities centering around this focal activity. Most of these hospitals had between three to eight neonatal nurse clinicians working in their units either on a separate clinician team or integrated within the team of physicians operating in the unit. Most of these clinicians are prepared in certificate programs with a number adding masters education to their preparation. The majority are employed by some department within nursing service with mutual supervision provided by nursing and medicine. Either flexible shift coverage or a ten-hour shift schedule is utilized for coverage with most clinicians working 37.5- to 40-hour work weeks. The different schedule patterns indicate the complexity of this issue in meeting coverage needs and maintaining job satisfaction for the clinicians. Jill Ragan, as a clinician involved with this problem, feels that adaptation and versatility in dealing with this allows for fairness to all team members as well as providing for special requests. This assists in giving individual clinicians a feeling of control over their own hours.7
Most neonatal nurse clinicians are being paid salaries ranging from $20,000 to $24,499, which seemed to fall in a special category for nurse clinicians within the levels for other nurses in those institutions. Increase in salaries may begin to be an issue as competition for nurse clinicians occurs due to the dearth of persons prepared to function in this role. As an educational program director, I may be approached several times a month by directors of nurseries or maternal-child nursing directors who are, sometimes desperately, searching for neonatal nurse clinicians to meet their staffing needs.
FUTURE CONCERNS FOR STABILIZATION OF THE ROLE
There can be no question that the expanded role for nurses in the neonatal intensive care unit is a norm for that service. This role exists in many units, and there are plans for adoption of the role in others. The educational programs available are successful in preparing individuals to function in the role. However, there are difficulties ahead in the continued development of this role.
One serious problem isthat of maintaining educational programs which can sufficiently provide neonatal nurse clinicians for the rising staff needs in NICUs. At present, few educational programs are able to train more than ten to 15 students per year. With government support for nursing education greatly diminished, these programs must rely on tuition and /or private sources to provide funding for continued operation. Because of this, programs open and close with some frequency, frustrating hospitals which look to these programs for prepared clinicians.
A second issue is that of credentialing. Because the neonatal nurse clinician role differs so greatly from the average nursing role in hospitals, care must be taken to provide legal support. Though expanded roles are generally provided for in most state nurse practice acts,8 this may provide unsubstantial legal support in the face of court suit. Harper et al4 noted that a number of the neonatalogists questioned in their study shared this concern. It may be that the time has come for evaluating types of credentialing based on experience with other comparable roles such as the pediatric nurse practitioner or the certified nurse midwife.
A note of acknowledgment is extended to Frances Tomasulo Roberecky, R.N., N.N.C., who jointly, with the author, developed and implemented the NYH questionnaire study.
1. American Congress of Nursing Practice: Kansas City, American Nurses Association, 1974.
2. Guidelines for Short Term Continuing Education Programs for the Nurse Clinician in Intensive Neonatal Care and the Nurse Clinician in Intensive Maternal- Fetal Care. Kansas City. American Nurses Association. 1975.
3. Committee on the Fetus and Newborn: Standards and Recommendations for Hospital Care of Newborn Infants. Evanston, Illinois, American Academy of Pediatrics, 1977.
4. Harper, R. Little G, Sia C: The scope of nursing practice in level III NICUs. Pediatrics, to be published.
5. Bellig L: The expanded nursing role in the neonatal intensive care unit. Clinics in Perinatology 1980; 7:159-171.
6. Honeyfield PR, Lunka ME: The transport role, in Sheldon RE, Dominiate PS (eds): 77»? Expanding Role of the Nurse in Neonatal Intensive Care. New York, Crune and Stratton, 1980.
7. RaganJB: An approach to scheduling, in Sheldon RE, Domi nia k PS (eds): The Expanding Role of the Nurse in Neonatal Intensive Care. New York. Grune and Stratton, 1980.
8. Trendel-Korenchuk D, Trendel-Korenchuk K: How state laws recognize advanced nursing practice. Nurs Outlook 1978; 26:713-719.
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