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Career opportunities for neonatal nurses
Career Opportunities for Neonatal Nurses Carole Kenner, RNC, DNS, FAAN Leslie Altimier, RN, MSN DeborahJ. Hess, RN, PhD This article will outline career opportunities now available for neonatal nurses in acute care and community settings. Healthcare reform has increased the emphasis on health promotion, holistic care, and patient teaching, vital aspects of all nursing education and practice. Nurses choosing to capitalize on these strengths have opportunities to develop and shape their future nursing careers.
Copyright 9 1998 by W.B. Saunders Company
ealthcare reform and work redesign are changing all aspects of health delivery systems. The emphasis often tends to be on the negative aspects of this transition rather than the opportunities created through change. This article outlines the career opportunities now available for neonatal nurses in the acute and intermediate care, community, private practice, and academic settings. Nurses today have more opportunities to use their expertise and creativity that they demonstrate in their current work settings to develop and shape their future nursing careers.
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THE FUTURE OF NEONATAL NURSING The specialty of neonatal intensive care began more than 30 years ago owing to the recognition that the at-risk neonatal population has unique needs that requires specialized care. Today there are more than 500 neonatal intensive care units (NICUs) in the country (Pickler & Reyna, 1996). This number is expected to decline as mergers and alliances occur and hospitals close. Nevertheless, the number of patients is not declining. There are still approximately 2.5 million at-risk neonates born annually in the United States (Bell, 1994; Pickler & Reyna, 1996). However, some of these infants will be cared for in settings other than the NICU. Numerous changes have occurred in the last decade that have brought neonatal care to this crossroad. The emphasis on primary care and the decreased number of rotations that residents make through pediatric settings affect neonatal care. Advanced practice nurses (APN), such as clinical nurse specialists (CNS) and nurse practitioners (NP), are Journalof PediatricNursing,Vol 13, No 5 (October), 1998
working in areas of neonatal care such as high-risk follow-up, where traditionally professionals from other disciplines have worked. This change is due in part to the shift from setting-specific care to population-based care. In addition, there is also a rationing of services in some areas of the country, which is limiting access to tertiary centers (Bell, 1994). This means that certain tests, treatments, and technology will be available only at limited sites. Access to the most acute levels of care may be determined based on insurance coverage and managed care contracts, not on who necessarily needs what type of care (McCanless, 1994). Managed care often shifts the responsibility for decisions regarding setting for care from the provider of services to the purchaser of these services. Lengths of stays are diminishing because of the high costs attached to in-patient days and third-party payer's unwillingness to pay these high costs. Therefore, some smaller, more complex neonates may go home still technology dependent. Ironically, at the same time, the RN pool is declining in the hospital where the most critically ill patients are found (Bell, 1994). The use of unlicensed assistive personnel (UAP) in NICUs today is not atypical. The implications for neonatal nurses are many. However, one clear message is that nurses who went
From University of Cincinnati College of Nursing and Health and Good Samaritan Hospital and Bethesda Hospitals, Cincinnati, OH. Address reprint requests to Carole Kenner, RNC, DNS, FAAN, University of Cincinnati College of Nursing and Health, 3110 Vine Street, Cincinnati, OH 45221-0038. Copyright 9 1998 by W.B. Saunders Company 0882-5963/98/1305-00953.00/0
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into neonatal nursing may now find it necessary to move from the NICU to a different setting to care for this unique population. It is important to recognize that nursing is population based and not setting specific.
NEONATAL NURSING: ACUTEAND INTERMEDIATECARE SETTINGS Acute Care Settings Some neonatal nurses will still be in demand in acute care settings. The recognition by associations such as the National Organization of Nurse Practitioner Faculties (NONPF) of the acute care practitioner or neonatal nurse practitioner (NNP) and the increase in NNP programs in the country speak to the need for more highly educated neonatal nurses. The acute care practitioner is an accepted and recognized role with a clear identity (Beal, Maguire, & Carr, 1996). Nevertheless, the neonatal nurses role is changing. Historically this role evolved from the need to provide more technically proficient bedside nurses to work side by side with the physician providing care for the high-risk neonate. At the same time, the CNS evolved to help with the education and support of the nurses providing the direct care (Clancy & Maguire, 1995). Today these roles have changed, and the boundaries are blurring (Cronenwett, 1995; Ditzenberger, Collins, & Banta-Wright, 1995). APN nurses now often share many tasks and roles. Case management is an example of a shared role. Case management's purpose is " , . . to provide consistent care based on measurable outcomes that are determined by standard management plans on negotiated alternatives" (Pickier & Reyna, 1996, p. 49). The case manager often advocates for the patient and family (Bell, 1994) and typically covers a caseload of 10 to 15 patients. Depending on the setting, caseloads may be much higher. This situation is especially true when doing case management in the community setting. When working with children birth to 3 years of age and their families, case management is often referred to as service coordination. Despite which term is used, the role provides the key ingredient to holistic, integrated, coordinated, collaborative, multidisciplinary care. The neonatal nurse would be an excellent candidate for the position of case manager for high-risk neonates and their families. Case managers are especially important when critical pathways are used to determine the length of stay in the acute care setting. Neonatal nurses in acute care settings are usually
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familiar with the concept of critical pathways. Belief that health is a continuum that needs to be supported from the acute care setting to home has led to use of critical pathways to determine shortand long-term measurable outcomes of care. These benchmark points also provide a method of costing out services and examining quality of care. Unfortunately these points often force healthcare decisions based on the progression along the critical pathway and not on the individualized family needs. For example, the neonate may be ready for discharge according to the critical pathway for a particular medical diagnosis. However, the infant's mother is not ready or able to provide the required specialized feedings. This scenario poses a familiar dilemma. The infant cannot stay in the hospital, but a caregiver may not be adequately prepared to care for the child at home. Therefore, the patient may be moved to a rehabilitative center often reserved for adults, or intense preparations need to be made so the infant can be cared for in the home. In some institutions, these plans and needs are often handled by discharge coordinators or case managers. If the family has been working with a case manager or service coordinator since the child's admission to the unit, this person would be ideal for assisting with discharge planning. Regardless of the term used to describe the role, this person is responsible for discharge teaching, family assessments, and documentation of these activities (Bell, 1994; Christian, 1996). Care coordination is a creative innovative program. The care coordinator (CC) for maternity service meets with expecting parents toward the end of the first trimester and follows them through the birthing process and into the home environment. The CC can seek resources for the patient or family if problems arise (e.g., the mother becomes a high risk or the baby requires home intravenous therapy) and coordinates overall care. This program appears to be satisfying for parents, as well as maternity staff. If the child needs the NICU or the special care nursery (SCN) because she or he requires more complex care, the neonatal care and maternity care coordinator collaborate to coordinate care (Altimier, 1997). The authors have mentioned several different terms or titles used to describe what is essentially case management services for young children and their families. The difference lies not in whether the term case management or service/care coordination is used, but on the philosophical approach the person in that role uses for working with families. Families and children should not be seen as cases
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that need to be managed, but as individuals who could use assistance in accessing and understanding services or care. Viewing each child and family as unique, listening to what their individual needs are, being empathetic, and advocating for the family will help coordinators become more family centered, even in the midst of a highly technical acute care setting.
Intermediate Care Settings Intermediate care facilities can mean many things today. It may be the old Level II SCN, a step-down or transitional care unit, a developmental care unit, or even a rehabilitation center. All these settings provide care for patients who no longer require acute care but who may still have chronic or supportive needs. In addition to working in Level I! settings, NNP may also attend high-risk deliveries in some primarily Level I institutions where a pediatrician or neonatologist may not be available. They are often responsible for the admission and discharge assessments (Casselden, 1995) and establish discharge referrals before the discharge date (Barton & Lawlor-Klean, 1994). To meet the declining RN pool, some nurse managers are cross-training their staff to provide perinatal, neonatal, and home care. These nurses move beyond the preceding description of roles and into either direct bedside care or supportive services (Lynch, 1995). These nurses are generally at the staff level but may be APNs. It is not unusual for a neonatal nurse to assist in the delivery room stabilization of neonates and the immediate postpartum period with mother and baby care. Other hospitals are consolidating their management and creating one functional unit head by using neonatal nurse managers across the traditional units of the NICU and the perinatal area. Any of these situations can be carried out only when there is extensive cross-training and clear nursing protocols for patient care. Other neonatal nurse managers are cross-training neonatal nurses to work as home care nurses providing follow-up care for mother and baby. This type of cross-training is usually done when the hospital staff is responsible for home follow-up care or if the hospital administration believes that continuity from hospital to home would be good for public relations. The community setting may be one of the newest arena for neonatal nurses.
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NEONATAL NURSING: COMMUNITY SETTINGS
High-RiskFollow-UpClinics Neonatal nurses are strategically well placed for being able to move into high-risk follow-up clinics. After discharge, these clinics may provide the first health or chronic follow-up care and make referrals to specialized services for at risk neonates. Nurses who have NICU experience understand the foundation for the problems that are seen in these clinics. Nurses often rotate from the unit to the clinic as they have established rapport with the family and add to the family confidence in the care. These rotations also provide respite to the nurses from the acute care environment (Liljeblad, 1993).
Developmental Follow-Up Teams Developmental care has received much attention from multidisciplinary teams during the last decade. Developmental follow-up is ongoing and continually explores means of providing ageappropriate supportive developmental care and opportunities. There has been extensive research on the effects of the NICU environment on the neonate as evidenced by the Annual Conference of the Physical Environment of the High Risk Neonate hosted by Dr. Stanley Graven (1997). Research has also indicated the need for developmental follow-up and parent teaching on how to provide a supportive environment. Many units have sent nurses for Newborn Individualized Developmental Care and Assessment Program (N/DCAP) training. This program focuses on individualized care, with special emphasis on being sensitive to the environmental impact on the neonate and how to minimize its potential stress. In addition, it also offers specialized training to NICU nurses, which promotes opportunities of developmental specialist careers. Als and colleagues (1986) found increased cognitive and psychomotor scores at 1 year when a team approach was used by nurses and pediatric occupational and physical therapists in supporting and following neonatal/infant development. These scores were based on individualized developmental care plans started in the hospital and continued after discharge and during the first year of life. Bell (1994) demonstrated the same findings at age 9 months after NICU discharge.
CONTINUITY OF CARE CUNICS WITH PEDIATRICNURSE PRACTmONERS Much of the developmental testing and follow-up care has been traditionally linked with
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primary care and the role of the Pediatric Nurse Practitioner (PNP). However, most PNP education does not include in-depth information on the neurodevelopment of the premature infant. Nor does this education focus on the unique needs of the 32to 36-week gestation infant who has been discharged from the hospital and is now being monitored by general pediatric practice rather than a high-risk follow-up clinic. Some agencies have started continuity of care clinics where NNPs and PNPs work together. Or the PNP may come to the NICU to meet the family and develop a discharge plan together. On the first clinic visit, the NNP goes to the clinic to assess the infant with the PNP and provide continuity from the acute care to community setting. This cross-training of practitioners is an excellent opportunity for NNPs to increase their knowledge base on well child care and typical infant/toddler growth and development. The United Kingdom has provided this type of coverage for many years. There. the Neonatal Liaison Sister follows the baby for the first 10 days of life. either through home or clinic visits (Dawson. 1996). This nurse provides continuity for the family. There are some turf issues in the United Kingdom. as the boundaries of practice blur between these two groups (Dawson, 1996). These turf issues could be diminished if there is cross-training between the two groups of practitioners. This is true whether assessment and care are provided in the clinic or in the home. Neonatal nurses need to learn more about well child care (e.g., dental care, immunizations, growth and development, eye examination at 1 to 2 years of age or more frequently if there is any evidence of retinopathy of prematurity [ROP], hearing examination at 3 to 6 months and then again at 1 to 2 years of age, speech examinations at every 6 months beginning at 18 months, temperament assessments at 4 to 6 months, and neurologic checks over the first year). PNPs need to understand more about the neonatal pathology and special needs of at-risk neonates (e.g., suck swallow incoordination for infants at or below 34 weeks' gestational age, nutritional needs of premature infants, providing age-appropriate developmental care in the home, genetics, and fetal development to understand high-risk family histories and critical periods of development for certain anomalies). In addition, the PNP could benefit from increased education regarding chronic conditions (e.g., ROE bronchopulmonary dysplasia [BPD], and post-high technology treatments such as extracorporeal membrane oxygenation [ECMO]). Some of these chronic conditions are now being managed
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in the home with high technology, whereas others need only support and parent education for specialized care.
HOME CARE Home care is another new and burgeoning arena for neonatal nurses. This setting may lack the somewhat predictable normal chaos of a NICU and the backup support available in most acute care settings. In the home, turf and control issues between the nurse and parents are somewhat different. It is still traditional for most NICU nurses to want to be in control of the care of the neonate. During this extremely stressful initial situation, parents may even prefer that others take control. Yet in the home, parents may want and need to take control for the care of their child. The visiting nurse is a guest in the family's home and may not always be comfortable. This setting allows parents to ask the "dumb" questions and for the nurse to assess parent infant interaction and to teach parents in a more relaxed atmosphere (Christian, 1996). Although parent teaching begins before discharge, the parent's learning needs to be reinforced in the home. Cardiopulmonary resuscitation (CPR) training and home infant monitoring are two growing areas of home education, even though this training is started before discharge (Brown & Sauve, 1994). Parents often do not remember what is taught before discharge and do not realize that void until they are at home. Phone consultations by neonatal nurses is a backup for parents when the parents are not eligible for, or are between, home visits. Before discharge a predischarge visit may be conducted to determine family needs and environmental safety issues. During this time, the NICU nurse and home visit nurse may work together in accomplishing tasks such as contacting the insurance case manager to determine the family's benefits and the services that would be covered in a home setting (Christian, 1996). If equipment is needed, it must be ordered, and tested, and parents must be trained in its use before discharge. Nurses making the home visits must be familiar with neonatal problems and the equipment to be used. The nurse doing these visits needs some inpatient acute care practice and confidence in skills before going on an unsupervised visit or teaching about unfamiliar topics. A minimum of 1 year's training for home care and a 2-month orientation in the community setting would be helpful for the community nurse caring for a technology-dependent infant. There should be a
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skills checklist to document accomplishments. Training on such technical skills as phototherapy, IV infusion, laboratory draws, dressing changes, wound care, central line care, medication administration in the home, clean tracheostomy suction, and documentation of a home visit are musts (Christian, 1996; Ludwig, 1990). Parents need support in the transition to home. Neonatal nurses understand first hand the stress the parents have been under. These nurses must realize that they already know how to care for neonates and they have a working knowledge of neonatal problems. The only difference is the setting. They will now be providing care in the home. Neonatal nurses recognize, too, that setting up a mini-NICU at home adds stress to a family and that even under the best circumstances, when the baby is healthy at discharge, additional stress is placed on any family after discharge (Brooten et al., 1986). Ross (1984) found that for home care for low socioeconomic families can increase the mother's involvement with her infant. All mothers can be taught to be more responsive to infant cues. This teaching is especially important for mothers of premature infants, as these infants do not always send clear signals. The promotion of positive maternal-infant interaction may decrease the incidence of child abuse and neglect, which occurs when mothers do not have realistic expectations of their neonate (Kenner, Flandermeyer, & Thornburg, 1996; Ross, 1984). The concern today is whether parent teaching through nursing home visits is cost effective. Brooten et al. (1986) found that there where cost savings when parents are taught how to manage the health care system, keep their infant healthy, and access respite care, financial aid, parent support and/or advocacy groups, and transportation services. These home visits were done by APNs who had neonatal expertise. In general, a home visit costs $120 versus $1200/day in hospital if the infant is readmitted (Clancy & Maguire, 1995). Another facet of these visits was the identification of need for early intervention referrals as it relates to cost-effectiveness of the use of these services.
EARLYINTERVENTION Early intervention is an exciting new field of practice that serves young children and their families. Traditionally, early intervention refers to working with families and children from birth to 3 years of age, who have, or are at risk for, developmental
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disabilities. However, some professionals consider early intervention to include children up through 5 years of age. This field of practice is truly interdisciplinary and involves many professionals from the health and social sciences (e.g., nurses, doctors, teachers, physical therapists, speech therapists, occupational therapists, nutritionists, and psychologists). Therefore, it is important to recognize that additional cross-training or education from other disciplines is an important component of early intervention practice. Nurses often do not recognize early intervention as a specific field of practice. Yet this field of practice is needed today more than ever because children with complex medical problems and/or serious disabilities are routinely being sent home. Institutionalization is rarely an option even for families who might consider it. Although the rapid advance in technology has increased the rate of survival for at risk neonates, it has also increased the number of children who may have lifelong physical or mental disabilities. Early, adequate, and appropriate health and educational services are needed to assist these children in reaching their maximum life potential. Both health and educational services need to begin on discharge from the acute care setting. Neonatal nurses could provide the expertise needed in understanding the related health issues of children with developmental disabilities. The current legislative mandate for services is the Individuals with Disabilities Education Act (IDEA) (Johnson, 1994). Part H of IDEA pertains to infants and toddlers with disabilities. Public Law 105-17 was signed into law by President Clinton in June 1997. Part H of IDEA or PL-195-17 pertains to infants and toddlers with disabilities. The eligible population for part H includes children up to age 3 years who have a measured developmental delay(s) or diagnosed physical or mental condition(s), which could result in developmental disabilities. Currently, individual states determine which children will be eligible for services (Hutinger, 1994). However, early interventionists generally recognize three widely accepted definitions of risk that were first introduced by Tjossem (1976): established risk, biological risk, and environmental risk. Children with established risk are those who have a definite medical diagnosis that has a known pattern of developmental disabilities (e.g., Down syndrome, cerebral palsy, spina bifida, autism). Biological risk identifies children who have prenatal, perinatal, or postnatal incidents that may have affected the central nervous system (e.g., premature
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infants, children exposed prenatally to drugs or alcohol, small for gestational age). Environmental risk includes children whose life experiences (e.g., abuse, neglect, lack of developmentally appropriate parent child interaction) may put them at risk for developmental delays. It is apparent that children discharged from the NICU are in one or more of these risk categories. Neonatal nurses could be service coordinator for these young children and their families. Service coordinators work in hospitals and community agencies providing the support families need in accessing health and educational services for their child and family. Their main role is to coordinate the services that have been designated on the individualized family service plan (IFSP). The IFSP is an ongoing plan developed by the early intervention team, with the family members being active major participants of this team. Each family should have only one service coordinator and one IFSP. The various agencies and providers collaborate as a team to coordinate services, avoid duplication, and help the family reach the goals they have set for their child. The care provided is often referred to as being "family driven" or "family centered" and is a philosophical change from professional care that is agency or provider centered. The last decade has seen many changes in the care of children with disabilities. Consequently, there are many opportunities for nurses working with young children and their families.
SICK DAY CARE AND PARENT CALL-IN HOURS Daycare for sick children has spread to support working parents. It is a much needed area as more women need or choose to work outside the home and may be unable to take time off when their child is ill. Concerns about cross-contamination among ill children has slowed progress toward sick care day centers. Nurses can play a vital role in establishing safe, caring environments for children with acute short-term illnesses. Numerous pediatricians have call-in hours for parents to ask questions. NICUs and SCNs are inundated with phone calls from parents of premature infants after discharge who have questions about their premature infant. The NICU nurse could offer a wealth of knowledge and support to parents, NICU/SCN staff, and physicians. Telephone triaging is a growing area of "telemedicine." It has legal ramifications, but it is a wonderful community service provided by nurses.
PRIVATEPRACTICESETTING: ENTREPRENEURIALACTIVITIES
Development of Continuing Education
Programs
Although in general continuing educational (CE) programs and on-the-job training have diminished, the need for increased education for practicing neonatal nurses is even greater owing to the vast changes in neonatal care (Ruth-Sancez, Lee, & Bosque, 1996). Neonatal nurses have the expertise to develop CE modules on specific topics, computer self-study programs, videotapes for professional and lay teaching, and interactive videos for instruction in schools of nursing. Publishing articles with attached CEs is another activity that is attracting many nurses. These activities can be money-making and not just altruistic. In the past, however, nurses have often given away their course content and materials. Now these must be considered a product of neonatal expertise. Home study institutions periodically put calls out for nurses to write CE programs on neonatal topics.
Lecture Circuit Neonatal nurses are being sought to lecture to local, regional, or national groups. There is a lecture circuit that can be cultivated. Nurses should respond to call for papers advertised in professional journals or direct mall fliers; offer to speak at local groups, serve on a panel of experts at a workshop; or do a guest lecture for a nursing, medical, respiratory therapy, EMT, or paramedic classes. They should contact the companies who offer multiple lectures that move across the country. All have contact numbers for more information about registration. Nurses could use this number to contact the person responsible for neonatal or pediatric content lectures. Once the nurse's name is known, she or he will be contacted to speak. Nurses should speak with colleagues who are doing lectures to determine appropriate current fees for speaking services, and they should set a fee for your services. Until a price tag is attached, there is often less thought about value of the content. It is important to develop a professional network of colleagues who can answer questions or help the neonatal nurse start a new career (Clancy & Maguire, 1995).
Expert Witness or Content Expert Neonatal nurses make good expert witnesses or content experts. Although some nurses have concerns about providing these services to hospitals or
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attorneys, the reality is that nurses do have the expertise to review merits of medical cases. Content experts provide expert reviews for the purpose of screening cases for the legal merits. This review may help in identifying expert witness who will later be deposed. Expert witnesses are also needed from neonatal nursing ranks. They serve as the expert to decide whether a standard of care has been violated or to support that in fact the care rendered was appropriate. The expert must be knowledgeable in direct patient care, as well as thoroughly versed in the neonatal literature, especially the standards, nursing practice acts, and policies of the time of the incident. The expert will usually be deposed and may, in some cases, testify in court. Through these case reviews, either as a content expert or expert witness, policies and procedures may be changed. The legal nurse consultant is a good avenue for a career change. Not all the need is for expert testimony, but it may be for case review even by insurance companies. Legal nurse consultants can also be used to link experts in other areas of the country or professional fields with attorneys or risk managers. It is important not to give away these contacts, but to provide this information for a fee. This is a legitimate charge for providing information linkage. There are multiple sources for information on how to provide this service, set fees for the service, and learn what to expect if the case goes to trial (Norris, 1991). Remember neonatal care is highly specialized and needs experts who are familiar with the specialty to do the review. The neonatal nurse's critical assessment of the case may help support a colleague who is involved in an unjust charge.
Pharmaceutical Research/Sales The trend is to create pediatric drugs and neonatal medications specifically geared to this population and home administration. Credibility and support of products are increased if neonatal nurses with an extensive knowledge of pharmacodynamics and administration procedures are used in the development. They may be responsible for coordinating clinical drug trials, ensuring adherence to research protocol, and training research nurses. Once the product is ready for sale, nurses can help market the product and answer the professional questions of staff nurses, physicians, nurse managers, and pharmacists. Drug development is not the only area for the industrial nurse.
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Researchand Developmentof Neonatal Products As more emphasis is placed on environmental neonatology, companies are concemed about developing products such as warmers, isolettes, phototherapy, and home care products that are environmentally friendly and developmentally supportive (Lynam, 1995). Neonatal nurses are being hired as consultants for product development, moderators of focus groups with health professions to determine new marketing niches a company should consider, or coordinators of research clinical trials of the equipment to provide scientific rationale for their product. These companies include those who are 'selling home phototherapy units, home or inpatient monitoring, respiratory therapy products, incubators and warmers, transfusion equipment, and IV infusion equipment. Neonatal nurses have the physiologic and behavioral assessment knowledge and understanding of the linkages between the environment and neonate's responses. Their knowledge regarding the sensitivity of the sensory and autonomic nervous system of a premature neonate is important, as this is a growing population of consumers for the companies' products. Product development is an area in which nurses can think of creative solutions to solve acute problems and sell these ideas to companies. Nurses are also good at product selling owing to their natural outreach educational workshops. In the case of a company's products, nurses can make presentations to companies to sell an idea for development. If hired by a company who has developed a neonatal product, the nurse could provide in-services for the personnel on the equipment's function. These in-services are viewed as more credible when they are done by professionals who have worked in NICUs.
Businesses:Home HealthA9encies and PersonnelStaffing Pools With their expertise in the special requirements of neonates and their families, neonatal nurses have used creative ideas for setting up their own businesses. They have established home healthcare agencies specializing in home parent education, direct care, and care coordination (Watkins, Kirchhuff, Hartigan, & Karp, 1992). Other neonatal nurses have set up personnel pools of temporary agency nurses who do only perinatal/neonatal care. Temporary pools of APNs have been created. Other nurses with neonatal backgrounds have become nurse recruiters in their own agencies. They specialize in temporary or permanent placements for
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neonatal nurses in practice and/or educational settings. The emphasis in all of these business ventures is that neonatal nurses serve a specialized population and have a defined knowledge base. These businesses require a keen sense of what is needed by neonatal patients and their families and what they have to offer these consumers. For nurses who wish to pursue entrepreneurial activities, many resources are available at the local libraries, through the Internet, and through the National Nurses in Business Association. Zagury (1995) presents a workbook approach to starting a business, which may be quite helpful for someone interested in becoming an entrepreneur.
ACADEMIC SETTINGS Health Policy Development: Fellowships Health policy development is critical to the future of neonatal nursing and care. Fellowships are advertised in professional journals and direct mailers, which speak to the need for nurses with specialized expertise to apply. These fellowships (e.g., the White House Fellowship, Robert Wood Johnson Fellowships, and governmental agencies fellowships) usually solicit proposals for what the nurse sees as an important health topic and how personal professional development could affect future healthcare legislation. These fellowships vary according to length, salaries, and the need for relocation. Fellowships often open other doors for serving on consensus panels, writing healthcare legislation, working with Congress as a paid "staffer." publishing pamphlets or briefs on health policies, or being hired as a lobbyist for nursing associations.
Education Neonatal nurses are natural educators. They teach under stressful conditions and often do not recognize their valuable contribution to families and colleagues. However, neonatal nurses have often been used for outreach education and orientation programs without extra pay. Some have been hired by nursing faculties. Now new career opportunities are available to be hired by Allied Health Schools for teaching in Physician Assistant programs, by Colleges of Medicine for medical student and resident education, for interdisciplinary education across specialties and disciplines, by community agencies as CPR trainers and lay public health seminars, and by colleges of nursing to teach pediatric and maternal child health nursing.
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Many hospitals encourage nurses to participate as preceptors for nursing students. This activity helps faculty, but also provides support for hospital clinical ladder promotions. Neonatal expertise is a firm foundation for teaching undergraduate students basic health assessment, communication skills, and generalized pediatric care. The majority of hospitalized pediatric patients have a basic congenital or genetic problem with which neonatal nurses are familiar. NNP education is growing and with it the need for masters and doctorally prepared neonatal nurses to become faculty or head faculty practice centers where the clinical training occurs. These programs are being more critically evaluated to determine whether neonatal experts are an essential part of the educational process (Mitchell et al., 1995).
Researchers Neonatal nurses are becoming well known for heading multidisciplinary research teams. This roles can lead to a career change. Position of Directors of Nursing Research at hospitals and Associate Deans for Research in academic settings are open to neonatal nurses. The process of research and grant writing is the same whether it is for neonatal or other areas of nursing. Coordinators of clinical trials for corporations or independent research firms are other positions available to neonatal nurses. Positions resulting from grant-funde d projects for finite periods are positions that neonatal nurses should pursue as full-time jobs, They can participate as members of the research teams in single site or multisite research projects, They could fulfill roles as project managers, data collectors, and research dissemination.
CONCLUSION The time is past when one job or career trajectory can be a lifelong path. Neonatal nurses may need to retool, shift direction, change their focus, and even work for several employers or become selfemployed. Professional development and learning are lifelong commitments. This article has attempted to highlight new areas open to neonatal nurses. There are more opportunities today than there have ever been. A large portion of nurses are not in the acute care setting where they thought they would be working. Now is the time to follow a personal dream and to use the creativity once focused at the bedside to one's personal professional advantage.
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REFERENCES Ahimier, L. (1997, January). Persormal communication. Als, H., Lawhon, G., Brown, E., Gibes, R., Duffy, EH., McAnulty, G., & Blickman, J.G. (1986). Individualized behavioral and environmental care for the very low birth weight preterm infant at high risk for bronchopulmonary dysplasia: Neonatal intensive care unit and developmental outcome. Pediatrics, 78(6), 1123-32. Barton, L.A., & Lawlor-Klean, E (1994). Discharge planning and the role of the visiting nurse in the special care nursery. Neonatal Network, 13(6), 77-79. Beal, J.A., Maguire, D., & Carr, R. (1996). Neonatal nurse practitioners: Identity as advanced practice nurses. Journal of Obstetric Gynecologic and Neonatal Nursing, 25(5), 401-406. Bell, P.L. (1994). Neonatal case management: A challenge for advanced practice nurses. Journal of Perinatal and Neonatal Nursing, 8(2), 48-56. Brooten, D., Kumar, S., Brown, L.P., Butt, P., Finkler, S.A., Bakewell-Sachs, S., Gibbons, A., & Delivoria-Papadopoulos, M. (1986). A randomized clinical trial of early hospital discharge and home follow-up of very-low-birth-weight infants. New England Journal of Medicine, 315(15), 934-939. Brown, K.A., & Sauve, R.S. (1994). Evaluation of a caregiver education program: Home oxygen therapy for infants. Journal of Obstetric Gynecologic and Neonatal Nursing, 23(5), 429435. Casselden, D. (1995). The role of the neonatal nurse practitioner. Nursing l~mes, 91(40), 42-43. Clancy, G.T., & Maguire, D. (1995). Advanced practice nursing in the neonatal intensive care unit. Critical Care Nursing Clinics of North America, 7(10), 71-76. Christian, A. (1996). Clinical nurse specialists: Creating new programs for neonatal Home care. Journal of Perinatal and Neonatal Nursing, 10(1), 54-63. Cronenwett, L.R. (1995). Molding the future of advanced practice nursing. Nursing Outlook, 43, 112-118. Dawson, B. (1996). Special care in the community: Role of the community neonatal liaison sister. Professional Nurse, 10(2), 78-80. Ditzenberger, G.R., Collins, S.D, & Banta-Wright, S.A. (1995). Combining the roles of clinical nurse specialist and neonatal nurse practitioner: The experience in one academic tertiary care setting. Journal of Perinatal and Neonatal Nursing, 9(3), 45-52. Graven, S. (1997, January). The Annual Conference of the Physical Environment of the High Risk Neonate, Sand Key, Florida. Hutinger, P.L. (1994). Integrated program activities for young children. In L.J. Johnson, R.J. Gailagher, M.J. Lalontagne, J.B. Jordan, J.J. Gallagher, EL. Hutinger, & M.B. Karnes (Eds.), Meeting early intervention challenges: Issues from birth to three. (pp. 59-94). Baltimore: Paul H. Brookes Publishing Co., Inc.
Johnson, L.J. (1994). Challenges facing early intervention: An overview. In L.J. Johnson, R.J. Gallagher, MJ. LaMontagne, J.B. Jordan, J.J. Gallagher, P.L. Hutinger, & M.B. Karnes (Eds.), Meeting early intervention challenges: Issues from birth to three. (pp. 1-12). Baltimore: Paul H. Brookes Publishing Co., Inc. Kennel C., Flandermeyer, A., & Thomburg, P. (1996). Parenting in the NICU. In J. Zaichkin, (Ed.), Newborn intensive care: What ever)"parent needs to know. (pp. 93-108). Petatuma, CA: NICU INK. Liljeblad, C.Y. (1993). Neonatal nurse practitioners: Paving the way for case management of chronically ill infants and their families. Journal of Perinatal and Neonatal Nursing, 7(3), 49-58. Ludwig, M.A. (1990). Phototherapy in the home setting. Journal of Pediatric Health Care, 4(6), 304-308. Lynam, L. (1995). Developmental care in the intensive care nursing: Putting prevention into practice. Neonatal Intensive Care, Sept~Oct., (14), 37-41. Lynch, M.E. (1995). Expanding the caregiving environment for advanced practice neonatal nurses. Journal of Perinatal and Neonatal Nursing, 9(3), 62-70. McCanless, E L (1994). Work redesign in the neonatal intensive care unit: Role development and training from an educational perspective. Journal of Perinatat and Neonatal Nursing, 8(33), 69-82. Mitchell, A., Watts, L, Whyte, R., Blatz, S, Norman, G.R., Southwell, D., Hunsberger, M., Paes, B., & Pinelli, J. (1995). Evaluation of an educational program to prepare neonatal nurse practitioners. Journal of Nursing Education, 34(4), 286-289. Norris, D.A. (Ed.). (1991). How I became a nurse entrepreneur Petaluma, CA: National Nurses in Business. Pickler, R.H., & Reyna, B.H. (1996). Advanced practice nursing in the care of the high-risk infant. Journal of Perinatal and Neonatal Nursing, 10(1), 46-53. Ross, G. (1984). Home intervention for premature infants of low-income families. American Journal of Orthopsychiatry, 54(2), 263-270. Ruth-Sancez, V., Lee, K.A., & Bosqne, E.M. (1996). A descriptive study of current neonatal nurse practitioner practice. Neonatal Network, 15(5), 23-29. Tjossem, T.D. (1976). Early intervention: Issues and approaches. In T.D. Tjossem (Ed.), Intervention strategies for high-risk infants and young children. (pp. 3-33). Baltimore: University Park Press. Watldns, S., Kirchhoff, K.T., Hartigan, E.G., & Karp, T. (1992). Development of a program for neonatal intensive care units managed by neonatal nurse practitioners. Nursing Clinics of North America, 27(1), 87-97. Zagury, C.S. (1995). Nurse entrepreneur: Building the bridge of opportunity. Long Beach, NJ: Vista Publishing, Inc.
Copyright 9 1998 by W.B. Saunders Company
ealthcare reform and work redesign are changing all aspects of health delivery systems. The emphasis often tends to be on the negative aspects of this transition rather than the opportunities created through change. This article outlines the career opportunities now available for neonatal nurses in the acute and intermediate care, community, private practice, and academic settings. Nurses today have more opportunities to use their expertise and creativity that they demonstrate in their current work settings to develop and shape their future nursing careers.
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THE FUTURE OF NEONATAL NURSING The specialty of neonatal intensive care began more than 30 years ago owing to the recognition that the at-risk neonatal population has unique needs that requires specialized care. Today there are more than 500 neonatal intensive care units (NICUs) in the country (Pickler & Reyna, 1996). This number is expected to decline as mergers and alliances occur and hospitals close. Nevertheless, the number of patients is not declining. There are still approximately 2.5 million at-risk neonates born annually in the United States (Bell, 1994; Pickler & Reyna, 1996). However, some of these infants will be cared for in settings other than the NICU. Numerous changes have occurred in the last decade that have brought neonatal care to this crossroad. The emphasis on primary care and the decreased number of rotations that residents make through pediatric settings affect neonatal care. Advanced practice nurses (APN), such as clinical nurse specialists (CNS) and nurse practitioners (NP), are Journalof PediatricNursing,Vol 13, No 5 (October), 1998
working in areas of neonatal care such as high-risk follow-up, where traditionally professionals from other disciplines have worked. This change is due in part to the shift from setting-specific care to population-based care. In addition, there is also a rationing of services in some areas of the country, which is limiting access to tertiary centers (Bell, 1994). This means that certain tests, treatments, and technology will be available only at limited sites. Access to the most acute levels of care may be determined based on insurance coverage and managed care contracts, not on who necessarily needs what type of care (McCanless, 1994). Managed care often shifts the responsibility for decisions regarding setting for care from the provider of services to the purchaser of these services. Lengths of stays are diminishing because of the high costs attached to in-patient days and third-party payer's unwillingness to pay these high costs. Therefore, some smaller, more complex neonates may go home still technology dependent. Ironically, at the same time, the RN pool is declining in the hospital where the most critically ill patients are found (Bell, 1994). The use of unlicensed assistive personnel (UAP) in NICUs today is not atypical. The implications for neonatal nurses are many. However, one clear message is that nurses who went
From University of Cincinnati College of Nursing and Health and Good Samaritan Hospital and Bethesda Hospitals, Cincinnati, OH. Address reprint requests to Carole Kenner, RNC, DNS, FAAN, University of Cincinnati College of Nursing and Health, 3110 Vine Street, Cincinnati, OH 45221-0038. Copyright 9 1998 by W.B. Saunders Company 0882-5963/98/1305-00953.00/0
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into neonatal nursing may now find it necessary to move from the NICU to a different setting to care for this unique population. It is important to recognize that nursing is population based and not setting specific.
NEONATAL NURSING: ACUTEAND INTERMEDIATECARE SETTINGS Acute Care Settings Some neonatal nurses will still be in demand in acute care settings. The recognition by associations such as the National Organization of Nurse Practitioner Faculties (NONPF) of the acute care practitioner or neonatal nurse practitioner (NNP) and the increase in NNP programs in the country speak to the need for more highly educated neonatal nurses. The acute care practitioner is an accepted and recognized role with a clear identity (Beal, Maguire, & Carr, 1996). Nevertheless, the neonatal nurses role is changing. Historically this role evolved from the need to provide more technically proficient bedside nurses to work side by side with the physician providing care for the high-risk neonate. At the same time, the CNS evolved to help with the education and support of the nurses providing the direct care (Clancy & Maguire, 1995). Today these roles have changed, and the boundaries are blurring (Cronenwett, 1995; Ditzenberger, Collins, & Banta-Wright, 1995). APN nurses now often share many tasks and roles. Case management is an example of a shared role. Case management's purpose is " , . . to provide consistent care based on measurable outcomes that are determined by standard management plans on negotiated alternatives" (Pickier & Reyna, 1996, p. 49). The case manager often advocates for the patient and family (Bell, 1994) and typically covers a caseload of 10 to 15 patients. Depending on the setting, caseloads may be much higher. This situation is especially true when doing case management in the community setting. When working with children birth to 3 years of age and their families, case management is often referred to as service coordination. Despite which term is used, the role provides the key ingredient to holistic, integrated, coordinated, collaborative, multidisciplinary care. The neonatal nurse would be an excellent candidate for the position of case manager for high-risk neonates and their families. Case managers are especially important when critical pathways are used to determine the length of stay in the acute care setting. Neonatal nurses in acute care settings are usually
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familiar with the concept of critical pathways. Belief that health is a continuum that needs to be supported from the acute care setting to home has led to use of critical pathways to determine shortand long-term measurable outcomes of care. These benchmark points also provide a method of costing out services and examining quality of care. Unfortunately these points often force healthcare decisions based on the progression along the critical pathway and not on the individualized family needs. For example, the neonate may be ready for discharge according to the critical pathway for a particular medical diagnosis. However, the infant's mother is not ready or able to provide the required specialized feedings. This scenario poses a familiar dilemma. The infant cannot stay in the hospital, but a caregiver may not be adequately prepared to care for the child at home. Therefore, the patient may be moved to a rehabilitative center often reserved for adults, or intense preparations need to be made so the infant can be cared for in the home. In some institutions, these plans and needs are often handled by discharge coordinators or case managers. If the family has been working with a case manager or service coordinator since the child's admission to the unit, this person would be ideal for assisting with discharge planning. Regardless of the term used to describe the role, this person is responsible for discharge teaching, family assessments, and documentation of these activities (Bell, 1994; Christian, 1996). Care coordination is a creative innovative program. The care coordinator (CC) for maternity service meets with expecting parents toward the end of the first trimester and follows them through the birthing process and into the home environment. The CC can seek resources for the patient or family if problems arise (e.g., the mother becomes a high risk or the baby requires home intravenous therapy) and coordinates overall care. This program appears to be satisfying for parents, as well as maternity staff. If the child needs the NICU or the special care nursery (SCN) because she or he requires more complex care, the neonatal care and maternity care coordinator collaborate to coordinate care (Altimier, 1997). The authors have mentioned several different terms or titles used to describe what is essentially case management services for young children and their families. The difference lies not in whether the term case management or service/care coordination is used, but on the philosophical approach the person in that role uses for working with families. Families and children should not be seen as cases
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that need to be managed, but as individuals who could use assistance in accessing and understanding services or care. Viewing each child and family as unique, listening to what their individual needs are, being empathetic, and advocating for the family will help coordinators become more family centered, even in the midst of a highly technical acute care setting.
Intermediate Care Settings Intermediate care facilities can mean many things today. It may be the old Level II SCN, a step-down or transitional care unit, a developmental care unit, or even a rehabilitation center. All these settings provide care for patients who no longer require acute care but who may still have chronic or supportive needs. In addition to working in Level I! settings, NNP may also attend high-risk deliveries in some primarily Level I institutions where a pediatrician or neonatologist may not be available. They are often responsible for the admission and discharge assessments (Casselden, 1995) and establish discharge referrals before the discharge date (Barton & Lawlor-Klean, 1994). To meet the declining RN pool, some nurse managers are cross-training their staff to provide perinatal, neonatal, and home care. These nurses move beyond the preceding description of roles and into either direct bedside care or supportive services (Lynch, 1995). These nurses are generally at the staff level but may be APNs. It is not unusual for a neonatal nurse to assist in the delivery room stabilization of neonates and the immediate postpartum period with mother and baby care. Other hospitals are consolidating their management and creating one functional unit head by using neonatal nurse managers across the traditional units of the NICU and the perinatal area. Any of these situations can be carried out only when there is extensive cross-training and clear nursing protocols for patient care. Other neonatal nurse managers are cross-training neonatal nurses to work as home care nurses providing follow-up care for mother and baby. This type of cross-training is usually done when the hospital staff is responsible for home follow-up care or if the hospital administration believes that continuity from hospital to home would be good for public relations. The community setting may be one of the newest arena for neonatal nurses.
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NEONATAL NURSING: COMMUNITY SETTINGS
High-RiskFollow-UpClinics Neonatal nurses are strategically well placed for being able to move into high-risk follow-up clinics. After discharge, these clinics may provide the first health or chronic follow-up care and make referrals to specialized services for at risk neonates. Nurses who have NICU experience understand the foundation for the problems that are seen in these clinics. Nurses often rotate from the unit to the clinic as they have established rapport with the family and add to the family confidence in the care. These rotations also provide respite to the nurses from the acute care environment (Liljeblad, 1993).
Developmental Follow-Up Teams Developmental care has received much attention from multidisciplinary teams during the last decade. Developmental follow-up is ongoing and continually explores means of providing ageappropriate supportive developmental care and opportunities. There has been extensive research on the effects of the NICU environment on the neonate as evidenced by the Annual Conference of the Physical Environment of the High Risk Neonate hosted by Dr. Stanley Graven (1997). Research has also indicated the need for developmental follow-up and parent teaching on how to provide a supportive environment. Many units have sent nurses for Newborn Individualized Developmental Care and Assessment Program (N/DCAP) training. This program focuses on individualized care, with special emphasis on being sensitive to the environmental impact on the neonate and how to minimize its potential stress. In addition, it also offers specialized training to NICU nurses, which promotes opportunities of developmental specialist careers. Als and colleagues (1986) found increased cognitive and psychomotor scores at 1 year when a team approach was used by nurses and pediatric occupational and physical therapists in supporting and following neonatal/infant development. These scores were based on individualized developmental care plans started in the hospital and continued after discharge and during the first year of life. Bell (1994) demonstrated the same findings at age 9 months after NICU discharge.
CONTINUITY OF CARE CUNICS WITH PEDIATRICNURSE PRACTmONERS Much of the developmental testing and follow-up care has been traditionally linked with
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primary care and the role of the Pediatric Nurse Practitioner (PNP). However, most PNP education does not include in-depth information on the neurodevelopment of the premature infant. Nor does this education focus on the unique needs of the 32to 36-week gestation infant who has been discharged from the hospital and is now being monitored by general pediatric practice rather than a high-risk follow-up clinic. Some agencies have started continuity of care clinics where NNPs and PNPs work together. Or the PNP may come to the NICU to meet the family and develop a discharge plan together. On the first clinic visit, the NNP goes to the clinic to assess the infant with the PNP and provide continuity from the acute care to community setting. This cross-training of practitioners is an excellent opportunity for NNPs to increase their knowledge base on well child care and typical infant/toddler growth and development. The United Kingdom has provided this type of coverage for many years. There. the Neonatal Liaison Sister follows the baby for the first 10 days of life. either through home or clinic visits (Dawson. 1996). This nurse provides continuity for the family. There are some turf issues in the United Kingdom. as the boundaries of practice blur between these two groups (Dawson, 1996). These turf issues could be diminished if there is cross-training between the two groups of practitioners. This is true whether assessment and care are provided in the clinic or in the home. Neonatal nurses need to learn more about well child care (e.g., dental care, immunizations, growth and development, eye examination at 1 to 2 years of age or more frequently if there is any evidence of retinopathy of prematurity [ROP], hearing examination at 3 to 6 months and then again at 1 to 2 years of age, speech examinations at every 6 months beginning at 18 months, temperament assessments at 4 to 6 months, and neurologic checks over the first year). PNPs need to understand more about the neonatal pathology and special needs of at-risk neonates (e.g., suck swallow incoordination for infants at or below 34 weeks' gestational age, nutritional needs of premature infants, providing age-appropriate developmental care in the home, genetics, and fetal development to understand high-risk family histories and critical periods of development for certain anomalies). In addition, the PNP could benefit from increased education regarding chronic conditions (e.g., ROE bronchopulmonary dysplasia [BPD], and post-high technology treatments such as extracorporeal membrane oxygenation [ECMO]). Some of these chronic conditions are now being managed
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in the home with high technology, whereas others need only support and parent education for specialized care.
HOME CARE Home care is another new and burgeoning arena for neonatal nurses. This setting may lack the somewhat predictable normal chaos of a NICU and the backup support available in most acute care settings. In the home, turf and control issues between the nurse and parents are somewhat different. It is still traditional for most NICU nurses to want to be in control of the care of the neonate. During this extremely stressful initial situation, parents may even prefer that others take control. Yet in the home, parents may want and need to take control for the care of their child. The visiting nurse is a guest in the family's home and may not always be comfortable. This setting allows parents to ask the "dumb" questions and for the nurse to assess parent infant interaction and to teach parents in a more relaxed atmosphere (Christian, 1996). Although parent teaching begins before discharge, the parent's learning needs to be reinforced in the home. Cardiopulmonary resuscitation (CPR) training and home infant monitoring are two growing areas of home education, even though this training is started before discharge (Brown & Sauve, 1994). Parents often do not remember what is taught before discharge and do not realize that void until they are at home. Phone consultations by neonatal nurses is a backup for parents when the parents are not eligible for, or are between, home visits. Before discharge a predischarge visit may be conducted to determine family needs and environmental safety issues. During this time, the NICU nurse and home visit nurse may work together in accomplishing tasks such as contacting the insurance case manager to determine the family's benefits and the services that would be covered in a home setting (Christian, 1996). If equipment is needed, it must be ordered, and tested, and parents must be trained in its use before discharge. Nurses making the home visits must be familiar with neonatal problems and the equipment to be used. The nurse doing these visits needs some inpatient acute care practice and confidence in skills before going on an unsupervised visit or teaching about unfamiliar topics. A minimum of 1 year's training for home care and a 2-month orientation in the community setting would be helpful for the community nurse caring for a technology-dependent infant. There should be a
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skills checklist to document accomplishments. Training on such technical skills as phototherapy, IV infusion, laboratory draws, dressing changes, wound care, central line care, medication administration in the home, clean tracheostomy suction, and documentation of a home visit are musts (Christian, 1996; Ludwig, 1990). Parents need support in the transition to home. Neonatal nurses understand first hand the stress the parents have been under. These nurses must realize that they already know how to care for neonates and they have a working knowledge of neonatal problems. The only difference is the setting. They will now be providing care in the home. Neonatal nurses recognize, too, that setting up a mini-NICU at home adds stress to a family and that even under the best circumstances, when the baby is healthy at discharge, additional stress is placed on any family after discharge (Brooten et al., 1986). Ross (1984) found that for home care for low socioeconomic families can increase the mother's involvement with her infant. All mothers can be taught to be more responsive to infant cues. This teaching is especially important for mothers of premature infants, as these infants do not always send clear signals. The promotion of positive maternal-infant interaction may decrease the incidence of child abuse and neglect, which occurs when mothers do not have realistic expectations of their neonate (Kenner, Flandermeyer, & Thornburg, 1996; Ross, 1984). The concern today is whether parent teaching through nursing home visits is cost effective. Brooten et al. (1986) found that there where cost savings when parents are taught how to manage the health care system, keep their infant healthy, and access respite care, financial aid, parent support and/or advocacy groups, and transportation services. These home visits were done by APNs who had neonatal expertise. In general, a home visit costs $120 versus $1200/day in hospital if the infant is readmitted (Clancy & Maguire, 1995). Another facet of these visits was the identification of need for early intervention referrals as it relates to cost-effectiveness of the use of these services.
EARLYINTERVENTION Early intervention is an exciting new field of practice that serves young children and their families. Traditionally, early intervention refers to working with families and children from birth to 3 years of age, who have, or are at risk for, developmental
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disabilities. However, some professionals consider early intervention to include children up through 5 years of age. This field of practice is truly interdisciplinary and involves many professionals from the health and social sciences (e.g., nurses, doctors, teachers, physical therapists, speech therapists, occupational therapists, nutritionists, and psychologists). Therefore, it is important to recognize that additional cross-training or education from other disciplines is an important component of early intervention practice. Nurses often do not recognize early intervention as a specific field of practice. Yet this field of practice is needed today more than ever because children with complex medical problems and/or serious disabilities are routinely being sent home. Institutionalization is rarely an option even for families who might consider it. Although the rapid advance in technology has increased the rate of survival for at risk neonates, it has also increased the number of children who may have lifelong physical or mental disabilities. Early, adequate, and appropriate health and educational services are needed to assist these children in reaching their maximum life potential. Both health and educational services need to begin on discharge from the acute care setting. Neonatal nurses could provide the expertise needed in understanding the related health issues of children with developmental disabilities. The current legislative mandate for services is the Individuals with Disabilities Education Act (IDEA) (Johnson, 1994). Part H of IDEA pertains to infants and toddlers with disabilities. Public Law 105-17 was signed into law by President Clinton in June 1997. Part H of IDEA or PL-195-17 pertains to infants and toddlers with disabilities. The eligible population for part H includes children up to age 3 years who have a measured developmental delay(s) or diagnosed physical or mental condition(s), which could result in developmental disabilities. Currently, individual states determine which children will be eligible for services (Hutinger, 1994). However, early interventionists generally recognize three widely accepted definitions of risk that were first introduced by Tjossem (1976): established risk, biological risk, and environmental risk. Children with established risk are those who have a definite medical diagnosis that has a known pattern of developmental disabilities (e.g., Down syndrome, cerebral palsy, spina bifida, autism). Biological risk identifies children who have prenatal, perinatal, or postnatal incidents that may have affected the central nervous system (e.g., premature
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infants, children exposed prenatally to drugs or alcohol, small for gestational age). Environmental risk includes children whose life experiences (e.g., abuse, neglect, lack of developmentally appropriate parent child interaction) may put them at risk for developmental delays. It is apparent that children discharged from the NICU are in one or more of these risk categories. Neonatal nurses could be service coordinator for these young children and their families. Service coordinators work in hospitals and community agencies providing the support families need in accessing health and educational services for their child and family. Their main role is to coordinate the services that have been designated on the individualized family service plan (IFSP). The IFSP is an ongoing plan developed by the early intervention team, with the family members being active major participants of this team. Each family should have only one service coordinator and one IFSP. The various agencies and providers collaborate as a team to coordinate services, avoid duplication, and help the family reach the goals they have set for their child. The care provided is often referred to as being "family driven" or "family centered" and is a philosophical change from professional care that is agency or provider centered. The last decade has seen many changes in the care of children with disabilities. Consequently, there are many opportunities for nurses working with young children and their families.
SICK DAY CARE AND PARENT CALL-IN HOURS Daycare for sick children has spread to support working parents. It is a much needed area as more women need or choose to work outside the home and may be unable to take time off when their child is ill. Concerns about cross-contamination among ill children has slowed progress toward sick care day centers. Nurses can play a vital role in establishing safe, caring environments for children with acute short-term illnesses. Numerous pediatricians have call-in hours for parents to ask questions. NICUs and SCNs are inundated with phone calls from parents of premature infants after discharge who have questions about their premature infant. The NICU nurse could offer a wealth of knowledge and support to parents, NICU/SCN staff, and physicians. Telephone triaging is a growing area of "telemedicine." It has legal ramifications, but it is a wonderful community service provided by nurses.
PRIVATEPRACTICESETTING: ENTREPRENEURIALACTIVITIES
Development of Continuing Education
Programs
Although in general continuing educational (CE) programs and on-the-job training have diminished, the need for increased education for practicing neonatal nurses is even greater owing to the vast changes in neonatal care (Ruth-Sancez, Lee, & Bosque, 1996). Neonatal nurses have the expertise to develop CE modules on specific topics, computer self-study programs, videotapes for professional and lay teaching, and interactive videos for instruction in schools of nursing. Publishing articles with attached CEs is another activity that is attracting many nurses. These activities can be money-making and not just altruistic. In the past, however, nurses have often given away their course content and materials. Now these must be considered a product of neonatal expertise. Home study institutions periodically put calls out for nurses to write CE programs on neonatal topics.
Lecture Circuit Neonatal nurses are being sought to lecture to local, regional, or national groups. There is a lecture circuit that can be cultivated. Nurses should respond to call for papers advertised in professional journals or direct mall fliers; offer to speak at local groups, serve on a panel of experts at a workshop; or do a guest lecture for a nursing, medical, respiratory therapy, EMT, or paramedic classes. They should contact the companies who offer multiple lectures that move across the country. All have contact numbers for more information about registration. Nurses could use this number to contact the person responsible for neonatal or pediatric content lectures. Once the nurse's name is known, she or he will be contacted to speak. Nurses should speak with colleagues who are doing lectures to determine appropriate current fees for speaking services, and they should set a fee for your services. Until a price tag is attached, there is often less thought about value of the content. It is important to develop a professional network of colleagues who can answer questions or help the neonatal nurse start a new career (Clancy & Maguire, 1995).
Expert Witness or Content Expert Neonatal nurses make good expert witnesses or content experts. Although some nurses have concerns about providing these services to hospitals or
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attorneys, the reality is that nurses do have the expertise to review merits of medical cases. Content experts provide expert reviews for the purpose of screening cases for the legal merits. This review may help in identifying expert witness who will later be deposed. Expert witnesses are also needed from neonatal nursing ranks. They serve as the expert to decide whether a standard of care has been violated or to support that in fact the care rendered was appropriate. The expert must be knowledgeable in direct patient care, as well as thoroughly versed in the neonatal literature, especially the standards, nursing practice acts, and policies of the time of the incident. The expert will usually be deposed and may, in some cases, testify in court. Through these case reviews, either as a content expert or expert witness, policies and procedures may be changed. The legal nurse consultant is a good avenue for a career change. Not all the need is for expert testimony, but it may be for case review even by insurance companies. Legal nurse consultants can also be used to link experts in other areas of the country or professional fields with attorneys or risk managers. It is important not to give away these contacts, but to provide this information for a fee. This is a legitimate charge for providing information linkage. There are multiple sources for information on how to provide this service, set fees for the service, and learn what to expect if the case goes to trial (Norris, 1991). Remember neonatal care is highly specialized and needs experts who are familiar with the specialty to do the review. The neonatal nurse's critical assessment of the case may help support a colleague who is involved in an unjust charge.
Pharmaceutical Research/Sales The trend is to create pediatric drugs and neonatal medications specifically geared to this population and home administration. Credibility and support of products are increased if neonatal nurses with an extensive knowledge of pharmacodynamics and administration procedures are used in the development. They may be responsible for coordinating clinical drug trials, ensuring adherence to research protocol, and training research nurses. Once the product is ready for sale, nurses can help market the product and answer the professional questions of staff nurses, physicians, nurse managers, and pharmacists. Drug development is not the only area for the industrial nurse.
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Researchand Developmentof Neonatal Products As more emphasis is placed on environmental neonatology, companies are concemed about developing products such as warmers, isolettes, phototherapy, and home care products that are environmentally friendly and developmentally supportive (Lynam, 1995). Neonatal nurses are being hired as consultants for product development, moderators of focus groups with health professions to determine new marketing niches a company should consider, or coordinators of research clinical trials of the equipment to provide scientific rationale for their product. These companies include those who are 'selling home phototherapy units, home or inpatient monitoring, respiratory therapy products, incubators and warmers, transfusion equipment, and IV infusion equipment. Neonatal nurses have the physiologic and behavioral assessment knowledge and understanding of the linkages between the environment and neonate's responses. Their knowledge regarding the sensitivity of the sensory and autonomic nervous system of a premature neonate is important, as this is a growing population of consumers for the companies' products. Product development is an area in which nurses can think of creative solutions to solve acute problems and sell these ideas to companies. Nurses are also good at product selling owing to their natural outreach educational workshops. In the case of a company's products, nurses can make presentations to companies to sell an idea for development. If hired by a company who has developed a neonatal product, the nurse could provide in-services for the personnel on the equipment's function. These in-services are viewed as more credible when they are done by professionals who have worked in NICUs.
Businesses:Home HealthA9encies and PersonnelStaffing Pools With their expertise in the special requirements of neonates and their families, neonatal nurses have used creative ideas for setting up their own businesses. They have established home healthcare agencies specializing in home parent education, direct care, and care coordination (Watkins, Kirchhuff, Hartigan, & Karp, 1992). Other neonatal nurses have set up personnel pools of temporary agency nurses who do only perinatal/neonatal care. Temporary pools of APNs have been created. Other nurses with neonatal backgrounds have become nurse recruiters in their own agencies. They specialize in temporary or permanent placements for
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neonatal nurses in practice and/or educational settings. The emphasis in all of these business ventures is that neonatal nurses serve a specialized population and have a defined knowledge base. These businesses require a keen sense of what is needed by neonatal patients and their families and what they have to offer these consumers. For nurses who wish to pursue entrepreneurial activities, many resources are available at the local libraries, through the Internet, and through the National Nurses in Business Association. Zagury (1995) presents a workbook approach to starting a business, which may be quite helpful for someone interested in becoming an entrepreneur.
ACADEMIC SETTINGS Health Policy Development: Fellowships Health policy development is critical to the future of neonatal nursing and care. Fellowships are advertised in professional journals and direct mailers, which speak to the need for nurses with specialized expertise to apply. These fellowships (e.g., the White House Fellowship, Robert Wood Johnson Fellowships, and governmental agencies fellowships) usually solicit proposals for what the nurse sees as an important health topic and how personal professional development could affect future healthcare legislation. These fellowships vary according to length, salaries, and the need for relocation. Fellowships often open other doors for serving on consensus panels, writing healthcare legislation, working with Congress as a paid "staffer." publishing pamphlets or briefs on health policies, or being hired as a lobbyist for nursing associations.
Education Neonatal nurses are natural educators. They teach under stressful conditions and often do not recognize their valuable contribution to families and colleagues. However, neonatal nurses have often been used for outreach education and orientation programs without extra pay. Some have been hired by nursing faculties. Now new career opportunities are available to be hired by Allied Health Schools for teaching in Physician Assistant programs, by Colleges of Medicine for medical student and resident education, for interdisciplinary education across specialties and disciplines, by community agencies as CPR trainers and lay public health seminars, and by colleges of nursing to teach pediatric and maternal child health nursing.
KENNER, ALTIMIER,AND HESS
Many hospitals encourage nurses to participate as preceptors for nursing students. This activity helps faculty, but also provides support for hospital clinical ladder promotions. Neonatal expertise is a firm foundation for teaching undergraduate students basic health assessment, communication skills, and generalized pediatric care. The majority of hospitalized pediatric patients have a basic congenital or genetic problem with which neonatal nurses are familiar. NNP education is growing and with it the need for masters and doctorally prepared neonatal nurses to become faculty or head faculty practice centers where the clinical training occurs. These programs are being more critically evaluated to determine whether neonatal experts are an essential part of the educational process (Mitchell et al., 1995).
Researchers Neonatal nurses are becoming well known for heading multidisciplinary research teams. This roles can lead to a career change. Position of Directors of Nursing Research at hospitals and Associate Deans for Research in academic settings are open to neonatal nurses. The process of research and grant writing is the same whether it is for neonatal or other areas of nursing. Coordinators of clinical trials for corporations or independent research firms are other positions available to neonatal nurses. Positions resulting from grant-funde d projects for finite periods are positions that neonatal nurses should pursue as full-time jobs, They can participate as members of the research teams in single site or multisite research projects, They could fulfill roles as project managers, data collectors, and research dissemination.
CONCLUSION The time is past when one job or career trajectory can be a lifelong path. Neonatal nurses may need to retool, shift direction, change their focus, and even work for several employers or become selfemployed. Professional development and learning are lifelong commitments. This article has attempted to highlight new areas open to neonatal nurses. There are more opportunities today than there have ever been. A large portion of nurses are not in the acute care setting where they thought they would be working. Now is the time to follow a personal dream and to use the creativity once focused at the bedside to one's personal professional advantage.
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