Neonatal Nurse vs Neonatal Nurse Practitioner

Coffee Nurse, BSN, RN · Jun 7, 2015

Hello! I am a student interested in neonatal nursing and was wondering about the differences between a neonatal nurse and a neonatal nurse practitioner in terms of job duties.

Hi and welcome! I've worked in the NICU my whole career; when I got started I assumed that at some point I'd want to go back to become an NNP, but I've come to realize that it's not really where my heart lies. The nurses are the ones at the bedside the whole shift; we do all the feeds, hands-on care, assessments, etc. for one to maybe 3-4 babies, depending on how sick/busy they are. We also do most of the parent teaching, getting them involved in helping to care for their little ones. NNPs usually function like junior doctors (although if I've got a tricky question or a baby who's a hard stick for an IV, I'll always go to an NNP first ) insofar as they're responsible for planning care for a part of the unit population, answerable to the attending(s) on duty. Their role tends to resemble the medical model more than the nursing model.

meanmaryjean, DNP, RN · Jun 7, 2015

Exactly! If you want to have hands on care for babies, teach parents and all that- neonatal RN is the way to go.

mirandaaa · Jun 8, 2015

Thank you for posting this!

I was wondering this before as well.

littlepeopleRNICU · Jun 8, 2015

All hands on care is done by the bedside nurse. The practitioners in my NICU have both, 12 hour and 24 hour shifts. During the day, they help round on patients and write orders for/with the attendings, and at night, they're the ones on call. Our attending will only come down if a patient is actively circling the drain and is needed, but otherwise(and even in a lot of those circumstances), our NNPs handle it all. They do admit orders/assess any new patients we get overnight, do emergency procedures, go to deliveries where the NICU charge team is needed, etc. like someone else said, "junior doctor".

nursing5275 · Jun 8, 2015

Thank you so much everyone for all the information! I realize now that being a NICU nurse and not a nurse practitioner is what I've always envisioned myself doing.

How did you get into working in the NICU after receiving your BSN?

babyNP., APRN · Jun 13, 2015

I don't really like the term "junior doctor"- almost as bad as the term, "physician extender." Words do matter and to be completely honest, it feels a little belittling to be called a "junior doctor" as though I'm like a resident, perpetually stuck in the non-expert role.

That being said, a lot of the duties of a NNP are as described above (and there are many NNPs in smaller NICUs that are independent for all intents and purposes, rounding on the phone with a doc, but having full autonomy otherwise), but it's important to keep in mind that they aren't mutually exclusive roles. In order to be a NNP, you must practice a NICU RN for a couple of years first (although technically you don't need to in order to sit for the boards, I know of no school that will admit one without any NICU experience). We are taught in the nursing model in nursing school (and generally a medical model in graduate school) and so have a different philosophical mindset as compared to our medical-only taught physician colleagues. This is especially true in how we approach parents and having better "instincts" for what may be going on with the patient based on RN descriptions of problems (as we've been in that same exact position) and noticing nursing issues at the bedside that may not otherwise be caught, but have really significant effects on the patient.

The NICU RN does the majority of bedside care and parent skills teaching- no doubt about that. But I also complete a physical assessment on my patients each day (often changing diapers), and I do teach parents- more about their baby's diagnoses and prognosis of care. I even still feed babies on occasion when I have time- my fellow RNs always appreciate it :) but it's true, the latter portion is not strictly in my job description, but just because it's not that doesn't mean that I don't.

Why did I become a NNP? I wanted more autonomy and wanted to go back to school to learn all the diseases and management process in more detail, not to mention going to deliveries and performing invasive skills. I really loved being a bedside NICU RN and while I do miss some of the bedside aspects, there are many benefits that I've found to being a NNP besides the differences in role function.

- It's much less emotionally taxing. As the NICU RN, you're at the bedside all the time, meaning you have to ask permission to use the bathroom from your colleague (someone needs to "watch" the babies) or take a lunch break, etc. I'm also not stuck all day with parents that are demanding and emotionally draining.

- I get to talk about actual problems/new diagnoses/test results and have the knowledge to explain them thoroughly to parents. As a RN, you're generally limited to telling normal results, but if your baby's head ultrasound comes back with a terrible head bleed, they wouldn't be the person to break the news to the parents

- I get to sit down and relax more. While there are (of course) many days that are busy and I sometimes have to stay late in order to catch up on work, there are other days when I am done with all of my work by early afternoon. And if my colleagues don't need my help, I can catch up on reading, go outside (our phones work in our court yard), or even feed babies :) It's so freeing to not be tied down to the bedside all the time.

- As a NP, we're treated much better than our RN colleagues (which is really a shame) in that we are constantly being treated to things like free lectures on different topics in neonatology, budgets to go to conferences, some free lunches, and just better overall perks from the hospital system. I think it's really too bad that the RNs don't have these types of opportunities (and some hospitals may offer this to their RN colleagues) because they are so crucial to the baby's care.

- Being "in charge." While of course we do collaborate with our physician colleagues (and who do have the final say on major changes), I handle most of the daily issues by myself. While RNs advocate for their patients on a daily basis (along with nutrition, consulting services, PT/OT, pharmacy, etc etc), we make the final decisions and it feels good to have the background knowledge to make those decisions and discuss the rationales of why we are or are not doing something with our fellow colleagues. And trust me- every service has their own opinion and they are smart people- but they don't always see the bigger picture or remember that our patients are babies, not little adults.

In any case, if you want to be a NICU RN and not be a NNP, that's completely fine and awesome. After being a NNP, I don't think I will go back to being a bedside RN for the above reasons listed. But a good NICU RN is worth his/her weight in gold and we need people like that in this field. I wish you the best of luck in getting a job in the NICU- people have asked how to get into the NICU many times on this forum- try doing a search. Let us know how things go!

Coffee Nurse, BSN, RN · Jun 13, 2015

I don't really like the term "junior doctor"- almost as bad as the term, "physician extender." Words do matter and to be completely honest, it feels a little belittling to be called a "junior doctor" as though I'm like a resident, perpetually stuck in the non-expert role.

I did compare NNPs to junior doctors in the context of your role, not your expertise -- in fact, made a point of extolling the latter, if you'll notice. And if you're one of the rare ones who changes a diaper or does a feed when you notice it needs doing, then you too are worth your weight in gold

babyNP., APRN · Jun 13, 2015

I did compare NNPs to junior doctors in the context of your role, not your expertise -- in fact, made a point of extolling the latter, if you'll notice. And if you're one of the rare ones who changes a diaper or does a feed when you notice it needs doing, then you too are worth your weight in gold

No worries, I did not have any bad impression at all from you or anyone else- just merely pointing out the phrasing maybe not the best of choices.

I also don't think it's right to find a dirty bum and not change it- just seems cruel to the baby! I don't always have time to feed, but love to when I get a chance.

happyinmyheart · Jun 13, 2015

Thank for taking the time to explain the difference BabyNP. I have often googled the difference, only to find generic answers and answers that didn't fully answer my questions :)

TiffyRN, BSN, PhD · Jun 15, 2015

Their role tends to resemble the medical model more than the nursing model.

Generally, I love our NNPs but I have concerns that of all the NP models out there, NNP seems to follow the medical model more than other NP specialties. I know they hate the term "physician extender" but that's what it boils down to. The NNP's job is to be assigned to an MD, take a portion of their caseload, round on them, review labs and x-rays, write progress notes and orders. They generally get assigned the less complex infants in the physician's lineup. That sounds like a physician extender to me. Whether or not the NNP brings a nursing perspective to the position is completely dependent on the individual, it is not "built into" the position, certainly not required. I know neonatologists in our group that are more wholistic in their patient care than many of our NNPs.

The NNPs that work in our unit work for the neonatology group and are accountable to the physician's model of practice. Perhaps if they had their own group there would be more autonomy and a more nurse-centric practice.

Let me finish by saying that NNPs are an invaluable resource to our unit, very approachable. I am happy to have them and enjoy working with them. In general, they bring years of valuable bedside nursing experience with them.

babyNP., APRN · Jun 15, 2015

^^ I would respectfully disagree and this AANP: Call us 'Nurse Practitioners' not 'physician extenders' - The Clinical Advisor and this Nurse Practitioners Are Not â€˜Physician Extenders' | Off the Charts are good overviews.

I don't know about the scope of practice that NNPs have at your own facility, but the NNPs in my unit take all complex cases- in fact, we do not allow our community neonatologists or residents handle our most critically ill infants (including ECMO) because it is felt that we do a better job taking care of the infants. Sometimes it actually gets a little weary taking care of only critically ill infants, because the residents get all the simple preemies.

NICU is a unique field, as you pointed out. In Level IV NICUs we generally consult multiple specialty services due to the nature of the infant's particular disease process, so the process of care is one that is truly collaborative with each of the consulting services, nutrition, social work, case management, nursing, and of course, neonatologists and NNPs. This is unlike a clinic setting, as you pointed out, but it doesn't mean that we never practice autonomously. I had different thoughts when I was a bedside RN, but once I started going to clinical and practicing as a NNP, I got to see what it was like on the other side of the curtain and I realized that I did not give the NNPs nearly as much credit in their practice that they deserved.

In closing, I guess we will have to agree to disagree.

eta: While there will always be NNPs that don't bring in their nursing skills from days past like communicating well with families and there will always be physicians that are fantastic about discussing plans of care with families, the difference is that NNPs were taught how to do this in nursing school and did it on a daily basis while working with parents throughout the entire shift whereas residents were not and have a more limited interaction experience with families as compared to bedside RNs. While it is up to the individual, as you said, there is a trend that I've seen in my years of experience and reading many threads on this board.