Why Is It So Difficult To Get Into A Neonatal NP Program?

Coffee Nurse, BSN, RN · Aug 25, 2016

Wow, what a thread. Just out of curiosity, where was it located before it was placed in the NICU forum?
I can speak to your questions as one of the few NNP posters on allnurses who has read a lot about getting into NNP school and the shortage of schools, now working as a NNP for almost two years now. There was a lot of good information laid out for you so far.
From your initial post:
1. It's not actually that difficult to get into NNP school as compared to other specialties (FNP might be easier since there are so many, CRNA is definitely harder). What is it that is making it so difficult in your mind? Just the required experience? I'll discuss that in this post.
2. Why do you have to work in a NICU prior to NNP school as compared to ACPNP or even ACNP?
Nursing school prepares you to work for adults right out of school. Every rotation is focused around adults (med-surg, elderly, psych, community, etc etc). You may get a smattering of experience with newborns in your OB rotation (although it's largely focused on the mother) and you generally just get one clinical rotation through pediatrics, of which you might get an introduction to the NICU. You certainly don't get a a semester's worth of knowledge in the NICU like other specialties (including peds), but if you're lucky, you might get to do a cap stone/senior practicum/etc rotation in the NICU during your last year in nursing school.
So while I personally still think it's somewhat questionable for a RN with no clinical experience to become an adult NP, at least if it's with the adult world, the nurse was specifically trained on common adult pathophysiology & treatments. It's a bit more circumspect for a nurse with no experience to become a PNP (particularly acute care PNP), but at least everyone has had a semester of didactic and clinical knowledge regarding pediatrics while in nursing school. I will tell you that it's probably virtually impossible to work in the PICU as a PNP with absolutely no experience as a nurse or a NP.
Then we come to NICU. The NICU is its own little world with a completely different way of doing things. You have to essentially unlearn nearly everything you learned in nursing school, down to the most basic of things like what a normal vital sign is. For example, adults breathe 12-20 times a minute. Babies breathe anywhere from 30-60 times a minute. Let me assure you that if an adult was breathing 60 times a minute as a regular rate, unless I'm mistaken, a rapid response would be called pretty quickly. An oxygen saturation of 85% may be of no cause for concern in the NICU whereas it can be a panic number on an adult unit. This small bit of representation doesn't take into account any of the "biggies" of just learning that a baby's organ systems are different than that of an adults (even things like basic blood circulation) and there is no way you can learn how it all works in graduate school with no nursing experience (unless we significantly extended the school education). They simply do not have the time to teach you basic pathophys- you are being taught on a much higher level on what to do with treatment and diagnosis differentials and it's expected that you already have a basic knowledge of this. This basic knowledge is not taught in nursing school.
I will also tell you that in my own experience, new grad nurses flourished much more easily in the NICU as compared to experienced nurses with non-NICU experience. It was very hard for the latter group to transition into this completely different way of thinking and we had very little success in training many of them as compared to our new grad groups.
Why isn't the NICU taught more in nursing schools? They are trying to prepare you to be a generalist nurse with the expectation that you can specialize later after you pass boards. There is simply not enough time in a nursing program to focus on niche specialties, of which NICU is one of them. NICU also has very little cross-over with other specialties, so there is little incentive for a school to give it any air time. Even a specialty like newborn nursery may be difficult for a NICU nurse to handle at first. For example, my unit sometimes gets newborns who are otherwise completely healthy and normal besides that they have a defect (in this case, an in-utero repaired spinal defect). Newborns do not eat hardly anything for a few days and certainly not much in the first 24 hours. Yet, I had many phone calls from multiple nurses who were concerned that the infant in question wasn't eating "enough" and wanted more interventions, such as placing a nasogastric tube for artificial enteral nutrition or an IV for fluid administration. I educated them and refused the interventions, but they were uncomfortable enough that I kept getting the same phone call for the first two days that this baby was in the unit. They were so far caught up in what they "knew" as a NICU nurse that it was hard for them to break out of that mentality.
3. Why is there a shortage of NNP programs?
There are about 20 or so, probably less at this point. I did a whole spreadsheet back in 2010 of all the schools I could find (posted somewhere in the bowels of this forum, but sadly outdated at this point) and read a lot about them. It's a national concern that there are so few and many of them closing. My own MSN program nearly shut down its NNP program. It was avoided by the board of directors who found out about this continual shuttering of programs and they didn't want to be another contributing program, as they are a top-ranked program for graduate nursing school in general and felt a responsibility to continue the torch (for now).
I am by no means an expert on this topic nor do I claim to know all the factors. I can tell you what I've read, heard, and experienced in my 8 years of working in the NICU. It largely boils down to finding instructors willing to get paid peanuts (when they easily make six figures in clinical practice) and finding clinical sites for students. Some schools flat out tell their students that they are responsible for finding their own clinical site (one of the most ethically wrong things in nursing graduate school, IMO). Hospitals are generally less willing to provide this type of education to students unless they are an academic center because it is completely altruistic on their part. When you put in the fact that many students are trying to get into just a few sites, the competition means that hospitals can be choosy about which schools they will accept students from. I made sure to choose a school who would set up the clinical for me, not the other way around. Another factor is that you are completing nearly all of your clinical time in a NICU (although I did have probably about 50 hours split among newborn nursery, NICU follow up clinic, and shadowing a midwife for L&D). Other specialties do not have this restriction. Adult clinicals can go to any number of floors or settings as well as PNPs, but there is only one NICU in the hospital. The amount of resources this requires of the NICU is large.
My own hospital is currently orienting 4 new NNP graduates who are FTEs on a 4 month orientation (standard at this hospital and not too far off the mark for other similar hospitals that are Level IV). I was recently asked to precept a NNP student even though it's not an ideal situation since I have
I hope to teach one day in a NNP program to give back to my profession, but I am under no illusions that I will put in more than I get out monetarily.
4. In regards to your question about requiring experience before starting school, that may be the case at that particular school, but it is not the case at all schools. Look further into this because many schools will let you take didactic non-NICU courses (like research or pathophysiology) before you start clinical. You generally have to have the clinical experience before you go into NICU didactic/clinical time though.
It actually used to be a requirement to become licensed by the NCC (where one takes the board exam to become a NNP), but this dropped a few years ago. It's more driven at this point by schools. It's still a good thing IMO for the reasons I said above. You would simply drown without the experience.
5. In response to GeneralistRN comparing to the medical field, as llg said, you go to medical school (which prepares you as a generalist in the adult world) and then you are required to have further training in residency and/or fellowship. As she pointed out, to become a neonatologist, it requires 3 years training in pediatrics and 3 years training as a neonatologist. Keep in mind that during these 3 years each, the doctors are working 80 hour weeks, largely clinically based (except in the last years of each). If nurses worked 80 hour work weeks they could probably get away with 1 year of nursing experience for appropriate entry into graduate school to become a NNP.
6. In response to GeneralistRN's comment about PAs working the NICU, they are very rare for a good reason. PA school is 2 years long and (like nursing and medical school) are equipping them to work in the adult world. A PA without experience working the NICU would require an extensively long orientation and many of those folks do not make it out because they have to (again) unlearn nearly everything they did while in school. They may know the basics of making a diagnosis or knowing basic drugs, but not as it applies to the NICU. Most employers are not willing to train someone for 6 months (paid) with a high risk of them not being able to transition successfully into the job. If they are hired, it's generally at large academic institutions where they can support them more fully. I know that my hospital refuses to hire them (even experienced ones) in my NICU.
There is a PA residency that has cropped up over the last few years, but only in a few sites as someone else pointed out. As I understand it, it is like a true residency where one is not working the general 40 hour week, but more on par with a medical residency type hours. I want to make it clear that this is not being created out of the desire for PAs to be in the NICU. They are not trained in neonates unlike NICU nurses who go to graduate school and solely focus on NICU. This is being propped up as a response to the national shortage of providers in the NICU and hospitals are becoming desperate just to hire people.
The average age of a NNP is older than other NPs and with programs shutting down, the shortage will only get worse. Couple that with the fact that pediatric residencies no longer require a full 3 months in the NICU during their training- so many programs have dropped the extra month. Someone has to fill that role for those months that there is no resident. PA residencies are a response to this national shortage.
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I hope this answers some of your questions. I can sense your frustration about the required clinical time, but trust me, it's needed. I had 4 years going into grad school and had 6 by the time I graduated. I didn't necessarily need all of that time (I lacked self-confidence about my own knowledge), but 2 years is definitely a solid number that I think people need. If not, then the clinical time and didactic time in grad school needs to be upped, which will not happen due to shortages as I listed above.
It's hard to get into the NICU as a new graduate but there are ways. Be the best candidate you can be, read the threads on this forum (for the love of everything, please don't ask on a new thread because there is so much information on this topic littered throughout dozens of threads).
Best of luck in your journey through nursing school and your transition in the RN role. Keep us posted on how it's going. Let me know if you have any other questions.

Is there not an applauding smiley? Because this deserves one.

SunshineeStudent · Aug 25, 2016

Wow, what a thread. Just out of curiosity, where was it located before it was placed in the NICU forum?
.............

thank you!! thank you!!!! Thank you! There are no words to express how thankful I am for you to give such a detailed passage! I know your days can be quite hectic being an awesome NNP and all but I appreciate you,wholeheartedly, for giving me the information I need! I wish you would write a book lol Also thanks for not making me feel incompetent and as if my question(s) were idiotic for a "student" just starting clinicals. I know you're an amazing person :)

TheCommuter, BSN, RN · Aug 26, 2016

Wow, what a thread. Just out of curiosity, where was it located before it was placed in the NICU forum?

This thread had previously been in the General Nursing Discussion forum before it was moved.

babyNP., APRN · Aug 26, 2016

Is there not an applauding smiley? Because this deserves one.

Very kind of you to say : ) I didn't even know that NICU existed prior to my peds rotation during my senior year in nursing school and read everything I could as a young 22 year old on this forum many years ago. I'm in a position to deliver information that is scarce on the internet and it's nice to help out future generations. Okay...now off to go teach NRP today : )

SunshineeStudent · Aug 27, 2016

Very kind of you to say : ) I didn't even know that NICU existed prior to my peds rotation during my senior year in nursing school and read everything I could as a young 22 year old on this forum many years ago. I'm in a position to deliver information that is scarce on the internet and it's nice to help out future generations. Okay...now off to go teach NRP today : )

Hopefully my NRP instructor is just as awesome as you!

Irish_Mist, BSN, RN · Aug 27, 2016

You would be doing our tiny patients a huge disservice by becoming an NNP without NICU experience. Even two years is barely enough. Just because the PNPs do it doesn't make it right.

THIS TIMES 100. As a parent, there is no way in heck I'd want an NP with no clinical experience in pediatrics or NICU treating my son. You have no foundation upon which to stand. Get the experience and then apply for NP school. It might be harrrrrddddddd but it'll be worth it for you and most importantly, the tiny humans.

bethab10 · Aug 31, 2016

This requirement comes from the national specialty education standards published by NANN - Education Standardsand Curriculum Guidelines for Neonatal Nurse Practitioner Programs. While the National Task Force standards that apply to all NP programs don't have practice eligibility criteria, many of the specialty standards do. Certification used to require the practice experience as well before you could take the certification exam but it is no longer a requirement. You might want to contact NANN to express your issues good or bad with these requirements. These programs are just complying with the national standards for neonatal NP programs