Neonatal personnel in Canada

Abstract

Although the need for trained personnel to care for neonates with complex needs is recognized, there has been no systematic analysis of present or future personnel requirements. The Canadian Paediatric Society’s Neonatal-Perinatal Medicine Section sponsored a symposium on neonatal personnel, inviting four Canadian experts to address issues related to future needs. Areas addressed included neonatal nurse practitioners providing increased patient care in some parts of the country as resident involvement in neonatal intensive care decreases, the extended roles of other health care personnel and increased direct patient care by neonatologists. There is no approved method to determine personnel needs, but paediatric department heads have indicated that the number of neonatologists needed is substantially greater than available funding allows. Considering economic factors and the need to educate perinatal care providers, it is important to assess present and future needs to ensure that quality care can be provided.

Care of the fetus and newly born baby benefits families and society in ways that last a lifetime, and often into subsequent generations. In Canada, considerable time, energy and resources are devoted to providing neonatal-perinatal care (1–3). There have been dramatic improvements in survival outcome over the past 30 years, especially for very low birthweight babies (4–7). The outlook for a newborn baby in Canada now is better than ever.

Health care professionals providing neonatal care include family physicians, paediatricians and neonatologists working in close conjunction with people providing obstetrical care, such as nurses, respiratory therapists and many others. As the discipline of neonatology has developed, there has been a trend towards neonatologists increasingly providing neonatal intensive care. Other health care professions (eg, nursing, respiratory therapy) have similarly developed specialized knowledge and expertise in the care of neonates. Many of these professionals have now assumed responsibility for many activities previously provided by physicians. With continuing educational programs, roles continue to evolve. This process may partially address the major concerns about neonatal personnel that have arisen in recent years (8–10).

In 1989 a National Conference of Directors of Canadian University Neonatal programs produced a White Paper on Canadian Neonatal Manpower: The Crisis in the Maintenance of Neonatal Health Care Services (unpublished data). This document was distributed to heads of departments of paediatrics and provincial Ministers of Health across Canada. However, in Canada no organized approach examining utilization and the future needs for recruiting neonatal care personnel has occurred. Concerns about neonatal physician requirements are not unique to Canada and have been expressed by British health care professionals (11). Serious concern is growing about Canada’s ability to maintain the present level of neonatal-perinatal health care (8–10), particularly in times of fiscal constraints.

PRESENT STATUS

Twelve Canadian programs in neonatal-perinatal medicine accredited by the Royal College of Physicians and Surgeons of Canada (RCPSC) exist today. The RCPSC, with its Specialty Committee in Neonatal-Perinatal Medicine, has instituted a process to follow the future careers of trainees. Previously, only a portion of neonatology trainees planned full-time neonatology positions in Canada. Other graduates used their neonatal training on a part-time basis in Canada or in other countries. The 1989 White Paper estimated a deficiency of 100 neonatologists in Canada based upon current American and Canadian recommendations (12–15), yet the number of available funded neonatologist positions in Canada is relatively small. This may be explained by the fact that most neonatology positions in Canada are academic positions where funds are often not available to provide salary support. In contrast, only 10% of Canadian physicians were full-time faculty members of Canadian medical schools in 1986; the challenges of attracting physicians into academic medicine have been described (16).

Factors that influence career choices of paediatric residents increasingly reflect issues related to lifestyle (17) and the stress created by the acuity and complexity of patient diseases (18). While non-Canadian graduates account for 33% of paediatricians in Canada and represent a considerable proportion of tertiary care paediatricians (19), two-thirds of the neonatologists in Canada are non-Canadian medical school graduates (9). Information suggests that relatively few Canadian paediatric residents identify with the exciting rewards and challenges of a career in neonatology (10). The decisions of graduates is often negatively influenced by the difficult lifestyle of neonatologists who work in neonatal intensive care units (NICU). Units operate in a similar manner 24 h a day, each day of the year, placing many demands on personnel. As in all intensive care units, physicians, nurses, respiratory therapists and others are expected to work a greater portion of their time at night and during weekends, compared with many other areas in health care. While these demands may be difficult to avoid, there is a need to identify future personnel requirements, implement educational programs effectively, analyze factors that determine career choices and develop a strategy to recruit adequate neonatology trainees to ensure that quality neonatal care is available in the future.

To date, no major study of Canadian neonatal personnel needs has been completed. Previously neonatology lacked recognition as an area of specialized care. The most recent personnel survey of the RCPSC grouped all paediatric subspecialties together without considering their vastly different roles (20). American Academy of Pediatrics’ recommendations (13–14) regarding the numbers of neonatologists required to provide care to newborns, which were accepted in Canada (15), reflect a previous time when there were adequate numbers of “physician trainees (interns, residents or fellows), other physicians, nurse clinicians and other health care providers working under the supervision of the neonatologist” (13). Recommendations for nursing, respiratory therapy and other personnel (15) have been based on traditional models of health care, while ignoring patient acuity or the significant needs of smaller and sicker babies. Coincidentally, changes in resident educational requirements have led to decreased time allocated to neonatal rotations. While some resident activities could be performed by others, the ‘traditional’ role of the physician still requires a large time commitment in the NICU (21). Extended and expanded roles for respiratory therapists and nurses have developed in several Canadian NICUs, although recognized educational programs remain few. The Canadian Society of Respiratory Therapy has approved specialized postcertification programs in neonatal intensive care but these programs have not yet been implemented. With recognition of the value of specialized nursing (22,23), masters level programs in neonatal intensive care nursing are available in two Canadian centres. Although neonatal nurse practitioners work effectively (24), the number of graduates currently is too small to meet personnel needs. Other personnel models for neonatal care may need to be considered to assess their effectiveness and cost.

Canada’s health care system is changing and will continue to change as indicated in the Barer-Stoddart (25) and other reports (26). With limited financial resources, more effective use of personnel and ways to minimize the overlap of responsibilities in the NICU setting need to be considered. Accurate predictions about the number and type of personnel required for future neonatal intensive care are needed to ensure sufficient personnel are trained.

NEONATAL MANPOWER SYMPOSIUM

The Canadian Paediatric Society’s Neonatal-Perinatal Medicine Section has a strong interest in neonatal personnel needs and the maintenance of high quality care for newborns and the unborn. Previous physician requirement considerations had either grouped neonatology with other paediatric subspecialties (20) or have been viewed as reflecting vested interests. Changes have been suggested to meet personnel needs in this area (8–10), but have been difficult to implement. To focus needed attention on the subject, a symposium on neonatal manpower was organized in conjunction with the Canadian Paediatric Society annual meeting and held July 25, 1994. Chaired by Dr D McMillan and Dr T Perreault, the panel included Dr G Chance, Ms D Fraser Askin, Dr JG Hall and Dr M Watanabe. The panel members were requested to address the following areas:

• What do you foresee in the future for neonatologists, other paediatricians, nurses (traditional or expanded roles), respiratory therapists (traditional or expanded roles) and other health care personnel in care of the baby in a neonatal intensive care unit?

• In addition to ensuring clinical care, how do we ensure that education and research meet future needs? Should these be provided by ‘clinicians’ or other personnel? How should they be funded?

• What mechanisms should be utilized to determine manpower requirements? How do we best ensure that we attract qualified people into the field of neonatal care for the future?

• Should resources for neonatal intensive care be ‘rationed’? If you were a parent of a seriously ill baby in an NICU, how, if at all, would your personal views differ from your professional views?

Dr Watanabe indicated that while the annual growth in the number of family physicians and specialists was 3% to 5.5% during the late 1980s, it had decreased to approximately 2% in the 1990s – roughly matching population growth. Growth in the number of paediatricians was less than 2% in the 1990s. Among paediatricians, the percentage of subspecialists ranged from 30% to 37% in different surveys. While the number of neonatologists was higher than any other paediatric subspecialty, the number of neonatologists decreased between 1986 and 1993 (see below). With the exception of immunology and pharmacology, the number of all other paediatric subspecialties in Canada increased during this period. Dr Watanabe noted that the percentage of Canadian medical school graduates among physicians increased from 70.2% in 1984 to 72.7% in 1992 (this may have significant implications to neonatology where traditionally two-thirds of Canadian neonatologists have graduated from medical school in countries outside Canada [9]). About 70% of paediatricians devoted more than 50% of their practice to primary care, raising the question of whether general paediatricians should act more as consultants, including in neonatology. He concluded his presentation by asking: What services are essential to maintain the health care status of the population? Who should provide these services? How should the health system be configured to maximize health outcomes? How should equity of access be guaranteed?

Dr Hall indicated that question of physician personnel needs is a common one. She asked, “How will we know what’s ‘enuf’?” Other subspecialties are asking the same question; neonatologists have been asking for a longer period of time. Determination of ‘enuf’ neonatologists could be based on a national standard (if this existed), but several other factors must come into play. These include whether the numbers should be based on primary, secondary or tertiary care or be calculated according to the population; availabilty of personnel and education resources; how a normal workload should be determined; and who should judge the quality of care –the patient, the doctor or the Ministry of Health.

Answers to these questions are often financially driven and have implications for training responsibilities including the replacement of personnel and maintenance of competency. The answers may help to plan for and encourage newcomers to enter the field and can serve to improve working conditions and the fee-salary level as well as be used as a political force to improve child health.

Dr Hall stated that less than 80% of the ‘full-time’ paediatricians in British Columbia were in active paediatric practice. Of these 200 paediatricians, 69 had faculty positions, 119 were in full-time private practice and 12 in part-time practice. (Information was not specific for neonatologists but not all are in full-time practice, and most are in faculty positions which have increased responsibilities beyond clinical work.) In spring 1994, 29 of 37 training positions in neonatal-perinatal medicine in Canada were filled (17 by Canadians). There were 106 neonatologists in Canada, with a ‘shortfall’ as determined by a national survey of the heads of department of paediatrics of 17.7 which differed from the shortfall of 100 neonatologists in the 1989 White Paper. It was uncertain how many of those in training intended to practise full-time neonatology in the future. However, the RCPSC Specialty Committee in Neonatal-Perinatal Medicine has now instituted a mechanism to keep track of graduates and their future practice.

Debbie Fraser Askin presented a vision for the future with neonatal care including neonatal nurse practitioners with 24 h ‘in-house’ neonatologist back-up. She reviewed the development of programs in the United States and the two Canadian programs (McMaster and University of Alberta) preparing neonatal nurse practitioners at the Masters level. Perceived advantages of neonatal nurse practitioners include continuity of care, economics and availability. Potential barriers include nursing practice acts, physician and nursing resistance, lack of educational programs, legal issues and the influence of union agreements. Collaborative research between physicians and nurses should be encouraged in an atmosphere of clinical excellence. She felt that personnel requirements vary in each province and depend on the mix of available personnel and types of patients. The need for neonatal nurse practitioners should be independent of the number of residents available. To attract qualified individuals, good training programs, good research programs, an appropriate mix of research education and clinical time, competitive salaries and a means to address lifestyle issues effectively are needed.

Resources have to used rationally. To determine the needs, it is necessary to remember that approximately 20% of time is needed for education and 20% for maintenance of health care standards. New ways to work and consequently new ways of remuneration will have to be found. Those entering neonatology today will have a different ‘job description’ that will include different working relationships with nurse clinicians and other health care personnel.

Dr Chance reported the results of a survey of 22 level III NICUs (20 responding) and 10 other units in Canada providing some level III care. Of the 118 total identified neonatologists, 82 (69%) were international medical school graduates. An additional 32 additional neonatologists were required (as identified by neonatal program directors), but only five new positions were funded. Approximately two-thirds of Canadian neonaologists were appointed in 1980 or later. Six level III programs required the consultant to ‘live in’ at night, and one other program did this on occasion. Eight level III units used associate physicians and eight used clinical nurse specialists. An additional four programs had plans to appoint clinical nurse specialists. Twenty-six clinical nurse specialists were employed. There was an indicated need for an additional 37 clinical nurse specialists but only seven funded positions were available. All but one level III unit had 24 h respiratory therapy coverage. In 13 of 19 programs respiratory therapists performed intubation, and in 10 they attended deliveries for resuscitation. All 20 level III units had social workers, 17 had nutritionists and 16 had pharmacists of whom 10 provided assistance with parenteral nutrition orders.

In the 10 modified level III units, there were 15 neonatologists working in eight units. In four programs there was a consultant in house at night. One program had a clinical nurse specialist and four had 24 h respiratory therapy coverage. Nine of the 10 programs had social workers, eight had nutritionists and six had pharmacists.

Dr Chance proposed several answers as to why there are insufficient numbers of neonatologists. This may be related to improving neonatal survival. Perhaps recruitment has occurred too slowly or maybe the neonatologist role is not very attractive anymore, because of the lifestyle associated with long hours and constant clinical demands. Appropriate steps are not being done to recruit and retain neonatologists.

Education and research are important aspects of the role of a neonatologist. The continuing presence of residents and fellows is very important because residents and fellows provide the challenges that contribute to improving care. Faculty is involved in important non-clinical activities: writing papers and grant applications, basic research, clinical research, epidemiology, teaching and administration. When calculating the number of required neonatologists, these factors should be taken into account. To allow health care personnel to fulfil these roles, alternative salary funding needs to be sought. While research, including cost effectiveness research, continues, there is also a need to educate government and health care administrators regarding the role of neonatalperinatal health care providers in today’s and tomorrow’s society.

Following the presentations, a discussion period occurred. The following points were raised. Neonatologists are required to direct the neonatal health care team. The ‘hands on’ care of each patient is shared with other health care personnel. Extended role nurses, respiratory therapists and other health care worker are taking on additional responsibilities in many NICUs. Each Canadian NICU appears to be approaching these issues in a somewhat different manner that is affected by licensing requirements, administrative issues and available funds, which are severely limited in relation to perceived needs.

Education and research should include physicians (eg, paediatric residents), nurses, respiratory therapists and others in a joint effort to improve health care and to use resources effectively.

No commonly accepted methods to determine neonatology personnel requirements exist. Even Canadian paediatric program directors’ perceptions of the number of neonatologists required are in excess of funded positions. There is a strong need to attract Canadian medical school graduates to neonatalperinatal medicine but many issues, including job availability, career opportunities, financial remuneration and quality of lifestyle, must be addressed.

Although neonatal personnel resources have been strained, dedication and ingenuity have maintained the quality of patient care in the changing economic climate.

CONCLUSIONS

In Canada, there is a continuing need to address issues related to personnel caring for newborn babies. Currently no national mechanism exists to determine present and future needs for physicians, nurses, respiratory therapists, other health care workers, administrators and the government.

Needs will likely continue to be met differently in various parts of the country, reflecting local economic factors and the availability of trained personnel. Although no single model for providing neonatal care can be presently recommended for Canada, analysis of future personnel needs should recognize existing trends, include specialty specific analyses in medicine, nursing and other health care fields, and consider future educational resources and funding to meet the needs of the newest members of society.