Sleep debt and outside employment patterns in helicopter air medical staff working 24-hour shifts

Fatigue risk assessment of a Helicopter Emergency Medical Service crew working a 24/7 shift pattern: results of a prospective service evaluation

BACKGROUND

The work of Helicopter Emergency Medical Services (HEMS) teams crosses the boundaries of several high-risk occupations including medicine, aviation, and transport. Working conditions can be challenging and operational demands requires a 24-h rota, resulting in disruption of the normal circadian rhythm. HEMS crews are therefore prone to both mental and physical fatigue. As fatigue in medical providers is linked to poor cognitive performance, degradation of psychomotor skills and error, this study aimed to explore the existence of predictable patterns of crew-fatigue in a HEMS service.

METHODS

HEMS medical crew members working a 3-on 3-off forward rotating rota with a 5-week shift cycle were asked to do psychomotor vigilance tests (PVT) as an objective measure of fatigue. PVT testing was undertaken at the start, mid- and at the end of every shift during a full 5-week shift cycle. In addition, they were asked to score subjective tiredness with the Samn-Perelli Fatigue Scale (SPFS), and to keep a Transport Fatigue Assessment shift log, wherein they noted shift characteristics potentially related to fatigue. Primary outcome of interest was defined as the change in PVT and SPFS scores over time.

RESULTS

Mean baseline resting PVT in milliseconds at the start of the study period was 427 [390-464]. There was an overall trend towards higher PVT-scores with shift progression mean [95% CI] PVT at the start of shifts 447 [433-460]; halfway through the shift 452 [440-463]; end of the shift 459 [444-475], p = 0.10), whereas SPFS scores remained constant. Within a 5 week forward-rotating cycle, an overall trend towards a gradual increase in both average PVT (from 436 [238-454] to 460 [371-527, p = 0.68] ms;) and SPFS (from 2.9 [2.6-3.2] to 3.6 [3.1-4.0], p = 0.38) was observed, although significant interindividual variation was present. Reported SPFS scores ≥ 4 (moderate fatigue) were mainly related to workload (number of jobs) and transport mode (car-based shifts).

CONCLUSION

An overall trend towards a decline in psychomotor vigilance and an increase in self-reported tiredness was found for HEMS crew over a 5-week shift cycle. Using a bespoke predictive fatigue tool on a day-to-day basis could increase fatigue awareness and provide a framework to which relevant mitigating options can be applied.

Eating Patterns among Emergency Medical Service Providers in the United States: A Qualitative Interview Study

Emergency medical service (EMS) providers experience demanding work conditions in addition to shift work, which increases risk for nutrition related chronic disease such as metabolic syndrome, diabetes, obesity, and cardiovascular disease. The high stress, emergent, and unpredictable nature of EMS may interfere with healthy eating patterns on and off shift, however little is known about how these conditions impact dietary patterns among EMS providers. This study aimed to understand factors impacting dietary patterns through semi-structured interviews with 40 EMS providers throughout the United States. Interviews were conducted virtually via Zoom video conference. Inductive coding was used to identify themes throughout the interviews. Salient factors mentioned in the interviews included hunger, fatigue, stress, coworker influence, ambulance posting, geographical location, agency policy, and culture. Factors were grouped into 4 domains: physiological factors, psychosocial factors, physical environment, and organizational environment, represented by an adapted version of the social ecological model of health behaviors to include factors influencing eating patterns specific to EMS, which may contribute to overall health. Various barriers to healthy eating exist within EMS, and future studies should explore interventions at each level of our proposed model to improve conditions and reduce nutrition related disease risk in this essential population.

Work schedule and seasonal influences on sleep and fatigue in helicopter and fixed-wing aircraft operations in extreme environments

Sleep and fatigue were investigated in aviation search and rescue, firefighting, emergency medical services and offshore transfer operations in 210 participants, for 21 days each, across 17 datasets in seven countries. Sleep data were collected using wrist-worn actigraphs and sleep diaries. Sustained attention was assessed using a 5-min Psychomotor Vigilance Task (PVT). Duty information was provided from corporate IT systems. Despite the number of 24 h operations, most work occurred during daytime hours, and most sleep occurred at night. There were seasonal changes in work and sleep patterns, with naps used to augment total sleep time. The proportion of sleep occurring during duty varied from zero to 30%. Differences in PVT response times were trivial to small. Legislation that defines flight, duty time and minimum rest limits assume that sleep is not obtained during duty periods, apart from some napping under Fatigue Risk Management Systems (FRMS). However, especially in cases where the aviation service requires waiting for tasks (e.g. search and rescue, emergency medical response), this assumption may not always hold. FRMS should accommodate different modes of working that safely facilitate sleep during duty time where appropriate.

Sleep and Sleepiness Measured by Diaries and Actigraphy among Norwegian and Austrian Helicopter Emergency Medical Service (HEMS) Pilots

The study examined sleep and sleepiness among shift working Helicopter Emergency Medical Service pilots from Norway (Norwegian Air Ambulance; NAA) and Austria (Christophorus Flugrettungverein; CFV). Both pilot groups (N = 47) worked seven consecutive 24 h shifts. Sleep was assessed by diaries and actigraphy while sleepiness was assessed by the Karolinska Sleepiness Scale, all administered throughout the workweek. The results indicated that all pilots had later bedtime (p < 0.05) and wake-up time (p < 0.01) as they approached the workweek end, but no change during the workweek was evident regarding wake after sleep onset, time in bed, total sleep time, or sleep efficiency. The NAA pilots had later bedtime (p < 0.001) and wake-up time (p < 0.001), spent more time awake after sleep onset (p < 0.001), more time in bed (p < 0.001), slept longer (p < 0.01), and had lower sleep efficiency (p < 0.001) compared with the CFV pilots. The sleepiness levels of all pilots were slightly elevated on the first workday but lower on the following workdays (day 2p < 0.001, day 3p < 0.05). For both pilot groups, no major change in sleep or sleepiness parameters throughout the workweek was detected. The NAA pilots reported somewhat more disturbed sleep but obtained more sleep compared with the CFV pilots.

Should public safety shift workers be allowed to nap while on duty?

Fatigue and sleep deficiency among public safety personnel are threats to wellness, public and personal safety, and workforce retention. Napping strategies may reduce work-related fatigue, improve safety and health, yet in some public safety organizations it is discouraged or prohibited. Our aim with this commentary is to define intra-shift napping, summarize arguments for and against it, and to outline potential applications of this important fatigue mitigation strategy supported by evidence. We focus our discussion on emergency medical services (EMS); a key component of the public safety system, which is comprised of police, fire, and EMS. The personnel who work in EMS stand to benefit from intra-shift napping due to frequent use of extended duration shifts, a high prevalence of personnel working multiple jobs, and evidence showing that greater than half of EMS personnel report severe fatigue, poor sleep quality, inadequate inter-shift recovery, and excessive daytime sleepiness. The benefits of intra-shift napping include decreased sleepiness and fatigue, improved recovery between shifts, decreased anxiety, and reduced feelings of burnout. Intra-shift napping also mitigates alterations in clinician blood pressure associated with disturbed sleep and shift work. The negative consequences of napping include negative public perception, acute performance deficits stemming from sleep inertia, and the potential costs associated with reduced performance. While there are valid arguments against intra-shift napping, we believe that the available scientific evidence favors it as a key component of fatigue mitigation and workplace wellness. We further believe that these arguments extend beyond EMS to all sectors of public safety.

Ambulatory blood pressure monitoring among emergency medical services night shift workers

OBJECTIVES

Higher 24-hour blood pressure (BP) and blunted BP dipping during sleep and night-time hours are associated with adverse health outcomes. Night shift work may affect 24-hour BP and dipping patterns, but empirical data in emergency medical services (EMS) clinician shift workers are sparse. We implemented ambulatory blood pressure monitoring (ABPM) in EMS workers to characterise BP during night shift work versus a non-workday, and sleep versus wake.

METHODS

Participants worked night shifts. Hourly ABPM and wrist actigraphy (to measure sleep) were collected during two 24-hour periods, one scheduled night shift and one non-workday. Blunted BP dipping was defined as a BP decrease of <10%.

RESULTS

Of 56 participants, 53 (53.6% female, mean age 26.5 (SD 7.5) years) completed the study. During daytime sleep on a workday, 49.1% of participants had blunted systolic BP (SBP) or diastolic BP (DBP) dipping. During night-time sleep on a non-workday, 25% had blunted SBP dipping and 3.9% blunted DBP dipping. Blunted SBP or DBP dipping occurred among all participants who did not nap during the night shift or who napped <60 min. Blunted SBP dipping occurred in only 14.3% of participants who napped 60-120 min.

CONCLUSIONS

During night shift work, the BP dipping of EMS shift workers is blunted; however, most who nap for 60 min or longer experience a healthy dip in BP. The potential health consequences of these observations in EMS clinicians warrant further study.

The Impact of Working Overtime or Multiple Jobs in Emergency Medical Services

Background: EMS professionals frequently work more than a standard 40-hour work week. For some EMS professionals, working overtime or multiple jobs may be necessary to make ends meet. Our objective was to evaluate the association between job satisfaction, intention to leave EMS, and financial dependence on overtime or working multiple jobs.Methods: We conducted a cross-sectional analysis of nationally-certified EMS professionals who completed an online questionnaire after submitting their recertification application (22,626/101,363, response rate = 22%) between October 2017 - May 2018. Items included dependence on additional work, satisfaction with job, and intentions of leaving the profession. Multivariable logistic regression models were used to describe the association between dependence on additional work, and job satisfaction and intention to leave EMS within 1 year and 5 years, controlling for age, sex, minority status, agency type, employment status, and urbanicity.Results: A total of 18,285 respondents were included in the analysis. The majority of EMS professionals (75%) worked over 40 hours per week. Most respondents (71%) were dependent on overtime or multiple jobs to make ends meet. Those who were dependent on extra work had higher odds of being dissatisfied with their job (aOR 1.92, 95% CI:1.64-2.44, and higher odds of intentions to leave EMS within 1 year and 5 years respectively (aOR 1.32, 95%CI:1.14-1.54; aOR 1.16, 95%CI:1.07-1.25).Conclusion: Many EMS professionals depend on additional work to make a living. Financial dependence was associated with increased odds of workforce-reducing factors, including job satisfaction and intention of leaving. This can lead to poor individual outcomes such as stress and burnout, as well as to turnover within the workforce, thus reducing the number of individuals available to provide high quality emergency care.

Impact of shift duration on alertness among air-medical emergency care clinician shift workers

BACKGROUND

Greater than half of Emergency Medical Services (EMS) shift workers report fatigue at work and most work long duration shifts. We sought to compare the alertness level of EMS shift workers by shift duration.

METHODS

We used a multi-site, 14-day prospective observational cohort study design of EMS clinician shift workers at four air-medical EMS organizations. The primary outcome was behavioral alertness as measured by psychomotor vigilance tests (PVT) at the start and end of shifts. We stratified shifts by duration (< 24 h and 24 h), night versus day, and examined the impact of intra-shift napping on PVT performance.

RESULTS

One hundred and twelve individuals participated. The distribution of shifts <24 h and 24 h with complete data were 54% and 46%, respectively. We detected no differences in PVT performance measures stratified by shift duration (P > 0.05). Performance for selected PVT measures (lapses and false starts) was worse on night shifts compared to day shifts (P < 0.05). Performance also worsened with decreasing time between waking from a nap and the end of shift PVT assessment.

CONCLUSIONS

Deficits in performance in the air-medical setting may be greatest during night shifts and proximal to waking from an intra-shift nap. Future research should examine alertness and performance throughout air-medical shifts, as well as investigate the timing and duration of intra-shift naps on outcomes.

Real-Time Fatigue Mitigation with Air-Medical Personnel: The SleepTrackTXT2 Randomized Trial

Objective: The aims of this study were: 1) to determine the short-term impact of the SleepTrackTXT2 intervention on air-medical clinician fatigue during work shifts and 2) determine the longer-term impact on sleep quality over 120 days. Methods: We used a multi-site randomized controlled trial study design with a targeted enrollment of 100 (ClinicalTrials.gov NCT02783027). The intervention was behavioral (non-pharmacological) and participation was scheduled for 120 days. Participation was voluntary. All consented participants answered baseline as well as follow-up surveys. All participants answered text message queries, which assessed self-rated fatigue, sleepiness, concentration, recovery, and hours of sleep. Intervention participants received additional text messages with recommendations for behaviors that can mitigate fatigue. Intervention participants received weekly text messages that promoted sleep. Our analysis was guided by the intent-to-treat principle. For the long-term outcome of interest (sleep quality at 120 days), we used a two-sample t-test on the change in sleep quality to determine the intervention effect. Results: Eighty-three individuals were randomized and 2,828 shifts documented (median shifts per participant =37, IQR 23-49). Seventy-one percent of individuals randomized (n = 59) participated up to the 120-day study period and 52% (n = 43) completed the follow-up survey. Of the 69,530 text messages distributed, participants responded to 61,571 (88.6%). Mean sleep quality at 120 days did not differ from baseline for intervention (p > 0.05) or control group participants (p > 0.05), and did not differ between groups (p > 0.05). There was no change from baseline to 120 days in the proportion with poor sleep quality in either group. Intra-shift fatigue increased (worsened) over the course of 12-hour shifts for participants in both study arms. Fatigue at the end of 12-hour shifts was higher among control group participants than participants in the intervention group (p < 0.05). Pre-shift hours of sleep were often less than 7 hours and did not differ between the groups over time. Conclusions: The SleepTrackTXT2 behavioral intervention showed a positive short-term impact on self-rated fatigue during 12-hour shifts, but did not impact longer duration shifts or have a longer-term impact on sleep quality among air-medical EMS clinicians.

The association between weekly work hours, crew familiarity, and occupational injury and illness in emergency medical services workers

OBJECTIVE

Emergency Medical Services (EMS) workers are shift workers in a high-risk, uncontrolled occupational environment. EMS-worker fatigue has been associated with self-reported injury, but the influence of extended weekly work hours is unknown.

METHODS

A retrospective cohort study was designed using historical shift schedules and occupational injury and illness reports. Using multilevel models, we examined the association between weekly work hours, crew familiarity, and injury or illness.

RESULTS

In total, 966,082 shifts and 950 reports across 14 EMS agencies were obtained over a 1-3 year period. Weekly work hours were not associated with occupational injury or illness. Schedule characteristics that yield decreased exposure to occupational hazards, such as part-time work and night work, conferred reduced risk of injury or illness.

CONCLUSIONS

Extended weekly work hours were not associated with occupational injury or illness. Future work should focus on transient exposures and agency-level characteristics that may contribute to adverse work events.

Real-time fatigue reduction in emergency care clinicians: The SleepTrackTXT randomized trial

BACKGROUND

We assessed performance characteristics and impact of a mobile phone text-message intervention for reducing intra-shift fatigue among emergency clinician shift workers.

METHODS

We used a randomized controlled trial of 100 participants. All participants received text-message assessments at the start, every 4 hr during, and at end of scheduled shifts over a 90-day period. Text-message queries measured self-rated sleepiness, fatigue, and difficulty with concentration. Additional text-messages were sent to intervention participants to promote alertness. A performance measure of interest was compliance with answering text-messages.

RESULTS

Ninety-nine participants documented 2,621 shifts and responded to 36,073 of 40,947 text-messages (88% compliance rate). Intervention participants reported lower mean fatigue and sleepiness at 4 hr, 8 hr, and at the end of 12 hr shifts compared to controls (P < 0.05). Intervention participants reported better sleep quality at 90-days compared to baseline (P = 0.01).

CONCLUSIONS

We showed feasibility and short-term efficacy of a text-message based assessment and intervention tool.

An observational study of shift length, crew familiarity, and occupational injury and illness in emergency medical services workers

OBJECTIVES

Emergency medical services (EMS) clinicians are shift workers deployed in two-person teams. Extended shift duration, workplace fatigue, poor sleep and lack of familiarity with teammates are common in the EMS workforce and may contribute to workplace injury. We sought to examine the relationship between shift length and occupational injury while controlling for relevant shift work and teamwork factors.

METHODS

We obtained 3 years of shift schedules and occupational injury and illness reports were from 14 large EMS agencies. We abstracted shift length and additional scheduling and team characteristics from shift schedules. We matched occupational injury and illness reports to shift records and used hierarchical logistic regression models to test the relationship between shift length and occupational injury and illness while controlling for teammate familiarity.

RESULTS

The cohort contained 966,082 shifts, 4382 employees and 950 outcome reports. Risk of occupational injury and illness was lower for shifts ≤8 h in duration (RR 0.70; 95% CI 0.51 to 0.96) compared with shifts >8 and ≤12 h. Relative to shifts >8 and ≤12 h, risk of injury was 60% greater (RR 1.60; 95% CI 1.22 to 2.10) for employees that worked shifts >16 and ≤24 h.

CONCLUSIONS

Shift length is associated with increased risk of occupational injury and illness in this sample of EMS shift workers.

Emergency healthcare worker sleep, fatigue, and alertness behavior survey (SFAB): development and content validation of a survey tool

BACKGROUND

Workplace safety is a recognized concern in emergency medical services (EMS). Ambulance crashes are common and injury rates exceed that of the general working public. Fatigue and sleepiness during shift work pose a safety risk for patients and EMS workers. Changing EMS worker behaviors and improving alertness during shift work is hampered by a lack of instruments that reliably and accurately measure multidimensional beliefs and habits that predict alertness behavior.

OBJECTIVES

We sought to test the reliability and validity of a survey tool (the sleep, fatigue, and alertness behavior survey [SFAB]) designed to identify the cognitions of EMS workers concerning sleep, fatigue, and alertness behaviors during shift work.

METHODS

We operationalized the integrative model of behavioral prediction (IMBP) and developed a pool of 97 candidate items and sub-items to measure eight domains of the IMBP. Five sleep scientists judged the content validity of each item and a convenience sample of EMS workers completed a paper-based version of the SFAB. We retained items judged content valid by five sleep scientists and performed exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and tests of reliability and internal consistency. We identified a simple factor structure for each scale and calculated means and standard deviations for each item and scale.

RESULTS

We received 360 completed SFAB surveys from a convenience sample of 800 EMS workers attending two regional continuing education conferences (45% participation rate). Forty-seven candidate items and sub-items/options were removed following content validation, EFA, and CFA testing. Analyses revealed a simple factor structure for seven of eight domains and a final pool of 50 items and sub-items/options. Domains include: attitudes, normative beliefs, knowledge, salience, habits, environmental constraints, and intent. EFA tests of self-efficacy items failed to identify a simple factor structure. We retained two self-efficacy items based on Spearman-Brown correlation of 0.23 (p<0.0001).

CONCLUSIONS

Measurement of sleep, fatigue, and alertness behavior among EMS workers is challenging. We describe the development and psychometric testing of a survey tool that may be useful in a variety of applications addressing sleep, fatigue, and alertness behavior among EMS workers.

Over-commitment of EMS personnel in North Carolina with implications for disaster planning

BACKGROUND

While large-scale disasters are uncommon, our society relies on emergency personnel to be available to respond and act. Faith in their availability may lead to a false sense of security. Many emergency personnel obligate themselves to more than one agency and so may be overcommitted, leaving agencies with unfilled positions in a disaster. We sought to describe the frequency of overcommitment of emergency medical services (EMS) personnel in North Carolina.

METHODS

We conducted a cross-sectional study utilizing the Credentialing Information System (CIS) of the North Carolina Office of EMS. The CIS database manages demographic and certification information for all EMS personnel in North Carolina. The state is divided into 100 EMS systems based on county boundaries. Utilizing de-identified provider data from the CIS, we collected system(s) affiliation(s) and level of certification. To calculate an overcommitment rate per system, we divided the number of personnel with more than one system affiliation by total number of system roster personnel. To compare urbanicity and certification level with overcommitment, analysis of variance and the chi-square test were used, respectively.

RESULTS

North Carolina credentials 14,717 EMS providers (8,346 EMT, 1,709 EMT-intermediate (EMT-I), 4,662 EMT-paramedic (EMT-P)). Of these, 10,928 (74%) are affiliated with a single system. Of the 3,789 committed to more than one system, 3,020 (21%) were committed to two systems, 571 (4%) to three, 138 (1%) to four, and 60 (<1%) to five or more. EMT-Is and EMT-Ps were more likely to be overcommitted when compared to EMTs (37, 32, 20% respectively, p < 0.0001). Statewide, the median overcommitment rate for EMS systems was 24% (IQR 16-37%). Personnel working in systems servicing less densely populated areas were more likely to be overcommitted: 33% wilderness, 29% rural, 20% suburban and 11% urban (p < 0.0001). Additionally, 40% wilderness, 23% rural, 4% suburban, and 0% urban systems had >37% of their personnel engaged in 9-1-1 response in more than one system.

CONCLUSION

Many EMS personnel have multiple EMS commitments. Disaster planners and emergency managers should consider overcommitment of emergency responders when calculating the work force on which they can rely.

Fatigue in Air Medical Clinicians Undertaking High-acuity Patient Transports

Abstract Background. Fatigue is likely to be a significant issue for air medical transport clinicians due to the challenging nature of their work, but there is little published evidence for this. Objective. To prospectively assess the levels and patterns of fatigue in air medical transport teams and determine whether specific mission factors influenced clinician fatigue. Methods. Physicians and flight nurses from two intensive care interhospital transport teams routinely completed fatigue report forms before and after patient transport missions over a 4-month period. Data collected included subjective ratings of fatigue (Samn-Perelli and visual analog scale), mission difficulty and performance. Multivariate hierarchical logistic and linear models were used to evaluate the influence of various mission characteristics on post-mission fatigue. Results. Clinicians returned 403 fully complete fatigue report forms at an estimated overall return rate of 73%. Fatigue increased significantly over the course of missions, and on 1 of every 12 fatigue reports returned clinicians reported severe post-mission fatigue (that is, levels of 6 or 7 on the Samn-Perelli scale). Factors that impacted significantly on clinician fatigue were the pre-mission fatigue level of the clinician, night work, mission duration, and mission difficulty. Poorer self-rated performance was significantly associated with higher levels of fatigue (r = -0.4, 95% CI -0.5 to -0.3), and for the 6-month period leading up to the study clinicians reported a total of 22 occasions on which they should have declined a mission due to fatigue. Conclusions. These results suggest that clinicians undertaking interhospital transports of even moderate duration experience high levels of fatigue on a relatively frequent basis. In the unique and challenging environment of air medical transport, prior fatigue, long or difficult missions, and the disadvantageous effect of night work on normal circadian rhythms are a combination where there are minimal safety margins for clinicians' performance capacity. Fatigue prevention or fatigue resistance measures could positively affect air medical clinicians in this context.

Mobile phone text messaging intervention to improve alertness and reduce sleepiness and fatigue during shiftwork among emergency medicine clinicians: study protocol for the SleepTrackTXT pilot randomized controlled trial

Background

Mental and physical fatigue while at work is common among emergency medical services (EMS) shift workers. Extended shifts (for example 24 hours) and excessive amounts of overtime work increase the likelihood of negative safety outcomes and pose a challenge for EMS fatigue-risk management. Text message-based interventions are a potentially high-impact, low-cost platform for sleep and fatigue assessment and distributing information to workers at risk of negative safety outcomes related to sleep behaviors and fatigue.

Methods/Design

We will conduct a pilot randomized trial with a convenience sample of adult EMS workers recruited from across the United States using a single study website. Participants will be allocated to one of two possible arms for a 90-day study period. The intervention arm will involve text message assessments of sleepiness, fatigue, and difficulty with concentration at the beginning, during, and end of scheduled shifts. Intervention subjects reporting high levels of sleepiness or fatigue will receive one of four randomly selected intervention messages promoting behavior change during shiftwork. Control subjects will receive assessment only text messages. We aim to determine the performance characteristics of a text messaging tool for the delivery of a sleep and fatigue intervention. We seek to determine if a text messaging program with tailored intervention messages is effective at reducing perceived sleepiness and/or fatigue among emergency medicine clinician shift workers. Additional aims include testing whether a theory-based behavioral intervention, delivered by text message, changes ‘alertness behaviors’.

Discussion

The SleepTrackTXT pilot trial could provide evidence of compliance and effectiveness that would support rapid widespread expansion in one of two forms: 1) a stand-alone program in the form of a tailored/individualized sleep monitoring and fatigue reduction support service for EMS workers; or 2) an add-on to a multi-component fatigue risk management program led and maintained by employers or by safety and risk management services.

Trial Registration

Clinicaltrials.gov NCT02063737, Registered on 10 January 2014

Are we really doing what is best for our tiny patients? NNP shift length and patient safety: our time has come

In the United States, 20% to 30% of the employed population does shift work. Neonatal nurse practitioners are a part of this group. Yet, there are no guidelines in place regarding shift length. Fatigue among shift workers is well documented and carries risks to both patients and health care providers. It is crucial to analyze this problem so that the neonatal nurse practitioner profession can move forward with establishing guidelines for practice; so safe, quality care to patients is assured and the health as well as the role satisfaction of the neonatal nurse practitioner is optimized.