Background: Because of the increasing constraints on the amount of time within a training program which residents spend in the Neonatal Intensive Care Unit (NICU), concerns have been raised about the adequacy of their exposure to acute emergencies in the delivery room and their hands-on experience with sick neonates. More importantly, with less NICU time there are also concerns about the consistency of the quality of supervision of PL-1's by second and third year residents. This is particularly true for small training programs of <20 residents and for those residents planning to practice in rural areas where they may be required to provide resuscitation and stabilization of critically ill infants without strong support available.Methods: To address these concerns, we have instituted an educational plan in our NICU which differs from the traditional resident to resident supervisory model. Instead we have linked experienced Neonatal Nurse Practitioners (NNP) one on one with a PL-1. The NNP orients the PL-1 to the routines of the unit, assists the PL-1 in the delivery room for all acute situations, teaches techniques and procedures, reviews nutrition including hyperalimentation and feeding advance, evaluates/helps to implement patient care plans developed by the PL-1, and acts as a preceptor while the PL-1 gains experience. PL-2 or PL-3 and other NNP's form a second team, as partners, each with independent patient responsibilities as in a collaborative group practice. The PL-2 or PL-3 is directly responsible for medical student teaching and for teaching the PL-1 when appropriate. He/she attends all deliveries commonly encountered in a general pediatric practice, including Cesarean births, meconium stained fluid and at-risk situations for larger infants. Results: We have surveyed/phoned 27 small residency programs with 15-20 residents. Of these, 21 have NNP's working in their NICU and 6 do not. The number of NNP's varies from 1-10 in those units with NNP's. NNP's care for acute, intermediate and chronic patients in all but one NICU where they are responsible only for chronic patients. Of the 21 units with NNP's, only three have formal educational programs linking the NNP's and the residents. These programs include precepting new housestaff for high risk deliveries, supervising procedures and weekly lectures. In addition, we have surveyed all residents (8) who have participated in our new program. They are pleased with the new teaching arrangement. This model has brought a consistency of approach resulting in an increased level of self confidence among the residents. NICU nurses are enthusiastic about the new program.Conclusion: NNP's as first-line teachers in the NICU provide a new approach to a potential problem in resident training, an approach which merits further consideration for training programs.