Their patients can’t talk. They can’t walk. They can be demanding, even difficult. They are often fussy and they even cry. In fact, they act like babies. Yet neonatal nurses wouldn’t trade their patients for any others, precisely because they are babies.
“Neonatal” refers to the first 28 days of life, and the specialty of neonatal nursing is a relatively new one. Neonatal intensive care units (NICUs) have only been around since the 1960s, following the establishment of adult intensive care units as mainstays in U.S. hospitals.
For nurses who want to work with newborns who need specialized care, neonatal nursing offers a wealth of opportunities and settings in which to do so, including hospitals, clinics and pediatric medical offices. A neonatal staff nurse in a hospital typically works in either a Level I, II, or III nursery. A Level I nursery is usually where healthy newborns are cared for. Increasingly fewer health care facilities have this type of nursery nowadays because mothers and babies have such short hospital stays and often share a room.
A Level II nursery offers intermediate care, primarily for babies who may be born prematurely or are suffering from an illness. These newborns may need supplemental oxygen, intravenous therapy, specialized feedings or extra time to mature before being discharged.
The Level III nursery–also known as the NICU–is for acutely ill neonates who cannot be treated in either of the other two nurseries. These babies may be small for their age, premature, or sick term infants who require high technology care, such as special equipment or incubators, ventilators and surgery. Level III units are typically found in large general hospitals or in a children’s hospital.
Approximately half of the newborns admitted to the NICU are born prematurely–that is, before 37 weeks gestation–while the other half are full-term babies. Premature babies have organs and systems that are not yet fully developed, which can lead to a host of problems that require interventions and constant monitoring. Full-term babies in NICUs may have conditions such as perinatal asphyxia, congenital or birth defects, pneumonia, meningitis, generalized infections in the blood, hereditary or genetic disorders, hyperbilirubinemia, or injuries suffered during the birth process or the newborn period.
“Traditionally, a neonatal nurse comes into a hospital setting as a staff nurse,” says Kathleen Campbell, RNC, MSN, president of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) in Washington, D.C. Neonatal nurses with good administrative skills can find themselves moving up the career ladder from staff nurse to charge nurse to supervisor.
Home health care is another good career option for neonatal nurses, because there is a significant number of chronically ill babies who require special nursing care at home, such as long-term ventilator care. Some neonatal nurses opt for home health after they have had some time to develop their specialized skills in the hospital setting, says Campbell. Home health is very autonomous practice setting, she notes.
A fair percentage of neonatal nurses go on to become neonatal nurse practitioners (NNPs), adds Campbell, whose association represents 22,000 health care professionals in the U.S., Canada and abroad.
While becoming an NNP requires a graduate degree, this advanced practice specialty offers more opportunities for teaching, research and consulting, says Catherine Witt, RNC, MS, NNP, president of the Glenview, Ill.-based National Association of Neonatal Nurses (NANN), which has more than 11,750 members. Neonatal nurse practitioners, who can also serve as case managers, are currently in great demand. According to Witt, some estimates suggest that for each NNP who graduates there are 80 positions open across the country.
And NNPs aren’t the only ones in high demand. It’s no secret that the nursing shortage is especially acute in the specialty areas–and neonatal units and ICUs have been hit particularly hard. According to the American Association of Critical-Care Nurses, the number of requests for temporary and traveling critical care nurses to fill staffing gaps has skyrocketed across the country in recent years, including a 50% increase in demand from pediatric/neonatal ICUs.
This urgent staffing need is just one reason why neonatal nursing is an especially fertile career field for minority nurses to enter. Nurses of color can also play a major role in raising the standards when it comes to providing culturally sensitive care to newborns and their mothers. Campbell, who is the nurse manager of the NICU at Richland Memorial Hospital in Columbus, S.C., points out that the birth process is a life event rich with cultural beliefs and traditions. When complications arise surrounding this process, the patients are particularly vulnerable and their families are thrown into crisis.
Witt, who is an NNP at Presbyterian-St. Luke’s in Denver, which serves a large Hispanic population, agrees. “Minority nurses have an understanding of some of the special needs and dynamics of families who come from different cultural and ethnic backgrounds,” she says. At her hospital, there is always a nurse available who can provide support and information to the many families who primarily speak Spanish. “It’s nice for them to see a nurse from the same culture who might understand some of their needs without their having to explain them,” she adds.
At the University of Chicago Hospitals, Jennifer Poueymirou, RN, a staff nurse for the NICU, has been called on several occasions to translate for families who speak Chinese. In fact, the Hong Kong-born Poueymirou, who is fluent in Chinese, cared for one seriously ill 24-week newborn with an infection of the bowels during his nearly yearlong stay in the NICU.
During that time, the baby’s parents, who spoke no English, wanted to partake in traditional Chinese cultural practices, such as taping red envelopes under the crib for good luck and feeding him an herbal broth to help his digestion. As a result, Poueymirou often had to help mediate cultural conflicts between the hospital staff and the family. For example, she had to explain to the parents that they couldn’t give the broth to the baby because it may have contained ingredients that would have been harmful to the child and because of the legal liabilities involved with bringing food into a hospital.
Poueymirou recalls having to sit in on many meetings between the parents and the case manager, social worker and doctors. “I was there mostly to translate, trying to figure out what the parents’ needs were and how they could be met,” she says. “Knowing a second language definitely helps, especially when the family doesn’t speak English. And you can understand and explain the cultural traditions when they start coming out.”
Cheryl L. Nicks, RN, CNNP, CGT, CLNC, an African-American neonatal nurse practitioner at Touro Infirmary Hospital in New Orleans, which serves a large African-American patient population, feels that part of her role is to serve as an advocate for infants of color and their parents. For example, she says, when African-American parents mention certain cultural beliefs and rituals–such as the burning of incense and candles during an illness to rid the person or environment of negative energy, or the healing power of the “laying on” of hands–“the other nurses think they’re crazy. I have to explain that these are spiritual beliefs in the African-American culture and that they are not unusual.”
The same goes for the cultural custom of giving African-American babies names that have African origins. “People outside [our] community don’t understand that and make fun of the ‘unusual’ names,” Nicks explains. “But names like Mary, Sarah and Nancy sound foreign to us because they’re not part of our culture.”
Having experienced life in a low-income African-American community herself, Nicks also understands that a black mother may have to choose between using her last dollar to buy food for her children at home or using it to take a bus to visit her sick baby in the NICU. “While other nurses may complain that the mother hasn’t visited her baby,” she says, “I understand that she has no money and no transportation.”
A Different Perspective
In addition to serving as “cultural interpreters,” minority neonatal nurses can bring to the table a different perspective, based on their experiences of a particular cultural or ethnic background, that can enrich the overall approach to patient care.
“Since I was born and raised in Pakistan and moved here when I was 14, I tend to look at things in a different light,” says Khairunnissa Karim, RN, a neonatal nurse at Parkland Hospital in Dallas, which serves a large Hispanic and African-American population. “I see cultural and ethnic differences in people born and raised outside this country and I’m sometimes able to perceive what they’re thinking and how they may perceive their child’s health in the NICU.”
Karim, who is pursuing a master’s degree which she expects to complete next summer, adds that this culturally sensitive perspective can be used to form the basis of a relationship with the baby’s family. “I think as long as you have cultural awareness and can appreciate other cultures, you can have a strong impact on the care provided in your unit,” she emphasizes.
AWHONN’s Campbell believes this ability to establish cultural connections can transcends the NICU environment to play a pivotal role in disease prevention and health promotion, as in the case of preterm births. “We know that African Americans have a higher rate of preterm births than Caucasians,” she says. “We know that a major risk factor is a previous preterm birth. That connection helps build a trusting relationship, which in turn enhances prenatal counseling. Also, having knowledge of the community can help identify approaches to prevention and improve people’s willingness to access the health care system to get what they need.”
As president of the New Orleans chapter of the National Black Nurses Association, Nicks hopes to serve as a link to the African-American community and help eliminate maternal-child health disparities by educating black mothers about health care issues, such as the importance of preventive care and screenings. “I understand firsthand the economic realities that lead to high minority infant mortality and morbidity rates, and why we have such a high premature birth rate in our community,” she says.
That desire to level the playing field, combined with the ability to give infants who need specialized care the chance for a good start in life, is what motivates minority neonatal nurses like Nicks. “As a practitioner, I get a lot of rewards from seeing babies go home whose survival was questionable at birth,” she declares.
Karim agrees. “Sometimes you question just how far we go to save a baby and think that it wouldn’t survive if it was born in another country. You question whether you’re trying to play God,” she says. “But then you see a child leaving the NICU who you never thought would live a normal life, and it’s a great feeling knowing that you played a role in saving that child.”
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