Neonatal nursing provides care for the tiniest and most vulnerable infants, and the nurses in this specialty are celebrated this week by the National Association of Neonatal Nurses (NANN) and other organizations marking this year’s National Neonatal Nurses Week.
When she took some time off to raise her family, Williams decided she was happy with nursing, but not fulfilled with the med-surg role. She decided to try something entirely different and was honest about what would be best for her personally as well as professionally. Caring for a pediatric population was appealing, but Williams knew she would see her own children in her patients and wanted to maintain separation from that age bracket. Neonatal nursing was a good age bracket to alleviate that concerns.
Three months into orientation as a neonatal nurse, Williams was all in. “I thought, ‘This is it. This is where I need to be,'” she says. “It was a real ah-ha moment. I have never experienced that before.”
Williams, who has been a nurse for 24 years and a nurse practitioner for 10, says she grew up with her parents talking about nursing as a great career, but it wasn’t something originally on her radar. “Once I got into it, my passion, goals, and thoughts on it all changed.” Williams current role has her spending half of her time managing a team of 20 nurse practitioners and half of her time spent clinically managing patients. “That means I am responsible for developing a team and still responsible for the care of babies and their families.”
As a nurse, Williams says her goals have always focused on helping people attain success and self-fulfillment. In her neonatal nursing role, working with babies allows her to continue working toward to that goal. “Whenever I have a patient, my goal is to help that patient become the best version of themselves they can be and then we can reunite them with their family.”
Saying she feels constantly rejuvenated by her work in neonatal nursing, Williams feels a strong connection with the families she works with. “Mostly we think of childbirth and pregnancy as a joyous time, and we don’t know how complicated it can be,” she says.
When things don’t go as expected or as planned, the experience is difficult. “Being able to support someone around this process and give them the best version of their child is such a responsibility,” she says. Williams says she has learned how to meet the families and the babies where they are and help them feel comfortable when their child is in intensive care. And while nursing skills in the NICU must be excellent, Williams says the skills required to work with families aren’t necessary clinical but are heavily rooted in empathy.
“These infants are the future and the parents are so invested in these children,” Williams says. She helps them understand they have experienced a loss of their expectation of and hope for a perfect or even a typical pregnancy and birth and a shift is necessary. Very premature infants might require extra care and require extra vigilance, but that doesn’t mean the child will be unable to participate in life. “You just have to pivot,” she says.
And Williams is buoyed by the advances in neonatal care and in neonatal nursing. In addition to the technology and medical care advances, “the focus on the whole baby has improved so much,” she says. Even understanding the downstream impacts of how a baby in NICU is positioned gives the healthcare team a deeper understanding of the whole picture of care.
“I am always talking about how I love what I do,” says Williams. “Neonatal nursing is rewarding. It’s a rollercoaster but well worth it.”
In honor of National Neonatal Nurses Day, we interviewed five nurses in different facets of the field to give you a glimpse of what it’s like to be a neonatal nurse, including the challenges and rewards involved in caring for the tiniest patients of all.
A Day in the Life
Rebecca L. Hunt, RN, MSN, APRN-CNP, CCNS, a neonatal nurse practitioner at SSM Cardinal Glennon Children’s Hospital in St. Louis, Missouri, walks us through a typical day in the NICU:
“Generally, each workday starts off by first ‘scrubbing in.’ Then the nurses will begin getting report from the off-going shift. This report will include a brief history of the mothers’ pregnancies, the birth histories, and what occurred in the delivery room. The nurses will
discuss a brief history of the babies’ hospital courses (types of respiratory support, any feeding difficulties, surgical history, etc.). Report will also include the babies’ current clinical status and what type of support they are receiving (respiratory, nutrition, antibiotics, etc.). Finally, the nurses will double check what medications the babies are receiving as well as all infusing IV fluids, including TPN/IL, and any other continuous medications.
From report, the nurse will prioritize which of the babies will need to be cared for first. The remainder of the day will include performing complete assessments on the babies being cared for every one to four hours depending on how critically ill they are, what types of interventions and care are required, and what type of feeding schedules they are on. All assessments, feedings, and medications given are charted into the electronic medical record in real time. The nurses will also do IV fluid changes and mix feedings as requested by the NICU care team.
Throughout the shift, the nurse will continually work with parents and family members on how to properly care for their babies. Feeding a premature infant is very different than feeding a baby who is born at term gestation and healthy. The nurses will also work with families on providing care (feeding, bathing, etc.) to babies who may be on a ventilator or have a tracheostomy in place. The nurses will also educate the families on signs and symptoms to look for to help distinguish if their babies are doing well or may need to be seen by a member of the health care team once they are home. The nurses will teach families about home oxygen, home apnea monitors, and how to safely put their baby to sleep at home. They will also take photos and help the families document the small victories their babies achieve, such as the first time wearing clothes, the first time taking a bottle, the first bath, etc.
During the nurses’ shift, they will also participate in rounds. The entire medical team (neonatologist, fellow, nurse practitioner, resident, dietician, and pharmacist) will gather at each baby’s bedside and discuss the infant and the expected plan of care for the next 24
hours. The nurses are major advocates for the babies and actively participate in making critical care decisions, such as whether babies should or shouldn’t have their respiratory support weaned, receive more food, or attempt to bottle feed more. The nurses will let the team know if they believe babies are showing signs and symptoms of becoming sick. Finally, the nurses will also encourage the parents to be an active participant in bedside rounds and provide their own observations of how their baby is doing.”
One of the biggest challenges in being a neonatal nurse is maintaining the professional boundary between yourself and the family says Gail A. Bagwell, DNP, APRN, CNS, the clinical nurse specialist for perinatal/neonatal outreach at Nationwide Children’s Hospital in Columbus, Ohio. “The babies are in a NICU for long periods of time, and you get to know the parents very well. Learning to be caring and compassionate, while maintaining a professional relationship is a learned skill and difficult for many nurses,” explains Bagwell. “I learned it early on in my career when a baby I was caring for developed some severe complications that led to her death. The pain of getting close to the baby and the family taught me that in order to survive in this field, I would need to learn to be caring and compassionate while maintaining a distance.”
Kim Guglielmo, BSN, RNC-NIC, Clinical Nurse III in the Newborn Critical Care Center at the University of North Carolina’s Children’s Hospital in Chapel Hill, North Carolina, agrees that losing patients is one of the toughest experiences as a neonatal nurse. “Those are the days that hurt my heart,” she says. “At the time before, during, and after the passing, I am there to support the family however they may need it. My goal is to make this last involvement with their baby the most beautiful experience ever.”
For Taryn M. Edwards, MSN, CRNP, NNP-BC, a surgical nurse practitioner of general, thoracic, and fetal surgery in the NICU of The Children’s Hospital of Philadelphia, sharing setbacks and obstacles with families is her biggest challenge. “The reality is that some of the most vulnerable infants do not make it. Supporting families through that difficult time is always challenging,” she explains.
While there are a lot of challenges and sad times in neonatal nursing, there are lots of great times as well. “There is nothing quite as rewarding as handing a mother her premature infant, sometimes still attached to a ventilator, and helping her position the baby for skin-to-skin time on her chest,” says Sherri Brown, MSN/Ed, RN, RNC-NIC, staff nurse at the Neonatal UCU at the University of Kansas Hospital in Kansas City, Kansas. “Or in watching parents’ faces light up when their infant curls his tiny hand around their fingers or helping them give their baby a bath for the first time or change a diaper. These things are taken for granted in the healthy newborn world, but they take on extreme importance in the premie world.”
Guglielmo says she feels blessed to care for the smallest and most fragile of patients and have an impact on their lives. “I get to meet so many brave, courageous families who go through so much and teach me more than they ever know,” she says. Many NCCC units and NICUs have reunions in which former NCCC or NICU babies and their families return to the hospitals to celebrate. “I can’t wait to see them all!” says Guglielmo.
Infant mortality. Sociologically, it is the litmus test for a nation’s overall health. Emotionally, it represents unfathomable loss.
Of course, nurses and other health care professionals must discuss the issue clinically, distancing themselves from the emotional ramifications. Yet, the shocking but rarely discussed statistics surrounding infant mortality in the United States merit more attention than calm discussion. Because when nearly twice as many minority babies are dying than their Caucasian counterparts, complacency is unacceptable.
There’s no dancing around the issue: African American infants are 2.5 times more likely to die than non-Hispanic white infants. Statistics are comparable among Native American infants. Research spanning the last 30–50 years shows these disparities have remained consistent for generations. On average the United States has an infant mortality rate of 6.7/1,000. Among non-Hispanic African Americans, the rates are nearly doubled, with 13.4/1,000 infant deaths, according to statistics compiled by Spong et al.1
The CIA publishes a list of the world’s countries ranked by their infant mortality rates. At the bottom, with the highest rates of neonatal deaths: Afghanistan, Angola, Somalia. At the top: Monaco, Singapore, Sweden. Where’s the United States? It doesn’t even crack the top 30, falling behind nearly all of its “first world” contemporaries.
Direct causes of infant death are primarily congenital anomalies/birth defects, followed by premature births, then SIDS. SIDS was the second-leading cause of neonatal deaths, but after years of concentrated efforts and outreach, it is now third. Yet, in some states, including Mississippi, Alabama, and Arkansas, the infant mortality rates among African Americans are comparable to those found in third-world countries, with 18–22/1,000 live births in certain counties.
The solutions seem so simple: take care of women before they become mothers and teach them how to properly care for their babies. But the statistics remain stagnant, pointing to an urgent need for more education, community resources, and government action. And, as always, nurses are on the front lines.
Spreading the word
The U.S. Office of Minority Health approached Tonya Lewis Lee, director of the documentary Crisis in the Crib, to act as its national spokeswoman for A Healthy Baby Begins with You Campaign about four years ago. She accepted, and soon learned the seriousness of infant mortality in the United States. She says she had no idea the rates were so high.
“I had to get involved to spread the word, to figure out why the rates are what they are, “Lewis Lee says. “I’ve learned a lot and shared a lot.” She says she is now healthier now than ever before. “I really feel that taking care of yourself first is critical,” she says. “We need to lead by example.” And the crux of A Healthy Baby Begins with You is teaching mothers the importance of self-care.
“Nurses have been extremely powerful in the information they give to patients,” Lewis Lee says. They have a relatively intimate relationship with patients, and with cross-cultural training nurses can help them at their most vulnerable and effectively treat people from different backgrounds.
Lewis Lee also works closely with the U.S. Health and Human Services Office of Minority Health’s Preconception Peer Educator (PPE) program, which coordinates student ambassadors educating others about healthy pregnancies. “The idea of peer education is great because it goes back to understanding the community they’re talking to,” Lewis Lee says. The program, which started with 60 students, now has over 1,000 ambassadors. “I’m very proud of our students,” Lewis Lee says. “It’s a movement. It’s a health movement for young people.”
Yet, while grassroots efforts are commendable, higher-level changes are needed as well. “A lot depends on what goes on politically,” Lewis Lee says. During the ongoing health care reform debate, infant mortality seems to be swept under the rug. Lewis Lee envisions a move toward preventable care, an improved focus on health disparities, and perhaps advances in genetic research and its affect on personal health, such as obesity.
Every child is an opportunity to improve the nation as a whole. “I don’t know that we as a nation really take the health of every citizen very seriously…. Some people we think are expendable,” Lewis Lee says. “Somehow we need to figure out a way to make that better.”
Room for improvement
“As a public health official, we are the eternal optimists,” says Garth Graham, M.D., M.P.H., F.A.C.P., Deputy Assistant Secretary for Minority Health for the Office of Minority Health at the Department of Health and Human Services.
Graham lists three reasons he sees potential for improvement in U.S. infant mortality rates:
Infant mortality is related to many other factors, such as the preconception health of mother, and with efforts to expand preventive care, “we will see healthier mothers” and subsequently, healthier babies.
Advances in medical care will continue to help care for premature babies and other complicated births, particularly as urban areas see medical advances.
A number of areas, such as Tennessee, following both local and federal efforts, has seen improved infant mortality rates, offering an imitable example and showing progress is possible.
But the eternal optimist acknowledged several obstacles as well, such as social determinants, lack of access to care, and high rates of teenage pregnancies. “The major challenge is how to deal with all of this holistically,” Graham says. “Nurses, more than any other profession, are on the front lines of infant mortality.”
Community resource nurses serve a key, multifaceted role in helping would-be and young mothers, Graham says. “We really want to encourage nurses…to be as proactive as they have been,” but even more so. “Nurses are more than just healers,” Graham says. They are influencers. “People who serve as role models make a huge impact.”
The situation in the United States
Despite the country’s wealth and technological advances, theUnited States’ infant mortality ranking has actually worsened since the 1960s, when the nation was 12th in the world. Today, according to CIA estimates, the United States is approximately 40th.
“This international standing is largely driven by large racial and ethnic disparities that exist in infant mortality in the United States,” says Peter C. van Dyck, M.D., M.P.H., Associate Administrator for Maternal and Child Health for the U.S. Department of Health and Human Services’ Health Resources and Services Administration. “If all United States infants had the infant mortality rate of white infants, the overall infant mortality rate would decline about 15%, and our infant rate mortality ranking would improve about four places.” The United States also lacks many European nations’ paid parental leave, welfare, and access to health care. “According to the latest data in 2007, less than 70% of women received prenatal care in the first trimester,” van Dyck says.
The clearest cause of racial disparity is the higher preterm birth rate for black infants. “Black women are four times as likely as white women to deliver very early,” van Dyck says. “This racial disparity may be caused by socioeconomic disparities not just in adulthood but across the lifecourse, stress and discrimination, environmental quality differences as a consequence of residential segregation (e.g., pollution, crime, access to parks and supermarkets), and also differences in infant sleep practices.”
Van Dyck points to the Patient Protection and Affordable Care Act of 2010 and its creation of the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV), a provision put in place “to respond to the diverse needs of children and families in communities at risk and provides an unprecedented opportunity for collaboration and partnership at the federal, state, and community levels to improve health and development outcomes for at-risk children through evidence-based home visiting programs.”
MIECHV aims to provide comprehensive health services to these children and families, particularly expectant mothers. “Maternal health, especially the health of the mother during the prenatal period, is a critically important factor to ensure a healthy birth outcome,” van Dyck says. Some of the benefits of home visits include decreased instances of smoking, substance abuse, hypertensive disorders, and domestic abuse. Regarding child health outcomes, families receiving home visits experienced lower risk of low birth weight children, higher attendance at well child visits, more prevalent health insurance coverage, higher intellectual, and improved rates of breastfeeding, among others.
“It is our vision that positive changes in maternal and child health outcomes will be significantly enhanced as the states implement evidence-based home visiting programs, embedded within a high-quality early childhood system,” van Dyck says.
Understanding and combating
“We strongly believe that a child needs a good beginning,” says Yvonne Maddox, B.S., Ph.D., Deputy Director of the National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH). She stresses that leaders need to take a more aggressive approach in making child health a top priority. “It is really very, very disappointing that we haven’t done more.”
In the infant mortality crisis, Maddox says other environmental factors must be taken into account as well, such as community and overall maternal health, the quality and accessibility of the health care system, the socioeconomic status of community, and public health regulations. “We are targeting all the areas,” she says.
Maddox focuses specifically with minority communities, including African Americans and Native Americans. Like the gross disparities that exist among black communities, Native American infants in some areas of the country, such as Minnesota and the Dakotas, are also twice as likely to die as their white counterparts. Routine nurse home visit to a young mother on a reservation, for example, may provide the hands-on care and continued support needed to ensure the child sees its first birthday. “It pains me” to see the extremes, Maddox says. “I don’t want my country to look this way.”
“We found that the way to address these issues is to launch strong education campaigns,” Maddox says. But health care providers also need to build a foundation of trust in their communities. As one of the most trusted professionals, nurses can hit the ground running.
“We need to really study these things in a systematic way,” Maddox says. And now, with the launch of the National Children’s Study, researchers are. Though still in the recruitment stages, this unprecedented study hopes to follow 100,000 children across the country from pre-birth to 21 years old. “There are a lot of things we can look at in 21 years.”
Researchers will monitor the environments American mothers and children occupy, and how factors such as air quality, nutrition, family dynamics, genetics, and culture affect children’s health, growth, and development. By working with expectant mothers, the study can incorporate the effects of family medical history and pre-pregnancy exposures on birth outcomes, providing important insights for the future.
Maddox says the study should shine new light on chronic issues such as obesity, autism, and depression/mental health. Though findings will be published throughout the study, researchers are years away from answers. Maddox hopes the economic downfall and recession do not damage the study’s viability—or the essential health care services already in place. “It’s critical that we work with our policy makers and educators,” she says. “We’re already working with such dismal numbers.”
Minority communities may not participate in infant mortality outreach as often, Maddox says, perhaps due to lack of trust or simply not knowing the resources were available. Some may assume these at-risk groups do not “get it” or don’t want to try to improve the situation, but “the communities want information. They want to know. They want the facts,” Maddox says. Such misunderstandings make group feedback essential.
“Cultural competency in messaging is critical,” Maddox says. Nurses and other providers must figure out how to best interpret results of current and future studies so the message is crystal clear to patients. While pediatricians and OB/GYNs may be expected to educate their patients, information can get lost in translation. That’s where nurses come in. “They are able to communicate the message very substantially,” Maddox says.
Hispanic communities or Native American tribal groups may require a different set of tools than a predominantly African American community. Nurses of all ethnicities should understand these unique backgrounds and cultural sensibilities. Pregnant women, women with disabilities, and other special populations also require special targeted messaging. Even nurses in the trenches in these areas may not realize the importance of translating info for patients and the community at large.
With the SIDS campaigns of the 1990’s, colleges and universities teamed with health educators, faith communities, nursing organizations, and continuing education programs, working together to design a safe sleeping program. They produced literature describing proper infant dressings, approved cribs, and do’s and don’ts for new mothers and even other health care professionals. Nurses who completed the program then disseminated the materials.
“We found that the way to address these issues is to launch strong education campaigns,” Maddox says. Researchers also point to increased training of health care workers, like midwives and community clinic staffers, so there are enough caregivers to attend to these mothers and babies.
Government agencies like the NIH need to understand how communities interpret campaigns as well, Maddox says, making bolstering public trust another priority. As one of the most trusted professionals, nurses can hit the ground running.
Solutions for nurses
“Minority nurses bring a breadth of knowledge and experience to every aspect of health, contributing to excellence in health care for women and children,” van Dyck says. “Public health nurses, for example, are leading the effort for community-based approaches to resolve infant mortality disparities.”
There’s Healthy Start; the Healthy Mothers, Healthy Babies campain; and Lewis Lee’s A Healthy Baby Begins with You. Nurses can also use the Fetal and Infant Mortality Review (FIMR) process to coordinate community dialogue and address community-specific issues related to infant mortality, from bereavement and postpartum depression to barriers to care, SIDS risk reduction, and substance abuse. “Community-based FIMR is an action-oriented continuous quality improvement process with a significant role in building community partnerships, understanding community issues, and developing culturally sensitive interventions,” van Dyck says. There are roughly 200 such programs located throughout the country 40 and U.S. territories.
“Communities will address their health issues if given information and forum for resolution,” van Dyck says. “FIMR teams have learned that many health messages are not culturally and linguistically appropriate, are not reaching all of the varied ethnic groups in each community, and are not being delivered by a messenger specific to each group and whom the community trusts.” Consequently, FIMR has developed culturally appropriate educational materials and services.
Karla Damus, Ph.D., M.S.P.H., M.N., R.N., F.A.A.N., a clinical professor of nursing at Northeastern University in Boston and a member of the CDC’s preconception health expert panel and March of Dimes’ Nurse Advisory Council is looking for a paradigm shift in neonatal care.
People don’t understand, Damus says, that to fully understand infant mortality rates, they must also incorporate fetal mortality rates, including miscarriages. “Families are just as devastated” and women are just as likely to experience another negative outcome and increased risk with subsequent pregnancies. She encourages nurses and health care providers to widen their scope as well. It’s not just about infant mortality, but the “near-misses,” the sickly infants, the NICU. We don’t just want our babies surviving, but thriving, she says.
Damus says nurses and their patients can think of the uterus as a muscle subject to the same risk factors as the heart; just as with heart attacks and disease, health care providers should look at family history of preterm labor and pay attention to red flags. Doctors should also know the pregnant woman’s birth weight and whether she was born early or late. “We’re talking about these life course perspectives,” Damus says. “We’ve got to do everything we can for men and women”
Healthy start initiatives may be targeting pregnant women in black communities, but “you’ve got to make them healthier long before they conceive,” Damus says. “It’s all about wellness promotion.” Damus speaks with a tinge of annoyance, perhaps anger, about the lack of advocacy for folic acid. One of the simplest, most cost-effective solutions to curbing infant mortality rates seems to be an afterthought for many health care providers. All sexually active women should be encouraged to take folic acid once a day or more, she says. “Did you take your folic acid?” should be one of neonatal nurses’ first questions, Damus says. Social media can be used to disseminate daily folic acid reminders. She even wants to see scrub caps with that question emblazoned on it. But what seems like the most obvious solution—ensuring the health of the mother to protect health of her unborn child—just leads back to overarching health disparities nurses and health providers have been and must continue fighting.
“We still do lousy despite all our priorities, and that’s because families aren’t a priority,” Damus says. “This is science as well as social justice.” In addition to lackluster infant mortality rates, the racial and ethnic disparities don’t seem to budge. “We should be outraged that we’re not making progress,” Damus says. “Yet, there are places that do, that show it is possible.” Damus’ former home, the Bronx, had an infant mortality rate of 15/1,000. Now, it is lower than the U.S. average, a result of years concentrated efforts.
Damus also advocates full-term deliveries whenever possible, avoiding scheduled earlier births. She categorizes the phrase “near term” with the saying “you’re a little bit pregnant.” You either are or you aren’t, she says, and advocates allowing women to postpone delivering until they full term. And nurses must arm themselves with adequate information, like making themselves aware of any medications that can compromise pregnancies. They can even teach expecting mothers to count kicks later in their development (a practice now back in vogue, she says). She also advocates healthy intervals between pregnancies and making sure fathers are involved too. “All the other stuff is just wellness!”
“The nurse is key as the advocate,” Damus says. But she maintains: “we can do a much, much better job.”
Life goes on
At the end of the day, perhaps the solution isn’t so simple after all: we need healthier people—healthy from birth—to grow up and conceive the next generation of healthy babies. Quite the chicken-and-the-egg scenario, and one dependent on an embattled and changing health care system.
What might happen in the next 10–20 years? “I’m not sure,” Damus says. “I don’t expect big changes.”
“If we look at the trend of the past 15 years, we expect the infant mortality rate to decline further in the coming years,” van Dyck says. However, the rate of decline during those years was “modest,” even largely unchanged from 2000–2007. He says recent infant mortality rates have been influenced by increased births among women over age 35 and little improvement in smoking before and during pregnancy.
“We really have to involve all the stakeholders,” Maddox says: nurses and doctors, mothers and fathers, government and community leaders. With an issue as complex as infant mortality, there can never be enough resources and research.
“A country’s infant mortality rate is one of the most important indicators of health,” Maddox says. “We have a lot of work to do.”
Spong, Catherine Y. MD; Iams, Jay MD; Goldenberg, Robert MD; Hauck, Fern R. MD, MS; Willinger, Marian PhD. (2011.) “Disparities in Perinatal Medicine: Preterm Birth, Stillbirth, and Infant Mortality.” Obstetrics & Gynecology. April – Volume 117 – Issue 4 – pp 948-955.
Jessica Tomer is a former editor of Minority Nurse magazine.
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.
So You Want to Be a Neonatal Here’s a look at what it takes to get started in this highly rewarding–and highly in-demand–career specialty: Education Although there is currently no special program for neonatal nursing in the basic registered nurse (RN) educational curriculum, some nursing schools do offer an elective course in neonatal nursing. After graduating and obtaining some experience as an RN in a NICU, you can earn a master’s degree to become a neonatal nurse practitioner or neonatal clinical nurse specialist. The National Association of Neonatal Nurses recommends having two years of experience before pursuing advanced training. As with other nursing specialties, continuing education requirements are mandated by your state board of nursing or a certifying body. Qualifications Entry-level requirements for neonatal nurses vary. Some hospitals may require one year of adult health or medical/surgical nursing, while others will hire new graduates from an accredited school of nursing who have passed a state board of nursing examination for RN licensure. The type and length of nursing experience required also varies among hospitals, but given the current neonatal nursing staff shortage, many don’t require any previous experience. Required competencies for neonatal nurses are established by the individual health care facility, which uses a list of practice skills to assess candidates’ abilities in using medications, math calculations, intravenous lines, cardiopulmonary resuscitation, and other knowledge needed for direct patient care.Salary Salary ranges for neonatal nurses depend on the cost of living in a particular location. In the Midwest, neonatal nurses with no previous experience may start out with an annual salary in the upper $30K to mid-$40K range. On the East and West coasts, the salaries tend to be higher. In Southern states, beginning neonatal nurses start at approximately $30K a year. The upper range for a new neonatal nurse without experience is approximately $48K. Salary ranges may be higher for experienced nurses and those with advanced training.Source: Nurses for a Healthier Tomorrow, www.nursesource.org/neonatal.html
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.
For More Information Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) 2000 L St., N.W., Suite 740 Washington, DC 20036 (800) 673-8499 or (202) 261-2413 Fax: (202) 728-0575 www.awhonn.org National Association of Neonatal Nurses (NANN) 4700 W. Lake Avenue Glenview, IL 60025-1485 (800) 451-3795 or (847) 375-3660 Fax: (888) 477-6266 Email: [email protected] www.nann.org
“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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