Nurses have enormous impact on lives and in ways they can probably never imagine. Although neonatal nurses care for newborns and infants, their lasting impact is often remembered over decades.
Today is National Neonatal Nurses Day and the end of National Neonatal Nurses Week, and is a tribute to the ways these nurses change the lives of the tiniest patients. But it’s not just the babies these nurses save—the families of those babies never forget the nurses who cared for their children when they were at their most vulnerable.
If you’re a neonatal nurse, today’s a good day to reflect on how your efforts have a ripple effect. As you care for your patients, think of all the families you have worked with and helped over your career. Then think of all the people who loved those babies as that child grew to a toddler, teenager, or adult and went out into the world.
If that’s an emotional thought, that’s the reason why neonatal nurses are so passionate about and committed to the sometimes joyous sometimes heartbreaking work they do. They care for the newborns who need medical care for a range of medical issues. Their life-saving work is generally done in neonatal intensive care units (NICU), but they may also work in varied level nurseries. Some of these nurses will also make home visits and work in the community to care for sick infants. The infants can range from the tiniest premature baby to a full-term baby born with a critical illness.
If you are interested in a career in this nursing specialty, the National Association of Neonatal Nurses is an excellent resource. Nurses can work as a registered nurse or as a neonatal nurse practitioner. Your educational path will include a master’s degree and potentially a PhD if you want to work as a neonatal nurse practitioner, while a bachelor’s if often sufficient as a registered nurse level. Responsibilities increase between the registered nurse and nurse practitioner levels, as do salary rates.
Neonatal nurses are expected to have a high level of technical competency, and they must remain up-to-date on the constant advances in the field. Certification, as with any nursing field, is always recommended. Certification gives you the advantage of keeping your skills and your knowledge current. The American Assocation of Critical Care Nurses offers three separate certifications for neonatal nurses: CCRN (Neonatal), Acute/Critical Care Nursing; CCRN-K (Neonatal) Acute/Critical Care Knowledge Professional; ACCNS-N (Neonatal), CNS Wellness through Acute Care. There’s no shortage of the ways you can continue your professional and academic path after you earn your degree.
Nurses in this specialty must also have a level of empathy and compassion to care for the tiny babies and the people who love them. You are, in essence, treating the entire family. Helping them navigate the scary ups and downs of daily life in the NICU isn’t easy and is sometimes distracting, but families look to neonatal nurses to guide them. The bond many nurses develop with the families they work with are often strong and lasting. Some of the biggest rewards are hearing back from families years later of the positive effect you had in their lives.
There’s no better time than during National Nurses Week to pay attention to the skills nurses have that aren’t acquired in any classroom. Kristi Tanisha Elizee, RN, BSN, and a current master’s degree student focusing on Clinical Nurse Leader (CNL), knows first-hand about the power of a nurse’s intuition.
This past February, Elizee was working the NICU night shift of a Kansas hospital and had been assigned to a mother-baby pair. From the hand-off report with the previous nurse, she had been told, and was able to observe, the baby had head-molding after delivery. Although Elizee noticed the baby’s head looked strange, continued observation revealed only typical behavior. The baby slept, woke, and breastfed well about every three hours.
When she went to perform a head-to-toe assessment of the baby (after notifying the parents), Elizee became alarmed. “When I assessed this baby’s head I could not believe what I felt,” she says. “This baby’s anterior fontanelle was very wide and bulging which extended to her forehead. On top of her head felt soft, the posterior fontanelle was not palpable, and in the same area where the posterior fontanelle was supposed to be, instead the skull was protruding.”
All the baby’s vital signs were good as were the other assessments of the baby, but Elizee knew something was wrong. She also knew she had to trust her intuition. “For me, this was not head-molding,” she says. “I brought the baby back to her mom’s room and immediately went to review the doctor’s documented assessment again on this baby.” Everything appeared to note head-molding, so Elizee, who would need to perform another assessment in four hours began researching information while monitoring the baby and her other patients.
Persistence Works
“I saw a variety of problems including pictures of the way this baby’s head was shaped, and it was called ‘Craniosynostosis,’” she says. According to the Mayo Clinic, “Craniosynostosis (kray-nee-o-sin-os-TOE-sis) is a birth defect in which one or more of the fibrous joints between the bones of [a] baby’s skull (cranial sutures) close prematurely (fuse), before [a] baby’s brain is fully formed. Brain growth continues, giving the head a misshapen appearance.”
Elizee wasn’t sure if what she found was the problem, but she had to speak up. “I was not sure what this baby was diagnosed with but I knew this baby’s head was not normal,” she says. She notified the other nurse on the NICU shift, then her supervisor, and the providing physician was immediately called. The physician initially believed the baby had head-molding as well. “I started to doubt myself again, but I knew deep down this was not normal,” Elizee says. After performing her own assessment, the physician agreed with Elizee. From there, a pediatrician came onboard, and Elizee says she carefully documented everything.
The experience has been simultaneously transformative and heartbreaking. “I have never cared for a baby diagnosed with this condition before so this was my first time,” she says. “The day after when I came back to work, the nurse whom I gave report to about this baby, told me that my assessment findings were right. They had to do a head CT scan and it revealed that this baby had ‘Craniosynostosis.’” The baby was referred to a different hospital, and although Elizee doesn’t know her current story, she’s confident that her persistence made a huge difference in the baby’s life.
“I just had a gut feeling that what I felt was not normal and knew I had to speak up,” says Elizee. Although she doubted herself based on what others were saying, Elizee says she had to honor her intuition. “Nurses just need to follow their instincts,” she says. “Once you know it is not normal or not right, then take action. Do not second guess yourself.”
Big Move for Her Career
Elizee hails from St. Lucia. “I made the decision to move to the U.S.A for growth and development through Avant Healthcare Professionals, an international nurse recruiting agency,” says Elizee, who says she initially considered a career as a veterinarian. “I want to take my nursing career to the next level.”
Oddly enough, Elizee had been considering a switch out of NICU because she was struggling with the role. “When I first started working as an RN new grad, I worked on the medical unit for a month, later I was sent to work in the NICU which I have been in for eight years,” she says. “The first few months being there was tough, and I almost made the decision to go to another unit to work. I was just not enjoying it.” But her NICU nurse-manager noticed and became Elizee’s mentor.
Under her guidance, Elizee says she gained confidence working with these tiny babies—none of whom can tell their caregivers what is bothering them. The experience made all the difference. “NICU is a challenging place to work,” she says now, “but I love the challenge. Every day is a learning experience, and I am embracing it. Now I want to become a neonatal nurse practitioner.”
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.”
Challenges
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.
The Rewards
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.
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