I am privileged. I have been to the other side and experienced that the grass is greener. The majority of my career as a Neonatal Nurse Practitioner (NNP) has been in a Level 3 NICU with all the bells and whistles of high acuity, ECMO, high-risk deliveries, transport, and high patient volume. However, I then gained the privilege to also work as a NNP in a Level 2 Special Care Nursery (SCN). What a difference! But also, how similar!
The job tasks are identical … morning signout, collection of data from the medical record, physical exams, and writing notes. I touch base with the bedside nurse, case management, social worker as needed, and any ancillary staff. Consults are typically by phone. Sporadically, we may physically see an ophthalmologist, ENT, or cardiologist; but these occasions are not usual and customary. In addition, I can stand in one spot with full visual assess to all patients; as long as the census does not exceed 7 in the ‘main unit.’ The unit has evolved from a one room unit with one light switch, where either all lights were on, dimmed, or off equally. The SCN now is a state of the art unit of 7 individualized spaces to offer developmentally appropriate care, more patient privacy, and family-centered care. It is phenomenal!
Now, one may be thinking what a piece of cake. Well before we slice the cake, the grass really is not always greener. You see, regardless of the nursery level, the families are all experiencing a crisis. Acuity and level of nursery does not matter! The hopes, dreams, and vision these families had for their pregnancy, birth, and hospital experience are all shattered in the blink of an eye. The level of medical acuity has no direct correlation to the level of crisis for families. Due to lower medical acuity and lower patient volume, I am afforded the privilege of being able to take more time with families. I have the pleasure of sitting next to them, listening with my ears and eyes, to be in the moment with them. I can truly experience what the crisis or fears are. I feel a great sense of connection with the families. Regardless of the nursery level, these families become our family during their infant’s hospitalization. The communication, both active and passive, are vital for these families to emotionally survive this experience.
I have never experienced cross-trained nurses prior to working in a Level 2. This certainly is another privilege! This has positively enhanced my perceptions of the significance of the staff nurse presence in the delivery room, nursery, and postpartum area. In a Level 2, there is a staff of one NNP per 24-hour shift with attending back-up. The attending does rounds and meets with us daily, is present for all high-risk deliveries, and is always just a phone call away. This was a change coming to a Level 2. I realized how much I depend on my colleagues by just randomly shouting out to a fellow practitioner … ”What do you think?” Here, there is no one to just ‘bounce’ something off. However, it does afford me the opportunity to strengthen my knowledge by needing to know the answer ‘why’ and utilizing resources to confirm, learn, or discover answers. Because of the lack of colleague presence, the cross-trained nurses are a life-saver. They have a different level of competency, assessment, and confidence. It was awkward at first coming from a staff of 20 nurses per shift to having only 1 or 2 nurses. It truly reinforces the impact of communication and establishing rapport with others. Since there are fewer nurses, you work with people more infrequently, so communication, planning, and evaluating are essential—especially when those emergent situations do occur.
I still have the privilege of experiencing transport in a Level 2. The exception is that instead of going to receive the infant, I am sending them out. What an eye opener! This is where experience, confidence, and collaboration are vital. I remember my first meconium that clinically decompensated and overhearing, ‘I can’t remember a baby being this sick here.’ What a powerful lesson! This has afforded me another privilege of truly understanding the significant impact on providers and staff in managing these infants in an environment where resources may be more limited or staff may not be routinely used to managing these infants. I feel I have gained a level of inner strength, confidence, and resilience in handling distress in the clinical setting. It also reinforces the magic of nursing. Just like a Level 3, in a Level 2 the level of teamwork is there with everyone pulling together to do what is needed. Though a sick patient who requires transport is not usual and customary, the nurses are able to stabilize and do what is needed to optimize patient outcome. As a NNP, it is a humbling experience. Typically, as I stated previously, on transport I would pick up these infants to ‘give them what they needed.’ Recognizing you can’t fix this and need help is a character builder and essential professional trait.
In summary, I am privileged to experience the green grass on both sides of my world. I am so appreciative for my Level 2 experience because I am more proficient in looking outside of the box. I am not only a better practitioner, but a better listener, communicator, and mentor as well. I certainly have gained more than I can ever give back. And with that …I will go slice that piece of cake!
Life as a Neonatal Nurse Practitioner (NNP) is like an ocean tide on a gray day! The only certainty is the start and end to the day. We deal with patients and families experiencing the shattering of the hopes, dreams, and plans they imagined when becoming pregnant. In an instant, their life is turned upside down and they enter a foreign world of new terminology, high technology, and their most vulnerable possession… their son or daughter at the hands of strangers. In some cases, there may have been some introduction and preparation of what to expect. However, for the majority, families are just trying to grasp the reality that their infant was born. After all, the birth of an infant is typically a joyous event enveloped with laughter, celebration, and family. Typically, our role is delivering the news of not only how we need to “take your baby to the NICU,” but also rattling off the list of what we did, what they can do, allowing them to see the infant (in some cases through a peephole), and then leaving with a door probably bellowing as it closes behind us.[et_bloom_inline optin_id=optin_52]
There are many things to love and hate about being a NNP. There is the black and white task of the position, which may not be the favorite part, yet it is an essential piece to assist in making optimal and safe management decisions. Our day traditionally starts with getting sign-out from the on-call team, dividing up our patient load based on acuity, obtaining pertinent stats from the medical record, and reviewing notes. Next, we join the multidisciplinary team for daily rounds. Since we are part of a teaching institution, this can be an overstimulating feat even as a neurologically intact adult. However, the benefits of daily rounds on each patient certainly outweigh the challenges of parading with what seems like a million people for an eternity. Rounds provide us with critical firsthand observations, vital feedback from nursing staff, and inclusion of the family if present. It is a way for all disciplines to hear the infant’s story, plans, challenges, and successes. Rounds allow us to be facilitators of the medical plan, advocates for the patients, and to mentor/teach other disciplines. After rounds, we pursue the downhill trajectory of our concrete tasks of entering orders, connecting with consults, writing notes, and updating the problem list. This is not the most glamorous part of our role, but vital for consistency and progression of care.
Then we enter the world of LOVE it! There is so much to love about being a nurse practitioner, especially in a tertiary center NICU such as ours. No patient is easy or straightforward. Our patient population comes from mothers typically of higher risk—medical, social, mental health, or a combination which accompanies challenges and obstacles separate from the infant. Infants born to these mothers often have multiple medical issues that lead to chronic issues and prolonged hospitalization. The diversity of illness and complications these infants possess challenge us as nurse practitioners to have a high level of knowledge specific to the neonatal population. This fosters our learning on a daily basis to continually be more proficient and knowledgeable; there is constant intellectual stimulation.
Due to the complexities of our infants and families, we are fortunate to collaborate with nurses, social workers, case management, child life, physical/occupation/respiratory therapists, medical staff, and multiple consults. In our facility, we truly have a village participating in the care of our most vulnerable patients and families. As a nurse practitioner we are able to build close relationships with these disciplines, respect their roles, and promote the best patient experience for our families with the hope of optimal outcomes.
A much respected neonatologist used to say “listen to the baby.” As NNPs, we use our knowledge and experience to listen to our babies. However, we also extend that skill to communication with the parents of our infants. We need to establish a sense of rapport with the families. We have the privilege of delivering good news, such as “your baby is going home.” However, sometimes we need to deliver difficult news or be physically present as parents receive difficult news. Typically, we remain present with the family afterwards to provide empathy, clarity, and support.
The role of a NNP extends beyond the NICU. At any time, the ringing of phones signal to us that our presence is needed in Labor and Delivery. We attend all deliveries of preterm infants, infants with identified anomalies, or any delivery where there is a potential risk to the infant whether it is preterm or term. We can be called to General Care Nursery to assess a well infant with an evolving issue or need for further assessment. Further, our role is not limited to our hospital. The NNPs in our facility go on both air and ground transport to pick up critically ill infants requiring escalation of care. Here we use all of our skills to not only stabilize an infant for transport, but also make an initial contact with the family and provide reassurance as we prepare to separate them from their infant.
As a NNP, our days are unpredictable like the tide of the ocean. The knowledge and resources we need to provide the care to our patients and families are vast. The path we take with each infant and family is unpredictable, ranging from a calm rippling stream to a raging tide feeling like a tsunami. But the rewards of seeing infants make progress and parents evolving from being hopeless to feeling empowered and connected makes every day worth it!
