At my nursing school pinning ceremony, the professor informed my graduating class that we would all become leaders. She gave her famous “oh the places you will go” speech as we all listened, and excitedly dreamed of our futures. In that moment, I don’t truly think I thought I would become a leader, innovator, or change maker in such a diverse and large field. Little did I know she was correct I would become a leader. Nurses are all leaders in a variety of ways.
A Typical Day as a NICU Manager
My day normally begins with a very lengthy to-do list. I enter the unit or my office and the organized chaos begins. My day is filled with meetings, completing tasks such as scheduling for 180 staff, managing time and attendance for 180 staff, rounding on patients, families, and staff—and much, much more. Often at the end of the day I look back at the to-do list, and I have accomplished none of the tasks that were high priority for the day.
Being flexible and adapting to the needs of the unit is a quality one must possess to become a nursing leader. Prioritizing tasks is helpful, but understanding that often priorities change depending on the needs of patients, families, and staff is how leading a large NICU is accomplished. Like the life of a preemie, the life of a NICU manager has many ups and downs.
Currently, as an organization we are working to obtain Magnet designation. Empowering nurses to be leaders, innovators, and change makers is very challenging. Recently when speaking with a physician, he compared NICU nurses to mother lions, and this comparison is fairly accurate. NICU nurses are advocates and the voice for the tiniest patients each and every day. NICU nurses are protective and territorial when caring for these tiny patients. They nurture them from 400-500 grams (and sometimes less) to discharge three to six months later. NICU nurses not only provide care for these tiny patients, but they also care for their parents/caregivers and are emotionally attached to these tiny humans and their families.
Convincing a NICU nurse to change a process or method that they have been using is often met with lots of resistance. Could this be generational, cultural, or learned? Possibly, but part of my job as a manager is working with the diverse, multidisciplinary team to provide quality, evidence-based care for all patients in the NICU. Finding a way to change the culture or resistance to improve practices is one of the hardest aspects of my job, and can be physically and emotionally just as draining as being a bedside nurse. I have found that listening to staff and families and asking for their input while providing the “why” behind change has become one of the greatest tools I have as a leader. Asking or empowering staff to take part in problem solving has also become a very useful skill that I am learning and getting better at each day. Becoming a NICU manager does not make a NICU nurse’s personality change. We simply protect different territories and advocate in different ways than before.
Being a NICU manager is a fine balancing act that I am still working to perfect. My inbox is always full, and just when I think I have it empty another problem, issue, or task is waiting. The NICU is a 24/7 operation that never stops, and rarely slows. Although I find it difficult to step away from the NICU at times or put down my electronic device that my email is constantly updating on, I have recently discovered that this pause makes me a better and more focused leader.
As a leader and in life I attempt to live each day, knowing not what tomorrow brings, but being optimistic that what I am doing today will impact positive change, and lead to innovations and improvements for future NICU patients and families. It is often said that it takes a village to rear children. It also takes a village to manage a NICU.
Working for the tiniest and youngest of patients may be tough, but it also has its rewards. We spoke with Aileen E. Takeshita, RN, BSN, CCRN, Program Coordinator—Education/NICU at Adventist Health White Memorial, and she took time to answer our questions about her experiences being a neonatal nurse.
What follows is an edited version of our Q&A.
As a neonatal nurse, what does your job entail? What do you do on a daily basis?
As an NICU nurse, I work with newborn infants born with a variety of problems ranging from prematurity, birth defects, infection, cardiac malformations, and/or surgical problems. These babies usually experience problems from the time they’re born or shortly after birth. I work closely with a multidisciplinary team to provide clinical care to our tiniest patients. Our multidisciplinary team consists of doctors, nurses, lactation consultants, social workers, pharmacists, OT/PT/ST, and respiratory therapists. Not only do we care for the baby, we also care for the family. We provide them with psychosocial support during this stressful time.
Why did you choose to work in the NICU? How long have you worked there? What prepared you to be able to work in this kind of environment?
It sounds cliché, but I always knew I wanted to be a nurse. I thought it would be in Labor and Delivery. And, I actually started off on the path to becoming a nurse midwife. I worked for a smaller community hospital. White Memorial was the regional center that we would send our sick babies to. Every time they would come pick up our sick babies I would be more and more intrigued with the skill set the team had and their ability to care for such little patients.
I’ve worked at White Memorial for 23 years.
I don’t think anything really prepares a NICU nurse for what they experience or see. But having a love for nursing, and, particularly a love/passion for moms and babies helps. If you can always remember why you got into nursing and who you serve, it will help you get through the tough shifts.
What are the biggest challenges of your job as a neonatal nurse?
I think the biggest challenge these days is providing quality health care in an ever-changing financial world. It’s not easy to provide care to a low-income population. They are usually sicker because of lack of means or resources. And every day the face of health care changes—payment is less, requirements are more. Most of us serve this type of population for the love of the community and its people.
What are the greatest rewards?
At the end of the day, the greatest reward is a genuine thank you from the parents or family. Of course, it is always sending a baby home. The harsh reality is that not all babies go home. But when a mother, father, or family member pulls you aside, gives you a hug, and says “Thank you for all you did to help me and my baby,” that’s the reward.
I live in this community. In 23 years, I’ve taken care of a lot of babies. I see these families [outside of the hospital]. And they always remember me and are so excited when they can say “Look at my baby. He/She is doing so well now. Thank you!”
What would you say to someone considering this type of nursing? What kind of training or background should he or she get?
I would tell someone considering this type of work to love what they do and love the community they serve. Know that they will not only need to be sharp with their clinical skills, but they will also need to be supportive of the mother and family. And to remember that they are the advocate for our tiniest patients who can’t speak up and tell us what’s wrong. They need to be like policemen…protect and serve.
I strongly believe future nurses should volunteer at the hospital where they are considering employment and in the department where they want to work. That way, they get a true feel if that’s really the place for them to be.
Is there anything I haven’t asked you about being a neonatal nurse that is important for people to know?
I love being a NICU nurse. There are so many opportunities for NICU nurses. It’s a great place to be that encompasses your clinical skills as well as your psychosocial skills. You don’t just take care of one patient. You take care of an entire family. You are a teacher—always educating the family about what’s going on. There are definitely days that are challenging. But, most of all, it’s really rewarding.
I presented some of the differences between the Doctor of Philosophy (PhD) degree in Nursing and the Doctor of Nursing Practice (DNP) degree. To recap, the PhD is an academic research degree and the DNP is a practice-focused or professional doctorate for advanced practice nurse (APN) preparation. The PhD prepares nurse scientists and the DNP prepares advanced nurse leaders/clinicians.
“PhDs create knowledge for practice and DNPs use knowledge in practice.”
Why Doctoral Degrees in Nursing is Important!
It can be a hard decision for many nurses to continue their education — doctoral education takes a lot of time and money and there may not be a substantial salary increase at the end of the road. Our students need to work and they have family, social, and professional obligations — add in school work, and that makes for one tired nurse! So is it worth the pain and effort of going back to school?
The Future of Nursing report stated that among the health professions, “nursing is the least well-educated.”(1,p.485) The more nurses we have at the doctoral level, the better it will be for nurses, our future patients, and the Nursing profession. “The current demand for master’s– and doctorally-prepared nurses for advanced practice, clinical specialties, teaching, and research roles far outstrips the supply.”2 I don’t know about you, but that sounds like job security to me!
We need doctorally-prepared nursing faculty, desperately! The nursing faculty shortage is being described as “dire” and has a direct impact on the number of applicants being turned away from nursing schools, and therefore on the number of nurses we can prepare—at all levels.3-5 Though faculty salaries are not as high as top-level clinical positions, there are perks to academic life to consider.
Here are some of the tangible and intangible benefits of doctoral education:
Personal growth and development. Besides the knowledge gained, the inherent satisfaction of knowing that you persevered through tough challenges and obstacles to graduate as a doctorally-prepared nurse. Maturity and independence, time management, and advanced skills are all considered prized results of doctoral education.6,7
Personal achievement.6,7 The high honor of knowing that you have attained the highest level of education in Nursing — fewer than 1% of all nurses in the country have a doctoral degree. Scholarly respect is how one author put it.8
Advanced transferable skills, such as critical thinking, clinical reasoning, analysis, research or quality improvement methodology, writing, presentation and communication skills, etc., that you can take with you to any job or position.6,8,9
Impact/transform the Profession by generating nursing science or improving systems of care.
Impact/transform your organization with the skills to deal with and solve complex problems.
Larger professional network,8,9 social relationships, and support systems with classmates, colleagues, and coworkers that you may not have had the opportunity to work with before.
Your future earning potential may be increased.7-9 Higher rank/position = higher pay (and greater responsibilities). In University, to get on the Tenure-Track or be promoted to a professorial rank, you need a doctoral degree. And doctorally-prepared faculty earn more on average than faculty without a doctorate.8 In the clinical setting, DNPs are frequently at a director, department, or administrator level. Higher degrees also qualify you for higher levels on the clinical or career ladder, which usually come with a salary differential.
Your job opportunities may be expanded because you can qualify for top-level positions and may have a greater choice of career paths. Job security goes hand-in-hand with career flexibility.8 Job satisfaction is the desired outcome.7,9
These are only some of the personal and professional benefits of doctoral education.
I urge you to strongly consider taking that next step and continuing your education. Whether you choose the PhD or the DNP, I believe you’ll see that the benefits will outweigh the struggles, in the end.
Strive for Excellence!
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If you are a NICU nurse, you’ve likely been in this scenario: the unit is quiet, you’re going about your shift, when out of nowhere the ventilator starts alarming. Next, the cardiac/apnea monitor blinks red in rhythm with high pitched chimes. You quickly assess the situation, and the feeling sinks in that your once intubated patient is now possibly, unintentionally extubated. Maybe you were handing a baby over to an eager parent for some much needed “kangaroo care” or you were doing your due diligence by changing old tapes to better secure your patient’s endotracheal tube (ETT). Whatever the case may be, accidental extubations are on the short list of NICU nurse nightmares.
Intubation is a life-saving intervention required for many NICU diagnoses and provides a stable, patent airway for the delivery of mechanical ventilation in high acuity patients. Much like central lines and feeding tubes, ETTs require specific placement to function properly. A malpositioned ETT can lead to complications ranging from atelectasis to pneumothorax requiring surgical intervention. Monitoring the securement and position of an ETT is often the responsibility of the bedside nurse and respiratory therapist (RT). A number of activities like re-securing an ETT or even handling a patient can precede its dislodgement. When this occurs, it is considered an unplanned extubation.
Despite the best intentions of the caregiver, unplanned extubations DO happen. They are considered one of the most common sources of preventable harm in NICUs when compared with IV infiltrates, HAIs, and adverse drug events. Unplanned extubations can lead to severe cardiopulmonary deterioration and are the source of over half of emergent intubations. We know they can lead to long-term damage, even sentinel events, but it doesn’t mean that we stop handling our intubated patients or letting our parents hold their babies.
So how we do we keep unplanned extubations from happening as much as possible? Do we know our practices are effective if we don’t know why unplanned extubations happen, when, and how often? Answering those questions starts with data collection. The collection of data on unplanned extubations is not consistent among NICUs nor is it mandatory due to several factors. One factor is the lack of a unified definition of what qualifies as an unplanned extubation in the first place. There is also a justifiable fear surrounding data collection due to the threat of legal repercussions to the caregiver. Despite these barriers, the occurrence of unplanned extubations is starting to be considered a quality indicator by sources like the U.S. News and World Report—so maybe it’s time put aside our fears and reconsider.
Our level IV NICU does not currently collect data on unplanned extubations. Previous attempts at collecting data proved to be inconsistent and unreliable. This prevents us from being able to quantitatively assess whether current practices are working and what our number actually is, but where to begin? The best place to start is always at the bedside. Respiratory therapists and nurses are the first responders when an unplanned extubation occurs, so a team consisting of RTs and nurses was formed. First, we determined who would collect data. The RT and nurse would debrief immediately after the unplanned extubation once the patient is stable. Because the nurse is usually consumed with hands-on care at this time, it was determined the RT should gather this information and record it.
It was important to the team that the process be user-friendly and simple. We created a data collection tool starting with the basics: name, DOB, gestational age, and date/time of the event. This could help us answer some important questions:
Do most of these occur during lunch hours or possibly during shift change when there are fewer hands on deck?
Are the majority of these micro-preemies or are they older, active babies?
We then needed to identify the activity during which the unplanned extubation occurred. Activities included re-securing the ETT, adjusting ETT placement, transferring a patient to be held, removed by the patient, etc. Simple checkmarks could be placed in the corresponding boxes with room for additional comments if necessary. We also included areas for date of the last chest x-ray, and finally, we wanted to know if resuscitation was necessary.
Current research identifies an average of one to three unplanned extubations per one hundred ventilator days so our next task will be to set a realistic goal for our unit. We can then evaluate our practices to identify strengths and weakness. No one wants unplanned extubations to happen. We have a large, dedicated unit that already goes to great lengths to keep our patients safe, but we are open to change. Through a streamlined process of data collection, we are looking forward to finding out not just what we can improve on, but what we are doing right.
By the year 2030, it is estimated that one in five Americans will be over the age of 65, and approximately 60% of this population will need treatment for at least one chronic condition. As the U.S. health care system faces the aging of the baby boomer population and the rise of chronic disease, nurse practitioners (NPs) are leading the way by demonstrating positive results in managing care for older patients and the complexity of chronic conditions. This includes innovative practice solutions, research and training, and policy advances at the state and federal level to strengthen access to NP-provided health care.
Demand for nurse practitioners is at an all-time high, and NPs are now the fourth most sought after health care profession, as well as one of the fastest growing. Last year, primary care nurse practitioner graduates outnumbered primary care medical school graduates by more than three times. It’s no surprise U.S. News & World Report ranked the NP second on its list of the 100 best jobs – naming formidable salaries, job security, and increased practice rights as enticements for students considering health care professions. Factor in the Bureau of Labor Statistics’ projection of 31% job growth between now and 2024 (five times the national average for all professions) and the need for more than 50,000 new positions, and we have the right incentives to recruit the next generation of nurse practitioners who can continue strengthening our health care workforce.
But the rising tide of chronic disease is not the only factor revolutionizing the role of the nurse practitioner. Growing recognition of nurse practitioners as key players in the health care delivery system is driving legislative change. Today, 22 states plus the District of Columbia, have made the historic shift to grant NPs full practice authority, providing examples for similar legislation in statehouses across the country. Massachusetts, North Carolina, Pennsylvania and other states are considering comparable legislation, foreshadowing a time when all 50 states provide patients with full and direct access to NP care.
The abilities of NPs to lower costs, improve patient outcomes, and increase patient access have been noted in national studies. In 2017, more than 89% of NPs were trained in primary care, as compared to 14.5% of their physician counterparts. In addition to providing care in traditional settings within hospitals and rehab centers, many are now opening their own practices, working on the community front lines where they deliver comprehensive care, including managing chronic diseases from diabetes to COPD.
With the demand for quality, accessible health care growing, the supply of providers must keep pace. Nurse practitioner graduate education programs are expanding to accommodate increases in qualified applicants, and nurse practitioners are graduating at higher rates. Today, there are roughly 350 colleges and universities with nurse practitioner programs in the United States. In 2016 alone, more than 23,000 nurse practitioner graduates entered the workforce, with the majority prepared in primary care.
With the confluence of aging baby boomers, the rise of chronic disease, health care reform, and focus on prevention and patient-centered care, the next generation of nurse practitioners and the skills they bring to patients are poised to thrive. We are just a few years away from the historic shift when, for the first time in human history, the number of people over 65 will outnumber children under five, and by 2050, this gap will widen to a 2:1 ratio. With this shift comes tremendous opportunity and responsibility for nurse practitioners to practice at the top of their license, serving patients in innovative and rewarding ways. For the 234,000 nurse practitioners and counting, there’s never been a better time to be an NP.
Developmental care is a philosophy utilized by the entire interdisciplinary team to coordinate medical, nursing, and parental interventions based on the developmental needs for a particular patient. This philosophy of care is to support the infant and their families with a focus on environmental influences affecting neurologic development. Developmental care encourages frequent assessment and responses to a baby’s needs. These responses are meant to decrease the stress of the preterm neonates in the neonatal intensive care unit (NICU), according to the Northern Neonatal Network’s guideline for family-centered developmental care.
Why use developmental care?
Neonatal medicine is an ever-expanding field. Babies born at progressively earlier gestational ages are able to survive due to advancements in modern medicine. Mortality rates have declined with the fast-paced achievements of neonatal medicine. However, evidence exists to suggest increased morbidity for neonates born prematurely or acutely unwell. Long-term studies have identified more subtle problems including neurosensory impairments such as cognitive delays and behavioral difficulties. “These can have a significant influence on a child and their families’ way of life.” Developmental guidelines for interventions, handling, inclusion of family and nursing protocols help to optimize neurodevelopmental outcomes for NICU infants and their families.
What is the goal of developmental care?
As caregivers, we want to protect the infant’s brain and create an environment suitable for neurobehavioral development of the infant. According to the Network, the outside environment now needs to mimic the inside environment, which is crucial for normal brain development. The inside environment provides containment and allows for the baby to maintain a supported flexed posture with limited noise and light exposure, as well as, protected sleep cycles with no separation from the baby’s mother. The goal is to support more positive experiences for the baby and thus achieve more positive outcomes for even the littlest of our patients.
How do we implement developmental care?
In the NICU, we use developmental care to support the infant and their families with individualized care which focuses on the environmental influences including handling, positioning, light, and sounds. The amniotic fluid serves as tactile sensory stimulus for the infant while in utero. When the infant is in the NICU, they are exposed to various touch stimuli versus constant tactile stimulus. Studies suggest that even routine handling during procedures can have adverse effects on the infant such as bradycardia, hypoxia, sleep disruptions, increased intracranial pressure and behavioral agitation.
One way to overcome this overwhelming tactile stimuli is to swaddle the infant. A systemic review published in Pediatrics found that swaddled infants have improvement in physiological and behavioral states such as lower heart rate, alleviates pain, prevents hypothermia and calms the infant. It also induces and prolongs sleep with fewer startles. The Network’s guideline suggests that these same benefits can also be achieved by the practice of developmental positioning utilizing positioning aids. Developmental positioning also provides the musculoskeletal support of flexed & midline postures, encourages self soothing behaviors and helps to conserve the baby’s body temperature and energy thus growth and weight are promoted.
Gentle human massage and touch is another intervention that can help decrease stress levels of premature babies. A Research in Nursing & Healthstudy found that gentle human touch increases respiratory regularity, improves sleep cycles, motor activity and behavioral distress during periods of gentle touch. Gentle massages have been reported to help improve weight gain, improved pain alleviation, reduced postnatal complications, improved physiological and behavioral states, shorter hospital stay and improved performance in developmental scores.
The NICU is quite often an overstimulating environment. Behaviors, which should be modeled by staff and taught to the parents can ease the constant stream of auditory and visual stimulation. The NICU staff can control the lights and sounds of the outside environment. A 2013 study published in Indian Pediatrics recommends that we keep the infant on a schedule to allow for uninterrupted rest and decrease stress by using non-nutritive sucking, kangaroo care with parents, swaddling, and containment.
In summary, developmental care should be utilized for all preterm infants during their adaption to extrauterine life. Creating a positive environment and protecting neurobehavioral development is crucial to an infant’s long term outcomes. Implementing developmental care practices such as positioning, swaddling, nonnutritive sucking, gentle human touch and massage can help alleviate pain and provide better outcomes for the premature babies and their families.