Staff Orientation in the NICU
I vividly remember my first day of working in the NICU. I had two years of adult nursing experience under my belt and was excited to transition my career to caring for the world’s tiniest humans. The first few months were humbling. This was a far cry from my previous unit where my patients were able to articulate their aches, pains, and needs. I was no longer privy to my patient’s feelings. No one was telling me what to ask the doctor or what felt different. Instead, I now had 12 hours to learn a baby’s baseline and communicate with the medical team when behavior and physical assessment differed from normal. In the NICU, subtle changes can mean something is wrong. A thorough, supportive orientation in the NICU made developing these new skills and critical thinking possible.
The hospital I work at conducts a 12-week orientation with an assigned preceptor and is structured for assignments to progressively increase in difficulty. Each week the babies get more complex and require stronger critical thinking. While the unit’s standardized pathway helps an orientee gain experience caring for a wide variety of patients, it is easily modified to individualize the orientation to meet an orientee’s needs. Multiple meetings with the NICU educator, preceptor, and orientee are conducted throughout this period to facilitate open communication. During these sessions, feedback regarding an orientee’s strengths and weaknesses aid in tailoring future assignments to support the orientee’s success in the NICU.
Orientees spend their first four weeks in our Transitional Care Unit (TCU) where they learn how to care for our feeder/growers and babies and their families preparing for discharge. This section of orientation hones in on learning “normals” and establishes a foundation for effective time management. From learning how to pace and feed an ex-28 weeker to learning to quickly intervene on a baby experiencing a bradycardia episode, my early days in the TCU were overwhelming. With back-to-back Q-3hr feeders, congenital heart screenings, car seat tests, and discharge instructions, time to sit down and chart is precious. Aside from its fast pace, the nurse plays a huge role in transitioning the baby and family to going home. The reality and implications of discharge often creates anxiety for parents. Their baby’s nurse serves as an empowering supporter, teaching families all the skills they need to leave the isolettes, loud alarms, and tangled wires behind.
Just when I started to feel comfortable in the TCU, I transferred to the intensive care unit, where I would finish out my eight remaining weeks of orientation. My newfound confidence quickly deflated. The dim lighting, the bright blue bili-lights, and sounds of babies crying and alarms buzzing put me into sensory overdrive. I’ll never forget seeing my first 24-weeker laying in that big isolette, small as could be, but strong as ever as she clenched her tiny fist onto her endotracheal tube. In those early days, I doubted my ability to care for these tiny, vulnerable patients, but the pathway continued. The more I learned each day, the more comfortable I felt. I transitioned from caring for just one baby to providing care for two babies. I graduated from stable babies on CPAP to unstable micro-preemies on high-frequency oscillating ventilators requiring frequent blood gases and multiple drips. I gained experience caring for them all. By the end of my orientation in the NICU, I was able to safely manage critical 1:1 assignments by myself. I learned to advocate for my babies during rounds, question new orders that sounded inappropriate, and trust my gut instinct when something just seemed “off.” Prior to my orientation concluding, I spent two weeks as the first admission nurse and participated in the resuscitations of my “new admits.” Needless to say, I gained a healthy appreciation for NRP.
Following orientation in the NICU, I began a 12-week “post-orientation pathway” that gradually advanced the acuity of my assigned patients. Additionally, at the start of every shift, I was assigned a “resource buddy.” Resource buddies were more experienced nurses that served as easily accessible sources of information. My resource buddy was always working in the same pod as me, so I always had someone to turn to if I ran into a problem or a question arose.
No one in the NICU expects new hires to know everything. The learning never stops. While the novelty of the NICU has faded and I am no longer intimidated by the sights and sounds that once took my breath away, the magnitude of the work we do has not.