Years ago, when I started working in the NICU (neonatal intensive care unit) I was explaining to a group of non-medical people what I do. I explained that I was a neonatal nurse, that I work with babies. With that came the naive question, “what do you do then, just feed babies all day?” The answer is yes and most definitely no. While of course even the tiniest babies need nourishment, this is just a small part of an enormous job that involves a keen eye, constant reassessment, a soft touch, empathetic heart, and super critical thinking skills. We carry a very heavy responsibility. Many of us at one time or another in our career have gone home with insomnia wondering if we did everything we could for our patients. Did we miss any subtle signs of our patient decompensating? NICU nurses have to be experts at reading subtle signs of danger as our patients lack the ability to communicate when they hurt or feel sick. The following is what is expected of a neonatal nurse in a day’s work.

Part Expert Clinician

This skill takes years to hone. A typical day for a NICU nurse starts after report, also called change of shift. Each patient has different problems, needs, requirements. It requires anything from understanding the pathophysiology of a congenital heart defect to knowing that a premature baby that exhibits a large belly and feeding intolerance can be a sign of necrotizing enterocolitis, a life threatening infection. We are expected to interpret a baby’s blood work and know when to react, know if the baby is getting too much or not enough fluid, and give all medications correctly and on time. We have to know that giving certain medications too quickly can cause ototoxicity or hearing loss. We are expected to know that certain IV fluids should never be given together and never given through small veins. We have to trouble shoot IV sites, IV pumps, ventilator settings. We have to interpret a low grade or high grade temperature. We have to quickly (but safely) give blood product after blood product to keep our tiny patients alive. We have to respond quickly to a dropping blood pressure and stimulate a premature baby who has gone apneic. We are expected to be fully aware (even at 5 or 6 am) and prepared to administer CPR to an asphyxiated baby born after being stuck in the birth canal.

Part Mind Reader

This applies only to working in certain areas in the U.S. Depending on where in the country one works, there still exists a very clear hierarchy where nurses are expected to anticipate the needs of the doctors and in a timely manner. I have through the years reluctantly become a sort of mind reader. It is the nurse’s responsibility to know that Dr. So and So gives all his babies a suppository every 12 hours round the clock (premies become easily constipated).
I have worked with doctors that expected the nurse to know that they require a small towel (rolled in a precise manner) to place under the baby’s neck before intubation and who have all but written me up (instead of simply asking) because I had not charted the baby’s weight in the timely manner they required. This adds unneeded stress in an already stressful environment.

Part Therapist

Parents of NICU babies are grieving. They are grieving the normal delivery they had hoped for, the healthy baby they dreamed of, and the diagnosis they have been given instead. Though they are usually referred to a support group or therapist early on, it is the nurse that plays the role of therapist most days. They witness the most critical moments in a NICU parent’s life in real time as it happens. They are there the day the baby is born and admitted, the day the baby is diagnosed with a brain bleed or life threatening sepsis and even on the good days when baby starts eating by mouth or gets closer hopefully to going home. Through this roller coaster ride that is the NICU, the nurse is by both the parents’ and baby’s side watching, monitoring, assessing, intervening, and guiding. The parents rely on the information we give them and sometimes that information determines whether or not they have a restful night, so we learn (hopefully) to tread gently and carefully.

Always Protector

In the 8 to 12 hours that a NICU nurse has assumed responsibility of a NICU patient, it is that nurse’s responsibility to protect the baby. It’s called patient advocacy and it’s a little like a female lion protecting not only her own cubs, but all the cubs in the pride. It can be reminding a parent, family member, or coworker the most critical element of hand washing before any contact with the baby. It can be questioning a doctor’s order that may not be in the best interest of that particular patient. Whatever it is, if it is not in the best interest of the patient, it is the nurse’s job to speak up.

I recently heard one of my favorite doctors here in Sweden say something that will be forever engrained in my brain. Toward the end of a tiring night that required admission after admission of unstable patients, she said to me something along the lines of “it’s best to always prepare for the worst, that way there are no surprises.” This is a good summation of working in the NICU, always preparing for the worst while hoping for the best. At the end of a sometimes very long and emotionally trying day, we are expected to show up for the dinner parties with smiles on our faces. This takes the super human ability of separating work from non-work. Some days are easier than others and that is why it is so much more than just feeding babies. Feeding babies is actually a cherished moment for NICU nurses because this means that we have hopefully done our job and done it well.