Practical Newborn Critical Care Nursing Dipak K Guha, Rashmi Guha, RD Srivastava
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1Neonatal Nursing2

Neonatal Nursing—The Challenge1

Normal, specialized and highly specialized neonatal care is coming up fast in India. One of the most important, rather the most important caregiver is the nurse posted in the neonatal unit. With the accreditation of many neonatal units for level II care by National Neonatology Forum (NNF) and development of many level III units in apex institutions, both government and private sectors, there is demand for specialist nurses in neonatal intensive care units (NICUs). Therefore, there is an urgent need for expanding the traditional role of registered nurses of the neonatal units. With the increasing acuity and technological complexity, rapid turnover (few months) of physician-in training (residents) and paucity of consultants, it is important that medical and nursing administration think seriously to train and create a cadre of specialized neonatal nurse (SNN) and critical care neonatal nurse (CCNN), if we want to sustain the achievements of the last 2 decades and want to march forward with the promise to provide the best quality neonatal care which is the birth right of every baby born in the country. NNF, apex medical institutions and Nursing Council of India have a big role to play in initiating the education and giving SNN and CCNN a status befitting her. This will go a long way in improving and sustaining quality neonatal care in the country.
 
 
Philosophy of Specialist Neonatal Nurse (SNN)/Critical Care Neonatal Nurse (CCNN)
Infant survival and parent satisfaction with the quality of care their infants receive is in part dependent on consistent evidence-based practice standard delivered by health professionals. The ability of physician-in-training to develop advanced technical skills is limited due to brief experience in neonatal critical care. The level of commitment and interest in neonatology by physician-in-training is variable unless they plan to pursue this area as subspeciality. Moreover, the rotation of physician-in-training on monthly or bimonthly basis may interrupt continuity of care.
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Over the years many of our staff nurses working in SCNU/NICU for reasonable length of time have assumed unofficially the role of SNN/CCNN even though they were not theoretically or technically prepared. Nonetheless many of them are successfully playing the role of SNN/CCNN but becoming frustrated because of lack of recognition and status, financial reward, promotion and avenue to advance their knowledge and skills in the clinical care. Thus, it is necessary that we develop educational program to prepare nurses to function as SNN/CCNN. Post-basic speciality education will positively influence the role of SNN/CCNN, give them more confidence and perhaps in due course of time enjoy the status and have better avenue for career advancement.
Recommendations of NNF on nursing education can be used as module for this purpose. The education and training can be in hospital settings, in the form of certified continued education program or university based graduate and postgraduate program. It is also important to give appropriate title to these specially trained nurses. It is suggested that those trained for level II care and certified be given the title of SNN and those trained for level II and/or level III care and degree holder are given the title of CCNN.
 
Role of Specialist Neonatal Nurse (SNN)/Critical Care Neonatal Nurse (CCNN)
The competence of qualified and well-trained SNN and CCNN in the medical management of ill neonates makes them not only an excellent alternative care providers, but their nursing experience, knowledge and skills make them invaluable members of health care team whose focus is on provision of high quality care. Beside playing role of traditional nursing care, these specially trained nurses will have specific role in neonatology in providing tertiary care for neonates in NICU and stabilize sick neonates being transferred to referral center. In due course of time with advancement in knowledge and skills, these nursing personnel should be able to provide help in follow-up for high-risk infants. Some with aptitude and interest should be encouraged and groomed to participate in education, research, presentations at conferences and publications in referred journals.5
 
Role of Neonatal Nurse Practitioner (NNP)
Though introduction of NNP in our set up seems unlikely in near future, it is appropriate to keep the possibility of such happening in due course of time at the back of our mind. NNPs can be created from the cadre of nurses who pass out from college of nursing with BSc/MSc degree with neonatology as speciality or any BSc nurse who undertakes specialization training in neonatal care and has hands-on-training in practical care of newborn for reasonable period of time.
Neonatal nurse practitioner (NNP) will be responsible for total patient management under the supervision of the medical staff. These expanded roles can become critical to the effective functioning of a neonatal department. In the NICU, it is highly desirable to provide 24 hours coverage for each of these roles. These nurses provide significant continuity of care for the infants and families while also serving as clinical experts for the nursing staff and junior medical staff. Another role that is essential in the NICU is that of discharge planning co-ordinator. NNP can act as the co-ordinator and help every staff nurse in planning the discharge of the patient and family.
The introduction of NNPs is seen positively from the perspective of clinicians working along-side them in neonatal care. The development of similar models of care in countries where the introduction of NNPs is being considered is likely to be similarly supported. To a large extent there is an overlap in the work of junior medical staff and NNPs in neonatal units but although the clinical work and areas of activity are similar, there are differences in emphasis and in work organization.
 
Introduction, Establishment and Assessment of Education and Training Program
In 1993, NNF developed a strategy to introduce education and training in neonatal nursing. The NNF recommended the following:
  1. The nurse posted to the newborn units should undergo a 2 weeks orientation course before being assigned to any formal responsibility.
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  2. Nurses who are likely to have a long-term commitment in newborn nursing should be given a 6 weeks refresher course in neonatal nursing.
  3. There is an urgent need to rationalize the neonatology component in the GNM (General nursing and midwifery) and BSc nursing course in accordance with suggestions made by NNF in the aforesaid recommendation of 1993.
  4. Postgraduate diploma in neonatal nursing needs to be started with the aim of creating a leadership cadre in neonatal nursing.
  5. All institutions conducting formal training in nursing must have level II neonatal unit accredited by the NNF to ensure proper clinical setting for the training of nurses.
  6. The focus of all efforts in nursing education and training must be on the acquisition of skills.
  7. The trained nurses association of India (TNAI) as well as other professional bodies representing nurses and the NNF should join hands to organize continuing nursing education activities in neonatal nursing in the country on a nationwide scale.
  8. The 1993 recommendations of NNF on education and training in neonatal nursing in regard to:
    1. Inservice training consisting of orientation and refresher course in neonatal nursing.
    2. Formal courses for GNM, BSc nursing and postgraduate diploma should be adopted and implemented at the earliest if we want to make any dent in the field.
It is recognized that caregivers selected for this role should have specific assets. These assets would include a dedicated commitment to neonatology, advanced critical thinking, problems solving and communication skills, technical expertise necessary in the management of critically ill newborns and familiarity with the psychosocial dimensions of intensive care. It is advisable to have a pool of care-giver nurses to choose from and once functional, these personnel would not constitute an economic burden to the health care system.
 
Definition of the Role and Educational Program
The role of advanced trained nurse should include clinical, educational, research and administrative responsibilities, with the 7majority of time devoted to clinical practice (70–75%). The clinical role of SNN/CCNN involves assessment, diagnosis, planning, intervention and evaluation of care. The preparation for and focus of the role of the SNN/CCNN produces a “hybrid” nursing professional which blends the medical and nursing aspects of care into a distinctive whole. The educational activities include sharing responsibilities for teaching rounds and conferences and participating in the clinical education of students from various disciplines. Research activities include evidence-based practice, identification of relevant nursing in the country on a nationwide scale.
 
Evaluation of the Role
MCQs and slides to test knowledge, semistructured oral examination for testing problem-solving skills, simulated/actual interaction with parents to appraise communication skills and simulated or actual procedure for evaluation of clinical skills may be used. Performance can be measured by time spent with routine nurses and attending physician, morbidity, mortality, quality of care and parent's satisfaction with care in the unit. As a clinical role models, the SNN/CCNN can influence the career paths of routine staff nurses who wish to remain involved in direct patient care.
As more of these advanced trained nurses are utilized in the provision of care in SNCU/NICU settings, the power of their role will be more fully realized.
 
Neonatal Nursing
Nurses form the backbone of neonatal care service. They are the ones constantly monitoring and caring for the sick neonate, they are the ones most often available to anxious mothers and they are the ones most suitable to report the course of the baby and problem to the doctors. Therefore, they have a very responsible role in the care of the newborns. Working with sick neonates especially in neonatal intensive care set up can be quite taxing and “burn out” is extremely common. Therefore, nurses working in the neonatal unit have to be highly motivated and should be committed to the care of the sick neonate. Since nurses are the ones most constantly in 8touch with the baby and the family, neonatal nurses should have adequate knowledge of problems in neonate. Minimum requirements for neonatal nurse working in NICU would be:
  1. Ability to perform resuscitation upto bag and mask and chest compression. Skill to intubate is desirable. Must undergo NRP course.
  2. Recognize neonatal emergencies and have the knowledge to treat emergencies.
  3. Should know the presentation, course, management and prognosis of neonatal disease conditions.
  4. Should know how to manage a normal preterm/LBW baby.
  5. Should know procedures as required in the care of a sick newborn.
  6. Should know the importance and techniques of infection control measures and universal precautions.
  7. Should know the functioning of and how to use neonatal equipment.
  8. Should know how to communicate with parents and family.
  9. Should have organizational and administrative capacity to run a neonatal unit.
  10. Should know about normal neonatal and physiological problems.
  11. Should have knowledge of breastfeeding.
  12. Should be able to counsel mothers regarding care of normal newborn and high-risk neonate at home.
 
Care of Normal Newborn
The nurse plays an important role in caring for the normal neonate from the time of its birth to discharge. Her role would include:
  • Providing initial steps at birth
  • Eye and cord care
  • Weighing the baby
  • Early initiation of breastfeeding
  • Recognizing normal physiological problems and illness
  • Counselling mother regarding breastfeeding and follow-up care of the neonate.
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Neonatal Resuscitation
Neonatal nurses should know how to administer bag and mask ventilation and chest compression and should be able to assist during endotracheal intubation. All nurses working in the neonatal unit and obstetric ward should have undergone the NRP course.
 
Handwashing
Handwashing is an extremely important infection control procedure which should be strictly followed by all health care personnel. The nurse plays an especially important role as not only does she have to practice this to perfection but should also ensure that others working with babies should practice it.
 
Neonatal Intensive Care Unit
Optimum nurse baby ratio per shift
Newborn needing routine care
1:6
Newborn needing intermediate care
1:3–4
Newborn needing intensive care
1:1–2
Newborn needing multisystem support
1:1
Considering that these requirements are per shift and considering “offs” and leave for every 1 nurse required per shift 4.5 nurses should be appointed. Therefore, a unit with 4 intensive care beds, 6 intermediate care beds and 10 routine care beds should have 8 nurses per shift and 36 nurses appointed. Though essential, these kind of recommendations seems highly impossible in our set up. More practically at least the above set up should have a minimum of 5 nurses per shift which would be about 20–22 nurses in the unit.
This requirement is based on dependency rating of babies, their stability and level of technical support required. The staff inspection unit (SIU) norms (1993) for nurses in the central government hospital for NICU is one staff nurse/nursing sister for every two beds,. Additional 10 percent leave reserve and 45 percent reserve for day off, etc. These recommendations are not for per shift but in toto. In addition, it also recommends 30 percent of the staff nurses should be supervisors.
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Patient Care in the NICU
Role of the nurse in actual patient care would include:
  1. Routine patient care
    • Feeding
    • Changing napkins and keeping baby clean
    • Suctioning baby as and when required
    • Providing oxygen as and when required and switching it off when not required
    • Monitoring vital signs like temperature, heart rate, respiration rate, capillary refill time, etc.
  2. Specialized patient care
    • Starting IV line
    • Monitoring
    • Blood sampling
    • Connecting IV lines
    • Helping with patient procedures
    • Administering medication
    • Recognizing problem and reporting physical condition of the baby
    • Reacting to emergencies, e.g. resuscitating an apneic baby, administering 10 percent dextrose to a convulsing baby who has hypoglycemia, etc.
  3. Care of ventilated baby
    • Suctioning
    • ET suctioning
    • Chest physiotherapy
    • Trouble shooting and reacting to ventilator alarms
    • Recognizing tube block/tube displacement
    • Reacting to saturation drop
    • Ability to react to monitor alarm and malfunction of equipment
  4. Patient related care
    • Hand-washing
    • Keeping environment of the nursery clean
    • Monitoring records and sheets
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    • Communicating with parents
    • Care and knowledge of neonatal equipment
  5. Administrative work
    • Supervising nurses work
    • Ensuring smooth functioning of the unit
    • Ensuring availability of stocks and linen, etc.
    • Ensuring proper functioning of equipment
  6. Seriously ill neonates
    Despite the limitations in term of number of nurses if a neonate is seriously ill the nurse has to organize herself to be available to take care of this baby and should inform the family periodically regarding the baby's condition.
  7. Discharge planning
    Most neonatologists prefer to take the nurses opinion prior to discharging of a high-risk neonate as she knows the baby and the mother best. Prior to discharge she should ensure that the baby is feeding well and the mother is capable of taking care of the baby at home.
  8. Communications
    There are many situations when a nurse plays an important role in communication and she should know the importance and should be able to communicate well.
    • Routine communication with the parents and family
    • Telling the parents about a sick baby
    • Grief counselling
    • Death of a baby in the NICU
    • Counselling during discharge
    • Lactation counselling
    • Communicating to the doctor regarding the baby.
  9. Teaching and training
    The incharge nurse and the senior nurse play an important role in training the newly recruited nurse and residents in neonatal care.
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  10. Role as in-charge of a neonatal intensive care unit
    Neonatal nursing emphasizes the need to be allocated to care for infants depending on their skills and experience. She has to be a role model for other staff. Effective communication will assist unit cohesion. Direct and clear leadership is essential to the well-being of NICU. Extended role of the nurses may be advantageous to provide holistic care, e.g. venepuncture, cannulation, intubation, etc. The incharge should ensure that the staff has received appropriate certified training and updating. As an incharge she has to be up-to-date with the policies, procedures and protocols of the unit.
    Facilitating a learning environment is part of a senior member of staff's role in order to help juniors increase their knowledge. This can be performed through lectures, clinical sessions, one to one teaching, journal club, unit meetings, feedback sessions, post hand-over, ward rounds and so on. An important requirement in seeking to exercise control and influence on the work of others is to control your own work planning and monitoring the use of time and concentrating this precious resource on the right priorities. This is essential for nurse manager at every level.
  11. Role of nursing research
    The NICU provides myriad opportunities for research. This area of neonatal nursing has not grown rapidly and many interventions are not research based and need to be scientifically validated. In their practice, neonatal nurses daily encounter problems that need to be examined and nursing care practices that require validation through research. It is through research that neonatal nurses can improve the nursing care and outcome of the high-risk babies. Langley (1997) reported that nursing research is an essential element of their evaluation of health programs. Neonatal nurses have initiated changes and innovations in practice, through research. Neonatal nurses in the clinical field are in the ideal position to identify programs and initiate research questions. Research is an essential element of evaluation of health programs and projects. Research 13in the context of evaluation can be viewed from a two-dimensional approach.
    • The evaluation of health programs or projects in existence, utilizing research to test economy, efficiency and effectiveness of the quality of service provided or to address specific problems.
    • A specific program of research can be evaluated and if suitable, act as a vehicle to introduce new services and innovate changes or practices in health programs or policies.