Caring for the Smallest Patients
The special skills of NICU and PICU nurses are on display each day.
By Joan Tupponce

For parents, the scene in a neonatal or pediatric intensive care unit can be frightening. The beeping equipment, the IVs, the ventilators, all can be overwhelming. But for nurses in those specialty units, the work is extremely rewarding.

Barbara Frisinger, RNC, MSN, CNS, serves as a clinical nurse specialist at Sentara Norfolk General Hospital. She oversees the high risk special care nursery, as well as the newborn nursery. Janice Lawrence, Clinical II RN, works primarily in the special-care nursery which takes babies that are 28 weeks gestation or 800 grams and above - a little less than two pounds.

"We work with babies that are sick but not so critical that they need [the highest level of neonatal intensive care]," Frisinger explains. "We don't take babies that require sub-specialty care. We don't keep the real small micro-preemies."

Sentara Norfolk General serves patients from Hampton Roads, northern North Carolina, the Eastern Shore, Williamsburg and the Franklin area. The campus includes Children's Hospital of the Kings Daughter and Eastern Virginia Medical School. The hospital also has a high risk perinatology unit for moms who are very sick before and after delivery.

"We get moms and babies from all over the state," Frisinger says. "We stay full and we stay busy."

Frisinger, who has worked in an NICU for 14 years, and Lawrence, who has worked in the nursery at Sentara for 25 years, see lots of multiples - twins, triplets and quadruplets.

"When you work in a specialty level nursery you get skilled in working with premature babies and families that have premature babies," observes Frisinger. "When you work in a [high-level] unit, you also have to deal with bereavement issues."

Teamwork is a priority in the unit. "When you have that number of children and high acuity, you have to work as a team," Lawrence says. "You have to also be family focused. These children are hooked up to monitors and that's scary for families."

Nurses in the unit have good basic and assessment skills. "You have to pay attention to detail," Frisinger remarks. "You can't let things slip through the cracks."

Sentara Norfolk General, unlike some other hospitals, will take new graduates in the specialty nursery. "Most of the time, it's a matter of training them and giving them experience," Frisinger says. "It's very fast-paced in the units. You have to be focused. You have to have a passion for the area. That's why nurses stay in this area; they love what they do."

Like any nursing position, working in a special care nursery does have its challenges.

"You're not just working with one patient," Frisinger explains. "You're taking care of the whole family, and every family is different. They have different needs. You have to adapt and work with them. You have to transition them to the point where they feel adequate in taking the baby home. Sometimes they panic. [When they do take the baby home], that's also one of the biggest rewards.

"You can't appreciate what these families are going through unless you have been in that position," Frisinger adds. "We try to put ourselves in that position. We try to get them involved from the beginning. Sometimes that takes a gentle push, especially with the dads who are afraid they will break the baby. We tell them that it's going to be okay. We give them small things to do at first."

Each nurse sees from one to four patients daily. "If a baby is really sick, you will only have one [to care for]," Frisinger says. "Generally you have two to four babies, based on acuity."

Both Lawrence and Frisinger enjoy their work. "It's really a blessing to see some of these babies grow on the outside," Frisinger says. "We get to develop a relationship with the family."

Some parents come back to visit during the holidays or on birthdays. "That's really fun," Frisinger says, adding, "We even have some repeat customers."

Melinda Kight, clinical coordinator for the PICU and Peds Progressive Care Unit at VCU Health System, had always been interested in an ICU environment when she moved from Labor and Delivery to the PICU. "Even though the patients are as sick as the adult ICU they are able to laugh, smile and play," observes Kight. "They can interact and I was struck by that."

Nurses in the unit conceptualize their patients differently than nurses in other, adult units. "Your patient becomes a family," Kight explains. "You have to include the caretakers in the patient's care. That can be both a strength and a weakness because there are so many people involved."

Making decisions about treatment when there are several family members involved can be difficult. "Everyone has to be on the same page," Kight says. "You want to be an advocate for the child when you know he or she feels strongly about something."

The PICU at VCU Health System has 12 beds that can flex up to 14 when the Progressive Care Unit is closed during the summer when the demand for such care is lessened. Patients in the unit are divided by age instead of disease process. "We can have a toddler in one room and a 17-year-old in the next room," Kight says.

The it-takes-a-village philosophy applies to caring for a child in the unit, she adds. "We have a specialty team that includes a childlife specialist who helps care for the child and normalize his or her hospital experience. We involve schoolteachers, music therapy and art therapy. Our Dogs on Call program comes up to the unit periodically."

Because of the wide range of ages in the unit, nurses must have a communication style that coincides with the developmental age of the child.

"We probably have more interaction family-wise than any other area aside from palliative care," Kight says. "In the NICU you can't have visitors come in and out. We tend to be pretty open. We have rules but we bend them. We try to have a parent at the bedside 24 hours a day if they are willing to do that. We do want them to have an opportunity to take a break. We don't want them to be completely and mentally exhausted."

Kight explains that working in the PICU has its own type of stress.

"When you work in an environment that is not a pediatric specialty and a child rolls through the door, the stress level increases," she explains. "We specialize in that. We have to learn to deal with that stress, that feeling that it's not fair when a child is involved in an accident or is critically ill. It's that feeling of wanting to do something so badly to change the outcome."

Kight's unit has a chaplain who works with nurses to help them cope with compassion fatigue. "We found that we needed a little more care for the caregiver to alleviate that stress," Kight says.

Nurses in the unit have a weighty responsibility, she adds. "A child doesn't have any preconceived notions about the way you treat them. They haven't had a bad experience. You have to be honest with them and tell them what is going on. You have to develop trust."

The gratification is instantaneous. "You know you made a difference," Kight says, "because you can see it."

Terry Lucas, RN, MSN, believes that nurses choosing any area of pediatrics must appreciate the nuances of growth and development.

"You have to understand how the child's response physically and emotionally is different dependent upon their age and achievement of developmental milestones, all within the context of a family," she explains. "One must truly love caring for the entire family, children in particular, to do this line of nursing."

As administrator of Children's Hospital and Women's Services at the University of Virginia Health System, Lucas works with both the NICU and PICU. An NICU nurse, she says, helps the family adjust to "an infant who was born not well and simultaneously must be a gifted, skilled professional who appreciates the intricacies of caring for an extremely ill infant."

"The physiology of the premature child is very different, and understanding and assessing that child requires specialized understanding," she says.

PICU nurses have to have vigilance along with expert knowledge of pediatric critical care.

"They have to have a heart that can bend with the sorrow but not snap," observes Lucas. "Both areas must assist with sadness as well, as not every child survives. Helping families grieve and giving comfort to the families is a big part of what these nurses must learn."

"I am definitely prejudiced after more than 30 years as a peds nurse," she adds, "but I do think we are special in what we do."