A day in the life of a NICU nurse

Acknowledgement to Queensland Health Strategic Communication Branch

In hospitals, the Neonatal Intensive Care Unit, or NICU, is a busy micro-world. The staff who run the NICU, a team of round-the-clock nurses and doctors, are highly trained to offer specialist care to the newborn babies and families in their ward.

We spent some time in the Royal Brisbane Women’s Hospital NICU ward with nurses Haley, Beth and Sarah, learning what life is like inside the NICU and what it takes to be a NICU nurse.

What is NICU?

A Neonatal Intensive Care Unit provides care for newborn babies that are very unwell. Often, these babies have been born prematurely, with some babies born as early as 23 weeks gestation. Full-term babies – babies who have been born around their expected due date – might also be placed in the NICU when they are born if they are very unwell.

Like an Intensive Care Unit for adults, the NICU is reserved for the sickest patients. “Sometimes people don’t realise it’s an Intensive Care Unit,” says Haley. “It’s not a normal ward for babies. They are receiving very high care.”

Some babies will require ventilation, which means a machine helps them to breathe through a tube down their throat, because their lungs aren’t fully developed. Most will also have different tubes and monitors attached to their bodies to help them feed, receive medicine and monitor their health.

As the babies gradually grow and get healthier, they can be moved to the Special Care Nursery of the hospital to receive ongoing care. Eventually they are released to go home with their families. Despite the best efforts of the team, some babies don’t respond to the medical care they receive in NICU, and the decision may be made to withdraw their care and provide palliative care instead.

Life inside the NICU

The NICU at RBWH is separated into a series of rooms, each containing six cribs. There can be up to 28 babies in the NICU, many who will stay for over 100 days until they are well and strong enough to move to Special Care and eventually go home.

The NICU is a busy place. Each NICU room is allocated a set of nursing staff, who look after one or two babies each throughout their shift. The nurses work with doctors and other allied health professionals to provide 24-hour care for the babies and their families. At any one time, there can be three nurses in a NICU room, a Neonatal Education Support Team (NEST) staff member who helps them with their work, doctors, other health professionals, and parents and families visiting their babies.

The NICU is not the type of environment new parents would typically dream of for their baby’s first home. Large cribs dwarf the babies they contain, who lie inside tiny and fragile, fighting for life. Bright fluoro lights line the roof so staff can see clearly when doing detailed work on their small patients. The air smells of the hand sanitiser that is constantly used to rid staff and visitors of infectious germs, and the monitors and machines beside each crib beep and flash to give second-by-second updates on the babies’ health.

Where possible, small details are put in place to make the NICU more homely. Rooms of the RBWH NICU are decorated with an ‘under the sea’ theme, and brightly painted dolphins, turtles, seahorses and fish splash, dive and swim along the walls. While the babies don’t wear typical baby clothes, in their cribs are pillows and blankets covered in colourful children’s fabric.

The NICU isn’t filled with the cries and coos of babies you would expect from most nurseries. Some of the ventilated babies aren’t able to make sounds around their breathing tubes, and because they have been born prematurely or are unwell, most NICU babies also spend a lot of time asleep. “They’re using a lot of energy,” Beth explains. “They’re learning to move in a different environment, learning to breathe and to eat – it’s exhausting for them, so they sleep a lot of the time.”

But, Beth says, the babies still behave like babies. “Like any baby, they do let you know when they need a nappy change!” she says.

Working to routine

The NICU revolves around routines. Nurse shifts can be either 8 or 12 hours, and a detailed chart updates them on where each baby is at when they start their shift.

Each baby is fed every couple of hours, and a large fridge sits outside the room with containers of mums’ breastmilk labelled for each baby, as well as donated milk supplies from the Milk Bank. Other regular forms of care include changing the babies’ nappies and turning their heads to rest on alternate sides.

Sarah says that people often think that NICU nurses spend their days holding babies, but in reality, they don’t touch the babies that often. “We turn the babies over every six hours. We try not to touch them too much, because it makes them uncomfortable,” she explains.

Cuddles are reserved for parents, though it can take a long time for some babies to be well enough to be held out of their crib. One mother is visiting her 10-week-old baby, born at 24 weeks, who she has only been able to hold twice. Instead of cuddles, she places her finger in his little hand and holds his head, soothing actions NICU teams called ‘hand cuddles’ that are beneficial for both child and parent.

There are some routines that vary for each patient. The babies may be prescribed medications that need to be given regularly. Some of the babies require frequent tests to monitor things like the levels of carbon dioxide in their breath, which gives an indication of their health. The nurses might also use charts to record the outputs of the monitors that track the babies’ vital signs and the work of their ventilators.

Some tasks only happen as needed. When one of the babies needs an x-ray, a medical imaging team come to the ward with a portable x-ray machine that they can use to complete her scan without moving her from her crib. One baby requires the tape securing her breathing tube to be replaced, as saliva and fluids have made it come unstuck. Two of the nurses are required to do this delicate task, as the tube must stay in place so that the baby continues to breath while the securing tape is changed.

Whole-of-family care

While the babies are their first priority, the nurses also provide support and care to their patients’ families. Having their baby stay in NICU is usually unexpected for parents and not part of the journey they had envisioned when planning a pregnancy and birth.

“I do the best I can to support families,” says Beth. “This work makes you appreciate how short life is, and how the impact of an experience like this can carry on over an entire lifetime. Their relationships can suffer, and it’s good for them to have someone to be able to listen to how they feel and say, ‘That’s normal’.”

The nurses provide emotional support for the parents and families, help them understand their baby’s condition and medical care, and refer them to support services like counsellors and social workers when needed.

Because NICU babies might stay in hospital for many months, visiting them in hospital can be difficult. Some parents need to go back to work after they’ve run out of available leave, and many don’t live close, meaning they might not be able to visit their babies as often as they want.

When a baby’s family isn’t able to visit often; because they live far away, have to work or have other children to care for, the nurses keep them up-to-date with regular phone calls, so they still feel connected to their child.

“You don’t just look after the babies, you’re looking after the families here and at home, too,” says Haley.

“They’re all amazing,” says one mum, who has driven to Brisbane from Warwick to visit her baby. “They keep me from going crazy and make sure I always know what’s going on and understand everything. They provide a listening ear and a shoulder to cry on when I need it.”

What is it like to be a NICU nurse?

When Sarah started her general nursing training, she didn’t know that NICU existed.

“I did six months in the Special Care Nursery during my training, and I discovered NICU during that time,” she says. “From the outside, you don’t really know NICU exists.”

She’s now worked in NICU for five years and says she enjoys the family care aspect of her job. “I love looking after the families and meeting people through my work.”

Haley has been working in NICU for 10 years, and is now part of the NEST program, which means she supports new NICU nurses as they do their work, and is on the ward to help out if anyone has questions or needs an extra set of hands.

“The best bits for me are watching the parents when they get to experience those normal milestones for the first time, like getting to bath their baby or getting to hold them,” says Haley. “Of course, seeing them spend so much time here and then finally get to go home is amazing.”

Beth echoes this sentiment. “That rush of emotions for parents when we’re getting them out the door is overwhelming,” she says.

This is Beth’s tenth year in NICU, and her fortieth in nursing, having spent her earlier career in paediatrics. “In nursing, you know when you’re in the right place,” she says, “and I’m in the right place. I find babies less difficult than adults – babies are what they are, they don’t have any other agendas. I’m getting to the end of my career and I can honestly say I’ve never wanted to do anything else.”

Like all nursing roles, there are also difficult parts of the job for the NICU nurses.

“Not all of our babies make it,” says Sarah. “Everyone gets affected by that in different ways.”

“The hardest part is end of life,” agrees Haley. “Having to watch the parents go through that is very difficult.”

Leaving work at work can be difficult. Time spent in the NICU can be tense, especially if a baby isn’t doing well.

“The babies are so little,” says Beth. “When they go downhill, they can go downhill really fast.”

“The hardest part is self-care,” she says. “There’s constant grief and loss. Not just if a baby passes, but of the whole experience. Mums and dads lose the experience they thought they were going to have. You have empathy and sympathy, but you also have to draw the line for yourself.

“On my days off, I’m an outside person. I get out in nature, go to the ocean, and remind myself that I’m a small cog in the machine; I don’t have to be responsible for the whole outcome.”

Even though there are challenging days, the nurses relish the opportunity to work with their NICU babies and families.

“The babies teach us so much,” says Beth. “Their fortitude, their will to keep going. They are my proof that here, miracles do happen.”