Hot Tips for Nurses Starting in the NICU!

Quick intro, for those who don't know me! My name is Tori Meskin, better known as @nurse.tori_ on insta. As a NICU nurse, blogger, and podcaster this is one of the most common questions I receive!

Let's dig into some of the basics when starting in the NICU!

What are the special educational requirements to start working a NICU nurse?

To become a neonatal intensive care nurse, you will first need to be a registered nurse (RN) with either an Associate’s Degree in Nursing or a Bachelor’s of Science in Nursing (BSN). While some hospitals will hire those with an ADN background, many hospitals are giving priority to RN’s with a BSN (versus an ADN) so I highly recommend pursuing a BSN if you know you want to work in the NICU. I am currently working on my MSN Leadership through Capella University and highly recommend their specialized, flexible undergrad programs as well if you are looking to advance your degree in Leadership & Administration, Education, Informatics, or Care Coordination.
 

Which certifications do I need to start working in NICU?

Typically, these are the standard certifications required to start in a NICU. (Side note: Many organizations will have you take them during your orientation or preceptorship periods and others will require them upon hire.) BLS, NRP, STABLE, and or PALS. NRP is most commonly required by hospitals, although Children’s Hospitals typically require PALS as well, incase you are required to float to other Pediatric units. Working in any intensive care setting has its challenges, but also can feel extremely rewarding when you are able to impact a life positively at its most critical point.
 

NRP = Neonatal Resuscitation Program. This certifies that you can safely give a baby life support whether it was just born and needs resuscitating at delivery or there is a code at the bedside. NRP MUST be renewed every two years to stay in compliance. (RQI with the American Heart Association are updating these requirements, you will stay up to date with your hospital organization).

PALS = Pediatric Advanced Life Support. PALS is an in-depth guide of how to provide life support to pediatric patients 30 days-18 years old. PALS also MUST be renewed every two years. (RQI with the American Heart Association are updating these requirements, you will stay up to date with your hospital organization).

STABLE = S.T.A.B.L.E. stands for the six assessment and care modules in the program: Sugar, Temperature, Airway, Blood pressure, Lab work, and Emotional support. A seventh module, Quality Improvement stresses the professional responsibility of improving and evaluating care provided to sick infants.

If you accidentally let your certification expire without renewing it on time, you will not be permitted to work until you’re certified again.

HOT TIP!!! To stay organized I suggest that you create a photo album or NOTES iphone page named “Nursing Compliance” or “Certifications / CEUs” in your phone with screenshots of each certification you have completed in order to best keep track of them!

Where can I work as a NICU nurse?

• Hospitals (Both Private and Public)

• Neonatal Intensive Care Units (Levels 1-4)

• Community Health Organizations (Consult or Board Member)

• Emergency Medical Evacuation & Transport Services

• Home Health Services (Less common)

What are the types of things I would be doing and seeing as a NICU nurse? Average day in the life?

The answer to this question really depends on what level NICU you are working! Here is a quick breakdown of the NICU levels.
 

Level I NICUs (Basic Newborn Care):

In these facilities, RNs help to maintain the stability of newborn infants at 35 to 37 weeks gestation who are physiologically stable. They help stabilize infants born at less than 35 weeks gestation and/or sick until they can be transferred to a healthcare facility that can provide an acceptable level of neonatal care.

 Level II NICUs (Advanced Neonatal Care):

RNs working at this level care for less critically ill newborns who may require breathing, feeding support, or special medication. Level II NICU units are found in smaller healthcare facilities called special care nurseries. (Respiratory support, IV antibiotics, feeding issues, jaundice, etc).

 Level III NICUs (Sub-specialty Newborn Care):

RNs working at these NICUs care for infants that have been born at less than 32 weeks' gestation and newborns suffering from severe afflictions at any gestational age. (Respiratory support, central line management, UAC / UVC / PICC lines, complex medical care, intubation, minor surgical repair, body cooling, prematurity, multiples, etc).

 Level IV NICUs (Regional NICU- Highest Level of Neonatal Care):

These facilities (Children's Hospitals, University Hospitals, Consult Centers) provide care for infants who are born as young as 22 to 24 weeks of gestational age. Level IV NICUs provide mechanical ventilation, high-frequency ventilation, SIMV, NIMV, CPAP, and a wide range of advanced surgeries, including "open-heart" surgeries needed to correct congenital heart defects. (Life support, complex surgical repair, pre / post op care, iNO, ECMO, consult specialties, congenital anomalies, etc.)

When I arrive at my level IV NICU I am met with my assignment, gather my report sheets and learn from the shift nurse before me which meds to give, labs to gather and tasks to perform. I do my safety checks, introduce myself to parents when applicable and then start hands-on care.
 

During an average 12 hour shift you will focus your attention on 1 to 4 patients (this largely depends on your STATE and hospital ratios) depending on staffing and their acuity. Your role varies from day to day but overall as the NICU nurse you perform assessments, monitor / record vital signs, draw labs, administer medications, admit & discharge, pre-op and post op surgical care, assist with procedures, assist with diagnostic imaging, monitor your patient for any sudden changes, prepare feedings, change out IV fluids, perform blood draws, educate family members, and ultimately be your tiny patient’s advocate! Not to mention charting, uhhhhh (my least favorite part, but one of the most important).

WHAT CAN I EXPECT WHEN I START MY NICU JOB?

Every NICU orientation is different. You may be reading this as a new grad NICU nurse or experienced nurse transitioning into the NICU setting. Here are some general things you may experience in your transition and orientation period!

1. Review New Hire Expectations

2. LOTS of paperwork!!

3. Introduction to NICU Standards of Care

4. Scheduling expectations (online or paper. Holidays/Weekends/Requirements etc)

5. Mandatory Class Sign-Ups

6. Pyxis and Medication Access information

7. Seek and Find on the Unit (Get to know the ins and outs of unit supplies, safety etc).

8. Orientation Pathway Competencies

9. Preceptor Education & Evaluations

10. Review Professional Expectations (Dress code, Fingernails, Attendance & Punctuality)

11. Meet your Management & Educators (Director, Mangers, CNS, Charge Nurses)

12. Skills Validations

SKILL VALIDATIONS MAY INCLUDE:

1. Blood Administration

2. Chest Tube Management

3. Medication Administration

4. Narcotic Continuous Infusion

5. NICU Central Vascular Access Devices (CVAD) Management

6. NICU Central Vascular Access Devices (CVAD) Blood Culture Draws

7. NICU Central Vascular Access Devices (CVAD) Blood Draw

8. NICU Line Change Procedures

9. Universal Protocol

10. Zoll Defibrillator

11. NICU Lactation

ROUTINE NICU TESTING TO CONSIDER IN YOUR ORIENTATION PERIOD

1. Eye Exams

2. Head Ultrasounds

3. Car Seat Challenge (some NICUs require, others do not per hospital policy)

4. Congenital Heart Screening

5. Bili Light Measurements

MEDICATION ADMINISTRATION EXPECTATIONS

This one of the most important parts of our job as nurses. Medication administration and something we should not take lightly. (Especially in our NICU patient population where every decimal / ml counts. First things first, don't freak out. This will become second nature to you the more you are in NICU practice.

It is nerving at first but the weight based medication administration gets easier with time. HINT: ALWAYS KNOW THE WEIGHT OF YOUR BABY! You will get to a point where you can literally eyeball an order and think to yourself "yep that's on point, OR NOPE!! Wayyy too much (Resident who is writing orders for the first time!)." You are the last line of defense, so when in doubt CLARIFY or ASK THE QUESTION.

Refer to your Safe Medication Administration Policies, but here are some general ideas.

NICU MEDICATION TIPS TO CONSIDER

1. Look up every medication!

2. You should know the following before administering

3. Take Medication bedside. With EMR and manual conduct review Medication Rights

3. Barcode scan (and or second nurse verification) administer safely once all checks have been thoroughly completed

4. Ensure proper documentation

GET TO KNOW YOUR TEAM!

This is KEY! And something we don't talk about nearly enough. NICU care takes a village and the faster you get to know your team, the easier it will be for you to provide tip top care to your patients!

1. Neonatologists

2. Fellow NICU Nurses

3. NP / PA Advance Practice Providers

4. RTs!!!! THESE ARE YOUR BEST FRIENDS, GET TO KNOW THEM WELL!

5. Nutritionists / Registered Dietitians

6. Developmental Specialists (OT/PT, SLP)

7. Social Workers

8. Secretaries

9. Lactation Specialists

10. Translation Services

The list goes on...but you get the idea! Get to know your resources and team members.

NICU RN ORIENTATION PATHWAY

1. Tour the Unit/Orient to patient rooms

2. Review the dress code policy

3. Seek and Find

4. Safety Checks (Oxygen, Suction, Code Sheets, Vital Sign parameters)

5. Code Sheets (critical care tables, how to print them, update them, DCW)

6. How to associate patients to the monitor

7. Give and receive report from ongoing / off going nurses

8. Physical assessment, head to toe

9. Care times (consider when you need to adjust them)

10. Documentation and time management

11. Blood draws (venipuncture and heel sticks etc)

NICU RN ORIENTATION GOALS

Here are a few things you can think about during your orientation periods!

NICU AMAZON BOOKS LIST

Here is a compiled list of NICU books and resources for you. These are books you might often find in your NICU. If you are looking to read up a little these are great to look into. Keep in mind...you will learn so much on the job. So don't go crazy here! But, they are all great resources for you, credible books we actually use, and can help you deep-dive into the neonatal population.

As with anything, it takes time to gain confidence and skill in practice. Don't be too hard on yourself. It took me several years to really feel comfortable working as a NICU nurse, and even after 8 years, these babies can throw me for a loop! I hope this blog was helpful for you!

Every unit and hospital offers different orientations and cultures in terms of NICU nurse care. Be fearless and humble. Take the good with the bad. If you make a mistake, own it and learn from it! We are human, and we have all been there! Love you guys! Let me know what you thought about this blog below! I love your feedback and always try to give you nurse life on the pulse.

If you are looking for a great listen, here is "Life of a NICU Nurse," where I breakdown my experiences as a NICU nurse over the past 8 years. It's a fun one full of the real real on being a NICU nurse!

Tori Meskin BSN RNC-NIC. Nurse. Blogger. Podcaster. Tori has been a clinician since 2012, works in acute care/inpatient NICU & Pediatric settings in southern California. She is a blogger, podcaster, NICU & Pediatric Critical Care RN, Sponsored Capella University MSN student, a Barco Uniforms Ambassador & Brave beginnings Ambassador. She has obtained her National NICU Nurse Certification (RNC-NIC) & has previously worked as a travel nurse, pursuing bedside experiences in several NICU settings. Follow her as she shares her NICU journey married life & juggles work, school, content creation, & brings you top notch Tips & Tricks along the way. Find her at www.tipsfromtori.com or info@tipsfromtori.com