Brand New NICU Nurse Needs Advice

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Specializes in NICU.

Hi everyone,

So I'm a new grad and new NICU nurse, and have just finished my orientation, although I'm still working closely with my preceptor in this transition period. This week I worked 3 in a row (my last of which was technically on my own,) and had a baby all 3 days who was born with several conditions that will inevitably be terminal. The family had no idea before birth, and they are understandably devastated and distraught. The focus this week was on getting a few procedures done that will allow for this baby to transition home on palliative care, and the family is definitely grieving. All that to say that the family is very involved, and has been at the bedside almost continuously.

Here is where my dilemma lies. I adore my preceptor, but she and I do not see eye to eye on family interactions. She views this family as very needy, and although she is perfectly nice and pleasant to them, she doesn't exactly ooze compassion. She keeps her interactions with them to the bare minimum, and doesn't ever go out of her way to interact with them if not providing hands on care to the baby. I on the other hand, specifically chose NICU because I love interacting with families and helping to care for not just the patient, but their loved ones as well. I feel for this family, and I've tried to be the best nurse I can to them as well as to their baby. I enjoy checking in on them occasionally throughout the shift when I'm popping into baby's room, and lending a simple listening ear when they clearly need to voice their feelings/emotions. I have been very careful not to provide any type of false future orientated hope, but this family is going through a major upheaval, and they need support. Based on how much they vocalize their appreciation for small acts of kindness (restocking tissues, encouraging/helping them to interact with their baby, listening as they process, etc...) and considering the fact that I am super conscious of maintaining professional boundaries, I don't see anything wrong with what I'm doing. I do feel like I'm being judged though or viewed under the condescending guise of "oh, she's so young and new and doesn't understand yet," because I like interacting with and supporting my families who some may view as needy.

Am I totally off the mark here? Should I try to be more plainly matter of fact and less outwardly compassionate? I would really appreciate anyone's input, because although I'm well aware of the risks of compassion fatigue and boundary crossing, I genuinely don't believe I have anything to be concerned about in this circumstance, and would like to know if this is just a simple case of personal preference differences, or maybe something more. Thanks in advance!

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Specializes in Pediatric Hematology/Oncology.

I'm coming from a way different area (peds hemonc) but we have sudden unexpected deteriorations that end up leading down the path to palliative care only with the expectation to prepare for the patient's death. I'm brand new as well and, yes, sometimes I see some nurses who may seem less willing to, I guess, "give of self" as it were for patients and families who definitely have more needs. In talking with how many of the veteran nurses cope with these situations of impending death, some have said they initially started out more giving and more involved but the repeated grief that has come with these cases (and, for us, we usually get to know the patients and families very well prior to the decision to go palliative) burns you out like nothing else. You step back. You didn't want to. You never expected that you would. But you must.

We recently had a spell where we were having many deaths on the floor in rapid succession. I saw very quickly how getting your heart broken over and over and being immersed in people's grief can lead one to start putting their guard up and letting go of the idea of being as emotionally supportive as possible. It wrecks you. I have even gotten to the point where I'll see the patient, see the prognosis and make careful, calculated decisions as to how close I will allow myself to be with the patient and the family, especially knowing that their odds are terrible. Sometimes, when I choose to recuse myself from becoming more involved, I suppose to the outside observer that it may not seem so compassionate or I just look like I'm getting in and getting out. I never thought it would happen so quickly but now I understand the need to protect myself and approach everything as clinically as I can.

I think, ultimately, we all end up switching off on how involved a particular nurse and aide will be with patients depending on the situation and how some people click with the families. I frequently get the "needy" families who, at the outset are complete PITAs for one reason or another, but when **** hits the fan and really can support them and be there for them, they remember it and are truly touched I can look past their fears and emotionally-charged irrational behavior and that's when I feel I actually make a difference. You're making all the difference for this family. But, you won't (and really, you shouldn't even hope to) do it for all families. I don't think it's so much a youth/experience thing. I think it's more that you work well with this family and your preceptor is stepping back to let you be their "chosen one" as it were. You will be surprised when you see your preceptor caring for a different family the way you are for this one (and you might not be able to get on with that family as you were with this one).

I hope my ramblings make sense. NICU is hard, it's so incredibly hard, especially when going home on palliative care is the only outcome (though, the best one, and thank god the family is understanding of this). It's taxing on the emotional senses as much as it is intellectually stimulating. You will strike your balance as long as your expectations are managed.

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Specializes in NICU.

Did your preceptor specifically say you were too interactive with the family? A few questions come to my mind...

Are your interactions turning into long conversations with the family that leave you unable to maintain time management with other things? This is sometimes unavoidable, of course, but it is very easy to get behind from chatting with families.

Does your preceptor think you just need to tone it back just a little, rather than pull yourself way back?

Sometimes it feels correct to just quietly do what you have to do and then excuse yourself so you aren't intruding. Maybe she perceives that's what the family wants.

Is your preceptor uncomfortable interacting with dying pts and families and shies away?

And finally, her opinion of the right thing to do may not necessarily be correct.

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Specializes in NICU.

Don't misinterpret her actions as being right and yours as being wrong. As previous posters have stated that her actions may be a coping mechanism for compassion fatigue or she is really uncomfortable with this type of patient. I have a few coworkers who have the ability to deal with these kinds of assignments in remarkable ways while not getting emotionally involved. We also have a NICU chaplain whose job it is to be involved as a support system for the families while they are in the NICU.

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Specializes in NICU.

I agree with what everyone has said here. I was a NICU nurse for close to 18 years. You don't want to lose compassion and empathy but you start guarding your own heart and it can come off as cold if that nurse never had any real training in grief/the grieving process. However, calling the family needy sounds like maybe your preceptor is a little busy with the other babies, training and just making sure you get everything you need in order to learn. She's right, they do need. They're scared. Anyone scared does need someone to guide them through it.

You are developing your own style, she has hers and it sounds like for this family, you are both complimentary to their needs. You have the time it takes to be there for the family and she has the skill needed to care for the baby. Don't take it personally if your style is not her style. She may well be shaking her head at your style, but that doesn't mean that you're wrong and she's right. You both are at different places in your career and have different perceptions.

Good luck! You're going to love NICU.

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Specializes in NICU.
I'm coming from a way different area (peds hemonc) but we have sudden unexpected deteriorations that end up leading down the path to palliative care only with the expectation to prepare for the patient's death. I'm brand new as well and, yes, sometimes I see some nurses who may seem less willing to, I guess, "give of self" as it were for patients and families who definitely have more needs. In talking with how many of the veteran nurses cope with these situations of impending death, some have said they initially started out more giving and more involved but the repeated grief that has come with these cases (and, for us, we usually get to know the patients and families very well prior to the decision to go palliative) burns you out like nothing else. You step back. You didn't want to. You never expected that you would. But you must.

We recently had a spell where we were having many deaths on the floor in rapid succession. I saw very quickly how getting your heart broken over and over and being immersed in people's grief can lead one to start putting their guard up and letting go of the idea of being as emotionally supportive as possible. It wrecks you. I have even gotten to the point where I'll see the patient, see the prognosis and make careful, calculated decisions as to how close I will allow myself to be with the patient and the family, especially knowing that their odds are terrible. Sometimes, when I choose to recuse myself from becoming more involved, I suppose to the outside observer that it may not seem so compassionate or I just look like I'm getting in and getting out. I never thought it would happen so quickly but now I understand the need to protect myself and approach everything as clinically as I can.

I think, ultimately, we all end up switching off on how involved a particular nurse and aide will be with patients depending on the situation and how some people click with the families. I frequently get the "needy" families who, at the outset are complete PITAs for one reason or another, but when **** hits the fan and really can support them and be there for them, they remember it and are truly touched I can look past their fears and emotionally-charged irrational behavior and that's when I feel I actually make a difference. You're making all the difference for this family. But, you won't (and really, you shouldn't even hope to) do it for all families. I don't think it's so much a youth/experience thing. I think it's more that you work well with this family and your preceptor is stepping back to let you be their "chosen one" as it were. You will be surprised when you see your preceptor caring for a different family the way you are for this one (and you might not be able to get on with that family as you were with this one).

I hope my ramblings make sense. NICU is hard, it's so incredibly hard, especially when going home on palliative care is the only outcome (though, the best one, and thank god the family is understanding of this). It's taxing on the emotional senses as much as it is intellectually stimulating. You will strike your balance as long as your expectations are managed.

Thank you for this! I 100% agree with what you said, and I certainly don't have the expectation of being able to provide this type of support for every one of my families. I had many different patients during orientation and though I always try to be the best I can be for all my patients/parents, this is one of the very few cases where I have felt like I needed to give a little more. I don't even feel like I've really invested myself in a personal connection sense so much as just making myself present and available to them a little more than my average family. Although naturally my heart hurts for the tragedy of this situation for them, I don't worry about my ability to cope with it after they've left, because I've tried hard to maintain a boundary on my personal emotional attachment. I'm sure as my career progresses there will be more families like this one who I feel the need to "be there" for more, as well as many families who I will simply do a great job for, but not necessarily extend myself to per se. Thanks again, and best of luck to you as well!

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Specializes in NICU.
Did your preceptor specifically say you were too interactive with the family? A few questions come to my mind...

Are your interactions turning into long conversations with the family that leave you unable to maintain time management with other things? This is sometimes unavoidable, of course, but it is very easy to get behind from chatting with families.

Does your preceptor think you just need to tone it back just a little, rather than pull yourself way back?

Sometimes it feels correct to just quietly do what you have to do and then excuse yourself so you aren't intruding. Maybe she perceives that's what the family wants.

Is your preceptor uncomfortable interacting with dying pts and families and shies away?

And finally, her opinion of the right thing to do may not necessarily be correct.

Hi there, thanks for your reply! My preceptor has never said anything to me about my involvement with this family, or insinuated in any way that I'm overly present or should tone it back. This is all simply about my awareness of the manner in which my preceptor interacts with this family and how she responds to my questions about my interactions with the family. Only once did I get sort of sucked into the room when both parents and both sets of grandparents were present, and in that case I had to just tell them that I had some other things I needed to get going on, but I would be happy to check back in later on after rounds and see if they still had questions, at which point I could call someone from the team. Based on all of the replies here, I'm feeling more confident in the idea that this is probably a personality difference between myself and my preceptor, and that there will likely be times like this where I am more involved, and she will at times have her own families for whom she is more involved.

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Specializes in NICU.
Don't misinterpret her actions as being right and yours as being wrong. As previous posters have stated that her actions may be a coping mechanism for compassion fatigue or she is really uncomfortable with this type of patient. I have a few coworkers who have the ability to deal with these kinds of assignments in remarkable ways while not getting emotionally involved. We also have a NICU chaplain whose job it is to be involved as a support system for the families while they are in the NICU.

Thanks Guy in Babyland! I agree, and thanks to all of the replies I'm feeling more assured that this is just a difference between my preceptor and myself, and not necessarily a right vs. wrong. I did end up calling the chaplain yesterday because although I am happy to be there to listen to the family process this new normal, I didn't feel it was my place to help walk them through some of the very personal quality of life decisions they still need to make. Thanks again!

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Specializes in NICU.
I agree with what everyone has said here. I was a NICU nurse for close to 18 years. You don't want to lose compassion and empathy but you start guarding your own heart and it can come off as cold if that nurse never had any real training in grief/the grieving process. However, calling the family needy sounds like maybe your preceptor is a little busy with the other babies, training and just making sure you get everything you need in order to learn. She's right, they do need. They're scared. Anyone scared does need someone to guide them through it.

You are developing your own style, she has hers and it sounds like for this family, you are both complimentary to their needs. You have the time it takes to be there for the family and she has the skill needed to care for the baby. Don't take it personally if your style is not her style. She may well be shaking her head at your style, but that doesn't mean that you're wrong and she's right. You both are at different places in your career and have different perceptions.

Good luck! You're going to love NICU.

Thank you so much! I completely understand that one cannot be emotionally involved with every family, because we would inevitably burn out. I do feel though that there is a difference between bonding with the family and becoming emotionally attached, versus simply providing more time/presence to them during the shift. I don't feel as though I really bonded with the family or am now more attached to them than I have been to my other families, but I do feel like I've given them more emotional support than the baseline norm, and I'm OK with that. In this case, there was really nothing I could do in terms of baby care that was going to make anything better, but I did feel like I could make a difference in the way that I engaged with this very scared and hurting family. I definitely agree that my preceptor may just not have had the mental/emotional/time resources this week to devote to what this family needed, and I on the other hand felt like I did. I'll definitely keep your words with me when I need to remember that even if she or other nurses don't always agree with my style, it's alright because it's my style not theirs :)

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Specializes in Pediatric Hematology/Oncology.
Thanks Guy in Babyland! I agree, and thanks to all of the replies I'm feeling more assured that this is just a difference between my preceptor and myself, and not necessarily a right vs. wrong. I did end up calling the chaplain yesterday because although I am happy to be there to listen to the family process this new normal, I didn't feel it was my place to help walk them through some of the very personal quality of life decisions they still need to make. Thanks again!

Yes, blessings to all chaplains! I think they have the hardest job because theirs is to confront the worst of emotional traumas and, for as much as my heart my hurt for another family, I can't even imagine how they are able to go through that day in and day out. The doctors, too. They're the ones responsible for the bad news. I overheard an interpreter the other day ask the doc who was talking to the family of a new diagnosis for a baby (so many babies and toddlers with cancer....:() how they were able to deal with giving that information to the family on a regular basis. The doc basically just said that keeping your heart guarded is about the best way to do it.

It's hard because I am still learning how to do that without becoming completely stony. But sometimes, after going through death after death, you start getting scared to even be a little bit available because of how it can get transmuted by the family into something more of an emotional connection than you intended it to become. I'll learn along the way, I guess. But, it sounds like you definitely have a fantastic grasp of what is going on. I think, as long as your preceptor hasn't made any comments to the contrary, it's just her personal difference with dealing with the family. Sometimes it's a time management thing and sometimes it's self-preservation.

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