Needed Change in the NICU

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I'm looking for feedback on the best and most constructive ways to implement a NICU-wide change in care. Basically, how not to be bitchy but still get things done.

The first NICU I was in was very focused on developmental and family-oriented care. They were also very good about listening to their nurses, had excellent pain control measures for the babies, and used a real "interdisciplinary team" approach. The past 2 NICU's I've been in all of these things were virtually non-existent. I would like to not change hospitals just because I'm unhappy, I would rather be a factor in a positive change for the unit. But the vast majority of the nurses are too chicken to take a stand and would rather complain about it all day. I can't say I don't complain either, but this has got to change or I'm gonna go crazy and/or half the staff is gonna leave b/c they're gonna go crazy:angryfire.

What do I do? A big problem is we haven't had a unit director in a year now, we've had one interim but she's just that: interim & she's not a NICU-experienced nurse. I would like the nursing staff to establish a meeting where the nurses can sit down with the neonatologists (most importantly the unit's medical director) and voice concerns that we would like addressed. I have mentioned this to our interim director, but she also was supposed to organize a meeting between me, her and a single neonatologist d/t a huge problem we had with one particular patient's parents and the care that the patient was getting and it's been 4 to 6 weeks since it was supposed to happen. I still don't know if this meeting will ever happen. So, how long do I wait before I take the next step if she still hasn't implemented a meeting for the nursing staff? 4 weeks, 12 weeks? And what if by then it still hasn't happened? Who do I go to next?

I've thought about filing an anonymous complaint about some of the stuff that happens in this NICU to JCAHO just because nothing ever gets addressed but I really don't want to do that unless it's a last-ditch effort. These babies are being affected, why has it got to be like pulling teeth to get anything done?

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Is there no one else in a supervisory position you could speak with? Assistant unit manager? Charge nurses even? In my experience change will never be implemented unless some of the old guard are into it.

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Specializes in Level II & III NICU, Mother-Baby Unit.

I agree with Fergus51 about change being very difficult when the members of the "old guard" are not in agreement with it. Not only do the neonatologists and managers need to be on board, but the nurses you work with in the trenches must be on board as well. Just one or two of those nurses not in agreement can sabotage the entire process if you let them.

Change is very slow, VERY slow when it comes to introducing developmental care to a unit which does not embrace it already. I've been in your situation and must tell you that the thing that worked best for me, a lowly staff nurse who came from another hospital (Read: "If you liked it so much where you used to work, why don't you just go back there?") was to first win over the likability factor. If people tend to like you they will often be more receptive to your ideas. Also, know your subject inside and out; this is another way to earn a little respect. Start slow with the simple things like making nests for your babies and covering their isolettes with blankets, doing some good positioning, and responding to and silencing alarms. Also, when new nurses come along you can help them to learn some developmental care tidbits. This entire process can take years, and I do mean years!

If you have several nurses who would like to see changes sooner, maybe you could develop a committee for implementing developmental care. You can gently and respectfully remind your neonatologists that you are nurses and they are doctors and as long as the way your care for your babies does not compromise the physicians medical plans then implementing some developmental care nursing activities should not be a problem. Research this area fully so you can speak with authority about how developmental care practices and family-centered care has been shown to decrease inpatient days, increase bonding, and increase parental patient satisfaction surveys. I can recommend a good book for you, Developmental care of Newborns & Infants: A Guide for Health Profesisonals Edited by Carole Kenner and Jacqueline M. McGrath, 2004, Elisevier-Mosby. ISBN# 0-323-02443-2

If nothing else, you can at least take good care of your tiny patients during your shift. People will watch you from afar and when they see your patients often sleep and eat better and generally do well on your shift, they just might begin to imitate you a little. Always be open and accepting of everyone and remember that they have been doing things their way for a very long time... they have bought into the way they care for their patients and honestly believe they are doing the best for their patients. You must respect this and never force anything on anyone because they will simply dig their heels in even more.

One last thought, are you able to contact the NICU clinical nurse specialist or educator at the previous NICUs where you enjoyed working under the philosophy of developmental care for their ideas and suggestions. I bet they would be very helpful to you. Who knows, your committee might even be able to get one of those experts to come and do an inservice for your NICU. If they get CEUs for it I bet they would attend. Just a thought...

Good luck in your endeavors. I applaud you for caring and hope things work out for you and your coworkers. Just remember that change occurs very, very slowly. I also believe that life often places us in situations where we can grow and help others to grow... possibly this is why you are working where you are and with the people you are... Make the most of it as you can.

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Ever consider doing a WeeCare inservice? I saw staff really embrace this after they were inserviced in one hospital.

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Specializes in NICU, PICU, educator.

Do you have a CNS or nurse educator? I'd start there.

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Ever consider doing a WeeCare inservice? I saw staff really embrace this after they were inserviced in one hospital.

They've had one in our unit already.

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Do you have a CNS or nurse educator? I'd start there.

We do and the CNS referred my issue over to the interim director. We have an educator but she is new and is focused on the new grad class even though I know she's responsible for educating all of the nurses.

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I agree with Fergus51 about change being very difficult when the members of the "old guard" are not in agreement with it. Not only do the neonatologists and managers need to be on board, but the nurses you work with in the trenches must be on board as well. Just one or two of those nurses not in agreement can sabotage the entire process if you let them.

Change is very slow, VERY slow when it comes to introducing developmental care to a unit which does not embrace it already. I've been in your situation and must tell you that the thing that worked best for me, a lowly staff nurse who came from another hospital (Read: "If you liked it so much where you used to work, why don't you just go back there?") was to first win over the likability factor. If people tend to like you they will often be more receptive to your ideas. Also, know your subject inside and out; this is another way to earn a little respect. Start slow with the simple things like making nests for your babies and covering their isolettes with blankets, doing some good positioning, and responding to and silencing alarms. Also, when new nurses come along you can help them to learn some developmental care tidbits. This entire process can take years, and I do mean years!

If you have several nurses who would like to see changes sooner, maybe you could develop a committee for implementing developmental care. You can gently and respectfully remind your neonatologists that you are nurses and they are doctors and as long as the way your care for your babies does not compromise the physicians medical plans then implementing some developmental care nursing activities should not be a problem. Research this area fully so you can speak with authority about how developmental care practices and family-centered care has been shown to decrease inpatient days, increase bonding, and increase parental patient satisfaction surveys. I can recommend a good book for you, Developmental care of Newborns & Infants: A Guide for Health Profesisonals Edited by Carole Kenner and Jacqueline M. McGrath, 2004, Elisevier-Mosby. ISBN# 0-323-02443-2

If nothing else, you can at least take good care of your tiny patients during your shift. People will watch you from afar and when they see your patients often sleep and eat better and generally do well on your shift, they just might begin to imitate you a little. Always be open and accepting of everyone and remember that they have been doing things their way for a very long time... they have bought into the way they care for their patients and honestly believe they are doing the best for their patients. You must respect this and never force anything on anyone because they will simply dig their heels in even more.

One last thought, are you able to contact the NICU clinical nurse specialist or educator at the previous NICUs where you enjoyed working under the philosophy of developmental care for their ideas and suggestions. I bet they would be very helpful to you. Who knows, your committee might even be able to get one of those experts to come and do an inservice for your NICU. If they get CEUs for it I bet they would attend. Just a thought...

Good luck in your endeavors. I applaud you for caring and hope things work out for you and your coworkers. Just remember that change occurs very, very slowly. I also believe that life often places us in situations where we can grow and help others to grow... possibly this is why you are working where you are and with the people you are... Make the most of it as you can.

I have to say the unit isn't terrible with developmental positioning. Older nurses have more trouble with the positioning than newer. But seeing everyone be so rough with the teeny ones is tough - they don't give time-outs and let the baby calm down. They go so fast and have abrupt movements. Midline positioning isn't maintained, there is no IVH protocol to protect their little heads. And pain, oh my gosh. Our developmental specialist has tried to tackle pain but we're getting nowhere - she's scheduled a meeting with our hospital pain team and the NNP's but she isn't sure any of the neo's will show up. That's where our problem lies - the neo's. They totally ignore pain - they think that maintaining the blood pressure or respiratory drive is more important than pain. When half the time, I believe, if pain medication had been ordered in the first place the blood pressure issue wouldn't have come up and the respiratory thing, well that's why we have ventilators. The kids typically have a rise in pressure & then a drop and they wind up on pressors (HELLO IVH). The NNP's are expected to do what the neo wants for everything - don't rock the boat. And nightshift is not allowed to think for themselves - just get them through the night and let them deal with it in rounds. Our pain score means NOTHING to them. They do not care. I can say more than 3 times in the past year, I have had either a fresh post-op or 2 or 3 days post-op with only Tylenol ordered either q 6 or q 8. You have to beg for pain meds. Rarely are nurses obliged with PRN Morphine or Fentanyl orders. Versed is given out more often - not touching pain! I wonder what these kids turn out like. How is their development later on since they suffered so much pain as a preemie. It kills me.

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Is there no one else in a supervisory position you could speak with? Assistant unit manager? Charge nurses even? In my experience change will never be implemented unless some of the old guard are into it.

I've talked with our clinical managers and all they do is listen and say they understand my frustration. Team leads (charges) do the same. I would really like to get our older nurses involved in this, I just don't know what to say. And we can't have a meeting unless a committee calls it and it's been okay'd by management. Maybe our clinical excellence team could help out.

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Specializes in NICU, PICU, educator.

It sounds like the CNS is pawning it off...that is part of her job to make sure that policy and procedures are in place. She should also be the one you guys go to so that she can advocate. Without these key people on board, you are going to be stuck. Lead by example...it goes a long way.

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