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Nervous to Return to NICU

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by adventure_rn adventure_rn, BSN (Member)

adventure_rn is a BSN and specializes in NICU, PICU.

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I'm a former NICU nurse debating a return to the intensive care nursery, and I'm wondering if other NICU defectors (or anyone else) can shine some clarity on my situation.

I worked in the NICU for several years, and absolutely loved it; in fact, I frequently posted on the forum about NICU being my dream job. A while back, I transitioned from the NICU into a PICU setting for the sake of professional development (long story). While I hoped that I might enjoy the unit, I was mentally prepared not to like it as much as NICU. Lo and behold, it is not my cup of tea; I've been feeling a ton of burnout (which I rarely experienced in several years of NICU), and I'm planning my transition back to NICU.

That said, I'm experiencing some anxiety about the transition back, mainly related to the relative acuity and autonomy I've experienced in the PICU. In NICU, I was fairly accustomed to the providers running the ship, and I was used to having a mix of feeder-growers in with my handful of sicker but relatively-stable intubated patients. In contrast, my PICU experience has been crazy high acuity with frequent codes/resuscitations, dozens of drips, and tons of ECMO. The nurses have a relatively high amount of autonomy; we have tons of meds ordered PRN that would never be PRNs in the NICU, and we titrate many of our own drips (sedation, paralytics, pressors, etc.) I could ask for just about anything (within reason), and the providers would give it to me. This is in contrast to NICU, where I had to fight tooth and nail to get a fentanyl order for a 12-hour-old kid with a fresh forceps-related skull fracture.

Truthfully, I don't love the unpredictability of my PICU shifts (i.e. that the most 'stable' kid on the unit, often in a busy pair, can code onto ECMO by the end of the night). However, after experiencing this high-acuity, high-autonomy nursing role, I worry that back in the NICU I might feel a little bored, especially with the three-patient feeder-grower type assignments. Part of my reservation stems from the fact that I've known many nurses who started in Level II settings before moving to Level III/IV settings; several of those nurses expressed to me that they didn't feel bored in the Level II role until they experienced the higher acuity of the Level III/IV role.

Has anybody else made a similar move? Am I making a big deal out of nothing? Support, encouragement, and/or blunt reality checks graciously welcomed.

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babyNP. has 10 years experience and specializes in NICU.

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I know you've said that you're not interested in the NNP role, but it sounds like it would be a good fit for you based on what you've written here, appreciating the autonomy. What about the role doesn't feel right to you?

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adventure_rn is a BSN and specializes in NICU, PICU.

1 Article; 1,044 Posts; 16,548 Profile Views

5 hours ago, babyNP. said:

I know you've said that you're not interested in the NNP role, but it sounds like it would be a good fit for you based on what you've written here, appreciating the autonomy. What about the role doesn't feel right to you?

Thank you for asking babyNP, that's a very thoughtful question. There are a handful of things that have made me feel hesitant about the NP role, especially in the neonatal specialty.

My main concern as an NNP is that I don't know if I'd love managing crises, like running codes or managing surprise bad deliveries (like the term kiddo who comes out shell-shocked and blue). One of the things I enjoyed about NICU was the steady flow and relative predictability of the workload. I liked to be able to make a game plan for my shift. It seems as though NNPs may be able to have a general sense for the shift (i.e. assessments, then rounds, then notes, etc.), but they're also frequently being pulled away for deliveries and/or responding to issues on the unit (i.e. calls from the nurses about labs/assessments/etc.)

There are certain NICU nursing tasks I really enjoyed that I worry I might miss out on in an NNP role. For instance, I enjoyed the "nurturing contact" infant care like diapers, bottle feeds, hand hugs, and snuggling in my downtime. I know you get a bit of that in the NNP role, but I'd imagine it's less so than the nursing role. The NNPs I work with seem to love it, but they only do it for a few minutes at a time (usually right after an assessment). Similarly, I really enjoy the intensive teaching opportunities that I have with families. I realize that teaching is a huge part of the NNP role as well (especially for the higher-level concepts like diagnoses, prognoses, and test results), but given their time constraints I feel like it's a smaller part of the job.

Big picture, I have some apprehension about how little flexibility NNPs have in their practice settings compared to other APRNs. As a PNP, if your employer is treating you like garbage, you can go down the street and find another specialty or clinic to work for (or even set up your own practice, should you feel so inclined). It seems that a lot of regions only have one neonatology practice covering all of the local hospitals; if they treat their NNPs badly, you have to move locations and uproot your life to find a new job. In addition, I don't know if I'll want to be working nights, weekends, and holidays for my entire career, which is part of the NNP territory.

Honestly, if I go back to NICU and find that I don't have the same love for it that I used to, I may pursue an acute care PNP degree, ideally working in a specialty practice that has inpatient rounding as well as outpatient clinic opportunities. I figure that would allow me to assume as more autonomous role in patient management without having to manage codes and crises like an NNP or PICU PNP.

I know that's a ton of info, but I'd love to hear your thoughts! I should also add that I have the utmost respect for NNPs. The role is so vital to the NICU; as as former bedside RNs I feel that you guys bring something really important to the provider role that MDs sometimes miss.

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babyNP. has 10 years experience and specializes in NICU.

1,733 Posts; 27,079 Profile Views

I think you've been very thoughtful about your career so far- I've seen a few of your other posts and I think it was great that you tried out PICU just to see what else is out there. Obviously I don't know you personally, but I'll reply to your posts for how I perceive your thoughts. This post's background comes from my experience as a RN & NNP in a couple of Level II, III, & IV units in 6 different cities in 4 regions (northwest, northeast, mid-atlantic, & southwest).

- Managing "crises" like codes, bad deliveries, etc etc aren't as common as you might think. I've worked in neonatology for over 10 years (nearly 5 as a NNP) and I've only directed chest compressions 3-4 times and only a few months ago put in an emergent UVC line for the first time to give epi. It does depend on the type of center you are at (sounds like you are at a Level IV), but the vast majority of NICUs are Level IIIs or IIs where this is a rare occurrence. 

- Being called away for various things like deliveries or calls from nurses also varies on the type of unit you are on. Even when I worked at my Level IV 150+ bed unit the "busy" days were less common than the "non-busy" days. I almost always had a couple hours to chill out and read outside or walk around the hospital to get my "steps" in. Now I have even more time than usual, although there are definitely shifts when I work the entire time trying to keep up with everything

- Definitely you will miss out on that one-on-one intensive contact with the babies. You'll get to spend a few minutes with more babies, but not as much as time as the bedside nurse, obviously. I love babies and I did have a lot of snuggle time with them as a RN. I thought I would miss it terribly as a NNP, but I'm not finding that as much as I thought I would. I still get to feed babies on occasion for fun, but I don't find that it draws me as much as it used to. I don't know why this is, but I had about 6 years as a beside RN, so maybe that was enough for me.

- I also loved teaching parents as a RN (although some were more challenging than others) and you're right, we also do teaching as NNPs. This part of the role is really what you make it. I know some of my colleagues who don't spend much time with the parents, but I make it a point to talk with all the parents and sit down with them to answer their questions. I actually find this more enjoyable as a NNP vs a RN because the parents tend to give me a lot of respect and "believe" me when I tell them things. Of course, this is ridiculous because the RN can usually explain things just as well and with a good amount of knowledge, but parents are fickle in that way sometimes. When I worked in the Level IV, I also had the same patients for months at at time. I had 6-8 "primary" babies rather than just 1 as a RN and I got to develop good relationships with parents.

- It's true that in some regions, there's only 1-2 employers. This is particularly true for southern regions, although there are also some mid-west monopolies. But this isn't always the case. There were at least a dozen employers for NICUs when I lived in the mid-atlantic state within 60 miles. It is true that you want to find a good group fit as it can vary widely. I have found in my own experience (not true of everyone, but what I have personally experienced and also heard from my colleagues) that private physician owned neonatology practices and big corporations (shall remain unnamed...) do not treat their NNPs as well as big hospital systems. I have heard so many terrible stories about working conditions & terrible pay. I don't know where you live, but it sounds like there is a monopoly in your region. If you are dead set on living in that city, then yes your choice is obviously limited and at the mercy of that employer. I moved around quite a bit in my career and it has helped strengthen me as a provider. I love my current employer and I'm lucky that it's in a region in which I also like

- Your nervousness around crisis situations is a common fear amongst NICU RNs that I've found. I myself had to bite the bullet when I wasn't sure if I was "ready" to become a NNP. I had never gone to a delivery before and didn't know what "other" people would think. I actually became a NRP instructor specifically to help allay my fears surrounding this and I now know that having delivery room skills is nowhere near as important as having the patho knowledge base I got from my years in a non-delivery Level IV NICU. Because at the end of the day...a code is a code. There are only a limited number of drugs you can use and a relatively simple algorithm to follow. If you're in a true high-complex case, you're going to be in a tertiary center where there are always 239082035 people helping out in the code. I also had a complex around not being able to "perform" for procedures. But this was also an unfounded fear. I've only put in about a dozen IVs in my career (as a RN we had an IV team that did most of the IV skills). I don't do PICC lines but all the places in which I've worked have a team of nurses who do them. It took me a year or two to get comfortable with intubations, but I have the skill now and even when I don't get the tube in, the neonatologist is there to back me up and I just bag the baby until that happens.

- Nights, weekends, and holidays are definitely a non-starter for some folks. Sometimes I struggle with the holidays part, but the pros out weigh the negatives for me. Keep in mind that you will get to sleep on most units at least some of the time on the night shift. While you work a "40 hour work week" it's really less, if you're sleeping for part of that time. I have some nights where I don't get a call all night, even in the Level III unit. The holidays obligation will vary with each group- but keep in mind that if you do any in-patient rounding as a PNP you'll probably have to do some holidays too since patients are in the hospital 24/7

***

Hope some of this perspective helps. Like I said earlier, you seem to be very introspective so I know you'll dig deep to figure out what you would like to do in your career. If it's a PhD and teaching, great! PNP in primary care? Awesome! Keep digging, keep researching. It sounds like you will excel to whatever you commit yourself.

Edited by babyNP.

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adventure_rn is a BSN and specializes in NICU, PICU.

1 Article; 1,044 Posts; 16,548 Profile Views

4 hours ago, babyNP. said:

I think you've been very thoughtful about your career so far- I've seen a few of your other posts and I think it was great that you tried out PICU just to see what else is out there. Obviously I don't know you personally, but I'll reply to your posts for how I perceive your thoughts. This post's background comes from my experience as a RN & NNP in a couple of Level II, III, & IV units in 6 different cities in 4 regions (northwest, northeast, mid-atlantic, & southwest).

- Managing "crises" like codes, bad deliveries, etc etc aren't as common as you might think. I've worked in neonatology for over 10 years (nearly 5 as a NNP) and I've only directed chest compressions 3-4 times and only a few months ago put in an emergent UVC line for the first time to give epi. It does depend on the type of center you are at (sounds like you are at a Level IV), but the vast majority of NICUs are Level IIIs or IIs where this is a rare occurrence. 

- Being called away for various things like deliveries or calls from nurses also varies on the type of unit you are on. Even when I worked at my Level IV 150+ bed unit the "busy" days were less common than the "non-busy" days. I almost always had a couple hours to chill out and read outside or walk around the hospital to get my "steps" in. Now I have even more time than usual, although there are definitely shifts when I work the entire time trying to keep up with everything

- Definitely you will miss out on that one-on-one intensive contact with the babies. You'll get to spend a few minutes with more babies, but not as much as time as the bedside nurse, obviously. I love babies and I did have a lot of snuggle time with them as a RN. I thought I would miss it terribly as a NNP, but I'm not finding that as much as I thought I would. I still get to feed babies on occasion for fun, but I don't find that it draws me as much as it used to. I don't know why this is, but I had about 6 years as a beside RN, so maybe that was enough for me.

- I also loved teaching parents as a RN (although some were more challenging than others) and you're right, we also do teaching as NNPs. This part of the role is really what you make it. I know some of my colleagues who don't spend much time with the parents, but I make it a point to talk with all the parents and sit down with them to answer their questions. I actually find this more enjoyable as a NNP vs a RN because the parents tend to give me a lot of respect and "believe" me when I tell them things. Of course, this is ridiculous because the RN can usually explain things just as well and with a good amount of knowledge, but parents are fickle in that way sometimes. When I worked in the Level IV, I also had the same patients for months at at time. I had 6-8 "primary" babies rather than just 1 as a RN and I got to develop good relationships with parents.

- It's true that in some regions, there's only 1-2 employers. This is particularly true for southern regions, although there are also some mid-west monopolies. But this isn't always the case. There were at least a dozen employers for NICUs when I lived in the mid-atlantic state within 60 miles. It is true that you want to find a good group fit as it can vary widely. I have found in my own experience (not true of everyone, but what I have personally experienced and also heard from my colleagues) that private physician owned neonatology practices and big corporations (shall remain unnamed...) do not treat their NNPs as well as big hospital systems. I have heard so many terrible stories about working conditions & terrible pay. I don't know where you live, but it sounds like there is a monopoly in your region. If you are dead set on living in that city, then yes your choice is obviously limited and at the mercy of that employer. I moved around quite a bit in my career and it has helped strengthen me as a provider. I love my current employer and I'm lucky that it's in a region in which I also like

- Your nervousness around crisis situations is a common fear amongst NICU RNs that I've found. I myself had to bite the bullet when I wasn't sure if I was "ready" to become a NNP. I had never gone to a delivery before and didn't know what "other" people would think. I actually became a NRP instructor specifically to help allay my fears surrounding this and I now know that having delivery room skills is nowhere near as important as having the patho knowledge base I got from my years in a non-delivery Level IV NICU. Because at the end of the day...a code is a code. There are only a limited number of drugs you can use and a relatively simple algorithm to follow. If you're in a true high-complex case, you're going to be in a tertiary center where there are always 239082035 people helping out in the code. I also had a complex around not being able to "perform" for procedures. But this was also an unfounded fear. I've only put in about a dozen IVs in my career (as a RN we had an IV team that did most of the IV skills). I don't do PICC lines but all the places in which I've worked have a team of nurses who do them. It took me a year or two to get comfortable with intubations, but I have the skill now and even when I don't get the tube in, the neonatologist is there to back me up and I just bag the baby until that happens.

- Nights, weekends, and holidays are definitely a non-starter for some folks. Sometimes I struggle with the holidays part, but the pros out weigh the negatives for me. Keep in mind that you will get to sleep on most units at least some of the time on the night shift. While you work a "40 hour work week" it's really less, if you're sleeping for part of that time. I have some nights where I don't get a call all night, even in the Level III unit. The holidays obligation will vary with each group- but keep in mind that if you do any in-patient rounding as a PNP you'll probably have to do some holidays too since patients are in the hospital 24/7

***

Hope some of this perspective helps. Like I said earlier, you seem to be very introspective so I know you'll dig deep to figure out what you would like to do in your career. If it's a PhD and teaching, great! PNP in primary care? Awesome! Keep digging, keep researching. It sounds like you will excel to whatever you commit yourself.

Wow, babyNP!! Thank you so much for your thorough, insightful response! It is so helpful to hear from someone with first-hand experience, especially in different practice settings. You've definitely given me a lot to think about.

I'm fortunate to have several great graduate programs nearby that offer PNP, NNP, and PhD opportunities. At this point, I think I have to do some soul-searching to decide what will best suit my interests and goals.

Thank you again for sharing your experience!

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