No autonomy or critical thinking as a nicu nurse. What is your unit like?

MGMR · Sep 19, 2017

I've only worked peds cardiac ICU, but from talking to many of the nurses who have come to my unit from adult ICU, it appears that there is huge difference in nursing autonomy in pediatric versus adult ICUs. I think the NICU has the least autonomy out of the three units at my hospital (NICU, PICU, PCICU), and that PCICU has the most. And that's not saying much because I feel like I don't have much autonomy most days. I titrate anti-hypertensive drips like Nitroprusside and Nicardipine to stated BP goals, and some sedation like Precedex as needed. But we typically need to ask to go up on Fentanyl drips (even though we bolus as much as we need), and we never touch Epi drips without an order. Obviously we don't titrate Milrinone, and we don't use Dopa or Dobutamine on my unit.

The adult ICU nurses told me that they could titrate pretty much any drip, and give fluid up to a certain amount before calling the provider. We would never be allowed to give fluid boluses on our own, even if their pressures are 40s/30s with a CVP of 2.

I think it's ridiculous you can't start an IV on your own, and don't get me started on giving intermittent IV meds sterilely or NICU's lack of sedation/pain management. Even our NICU isn't THAT bad. Yours sounds particularly stifling.

I think that if you love the specialty, stay and get the experience you need and go elsewhere. I have many friends who have come to my unit from a NICU background where the nurses re-taped tubes on their own without asking the medical team, went to deliveries and put in their own PICC lines. So it definitely can be done. I also believe that, sometimes, if you earn the respect over time, you gain more and more independence to do things as long as they're correct things to do. For example, even if it isn't your unit culture to check a glucose, I think it would not make your resident explode in anger if you did it with sound clinical judgment. Something like, "Hey, I noticed that the blood sugars have been trending down, so I checked and their sugar is 20. Do you want to give a D10 bolus?" Or something along those lines. It shows you have an idea of what's going on, and they can't be mad really because, well, you're right.

**NICU Guy, BSN, RN** · Sep 19, 2017

There is a big difference between an adult vent patient and a preemie vent patient. A 1-2 cm displacement can cause a preemie to not be ventilated, for a micro-preemie it could be .5 cm. We utilize 2 person transfer for skin-to-skin for vent babies, either 2 nurses or nurse and RT. Why are you against RT helping transfer? We do not use Neo fits because of it's lack of ability to properly secure the airway, we tape the tube per STABLE protocol. So, we don't need assistance to turn vented babies.

We have standing orders on some tasks. Drs will write for prn Accuchecks and the ability to put baby on a nasal cannula if their O2 sats are trending down, but we notify the Dr once we start O2. They will also usually write a "wean O2 to off as tolerated" for babies already on Nasal Cannula, that way we can trial the baby without O2 and make sure they don't need it before having the Dr. discontinue the order. Our Dopamine orders are usually "Titrate to means of XX to XX".

All nurses are expected to attempt IV starts unless the infant is a micro preemie or a known difficult stick. We call our PICC nurse to start an IV on those patients.

We are definitely not brainless slaves. Our opinion and clinical judgement is highly valued by our neonatologists (most times, more valued than their residents) and given autonomy on certain tasks. We are expected to use good clinical judgement when it comes to the care of our sicker babies. Failure to use good clinical judgement means feeder/grower assignments until the charge nurses can trust you again.

rnkaytee · Sep 19, 2017

A 1-2 cm displacement can cause a preemie to not be ventilated, for a micro-preemie it could be .5 cm.

^^ This -- could it be your unit had a history of unplanned extubations and this 2-person turns was part of a new protocol to avoid them? I would start by bringing your concerns to a unit educator, they may be able to fill in the blanks as far as where some of this is coming from. The IV start protocol seems odd to me - almost all nurses (once trained) are expected to try unless it's a difficult baby (it's kind of a badge of honor to be able to start them successfully).

In general, adults and babies are so different and you may be finding this is just part of the very different patient populations.

MGMR · Sep 20, 2017

A 1-2 cm displacement can cause a preemie to not be ventilated, for a micro-preemie it could be .5 cm.
^^ This -- could it be your unit had a history of unplanned extubations and this 2-person turns was part of a new protocol to avoid them? I would start by bringing your concerns to a unit educator, they may be able to fill in the blanks as far as where some of this is coming from. The IV start protocol seems odd to me - almost all nurses (once trained) are expected to try unless it's a difficult baby (it's kind of a badge of honor to be able to start them successfully).
In general, adults and babies are so different and you may be finding this is just part of the very different patient populations.

While I agree about the huge difference in turning an intubated preemie and adult, that still doesn't explain the rest of the OP's situation: not being able to start a peripheral IV, titrate Dopamine, or check a blood sugar on your own is extremely restrictive. Especially for an ICU nurse.

rnkaytee · Sep 20, 2017

I agree, some of the policies are not ones I'm familiar with or have a real rationale for, but the OP did state they had a high infection rate with IV starts/administration. I can't begin to guess the "why" behind these policies, but if OP did a little digging there may be reasons they had to implement them. If OP has only been there for a year, there may be a whole backstory that she/he is missing.

vintage_RN, BSN, RN · Sep 20, 2017

I work in a large academic level IV NICU. I find I do have less autonomy here in some ways than when I worked adult surgical and more in other ways. In my NICU, only charge and admit nurses start IVs and do venous blood work. So if I need either of those 2 things I need to call someone on that team. As an adult nurse I did all my own bloodwork and IVs....I've been told the rationale is that when one team is trained very well in an area and there is consistency then there are fewer infections and adverse events. The same is with central lines...in adult nursing I managed all my central lines...changed the dressings, flushed, removed them....here only certain charge and admit nurses are allowed to touch them. If I notice something off during my assessment I have to call one of them to come have a look at it. This is mildly annoying as I'm used to managing everything myself....but a different area I suppose. I find peds in general to be much more "anal" if you will about many things.....as it should be. I would like to be trained to do these things but usually to be an admits nurse (attending deliveries) you have to be working here for about 5 years or so.....one day.

In terms of sugars..if I feel something is off or want to know what a sugar is after titrating TPN or something...I just use my judgement and check it...I don't need an order. That seems pretty restrictive. We usually have medical directives when titrating drips so we follow those perameters.

in the NICU I find the docs and the team really value my opinion on the baby and actually listen to my concerns. They base their plan partly on my observations of the baby...since I am with them all the time. I worked on adult surgical for 4 years and the surgeons didn't even know my name or give 2 craps what I thought.....so that is a welcome change.

applewhitern, BSN, RN · Sep 20, 2017

No, all NICU's are NOT like that! I have worked in several over the years, and always felt like I had more autonomy there than anywhere else. That said, every place is different, and has their own policies. Funny what you said about respiratory personnel feeling the need to "be there," because in one large unit I worked in, we didn't allow anyone but the NICU RN to touch the babies! We micro-managed everything, and didn't allow anyone but us to stick the babies, or to position them for xrays! We were highly protective of them. The residents and interns came to us before they did anything.

babyNP., APRN · Sep 21, 2017

When you're at a large center, a lot of things are safety/protocol based. I've heard that at Mayo, for example, there is a "team" for everything like IV starts, central line insertion, transport, etc etc so that nurses are actually doing more care coordination. It makes sense from a safety perspective- you might see something like a milk bank technician in a NICU where a dedicated team mixes all the breast milk so that none is accidentally wasted, for example. I agree that it's not the best for nurse learning, but that's the way it is at a lot of academic centers versus a community hospital simply because the patients are more sick.

TBH though, procedures that a nurse may think is benign actually aren't when you think about it...I remember once that one of my patients was almost off of IV fluids and on full feeds- not an IDM/LGA/SGA baby at risk for hypoglycemia. The dextrose percentage in the bag was pretty high, but that was because we tried to pack as much nutrition as possible before we discontinued the line. However...the rate was very low, so the glucose infusion rate was actually quite low (like 1-2 mg/kg/min) by the time we were getting off IV fluids. The nurse called me and insisted on getting a blood sugar because the dextrose percentage in the bag was so high. I told her no and took the time to explain why- no risk factors for hypoglycemia, tolerating feeds, and the baby was not even getting physiologic GIR (which is 4-6 mg/kg/min). She still didn't believe me despite me taking the time to explain it to her, so she waited to ask the night shift NNP (who also told her no).

What are the cons? Risk of infection from an invasive needle poke, cost of a test ($80 for a bedside chemstrip), and exposing a baby to an unnecessary painful procedure. NICU babies can go through dozens if not hundred of painful procedures and can develop abnormal reactions of pathway to pain perception.

edited to add-

It's also the same for me as a NNP. I've now had the pleasure of working Level IV as a NNP and now community Level III as a NNP. I have a lot more autonomy out in the community than in an academic center.

NICUismylife, ADN, BSN, RN · Sep 22, 2017

While I agree about the huge difference in turning an intubated preemie and adult, that still doesn't explain the rest of the OP's situation: not being able to start a peripheral IV, titrate Dopamine, or check a blood sugar on your own is extremely restrictive. Especially for an ICU nurse.

^^^This. I would never attempt to re-position my vented baby independently and I value my RT and the two of us work as a team. All the other stuff you mention is fairly routine nursing care in my unit. If my baby's IV goes bad, I start a new one. I do all my own labs. If I thought my baby's sugar was low and called the Dr. without having done a dex check, I would probably get an ear-full, lol. We have set orders when a baby is admitted that include titration of O2 and pressors to maintain a particular sat or MAP. And while we do need a Dr's order to sedate PRN, it is our own judgment as to when to administer it.

ThePrincessBride, MSN, RN, NP · Sep 25, 2017

I work in a level III that has mostly feeder/growers and bubblers, and I do agree that sometimes I feel as though my job is mind-numbing. Occasionally, we will get a super-sick kid, but that kid is usually watched like a hawk by the NNPs. Drips are extremely rare on our unit. We are allowed to check blood sugars PRN, but we can't just up and start IVs and give dextrose boluses without an order. We are allowed to titrate oxygen to keep oxygen sats within a certain range, but in terms of PEEP and other settings, we have to have an order. We need an order to put a NG/OG feed on a pump. We don't need respiratory, but when it comes to caring for a vented kid, I almost always call them to help me re-position the patient.

Julius Seizure · Sep 25, 2017

When you're at a large center, a lot of things are safety/protocol based. I've heard that at Mayo, for example, there is a "team" for everything like IV starts, central line insertion, transport, etc etc so that nurses are actually doing more care coordination. It makes sense from a safety perspective- you might see something like a milk bank technician in a NICU where a dedicated team mixes all the breast milk so that none is accidentally wasted, for example. I agree that it's not the best for nurse learning, but that's the way it is at a lot of academic centers versus a community hospital simply because the patients are more sick.

This has been my experience too. In the smaller community hospital PICU/CVICU, I could check a glucose or a blood gas, titrate drips, etc. It was common practice for the nurses to write their own Tylenol orders (say what you will, that was the culture there).

Then I went to a major teaching center in the peds CVICU. You were supposed to call the NP or Fellow before suctioning your patient, and the provider was supposed to be AT THE BEDSIDE for it if they were a single ventricle physiology patient. I always thought....so I am supposed to call and wait for you to show up while the baby bradys from having a mucus plug?? Most times, of course, the provider was too busy elsewhere down the hall and would say "ok just do it and yell if you need me to come quick"