Handle Hard Better – My First Week on Preceptorship

I viewed this coaching/motivational video (https://www.youtube.com/watch?v=oDzfZOfNki4) by Duke Women’s Basketball’s Kara Lawson about how we need to “Handle Hard Better.” I share this post and video to motivate you as we reflect and head toward the weekend. Things get more challenging as we grow, develop, and learn. We become more skilled and adept at facing what’s in front of us. Again, things didn’t get easier – we just got better!¬†We learned to handle hard better.

Another way to look at it: Walking was once difficult, but once I mastered that, I learned to use the stairs, jump, and eventually run. Once we become comfortable handling what we once thought was a challenge, it’s time to take on a new challenge to continue our growth and development. I didn’t even get “comfortable” with my old job or feel like I “mastered” it, yet I left and started a new one! I left my previous NICU (Level 2) to move to a higher acuity NICU (Level 4) because I knew I wanted to be able to handle more seriously ill patients.

I completed my first week with my preceptors at my new job, and it was a little overwhelming. Moving from a Level 2 NICU to a Level 4 NICU feels like a big jump. There’s so much to learn! In some ways, I feel like a new grad nurse all over again and have to familiarize myself with new equipment, processes, and diseases for my higher acuity patients. The video is a reminder to “handle hard better.” The way I handle hard better is to practice and expand my skills and to be willing to learn and open to coaching. I reflect on my performance and search for ways to improve. The way I handle hard is to do what I can to make myself better.

What does that look like for me? I am making report sheets or brains that work for me on my new unit and make me more efficient. I am learning about different disease processes by reading about them and watching YouTube videos. I am giving shift report even though I don’t feel like I’m ready because “doing” is better practice for me than “watching”. I’m learning the new charting system and what my new hospital requires for each shift. I’m learning about the workflow and general day-to-day schedule and expectations. I’m reflecting on my week by writing this post…and I’m giving myself grace that I’m still learning and will improve with more practice and time.

You may be hesitant to pursue a new job or career. You may be reluctant to go back to school. I am here to encourage you. I have met many second-career nurses, older students, and moms returning to college or joining nursing school since I became a nurse. My story is not unique. I share my life as a second-career nurse hoping to inspire others to pursue their dreams even when circumstances may seem hard. You can do it – you can “handle hard better”! Good luck on your journey!

Placing IVs in Babies

NICU nurses in my hospital are responsible for putting IVs in our neonatal patients. We don’t have an IV team to do it for us, and often, our nurses are called to other units when other units have difficulty putting IVs in babies. Regardless, IV placement is an essential nursing skill, and putting IVs in infants is different than putting IVs in adults. For adults, I can usually see or palpate (feel) veins. For babies, it can be difficult to see veins, and I’ve never been able to palpate them. It had been a while since I placed an IV in a baby, so I asked and volunteered to do it for a colleague needing to replace an IV in her patient on my last shift.

Photo by Isaac Hermar on Pexels.com

I placed the IV in the patient, but not without almost giving myself a needle stick (I dropped the needle, and it rolled away from me before I could retract it) and having some blood splash from quickly releasing a used hub on a bedside table. I’ve never come close to giving myself a needle stick, nor have I created such a mess from attempting to place an IV. Senior nurses were present to help me hold down the baby and hold up a vein finder. I felt like I was fumbling through the process with an audience. I hadn’t worked with these nurses before to place an IV because I was still new to the night shift. And while I eventually got the IV in, I felt foolish with how long it took and how I splashed blood on the table. I’m embarrassed that this is the first impression I’ve given these nurses on my IV skills. In a way, however, it was confirmation that I needed the practice.

While I was placing the IV on my colleague’s patient, the IV on my patient stopped working and needed replacement. As soon as I placed the IV on my colleague’s patient, I hurried to my patient’s isolette. I attempted to put a new IV on my patient, got it during my second attempt (the vein blew during the first attempt), but then accidentally pulled out the catheter as I tried to remove the tape and Tegaderm to retape the IV. It had stopped flushing smoothly, and the other nurse and I thought we could retape it to prevent it from getting kinked or occluded. As a guideline, a different nurse should take over the IV placement after two unsuccessful attempts. I stopped with further IV attempts on my patient beyond my two tries but got the lesson to remove tape individually so as not to pull out an entire catheter when retaping. (I had initially tried pulling off the tape before the Tegaderm, but it was hard to separate it from the Tegaderm). My colleagues eventually got a new IV in my patient. I appreciate the teamwork, but I still feel embarrassed by how I kept “messing up.”

I wanted IV practice on my last shift, and the universe gave me multiple chances! As humbling as my previous shift was, I realize the only way to improve my nursing skills is with experience and practicing essential skills: I will be more consistent and successful at putting in IVs only by putting in more IVs. Luckily, NICU nurses support each other and help and assist one another during IV placements. However, there are times when the unit is busy, and nurses may not always be available to help each other. I want to feel more confident with doing IV placement alone. I will have to request to do IVs whenever there is a chance.

Sometimes, it feels weird to be older and yet so new in work experience. I must remind myself and give myself the grace that I am still relatively new to my profession. There’s a lot I’m still learning to do that senior nurses do effortlessly and automatically. And even the most experienced nurses make mistakes or are sometimes unable to get an IV placed on the first try. I can’t expect perfection, but I can at least aim for improvement.

Missing My PPE – the realities of being a working parent and night-shift nurse

I came home from my shift this morning and had a strange moment feeling lost without my hospital PPE in my own home. Before I could even shower, I had to take on the dreaded parenting task of cleaning up my child’s vomit. My daughter wasn’t feeling well, so she decided to stay home from school during the intended morning drop-off and vomited in her car seat before returning home. In an instant, I wished I had access to everything I would have had at work.

Photo by EVG Kowalievska on Pexels.com

Luckily, my daughter took it in stride and was patient while I searched for gloves and wipes to clean up the vomit. I was still wearing my scrubs but wished I also had access to a gown and toothpaste sandwiched between two surgical masks (a trick I learned in dealing with malodorous tasks or patients). I tried not to make faces as I collected and cleaned up the mess. In the hospital, I could’ve hidden my face behind [two] masks to obscure any traces of disgust. This morning, I hope I showed concern and care for my daughter over being grossed out while I wiped off her partially digested breakfast from her body and car seat.

I briefly wondered why this seemed harder than work. I clean up vomit and poo as part of my job, but an infant vomiting breast milk or formula is very different than an elementary student throwing up solid food. When a NICU baby vomits, it’s rarely due to the stomach flu or communicable illness. When my school-age child vomits, I wonder and hope I don’t catch what she has. Cleaning up and wiping down a plastic bassinet or hospital crib is much simpler than washing a car seat. I also don’t have access to a hospital laundry bin at home. It is much more convenient for someone else to collect and wash soiled materials I place in a blue plastic bag than for my husband and me to clean and hand-wash clothing and a car seat drenched in vomit.

My daughter is doing better, thank goodness. I’m feeding her lunch while I type this (and hoping she keeps it down). My husband and I get to figure out how to care for her the rest of the day while I’m supposed to be sleeping, and he’s supposed to be working. Ahhh – the realities of being a working parent and night-shift nurse. Here’s to hoping my daughter continues to feel better and that my husband and I don’t get sick!

What I Wish I Knew As a New Mom about Feeding my Newborn – and what I try teaching as a NICU nurse

When I had my baby, my husband and I struggled to feed our newborn. I wanted to breastfeed my baby exclusively, but she would not breastfeed well. Influenced by various sources and committed to breastfeeding, I refused to pump or bottle-feed my baby while in the hospital. My baby and I roomed in together while I tried to breastfeed. My husband recalls having to travel with my baby somewhere for light therapy. I vaguely remember this too, but I was tired, delirious from lack of sleep, and recovering from a C-section. I only remember sleeping while my husband and baby were out of the room. In retrospect, my baby most likely went to the NICU because she was jaundiced. She may have been there for only a few hours because I remember waking when my baby and husband returned from wherever they went. Thankfully, the hospital did not admit my baby to the NICU, and we could leave the hospital together. However, our struggles to feed our newborn continued when we got home. Looking back at our experience as new parents, I wish I had known some things about feeding our baby that I know now as an experienced mom and NICU nurse.

Photo by Helena Jankoviu010dovu00e1 Kovu00e1u010dovu00e1 on Pexels.com

Fed is Best

As a NICU nurse, I see term or late pre-term infants (born at 34-37 weeks gestation) who come to our NICU for hypoglycemia (low blood sugar) or hyperbilirubinemia (seen as jaundice/yellowish skin). Often, these term babies come to our unit because they are not eating well. For some babies, parents refuse to feed baby formula while postpartum, and the mom may not have established her breastmilk supply yet. This description reflected us as newborn parents and a likely reason why my baby needed phototherapy.

A build-up of bilirubin in a baby’s body can cause jaundice. Bilirubin is usually processed by the liver and leaves the body as waste. A newborn’s liver may not yet efficiently function, but the baby should be eating/drinking something to produce waste and encourage processing out bilirubin. A newborn baby drinking breastmilk or formula helps curtail jaundice. If a baby is not feeding well or is still jaundiced despite attempted feedings, however, hospitals can treat elevated bilirubin levels (hyperbilirubinemia) through light phototherapy.

Jaundice is normal in newborns, but the hospital monitors bilirubin levels and treats when levels rise above certain thresholds. If the baby’s bilirubin is too high, brain damage can occur. In our hospital, if a postpartum baby needs phototherapy, the baby is admitted to the NICU. Phototherapy in the NICU only happens after multiple attempted feedings and when bilirubin levels exceed treatment thresholds.

Frequent feedings are how parents can reduce bilirubin levels in otherwise healthy babies (and hopefully prevent hyperbilirubinemia that requires NICU care). However, frequent feedings can also help prevent another common condition in our NICU: hypoglycemia, or low blood sugar. If an otherwise healthy baby born to a non-diabetic mom takes enough breastmilk or formula, the baby can usually avoid hypoglycemia. However, if the baby is unable to feed adequately, the baby can develop low blood sugar.

Before a baby goes to the NICU for hypoglycemia treatment and monitoring, the mother and the postpartum staff will attempt to feed the baby. If the mother consents, the baby can be offered formula. If bottle-feeding is still insufficient, a sugar gel is given to the baby orally. The postpartum unit will attempt several feeding and sugar gel administrations before the baby goes to the NICU. If the NICU admits a baby for hypoglycemia, we will place an IV to deliver sugar to the baby as IV fluids. Once the sugar levels in the baby are sufficient, and the baby is drinking adequately, we can reduce the IV fluids and eventually remove IV fluids if the baby can orally consume the needed calories and fluids while maintaining healthy blood sugar and hydration. In the NICU, we try feeding our babies breastmilk if it’s available and not contraindicated (i.e., substance-abusing mother). If breastmilk is unavailable and we need to feed a baby orally, we will give provider-ordered formula to our babies.

For babies admitted for hyperbilirubinemia or hypoglycemia, I sometimes hear the baby barely drank anything because the baby was unable to breastfeed from a mom who wanted only to breastfeed exclusively. Before doctors send the baby to the NICU, the nurses can offer the baby formula if the mom consents or requests it. However, by this time, the baby may have worn themselves out or be too tired to drink from the bottle. It makes me and other NICU nurses wonder, “If the parent or nurses fed the baby from the bottle sooner, would the baby still need to go to the NICU? Is the mother promptly informed of her options if her milk supply hasn’t come in or the baby cannot latch or breastfeed?”

While I’m glad my husband got to go with my baby and accompany her for phototherapy, I would have preferred that my baby not leave my postpartum room at all for treatment or tests. To prevent my daughter from needing to leave our room, I would have pumped sooner to encourage my milk supply and produce milk that my husband or I could bottle-feed my baby. We did not learn until weeks later that my daughter was tongue- and lip-tied, which may have initially made it difficult for her to breastfeed. From my perspective, it’s better to feed a newborn some formula to keep the baby with mom and out of the NICU than to rely solely on breastmilk that may not be available yet or difficult for the baby to access.

Pumping is Okay

I was offered to pump in the hospital but refused, thinking I would breastfeed. My doula recommended not to pump until after the first month, so I tried holding off on pumping in an attempt to have my baby latch, help establish our breastfeeding rhythm, and set my breastmilk supply.

I didn’t want to feed her from a bottle because I didn’t want to cause nipple confusion and have my baby prefer the bottle over breastfeeding. When we got home, I thought I was doing okay breastfeeding, but when we brought our baby to her 1-week checkup, she wasn’t gaining enough weight. We brought her to her 2-week checkup, and her pediatrician still didn’t think she was gaining enough. My daughter fell in the 2nd percentile on the growth chart. (I did not discover until months later that my husband and his siblings were so small as newborns they were not even on the growth chart). We were strongly encouraged to start bottle feeding her formula.

Wrought with guilt, we decided to feed her some formula, and I began to pump. By this time, I had developed mastitis (Mastitis is a painful infection in the breast caused by bacteria introduced by breastfeeding. It also caused me to have body aches, a high fever, and chills. Imagine dealing with this while trying to care for a newborn!) My supply was woefully insufficient, and most of my daughter’s caloric intake was formula once I started to pump while battling mastitis.

Formula is Okay

It is okay to use formula if you are not producing breast milk or enough breast milk/colostrum to feed your baby. I wanted to exclusively breastfeed because I learned about the benefits of breastfeeding and how it’s the best, natural, and easiest way to feed my baby. It’s great for baby bonding and helps provide passive immunity to the baby. However, I got mastitis TWICE within the first month or so of my daughter’s life. We also learned my daughter was tongue-tied, making it difficult for my daughter to breastfeed. Not until later did I meet other mothers who breastfed AND bottle-fed their babies or moms who exclusively pumped. (Moms who exclusively pump only feed their babies breastmilk from a bottle). Had I not been so attached to exclusively breastfeeding, I could have adapted and explored these other options earlier as a new parent.

Do What’s Best for You and Your Family

Aside from taking antibiotics, the way to clear a mastitis infection from the breast is by breastfeeding or pumping. My daughter preferred the bottle by this time, so I relied on pumping to clear my infection. Pumping (and antibiotics) eventually relieved the pain and released the mastitis in my breasts, but the repeated infections impacted my supply. Encouraged by my doula, I remember three days where I spent about 9 hours pumping (diligently pumping 45 minutes every 2 hours, per her recommendation) only to produce about 1 ounce of breastmilk daily. I was so exhausted and upset by the results of my efforts. I also felt cut off from my daughter while I pumped (Because I couldn’t figure out how to safely hold her with all the pumping tubes hanging from my body, my husband or parents would take her while I pumped). After the three days dedicated to pumping round-the-clock, I decided it was not worth it to continue to pump. It was more important for me to be with my baby than to try giving her my pumped breastmilk.

I still held out hope for breastfeeding. Once my infection cleared, I tried to breastfeed my daughter using an SNS (supplemental nursing system – a tube placed on the breast but connected to a bottle to measure and ensure the baby has adequate intake). She was already used to the bottle nipple and did not take to the SNS. I attempted multiple times, but she would refuse to feed through the SNS, and I would end up with formula spilling all over my chest.

I share a bit of my breastfeeding journey to emphasize that there are many ways to feed and nourish a baby. In the end, so long as the baby is healthy and safe, parents decide what works best for them and their family. The caregivers’ mental health and well-being are as important as the baby’s. The way you choose to care for your baby may not resemble how other families do things, and that’s okay. I was ashamed for not breastfeeding my daughter for as long and in the way I hoped, but I felt my attachment to breastfeeding distanced my baby from me and caused so much anxiety and distress. Parents should not be ashamed of doing what is best for them and their families.

In the NICU, I meet moms who feel nervous they cannot directly breastfeed, yet they can pump and produce enough breastmilk to meet their baby’s needs. I meet parents who are ashamed they don’t have a separate nursery for their baby. We live in Los Angeles – not every family can afford to pay for a home with different bedrooms for each of their children! Many of our parents rely on WIC because they can’t afford to purchase formula. Getting formula from WIC is better than diluting formula or not feeding the baby enough nutritious calories. I try to assure the parents I see they can do what works for their family – it doesn’t need to match other families.

I felt defeated when I finally gave up pumping and breastfeeding. I wish I gave myself a little grace as a newborn mom and wasn’t so hard on myself. I felt so much grief over my inability to mother and feed my child as I thought I should that it made me feel inadequate as a mom. I was separated from my baby while I pumped, trying to salvage any breastmilk I had. I cried every day when I was pumping or trying to breastfeed. Ultimately, I fed my baby adequately, thanks to formula, and my child is now a healthy school-age girl. She still falls on the low end of the growth chart, but her father and I are not tall, so my daughter’s standard is the tenth percentile or less.

As I reflect on my experience as a new mom, I hope to impart grace and support to other new parents now that I’m a NICU nurse. If a caregiver is feeding their baby adequately, caring for and bonding with them, and keeping them safe, I want them to know they are doing a great job! I also want them to know it’s okay to make adjustments as needed or change their minds about how they want to do things. Parents can adapt their plans according to the family’s needs.

I originally wrote this post to give insight on how to lower the likelihood of hyperbilirubinemia or hypoglycemia (and admission to the NICU) through frequent feedings. If this information helps reduce NICU admissions and prolong in-room bonding between caregiver and baby, I would be ecstatic. Ultimately, I hope this post reassures parents (and serves as a reminder to myself) that there are many ways to care for a baby. There are no perfect parents; there are no perfect children. We’re just doing our best with the information and resources we have. Good luck to you on your journey!

Sweet Gestures

Every once in a while, NICU families will bring treats or food for the nurses as a thank you. It’s [literally] such a sweet gesture. This past week, a family brought in fancy doughnuts, and they were the prettiest doughnuts I had seen, so I took a picture.

Fancy doughnuts given to the NICU from one of our patient’s families. (Tastes as good as it looks – I had the Nutella cronut on the bottom right and it was amazing)!

However, the sweetest gesture I wanted to remember from this past week was not what we received as nurses but what one family did for another family in the NICU. Due to supply chain shortages, our unit has run short on nursing bottles and caps and can’t give as many away to our patients’ families. Moms use these bottles to pump and store breastmilk for their babies to use while in the NICU. When our supply is limited, we recommend that families purchase and use milk storage bags as an alternative to the storage bottles.

One family overheard another talking about how it’s been hard to find the milk storage bags and how expensive they can be. The parents talked to the other parents and offered to bring them a box of bags. They brought them a box the next day. It was such a sweet thing to witness NICU families supporting other NICU families. Having a baby in the NICU can be challenging, so seeing our patients’ families support one another is reassuring that people can still be kind and thoughtful even when faced with difficult situations.

I have one more thing I want to remember/share from working this past Father’s Day weekend. (I hope everyone had a Happy Father’s Day – I’ll celebrate it late with my father and husband this week). I typically see mothers in the NICU more than I see fathers. Lately, I’ve seen a lot of dads visit with moms. In particular, one father of twin patients has been visiting and caring for his babies more frequently than the mother. The dad lets the twins’ mom continue to rest and recover while he travels to the hospital to bond with his babies. We didn’t make Father’s Day cards for the dads as we did for the moms of our babies for Mother’s Day. However, I hope the dads realize what a difference they are making by being in their child’s life and supporting their child’s mom. I know there are cultures where mothers are primarily responsible for parenting and the domestic duties of diapering or feeding a child. However, it’s been refreshing to see so many fathers involved in caring for their babies in our NICU.

I hope you can draw inspiration from the sweet moments you encounter in your work or training. Did you witness anything that inspired you this past week? Feel free to share in the comments!

Reflection for the Week of 22-May-2022

As a mother of a school-aged child, the mass shooting at a Texas school earlier this week impacted me. I felt a mixture of grief, anger, and helplessness. Like other parents, I dropped off my child at school the next day, holding them tight as we hugged goodbye before the school day. It’s devastating to consider the victim’s families said goodbye to their loved ones the morning before without knowing it would be their last.

On a nursing community page, fellow nurses asked what they could do to support the healthcare workers caring for the mass shooting victims. I’m a neonatal and pediatric nurse and always find it difficult to see children suffering in a hospital due to the brutality or neglect of adults. It’s inevitable to encounter child abuse cases in my line of work, but dealing with the mass murder of children is unfathomable. I became emotional as I imagined trying to care for the victims and facing so many deaths at once.

I’m so tired of mourning, crying, and feeling helpless. I pray but cannot accept that it’s now the responsibility of parents to search for bullet-proof backpacks or for kids to know where to hide or how to play dead to protect themselves from an active shooter. We have to do better for our children. We need to act and demand action from our leaders.

I have always believed that one cannot complain about issues if you’re unwilling to do something about them or propose solutions. One way to start taking action is to consider donating to Everytown for Gun Safety at everytown.org. I have contributed to the organization based on the guidance of other mothers and family members I trust. Other mothers I know have chosen to participate in their Moms Demand Action groups; I hope to join them.

Have a peaceful week – and if you are not at peace, may your internal discord inspire you to act and make positive life-giving changes. Take care and good luck on your journey.

Mother’s Day in the NICU

Mother’s Day coincided with my 3rd consecutive day working in the hospital. I get pretty exhausted after three-in-a-row shifts, even working on dayshift. Knowing how tired I get, my husband thoughtfully ordered food for us to have dinner at home last night. After dinner, I finally opened my daughter’s Mother’s Day card/gift she made at her school. (She’s been eager to have me open it since she brought it home on Friday – I insisted on waiting until Mother’s Day)

A portrait – part of my daughter’s Mother’s Day gift

My shift was hectic yesterday, but I didn’t mind working on Mother’s Day in the NICU. For our babies who have parents that visit them, I get to be there to comfort and support the parents and to celebrate the mothers on their special day. Some parents have difficulty being separated from their babies while their babies heal or recover in the NICU, especially on days like Mothers Day. NICU nurses often provide emotional support and assurance for patients’ caregivers. Some parents don’t yet feel comfortable handling or caring for their babies. As nurses, we educate and guide caregivers in their new roles.

All the NICU nurses made Mother’s Day cards using our babies’ various handprints or footprints on Saturday. I don’t usually have much downtime to craft cards for parents, but I enjoyed making memorable print keepsakes for our patients and their caregivers. Some of our babies have no parents visiting them and are awaiting placement in foster care or adoption. We still made Mother’s Day cards for them – their future families may appreciate their teeny baby prints!

Until this past weekend, I’d never seen these cards or prints on our unit. At my children’s hospital preceptorship in nursing school, I often saw footprint cards made by nurses in the NICU. However, those patients were at higher acuity, so 1) had longer stays and 2) had 1:1 nurse-to-patient ratios. Still, I want to try making more of these cards for our NICU babies in the future. It’s a great souvenir for caregivers, and it allows me to practice my beginner calligraphy skills!

Since I worked on Mother’s Day, my family decided to celebrate Mother’s Day with my parents on Tuesday, May 10, when my Mexican friends celebrate Mother’s Day / Dia de la Madre. (Cultural Awareness Tip: El Salvador and Guatemala also celebrate their Mother’s Day on May 10). We have many patients from immigrant families at work, so I told some nurses to keep displaying their Mother’s Day cards/signs until Tuesday.

Wherever or whenever you happen to celebrate it, I hope you have (or had) a “Happy Mother’s Day”!

Why I Cried At Work

I spent last Friday morning at work crying. I was in my new job at my new hospital and in training. The training I took Friday morning was a mandatory two-hour computer-based session about the Commercial Sexual Exploitation of Children or CSEC. I cried with the testimonials and the trauma described by survivors and experts in the field. I felt a combination of rage and helplessness while I watched and listened to the videos. Luckily, I was in an area where no one else was sitting around me, so I felt I could express my grief and despair without too much concern.

I think this is part of what scares me about being a pediatric nurse. I worry if I can emotionally regulate myself when working with abused or neglected children. I also wonder and hope I can recognize and report abuse should I ever encounter an abuse victim. As difficult as it was, I appreciated completing the training and felt it was valuable. As a nurse, I am a mandatory reporter and must report child abuse when I suspect it. However, I think the general population should also take the introductory training about the Commercial Sexual Exploitation of Children to increase awareness, recognize and reduce risks, and maybe correct misconceptions about victims.

It is unlikely that the public would voluntarily take a two-hour training about the Sexual Exploitation of Children. Despite this, I hope to educate my readers and others who come across my blog or social media posts, because I think it’s important and is something I can easily do to help victims of CSEC. Some of the things I learned from the training are found below:

I can cry and grieve for these children, but I also want to take action. Let me know if you learned anything new from this post or if you found it helpful. I’m also curious to learn and hear from others about ways they support victims of the commercial sexual exploitation of children.