Scope of Neonatal Nursing Practice
Definition and Overview of Professional Neonatal Nursing
Neonatal nursing is the specialized practice of care for the neonate, infant, and family from birth and initial hospitalization through discharge and early follow-up care. This highly specialized nursing practice includes care of infants born prematurely and those born at term or beyond who are experiencing illness or complications following their birth, as well as newborns who remain at risk for disorders of transition and later onset of symptoms of pathology.
Medical and technological breakthroughs have expanded the ability to save extremely small and immature infants as well as profoundly ill infants, which has inevitably and extensively changed practice. With these innovations and practice changes, the nursing care needs of this population have grown. As a result, the population served has expanded to include infants during the first 2 years of life who have healthcare needs related to their neonatal period (National Association of Neonatal Nurses [NANN], 2009b).
The population served by neonatal registered nurses is diverse and increasing. According to the Centers for Disease Control and Prevention (CDC), 1 in 8 infants is born preterm, and 7% are born with low birth weight in the United States (CDC, 2006). The U.S. Department of Health and Human Services reported that in 2006, 4% of all births required assisted ventilation immediately after birth, and of those, 20% required assisted ventilation for more than 6 hours after delivery. This same report, derived from data from
the 19 states that had implemented the 2003 U.S. Standard Certificate of Live Birth, reported that 6% of all infants reported were admitted to a neonatal intensive care unit (NICU) (Osterman, Martin, & Menacker, 2009). Overall infant mortality in 2012 was 6.61 infant deaths per 1,000 live births, and the leading cause of death was congenital malformations, which accounted for 20% of all deaths. The second leading cause of death was disorders related to short gestation and low birth weight, which accounted for an additional 17% of all infant deaths (Mathews & MacDorman, 2008). Data from 2005 suggested that the annual societal economic costs (medical and educational expenses and costs of lost productivity) associated with preterm birth in the United States were at least $26.2 billion (March of Dimes, 2010).
the 19 states that had implemented the 2003 U.S. Standard Certificate of Live Birth, reported that 6% of all infants reported were admitted to a neonatal intensive care unit (NICU) (Osterman, Martin, & Menacker, 2009). Overall infant mortality in 2012 was 6.61 infant deaths per 1,000 live births, and the leading cause of death was congenital malformations, which accounted for 20% of all deaths. The second leading cause of death was disorders related to short gestation and low birth weight, which accounted for an additional 17% of all infant deaths (Mathews & MacDorman, 2008). Data from 2005 suggested that the annual societal economic costs (medical and educational expenses and costs of lost productivity) associated with preterm birth in the United States were at least $26.2 billion (March of Dimes, 2010).
Neonatal care in the developed world tends to focus on highly technological solutions to infant mortality. In the developing world, infant mortality is an enormous problem. In some areas, more than 100 of every 1,000 live births die before the age of one (World Health Organization, 2012). The direct causes of death and disability vary considerably throughout the world, as do the causes of low birth weight and prematurity. Infant and child mortality are rising in some resource-poor areas of the world, where the challenge is to have a skilled attendant provide seamless care throughout the entire pregnancy and neonatal period, addressing the health issues prevalent in that region (WHO, 2005). The neonatal nurse practicing in these areas faces the challenge of providing lifesaving care with limited resources in the context of difficult social and governmental structures.
The numbers of critically ill infants surviving to discharge has increased, and the specialty has evolved to encompass the care of convalescing or fragile infants up to 1 year of age. The neonatal registered nurse recognizes and respects each infant as a unique, individual human being, with the right to a pain-free, developmentally supportive care environment. The nurse assists the family’s adaptation to a new, highly technical environment, while encouraging attachment to and bonding with the newborn. The neonatal registered nurse recognizes the family’s attachment to the newborn as crucial for the infant’s physical, psychological, and emotional well-being. The neonatal registered nurse strives to empower the family through education, practice, and competence in caring for the newborn. This is achieved through promoting family-focused care, assisting parents with adapting to and gaining meaning from the neonatal experience, and fostering their independence in assuming care of the neonate/infant. This process begins at the time of birth, when the parents are taught developmentally and physiologically appropriate handling.
As the infant’s physiologic status improves and the infant matures, the family is encouraged to participate in the infant’s care increasingly until the time comes when the family is able to care more completely for the child.
As the infant’s physiologic status improves and the infant matures, the family is encouraged to participate in the infant’s care increasingly until the time comes when the family is able to care more completely for the child.
This document is intended to identify some of the issues and trends that have an impact on the practice of professional neonatal nursing. It is not intended to restrict role development and nursing practice, but rather to frame and clarify the scope and foundation of the work of professional nurses at all levels of practice. It is intended to be used in conjunction with Code of Ethics for Nurses with Interpretive Statements (American Nurses Association [ANA], 2001), Nursing’s Social Policy Statement: The Essence of the Profession (ANA, 2010b), and Nursing: Scope and Standards of Practice, Second Edition (ANA, 2010a).
The scope of neonatal nursing practice describes the “who,” “what,” “where,” “why,” “when,” and “how” of nursing practice within this specialty area. These descriptors create a complete picture of the dynamic and complex practice of neonatal nursing. The total scope of neonatal nursing practice that an individual nurse engages in is influenced by education, experience, role, and population served (ANA, 2010a).
History of Neonatal Nursing
The roots of neonatal nursing are in the care of mothers and babies throughout history. Midwives and experienced female elders have cared for women through pregnancy and delivery and shortly after delivery for centuries. However, the focus of their care was clearly on the woman, and infant mortality was very high. Modern neonatal nursing as a subspecialty began with the invention of the incubator in 1878 by the French obstetrician Étienne Tarnier. In 1884, Tarnier also invented a small tube for the administration of gavage feedings (Raju, 2011). These two interventions revolutionized the care of sick and preterm infants. Two decades later, “premature baby shows” began in Europe and the United States. These shows were quite successful and eventually led to the establishment of a Premature Infant Station at Michael Reese Medical Center in Chicago in 1914. This unit was run by Julian Hess, a pediatrician, and Evelyn Lundeen, the head nurse. They achieved unparalleled survival rates, in part because of rigorous attention to the details of environmental control, asepsis, and feeding (Raju, 2011). These facets of care—thermoregulation, infection control, and nutrition—underpin the care we provide today.
As the 20th century unfolded, the options available for care of newborns expanded. Blood transfusions, intravenous fluids, and ventilators all became commonplace. In 1950, the first federal grant funding the Premature Institute program was allocated to train hospitals in caring for this group of infants. Despite this, in 1963, President John Kennedy’s newborn son, who was born at 4 lbs 10 oz and 34 weeks’ gestation, died of respiratory distress syndrome. He was 39 hours old (“The presidency,” 1963). This family tragedy was widely reported and illustrated to the public that tremendous work in the field remained to be done.
In the ensuing years, basic research into the physiology of the premature infant has led to an explosion of drugs, devices, and treatments for even the tiniest and most immature of infants. As these treatment options became prevalent and survival of smaller and sicker infants became common, neonatal nurses developed innovative methods of improving infant outcomes. Developmental care and skin-to-skin care have become essential components of the nursing care provided to these infants. Nurses have been instrumental in developing methods to assess and treat pain in the infant. The modern NICU employs evidence-based nursing and medical care in a collaborative manner.
Underlying Assumptions of Neonatal Nursing
The following assumptions were made in the development of Neonatal Nursing: Scope and Standards of Practice:
The standards focus primarily on the process of providing nursing care to newborns/infants and their families.
The healthcare facility has the responsibility to provide a sufficient number of qualified registered nurses to deliver safe and effective neonatal nursing care.
Nursing care is individualized to meet the unique needs of each newborn/infant and family.
The nurse considers and respects the family’s goals and preferences when developing and implementing a plan of care.
The nurse respects culture and diversity in all aspects of newborn/infant and family care and administers nursing care accordingly.
The nurse respects the privacy rights of the newborn/infant and family and manages all information accordingly.
The nurse provides information to the family so informed decisions can be made regarding the care of the newborn/infant and family.
The nurse functions within the Nurse Practice Act of the state and the established policies and procedures as described by the healthcare institution in which the nurse is practicing.
The nurse works in coordination and collaboration with other healthcare providers to render care to the newborn/infant and family.
The nurse strives to provide the highest quality of care while utilizing available resources.
The nurse strives to promote optimal outcomes within the confines of current practice standards.
The nurse strives to ensure use of evidence-based care when possible and advocates for research in areas lacking evidence to support practice.
The family is the integral unit for care.
Practice Characteristics of Neonatal Nursing
The unique physiology of the neonate and the care of her or his family is the foundation upon which neonatal nursing is based. Neonatal registered nurses understand the complex conditions and disease processes affecting a patient population that includes those born at a range of gestational ages. The transition to extra-uterine life is a unique period of rapid physiologic change, found only in this age group. Critically ill neonates may include those born prematurely with incompletely developed or functional organ systems, those suffering the effects of impaired transition to postnatal life, and infants with a variety of congenital abnormalities. The newborn infant’s ability to accomplish the complicated task of transition to extra-uterine life is influenced by gestation, presence of physical defects, perinatal risks such as chronic maternal illness or drug exposure, infection, and other factors. Infants who have required intensive neonatal support for early illness or prematurity are at additional risk for long-term complications such as chronic lung disease, impaired growth,
and poor neurodevelopmental outcomes. The interplay between the infant’s relative immaturity, genetic background, and the complications associated with lifesaving treatment modalities can produce physiologic changes that are unique to this population.
and poor neurodevelopmental outcomes. The interplay between the infant’s relative immaturity, genetic background, and the complications associated with lifesaving treatment modalities can produce physiologic changes that are unique to this population.
Maternal health and disease can have profound effects on the developing fetus. Placental function influences growth and development both in utero and ex utero. Placental dysfunction can produce a myriad of effects in the infant, which can in turn produce significant complications, both short-term and long-term. A growing body of evidence shows that adult diseases can have their origins in fetal pathology (Devaskar & Calkins, 2011). Neonatal nurses are aware of the potential effects of maternal health on the developing human and evaluate the infant for subtle signs of these complications in an attempt to ameliorate these problems.
The challenges to nursing care that these maternal and neonatal factors present require a skill set that is highly specialized and an extremely high level of vigilance and attention to minute detail. In caring for newborn infants, the neonatal registered nurse recognizes the importance of holistic care and supports the family’s adaptive coping skills in this setting.
The care of infants in the NICU must be provided in a manner that is age appropriate. Age-appropriate care for infants includes attention to five core measures: protected sleep, pain and stress assessment, age-appropriate activities of daily living, family-focused care, and the healing environment (Coughlin, 2011). These core measures and other specific tenets that form the framework for neonatal nursing practice include the following.
Continuous Assessment
Vigilance—reflected in continuous assessment and monitoring of the fragile, preverbal infant—is vital. The neonatal registered nurse detects subtle changes in the infant’s physiologic status and communicates these changes to the appropriate interprofessional team members, including physicians; advanced practice registered nurses; case managers; laboratory technicians; occupational, physical, and respiratory therapists; nutritionists; social workers; and childlife specialists. The critical care skills of continuous assessment and response to findings are employed in the first moments of life and then throughout the infant’s convalescence. For instance, early identification of the subtle symptoms of hypothermia or of increased apnea, bradycardia, and lethargy in a previously stable infant can lead to the early identification of sepsis in this population.
The goal is to provide safe, timely, and comprehensive intervention and care for the fragile newborn and family, within the context of larger systems and environments. The neonatal registered nurse identifies and treats pain and prevents suffering through management of the infant’s discomfort, employing a variety of both pharmacologic and nonpharmacologic interventions (Walden & Gibbins, 2008).
The goal is to provide safe, timely, and comprehensive intervention and care for the fragile newborn and family, within the context of larger systems and environments. The neonatal registered nurse identifies and treats pain and prevents suffering through management of the infant’s discomfort, employing a variety of both pharmacologic and nonpharmacologic interventions (Walden & Gibbins, 2008).
Developmental Care
The neonatal registered nurse provides care for medically fragile infants who may be physiologically and developmentally immature. Infants in neonatal care units face the dual challenge of meeting appropriate developmental milestones and enduring a period of critical illness. The neonatal registered nurse provides a therapeutic environment that utilizes evidence-based practices favoring optimal developmental outcomes and supporting physiologic stability. Ultimately, the goal is to maximize outcomes while supporting the infant’s development, thereby enhancing the infant’s growth and neurodevelopmental potential. The neonatal registered nurse utilizes knowledge of the dynamic relationship between innate behaviors and the environment to shape the care that is provided, allowing for wake-sleep cycles, circadian rhythms, and appropriate sensory experiences, and fostering homeostasis (Gardner & Goldson, 2011). Sleep plays a critical role in the development of synapses, in learning, and in memory. The protection of sleep is fundamental to the care provided (Coughlin, 2011).
