Neonatal nursing: the first six weeks

Neonatal nursing: the first six weeks

Joy Jones

As a general rule the term neonatal refers to the first six weeks after birth. Therefore, neonatal care or Neonatology is the medical specialty that involves taking care of newborn babies, sick babies, and premature babies.


Neonatal care in specialized nurseries and intensive care units for infants has been around since the 1960’s. Many of us remember the tragic death of President Kennedy’s infant son Patrick Bouvier Kennedy in 1963. Born prematurely, the Kennedy baby lived only a very short time because his lungs were immature and underdeveloped. The Kennedy child was born several weeks before his scheduled delivery date, but by current standards he would not have been considered extremely immature and quite possibly would have lived if today’s level of neonatal care had been available at that time.

With modern neonatal care, prematurely born infants that have had as little as 22 or 23 weeks gestation out of a normal 40-week pregnancy are able to survive. This great leap in medical care has taken place due to technological advances and the education of physicians and nurses who are dedicated to saving the lives of the many very vulnerable premature infants who are born each year.

Today there are approximately 40,000 low birth weight infants born annually in the United States. But at any given time, most of the babies in a typical Neonatal Intensive Care Unit (NICU) are not considered critically ill. A high percentage of NICU babies are simply premature babies that are doing well and are just waiting to grow big enough to go home. Other NICU infants are typically treated for hyperbilirunemia, which is an excessive amount of yellow bile pigment leading to jaundice, while other babies in the NICU are recovering from infections or surgery.

In the 1970’s the medical specialty of neonatology came into its own. Out of that grew the need for nurses to specialize in this area. It is a specialty in which high technology and high touch are interwoven to help infants survive.

A major event in the evolution of neonatal nursing was the regionalization of neonatal care, which categorized nurseries by the level of care they were able to provide. This happened in the early 1980’s. Under the regionalization plan, premature or very ill newborns were to be transferred to the nearest designated center to receive the level of care each infant required. The transport involved assessment of the newborn’s condition, stabilization, and provision of continuous high-level care during the actual transfer. The neonatal nurse was identified as an integral member of the transport team, and the transport nurse role began to evolve.

A neonatal staff nurse generally works in either a Level I, II, or III nursery. The levels of care designation can be found in the Perinatal Regionalization Model outline in Guidelines for Perinatal Care, 4th Edition, 1998, published by the American College of Obstetrics and Gynecology and the American Academy of Pediatrics.

A Level I nursery is traditionally a nursery for healthy newborns. These types of nurseries are all but nonexistent now, because today mothers and babies generally have very short hospital stays and often share the same room.

A Level II nursery is an intermediate care or special care nursery in which the babies may be premature or suffering from an illness. These babies may need supplemental oxygen, intravenous therapy, specialized feedings, or more time to mature before discharge.

The Level III nursery is a neonatal intensive care unit (NICU), which is a tertiary care center that admits all neonates (newborn infants in the first six weeks of life) who cannot be treated in either of the other two nursery levels. These babies may be small for their age, premature, or sick full-term infants who require high technology care, such as ventilators, special equipment or incubators, or surgery. Generally, Level III units are located in large general hospitals or in specialized children’s hospitals. Neonatal nurses provide direct patient care to infants in these units.

Requirements for Becoming a Neonatal Nurse

Requirements for neonatal nurses are dictated by the particular institution(s) at which they practice. Most institutions use a practice skills list to assess the nurse’s ability in giving medications, performing math calculations, starting and maintaining intravenous lines, cardiopulmonary resuscitation, and any additional skills and knowledge needed for direct infant care. These additional skills could include suctioning, gavage feedings, and ventilator care, among others.

Entry-level requirements for neonatal nurses vary from institution to institution. Some hospitals or medical centers may require one year of adult health or medical surgical nursing, while other health care providers hire registered nurses after graduation from an accredited school or college of nursing who have passed state board of nursing (NCLEX) exams for licensure. The type and length of nursing experience also varies from one institution to another, but many require no previous experience. In the midst of the current nursing shortage, experience requirements for neonatal nurses at an institution can depend on the scarcity of qualified nurses in that particular area of the country.

Continuing education requirements for neonatal nurses are mandated by the individual states or particular certifying bodies. The state board of nursing sets the number of CE hours, if any, that are required for a nurse to maintain his or her license. A staff or an advanced practice nurse may hold national certification in neonatal nursing, which involves an additional exam that demonstrates specialized knowledge in neonatal nursing. The certifying body dictates the number of hours required to maintain certification without retaking the test.

How to Become a Neonatal Nurse

At this time, to this writer’s knowledge, there are no schools that actually specialize in Neonatal Nursing at a basic RN entry level, and there is no special program for neonatal nursing in basic RN education; although some nursing programs have elective courses in neonatal nursing. To become a neonatal nurse, an individual must first earn a RN degree. From there, one can obtain a Master’s Degree in the specialty Neonatal Nursing. But by far, the most common way that nurses become Neonatal Nurses is by working in a Neonatal Intensive Care Unit (NICU), Special Care Nursery, or Level I Nursery.

Two other nursing options that prepare a nurse to work with babies, especially premature and sick newborns, are the specialties of Neonatal Nurse Practitioner and Clinical Nurse Specialist. Once a nursing student graduates and obtains some experience as a RN in a neonatal intensive care unit (NANN recommends two years), some then consider going to graduate school to become a Neonatal Nurse Practitioner or Clinical Nurse Specialist. A nurse can obtain NNP (Neonatal Nurse Practitioner) or CNS (Clinical Nurse Specialist) designation by completing 1 of the 30 programs listed in the NNP Directory, available for sale from the Natiional Association of Neonatal Nurses.

What to Expect as a Neonatal Nurse

Of course the benefits, job availability, and salary levels for neonatal nurses vary from region to region and city to city. In the Midwest and South, many institutions are currently advertising job openings; while in the West and Northeast, there seem to be fewer job vacancies. However, as with all nursing specialties, the current nursing shortage virtually insures that finding a job in neonatal nursing is not a difficult task.

It is predicted that an increasing number of staff nurses and advanced practice (master’s degree or higher) positions in neonatal nursing should continue to be available in the near future due to the general downsizing that took place a few years ago, which led to a decrease in the number of nurses choosing advanced practice education. It is also surmised that since the average neonatal nurse is middle-aged, it is likely that many will move into less stressful areas of nursing.

The salary of a neonatal nurse is highly dependent on the cost of living and the mean salary in the area in which the nurse is located. As a general rule, in the Midwest, nurses with no experience may start in the upper 30s to mid-40s for an annual salary. On either coast, the salaries are usually higher; while in the South, beginning neonatal nurses start at about $30,000 per year. The upper range for someone with no experience is around $48,000. Salary ranges may be higher for experienced neonatal nurses.

Any full-time nurse usually receives a percentage of health care benefits paid by the employer. Paid vacation is usually two weeks. Paid sick time is earned as a fraction of days worked during each pay period. Most employers offer life insurance, and some may have retirement plans, often beginning after 10 years of employment. Tuition reimbursement for continuing education or classes for academic credit, undergraduate or graduate, is available at an increasing number of institutions.

Most hospitals offer a clinical promotion ladder system with specific criteria for advancement. More employment opportunities are available with increased education either at the master’s or doctoral level. The master’s prepared Neonatal Nurse Practitioner or Clinical Nurse Specialist can expect higher levels of job availability, responsibility, and pay. Some are employed by high-risk clinics for neonatal intensive care ‘graduates’ or home follow-up care.

Because there are nearly 40,000 low birth weight babies born in this country annually, there is a growing market for the neonatal nurse. The future will continue to be strong and steady for neonatal nurses. The Workforce Report published by the American Nurses Association and the Association of Nurse Executives in 1998 reported that there is a shortage of acute care neonatal nurses. This shortage is projected to continue for the next decade.

Neonatal nurses have the unique privilege of working with newborn babies and experiencing the true wonder of birth on a daily basis. On the other hand, neonatal nurses working in the NICU must also occasionally experience the death of a seriously ill or premature child, which can be extremely traumatic. But for the most part, neonatal nursing is one of the most rewarding nursing specialties that is available to today’s qualified nurses.

If you do decide to pursue a career in neonatal nursing, you can get out your pink and blue ribbons, fluff up the Teddy bears, and be prepared to receive a cigar or two from some happy new fathers–and most of all, get ready to say, “Oh, what a beautiful baby!”

Joy Jones is a professional healthcare writer employed full-time by Opportunities In Nursing Magazine. This article is reprinted courtesy of Opportunities In Nursing Magazine.

COPYRIGHT 2004 American Association of Critical-Care Nurses

COPYRIGHT 2004 Gale Group