Prioritization is a huge part of the job, especially during times of high acuity and a high number of occupied beds. You could have 2 infants who self-extubate at the same time and you need to respond to the one that is not tolerating bag mask ventilation before intubating the second child.
About Terri Jo Peterson, MSN, NNP-BC: Terri Jo Peterson is a Neonatal Nurse Practitioner with over 35 years of experience caring for premature and sick neonates in the neonatal intensive care unit, the pediatric intensive care unit, in ground and helicopter medical transport settings, and NICU follow-up clinics. She currently works as an NNP at UnityPoint Health, the University of Minnesota Medical Center, and Hennepin County Medical Center. Prior to her current positions, Ms. Peterson worked at Rapid City Regional Hospital in the Level II and Level III NICU, caring for patients in collaboration with neonatologists and pharmacists, attending high risk deliveries, and collaborating with social services and case management staff. She also worked as an NNP specializing in high risk deliveries at Allina Hospitals and Clinics. In the summer of 2012, Ms. Peterson spent a month in a developing country, where she collaborated with the Minnesota group to bring neonatal medical care, resources, and education and trainings to the NICU staff at the 60-bed NICU within a maternity and pediatric hospital.
Ms. Peterson earned her BSN from The College of St. Scholastica in 1978 and her MSN from St. Catherine University with a concentration in Neonatal Nurse Practitioner in 1996. Prior to enrolling in her MSN program, she worked for over 22 years as a Registered Nurse, Charge and Transport Nurse, Preceptor, Nurse Educator, and NICU Follow Up Clinic Coordinator at St. Mary’s Medical Center. She is certified as a neonatal nurse practitioner by the National Certification Corporation (NCC), and is licensed as an RN and an Advanced Practice Registered Nurse in South Dakota, Minnesota and Iowa. She is Neonatal Resuscitation Program (NRP) hospital-based instructor, Basic Cardiac Life Support (BCLS) certified and working on obtaining PALS certification.
[OnlineFNPPrograms.com] Could you please describe your current responsibilities as an APRN at UnityPoint Health and as a Neonatal Nurse Practitioner at the University of Minnesota Medical Center?
[Terri Jo Peterson, MSN, NNP-BC] My job at UnityPoint Health is as an Advanced Practice R.N. I manage patients both in the nursery and the level 2 NICU on a daily basis, along with attending high risk deliveries when requested by the OB or nurse midwife. I also am an NRP instructor and have been teaching the nursing staff and MDs, along with offering CEU classes for the nursing staff to increase their level of knowledge and comfort while dealing with sick neonates and preterm infants.
My job at the University of Minnesota Children’s Masonic Hospital as a Neonatal Nurse Practitioner APRN is to manage the infants in the Level 3 NICU during my shifts. These infants span from micro preemies (an infant that is born under 1.3 pounds, or 600-800 grams) to term infants who are sick, while following the plan of care that was made with the Neonatologist on that day.
[OnlineFNPPrograms.com] What kinds of medical conditions and challenges do your patients face, and how do you help them manage their conditions? What are your daily and long-term responsibilities in this role?
[Terri Jo Peterson, MSN, NNP-BC] My role at UnityPoint Health is to help keep sick infants in the NICU and not separate the parent child group by transferring the child to another hospital. In the past infants who were sick were being transferred to another facility for advanced care. I round daily in the NICU and the nursery.
Since the start of the NNP program here at UnityPoint Dubuque a year ago, we have kept children who needed continuous positive airway pressure (CPAP) after obtaining proper equipment to maintain infants with mild respiratory distress. We also manage infants who are showing signs of infection or hypoglycemia and require prolonged hospitalization. We are now able to maintain infants 34 weeks and older in the NICU.
Our short-term goals for this program: Further education of nursing staff, so they are more comfortable caring for ill and premature infants. Another short term goal is getting Total Parental Nutrition started here for premature and ill term infants. I speak with parents daily either in person or via phone if the parents have gone home to care for other children. During these conversations, we discuss the plan of care and any changes that have been seen or made.
Our long-term goals for the program: Obtaining donor breast milk to use for feeding premature infants, whose mothers don’t want to breast feed and to use for hypoglycemic infants whose mothers don’t have breast milk yet.
Our current team members are another NNP and I; we are backed by the nursing staff, respiratory, lab, pastoral care, pharmacy and x-ray staffs. We collaborate with the Neonatologists at our sister hospital, which has the level 3 NICU. We are supported by the Pediatricians and Family Practice doctors who like us seeing their well babies during their hospital stay, freeing up the doctors’ clinic days.
At the Level 3 NICUs, I work with micro-preemies to term infants who are in the NICU for various reasons. The micro-preemies are of course, having respiratory distress and need support both with respiratory issues and numerous other issues during their prolonged stays in the NICUs. Term infants also can have respiratory problems, infection, neurological issues, electrolyte issues, and hypoglycemia. Infants can also experience Neonatal Abstinence Syndrome, a condition that may occur when pregnant women take drugs such as heroin, codeine, methadone, oxycodone, and buprenorphine.
During my shifts, I manage any problems that occur with patients, attend high risk deliveries, speak with mothers who come in to the hospital with preterm labor about what will happen at their delivery, and discuss all potential problems that may occur in the infant from head to toe going by systems. During the day shift is when the team rounds with the neonatologist on call to form a plan of care for the babies each day.
Our team at the University includes neonatologists who are available by phone during the evening and night hours, respiratory care therapists, pharmacists, social workers, hospital chaplains, speech therapists, and occupational therapists. We have weekly multidisciplinary team meetings to discuss the infants’ progress and plans of care for the week. The neonatology staff speaks with parents daily with updates on the infants’ status.
[OnlineFNPPrograms.com] You have extensive experience in high-risk pregnancy settings, as an NNP at both Hennepin County Medical Center and Rapid Regional Hospital, and in high-risk deliveries as an NNP at Allina Hospitals and Clinics. Could you please describe what it is like to work in such settings with mothers and neonates in need of intensive care and monitoring?
[Terri Jo Peterson, MSN, NNP-BC] Parents who have infants in the NICU, no matter what level of NICU care the infants require, are stressed. Reasons for stress are feelings of disappointment that the birth plan they typed so nicely for the OB staff wasn’t followed, because of urgent situations during labor and delivery with mom or baby. I always tell these parents the following: a birth plan for your labor and delivery can be read by the medical staff, but it is not read by your baby. If the baby is in trouble, the medical staff has to respond to what the baby or mom needs. I also tell them I can write what I want their baby to do as far as feeding etc. But the baby can’t read them either, so if he or she isn’t developmentally ready to do something, it won’t happen. It is a part of parenthood, your life suddenly revolves around this tiny human being and the babies are calling the shots. We have to react to what they need and they tell us with non-verbal cues. Open and frequent communication with parents and involving them in daily rounds helps the parents feel like they are a part of the infant’s daily care planning.
[OnlineFNPPrograms.com] Could you please explain the different levels of care within the NICU, and the responsibilities that NNPs have at each level of care?
[Terri Jo Peterson, MSN, NNP-BC] The different levels of care in the NICU relate to how the hospital is licensed by the state. The level 2 NICU takes care of infants from 30 -34 weeks to term infants, and is usually staffed by neonatal nurse practitioners who round with the neonatologists or pediatricians, or round independently and manage the infants during the majority of the day, handle any problems that occur, admit and discharge infants along with attending high risk deliveries. Micro-preemies and infants requiring intubation with ventilation or having seizures, or in need of surgery or total body cooling will be transferred to the Level 3. The level 3 NICUs have the neonatologist on shift during the day for rounding along with 1-3 NNPs who help manage the infants during the day. At night, the NNP on call will manage any problems or admissions that occur in phone collaboration with the neonatologist on call.
[OnlineFNPPrograms.com] How do you assess and address patients’ needs in a fast paced and high risk environment, and how do you coordinate with social services and case management staff?
[Terri Jo Peterson, MSN, NNP-BC] Prioritization is a huge part of the job, especially during times of high acuity and a high number of occupied beds. You could have 2 infants who self-extubate at the same time and you need to respond to the one that is not tolerating bag mask ventilation before intubating the second child. The other thing is to know when and whom you need to call for help or to have questions answered. Depending on which neonatologist is on call, you may need to spend a good amount of time consulting with said neonatologist. Some neonatologists want to be called with every little thing; others trust your judgement more and will trust you will call with questions or to discuss something on which you need a second opinion.
Social service is contacted whenever we have difficult situation or difficult family, certainly contacted anytime we have a mother who tests positive for drug use. They are also involved when we have babies dying, to help connect families to community resources. Case management attends rounds twice a week and attends multidisciplinary rounds weekly.
[OnlineFNPPrograms.com] You were the Lead Neonatal Nurse Practitioner from 2004 to 2010 at Allina Hospitals and Clinics–could you elaborate on your responsibilities in this role, and how you connected and educated different members of your team?
[Terri Jo Peterson, MSN, NNP-BC] In my roles as Lead NNP at the Level 2 NICU at two of Allina’s hospitals, I was on call 24/7 for any problems the NNPs may have had with computer issues, staffing issues, and issues with communication with the neonatology doctors. I acted like a liaison between the nursing and NNP staff with neonatology and pediatrics. I was responsible for making sure all the NNPs had their hospital based annual training completed along with their NRP and CRP certificates up to date. I also collaborated with our director to send out a monthly newsletter to our NNP staff which flew in from all over the country, to communicate anything that was going on as far as computer updates, changes in policies etc. I fortunately did not have to do the scheduling of the NNP staff, which was done by our staffer who also purchased airline tickets for our fliers at the same time.
[OnlineFNPPrograms.com] You also worked for over 22 years at St. Mary’s Medical Center as a Registered Nurse, a Charge Nurse managing a Level III NICU, a Clinic Coordinator, a Transport Nurse, and a Nurse Educator. Could you explain how your career evolved at St. Mary’s Medical Center, and how your years there motivated you to become a Neonatal Nurse Practitioner? On a related note, how did you discover your passion for neonatal nursing–was it a result of an experience you had while in nursing school or while on the job?
[Terri Jo Peterson, MSN, NNP-BC] I started at St. Mary’s right out of nursing school. I trained at the College of St. Scholastica, and we had our clinicals there at the hospital; both the hospital and College at the time were run by the Benedictine nuns.
I initially worked on a 50 bed medical/surgical floor for 18 months. This gave me a vast amount of different experiences in nursing care, from cancer patients, surgical patients, infectious disease patients, gynecologic patients and occasionally psychotic patients. While I was in nursing school, on my pediatric and OB rotations, I loved those areas; I was intrigued by the NICU, which we were not allowed to rotate through at the time. I had to wait for an opening in the NICU, and it took 18 months before an opening happened. Plus at the time, working in the NICU required candidates to have had previous med/surg experience.
My orientation in the NICU was mainly baptism by fire; I had a senior staff nurse assigned to me to answer my questions. But when she was gone or at a delivery, I was by myself. I was initially assigned to feeders and growers and then eventually ventilator infants and going to high risk deliveries with neonatology or another nurse at night.
You eventually were made charge nurse, once the doctors thought you were ready. That meant that they trusted you to do a needle aspiration of a pneumothorax on an infant or were able to maintain an extubated infant with bag mask ventilation during the evening or night hours until the physician came in from home which could be up to 30 minutes away.
You had to be very experienced before becoming a transport nurse, since out in the field it was only you and a neonatologist at an outlying hospital. We had to know where everything was in the transport kits, so we could grab it rapidly on arrival to the referring hospital. Transport could be by ground or helicopter depending on how far away the referring hospital was or how critical the infant was at the time of the transport call.
I had always wanted to be a nurse practitioner, after learning about that role in school, but I met my husband, got married and had kids, so I forgot about that goal until after the birth of my youngest child. When I came back from maternity leave, two of the neonatologists asked if I would consider going back to school to become a NNP. With a brand new baby, I said not at this time, maybe when she starts school. So that seed was planted, and once my youngest was ready to start kindergarten, I looked into grad school and got accepted into the Neonatal Nurse Practitioner track at St. Catherine. So I started school at the same time my youngest started school, only I had to travel to St. Catherine’s for classes two days a week, which was why I chose that program.
[OnlineFNPPrograms.com] You recently took a sabbatical to join a team of doctors, nurse practitioners, and other medical staff to go to a developing nation to improve the patient outcomes at a maternity and pediatric hospital’s 60+ bed Level III NICU through various advanced staff trainings in bedside nursing, infection control practices, and code situation responses. Could you elaborate on this experience?
[Terri Jo Peterson, MSN, NNP-BC] I heard about a NICU in a developing country (which, due to confidentiality reasons, I do not wish to specify) that was losing many babies to a bacterial infection, 50 kids in one month. Minnesota had teams of neonatologists, nurses, NNPs, RTs and nurse educators going over to help figure out the problem in this NICU. I volunteered to go to in the second team. I had thought this nation was as fairly advanced as the United States as far as medical practices, but I was wrong. I thought I was walking into a M.A.S.H. hospital when I got there. The outside of the hospital was all shining marble, but stepping through the door was totally different. Remember in some developing nations, women and children do not have the same rights and privileges as do women and children in the United States. Medical resources can also be much more scant, despite initial appearances. First thing I saw was a stretcher in the hall; it was a sheet of plywood that was partially covered by a sheet.
This developing country does not have prenatal care like here in the United States, and women over there do not have all the health care that American women do. Prenatal care in this nation was explained as this, if a woman sees a doctor during her pregnancy, she brings a notebook to the visit and she writes down the date and what the doctor says. Thus it is called, “booked or un-booked.” So during the month in the NICU, we never knew the gestational age of any woman who walked in to deliver, it was always a surprise. I would say the babies over there even at full term are smaller than babies in the United States and have multiple problems that are unknown prior to birth because of lack of ultrasound.
I learned nursing is not a respected career in this nation. This explained why half the nursing staff was from a different country. Cultural rules also interfered at times with the delivery of care. One of this culture’s rules is a woman cannot touch a man, unless she was married to him. This was difficult to remember when changing positions during a code, when part of our team was male.
One of the first things we were told was to bring hand sanitizer with us, as the first group found that there was limited soap and paper towels at the sinks in the NICU. We had to constantly make sure we had enough soap and paper towels to do hand washing over the weekend, especially as the weekend approached.
Handwashing upon entering the NICU and between patients was a rule we had to enforce with all the staff entering the NICU. We had to also teach x-ray techs to wash when entering the unit and between patients. This is something we take for granted in the USA; it was a new skill for the staff. Our conclusion was the bacterial infection causing infant deaths was likely caused by poor hand hygiene and lack of handwashing between patients etc. The hospital group had blamed the nursing staff on spreading the infection and thought that it was the nurses spreading infection, because they did not cover their hair. The Infectious Disease doctors enforced a rule that the nurses and the females of our group had to wear surgical caps over their hair to stop infections in the NICU.
On my first day in the unit in the NICU, I walked into a room in the NICU and saw two infants lying side by side, sideways on an open warmer with only one side rail up. I approached the bed and asked if the babies were twins. The response was no. I also saw that there were no other side rails to even put up on the warmer because they broke off. I tried teaching them that two newborns should not be on the same bed together if they are not twins, but the unit was so busy that there were no other beds.
Looking across the same room, I saw an infant on a ventilator who was obviously fighting the vent. The RT with me went to look at the infant’s vent settings. We found the positive end expiratory pressure (PEEP) was set to 15 cm (a normal setting would be between 3 and 6 cm). We immediately changed the vent settings and the infant settled down. This unit also had a high incidence of pneumothoracies requiring chest tubes. The chest tubes were placed into glass bottles of tap water. We introduced gentle ventilation and pleurovacs, TPN, and explained how to place PICC lines to the unit.
One of the saddest things I saw was the “white room” which our team called it. It was the room of babies who were abandoned by their parents at birth because of birth defects. These infants and toddlers were up to age 3 and still in incubators. I had read about “institutionalized infants” from orphanages in the past. These children were truly the example of this, no response to me talking to them, they just stared straight ahead, no verbal response either. It truly broke my heart to see them. But remember in developing nations, there are no pediatric home care services and parents would not be able to care for these children at home without daily help.
I saw more codes during the 30 days I was in this nation, than during my entire career. It seemed like 2-3 times a day. Infants who had one apnea spell would be automatically intubated and placed on a ventilator. We needed to teach nurses how to respond to apnea spells and explain to physicians that apnea spells are normal in preterm infants and infants did not need to be intubated.
Code responses were awful. Nursing staff didn’t know how to respond to an infant with a dropping heart rate. The physicians would extubate and re-intubate infants before even checking to see if there was chest rise with bagging, thus delaying the resuscitations. Nursing staff were afraid to tell the docs that an infant was unstable, because doctors blamed the nursing staff if a child got worse or coded. Thus the nursing staff may have known the kid was not doing well, but would never tell the doctors. Lack of open communication was a big problem.
We taught Neonatal Resuscitation Program (NRP) multiple times to the nursing staff and the medical staff. This training helped improve responses during codes. We demonstrated proper technique and how to communicate during the code as to what needed to be done.
One of the things I undertook while I was there was looking at their code carts. When I opened the code cart, I found adult medications in the NICU. The epinephrine was in a glass vial and needed to be diluted to neonatal doses. There were no filter needles available in the entire hospital. My mission was to get the appropriate drugs for the carts before the end of 30 days. I had to write a letter to the minister of health in order to get the proper equipment for the cart. It was a lot of learning how the health system works and whom I needed to contact about problems to get the problem fixed.
I was able to obtain the neonatal pre diluted epinephrine boxes with syringes that you put together and train the nurses on how to open, assemble the syringe and draw up and label the proper dose. We labeled all the drawers on the crash cart, removed the adult intubation equipment and replaced it with neonatal size ET tubes. I gave the adult drugs and intubation equipment to the doctor in charge of the adult code team who was very grateful to obtain the drugs.
The staff at the hospital was very open to suggestions and learning new techniques and skills. We gave them a list of recommendations at the end of our month. I would love to go back to see how the unit is doing now. The experience made me very thankful for all the freedoms, rights and privileges American women have here, especially with health care.
[OnlineFNPPrograms.com] What have been some of the most rewarding aspects of working in advanced neonatal nursing? On the other hand, what specific challenges have you encountered in this field of work, and how have you managed these challenges?
[Terri Jo Peterson, MSN, NNP-BC] The most rewarding part of my job is seeing or hearing from parents as their child grows up and seeing pictures of how the child is doing. Challenges in this field can be many. One of the biggest challenges is when an infant has maximized all resources to the fullest and is failing or coding. This is especially trying if the parents want full resuscitation. Even with them watching the resuscitative measures, there is a time when you need to be able to tell the parents, there is nothing more we can do and then stop all efforts and place the baby in the parents’ arms to hold while the infant dies. You have to believe that sometimes there are things worse than death.
[OnlineFNPPrograms.com] For current and prospective MSN students who are interested in becoming neonatal nurse practitioners, what advice can you give them about optimally preparing for this field while pursuing their degree?
[Terri Jo Peterson, MSN, NNP-BC] For those interested in becoming an NNP, I would suggest working in a level 3 NICU for at least 5 years, and during that time seek out all new learning experiences and read anything and everything about neonatology, and all the diseases affecting neonates. Being a transport nurse gives you experience working alone and not having others in the unit to back you up at a time of crisis or code on transport. I think being able to have docs trust you to go out and pick up a sick baby on your own with RT or an EMT builds confidence in your own skill level and judgment.
Thank you Ms. Peterson for participating in our APRN career guide interview series.