A Letter to the New NICU Nurse I Used to Be

Dear Little Lisa,

Hi! It's crazy to think you started this job when you were just 22 years old! You have grown so much but I wish I could make you feel safe exactly where you are.

You are going to spend a lot of time worrying about whether you are doing enough.

You will worry that you are too slow. You will worry that your questions are obvious. You will worry that everyone else understands the NICU in a way that you do not. You will watch experienced nurses move through a shift with a confidence that feels impossible to imagine for yourself.

You will assume that becoming a good NICU nurse means reaching a point when you no longer feel uncertain.

It does not.

A good NICU nurse is not the nurse who always knows the answer. It is the nurse who notices when something has changed, pauses when something does not make sense, and asks for help before uncertainty becomes danger.

You do not need to know everything.

You do need to pay attention.

Learn the Tasks, but Do Not Stop There

At first, so much of your energy will be spent learning how to do things.

How to complete an assessment. How to organize care. How to give medications. How to manage respiratory equipment. How to prepare a feeding. How to document everything correctly and still finish before the end of the shift.

Those skills matter. You need them.

But completing a task is not the same as understanding the care.

Do not become so focused on doing everything correctly that you forget to ask why you are doing it.

Why is this baby receiving this medication?

What problem are we trying to treat?

How will I know whether it is working?

Why did the feeding plan change?

Why did the oxygen requirement increase?

What does this baby normally look like?

What is different today?

The habit of asking why will teach you more than memorizing another list of normal values.

You will not always receive a satisfying answer. Sometimes the answer will be, “That is how we do it here.”

Do not assume that means the question was wrong.

Pause. Look at the policy. Review the evidence. Ask someone who can explain the reasoning. Be willing to learn that there may be context you do not yet understand, but do not let that stop you from thinking.

Curiosity is not disrespect.

You Are Allowed to Say That You Are Concerned

There will be moments when you notice something before you fully understand it.

A baby will look different.

The oxygen requirement will continue to rise.

The events will become more frequent.

The baby will be less responsive, more mottled, more irritable, or simply not acting like the baby you cared for earlier.

You may not know exactly what is wrong.

You may be tempted to wait until you have more evidence.

You may worry that the provider will not agree. You may worry that your preceptor will think you are overreacting. You may worry that the concern is too small to mention.

Say it anyway.

“I am concerned.”

“This is different from the baby’s baseline.”

“The current plan is not improving the baby’s condition.”

“I need someone to assess this baby.”

Those sentences will matter more than sounding polished.

You are not expected to diagnose the problem before you speak. Your responsibility is to recognize that the baby may be changing and make sure the right people know.

Do Not Let Fear Make You Quiet

There will be times when the first person you call is not concerned.

You may be told to keep watching.

You may be reassured that the finding is normal.

You may wonder whether you should let it go because the person on the other end of the call has more experience, more education, or a different title.

Listen to their reasoning. Continue assessing the baby. But do not confuse someone else’s confidence with proof that your concern is wrong.

If the baby continues to deteriorate, speak again.

Restate what has changed.

Use objective findings.

Ask for a bedside assessment.

Involve the charge nurse.

Use the chain of command.

Do not worry so much about whether someone will think you are difficult that you forget who may suffer if you stay silent.

The baby will not be the one calling the provider.

The family may not know that something has changed.

You are their voice.

The only people who truly suffer from your silence or fear are the baby and the family.

That does not mean every concern will become an emergency. It does not mean you will always be right about the cause. It means the baby deserves a nurse who is willing to say, “Something is different, and I need help understanding why.”

Confidence Will Not Arrive All at Once

You will expect confidence to grow steadily...it will not.

Some shifts will make you feel capable. The next shift may make you feel like you have learned nothing.

You will finally become comfortable caring for one type of patient, and then you will receive an assignment with a diagnosis, medication, procedure, or piece of equipment you have never seen.

This is not failure.

It is the NICU expanding in front of you.

Your assignments will become more complex as your skills grow. That means you may not always feel your progress because the expectations are changing at the same time.

Look for growth in smaller places.

You notice changes sooner.

Your questions become more specific.

You prepare before someone asks.

You understand why an intervention is being used.

You give a report that tells the baby’s story instead of listing numbers.

You ask for help earlier.

You know when a response does not match the level of concern.

You reflect after a difficult shift and recognize what you might do differently next time.

That is progress.

Find the People Who Explain Their Thinking

Pay attention to the nurses who tell you why.

The ones who explain what they are watching.

The ones who ask what you think before giving you the answer.

The ones who welcome questions without making you feel small.

The ones who can say, “I am not sure either. Let’s look it up.”

Learn from them.

You will meet people who are very skilled but not very good at teaching. You will meet people who have years of experience but no longer question their routines. You will meet people whose confidence makes you believe they must always be right.

Experience matters, but experience without reflection can become habit.

Find mentors who continue learning.

Become that kind of nurse for someone else one day.

The Goal Is Not to Become Fearless

You may never stop feeling nervous before certain conversations.

You may still feel your heart race when you call a provider about a deteriorating baby.

You may still rehearse the first sentence before speaking.

You may still wonder whether you are making too much of a change.

Courage in the NICU does not mean the fear disappears.

It means the baby matters more than the fear.

One day, a new nurse will look at you the way you once looked at experienced nurses. They may assume that you have always been confident, that you always knew what to say, and that speaking up came naturally.

Remember that it did not.

Remember how hard it was to ask questions when you were afraid of looking unprepared.

Remember how much it mattered when someone took the time to explain.

Remember that the quiet nurse standing beside you may already see the problem but not yet believe they are allowed to say it.

Teach them that they are.

-Lisa

To the newer NICU nurses reading this, this letter is also for you.

You do not need to know everything today.

Keep learning. Keep questioning. Keep paying attention.

Most importantly, when something does not feel right, use your voice.

The baby and family are depending on it.