Nursing and Leading Under Pressure in the NICU

We’re excited to bring you this exclusive interview with Ash Stewart who curently is a University Lecturer and a former Surgical NICU Associate Nurse Unit Manager. Ash delves into the role of leadership, what a day in the life as a NICU nurse looks like, the emotional toll it can take and her passion for neonatal intensive care and end-of-life care.

If you’re interested in more stories like this, explore our PICU & paediatric nursing articles or check out our live interviews with nurses across Australia.

We’d love to hear your reflections on Jess’s story — share them in the comments or join the conversation in our private Facebook Community.

What drew you specifically to Neonatal Intensive Care?

Thank you so much for inviting me to share my story. I’ve really enjoyed the opportunity to reflect on my career so far and I think the work you are doing is fantastic!

After completing my degree, I began to pursue my passion for paediatrics, specifically Neonatal Intensive Care (NICU). I came across this working in the Emergency Department and as a Graduate Nurse. I really liked taking care of the babies and investigated where this could take me in my career. From there I applied for a job where I could study my Postgraduate Certificate in NICU and work at the same time through the Mercy Hospital for Women in Heidelberg and made the move to Melbourne from Geelong. This is what is called a Perinatal Centre (where women birth babies). Here I consolidated my skills and knowledge and progressed on to be taking care of the most unwell premature infants.

I was part of the team that went to high-risk deliveries to ‘receive the baby’ along with a doctor and take them back to the NICU providing them with the specialist care they needed. I worked at the MHW for 3years and then went on to apply for a role at The Royal Children’s hospital in the surgical NICU unit which I was successful in. I then began broadening my career as a surgical NICU nurse. Babies admitted to the RCH NICU have a wide range of complex medical and surgical problems. I progressed into leadership and management from there.

Along with my career I have a husband, 2 beautiful little girls and a dog. We live a very busy life but a great one. I’m one of those people who is not entirely sure what to do with themselves if they aren’t busy doing something. My husband always says that I think I can fit far more into my days than is actually physically possible haha. 

Can you describe what a typical day looks like in a high-dependency or surgical NICU?

Very fast paced and new days often bring new challenges in this environment. At the Royal Children’s Hospital the most unwell neonates from all over Victoria and sometimes interstate are transferred in to be taken care of by a variety of highly trained specialist teams. Some babies are too unwell to be transferred to the Operating Theatre and so the Unit is set up so that Surgical operations can be performed on the Unit when needed. 

NICU babies often have complex needs. What are the most critical skills or qualities a nurse needs to thrive in that environment?

Gosh, where do I start with this one?

Empathy

NICU nurses must have the inherent characteristics of caring and compassion for tiny, helpless babies. The NICU nurse combines emergency-quality medical skills with genuine sympathy and care for the child.

Excellent Communications Skills

NICU nurses serve as mediators between doctors and parents, as well as infants and their parents. It is essential that they have excellent communication skills. NICU nurses must be able to clearly explain often complex situations and terminology to parents, as well as the procedures performed on newborns as directed by doctors. NICU nurses also must be able to support parents on how to care for their newborns in an ‘abnormal’ situation. In addition to these skills, the nurses must be able to communicate with patience, realizing that highly stressed parents/ carers may need information to be repeated.

Emotional Stability

The work of a NICU nurse is extremely emotionally taxing, as this brings you face to face with many heartbreaking situations in the form of emergencies and suffering. Constantly seeing helpless infants in peril and their distressed parents can put major stress upon nurses. Emotional stability allows them to be a support for families and to stay focused on the important medical challenges of their job.

Ability to Problem-Solve and Think Critically
NICU nurses must rely on critical thinking skills to quickly assess situations involving newborns. They must be able to respond immediately to emergencies and deteriorating situations. Nurses must remain vigilant, observant and detail-oriented to offer the best care to their tiny patients. 

Can you share a moment — joyful or heartbreaking — that has stayed with you throughout your NICU career?

To me there is nothing that quiet compares to the moment a family turns to you after a life threatening situation and says to you “thank you so much I watched what you and your team did and I saw how you helped save my babies life”. I’ve been able to experience this many times in my career and it has been a driving force behind delivering the highest quality care.

“thank you so much I watched what you and your team did and I saw how you helped save my babies life”

How do you personally manage the emotional toll of working with critically unwell infants and their families?

It’s so important to utilise your support network that you have around you. I am very lucky to have an amazingly supportive husband who has been a great support to me throughout my career and still is. He doesn’t have a medical background but is a great listener and empathiser. I have also been lucky enough to have many amazing colleagues along the way that I am so grateful for! After the unfortunate loss of a patient, something I began early in my career was lighting a candle and taking time to reflect on and acknowledge that patient’s life. Sometimes there may be tears and that’s ok, we are all human.

As an Associate Nurse Unit Manager in one of Australia’s busiest NICUs, what were your biggest responsibilities?

As an ANUM I had responsibility for daily management of the unit alongside the Nurse Unit Manager and duty Neonatal Consultants. This included daily staffing requirements and support of clinical staff on shift. Working alongside RCH teams for timely access and patient flow and communicating with referring and receiving units throughout Victoria and interstate.

What did you learn about leading under pressure and supporting your team during high-acuity situations or emotionally charged moments?

When things become difficult or you are in a tricky or stressful situation, I believe staff on the floor should be able to look to their leader for support. You can’t expect staff to be calm and level-headed in intense situations if that is not what you are displaying yourself. A way I help deal with emotions in a stressful situation is to take a step back, take a deep breath and re-assess the situation. It’s so important that as a leader you have the experience and ability to support staff in any situation with a level headed approach. I always lead with kindness and compassion. People have lives outside of work and you never know what else may be going on for them,

As leader I also believe you are always learning and developing new skills. I have always taken the approach of being a “hands on” leader not an observer. This means jumping in and helping out- especially with the more challenging situations. In my experience staff really respect and value this.

You helped develop an ANUM orientation guide — what were some non-negotiable lessons or values you wanted new leaders to take into the role?

To me a good leader should be ‘firm but fair’. Firm to be able to competently and confidently lead your team in stressful situations giving clear and concise direction. Fairness should always be part of every decision you make as a leader. You should always be able to justify the decision you have made as the best one you could make at the time for both the patients and staff, whatever that decision may be.

When I think about leadership I always think of the quote
“In the chaos, look for the calmest person in the room. That’s your leader”.

I believe calm is contagious, ideally everyone is able to think clearly and act decisively, even in the chaos.

How did you become involved in end-of-life and palliative care committees within the NICU?

I believe part of being a great nurse is not just accepting but asking why and reflecting on how we can improve and do things better for our patients and their families. Very early on in my career I started asking the question “why do we do it this way and how can we do it better?” This led me to investigate what systems and processes that were currently in place and how we as a team could improve. Eventually leading to becoming a teacher and mentor in the area of palliative care over two major hospitals.

How do you balance the highly clinical side of NICU work with the deeply human moments at the end of life?

It’s so important that you create time and space for these moments no matter what else may be going on around you. It’s important to remember that every patient and family is different and may want different things. Our job as nurses is to support our patients and families through this the best we can while respecting the wishes of what they would like during this difficult time. It can be challenging when you may not agree with decisions that are being made but at the end of the day the decision is the patients and families not ours to make, we are there to support them.

After years on the floor, what made you decide to step into an academic teaching role?

I see my transition as a way for me to make a positive impact on nursing in Australia. I want to help student nurses by improving their clinical decision-making skills and optimising the quality and safety of health care being delivered. I hope to do some academic work around leadership in Neonatal ICU’s and combine my love of both areas in the future.

How do you bring your NICU and ANUM experience into the classroom to better prepare future nurses?

I love to share stories based on my experience with my students. I remember back to when I was a student nurse and how I would love to hear stories about how what we were learning could be able to be practically applied to practice. I remember sitting there with some lecturers and thinking ‘wow, what a fantastic role model in nursing, hopefully I will grow to be like that someday’. I always keep that in the back of my mind when teaching and it really motivates me.

I like to try and bring fun into the classroom environment. I truly believe when you connect this is when the best learning is able to take place.

What are the biggest misconceptions students or new nurses have about NICU nursing?

That all you do is ‘feed babies’ this could not be any further than the truth. I’ve been so lucky to work with so many highly skilled and talented nurses over my career so far. A lot of people usually don’t realise this is a specialty nursing area until unfortunately the themselves or a family member might need it when there is a neonate who is unwell. 

What advice would you give a nurse considering a career in NICU?

Go for it, you get so much variety and it is a fantastic career path! Teams I worked with on a day-to-day basis included: Surgical teams from areas including General Surgery, Thoracic Surgery, Urology, Neurosurgery, Otolaryngology, Plastic Surgery, Maxillofacial Surgery, Orthopaedic Surgery and Cardiac Surgery. Sub-specialist medical teams including Neurology, Gastroenterology, Clinical Nutrition, Thoracic Medicine, Cardiology, Nephrology, Ophthalmology, Endocrinology, Genetic Medicine, and Metabolic Medicine. I really enjoyed the variety and complexity in Nursing. A surgical NICU is a fantastic path for someone who is looking to combine a variety of specialties with paediatric nursing.

One hope for the future of neonatal nursing in Australia?

In an ideal world I would really love the future of neonatal nursing to mean that it was possible to have the mother and unwell infant cared for after birth alongside each other in the same room when needed. After everything I have seen I genuinely believe this would help to create the best possible outcomes for both mother and baby. It’s heart breaking to think that babies sometimes need to be separated from their mothers/ family at birth and can often even end up being in different hospitals and sometimes even different states. Sweden does this model of care very successfully.