Neonatal nursing

Safe staffing of neonatal services

Neonatal nurses care for newborn babies who are born premature or sick – see Health careers - Neonatal nurse.

Staff in neonatal and special care baby units need to be available in sufficient numbers and with sufficient knowledge, experience and training to offer safe, effective care to babies and their families.

The minimum standards for staffing levels for neonatal services are:

Neonatal Intensive care: 1:1 nursing for all babies
Neonatal Intensive care: 1:1 nursing for all babies
Neonatal Special care: 4:1 nursing for all babies
Neonatal Transitional Care 4:1 nursing for all babies

RCN - Defining staffing levels for children's and young people's services
NHS Improvement - Safe, sustainable and productive staffing for neonatal care and children and young people's services
BAPM - Optimal arrangements for Local Neonatal Units and Special Care Units in the UK including guidance on their staffing: A Framework for Practice

The recommendations include ensuring:

70% of the nursing establishment must be ‘qualified in specialty’ (QIS)
a minimum of two qualified nurses/midwives should always be on duty (one of whom must be QIS)
a supernumerary team leader additional to the staff caring for the babies on each shift
a minimum percentage of registered staff should be:
80% for intensive and high dependency care
70% for special care
See: Toolkit for high quality neonatal services

There is clear evidence that both the ratio and level of knowledge and skill of registered nurses affects the outcomes of premature infants. See: The effects of a one-to-one nurse-to-patient ratio on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population-based study

The RCN has outlined the required knowledge, skills and competence for the neonatal nursing team – see Career, education and competence framework for neonatal nursing in the UK.

Clinical care needs

A newborn baby can suffer from a range of conditions requiring treatment, including infections (see below), conditions which may be life threatening such as necrotizing enterocolitis (see below). Some conditions can have long term consequences and may occur as a result of the management strategies used to save the infants life such as Bronchopulmonary dysplasia (see below). A very significant proportion of newborns will require treatment for Jaundice and the guidelines are kept under periodic review. See: NICE - Jaundice in newborn babies under 28 days.

Necrotizing enterocolitis (NEC) is a serious illness in which the tissues of the intestine become inflamed and start to die. This results in a paralytic ileus and can lead to perforations of the bowel which allows the contents of the intestine to leak into the abdominal cavity. This can cause a very dangerous sepsis (GOSH 2016). Treatment may be surgical or medical and involves management with multiple antibiotics and most of these infants will require Parenteral Nutrition (NICE Guideline in development) to avoid starvation and malnutrition while their gut recovers.

Neonatal sepsis is a significant cause of mortality and morbidity in newborn babies. It may be early-onset (within 72 hours of birth) or late-onset (more 4 than 72 hours after birth). Neonatal infection can lead to life-threatening sepsis, which accounts for 10% of all neonatal deaths. Neonatal infection is present in 8 of every 1000 newborn babies and is responsible for 71 of every 1000 neonatal admissions. Of these infections, 82% occur in premature babies (born before 37 weeks) and 81% in low birthweight babies (below 2500 grams). As an indication of how quickly progress is made in neonatal care the 2012 NICE guidance is currently being reviewed.

NICE quality standards (See: Neonatal specialist care and guidelines cover key aspects of care such as specialist respiratory care for babies born prematurely (See: Specialist neonatal respiratory care for babies born preterm).

Key aspects and concepts in caring for premature babies and their parents include:

fully family integrated care
environment and noise reduction
positive touch
skin to skin and Kangaroo care
supportive positioning

A neonate is a newborn baby, specifically a baby in the first 4 weeks of birth. Neonatal care includes providing support for parents and other family members.

In England, a taskforce established by the Department of Health produced a Toolkit for High-Quality Neonatal Services in 2009 which:

outlined the quality principles required of services providing specialist neonatal care
provided a consistent definition of three categories of neonatal care
described three types of units working in a network of units
described a set of quality metrics
gave examples of how to address Quality, Innovation, Productivity and Prevention (QIPP)

In England, Neonatal services since 2013 have been managed within Operational Delivery Networks. There are now 11 of these and they provide a network to provide the different levels of care for their population. A high proportion of care for newborn babies, either healthy babies or those with lesser problems, is carried out at the district hospital where they are born. Complex and intensive care, particularly of very preterm babies, is carried out in tertiary centres – see: National Programmes of Care and Clinical Reference Groups - Neonatal Critical Care.

As foetal and neonatal care has developed, pre-term birth is now more common and the survival rate of sick newborn babies continues to improve. The NHS England Long Term Plan aims to reduce stillbirths, maternal mortality and serious brain injury – see: NHS England Long Term Plan - Maternity and neonatal services. Actions identified by the Neonatal Critical Care review include expanding critical care services to improve the effectiveness and safety of service provision.

In Wales, around 9-10% of babies born each year need admission to a Neonatal Unit – see: Wales Neonatal Network. The key principles of the Department of Health Toolkit for High Quality Neonatal Services are relevant across the whole of the United Kingdom, with Wales also establishing standards expected of neonatal service providers. Wales recently standardised neonatal nurse competences. All neonatal nurses in Wales will have the same level of education, skills and competence.

In 2017 a national review of Maternity and Neonatal Care in Scotland resulted in recommendations and a five year plan to improve care standards and service provision – see: Scottish Government - The best start: maternity and neonatal care plan executive summary and Scottish Government - The best start: five-year plan for maternity and neonatal care. Scotland led the way in developing Neonatal nurse education and all neonatal nurses educated and trained in Scotland follow the same curriculum and programme of education.

Northern Ireland does not currently have specific national standards for neonatal service provision.

Useful links