Next month, Ashley Puckett, RN, will mark seven years working in Saint Francis Healthcare System's Level III neonatal intensive care unit (NICU) in Cape Girardeau.

On Sept. 10, Saint Francis' NICU and the Family BirthPlace celebrated their 20th anniversary.

We caught up with Puckett, a 2011 Jackson High School alum, to ask about her work. Some of Puckett's remarks are condensed or paraphrased for clarity and space reasons.

The National Association of Neonatal Nurses (NANN) said a NICU nurse cares for infants who are born with various issues — premature birth, birth defects, infections or cardiac issues. How did you get started in the NICU at Saint Francis?

I came straight out of nursing school straight to the NICU. It didn't seem like there was a fit for me in any other department. Thankfully, there were three positions open as soon as I graduated. I really do love it and don't see myself going anywhere else anytime soon.

You indicated the NICU is the best fit for you personally. Why?

It's not the same as on other floors of the hospital where you know your patients are coming and going all the time. We have some babies who will stay one or two days while others may stay more than 100 days.

It's fun to see them hit milestones — their first bath, seeing them come off the ventilator or get the feeding tube out or witnessing them putting on their first outfit.

While a preemie is the NICU patient, parents and guardians are also part of your responsibility, correct?

We definitely have to make a connection with them. It's difficult for parents to watch someone else take care of their baby, an infant who is sometimes no larger than a pound at birth, about the size of a hand. A NICU nurse is there from Day 1 and all the way until the baby goes home. We try our best while the babies are here to have parents do non-nursing tasks so they know we're just the nurses helping them get their baby successfully out of the unit.

What is the typical workload for a NICU nurse?

We can accommodate 36 babies in the unit at full capacity, and we have 18 rooms. We usually have one to three babies assigned at a time. The number depends on how sick they are. We work 12-hour shifts.

You deal with very small human beings who cannot talk to you and yet their lives literally are in your hands. How daunting is such a responsibility?

When I'm at a delivery, you have to have a level of fear if you're going to be any good at your job because you understand something out of the ordinary can happen. I'd rather use the word "privilege," though, to describe what we do. You get to take care of your miracle every day. You're caring for patients who shouldn't even be outside the womb yet.

How did nursing school prepare you for the NICU?

We hit on neonatal care very briefly there. You learn good basics but we got only one or two days in the NICU throughout the whole nursing school process. Once I got to Saint Francis, we got 12 weeks of learning with a wonderful preceptor (supervisor) who is now a nurse practitioner. She guided me through those three months of training on how to become a NICU nurse.

What's a misperception about what you do?

I think some see it as we sit around with babies and feed them bottles, rocking them, feeding them, coddling them. We get to do that but not as much as everybody thinks. Our good days are really good; our bad days are really bad. If we're going to have a bad day, it's going to be because you're standing next to a mom who's going to watch her baby breathe a last breath. On a good day, we're taking a picture of the child with her parents going out of NICU on the last day with us. They become part of our family and we get to see them on visits 18 months to 2 years out.

How do you know a baby is ready to go home from NICU?

It's the physician's call about discharge, but we look for different things. For example, they need to be eating everything by mouth or they need to be coming off their respiratory equipment. Some preemies like to hold onto their oxygen a bit longer than others, and some do go home with equipment. We try our best, though, to get them to a point where they don't have to have at-home oxygen or a feeding tube.

How do you handle a baby's death?

I haven't had a death with one of my patients yet. I've been present in the NICU when a baby has passed, but at our hospital, infant deaths are few and far between. I have to rely a lot on my faith and knowing God has a plan. But that's me personally. Things changed a lot when I became a mother myself two years ago. Before I was a mom, I couldn't empathize as much. Coming back from maternity leave, it's as if my whole mind shifted. I could understand better why a parent was so upset. I've always been good at the task work, but with motherhood, I can now connect on another level, especially about the tiredness moms feel. It's easier to form a bond which makes parents feel safer leaving their child in my care — and with the whole NICU team. I want to say a word about the team. I think people would be surprised to know we have a physician, a nurse practitioner, a social worker, a discharge planner plus respiratory, occupational and physical therapists. There's a lot of moving parts here. We're all trying to get that baby home.

Can you describe your worst day on the unit?

Thankfully, it happened on a day when my preceptor was there. I wasn't under her supervision anymore, but she was a rock. She carried me through. I actually got a personal phone call from our physician telling me everything was going to be fine and that there was nothing anybody could have done.

What is the protocol Saint Francis follows in the event of a bad outcome?

If an infant passes away, we have a bereavement team. We provide packets with handouts. We give the parents little boxes with memorabilia — e.g., the baby's footprints, castings with their little hands and feet. We offer pictures for photography. We have little gowns and stuff made from old wedding dresses that people have donated and made for us to use. We try, in other words, to make that sad time not as hard in the moment — even though it's probably a parent's worst day. You just know you're trying to at least ease the pain as much as you can.

Every parent knows babies cry. Some can't stop crying. How do you deal with colicky infants?

We've been given a lot of swings from nice families. Some can't be here with us in the NICU a lot because they have other children and jobs, and sometimes they don't live close by. It's hard for them to be at the bedside on a 24/7 basis. We have swings, we have vibrating pads that lay under the beds for some of our drug withdrawal babies. We have white noise machines. We also have wonderful volunteers who will come and hold them and love them up.