Baby Zack touches many lives during his short life: nursing baby Zack and supporting his family through the months he struggled to live and his eventual death was a privilege for members of Dunedin Hospital's neonatal nursing team.

As I came into the nursery, I could hear baby Zack crying. I noticed the frustration on the face of the nurse holding him. I quickly washed my hands and, as I approached the nurse, she handed Zack over and said, "It's been like this all night."

I sat down with him, snuggled him into my arms and started to pat him on the back gently and rhythmically. I could feel him relax and in a few minutes he had gone to sleep. I cuddled him for about an hour and, as I settled him back into bed, I noticed him stir and knew it would only be a brief sleep before he would want to be cuddled again.

Zack was born at 24 weeks' gestation. He had been ventilated for several weeks, had progressed to continuous positive airways pressure and was now on low flow oxygen. He had chronic lung disease and always worked hard to breathe. He had survived many battles and was still only three months old.

As he was often struggling for breath, he had difficulty taking a bottle and needed to feed more frequently, as he sometimes only took small amounts each feed. Over the next week I cared for Zack each shift I worked and I noticed that, if Zack had been looked after by a nurse he was familiar with, he was much more settled. As a result, the following shift was easier than if he had been nursed by someone who did not know him well.

By the second week I was convinced it would be better for both Zack and the nurses if he could be cared for by those he was familiar with as much as possible. I broached this subject with the coordinator and offered to look after him each time I was rostered.

The nurses who had spent time with Zack were able to anticipate his cues and could often avert an attack of shortness of breath and desaturation by responding quickly to his early distress cues. Zack was starting to bond with some of the nurses. Often when he heard my voice he would turn to find where I was. Zack did not like to lie in his cot when he was awake, and often preferred to sleep in the arms of whoever was caring for him.

Zack had loving parents who were unable to spend much time with him each day. Zack's father found the hospital a difficult place to be and did not visit often. Zack's mother Belinda came most days for a short time as she had two other preschoolers at home to care for. Her other two children had asthma as she did and so she often had ill children or was ill herself, which prevented her being with Zack as much as she would have liked. I believe Zack's parents were frightened of getting too close to him as he had been so unwell for so long and his long-term prognosis was still uncertain. As the weeks went by, I continued to look after Zack each shift I worked and offered to be his primary nurse so Zack's care would be consistent. I started a "likes" and "dislikes" chart and wrote down hints on how to comfort him and what some of his early distress cues were. I worried about him if I had handed his care over to a nurse who did not know him, and often came into the unit when I was studying downstairs in the library to say hello to him. I noticed that when I was caring for Zack, each nurse on duty would come and talk to him and tell him how beautiful he was, and to ask how he was doing. I realised I was not the only one who had grown to love this little boy.

Zack's first trip outside the unit

It was becoming clear that Zack was not getting better. One morning shift I commented to one of the other nurses that I wanted to take Zack outside as he was now nearly six months old and had never been outside in the fresh air. She tow me she had felt the same but did not want to take him out alone in case something went wrong. We got permission from the registrar and coordinator and decided to take him outside together. We waited until his mother arrived and surprised her with our plans. We put Zack into a pram, loaded the oxygen and all the emergency equipment we might need and left the unit.

Once outside, Belinda asked if we could go to the nearby shopping mall to a cafe where a friend of hers worked. We agreed and she wheeled Zack to the cafe and showed him off: to her friends while we stood well back and watched. On the way back we stopped at the children's ward park and took photos. Zack behaved beautifully and we did not need to intervene at all; we were able to stay back and let his mother have a brief time of normality with her son.

A six-month celebration

Zack turned six months old two weeks later. In our hearts we knew the chances of him making his first birthday were slim, so we decided to celebrate this as a birthday. We decorated his cot with balloons and streamers and got a cake. I took a photo of Zack in an outfit his mother had brought in for him and made this into a card celebrating his six months.

When his mother arrived we brought in the cake and took photos of her, Zack and the cake. Belinda did not say much and I wondered if we had upset her by reminding her how long her baby had been in the unit, but she phoned later in the evening and told the afternoon nurse all about the cake, decorations and photos and how much she had enjoyed being part of it.

A week later Zack started to get worse. He was beginning to have more frequent and longer lasting desaturations. He spent most of his time being cuddled. I spent many hours each day cuddling him and each time he desaturated he would clutch at me, trying to get closer.

I came on duty two weeks later, after three days off, to find that Zack had improved and had only been desaturating occasionally over the past two days and I Looked forward to a similar night. At handover, the night staff were told he had had a good day, but it turned out to be a very different night.

Desaturations increasing

Zack started to desaturate around 9pm and, after two hours of cuddles, nebulisers and inhalers, I managed to get him to steep propped up in the pram. He slept for two hours and then had a prolonged desaturation, followed an hour later by another and then another. I had called the registrar who said it was his lung disease worsening. He advised me to just keep on giving the nebulisers as needed. By morning he was desaturating every 30 minutes and was not moving much air. I had to move him into the hot room as the unit was getting wired for new monitors over the next few days. I transferred him with the help of the morning staff and stayed with him until he was settled. I spent most of the day out at the library and called into the unit in the late afternoon to sort out some study issues and was greeted with, "Oh good, you got my message." I was told Zack had deteriorated and they had called the family in but he had improved again and was now settled. I went in to see Zack and Belinda to let her know I was around if she needed me. I also talked to my colleague looking after him who gave me a rundown on what had happened that day.

Palliative care started

The next morning I got a phone call from the unit saying they were going to change the focus of Zack's care to palliative care now and that Belinda wanted me to come in. My heart sank as I realised this was it. Even though deep down I had been expecting this for some time, I had always hoped for a miracle. I sat for a few minutes, tears pouring down my face, convincing myself I had to go and see Zack. I composed myself, picked up my camera and headed to the unit. When I entered the unit I found the tears starting again, so I headed to the staff room where I was able to sit and compose myself. When I was able to, I went to the self-care room where Zack had been moved and talked to his parents who were both there with their other two children. I told Belinda that I had brought my digital camera as I had promised earlier and that I would take some family photos for her. The nurse Rachael * who was caring for Zack asked me if I would stay with the family white she had morning tea, which I agreed to. She showed me the infusions that were going through and left. I chatted with Zack's parents and tow them how sorry I was this was happening for them.

When Rachael came back from morning tea I told Belinda I would be in the staff room when they were ready for the photos and Left them atone. When they were ready I went back and took some photos of Zack with his family, the first that included them all.

I left, telling Belinda I was going home to collect my camera charger and would be back later in the day. I had been home 20 minutes when I was phoned and asked to return immediately. Zack was being started on a morphine infusion as his respiratory distress had caused his bowel to prolapse and he was in pain. I rushed back to the unit and when I went back into the room Zack was being cuddled by his mother. They Looked at me and said they wanted to go outside for a break and would I like a cuddle white they did. It was such a lovely gesture and I was so grateful for the time atone to say goodbye. I cuddled him, reminding him of how beautiful he was. When his parents came back, they allowed me to have a photo taken with him. I then gave him to his aunty to cuddle and Left them to have some family time. I stayed in the unit for the rest of the day, as I wanted to be nearby if needed. I realised that many of the staff who had been looking after Zack had been off for the Last few days, so I started to make some phone calls to let them know he was dying. As the day progressed, art the nurses who had cared for him and Loved him came to say goodbye. At first I worried we were being too intrusive but Rachael assured me that Belinda was thrilled so many people were coming to show they cared.

By the end of the day, every nurse who was on days off had been to see Zack. I left the unit at 5.30pm, as I had to instruct a first aid course. I was at the course when I received a phone cart to ask me if I would work the night shift Looking after Zack. I agreed at once. I received another call just before the course ended to tell me to come back as soon as possible. I wrapped things up quickly and returned to the unit. I arrived at 9pm and found the consultant with Zack and his family. The consultant was explaining that it was just a matter of time now and that he felt Zack would die very soon. Zack was tying peacefully propped up on soft pillows on the single bed with his mother beside him. For the first time since his birth, his breathing was not laboured and he was sleeping peacefully. Belinda asked if the oxygen could be removed. After consultation with me and the afternoon nurse, it was agreed the oxygen was no longer required and it was to be stopped.

Shortly after this, Belinda said, "I think he is going." She picked him up and cuddled him close and we watched as he took his Last breaths. After a life of struggle, his Last few moments were very peaceful. Over the next few hours I supported the family through the things that had to be done. Family members came to grieve with the immediate family. Belinda decided she did not want to take Zack home as she did not feet her older son would be able to cope. She chose to leave him with us overnight and the undertaker would pick him up from us. Belinda had dressed Zack and we took footprints and handprints for her and she had taken a lock of hair. I got a cot from postnatal to replace the huge twin cot and Belinda placed him in it. Then she left the unit.

I spent some time completing the paper work, then cleared the family room of all the equipment. When Belinda came back the next day, I wanted Zack to be the focus of the room rather than the equipment we had been using. It was when I completed all I needed to do and stood looking down at Zack that I shed some tears and gave him a kiss goodbye The next day I came back to the unit to see Zack leave. I went in and said my last goodbye and, when his parents arrived, left them to have some time alone with their son.

I was on duty the next two days. When I arrived in the next morning I was told I had been mentioned in the death notice; I shed a tear as I read it.

It was difficult at first to carry on and Look after other babies. It felt as if everything should have stood still until we were ready to move on, but it got easier as more babies arrived needing our care. As it was a Long weekend, the funeral was five days after Zack died. On arriving for the funeral service, I went into the chapel to find no one else there. I stood looking at the tiny white coffin with tears pouring down my face. I turned and walked out again to wait for my colleagues, who arrived a short time Later. Those few minutes alone with the coffin was the preparation I needed, as now I was able to focus on the service. At the funeral there was an opportunity for people to speak about Zack. The staff had asked me if I would say something, which I did, along with one other nurse.

We spent some time with Belinda after the service and she presented us with a photo of Zack for the unit, which we have on display in the staff room.

Can nurses care too much?

ft is now more than a year since Zack died, but we still talk about him. All our babies are important to us, but Zack had been with us for so Long, we had formed a particular bond with him. He is still a part of our unit. I Like to think he always will be.

Can nurses care too much or get too involved? In those first few days after Zack died I thought, "yes", but with time I realise that the ability to care for a baby Like Zack is a gift to be treasured. It can be difficult, when caring for babies for extended periods, not to become fond of them and to become close to their parents. When nurses do get involved like this, the key is to took at whose interests are being served. In the case of Zack, the family requested I be present during the Last two days of his life and at the funeral. This was because of the relationship and trust that had built up between us during the time I had cared for their son. While it is essential to be professional at all times, this does not preclude nurses from caring. As long as the situation remains professional and comfortable for all concerned, and remains within safe boundaries, then it cannot be inappropriate.

After Zack's death, I used reflective practice to examine my thoughts and actions during this period. I believe the ability to be close enough to a family to support them through the death of their infant is a privilege and one that should be valued. But getting involved to this extent must be because that's what the family wishes rather than what the nurse wants or thinks is best.

Zack was in the unit for such a Long time and, in the last few months of his life, he had a nurse to himself each shift. Because of his parents' other responsibilities, he bonded with both his mother and several staff. He was a character whose antics made us smile, Laugh, shake our heads with frustration and of course cry. He only lived six short months but he touched many lives and we are the better for it.

* Not the nurse's real name

The story has been written and published with the permission of, and in consultation with Zack's family.

WORKING IN THE NEONATAL UNIT OFFERS NEW CHALLENGES

Lynette Will, RN, had only been working at Dunedin Hospital's neonatal unit for six months when baby Zack was admitted. She had spent the previous 11 years in orthopaedic trauma at Dunedin hospital and transferred to the unit in early 2004 in search of new nursing challenges.

With 20 months' experience in the unit now behind her and having just finished her Last paper for the one-year, post-graduate neonatal intensive care certificate course, she is stilt absolutely committed to working with premature and very sick babies.

"I love working with babies. Even when the days are full on and very stressful there are always little babies to cuddle, which is such a pleasure. Best of all is seeing families taking their babies home once they've reached full term or got better. We can get some really sick babies in the unit and some from remote areas outside Dunedin, so caring for them can be a real challenge. Dealing with very stressed families, who are facing the fact that the birth of their baby has not gone according to plan, is also very stressful You have to be able to deal with this stress, have plenty of compassion and good clinical skills," said Will.

Dunedin Hospital's neonatal unit has 18 beds and is divided into a "hot" room and a "cool" room, where babies are placed depending on the Level of care needed. Only a very few babies are admitted at 24 weeks' gestation like Zack. The majority are admitted between 25 and 38 weeks' gestation. The unit covers the Otago region, as well as "level three" (the most acute) babies from Southland and the Lakes District. Families from out of town will either stay in the hospital with their babies or close by.

Will intends continuing her studies with two diploma papers next year. These may eventually be included in her master's studies .