SLPs in the NICU: more than competency, it’s about building trust with the team
"We need speech therapists who know what they're doing and are comfortable down here."
That was actual feedback I received from a nurse in my first neonatal intensive care unit (NICU) job.
The circumstances surrounding this feedback involved my push for appropriate positioning during feeding and the use of a slower-flowing nipple.
While I admit, this seems like an errored judgment on the nurse's part, I must warn you that I did not contribute positively to this situation.
“It’s not my job to educate others on things they should already know”
Hurtful versus Helpful
Instead of building rapport with that unit, I used every excuse I could to get away and work on the adult service line.
Instead of making the nurses feel included in the care plan, I isolated them and railed against their recommendations.
My discomfort with conflict and lack of knowledge regarding what it takes to create a healthy working relationship caused me to miss a teaching moment with that nurse, potentially creating an ally relationship between nursing and therapy.
The “it’s not my problem” mentality
"It's not my job to educate them on things they should already know," I thought.
"They'll never listen to what I have to say," I reasoned.
"My time is better spent on units that value my opinion," I decided.
When I left that job, I thought the poor relationship I had with the nurses was all their fault.
But it was my job to do better.
Understanding the role of the neonatal therapist
Speech-language pathologists, occupational therapists, and physical therapists that work in the NICU are also known as neonatal therapists. Neonatal therapists possess specialized knowledge and skills to evaluate and treat medically complex premature infants in the NICU.
The evaluation and treatment of feeding and motor skills is only part of the neonatal therapists' role (Nightlinger, 2011). The neonatal therapist's main job is to provide support and education to staff and parents regarding the importance of neuroprotection in the medically fragile infant (Craig & Smith, 2020). Specific forms of neuroprotection that the neonatal therapist offers include:
Gentle touch during painful procedures
2-person positioning with aids and/or swaddling designed to maintain midline containment and flexion (Madlinger-Lewis et al., 2014) (Waitzman, 2007)
Promotion of positive oral experiences with the use of a pacifier while the baby is tube-fed (Shaker, 2017)
Promotion of a quiet environment devoid of noise and bright lights
Ongoing education to current staff, future staff, parents, and caregivers on the role of therapy in the NICU and the importance of neuroprotection
Regular education on infant-driven feeding protocol and the need to cease feeding when the infant presents with stress cues (Wellington & Perlman, 2015) (Shaker, 2018)
Ongoing discussions about the negative impact of volume-driven feeding on feeding outcomes of NICU graduates with nurses, providers, parents, and caregivers (Shaker, 2013)
And so much more!
If in my early days of NICU practice I understood the neonatal therapist's role, I would've taken more responsibility for my lack of initiative and its effect on the relationships I had with staff in the NICU.
I might've said the following:
"You know, your opinion is really important to me. I am interested in sitting down and talking to you more about your infant feeding views and experiences. I know I'm new to this unit, and I really want to do a good job and show you that I'm committed to growth and continuity of care for every baby. Neonatal therapists have so much to offer, and we should be providing complimentary care to nursing, not contradictory care."
Successful NICU collaboration
Who knows what would've happened if I had taken the initiative to have honest conversations like this with staff. The NICU is a very protective environment with a culture all its own. Tips that I have found for creating influence and positive working relationships include:
Don't come in and act like you "own" feeding. The care is interdisciplinary, so recognizing that upfront will help you in conversations with staff.
Consider your wording and facial expressions during a conflict. You will experience conflict and differing opinions in this setting. Your response during those times can make or break your relationships with staff.
Acknowledge the expertise of the nurses and neonatologists. This is such a specialized field of medicine! You are not the only one who worked hard to get into this unit!
Assist nurses outside of your job role. Gather linens, help with positioning, answer phones, etc.
Always ask them if you can work with the infants. This is respectful, even if you know they don't mind.
Get to know the staff on the unit. Rapport building always starts with transparency and empathy from one person to another. This builds trust!
In any working relationship, a conflict will arise. The severity of that conflict will be significantly diminished if the neonatal therapist, nurses, and providers have an excellent working-relationship built on respect. I can say with confidence that while I still don't do everything right, these principles have helped me establish a better relationship with my current staff, increasing the effectiveness of the therapy I provide in our NICU.
References
Craig, J. W., & Smith, C. R. (2020). Risk-adjusted/neuroprotective care services in the NICU: the elemental role of the neonatal therapist (OT, PT, SLP). Journal of Perinatology, 40(4), 549–559. https://doi.org/10.1038/s41372-020-0597-1
Madlinger-Lewis, L., Reynolds, L., Zarem, C., Crapnell, T., Inder, T., & Pineda, R. (2014). The Effects of Alternative Positioning on Preterm Infants in the Neonatal Intensive Care Unit: A Randomized Clinical Trial. Research in Developmental Disabilities, 35(2), 490–497. https://doi.org/10.1016/j.ridd.2013.11.019
Nightlinger, K. (2011). Developmentally Supportive Care in the Neonatal Intensive Care Unit: An Occupational Therapist’s Role. Neonatal Network, 30(4), 243–248. https://doi.org/10.1891/0730-0832.30.4.243
Shaker, C. S. (2013). Cue-Based Feeding in the NICU: Using the Infant’s Communication as a Guide. Neonatal Network, 32(6), 404–408. https://doi.org/10.1891/0730-0832.32.6.404
Shaker, C. S. (2017). Infant-Guided, Co-Regulated Feeding in the Neonatal Intensive Care Unit. Part I: Theoretical Underpinnings for Neuroprotection and Safety. Seminars in Speech and Language, 38(2), 96–105. https://doi.org/10.1055/s-0037-1599107
Shaker, C.S., (2018). Reading the Feeding. The ASHA Leader. https://doi.org/10.1044/leader.FTR1.18022013.42
Van McCrary, S., Green, H. C., Combs, A., Mintzer, J. P., & Quirk, J. G. (2014). A delicate subject: The impact of cultural factors on neonatal and perinatal decision making. Journal of Neonatal-Perinatal Medicine, 7(1), 1–12. https://doi.org/10.3233/NPM-1476313
Waitzman, K. A. (2007). The Importance of Positioning the Near-term Infant for Sleep, Play, and Development. Newborn and Infant Nursing Reviews, 7(2), 76–81. https://doi.org/10.1053/j.nainr.2007.05.004
Wellington, A., & Perlman, J. M. (2015). Infant-driven feeding in premature infants: a quality improvement project. Archives of Disease in Childhood. Fetal and Neonatal Edition, 100(6), F495-500. https://doi.org/10.1136/archdischild-2015-308296
authored by:
Rebecca Smith, MS, CC-SLP, CNT is the Lead Inpatient Speech-Language Pathologist and primary SLP in the neonatal intensive care unit. Rebecca is responsible for the evaluation and treatment of medically complex neonates, adults, and geriatric patients in the ICU. She develops policies, procedures, and all of her team's education. Rebecca is an adjunct instructor at two universities and is completing her Ph.D. in Health Sciences at Rocky Mountain University of Health Professions with a Neuro Rehab concentration. Rebecca serves on various committees at the local, state, and national level. Rebecca is on the board of a local non-profit dedicated to the provision of education and resources for expectant parents. She is the 2021 Spring Fellow for the Speech Uncensored Podcast.
