Problem-Solving with Catherine: Critical Thinking in the NICU and Beyond

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I am an adult acute care SLP. My hospital has an accredited NICU that is fairly busy. We have NICU trained PT’s that work w/ the babies but currently no SLP. An SLP who no longer works in our hospital used to service this population. I am wondering what type of credentials an SLP is required to have to service this population (NICU)? Any specific course and training required? I am inquiring about this for future candidates when interviewing. What training is an absolute “must-have” before an SLP can work with these critical babies? Thank you for any information you can share. From reading this SIG, I know many of you have this area of expertise.


Working as a speech-language pathologist in the neonatal intensive care unit (NICU) requires many specific skills and advanced learning. These tiny patients and their families are fragile. The family-centered care we provide as SLPs, in support of neuroprotection, communication and safe feeding, create the foundation for a thriving parent-infant relationship. The NICU infant’s history and co-morbidities are often complex and require high-level problem-solving to keep them safe and to sort out all the pieces. It is a privilege to be a part of the NICU team, and it comes with much responsibility. The following are some of the elements of professional skill, expertise and that stand out to me as key for practicing in the NICU.

There are to my knowledge no agreed upon credentials for working with this fragile population, unfortunately. ASHA does have guidelines that you can take a look at. It reflects your thoughtfulness that you reached out to plan ahead for future interviews and hiring. I often receive e-mails asking for insights from adult SLPs working in a medical center, who have been “selected” to staff a new NICU. There are of course no black and white answers to your questions. And we all have to start somewhere. And no one knows everything. It would be no different if tomorrow I were asked to work in adult ICU at the very large medical center in which I have work as a senior neonatal/pediatric swallowing specialist. I could technically treat adults in ICU because it is in our scope of practice as SLPs, but it would be ill-advised, unfair to the patient and family and likely place me in a potentially litigious situation should something adverse happen based on my recommendations or lack of insight and would be clearly noted by an attorney or an expert witness. The risks all around would not be a good situation. But often inpatient pediatric specialists are asked to “cover” adult care when peds volumes are “down”. Each of us has a different perspective on risk and what is an acceptable risk for our patients and for ourselves.  Practice in the NICU is a subspecialty of pediatrics, and is to me the riskiest of all, as these are our most fragile patients.

Infants in the NICU are critically ill or were in the recent past. These most fragile patients can become physiologically unstable at any time-and it might happen during our therapy session. It’s not easy to practice in the NICU environment. Quick and constant losses and triumphs cause emotions to run high. An infant’s status can change at any time. Caregivers are highly skilled and passionate, which sometimes leads to strong opinions and respectful disagreements. The SLP needs to thoughtfully collaborate, yet at times take a stand. Another key trait: humility, and a passionate willingness to learn along with other disciplines. No one knows everything, or if they get to the point that they think they do, it is time to step away and retire. The NICU is too demanding in my opinion to be an initial independent placement after graduate school.

The NICU SLP requires advanced practice skills: It’s not just knowing what to do, but what not to do.  A large focus of our work is supporting feeding/swallowing, so the risk of compromising an infant’s airway is significant. Another essential skill: solid critical reflective thinking. As Drs. Evangelista, Blumenfeld and Coyle told us, “In our work as dysphagia practitioners, we’ve found that a combination of clinical experience and deliberate, effortful reflection on our own practice picks up where graduate school left off. This combination continues to serve an invaluable developmental purpose as we hone our clinical expertise in dysphagia.”

Another key element is solid mentored experience with progressively complex birth-to-3 patients, optimally in a setting which provides an interdisciplinary team approach with PT-OT-ST that supports families and each other as professionals, for a wide variety of infants ranging from very mild to complex feeding and swallowing problems and co-morbidities. It is so hard to access that kind of guided learning when an SLP has to be on the road so to speak and practice in a silo. It is hard to even conceptualize what you don’t know, and to not have someone to bounce questions off of in the moment or really “look” at an infant when you have only your own set of eyes, yet those eyes are still “learning”.

The right foundational pediatric environment will provide critical experience communicating with and supporting parents who are in various stages of grief. These stages of grief are experienced by families in EI even when the infant has never been in an NICU. It provides an opportunity for us as compassionate SLPs to listen, understand and learn how to support in ways that offer guarded optimism, and talk about difficult considerations that underpin airway protection. So that then, later in the NICU, when we work with families who nearly lost their infant, have an infant who is getting worse, or who is unsafe when PO feeding, we have some understanding of the thoughtful communication that is required. The communication from the infant, the child, and the family must always be the lens through which we problem-solve and intervene.

Another key element is the ability to complete a differential, and utilize broad, multi-system knowledge about preterm development and swallowing/feeding and complex medical co-morbidities that are common in the setting of an arduous medical course. This learning comes from multiple sources—previous birth-to-three mentored experience, previous complex patients prior to the NICU, on-going reading of the literature (not just within our field but also in medical, nursing and OT/PT journals) And then the NICU SLP must be ready and willing to not only understand the evidence base, but to bring it to the NICU team. Neonatologists and neonatal nurses will often ask “why?” and we must be able to discuss the research-based evidence along with our clinical wisdom. Ideally guided participation can be provided by learning along with a skilled NICU SLP to further support the critical thinking that is part of this “element” to look for during an interview.

Continuing education is essential because much of our learning about the NICU population comes after graduate school.  That means the hiring hospital must be dedicated to providing the support for education that will best avert sentinel events and optimize the risk-benefit ratio for the institution, the SLP, families, and most importantly, the infant. The courses should be functional, bring the current pertinent research, promote critical thinking not just information, and offer a deep dive across multiple components of assessment, intervention, and co-morbidities – because NICU SLPs will likely see many of them – often in a complex combination that will take patient problem-solving to peel apart. Underpinnings for (and aberrations of) feeding and swallowing in preterm and sick newborns are essential—WOB, state regulation, airway, postural control, sensory, GI, and neurodevelopment, and also the breadth of infant-guided interventions and their rationale in the NICU—-as they will all need to be a part of a differential and plan for safe swallowing. Also, the interaction of the evolution of swallowing physiology (unique to the impact of preterm delivery and/or critical illness for the term infant), airway protection and considerations for instrumental assessment (why, when, how, analysis and collaboration with the team). When I first started in the NICU in 1985, I was fortunate to come to this unique setting after 12 years of solid Birth-to-Three experience with complex infants and children, with wonderful mentors who helped hone my skills over many years.  Despite that, there were so many gaps, and starting in the NICU back then still required me to embrace being a lifelong learner and building a dynamic foundation. Even after many years of complex infant feeding and swallowing experiences (across outpatient, EI, acute care and NICU settings), I still have to pause and really think through these complex little ones, because every experience matters in the NICU. My continuing education offerings, especially my new Advanced Infant/Pediatric Dysphagia seminar are all infused with critical thinking. As Drs. Evangelista, Blumenfeld and Coyle told us, “In our work as dysphagia practitioners, we’ve found that a combination of clinical experience and deliberate, effortful reflection on our own practice picks up where graduate school left off. This combination continues to serve an invaluable developmental purpose as we hone our clinical expertise in dysphagia.” See: Evangelista, L., Blumenfeld, L., & Coyle, J. (2022). How Do We Cultivate Critical Thinking in Dysphagia Decision-Making? ASHA Leader Live.

I hope this is helpful. This relationship-based nature of our work in the NICU, and its potential to influence lives in so many ways, must remain as much a part of our day-to-day interactions with families, always inextricably linked to our critical thinking and problem-solving. As you can see, I am passionate about our work in the NICU, and the tiny humans we care for deserve no less.


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