Home Speech-Language Pathology The Road to Success in the NICU Is Paved with Questions

The Road to Success in the NICU Is Paved with Questions

by Catherine Shaker

When I first started in the NICU in 1985, I was excited but also concerned that I could potentially cause harm working with such fragile babies. And this was even after I already had nearly eight years of experience treating complex pediatric feeding/swallowing patients ages birth to 3.

The NICU is a different world: the medical terminology, the co-morbidities and their impact, and the fragile population. Working there, I thought of many clinical questions. Was what I saw normal feeding behavior for a preemie? A variant of normal? Immaturity? Or pathology? I started to build my knowledge base and framework for problem-solving by asking questions. I asked questions of neonatologists, nurses and respiratory therapists at every juncture. And I still do today!

So my number one tip for success in the NICU is ask questions! It paved the road for my success and will help you, too.

  1. A question is like a flashlight that we shine into the darkness allowing us to move forward into the unknown and uncertain. We can organize our thinking around what we don’t know, as a guide.
  2. For various reasons, we tend to ask fewer questions as we mature. Students get graded more for their answers than their questions. Bosses get impatient when their staff ask too many questions, especially ones that challenge assumptions.
  3. Some often stop asking questions out of fear of looking foolish or appearing uninformed. Not asking often leads us down the wrong path, be it the wrong path for diagnosis or the wrong path for intervention.
  4. Advanced clinicians contemplate these two questions, repeating the cycle many times: “Why?” and “What else?” (What else do I need to consider? What else might be the etiology? What else might make a difference?)
  5. But who has time to pause and question? We’re so used to getting quick answers on Google, but clinical questions call for a different search. You may have to follow them into unfamiliar places, grapple with them and change them over time. Einstein said: “It’s not that I’m so smart, it’s just that I stay with problems longer.”

In the NICU, answers may become obsolete or insufficient over time. Only the questions endure.

If you are thinking about moving into NICU practice, feel free to comment below, email me or read my previous posts. And stay tuned for more tips to guide your journey!


Catherine S. Shaker, MS, CCC-SLP, BCS-S, works in acute care/inpatient pediatrics at Florida Hospital for Children in Orlando. She specializes in NICU services and has published in this practice area. She offers seminars on a variety of neonatal/pediatric swallowing/feeding topics across the country. Follow her at www.Shaker4SwallowingandFeeding.com or email her at pediatricseminars@gmail.com.

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Full Spectrum Mama July 28, 2015 - 12:27 pm

As the mother of a child who spent a harrowing week in the nicu with meconium aspiration, I am heartened to hear about your involvement at this stage.
I strongly believe the sensory barrage my son endured as a newborn contributed to his sensory processing differences!
Thank you!

Alicia Mahaney July 28, 2015 - 9:14 pm

You are an inspiration for all of us trying to stay afloat in the NICU! Thank you!

Catherine Shaker July 30, 2015 - 1:48 pm

You are quite intuitive. The overwhelming sensory enveiroment of the NICU is one of the key factors that msut eb carefully managed in order to promote neuroprotection for all NICU infants, not just preemies.

Catherine Shaker July 30, 2015 - 1:54 pm

Thank you, Alicia. I so appreciate all my colleagues out there in the NICU, as I know the daily struggles we all face, from sick infants who weigh on our minds as we look for ways to help them, to keeping up with new technology and research, to constantly needing to articulate our value and our rationales. It is the parent who thanks us with a smile, or the nurse who lets us know that co-regulated pacing worked, or the neonataologist who says “We will do what you recommend.You are the expert” that keep us going. We are all here to support each other in this amazing journey of which we are blessed and honored to be a part.

Angela TOwnsend July 30, 2015 - 8:34 pm

I am in Massachusetts. Both of my children were preemies and spent a combined 5 months in the NICU and many of my nieces did as well. I have often thought of specializing in the NICU but don’t really know where to start. I was told that you need experience prior to working in the NICU but was also told that you cannot intern or be placed in a NICU. I would gladly accept and advice, guidance, or information regarding how to go about getting into the NICU. Thanks So much!!!

Catherine Shaker, MS/CCC-SLP, BCS-S August 1, 2015 - 10:51 am

Not sure if you are already working but it sounds like it. Solid pediatric Birth to Three experience provides an essential foundation for future NICU work, with exposure to and comfort with both normal and disordered infant and toddler feeding, and parental dynamics related to feeding.

You may want to look for part-time in such a setting or an extended mentorship. You will meet many NICU grads there too! If you were a CFY, I would try to get a CFY in a hospital with an NICU or in their outpatient–based Birth-to-Three program. You may want to shadow and meet the team for future opportunities.

Read as much as you can – my publications on my website and their references at the ends of the articles will guide you toward salient works. Look for a wonderful mentor who is kind and smart too!

I have designed my seminars to provide solid foundations for practice in pediatrics and the NICU. Perhaps you might be able to attend at some point.

It is true that NICU positons are hard to find, partly because we can indeed cause harm inadvertently with this fragile population but also because of the unique and challenging dynamics of the NICU team and the often volume-driven focus. Even when we come with current research, years of NICU experience and evidence-based interventions, we are often challenged daily by neonatologists and nurses to articulate our role, to dialogue about why we are recommending what we are, explain physiology, repeatedly work to change old team habits that interfere with neuro-protection, as well as evaluate and treat sick infants who are high risk and fragile.

Know that working in the NICU is a commitment that goes above and beyond and means, as I always say, you have to pick yourself up, dust yourself off and start again. With the right support in the right SLP team it can be so rewarding but still exhausting as well. It is important to know this at the start to set one’s expectations and readiness for dedication and patience. I hope this helps.

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