Clinical Focus
· · · Current Roles and Continuing Needs
of Speech-Language Pathologists
Working in Neonatal Intensive Care Units
Shanna L. Dunn
Rehabilitation Hospital ofAustin, TX
Anne van Kleeck
University of Texas at Austin
Louis M. Rossetti
University of Wisconsin, Oshkosh
This study surveyed 45 speech-language
pathologists working with infants who are
medically fragile in neonatal intensive care
units (NICUs) across the United States. It
explored current roles in the NICU setting,
considering such issues as factors affecting,
and support available for, NICU involvement,
assessment and intervention goals and
procedures, educational activities conducted,
and training levels and needs. Results demon-
strated that speech-language pathologists have
begun establishing a multifaceted role in the
n the last two decades, medical, theoretical, empirical,
political, and clinical interests in the birth-to-age-3
population have combined in complex ways to
broaden the roles of the speech-language pathologist in
working with children in this age range. One of these
newly emerging roles is that of the speech-language
pathologist in the neonatal intensive care unit (NICU).
Although other emerging roles of the speech-language
pathologist with infants and toddlers and their families
have begun to receive widespread attention in the litera-
ture, there has been little documentation of the clinical
developments pertaining to the role of the speech-language
pathologist in the NICU. The purpose of this study was to
investigate the speech-language pathologist's role in the
assessment and intervention of infants who are medically
fragile, both preterm and term, in the NICU. We used a
survey method to explore the current role, and attempted to
predict the direction in which this role is likely to be
extended in the future.
Several factors have contributed to the emergence of
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NICU setting, including providing assessments
and intervention focused on feeding and
communication interaction, and education to
medical professionals, team members, and
parents. These findings should be valuable to
other speech-language pathologists currently
considering NICU involvement. They should
also be helpful to university training programs
that are planning to develop coursework and
practicum experiences to meet the needs of
this newly emerging role.
this new role for the speech-language pathologist. One
factor is recent medical advances in NICUs that have
increased the survival rate of preterm infants-a population
known to be at risk for later developmental delays,
including communication difficulties (Fitzhardinge, 1976;
Fitzhardinge & Pape, 1981; Knobeloch & Kanoy, 1982;
Parmelee, 1981; Rubin, Rosenblatt, & Salow, 1973; Siegel
et al., 1982). Second, federal legislation supports interven-
tion as early as birth (Public Law 101-476, previously
known as P.L. 99-457). This law recognizes that "the
potential for prevention [of developmental delays] is a
mandate that cannot be denied" (Ensher & Clark, 1986, p.
11). Additionally, evolving theoretical viewpoints have
also fostered both a greater focus on serving the family and
a closer look at the positive and negative impact of
stimulation within the NICU (see Gunzenhauser, 1987, for
a detailed discussion of the stimulation issue).
The likely goals of the speech-language pathologist
working in the NICU would derive directly from increased
knowledge regarding early communication and language

development (of infants developing normally and atypi-
cally) and associated oral-motor functioning. Researchers
of atypical infant communication development have
identified why communication treatment might be an
important focus of the speech-language pathologist in the
NICU, because they have highlighted the tendency for a
limited and different communicative signaling among these
infants. We know that, without intervention, this different
signaling disrupts communication between parent-infant
dyads and may eventually lead to both the parent and the
infant withdrawing from interactions (Goldberg, 1977).
Regarding the speech-language pathologist's expertise
in the oral-motor domain, the feeding therapies tradition-
ally implemented by the speech-language pathologist with
older children who have handicaps can be adapted for
babies in the NICU (although in many hospitals this
function might be served by an occupational therapist).
Indeed, feeding is one of the infant's most critical activities
during his or her stay in the hospital. Highly nutritional and
efficient feedings provide the infant with the building
blocks to advance development within deficient and/or
immature systems.
The current study was designed to explore how and to
what extent these developments in the field have been
translated into actual practices among speech-language
pathologists who serve NICU infants and their families.
This survey study was designed primarily to explore the
current roles speech-language pathologists are serving in
the NICU, but we also hoped to shed some light on how
these roles might be likely to expand in the future. Specifi-
cally, we explored NICU roles, issues relating to them,
assessment procedures, treatment protocols and goals,
issues of relevant training, and available support systems.
Method
The data collection used in the current study was carried
out in two stages. The first group of subjects (n = 10) were
interviewed over the telephone for approximately one hour.
The second group of subjects included those responding to
a written questionnaire (n = 35). The written questionnaire
was similar to the telephone interview questions, but it also
contained revisions based on the telephone interview phase
of data collection. The method used to obtain subjects for
these two phases of the study is described below.
To initially recruit subjects for the telephone interviews,
speech-language pathologists involved in NICU services
were located by searching the literature for articles
pertaining to speech-language pathology services in
NICUs. We then contacted the authors of these papers
directly. Of five authors recruited by this method, three
were directly involved in NICU services and two were
researchers. All three authors who were directly involved
in NICUs agreed to, and subsequently completed, the hour-
long telephone interview.
With the initial five contacts, a "snowball" procedure
was initiated; that is, these contacts provided names of
other speech-language pathologists they knew to be
directly involved with intervention in the NICU. By this
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I I
method, an additional seven speech-language pathologists
involved in direct services in an NICU were identified.
These were contacted by telephone and asked to participate
in the telephone interview. All agreed, bringing the number
interviewed by telephone to a total of 10. These 10 speech-
language pathologists were located in eight different states.
All telephone interviews were tape recorded.
From the information obtained during the telephone
interviews, a written questionnaire was developed for use
with a larger sample. Again, because of the newness of
speech-language pathologist services in the NICU, there
was no straightforward way to obtain names and addresses
of speech-language pathologists who were involved in
such services. Therefore we used two different sources to
come up with a mailing list. First, during the telephone
interviews, each respondent was asked to provide the
names of all the speech-language pathologists they knew to
be involved in providing NICU services. The result was a
list of 22 speech-language pathologists who were definitely
known to be employed in an NICU, and to whom question-
naires were mailed. Second, the third author had conducted
many workshops nationwide in which the role of the
various professionals in the NICU had been addressed. He
had kept names and addresses of some workshop attendees.
Although we knew that this mailing list contained the
names of other professionals (such as audiologists and
physical therapists), as well as speech-language patholo-
gists who were interested in the infant population but did
not currently work in the NICU, we expected that this
would provide access to more speech-language patholo-
gists who provided services in the NICU. We realized, of
course, that this would make it extremely difficult to
interpret a response rate, but it appeared to be the best
strategy for recruiting a sample of the population we
wished to study. We did attempt to address this issue by
asking recipients of the mail-out questionnaire who were
not providing speech-language services in an NICU to
respond to the initial three questions that explained why
answering the questionnaire would not be appropriate
(i.e., did not work in a hospital setting, did not have an
NICU in the hospital, or did not work in the NICU). From
this mailing list of workshop attendees an additional 198
professionals were mailed questionnaires, bringing the total
number of questionnaires mailed to 220. The question-
naires went to people in 40 states; major metropolitan areas
as well as smaller cities were represented.
Though a random sampling procedure would have been
optimal, the cost of obtaining complete lists of hospitals in
order to do so was prohibitive. It should be noted that the
method we used to obtain our subjects was untraditional
and may have resulted in a somewhat biased sample.
Questionnaire Development
The goal of both the telephone and written question-
naires was to compile comprehensive information regard-
ing the newly emerging role of speech-language patholo-
gists in the NICU setting to enlighten not only the speech-
language pathology profession, but all professionals
involved in the habilitation of NICU infants.
May 1993 AJSLP 53
 The written questionnaire was developed in two stages.
First, a telephone interview questionnaire was developed
with 43 questions divided into five sections: general
information, role of the speech-language pathologist,
assessment, treatment, and support systems. The questions
were developed by reviewing the limited literature on the
role of the speech-language pathologist in the NICU, and
by visiting several NICUs. These five sections are briefly
described.
The first section, general information, was designed to
gather background information about those who were
providing services, the size and level of the facilities being
served, and the types of NICU infants being served. This
information helped define the setting where the speech-
language pathologist's role was being developed. The
second section, the role of the speech-language pathologist,
was developed to provide not only a description of what
roles speech-language pathologists were serving in their
NICUs, but also to determine what personal (endogenous)
and external (exogenous) factors affected their involve-
ment. The personal factors explored issues such as training
and professional interest. The external factors considered,
for example, the attitudes of other professionals involved
in the NICU toward incorporating speech-language
pathologist services.
The third section, assessment, was designed to deter-
mine who was being assessed, on what criteria, and in what
domains. It also examined the frequency of audiological
screenings. Treatment, the fourth section, was devoted to
what goals are typically chosen for the population of
infants who are medically fragile whom the speech-
language pathologists were treating. This section also tried
to determine the need for further information in any area in
order to better fill their role. Additionally, speech-language
pathologists were asked if there was a need to further
expand their role and, if so, what barriers were restricting
this desired role expansion. The fifth and final section,
support systems examined what support mechanisms were
in place in the NICU program; that is, which professionals
were involved in the infants' habilitation, and if these
professionals worked as a team.
To ensure the comprehensiveness of the telephone
interview questionnaire, it then underwent an independent
review and was subsequently revised before the telephone
interviews were initiated. After the telephone interviews
were completed, the information obtained was used to
further revise the questionnaire into the written version that
was then mailed out. This resulted in the written question-
naire containing one additional section on training. It was
included to address the concern of what research or
training supported the role of the speech-language patholo-
gist, and what training or skills were necessary to compe-
tently fill the role speech-language pathologists were
currently serving in the NICU (see Appendix for complete
written questionnaire).
Results and Discussion
The results of the present study were based on a high
return rate, both for the telephone interviews and mail-out
54 May 1993 AJSLP
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questionnaires. For the telephone interviews, 100% of the
10 speech-language pathologists who were contacted
agreed to and completed the one-hour interview. Of the
220 questionnaires mailed out, a total of 154 (70%) were
returned. Thirty-five questionnaires (16%) were answered
completely; those who returned the remaining 119 ques-
tionnaires had completed the initial questions explaining
why they were not appropriate for our study. The 35
speech-language pathologists who did complete the entire
questionnaire represented different NICUs in 19 states.
General Information
NICU GeneralInformation. Half (51%) of the hospitals
in which the respondents worked had less than 500 beds,
and 69% of the NICUs had less than 30 beds. Thirteen
percent of the NICUs were large, with more than 50 beds.
Two of the respondents provided services to NICUs in
more than one hospital. Just under half (49%) of the
NICUs had been in service 15 years or less.
The level of care provided by the NICU was also
examined: 67% were Level III NICUs (providing the most
comprehensive services); 16% were Level II, and only 2%
were Level I (providing the least comprehensive services).
Fifteen percent of those surveyed did not provide informa-
tion regarding the level of NICU care. Forty-four percent
of the NICUs maintained an occupancy rate of at least
85%, 31% maintained an occupancy rate of 50-84%, and
9% had an occupancy rate below 50%. Four percent
reported extremely variable occupancy rates, and 11% did
not answer this question. Eighty-nine percent of NICU
programs served sick preterm infants, with 78% serving
sick term infants. Only 53% of the programs served
healthy preterm infants.
GeneralInformation About Speech-LanguagePatholo-
gists. Most of the speech-language pathologists (58%) had
been in practice less than 10 years; 60% had been working
in NICU settings for more than 3 years. Only 11% of the
speech-language pathologists worked exclusively with the
birth-to-three population; 44% reported that they worked
with all ages; another 44% worked with birth-adolescence
(e.g., in a children's hospital). This appeared to indicate
that few speech-language pathologists were able to com-
pletely specialize their work with the NICU population.
Thirteen percent of the NICUs had had speech-language
pathologist services for less than 1 year, 47% for between 1
and 4 years, and 38% for over 5 years (one respondent did
not answer this question). Of the respondents, 54% had
other speech-language pathologists working with them in
their NICU, 56% worked full-time with the hospital, and
60% spent at least three-fourths of their time in the NICU
doing direct intervention as opposed to consultation
(educational interactions). Although most programs
required a physician's order to assess and/or treat, 9% of
the programs allowed speech-language pathologists to
assess without a physician's order, and 6% allowed them to
treat without a physician's order.
Most of the speech-language pathologists did not work
weekend hours (57%) or evening hours (60%); however,
about one-third noted they would work these hours as
 needed. Sixty-four percent of the speech-language patholo-
gists worked 10 hours or less per week in the NICU; only
9% worked in the NICU for more than 20 hours a week.
Defining Speech-Language Pathologist Roles
in the NICU
All 45 speech-language pathologists believed that part
of their role was to be a diagnostician; most also served as
a communication therapist (69%), a feeding therapist
(84%), an educator (91%), and/or in the role of providing
parent support (71%). Figure 1 shows the factors that
influenced speech-language pathologist involvement in the
NICU and what percentage of the respondents believed
them to be facilitative, inhibitive, or neutral. The factors
that most facilitated their involvement in NICU interven-
tion were training with the birth-to-three population (71%),
support from occupational and/or physical therapists
(74%), their interpersonal communication skills (89%), and
their professional interest (98%). Factors that most
inhibited their involvement included a lack of training with
the premature population (22%), unavailability of continu-
ing education (26%), and a lack of time in their caseload
(33%).
It should be noted, however, that the format used for
these questions regarding whether factors were facilitory,
inhibitory, or neutral may have created some confusion.
Some respondents may have thought, for example, that the
training they had received was facilitative, but that their
need for even more training was a prohibitive factor. Thus,
a speech-language pathologist may have responded on the
FIGURE 1. Percentage of answers that identified each factor affecting NICU involvement as facilitative, inhibitive, or neutral.
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basis that the training she or he had already received was
beneficial and, therefore, indicated that this training was a
facilitative factor. Another may have thought this training
was beneficial but not sufficient. As such, a respondent
may have indicated that current training was an inhibitory
factor.
The respondents provided varying answers when asked,
"How did you get your foot in the door?" Most often
(23%), the speech-language pathologist began working in
the NICU because the occupational and/or physical
therapist saw the need and made referrals. In some cases
(17%), communicating with and educating the physician or
nursing staff provided speech-language pathologists the
opportunity to add their expertise. Fourteen percent
established the role of the speech-language pathologist by
marketing and in-services. Some speech-language pathol-
ogy services (11%) were initiated when the speech-
language pathologist developed a program or protocol for
assessment and treatment. Other methods of establishing
speech-language pathology services (6% each) included:
the speech-language pathologist had previous practicum
experience in the NICU; the speech-language pathologist
had previous work experience in an NICU setting; other
speech-language pathologists had previously worked in the
hospital's NICU; follow-up programs for NICU graduates
were extended into the NICU; the speech-language
pathologists had previous involvement with infants who
have craniofacial disorders and thereby extended their
work to infants in the NICU; when a team of professionals
was established to work in the NICU, the speech-language
pathologist was included; and the speech-language
May 1993 AJSLP 55

pathologist used the first referral as a stepping stone,
thereby establishing the role one client case at a time.
The role of the parents of infants in the NICU varied
from one hospital to another, but few facilities reported
that the parents were uninvolved (4%). Over half of the
programs reported parent participation: 31% of the
programs reported that they encouraged the parents to
participate, and 22% said that the parents were directly
involved in the habilitation of the infant. Some of the
perceived roles of the parents included being a team
member, being a client in addition to the infant, providing
nurturance to the infant, having a lead role in care and/or
feeding, and providing carryover for treatment suggestions.
Unfortunately, our questionnaire did not probe further into
issues of family involvement with speech-language
pathologist services in the NICU. This is clearly an area in
which further research is needed.
When describing the role of the occupational therapist
and/or physical therapist, the speech-language pathologists
most frequently reported four areas: positioning, education,
range of motion, and sensory stimulation. When describing
the occupational therapist's role separately, the respondents
stated that the occupational therapist was responsible for
sensory stimulation, feeding, splinting, assessment and
treatment, working with upper extremities, and positioning.
The speech-language pathologists described the physical
therapist's role as primarily positioning, yet occasionally
they mentioned that the physical therapist was responsible
for assessment, handling, range of motion, and splinting. It
was sometimes reported that occupational therapists had
the primary intervention role in the NICU, and that both
physical therapists and speech-language pathologists
handled a smaller caseload.
Our questionnaire probed the nature of the speech-
language pathologist's education of other team members.
Respondents were asked to identify what types of informa-
tion (for example, infant communication, communication
FIGURE 2. Percentage of respondents who provided each type of information to parents, nurses, administrators (admin.) and
neonatologists (neos.)
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1
development, specific disorders, anatomy and physiology
of feeding) they were providing when educating others
(such as parents, nurses, administrators, and physicians).
Speech-language pathologists provided the parents and
nurses with the most information in all areas. Figure 2
demonstrates the percentage of speech-language patholo-
gists who provided various types of information to parents
and other professionals. Parents were most often given
information regarding the anatomy and physiology of
feeding (82%). They were least often given information
regarding specific disorders (63%) and the speech-
language pathologist's role (66%). The nurses were most
often given information regarding the role of the speech-
language pathologist (80%); they were least often given
information on specific disorders (54%). Administrators
were given little information (on an average, only 13% of
the speech-language pathologists provided information in
most areas); however, the administration was informed of
the role of the speech-language pathologist by almost half
of the respondents (46%). The speech-language patholo-
gists frequently provided the physicians with information
regarding the role of the speech-language pathologist
(71%); only 46% of the speech-language pathologists gave
them information regarding infant communication.
Assessment
Great variability was noted in the means of assessment.
Almost all (91%) of the speech-language pathologists were
using informal (systematic observations) assessment
methods; 25% were using both formal and informal
assessments. These assessments were based on a variety of
assessment measures, published and unpublished proto-
cols, and books.
Seventy-six percent of the speech-language pathologists
only assessed infants when given a physician's referral.
However, a few programs had begun reviewing all infants

and then making referrals for intervention if appropriate
(9%). Several programs also automatically assessed infants
with specific diagnoses (9%), such as bronchopulmonary
dysplasia and facial anomalies.
The domains that speech-language pathologists assessed
were also examined and, once again, variability was found.
In order of most frequently assessed, the domains included:
feeding and oral motor, 87%; communication, 73%;
cognition, 64%; respiration and phonation, 63%; emotional
state regulation, 60%; gross and fine motor, 31%.
In most programs (71%), the audiologist was doing the
audiological screenings. In other programs, the individual
performing the screenings varied (e.g., neurodiagnostic
technician, speech-language pathologist, perinatal nurse
practitioner, neurologist, or EEG technician). Only 17 of
the 45 programs (38%) were doing routine audiological
screenings on these medically at-risk infants; 53% were
done on referral. The most frequently used criteria for the
audiological screenings were previously established
protocols (31%) or the high risk register (49%).
Treatment
In most NICU programs (77%), there were no restric-
tions on the age of the infants being served by the speech-
language pathologist. Eleven percent of the respondents
volunteered that there was a restriction that the infant be
medically stable before initiation of speech-language
pathology services. Since we did not directly question this
particular restriction, it may have applied in a greater
percentage of the sampled NICUs than is apparent.
Figure 3 displays the results of individuals for whom the
speech-language pathologist provided services when
focusing on communication and feeding. Once intervention
had begun, the speech-language pathologists most often
worked on feeding with the family and the infant (89%),
and the staff and infant (82%). Over half (58%) of the
speech-language pathologists worked on feeding with the
infant alone. In terms of communication, intervention once
again was most often with the family and infant (60%),
FIGURE 3. Percentage answered who worked with each group while providing communication and feeding intervention.
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NON
and/or the staff and infant (60%); only 42% of the speech-
language pathologists worked on communication interac-
tions only with the infant. Less than one-third of the
speech-language pathologists provided communication or
feeding services focused only on the family (communica-
tion-23%; feeding-29%), or only on the staff (commu-
nication-26%; feeding-29%). These percentages
indicated that many speech-language pathologists worked
on feeding in various contexts: with the family, with the
staff, and/or with the infant alone.
Another focus of treatment for 74% of the speech-
language pathologists was treating hypo- and/or hypersen-
sitive infants. Of those treating hypo- and/or hypersensitive
infants, 23% were using vibratory techniques, and 14%
were using icing techniques as part of treatment.
From an open-ended question asking respondents to
indicate the kinds of treatment goals they implemented, it
appeared that intervention with this population is individu-
alized. Goals focused primarily on feeding (oral motor
skills, non-nutritive suck and nutritive suck, coordination
of the suck/swallow/breath sequence, and dysphagia),
communication interaction, positioning and handling of the
infant, family education, assisting in emotional state
regulation, and improving hyper- or hyposensitivity. Only
one respondent addressed environmental modification
(decreasing overstimulation of environmental effects of the
NICU environment).
Training
The percentage of respondents who had no graduate
school training, a unit within a course, or an entire course
on either the birth-to-three population or the NICU
population more specifically, is portrayed in Figure 4.
Twenty-six percent of the respondents currently working in
the NICU had had no training with the birth-to-three
population prior to graduation (not even units within a
course); 40% had had an entire course. The majority (77%)
had received no training with the NICU population in
graduate school.
May 1993 AJSLP 57
 Most speech-language pathologists obtained NICU
training after graduation through various means: self-
taught (82%, via reading journals, books, assessment and
intervention procedures), workshops (80%), and on-the-job
training (82%). Very similar percentages were reported for
means of obtaining more general training with the birth-to-
three population.
Many resources were described as being most helpful in
the speech-language pathologist's training to serve the
NICU population. The most frequent response was the
education provided by other professionals, which included
that from occupational therapists, physical therapists,
child-infant specialists, nurses, neonatologists, clinical
dietitians, and other speech-language pathologists. Hands-
on experience, research, and conferences were mentioned,
as well as neurodevelopmental treatment training and
previous practica.
Seventy-five percent of the speech-language patholo-
gists believed that changes in training could better facilitate
their knowledge and skills. They suggested that more
workshops be offered (especially focusing on the speech-
language pathologist's role), that courses dealing with this
population need to be offered (especially at the graduate
level), and that hands-on training would be the most
helpful in gaining the skills necessary to fill their role in
the NICU. In addition, they acknowledged the benefit of
videotape training and observations. They also expressed a
need for additional research to guide and validate their
NICU interventions.
Open-ended questions were asked to tap competencies
that would be recommended for speech-language patholo-
gists who are beginning to provide services in the NICU.
The speech-language pathologists' responses to these
questions presented various issues. Here are examples of
the respondents' recommendations of professional traits for
speech-language pathologists who are beginning to provide
intervention to infants in the NICU. "Be visible to all
NICU staff and don't be afraid to ask questions." "Expect
gradual acceptance, yet be persistent in asserting yourself
FIGURE 4. Percentage of respondents who had had an entire course, units within a course, or no training at the graduate level on
the birth-to-age-3 population and the NICU population.
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with medical staff to help them realize you are providing a
valuable service." "Be careful, cautious, watchful, open-
minded, and resourceful." "Keep communication open, and
explain what you are doing and why." "Be consistent while
at the same time maintaining a sense of flexibility."
"Always be a good observer while keeping a healthy fear
while treading into the unknown, and never start to think
you've learned it all." Finally, on a daily basis, the speech-
language pathologist should be sensitive to the needs of
and subtle cues from the infants by letting them "run the
show"; that is to say, "honor the child's needs by always
having a willingness to learn from the infants and about
their signals of stress."
In addition to the professional traits, it was recom-
mended that the professional's knowledge base should
include, but not be limited to:
1. neonatal neuroanatomy/-physiology
2. fetal development
3. normal and abnormal infant development in these
domains:
a. cognitive
b. communicative
c. feeding and oral motor
d. motor
e. social-emotional
4. positioning and handling of neonates
5. medical issues, terminology, and diagnoses
6. medical equipment
7. how associated problems impact on
a. developmental expectations
b. anatomy and physiology of the neonate
c. respiration
The speech-language pathologists further recom-
mended: (a) that other professionals (neonatologists, other
speech-language pathologists, occupational therapists,
physical therapists, respiratory therapists, and nurses) be
used as resources; (b) that speech-language pathologists in
the NICU maintain public relations, especially with
physicians, by attending rounds, care plans, and discharge

meetings; (c) that speech-language pathologists in the
NICU obtain and/or update information through attending
continuing education workshops (especially neurodevelop-
mental treatment training), and vast independent reading;
(d) that speech-language pathologists clarify, especially to
physicians, that their services are fulfilling a unique role
and not merely taking over in areas already well covered
by nursing; and (e) that interventions need to be provided
through a multidisciplinary team.
Of the programs represented by the respondents, 31%
offered university practicum experience or other types of
training programs in the NICU. These practicum/training
programs ranged from students only being allowed to
observe (because the supervising speech-language patholo-
gists did not feel comfortable with their students providing
direct intervention) to students being trained, and then
working in the NICU under strict supervision. Some
students had the opportunity to write goals and interact
with the families.
Also, 91% of the speech-language pathologists ex-
pressed a need for continued information. In an open-ended
question regarding the need for additional data, the speech-
language pathologists' responses varied. Some respondents
wanted general, yet concrete, ideas on how to present
speech-language programming in the NICU to doctors and
administrators. Others were interested in more information
about specific disorders; for example, (a) the characteris-
tics of the disorganized feeder as opposed to the dysfunc-
tional feeder, (b) when nipple feeding should begin with
infants who are dependent on ventilators, (c) dysphagia
concerns and development of infants with bronchopul-
monary dysplasia, and (d) strategies for dealing with hy-
persensitive gags of infants who refuse to accept a pacifier
or a nipple due to multiple intubations. Additionally, some
speech-language pathologists were concerned with
obtaining more longitudinal studies that could provide
support for the efficacy of communication intervention.
The speech-language pathologists (84%) who recog-
nized a need for expanding their role expressed a need for
FIGURE 5. Percentage of respondents who have a member of the discipline working in their NICU setting.
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M
increased consultations (earlier, more consistent, or
automatically referred for all at-risk infants), increased
education of medical personnel (especially neonatologists
and nurses), increased speech-language influence on NICU
feeding protocols, and increased involvement in facilitation
of early communication interactions. When asked about
barriers to expanding their NICU roles, the perceived
attitudes of other professionals and even parents were
mentioned. However, as noted earlier, it was also true that
other professionals helped speech-language pathologists
"get their foot in the door." The speech-language patholo-
gists seemed aware that they needed to invest time to
further educate other team members regarding the benefits
the infant would receive from intervention with a speech-
language pathologist. Time and financial concerns were
also indicated as barriers. Scheduling demands with other
populations and lack of administrative support for program
development prohibited the speech-language pathologists
from expanding their current role in the NICU. Financial
constraints surfaced as a result of (a) concern about a loss
of revenue if the team was rotated or patients were shared,
(b) limited funding and exorbitant medical expenses, and
(c) restricted funding for continuing education and certifi-
cation on assessment measures. At times, staffing of
appropriately trained speech-language pathologists and the
sometimes fluctuating caseload in the NICU were a
problem.
Support Systems
As noted in Figure 5, a number of different profession-
als were involved in the habilitation of the infants who are
medically fragile. These professionals included, in order of
most often involved to least often involved, speech-
language pathologist (100%, as this was a criterion for
responding to our questionnaire), physician (100%), nurses
(100%), parents (100%), either occupational therapist
(83%) and/or physical therapist (71%), social worker
(94%), respiratory therapist (86%), dietitian (54%),
May 1993 AJSLP 59
 psychologist (20%), and parent educator (20%).
In almost half of the programs (49%), the group of
professionals worked as a multidisciplinary team; only
31% were functioning as an interdisciplinary team.
Regardless of the service delivery approach in place, 73%
of the speech-language pathologists reported that everyone
provided information to the parents, as opposed to such
information being conveyed only by a physician or case
manager.
In many programs, there were several neonatologists
and their attitudes often differed. As previously noted, a
physician's order was required in almost all programs for
the speech-language pathologist to assess and/or treat.
When asked, "What is the physician's attitude toward
habilitative intervention within the NICU?", the speech-
language pathologists expressed that the physicians were
supportive (58%) and/or cautious (29%). Only 7% of the
speech-language pathologists rated the physician's attitude
as negative.
Many of the speech-language pathologists (37%) did
not have colleagues in the city working in NICUs with
whom to share information. Fifty percent stated that they
did not have an adequate mechanism for exchanging
information with their colleagues.
Summary
The current study demonstrated that speech-language
pathologists have begun establishing a firm diagnostic and
therapeutic role within the NICU setting throughout the
United States, a role that is multifaceted. Speech-language
pathologists are providing assessments, intervention
focused on feeding skills and communication interaction,
and education to medical professionals, other professional
team members, and parents.
In the present study, the speech-language pathologists'
involvement in the NICU assessment and intervention was
most facilitated by their training with the birth-to-three
population, their professional interest, their interpersonal
communication skills, and support provided by the
occupational therapist and/or physical therapist. Factors
that most inhibited their involvement included lack of time
in their caseload, lack of training with the premature
population, and lack of availability of continuing educa-
tion. Intervention was primarily focused on feeding goals,
and was carried out with the family and the infant, or the
staff and the infant. When working on communication
goals, the intervention again was most often with the
family and infant, or the staff and infant.
The issue of training yielded multiple suggestions for
further expansion in the specialized work with infants who
are medically fragile. The speech-language pathologists
expressed a need for formal coursework at the graduate
level to address the unique considerations during assess-
ment and intervention of preterm and neonatal infants who
are medically fragile. Further suggestions included
practicum opportunities, workshops geared specifically for
speech-language pathologists working in NICUs (including
hands-on training), videotape training, and observations in
NICUs with experienced professionals.
60 May 1993 AJSLP
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Nearly every respondent saw a need for expanding his
or her current role within the NICU. Primarily, the respon-
dents reported a need for increased consultation in order to
become involved with the infants' habilitation earlier and
more regularly. The respondents also acknowledged the
need to enhance the education of medical professionals
regarding the role of the speech-language pathologist in the
NICU, and how the speech-language pathologist's exper-
tise could improve infants' functioning. The most fre-
quently stated prohibitive factors expressed were lack of
time and funding, insufficient or inadequately trained staff,
and perceived attitudes of other team members.
The respondents often noted that supportive and
coordinated services (a team approach) are important when
providing services for infants who are medically fragile.
Most programs had at least six or seven team members
(including the parents). This large number of individuals
dealing with an infant who is medically fragile requires
coordinated and supportive teamwork. Unfortunately,
rather than having an integrated team approach, almost half
of the programs were operating with a multidisciplinary
team approach in which the specialists assess and treat the
infant separately. Given the relative newness of the speech-
language pathologist's role, it was reassuring that in over
half the NICU programs, the respondents had colleagues in
the hospital with whom they could share information.
However, despite the support from neonatologists and
colleagues in the hospital, half of the speech-language
pathologists stated that they did not have an adequate
mechanism for exchanging information with their col-
leagues.
Although conducted with a limited and potentially
biased sample, this survey nevertheless demonstrated that
speech-language pathologists have begun establishing
service delivery for infants who are medically fragile in the
NICU and their families. However, the work has only just
begun. There is a need to initiate speech-language pathol-
ogy services in more NICUs and to expand the range and
improve the quality of NICU services already being
provided, as well as a need to document the efficacy of
such treatment. These goals can be accomplished only by
concerted efforts on multiple fronts-by educators in
training institutions, by researchers, and by speech-
language pathologists already working in NICUs.
Acknowledgments
We would like to thank Fredric Jablin for his assistance
regarding survey methodology and Shirley Sparks for her
suggestions when we were developing our questionnaire. We are
also grateful to two anonymous reviewers and to Jeanne Wilcox,
all of whom provided extremely helpful comments and guidance.
References
Ensher, G. L., & Clark, D. A. (1986). Newborns at risk:
Medical care and psychoeducationalintervention. Rockville,
MD: Aspen.
Fitzhardinge, P. M. (1976). Follow-up studies on the low birth
weight infant. Clinics in Perinatology,3, 503-515.
Fitzhardinge, P. M., & Pape, K. E. (1981). Follow-up studies of
 the high risk newborn. In G. B. Avery (Ed.), Neonatology:
pathophysiology and management of the newborn. Philadel-
phia: J. B. Lippincott.
Goldberg, S. (1977). Social competence in infancy: A model of
parent-infant interaction. Merrill-PalmerQuarterly,23, 163-
177.
Gunzenhauser, N. (Ed.). (1987). Infant stimulation:Forwhom,
what kind, when and how much? Skillman, NJ: Johnson &
Johnson.
Knobeloch, C., & Kanoy, R. C. (1982). Hearing and language
development in high risk and normal infants. Applied
Research in MentalRetardation,3, 293-301.
Parmelee, A. H., Jr. (1981). Auditory function and neurological
maturation in preterm. In S. L. Friedman & M. Sigman (Eds.),
Preterm birth and psychologicaldevelopment. New York:
Academic Press.
Rubin, H. A., Rosenblatt, C., & Salow, B. (1973). Psychologi-
cal and educational sequelea of prematurity. Pediatrics,52,
352-363.
Siegel, L. S., Saigal, S., Rosenbaum, P., Morton, R. A., Young,
A., Berenbaum, S., & Stoskopf, B. (1982). Predictors of
development in preterm and term infants: A model for detect-
ing the at risk. Journalof PediatricPsychology, 7, 135-148.
Received February 6, 1992
Accepted January 11, 1993
Contact author: Shanna Dunn, 505 Kathleen, Austin, TX 78641
Key Words: Neonatal intensive care unit, NICU, speech-
language pathologist, preverbal communication interven-
tion, infant feeding intervention

Appendix

Written Questionnaire-The role of the speech-language pathologist within the neonatal intensive care unit

General Information

1. Are you currently employed in a hospital setting? (Circle one) a) yes b) no

IF NO: Please stop and RETURN THE SURVEY.
Thank you for your time.

2. Is there an NICU in your hospital? a) yes b) no

IF NO: Please stop and RETURN THE SURVEY.
Thank you for your time.

3. Do you work in the NICU? (Circle one) a) yes b) no

IF NO: Please stop and RETURN THE SURVEY.
Thank you for your time.

4. What state do you live in?

5. When and where did you receive your degree?

6. How many years have you been in practice?

7. How many years have you been in the NICU?

8. Are there other speech-language pathologists working in your NICU? a) yes b) no If yes: How many?
9. What disorder areas do you currently work with?

10. What age populations do you work with (0-3, adult, adolescent)?

11. How large is your hospital (number of beds)?

12. How large is the NICU (number of beds)?

13. How long has the NICU been in service (number of years)?

14. What is the typical occupancy rate in the NICU (percentage)?

15. What is the level of your NCU? { } Level I { } Level II { ) Level lII

16. What groups of infants do you serve in the NICU? { } sick term { sick preterm { healthy preterm

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 I

Role of the Speech-Language Pathologist

1. How many years have speech-language pathologists provided services in the NICU?

2. How many speech-language pathologists provide services in the NICU?

3. What is your employment status in the hospital? (Circle one) a) contract b) full-time c) part-time

4. Do you work evening hours? Weekend hours?

5. Are physician's orders necessary? (Yes or No) a) to assess b) to treat

6. How many hours a week do you spend in the NICU?

7. What percentage of your time in the NICU is direct service (hands-on intervention)? Consultative (educational interactions)?

8. What roles do you serve? (Check as many as apply) { } diagnostician ( } hearing screenings { } educator
{ } parent support ( } communication therapist { } feeding therapist { } communication facilitator only as it relates to feeding
{ } referrals to other support services { } assist in the transition from NICU to home ({ assist in the transition from NICU to
other agencies { } other (Please specify)

9. To which people do you supply the following types of information?

Parents Nurses Administrators Physicians
a) infant comm. { } { } { } {
b) comm. development { } { } { } {
c) specific disorders { } { } { } {
d) role of speech-language pathologist in NICU { } { ) { }
e) anatomy of feeding { } { } { } { }
f) physiology of feeding { } { } { } { }
10. How does each factor affect your INVOLVEMENT in the NICU?
Facilitates Inhibits Neutral
a) time in your caseload { } { } { }
b) current training w/ 0-3 population {I { }
c) current training w/ premature population { } { }
d) support from neonatologists { } {
e) support from nursing staff { } { } {
f) support from physical/occupational therapist { } { }
g) support from administration { } { } { }
h) funding within hospital's budget { } { }
i) types of speech-language pathologist services allowed to bill for { } {
j) your interest in this population { { } { }
k) your interpersonal skills in interacting with other NICU professionals { } } { { }
I) availability of continuing education { } } { }
m) other (Please specify)
[Please feel free to elaborate on any factor above to provide further understanding of individual circumstances.]
11. How did you get your "foot in the door"?

12. What is the physical therapist/occupational therapist's role in the NICU?

13. What is the parents' role in the NICU?

Assessment
1. Who is assessed? (Circle one) a) all infants in the NICU b) referrals from physicians only
c) infants with specific diagnosis; if so which diagnosis d) other (Please specify)

2. What type of assessment do you do? (Circle one) a) informal: systematic observations
b) formal: developed scale or measure If formal measures are being used, which ones?

3. Which domains are being assessed? { communication { } cognitive { } gross/finemotor

{ feeding/oral motor ( } respiration/phonation ( } emotional state regulation { other (Please list)
4. When are audiological screenings being done? (Circle one) a) routinely b) on referral
c) not done because:

5. Who is doing the audiological testing?

6. What are the criteria for audiological screenings? (Circle one) a) protocol b) high-risk register c) birthweight

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 Treatment
1. Who do you work with when doing communication and feeding intervention? (Check as many as apply)
Communication Feeding/oral motor
a) family alone { } {
b) family and infant { } {
c) staff alone {
d) staff and infant {
e) infant alone { } { i
2. What are typical kinds of goals written for your NICU infants? (Please list. Use another sheet if necessary.)
3. Are there any restrictions on the age of infants for whom the speech-language pathologist is allowed to provide services? (Circle one)
a) no b) yes If yes: Please specify
4. Do you treat hypo- and/or hypersensitive (tactile defensive) infants? (Circle one) a) no b) yes
If yes: Does treatment include { } icing { } vibratory stimulation

Training
1. What type of specialized training did you have before graduation?
0 to 3 years NICU infants
a) entire course { } { }
b) units within other courses { } { }
c) none { } { }
2. What type of specialized training did you have after graduation:
0 to 3 years NICU infants
a) self-taught methods (i.e., reading journals,
books, assessment &intervention procedures) { } { }
b) workshops, seminars, conferences { } { }
c) on the job training { } {
d) none {

3. Are there any references you would recommend? (Circle one) a) no b) yes
If yes: Please list.

4. Who or what has been most helpful in training you to serve the NICU population?

5. How can the training procedures be adapted to better facilitate your knowledge and skill of intervention with the NICU population?

6. Do you have recommendations for those starting to provide intervention to infants in the NICU? a) no b) yes
If yes: Please describe.

7. What skills are required for a speech-language pathologist to be a competent service provider in the NICU?

8. Does your speech and language department offer university practicum experience or other types of training programs in the NICU?
a) no b) yes if yes: Please describe briefly.

9. Do you see a need for continued information in any areas? (Circle one) a) no b)yes
If yes: Please describe what further data you would like.

10. Where could this information be obtained? { } further research

{ }increased CEU/inservice training { } other professional domains (Please specify)
11. Do you see a need for expanding your role (further intervention) within the NICU? (Circle one) a) yes b) no
If yes: Please explain.
If yes: What barriers are in place that might prevent achieving this expanded role?

Support Systems
1. Who is involved in the treatment of the NICU infant's habilitation? { } speech-language pathologist { } psychologist
{ } occupational therapist { } chaplain { } physical therapist { } socialworker
{ } parent educator { } dietician { } respiratorytherapist { } nurse
{ } physician { } parent
2. Which service delivery approach is used? (Circle one) a) interdisciplinary b) transdisciplinary
c) multidisciplinary d) consultation e) other (Please specify)

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 3. Who is responsible for providing information to the parents? (Circle one) a) everyone b) case manager
c) nursing staff d) neonatologist e) other (Please specify)
4. What is the physician's attitude toward habilitative intervention within the NICU?
{ supportive { } neutral { } cautious { } negative
{ } other (Please specify)

5. Do you have colleagues who are working in the NICU with whom you share information?
Yes No
a) inyour hospital { }
b) in your city { } { }
c) in your state { } { }

6. Do you have an adequate mechanism for exchanging information with colleagues? (Circle one)
a) no b) yes

7. Would you be interested in sharing your name, address, and/or phone number for a national neonatal network for speech-language
pathologists?
a) no b) yes
If yes: Please print the information or maintain confidentiality by sending the information separately.

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