American Speech-Language-Hearing Association

Knowledge and Skills

Knowledge and Skills Needed by Speech-Language Pathologists Providing Services to Infants and Families in the NICU Environment

Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit (NICU)


About this Document

This knowledge and skills document is an official statement of the American Speech-Language-Hearing Association (ASHA). The document was prepared by the Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit (NICU). Members of the committee were: Justine J. Sheppard (Chair), Joan C. Arvedson, Alexandra Heinsen-Combs, Lemmietta G. McNeilly, Susan M. Moore, Lisa A. Newman, Meri S. Rosenzweig Ziev, and Diane R. Paul (ex officio). Alex F. Johnson and Celia Hooper served as monitoring officers (vice presidents for speech-language pathology practices, 2000–2002 and 2003–2005, respectively). The ASHA Scope of Practice (2001) states that the practice of speech-language pathology includes providing services for communication, cognition, feeding, and swallowing problems. The ASHA Preferred Practice Patterns (1997) are statements that define universally applicable characteristics of practice. Speech-language pathologists who practice independently in the NICU environment and provide services to infants and families are required to hold the Certificate of Clinical Competence in Speech-Language Pathology and abide by the ASHA Code of Ethics (2003), including Principle of Ethics II Rule B, which states: “Individuals shall engage in only those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience.” This document was approved by ASHA's Legislative Council (LC SLP/SLS 10-2003) in November 2003.



Recent attention to recognizing the role of speech-language pathologists (SLPs) providing services in the Neonatal Intensive Care Unit (NICU) environment has resulted in the development of a position statement and technical report (ASHA, 2004a, b). These documents are designed to define roles and responsibilities, evidence-based practice, and the needs in research and education. This knowledge and skills document further delineates the essential areas of competent practice in the NICU. Recognizing the significant impact of development of communication, cognition, feeding, and swallowing in the developing infant, it is essential that speech-language pathologists possess the knowledge and skills to be proficient in the delivery of team based services to preterm and medically compromised infants and their families.

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Basic Competencies

The purpose of this document is to outline the knowledge and skills needed by speech-language pathologists to provide services to infants and their families. These knowledge and skills areas form the basis for assessing clinical competence in this specialized area of practice. Knowledge and skills are related to culturally appropriate, team based, family-centered, ecologically based, developmentally appropriate assessment and intervention practices. The knowledge and skills specific to serving infants within the NICU environment focus on communication, cognition, feeding, and swallowing in the developing infant within the context of the family.

In addition, speech-language pathologists who assess and provide intervention with infants at risk or who are identified with communication, cognition, feeding, and/or swallowing disorders should have a primary knowledge base of the following:

Knowledge required:

  • Normal embryology, perinatal, and postnatal infant development including an understanding of current research in neurobiology, physiology, and genetics as they relate to infant behavior.

  • Atypical infant development which includes theories and research findings, risk factors in prenatal and perinatal development, etiologies, and medical conditions.

  • Family-centered practices including the impact of the NICU experience on family dynamics and function, information about family systems, parent-infant interactions, parent empowerment, and meaningful professional alliances.

  • Team-based processes that involve ethical decision-making, interactions with multiple disciplines, respect for differences in the perspectives of multiple disciplines, and legal issues.

Specialized knowledge is also needed in the following areas:

  • Foundations of developmentally supportive care (e.g., synactive theory, behavioral state organization).

  • Medical complications affecting infants as well as the medical equipment and procedures used in the NICU.

  • Staffing patterns in the NICU.

  • Ecology of the NICU.

  • Parenting in the NICU.

The specific knowledge and skills required to meet these basic competencies are presented in detail in the remainder of this document.

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Roles and Knowledge and Skills

The following roles, knowledge bases, and skills enable the speech-language pathologist to provide a continuum of services for infants and families in the NICU with regard to communication, cognition, feeding, and swallowing, family, caregiver, and staff education and clinically based research. These areas include, but may not be limited to, the following:

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Communication and swallowing/feeding evaluation

1.0 Role: Identification of infants at risk for and with existing developmental communication, cognition, feeding, and swallowing problems.

Knowledge of:

  1. Normal embryology, anatomy, physiology, behavioral organization and self-regulation, and pathophysiology of infant communication, cognition, feeding, and swallowing in a developmental framework.

  2. Etiologies and medical/surgical conditions that indicate risk for communication, cognition, feeding, and swallowing problems.

  3. Normal developmental continuities from prenatal to neonatal and infant stages.

  4. Psychosocial and cultural aspects of the family relative to the social-emotional development of the infant.

  5. Risk factors related to psychosocial and cultural aspects of the family.

  6. Strategies for identification of infants at risk for communication, cognition, feeding, and swallowing problems.

Skills:

  1. Recognize, observe, and interpret signs and symptoms of potential problems in infant communication, cognition, feeding, and swallowing problems.

  2. Gather information of relevant medical history and current status of the infant.

  3. Participate as an integral member in team based decision-making.

  4. Recognize the presence of disruptions or disabilities in infant communication, cognition, feeding, and swallowing functions.

  5. Educate caregivers and staff to identify the presence of disruptions or disabilities in infant communication, cognition, feeding, and swallowing functions.

  6. Gather information of psychosocial and cultural aspects of the family.

2.0 Role: Conduct clinical assessment of the infant and family for communication, cognition, feeding, and swallowing problems, including neurodevelopmental assessments.

Knowledge of:

  1. Anatomic structure, physiology, behavior, and neurodevelopment in preterm and term infants.

  2. The significance and implications of disruptions in expected development and function.

  3. Various oral, non-oral (enteral) feeding methods to establish and maintain hydration and nutrition.

  4. Developmentally appropriate and culturally sensitive assessment tools and procedures used with infants and their families.

  5. The strengths and limitations of the clinical assessment and the need for additional procedures.

  6. How to provide documentation and contribute to team based decision-making.

Skills:

  1. Perform developmentally appropriate assessment of structure and function that includes, but is not limited to, reflexes, postural control, state regulation, interactive abilities, prefeeding behaviors, oral feeding and swallowing behaviors, and other oral sensory motor functions.

  2. Identify normal and abnormal structure and function.

  3. Determine potential and timing for transition from non-oral to oral feeding and for advancing non-oral as well as oral feeding.

  4. Interpret assessment findings.

  5. Apply appropriate criteria for determining the need for and referring for additional procedures necessary to make management decisions (e.g., videofluoroscopic instrumental swallow studies, endoscopic assessments of swallowing function, , pulmonary testing, pH probe, scintigraphy).

  6. Use cervical auscultation as an adjunct to clinical observations for appreciating breath sounds and timing of swallowing.

  7. Document and communicate findings and recommendations with families, other caregivers, and members of the NICU team in a concise, thorough, and objective manner.

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Feeding and swallowing evaluation

3.0 Role: Conduct instrumental evaluation of the infant for feeding and swallowing problems.

Knowledge of:

  1. Existing instrumental techniques, including their advantages and limitations (e.g., endoscopic examination).

  2. Cervical auscultation.

  3. The variability and developmental progression of swallowing behaviors in pre-term and other young infants.

  4. Techniques to modify procedures for exploring the variables that may impact an infant's swallowing behaviors.

  5. The variability in findings for specific pathologies and their relevance as a part of team based decision-making for management.

  6. How to provide documentation that is concise, thorough, objective, and contributes to team-based decision-making.

Skills:

  1. Identify appropriate testing resources (e.g., equipment, personnel).

  2. Recommend appropriate instrumentation techniques as indicated.

  3. Perform appropriate instrumental assessments according to accepted professional practice.

  4. Interpret instrumental assessment.

  5. Document and communicate findings and recommendations with families, other caregivers, and members of the NICU team in a concise, thorough, and objective manner.

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Communication and feeding/swallowing intervention

4.0 Role: Provide support and intervention/treatment for the infant's communication, cognition, feeding, and swallowing problems (evidence-based when available).

Knowledge of:

  1. Developmental sequences in acquisition of preverbal audition, including attention to and recognition of sounds in the environment, and communication, including, gesture, vocal behaviors, and cognition.

  2. Development of sensory systems.

  3. Development of the infant's sensory competencies and their relevance for self-regulation and learning.

  4. Synactive system of behavioral organization and developmentally supportive family-centered care.

  5. Strategies to facilitate parent-infant interactions, infant communications, caregiver understanding of strategies, and to establish the foundation for the ongoing development of the infant's communication and cognitive skills.

  6. Oral versus non-oral (e.g., parenteral and enteral) intake methods and medical and behavioral risks.

  7. Existing intervention procedures for communication, cognition, feeding, and swallowing disruptions.

  8. Advances in intervention and potential application from other fields.

  9. Appropriateness and safety for specific intervention procedures.

  10. Ethical and quality of life issues to incorporate into decisions concerning the care of the infant.

  11. Cognitive, communication, behavioral, psychological, cultural, and social issues that may have an impact on the care of infants and their families.

  12. Status of various genetic, medical, and surgical conditions underlying communication, cognition, feeding, and swallowing disabilities and their impact on advancement or deterioration of skills.

  13. Documentation procedures.

Skills:

  1. Provide developmentally appropriate and family-centered care (e.g., environmental modulation, appropriate positioning and handling, timing of interventions).

  2. Read, interpret, and respond to infant's behavioral cues.

  3. Facilitate development of basic skills for advancing communication, cognition, feeding, and swallowing.

  4. Determine readiness for interaction and intervention, and adjust interaction on the basis of variability in responses, including appropriate modes for nutritional intake.

  5. Identify acceptable and appropriate oral intake methods.

  6. Develop intervention strategies appropriate to infant's medical or surgical condition, behavioral status, and swallowing safety and competencies.

  7. Identify potential risks of aspiration and physiologic compromise to recommend and implement appropriate precautions to minimize those risks.

  8. Identify measurable short- and long-term treatment goals targeting functional outcomes.

  9. Use evidence base as available for selecting intervention strategies and making management decisions.

  10. Document management decisions and changes in decisions overtime.

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Parent/caregiver education and counseling and staff (team) education

5.0 Role: Provide education, counseling, and support to families, other caregivers, and staff regarding preferred practices in the NICU to support current and future communication, cognition, feeding, and swallowing skills.

Knowledge of:

  1. Principles of instruction.

  2. Counseling principles.

  3. Prenatal to postnatal continuities relative to communication, cognition, feeding, and swallowing.

  4. Psychobiology of early learning in the fetus and neonate.

  5. Cultural values and their impact on professional practice in the NICU.

  6. Family systems, family dynamics, parent-infant interactions, and approaches to family empowerment.

  7. Developmentally supportive care and family-centered practice.

  8. Ethical decision-making processes.

Skills:

  1. Identify educational and counseling needs of families, other caregivers, and staff.

  2. Provide education, counseling, support, and empowerment strategies for families, other caregivers, and staff.

  3. Adjust content and delivery, in the context of cultural values, to the specific needs of the persons being educated, counseled, and supported.

  4. Provide education for varied purposes and venues (e.g., rounds, staffings, and in-service educational programs).

  5. Provide advocacy for infants and families.

  6. Document education, counseling, and support provided.

  7. Evaluate effectiveness of the education, counseling, and support provided.

  8. Participate in developmentally supportive care and family-centered practice.

  9. Participate in ethical decision-making processes.

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Parent/caregiver education and counseling. Staff (team) education and collaboration

6.0 Role: Collaborate with other team members in identifying the need for additional assessments and consultations.

Knowledge of:

  1. The roles and responsibilities of all professionals on or associated with the NICU team.

  2. The implications of the infant's condition and the family concerns as they relate to the need for additional information to resolve issues of comprehensive care.

  3. Related assessments and procedures that may facilitate comprehensive care of the infant.

  4. Models of collaborative team based decision-making.

Skills:

  1. Delineate the roles of the SLPs and identify roles of other professionals on the NICU team.

  2. Apply knowledge to initiate timely and pertinent referrals.

  3. Use appropriate referral procedures.

  4. Participate with other professionals in interpreting information and planning culturally appropriate interventions.

7.0 Role: Collaborate with the family and other team members regarding management decisions for care of the infant and family.

Knowledge of:

  1. The roles and responsibilities of team members in management of infants and their families in the NICU environment.

  2. The specialized expertise of team members pertinent to assessment and intervention of infants with communication, cognition, feeding, and swallowing disruptions and disabilities.

  3. The techniques or processes in effective facilitation and maintenance of team communication and interaction.

  4. Team management and service delivery models.

  5. The appropriate methods of documentation that delineate team decisions and recommendations.

  6. The data and procedures that are needed to support SLP participation as an integral member of the NICU team (e.g., cost accounting and productivity factors).

  7. Knowledge of the impacts of cultural beliefs, values, and practices on team interactions.

Skills:

  1. Identify core team members and supportive services.

  2. Facilitate culturally appropriate and family-directed communication among team members.

  3. Participate as an integral member in team based decision-making.

  4. Document team activity and data for supporting the SLP as an integral team member to maximize quality of care.

  5. Acknowledge and respect multiple perspectives of culturally diverse families and other team members.

  6. Acknowledge and respect professional perspectives of all disciplines involved in the NICU.

  7. Demonstrate use of a solution focused approach to resolution of differences and conflicts among team members.

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Other roles

8.0 Role: Maintain quality control/risk management program.

Knowledge of:

  1. Quality improvement policies established by accrediting bodies.

  2. Institution-specific risk management policies and procedures.

  3. Appropriate performance indicators that are evidence- based with focus on outcomes for quality improvement program development.

  4. Methods used for measuring and monitoring quality improvement goals and processes.

  5. Processes for resolution of identified problems that include collaborative team efforts.

  6. Infection control procedures.

  7. Risks and consequences of aspiration and other health issues (e.g., nutrition, hydration, apnea, bradycardia).

  8. Causes and precipitating factors for aspiration and other health issues (e.g., tachypnea, apnea, bradycardia).

  9. Ways to reduce risk of aspiration and other negative health consequences.

  10. ASHA's Code of Ethics and Scope of Practice in Speech-Language Pathology.

  11. Institution-specific policies and procedures affecting risk management.

  12. Professional and institution-specific documentation policies and procedures.

  13. Patient safety measures and universal precautions as pertinent to specific setting and institution guidelines (e.g., CPR, suctioning, radiation safety).

Skills:

  1. Identify quality improvement indicators that are appropriate to meet requirements or standards for specific accrediting bodies.

  2. Perform systematic measurements and monitoring of quality improvement indicators.

  3. Resolve identified problems through collaborative team efforts.

  4. Identify and communicate risk factors to families, other caregivers, and team members.

  5. Use appropriate risk management procedures (e.g., resolution of identified risk factors, routine revision of quality improvement monitors).

  6. Document quality improvement plans, goals, and processes for reaching desirable outcomes.

9.0 Role: Provide discharge/transition planning and follow-up care.

Knowledge of:

  1. How to facilitate parental follow-up and implementation of intervention procedures.

  2. How to facilitate transition from NICU to home and community-based follow-up services (e.g., birth-to-three programs).

  3. Discharge criteria

  4. Discharge needs, how to establish a team-oriented discharge plan to transition to community-based programs, and coordinate required services.

  5. Determining criteria for follow-up care and transitioning to community-based intervention programs to meet identified needs.

  6. Appropriate documentation of discharge criteria, discharge plan, and transition to follow-up care

  7. How to access team recommendations pertinent to follow-up care in the community and procedures for medical follow-up and community-based birth-to-three programs.

Skills:

  1. Identify discharge criteria.

  2. Identify discharge needs for infants and their families.

  3. Participate in NICU team discharge planning.

  4. Identify the need for follow-up care and transitioning to community-based intervention programs to meet identified needs.

  5. Document discharge criteria, discharge plan, and follow-up care.

10.0 Role: Educate and supervise SLPs, including clinical fellows and students-in-training.

Knowledge of:

  1. Previous course work and current proficiency of the trainee.

  2. Education principles.

  3. Supervision principles.

  4. Requisite documentation requirements.

  5. The methods of evaluating trainee performance.

Skills:

  1. Identify education and clinical training needs.

  2. Apply education techniques.

  3. Provide supervision.

  4. Document teaching and supervision.

  5. Evaluate teaching effectiveness.

11.0 Role: Provide public education and advocacy for serving infants and families in the NICU.

Knowledge of:

  1. Public education sources and procedures for increasing awareness of families and their NICU infants with special needs.

  2. Available education resources designed to assist pertinent education and advocacy positions.

  3. Advocacy, legal, and regulatory procedures that affect the needs of infants and their caregivers as they transition from the NICU to the community.

  4. Funding sources pertinent to birth-to-three programs as indicated by IDEA.

Skills:

  1. Demonstrate skills in methods for public education and advocacy regarding the needs of families and their infants in the NICU with risks for communication and feeding/swallowing difficulties.

  2. Provide testimony to various governmental, regulatory, and educational agencies.

  3. Provide assistance in obtaining funding for services from appropriate sources.

12.0 Role: Conduct basic and clinical research in fetal and neonatal development and function and effectiveness of treatments.

Knowledge of:

  1. Existing literature in normal development and disorders of communication and feeding/swallowing skills in term and preterm infants.

  2. Research design.

  3. Appropriate methods for protecting human and animal subjects and obtaining informed consent.

  4. Accurate data collection techniques.

  5. Procedures for statistical analyses and interpretation.

  6. Scientific writing for dissemination of research findings.

Skills:

  1. Obtain and interpret literature.

  2. Develop and apply research design.

  3. Collect data.

  4. Ability to keep up with new information and make appropriate adjustments.

  5. Carry out procedures for statistical analysis.

  6. Demonstrate skills in writing dissemination of research findings.

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References

American Speech-Language-Hearing Association. (1997). Preferred practice patterns for the profession of speech-language pathology. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2001). Scope of practice in speech-language pathology. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2003). Code of ethics. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2004a). Roles of speech-language pathologists in the neonatal intensive care unit: Position statement. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2004b). Roles of speech-language pathologists in the neonatal intensive care unit: Technical report. Rockville, MD: Author.

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Index terms: newborns, early intervention, neonatal intensive care units

Reference this material as: American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists providing services to infants and families in the nicu environment [Knowledge and Skills]. Available from www.asha.org/policy.

© Copyright 2004 American Speech-Language-Hearing Association. All rights reserved.

Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.

doi:10.1044/policy.KS2004-00080

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