Neonatal Therapists' Perceptions of Using Integrated Collaborative Care in the Neonatal Intensive Care Unit

Sarah Elkington, University of Texas at El Paso


Occupational therapists (OTs), physical therapists (PTs), and speech-language pathologists (SLPs) who have advanced clinical knowledge in gestational and infant development can work in neonatal intensive care units (NICUs) as neonatal therapists (NTs). NTs apply their developmental expertise, therapeutic use of self, and client-centered training to create individualized goals for infants and families amid a complex, critical care medical setting. Each discipline (OT, PT, and SLP) brings a unique professional perspective and their own empirical knowledge to the NICU. Researchers have made efforts to capture work trends of NTs as they relate to direct patient care; however, researchers have also recognized the potential role NTs have within NICUs to influence and impact policy and unit culture. Integrated collaborative care (ICC) is a term that describes how healthcare professionals manage, organize, and integrate patient care coordination with an aim to ensure patient wellness. There are several proposed frameworks of ICC; however, ICC can be defined differently according to the stakeholders in any given healthcare setting. Previous publications about neonatal therapy in the NICU focus primarily on NTs’ service availability (i.e., full-time equivalents), interventions provided, and professional competency and qualifications to work in the NICU. NTs work as part of a team of healthcare professionals in the NICU; team collaborative care and workplace relationships have been the topics of recent research because workplace relationships have been associated with patient safety, improved shared-decision making, and cost savings. Collaborative care models often include roles that NTs may hold on a NICU team, but do not specifically require an NT. No identified studies have investigated the characteristics of neonatal professional teams with a focus on the role of NTs. Additionally, how OTs, PTs, and SLPs in the NICU perceive their work both as individual disciplines and with a shared identity as NTs has not been described. Additionally, how NTs define ICC in the NICU setting has not been explored. This doctoral work used a two-phase research study to explore how NTs perceived they used ICC in the NICU among themselves, and among other neonatal healthcare professionals.Phase 1 was a scoping review that explored the published ICC models or descriptions of practice specific to the neonatal intensive care setting that include a role for NTs and are available to guide neonatal therapy practice patterns. Phase 2 involved a qualitative multi-case research study where six individual teams of NTs were interviewed using a semi-structured interview template. From the thematic analysis of the transcribed interviews, research results yielded operational (daily work tasks) and relational (how co-workers relate) themes. Additionally, a definition of ICC from the NTs’ perspective was determined from interview responses. The first manuscript presented in this dissertation (Chapter 2) represents a scoping review that included 28 articles that had either a stated or inferred role for NTs. Of those 28 articles, only 13 articles specifically stated a role for NTs. Other roles could be held by any number of healthcare disciplines. The included articles were organized by which of seven aspect(s) of ICC were represented. Few articles representing integration among or between settings were identified. Additionally, there were limited articles representing NTs in leadership roles. The conceptual distinction between ICC and family-centered developmental care was difficult to discern within the literature.The second manuscript presented in this dissertation (Chapter 3) describes operational aspects of ICC in the NICU. Four themes were presented following hybrid thematic analysis. Themes included: 1) Feeding decisions are a source of collaboration and conflict; 2) Co-assessment and co-treatment are logistical strategies to meet infant needs; 3) Service planning and the ripple effect of leadership; and 4) Collaborative culture impacts NTs’ empowerment. The operational themes transected all identified aspects of ICC. Operational themes described daily care coordination and integrative characteristics among NTs, and between NTs and other NICU professionals. However, the themes also alluded that the decisions that leaders make impact staffing patterns, hiring patterns, and unit culture, all of which also influence the quality of relationships.The third manuscript (Chapter 4) added further insight into the results of Phase 2 of the study and described relational care themes. These themes included: 1) Learning together leads to growth and respect among peers; 2) Interpersonal relationships: the connective tissue of the unit’s daily operations; 3) Intentional actions facilitate trust and respect among peers; and 4) Poor relationships threaten ICC. Themes supported relational coordination theory, which supposes that communication ties and relationship ties mutually reinforce each other. The latter two articles demonstrate that operational and relational themes are inter-related. Operational work tasks are heavily influenced by how leaders assign service availability, and their understanding of the nature of a neuroprotective, habilitative approach which differs from a rehabilitative approach in other acute care settings. Visibility in the NICU supports respectful and trusting work relationships between NTs and other NICU staff, but especially between NTs and nursing and medical staff. Perceptions of belonging and inclusion on unit quality improvement committees empowers NTs. ICC in the NICU supports the theory of relational coordination. The frequency of communication, attitudes of co-workers, and the support leaders provide to establish a collaborative culture potentially influence the quality of patient care. Relationships with infants and families as well as with co-workers influence how well NTs perceive the integration of their unit. Relationships are built over time and through frequent interactions regarding a shared goal or purpose. Chapter 4 presents strategies NTs can use to improve relational coordination and thus ICC in their workplaces. Chapter 5 provides a model summarizing how ICC functions in the NICU setting based on research results as well as a definition of ICC from the participants’ perspective generated by inductive thematic analysis. Future studies are indicated to validate the presented model and to explore the value of ICC and relational coordination to patient and family outcomes as well as staff well-being.

Subject Area

Occupational Therapy|Health care management|Speech therapy

Recommended Citation

Elkington, Sarah, "Neonatal Therapists' Perceptions of Using Integrated Collaborative Care in the Neonatal Intensive Care Unit" (2023). ETD Collection for University of Texas, El Paso. AAI30485492.