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The development of a neonatal communication intervention tool
Esedra Strasheim
Alta Kritzinger
Department of Communication Pathology, University of Pretoria
Brenda Louw
Department of Audiology and Speech-Language Pathology, East Tennessee State University
Correspondence to: E Strasheim (esedra1@gmail.com)
ABSTRACT
Neonatal communication intervention is important in South Africa,
which has an increased prevalence of infants born with risks for
disabilities and where the majority of infants live in poverty. Local
literature showed a dearth of information on the current service
delivery and roles of speech-language therapists (SLTs) and
audiologists in neonatal nurseries in the South African context. SLTs
have the opportunity to provide the earliest intervention, provided
that intervention is well-timed in the neonatal nursery context. The
aim of the research was to compile a locally relevant neonatal
communication intervention instrument/tool for use by SLTs in neonatal
nurseries of public hospitals. The study entailed descriptive,
exploratory research. During phase 1, a survey was received from 39
SLTs and 2 audiologists in six provinces. The data revealed that
participants performed different roles in neonatal nurseries, which
depended on the environment, tools, materials and instrumentation
available to them. Many participants were inexperienced, but
resourceful in their attempts to adapt tools/materials. Participants
expressed needs for culturally appropriate and user-friendly
instruments for parent guidance and staff/team training on the topic of
developmental care. During phase 2, a tool for parent guidance titled Neonatal communication intervention programme for parents was
compiled in English and isiZulu. The programme was piloted by three
participants. Suggestions for enhancements of the programme were made,
such as providing a glossary of terms, adapting the programme’s
language and terminology, and providing more illustrations. SLTs and audiologists must contribute to neonatal care of high-risk infants to facilitate development and to support families.
Keywords: developmental
care, early communication intervention, neonatal communication
intervention, neonatal nursery, public health context
Comprehensive management in the neonatal nursery includes not only
medical treatment of the infant but also developmental care and the
provision of guidance, counselling and information to the family who
are part of the decision-making process regarding the infant’s
care (ASHA, 2005). A programme that has shown positive results for
premature infants is the Newborn Individual Developmental Care and
Assessment Programme (NIDCAP) (Als et al.,
2004). This programme requires specialised training based in the USA,
which makes it inaccessible to most South African professionals.
Kangaroo mother care (KMC) has been shown to be a safe alternative for
Third-World countries, where 96% of the world’s premature infants
are born (Bergman, Linley & Fawcus, 2004). The effectiveness and
safety of KMC is well established (Bergman, Malan & Hann, 2003) and
it is regarded as an important developmental care practice for
developing, as well as developed, contexts (Bergman et al., 2004).
In South Africa’s public health sector, early communication
intervention (ECI) services to neonates are less developed and less
comprehensive in comparison with those of a developed country such as
the USA (Kritzinger, Louw & Hugo, 1995). While the role of the
speech-language therapist (SLT) in the neonatal intensive care unit
(NICU) is clearly described in international literature (ASHA, 2005;
Rossetti, 2001; Ziev, 1999), currently no guidelines for service
delivery in the NICU in the South African context exist (De Beer, 2003).
SLTs who are employed in South African provincial hospitals are
often faced with difficult working conditions, such as lack of
community awareness of services, inadequate instrumentation and tools,
insufficient services of trained interpreters and limited literacy of
caregivers (Fair & Louw, 1999). The diversity of language and
culture in South Africa poses a challenge for SLTs in providing
family-centred early intervention services (Louw & Avenant, 2002).
Current health care policies in South Africa prioritise care of
mothers and young children, as can be seen in legislation that
emphasises the provision of free primary health care to children under
the age of 6 years (National Health Act, 2003). Although ECI may be
regarded as a component of services to women and young children, it is
still not a health care priority in South Africa. The undervalued
perception of ECI is not only due to the HIV/AIDS pandemic, but also to
the limited knowledge about the benefits of ECI, a shortage of ECI
facilities and early communication interventionists, an insufficient
referral system and poor teamwork (Kritzinger, 2000).
In a study conducted by H. Louw (2007) regarding ECI service
delivery in public hospitals in four provinces in South Africa, it was
concluded that some of the high-risk infants and families were still
not receiving linguistically appropriate services. A shortage of
qualified and trained interpreters was also identified (H. Louw, 2007),
which presents an obstacle to effective ECI service delivery in public
hospitals. South Africa has 11 official languages, of which isiZulu is
the most commonly spoken (24%) with English in 5th place (8%)
(Population Census Key Results, 2001); English is the language most
commonly spoken by SLTs. Language differences may pose a considerable
barrier to effective understanding between professionals and families
(Madding, 2000). H. Louw (2007) found that only 11% of the respondents
in her study worked with trained interpreters at their hospitals. Since
the multilingual nature of the South African population creates
barriers to service delivery, it necessitates different approaches to
intervention.
The shortage of SLTs who can provide ECI and initiate prevention
campaigns (Fair & Louw, 1999) and the insufficient number of
therapists in the public hospital context result in large caseloads.
Another challenge to ECI in South Africa is a dearth of apparatus and
materials for the assessment and treatment of high-risk and at-risk
infants. H. Louw’s findings (2007) indicated that 93% of
community service SLTs employed in Mpumalanga, Western Cape,
KwaZulu-Natal and Gauteng in the public health sector expressed the
need for more culturally and language-appropriate materials
specifically designed to address the unique needs of the South African
community. The results confirm the earlier findings of Kritzinger et al.
(1995) that there are limited diagnostic tools developed from a
speech-language pathology and audiology perspective for neonatal
assessment and management.
In South Africa, poverty is a characteristic of the majority
of the neonatal population requiring ECI. Poverty in itself may not be
the direct cause of developmental problems in young children, but
family conditions such as malnutrition, inadequate prenatal care,
exposure to infectious diseases and toxicants in utero,
unsafe living conditions, living with parents who are addicted to
alcohol or drugs and inadequate educational opportunities are all
common in circumstances of poverty (Thompson, 1992). Certain risk
conditions associated with communication disorders, such as low birth
weight, cerebral palsy, fetal alcohol spectrum disorder and HIV/AIDS,
also have a higher prevalence in South Africa than in developed
countries (Kritzinger, 2000; Swanepoel, 2004). The high prevalence of
conditions affecting young children is of significance to SLTs, as
these conditions can be related to many developmental disorders but
more specifically to communication delays and disorders (Kritzinger,
2000; Rossetti, 2001).
ASHA (2004) states that SLTs have the responsibility to fulfil
ECI roles using practices that are based on research, family-centred,
culturally and linguistically appropriate, developmentally appropriate
and collaborative. The execution of these responsibilities and
functions is dependent upon a well-developed theoretical and clinical
foundation. Evidence-based practice is a framework for clinical
decision making that entails the integration of best research evidence
with clinical expertise and patient values (Johnson, 2006). According
to Louw (2007), basing clinical decisions on scientific research is
fundamental to ethical practice in ECI. In order to fulfil the roles
and responsibilities in neonatal communication intervention
effectively, the SLT requires certain tools. Local research already
provides guidelines to useful training strategies. Gani (2004) found
materials based on the Hanen programme (Pepper & Weitzman, 2004) to
be useful in training a group of caregivers in communication
stimulation in a care centre, and a positive effect on caregiver-child
interaction patterns was determined.
Best practice in developmental care in neonatal nurseries needs to
be encouraged and facilitated, which necessitates the development of
appropriate tools for the local context. ASHA (2005) urges
speech-language pathologists to develop culturally appropriate
programmes that meet the needs of ethnically and linguistically diverse
families. Culturally and contextually appropriate tools and programmes
for neonatal communication intervention therefore need to be developed
for the South African context, in order to serve the unique high-risk
population in South Africa in an effective and ethical manner.
The unique contextual reality of South Africa should be taken into
account. To be contextually relevant, tools should be based upon an
expressed need within a given context. If based on Western models of
communication stimulation, these tools should be adapted appropriately
for the South African context. Because of the diversity of cultural
groups in South Africa, overseas tools and programmes cannot merely be
translated (Visser, 2005). The interdependent relationship between
culture and language must be carefully considered during cross-cultural
service delivery, otherwise the tool will still not be suitable even
once translated (Pakendorf, 1998). It may also be beneficial to
consider other adaptations in order to bridge additional challenges
such as limited literacy among caregivers. According to Louw, Shibambu
and Roemer (2006), literacy issues may be overcome by using visual
sources such as pictorial illustrations and demonstrations, as written
materials are not necessarily viewed as important, especially by
individuals with low literacy levels.
To propose a solution to address the dearth of tools in the public
health context, a survey was conducted to determine the perceptions of
SLTs and audiologists providing services in provincial hospitals in
South Africa. The aim of the survey was to investigate the role of SLTs
in the neonatal nurseries and to identify participants’ needs in
terms of neonatal communication intervention instruments/tools. This
information was utilised to compile a preliminary instrument/tool based
on the selection of one of the perceived needs of the participants.
Method
Aim
The overall aim of this study was to compile a locally relevant
neonatal communication intervention instrument/tool for use by SLTs in
the neonatal nurseries of public hospitals.
The following objectives were formulated in order to reach the main aim:
• to describe the perceptions of SLTs and audiologists
providing ECI services in provincial hospitals in South Africa
regarding their role in the neonatal nurseries
• to identify participants’ needs in terms of neonatal communication intervention instruments/tools
• to select and justify a specific need of the participants in
terms of neonatal communication intervention instruments/tools in the
public hospital context
• to compile a preliminary instrument/tool based on the selection of one of the perceived needs of the participants
• to pre-test the completed instrument/tool and make changes, if necessary.
Research design
For the purpose of this study a descriptive, exploratory study within the quantitative and qualitative frameworks of research design was selected.
Ethical considerations
Ethical clearance to conduct the study was obtained from the
Research Ethics Committee of the Faculty of Humanities, University of
Pretoria. All participants gave written informed consent. Data were
treated with confidentiality and no identifying information of the
participants or their hospitals was reported.
Participants
All the participants in this study had to provide ECI to infants in
a neonatal nursery such as an NICU, a neonatal high-care ward or a KMC
ward, as this study specifically focused on the participants’
needs regarding neonatal communication intervention. Permission was
obtained in writing from 6 of the 9 provinces contacted, namely
Gauteng, KwaZulu-Natal, Eastern Cape, North West, Northern Cape and
Mpumalanga. The Departments of Health of the Free State, Western Cape
and Limpopo provinces did not respond within the time constraints of
this study, which further reduced the population available for the
research. The provincial health departments were requested to provide
statistics regarding the number of SLTs and audiologists employed at
the hospitals in their province, as well as to provide each
hospital’s contact details. The potential participants targeted
for the study were contacted telephonically at the hospitals to explain
the aim of the study and discuss participation. All participants who
responded were included in the study.
Questionnaires were sent to 175 SLTs and audiologists in public
hospitals in the six provinces. A total of 41 SLTs and audiologists
returned a completed questionnaire, a return rate of 23%. The responses
obtained are therefore not representative of speech-language therapy
and audiology services in the public health sector in South Africa. The
majority of participants worked mostly at district or regional
hospitals, as well as at community outreach clinics. They mostly
provided ECI in neonatal high-care units and KMC units of their
hospitals. Most participants appeared to be inexperienced in providing
neonatal communication intervention services. They may have been
without supervision, as most participants were the only
SLTs/audiologists employed at their hospital and had limited access to
interpreters and assistants. The participants’ characteristics
are displayed in Table I.
Research process
The research was conducted in two sequential phases.
Data collection: phase 1
A self-designed questionnaire was selected as the data collection
tool to conduct the survey. A pilot study was conducted to pre-test the
questionnaire which provided recommendations to enhance its efficacy
and practicality. The questionnaire was e-mailed or faxed to the
potential participants during phase 1 of the study. The first section
gathered biographical data, which was used to describe the participants
and to interpret the data from other sections of the questionnaire. The
following section enquired about the service delivery regarding ECI in
the hospital, task allocations, contexts for ECI (NICU, neonatal high
care, KMC) and the participants’ functions and roles in terms of
assessment and intervention with the infant, parents or staff. The
questionnaire enquired about the participants’ needs in terms of
service delivery, their perceptions of culturally appropriate and
user-friendly tools, and their needs in terms of tools regarding
assessment, intervention directed at the parents/caregivers and
intervention directed at the staff/team.
Data analysis: phase 1
Frequency distribution was set up from the raw data to obtain an
overall view of the data (Maxwell & Satake, 2006). Descriptive
statistics were used to examine the data and to graphically display the
data (Maxwell & Satake, 2006). The qualitative data were presented
as detailed textual descriptions, and phase 1 included direct
quotations from participants (Fossey, Harvey, McDermott & Davidson,
2002).
Method: phase 2
The needs analysis in phase 1 informed the type and the format of
the tool, which was compiled during phase 2. The tool could therefore
only be compiled after the results of phase 1 were obtained. For this
reason, the instrument/tool was pre-tested in a pilot study as part of
phase 2 and presented in the results. The evaluation of the training
tool entailed descriptive data, which were analysed according to
recurring themes.
Validity
In this study SLTs’ and audiologists’ perceptions of
their roles, their competence, work satisfaction and their needs were
constructs that could not be measured directly. The construct validity
could therefore be influenced by the participants’ subjective
opinions and by the wording of questions in the questionnaire. The
content of the questionnaire was reviewed by a statistician to
determine whether the questions were relevant and appropriate for
statistical purposes. The construct and content validity of the
questionnaire were determined by making use of a pilot study, and
certain changes were implemented according to the recommendations made.
Because of the small sample size, the results of this survey were
not representative of the perceptions of all SLTs and audiologists
employed in government hospitals. Therefore no attempt will be made to
generalise the findings.
Reliability
The questionnaire was piloted to determine whether any items were
misleading or unclear, which could result in participants
misinterpreting some items. The pilot study therefore also contributed
to the reliability of the questionnaire. The data collection procedures
were described in detail, contributing to the repeatability of the
study and thereby increasing its reliability.
Results and discussion: Phase 1
Participants’ roles in the neonatal nursery
Figure 1 illustrates that some participants performed roles in the
NICU that require specialised equipment, such as hearing evaluation and
video-fluoroscopy. Video-fluoroscopic instrumentation is not readily
available at all hospitals and is usually only found in tertiary or
academic hospitals because of the costs involved, which explains why
few participants performed this role. This finding can be explained by
the fact that most of the participants were employed at district or
regional hospitals that would not have specialised equipment such as
video-fluoroscopy. Participants appeared to be performing
multidimensional professional roles relating to screening and
assessment, which is attributed to their awareness of the risks of
development problems in the areas of attachment and communication
development in infants with low birth weight and preterm birth.
The majority of the participants reported that they fulfil a number
of roles in direct intervention with infants and parents, as seen in
Figure 2. Most SLTs were the only SLT/audiologist employed in their
department and had large caseloads, which possibly did not leave time
to engage in discharge planning and planning of follow-up services.
Because patients come from a wide geographical area and have limited
finances and transport to return to the hospital or clinic, regular
follow-up services are a problem area in the South African public
health sector (Fair & Louw, 1999). Given the nature of the South
African context, the roles performed by the participants need to be
expanded and adapted to meet local needs to improve neonatal
communication intervention service delivery.
According to Figure 3, most participants appeared to be aware of the
impact they might have in this context through teamwork, as this is
preferred practice because of the benefits for the infant, the family
and the SLT. Early intervention in the NICU should follow a
transdisciplinary team approach (Rossetti, 2001).
However, in-service training of staff members was not yet performed
by all facilities, and their service delivery was limited by poor
attendance of ward rounds. Ziev (1999) describes this function as an
opportunity to learn from others and to become a familiar face among
team members, as well as to request referrals based on infants’
symptoms or histories. As mentioned earlier, many participants were the
only SLT/audiologist employed in their department, which may have
limited the time available for them to attend neonatal ward rounds as
they may have been involved in other paediatric or adult ward rounds,
clinics or consultations. This is problematic as many participants had
limited experience, which resulted in missed opportunities in the
neonatal nursery.
Two of the participants in this study were qualified as
audiologists only. Only one of the two audiologists performed hearing
screenings, which is ascribed to the fact that hearing screening
equipment is not readily available in government hospitals (Theunissen
& Swanepoel, 2008). Both audiologists worked as part of a
team and consulted with other team members in accordance with
ASHA’s guidelines for audiologists (2008B). Current literature
emphasises the importance of ongoing audiological and medical
monitoring of any child who demonstrates risk indicators for delayed
onset or progressive hearing loss for at least 3 years (Northern &
Downs, 2002). Interestingly, both audiologists also assisted in
discharge planning and planning of follow-up treatment/management after
discharge, while only half of the larger group of 39 SLT participants
performed this role. This may be due to a lack of infant follow-up
clinics at many district or regional hospitals. Families need
information, consistent encouragement, reassurance, and positive
feedback regarding their competency and ability to cope with the birth
and hospitalisation of their critically ill newborn (Northern &
Downs, 2002).
Participants’ needs in the neonatal nursery
An overview of the needs of the SLTs as determined in phase 1 was
compiled in Table II. The 5 most frequently indicated needs are
highlighted, namely tools for parent guidance (4 topics), a tool for staff and team training (1 topic) and an assessment tool (1 topic) (2 needs in 4th place).
ECI services are required to be family-centred, as well as
culturally linguistically responsive (ASHA, 2008A). Neonatal
communication intervention services therefore cannot be effective
without culturally appropriate tools. An urgent need for culturally
appropriate materials for use in the neonatal nurseries of provincial
hospitals was identified. Participants were aware of the importance of
providing culturally sensitive services, but were hampered by the
dearth of tools and materials that could be utilised in clinical
practice.
Phase 1 demonstrated that participants performed different roles in
neonatal nurseries, which were determined by the environment, tools,
materials and instrumentation available to them. Although many
participants were relatively inexperienced, they were resourceful in
their attempts to develop and adapt tools and materials. The fact that
these self-developed and adapted tools are not research-based
compromises the quality of services and precludes best practice. The
participants expressed a need for culturally appropriate and
user-friendly instruments specifically for parent guidance and
staff/team training. These descriptive findings justified the
compilation and development of a locally relevant instrument/tool for
use in public hospitals’ neonatal nurseries.
Results and discussion: phase 2
The compilation of a neonatal
communication intervention tool
A tool regarding parent guidance with the topic of developmental care
was selected as the tool to be compiled, as this was a need indicated
by the majority of the SLT participants. Most participants were also
involved in services directed at parents/caregivers in the neonatal
nursery. The
‘Neonatal
communication intervention programme for parents’ aimed to
provide SLTs in local public hospitals with a programme to educate and
guide parents/caregivers of infants in the neonatal nursery regarding
developmental care, early reciprocal interaction and appropriate
stimulation of their infants. Adult-learning principles were utilised
in the compilation of the programme. Guidelines to teach adult learners
consider mature learners as independent and self-directed (Kaufman,
2003).
The researcher formulated an aim as well as outcomes for the
programme (Popich, 2003). The structure and sequence of the programme
as conceptualised is illustrated in Figure 4. The programme is divided
into four sections, which include an introduction with ‘warm-up
time’ and definitions, information on the behaviours of the
neonate, information on how parents may respond to these behaviours,
and a conclusion that informs parents of options for follow-up services
and provides time for reflection and questions. Informal terminology
was used to make the language more accessible to the
parents/caregivers. The term ‘baby’ is used in the
programme instead of ‘infant’ as this is the term most
commonly used by South African parents in conversation (Popich, 2003).
It was decided that the programme should consist of a Microsoft
PowerPoint presentation and a handout for parents. The PowerPoint
presentation was provided in two different formats as it allows each
clinician to select a method that is conducive to his/her working
environment. Some SLTs and audiologists in public hospitals have
limited technical resources, and the PowerPoint presentation was
therefore provided on a compact disc as well as transparencies.
Handouts were provided to parents during the programme to generalise
and reinforce the newly learnt information as well as to actively
involve each parent during the presentation. The handout included
photos and images to manage literacy barriers. The content of the
handout was translated into isiZulu by a private translation service to
address language barriers. IsiZulu was selected as it is the home
language of almost a quarter of South Africans and is the language most
spoken in South Africa (Population Census Key Results, 2001).
The programme was pre-tested in a pilot study, which concluded that
the programme was enjoyed by the parents who received the training. It
was further determined that the content was appropriate but that the
programme should be more concise and shorter so as to be more
user-friendly. The parent handout was deemed suitable for the training.
Certain suggestions for enhancements of the programme were made during
the pilot study, such as providing a glossary of terms with definitions
for therapists to use and adapting the programme’s language and
terminology.
Clinical and theoretical implications
The current research identified and attempted to fulfil a need
expressed by SLTs and audiologists. The study managed to achieve the
aim of compiling a programme for SLTs for use with parents and
caregivers in the neonatal nurseries in South African provincial
hospitals. This study highlighted the role of the SLT and audiologist
in terms of prevention of communication delays
and disorders. This research is an example for SLTs and audiologists in
the public health sector on how to use adult education principles in
parent training to prevent communication delays and disorders in
infants. The programme could also be used for raising awareness of ECI services
within a certain community. South Africa has an increased prevalence of
infants at risk for communication disorders (Kritzinger, 2000), and
marketing of ECI among the general public, as well as health care
workers, should therefore be a priority of local SLTs working in the
public health sector. According to ASHA (2008a) ECI services must
promote children’s participation in natural environments, which
include community settings outside the home environment, where children
without disabilities participate. Community work increases the existing
professional knowledge on diverse communities within South Africa,
which presents therapists with the opportunity to implement prevention
programmes such as adult training (Popich, 2003). This study emphasised
involvement in community work and not only in the lives of individual families.
The research could be used as an example of caregiver training within a
specific community in order to reach more infants and toddlers in need
of ECI services and to improve the current services in communities.
This study highlighted information on the roles of SLTs and audiologists in the neonatal care of high-risk infants in the public health sector.
This research gathered valuable information regarding the roles and
responsibilities of SLTs and audiologists in local NICU, neonatal
high-care and KMC nurseries. It can therefore be used to guide future
attempts to compile local guidelines for SLTs in the NICU.
Conclusion
The study complied with the guiding principles for best practice in
ECI (ASHA, 2008a) as it aims to be family-centred, culturally and
linguistically responsive and developmentally supportive, to promote
children’s participation in their natural environments, to be
comprehensive, co-ordinated and team-based, and is based on evidence.
This research therefore contributed to neonatal care of high-risk
infants in South Africa.
The increased prevalence of infants at risk for communication
disorders in South Africa (Kritzinger, 2000) necessitates early
interventionists to become involved in clinical and research efforts to
develop ECI services for provincial hospitals. SLTs and audiologists
not only have an essential role to fulfil in the neonatal nursery, but
also have an ethical responsibility to develop creative solutions for
challenges arising from service delivery in the South African public
health context. SLTs and audiologists must contribute to neonatal care
of high-risk infants to facilitate their optimal development.
Acknowledgements. The
authors would like to thank the professionals who participated in this
study and who are committed to early communication intervention.
The corresponding author (esedra1@gmail.com) may be contacted for more information about obtaining
the ‘Neonatal communication intervention programme for parents’.
Authors’ note.
Since the article was accepted for publication, SASLHA has adopted
revised guidelines for early communication intervention, which include
specific guidelines on neonatal communication intervention. The
document may be obtained from the Ethics and Standards Committee
(2011). Guidelines: Early Communication Intervention. www.saslha.co.za
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Fig. 1. Speech-language therapists’ indication of their roles regarding screening and assessment of the high-risk infant (N=39).
Fig. 2. Speech-language therapists’ roles in intervention specifically directed at the infant and parents/caregivers (N=39).
Fig. 3. Speech-language therapists’ roles in intervention specifically directed at staff and team members (N=39).
Fig. 4. Structure and content of the programme.
Table I. Characteristics of the participants
Professional qualifications
SLT – 49%
SLT & audiologist – 46%
Audiologist – 5%
Provinces where employed
Eastern Cape – 5%
Gauteng – 8%
KwaZulu-Natal – 25%
Mpumalanga – 29%
Northern Cape – 28%
North West – 5%
Years of experience in government sector
1 year or less – 25 participants
2 years – 6 participants
3 years – 3 participants
5 years or more – 6 participants
Contexts of service provision
Clinics/community health centres – 26 participants
(participants indicated more than one working context)
District/regional hospital – 30 participants
Tertiary/academic hospital – 12 participants
Other – 1 participant
Wards where EI was provided
NICU – 14 participants
Neonatal high-care unit – 23 participants
Kangaroo mother care ward – 20 participants
Number of SLPs and/or audiologists in the department
1 – 15 participants
2 – 10 participants
3 - 5 participants
4 or more – 11 participants
Trained interpreters or assistants at their disposal
Yes – 10%
No – 90%
Table II. Speech-language therapists’ needs (N=39)
Need
No. of responses (
N
=39)
No. who indicated need
%
Hierarchy 1 - 14
Assessment tools
Neonate’s communication development
36
15
41.6
9
Feeding
34
15
44.1
8
Mother-child communication-interaction
33
16
48.4
7
Neonatal nursery environment
33
19
57.5
3
Parent guidance tools
Neonatal nursery environment and staff
36
24
66.6
1
Paediatric dysphagia and feeding therapy
34
18
52.9
5
Over-stimulation, identifying infant’s stress cues
35
19
54.2
4
Developmental care
35
19
54.2
4
Kangaroo mother care (KMC)
35
8
22.8
14
Communication interaction with infant
35
12
34.2
11
Developmental milestones and follow-up after discharge
34
9
26.4
12
Normal communication development
36
9
25.0
13
Staff/team training tools
Developmental care
36
23
63.8
2
KMC & ECI
35
13
37.1
10
Role of the SLT in the neonatal nursery
36
19
52.7
6
Highlighted sections indicate the most frequently mentioned needs.