Transcript for
The lived experience of infants in neonatal intensive care – part two

Dr Natalie Duffy (00:00): 

If you can give yourself the opportunity to slow down and to go at the baby’s pace to see what they’re communicating, then that is one way to be able to get you both on the same path. And I would argue that you then have a connection with your patient and they become a person, an individual, with all these hopes and dreams for the future. And then your care is not just about their physical health, it’s about their holistic care. 

Narrator (00:32): 

Welcome to the Emerging Minds podcast. 

Vicki Mansfield (00:38): 

Hi, I’m Vicki Mansfield and you’re listening to an Emerging Minds podcast. 

(00:43): 

Before we start today’s episode, we would like to pay respect to the traditional custodians on the land on which this podcast is recorded, the Wurundjeri people. We also pay respect to all Aboriginal and Torres Strait Islander peoples, their ancestors and elders, past, present, and emerging from different First Nations across Australia. 

(01:06): 

Welcome to episode 2 of The Lived Experience of the Infant in the Neonatal Intensive Care Unit. 

(01:12): 

In episode 1, Dr. Natalie Duffy described the vulnerability which infants and parents can experience within the neonatal intensive care unit. And she also shared the resilience and strength families display as they navigate the physical and emotional challenges of this time. 

(01:30): 

In today’s episode, we continue to explore with Natalie, her PhD findings about what infants are communicating and needing, and we look at how health professionals can listen and respond in ways that promote the healing power of relationship for growth and connection. 

(01:50): 

Natalie, from your data, what can we learn about infants’ needs in NICU? 

Dr Natalie Duffy (01:54): 

Pleasingly, we’ve just had our first paper published, which just feels incredible and it’s also fantastic to be able to honour the babies and know that this is important work and it’s getting out there. But our first paper that we’ve just published is kind of an overview of the whole experience and we broke that experience down into themes. 

(02:14): 

So our first theme is called scary and safe, and that really encompasses the inherent tension within the NICU. Neonatal care saves lives, but the environment and the place in which that’s happening and the baby is growing and thinking and feeling is scary, and it’s foreign and it’s hostile. And those are words that were used by people in interview. And I could see the babies reacting through their physiology, the way they were moving and holding their bodies, the way they were organising their states of alertness, or even their ability to respond to what was going on. I could see all the changes and what the babies were communicating depending on what thing was happening in that bright and in that very loud environment. 

(03:01): 

And part of the data is also my own reflections. And I think for that particular theme, it was really quite powerful to just sit there, to not have another responsibility. My responsibility was to be with that baby and understand what was happening. So that meant that I could kind of see it for… It was almost like being woken up, like seeing it again, hearing it, feeling it, smelling it, which doesn’t always happen on the day to day. 

(03:28): 

We moved on to talk about another theme, which is all the hard things, and that encompasses all of the physical things that happen to a baby, all of the procedures, all of the interventions, and just what they might feel like for the baby themselves and their response to all of these different necessary life-saving interventions, but just kind of gave us a window into how perhaps we could approach those things differently. 

(03:55): 

We talked earlier about how parents are on this big emotional rollercoaster, and I saw that in the babies also. They’re experiencing this really varied emotional response to this environment, and that was our third theme. 

(04:11): 

And then most importantly, I think in our fourth theme, we pulled out the human side of NICU, and this theme’s called moments of meeting. And there were these incredible moments of meeting, predominantly between the babies and their parents, but also between the babies and the staff members where the hustle and bustle faded away and the babies were able to be with that safe and responsive caregiver, and you get the impression of them feeling safe, of them feeling known and heard and understood, and that in those moments, we’re helping their emotional wellbeing and helping them for the future. 

(04:52): 

The MBO gave me a framework to think about babies’ behaviours and to think about how they are using their behaviours and their cues to communicate. So when a baby was with their parent, perhaps they were skin-to-skin. So that is when a baby’s just wearing their nappy and their skin is touching the bare chest of their parent and they’re together. So you can imagine in that moment that their physiology, so all the things that we look at on the monitor, their respiratory rate, their heart rate, their oxygen numbers, everything was nice and calm, their colour was normal for them because if babies are stressed, their colour might go red or they might even go a bit mottled or white around the mouth, for example. But in these moments of calm and connection, they looked calm, their physiology was normal, their colour was normal, there wasn’t too much digestive disturbance or positing or maybe passing wind. 

(05:51): 

And the babies were then either asleep, so organised enough in their states to be asleep, or they might have been awake, but their bodies were also calm. They were holding themselves flexed, which is the safest way for a baby to hold their posture. Their movements, if they were having movements, were quite fluid and organised, or their bodies were still. 

(06:15): 

And in that moment, and hopefully I kind of painted a picture that if the baby feels so calm and relaxed, then the parent is also calm and relaxed, and their behaviours are mirroring one another. And if the baby’s awake, they’re then actually able to share in moments of connection. And that’s what it’s all about for a newborn baby, trying to organise their behaviours, organising their state of alertness so they can be responsive, so they can be interactive and attune with the person that’s there with them. 

(06:48): 

So there were moments of real calm when everyone was perhaps sleeping. But then I saw these powerful moments where babies were having shared eye contact with their parents. They were maybe having a story or they were just sharing in little stories that are important to them, their beliefs and their culture and the babies felt seen, heard and interacted with. And we know that in those moments, that’s when the baby’s brains are growing and developing. And the sleep that we seen when everything was calm, that’s when they store their memories and they’re able to remember these things and wire all their synaptic connections for really positive growth and development. 

Vicki Mansfield (07:33): 

Yeah. And that’s such a beautiful image that you described in that it gave a real felt sense of that being safe and connected and nurtured, but at the same time, all of the amazing things that are happening for their brain and growth and development. I’d imagine it’s been really powerful for people to have that deep dive into the infant’s experience. 

Dr Natalie Duffy (07:56): 

I think so. The MBO allows us to talk about baby behaviours that first-time parents or even second-time parents might not necessarily have thought about in quite a way or in such a structured way anyway. 

(08:12): 

And I mentioned that the first paper has now been published, but the next papers are a real deep dive into the relationships themselves. So we know that a baby experiences their world through this complex system of relationships, and how a baby experiences relationships in NICU is different to how they experience relationships out in the community. So we’re now going to focus on what it’s been like for the baby in their experience to form connections and relationships with their parents and then with their healthcare providers. 

Vicki Mansfield (08:48): 

And from the point of view of healthcare professionals and the systems of care that surround our infants, what changes might be considered? 

Dr Natalie Duffy (08:57): 

From the staff side of things and… It’s really complicated and there is so much to learn from and so much to probably understand. And I think one of the powerful things is going to be about that intersection that I spoke of of when neonates met infant mental health for me. Maybe we need to all work collaboratively together to do that on a much bigger scale and really foster connection, empower clinicians through things like this, learning and going out and finding other ways. You’re already doing a great job, you’re already providing great care, but we can always do it better. And maybe using principles from different disciplines is the way forward for that. But I think teamwork is hugely important in NICU. It’s important in all disciplines in medicine, isn’t it? 

(09:49): 

And allowing yourself the time to reflect, I have to do that. I have to give myself the opportunity to pause and reflect and think about how my emotions and my experiences are impacting on the care that I’m providing. The hustle and the bustle and the acuity of NICU is overwhelming. I need to remember to slow down and be with and connect with the babies and their families to be able to provide the care that I want to. I think sometimes also it’s about remembering that it doesn’t need to be perfect, that we’re all human, but just showing up and wanting to connect is really, really important. 

Vicki Mansfield (10:31): 

How does the pace of the infant and the pace of the care environment impact how a practitioner can keep infant and toddler in mind? 

Dr Natalie Duffy (10:41): 

The pace can be different for both. And the pace of the baby and the pace of the clinician, we’re sometimes not on the same page because of the complexity and because of the acuity. NICU’s life-saving. We’re doing incredible work every day, but it’s not always emergency work. So then I think in the moments when we, in our day-to-day work in NICU, we have to really slow down and we have to be truly infant-focused if we can be, and go at the pace of the baby. Because this is a whole new world to them. Even if they weren’t in NICU, the world is fast-paced and loud and bright and completely different to what they were experiencing in the womb, and we need to afford them the opportunity as all to take a breath and slow down. And I think that’s when we come back to babies’ behaviours. 

(11:38): 

So if you can attune with their behaviours, if you can give yourself the opportunity to slow down and to go at the baby’s pace to see what they’re communicating, then that is one way to be able to get you both on the same path. And I would argue that you then have a connection with your patient, and they become a person, an individual with all these hopes and dreams for the future. And then your care is not just about their physical health, it’s about their holistic care, and we’re sending babies off into the world to live happy and healthy lives. 

Vicki Mansfield (12:15): 

And in lots of ways, my sense of that is that you’re creating quite a change in the care environment. There’s this really intentional kind of awareness of the infant’s experience, bringing that to life, validating that, and that that’s a changing culture in some ways it may be in terms of our care environments as well. 

(12:39): 

And I know you’ve mentioned before that one of the steps that you’ve taken to kind of operationalize that is the co-authoring the Newborn Traffic Light Tool. Yeah. Is that a tool that brings into the practicality, the ways of things that you’ve been talking about in terms of observing babies, responding to them? 

Dr Natalie Duffy (12:59): 

The Newborn Traffic Light Tool has… I’ve had the opportunity to co-author that within a group of colleagues that span neonatal intensive care, infant psychiatry, perinatal mental health, and the traffic light tool uses the framework of the MBO. Babies communicate with us through their behaviours, and those behaviours are quite organised, and we think about them in terms of different categories. And then within the categories, we think about their behaviours on a traffic light metaphor. 

(13:33): 

So red behaviours being I’m completely stressed and dysregulated, and I need you to use your nurturing hands, your soothing voice, your touch to make me feel better. Amber signals where the babies are starting to show dysregulation, and we need to, again, provide that comfort and care, through to their green cues where they’re able to be responsive and interact. And my colleague came up with this idea of using that metaphor and applying those behaviours to the hard times in NICU. Pain, painful procedures, stressful procedures. 

(14:10): 

So we’ve taken all those learnings and we’re trying to use this educational tool to let clinicians be aware of the baby in the moment and respond to the baby’s individuality and go at their pace to help. We can’t take away the procedures that they need, but we can respond to their cues and we can slow down and make them feel as comforted and contained as they can be and support them through the necessary. And that’s what the Newborn Traffic Light Tool is all about. And we hope that there’s huge scope to expand it into lots of different areas within the NICU. 

(14:51): 

And actually, it’s applicable to the community, to community nurses who are perhaps giving vaccinations, to midwives who are giving vaccinations on the postnatal ward, to babies that are coming into general practise because they’re unwell. They need to feel the safe hands and the security of the person that’s looking after them. So if we can be infant-focused and use their behaviours to guide that consultation, everybody just feels a little bit safer. 

Vicki Mansfield (15:20): 

There’s the essence of it is this little person can communicate and be a participant, an active participant in their care, which the tool has kind of helped, in some ways, practitioners to have a bit of a language to understand. 

Dr Natalie Duffy (15:36): 

But exactly as you said, that the baby is a person with their own individual needs and wants. And if we help to foster that understanding and we show that to the families, then right from the get go, this little developing person is the centre of everybody’s world, and that fosters their physical health, their emotional health, and their cognitive health for all the years to come. 

Vicki Mansfield (16:01): 

I have two questions to finish up, and I’m wondering if there was one take-home message for health professionals that infants have been sharing with you in your research. What might it be? 

Dr Natalie Duffy (16:15): 

I think that my biggest take home from all of it is to slow down, to allow yourself the opportunity to take a breath, a breath for you, because it is overwhelming, but a breath for the baby and for their parents. Slow down and give yourself the opportunity to get to know your patient as a person, because then once you see them as an individual with all these needs and the possibility of this big, bright future, everything kind of tumbles or spreads from there, and you and yourself, just that connection is therapeutic. I think that listening in NICU is just as important as all of the things that we have to do in NICU. 

Vicki Mansfield (17:04): 

So the power of presence and listening. And similarly, I’m wondering, is there one piece of take-home advice from infants that you think they’d like their parents to know? Because you’ve been listening to them for a while now. 

Dr Natalie Duffy (17:18): 

Yeah, I have. If I could speak in their voice and use their voice, then I would say, “I’m here. My behaviours, my cues. They’re teaching you about who I am, about who I’m going to be, and your love is helping me to grow, your touch is making me feel protected, and I’m just so grateful that you’re here with me, helping me through this journey, and that you’re seeing me as a little person and you’re not seeing all these other things that are in the background.” 

Vicki Mansfield (17:55): 

Yeah. Thank you so much, Natalie. That was just a beautiful description, and thank you so much for sharing your wisdom and knowledge with us today. 

Narrator (18:06): 

Visit our website at emergingminds.com.au to access a range of resources to assist your practise, brought to you by the National Workforce Centre for Child Mental Health. Led by Emerging Minds, the centre is funded by the Australian Government Department of Health and Aged Care under the National Support for Child and Youth Mental Health Programme.