Why Words Matter in the NICU

A Cleveland Clinic neonatal nursing team significantly improved their patient-parental experience scores, closing out 2024 with a 100% likelihood to recommend, following a project focused on one simple question: What do you want patients to say about you?

“I asked every caregiver across all of our disciplines, physicians, nurse practitioners, nurses, aides—everybody filled out a card and listed three things they wanted the patients, or in this case, the parents, to say about them,” says Julie Gamary, BSN, NICU Nurse Manager.

The team compiled a list of words. Kind, patient, trustworthy, personable, advocate and others topped the list. Gamary turned the results into a word cloud that’s now on display at the main desk of Cleveland Clinic Fairview Hospital NICU.

To parents and families, it’s a promise from the team about how they will deliver care to the hospital’s most vulnerable patients. It’s symbolic for Cleveland Clinic caregivers as well, and it also serves a functional purpose.

“When we get satisfaction scores and comments back, I pull up the comments and highlight when one of these words comes up. We talk about them in our huddles and our monthly quality meetings. If any of these words come up in the context of not meeting expectations, we talk about what went wrong and how we can make it better,” Gamary adds.

How it started

The motivation for the project began in 2023, and the initial goal was to promote and honor the excellent teamwork among the Fairview Hospital NICU. Part of this was shifting into a positive mindset. “We started every huddle with a note of positivity. We would turn it over to the team and ask, ‘What have we done today that’s positive?'"

This exercise would inevitably bring awareness to recent patient wins and milestones, like a mom feeding her baby for the first time or a momentous discharge day.

Being intentional about culling these moments to the forefront helped usher in a renewed sense of positivity and appreciation for teamwork. In 2024, they used this same approach but with a sharper focus on empathy, kindness, and improving the parental experience.

The word cloud initiative was a natural extension of this. It’s a simple premise, but it’s been working. Other pediatric nursing teams across the healthcare system have adopted versions of the project, and Gamary says there has been interest from other units as well.

The patient population and parental experience

The course of care can be tenuous for NICU patients and their families. “We care for babies at 22 weeks of gestation and on. When a baby is born this prematurely, their length of stay could be around six months. There are so many ups and downs.” This is true of the parental hospital experience as well.

At the beginning, lifesaving interventions can result in gratitude and enthusiasm, but toward the end of the stay, managing expectations and keeping the experience positive can be more challenging, Gamary explains.

“It’s difficult because here is this baby who now looks like a healthy newborn but may still require significant support. We are all working toward discharge, but this can be a really frustrating time for parents.”

This is the most important time to keep the experience positive. The home stretch is one of the hardest parts of their journey, she says.

More than words

Gamary, who was a teacher before becoming a nurse, is naturally drawn to finding creative strategies to help promote a culture of care and learning. She was heartened by her colleagues’ embrace of this project and also stresses it’s more than just a word cloud.

“When you see the same thing every day, you start to overlook it, you just do. I think the fact that we talk about these values every day in our huddles and our conversations, that’s what makes the real difference.”

Likelihood to recommend boils down to attention to physician communication, respect for the parental role, and attention to patient and parental needs. Cultivating those key drivers means the team talks often about how they deliver care, especially to accommodate fluctuations in the care team. The attending on service rotates every two weeks, so keeping these values at the forefront for new configurations of the team is essential.

Hany Aziz, MD, a neonatologist at Cleveland Clinic Children’s, reinforces the importance of communication and teamwork. “In our meetings, huddles and clinical rounds, we regularly review and audit our performance and outcome to guarantee state-of-the-art patient care associated with the best parent experience during the NICU stay and beyond.”

Positivity and persistence

Gamary adds that positive cultural change in the care environment can take time. When she implemented the positive mindset shift to begin huddles, it wasn’t immediately well received. “It’s easy to say, ‘This isn’t working’ and just give up on something after a month.”

On positivity and intention setting, she adds, “It motivates you—even if it’s simple—it motivates you to be better.”