Learning to Trust Parents

A few weeks ago, Dr. Lehtonen and her colleague Sari Ahlqvist-Bjorkroth invited me to participate and help with an information session for the Close Collaboration with Parents training program. This was held for several interested physicians and nurses from countries like Israel, Estonia, and the Czech Republic. I’ve already discussed a little bit about the program in one previous post, but I now have a better understanding of all that the program entails. The information seminar lasted two days, with the first spent discussing why the program is important and some of the research findings related to its success, and the second day showing how it is executed in the unit in Turku. Of course, most of my time here has been spent seeing how the program has been executed in the unit, even if I didn’t realize it, but it was still wonderful to get a glimpse of how the magic that the staff in the NICU create begins.

It was fascinating to hear the questions that many of the participants raised during the information session. Before seeing the unit and understanding the ways they do things here, I probably would’ve asked similar questions. How do you minimize infections if you allow siblings to visit? Do families actually give you a good description of how their infant is doing? So babies sit in rooms alone if nurses or family members aren’t there? It does sound impossible to implement this type of care when you come from units that barely have any parental presence, never allow siblings, and have 10+ babies in one room with several nurses caring for them all. But slowly, as the participants watched videos and saw the unit, they began to see that it really is possible. By understanding that it is a step by step process that doesn’t happen overnight, but requires slow, intentional steps toward family-friendliness, replicating the care culture that the unit in Turku has built doesn’t seem so far off.

The training program has already been implemented in 11 international NICUs and has shown great success in all of these different cultures and healthcare structures. Generally, the units go through an iterative training process, where part of the unit is trained and then those staff members become the trainers for the rest of the team. It is an extremely holistic approach, with leadership, physicians, nurses, and therapists necessarily involved for the curriculum to work. While it hasn’t been implemented in any U.S. units, the program could finally help us actually implement real family-centered care. Clearly, even Europeans have hesitations about letting go and fully trusting parents, but if they can do it, so can we.

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A Little Piece of Home

*Disclaimer: I’m posting this weeks late because life. I wrote it just a few days after my dad and Suze left town, but didn’t get a chance to edit it until now so please forgive the messed up timeline.  🙂

A little bit of Ohio came to visit me this week! My dad and step-mom, Susan, came all the way to Turku with American snacks, winter necessities, and lots of hugs for me in tow. They have been planning lots of trips around my time here in Turku, and this is the first of two visits they plan to make to Finland while I’m here. Of course they weren’t pleased when I asked them to bring half my closet and half the grocery store across the Atlantic, but they made it happen and I couldn’t have been more grateful.

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I met them Tuesday evening at the Helsinki airport, taking the train from Turku to Vantaa and then directly back again. They were jet-lagged and wide-eyed, but nonetheless ecstatic to see me when I found them at the airport train station. I had booked a dinning car table on the train back to Turku, so we were able to eat and catch up all at once. We were, as expected, the only people talking on the train, and my dad and Susan couldn’t get over how quiet nearly all public spaces here are. I remember the peace and quiet being a difference I noticed immediately as well, but have since gotten used to it I guess. It’s funny how you forget those small differences once you’re here for a while, but noticing them again makes me appreciate them even more.

Although my parents were only here for four days, we packed them with Turku’s famous sights, lots of nature, and heartfelt meetings with some of my favorite people here. The castle and cathedral were some of my dad’s favorites, while Suze loved the Fazer chocolate cafe and Marimekko. They also got to stop by the NICU one morning to see where I work and compare the unit to the one they experienced back home in North Carolina. The preterm birth of my twin niece and nephew almost 5 years ago was a huge moment in all of my family members’ lives, and its the inspiration for why I do what I do. My dad and Susan spent hours with my sister and her husband in the NICU, and so they have a good idea of what the NICU is like in the U.S. The unit here is so strikingly different that it is sometimes hard for me to believe its real, and they felt the same way when they visited.

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Our evenings were filled with meeting my friends and mentors here over good food. We had dinner Wednesday night with my good friend Michelle, another Fulbrighter living in Turku. On their final night here, Liisa, the physician I work with, made us the most lovely dinner full of traditional Finnish dishes–Smoked salmon and rye appetizers, reindeer and potatoes, and Glogi for desert. Although it’s always nice to have your family meet your friends and mentors, these meetings felt particularly joyful, and I think it left my parents feeling a little more at peace.

Although I haven’t really missed home all that much outside of the occasional cravings for certain foods or the intermittent FOMO I have for Elon events or family gatherings, words can’t describe how nice it was to have people who really know me be here. People always talk about “discovering yourself” while abroad, but that paints an oversimplified picture. Of course, the suggested self-discovery of travel results from the experience of truly being an outsider in a new place, but I’m not sure if this experience is ever fully translated to normal life once you return. The person you were at home and the person you become out of necessity while abroad are very hard to congeal. I’m not sure I’ve ever been able to fully integrate these two versions of myself after any of my travels, and maybe that will change because I’m actually living in Finland, but I still feel that there is this huge difference between the Sarah I know and the Sarah those in Finland perceive me to be. Be it the language barrier or the cultural differences, it can be hard to feel like I’m ever fully portraying myself accurately in my actions and words, but with my family here a little bit of that dissonance subsided.

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We said goodbye for now on Friday evening, and they successfully caught the train to the airport early that next morning. It was hard to break our hugs when I left, but I will see them (and the rest of my family) at Christmas. Overall, it is always a good feeling to have your family fall in love with the places and people you’re falling in love with, and I’m already looking forward to the next time they visit.

SCENE Symposium

This past weekend I had the opportunity to present at the annual Separation and Closeness Experiences in the Neonatal Environment (SCENE) symposium. SCENE is an international collaboration of neonatal scholars interested in increasing family centered care and family inclusive practices in the NICU. The hospital in Turku plays an integral role in the collaboration, and so it was a great experience to travel with colleagues, learn more about the state of international research on the topic, and of course, see Italy.

The beginning of the symposium introduced the state of research on separation and closeness in the NICU throughout Europe. Because the collaborators in Italy served as our hosts this year, much of the morning was spent discussing the differences between southern and northern European NICUs. It was fascinating to hear about the regional differences in Europe, as we also see some regional differences between NICUs in the U.S. For instance, from my observations the patient population of NICUs in Ohio generally has a higher incidence of neonatal abstinence syndrome than other NICUs outside of rural Appalachia (although this disparity is unfortunately decreasing as the opioid epidemic spreads outside of rural Appalachia).

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Dr. Maastrup presenting on compliance with Neo-BFHI standards.

The symposium also provided opportunities for scholars to present new research, and this was when I was able to present my previous research. It was really wonderful to share my previous work with international scholars, many of whom I’ve read and cited, and answer their questions about infant feeding, separation, and closeness in U.S. NICUs. Other presentations that day included a cross-national study on neo-baby friendly hospital initiative (neo-BFHI) compliance, as well as studies on the success of Turku’s Close Collaboration with Parents Curriculum in the 11 international units it has been implemented in so far. On the last day of the symposium, we were all able to join workgroups about specific topics in the NICU to contribute our own expertise and hopefully develop future cross-national studies for the collaboration.

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Some research shared in the “Fathers in the NICU” workgroup. The findings suggest that when holding infants skin-to-skin, an MRI shows that parts of the brain related with (a) emotion-light up for heterosexual women, (b) logic- light up for heterosexual men, and (c) both emotion and logic- light up for homosexual men. This suggests that maybe it is gender roles, not biology that we should be taking into account when encouraging family members to be involved in care. CULTURE, MY FRIENDS!

Although I spend a lot of time thinking about separation and closeness in the NICU, being around like-minded colleagues really made me really reflect on the universality of family separation and closeness, and the ways in which the topic is prevalent across cultures and disciplines. For instance, the trauma that results from families being separated from their infants in the NICU is similar in some ways to the trauma that migrant families experience when separated from their children. The inherent causes of each are also similar: an underlying assumption that in times of vulnerability, “experts” rather than parents know what is best for children. Of course, at least in Finland, we know that the only real experts on individual children are their parents. While SCENE only focuses on separation and closeness in the NICU, it is an important reminder that this work is critical throughout the lifespan.

So I guess what I’m wondering now is why, when we know that families should not be separated whenever possible, we continue to perpetuate cultures in which human structures (politics, policies, technology, etc.) are allowed to come between our inherent human instinct to nurture. How do we balance our own inherent expertise at nurturing with new, evidence-based care recommendations and technologies? It is a hard question to answer, but the SCENE collaboration gives me hope that we will eventually find better ways to strike the right balance.

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SCENE Symposium attendees

The Not So Glamorous Things I Haven’t Written About

So, I’m a little over a month into my Fulbright, and I have to be honest and say that my first few posts, while true reflections of my occasional life here, have not fully captured my day to day experiences in Turku. Although living abroad, traveling to different places, and being a fly on the wall in a foreign hospital are quite glamorous, sometimes life here is also just hard. A day doesn’t go by where I feel like I haven’t made some sort of awkward cultural mistake, and I always come home exhausted, not necessarily from a busy day, but just from a day full of differences that my body and mind are still trying to process. It’s in times like these that I have to remind myself that this is the sheer purpose of living abroad: to challenge myself, to make mistakes, and to hopefully find some humor and joy in it along the way. So, here’s a list of some funny (potentially embarrassing) occurrences from my first month:

-Riding my bike and consistently being passed by bike-riding Finns of all ages: toddlers, the elderly, mothers with three children riding on the back and groceries in the basket on the front…

-Being asked if I wanted to do a vaginal exam and/or be first assist in a c-section, as these are normal things for Finnish medical students, but alas, I am neither Finnish nor officially a medical student.

-Outing myself as the only native English speaker in my Finnish class full of European exchange students, only to then be asked by my professor to read out loud in English every time there are written instructions for the class.

-Laughing when my colleagues at the hospital begin laughing, even though I have no idea what they have said that has caused this laughter. This is usually followed with a range of sad to confused looks from them once they realize I have no idea what I’m laughing at.

-Smiling when I walk past any stranger on the street, even though I know by now that said stranger will only glare back at me in confusion.

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Image taken from Finnish Nightmares

-Assuming all barre workout classes in the world are the same, and quickly realizing that in Finland a barre class is actually a legitimate ballet class.

-Falling into the traditional American stereotype when you accidentally share your love for McDonalds with your European friends who hard core judge your affinity for greasy, processed foods.

-Attempting to make a recipe from home that has measurements in cups, and realizing that measurements only come in deciliters here.

-Nearly missing the boat to Estonia because when people call a boat a “ferry”, you don’t picture a cruise ship, nor factor in the extra time to go through the boarding process of said cruise ship.

-Accidentally eating horrid hospital cafeteria food at least twice a week because you can’t read the menu nor do you really know what it is by the looks, so you think, “well might as well give it a try”.

Even when everything feels messy though, I am slowly figuring things out and counting my small wins. For example:

-The time when the lady sitting next to me on the bus asked in Finnish if this was my stop and I responded with “Joo kiitos,” to which I received a “Ole hyvaa” back without her realizing I was not Finnish speaking and switching into English.

-Finally finding almond milk in the grocery store, once realizing that they don’t put it in the refrigerator and learning that it is called “maantali maito.”

-Picking up words during neonatal rounds that help me actually understand the infant’s diagnosis, how the mother is doing with pumping/breastfeeding, and when the infant might be able to go home.

-Actually learning to enjoy all of the rye bread here, and beginning to think you might miss it once you go home.

-Finding some like-minded Finns who also want to talk about social issues, health, good books and podcasts, etc. and getting them to open up enough to start becoming friends.

-Enjoying some sunshine while waiting for friends to meet you outside of Turku Cathedral, and having your own “Finnish Nightmare” moment when a group of tourists pulls up and completely ruins your nice Finnish peace and quiet.

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Image taken from Finnish Nightmares

(Is that last one a win or a loss, I’m not really sure?)

I’m Tallinn you what…

Being in Tallinn, Estonia for the weekend was wonderful. It was the first of what I hope will be many spontaneous travel adventures with friends over the next nine months. A group of Fulbrighters decided to hop on the ferry (cruise ship?) from Helsinki to Tallinn for a few days of exploring. Although we were in the country for less than 48 hours, we saw so much and all left in awe.

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Post ferry breakfast outside.

Mihkel, one of the Fulbright Finland interns, is actually from Tallinn, and he joined us as well, serving as our local tour guide for a few days. It was beyond kind of him to show us his city, and we all loved getting an insider’s take on its history. Estonia is a very young nation, just gaining its independence from the Soviet Union in 1991. Estonian culture is quite ancient though, and so this unique history produces a nation with interesting juxtapositions of old Europe and Soviet influences.

The “ferry” to Tallinn left early in the morning, and so we were able to have almost all day Saturday to explore. We started our day at the Tallinn TV tower where we were able to enjoy views of the whole city and also explore the “There are no bananas: Time Travel to Soviet Daily Life” museum. The TV tower in Tallinn has had an important role over the past 30 years, as Estonian nationalists chained themselves to the tower to maintain the nation’s connection to western culture during the nation’s fight for independence. The museum attached to the TV tower gave us a striking insight into what life was like for Estonians less than 30 years ago. Its name is indicative of some of the items that many Estonians lived without during the communist occupation.

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The TV tower
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Part of the Victims of the Communist Occupation memorial. When you look through the gunshot holes you see the image of a fallen Estonian soldier.

We followed the TV tower with a visit to the Victims of the Communist Occupation memorial, which just opened this year. The memorial begins with an upward climb lined with marble walls called The Journey and ends in an open field entitled the Home Garden. The 22,000 names of those who went missing or were murdered during the occupation are inscribed on the walls which lead up to the garden full of apple trees. The design of the memorial reminded me a lot of the Vietnam War memorial in DC, and was just as humbling to walk through.

After finishing our tour of Soviet Tallinn, we headed toward Old Town, which is the Gothic part of Tallinn and is a UNESCO world heritage site. Old Town was the first time I experienced what I had always imagined old European cities to be like: cobble stone roads, colorful buildings with terraces full of flowers, and old churches with tall bell towers on every turn. It was stunning. We spent the evening and next morning just wandering the streets of Old Town until we finally had to get back on the “ferry” home.

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Old Town
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Some of the eerie statues around town

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The view from the balcony of our air bnb. Literally stunning.

 

A Proper Finnish Welcome

Fulbright Finland definitely knows how to welcome their American grantees. I’ve just finished a wonderful week of orientation in Helsinki where I was finally able to meet the other grantees, learn more about Finnish culture, and see the energetic Fulbright Finland team in action.

Fulbright Finland is fairly unique in terms of the work it does to support both American and Finnish grantees. As a Fulbright commission country, rather than a Fulbright consulate country, Finland has really put energy into creating a strong bilateral program that allows for innovation and free trade of ideas between our nations. The long history of exchange between our nations began even before Finland joined the Fulbright program in 1952.

In order to make us feel welcome and learn as much about Finland as we possibly could in 4 jam-packed days, we had speakers from various Finnish ministries and U.S. departments. A representative of the Ministry of Education and Culture and two higher education representatives came to discuss the Finnish education system. The Ministry of Foreign Affairs coordinated discussions on Finnish international relations and the Finnish economy. There, I got my first in-person glimpse of a Finnish baby box, and pure joy obviously ensued.

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Image from the Finnish Ministry of Education and Culture
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The baby box!

We also had some time to engage in Finnish culture this past week. Our first evening in Helsinki was spent at a Finnish cultural center on the island of Hanasaari learning how to properly sauna, ice swim, and play Molkky. Sauna and ice swimming were quite invigorating, although I don’t know how the Finns cope with the cold water once winter comes. With the air temperature currently less than 60 F in the evenings, the water is already cold enough to knock the wind out you. Molkky is a traditional Finnish yard game that requires tossing a wooden mallet at pins labeled with numbers. I would describe it as a mix of corn hole and bowling.

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Find me to the left bracing myself…
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Post-sauna and swim Molkky. Clearly its an intense game…

The week ended with a celebration of our achievements (although we all know that there are lots more to come before the year ends). Meeting my fellow Fulbrighters was exactly the energy-boost I needed to start my research. It was good to be in a group of people just as passionate about the work they are doing as I am about my own. Even though many of us are in different cities throughout the country, it is nice to know that there are people going through a similar process, and that we will all see each other soon. Until then, it’s time to get to work!

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The Transformative Power of Trust (and Other Really Wonderful Things about the Hospital)

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“Department of Pediatrics”

My first week at the hospital was spent mostly shadowing and getting to know the unit and their practices, and it has already exceeded my expectations. I’ve mostly been spending my time rounding with the attendings and residents, and even though I can’t understand much of what they discuss because they round mostly in Finnish or Swedish, I can already tell the difference in the care here. Much of this difference has to do with a culture of trust. 

One of my first observations was that the parents are nearly always present during rounds (and at other points of the day), and they don’t appear frazzled or stressed to be there. This is quite different from the parents that I’ve observed at home, many of whom have either slept poorly in a chair at the bedside or have woken up very early to make it to the hospital before the doctors begin discussing their baby. Here, many of the parents sleep in a hospital bed next to their infant and are able to shower, cook, and do laundry in the parent facilities just down the hall. This, to say the least, allows the parents to be present at rounds, but also provides some much needed normalcy to this very hectic time in their lives. 

I shadowed a nurse for a day, following just one mother and baby. This mother, like many of the other mothers and fathers in the unit, stays every night in the unit and is extremely involved in her infant’s day to day care. She is provided opportunities to participate in nearly everything–from changing diapers and picking out clothes to holding/kangarooing her infant and filling the feeding tube with her milk. She and her infant were always first encourage to attempt breastfeeding before her expressed breastmilk was put through her infant’s feeding tube, and even then the milk that the baby received was usually unfortified, unrefrigerated breastmilk. This is an important distinction to make because breastmilk looses some of its benefits when it is refrigerated/frozen, pasteurized, or fortified. We scientifically understand this nutritional difference, but U.S. policies don’t allow for the same flexibility of breastmilk use as exists here. 

One of the most amazing things I’ve seen has occurred during conversations between parents and physicians on rounds. The first thing the physicians do when rounding is ask the parents what they think about their infant’s health. We say we do this in the U.S., but I’ve seen rounds where parents are an afterthought, only being asked once labs and prescriptions are ordered and the team is on its way to the next baby. Even when we do ask at home, I’ve always felt that parents aren’t really sharing their true thoughts, but are instead saying what they think the physicians want to hear. Here in Finland, the families already feel supported by the NICU staff in so many ways that they aren’t afraid to share what they think. They know the physicians genuinely want to hear from them because, while they may not have much medical knowledge, they do have an instinctive understanding of their baby. These instincts exist partially because they are genetically related to the infant, but also because the physicians trust them to get to know their infant extremely well by providing direct care. 

Although I knew the NICU here was very advanced in its family-centered care and support of breastfeeding, I am still stunned that it can actually exist. The inherent trust that exists between families and clinicians here makes a world of difference. When we trust that parents know what is best for their infants and are motivated to take action on that, then physicians and nurses can spend their time practicing medicine for the infant instead of trying to exert control over the family.