NICU Rhythms as a Metaphor for Organizational Effectiveness
It’s pitch black. There is not a sound to be heard at 5:15am as I wake to skip to morning Vigil’s at St. Andrews Abbey, Valyermo, California. I do not want to fill up the space with noise so I prepare for my day in quiet, welcoming the early morning without unnecessary chatter – in my mind, spirit or mouth. Kathleen Norris writes, “I’ve often sensed that the rhythms of monastic life…are set to a liturgical pace, foster a way of knowing that values image over idea, the synthetic over the analytical, the instantaneous over the sequential, the intuitive and associative over the formal and prescribed” (Norris, 1996). By the second morning at St. Andrews Abbey, waking before dawn came easily, welcomed by what felt like participation in an ancient rhythm instinctual to human flourishing.
It would be several days following my return from St. Andrews Abbey that I discovered why the rhythms of monastic life appealed to me and an additionally few days to peel apart it’s meaning within my worldview of community. Five years ago I gave birth 2 ½ months premature at 2 ½ pounds to my son Giovanni Victor Angelo Cascamo. We spent 56-days in a Neonatal Intensive Care Unit participating in macro-, micro- and seasonal organizational life that exists both at our individual hospital as well as NICU’s worldwide. Like Benedictine’s, NICU organizational life is both individual and worldwide.
This paper aims to explore Benedictine life as a metaphor for life within the Neonatal Intensive Care Unit. I will identify rhythms, rituals, cycles, structures, practices, procedures, empowerment, collaboration, lectio divina, the ego, humility, place and purpose as Benedictine life relate to life within the walls of the Neonatal Intensive Care Unit. From this analysis I will draw associations to prescribe a model of organizational development for volunteer engagement at Hand to Hold, a 501 ( c ) 3, where I am employed as an Organizational Development Consultant.
Parker Palmer writes, “This ‘community of truth’ is what I originally meant by ‘obedience’ – a rich and complex network of relationships in which we must both speak and listen, make claims on others, and make ourselves accountable” (Palmer, 1993). In Benedictine life, obedience is, “……”. In the Neonatal Intensive Care Unit, obedience demands a responsibility first and foremost to the care of the neonatal infant.
The Benedictines have followed a text called ‘The Rule of St. Benedict” for 1500 years. When St. Benedict first wrote The Rule between 530-560 A.D., his society shared similar traits to 21st century organizational life. The values of society were centered on external qualities. Internal growth individually or communally played little importance in the organizational development of societies. St. Benedict writes, “We have therefore, to establish a school of the Lord’s service. In instituting it we hope to establish nothing harsh or oppressive” (Dysinger, 1997). Dysfunctional life in the 21st century needs a 1500-year-old wake up call. A wake up call that is not harsh or oppressive but carefully integrated in to the needs of the human spirit, however one defines their spirituality.
Like Benedictine rhythms, NICU rhythms are macro-, micro- and seasonal. For Benedictines, macro rhythms are multifaceted. At a macro-level, the Benedictine order exists in every society worldwide, connected by a commitment both to St. Benedict’s “The Rule” and the Roman Catholic faith. The same rhythms found at St. Andrews Abbey in California are similar to the rhythms found in Europe, Asia, Africa or South America. In a conversation with Father Francis O.S.B.: the connection between Rome (the Vatican) and St. Andrews Abbey is that both are Catholic and share obedience to the faith doctrinally and must honor the liturgical of faith (F. Benedict, Personal communication, April 14, 2015). At a macro-level, all Benedictine’s make this vow for life and for some, while they do participate in the decision they are chosen for this life.
At a micro-level, Benedictine’s are individual’s within a community. Lectio Divina is an individual practice shared communally. All Benedictine’s practice the art of Lectio Divina. Lectio Divina is listening to God through prayerful reading. It can be applied to religious as well as non-religious texts. Lectio Divina includes four aspects of engaging in the text. Lectio, or reading/listening, begins by cultivating the ability to listen deeply, reverential listening; and reading slowly, attentively and gently listening to hear just a word or phrase that is God’s word for the day. Meditatio, or meditation, invites us to reflect on the words given, interacting with the powerful phrase as to its impact in one’s personal life. Oratio, is prayer, or dialogue with God. This is where one reflects back on the word or phrase and identifies purpose in one’s life, or, how will he/she respond and act. Contemplatio, or contemplation, is how this experience lives through a person integrating in to one’s existential being (Dysinger, 1997). Lectio Divina is significantly different from the reading many 21st century academics do. With Lectio Divina one seeks depth and applicability in one’s personal life, seeking transformation and growth. In most 21st century texts, reading is based on word count, chapters or textual volume. For a graduate student it’s skimming the surface with hopes of collecting just enough to engage in academic dialogue. Benedictine’s have practiced Lectio Divina for 1500 years, well before Twitter decided on 140 characters length.
At a seasonal level, Benedictine’s recognize the liturgical calendar of the Roman Catholic Church. The liturgical calendar is based upon the General Roman Calendar published annually by the Vatican. The cycles and readings prepared by the Vatican and shared worldwide by 1.2 billion Catholics join the faithful together in a shared journey. Principal celebrations of the liturgical year are: First Sunday of Advent, Ash Wednesday, Easter Sunday, the Ascension of the Lord, Pentecost Sunday, and The Most Holy Body and Blood of Christ (United States Conference of Catholic Bishops Committee on Divine Worship, 2014).
Like Benedictines, families who spend time in a Neonatal Intensive Care Unit (NICU) also discover macro-, micro- and seasonal rhythms. At a macro level, over 15 million infants are born premature each year (World Health Organization, 2014). Prematurity impacts every society, every culture, every country worldwide. At a worldwide level, all neonatal premature infants share several macro-rhythms in common based on medical necessity. At a macro-level, prematurity is defined as birth before 37 weeks gestation leading the baby to not have the normal time for intrauterine development. Risk factors include: having a previous premature birth; pregnant with multiples; an interval of less than six months between pregnancies; in vitro fertilization; problems with uterus, cervix or placenta; smoking cigarettes or using illicit drugs; poor nutrition; not gaining enough weight during pregnancy; certain infections; certain chronic conditions; being under- or overweight before pregnancy; stressful life events; multiple miscarriages or abortions or physical injury or trauma. All societies worldwide agree on the definition of prematurity, it’s causes and in many cases how to care for a neonatal infant. Thanks in part to work by the World Health Organization and March of Dimes, NICU’s worldwide look to research to decrease prematurity’s impact globally (Mayo Clinic, 2014).
As a NICU parent serving with a national non-profit, I am familiar with the macro-level rhythms shared by families. While Hand to Hold is a Texas-based non-profit serving within the United States, as a primarily online resource for families, we have social media analytics pointing to individuals accessing our site in ( ) countries. It is a very reasonable belief that parents of premature infants worldwide share similar experiences and macro-rhythms similar to that of worldwide Benedictines.
Rituals, practices and procedures play a significant role in Benedictine organizational life. Jager writes: rituals interpret reality. They must be frequently repeated, using the same words, gestures and signs to capture our attention. Ritual awakens us. By repeating the same steps, gestures and sounds, our disordered interior lives are restored and healed (Jäger, 1995). In Benedictine life, monastery bells call out as an invitation to meet as a community four times per day. Everything stops. The busy nature of life is reordered and everyone attends to what matters through building community.
Though the times may vary, Benedictine’s celebrate community four times per day: Vigils, Lauds, Vespers and Compline. Benedictine bells call the community to the chapel invoking immediate recognition that one must stop whatever activity they are doing and attend to prayer. There is a flutter of excitement that occurs when one hears the Benedictine bells notifying the community to come together. The Rule states in Chapter 47 that the announcing of the hour dedicated to the work of God day and night is the Abbot’s responsibility to decide whether he gives it himself or invites a conscientious brother to make the signal known to the community. This signal given is to be done with humility, taken very seriously and with reverence (Dysinger, 1997). At 8:15 on Monday evenings, Benedictine’s celebrate Benediction. It’s very Catholic high church and a time set aside to honor Catholic tradition. In Benediction, Catholics believe that when the host and wine is consecrated, it becomes the body and blood of Christ.
The Neonatal Intensive Care Unit has rituals that all neonatal practitioners and families with a neonatal child are attuned. Like Benedictine bells, when NICU alarms go off, practitioners immediately cease all activity and attend to the neonate. This means the neonate has forgotten their heartbeat or breathing and need a little reminder in the way of a tap by a nurse. Kangaroo care is a practice that originated in Bogata, Columbia in 1979 in response to a shortage of incubators and the unavailability of medical care. Kangaroo care is skin-to-skin contact between parent and child helping neonates regulate their heartbeat, improve growth, stabilize organ function, experience a shorter stay to name a few benefits ("Neuroscience," n.d.; "Hand to Hold ," n.d.). This ritual of connecting with one’s parent on a regular basis increases the parent to child bond.
Benedictine’s honor cycles as part of one’s individual and community life. Vigils occur each morning before sunrise. Benedictine’s quietly enter in to the chapel, sleepiness still on many of their minds. Three different readings occur, one from the Hebrew scriptures, one from the writings of a holy person and one from the Gospels. Lauds occur soon after sunrise. At St. Andrews Abbey, it was at 7:30am. Lauds is another word for praise. The Psalms are joyful, full of promise and possibility. Vespers occurs just before dusk. The workday is coming to a close. The sun is falling in the sky and we’re reconstructing the day’s events. Benedictine’s acknowledge this time as a transition between work and rest and the focus is on thanksgiving. Compline is the final celebration of the day. It is the time Benedictine’s self-reflect on their day reflecting on how they’ve been an instrument of God’s grace and asking forgiveness for where they’ve fallen short of God’s will (Carey, n.d.). At a macro-level, the same four cycles honored on a daily basis are also recognized seasonally. Winter is like vigils, a time before the sun peaks and spring awakens. Lauds equates to Spring as the world begins coming back to life. Vespers is similar to Autumn as we prepare for winter’s rest. And early winter is symbolic of Compline as one prepares for rest.
In the NICU, every three hours (depending on the health of the neonate), the infant has their diaper changed, is fed and temperature checked (to ensure they are keeping body heat). This three-hour cycle is 24-hours-per-day for the length of the NICU stay. Recent research has pointed to the necessity of diurnal cycles in a NICU setting, both for the neonate and for the nursing staff. Previously, it was thought a neonate needed consistent 24-hour unchanging, continuous low lights. New studies show by integrating a more natural diurnal cycle, when neonates graduate they are better prepared for the transition to day and night.
Structures play a significant role in Benedictine life. There is something exceptionally healing about order and structure. There is order and structure when one builds community with others. As humans, we are all yearning for a deeper, richer form of community (Carey & Horsman, 2015). The way Benedictine’s model community is dictated in many ways by order and structure. The design of the monk refectory where everyone meets for meals is intentionally designed to closely resemble a chapel. Morning and evening meal is taken in silence emphasizing honor and respect. Monasticism developed 1500 years ago recognizing the spiritual elements of partaking in community as a whole. This silence creates an atmosphere of reflection; the value of silence has a transcendent value for it’s own sake. Everyday conversation can be a burden and can fill up unnecessary space therefore allowing time for silence while in community becomes sacred (F. Benedict, Personal communication, April 14, 2015).
NICU structure and order is intentionally designed to bring out a greater intention to the needs of the neonate. Silence plays an integral role primarily due to the care and concern of the neonate’s sensory system. Excessive noise increases a neonate’s blood pressure, heart rate, respiration rate and oxygen saturation. The climate is kept at 71.6 to 78.8 degrees Farenheit with humidity of 30-60% (McCusky Shepley, 2014). In addition to the three hour cycles and consistency in care, this structure and order has an ability to bring out healing both to the neonate and to the family participating in the care of the neonate. Just as bells call Benedictine’s to meet, every three hours you’ll find neonatal parents rush for an opportunity to participate in the care of their infant. As a neonatal parent myself, upon our NICU graduation I continued the 3-hour cycle consistently for the first six months every 24-hours. Like Benedictine bells, I rushed for the opportunity to be with my son. Once he turned six months old and started gaining sufficient weight and health, he began sleeping through the night and our 3-hour-cycles were honored during the daytime until he was 18-months. This consistency within our schedules provided space for us to bond regularly and consistently (my son Giovanni knew when it was feeding time and started to cry at exactly 2 hours, 50 minutes).
Leadership within the Benedictine community is a balance of both individual and community participation. The Abbott takes the fatherly role of leader within a Benedictine community. In Chapter 2 of The Rule: an Abbott must not teach or enact anything contradictory to the Lord; the Abbott’s teaching and the obedience of the monk’s will be examined by God; an Abbott is to develop disciple’s through demonstration by deeds rather than words; an Abbott is to love all in his community equally; the Abbott must adapt to individual circumstances mingling gentleness and sternness, alternating between the strictness of a master and the loving affection shown by a father; the Abbott must recognize that such leadership is difficult and that by ruling souls and serving different temperaments requires he compliment some, rebuke others and use persuasion with even others in accordance with the unique personality of each individual within the community (Dysinger, 1997). Leadership in a Benedictine Monastery is a vocation. It requires an interior life of prayer and lectio divina where leadership determines what is most important to those being led. The Abbott recognizes each individual’s natural abilities while growing each individual as co-creators in the community as a whole (F. Benedict, Personal communication, April 14, 2015).
Likewise, leadership within a Neonatal Intensive Care Unit also requires a balance of individual and community participation. One of the most powerful moments during our NICU stay occurred soon after my son’s birth as I was just acclimating to the rhythm of this NICU community that would become ours for several months. Our lead neonatologist sat down with me beside my son’s isolate explaining sternly yet with persuasion the effect of noise on my neonatal son’s sensory development. The conversation was so powerfully transformative that it transformed not only my behavior while in the NICU but continues to this day when I cuddle with my now 5-year-old in peace recognizing his sensory needs. Through this conversation I became aware of the rhythms of my son’s individual needs and the community as a whole including other neonatal infants.
Community within an individual NICU is a continual challenge. On one side there are HIPPA rules, a consistent presence reminding parents to keep to their own business and disengage from building community. On the other side, community is deeply essential and needed for survival. The utter extreme loneliness and fear being a parent in the NICU is indescribable. It is this desperate need for community that led Founder and Executive Director Kelli Kelley to build Hand to Hold (www.handtohold.org). Fifteen years ago her son Jackson was born at 24-weeks gestation and she and her husband Michael spent four-months in the NICU by Jackson’s side. Three years after Jackson’s birth, their daughter Lauren was born at 34-weeks and yet again they left the hospital without a baby in their arms ("Hand to Hold ," n.d.). The sense of loneliness Kelli describes is felt yet rarely communicated among parents of premature infants. Like an emotional black hole, it just is. It is this deep knowing from personal experience that led Kelli to build a non-profit emphasizing community through online resources and programs nationwide. Kelli surrounds herself around other preemie parents who have the professionalism and skill set to serve Hand to Hold bringing her vision to life. As a servant-leader, she is our Abbot and all who have an opportunity to meet or work with her are awe-inspired by her authentic and strategically brilliant leadership abilities.
As Hand to Hold’s Organizational Development Consultant, in October 2015 I was invited to support our Family Support Navigators (Social Worker’s) building what we coined a Liaison Program. Our mission statement at Hand to Hold organizationally is, “to provide comprehensive navigation resources and support programs to parents of preemies, babies born with special healthcare needs and those who have experienced a loss due to these or other complications” ("Hand to Hold ," n.d.). Our Liaison Program is a reflection of our organizational mission. Our Liaison mission statement is, “to build relationships between Hand to Hold and a NICU helping to equip a NICU to integrate Hand to Hold programs and resources in the care of NICU families”. Our vision for Liaison’s are: 1) to recruit and train NICU graduate families that will offer invaluable support on behalf of Hand to Hold in NICU’s throughout the United States 2) provide navigational resources and information to families currently in the NICU through trained Ambassador’s 3) to partner with NICU’s in an effort to offer family-centered care through the services provided by Hand to Hold 4) to increase fundraising pool that will allow Hand to Hold to continue offering services free of charge to NICU families (Cascamo & Beatty, n.d.). As an organizational structure, our goal is to have a Director of Volunteer Engagement (nationally) leading several Regional Coordinators (i.e. West Coast, Midwest, East Coast). Our Regional Coordinators will lead one Liaison per hospital. Each Liaison will lead between three and five Ambassadors within one NICU (hospital). The distinction between a Liaison and an Ambassador primarily rests on who they serve. The Liaison serves NICU administration (i.e. medical staff) and Ambassadors. The Ambassador role serves families face-to-face. Both our Liaison’s and Ambassadors are being trained and mentored throughout the United States without a clear locus of control. We select and trust our volunteers to represent Hand to Hold while maintaining our commitment to excellence and branding.
We are currently piloting our Liaison Program in four hospitals nationwide. Our original launch occurred in November 2014. After recognizing the need for reflection and additional strategic planning action, we tabled the program as we complete Hand to Hold’s 5-year-anniversary as an organizational whole, anticipated in August 2015.
For the final portion of this essay I will explore Benedictine community development in conjunction with NICU community development seeking to prescribe an organizational model of community building that will allow our Liaison volunteers to successfully represent Hand to Hold while maintaining our commitment to excellence and branding.
According to Peter Block, “communal transformation is best initiated through those times when we gather”. (Block, 2009). Due to geographical distance, gathering together requires creative licensing. In addition to operating in several time zones all of our Liaison’s work full time (whether it’s in the home or externally in the professional world). At an organizational level, Hand to Hold has found Facebook Chat to be an effective modality allowing families nationwide to gather together simultaneously on a shared topic. Our average monthly attendance is 3000 individuals. It takes a team of quickly responsive staff to affirm and offer parent and research centered insight to families experiencing a prematurity journey. An additional resource recently discovered is Google Hangouts. One of my Liaison’s runs an online support group with micro-preemie parents (babies born less than 28 weeks gestation) who are housebound and unable to attend in person support groups (H. Strawser, personal communication, 14 March 2015). It is taking the lead of our Liaison Heather that led me to complete my profile set up and turn on the program regularly this afternoon.
As the Organizational Development Consultant I experience anxiety about managing Liaison’s nationwide without much locus of control. With four Liaisons it’s manageable but what happens when we have 400 Liaison’s? Our long-range goal is to have one Liaison and three to five Ambassadors in over 600 Level III NICU’s nationwide. It’s a big vision with the need for effective yet authentic organizational development. I empathize with our Executive Director’s role in trying to effectively keep Hand to Hold afloat while remaining vigilantly intentional by integrating our mission statement in to every fiber of our organization.
Peter Block outlines ways in which effective organizations initiate creative and original conversations: 1) to create a community of accountability and belonging, we must discover an intimate and authentic relatedness; 2) focus on invitation to the community over mandate; 3) focus on possibility over problems; 4) create a sense of ownership; 5) allow space for diversity and dissent in thought and ideas; 6) and acknowledge the gifts (of time and talent) to the community (Block, 2009).
Expanding on Block’s outline of creative and original conversations, 1) I must create a community of accountability and belonging for our Liaison’s discovering authentic relatedness. All of our Liaison’s are NICU graduate parents (who have spent time with their neonatal infant at the particular NICU they are serving); all Liaison’s relate to the rhythms, rituals, cycles, structures, practices and procedures at a macro-, micro- and seasonal level; all Liaison’s are humbly aware of the NICU experience holding a deep reverence and respect for families in their care. 2) As a Liaison coordinator, building community among Liaisons through the lens of invitation over mandate will play integral in our development. Ways I can do this is through asking engaging questions with opportunity for further dialogue and inviting our Liaison’s to be leaders among leaders teaching and creating with one another with my support as a co-creator 3) By focusing on possibility over problems (i.e. envisioning how growing our Liaison program and their role in it) I will invite Liaison’s to use their time and talents towards providing resources and support to NICU’s in need. By providing quality information to NICU’s who are often strapped by federal law and finances, families in the NICU are benefitted with access to our myriad of navigational and support resources. 4) Focusing on a sense of ownership will be essential for our Liaison’s as independent volunteers without a clear locus point or central command. Relationship will be essential in maintaining engagement. Relationship with Hand to Hold staff as well as other Liaison’s. 5) invite opportunities for new and creative ways to approach NICU administration. Historically, medicine moves bureaucratically slow. By inviting Liaison’s to innovatively recommend and establish such ideas as Google Hangout or other inclusive ideas we are growing leaders of leaders to teach and grow one another. 6) Lastly, acknowledge the gifts of time and talent offered to the Hand to Hold community. Our Founder and Executive Director Kelli Kelley modeled this final point this afternoon writing, “I just wanted to take a moment to congratulate you on your upcoming graduation. You have worked so hard for this and I could not be more proud of you or happy for you!...Just wanted you to know that I will be thinking of you on Saturday! You go girl!” (K. Kelli, personal communication, 5th May 2015).
As a Liaison leader, it will be my process and implementation over the next several months to build upon the connections presented in this essay. It may require additional study and relationship development as I explore how the Jesuit’s are organized. The Jesuit’s drop recruits off and invite them to find their way home (B. Paul, personal communication, 14 April 2015). A tangible example of this is Gonzaga University’s Master of Arts in Organizational Leadership program. Dr. Michael Carey trusts professors to build authentic relationships with students, engaging them regularly and supporting holistic growth. Likewise, I need to reflect and think of how I will apply this model I have come to know intimately thinking at an organizational level and applying it at Hand to Hold.
In closing, I am proverbially standing at the top of a valley looking at the whole of neonatal support. As I descend in to that valley greater details will emerge requiring I examine further developments. It may lead me down an unexpected path and I must be prepared for the unknown. At the bottom will be a lush valley, a creek of meaning and significance running through it waiting for me to rediscover the reason for this journey. Returning to the top will require I closely remember and regularly examine the heart of why I serve NICU organizations as I create a vision for organizational effectiveness.
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