Student Essay Winner 2024

The winner of the BAPM Student Essay Competition.

The winner of the inaugural BAPM Student Essay Competition was Sarah Jane Williams from the University of Leicester.

Runners up

Caitlin Bryant - University of Birmingham

Jemima Clarke - University of Southampton

Rachel Rubinsztein - University of Leeds

Their essays on the topic 'A Student's Experience of Neonatology' are included below.

Winner - Sarah Jane Williams - University of Leicester

Neonatology is a sub-specialty of paediatric medicine, involving the provision of comprehensive care to critically-ill infants in the Neonatal Intensive Care Unit (NICU) setting as well as providing care to well, term infants on the postnatal ward1. Neonatal medicine covers an extensive range of clinical conditions, requiring specialists to possess an equally vast assortment of knowledge and skills.

Paediatric experience remains a relatively minimal component of UK undergraduate medical training, with time allocated to neonatology even more limited. My own medical school delivers a seven week child health clinical placement in the penultimate year, with just two days allocated to the NICU. I was fortunate to be placed in an NHS Trust with a level 3 tertiary NICU, however, other students had variable experiences, having completed their rotations in District General Hospitals. The General Medical Council’s (GMC) Outcomes for Graduates contains no direct reference to the subspecialty, merely indicating graduates should have knowledge of physiology and safe prescribing at ‘extremes of age’2. This, combined with the challenge of preparing the future medical workforce to work with an aging population, has resulted in an undergraduate curriculum directed more towards managing frailty, polypharmacy and multiple co-morbidities, with restricted exposure to neonatology. 

A common theme among students attending placements in the NICU is anxiety arising from lack of experience with infants, especially those who are very unwell3. This apprehension is present across medical, nursing and midwifery disciplines, with concerns ranging from fear of inadvertently harming vulnerable neonates or transmitting viral illnesses, to insecurities about their clinical performance in this setting4. Many of my peers also expressed feeling a sense of helplessness, due to a lack of transferable clinical skills, and indicated that additional practical teaching of basic neonatal procedures would have been beneficial in preparation for a NICU placement. Another source of unease, voiced by colleagues prior to placements in this environment, stemmed from a perception of intrusion at a time when new parents are trying to form a bond with their babies under already difficult circumstances.

In 2017, medical students at the University of Cambridge, receiving only two half days of neonatology experience during their undergraduate training, founded ‘Comfort Club’ to meet the needs of students, infants and their parents, as well as offer support to NICU staff5. This volunteering initiative enabled students to access further exposure to neonatology and improve their confidence in working with this age group, offered reassurance to parents and, importantly, provided positive touch to support developmental needs of the infants when parents were unable to be present at the NICU. The idea was inspired by volunteer comforting initiatives in the United States6 and, with wider promotion and considered planning, is a scheme that could be implemented across all UK Medical Schools linked to NHS Trusts with a NICU.

Despite my own placement on the NICU being brief it was, nonetheless, extraordinarily impactful. This was, in part, due to the need to rapidly become accustomed to seeing pre-term infants in critical condition and, primarily, thanks to the willingness of the neonatal team to welcome students and include them in teaching opportunities on the unit. Unfortunately, during my time on the unit, one of the infants passed away. I have become seasoned to mortality during my undergraduate training, however, no patient will I ever recall so vividly as that impossibly small little girl. This death affected me quite profoundly, yet it was also a catalyst in my desire to pursue a career in this field. Working in paediatrics requires tremendous resilience when processing situations such as these and neonatology is a particularly emotionally demanding sub-specialty. The flip side of this coin is that it can also be immensely rewarding.

Whilst on the NICU, I became aware of a number of measures designed to better enable parents to bond with their new infant, including unrestricted visiting hours, comprehensive education on caring for a baby with complex needs and the promotion of breastfeeding and skin to skin contact, wherever possible. It is natural for doctors to focus mainly on medical concerns when providing care, however, it is evident that a successful outcome in neonatology is only made possible with the input of a cohesive multidisciplinary team (MDT). Indeed, a 2019 report outlining recommendations for neonatal critical care transformation identifies the importance of allied health professionals within the MDT7. Contributions from dietitians, physiotherapists, occupational therapists, speech and language therapists, pharmacists and support staff, to name a few, are essential in providing holistic and comprehensive neonatal care. Each professional I met had a different, yet crucial, role to play in ensuring infants can be discharged safely home with their families.

I welcome the opportunity to champion a local initiative that increases medical student exposure to neonatology and would support extended clinical placement time in paediatrics as a whole. Previous national reports have called attention to shortages in neonatal medical and nursing staffing7,8 and programmes providing greater insight into the sub-specialty could be one component of addressing these shortfalls, alongside changes to the undergraduate curriculum.
 
References

Royal College of Paediatrics and Child Health (no date) Neonatal medicine – sub-specialty. Available at: https://www.rcpch.ac.uk/resources/neonatal-medicine-sub-specialty (Accessed 19 November 2023)

General Medical Council (2018) Outcomes for Graduates 2018. London: GMC. Available at https://www.gmc-uk.org/-/media/documents/outcomes-for-graduates-2020_pdf-84622587.pdf (Accessed 19 November 2023)

Büyük, T. (2020) ‘Problems of midwifery and nursing students in a neonatal care unit’. Progress in Health Sciences, 10(1), pp. 6-12. DOI: 10.5604/01.3001.0014.1908
Choi, E., Lee, K.E., Lee, Y.E. (2015) ‘Nursing Students’ Practice Experience in Neonatal Intensive Care Units’. Child Health Nursing Research, 21(3), pp. 261-271. DOI: 10.4094/chnr.2015.21.3.261

Thompson, R., Jones, G. and Beardsall, K. (2022) ‘’Comfort Club’: Student-run volunteering on the neonatal intensive care unit’. The Clinical Teacher, 19(1), pp. 59-62. DOI: 10.1080/14767058.2019.1660767

Evangelista, J. (2015) Why I started a cuddling program in the NICU, KevinMD.com. 25 March. Available at: https://www.kevinmd.com/2015/03/why-i-started-a-cuddling-program-in-the-nicu.html (Accessed 19 November 2023)

NHS England and NHS Improvement. (2019) Implementing the Recommendations of the Neonatal Critical Care Transformation Review. London. NHS England. Available at: https://www.england.nhs.uk/publication/implementing-the-recommendations-of-the-neonatal-critical-care-transformation-review/ (Accessed 22 November 2023)

Royal College of Paediatrics and Child Health. (2022) National Neonatal Audit Programme 2022 Data: Extended Analysis Report. RCPCH: London. Available at: https://www.rcpch.ac.uk/sites/default/files/2023-10/nnap_2022_data_extended_analysis_report_v1.0.pdf (Accessed 23 November 2023)

Runner-up - Caitlin Bryant - University of Birmingham

Neonatology is a sub-specialty of paediatrics centred around the care of newborn babies (1). The clinical severity of conditions varies greatly, but a significant proportion of the work centres around caring for babies that are born prematurely (2), an area which has increased over recent years due to the resuscitation of babies at earlier gestations.

It is an area of medicine that students do not typically get much exposure to throughout their training, yet I found it to be an invaluable experience and feel it contributed to my development as a future doctor. Neonatal care is an emotionally demanding area of medicine for several reasons. Attending deliveries can be stressful, as you are usually only attending if there are complications or anticipated difficulties with the birth. Resuscitation of preterm babies is essential to a neonatal doctor’s role; however, this is associated with high rates of morbidity and mortality (3), which is understandably difficult to cope with. Furthermore, the patients you see on the ward are often severely unwell and unlikely to recover, which provides further mental challenges.

I undertook my elective placement in the Jessop Wing in Sheffield, which provides care for babies from across Yorkshire (4). I was placed on the unit for 4 weeks, observing a range of services, including Neonatal Intensive Care Unit (NICU), High Dependency Unit (HDU) and Special Care of Babies Unit. I also shadowed the neonatal team providing clinic follow-up once discharged and visiting neonates throughout the maternity unit.
 
This essay will focus on the emotional challenges of working in neonatal care, and my experiences of this as a medical student.

As future doctors, we are encouraged to show empathy towards our patients, as this has a greatly positive impact on patient care (5), however, the need to look after our emotional wellbeing must also be considered, and this is an aspect that is often overlooked. While our placements throughout medical school are a time to gain knowledge, another key part is developing our professional identity.

Throughout placements, we are exposed to a variety of emotionally challenging situations, including illness, death, and witnessing disagreements between healthcare professionals. For me, my neonatal placement brought this to the forefront of my mind (6).

Working in a hospital can be very intense and stressful at times, epitomised by attending deliveries with the neonatal team. I attended multiple deliveries of premature babies throughout my placement, which was a very daunting environment to enter. There are so many healthcare professionals in the room, everything happens at a much faster pace than anything I had experienced prior to this. I found that during my 4 weeks in the Jessop wing, I became much more comfortable with this kind of environment and coping with the associated stresses felt more natural. In addition to the stresses of the clinical situation, issues such as bed and staff shortages provided extra pressure to the clinical team. This is something that I hadn’t observed as much in hospitals previously, but the limited number of NICU and HDU beds did make this challenging for staff. As a student, I was not involved in this, but I found it useful to see how staff worked around these pressures.

This placement was my first exposure to palliative care in children, and this was very emotionally challenging. High levels of mental health problems are reported among people who work in neonatal care (7), and I can understand why. It is very difficult to maintain a distance emotionally from your patients and their families, especially when the patients are often in hospital for months if they are born very prematurely. Even in the short time I was there I developed relationships with some of the parents, and when something went wrong, it was very difficult not to feel some of the pain they felt. For me, this is an area I am trying to work on before I start work as a doctor because I am going to encounter similar situations far more frequently, but this placement acted as a catalyst for me to start considering my coping mechanisms and how I am going to look after myself in the future.

One situation I found very challenging was when there was an unplanned extubation in the NICU. A mum was caring for her baby when the baby started to desaturate, and help was called for. I felt very useless and in the way in this situation. The mother was there throughout, but I did not know what to say to her, and I was far less qualified to help than anyone else. Talking to my peers, feeling like a spare part is common when on hospital placements. You have no fixed role and no responsibilities, unlike the rest of the team. This can cause emotional conflict.

Given the emotional challenges faced, it is of utmost importance to develop effective coping strategies, to reduce distress and prevent burnout (8). I found that in the neonatal unit, healthcare professionals placed a large emphasis on checking up on people and identifying anyone who needed support. This was really encouraging to see and makes it much easier to cope under the difficult work pressures.

Despite this placement being a valuable experience to develop my emotional resilience, it is difficult to know how this will translate to working as a doctor. Being a medical student who takes no responsibility for any decisions made, and, therefore, the outcomes as a result of this, is very different to what clinical practice will be like. Nonetheless, I learnt a lot about myself through this placement, and how I respond to stress, and I am hopeful that I can take this forward into the future.
 
References

RCPCH. Neonatal medicine - sub-specialty. [Internet]. Not dated [cited 2023 Aug 19]. Available from: https://www.rcpch.ac.uk/resources/neonatal-medicine-sub-specialty

Latest ONS statistics highlight rise in preterm birth and deepening ethnic disparity. [Internet]. 2023 [cited 2023 Aug 19]. Available from: https://www.bliss.org.uk/news/2023/latest-ons-statistics-highlight-rise-in-preterm-birth-and-deepening-ethnic-disparity

Brumbaugh JE, Hansen NI, Bell EF, et al. Outcomes of Extremely Preterm Infants With Birth Weight Less Than 400g. JAMA Pediatr. 2019; 173(5):434-445. doi: 10.1001/jamapediatrics.2019.0180

Sheffield Teaching Hospitals. Neonatal Unit. Not dated [cited 2023 Aug 19]. Available from: https://www.sth.nhs.uk/services/a-z-of-services?id=171&page=99
Kerasidou A, Horn R. Making space for empathy: supporting doctors in the emotional labour of clinical care. BMC Med Ethics. 2016 Jan; 17:8. doi: 10.1186/s12910-016-0091-7

Weurlander M, Lönn A, Seeberger A, Hult H, Thornberg R, Wernerson A. Emotional challenges of medical students generate feelings of uncertainty. Med Educ. 2019 Oct; 53(10): 1037-1048. doi: 10.1111/medu.13934

Nazzari S, Grumi S, Ciotti S, Merusi I, Provenzi L, Galgliardi L. Determinants of emotional distress in neonatal healthcare professionals: An exploratory analysis. Front Public Health. 2022 Sep; 10:968789. doi: 10.3389/fpubh.2022.968789

Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ. 2016 Jan; 50(1):132-49. doi: 10.1111/medu.12927

Runner-up - Jemima Clarke - University of Southampton

Walking onto the neonatal unit as a student is an oddity. On approach, there is little to no noise coming from the ward bar the intermittent beeping of various equipment and the weak cry of an infant muffled by the box that holds them. The lights are dimmed and the ward heated. I grab a glass and swig some water.

On ward round, I feel as if I am melting into the ground beneath me but the questions from many consultants keep me present and upright. The physiologically heavy answers scrape the disjointed fragments of knowledge that remain from first year, creating a mild sense of panic in both me and the other blank looking students beside me.

Once a case has been discussed, the consultant turns from our fearful gaze. We take a second’s breath as he reconvenes with the team before we all move to the next infant. As we pile into the ordinary sized bay it feels vast with the absence of family to fill the space. The remote and clinical touch of the consultant seems so far from the warm comfort of home. The overwhelming warmth that so often surrounds a child’s arrival into the world put on hold. Pink and blue crocheted hats and blankets, providing an ounce of homeliness to the stark environment that surrounds them, covering more of the incubator than they themselves. Each patient so small, their length not yet the size of my forearm.

When the quiet is pierced, the solitary Mum slowly walks in from the adjoining wards to be with her baby. Her child that once was with her, now feels surgically removed, suddenly, they exist in different rooms. Dreading the day she is discharged before her child, going home for the first time without her baby.

The few parents present at the time of early rounds, their thoughts audible as they strain to hear the conversation between colleagues, desperate for a word they can thread to the last. Yearning for the talking between colleagues to halt and for one face to break from the crowd and explain in words being said. The temptation, as a student, to reassure their worried faces, ironing their anxious foreheads with soothing words. Words that, in reality, you have no place to say and so you say nothing but smile with longing and hope.

Getting to the end of rounds, you start to feel your emotions seeping from your feet. The heat of physiology, the anguish of parental despair and your own discomfort seeing infants with skin so translucent and limbs so brittle. In your mind knowing that you must revise to fill the ever-growing gaps in your knowledge just to return again tomorrow with a glimpse of hope. Hope that one day soon you too can walk on to the ward with place, purpose and confidence in your knowledge. Power that enables the reassurance of worried parents, restoration of premature babies to health and most crucially, the comfort of wriggling a pink knit hat on their delicate heads. 

Runner-up - Rachel Rubinsztein - University of Leeds

Before attending my placement on the neonatal unit, I was conscious of many things. The recent Lucy Letby scandal was prominent in my mind accompanied by stories my mum told me about my time as a premature twin on a neonatal unit. The vulnerability of babies on these units and the responsibility healthcare professionals have is possibly one of the greatest duties a doctor can have.

During my first day, the initial ward round was extremely complex, underscoring the intricacies of caring for babies on the neonatal ward. As the doctors explained, the fate of premature babies changes rapidly, with glucose levels fluctuating day by day and volatile temperatures leading to significant consequences. Having spent my previous rotation on obstetrics and gynaecology and observed the high quality of maternity care, I was not surprised to see the same attention to detail in the neonatal unit.

I was privileged enough to see baby’s as young as twenty-six weeks and it really struck me how complex the treatments and technology are. The multiple machines and tubes which are connected to the tiny babies markedly emphasise how unwell the babies truly may be. We are fortunate to live in a country and time where these are available.

It was interesting to discuss with the doctors the benefits of ‘skin to skin’ as a remedial technique for premature babies, particularly for babies in countries where high level healthcare is not accessible. The simplicity of this treatment juxtaposes the complexity of the other treatments offered in countries like the UK, however, the benefits are considerable regardless of healthcare access.

As medical students, we have the fortunate opportunity of having the time to get to know and talk with patients and their parents. When talking to parents of babies on the unit, they discussed how challenging the time had been.
 
What I learnt is imperative with neonatal care is understanding that the lasting effect is really on the parent not the child. Clearly the baby does not remember its time on the unit, however, for a parent it is likely to be one of the most challenging periods of their life, with the anxieties lasting years after the new-borns stay. Moreover, the parents face the burden of further worries over the possibility of additional issues in the future which relate to the early trauma of their baby. Therefore, the way neonatal healthcare staff communicate and support parents is crucial. It is easy for healthcare staff to become complacent and forget to recognise the magnitude of their jobs and the consequences it may have. As healthcare professionals, it is important to maintain a level of resilience, but this must be balanced with compassion and empathy. Regarding the neonatal unit, this includes not forgetting why certain guidelines are in place, such as basic safety measures like hand hygiene. Furthermore, ensuring that parents are granted the time and kindness they deserve.