Journal of Perinatal and Neonatal Nursing

Journal of Perinatal and Neonatal Nursing
April/June 2008
Volume 22 Number 2
Pages 133 - 144

Corresponding Author: gretchen Lawhon, PhD, RN, The Children's Regional Hospital, Cooper University Hospital, One Cooper Plaza, Dorrance Suite 755, Camden, NJ 08103, (lawhon-gretchen@cooperhealth.edu).
Keywords: developmentally supportive care, individualized, NICU training and education, NIDCAP
Abstract

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) was developed from a multidisciplinary study of the preterm infant's behavior, and serves as a guide for the newborn intensive care unit (NICU) professional to provide individualized developmental care. Implementation of the NIDCAP approach has reduced the iatrogenic complications of prematurity and enhanced the infant's neurobehavioral competence. This theory- and evidence-based approach involves formal training and education and requires a multidisciplinary commitment to change within the context of the hospital system. Site assessment and self-assessment of individual trainees initiate the process for a thorough and reflective change in clinical practice within the NICU. The training consists of work sessions with the NIDCAP trainer, interspersed with guided independent neurobehavioral observations. The clinical report interprets the meaning of the infant's observed behavior within the context of the NICU environment, the infant's medical status, and the family concerns in order to best articulate the infant's goals, from which individualized suggestions for care are developed. NIDCAP is a system-wide intervention approach that strives to enhance relationships between infants and families and the professionals who care for them.

There is always the inherent challenge facing healthcare professionals in the newborn intensive care nursery of combining the often-extraordinary technological advances in care of the early born and/or high-risk infant with a sensitive and humane approach that acknowledges and builds on the emerging strength of the infant and family. In 1981–1982, a small pilot research study was done by an infant neuropsychologist with support of a neonatologist and nurse administrator in collaboration with the clinical nurse specialist in the intensive care nursery. 1 The study was conducted to evaluate the effectiveness of attending to the very low-birth-weight preterm infant's behavior as a guide to modification of the environment and clinical approach to care in an effort to reduce iatrogenic effects and enhance the emerging competence of the infant. From this research effort, a clinical observational methodology for the formal naturalistic detailed observation of the infant's behavior before, during, and after caregiving interactions was developed. It was at this point that the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) was created with the goal of teaching other newborn intensive care unit (NICU) professionals this same methodology and thereby enabling them to document and utilize the infant's behavior as a guide to providing care to the premature infant.
THEORETICAL BACKGROUND

In 1982, there was little, if any, observational methodology available to glean the intricate details of the preterm infant's behavior. Als had recently completed her work on the Assessment of Preterm Infant's Behavior (APIB), 2 which provided a direct hands on evaluation of an infant's behavior and was developed from the assessment protocol of the Brazelton Neonatal Behavioral Assessment Scale. 3 The APIB was a culmination of Als's unique conceptualization of the developing human newborn from the simultaneous perspectives of ethology, anthropology, physiology, and psychology. These perspectives were used to articulate subsystem differentiation and integration within the newborn in interaction with the environment. Als cataloged the reliably observable newborn's behavior according to the subsystems of the Synactive Theory. 4 This theory delineates infant's behaviors into 3 major subsystems: (1) the autonomic subsystem (color fluctuations, breathing patterns, and visceral stability); (2) the motor subsystem (body tone, posture, and movement); and (3) the state subsystem (range of available states, state robustness and modulation, and transition from one state to another). 5 Within the infant's state subsystem, the infant's alertness and attentional and interactive ability is assessed as well.

Two categories of behaviors emanate from each of these 3 subsystems, approach/self-regulatory behaviors and stress behaviors. The infant has strategies or behaviors available to him or her to move toward and take in stimuli (approach/self-regulatory behaviors) if the input is appropriate in timing, complexity, and intensity in relation to the infant's thresholds of functioning. Such behaviors might include smooth stable respiration (autonomic subsystem), the resting of the hands upon the chest (motor system), and quietly looking upon the adult's face with invested attention (state subsystem). Conversely, the infant has strategies to move away from or avoid inputs that are too complex or intense or are inappropriately timed. Such behaviors are thought of as stress behaviors. These behaviors may include a color change from a pinkish hue to pale (autonomic system), stretching out of his or her legs and feet away from his or her body (motor subsystem), and/or facial grimacing (state subsystem). Rather than labeling each behavior as always stress or approach/self-regulatory, the meaning of any specific behavior must be interpreted within the context in which it occurs. The infant's self-regulatory ability and success of his or her efforts to maintain or regain balance are assessed across subsystems. One of the most important aspects in understanding the preterm infant's behavior is in the appreciation of his or her level of organization and overall subsystem balance while simultaneously being attuned to the infant's stress threshold. When subtle signs of stress begin to appear (eg, diffuse squirming), the caregiver respectfully and sensitively responds to the infant's signs of disorganization (eg, supporting the infant to maintain his or her arms and legs tucked up close to his or her body through gentle hand containment) to support the infant in maintaining subsystem balance. The sensitive and supportive responses to the infant are the basis for the NIDCAP recommendations for care.
NIDCAP RESEARCH

The NIDCAP program grew from the first pilot controlled trial of individualized developmental care conducted by Als. 1 It was during this study that the observational methodology was created (ie, naturalistic observation sheet) and from which the first NIDCAP reports were written. Since then, 9 additional studies have been conducted and form the basic evidence for this approach to care (see Table 1 ). 1,6–15 The original small study 1 consisted of 16 infants who had birth weight less than 1250 g, were under 28 weeks' gestation at birth, and required ventilation within 12 hours for at least 48 hours. A psychologist observed infants in the experimental NIDCAP group before, during, and after caregiving interactions every 10 days throughout hospitalization. The behavioral information was shared with the clinical nurse specialist who met with the primary nurses and together they creatively identified caregiving recommendations that would enhance the development of these infants and families. Control group infants were provided traditional neonatal care. The NIDCAP group showed a statistically significant ( P < .05) reduction of days on ventilator, days requiring supplemental oxygen, days requiring gavage feeding, and improved neurodevelopmental outcome utilizing the APIB at term (44 weeks' corrected age) and significant differences in their development at 3, 6 and 9 months in favor of the comparison infants.

Graphic
Table 1. Primary NIDCAP research

Additional studies have been conducted using the NIDCAP approach with preterm infants with birth weight less than 1500 g. These studies reported decreases in gavage feeding days, length of hospital stay, need for mechanical ventilation, increased weight gain, head growth, and improved neurodevelopmental outcome for the NIDCAP intervention group. 6–9,11,13 In recent studies of preterm infants (birth weight <1200 g), results in favor of the comparison group (those receiving the NIDCAP approach to care) included reductions in the need for supplemental oxygen and reductions in the severity of bronchopulmonary dysplasia and intraventricular hemorrhage. 10,13,14 These studies also reported decreased days on the ventilator, earlier discharge, and less requirement of gavage feeding as seen in earlier studies. 6,10,11,13,14

Buehler and colleagues 12 conducted a randomized controlled trial of the NIDCAP approach with low-risk healthy preterm infants and a cohort of healthy term infants to demonstrate the effectiveness of this care in a healthy population. As would be expected, because of their initial healthy clinical status, there were no differences in medical outcomes among the groups. However, in evaluating all 36 infants at term with the APIB, the NIDCAP preterm infants were comparable to the full-term infants and both groups demonstrated greater neurobehavioral organization than the control preterm infant group. In terms of their neurophysiological functioning, the full-term infants were significantly better than the NIDCAP preterm infants who were significantly better than the control preterm group, specifically in terms of the frontal and occipital lobe functioning. Both this study and a more recent one by Als and colleagues 15 add a unique finding in demonstrating the efficacy of the NIDCAP approach in the healthy preterm population. The study by Als and colleagues 15 was a randomized controlled NIDCAP study to explore the effect of NIDCAP care on neurobehavior, electrophysiology, and brain structure. The study included 30 infants who were medially low risk, had birth weight of less than 2000 g, and aged between 28 and 33 weeks' gestation. The NIDCAP group infants' weekly NIDCAP observations were supplemented with daily support of the NIDCAP developmental specialist, whereas control group infants received traditional neonatal care. In this medically low-risk population, there were no significant medical differences. These were neither expected nor demonstrated. At term (42 weeks' corrected age), all infants were fully evaluated with the APIB and neurophysiological parameters, including electroencephalogram spectral coherence, magnetic resonance diffusion tensor imaging, and measurements of transverse relaxation time. The NIDCAP group in comparison with the control group demonstrated statistically significant improvement in neurobehavioral functioning, enhanced neurophysiology with greater spectral coherence between left frontal to parietal regions, and enhanced brain structure primarily in the left frontal region. The correlations of the brain structural measures (magnetic resonance imaging) with the brain functional measures (behavioral and spectral coherence) showed that improved behavioral regulation (less intensity and hypersensitivity) was associated with more mature frontal brain structural development. 15 When all infants were examined at 9 months, the NIDCAP group in comparison with the control group demonstrated significantly improved neurodevelopmental outcome.
NIDCAP TRAINING AND EDUCATION

NIDCAP was established in 1984 to provide education and training in developmental observation for healthcare professionals who cared for high-risk infants and their families on a daily basis. 16 In collaboration with the NICU's multidisciplinary team, it soon became evident that NIDCAP involved more than a specific infant's caregiving approach. NIDCAP required changes in the immediate and extended environment. Caregiving processes needed to change from protocol-driven, crisis-oriented intensive care to a calm and nurturing family-centered environment that acknowledges the infant as the guide or structurer of care.

The primary focus of the NIDCAP training was to observe and interpret preterm infant's behavior. From this observation, an individualized report was developed to enhance the emerging competence of the infant and reduce iatrogenic effects of the NICU environment. This report articulated the infant's goals in striving to achieve greater balance and organization as well as offering specific individualized recommendations for care. NIDCAP suggestions for caregiving may include specific ways to structure the physical environment for both the infant and family. For example, providing greater protection of the infant within the incubator (eg, shielding the incubator with a blanket to protect the infant from the surrounding light, sound, and activity level within the NICU); offering specific recommendations for care that will support the infant in achieving his or her apparent goals (eg, providing a specific position to facilitate the infant to bring his or her hand to mouth); or supporting the family in nurturing their infant along his or her developmental trajectory (eg softly speaking to him or her while hand swaddling). This report was then shared with both the professional and family caregivers.

Successful implementation of the NIDCAP approach to care typically requires a 5-year process. There are 6 key components, which ensure the successful implementation of NIDCAP. These include (1) training a developmental specialist and developmental care nurse educator; (2) ensuring 2 full-time equivalent salaried positions dedicated to these 2 positions; (3) training a multidisciplinary leadership support team; (4) training a core group of the nursing staff representing both day and night shifts; (5) the development of a parent council; and (6) the development of reflective process and continuing education opportunities. 16 NIDCAP level I training involves the behavioral observation and implementation of developmental care whereas level II training consists of consultation with the multidisciplinary staff of the NICU to enhance environment and developmental care implementation on a nursery-wide basis.
NIDCAP LEVEL I TRAINING PREPARATION

Once the decision has been made within the NICU multidisciplinary leadership group to embark on NIDCAP level I training, the first step is a thorough assessment of the current situation. Because this training is a system-wide intervention approach to providing care to the infant and family, the NIDCAP's Site Assessment 17 provides the framework for evaluating the strengths and challenges within a unit and hospital system. The site assessment provides a good process for the leadership group of an NICU to assess the organizational structures that are supportive of the implementation of developmental care and serves as a basis for the consultation and guidance with the NIDCAP trainer. In addition to the assessment of the training site, each identified NIDCAP trainee goes through a similar process of self-assessment and reflection at the initiation of NIDCAP training. The Trainee Self-Assessment 18 provides the starting point for joint reflection and assessment of the opportunities for the individual trainee and a base for guidance and consultation with the NIDCAP trainer. In preparation for NIDCAP level I training, required readings lay the groundwork for the understanding of the theoretical background. Many units accomplish the preparatory readings within the context of a journal club to work together and promote discussion of the information. The NIDCAP trainer collaborates with the training site to formulate the NIDCAP training plan, which typically outlines the next several years of training with a corresponding budget. 19
INTRODUCTORY NIDCAP TRAINING

There are 3 key components to the introductory NIDCAP level I training. These include (1) the theoretical introduction, (2) direct observation in the NICU, and (3) site consultation and guidance with key leadership of the unit and hospital. The theoretical introduction contains an overview of embryological and fetal development, the Synactive Theory with full examples of the observable behaviors, theoretical background of both the APIB and NIDCAP, and the implementation of NIDCAP care in the NICU. In addition, a work session is designed to prepare the NIDCAP trainee for the direct observation in the NICU and includes a full discussion of the behaviors included on the NIDCAP Observation Sheet 20 (see Fig 1 ); a review of the impact of training on the NICU; and opportunities for discussion of support for staff. The second key component is the direct observation in the NICU, which is typically done with 2 trainees and begins with the experience of following the path to the infant from an outside entrance. This provides trainees an orientation to the NICU environment and the specific area of the infant's bedside. The NIDCAP trainer then guides the 2 trainees in a complete observation of an infant before, during, and after a caregiving interaction, using the NIDCAP Observation Sheet . 20 This observation tool was developed for the recording of detailed observations of an infant's naturally occurring behaviors in the NICU. The autonomic subsystem has been placed in the upper 4 blocks of the left column followed by motor behaviors. The right column begins with identified observable states of consciousness within the state subsystem and is followed by the continuation of specific motor behaviors. The lower right column contains attentional/interactional behaviors and ends with an area to record the infant's posture, head position, location, and caregiving events (manipulations) as they are offered to the infant. In addition, space is provided (below the manipulations section) to record the sampling of the infant's physiological data: heart rate and blood oxygen saturations are taken from the monitor, and the respiration rate is counted (for 30 s) and recorded as well. The observation involves a continuous systematic 2-minute time sampling of behavior combined with environment and physiologic data as described above. Each observation sheet allows the recording of 10 minutes of the infant's behavior. The observation is done as a continuous recording and typically includes a minimum of 10 to 20 minutes before the caregiving interaction; during the entire caregiving interaction of the infant (eg, checking vital signs, repositioning, diaper changing, and feeding); and an additional minimum of 10 to 20 minutes following the hands-on caregiving interaction with the infant. This method of observing the infant before, during, and after caregiving provides the comprehensive view of the infant's baseline behavior with his or her response during care and handling and the degree to which he or she is able to settle with varying degrees of support following his or her care.

Graphic
Figure 1. Observation Sheet.

While the trainee may not yet be able to identify all the infant's behaviors, the trainer highlights the pattern of behavior observed. Following the direct observation, the trainer and trainees discuss the observation and reflect on the experience before formulating a NIDCAP write-up, which includes a description of the environment and the infant's behavior (see Fig 2 ). Together the trainer and trainees glean the necessary clinical and family information from the infant's medical record and use this as the additional context for appreciating the meaning of the infant's observed behavior. From the clinical information, a behavioral summary is written. The infant's goals are formulated and suggestions and recommendations that will support the infant in achieving these goals are developed. In addition, the trainer and trainees review the Profile of the Nursery Environment and of Care Components Template 21 and come to consensus on the quantitative scoring of these components. The Profile scales, of which there are currently 24, measure aspects of the environment and care using a 5-point scale (ie, 1 reflecting a less than optimal example or missed developmental opportunity and 5 representing the highest degree of developmental sensitivity). At the end of this session, the trainer and trainees explore and discuss the trainees' perceived strengths, difficulties, and needs in accomplishing the training goals and then formulate a realistic schedule to accomplish the next training objectives. Site consultation and guidance with the key leadership of the unit and hospital are the third key component. This usually includes the NIDCAP trainees and those who will provide ongoing support. The consultation is very important in clarifying training expectations for the trainees and assisting in the review of the process of change in the unit. It helps build on the working relationship between the NIDCAP trainer and the NICU leadership as well as guide and consult on the organizational planning and evaluation of the NIDCAP process.

Graphic
Figure 2. Neurobehavioral observation (Newborn Individualized Developmental Care and Assessment Program) report. ( Continues )
Graphic
Figure 2. ( Continued ) Neurobehavioral observation (Newborn Individualized Developmental Care and Assessment Program) report.
GUIDED INDEPENDENT PRACTICE OF DIRECT OBSERVATIONS AND WRITE-UPS

As outlined in the NIDCAP Program Guide , 16 the individual NIDCAP trainee must gain an appreciation of the full 24-hour experience of 3 preterm infants in the NICU, who represent varying levels of acuity. In addition, the trainees are to observe 5 healthy full-term infants to gain a broad perspective of the range of newborn behavior to be observed. The trainees are then expected to conduct observations on a minimum of 15 infants in the NICU, who represent different age ranges and different acuity levels from extremely ill to just preparing to be discharged. Each of these observations is written up. At this point, the NIDCAP trainee sends 1 write-up, reflecting his or her best effort thus far, to the trainer for critical review. Through this process, the trainer evaluates the trainee's level of observational skill and ability to write a NIDCAP report. The quality of the report determines whether the trainee is ready for a formal NIDCAP Bedside Workday and the implementation of the Advanced Practicum.
NIDCAP BEDSIDE WORKDAY AND IMPLEMENTATION OF THE ADVANCED PRACTICUM

The NIDCAP workday follows the same training format as the introductory observational training. This session is typically more collaborative in nature because the skill level of the trainee has increased since the first introductory training was initiated. When the NIDCAP trainer returns to a training site for a bedside workday(s), another full site consultation is conducted with the hospital and NICU leadership team. After the NIDCAP Bedside Workday has been completed, the NIDCAP trainee is often ready to begin the Advanced Practicum. 22 This experience provides the NIDCAP trainee the opportunity to practice skills in working collaboratively with the multidisciplinary team and the family during the course of the infant's stay in the NICU. The Advanced Practicum typically consists of weekly observations of a very low-birth-weight infant from admission to discharge, as well as following the infant and family as they transition home. Each observation is followed by a formal write-up. The Advanced Practicum is presented in the form of a bedside binder or Developmental Diary. It contains the formal write-ups as well as entries by the family and care team, photographs, and other items that chronicle the infant's progress. One copy is presented to the family. The second copy is submitted to the trainer. The trainer's copy also includes the trainee's reflective process documentation and the formal evaluations of the usefulness of the trainee's support that have been completed by the family and the key team members. The trainer then reviews and evaluates the trainee's progress and, as deemed appropriate, schedules a NIDCAP reliability session.
NIDCAP RELIABILITY

The NIDCAP trainer and trainee(s) observe the same infant simultaneously yet independently and compare and discuss their complete write-ups. NIDCAP reliability is judged in terms of completeness of the observation; astuteness in understanding; articulation of the infant's strengths, difficulties, and goals; articulation of the dynamic process of the infant's current developmental issues and coregulatory context of family and NICU environment; conceptual astuteness and effectiveness in formulation of the infant's goals and appropriate recommendations; and the accuracy of the assessment of the environment and care. 16 The NIDCAP reliability session(s) presents another opportunity for the NIDCAP trainer to meet with the hospital and NICU leadership to discuss the accomplishments of the NIDCAP training and potential next steps and plans for further integration of the NIDCAP approach to care with infants and their families. For a summary of the NIDCAP training and education process, please refer to Table 2 . NIDCAP trainers often develop long-lasting relationships with those clinical sites in which they have provided training and remain a consultant and resource over many years.

Graphic
Table 2. NIDCAP training and education
SUSTAINING THE NIDCAP APPROACH WITHIN THE NICU

From the early planning for NIDCAP training in a NICU, the NIDCAP trainer provides guidance and site consultation for the administrative and leadership structure to fully appreciate and sustain the integration of NIDCAP in the NICU. Through the developmental evolution of the NIDCAP program, it soon became obvious that nursery-wide implementation is needed to avoid the ineffectiveness and frustration of isolated NIDCAP trainees who fail to have the support of the unit leadership. Ideally, the NIDCAP trainees, who have achieved reliability, are then recognized as the key professionals who will work with the staff to ensure the integration of developmentally supportive relationship-based care. NIDCAP reliable professionals have typically gained a strong sense of both competence and confidence in their approach to caring for infants and families and should be well utilized in a leadership capacity. For most NIDCAP professionals, there is a much stronger sense of pleasure and pride in their work with infants and families. For the NIDCAP approach to be sustained over time in a unit, there must be an integration of the relationship-based developmental care in the philosophy and mission of the unit. Specific aspects of unit functioning, such as multidisciplinary developmental rounds, provide strong administrative support until the true integration is evident in all aspects of unit operations, including daily medical rounds. Once all patient care policies and procedures reflect the relationship-based developmental approach in caring for infants and families, it no longer is viewed as an adjunct or enhancement of care, but rather the inherent underlying philosophy that is evident in every aspect of our interactions with patients, family members, and one another.
FUTURE DIRECTIONS

From the first scientific investigation of the NIDCAP approach to care in 1981, this training and education program has evolved to an international nonprofit corporation that was established in 2001. The NIDCAP Federation International, Inc. (NFI) has a mission to provide the highest quality of educational training in the implementation of individualized, developmentally supportive, and family-centered care for infants requiring intensive and special medical care, as well as care and support for the families of these infants. The NFI's mission also advocates and upholds such developmental care standards in practice as well as in research. In support of this mission, the NFI strives to be the leading source for formal training and education; research into the effectiveness of best practices; and providing the vision for the future of appropriate newborn intensive and special care delivery. From the original NIDCAP Center in Boston, Massachusetts, there are now 16 NIDCAP centers in 6 countries (see Table 3 ). For more information about NIDCAP training, please refer to the Web site at: www.nidcap.org .

Graphic
Table 3. Newborn Individualized Developmental Care and Assessment Program training centers
REFERENCES

1. Als H, Lawhon g, Brown E, et al. Individualized behavioral and environmental care for the very low birth weight preterm infant at high risk for bronchopulmonary dysplasia: neonatal intensive care unit and developmental outcome. Pediatrics . 1986;78(6):1123–1132. [Context Link]

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3. Brazelton TB, Nugent JK. Neonatal Behavioral Assessment Scale . 3rd ed. Cambridge, UK: Cambridge University Press; 1995. Clinics in Developmental Medicine No. 137. [Context Link]

4. Als H. Toward a Synactive Theory of development: promise for the assessment of infant individuality. Infant Ment Health J . 1982;3(4):229–243. [Context Link]

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11. Fleisher BF, VandenBerg KA, Constantinou J, et al. Individualized developmental care for very-low-birth-weight premature infants. Clin Pediatr . 1995;34:523–529. [Context Link]

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16. Als H. Program Guide: Newborn Individualized Developmental Care and Assessment Program (NIDCAP): An Education and Training Program for Health Care Professionals. Rev ed. Boston, MA: NIDCAP Federation International Inc; 2006. [Context Link]

17. Als H. Site Assessment. Rev ed. Boston, MA: NIDCAP Federation International Inc; 2006. [Context Link]

18. Als H. Trainee Self-Assessment. Rev ed. Boston, MA: NIDCAP Federation International Inc; 2006. [Context Link]

19. Als H. Cost-Effectiveness Analysis of Developmental Care (NIDCAP) in the Newborn Intensive Care Unit (NICU). Rev ed. Boston, MA: NIDCAP Federation International Inc; 2006. [Context Link]

20. Als H. NIDCAP Observation Sheet . Rev ed. Boston, MA: NIDCAP Federation International Inc; 2001. [Context Link]

21. Als H, Buehler D, Kerr D, Feinberg E, Gilkerson L. Profile of the Nursery Environment and of Care Components Template Manual, Part 1. Rev ed. Boston, MA: NIDCAP Federation International Inc; 2006. [Context Link]

22. Als H. Guidelines for Advanced Practicum: Following an Infant and Family From Admission to Discharge and Transition to the Home. Rev ed. Boston, MA: NIDCAP Federation International Inc; 2006. [Context Link]

Key words: developmentally supportive care; individualized; NICU training and education; NIDCAP

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