Jennie Sizemore knows the neonatal intensive care unit (NICU) at Cincinnati Children’s Hospital Medical Center well. For about 10 weeks, Sizemore made the one-hour drive from her home in Springboro, Ohio, to Cincinnati Children’s to be with her infant son Caleb.
Born at 28 weeks, Caleb experienced both breathing and eating problems, as well as a benign mass on his liver that had to be surgically removed. Despite her son’s precarious condition, Sizemore developed an intimate relationship with Caleb. She got to know his needs, his likes and dislikes, and his care plan. And most important, she bonded with him.
Instead of standing in the background and watching nurses attend to Caleb, Sizemore became a team member in his care. She talked with nurses and physicians during their daily rounds, she helped change his diapers, and she bottle-fed him. And when nurses provided care, she comforted Caleb by holding his hand or gently touching his tiny body. Even though Caleb was on a ventilator, Sizemore was allowed to provide kangaroo care — skin-to-skin contact.
“By being an active participant, it really helped me mature in my ability to provide care to Caleb,” Sizemore says. By the time Caleb was ready to leave the hospital, she felt confident and prepared to continue his care at home, she says.
International training center
Cincinnati Children’s NICU uses an observational tool called the NIDCAP — Newborn Individual Development Care and Assessment Program — to monitor premature infants’ behavior and determine their individual needs. The NIDCAP Training and Research Center at the hospital is one of 17 facilities worldwide (10 in the United States) recognized by the not-for-profit NIDCAP Federation International as a NIDCAP training center. As a training center, the facility can provide training to its own staff and employees at other hospitals.
Developed in 1984 by Heidelise Als, PhD, NIDCAP Federation International founder and president, NIDCAP is a comprehensive approach to care that is developmentally supportive, family centered, and individualized to an infant’s needs and level of stability so each infant may realize optimal health and developmental outcomes.
According to early research conducted by Als and her colleagues, babies who receive individualized developmental care have improved growth and weight gain, decreased days on the ventilator, decreased severity of lung disease, fewer medical complications, and shorter lengths of stay. Additional research on long-term outcomes reveals that babies cared for with NIDCAP also show better intellectual processing and improved neuropsychological functioning at later ages.
Developmental care was adapted as a standard of care by the National Association of Neonatal Nurses in the early 2000s.gretchen Lawhon, RN, PhD, cofounder and vice president of the NIDCAP Federation
“Nearly every NICU or special care nursery in the country today practices some form of developmental care, although it may not include the full NIDCAP methodology,” says gretchen Lawhon, RN, PhD, cofounder and vice president of the NIDCAP Federation and director of the Mid-Atlantic NIDCAP Center at Children’s Regional Hospital at Cooper University Hospital in Camden, N.J. (Lawhon spells her first name with a lowercase “g” to honor the premature babies she cares for.) “While it has not yet spread into the fiber of learning and education, that is one of our major goals.”
Baby-oriented, not task-oriented
NIDCAP is a holistic approach to newborn care, says Tammy Casper, RN, MSN, nursing education specialist and certified NIDCAP trainer at Cincinnati Children’s Hospital Medical Center. “It’s about looking at the whole needs of the baby and focusing your care around the baby’s needs, not on accomplishing your tasks,” Casper says.
Most NICU nurses have been trained to be task- oriented. “We now know that is not the best approach to care,” Casper says. “[Nurses] have a list of tasks that must be performed on an infant throughout the day — vital signs, blood work, diaper changes, feedings, and repositioning — and they are completed whether the baby is asleep or receptive to care or not.”
With developmental care, the nurse waits until the infant is awake and receptive to the interventions, Casper says. Under NIDCAP, nurses learn to read a baby’s behaviors and cues and understand what they mean.
For instance, a baby that is stressed might experience a darkening of the skin, labored breathing, and increase or decrease in vital signs. The baby might stretch out his/her arms and legs or spread his/her fingers. If a baby shows signs of distress, the nurse will stop and soothe the baby. The nurse might place his or her hands gently over the baby in a method called “containment,” which helps calm the baby. When the baby’s vital signs return to normal and the infant shows other positive cues, the nurse then will proceed with care.
“This provides a more positive experience for the baby and improves development of brain function,” says Casper.
NIDCAP also incorporates environmental changes that support a baby’s growth and development. For instance, at Cincinnati Children’s, babies stay in private rooms that include overnight accommodations for parents. Noise level is kept at a minimum, and indirect lighting and darkened rooms at night are standard in the NICU.
A change for the better
Frances Gadd, RN, who has worked as a staff nurse in the NICU at Cincinnati Children’s for 11 years, says the NIDCAP philosophy of care has completely changed how she provides care to infants. “My approach is very different,” she says. “Now I use a more gentle and quiet approach to care. I follow their cues when providing care. If a baby is not tolerating my care, then I do not proceed. I wait until the baby relaxes and shows me that he or she is ready to go on and then I proceed.”
Gadd says she has seen a difference in the way babies respond to care. “They tolerate care better; their vital signs are better. We are seeing less erratic heart rates, decreased need for oxygen, and better feedings.”
NIDCAP is also better for parents and families. “Typically, parents lose some sense of control when their babies are in the NICU and they are not able to connect with their babies,” says Gadd. The NIDCAP practice involves parents in everyday caregiving by encouraging them to perform tasks such as diaper changes, bottle-feeding, kangaroo care, and comfort measures when the baby is in distress.
“It helps parents feel more confident with their baby’s care when it is time to come home, and they have already built a relationship with the baby,” says Casper.
Observing baby’s behavior
An important component of NIDCAP care involves the performance of NIDCAP observations and assessments on premature infants by certified trainers. Using a detailed observational tool referred to as the NIDCAP observation, certified observers evaluate an infant’s behavior and note when the baby is steady and relaxed and when the baby is experiencing stress or discomfort.
By observing and then interpreting behaviors of infants within their environment and the reactions to care they receive, the NIDCAP observer creates a developmental care plan with the caregiving team that best supports the infant’s overall goals and efforts at self-regulation. This is shared with the parents and all clinicians providing care to the infant.
Casper says Cincinnati Children’s seeks to provide NIDCAP training to all clinicians and consultants — including neonatalogists; advanced-degree nurse clinicians; physical, occupational, and speech/language therapists; and infant or developmental specialists — who provide care in the NICU. Casper and certified NIDCAP trainer Linda Lacina, RN, provide NIDCAP training in the orientation for all NICU nursing staff. Additional educational offerings are offered twice a year and are open to all clinical staff.
“It’s not just nurse-oriented; it’s a whole team approach to care,” says Casper. “Engraining this into your culture requires great support from leadership and management. But once staff begin to see the changes in the way babies respond and the differences in outcomes, they know this is the right thing to do.”