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Developmental Care in the NICU

EBP drives implementation of multidisciplinary, family-centered care.

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In the ever-changing world of best practices, healthcare providers have more and more opportunities to implement care based on recent research or evidence-based practice.

Nurses, physical therapists and speech therapists in the NICU at Adventist Hinsdale Hospital's Birck Family Women's and Children's Center recently initiated a method of family-centered care that brings science and compassion together.

Interdisciplinary Force

Nariza Bangayan, MSN, RN, nurse manager, Women and Children's Services, thought developmental care would benefit infants in their level III NICU, and sought the support of physical therapist Julie Wattenberg, DPT, MPT, PT, who works closely with premature infants and their parents.

Buoyed by the support of the director of Women and Children's Services, BettySue Netzel, MPH, CPNP, RN, Bangayan took her case for developmental care to the Hinsdale Hospital Foundation.

With funding from the foundation and from the community, Lisa Maloney, BSN, RNC, Nancy Gozder, BSN, RN, speech therapist Beth Fraley, MS, CCC-SLP/L, and Wattenberg were able to attend a national conference where they received education about developmental care.

They brought that knowledge back to the hospital and disseminated it through inservices for staff with the guidance of Cathy Wishba, MS, RNC, neonatal clinical consultant.

Stress-Free Zone

Developmental care emphasizes decreasing the number of stressors in the NICU. During the inservice presentation for staff members, Maloney, Gozder, Fraley and Wattenberg explained how nurses could apply developmental care concepts in the NICU.

Topics of discussion included brain development in late preterm infants and chronically ill micropreemies; incorporating parents as active participants in the development care approach; assisting infants with proper posture; and feeding development.

Staff were educated to make changes while on the unit, such as holding conversations in low tones and holding conversations away from the most exposed infants, reducing the use of bright lights, creating boundaries for babies that recreate the uterine environment and using swaddling or nests, also called "snugglies," to promote appropriate postures and motoric stability.

Maloney noted that not only were nurses invited to the presentation, but also respiratory, housekeeping, social work, labor and delivery - essentially anyone who might come through the NICU. "We make every attempt not to disrupt sleep [and] care is clustered to allow for longer rest periods." 

She added that decreasing or eliminating external stimuli is vital for optimal brain growth. So, maintaining a dark, quiet and confined environment is essential to appropriate neonatal growth and development.

"A housekeeper might not understand why they need to be quiet when they are emptying our trash cans," Maloney said. "After the reason for the 'shushing' was explained - that quiet is one element that helps the babies have better long-term outcomes - everyone was on board."

On Cue

According to Maloney, the developmental approach to care is a move away from task-oriented care and an emphasis on assessment and intervention.

"We're providing care with appropriate stimulation based on infant cues," Maloney explained. "We educate the families about the cues and teach appropriate touch techniques based on the infant's gestational age. For example, an extremely premature infant is not going to handle touch the way a full-term baby would."

Instead of rubbing a baby's arm or holding him, which isn't always possible in the NICU environment, nurses and parents are encouraged to use hand containment to provide a sense of the confined space the infant was accustomed to in the womb. Resting a hand on the baby's bottom or on top of his head imparts comfort and security.

In addition, equipment purchased through community donations is used to assist with positioning. Wattenberg works with nurses and parents to demonstrate how positioning aids support the infants. She performs exercises with these tiny patients, using touch and massage to strengthen their developing muscles.

Wattenberg also looks for cues that indicate a baby needs to rest.

"There are clinical signs, physiologic stress like a raised heart rate or frequent desaturations," she explained. "Or, they might show motoric signs, such as appearing flaccid or floppy, having trouble bringing themselves to midline, or reaching out with a finger splay."

If an infant has a high stress level and they aren't able to be calmed, she added, the physical therapy session will be postponed until a later time.


Developmental Care in the NICU

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I am very much a fan of Developmental Care, my problem with it is that it's scope is too limitied. Premies and Congenitally ill infants end up spending months in NICU. These are important developmental months and there is little written on how to support the growing infant in NICU.

Charlie Smithson,  RN,  Loma Linda Medical CenterNovember 16, 2009
CA



Thank you to those who commented on the article. We are pleased to have inspired you to want more information about developmental care.

One comment was wondering how to get started . . .The best way to start would be to go to a Developmental Care Conference. There is one this November 2009 in Washington D.C. put on by contemporary forums. It is an excellent conference and would be a great start to your developmental care program. The two nurses, physical thearpist and speech therapist in our NICU who went to this conference, then came back and provided three inservices to the nursing staff. We were so lucky to have such excellent support of creating a program and we had management support for this training. Our management also supports having a Developmental Care team that is comprised of PT, ST and 4 nurses who talk about any developmental care issues and come up with research based developmental changes in the NICU.

I would also suggeest that you do some research on what NIDCAP (neonatal individualized developmental care assessment protocol) which is what Developmental Care is based on, this will help you to create a program that works for your NICU.

Again, we were so lucky to have the support from our management team that went pretty high who were very interested in eventually having staff that are NIDCAP trained and including this in our program.

Good luck to anyone who would like to start a program, and I would be more than happy to answer any questions, at julie.wattenberg@ahss.org.



Julie Wattenberg,  Senior Pediatric Physical Ther,  Adventist Paulson Pediatric Rehabilitation CenterSeptember 02, 2009
Hinsdale, IL



We are currently trying to establish a protocol/care plan for developemental care in our unit and would like any info you have to share.
Thanks, Laurie Hickman

Laurie Hickman,  RN,  Trinity HealthSeptember 02, 2009
Minot, ND



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