Nurses at the University of Illinois Medical Center at Chicago's (UIMCC) NICU describe their work as "the antithesis of protocol-driven care." The unit is Illinois' only Newborn Individualized Developmental Care and Assessment Program (NIDCAP) training center and these NIDCAP-schooled employees quickly learn what soothes one baby may not relax the next.
NIDCAP is a model of prevention that uses physiologic, motor, state and attentional parameters of preterm infant behavior as a window into their neurodevelopment status. Beena Peters, MS, RN, associate director of nursing for the medical center and the director of the UIMCC NIDCAP training center, became interested in pursuing NIDCAP certification after learning the long-term prognosis for babies exposed to NIDCAP showed improved outcomes. She wholeheartedly recommended the facility commit the time and resources to the training. Today, UIMCC admits 600-700 babies annually. The NICU admissions include babies born at the medical center and others transferred from different hospitals for special care.
"We supported NIDCAP because it's best for the babies," she said. "We value family- and patient-focused care. An adult can say 'I have pain,' but a baby cannot. NIDCAP trains us to understand the cues and communication of a premature baby."
Nuances of Newborns
Development specialists Jean Powlesland, MS, RN, and Jennifer Hofherr, OTR/L, took on the challenge of becoming certified as the center's official NIDCAP trainers. Their commitment to becoming trainers was a big one, requiring more than 6 years of intensive work to become certified in two neurobehavioral assessments (NIDCAP and APIB), as well as supervised teaching of peers to become reliable in using the NIDCAP methodology under the guidance of Heidelise Als, PhD, founder of the program.
The learning curve was steep, as babies born at 37 weeks gestation or less express themselves differently than full-term infants. One of the hardest aspects of the NIDCAP training, Powlesland said, is it essentially reframed everything she was taught in nursing school.
"We recognize premature babies act like they are still in the womb. Limp or floppy posture tells us they are experiencing stress. Babies who are overwhelmed and not moving might appear restful to a conventionally trained nurse. In actuality, that baby is so exhausted he can't put up a fight," she said.
NIDCAP-trained RNs monitor subtle changes in breathing patterns, skin color, the level of consciousness, muscle tone and any sign of irritability that may not be clinically significant but speak volumes as to the general stress level of the infant. For these newborns, even a diaper change can be disturbing.
Kristen Greif, BSN, RN, staff nurse and NIDCAP professional, demonstrates a routine diaper change on Baby X. At 4 pounds, Baby X "is enormous for us." Born to a mother addicted to cocaine, traces of the drug have been found in the infant. The UIMCC staff is working with the Department of Children and Family Services to find placement for Baby X after discharge from the NICU. In the meantime, they're trying with some difficulty to locate the mother to obtain permission for a surgery.
Changing her diaper was hardest when the baby first arrived at the NICU because she lay on her back, arms and legs stretched out. Nurses adjusted her bedding to surround her with blankets, giving her some resemblance of the envelope the womb would have provided, thus increasing her comfort level.
Greif said traditional nursing philosophy guides them to continue working, even when the baby seems disturbed, as long as the heart rate and oxygen saturations don't change. NIDCAP taught nurses to stop what they're doing when they see small signs of stress, give the infant a chance to recover and adjust their care to minimize stressful procedures.
"A lot of what we do is regular baby care," Greif said. "What you can see here is that the act of changing her diaper can be very difficult for her because we're moving her hips and legs just to untape the diaper. Most full-term babies can hold their posture on their own, but preemies, with lower muscle tone, often do better when positioned on their sides."
Even though the nurses turned the baby on her side extremely slowly, her heart rate still increased by 15 points. What appeared to soothe her was the presence of a second nurse, who caressed the infant's feet and let the baby hold onto a finger during the diaper change.
Whenever it's feasible, NIDCAP recommends the presence of a second person to keep the most fragile babies relaxed while the nurse does the necessary care. On any given shift, 18-20 of the NICU's 100 RNs are on the floor, but it's not always possible to double up on care for an individual child. Approximately 20 "cuddlers" volunteer in the NICU and are specially trained to be an adjunct to the nursing staff by holding the newborns in a way that stimulates their development. Greif said the cuddling is especially important in the cases of drug babies and other times when the nurses "wish we had 12 arms."