The Role of Relationship-Based
Developmentally Supportive Newborn
Intensive Care in Strengthening Outcome of
Preterm Infants
Heidelise Als and Linda Gilkerson
This article details the conceptual framework, clinical application, and efficacy of a relationship-based
developmentally supportive approach to newborn intensive care referred to as NIDCAP (Newborn
Individualized Developmental Care and Assessment Program). Outcomes of the approach are reported in regard to infant health and development, reduction of hospital costs, and family adaptation.
The approach is guided by a neurodevelopmental framework for understanding preterm infants and
depends on the capacities of professionals to collaborate with one another and with families in
support of the infants' medical, developmental, and emotional well-being. The primary vehicle for
clinical implementation is detailed behavioral observation with subsequent recommendations for
individualized caregiving based on the infant's current functioning and apparent developmental
goals. A series of essential components of developmentally oriented caregiving are described, including strategies for coordinated discharge planning, and linkage to community services. The voices of
individual clinicians highlight the process of change from protocol-based to relationship-based care.
Copyright 9 1997 by W.B. Saunders Company
S the science and technology of newborn
intensive care have evolved, expectations
A
have increased for the positive long-term outcome of newborn intensive care unit (NICU)
graduates. Over the past decade, the goals of
NICU care have changed from securing infant
survival to optimizing long-term health and development. The family support goals have
shifted from crisis intervention to relationshipbased support with the goals to insure that families continue as primary nurturers of their infants and that parents are strengthened by the
From the Department of Psychiatry, Harvard Medical School and
Children's Hospital Boston, MA and Erikson Institute, Chicago,
IL.
Supported in part by US Department of Education Grants no.
H133G50016 from the National Institute on Disability and Rehabilitation Research and no. HO24D50011 from the Office of Special
Education Programs to H.A.; grants from the Harris Foundation,
Chicago, to H.A. and to L.G. and by Grant no. P30-HD18655-12
from the National Institutes of Health to J.f Volpe.
Portions of this paper were adapted from Als H: Earliest intervention
for preterm infants in the newborn intensive care unit, in Guralnick
MJ (ed): The Effectiveness of Early Intervention. Baltimore, MD,
Brookes, 1996, pp 47-76.
Address reprint requests to contact Heidelise Als, PhD, Children's
Hospital, 300 Longwood Ave, Enders Bldg, ER029, Boston, MA
02115.
Copyright 9 1997 by W.B. Saunders Company
0146-0005/97/2103-0008505.00/0
178
NICU experience, with increased competence
and security in their roles.
These goals rest on the delivery of relationship-based, developmentally supportive, individualized care geared to enhance the strengths of
each infant and family. Developmentally supportive newborn intensive care has been defined
as a professional alliance, that supports the parents' engrossment with their child and the
child's neurobiologically based expectations for
nurturance from the family, an alliance that listens to the language of the infant's behavior and
uses the dialogue between the infant, family and
professional caregiver to guide care. 1 Each aspect of this definition refers to relationships: relationships between colleagues, between infants
and families, as well as between infants, families,
and professional caregivers. Thus, the term relationship-based, developmentally supportive care
has emerged to capture the high degree of interpersonal and intrapersonal investment and benefit from this evolving model of NICU care. 2
This article describes the conceptual framework for relationship-based developmental care,
necessary elements for its clinical application,
and the research findings on the effectiveness of
the model. C o m m o n issues in implementation
of the model are outlined and recommendations
Seminars in Perinatology, Vol 21, No 3 (June), 1997: pp 178-189
Relationship-Based Developmental NICU Care
offered regarding implementation in acute and
intermediate intensive care nurseries.
Neurodevelopmental Conceptual
Framework
From an evolutionary perspective as members of
the h u m a n species, infants are neurobiologically
social 3 and expect the security o f three inherited
environments to continue their development:
their mother's womb, their parents' bodies,
and their families' and communities' social
group. 4 Brain development in the full-term infant occurs in the intrauterine environment, an
environment mediated by maternal protection
from environmental perturbations, with an ongoing supply of nutrients, continuous temperature control, and regulating chronobiological
rhythms. Premature infants, however, are thrust
out of their in utero econiche at the time when
their brains are growing more rapidly than any
other period in their lives. 5 Their survival requires the specialized medical-technical care
only available in the NICU. Thus, the preterm
infant's brain is being shaped in a setting characterized by a stark sensory mismatch to the developing nervous system's biologically shaped expectation for environmental inputs. 6"9
T h e h u m a n cortex begins development
a r o u n d the sixth week of gestation, when the
embryo is less than 1.5 cm in length. 1~ Each of
the millions of neurons in the cerebral cortex
originates in the germinal lining of the ventricular system. In its prime, the germinal matrix releases as many as 100,000 cortical neurons per
day, each of which migrates through the entire
thickness of the cortex to specific locations, x2
These migrations occur in waves, beginning at
a r o u n d 8 postovulatory weeks and gradually trailing off a r o u n d 24 weeks of pregnancy when neuronal maturation and organization increase dramatically. Each of the estimated I trillion h u m a n
neurons, once migrated, develops dendritic and
axonal interconnections, yielding a total of
about 1 quintillion (10 TM) synapses. This process
is ongoing during the second and third trimester
of pregnancy and continues actively through 5
years o f age, more slowly through 18 years, and
most likely, t h r o u g h o u t life. x3 As cells increase
their connectivity at the e n d o f the second trimester, there is a c o n c u r r e n t growth in brain
weight 1~ and change in head shape. This is
179
also a time when fetal behavior becomes more
complex, with increased sucking on fingers and
hand; grasping, extension, flexion, and rotations
of limbs and trunk; increasingly discernible sleep
and wake periods; and reactions to sound. During this period, the developing sensitivity and
density o f receptors for certain neurotransmitters are very m u c h influenced by the nature o f
experience.
Animal models provide substantial evidence
for the fine-tuned specificity of environmental
inputs necessary for normal cortical development. t5-18 T h e mechanisms implicated when expected inputs are not forthcoming are largely
active inhibition o f developing pathways consequent to overactivation of prematurely functioning pathways. T h e subplate n e u r o n layer in the
h u m a n frontal cortex reaches its peak as late as
32 to 34 weeks o f gestation, a time the p r e t e r m
infant spends outside the womb experiencing
quite u n e x p e c t e d sensory inputs to primary cortical areas such as the visual, somatosensory, and
auditory cortices. It is highly likely that pruning
events are modified when the brain finds itself
prematurely outside of the womb and that cells
that otherwise would be eliminated are preserved and, inversely, cells that would be preserved are eliminated. In a set of experiments,
the brains of monkeys delivered experimentally
prematurely, although u n c h a n g e d in visual cortex cell number, showed significantly different
visual cortical synapse formations, in terms o f
size, type, and distribution when c o m p a r e d with
those of full-term monkeys tested at comparable
postterm agesJ 9 Thus, although some events
may influence neuronal migration per se, 2~
other events, including differences in sensory input, appear to alter corticocortical connectivities
and lead to unique cyto- and chemoarchitectures
of the cerebral cortexfl 1
This supports the finding that preterm infants
show brain-based differences in neurofunctional
performance. Premature activation of cortical
pathways are assumed to inhibit later differentiations, alter pruning, and interfere with appropriate development, especially o f cross-modal
and prefrontal connection systems, thereby implicating complex mental processing as well as
attention and self-regulation-the very areas
where p r e m a t u r e infants are known to have difficulty in the early childhood and school age
years.16, 22-25
180
Als and Gilkerson
T h e r e is direct evidence that the traditional
NICU e n v i r o n m e n t has adverse developmental
effects resulting f r o m p r o l o n g e d diffuse sleep
states and u n a t t e n d e d crying, 26'27 supine positioning, 28 routine a n d excessive handling, 29-32
a m b i e n t noise, ~ lack of opportunity for sucking, 34 and poorly timed social and caregiving interactions. 35 U n d e r s t a n d i n g the neurodevelopmental expectations of the fetal infant and the
consequences of environmental mismatch is increasingly providing a basis for modification of
traditional N I C U care to b e c o m e developmental
care. Developmental care serves as " b r a i n care"
and seeks to provide protective and ameliorative
effects.
Clinical A p p l i c a t i o n
Developmental care views the infant as active collaborator in his or h e r own care, determinedly
striving to continue the fetal developmental trajectory b e g u n in utero. ~6 This a p p r o a c h postulates that the infant's behavior provides the best
information base f r o m which to design care. 37
Collaborating with the infant involves inferring
f r o m the infant's own behavior what the infant
seeks to accomplish a n d what strategies the infant is using. This information is then used to
estimate what supports m i g h t be useful to facilitate the infant's overall d e v e l o p m e n t and neurobehavioral organization in the face of necessary
medical and nursing interventions. T h e questions become: (1) what are the infant's developmental agenda, 3s a n d (2) how can caregiving be
i m p l e m e n t e d in a way that respects and furthers
the infant's own development, while at the same
time accomplishing the intensive caregiving
goals required?
T h e Newborn Individualized Developmental
Care and Assessment P r o g r a m (NIDCAP) m o d e l
was developed as a clinical framework for the
i m p l e m e n t a t i o n of developmental care. ~9'4~The
NIDCAP a p p r o a c h includes a systematic m e t h o d
for the detailed observation of infant behavior
and for the use of each infant's unique repertoire of strategies as a guide for caregiving. Typically, a developmentally trained professional
works in partnership with a developmentally
trained nurse to c o n d u c t the observations, prepare detailed reports with suggestions for ways
to support the infant's physiological stability, behavioral organization, and developmental pro-
gression, and share this information with the
caregiving teams a n d the family.
T h e detailed behavioral observations docum e n t the language of the infant's behavior along
three channels of communication: the autonomic system, m o t o r system, a n d state system. 41
T h e autonomic nervous system's functioning
can be observed in the infant's breathing patterns, color fluctuation, visceral stability or instability, and a u t o n o m i c behaviors such as tremors
a n d startles, s6'~7 Simultaneously, m o t o r system
functioning can be observed in the infant's body
tone, postural repertoire, a n d m o v e m e n t patterns. The infant's state organization can be observed in terms of the infant's range of states,
the robustness a n d modulation of the available
states, and the patterns of transition f r o m state
to state.
All observations are seen in the context of the
infant's efforts at self-regulation through approach and avoidance behaviors, s6,s7 This framework assumes that the infant has strategies available to move toward and take in stimuli, if the
input is appropriate in timing, complexity, and
intensity in relation to the infant's thresholds of
functioning and, conversely, that the infant has
strategies to move away f r o m or avoid inputs that
are too complex or intense or are inappropriately timed. Such behaviors are t h o u g h t of as
stress behaviors. A p p r o a c h and self-regulatory
behaviors may shift intensity a n d b e c o m e stress
behaviors; the same behaviors, when successful
in reducing stress, may serve as self-regulatory
strategies. For example, for the very young infant, a h a n d covering the face or m o u t h i n g may
represent stability, yet if overly f r e q u e n t or frantic, these behaviors may indicate stress, if not
possibly seizure activity. Self-regulatory balance
is reflected by the presence of regular respirations, pink color, a stable visceral system, smooth
movements, m o d u l a t e d tone a n d softly flexed
posture, and steady sleep a n d awake states. As a
general rule, extension behaviors are t h o u g h t to
reflect stress, and flexion behaviors are thought
to reflect self-regulatory c o m p e t e n c e . Diffuse behaviors are t h o u g h t to reflect stress, and welldefined behaviors are t h o u g h t to reflect regulatory balance.
The developmental professional prepares a
descriptive narrative based on the observed behavioral dialogue between the infant and caregiver. The narrative includes a description o f the
Relationship-Based Developmental NICU Care
environment surrounding the bedspace, the behavioral picture of the infant before active caregiving, and the caregiving interaction with detailed focus on the infant, including the infant's
initiations and responses, as well as the caregiver's efforts to aid the infant. The infant's behavior is then interpreted as to the infant's apparent
current developmental goals. The narrative concludes with caregiving suggestions and environmental modifications to be considered to more
finely attune care to the infant's behavioral
thresholds and to support the infant's developmental trajectory. The narrative is shared with
the infant's professional caregivers and with the
family, and, depending on the nursery's stage in
developmental care integration, included in the
infant's medical chart. 42'43The observations and
reports are p e r f o r m e d serially, as needed,
t h r o u g h o u t the infant's hospital stay.
NIDCAP Guidelines for Care
To effectively implement developmentally supportive care within the NIDCAP framework, specific guidelines for care have been outlined and
summarized elsewhere. 21'36'44-4s They include
suggestions to ensure consistency of caregiving,
individualized structuring of the infant's 24--hour
day; pacing of caregiving based on the infant's
cues and communication; support during transitions, particularly between caregiving activities;
individually appropriate positioning; individualized feeding support; opportunities for skin-toskin holding (Kangaroo Care); collaborative
care for all special assessments, examinations,
and procedures and facilitated as possible by the
parent to support the infant's comfort and wellbeing; a quiet, soothing environment, which supports the family's comfort and provides opportunities to feel close to and cherish their infant;
as well as discharge planning and community
linkage. 49,5~
To ensure that these elements are in place, a
range of resources is required including a salaried developmental position, ongoing staff
education and support, establishment o f a multidisciplinary developmental team, and opportunities for supervision, mentorship, and
reflection on the process of change. 2'21 Recommendations for n e e d e d supports are described
in the section R e c o m m e n d e d Strategies.
18 1
Research Findings
The relationship-based, individualized developmental approach to care has been formally and
rigorously tested in several studies. An initial
study 42 found improved medical outcomes of
very low birthweight (VLBW) ventilated preterm
infants in terms of shorter stays on the respirator,
in supplemental oxygen, and on gavage feedings; improved behavioral outcomes at 2 weeks'
corrected age as assessed with the Assessment o f
Preterm Infants' Behavior (APIB) 51'52 and at 9
months in terms o f Bayley Scales scores and improved behavioral regulation as assessed in a videotaped play paradigm. 53 A second study 54-56
found significantly lower scores of morbidity in
the first 4 weeks of hospitalization, as measured
with the Minde Daily Morbidity ScaleY significantly earlier onset of oral feedings, better average daily weight gains, shorter hospital stays, and
improved overall behavioral functioning at discharge, as measured with the Neonatal Behavioral Assessment Scale. 5s
These two early studies 42'5.56 used a phase lag
design. Two studies since then 43'59have used random assignment o f VLBW infants. For one of
them, 4"~ formal behavioral observations began
within the first 24 hours and were repeated every
tenth day until discharge from the nursery.
Highly trained developmental specialists worked
with NIDCAP trained nurses to implement the
intervention approach. The experimental group
infants required less ventilator support, less supplemental oxygen, and moved more quickly
from gavage to nipple feedings. The experimental group infants were discharged on average 2
months earlier than the controls, resulting in an
average cost savings of $90,000 per child. These
infants maintained their improved weight gain
to 2 weeks after their due date. The two most
dramatic findings of this study were the reduced
incidence of intraventricular h e m o r r h a g e (IVH)
and the reduced severity of chronic lung disease.
Only one of the 20 experimental group infants
developed IVH, whereas 10 of the 18 control
group infants did. Radiological evidence shows
that at least eight of the 10 bleeds in the control
group occurred after the first 24 hours. Although almost all study infants developed
chronic lung disease, n o n e o f the experimental
group infants developed severe chronic lung disease, yet six of the 18 control group infants did
182
Als and Gilkerson
so. They were not, however, the infants who
showed significant IVH. The experimental
group also showed improved developmental outcome at 2 weeks' corrected age, as measured
with the APIB, 62 with much better functioning
in terms of autonomic regulation, motor system
performance, and self-regulation. Systematic
electrophysiological group differences by quantified electroencephalography with topographic
mapping 6~were also f o u n d at 2 weeks postterm,
implicating a m o n g others a large central region,
as well as a large occipital region, of brain function difference. The advantage for the experimental infants continued to 9 months corrected
age in mental and m o t o r abilities assessed with
the Bayley Scales of Infant Development. 61 In
terms of both the Mental Development Index
(MDI) and the Psychomotor Developmental Index (PDI), the experimental group showed an
advantage of more than one standard deviation
over the control group and p e r f o r m e d at or
above the mean of the standardization sample
o f the test, while the control group p e r f o r m e d
significantly below the mean for age. Measures
of behavioral regulation as assessed in an experimental play paradigm (Kangaroo Box) 53 also favored the experimental group. This paradigm is
based on the same model of subsystem integration that underlies the NIDCAP intervention.
O n 17 of the 20 infant variables measured in the
6-minute videotaped play episode of infant and
parent a r o u n d a complex toy apparatus, the experimental group p e r f o r m e d significantly better
than the control group. The largest differences
were f o u n d in gross and fine m o t o r modulation,
overflow postures and associated movements,
complexity of object and social play, task persistence, and degree of examiner facilitation necessary. In the Still Face Episode, when the parent
was asked to no longer engage with the child,
but sit at the side of the r o o m and observe the
child without encouraging or acknowledging facial expressions, words or actions, 12 of 19 infant
variables showed significant group differences,
again in favor of the experimental group. None
of the 14 parent variables showed a significant
group difference, yet all three interaction variables measured favored the experimental group;
these include turn taking, synchrony of interaction, and overall quality of the interaction. Thus,
the infants in the experimental group appeared
significantly more well-organized, well-differenti-
ated, and modulated than the control group infants. Canonical correlation between APIB at 2
weeks and Kangaroo Box factors at 9 months
was very high, indicating a strong relationship
between overall neurobehavioral regulation at 2
weeks and at 9 months.
Another study 59 involved 18 control and 17
experimental group infants meeting the same
criteria as in the previous study. 4~ A developmental specialist provided ongoing support to
caregivers based on weekly observations. The intervention did not begin in the first 24 hours
and the caregivers had only been introduced to,
yet not formally trained in, the developmental
approach. Despite this much less intense support, the results showed reduced n e e d for gavage
tube feeding, reduced need for positive airway
pressure, fewer children with chronic illness, and
decreased length of hospitalization in experimental versus control infants. Reduction of hospital cost a m o u n t e d to an average savings of
$130,000 per child. The experimental group
children also showed markedly improved neurobehavioral functioning in all six systems measured with the APIB.
A recent national, multisite study involving
four different NICUs and using r a n d o m assignment, focused again on ventilator-dependent,
preterm infants at very high-risk. 62 Preliminary
results appear to validate the effectiveness of the
developmental care model in terms of significant
improvement, especially in terms of weight gain
and growth parameters, and in reduction of
length of hospital stay and hospital cost. Developmental outcome, as measured with the APIB,
also shows significant improvement. Furthermore, preliminary analyses of the assessment of
family functioning show the experimental group
parents to be significantly less stressed and depressed and more effective in the understanding
of their infants as individuals and themselves as
parents. 63,64
The efficacy of the NIDCAP approach to care
has also been tested for a sample of medically
healthy, less than 34 week preterm infants, randomly-assigned to a control and experimental
group. 65A group of healthy, full-term infants was
studied in comparison to the experimental and
control preterm groups. The preterm control
group displayed the least well-organized behavioral performance on the APIB and the Prechtl
Neurological Evaluation 66 at 2 weeks postterm,
Relationship-Based Developmental NICU Care
183
whereas the preterm experimental and full-term
groups were behaviorally comparable. Electrophysiological outcome at 2 weeks postterm also
showed significant improvement for the intervention preterm group. In 32 of 41 electrophysical measures, the preterm experimental group
was comparable to the full-term group, while
both differed significantly from the preterm control group. The area most frequently involved
was the frontal lobe. The frontal lobe variables
demonstrated significant correlation with behavioral indices of attentional control and state organization, indicating differential vulnerability
in the preterm control group. This may not be
surprising given that neuronal organization of
this regions occurs, as pointed out, relatively late
in the developmental sequence 67-69 and appears
to show differential vulnerability in preterm infants. 2s It appears that the developmental intervention supports a more full-term-like pattern
of brain functioning.
The studies reviewed involving developmental
care in the NIDCAP model for very early born
infants at very high-risk and for medically healthy
preterm infants suggest that developmental care
during the last 16 weeks of gestation positively
influences infants' neurodevelopmental functioning. The differences have so far been measured and published for 2 weeks and 9 months
postterm. Especially in view of the recently published negligible effects at school age o f the extensive post-NICU intervention provided by the
Infant Health and Development Program, 7~ it is
important to ask whether earliest in-NICU intervention in the NIDCAP model has lasting positive effects and if so, what the clinical implications of the neurodevelopmental model of
intervention are beyond the NICU and immediate infancy period.
Motor, Memory, and General Cognitive Indexes.
Group differences range from half a standard
deviation to close to 2 standard deviations, with
the experimental group consistently above the
standardization group mean and the control
group well below it. Expressive language abilities
assessed at age 7 years were also improved as
were several neuro-organizational measures, derived from Testing Behavior Rating Scales. 7s
These include less perseveration, better sentence
complexity, fewer associated movements, reduced staticness o f facial expression, and enhanced behavioral attractiveness. Parent Report
Ratings TM corroborate these results. Experimental group parents saw their children as less aggressive and more socially engaged with better
social abilities, activity regulation, attention
skills, and somatic well-being. In addition, parents j u d g e d their children's gross motor, fine
motor, and m e m o r y skills more positively than
did parents o f control group children.
Neuropsychological outcome at age 8 years
has been analyzed preliminarily for the second
study. 43 Results again show substantial and continued advantage of the experimental group
children when assessed with a comprehensive
neuropsychological battery. 75 The factor loading
on attentional and visual spatial measures, capturing aspects of fluid intelligence and evidencing frontal lobe functioning, continued to show
significant group differences. Examination o f
the subtests showed the differences to be again
typically more than one standard deviation, with
the experimental group children ranging in performance from test mean to well above the mean
and the control group children performing significantly below the mean.
Long-Term Outcome and Clinical PostNICU Implications
It appears that the preterm infant continues to
remain vulnerable and differently organized well
into school age. T h e areas of difference c o n c e r n
self-regulation, attentional structuring, appreciation of the bigger picture, simultaneous processing abilities, filtering and sequencing capacities, managing transitions, and self pacing.
Language and m o t o r system integration and
modulation, including facial affect expression
are also involved.
To facilitate optimal functioning, situations
need to be well-structured for the preterm child
At this point, preliminary results are available in
terms of cognitive, motor, and neuro-organizational assessment at ages 3, 7, and 8 years. Longterm outcome assessed at 3 and 7 years of the
first NIDCAP intervention study 42 is showing, despite the small sample size, significant and substantial, lasting advantage of the experimental
group. 71 Advantages are demonstrated on the
McCarthy Scales of Children's Abilities 72 Verbal,
Clinical Implications Beyond the NICU
184
Als and Gilkerson
to succeed in applying his or her skills. The
child's own awareness of his or her specific processing and functioning style has been found to
be very beneficial. Concrete strategy practice can
increase the child's mastery of typically difficult
situations and tasks. This may include pausing
and assessing the situation before acting, selftalk, list and verbal map making, and repeated
review and rehearsal. With step-by-step role modeling and guided practice, these strategies can
b e c o m e important tools in supporting the
child's use of his or her strengths. Input overload, as well as affective spiraling, is to be
avoided. Structured schedules, well-organized
spaces, and predictable routines for work, play,
eating, and sleeping are very helpful. Committing daily activities to automatized, predictable
routines frees up n e e d e d processing acumen for
new learning. Review and integration of the new
into the well practiced, and formal closure of
activities before preparing to move to the next
activity is key.
Thus, the model of individualized developmental care applied in the NICU continues to
have applicability well into school age. The focus
on its pacing of activities, transition facilitation,
and regulatory strategies continues to support
the emergence of the child's strengths and developmental goals. This model of care appears to
improve not only medical outcome, but also neurodevelopmental outcome, perhaps by preventing active inhibition of central nervous system (CNS) pathways due to inappropriate inputs
and supporting the use of modulating pathways
during a highly sensitive period of brain development. Developmentally appropriate care in the
NIDCAP model may thus be associated with improved cortical and specifically frontal lobe development from early on, showing lasting effects
into school age. Given the effectiveness of developmental care outlined, why does it appear so
difficult for nurseries and clinicians in NICUs
and post-NICU settings to practice in this model?
Implementation Issues
Over 25 years ago, a senior neonatologist observed the benefits of developmental care. He
also anticipated the major implementation challenge:
Let me tell you about the first developmental
nurse. She seemed to do better at gavage feed-
ings than the others. I watched how she fed the
babies. She put the tube in and then she'd stroke
a r o u n d the baby's belly, just like she was calming
him. We noticed that the babies fed a lot better,
didn't spit up as much, and gained weight better.
So we noticed that, and our thought was, why
doesn't everybody do it? 2
In addition to the experimental component,
the national multisite study 62 included a qualitative study of the process of implementation of
developmental care. 2 T h r e e aspects of developmental care emerged from the preliminary analysis as primary sources of tension in the implementation process. These three aspects parallel
the major conceptual elements of the model; it is
process-guided, relationship-based, and systemsoriented.
Process-guided. This type of highly attuned, individualized approach requires a flexible mind to
continuously assess the infant's behavioral and
physiological needs and requires flexible procedures that allow one to creatively adapt caregiving.
A senior staff nurse noted: "So m u c h of nursing is doing routine things in a routine way." In a
unit which encourages developmental care, her
capacity for critical thinking grew: "I used to
suction every 3 hours, regardless. Now I think,
'Who am I suctioning f o r - m e or the baby?' I
watch now for the signs that he needs to be suctioned. I knew what to do before, now I know
why." 2
Implementing a process-guided rather than a
task- or procedurally-based model is challenging
in any setting, and particularly so in an acute
care environment, which by necessity, is oriented
to standard protocols and caregiving routines.
Two c o m m o n difficulties arise: (1) developmental practices may focus on the static rather
than the dynamic aspects o f caregiving, and (2)
disagreements may arise among staff regarding
changes in accepted procedures. For example,
staff may focus primarily on environmental controls (light and sound levels) and positioning
aids (use of nests, boundaries), rather than on
reading the individual infant's cues and adjust
their own behavior to be supportive of the infant's efforts. Staff conflict can arise when accepted procedures for frequency of suctioning
or vital signs or feeding schedules are questioned. This model requires a highly coordinated approach to care, which crosses discipline
and shift boundaries.
Relationship-Based Developmental NICU Care
Relatlonship-based. Developmental care is a particularly challenging innovation to i m p l e m e n t
because it is an innovation in the way people
think and relate to one another. Rogers v6 differentiates innovations d e p e n d e n t on changes in
hardware from innovations d e p e n d e n t on the
values, beliefs, and interactions o f people. T h e
latter is m u c h m o r e complicated to achieve and
m u c h m o r e d e p e n d e n t on the qualities of the
change agents. While an extensive knowledge
base is required, the interviews showed that the
interpersonal a n d intrapersonal capacities of the
developmental professionals were seminal to the
success of the effort. Physicians were particularly
affected by the way that the developmentalists
interacted with t h e m and the way that information was conveyed.
Developmental care supports the relationship
between the infant and the family. Nurses who
e m b r a c e a developmental a p p r o a c h acknowledge in a new way the connections between
themselves and the infants and families for
w h o m they care.
I used to think " I ' m going to go in, put a
suction catheter down the endotrachial tube.
I ' m going to change a diaper, I ' m going to flip
him . . . .
close the d o o r . . ,
and go on to my
next j o b . . . until I have m o r e tasks to do to
him . . . .
My mindset is different now. Now I
think when I go into the isolette it's almost like
a visit. I ' m going to observe and assess the infant
and there are some things I have to do but I ' m
going to watch what he's telling m e and adjust
what I do given the cues he's giving me. 2
This new connection with the infant strengthens the capacity to nurture relatedness between
parent and child.
Before I learned a b o u t the developmental approach . . . .
[in talking with parents], I focused
on fixed traits like he has blue eyes . . . . I d i d n ' t
talk a b o u t his humanness. Now I think I facilitate
parents seeing their infant like a family would,
knowing their baby at home. 2
For many NICU professionals, relationship
work adds a new, fulfilling dimension to their
roles. For others, it can be very threatening, especially for caregivers whose identity is tied to competence with science and technology. A p r o b l e m
that may e m e r g e f r o m these differences is polarization of s t a f f - t h o s e who are " f o r " developmental care and those who are not. This can be
particularly challenging if the polarization
185
a r o u n d developmental issues overlaps with preexisting subgroups in the n u r s e r y - s u c h as night
versus day staff, e x p e r i e n c e d versus new nurses,
or particular social cliques. T h e developmental
m o d e l must include processes designed to solicit, value, and learn f r o m staff with different
perspectives.
Systems-or/ented. In addition to its f u n d a m e n t a l
relational nature, developmental care is a multifaceted, system-wide intervention affecting the
interdependencies in the nursery as a whole. To
grasp the systems perspective, it is necessary to
step back f r o m the i m m e d i a t e situation and exa m i n e the forces operating in the larger environm e n t - p o s i t i v e forces a n d constraining forces.
Over the course of the multi-site study, nurseries
were observed to cycle t h r o u g h periods o f equilibrium a n d disequilibrium. T h e degree o f organizational stability in the setting a p p e a r e d to
have an impact on the receptiveness of the nursery to developmental care. 2 A range of organizational factors influenced nursery equilibrium,
eg, financial stability, leadership and staff
changes, or critical events such as a physical
move. 77 In addition, nursery culture was observed to have a major influence on staff relationships a n d on the c o m m u n i c a t i o n a n d conflict resolution patterns p r e d o m i n a n t in each
nursery. 7a
Developmental care is i m p l e m e n t e d within
the dynamics of an existing social system. These
dynamics will shape the form that developmental
care takes a n d will influence the ease with which
this innovation is adopted. It is particularly imp o r t a n t that change agents develop the capacity
to take the pulse of the larger system and to
differentiate issues related to their efforts f r o m
those e m a n a t i n g f r o m larger effects over the entire system. Appreciating the nursery's history
and identity are often overlooked aspects o f a
systems perspective: What gives this nursery life,
vitality a n d distinctive c o m p e t e n c e ? 79
Recommended Strategies
Given these challenges, what resources are
n e e d e d to enable a nursery to b e c o m e a relationship-based, developmental nursery?
Developmental staff position. To effectively implem e n t developmental care, e x p e r i e n c e has shown
that two salaried positions are needed: a developmental specialist and a developmental care
186
Als and Gilkerson
nurse educator. For an NICU of 40 to 50 beds
with 120 to 150 nurses, it is r e c o m m e n d e d that
each position is full-time. Without such support,
the developmental effort quickly diminishes,
given the many pressures and competing priorities in an NICU.
T h e roles and training of the developmental
specialist and developmental care nurse educator have been described in detail elsewhere. 21'8~
Briefly, the developmental specialist is responsible for building the developmental knowledge
and skill base of the NICU caregiving staff
through ongoing developmental in-service programs, mentoring, leadership of the developmental team, participation in daily rounds, and
developmental observation and consultation regarding complex care issues. It is r e c o m m e n d e d
that the developmental specialist have a master's
or doctoral degree or professional equivalent in
a developmental discipline such as psychology,
developmental pediatrics, early childhood special education, or pediatric physical or occupational therapy, and specialized training in NICU
care and the NIDCAP model.
The developmental care nurse educator
should be a master's-prepared or equivalently
experienced NICU nurse with a m i n i m u m of 3
years o f clinical experience and training in the
NIDCAP model. This individual must have the
interpersonal skills to be a leader, role model,
and teacher. Further, the developmental nurse
must be respected by medicine and nursing for
intensivist expertise, as well as for family support
and interdisciplinary communication and conflict resolution skills. The developmental nurse
works closely with the developmental specialist
and is the key link to the day-to-day implementation of a developmental model of NICU nursing
care.
A salaried parent representative (0.10 fulltime equivalent [FTE]), parent council, or both
are additional essential resources required to enable a unit to move toward family-centered care
practices. 81 In a n u m b e r of hospitals, the Patient
Relations Department provides funding for a
such p a r e n t position.
Initial and ongoing training. Developmental care
training is available at 11 NIDCAP centers
a r o u n d the country. NIDCAP training focuses on
clinical knowledge in the observation of preterm
infant behavior and the adaptation of caregiving
based on behavioral observation and assessment
and developmental consultation to families and
to primary caregiving teams. The developmental
specialist and developmental nurse educator require advanced levels of knowledge and skill in
these areas. At least 10% of the nursing staff
across shifts should complete NIDCAP training
to insure a minimum m o m e n t u m for successful
unit-wide implementation. Cost savings from the
implementation of a developmental program
will readily recover the funding required for staff
training.
Leadership involvement. Typically, the developmental effort is initiated by a small n u m b e r of
invested practitioners, usually several nurses, a
neonatologist, or developmental therapists. To
succeed, however, the effort must receive the
e n d o r s e m e n t of the formal leadership in the
nursery. The medical director and the nurse
manager must establish developmental care as a
priority through the NICU mission statement,
staffing allocations, performance appraisal standards, caregiving policies, procedures, and
guidelines, and education requirements.
In addition to administrative leadership, it is
r e c o m m e n d e d that each of the five key disciplines in the NICU identify a representative to
become a clinical developmental leader for that
discipline. For neonatology, this might be the
neonatologist in charge of the curriculum for
house officers or the NICU clinical director. For
nursing, this might be the nurse educator or
clinical nurse specialist. Should the NICU employ neonatal nurse practitioners, such professionals are in a prime position for NIDCAP training, as is the NICU caseworker. The NICU
supervisory respiratory therapist, occupational
and physical therapists, and social worker should
avail themselves of NIDCAP training in support
of their disciplines.
Multidisciplinary developmental team. A multidisciplinary developmental team is critical for the successful adoption of the relationship-based developmental framework. This team should include
the developmental specialist, developmental
nurse, developmental leaders from each discipline, parent representative, and key staffnurses.
It is r e c o m m e n d e d that the group m e e t on a
regular basis, eg, monthly, to coordinate the
growth of developmental effort and that a group
leader be designated. The nurse manager and
chief neonatologist should be available for at
least quarterly meetings to ensure cohesive coor-
Relationship-Based Developmental NICU Care
dination o f all practice a n d e d u c a t i o n aspects.
Further, it is r e c o m m e n d e d that this g r o u p establish a regular vehicle for c o m m u n i c a t i o n with
staff o n each shift to identify p r o b l e m s a n d to
recognize creative adaptations. As the nursery
evolves its d e v e l o p m e n t a l practice, the multidisciplinary team may establish s u b c o m m i t t e e s to
address specific topics such as physician education a n d involvement, integration o f the family
into all aspects o f care f r o m admission, environm e n t a l a n d aesthetics p l a n n i n g , c o n t i n u o u s
quality i m p r o v e m e n t studies, d e v e l o p m e n t a l research protocols, a n d the e m o t i o n a l s u p p o r t
needs o f staff. T h e team will n e e d to prioritize
c h a n g e s a n d differentiate m o r e readily accomplishable steps f r o m long-term goals.
Reflectiveproeess. O n c e the s t a f f d e v e l o p m e n t initiatives a n d the developmental team are functioning, the o n g o i n g m a i n t e n a n c e o f the process
must be assured t h r o u g h opportunities for individual, team, a n d nursery reflection a n d self-assessment. Opportunities for regularly scheduled
supervision 2'4s a n d c o n t i n u i n g education must be
available for the developmental specialist a n d the
developmental nurse given the c o m p l e x a n d dem a n d i n g nature o f their positions. T h e developmental team should build into its a p p r o a c h regular opportunities to reflect o n the process o f
i m p l e m e n t a t i o n itself. At a m i n i m u m , at 6 - m o n t h
intervals, the team a n d nursery leadership, with
the s u p p o r t o f a process consultant, should set
aside a specifically scheduled time to take stock
o f the work. Strategies to assist the nursery in
reflection a n d self-assessment have b e e n outlined
by Gilkerson and Als 2 a n d Browne a n d SmithSharpe. s2 Relationships are central to the delivery
o f N I C U care. Like o t h e r practitioners whose
work focuses on relationships, each nursery
should have available individual a n d g r o u p support for all staff to process the emotional c o n t e n t
o f the work. At a m i n i m u m , as Pawl sa states, regardless o f discipline, each individual should have
the o p p o r t u n i t y to explore his o r h e r own view
o f people a n d the world, his o r h e r biases a n d
expectations a n d be s u p p o r t e d in appreciating
that o n e will be the recipient o f those same kinds
o f p r e f o r m e d expectations f r o m others. T h r o u g h
this process, N I C U personnel can grow a n d
strengthen personally as well as professionally.
Summary
T h e biggest c h a n g e in N I C U care, the m o v e
f r o m p r o t o c o l a n d p r o c e d u r e - d r i v e n to relation-
187
ship-based d e v e l o p m e n t a l care, is g a i n i n g mom e n t u m . E d u c a t i o n in this a p p r o a c h to care is
n o w available. Research d o c u m e n t i n g the efficacy o f the a p p r o a c h is increasing; insights into
individual a n d system s u p p o r t s n e e d e d to e n s u r e
success are b e c o m i n g increasingly articulated. As
N I C U s b e g i n to define themselves n o t only as
physical care settings, b u t also as settings that
s u p p o r t d e v e l o p m e n t a l a n d e m o t i o n a l well-being, infants, families a n d staff will grow in an
e n v i r o n m e n t w h e r e strengths are e m p h a s i z e d
a n d vulnerabilities are p a r t n e r e d . 84
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