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Not long ago, newborns were subject to what is now often referred to as "barn-style" care, in which they were lined up in one large room.

Linda Kessler, RN, BSN, nurse manager in the intensive care nursery at WakeMed Health and Hospitals, Raleigh, N.C., recalls her early days of nursing in the NICU, about 25 years ago. It was loud and chaotic with the sounds of crying babies, beeps, and buzzes of equipment, nurses talking, bright lights, and sometimes even loud music. "We would go home at the end of the day just frazzled," recalls Kessler. "It was not only a bad place for babies, but a bad place for nurses too."

That began to change, however, when WakeMed adopted a developmentally supportive model of care called NIDCAP (newborn individual developmental care and assessment program) that is family-centered and individualized to an infant's goals and level of stability. Seeking to mirror the mother's womb for these young preterm infants, the NIDCAP model minimizes outside stimuli, uses gentle-touch interventions, pain control, and other comfort measures such as skin-to-skin care, swaddling, and containment to support a baby during care and at rest.

Living Proof

"I quickly became convinced that developmental care was right," says Kessler. "The babies that were positioned correctly and nestled in their beds with boundaries were much happier and content."

WakeMed is one of 17 facilities worldwide (10 in the U.S.) recognized and certified by the NIDCAP Federation International as a NIDCAP Training Center.

Developmental care was created by NIDCAP Federation International Founder and President Heidelise Als, PhD, in 1984, and was adopted as a standard of care by the National Association of Neonatal Nurses in the early 2000s.

According to early research conducted by Als and her colleagues, babies that receive individualized developmental care have improved growth and weight gain, decreased days on the ventilator, decreased severity of lung disease, and fewer medical complications, as well as shorter length of stays.

It didn't take long before Shelly Alston, RN, a staff nurse in the NICU at WakeMed, became a believer. Alston remembers following a tiny pre-term baby boy who was transferred from a different hospital. In the beginning, he was very fussy and irritable and didn't interact or eat well. Then Alston and her staff went to work putting what they learned about developmental care into practice. They kept the room dark and quiet. They positioned the tiny infant on his side, supporting his hands to reach his face. They created boundaries for him by creating a little nest in his incubator.

"You could see him test the boundaries and then curl up and go to sleep," recalls Alston. "Watching him evolve was just amazing. He quickly became a very happy baby and one of the most well-adjusted babies in the unit. When you see that kind of transformation, you know you are doing the right thing to help these babies grow and develop."

Interpreting Babytalk

"Before NIDCAP, people didn't think babies could communicate to us," says Kessler. "But now we know they can through very subtle cues." These might include a change in skin color, labored breathing or an increase in other vital signs, stretching out their extremities, spreading their fingers in a stop-like gesture, or grimacing.

Developmental care teaches nurses and doctors to observe and read these cues and respond appropriately to suit each infant's strengths and weaknesses. "There is no recipe that fits every baby," says Kessler.

"The individualization in NIDCAP may be the most difficult part about practicing NIDCAP," notes Als. "Nursing care today is very technically oriented and protocol-based. But that doesn't work for adults, it doesn't work for older children, and it doesn't work for babies."

Ann Anderson, RNC, BSN, a certified NIDCAP nurse in the NICU at WellStar Cobb Hospital in Austell, Ga., says she used to follow a regimented schedule when caring for NICU babies. Today, she waits for the babies to provide her cues that tell her when they are ready to eat or to be disturbed so she can perform nursing tasks.

"If a baby shows signs of distress, instead of continuing with care, I back off and nurture the baby," says Anderson. "Or some babies are not ready for stimulation and need more hands off. When I start to see positive cues again, then I will proceed with care."

At WakeMed, certified NIDCAP trainers perform observations and assessments on the highest risk infants and trauma babies. This detailed observational tool allows the trainers to evaluate an infant's behavior and note when the baby is relaxed or is experiencing stress or discomfort. Using this information, the NIDCAP observer creates a developmental care plan that best supports the infant's overall goals and efforts at self-regulation and is shared with the rest of the care team.

Developmental care also promotes the clustering of care to reduce the number of times a baby is disturbed. This allows babies to get more sleep and to reach deep sleep, which is essential for growth and brain development. "These babies are being brought into an environment and having interactions that they are not supposed to have yet," says Cherie Budde, RN, BSN, certified NIDCAP nurse in the NICU at WellStar Kennestone Hospital in Marietta, Ga.

At WellStar Kennestone, babies now stay in semi-private rooms that are carpeted to minimize noise, dimmer switches reduce bright lighting, and accommodations are available for parents to room-in with their babies.

Parents are encouraged to stay with the baby as much as possible, to provide skin-to-skin care, and participate in care tasks whenever possible. "The parent is the one constant for the baby and can have a significant impact on helping the baby grow and develop more quickly," says Budde.

Susan Meyers is a freelance writer.

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