The art of developmental care in the NICU: a concept analysis

INTRODUCTION: The survival rate of infants born prematurely and hospitalized in Neonatal Intensive Care Units (NICUs) has increased due to improvement of the technology in obstetrics and neona tology that allows saving preterm infants at earlier gestational ages. Preterm infants are hospitalized in a care environment which is quite different from the maternal womb. Therefore the application of developmental care in NICUs is critical to promote the development of preterm infants while they are hospitalized. AIM: This concept analysis contributes to the body of knowledge in developmental care and clarifies its understanding as well as its involvement in neonatal practice and research. METHODS: Using the method of concept analysis of Walker and Avant, this article identifies the definitions and uses of the concept of developmental care, exposes its main attributes and introduces a model case representing the acknowledged attributes. The antecedents of the concept and consequences of the application of developmental care are discussed. CONCLUSION: This concept analysis provides guidelines for nurses and health professionals to establish a 'developmental care' environment which is conducive for preterm infants. Moreover, it suggests conceptual and operational foundations of developmental care for clinicians and researchers in the neonatal field.     

Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice

Title. Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice. Aim. This paper is a discussion of evidence‐based core measures for developmental care in neonatal intensive care units. Background. Inconsistent definition, application and evaluation of developmental care have resulted in criticism of its scientific merit. The key concept guiding data organization in this paper is the United States of America’s Joint Commission’s concept of ‘core measures’ for evaluating and accrediting healthcare organizations. This concept is applied to five disease‐ and procedure‐independent measures based on the Universe of Developmental Care model. Data sources. Electronically accessible, peer reviewed studies on developmental care published in English were culled for data supporting the selected objective core measures between 1978 and 2008. The quality of evidence was based on a structured predetermined format that included three independent reviewers. Systematic reviews and randomized control trials were considered the strongest level of evidence. When unavailable, cohort, case control, consensus statements and qualitative methods were considered the strongest level of evidence for a particular clinical issue. Discussion. Five core measure sets for evidence‐based developmental care were evaluated: (1) protected sleep, (2) pain and stress assessment and management, (3) developmental activities of daily living, (4) family‐centred care, and (5) the healing environment. These five categories reflect recurring themes that emerged from the literature review regarding developmentally supportive care and quality caring practices in neonatal populations. This practice model provides clear metrics for nursing actions having an impact on the hospital experience of infant‐family dyads. Conclusion. Standardized disease‐independent core measures for developmental care establish minimum evidence‐based practice expectations and offer an objective basis for cross‐institutional comparison of developmental care programmes.     

The effects of education levels of developmental care in Australia: Perceptions and challenges

BackgroundDevelopmental care consists of a range of clinical, infant-focused, and family-focused interventions designed to modify the neonatal intensive care environment and caregiving practices to reduce stressors on the developing brain. Since the inception of developmental care in the early 1980s, it has been recommended and adopted globally as a component of routine practice for neonatal care. Despite its application for almost 40 y, little is known of the attitude of neonatal nurses in Australia towards the intervention.Aims and objectivesThe objective of this study was to establish Australian neonatal nurse perceptions of developmental care and explore associations between developmental care education levels of the nurses and personal beliefs in the application of developmental care.DesignThis involves a cross-sectional survey design.MethodsAn online questionnaire was completed by 171 neonatal nurses. Participants were members of the Australian College of Neonatal Nursing (n = 783). Covariate associations between key components of developmental care and respondents' geographical location, place of employment, professional qualifications, and developmental care education level were analysed. The reporting of this study is in accordance with the Enhancing the Quality and Transparency of Health Research Checklist for Reporting Results of Internet E-Surveys.ResultsDifferences were observed between groups for geographical location, place of employment, and professional qualification level. Rural nurses were less likely to support the provision of skin-to-skin care (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.2–1.8) than nurses in a metropolitsan unit. Nurses working in a neonatal intensive care unit and nurses with postgraduate qualifications were more likely to support parental involvement in care ([OR: 2.3, 95% CI: 0.9–6.2] and [OR: 2.1, 95% CI: 0.6–7.4], respectively). Rural respondents were more likely to have attended off-site education (OR: 3.6, 95% CI: 1.3–9.9) than metropolitan respondents.ConclusionThe application of developmental care in Australia may be influenced by inadequate resources and inequitable access to educational resources, and similar challenges have been reported in other countries. Overcoming the challenges requires a focused education strategy and support within and beyond the neonatal intensive care unit.     

Components of developmental care and the evidence for their use in the NICU

Developmental care, a philosophy of care that requires rethinking the relationships between infants, families, and healthcare providers, is in place in the majority of neonatal intensive care units in the United States. Developmental care includes a variety of activities designed to manage the environment and individualize the care of the premature infant based on behavioral observations. The goal is to promote a stable, well-organized infant who can conserve energy for growth and development. Research about the effects of developmental care has shown a trend toward improved short-term physiologic, development, and resource utilization outcomes for infants up to 24 months of age, but benefits beyond this age are unclear. Most of the research has focused on developmental care as a whole, but there is also strong scientific evidence for specific components of developmental care. The NICU care provider should use developmental care interventions that are clearly supported by evidence, and use others based on judgment and the infant's responses.     

Integration of developmentally supportive care and family-centered issues into neonatal nurse practitioner education

Arizona State University (ASU) undertook an innovative master of science in nursing (MSN) program designed to implement a neonatal nurse practitioner program that incorporated developmental and family-centered care as cornerstones of the educational process. The ASU program is unique in its emphasis on developmental and family-centered care as foundational knowledge for the neonatal nurse practitioner graduate. This article describes the development of the ASU program and the integration of developmental and family-centered care into the curriculum plan. Copyright 2002, Elsevier Science (USA). All rights reserved.     

Effects of light and sound in the neonatal intensive care unit environment on the low-birth-weight infant.

There is growing concern that aspects of the neonatal intensive care unit's physical and care giving environment may contribute to the development of subtle developmental problems in infants with significant exposure. The effects of auditory and visual stimuli on infants are areas that have been studied. A review of relevant research studies is provided, along with recommendations for nursing practice.     

Research on developmental care: helping both preemies and parents

Developmental care for premature infants was introduced by Dr. Heidi Als more than 20 years ago, and has become an accepted standard of care. Research into developmental care has shown some benefits in neonatal outcomes, but there is no standard definition of developmental care, and its practice can vary widely across different neonatal units. Dr. Bernadette Melnyk developed a program entitled "Creating Opportunities for Parent Empowerment" (COPE) to help parents of premature infants learn about the common appearance and behaviors of these infants, and about developmentally appropriate parenting skills. COPE has helped to reduce parental anxiety and stress and to improve outcomes for premature infants.     

Developmental care: The impact of Wee Care developmental care training on short-term infant outcome and hospital costs

This article explores the effect of a comprehensive developmental care training program on the medical outcome and cost of care for premature infants. Premature infants less than 34 weeks' gestation admitted to 2 regional neonatal intensive care units were prospective studies 6 months before and after implementation of the Wee Care program (Children's Medical Ventures, Norwell, MA). Environment, medical outcome, and hospital charges were recorded. The sample consisted of 242 infants (139 pre- and 103 postintervention). Although the medical outcomes of chronic lung disease, infection rate, mild retinopathy of prematurity, and intraventricular hemorrhage were significantly decreased, there was no change in incidence of severe retinopathy of prematurity. Hospital stay and hospital costs were significantly decreased. The authors conclude that a multidisciplinary, structured program in developmental care can lead to alterations in the neonatal intensive care unit environment associated with improved medical outcome, decreased length of hospitalization, and decreased cost of care. Copyright 2002, Elsevier Science (USA). All rights reserved.     

A model of neurodevelopmental risk and protection for preterm infants

The purpose of this article is to introduce a model of neurodevelopmental risk and protection that may explain some of the relationships among biobehavioral risks, environmental risks, and caregiving behaviors that potentially contribute to neurobehavioral and cognitive outcomes. Infants born before 30 weeks of gestation have the poorest developmental prognosis of all infants. These infants have lengthy hospitalization periods in the neonatal intensive care unit (NICU,) an environment that is not always supportive of brain development and long-term developmental needs. The model supports the premise that interventions focused on neuroprotection during the neonatal period have the potential to positively affect long-term developmental outcomes for vulnerable very preterm infants. Finding ways to better understand the complex relationships among NICU-based interventions and long-term outcomes are important to guiding caregiving practices in the NICU.     

Moving forward with developmental care: Education and beyond

The philosophy of practice and research in neonatal developmental care is not new; however, the implementation and integration of the philosophy continues to lag behind in neonatal units. Successful integration of developmental care is multidimensional. A clear and concrete plan is needed to produce the desired change. A variety of educational options are available to prepare unit staff. These include comprehensive, formal, and continuing education programs. This article provides information on the available educational options and discusses an approach to incorporating developmental care principles into a specific unit's health care delivery culture. Copyright 2002, Elsevier Science (USA). All rights reserved.     

家庭参与式照护模式在新生儿重症监护室应用的研究进展

家庭参与式照护模式鼓励患儿父母积极参与新生儿重症监护室中非医学性生活护理工作。笔者依据家庭参与式照护模式的概况、临床应用效果进行综述,并提出在实施过程中存在的问题,以期为临床提供参考。     

State systems development in high-risk newborns in the neonatal intensive care unit: identification and management of sleep, alertness, and crying

The state system is a fundamental component of newborn neurodevelopmental function and demonstrates the newborn's underlying neurologic and behavioral competence. The role of the state system in newborn developmental assessment reflects the newborn's ability to respond to the environment. This overview examines the importance of the state system as a significant developmental process, identifies specific variations in sleep and wakefulness, and describes behavioral patterns of state in full-term as well as high-risk newborns. Specific intervention techniques are outlined for caregivers and parents, which address consolability, adjusting the environment, handling, and interactions. This information contributes to the nurse's ability to identify and assess neurobehavioral integrity and provides appropriate behavioral individualized developmental interventions during neonatal care.     

A focus of care for neonatal nursing: the relationship between neonatal nursing practice and outcomes. Part 1

The developmental outcomes of survivors of neonatal intensive care are, in part, a measurement of the quality of care provision. The relationship between neonatal nursing practice and long-term outcomes of survivors remains unclear. This study aimed to determine the focus of care currently influencing qualified neonatal nurses' practice, to ascertain if nursing care is provided in response to the developmental needs and consequent future quality of life of high risk babies. Following a detailed literature review, a case study combining semi-structured interviews with documentary evidence was undertaken within a regional neonatal intensive care unit. The primary focus for the study was the perspective of qualified neonatal nurses working in the field. This first part of a two-part report, presents the background, aims, literature review and design of the study. The findings, discussion and conclusion will be presented in the June issue.     

A focus of care for neonatal nursing: the relationship between neonatal nursing practice and outcomes. Part 2

A case study combining semi-structured interviews with documentary evidence was undertaken to ascertain whether neonatal nurses provide care in response to the developmental needs and consequent future quality of life of high risk babies (See Part 1 in May 2003 issue for the background, literature review and design of this study). Findings indicated that neonatal nurses are unable to focus their priorities for care on the long-term development of babies. Limited knowledge of, and unrealistic attitudes towards, potential outcomes posed a high challenge for nurses. Low staffing levels, reduced autonomy and conflicting responsibilities within the multidisciplinary team, were seen to be the main factors obstructing nurses in their caring roles. The overall picture was of a nursing service under pressure, with no continuous focus for care. Raising the profile of neonatology nationally may lead to the allocation of resources necessary to develop nursing practice in relation to outcomes. Creating a focus for care via a nursing model, with continuing infant development at its core, could enhance care provision and allow all babies to receive the optimal care to achieve their full potential.     

Overcoming challenges for nurse-led research in the neonatal intensive care unit

Nurse researchers have made considerable contributions to the science of nursing. Conducting studies in the clinical environment is the best way to determine what interventions are most effective. Because most research is conducted by nurses from academic settings, they often are not viewed as credible by nurses in clinical practice, nor are they accepted readily into the neonatal intensive care unit (NICU) to conduct research. This article addresses the barriers to implementing and conducting studies in the NICU setting, and provides suggestions for creating collaborative and mutually satisfying relationships between nurse researchers and healthcare staff in the NICU. Partnerships built on mutual respect are necessary to have successful research outcomes, and to continue to build knowledge for the best neonatal care.     

Positive practice environments in critical care units in South Africa

PRETORIUS R. & KLOPPER H.C. (2011) Positive practice environments in critical care units in South Africa. International Nursing Review 59 , 66–72 Background: The demanding nature of the critical care unit (CCU) presents a challenge to many nursing professionals and carries the risk of a high turnover rate. The critical care nurse (CCN) is responsible for caring for the most ill patients in hospitals, and the acute shortage of nurses contributes to the intensity and pressure of the environment. While the reasons for the nursing shortage are varied and complex; a key factor seems to be an unhealthy work environment. Little evidence exists of research conducted to investigate the practice environment of CCNs in South Africa (SA). Purpose: This study aimed to construct a grounded theory for positive practice environments (PPEs) in private CCUs in SA. Methods: Intensive interviews and a constant comparative approach to data collection and data analysis were used to explore the participants' (n = 6) perceptions of the elements of a PPE. Findings: A theory depicting the core conceptual category of being in control and its relation to the other six categories was constructed from the data to explain a PPE for private CCUs in SA. Conclusions: The study provides a robust overview of the elements of a PPE and contributes to the constructivist application of grounded theory. Study limitations: The study was conducted in the private healthcare sector in SA, thus limiting the findings to this context.     

Pulse oximetry: application in the pediatric and neonatal critical care unit

The use of pulse oximetry in the pediatric and neonatal intensive care units has grown tremendously in recent years. Opinions about this growth are divergent. Arriving at a generalized statement about the accuracy of pulse oximeters is difficult, but it has generally been found to be acceptably accurate in most patient populations under most conditions. However, there are limitations to its application. Pulse oximetry accuracy can be adversely affected by elevated levels of certain abnormal hemoglobin varieties as well as motion artifact and low peripheral perfusion. Some authors suggest a caveat against the use of pulse oximetry to prevent hyperoxemia in the neonatal population, whereas others suggest it is an important advancement. The affect of the use of pulse oximetry on respiratory morbidity and mortality has not been established, and suggestions that all mechanically ventilated patients should be continuously monitored are unsubstantiated.     

Mothers' experiences of having a preterm infant in the neonatal care unit: a meta-synthesis

Neonatal nurses today are challenged not only to provide the best possible developmental care for a preterm infant but also to help the mother through an uncertain motherhood toward a feeling of being a real mother for her preterm baby. An increasing interest in mothers' experiences of having a preterm baby is seen. A meta-synthesis of 14 qualitative research studies on mothers' experiences of having a preterm baby in the neonatal intensive care unit, published from 2000 onward, was conducted. Noblit and Hare's methodological approach was used. The meta-synthesis revealed five metaphors that captured the mothers' experiences. These metaphors centered on reciprocal relationships that consisted of mother-baby relationship ("from their baby to my baby"), maternal development (a striving to be a real normal mother), the turbulent neonatal environment (from foreground to background), maternal caregiving and role reclaiming strategies (from silent vigilance to advocacy), and mother-nurse relationship (from continuously answering questions through chatting to sharing of knowledge). Implications of the meta-synthesis for neonatal nursing are addressed.     

Part 1: Narrative overview of developmental care interventions for the preterm newborn

The development of synaptic connections in the foetus' brain peaks during the third trimester of gestation. In case of preterm birth, the infant is vulnerable in the neonatal intensive care unit because of its immature and rapidly developing neurologic system. Therefore, developmental care interventions (DCI) are particularly important during the NICU hospitalization to optimize short and long-term outcomes, as well as neurodevelopment, in infants born prematurely. The aim of this article is to provide a narrative overview by summarizing findings of a thorough literature review on the latest findings regarding the effectiveness of six DCI on preterm infant's outcomes such as sleep, stress and neurodevelopment. Various DCI have been evaluated in empirical studies. Research related to these interventions is rapidly evolving but is still a priority in the neonatal research field.