J ournal of Caring Sciences, 2013, 2(1), 61-71

doi: 10.5681/jcs.2013.008
http:// journals.tbzmed.ac.ir/ JCS



* Corresponding Author: Fatemeh Gholami (MSc), E-mail: [email protected]
This article was derived from MSc thesis in Tabriz University of Medical Sciences, No: 303..

Copyright 2013 by Tabriz University of Medical Sciences
The Congruence of Nurses Performance with Developmental Care
Standards in Neonatal Intensive Care Units
Leila Valizadeh
1
, Malihe Asadollahi
1
, Manizheh Mostafa Gharebaghi
2
, Fatemeh Gholami
1*


1
Department of Pediatrics Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, I ran
2
Department of Pediatrics, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, I ran

ARTICLE INFO

ABSTRACT
Article type:
Original Article

I ntroduction: Many studies support the positive short and long-term developmental
care for premature infants. This study aimed to determine the congruence of nurses
activity in four areas of developmental care in order to obtain basic information for
authorities to provide a program to achieve related standards in the future. Methods:
The study was performed on 70 nurses working in neonatal intensive care units in
Tabriz, Iran. Nurses answered to a questionnaire retrieved from Robisons
developmental program. Content validity and reliability (Cronbachs alpha) of
translated version were evaluated. Data were analysed using SPSS. Results: The mean
(standard deviation) of total score was 3.06 (0.44). It was 3.02 (0.50) for individualized
care, 3.01 (0.63) for appropriate development environment for the child and family, 3
(0.46) in supporting family relationship and approving the relationship between infant
and family and 3.22 (0.56) for collaboration among all care factors. Score 4 was
considered as completely meet standards. Therefore, a mean of 3.20 and above was
considered as observance higher than 80% and was favorable. The Friedman test
showed statistically significant difference among the activities related to the four areas
(p = 0.001). The collaboration field had the highest mean score and providing services
in this field had more congruence with the related standard of developmental care.
Conclusion: The study showed that the congruence of nurses performance with
standards of developmental care still requires more efforts. Therefore, it is necessary to
train the staff in this regard and prepare them for structural and functional facilities.
Article History:
Received: 11 Mar.2012
Accepted: 11 May.2012
ePublished: 26 Feb. 2013
Keywords:
Nurses
Neonatal intensive care unit
Care standard



Introduction
The progress of science and technology in
neonatal care has had important results in the
survival rate of premature infants. Premature
infants are embryos that evolve outside
uterus which the infants brain has the fastest
growth at that time. Despite the progresses in
neonatal intensive care, the special methods
for neonatal care in neonatal intensive care
unit (NICU) put infants at high risk of organ
injury such as lungs, brain, eye and digestive
system. These injuries include chronic lung
disease, bronchopulmonary dysplasia, intra-
ventricular hemorrhage, retinopathy of prem-
aturity and necrotizing enterocolitis (NEC).
1

Peters et al.
2
refers to the effects of
physiological stress due to care in NICU on
the structure and function of infants brain
and developmental disability.
A healthy infant is under mothers care
and grows with the appropriate kinds of
stimulus. Forty weeks healthy infant has
passed the development stage in uterus and
is ready to experience a variety of feelings
such as tactile, auditory, olfactory and
gustatory. When the senses are experienced,
appropriate patterns of adapting, learning,
cognition and controlling are stablished.
3
For
premature infants, most of the existing
environmental stimuli in NICU are unilateral
Valizadeh et al.
62 | J ournal of Caring Sciences, March 2013; 2 (1), 61-71 Copyright 2013 by Tabriz University of Medical Sciences
and occurs regardless of the infants needs.
Loud environmental noises, bright lights and
frequent aggressive actions destroy the
adequate opportunity for the infants sleep,
and physical and social appropriate condition
does not exist for a premature infant.
Although NICU is necessary for a premature
infant but compared to the uterus, this
environment is problematic for infants brain
development and neurodevelopmental
expectations. Using care based on
developmental support is a solution to
reduce premature morbidity.
1,4
Coughlin et al.
5
summarized that according
to Florence Nightingale, the origins of
developmental care can be found in the
principles of nursing and nurses responsibility
in creating and maintaining an appropriate
environment to improve the process. This
principle in cohesion with the initial nurses
work and neonatal specialists and pioneers
was the theoretical basis for others work.
5

They described the complexity of the
relationship among the brain development of
premature infants, advancement of technology
and the environment of NICU.
6
According to
Als theory, developmental care emphasis on
four key concepts including: (a) personality,
humanity, value and integrity of each infant;
(b) the importance of parents and family; (c)
effective relationship and human interaction
and (d) responsibility and opportunity
that encompasses the social nature of all
human beings.
6

The developmental care principles consist
of four standards; individualize care,
providing a supportive environment for
development, supporting family and
continuity of care. Its philosophy consists of
child and family support, staff and family
relation and the general policies in NICU.
This principal emphasizes on concepts such
as emotional care, family centered care,
parents participation in care and decision
making for infant, meticulous care with the
emphasis on infants reaction, ensure enough
sleep, minimal invasive and painful actions,
pain management, team work and
coordination.
7
In developmental care, the aim
is to provide an environment with a structure
which supports, promotes and guides the
development of premature infant or severely
ill infant, so the infant and the family
experience the least vulnerability.
5

Several studies have shown the positive
impact of developmental care on short and
long term outcomes of infants hospitalized in
NICU. A study was conducted in Edmonton,
Canada based on newborn individualized
developmental care and assessment program
(NIDCAP) and showed the short-term results
of decreased hospitalization time and
decreased prevalence of chronic lung disease,
long-term results of decreased disabilities,
specially mental retardation.
2
In another
study in NICU of Royal United Hospital in
Bath, Britain, the infants who received
developmental care had more development
in neurodevelopment until two years of age
compared to the others. It was also estimated
that they would suffer less from risk of long-
term disability and behavioral problems until
the age of five.
8
Another clinical trial was
performed based on NIDCAP and revealed
that children in experimental group had
higher mental developmental index than the
control group, and the findings indicated that
NIDCAP can have a positive impact on
cognitive development of premature infants.
9

An article entitled Family centered neonatal
care assessed the parents access to wards,
individual infant care practices, environment,
breastfeeding, kangaroo mother care (KMC)
and in 29% of NICUs mothers had unlimited
access to the ward.
10
The main reasons for
parents limitations were structural and
organizational factors and interference with
staffs performances. Most NICUs reported
the reduction in light and noise for
improving the care environment. In 67% of
the wards KMC was performed. An
important conclusion from this study was
that there was a clear correlation between
KMC and visiting time. In NICUs that
parents had unlimited visit time, the KMC
was reported 87%, and in wards that had
Nurses and developmental care standards in NICU

Copyright 2013 by Tabriz University of Medical Sciences J ournal of Caring Sciences, March 2013; 2 (1), 61-71 | 63
scheduled visiting time, KMC was 62%.
Breastfeeding at discharge in association with
KMC was reported to have higher rate.
10

The success in increasing the survival rate
of infants (low birth weight, prematurity)
brings the next development issue for these
vulnerable infants. In a study based on major
depressive disorder (MDD), the rate of
developmental movement disorder was
about 8 in 1000.
11
Considering the importance
of developmental care in decreasing the
developmental complications of premature
infants, it is important that the
developmental care policy planning in NICU
be updated with the advancement of
technology. By upgrading the knowledge and
attitude of the nurses in advantage of
developmental care in four areas, infant as a
dynamic individual should be placed in the
center of care. The task oriented care model
should be changed to collaborative model
based on the infants behavior. It helps the
physical, mental and social well-being of the
infant admitted to NICU.
In Iran, the kangaroo mother care program
for those weighing less than 2500 g, was
formed as pilot in Tabriz, 1994. From 2007,
this plan has widely been running in Tabriz
University of Medical Sciences, Iran. The first
national workshop on mothers embracing
care and secure attachment to children was
held in Neonatal Research Centre in
collaboration with Khorasan Razavi Health
Centre, Iran, in April 2007. There have not
been serious works on developmental care
based on the four standards. Minor changes
for this kind of need are being placed such as
making a nest for the infant, reducing light
by covering incubators and such cares that
need structural changes with low costs based
on the policies of each hospital. The NICUs of
this study were managed based on traditional
care (task oriented) with emphasis on
breastfeeding and kangaroo mother care. The
aim of this study was to examine the nurses
practice in four areas of developmental care,
provide baseline information for nurses and
authorities and to identify the needed
interventions and future changes in order to
comply with the four standards of
developmental care.
Materials and methods
The present study was conducted in NICU of
Tabriz hospitals, including 3 university
hospitals and 2 non-educational hospitals,
based on task driven care (routine care or
traditional care) with the policy to promote
kangaroo mother care and breastfeeding.
Although the base of care in the mentioned
sections were not developmental care, but
some aspects of this care was performed such
as making nest for the infant and decreasing
the light during night.
From the five sections under the study one
NICU was in a hospital without delivery
section. Three hospitals had all the levels of
NICU (one, two and three) and the other two
hospitals had only levels I and II. The study
population was nurses working in shifts of the
NICU. The study sample was equal to the
population. From the total of 71 nurses, one
did not return the questionnaire. Participating
nurses had at least six months of working
experience in NICU. To perform the study,
necessary permits was obtained from the
Research Council and the Ethic Committee of
Tabriz University of Medical Sciences.
Confidentiality of the information was met by
not naming the subjects of the study.
The questionnaire was retrieved from
Robinsons developmental program. This
program was obtained from chapter 22 of
infants developmental care
12
in a five
point scale [never (0) to always (4)]. Some
long items were grouped under separate
options and editorial changes were
implemented. The first standard (individual
care) had 17 items, second standard
(developmental environment) had 10 items,
third standard (supporting and confirming
the child and parent relationship) had 17
items and forth standard (collaboration) had
8 items. Total reliability was 0.95; for the first
standard it was 0.85, second standard 0.88,
Valizadeh et al.
64 | J ournal of Caring Sciences, March 2013; 2 (1), 61-71 Copyright 2013 by Tabriz University of Medical Sciences
third standard 0.84 and forth standard had
reliability of 0.86.
The data were analyzed by Friedman test
to examine the differences between the four
areas. Score of 4 was considered as completely
meet standards; therefore a mean of 3.20 and
above was considered as observance higher
than 80% and was deemed favorable.
Results
From 71 qualified nurses, 70 enrolled in the
study. Mean age (standard deviation) of
participants was 34 (6.5), with experience
duration of 9 (5) years and NICU experience
of 5 (3.4) years. Most of the nurses had
changing shift (72.4%) and had bachelors
degree (97%) and the number of child under
each nurses care was 7 (2.3).
Total mean score was 3.06 (0.44). Standard
observance was 76%. The results of each
developmental care area are given in tables 1,
2, 3 and 4. Table 5 shows the difference
between each developmental care areas.
Mean score of individualized care was
3.02 (0.50). Standard observance was 75.5%
and unfavorable. The items that had the
highest rating in this field included
medication, nutrition, chest physiotherapy
and suction, paying attention to behavior and
reactions during and after feeding, observe
proper nutritional protocol according to the
poor digestive system of the infant and
necessary actions to deal with problems.
Items that support the state of the infant
(calm sleep crying) such as staying with
the infant to relax and sleep, paying attention
to the infants behavior to determine
activities, coordinate what should be done for
the infant and the things that need certain
time were items that had the lowest rating.
The second standard which included
suitable developmental environment for the
infant and parents had mean score of 3.01
(0.63). Standard observance was 75.5% and
unfavorable. Recognizing the infants vision
and preventing infants state change and
helping the family in providing sleeping area
for the infant the same as home were
the aspects which had the lowest
mean. Quickly turning off the alarms and
avoiding unnecessary alarm sounds had the
highest rating.
The third standard about supporting the
family and infants relationship had mean
score of 3 (0.46). Standard observance was
75% and unfavorable. The lowest mean rate
was for giving permit to the babys brother
and sister to visit and the highest mean rate
was for having the same behavior in
agreement with my utterance.
The forth standard had mean rating of
3.22 (0.56) which was collaboration among all
care agents. Standard observance was
80.5% and favorable. Highest mean in
these performances belonged to changing
working shifts, informing colleagues about
information on verge, ability and
vulnerability of the infant. The Freidman test
showed significant difference among four
areas of developmental care (p = 0.001).
Discussion
Recent studies on the impact of
individualized developmental care for
premature infants in NICU showed different
positive effects. The most important
effects for infants receiving individualized
developmental care was improved
neural behavioral performance based
on physio logical, movement, state, self-
regulation and more positive interaction with
mother during childhood.
13
The advantage of
using Robisons questionnaire was its
professional behavior, which increased the
qualification of check-list for new staff or
current staff orientation. This program has
been used effectively for clinical purposes
and guiding caregivers for all the disciplines
in NICU that have interaction with parents
and children such as nurses, physician,
respiratory therapists and developmental
therapists and subsidiary caregivers.
13


Nurses and developmental care standards in NICU

Copyright 2013 by Tabriz University of Medical Sciences J ournal of Caring Sciences, March 2013; 2 (1), 61-71 | 65

Table 1. Nurses performance in Neonatal Intensive Care Unit based on individualized
care standard (n = 70)
Standard 1: Individualizedcare
No
answer
Never Rarely Sometimes
Most of the
time
Always Mean (SD)
The behaviors that the infant show
determine m y performance
2 (2.9) 1 (1.5) 1 (1.5) 15 (22.1) 39 (57.4) 12 (17.6) 2.83 (0.82)
Between care I give time to the infant to
cope with the changes
- - 1 (1.4) 9 (12.9) 28 (40) 32 (45.7) 3.19 (0.77)
If necessary I take care of the infant that
I am not in charge of
- - 1 (1.4) 12 (17.1) 33 (47.1) 24 (34.3) 3.16 (0.69)
I pay attention to the changes of sleep
sign and awareness; when the infant
wake up I start looking after him
- 2 (2.9) - 13 (18.6) 25 (35.7) 30 (42.9) 3.19 (0.49)
I do not do the unnecessary care when
the infant is sleep
2 (2.9) 2 (2.9) 7 (10.3) 10 (14.7) 30 (44.1) 19 (27.9) 2.73 (1.16)
I do the things that need specific time
with the things that do not need a
specific time
1 (1.4) 4 (5.8) 10 (14.5) 11 (15.9) 29 (42) 15 (21.7) 2.73 (1.16)
I perform the infants care without
making him tired
- - 3 (4.3) 9 (12.9) 38 (54.3) 20 (28.6) 3.09 (0.82)
I perform tasks such as medication,
nutrition, chest physiotherapy with
care and gently
- - 1 (1.4) 2 (2.9) 29 (41.4) 38 (54.3) 3.52 (0.55)
When it is time for the infant to wake
up, I gently touch him and whisper to
him until he is awake
1 (1.4) 1 (1.4) 6 (8.7) 11 (15.9) 30 (43.5) 21 (30.4) 3.04 (0.98)
Before any examination, I wait for a
few minutes until the infant is
completely awake
- 3 (4.3) 11 (15.7) 15 (21.4) 30 (42.9) 11 (15.7) 2.64 (0.98)
I do not do any procedure while the
infant is in prone position
- 2 (2.9) 9 (12.9) 16 (22.9) 26 (37.1) 17 (24.3) 2.73 (1.08)
During procedure, I have all the
necessary equipment so I do not need to
leave the infant
- - 3 (4.3) 5 (7.1) 29 (41.4) 33 (47.1) 3.33 (0.81)
I pay attention to any unfavorable
reaction during and after feeding the
infant
2 (2.9) - 2 (2.9) 1 (1.5) 22 (32.4) 43 (63.2) 3.54 (0.63)
Considering the vulnerability of the
infants digestive system, I follow the
diet protocol
3 (4.3) - - 2 (3) 21 (31.3) 44 (65.7) 3.59 (0.59)
If there is any problem, I stop the
procedure on the patient and take action
to solve it
1 (1.4) - - 3 (4.3) 22 (31.9) 44 (63.8) 3.59 (0.58)
I interact with the infant when he is
awake
1 (1.4) 1 (1.4) 9 (13) 22 (31.9) 23 (33.3) 14 (20.3) 2.64 (0.98)
After performing care, I stay with the
infant until he is relaxed and calm
3 (4.3) 1 (1.5) 21 (31.3) 20 (29.9) 13 (19.4) 12 (17.9) 2.28 (1.13)
Values are expressed as Number (%)








Valizadeh et al.
66 | J ournal of Caring Sciences, March 2013; 2 (1), 61-71 Copyright 2013 by Tabriz University of Medical Sciences
Table 2. Nurses performance in Neonatal Intensive Care Unit based on favorable standard of
developmental environment for the infant and family (n = 70)
Standard 2: Appropriate
developmental environment for
each infant and family is provided
No
answer
Never Rarely Sometimes
Most of the
time
Always Mean (SD)
I always perform care interaction in a
calm environment with low light and
sound
2 (2.9) 2 (2.9) 7 (10.3) 20 (29.4) 21 (30.9) 18 (26.5) 2.85 (1.02)
During care, I pay attention to the
sources of light, sound, scent and
motions, and I eliminate the
unnecessary ones
1 (1.4) 2 (2.9) 3 (4.3) 11 (15.9) 30 (43.5) 23 (33.3) 3.02 (1.04)
I speak with a low voice and do not
make noises during working
1 (1.4) 2 (2.9) - 8 (11.6) 33 (47.8) 26 (37.7) 3.16 (0.98)
I immediately turn off the alarms and
avoid unnecessary alarm noises
1 (1.4) 1 (1.4) 1 (1.4) 6 (8.7) 24 (34.8) 37 (53.6) 3.42 (0.91)
I place the eye support in a way that does
not block the infants vision
7 (10) 4 (6.3) 1 (1.6) 7 (11.1) 25 (39.7) 26 (41.3) 3.07 (1.04)
I provide the sleep equipment for
appropriate infants position
3 (4.3) 1 (1.5) 2 (3) 7 (10.4) 34 (50.7) 23 (34.3) 3.11 (0.88)
I determine the vision style of the infant
and prevent changes in infants vision
6 (8.6) 1(1.6) 9 (14.1) 12 (18.8) 29 (45.3) 13 (20.3) 2.64 (1.05)
I provide a calm environment for the
family taking care of the infant
1 (1.4) 2 (2.9) 2 (2.9) 10 (14.5) 36 (52.2) 19 (27.5) 3.04 (0.93)
I encourage the family to make a home
like environment for the infants sleep
3 (4.3) 1 (1.5) 5 (7.5) 15 (22.4) 29 (43.3) 17 (25.4) 2.95 (0.88)
I place the infant in a sleep position in
the bed to prevent unnecessary
movement
1 (1.4) - 5 (7.2) 4 (5.8) 38 (55.1) 22 (31.9) 3.23 (0.69)
Values are expressed as Number (%)
According to the overall mean score of all
the four standards individually, nurses
performance in the collaboration area among
all the care factors has higher mean. By
examining the individual items within the
domains, the highest mean was related to the
items that are part of nurses routine care
practices and were favorable. There are
challenges associated with developmental
care, which are discussed according to its
importance.
In individual care the infants nutrition is
important. Safe nutrition and assisting in oral
feeding are not discussed but attention to the
infants enjoyment of food is important.
Getting parents assistance in feeding the
infant makes them feel satisfied. Nutrition is
an interaction factor between infant and
parents. Caregivers need to develop this
relationship; so families can obtain the skills
needed to assess infant during nutrition.
3,7
In
NIDCAP, the caregiver determines his/her
performance according to the infants
behavior. The infants behavior is the way for
infants communication. According to the
infants behavior, care program is planned
and the infants reaction to everyday care is
evaluated. Thereby, the types of
environmental protection that helps
maintaining stability are determined and the
family care is planned. Infant care based on
sign is a part of providing developmental
care. These signs provide connection between
the infants needs and opportunities.
1,3,7,14

In Symington and Pinelli study,
15

developmental care support to estimate the
effect of specific developmental care
intervention on the results of treating
premature infants was examined.
Interventions included positioning, clustered
care performances, adjusting external stimuli
and individualized developmental care
interventions. The overall results of
developmental care interventions showed
improve in growth in short time, decreased
respiratory support, decreased incidence of
chronic lung disease, reducing the length and
cost of hospital stay and improved
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Copyright 2013 by Tabriz University of Medical Sciences J ournal of Caring Sciences, March 2013; 2 (1), 61-71 | 67
Table 3. Nurses performance distribution in Neonatal Intensive Care Unit based on support
and approval standard of infant and family relationship (n = 70)
Standard 3: Support and approval of
infant and family relationship from birth
No
answer
Never Rarely Sometimes
Most of
the time
Always
Mean
(SD)
I interact with the infants family respectfully 1 (1.4) 1 (1.4) 1 (1.4) 3 (4.3) 29 (42) 35 (50.7) 3.38 (0.85)
My behavior is the same as my utterance - - - 1 (1.4) 37 (52.9) 32 (45.7) 3.47 (0.55)
Any time of the day, I support the family
generously
1 (1.4) - 1 (1.4) 6 (8.7) 32 (46.4) 30 (43.5) 3.38 (0.73)
During changing shifts, I am prepared at the
admitted infants area and politely provide the
family with the information
2 (2.9) 1 (1.5) 2 (2.9) 15 (22.1) 32 (47.1) 18 (26.5) 3.09 (0.90)
At the presence of the family, I perform support
and interaction with the infant
- - 1 (1.4) 7 (10) 33 (47.1) 29 (41.4) 3.40 (0.70)
I interact with the family and patiently listen to
them
- - - 8 (11.4) 36 (51.4) 26 (37.1) 3.35 (0.570
I record the interactive activities that the family is
involved in
- 3 (4.3) 4 (5.7) 12 (17.1) 29 (41.4) 22 (31.4) 3.14 (0.92)
I participate the family in training activities - - 1 (1.4) 10 (14.3) 30 (42.9) 29 (41.4) 3.38 (0.79)
I explain the positive feedback of parents
interaction and their role in developmental care
- - 2 (2.9) 13 (18.6) 33 (47.1) 22 (31.4) 3.26 (0.76)
I ask the parents to help in reducing stress during
aggressive procedures
1 (1.4) 4 (5.8) 13 (18.8) 19 (27.5) 24 (34.8) 9 (13) 2.57 (1.06)
I help the parents in performances that are related
to them like bath
2 (2.9) 4 (5.9) 4 (5.9) 23 (33.8) 20 (29.4) 17 (25) 2.73 (1.01)
I assist the parents in interacting with their infant
and understanding the behaviors
2 (2.9) - 2 (2.9) 13 (19.1) 27 (39.7) 26 (38.2) 3.23 (0.79)
I explain to the family to perform according to the
infants behavior
- - 1 (1.4) 10 (14.3) 35 (50) 24 (34.3) 3.26 (0.73)
I examine the mothers tendency towards KMC - - - 4 (5.7) 34 (48.6) 32 (45.7) 3.45 (0.63)
I allow the infants brother and sister to visit
him/her
2 (2.9) 16 (23.5) 22(32.4) 16 (23.5) 8 (11.8) 6 (8.8) 1.69 (1.37)
Do the families complain about not having the
same care for each infant?
3 (4.3) 25 (37.3) 24 (35.8) 8 (11.9) 7 (10.4) 3 (4.5) 2.69 (1.21)
Parents are satisfied with the permanent care 2 (2.9) - 2 (2.9) 9 (13.2) 32 (47.1) 25 (36.8) 3.11 (0.80)
KMC: Kangaroo mother care, Values are expressed as Number (%)
Table 4. Nurses performance in Neonatal Intensive Care Unit based on standard of
collaboration among care agents (n = 70)
Standard 4: Collaboration exists among all
the care agents
No
answer
Never Rarely Sometimes
Most of the
time
Always Mean (SD)
To support the infant during stressful procedures, I
stay close to the infant
1 (1.4) 1 (1.4) 3 (4.3) 6 (8.7) 35 (50.7) 24 (34.8) 3.02 (0.78)
While the staff or the parents are present during a
procedure, I will talk to them about my performances
in a right time
2 (2.9) 1 (1.5) - 11 (16.2) 39 (57.4) 17 (25) 3.07 (0.63)
Before any act, I talk to the other persons who are in
charge of the infants care
2 (2.9) - 3 (4.4) 15 (22.1) 30 (44.1) 20 (29.4) 3.02 (0.78)
When the infant is ready for other procedures, I will
coordinate with the caregivers for future procedures
1 (1.4) - 3 (4.3) 8 (11.6) 31 (44.9) 27 (39.1) 3.28 (0.74)
During potential stressful procedures, I ask for help
from others for the infants care
3 (4.3) - - 14 (20.9) 26 (38.8) 27 (40.3) 3.16 (0.76)
During stressful procedures, I help my colleagues 1 (1.4) - 3 (4.3) 3 (4.3) 31 (44.9) 32 (46.4) 3.47 (0.67)
During shift change, I provide my colleagues with the
infants information on abilities and vulnerabilities
2 (2.9) - 1 (1.5) 4 (5.9) 23 (33.8) 40 (58.8) 3.52 (0.70)
I respect everyone involved in the infants care and
provide opportunities for them to perform their
duties
2 (2.9) - 1 (1.5) 7 (10.3) 21 (30.9) 39 (57.4) 3.42 (0.70)
Values are expressed as Number (%)
Valizadeh et al.
68 | J ournal of Caring Sciences, March 2013; 2 (1), 61-71 Copyright 2013 by Tabriz University of Medical Sciences
Table 5. Freidman test for differences between the four areas of developmental care
Developmental care Mean (SD) Mean score Freidman test
Individualized care 3.02 (0.50) 2.35
Chi-square = 16.62
df = 3
p = 0.001
Appropriate developmental environment for the infant and family 3.01 (0.63) 2.31
Support and approval of the infants and family relationship 3.00 (0.46) 2.30
Collaboration among care agents 3.22 (0.56) 3.04
Total 3.06 (0.44) - -

neurodevelopmental outcomes until the age of
24 months for premature infants.
15
In Kleberg
et al.
9
study, babies in experimental group
showed higher intellectual development
compared to the control group. It can have a
very positive effect on the cognitive
development of very premature infants.
15

Categorizing routine care in individually
defined unique care and carried out them
together at the same time (clustered care)
allows the baby to rest in longer periods, and
can be integrated with routine nurses care.
3,7

Bertelle et al.
16
conducted a study to
determine the impact of developmental care
on premature infants sleep. In one group
infants received developmental care based on
NIDCAP, reducing direct light by covering
incubator, reducing environmental noise by
closing the door and head as well as back and
leg support during sleeping. In the control
group infants received care based on the
method before using NIDCAP which means
without reducing light, noises and sleep
supports. Researchers believed that
developmental care had positive effect on
improving sleep. More studies should be
done on the impact of developmental care on
neural behavioral outcomes.
This study showed that sleep is the
important reason for premature infants
behavior. Evolution and differentiation of the
brain, memory consolidation and learning,
supporting behavioral patterns and emotions
are the possible aspects of active sleep (REM:
rapid eye movement). Energy storage,
increase in protein synthesis and release in
growth hormone are known consequences of
quiet sleep (non-REM).
16
Before starting any
examination, the infant should be conscious.
It is emphasized that even when the baby is
awake he/she should be allowed to
recognize touch and care, and to start with
soft talking, calling their names, familiar
scent and finally touching them.
3,7
After any
treatment, as long as the baby is not in a
comfortable situation, he/she should not be
left alone. By paying attention to the infants
behavior, his/her satisfaction can be
recognized. Very premature infants have
hypotonic ends. Nest or restricting areas help
in maintaining proper position of infant
which prevents disorganization of
physiological balance and energy loss.
3

Another study aimed to discover the
relationship between specific behavior of
nurses care and behavioral responses of
premature infants during bath, and to
determine nurses behavior associated with
infants stress.
17
The results showed that
when nurses provide additional support the
infants stress decreased, and self-regulation
increased during bath specially when the
infant had limited holding and support.
17

Salimi et al.
18
study showed that mothers
skin contact decreased the heart rate and
respiration rate, and enhanced the premature
infants behavior toward relaxation.
The area of supporting and approving the
parents and child relationship has an
important developmental care role in the
family centered care. There are also some
challenges in this area. For example, there
was no interest in getting parents assistance
in reducing the infants stress during invasive
procedures. Skin to skin contact with the
mother during getting blood from the infants
heel reduces pain.
7
In an article entitled
supporting family and family centered care
in NICU, supporting palliative care was
emphasized.
19
Allowing the infants brother
or sister to visit helps them in feeling
important and to start knowing the new
Nurses and developmental care standards in NICU

Copyright 2013 by Tabriz University of Medical Sciences J ournal of Caring Sciences, March 2013; 2 (1), 61-71 | 69
member.
19
Nurian et al.
20
compared the
impact of KMC and traditional care on
physiological criteria of low birth weight
infants. This method can be effective for
infants physiological stability criteria and
provide the family centered care.
20
Valizadeh
et al.
21
showed that nurses can distinguish the
mother-infant attachment cues when KMC
continues for a mother-infant diad in NICU.
The results of Cooper et al.
22
study showed
the positive impact of family centered care on
the stress level, ease and confidence.
In providing a favorable developmental
environment for the family and child,
immediate turning off the alarm was
emphasized. Since most of the alarms like
pulse oximetry and apnea alarms are
associated with the infants physiological
status, nurses are more sensitive about them.
Other issues are different, such as the infants
visual system, there are less days needed for
mechanical ventilation, lowering the heart
rate and reducing activity, increasing sleep
and improving nutrition by creating day and
night cycle using different lightening.
For hearing environment, sleep disorder
model and behavioral and physiological
responses in term and premature infants in
NICU can be mentioned.
7
Kangaroo care by
creating a favorable environment helps the
baby to have a deep sleep and harmful
stimuli such as loud noises, bright lights and
even taking blood will not hurt the infant.
4

Amiri et al.
23
study showed the effect of
lullaby on the percentage of oxygen
saturation of blood in premature infants.
Valizadeh and Hasani
24
studied experiences
of mothers in NICU in Iran and revealed
stressors affecting them. In other
questionnaire based quantitative study,
Valizadeh et al.
25
and Borim Nejad et al.
26

studied the mothers stressors in NICU.
According to mothers, the most stressors
were 'parent role and parental relation',
'environmental factors' and 'the appearance
and behavior of infants and special
treatments', respectively.
25
Environmental
factors were 3
rd
in Borim Nejad et al. study.
26

Environmental stressors such as infants
respiratory device, sudden monitor alarm
sounds and special equipment were the
most experienced stressors by mothers.
25,26

Mothers experience disappointment in
NICU can affect the interaction between
mother and child, emotional development
and infants health.
25

The last developmental care is the
collaboration between health care agents. The
performances related to this area had the
highest mean and was favorable. The
intensive care unit is a professional practice
environment. Without collaboration there is
the possibility of irregularities, therefore
collaboration observance in nurses
performances is crucial. Communication
through medical records or direct
communication between caregivers, shifts or
doctors rounds, parental participation in care
and trust is important in ensuring effective
care.
7
The results showed that nurses
performance in association with collaboration
was different from other areas. It also pointed
out the importance of planning for future
changes related to the other three areas.
Based on the results of the present study, it
is required that authorities and experts
prepare this kind of care model in NICU.
Advanced technology and neonatal
professionals cause survival of more
premature infants. To implement this plan, it
is required to train more nurses. In national
neonatal audit program the aim is to provide
clinical information of care with national
standards such as one nurse for each infant in
NICU.
27
According to the classified level of
services for mothers and infants, by
Association of Iranian Neonatologists, one
nurse is assigned to two infants in a third level
NICUs. However, in the present study the
number of infants under the supervision of one
nurse was 7 2.3. Studies on developmental
care in developing countries have been started
for two decades. In Iran, except effect of KMC,
breastfeeding and massage, there is no other
study in this regard. The present study
Valizadeh et al.
70 | J ournal of Caring Sciences, March 2013; 2 (1), 61-71 Copyright 2013 by Tabriz University of Medical Sciences
introduces the developmental care approach to
the nurses of NICU.
Due to ethical considerations, no
comparison was made between educational
and non-educational hospitals in Tabriz, Iran.
Training developmental care standards should
be in the lead of all the future training
programs due to its importance in NICU. It is
recommended that an experimental study
with training interventions be conducted in
this matter. This study cannot be extended to
other nurses in NICU of Iran. Self-report may
not be entirely consistent with the reality, and
research objectives were explained at the
beginning of the research to reduce the errors.
It is also recommended to use observation
tools for measuring developmental care
standards in future studies.
Ethical issues
None to be declared.
Conflict of interest
The authors declare no conflict of interest in
this study.
Acknowledgments
The present study was performed by the
financial support of Research Deputy of
Tabriz University of Medical Sciences (project
code: 9023). Appreciation goes to authorities
and all the participating nurses.
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