Current
Concepts
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Developmental Care Teams in the Neonatal Intensive Care Unit:
Survey on Current Status
Jacqulin B. Ashbaugh, RN, BSN
Mary Kay Leick-Rude, RNC, MSN
Howard W. Kilbride, MD
Developmental Care Teams (DCT) have evolved in Neonatal Intensive
Care Units (NICUs) in response to mounting evidence that
developmental care is cost-effective and improves outcomes of critically
ill newborns. Lack of national practice guidelines and standardized roles
for DCT members prompted formulation and distribution of a
questionnaire to obtain information regarding staff membership of
DCTs, budgeting for DCTs, utilization of developmental care in practice,
and education and developmental training of NICU staff.
Questionnaires were sent to 50 NICUs in 30 states, with a return rate of
62% (31 of 50), representing 18 different states. Of those who responded,
64% had a DCT, and an additional 24% were in various phases of starting
a team. Forty-three percent of the teams meeting on a regular basis did
so monthly. Only 30% of those with a DCT had a dedicated budget to
cover operating costs of their developmental program. Fifty-two percent
of respondents had Neonatal Individualized Developmental Care and
Assessment Program (NIDCAP)-certified staff at their institutions; how-
ever, nine other types of developmental specialists were also listed. Only
four respondents indicated utilization of set criteria for initiation of a
DCT consult, and 74% of those with DCTs initiated consults “when the
need arises.” NIDCAP assessments were used for parent teaching (54%),
care plans (69%), care recommendations (46%), and at caregiver “dis-
cretion” (39%).
The results of the survey validated an intense interest in developmental
care. Approach to developmental care is variable between NICUs and
implementation as outlined by NIDCAP is unusual. Practical guidelines
for utilization and funding of DCTs are needed.
Many hospitals throughout the country have implemented, or are
in the process of implementing, developmentally supportive care
practices in their neonatal intensive care units (NICUs). Develop-
mental care focuses on assessing infant cues and providing consis-
tent, appropriate interactions to enhance optimal neurodevelop-
Departments of Pediatrics (HR) and Nursing (JA, MKLR), The Children’s Mercy Hospital,
Kansas City, MO.
Address correspondence and reprint requests to Howard Kilbride, MD, Section of Neonatol-
ogy, The Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108.
48
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mental outcomes. Infants receiving individualized neurobehaviorally
supportive care have been found to experience improved outcomes,
including less need for mechanical ventilation and supplemental
oxygen, earlier oral feeding, decreased incidence of intraventricular
hemorrhage, greater weight gain, shorter hospital stays, lower hospi-
tal charges, and better neurobehavioral outcomes at 42 to 44 weeks’
postconceptual age, when compared with infants receiving standard
NICU care.1– 4 Studies of parents of preterm infants have also revealed
that parents taught to understand their infant’s developmental needs
and infant cues experience enhanced satisfaction from caring for and
interacting with their infants.5
The synactive theory of infant development from Als et al.6 is the
basis for the developmental approach to newborn care, focusing on
the interplay of an infant’s autonomic, motor, and regulatory sub-
systems with each other and with the environment. The NIDCAP
(Neonatal Individualized Developmental Care and Assessment Pro-
gram) assessment is based on this theory and includes systematic
observation of infant behaviors before, during, and after caregiving.
Professional staff, who have been trained to perform these assess-
ments, describe their observations and follow them with individual-
ized recommendations for caregiving, including aspects of the envi-
ronment, bedding, positioning, responding to infant cues, and
promoting appropriate family–infant interactions.
Initiation of Developmental Care Teams (DCT) has been sug-
gested as a way to implement and integrate developmental care into
the NICU.7–11 The initial step in the creation of a DCT in our NICU
was the training of selected nurses and occupational therapists in the
NIDCAP approach to assessment and care. As we worked to further
incorporate this approach in our unit, we sought the involvement of
other staff members with developmental expertise and interest, but
were unable to find any recommendations or national practice guide-
lines related to DCT composition, function, and standardized roles for
DCT team members. This prompted us to develop a survey question-
naire, which was distributed to other NICUs, to obtain information
regarding developmental care practices, staff membership of DCTs,
budgeting for DCTs, utilization of DCTs, and education and develop-
mental training of NICU staff.
SURVEY METHOD
Questionnaires were developed requesting information regarding type
and size of NICU, whether a DCT was utilized and who was on the
Journal of Perinatology (1999) 19(1) 48 –52
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Developmental Care Teams in the NICU Ashbaugh et al.

team, frequency of DCT meetings, utilization of DCT in care practices,

staff training in developmental care, use of developmental care for
parent teaching, environmental modifications utilized to provide
developmental care, and financial support for DCTs. Respondents
were asked to mark appropriate responses to multiple-choice ques-
tions and provide additional comments when indicated (Figure 1).
Questionnaires were sent to nurse managers of 50 NICUs in 30 states.
NICUs, other than the authors’ institution, were selected by a random
drawing of names, which had been taken from the 1996 United States
Neonatal Directory (American Academy of Pediatrics, Perinatal Pedi-
atric Section, supported by the Mead Johnson Company). Fifty percent
of the units were first selected from midwestern states to determine
practice in the geographical region of the authors’ institution. The
remaining 50% of questionnaires were approximately distributed
equally between the eastern, western, and southern geographical
regions. Responses were received from 31 centers in Arizona, Arkan-
sas, California, Colorado, Indiana, Iowa, Kansas, Louisiana, Minne-
sota, Missouri, Nebraska, New Hampshire, North Carolina, Ohio,
Oklahoma, Texas, Virginia, Washington DC, and Wisconsin. Response
rate was greatest from hospitals in the Midwest (67% returned) and
least from the southern region of the country (38%). Ninety percent of
respondents identified their NICU as a level III, and 63% had a bed
capacity of $25 beds. Two-thirds were listed as teaching hospitals,
43% had extracorporeal membrane oxygenation facilities, and 70%
were affiliated with a perinatal department.

Table 1 Developmental Care Team Composition

Team member Frequency of representation
on team (%)*

Staff nurse 80
Occupational therapist 70
Neonatal nurse practitioner 60
Developmental specialist 60
Neonatologist 50
Nurse manager 50
Physical therapist 50
Clinical nurse specialist 45
Lactation consultant 40
Social worker 40
Discharge coordinator 30
Charge nurse 20
Speech therapist 10
Child life worker 10
Parent 5
Clinical educator 5
Neurologist 5
Developmental pediatrician 5
Public health 5
Audiologist 5

*N 5 20 institutions with DCTs.

Figure 1 Questionnaire sent to selected NICUs.

Journal of Perinatology (1999) 19(1) 48 –52 49

Ashbaugh et al.
Figure 2 Bar graph representing percentage of institutions utilizing these methods to educate staff about developmental care.
RESULTS
Sixty-four percent of respondents indicated that their NICU had a
DCT, 16% noted that formation of a DCT was in progress, and 19% did
not currently have or plan a DCT. Private institutions and those iden-
tified as “teaching hospital” were more likely than public institutions
to have a DCT or be in the process of forming one (83% private, 70%
teaching, and 25% public). Team membership varied by institution,
with staff nurses, occupational therapists, neonatal nurse practitio-
ners, and developmental specialists represented on more than half of
the teams (Table 1).
Developmental care team consultations were initiated on an
“as-needed” basis in 74% of the units with DCTs. Other criteria cited
for requesting developmental assessments were all infants ,800-gm
birth weight (16%); infants ,28 weeks’ gestation (5%); infants
weighing ,1000 gm (5%); infants ,1500 gm (10%); and those with
neurologic problems (11%). Sixteen institutions utilized NIDCAP-
trained staff to perform observational assessments and prepare devel-
opmental care plans. Where NIDCAP observations were done, the
frequency of assessments was “as needed” in 42% of the NICUs, every
2 weeks in 21%, as well as per nurse’s request (53%), and physician
request (53%). Nurseries utilizing NIDCAP observations indicated
assessments and recommendations were used by caregivers for parent
teaching (54%), nursing care plan development (69%), posting at the
bedside (61%), and recommendations only (46%).
Respondents indicated that DCT responsibilities included teach-
50
Developmental Care Teams in the NICU
ing NICU staff and parents about developmentally supportive care.
Staff educational approaches reported were inservices, newsletters,
self-learning packets, videos, networking, lectures, developmental
rounds, journal club, and posters (Figure 2). Parent education related
to developmental care was offered in 54% of the institutions using a
variety of methods (Table 2).
Every institution returning a questionnaire indicated that some envi-
ronmental aspects of developmental care had been incorporated in their
nurseries. Reduction of lighting, noise abatement, and modification of
staff and visitor behaviors were major areas of focus (Table 3).
Of developmental teams meeting on a regular basis, 64% met at
least monthly (Figure 3). Financing was considered the greatest ob-
stacle to team formation. Less than one-third of the DCTs had a dedi-
cated budget. Three percent were in the process of formulating a bud-
get, but 54% used existing resources and operated without a budget.
Nonbudgeted sources of funds for developmental care were donated
funds and “in kind” services, grants and foundation requests, and
charitable fund raisers.
DISCUSSION
Although there is increasing documentation of the importance of
developmental care in the NICU,1–5,11–12 approaches to initiating and
maintaining developmental care programs are not well established.
Data from this questionnaire indicate that, although most institutions
Journal of Perinatology (1999) 19(1) 48 –52
Developmental Care Teams in the NICU Ashbaugh et al.

Figure 3 Frequency of developmental care team meetings.

have initiated parts of the NIDCAP program, availability and roles of Table 3 Environmental Interventions Reported
developmental care specialists vary. Many institutions have imple- Frequency
mented some of the environmental interventions suggested by Als et of use (%)*
al.,1,2 but training and expertise of team members and approach to
Lighting
patient assessments are very different from those initially suggested. Variable bedside lighting controls 60
Since completion of this project, additional strategies for imple- Isolette covers used 50
mentation of developmental care have been published by Als and Subdued overhead lighting 60
Indirect lighting 43
Partial covering of isolette 43
Table 2 Parent Education Resources for Developmental Care Use eye covering on infants 3
Noise abatement
Resource Frequency Limited bedside conversations 70
of use (%)*
Traffic flow control 50
Individualized teaching offered to all parents 54 Lowering alarm decibels 40
Developmental care information in admission parent package 10 “Quiet design” equipment 37
Developmental care class 20 Floor and wall covering (carpet, sound boards, acoustical tiles) 27
Offered as separate class 17 Use decibel meters 3
Incorporated with other parent classes 10 Place ear muffs on infants 3
Small group luncheon series 3 Staff/visitor behaviors
Videos 40 Minimal stimulation of infants 80
Books 37 Role modeling positive behaviors 73
Posters in parent visiting rooms 3 Visual reminders 60
Slide presentation/lectures for parents 3 Use of quiet times 10

*N 5 17 Institutions offering developmental care teaching to parents. *N 5 30 Institutions.

Journal of Perinatology (1999) 19(1) 48 –52 51

Ashbaugh et al.
Gilkerson.9 They recommend staffing two full-time salaried positions:
a developmental specialist with a master’s or doctoral degree in a
developmental discipline and specialized training in neonatal care
and the NIDCAP model; and a developmental care nurse educator
with at least 3 years of clinical experience and training in the NIDCAP
model, who works with the developmental specialist and acts as the
key link to the day-to-day implementation of a developmental model
of nursing care. They also considered a part-time (0.10 FTE) salaried
parent representative or parent council important for implementation
of family-centered care. In addition, they recommend that at least
10% of nursing staff on all shifts complete NIDCAP training and that
a multidisciplinary team comprised of the developmental specialist,
the developmental nurse, developmental leaders from each discipline,
the parent representative, and key staff nurses meet regularly, such as
monthly, with the nurse manager and chief neonatologist attending
at least quarterly. The role of the team depends on the needs of the
unit. Important functions of the team are to provide necessary re-
sources for educating and involving physicians, nurses, and ancillary
staff in developmental care, family integration, environmental issues
and planning, continuous quality improvement studies, and assessing
ongoing team goals and progress.
Incomplete program development may reflect insufficient fund-
ing reported by most respondents. Introduction of developmentally
trained individuals into the nursery setting represents additional costs
that are difficult to justify at a time of decreasing medical care reve-
nues. Administrative support of an extensive program requiring mul-
tidisciplinary team involvement is necessary for establishment of
developmental care in the NICU.7,9,11–13 Additional educational costs
must also be appreciated to teach staff about developmentally sup-
portive care via such methods as videotapes, newsletters, self-learning
packets, didactic programs provided by developmental specialists, role
modeling, mentoring, developmental rounds, positive reinforcement,
and educational bulletin boards.7,10,14 –16 Lower nursing costs associ-
ated with earlier discharges have been suggested as a source of poten-
tial savings, which could be used to offset expenses involved in imple-
menting and maintaining a developmental program.2–3,9,12–13
Although studies have reported improved medical outcomes in
low birth weight infants receiving developmental care based on the
NIDCAP program, instituting only a portion of the program may not
have resulted in the desired outcome. Most institutions surveyed re-
ported program development significantly different from the NIDCAP
program. The clinical and financial impact of limited or modified
interventions require additional investigation.
CONCLUSION
Results of this survey validate an intense interest in developmental
care. Anecdotal comments by respondents demonstrated a pervasive
52
Developmental Care Teams in the NICU
frustration with the lack of consistency in DCT membership and frag-
mented utilization of data obtained from developmental assessments.
Practical guidelines are needed for applying published NIDCAP guide-
lines to create effective developmental care programs in NICUs.
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