Introduction
The Universe of Developmental Care
Implication for practice
References

The Universe of Developmental Care

Sharyn Gibbins, NNP, PhD
Head of Interdisciplinary Research and Evidence-Based Practice
Sunnybrook Health Science Centre, Toronto, Ontario, Canada

Evidence from adult and pediatric settings over the past three decades has demonstrated that critically ill patients are affected by their hospital environment, but the degree of involvement is dependent on factors such as severity of illness, previous hospital experience or co-morbidities.1, 2 Qualitative data from ICU patients indicate that constant care-related activities coupled with loud, bright environments prevented restorative sleep and significantly affected their clinical outcomes and perceived hospital experience.3 Much attention is now focused on the relationship between the environment and the adult or pediatric patient who is experiencing care in an ICU setting. Further, it is argued that changes in practice, such as the surge of single-patient rooms, core nursing performance, family-centered care approaches and patient advocacy groups are a result of an increased awareness of the influence environment has on quality care. Although minimizing environmental stressors on adult ICU patients has been an extraordinary accomplishment, its translation into neonatal units has been at a much slower pace.

The notion of how environmental factors affect health outcomes of high-risk infants has its origins in developmental pediatrics when the focus shifted from reducing infant mortality to improving the quality of life for neonatal survivors. Unlike previous decades, it is no longer acceptable to deny preterm infants pain management, exclude parents from decision making or fail to protect infants from infection risks and safety hazards.4-6 The focus now rests on delivering safe and effective care in a manner that meets the physiological and developmental needs of the infant and family. The concept of developmental care was introduced as both a philosophy and care model that valued the individuality of the patient within a complex NICU environment. The care model was pioneered by Dr. Heidelise Als and colleagues who argued that infants have the capacity to communicate their needs through physiological and behavioral indicators, but the onus should be on caregivers to interpret their cues and adjust their behaviors accordingly.7-11

Developmental care is practiced in neonatal units worldwide. However, evidence to support its universal adoption has been fraught with difficulties.12, 13 Inconsistent definitions within institutions and amongst practitioners have threatened the validity of the research, which, to date, influences where resources are spent and attention is devoted. Clear definitions that delineate the tenets of developmental care are required in order to deliver quality care and to measure relevant neonatal and family outcomes. The Universe of Developmental Care (UDC) is the first major reformulation of neonatal developmental care theory since Als' Synactive theory.8 The concept of a shared surface is advanced in the paper to signify the critical link between the body/organism and environment. The shared surface is analogous to the site where touch occurs; a locus for healthcare delivery.14

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The Universe of Developmental Care

The UDC is a theoretical framework that provides a practical focus for patient care, education and research. It visually resembles our solar system, where planets are distinct entities that share a common orbit. There is no hierarchy within the model, as each planet is integral to the universe and bound by "gravitational force" that promotes balance and cohesiveness. Exclusion of one planet risks the healthy development of the remaining. The "gravitational force" within the UDC is the infant, who cannot be separated from the physiological systems that are essential for all life. It is by thoughtful and well-timed actions of both caregivers and families that these systems are preserved. Once physiological stability is achieved, it is believed that infants attempt interaction with their environment (as represented by the yellow sleep-wake ring). It is only at this time that care practices such as feeding, positioning, providing comfort, skin care or thermoregulation can be initiated by an individual who continuously monitors the physiological systems and sleep-wake states. Changes in these parameters dictate when care practices need to be adjusted.

Immediately beyond the care planets is the family, which has the most intimate relationship with the infant. Unlike traditional views that place parents outside of the immediate care circle, the UDC encourages early and ongoing involvement with all aspects of neonatal life. The NICU staff is represented in the UDC as a separate orbit that supports the family. Although visually removed from the core, it represents the partnership that must emerge between the NICU care providers and the parent/family as parents move from foreigners/visitors in the NICU to parents of a newborn infant. The outermost orbit in the model is the environment, which includes both micro (light, noise, privacy) and macro (culture, values, team behaviors) elements that provide structure and sustainability for developmental care. Without an intact environment planet, the universe cannot exist. It is this fundamental orbit that must be addressed with each individual who touches the lives of high-risk infants.

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Implications for practice

Throughout the UDC is the premise that education promotes, sustains and advances developmental care. For this reason, education is visually represented as a Milky Way within the solar system that transects the entire universe. Developmental care crosses all ages, diagnoses and healthcare settings; and as such requires educational opportunities for all involved. The UDC provides the structure to examine developmental care and to operationalize its tenets to achieve quality care. Without clearly defined variables, the UDC offers no more information about developmental care than the numerous theories that have come before. The UDC has defined each planet and provided practical information such as (i) why the planet is essential for developmental care, (ii) what are the desired outcomes for each planet, (iii) how do the planets relate to each other, (iv) what educational needs, equipment and resources are needed to achieve optimal outcomes, and (v) what measures are required to determine changes in infant or family outcomes or areas for improvement.

The UDC can be used for clinical practice such as the planned removal of adhesives from the skin of an extremely low birth weight infant. The procedure can be performed perfunctorily or, the care provider, utilizing a developmentally supportive approach, may position the infant comfortably, employing a facilitated tuck and non-nutritive sucking while gently removing the adhesive with a water-moistened cotton ball. The UDC can also be used as a platform for education to address how the clinical activity in one planet, such as feeding an infant with chronic lung disease, can be affected by activity within another planet, such as an attempt to feed the infant in a bright and noisy environment or the failure to adequately assess respiratory effort.

The strength of the UDC is in its consistent language and definitions. The concept of a universal language that objectively defines each planet and specifies actions needed to achieve improvement will enable clinicians, educators and researchers to standardize care, measure performance, and identify areas for further development. Testing of the UDC is currently underway. Educational and mentorship opportunities, as well as human resources and equipment to affect change, have been provided and baseline data to determine effectiveness have been collected. A plan for a systematic evaluation of infant, family and staff outcomes has been developed. It is believed that the overwhelming evidence to support developmental care will only occur once standardization of terms has been achieved. It is further believed that the UDC is the first step in providing this evidence.

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  1. Al-Samsam R, Cullen P. Sleep and adverse environmental factors in sedated mechanically ventilated pediatric intensive care patients. Pediatr Crit Care Med. 2005;Sep;6(5):562-567.

  2. Gabor J, Cooper AB, Crombach SA, Lee B, Kadikar N, Bettger HE, Hanly PJ. Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. Am J Respir Crit Care Med. 2003;167 (5):708-715.

  3. Freedman N, Kotzer N, Schwab RJ. Patient perception of sleep quality and etiology of sleep disruption in the intensive care unit. Am J Respir Crit Care Med. 1999;159(4):1155-1162.

  4. Anand KJ. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. Feb 2001;155(2):173-180.

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  7. Als H. Developmental care in the newborn intensive care unit. Curr Opin Pediatr. Apr 1998;10(2):138-142.

  8. Als H. Toward a synactive theory of development: promise for the assessment and support of infant individuality. Infant Ment health J. 1982;3:229-243.

  9. Als H, Tronick, E, Lester BM, Brazelton TB. The Brazelton Neonatal Behavioral Assessment Scale (BNBAS). J Abnorm Child Psychol. 1977;5(3):215-231.

  10. Brazelton TB, Als H. Four early stages in the development of mother-infant interaction. Ps choanal Study Child. 1979;34:349-369.

  11. Brazelton TB, Tronick E, Adamson L, Als H, Wise S. Early mother-infant reciprocity. Ciba Found Symp. 1975(33):137-154.

  12. Symington A, Pinelli J. Developmental care for promoting development and preventing morbidity in preterm infants. Cochrane Database Syst Rev. 2006(2):CD001814.

  13. Jacobs SE, Sokol J, Ohlsson A. The Newborn Individualized Developmental Care and Assessment Program is not supported by meta-analyses of the data. J Pediatr. Jun 2002;140(6):699-706.

  14. Gibbins S, Hoath SB, Coughlin M, Gibbins A, Franck L. The universe of developmental care: a new conceptual model for application in the neonatal intensive care unit. Adv Neonatal Care. Jun 2008;8(3):141-147.

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