Original Article

Journal of Perinatology (2007) 27, S75–S93; doi:10.1038/sj.jp.7211843

Implementing potentially better practices to support the neurodevelopment of infants in the NICU

S Laudert1, W F Liu2, S Blackington3, B Perkins3, S Martin4, E MacMillan-York5, S Graven6 and J Handyside7 on behalf of the NIC/Q 2005 Physical Environment Exploratory Group

  1. 1Department of Neonatology, Wesley Medical Center, Wichita, KS, USA
  2. 2Department of Neonatology, The Children's Hospital of Southwest Florida/Lee Memorial Health System, Fort Myers, FL, USA
  3. 3Department of Neonatology, Benefis Healthcare, Great Falls, MT, USA
  4. 4Department of Neonatology, Mississippi Baptist Medical Center, Jackson, MS, USA
  5. 5Department of Neonatology, Sunnybrook Health Sciences Centre, Toronto, Canada
  6. 6University of South Florida, Tampa, FL, USA
  7. 7Improvision, Ontario, Canada

Correspondence: Dr W Liu, The Children's Hospital of Southwest Florida, 9981 South HealthPark Drive, Suite 281, Fort Myers, FL 33908, USA. E-mail: william.liu.md@leememorial.org





The purpose of the Vermont Oxford Neonatal Quality Improvement Collaborative 2005 was to explore improvements related to the physical environment of the newborn intensive care unit (NICU) in order to optimize the neurodevelopmental outcome of newborns.

Study Design:


Five centers were involved in a focus group examining NICU environmental design and its impact on the neurodevelopmental outcome of the neonate. Using an evidence-based approach, the group identified 16 potentially better care practices. This article describes the implementation approaches for some of these practices. The practice areas include tactile stimulation, providing early exposure to mother's scent, minimizing exposure to noxious odors, developing a system for noise assessment of the NICU acoustic environment, minimizing ambient noise in the infants environment, and preservation of sleep.



Approaches to implementation were center specific. Optimizing neurodevelopment of the newborn was the desired goal, but this outcome is difficult to measure with a limited number of subjects over a short study period. Many of the changes although intuitively beneficial are difficult to measure. Education of all participants was considered essential to the process of implementation.



The process of collaborative quality improvement is useful in identifying ways to optimize the physical environment of the NICU to improve the neurodevelopmental outcome of the neonate.


collaborative quality improvement, neonatal intensive care, NIC/Q 2005, potentially better practices, neurodevelopmental



The physical environment of the neonatal intensive care unit (NICU) and the practices involved with administering intensive care may adversely influence the neurodevelopmental outcome of neonates. The implementation of evidence-based potentially better practices (PBPs) identified by collaborative quality improvement techniques has been shown to be beneficial in improving quality of care.1 Five centers that participated in the Vermont Oxford Network (VON) Neonatal Intensive Care Unit Quality Improvement Collaborative Year 2005 (NIC/Q 2005) identified PBPs to support brain development in infants in the NICU. The implementation of these PBPs is the focus of this report, utilizing illustrative examples of improvements made and results obtained by individual sites that participated in this collaborative.



From November 2004 to December 2006, five member hospitals of the VON-sponsored NICQ2005 formed the physical environment exploratory group (nickname: Senses and Sensibilities), which worked to identify and implement care practices that would be potentially supportive to newborn brain development. These hospitals were Benefis Healthcare, Great Falls, MT; Mississippi Baptist Medical Center, Jackson, MS (MB); Sunnybrook Health Sciences Centre, Toronto, Ontario (Sunnybrook); The Children's Hospital of Southwest Florida/Lee Memorial Health System, Fort Myers, FL (TCH) and Wesley Medical Center, Wichita, KS (Wesley).

Each hospital center took a lead role in the development and implementation of care practices that operationally involved a predominant sensory system: tactile, chemosensory, auditory and visual, and the fifth center focused on sleep preservation strategies. Coordinated by our group Facilitator (Jim Handyside), with input from the Clinical Expert (Stanley Graven) and Clinical Leader (William Liu), we pursued a 2-year project. Collaboration and shared learning were emphasized and facilitated using: (1) Four National NIC/Q conferences, (2) Fifteen teleconferences, (3) Web-based Listserv and (4) Sharepoint website to facilitate document sharing, review and revision.

Steps toward this goal, patterned after previous NICQ projects,2 included:

  • Initial review of goals and interests of each participating center
  • Identification of a shared aim
  • Identify measurement goals, and create appropriate tools: surveys, acoustic and light measurements, random audits
  • Evaluation and development of PBPs
  • Case studies: Operational strategies and implementation of care practices
  • Shared learning:
    • Group understanding of use of sound and light measurement tools
    • Common need for educational tools for staff and family
    • Implementation challenges: Shared strategies to deal with staff resistance and culture changes.

Our first step was to identify a shared aim or goal. Our overall aim was to 'Create an NICU environment that optimizes the neurodevelopment of the infant while supporting the well being of family and staff'. The purpose of this aim was to provide an over-riding mission statement, understanding the 'work in progress' nature of our endeavor. With the direction of our clinical expert, facilitator and clinical leader, in an environment of shared learning, we identified the role of the environment and care practices in brain development. Through a process of literature review and consultation with a clinical expert, PBPs were defined.

Each center established functional groups composed of neonatologists, nursing management, staff nursing, respiratory therapy, administration and other opinion leaders of the NICU care team. These groups represent the integral components of care in any NICU, and they drive the ability to identify needs and implement change in the NICU setting. In a collaborative manner, the first task of these groups was to develop a tool for describing/measuring the state of existing practices, as well as staff understanding of these concepts, and thereby identify unit-specific deficiencies and needs. A survey tool was designed to assess staff perception of how well their unit incorporated specific supportive practices, and the degree to which education or information had been provided (Appendix 1). The questions were grouped to cover the predominant sensory systems, sleep preservation, family centered care and the physical structure of the nursery. Each center organized a method to distribute the surveys and gather responses from nursing and respiratory therapy staff, nurse practitioners, physicians, administrative staff and others they deemed appropriate. Responses were tallied and compared across the focus group centers. Our goal was to compare baseline results to a similar survey that would be distributed at the end of the collaborative.

A PBP matrix identified the stages of implementation of the various identified PBPs at each center (Table 2). Multidisciplinary teams from each center selected some of the PBPs to implement at their site, developed strategies for implementation and measured their performance. Changes were implemented using the plan-do-study-act model.3

Although methods differed, all teams addressed issues such as staff education and barriers to implementation. In this article, some of the case studies with specific process changes and measures implemented at each site are described.



We evaluated the clinical literature organized by sensory systems: tactile, chemosensory, auditory and visual, and the need to develop strategies to preserve newborn sleep interwoven among these practices. Recognizing that sensory stimulation is multimodal, these practices are bundled into two major gestational age grouping: (1) 11 PBPs with implementation at 23 weeks and continued to term; (2) five PBPs with implementation at 31–32 weeks and continued to term and beyond in some cases. There are also practices that occur past 44 weeks and move into the realm of infant developmental practices. We identified three environmental factors with impact on staff and families that do not involve direct newborn care (Table 1).

The Current Practice Assessment survey tool developed at the beginning of the project allowed unit-specific assessment of need (Appendix 1). The baseline assessment reported high scores for staff education and policies and procedures related to tactile development, the visual environment and family centered care strategies. All centers had an open unit design configuration NICU, and shared a concern about the amount of space available for infants and families. The tool helped guide educational plans and reflected staff understanding of the dichotomy between current clinical practices and those proposed as PBPs. Individual centers utilized the survey results to guide unit-specific educational plans and to target those practices that were the highest priority for each unit.

All centers shared a need to develop educational strategies targeting staff understanding of the science supporting the recommended PBPs. This common need resulted in a collaborative development and sharing of educational tools among the participating centers. A follow-up survey taken at the end of the collaborative period demonstrated consistent overall approbation of the PBPs. Among all centers, there was a staff perception of improvement (Figure 1). Each center demonstrated the greatest improvement in staff perception for their individual focus area. This change in staff perception may be more than measured. In some cases, as the staff learned more about neurosensory development and the recommended PBPs, they became more critical of their original assessment of pre-existing practice, and less confident that supportive care practices were in place.

Figure 1.
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Current practice assessment survey: before and after.

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Participating centers implemented PBPs based upon self-assessment of the needs of their own units. A matrix identified which PBPs each center might focus upon. Although many PBPs were implemented among the centers, 12 practice change case studies were reported at subsequent NICQ conferences. No site implemented changes related to all of the PBPs, although all centers had already or planned to adopt many of the PBPs (Table 2).

A resource kit was created by the focus group, which included the PBPs, description of implementation projects, barriers to and suggestions for implementation, and related tools and references. The resource kit was distributed to members of the NIC/Q 2005 collaborative and made available on the VON web site (www.nicq.org).

Individual centers developed several general and specific educational tools that facilitated implementation, and these tools were shared among centers. For example, several centers developed summarized educational tools explaining the rationale behind recommended interventions, individualized to both staff and family education. The Children's Hospital of Southwest Florida (TCH) included this in staff competency reviews, and utilized a worksheet to organize operational steps for implementation of each recommended intervention (Appendix 2). The open unit design of the NICUs in our group resulted in many babies of varying gestational ages in close proximity to each other. However, in units where newborns tended to be housed based upon some acuity assessment into level 3 and level 2 areas, the implementation of PBPs were operationally facilitated by utilizing strategies for implementation of neurodevelopmental bundle no. 1 for all newborns, and initially targeting the level 2 infants for implementation of neurodevelopmental bundle no. 2.

All centers already had some PBPs in place prior to the project, or planned to implement multiple PBPs. Measurement of compliance was performed at each center based upon the PBP being implemented. Consistent measurement among centers was a challenge, as each center tailored their implementation strategies to their unit-specific needs. TCH developed a bedside tool for auditing compliance for all of the recommended PBPs (Appendix 3).

Tactile stimulation/gentle hands/infant massage/kangaroo care

The skin is the earliest sensory system to become functional. The preterm infant skin is a sensory surface for the infant and a psychological and perceptual interface with caregivers and parents.4

Sunnybrook wanted to improve parent satisfaction and increase skin-to-skin contact for infants who were unable to participate in Kangaroo care through 'hand hugging' without having a negative effect on the staff or patient. A 'hand hug' education package and survey was given to each nurse and participating parent. Participating parents and infants were designated with a bedside card stating, 'I'm a hand hugged baby'. Satisfaction was measured with a survey of staff and parents after implementation of the practice. The survey showed that families enjoyed hand hugging and they felt more connected with their baby. Based upon staff perception, there was no disruption to their day or increase in their workload, and the infants tolerated hand hugging well.

Non-nutritive sucking may assist premature infants to manage stressors encountered in the extrauterine environment and also facilitate the development of sucking behavior, improve digestion of enteral feedings and decrease length of hospital stay. At Benefis, non-nutritive sucking was offered to preterm infants at least once a shift. A tool was developed to evaluate the infant's response and non-nutritive sucking was documented on the flow sheet with any abnormal response or assessment noted by documentation. Guidelines were developed to describe abnormal cues and need for occupational therapy or speech referral. Random bedside audits were carried out to monitor documentation. The number of days to nipple feeds was recorded and trended. Although no conclusions can be drawn, days to full feeds did not increase.

Kangaroo care has a large clinical base of supportive evidence,5 and yet it initially had variable levels of acceptance among the participating centers. TCH had no acceptance of this practice prior to this project. Utilizing the multidisciplinary group to communicate with all local opinion leaders, the first step in implementation involved improving awareness of existing evidence. This information was directed primarily at the physician group. Buy-in involved a process of facilitated negotiation utilizing a multidisciplinary forum, with physician-led review and discussion of available clinical evidence. This resulted in heightened awareness of potential benefit and dispelling misconceptions about perceived risk. A consensus-derived policy and protocol were developed. Concurrently, a consistent educational message was directed toward all staff. Once uniform awareness and buy-in was achieved among staff and physicians, a secondary educational strategy was directed to the families. Implementation was initially directed at the lowest risk patients (level 2 newborns on full feedings and without supplemental oxygen). There was a uniformly high satisfaction response from families and staff, with no reports of intolerance. Bolstered by this anecdotal experience, acceptance of this practice has grown among the initially reluctant physician group, and implementation now includes not only stable growing premature infants, but selected ventilator dependent newborns as well.

Provide early exposure to mother's scent

After birth, the NICU environment provides the newborn with some of their earliest postnatal chemosensory exposures, and this may be influential in shaping subsequent chemosensory responses. Studies have shown that biologically meaningful odors such as amniotic fluid, colostrum and breast milk are soothing to infants particularly when obtained from the infant's own mother.6 Introducing mother's scent may prove beneficial to preterm as well as term infants in the NICU environment by eliciting a suckling reflex and reducing crying.6

As part of their routine developmental care, Mississippi Baptist Medical Center (MB) was already using cloth dolls as a means to expose infants to mother's scent and to facilitate bonding. They hoped to improve compliance with the use, cleaning and refreshing of the dolls by better education of staff and parents. A cloth doll was provided for each infant. Both verbal and written instructions were given to the parents and staff. Reminder cards were placed at each infant's bedside to remind the mother to refresh the dolls. Additional dolls were provided for replacement/refreshing. Bedside random audits were used to monitor performance improvement. Observations were made to see if every infant had a cloth doll by 72 h after delivery, if the mother wore the cloth doll for 2 to 3 days for her scent to be effectively absorbed in the material, if mothers verbalized understanding of the appropriate use of the doll, if reminder cards were placed at each bedside, and if the mothers signed and dated when the doll was refreshed. Trended random audits suggested improved compliance with initiation of educational interventions.

Minimize infant's exposure to noxious odors

Unpleasant or noxious odors may result in detrimental responses such as diminished respiratory rate, periodic apnea and increased heart rate.7 Removal and avoidance of such odors may have potential benefit at all gestational ages.

MB investigated ways to reduce neonatal exposure to noxious odors. Substances and odors were initially identified as potentially noxious. This included alcohol, povidone-iodine, cleaning solutions. The NICU staff was discouraged from wearing perfumes and odiferous body lotions, and staff and families were educated using visual and verbal reminders on ways to prevent exposing infants to unpleasant or harmful odors. Unnecessary chemicals were removed and less odorous alternatives used. Recommendations included allowing alcohol foam to dry completely before infant contact, using saline wipes or lemon-scented adhesive remover instead of alcohol pads, prompt removal of skin preparation solutions from infant skin, judicious use of patient preoperative skin preparations and liquid adhesives, using unscented personal hygiene products, preventing cigarette smoke exposure by changing clothes after smoking, and prewashing materials brought from home. Utilizing random audits, MB was able to demonstrate a decrease in exposures to noxious odors after an educational intervention (Figure 2).

Figure 2.
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Noxious exposures before and after educational intervention MB.

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Develop a system for noise assessment of the NICU acoustic environment

It was recommended that a methodology be determined for ongoing measurement of the NICU acoustic environment, so that recommended limits for permissible noise exposure could be implemented.8 TCH established a standardized methodology for measurement and trended monitoring of the NICU acoustic environment. Twenty-four hours measurements at biweekly intervals were taken with a dosimeter using a standardized configuration and protocol at various locations in the NICU including a central location, (entry and clerk area), bedside/ambient, inside the isolette, staff work areas. Measurements were in decibels, A-weighted (dBA) and included Leq (equivalent sound pressure level. The level of a constant sound, expressed in dB, which in a given measurement period has the same energy, as does a time varying sound over the same period), L10 (the sound pressure level exceeded for 10% of the measurement period: reflects the level of relative loudness), L50 (the SPL exceeded for 50% of the measurement period. This is the median value.), L90 (the SPL exceeded for 90% of the measurement period: reflects the level of relative quiet), Lmax (the highest SPL recorded over a measurement period) and Lmin (the lowest SPL recorded over a measurement period), and were analyzed with noise exposure analysis software. This methodology was replicated at several of the other centers as well.

Minimize ambient noise level around the infant's environment

There is concern that excessive noise levels in the NICU may negatively impact infants because of the increased risk for hearing loss9 and disruption of sleep,10 as well as staff because of the affect on attention, communication and risk of medical errors.11 TCH identified several noise reduction strategies. Efforts were made to identify common noise sources derived from staff behavior and trafficking patterns, and equipment. This information allowed for empiric recommendations for changing staff behavior, as well as minor renovations in unit design. With input from an architect in our group (Brett Shivers) as well as published resources,12 major renovation strategies were identified.

Behavioral strategies included staff education with instruction to decrease conversational tone to 'library voice', move conversations away from bedside when possible so that bedside areas should be quiet enough for infant to hear mother's voice and define the infant bedside area, medication and feeding preparation areas as quiet zones. Isolette noise was to be decreased by minimizing contact with the surface of the isolette, and using care when opening and closing portal doors. Pagers were set to vibrate, and monitor alarms, phones and doorbells were to be responded to quickly. Alarms were silenced when providing care. Attention was given to noise generating activities such as hand washing, opening disposable equipment packages, storage drawers, cabinets and equipment carts, opening and closing entry doors, and disposing of trash, linens and glass bottles. The use of infant earphones, audio recordings and other sound transmission devices as well as televisions and videos was eliminated. Padding around doors was installed and noisy door latches removed. Metal garbage cans were replaced with plastic ones. The intercom was turned off in the unit, ringer volume was decreased on phones, and the volume of ventilator alarms and the audio component of the audio/video cam for NICU entry was decreased. Sliders were placed on furniture and garbage cans. Sinks were changed to decrease spray noise. They measured the ambient noise and found that their baseline unit noise levels were lower than historically published ranges. Sound measurement data were posted in the staff lounge and all staff required using the dosimeter in the unit to observe the sound producing level of their own conversational speech and beside care activities. There was a strong opinion among staff, and visitors of a perception of diminished noise levels, although measurable improvement was not demonstrated (Figure 3).

Figure 3.
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Trended 24 h sound measurements in Level 3 Bedside area-TCH.

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Sunnybrook consulted sound engineers for recommendations for ways to reduce ambient noise in their unit. They installed new sound-absorbing ceiling tiles and baffles over stainless steel headwalls, sound-attenuating rubber flooring, bedside task lighting, doors to separate nurse's station from care areas and infant spaces. They replaced the refrigerators with a quieter model. Task lighting kept the unit darker, which also subjectively decreased perceived noise.

Using sound measurements, Sunnybrook found that morning rounds were a significant noise producer. Peak levels (Lmax) within the closed incubator were found to exceed 80 dBA. They first tried moving rounds away from the infants bedside to the nurses station and found that although it decreased noise at the beside, it was very disruptive to the nursery routine. They reverted to rounds at the bedside, but decreased noise by closing the doors to the nurses' station, and allowed only one person to speak at a time using a lower tone. With these changes the noise level dropped from a pre-renovation spot measurement of 62.5 dBA to a post-renovation level of 50 to 55 dBA. They plan to continue spot measurements of noise levels, especially during admissions.

Sunnybrook and Benefis wanted to minimize ambient noise level in the infant's environment by instituting a formal period of decreased noise with decreased activity and lighting. They posted a notice in prominent areas throughout their unit to communicate the idea of quiet time, which was defined as a period of low lighting and minimal, whispered conversations. Procedures were limited to emergent only and families were encouraged to be with their infants. Staff selected their preference 1-h periods twice daily. Education was provided to staff, parents and other members of the multidisciplinary team. Parents and staff completed a brief questionnaire with positive feedback regarding the practice.

Wesley found running water in the sinks contributed to the environmental noise in the nursery. A rubber mat was placed at the bottom of the sink to absorb noise and a different type of faucet nozzle was installed on the sink that would sprinkle spray instead of having a jet spray. Using the sprinkle spray reduced the spot measured dBA level at the nearest bedside from 59 to 55 dBA and at the sink from 77 to 69 dBA. Using the mat was noisier than using the sprinkle spray alone. As a result, all faucet nozzles were converted to a sprinkle spray apparatus.

Several centers also measured sound within the incubator to illustrate the decibel level of routine care giving activities. Benefis, MB, TCH and SB all did extended measurements of sound levels within the isolette. Different model isolettes were found to have varying Leq measurements, but all of them uniformly had a higher noise floor compared to ambient noise measurements. External noise sources were attenuated, with decreased periodicity above baseline. However, bumping of the isolette surface, or internal sources of noise appeared accentuated, with associated clustered noise peaks.

Caregivers completed a questionnaire based on the results of the dosimeter readings and they found opening packets inside the incubator, pulling tape off roll and off roof of incubator, opening the doors, and removing plunger from syringe were the noisiest activities. A survey at Sunnybrook found that this information surprised most staff, and almost all would change their practices based on this information.

Wesley observed that auditory protection was not provided to neonates undergoing magnetic resonance imaging (MRI). A combination of noise reducing products was tested, including MRI safe earplugs, foam earmuffs and headset. Compliance in use and evaluation of the products was measured by staff survey. Of the five infants tested, only one infant did not use the MRI earphones, because a technician was unaware of their availability. All five nurses reported that the infant tolerated the MRI test well wearing the ear protection. The change was adopted and a policy of hearing protection during MRI test was written.

At TCH, all direct caregivers participated in a 'developmental care competency', which required each staff member to measure sound and light levels in the infants' environment. Measurements recorded on the hand held dosimeter and light meter were recorded and each caregiver reviewed their findings. Based upon their assessment, recommendations were made for decreasing noise sources or for maintaining appropriate levels of lighting. Most staff reported that this exercise heightened their awareness for recognizing appropriate bedside light and sound levels. It also provided an opportunity for all caregivers to contribute suggestions for improvement and be actively involved in working toward the team goal. The importance of interdepartmental collaboration was identified when noise sources from supply stocking or housekeeping were noted.

Avoid exposure of the infant to direct ambient lighting

Direct ambient light has a negative effect on the development of the preterm infant's visual neural architecture and early exposure to direct light may adversely affect the development of other neurosensory systems.13

All centers purchased photometers and did spot measurements of ambient light levels. TCH developed a lighting competency where staff received education with utilization of the photometer in the working areas of the NICU, to increase awareness of lighting goals. Goals were to avoid direct infant lighting exposure and to keep ambient bedside lighting levels at 5 to 10 foot candles (about 50 to 100 lux). After 31 weeks, ambient lighting could be increased to 20 to 50 foot candles. Staff work areas were maintained at 75 to 100 foot candles. Isolette covers, covers over open bassinettes, area-specific adjustable lights and adjustable window shading were all readily available tools utilized by centers to achieve these goals.

Following the sound and light competency review at TCH, overall levels of lighting were found to be within recommended levels for infants. Concern did arise that the low level of lighting in some staff work areas may present some safety risks. This led to the placement of some temporary light sources while consultation with the engineering department will review some more permanent solutions.

Wesley designed a protective eye shield to protect the infant from direct light used during examinations and procedures. The eye shields consisted of 6 times 12 inch double layer of fabric, which limited light exposure to less than 20 lux. Data were collected to measure compliance in use of the shields. Measurement findings revealed that protecting infants from direct ambient light is challenging in an open NICU environment, which is a shared responsibility among all caregivers. Eye shields were not always removed when ambient light is at an acceptable level. Overall, there was an improvement in awareness and practice to minimize direct light exposure (Figure 4). The next steps are to review and refine the criteria for use of the eye shields.

Figure 4.
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Eye patch compliance—Wesley.

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Develop practices that preserve and promote infant sleep within the NICU

Sleep is important to the neurodevelopment and growth of the infant, and disruption of normal sleep cycles may be detrimental.14 In utero, the majority of the fetus' time is spent sleeping, most often rapid eye movement sleep. Individualized care, with increased awareness of infant sleep states, may increase total sleep time as well as optimizing the environment to support sleep.

Sunnybrook wanted to minimize disruption of infant sleep. They observed that non-emergent hands on care were generally provided based on nursing routine, and not on infant state. They sought to improve practitioner recognition of infant sleep states, by preparing a sleep state tool for use at the bedside. Educational intervention utilizing this tool had a positive impact and care practices changed. They found it difficult to distinguish active REM sleep from the drowsy state especially in the very small babies. High acuity leaves nurses with little time to spare and some were unsure of their ability to alter the usual schedules. Education, encouragement and reinforcement about the importance of sleep to the developing infant were emphasized.



Centers that participated in the focus group on environmental design improved several aspects of care and environment to optimize the neurodevelopment of infants in the NICU. All centers found that education of the staff and parents was essential to the success of any of the improvement projects. Dr Stanley Graven, the content expert and advisor for the group, provided a DVD of his lecture about neurodevelopment of the newborn, which was used at all centers for staff education and introduction of the project. The presentation of the lecture material was considered key to staff buy-in by all of the sites. Methods of presentation for the material have varied from one site to another. In-service presentations or interactive discussions of articles have been more effective than independent study. The outcome of an effective educational process is that the staff will embrace the implementation of the identified 'potentially better practices' as an integral part of the care of the infant. No longer is the provision of developmentally supportive care considered something 'extra' that will be done 'if' time allows.

Multiple forms of education were used and varied from site to site, but included lectures, journal clubs, posters, local conferences, reminder cards and newsletters. Policies and procedures were updated to reflect the changes. Implementation of one PBP overlaps with others—for example noise and light affect preservation of sleep, and this understanding favors strategies with a more global implementation, where many of the PBPs are implemented together, hence the bundled approach. However, practically, it may be more feasible to introduce individual PBPs based upon the resources and conditions of each unique unit. Lessons learned and the suggested PBPs should be taken into consideration when planning nursery design and determining practices.

Not all implementation plans were successful. Barriers varied from case to case but included lack of staff buy-in, patient volume and acuity, leaving nurses with little time to implement, cost issues and limitations based on the physical design of the nurseries. Published evidence appears to be a necessary component for consideration of a new practice, especially by the physicians. However, as reflected in individual physician practice, anecdotal experience seems to be a major factor that will lead to acceptance.

With quality improvement projects, we recognize that measurement is often confounded by multiple uncontrolled variables and imprecise and variable measurement methodology. Our measurement examples are generally provided more as illustrations of approaches, rather than conclusive proof of benefit or effectiveness.

Each team has the challenge of evaluating the culture of their unit. Similarities are found among many sites, and yet, aspects of staff receptiveness to changes in practice, involvement in family-centered care practices, and availability of resources to support environmental projects were clearly unique to each unit.

One of the challenges of making developmentally supportive changes to practice is that the caregiver often does not experience the immediate effect on the infant. NICU care gives minute-to-minute attention to physiologic changes in the infant's condition and the effectiveness of the intervention is usually immediately evaluated. In contrast, the effectiveness of a quiet, dimly lit environment where the infant has undisturbed periods of sleep are often more subtle and may initially go unrecognized by caregivers. When these practices are new, and there is no feedback that they are making a difference, staff that have not been adequately educated to convince them of the importance of this aspect of care, may not sustain the intervention. This has been found to require vigilance and constant reinforcement of the evidence-based material, on a general and an individual basis.

Common feature of all implementation efforts can be grouped into the following:

(1) Developing a coordinated organizational structure that allowed for effective communication between physician and nursing caregivers at all levels of care.

  • A core group of dedicated caregivers who have the dedication and belief in the goal are needed to initiate improvement initiatives.
  • This core group should be allocated an adequate amount of time and resources to initiate and follow-through on projects.
  • Physician buy-in is critical.
  • Opinion leaders at the staff level can facilitate or subvert improvement efforts.
  • Communication networks should include interdepartmental collaboration; that is, do not forget housekeeping, radiology, occupational therapy and other sub-specialist physicians.

(2) Change is difficult

  • The more effective your underlying organizational structure, the easier to overcome the challenges of achieving generalized buy-in from staff and physicians.
  • Engaged and supportive physician leadership, early in the process, will lead to more effective implementation of new medical practices.
  • Involve staff in new processes. The more staff has a sense of personal ownership of the process, the more effective will be its incorporation into practice.
  • New habits of care are difficult to implement when staff are stressed, with limited time for non-care giving tasks, that is high patient census, inadequate staffing, high staff turnover, more newly orienting, part-time or floating staff.

(3) Maintaining the gains: the progression of novel change to new culture

  • Nurture dedicated 'champions' that continue to emphasize its importance.
  • Integrate the new knowledge base into ongoing teaching and educational programs for new staff.
  • Plan on periodic re-emphasis of the goals, and display trended measurement.

These are general lessons learned, and their recognition by no means implies that they are uniformly incorporated into our culture. In fact, this project is more a beginning than a final product. The ongoing, 'work in progress' nature of this endeavor is characteristic of the quality improvement approach.

A multicenter collaborative approach toward development and implementation of potentially better care practices to support brain development is useful and facilitates a shared learning that is necessary for continued improvement.



  1. Horbar JD, Plsek PE, Leahy K. NIC/Q 2000: establishing habits for improvement in neonatal intensive care units. Pediatrics 2003; 111(4). Available at: www.pediatricds.org/cgi/content/full/111/r/Sel/e397.
  2. Horbar JD, Rogowski J, Plsek PE, Delmore P, Edwards WH, Hocker J et al. Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network. Pediatrics 2001; 107: 14–22. | Article | PubMed | ISI | ChemPort |
  3. Langley GI, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass Publishers: San Francisco, CA, 1996.
  4. Bond C. Positive touch and massage in the neonatal unit: a British approach. Semin Neonatol 2002; 7: 477–486. | Article | PubMed |
  5. Conde-Agudelo A, Diaz-Rossello JL, Belizan JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev 2003; 4: CD002771 (Available at: http://www.nichd.nih.gov/cochrane/conde-agudelo/conde-agudelo.htm).
  6. Schaal B, Hummel T, Soussignan R. Olfaction in the fetal and premature infant: functional status and clinical implications. Clin Perinatol 2004; 31: 261–285. | Article | PubMed |
  7. Marlier L, Schaal B, Gaugler C, Messer J. Olfaction in premature human newborns: detection and discrimination abilities two months before gestational term. Chem Signals Vertebr 2001; 9: 205–209.
  8. Gray L, Philbin MK. Measuring sound in hospital nurseries. J Perinatol 2000; 19: S100–S104.
  9. Gray L, Philbin K. Effects of the neonatal intensive care unit on auditory attention and distraction. Clin Perinatol 2004; 31: 243–260. | Article | PubMed |
  10. Gadeke R, Doring B, Keller F, Vogel A. Noise levels in a children's hospital and wake-up thresholds in infants. Acta Paediatr Scand 1969; 58: 164–170. | PubMed | ChemPort |
  11. Gray L, Philbin K. Effects of the neonatal intensive are unit on auditory attention and distraction. Clin Perinatol 2004; 31: 243–260. | Article | PubMed |
  12. White R, Martin GI (eds) New standards for newborn intensive care unit (NICU) design. J Perinatol 2006; 26: S1–S30. | Article | PubMed |
  13. Graven S. Early neurosensory visual development of the fetus and newborn. Clin Perinatol 2004; 31: 199–216. | Article | PubMed |
  14. Graven Stanley. Sleep and brain development. Clin Perinatol 2006; 33: 693–706. | Article | PubMed |


NICQ2005: Physical Environment Focus Group Senses and Sensibilities
Appendix 1. NICU Current Practice Survey
NICU Current Practice Assessment
Completed by (circle one):
Staff Nurse or RT/ Management- Administration/ NNP /Physician


Please read each statement carefully. Indicate the extent to which you agree or disagree with the statement by circling the appropriate response (1=Disagree, 3=Agree). These answers should reflect how you feel your Neonatal Intensive Care Unit is at the present time, not how you think it might be in the future or how you might wish it to be.

Response Categories:

You should circle Agree when the statement is a generally accurate description of your unit. You should circle Disagree when the description is a generally inaccurate description of your unit. The response Neither Agree or Disagree should be circled when you believe the statement is neither a particularly accurate nor a particularly inaccurate description of your unit. This may occur if there is wide variation in the accuracy of the statement. If you do not have enough information to answer the question, please circle "Don't Know"

Unless specified otherwise by the question, please answer as follows:


2=Neither Disagree or Agree


4=Don't know

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NICQ2005: Physical Environment Focus Group Senses and Sensibilities
Appendix 2. Implementation worksheet

PBP Neurodevelopmental Bundles and Implementation Strategy Worksheet:

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NICQ2005: Physical Environment Focus Group Senses and Sensibilities
Appendix 3. Bedside Audit for Implementation Compliance

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This report was completed as a part of the NIC/Q 2005 Collaborative to Improve Neonatal Care, which was sponsored by the Vermont Oxford Network. The Group thanks Stanley Graven, MD for clinical expertise, William Liu as the clinical leader and Jim Handyside for expert facilitation. We thank the representatives of the participating centers that contributed their efforts to the preparation of this paper: Benefis Healthcare: Beckett Perkins NNP, Vicki Birkeland RN, BSN, Rob Archer RT, Cheryl Worden RN; Mississippi Baptist Medical Center: Sanjosa Martin RN, Jack Owens MD, Jennifer Richardson NNP; Sunnybrook Health Science Center: Michael Dunn MD, Elizabeth MacMillan-York, Dorothy Dougherty RN; The Children's Hospital of Southwest Florida: Sandra Blackington RNC, MS, Sandra Eanes-McGugan RN, BSN, Marilyn Farley NNP; Wesley Medical Center: Susan Laudert MD, Paula Delmore RNC, MSN.