Developmental Observer  •  2019  •  17  

Aims 

The overarching goal of the project was to assess the need for, 
implement and evaluate the change process of bringing the 
NIDCAP approach to developmental care to Newborn Intensive 
Care Units (NICU) in KSA by:

• Implementing changes in the hospital culture to fully com-
prehend NIDCAP as a systematic framework to support new-
borns and their families;

• Supporting staff to appreciate the family as vital members of
the NICU community and recognizing family involvement
as essential for sustaining positive effects on physical, cogni-
tive, and psychosocial development as well as to prevent or
ameliorate complications of prematurity;

• Supporting the caregiving staff to understand the importance
of skin-to-skin Kangaroo Care (KMC) to infant development
and infant/parent relationships.

Background 

In Saudi Arabia, 264 hospitals provide tertiary NICU care to 
64% of the population, which in 2017 included 277,431 live 
births, of which 3% were considered high medical risk prema-
turely born infants. NIDCAP was introduced in 31 KSA Minis-
try of Health (MOH), Maternal Child Health (MCH) NICUs. 
These units had essentially no previous exposure to developmen-
tal care except for a three month introduction from a US group 
from Minnesota without consistent follow-up. 

Changes of Culture in Implementation of Developmental Care 
(NIDCAP Approach) 
Cala B

NICU Department Improvement Program, MOH, Saudi Arabia (KSA)



18  •  2019  •  Developmental Observer

Methods

For this project, NIDCAP introduction began initially in one 
hospital in Riyadh in 2013; the Ministry of Health NICUs 
were introduced in May, 2017. The introduction included the 
NIDCAP goals to change the culture of practice to one in which 
caregiving staff demonstrate attitudes, values, knowledge, and 
skills individualized to each infant’s developmental agenda and 
based on behavioral observation.

Discussions during the presentation included: shifting care 
from a task-oriented to an individualized care approach; elimi-
nating the standard one hour per day parent visiting policy and 
supporting active participation of the family in caregiving. These 
concepts were novel, and described as ‘eye opening’ to the nurs-
ery caregiver representative from the Ministry of Health.

Subsequent training activities included: Neonatal Mini Sym-
posia offered to different regions, updates and orientation for 
health workers, visits and assessment using the NIDCAP Nurs-
ery Assessment Manual, implementing mandatory Developmen-
tal Care Competencies for NICU nurses and orientation to mul-
tidisciplinary staff, introductory training with FINE Level 1 to 
79 NICU caregivers at investigator’s own NICU (The Children’s 
Hospital, King Fahad Medical City, Riyadh) with plans to bring 
professionals to NIDCAP Training. Outcome of this work has 
already resulted in a change in the culture of care as shown by 
a move to implement Developmental Care, and the institution 
of a NICU Improvement Program within the Ministry of Health. 
The MOH NICU Improvement Program oversees developmental 
care for premature infants in the NICU which will have a major 
impact on the future of newborns in KSA. The program supports 
standardizing NICU facilities according to NIDCAP prin-
ciples; screening for hearing, Critical Congenital Heart Defects 
(CCHD), Retinopathy of Prematurity (ROP), and Respiratory 
Syncytial Virus (RSV); vaccination; breastfeeding advocacy; free 
Natural Family Planning (NRP) consults; S.T.A.B.L.E. (Sugar, 
Temperature, Airway, Blood pressure, Lab work, Emotional sup-
port) Program course enrollment for NICU nurses and physi-
cians; and monthly reports of Key Performance Indicators (KPI) 
based on the Vermont Oxford Network benchmarks.

In support of this effort, the investigators have embarked 
on NIDCAP Nursery Certification from the NIDCAP Federa-
tion International (NFI) and joined the NFI and the European 
Foundation for the Care of Newborn Infants (EFCNI) in the 
celebration of 2017 World Prematurity Day and International 
Kangaroo Care Day. 

Results/Progress to date

• Policy development permitting and encouraging parents to
have unrestricted access to their infant and to hold skin-to-
skin (KMC) is the most challenging part. This is related to
culture sensitivity around clothing and modesty and in com-
municating the documented importance of KMC.

• Developmental Care began in May 2017 with follow-up
visits scheduled for twice a year.

• One hospital successfully initiated KMC to their nursery dur-
ing the first year of implementation.

• Three day courtesy visits were scheduled to hospital leaders
of nurseries using the NIDCAP Nursery Assessment Manual
scoring tool.

• Orientation and lecture were made available to multidis-
ciplinary staff of the hospital including NICU nurses and
physicians.

• Recommendations based on the Nursery Assessment Manual
scoring, that indicated strengths and challenges, were dis-
cussed with multidisciplinary NICU staff with reassessment
planned after 6 months.

• Orientation, awareness and lectures given introducing NI-
DCAP Developmental Care reached:

o NICU Nurses 1,337/2000, 66.85%;

o NICU Physicians 334/700, 47.71%;

o Multidisciplinary Teams 905/6,500, 13.92%;

o Lecture, awareness, symposium and orientation
31/77, 40.25%;

o Hospital Visits 31/35, 88.57%;

o Professionals from the 4 hospitals not visited due to
critical area and culture, were however, identified and
guided to introduce developmental care to their staff.

Conclusion

The NIDCAP approach to Developmental Care necessitates a 
change of NICU culture which helps healthcare professionals 
and healthcare institutionsmost fully benefit from the impact of 
Developmental Care. Developmental Care improves the NICU 
culture and gives parents and families the opportunity to play 
a major role in the care of their newborns and itchanges the 
culture to fully comprehend how NIDCAP Developmental Care 
supports newborns and their families.

CALL for EXPRESSION of INTEREST 
to JOIN the EDITORIAL TEAM

We are calling for expressions of  

interest from NFI members to join the 

Editorial Team. We would like global 

representation. Email Senior Editor 

Kaye Spence at: 

developmentalobserver@nidcap.org

developmentalobserver@nidcap.org