14 • 2019 • Developmental Observer Of all the advances in neonatology in the past several decades, develop- mentally supportive, family-centered care is arguably one of the most powerful tools for improving outcomes in countries with limited economic resources. Developmen- tal care does not require expensive tech- nology, and rather it is based on sensitive observation, responsive hands-on care, and strengthening relationships among infants, families and caregivers. While some aspects of the highest quality, Newborn Individu- alized Developmental Care and Assessment Program (NIDCAP) based developmental care can be relatively costly (for example, single-room NICU design including family accommodations), resourceful and adaptive planners in develop- ing countries are no strangers to finding creative solutions to such challenges. We have only to look at the history of kangaroo care to see strong proof of this concept, as countries as diverse as Colombia, South Africa and Argentina have led the way in developing and implementing this critical strategy. A Collaboration Opportunity These issues were clearly demonstrated in a recent educational effort that this trainer was fortunate to participate in during a visit to the beautiful country of Belize in the fall of 2017. Belize is a fairly small independent and sovereign country located on the north-eastern coast of Central America bordered on the northwest by Mexico, on the east by the Caribbean Sea, and on the south and west by Guatemala. Belize is about 180 miles long and 68 miles wide on the mainland, with a population of around 370,000 people, a relatively low density. It is geographically impressive, with famous coral reefs, rain forests, and mountainous areas. The population is extremely diverse culturally, ethnically and linguistically. Though the official language is English (independence from Great Britain was obtained in 1981), over half the population is multi-lingual, with Creole and Spanish spoken by many. The health care system is a complex combina- tion of advances and limitations, with an active health ministry working hard to improve outcomes, but limited numbers of locally trained professionals available to serve the geographi- cally dispersed population. One of the strategies currently in use is close collaboration with high-quality nonprofit agencies to provide not only direct care, but also training and professional development. The non-profit agency World Pediatric Project (WPP), based in the United States (Richmond, Virginia and St. Louis, Mis souri) has been a leader in this work, by coordinating visits from leading pediatric specialists from the U.S. who work closely with professionals in Belize to help children with complex medical and surgical needs. WPP works with physicians and families to bring children who require specialized care to U.S. facilities (arranging visas, transportation and financial support for parents as well as chil- dren). Of equal importance in WPP’s work is the facilitation of professional visits that provide intensive, person-to-person training on issues requested by the local medical staff. The physicians, nurses, and other specialists donate their time and expertise, with WPP providing logistical support and maintaining ongoing relationships with the facilities and professionals involved. (Note: WPP operates in twelve countries in Central America and the Caribbean.) Newborn Care in Belize One important activity for WPP in the past several years is enhancing newborn care in Belize, which has one Newborn In- tensive Care Unit for the entire country, located at Karl Heusner Memorial Hospital in Belize City. Local leaders have drawn on multiple resources, including support from such varied donors as the government of Japan, to allow the construction of an im- maculate and fairly spacious new facility that includes not only impressive technology but also parent sleep rooms and a roomy family lounge. Additionally, the hospital has achieved Baby- Friendly designation and is strongly committed to breastfeeding for all infants. However, the staff of the NICU, including admin- istrative leaders, nursing leaders, and physician leadership includ- ing Belizian and Cuban physicians, strongly desired to continue to improve the quality of care. They were able, with the help of WPP, to link with a number of U.S. specialists, in fields just as pediatric surgery and urology. Volunteer physicians include North Carolina-based neonatologist Dr. Claudia Cadet, who has training and experience in international health. Dr. Cadet began her work in Belize focusing on improvement in respiratory care. As she planned a return visit in close conversation with the pro- fessionals in Belize, she was asked to include developmental care in the materials to be shared during her next visit. In response to this request, she included this trainer on her team, which also included an experienced nurse practitioner and a nurse educa- tor who is actively pursuing NIDCAP professional status. The team was very clear that the goal of the visit was to support and strengthen the efforts begun by the local professionals, who had made a great start but wanted to continue to progress, with formal training programs belonging in the future. The visit by the team of four (all current or recently part of WakeMed’s NICU) was a wonderful experience due to several key factors. A primary factor was the relationship that Dr. Cadet Global Perspectives of Developmental Care – Belize Melissa R. Johnson, PhD Senior Trainer, Carolina NIDCAP Training Center, Raleigh, NC, USA Developmental Observer • 2019 • 15 had built with the staff of WPP and the local medical team, who were able to discuss in detail what their needs were prior to the team’s visit. Another factor was the caliber of the WPP staff in Belize, whose understanding of the local health care system, the hospital’s history and structure, and the cultural issues impact- ing care, were all critical. The nursing leadership in the unit was paramount to success, with the head nurse demonstrating the qualities of leadership of her staff, dedication to quality, and motivation to strengthen developmental care that would be the envy of any nursery. It was especially striking when several super- visors, including the nurse manager, took over the care of all the infants for an hour so that the entire afternoon shift could attend a developmental care lecture. An additional key component, as is so often the case, was flexibility. For example, topics needed to be shortened or expanded depending on issues noted at the bedside (i.e. more time on issues of nutrition and a last-minute addition of a talk on developmental follow-up), and many key concepts were so much better communicated through demon- stration than lecture (i.e. four-handed care). Finally, we quickly discovered that the word “can’t” was not in the vocabulary of these professionals; some of the recommendations that we made fairly tentatively, not sure if they would be possible, started to be implemented before the end of the first week (i.e. dimmers on light switches). Lessons Learned What were some of the key lessons learned during this visit that might be useful to other NIDCAP professionals with an interest in sharing this work in countries not yet included? • Begin by building on existing strengths, where nurseries have the creativity and motivation to push forward even with the existence of real challenges. • As always, relationships are critical, and time spent discussing local priorities and interests is perhaps even more important than when you are training in your own culture. • Flexibility is everything; think of your original itinerary and curriculum as gentle suggestions to get you started, with the real schedule emerging based on what is happening that week or that day. • Never assume that something is impossible; professionals in developing countries have resilience and adaptive skills, from which we have much to learn. • Identify an existing organization that has experience and expertise in facilitating health care improvement in the region in which you will be working. • Take advantage of the “low tech high touch” aspects of our work, such as skin-to-skin and four-handed care, as you help build confidence and capacity. In thinking about these lessons, it also appears that some of them apply to work in the trainer’s own cultural context. Devel- oping and building relationships, starting with strengths, and adapting to the unique needs of each nursery and community are important in all training and consultation activities. As the work of the NIDCAP Federation International con- tinues to expand throughout the world, sharing our knowledge with countries who have fewer financial resources will pay us dividends as we gain from their resources of energy, commitment and creativity. The WakeMed Neonatology Team and Belize leadership Local headquarters for the sponsoring organization, World Pediatric Project The nursing leadership in the unit was paramount to success, with the head nurse demonstrating the qualities of leadership of her staff, dedication to quality, and motivation to strengthen developmental care that would be the envy of any nursery.