20 • 2022 • Developmental Observer N I D C A P T R A I N I N G C E N T E R S W O R L D W I D E DOI:10.14434/do.v15i2.34368 French NIDCAP Center, Brest The University Hospital of Brest is in the Brittany region of France, in the westernmost department of the Finistère. There are approximately 2200 births each year in the maternity department, which is the only Level 3 maternity department that can receive children and newborns needing critical care including extremely preterm infants. The Neonatal and Pediatric Intensive Care Unit of Brest has 12 beds open to children from 0 to 15 years of age with medical or surgical needs. A large majority of admissions are premature newborns. Approximately 400 newborns are admit- ted each year in our different units, including about 100 very preterm babies born between 24 and 32 weeks gestational age. Our intermediate and special care nursery has a capacity of 18 beds divided into two sections. Six intensive care beds and twelve intermediate care beds. Since 2007, six intermediate care beds have been relocated to the maternity unit. When the nursery was established, we named it ‘Koala Unit’ as it is not a true ‘Kangaroo Care’ service. Indeed, even if the parents are close to their baby, they do not perform skin-to-skin contact 24 hours a day. The Road to NIDCAP The arrival of NIDCAP in Brest was a process and great col- lective adventure. In the 1990s due to advances in perinatal medicine, the mortality of preterm infants, especially those with a gestational age of less than 30 weeks, decreased signifi- cantly. These infants were hospitalized for several weeks in the NICU. During this hospitalization, preterm infants were cared for in an inadequate environment for the harmonious devel- opment of the brain – sudden separation from their parents, noise, pain, unusual positions, frequent handling, and early, excessive, and often inappropriate stimulation. We were faced with increasingly important problems, for which we did not have satisfactory solutions that were applica- ble to all infants. Infants were uncomfortable, and sometimes stressed and in pain. Pain was diagnosed on the basis of the infant’s behavior, and it was often difficult to determine its severity and differentiate it from stress. Respiratory morbidities, such as bronchopulmonary dys- plasia leading to prolonged ventilatory support, were difficult for the infant, their family, and for caregivers. Increasingly, frequent questions arose within the medical and paramedical team about the medium and long-term future of these very premature infants. What would be the impact of this NIDCAP Brest team Sylvie Minguy (RN NIDCAP trainer Brest France) NIDCAP Trainer 2022 • Developmental Observer • 21 environment on the developing brain? What would be their achievements and at what pace? What were their chances of getting into school? Their psychological future? Their behavior in everyday life? Families were present in the NICU more often but were finding it difficult to know their infant. The hospital pediatri- cians or private doctors who followed these former premature babies reported to the hospital teams that the parents absolute- ly did not know their infant upon discharge from neonatology and intensive care. It was as if the parents had never been involved in the care and development of their baby during hospitalization. Various programs were set up at that time within the hos- pital and the intensive care unit to improve the care of babies and their families. Skin-to-skin techniques were used, even for the mechanically ventilated children. In 1993, a study on noise, conducted by nurses, led to a change in practice that reduced the noise level in the neona- tal unit. Between 1993 and 1998, instructions for additional examinations, in particular biological examinations, fell by 70% in the neonatology unit. This process of change led to a reduction in orders of systematic, painful, and non-essential examinations, all accomplished without compromising the safety of the infant. In 1997, there was a lot of work done on pain within the entire pediatric department of the hospital. No invasive proce- dure such as intubation, placement of a chest tube, placement of a catheter was performed without analgesic cover. Unfortu- nately, this coverage was not always completely effective. Between 1996 and 1998, 80% of the department’s nurs- ing staff benefited from training in the sensory awakening of full-term newborns and in massage techniques. The caregivers thought they could relieve the infants with massages but quick- ly realized that some infants did not tolerate massage at all. Parents were increasingly present in the service. They were admitted to the units, but they were excluded at certain times, during rounds, whether medical or nursing, and especially during care. They remained mere visitors. It was difficult for families to find their place with their infants due to a lack of autonomy, but also due to a lack of privacy. Parent/infant contact was difficult and only possible when the caregiver wanted it. The siblings or the grandparents could visit the baby only when the infant had stayed in the unit for a long time. Devel- opmental care techniques were used only after medical stabi- lization of the infant. There were different attitudes between different caregivers and between different units. The Arrival of NIDCAP All these reflections and the desire to change our practices fostered the implementation of NIDCAP. It appeared to us that rather than focusing and acting on an isolated environmental factor, a more global modification of the structures and organi- zation of care was necessary. We were missing the overarching theme which was de- termined ultimately thanks to an internet search carried out by Dr Jacques Sizun in 1996. One night while on call, he read the word ‘NIDCAP’ for the first time and it suddenly seemed obvious to him: ‘If it exists, that’s really what we need!’ From that night on everything moved very quickly. We needed to inform the teams, find funding, convince the hospi- tal directors, find a trainer in the United States. Dr Jacques Sizun, Dr Nathalie Ratynski and the Nursing Staff Director at the time, Ms Catherine Mambrini, flew to Denver, Colorado to participate in a NIDCAP training session conducted by Dr Joy Browne. They returned to Brest a few days later with a new perspective on the infants in the unit. Several meetings later, five nurses came to support the team. In just over two years, thanks to Joy’s guidance, these seven professionals became NIDCAP certified (five nurses and two physicians). Jacques thought that the work stopped there, in reality it was only beginning. ‘The child and his parents are at the center of care. Care- givers gravitate around.’ Now that the theory had been absorbed and understood by the core team in the unit, it was time to disseminate the program across the services and influence change within the system without being too “pushy”! Little by little the premises, the realization and the organization of the care, the relation- ships with the infants, with the parents, and between profes- sionals had effected a real paradigm shift and inspired the establishment of a new philosophy of care: Quickly, the demand for the formation of new NIDCAP training centers appeared. The French NIDCAP Center, Brest opened in 2004 directed by Dr Jacques Sizun and co-directed “We were missing the overarching theme which was determined ultimately thanks to an internet search carried out by Dr Jacques Sizun in 1996. One night while on call, he read the word ‘NIDCAP’ for the first time and it suddenly seemed obvious to him: ‘If it exists, that’s really what we need!’” 22 • 2022 • Developmental Observer by Dr Nathalie Ratynski, who became the first French NIDCAP trainer. Observations in the unit were conducted mainly by Nath- alie and periodically by other trained nurses. In 2005, a nurse coordinator position in developmental care was created. From then on, all infants born before 33 weeks and their parents were able to benefit from individualized NIDCAP monitoring. This position makes it possible to maintain cohesion between the numerous services, but also to establish links with external services specializing in the care of vulnerable infants. That same year, Dr Heidelise Als spent a few days in Brest to offi- cially inaugurate the first French Training Center. Outstand- ing! The program continued to promote NIDCAP in Brest and throughout France and Europe. A training center opened in Brussels. In 2007, the French NIDCAP Center, Brest hosted the 18th Annual NIDCAP Trainers Meeting in Combrit, Brittany, France and invited Professor Sunny Anand, an internationally renowned neonatologist for his research work on neonatal pain. In 2011, the first French-speaking NIDCAP days were organized in Brest. Since then, every year, these sessions take place in one of the French or Belgian centers with staff trained in NIDCAP and in the past few years for those with FINE 2. These allow the opportunity for beautiful reflections and reunions around a different theme each year. NIDCAP progress in Brest continued with the training of additional NIDCAP Professionals. At the beginning of 2013, I, Sylvie Minguy, became the second NIDCAP trainer, guided by Agneta Kleberg and Deborah Buehler. Over time, the two trainers expanded their training efforts and obtained authorization to provide new training such as FINE 2 and the SOFFI program. A little later, Jacques Sizun and Isabelle Olivard became NBO trainers with the help of Yvette Blanchard. These three training programs are very suc- cessful among French teams. Expansion of NIDCAP As the demand for NIDCAP training grew, the second French NIDCAP Training Center opened its doors in 2017 in Tou- louse. In January 2020, Jacques Sizun and Nathalie Ratynski left Brest Hospital to join Toulouse Hospital. Dr Jean-Michel Roué took over the directorship of French NIDCAP Center, Brest which now has six NIDCAP Professionals, two of whom are working full time in the unit. This time is shared between the various trainings, the NIDCAP follow-up of children and their families and the coordination with the outpatient follow-up services for vulnerable children. The training of new NIDCAP Professionals is being planned. We work in close collaboration with the French NIDCAP Center, Toulouse and organize regular meetings. We distribute the training according to requests, availability, and the geo- graphical location of the requesting centers. There is a frequent exchange between trainers and trainers in training. Indeed, two new NIDCAP trainers guided by Delphine Druart will be operational in France in the near future. Although it has not always been easy, over the past twenty years the program has continued to grow. We have evolved enormously and integrated all the techniques of developmen- tal care into the organization of care, always keeping in mind to place the infant and his family at the heart of the system. It seems to me that if, at the beginning of NIDCAP implemen- tation, we had been told that system-wide changes would take place during these years, we would not have believed it! Achievements Among many, two great moments enriched the process of setting up the NIDCAP program in Brest and provided even greater motivation to all the teams: After several months of hard work in 2011, the intensive care and neonatology departments obtained NIDCAP Nurs- Team of resuscitation and neonatology caregivers at the 20th anniversary celebration of NIDCAP in Brest. Parents and former premature children came to share their stories and the impact of NIDCAP on their hospitalization. 2022 • Developmental Observer • 23 ery Certification. This work carried out by all the units of the Women-Mothers-Children Department of the hospital has brought about a common dynamic and made it possible to continue the dissemination of the NIDCAP philosophy to all the units. During the NIDCAP Nursery Certification visit in De- cember 2010, the expert site visitors, Karen Smith, MSN, James Helm, PhD and Roger Sheldon, MD pointed out the strengths of the unit. They highlighted: • The quality of care provided to newborns: One of the best among all the units visited by them. • The quality of relationships between caregivers, infants, and families with mutual respect • Single room architecture. Another great moment was the big event in 2018 orga- nized to celebrate the 20th anniversary of the implementation of the NIDCAP program. Supported by the hospital directors’ board, we were able to organize two memorable days of events for all the teams. The first day was devoted to children and their families with make-up workshops, clown shows, a music concert, and a gigantic snack. It was an opportunity for parents, children, and professionals to meet and celebrate. The demand was so great, we were unable to accommodate everyone. The second day brought together professionals from different units and peripheral hospitals in the region, as well as many parents and representatives of the “SOS Préma” parents’ association with whom we have been working closely for 15 years. Parents and former premature children came to share their stories and the impact of NIDCAP on their hospital- ization. Among them, Morgane, born at 25 weeks, and her mother, came to tell their journey, sometimes difficult but so moving, from a little girl born at 25 weeks to a brilliant student in foreign languages at the University. Morgane and her family were featured in my “advanced practicum” during my NID- CAP training 20 years earlier! During these days, we also had the chance to welcome Joy Browne for a conference on the role of parents in neonatology services. It was a real joy to see Joy back in our department! In addition, several nurses and doctors from the resuscita- tion and neonatology units spoke to the evolution of their daily work with children and their families. We said to each other as we left “Rendez-vous for the thirty year anniversary!!” Just one final story… On May 1, 2022, Benoit, the father of Gabin who was born in Brest in May 2020 at 26 weeks gestation, sailed across the Atlantic Ocean in an amateur transatlantic race, ‘Cap Martinique’. All skippers sailed under the logos and colors of a cause near and dear to their hearts. Gabin’s father chose to sail under the colors of NIDCAP in recognition of the care of his baby, but also of his family during his hospitalization! The NFI sent him the logo that was displayed on the sails of his boat throughout the crossing, from La Trinité-Sur-Mer, Brittany, France to Fort- de-France, Martinique. Thus, the NIDCAP adventure contin- ues for all! I was present for the start of the race on May 1st in La Trinité-sur-mer. Here are some photos of the event.