16 • 2025 • Developmental Observer M y perception of training within the NIDCAP model framework is that of a gradual and increasing approx- imation to the needs of the infant and their family, as well as a deeper understanding of the professional team's impact on their care. This idiosyncrasy - gradual and increasing - is es- sential in a training process aiming to understand and care for the infant's individuality. NIDCAP training consists of several phases.1 Once the professional in training (hereafter, "trainee") has demonstrated an appropriate conceptualization of the infant's behaviour and can formulate appropriate observations and care recommen- dations, the next phase in training is the Advanced Practicum (hereafter, "AP"). The AP consists of periodic observations, following the learned methodology, of the infant and family, from admission to the neonatal intensive care unit (NICU) until hospital discharge and transition home.2 The AP is an important turning point in the training pro- cess and a unique component. Both trainees and trainers come to the AP with a good deal of excitement and expectation, and perhaps holding various questions in mind: Will we be able to create a genuine relationship of support and collaboration with the family? How will it evolve? What will be its nuances as the weeks go by? How will we express, both in writing and through actions and deeds, our commitment to the care of the infant and family, and to the training process itself? Will we be able to build and ensure the supportive envelope needed for the baby, the parents, the trainee, and the NICU Professionals that the NIDCAP model3 advocates for? These questions invite us to reflect on those less apparent or explicit opportunities, yet to be revealed, that this phase of training offers to both trainees and trainers. If we come with curiosity, with open minds and hearts, what "hidden treasures" can we discover in our experience with AP? In this article, I would like to discuss some of those I have discovered in my own training experiences. A call for individuality The AP spans several weeks. It begins in the first days after birth, continues through hospitalization and discharge, and ends in the home environment. Throughout this time, longi- tudinal and regular follow-up of the infant through NIDCAP observations provides us with a better understanding of their needs; it engages us in a new way in promoting their ongoing evolution and development. The AP tests our ability to adopt, develop, and maintain an individualized approach to care over time. This stage of training calls upon us to further adjust and refine that capacity, which we have been developing in earlier stages of NIDCAP training. It prompts us to refine our analysis further and to articulate our recommendations for this unique infant we are following. It places us in the need to tailor those recommenda- tions to the infant's strengths and vulnerabilities, their clinical evolution, their family, and their circumstances. The core competence to be developed in NIDCAP training is the ability to ensure the individualization of care.1 Because of this, during AP, our ability to maintain the perspective of change and evolution advocated by the Synactive Theory of Develop- ment3 becomes essential and more evident. It is important to remember that the NIDCAP model stems from this theory. Since it is a fundamental pillar of the model we are study- ing, the trainee must have begun to develop this competence in the early stages of their training, prior to the AP. However, the trainee's ability to individualize care recommendations be- comes more visible during the AP. Consequently, the require- ment to individualize care emerges even more strongly at this stage of training. A situation to exemplify this is the care recommendation "maintain close physical contact with mother". This recommen- dation is appropriate for every stage of the infant's life. It has been relevant and crucial from the very moment of birth, and constitutes a need that is present, without exception, at every phase of the infant's hospitalization.4 However, the way of addressing and updating it for the infant and family differs at The Advanced Practicum in NIDCAP Training: Hidden Treasures for Trainees and Trainers Dalia Silberstein, PhD, RN DOI: 10.14434/DO.V18I2.41643NIDCAP Trainer, Israel NIDCAP Training Center Finding new ways to build a dialogue 2025 • Developmental Observer • 17 each developmental stage. We must anticipate that our ap- proach to this core developmental need will change and evolve in each of the observations that make up the AP. It is therefore very important that in these NIDCAP ob- servations, which the trainee formulates and the trainer eval- uates, we can identify and highlight the unique evolution of each infant and family. Thus, following the previous example, if it was a physiologically unstable and medically labile two-day old infant, the previously proposed "universal" recommenda- tion above might take the singular form of: "Consider guiding J's parents on how to help her maintain a relaxed position by gently placing their hands around her, so that J's feet and arms are slightly bent and close to her body." In future observations we need to clearly formulate (the trainee) and identify (the trainer) how that unquestionable, constant and immovable need "to maintain close physical contact with his mother" takes on different nuances. Such nu- ances are the unmistakable manifestation of individualization. Therefore, they should become apparent in the AP as individ- ualized care recommendations that vary according to changes in the infant's circumstances, e.g., their clinical situation; their ability to be alert or organize their posture; the parents' compe- tence, etc. In short, as I have tried to articulate, the AP confronts both trainees and trainers with the challenge of individualization. It is at this stage of the training process that we can most clearly demonstrate our ability to perceive care in an individualized way. This is the first of the AP's hidden treasures: the unparal- leled opportunity that this learning path offers to the trainee and the trainer. It allows trainees to demonstrate their compe- tence in individualizing their assessments and suggestions. In turn, it allows the trainer to identify and evaluate the degree to which this competence is in use during the trainee's work with the infant and family. Uses and misuses of language As previously pointed out, during the AP, the infant is ob- served over the course of several weeks. This kind of "narra- tion" over time about the infant in interaction with their envi- ronment, their family, and the professional caregivers, provides a context in which to examine our language and to recognize ourselves in it. The written text of the observations provides a further opportunity to identify the extent to which we succeed in being facilitators of development. The AP enables us to take a broad and integrative view. At this stage of NIDCAP training, we can more fully examine our discourse and language. I will briefly address this personal perception in relation to three components of care that have already been mentioned: the baby, the parents, and the profes- sional caregivers. Regarding the infant, the AP places us in a position where we must choose carefully the words and expressions to use in our communications (reports) about their de velopment. It therefore prompts us to pay attention to how fully our perception of the infant as a competent being is reflected in the language we use.5,6 Consequently, it leads us to explore whether we have been able to reflect about their strengths and vulnerabilities. Exploring the language we use in AP, ultimately means assessing the extent to which it reflects the NIDCAP model of care. Regarding the parents and professional caregivers, the training program guidelines1 encourage us to articulate NIDCAP reports that are clear and supportive for them; that enable their understanding of the infant's behavioural language; and that foster their creativity and confidence to support and promote infant's development. The guidelines further recommend that what we communicate and write does encourage parents to feel pleasure and confidence in their parental role in the complex environment of the neonatal unit.2 None of the above can be achieved without the thoughtful use of our own language, both in written reports (which make up the AP) and in the dialogue we engage in with parents and members of the professional team. The language we use can, in turn, contribute to professional growth and to the transforma- tion of the unit's culture of care. Therefore, I suggest that when evaluating the AP, it might be helpful to answer some questions central to our commitment to support infant's development. Among them, the following stand out: Have we been able to convey the strengths and vulnerabilities inherent in the infant's behavioural language? Have we been sufficiently skillful in articulating the next steps in the infant's developmental trajectory? Have we mustered the necessary sensitivity and delicacy to suggest care recommendations that contribute to the infant's development? Finally, it is also worth asking In short, as I have tried to argue, the AP confronts both trainees and trainers with the challenge of individualization. It is at this stage of the training process that we can most clearly demonstrate our ability to perceive care in an individualized way. 18 • 2025 • Developmental Observer whether we have undertaken the necessary process of introspection that allows us to prioritize our role as guides and facilitators of care7 as an integral part of our professional identity. Here, then, lies a second hidden treasure of the AP: the language used in writing down observations and communicating them offers a window from which to appreciate the deeper and more genuine insights we have into the care we provide to the infant and family within the NIDCAP model. Building a dialogue Trainees and trainers bring their own perceptions and perspec- tives of care into the NIDCAP training process. As trainers, we face the challenge of being warm, sensitive and respectful, to identify and understand our trainees' perceptions and at the same time make our own perceptions explicit, without impos- ing them or assuming that they are taken for granted. A question I have asked myself in my role as NIDCAP trainer is the following: How can a dialogue that is necessary and vital, be initiated, promoted and kept alive in a training that is partly carried out remotely? In my case, I have used the resource of written margin notes inserted in the trainee's text. I have used these notes as a first and very basic platform from which to build a basis for a dialogue that will be established later, through conversations - in person or remotely. These notes have provided me with a modest foundation from which to foster a reflective, open, and enlightening dialogue between trainees and me. I have learned, in turn, that some trainees may be unfa- miliar with this "method" and may feel some discomfort at receiving a paper that includes numerous notes. Coming from traditional educational systems, many of us have been brought up on the premise that the more flawless and less marked a paper is returned to us, the better. A paper that contains a lot of remarks from the teacher or mentor is, according to that conception, a less successful one. However, in my experience, notes are vital to encourage reflection and dialogue, which is why I try to include them. Not to do so would mean, in my view, giving up to a more open exchange of ideas about what has been observed about the baby and family. I have often felt the need to explain this point of view, and to reassure the train- ee that these notes are an inherent element in the construction of a freer dialogue, which will lead to deeper learning. Without the mutual exchange of perspectives, the learning process is impoverished. From my perspective, it is in these trainer's margin notes that lies another hidden treasure in the AP: the use of a simple instrument as a platform from which to foster dialogue. Threading reflections The practice of NIDCAP consists of observing, articulating what we have observed and reflecting on it. The sequential observations of the AP allow us to look in a structured and individualized way at the infant's behaviour and developmen- tal needs over time. It is reading these observations that allows the trainer to assess what the trainee has observed and inferred. However, it is the written reflections attached to each of the AP observations that give the trainer a glimpse of what the trainee has felt and experienced. Reflection, supported by the topics provided in the "Journal Page",8 provides a unique window into the inner world of the caregiver, in this case - the trainee. The opportunity to reflect what the AP affords, tests our ability to think more freely, to remove boundaries from our minds and spontaneously express those thoughts that the ob- servation provoked. Perhaps it is in this implicit invitation to freely reflect that its apparent complexity lies. It is not unusual for trainees to express a certain "difficulty to reflect". Indeed, they have often asked what sort of thoughts would be pertinent to this section of the AP. It is the need and desire to look at a seemingly familiar situation from new perspectives that triggers the demand to reflect on professional practice. Doing so requires a certain amount of introspection, sensitivity and tolerance. Above all, to reflect means to be willing to pause, to slow down. Per- haps in each of these attributes lies the difficulty of exercising reflection that sometimes manifests itself during the training process. However, if approached with genuine freedom, reflection, an essential component of NIDCAP training, is simpler than it may seem at first glance. My advice would be to approach reflection with an open mind - and especially with an open heart. To allow ourselves the freedom to consider whatever comes to mind from the observation we have made. That we do not impose strict limits, nor do we necessarily adhere to a certain method or structure in doing so. Let us make a small "inventory" of the thoughts and feelings that each observation has awakened in us. At this point, let us choose which of them From my perspective, it is in these trainer's margin notes that lies another hidden treasure in the AP: the use of a simple instrument as a platform from which to foster dialogue. 2025 • Developmental Observer • 19 we would like to pause and reflect on in our writing. It would suffice, in my view, for trainees to address one or two "themes" from their "inventory" in each observation. In so doing, each observation and its corresponding reflection would surely present us with the hidden treasure of discovering a new nu- ance, a new facet in our trainee. Thus, as we read the AP, the trainee's reflections on each observation get threaded through our reading in a kind of imaginary necklace. These reflections provide us with another tool to appreciate the various ways in which the trainee perceives the infant, their developmental trajectory and the care interac- tions they experience. Cultivating pride One of the main goals of the AP is that the trainee learns to support the baby and family, as well as the professional team that collaborates with them, to help them feel more competent in caring for their baby and to promote their development.1 As a nurse practicing from the NIDCAP model perspec- tive, I have identified that one of the most valued and effective ways to provide such support is to cultivate a sense of pride in both parents and professionals. There are many reasons to feel pride and satisfaction in the day-to-day life of a neonatal unit. For example: for the care provided; for the ability to individu- alize decisions; for keeping the focus of care on the infant and family; for the emerging abilities that the infant is showing day by day, despite the fragility of prematurity or the medical complexities they may present. The AP, with its methodical follow-up of the infant over several weeks, allows us to bring that pride to the forefront, and offers us (both parents and professionals) an arena in which to rejoice in the infant's achievements. The AP invites us to showcase the joy of being part of the joint effort to help that infant and their family express their most optimal de- velopmental potential. In the complex environment of the NICU, where urgency can often take the place of important experiences, the AP presents us with another small treasure: a context in which to pause, to highlight and cultivate joy and pride in the infant we care for. Conclusion The AP of NIDCAP training provides an experience full of learning opportunities for both trainees and trainers. Acquir- ing better competence and ability to individualize care, using language more appropriately, reflecting, fostering dialogue and cultivating pride are - from my perspective - some of the most salient ones. However, the concepts and competences that we develop at this stage of NIDCAP training are not limited exclusively to the AP, but in fact transcend it. If we extend these concepts and competences further, we will be able to exercise and implement them in additional contexts of our professional practice. In this way, we will benefit and enrich each of the care interactions in which we take part, and each of the learning experiences that we facilitate. In this sense, the AP holds great potential to turn us not only into NIDCAP Professionals, but also into better caregiv- ers within the multidisciplinary care team of the neonatal unit and elsewhere. Acknowledgement I sincerely thank María Maestro and Josep Perapoch from the NIDCAP Federation International for providing me with their valuable reflections, which I incorporated into this manuscript. I also thank Consuelo López from the University of Cádiz for reviewing this work and suggesting important improvements to the text. References 1. Als H. Program Guide. Newborn Individualized Developmental Care and Assessment Program (NIDCAP): An Education and Training Program for Health Care Professionals. Copyright, NIDCAP Federation International, 1986, rev 2009. 2. Als, H. Guidelines for Advanced NIDCAP Practicum: Following an Infant and Family from Admission to Discharge and Transition to the Home. Copyright NIDCAP Federation International, 2010. 3. Als H. Toward a synactive theory of development: promise for the assessment and support of infant individuality. Infant Ment Health J. 1982; 3(4):229-43. doi: CO;2-H 10.1002/1097- 0355(198224)3:43.0. 4. Flacking R, Lehtonen L, Thomson G, Axelin A, Ahlqvist S, Moran V et al. Closeness and separation in neonatal intensive care. Acta Paediatrica, 2012; 101, 1032-1037. 5. Brazelton TB. Preface. Pediatrics, 2005;113, 632-633. 6. Tronick E. The neurobehavioral and social-emotional development of infants and children. 2007; W. W. Norton & Company. New York. London. 7. Als H & Gilkerson L. The role of relationship-based developmentally supportive newborn intensive care in strengthening outcome of preterm infants. Seminars in Perinatology, 1997; 21 (3):178-189. 8. Als H. Documentation of NIDCAP Observations: Journal Page. Copyright NIDCAP Federation International, 2018. One of the main goals of the AP is that the trainee learns to support the baby and family, as well as the professional team that collaborates with them, to help them feel more competent in caring for their baby and to promote their development.