Ab Initio International Fall 2000
Feature Article

The NBO and the March of Dimes NICU Family Support program:
The effects of the NBO as an educational and emotional support system for parents of premature infants

By J. David Nugent Shriver Center, University of Massachusetts Medical School and Dana Alhaffer of University of Massachusetts at Amherst

Introduction
Kevin Nugent and Rachel BalckThe Newborn Behavioral Observations (NBO) system was developed as a scale or set of observations to provide educational and emotional support to new parents, by sensitizing them to the competencies and individuality of their newborn infants (Nugent, Keefer, O'Brien, Johnson, Blanchard, 2005). It grew from the need to develop a clinical tool that could be used as an interactive observation, to provide a forum for parents and clinician to observe and interpret the newborn's behavior, to help them read their baby's communication cues and thereby help them better understand their new baby. The information derived from the NBO can be used, therefore, as a form of anticipatory guidance to help parents make informed choices about caregiving. The development of the NBO drew on over twenty-five years of research and clinical work with the Neonatal Behavioral Assessment Scale (NBAS) (Brazelton, 1973, 1985; Brazelton and Nugent (1995) and was developed specifically, as a relationship-building method, to sensitize parents to their newborn's capacities and individuality, with the goal of fostering the bond between parent and infant and between clinician and family. In sum, the aim of the NBO is to provide enhanced informational and emotional support to parents, by providing them with information that can help them better understand their baby and his/her needs and thus enable them to support their baby's growth and development.

The Brazelton Institute/March of Dimes Family Support Program Partnership
The Brazelton Institute and the March of Dimes Family Support Program entered into a partnership to train pediatric practitioners (NICU Specialists) from selected March of Dimes Family Support Program sites across the country, in the use of the NBO, to help them integrate the NBO into their practice with parents of premature infants, as a way of fostering the parent-child relationship and helping the family achieve specific outcomes that are both child and family-centered. The Newborn Behavioral Observations (NBO) system is based on the assumption that it is the quality of the caregiving environment that hinders or halts development and that protective factors, such as providing strong support to parents, can improve resistance to risk factors and contribute to successful outcomes, adaptation and child resiliency. Finally, it was proposed that the NBO had the additional benefit of being practical and cost-effective and could easily be incorporated into the March of Dimes Family Support initiative.

The aims of the NBO training program are consistent with at least two of the four main aims of the March of Dimes Prematurity Campaign, namely, to educate parents and to assist practitioners who work with premature infants and their families (www.marchofdimes.com). Since the March of Dimes NICU Family Support program is specifically designed to provide emotional and informational support to families by contributing to NICU staff professional development, it was assumed that the use of the NBO could serve to facilitate the attainment of these goals. Moreover, the NBO is based on a philosophy of family-centered care and promotes the development of a partnership between the practitioner and the family.

The Training Program
This one-day training program was designed for groups of 15-20 pediatric professionals, all of whom were working in the March of Dimes Family Support site. Eligible professionals must have experience working with newborn infants. Faculty from the Brazelton Institute provided training at the host site.

The goals of the training program curriculum were:

  1. To provide trainees with information on neurobehavioral development and the emerging parent-child relationship in the postpartum period
  2. To teach the content, uses and administration of the NBO
  3. To teach trainees essential clinical/communication skills in the context of using the NBO with parents of premature infants

Objectives for participants

  1. Participants were introduced to the NBO, its contents and the research and theoretical framework on which it is based
  2. Participants would learn to administer the NBO
  3. Participants would learn how to use the NBO with parents of premature infants, as a way of providing anticipatory guidance and promoting the development of a strong clinician-family partnership

Teaching Methods:
Power-point presentations, discussions, break-out demonstrations with infant and family (where possible), video case-studies and post-training on-line mentoring made up the curriculum.

Results
Training took place in five March of Dimes NICU Family Support sites: Greenville, South Carolina; Oregon Health Sciences University Hospital, Portland, Oregon; Trenton, New Jersey; Shands Hospital, University of Florida Medical Center and Parkland Hospital, Dallas, Texas. The total sample consisted of 80 practitioners, made up of neonatal nurses, neonatologists, physical and occupational therapists and Child Life Specialists.

Professional Background:
Neonatologists 3
Neonatal Nurses 32
Nurse practitioner 15
Child Development Specialists 5
PT 4
OT 3
SLP 1
Respiratory therapist 2
Pediatrician 2
Lactation consultant 1
Maternal Child Health Nurse 3
Social worker 3
Educators 3
Registered Nurses 2
MOD NICU support coordinator 1
Total 80
Age of participants m=40, range 23-61
Professional experience
in years		 m=12.5, range 2-30
1. How helpful were the specific components of the training?
  • Aspects of neurobehavioral development underlying theory behind the use of the NBO:
      95% found it quite helpful or very helpful
      5% found it to be only a little helpful

  • Understanding the behavior of the premature infant:
      94% found it quite helpful or very helpful
      6% found it to be only a little helpful

  • The NBO: Administration:
      99% found it quite or very helpful
      1% found it to be only a little helpful

  • NBO demonstrations with newborn infant and family:
      100% found it quite or very helpful
      0% found it to be only a little helpful

  • The NBO as a relationship building model:
      97% found it quite or very helpful
      3% found it to be only a little helpful

  • Incorporating the NBO into your practice:
      97% found it quite or very helpful
      3% found it to be only a little helpful


2. Instruction on the Administration of the NBO
    96% found it very clear
    4% found it to be somewhat clear


3. General Satisfaction with the NBO training

    85% were very satisfied
    15% were generally satisfied
    0% somewhat or very dissatisfied


4. Did the trainees learn any NEW information on the theoretical principles underlying the NBO?

  • Newborn behavior and development
      74% learned a lot or quite a lot new
      20% learned only a little new
      6% learned no new information

  • The behavior of premature infants:
      75% learned a lot or quite a lot new
      20% learned little or no new information
      5% learned no new information

  • Interacting with parents of premature infants:
      91% learned a lot or a great deal new
      6% learned little or no new information
      3% learned no new information

  • Administering the NBO:
      98% learned a lot or a great deal
      2% learned only a little new information

  • Being able to provide parents with guidelines on care-giving based on the NBO:
      99% learned a lot or a great deal new
      1% learned only a little new information


5. Were the objectives of the NBO training very clear?
    100% found the objectives of the NBO training to be very clear.
    0% somewhat or very dissatisfied


6. How well prepared were you to use the NBO to address the following specific clinical topics?

  • Sleep behavior:
      97% were generally or very well prepared
      3% were prepared a little

  • The Newborn's Responses to Stress:
      98% were generally or very well prepared
      2% were prepared a little

  • Newborn Motor behavior:
      98% were generally or well prepared
      2% were prepared a little

  • State behavior (crying and consolability, state transitions):
      97% were generally or very well prepared
      3% were prepared them a little bit

  • Communication cues:
      98% were generally or very well prepared
      2% were prepared a little

  • Newborn Visual and Auditory capacities:
      98% were generally or very well prepared
      2% were prepared a little


7. How confident are you in your abilities in each of the following areas?
  • Examining premature infants:
      53% have complete confidence
      40% are somewhat confident
      7% said they have no confidence

  • Describing premature infant's behavior to parents
      64% have complete confidence
      34% said they are somewhat confident
      2% said they have no confidence

  • Responding to parents questions about their infant's development:
      65% have almost complete confidence
      32% are somewhat confident
      3% said they have no confidence

  • Calming newborn infants:
      60% have almost complete confidence
      38% said they are somewhat confident
      2% said they have no confidence

  • Helping parents learn what their infant's behavior means:
      61% have almost complete confidence
      37% said they are somewhat confident
      2% said they have no confidence

  • Helping parents respond appropriately to their infant's cues:
      65% have almost complete confidence
      35% said they are somewhat confident

  • Communicating with parents:
      90% have almost complete confidence
      10% said they are somewhat confident

  • Establishing a connection with parents:
      92% has almost complete confidence
      8% are somewhat confident

  • Helping parents learn about their infant's unique behavior or temperament:
      92% have almost complete confidence
      8% said they are somewhat confident

  • Informing parents about Early Intervention and follow-up support:
      85% have almost complete confidence
      10% said they are somewhat confident
      5% have no confidence

  • Providing guidance to parents about their infant's behaviors during the first months of life:
      87% have almost complete confidence
      13% said they are somewhat confident

  • Discussing feeding issues with parents:
      90% have almost complete confidence
      10% said they are somewhat confident

  • Discussing sleep issues with parents:
      90% have almost complete confidence
      10% said they are somewhat confident

  • Discussing newborn crying issues with parents
      90% have almost complete confidence
      10% said they are somewhat confident


8. Implementing the NBO in clinical practice
    36% said it will be very easy.
    45% said it will be somewhat easy
    18% said that it will be somewhat difficult
    1% said it will be very difficult


9. Describe any specific challenges to using the NBO with parents and newborns in your practice

    41% anticipated no specific challenges
    59% anticipated challenges such as the:
    • physical environment not conductive to using the NBO with families
    • visits with families are too short to administer the NBO
    • the language barrier


Conclusions
In general, 100% of the pediatric professionals, who were trained on the NBO across the five March of Dimes sites, were either very satisfied or generally satisfied with the training in preparing them to use the NBO in their practices with parents of preterm infants. They felt very well prepared to use the NBO in their practices. They agreed that they learned a great deal about newborn behavior and development and 91% said they learned a great deal new about how to interact with parents of premature infants. In addition, they felt very confident to address a range of clinical topics with parents. However, 59% said they anticipated difficulties in implementing their NBO into their practices due to the physical environment in the NICU not being conducive to including families, while for others the language barrier constituted an obstacle to using it with certain families.

In conclusion, the following direct quotes were offered by NBO trainees to show how the NBO would benefit them in their work with parents of preterm infants:

    The NBO allows me to give parents control, acknowledging them and giving them credit
    The NBO is way to reinforce positive behaviors for parents
    It Reinforces the fact that parents do know their babies
    I learned that parents do know their babies despite the NICU invasive environment and they can teach us
    I learned how to listen to parents better
    I learned how to slow down and read the baby's and parents' cues
    Utilizing the NBO as a teachable moment
    How to communicate what I observe in infant's behavior to parents from a baby's centered view point
    Making parents aware that their baby knows them
    Involving the parents is very valuable
    The NBO is a great tool not only to "assess" but to use as a push toward other topics and better relationships
    As physicians, we tend to talk to parents about pathology. The NBO enhances confidence in the physician-family relationship

For references and further information please contact Mary Young at: myoung3@worldbank.org

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