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The Newborn Intensive Care Unit Environment of Care:

How We Got Here, Where We’re Headed, and Why


Robert D. White, MD*,†,‡

The newborn intensive care unit (NICU) is a life-defining place for many infants, families,
and caregivers. The place in which such events occur is often remembered for its sights,
sounds, and smells, but the physical environment of the NICU is far more than a memory
tag; it can directly influence the quality of the experience for all of its inhabitants. A growing
body of evidence demonstrates the profound impact of the physical environment on growth
and development of the neonatal brain. The value of skin-to-skin care is now established.
Psychology, sociology, and occupational health provide additional insight into the effect of
the NICU setting on families and caregivers. Together, these lines of evidence point to the
need for individualized environments. Single-family rooms are a growing trend in the NICU
because they allow for individualized environments. Careful planning can avoid pitfalls and
bring benefit to babies, families, and caregivers alike.
Semin Perinatol 35:2-7 © 2011 Elsevier Inc. All rights reserved.

KEYWORDS NICU design, skin-to-skin care, single-family room, NICU lighting, NICU sound

Newborn Intensive “healthy.” In the midst of our dedication to saving lives, it was
easy to miss possible adverse effects of the physical environ-
Care Unit Environment ment. As survival has become commonplace, nagging ques-
of Care—Why It Matters tions become more persistent—should we worry more about
the possible effects of the physical environment on the fragile,
I t is easy to overlook, especially for those who work there
every day, how extraordinary a place the newborn inten-
sive care unit (NICU) is. For infants, it is the environment in
growing brain of our patients? Increasingly, it appears that
the answer to that question is “yes”—and not only for infants,
which brain growth and development proceed at a pace un- but also for their families and caregivers.
matched at any other time in life, with millions of neurons For a time, when the survival of extremely preterm infants
firing and wiring, for better or worse, minute by minute. For was a novelty, it was tempting to accept external appearances
parents, too, it is often a defining time in their relationships that these infants were unaffected by the stimuli that surrounded
with their baby, each other, the health care system, and for them. Soon, though, this naïveté was pierced by articles that
many, in their spiritual life. Even for caregivers, the NICU showed that preterm infants were influenced by NICU noise1
and what we do there largely shape who we are and how we and lighting.2,3 These seminal works have been followed by
feel about ourselves. many more, establishing that preterm infants are in fact very
In the early days of NICU care, the physical design evolved sensitive to many elements of their external environment, prob-
with a single-minded purpose to facilitate life-saving treat- ably more so that at any other time in life. This literature has
ment. It is stating the obvious that in this evolution, we cre- been well-reviewed elsewhere4 and continues to grow.
ated an environment quite unlike the womb, or even some- For a time, the major focus of clinicians interested in this
thing a patient of any age might consider nurturing and area was the physical environment of the NICU itself, and
that attention was well-deserved. However, in the back-
ground, another area of interest preceded the development of
*Regional Newborn Program, Pediatrix Medical Group, Memorial Hospital, the NICU and has continued to grow in parallel. It concerns
South Bend, IN. the effects of maternal separation at birth and the remarkable
†Adjunct Professor of Psychology, University of Notre Dame, Notre Dame, IN. breadth and depth of biological interaction that occurs be-
‡Assistant, Clinical Professor of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN.
tween mother and infant when they are in skin-to-skin con-
Address reprint requests to Robert D. White, MD, Newborn ICU, 601 N. Mich- tact with one another in the hours and days after birth. Al-
igan St, South Bend, IN 46601. E-mail: Robert_White@pediatrix.com though it is not within the scope of this discussion to review

2 0146-0005/11/$-see front matter © 2011 Elsevier Inc. All rights reserved.


doi:10.1053/j.semperi.2010.10.002
The NICU environment of care 3

Table 1 Contrasting the Sensory Environment of the Fetus with that in the NICU
Stimulus In Utero Skin-to-Skin with Mother Incubator or Warmer
Sound Primarily mother’s voice and body Primarily mother’s voice and White noise and a cacophony of
sounds, transmitted through body sounds, transmitted unfamiliar sounds, transmitted
liquid and solid media through air and solid media through an air medium
Odor/taste Mother’s, transmitted through a Mother’s, transmitted A multitude of unfamiliar smells
liquid medium primarily through an air and tastes, many of them
medium noxious
Touch/kinesthetic Mother’s movement, with a liquid/ Mother’s movement, with a Flat, nonhuman surface with no
muscular interface providing skin-to-skin interface natural movement
containment providing containment
Circadian Multiple biorhythms in mother and Multiple biorhythms—activity, None
fetus—hormonal, activity, temperature, and (via
chemical, temperature, heart rate breast milk) chemical and
hormonal

that literature, it is worthwhile to compare the in utero sensory Scher et al8 demonstrated that skin-to-skin care accelerated
environment with that of an infant when they are skin-to-skin electroencephalographic signs of brain maturation in pre-
with their mother or in an incubator or warmer (Table 1). term infants, while Milgrom et al showed that training par-
Beyond the focus of neonatal medicine, robust research ents about the neurosensory needs of their babies enhanced
has been conducted in the fields of mother–infant interac- white matter development.9 Fifer et al have recently shown
tion, patient satisfaction, and healthy work environments. that newborn infants learn to respond to an environmental
Until recently, however, NICUs were designed with little stimulus even when asleep,10 emphasizing the continuous,
attention to these disciplines. The result was that, although intense nature of the learning process in newborns. These
support of new medical technology was nearly always well- studies confirm a much larger body of work in animals that
addressed, the needs of families and caregivers were not. demonstrates how important the external environment, and
Now that it has become apparent that the health of an infant especially parental interaction, is to the newborn.
is linked to the well-being of its family and caregivers, the
environment of care has taken on a broader meaning, and has
become an important component of NICU design and care. Evidence That
the Sensory Environment
Evidence That Is Important to Caregivers
the Sensory Environment Caregivers, too, are affected by the sensory environment. An
Is Important to Newborns extensive literature documents that factors, such as noise,
lack of access to daylight, crowding, and noxious odors im-
The fetus occupies a richly stimulating environment in utero. pair job satisfaction and at times, job performance.11 These
Touch, movement, taste, sounds, and circadian rhythms of same factors influence family and patient satisfaction in the
hormones, body temperature, and activity of the mother are hospital setting.12,13 Circadian physiology serves as a good
closely linked to evolving neuronal development. These example, again, of the complexity of environmental influ-
stimuli are much different in the NICU—some are more ences. There is evidence that night shift workers can be more
prominent (eg, sound), others much less prominent than in alert and demonstrate improved performance when exposed
utero, (eg, kinesthetic) and all are delivered in a much differ- to brief periods of bright light at night,14,15 but it is also clear
ent fashion. that they are more prone to various neoplastic diseases.16
Perhaps the most-studied aspect of the physical environ- Melatonin suppression may be a factor in both instances, so it is
ment for preterm newborns is circadian lighting, which has not possible to give clear recommendations for the appropriate
been shown to be superior to either continuous dim or con- lighting levels at night for caregivers. Nevertheless, it is obvious
tinuous bright lighting.5 Noise is clearly disruptive to infants, that while some sensory needs of infants are congruent to those
precipitating apnea and desaturation.1 It has long been rec- of their caregivers, others might be quite disparate.
ognized by clinicians that preterm infants are very sensitive to
touch, responding in either a positive or negative fashion
depending on the stimulus. Smell, too, is active in preterm The Case for Skin-to-
infants who have a positive response to breast milk and other Skin Care as the Optimal
pleasant odors,6 but react adversely to disinfectant and deter-
gent.7 Importantly, skin-to-skin care provides rich, familiar
Environment of Care for the Infant
stimuli to the infant, especially when accompanied by the Making the theoretic/philosophic case for the mother’s body
smell, taste, and hormonal content of breast milk feedings. as the optimal environment for a preterm infant is straight-
4 R.D. White

forward. Throughout human history and in virtually all cul- The Case for Single-Family
tures until modern-day Western civilization, mothers and
their infants were an inseparable dyad. As altricial mammals,
Room Design in the NICU
we are completely dependent on our mothers in early infancy Given the disparate needs of infants, families, and caregiv-
for nutrition, warmth, and protection. Only with the advent ers—and even the differing needs of individual infants, fam-
of neonatal intensive care did the mother become no longer ilies, and caregivers—a strong case can be made for individ-
essential; in the early days of NICU care, she was even con- ualized environments in the NICU. Single-family rooms allow
sidered a danger to her infant. Early guidelines allowed vis- infants to be cared for in a room where they are shielded from
iting but limited this to a few minutes a day, and then only medical or social activity at a neighboring bed. The risk of cross-
when fully garbed with gown, gloves, and mask. With the contamination may also be reduced; in fact, the first all-private
introduction of “family centered care,” we allowed families room NICU (in Brest, France) was built for the express purpose
into “our” world but even in the most liberal family-centered of minimizing nosocomial infection. Families benefit from the
units in the United States, most infants still remain in contact increased privacy, space, and sense of control they receive in
with inanimate technology for many more hours a day than a private room. Caregivers benefit from the ability to have
with human skin. their own space away from the baby’s bedside where they,
For those who consider the incubator as the gold standard too, can have some privacy, and a sensory environment more
for an optimal environment for a preterm infant, it is impor- appropriate for their needs, rather than sacrificing their needs
tant to remember that its superiority was established not in to those of the babies and families when all occupy the same
comparison with skin-to-skin, but to infants in an unheated space.
crib. We have years of experience in incubator care of infants, Indeed, the NICU is the only inpatient unit in the hos-
and are very comfortable with its ability to keep infants warm pital where individual rooms are not mandated for new
in a reasonably stable fashion. However the thermoneutral construction,19 even though there is nowhere else in the
environment established many years ago was established by hospital where the physical environment has a more im-
the temperature at which metabolic needs were minimized, portant impact on neurological development of the pa-
which may not be the optimal goal for an infant whose largest tient. The infant brain grows in size and complexity by
metabolic demand comes from its very active and rapidly 400% in the third trimester, comparable with the growth
growing brain. Skin-to-skin has been shown to be quite ef- experienced from term birth until adulthood. Thus, a
fective in keeping even the smallest infant as warm as or spectacular amount of growth and development is sand-
warmer than the thermoneutral setting of an incubator17— wiched into a very brief time frame, and we know that it is
and with a built-in circadian rhythm. influenced by external stimuli. It is not scientific evidence
Perhaps the best analogy is our history using breast milk that has delayed the institution of private rooms in the
and formula. For a time early in our specialty, there were NICU; more research on the physical environment has
suggestions that mother’s milk was inappropriate for the been conducted in NICU and pediatric populations than
feeding of preterm infants and that infant formulas were bet- anywhere else in the hospital. Rather it is the reluctance of
ter options, partly because of their more desirable levels of clinicians and hospital administrators to accept this
protein and mineral intake and partly because they were so change, in some cases for reasons that have nothing to do
much easier to store and deliver. Gradually, though, this with patient well-being.
trend was reversed as it became apparent that mother’s milk In an era in which the Health Insurance Portability and
was the best source of basic enteral nutrition for infants of any Accountability Act is aggressively enforced, the open
gestational age. Formulas have been improved to come closer NICU is an anomaly. Attempts to preserve privacy inter-
to mother’s milk, although even now it is clear that we cannot fere with open communication between clinicians and
deliver the rich diversity of nutrients, hormones, trace min- families and sometimes among clinicians themselves. Too
erals, and other (some as yet undiscovered) bioactive sub- often, privacy is breached in a setting in which no good
stances through any medium other than mother’s milk. The alternative is available. There is no reason this should be
same is true for environmental stimuli. We can improve the considered acceptable when new construction is planned.
NICU at large and incubators in particular to provide more Nevertheless, there are legitimate concerns that must be
suitable stimuli to infants, but they will never be better than addressed before recommending private room design in
a meager alternative to direct and extended contact with the the NICU because it is possible to do it in a way that is
mother, either in quality or quantity of all the sensory stimuli. worse than existing open unit design. Most of the valid
This is not a new, or even newly rediscovered concept; concerns revolve around safety. It is important to note that
even in the early days of NICU care, Dr Roberton, and his private rooms have been shown to be safe for patient care
colleagues reminded us that “It must never be forgotten that, in many other areas of the hospital, including critical care
ultimately, the care of even very sick newborns is the respon- settings in adult and pediatric units. Many pioneering
sibility of the parents and that medical and nursing staff exist NICU units throughout the United States and in several
to assist them in doing what needs to be done while not other countries have also shown that single-family room
usurping the parents’ role.”18 design in the NICU is safe and desirable.
The NICU environment of care 5

Table 2 Effect of Enhanced Family Presence on Neonatal Out- space, ventilation, and finishes are generally improved re-
comes gardless of the design chosen, so one would expect improved
<30 Weeks’ Standard FCC outcomes with almost any design. It is still notable, however,
Gestation Care (Rooming-In) that never has the change from open to single-family room
LOS, ICU 43.1 d 32.4 d P ⴝ 0.02 design been found to be unsafe, allaying that most important
LOS, total 66.7 d 56.6 d P ⴝ 0.04 concern about the potential downside of this concept. Also of
Mod/severe 6.0% 1.6% OR 0.18 note is that in every unit that has converted from open to
BPD (0.4-0.8) single family room design, the vast majority of nursing staff
Abbreviations: BPD, bronchopulmonary dysplasia; FCC, family-cen- say they would never want to return to an open unit, even
tered care; ICU, intensive care unit; LOS, length of stay; OR, when they identify deficiencies of their particular single fam-
odds ratio.
ily room design.
*Adapted from Ortenstrand et al.20

Evidence for How to Get


the Benefits of Single-Family It Right—Design Ideas
Room Care in the NICU There is no substitute for adequate space in a new NICU
design. With sufficient clinical space (at least 750 gross
The most convincing evidence for the benefit of single-family square feet per bed position, calculated as total gross floor
room care was recently reported from the Karolinska group area divided by the number of beds), private rooms and
in Stockholm,20 where a randomized control trial showed
sufficient support space can be provided. Noise abatement
marked reduction in intensive care unit (ICU) and total hos-
is easier, and flexibility for overload situations is greater.
pital days, as well as a reduction of bronchopulmonary dys-
Every design must also provide for multiple modes of com-
plasia in premature infants cared for in private rooms com-
munication. Families want to communicate with their baby’s
pared with those cared for in 4-bed open rooms (Table 2).
caregivers; this can be facilitated by private rooms, but only if
Family participation was encouraged in both units, and the
hospital staff and procedures were identical in both areas. it is still easy for a family to find their baby’s nurse when she
The major difference between units was that sleeping space is not at the bedside. They also want to communicate with
was available for the families in the private room area, and other families and should not have to leave the NICU to do
consequently, those infants spent much more time in skin- so. Small gathering areas scattered throughout the NICU are
to-skin proximity with their parents. It should be noted that more desirable than a large waiting room outside the unit.
Newborn Individualized Developmental Care and Assess- Gathering areas are more likely to be used if they have amen-
ment Program care was practiced throughout the NICU, and ities needed by families who are staying in the unit for long
that even in the “control” open-room setting, parents typi- periods, and if they provide access to sunlight (Fig. 1).
cally spent several hours a day with their babies, usually in Communication is also crucial for caregivers. They need to
skin-to-skin care. This finding suggests that extensive inti- communicate with one another, and the single most common
mate family presence confers benefit even in settings in mistake made with SFR units is the failure to provide central
which family-centered and developmental care are well-es- gathering areas for staff. In larger units wireless phones allow
tablished.
In a study from Vanderbilt, parents who spent time in both
open and private rooms felt that the single-family room facil-
itated more time with their infant, more privacy, greater ac-
cess to the doctor, and provided less overstimulation to their
infant by noise and light.21 A number of units, by using
historical controls, have found marked improvement in fam-
ily and caregiver surveys,22,23 although these have not been
favorable in all regards. Although families appreciate the in-
creased privacy and ownership they feel in a private room,
they can also feel somewhat isolated. Caregivers likewise can
feel isolated from their colleagues, especially if a central gath-
ering area is not provided.
It should be apparent that randomized controlled trials are
very difficult to perform. NICUs are usually transformed
from open to single-family room units in entirety. Thus, his-
torical controls have been the most widely used. These must
be taken with considerable caution because it is almost al-
ways the case that many more changes are made than just the Figure 1 Family gathering area in the NICU of the Women and
transition from open to single-family room design. Total Infants Hospital of Rhode Island.
6 R.D. White

a nurse to contact any of her teammates as needed, as well as Q. What about twins and higher order multiples?
the support areas of the hospital, and to be accessible to A. In many units (especially those with a high-risk obstet-
families and others who wish to reach her. Nurses also need rical service), multiples may comprise 20%-25% of the
to receive communication from the monitors of the babies, typical census. In keeping with the concept of single-
which can be accomplished through the same or a second family rooms, a typical strategy has been to either de-
personal communications device. With these devices, most sign some semiprivate rooms or to place doors or slid-
audio alarms and cross-room conversation can be eliminated, ing room dividers between some rooms. When
reducing major sources of noise in the NICU. semiprivate rooms are designed, it is advisable to de-
Successful noise control in the NICU requires multiple sign enough of these rooms to accommodate the great-
strategies. Background noise can be reduced through careful est percentage of multiples that might be expected,
planning of the HVAC (ie, Heating, Ventilating, and Air Con- anticipating that it might occasionally be necessary to
ditioning) system, proper insulation of outside walls and put unrelated babies in those rooms when the unit
windows, and making this one of the selection criteria for all reaches full census.
equipment purchased. Occupant noise production can be Q. What is the best headwall design?
reduced through use of resilient flooring, reduced lighting A. Choosing from a dizzying array of headwall designs, each
levels, careful planning of traffic patterns, and the communi- with their own advantages and drawbacks, can be daunt-
cation strategies outlined above. Ambient noise can also be ing. The biggest error lies in forgetting the importance of
reduced through use of acoustical ceiling tile and other making it easy to transfer a baby from a warmer or incu-
acoustical surfaces, as well as by increased area (that allows bator to a parent’s arms, with the result that the headwall
for dissipation of sound) and walls (that interfere with long- becomes a tangle of extra-long wires and cords and con-
distance transmission of sound). Excellent resources for fur- stitutes an unnecessary barrier to skin-to-skin care for
ther planning of sound control are available.24 high-acuity infants. This can be minimized by thoughtful
NICU lighting has many functions, most of which were not placement and redundancy of outlets and use of articulat-
considered until very recently. Obviously, ambient lighting ing arms. Often for the sake of cost, headwalls are also
must be appropriate for the tasks being performed on a reg- designed with little ergonomic flexibility; here again, the
ular basis, and additional task lighting is needed at the bed- use of articulating arms and/or tracks that permit variable
side for special procedures. However, lighting also affects placement of equipment and redundant outlets will make
mood, noise levels, way finding, and visual fatigue. Because caregiving tasks easier.
preterm infants have very thin eyelids and usually limited Q. What is the best way to cluster beds or patient rooms?
ability to move their head, there should be no direct ambient A. Clusters of 8 or fewer beds creates substantial problems
lighting within the infant’s visual field. Because adult occu- with nurse staffing and collaboration, whereas larger
pants have repeatedly been shown to benefit from access to clusters are less likely to require frequent patient trans-
daylight, this must be provided in gathering areas. A circa- fers to maintain appropriate staffing ratios when an
dian lighting scheme should be used in the patient care area, infant is admitted or discharged. Clusters of more than
with at least a 200 lux change between daytime and nighttime 12 rooms become geometrically challenging, although
ambient lighting levels. Excellent resources are also available not impossible. In general, the optimal arrangement
for further planning of NICU lighting.25,26 places beds or rooms around the perimeter of a central
The patient care space demands considerable planning ef- nursing area although alternative designs are possible,
fort, and here there is no substitute for a mockup room in as long as sight lines for nurses to babies, nurses to
which ideas can be visualized and tested repeatedly until a other nurses, and families to nurses are optimized and
satisfactory plan is found. Conceptually, the patient care daylight is accessible in adult gathering areas.
room is often divided into staff, patient, and family space—
usually arranged in that order from the corridor to the pos-
terior wall, which is often an exterior wall with a window.
Closing Thoughts
Placing the staff space nearest the corridor allows for sup- We have nearly come full circle, from eons when infants
plies and waste materials to be easily brought into or taken spent most of their time in direct human contact, through a
out of the room without disturbing the patient or family period where human contact was rare and usually unpleasant
spaces. Using the posterior area of the room for family space in our early NICUs. We are now approaching a day when the
maximizes privacy; in some cases, this space is further sepa- best medical care and nurturing are not mutually exclusive
rated by a curtain, moveable wall, or even designed as a suite concepts, and where the mother’s arms are considered the
with a fixed wall. In the middle, the patient care space should optimal locus of care.27 The goal of NICU design has evolved
be designed from the start with the philosophy that infants from efficient provision of optimal medical technology to
will spend extended periods in the arms of their parents, and providing the best environment of care for babies, families
the headwall designed accordingly. and caregivers alike. State-of-the-art technology and design
Within these constructs hundreds of decisions will still are necessary but not sufficient to reach this goal. Optimizing
need to be made. Some questions frequently asked that are brain growth and development in the preterm infant and
relevant to this paper’s focus on the needs of babies, families, mental health in families and caregivers requires collabora-
and caregivers include the following: tion and a nurturing environment for all to thrive.
The NICU environment of care 7

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