Implementing intelligent nursing interventions to enhance self-efficacy and hospital readiness in parents of preterm infants: a randomised controlled trial protocol

Abstract

Introduction

The discharge readiness of preterm infants and parental self-efficacy are crucial for ensuring high-quality postdischarge care and positive health outcomes. However, many parents face significant challenges, including anxiety, lack of confidence and insufficient support. Research indicates that greater discharge readiness and self-efficacy enhance adherence to care plans, parenting confidence and stress management. Despite this, existing interventions often lack personalisation and real-time support to meet the evolving needs of parents. Intelligent, adaptive interventions may bridge this gap by providing tailored, data-driven guidance.

Methods and analysis

This randomised controlled trial will evaluate the effectiveness of an intelligent intervention based on just-in-time adaptive interventions and the Kenner Transition Model in enhancing parental self-efficacy and discharge readiness. A total of 84 parents of preterm infants from a tertiary hospital will be randomly assigned to either a control group that receives routine discharge education or an experimental group that receives additional support through a WeChat program, which includes personalised guidance, real-time feedback and one-on-one online support. Primary outcomes include discharge readiness (measured using the Chinese version of the Readiness for Hospital Discharge Scale-Parent Form), parental self-efficacy (measured using the Chinese Parent Self-Efficacy Scale), breastfeeding rate, rehospitalisation rate and infant growth indicators (eg, body weight). Secondary outcomes include parental anxiety, caregiving ability and satisfaction with continuity of care. Data will be collected at baseline, 24 hours before discharge, and at 1 week, 1 month and 3 months after discharge. Statistical analysis will be performed using SPSS, Python, RStudio and EpiData to evaluate the effectiveness of the intervention.

Ethics and dissemination

This study has been approved by the Ethics Review Committee of the First Affiliated Hospital of Shantou University (ID: SDFY-B-2024-185). Informed consent is required from all participants or their guardians. The authors intend to submit their findings for publication in peer-reviewed journals or academic conferences.

Trial registration number

NCT06635473.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study employs a randomised controlled trial design to minimise selection bias.

• The intervention follows a structured, stage-based framework aligned with the Kenner Transition Model and incorporates dynamic tailoring based on the just-in-time adaptive intervention approach.

• A digital platform (WeChat program) enables standardised delivery and real-time engagement throughout the care process.

• The study is monocentric.

• The follow-up period is limited to 3 months, which may not capture the long-term effects of the intervention.

Introduction

According to the WHO,¹ approximately 15 million preterm infants are born worldwide each year, with China having over 750 000 preterm births, ranking fourth globally. About 84% of preterm infants require strict care in the neonatal intensive care unit (NICU) due to issues like low birth weight and hypothermia. This leads to potential complications during hospitalisation and after discharge and poses challenges for family care.² After discharge, the health management and care of preterm infants largely depend on families, particularly the parents’ direct involvement. However, many parents feel uncertain about infant care on discharge, lacking sufficient confidence, knowledge and skills to handle sudden health issues or daily care tasks. Poor discharge readiness impacts parents’ quality of life, reduces self-efficacy and affects the infant’s emotional development and sense of security.^{3 4}

Countries such as the USA, Canada and many European nations have started using intelligent nursing interventions to implement preterm infant parental care plans, improving parents’ discharge readiness.⁵ In China, NICU discharge standards primarily focus on the infant’s health issues, with insufficient understanding of parents’ discharge readiness and the preterm infant family support system. There are few interventions targeting parents’ discharge preparedness. Many hospitals rely on short-term predischarge training; however, these interventions often lack real-time, dynamic support mechanisms and fail to address the complex circumstances of family care, leaving personalised needs unmet.⁶ Research in China mainly focuses on optimising predischarge education, with limited attention to postdischarge interventions, and few studies have examined the application of intelligent tools.⁷

To address these challenges, intelligent nursing, characterised by personalisation, adaptability and real-time feedback, emerges as an effective solution. Overall, it is necessary to develop an intelligent intervention programme to enhance the discharge readiness of parents of preterm infants and validate its effectiveness and feasibility. By continuously monitoring parents’ emotions and care tasks, the programme can automatically adjust interventions to provide personalised support, thereby enhancing parental self-efficacy and discharge readiness.

Intelligent nursing

In today’s rapidly advancing digital and intelligent healthcare environment, intelligent nursing has emerged as a new intervention method. With its characteristics of personalisation, adaptability and real-time feedback, it is becoming a key means of enhancing nursing quality and efficiency.⁸ Intelligent nursing uses advanced information technologies, artificial intelligence, big data analytics and machine learning to optimise and manage nursing work.^{9 10} Furthermore, it enhances interaction between patients and healthcare providers through virtual nursing assistants and telemedicine, improving the convenience and continuity of care.¹¹

Discharge readiness and self-efficacy

Discharge readiness involves planning, assessing preterm infants, providing medical care and training parents to enhance their caregiving and emergency skills, support family involvement, alleviate anxiety and boost confidence. The Canadian Paediatric Society proposes key standards, including maternal-infant physiological stability, nursing knowledge and skills, family support and the accessibility of follow-up care. Parental self-efficacy, or the confidence in one’s ability to parent, serves as the foundation for effective child rearing. Studies show a strong link between self-efficacy and both parent and child health outcomes. High self-efficacy helps reduce negative emotions in parents and promotes the healthy development of children.^{12 13}

Discharge readiness focuses on enhancing parents’ caregiving and emergency preparedness skills. High self-efficacy helps parents acquire caregiving skills, boost confidence and better handle postdischarge challenges. Together, these factors influence the quality of home care for preterm infants.

Theoretical framework and methods

The study employs the Kenner Transition Model (KTM) and just-in-time adaptive intervention (JITAI) theories to guide its objectives, transforming traditional transition theory interventions into dynamic, real-time and personalised nursing support.

Theory selection and integration

To construct the theoretical framework for this study, a systematic search was conducted in databases such as PubMed, Embase, Web of Science, Cochrane Library, CINAHL, China Biological Literature Database, CNKI and Wanfang using the keywords ‘preterm infants, discharge readiness, nursing, theory, model, framework’. The search encompassed studies from the database’s inception to August 2024. Four nursing theories were identified, with a focus on their reliability and validity. We used the T-CaST tool for final selection. After evaluating the four theories, the KTM theory scored the highest and was selected to guide this project. However, recognising the limitations of KTM theory in personalisation, JITAI theory—which offers personalised interventions—was also considered for its superior applicability. Ultimately, the study chose to combine JITAI and KTM theories to guide the research.

KTM theory^{14 15} describes the dynamic process of parents transitioning from hospital to home care, encompassing five dimensions: information needs, stress and coping, professional support, social interactions and parent-child role development. Information needs are the core concept. JITAI theory^{16 17} provides personalised interventions based on an individual’s real-time status and context, using mobile devices and sensors to continuously monitor behaviours and environments, offering immediate support and guidance at critical moments. This approach has been widely applied in the field of health behaviour change.

In this study, KTM emphasises the five-dimensional interventions for parents during the care process, as well as the timing of each phase during the discharge transition period. By integrating JITAI theory, the study designs real-time, adaptive intervention content tailored to the specific needs of parents and infants, offering personalised nursing advice. Using intelligent tools like WeChat official accounts, the study can offer on-demand care guidance, real-time monitoring and feedback, enabling parents to make informed decisions during daily care, thereby enhancing the quality of care.

Research objectives and goals

Theoretical significance

This study aims to explore the impact of intelligent interventions based on the JITAI model and the KTM on parents of preterm infants in terms of self-efficacy, discharge readiness, feeding and caregiving knowledge and skills, rehospitalisation rates and exclusive breastfeeding rates. The findings are expected to provide both theoretical and practical foundations for improving discharge readiness and self-efficacy among parents of preterm infants in clinical settings.

Practical significance

This study aims to identify the factors that influence the readiness of parents for the discharge of preterm infants. Additionally, it aims to develop an intelligent intervention platform via WeChat, offering personalised nursing guidance, information dissemination, real-time monitoring and feedback to help parents better care for their preterm infants after discharge. By enhancing parental discharge preparedness and caregiving abilities, the study aims to reduce rehospitalisation rates, lower healthcare costs and improve the long-term quality of life for preterm infants. Furthermore, the findings will provide valuable insights into the application of KTM and JITAI theories in clinical nursing practice in China.

Methods

Study setting

This study will be conducted from October 2024 to October 2025 at a tertiary hospital NICU in Shantou. A randomised, parallel, single-blind controlled trial design will be used to implement and evaluate the intervention, with participants randomly assigned to the intervention or control group in a 1:1 ratio. Questionnaires will be collected at admission, discharge, and 1 week, 1 month and 3 months after discharge to assess the effectiveness of the intervention.^{18 19}

PICOS framework

To address the clinical nursing issue of enhancing discharge readiness among parents of preterm infants through intelligent interventions, this study is structured based on the PICOS model:

• P (Population): parents of preterm infants admitted to the NICU.

• I (Intervention): intelligent discharge readiness interventions, including disease knowledge and skill training, psychosocial support and other tailored interventions.

• C (Comparison): standard care, such as short-term predischarge training.

• O (Outcome): primary outcomes include discharge readiness, self-efficacy, breastfeeding rate, rehospitalisation rate and infant growth. Secondary outcomes include parental anxiety, caregiving competence and satisfaction with postdischarge care.

• S (Setting): neonatal unit.

Summary of best evidence

The intervention plan was developed based on an evidence summary conducted prior to this study. A comprehensive literature search was performed across multiple databases, including BMJ Best Practice, UpToDate, Joanna Briggs Institute(JBI), National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network, Registered Nurses’ Association of Ontario, Guidelines International Network, Agency for Healthcare Research and Quality, American Academy of Pediatrics, Medlink, Chinese Medical Association, CINAHL, Cochrane Library, PubMed and so on, focusing on evidence related to intelligent nursing interventions to improve discharge readiness in parents of preterm infants. The search included guidelines, systematic reviews and randomised controlled trials, covering studies published up to 8 October 2024. A total of 22 studies were included, spanning 45 stages from admission to postdischarge, and four key pieces of evidence were summarised to inform the development of a personalised intervention aimed at enhancing discharge readiness and self-efficacy among parents of preterm infants.

Inclusion/exclusion

Inclusion and exclusion criteria for preterm infants

• Inclusion criteria: gestational age <37 weeks; admission to the NICU; hospitalisation for more than 5 days.²⁰

• Exclusion criteria: intrauterine growth restriction; major congenital abnormalities or genetic disorders; history of major surgery; unplanned discharge, transfer to another department/hospital or death.

Inclusion and exclusion criteria for parents of preterm infants

• Inclusion criteria: primary caregivers of preterm infants (<37 weeks of gestational age) admitted to the neonatal unit; willing to assume primary caregiving responsibilities; no known history of psychiatric disorders, normal language communication abilities; aged ≥18 years, proficient in using WeChat; signed informed consent.^{21 22}

• Exclusion criteria: recent history of significant psychological trauma unrelated to hospitalisation; severe cardiac, cerebrovascular, pulmonary or renal diseases.²³

Intervention measures

Control group comparison

In the control group, caregivers will receive routine admission guidance, education on caregiving during hospitalisation and standard discharge instructions, as outlined in table 1.

Table 1. Control group nursing.

Time	Mission content	Form
Admission day	Admission guidance: covers the visitation policy and hospital environment. Parental briefing: the nurse explains the breast milk delivery process and confirms admission procedures.	Oral communication, questionnaire survey
Hospital stays	Discharge education: the nurse provides guidance on daily care, feeding, vaccinations, medication use and managing common issues.	Oral communication
Postdischarge follow-up	Weight monitoring	Follow-up visit

Intervention group intervention programme

Establishment of an integrated medical and nursing management team for preterm infant parents

The team consists of nine members: two doctors, one head nurse of the neonatology department, two specialised nurses, one doctoral nursing student and three graduate students. The doctors assess the infants’ conditions, create clinical plans and determine the discharge timing based on clinical indicators. At different stages of the hospital stay, we conduct home discharge preparation interventions. Specialised nurses, doctoral nursing students and graduate students will receive standardised training on the discharge readiness intervention, ensuring consistent and unified nursing practices across all settings.

Intervention plan for parents’ discharge readiness of preterm infants

Each stage of the research plan is closely related to the next, and it is divided into five stages: T0, baseline visit; T1, pretransition period; T2, preparation period; T3, post-transition period; T4, long-term adaptation period. The intervention details for each stage are presented in online supplemental file 1, and the overall framework is illustrated in figure 1.

Figure 1. Framework of the intervention plan.

Intelligent programme set-up

After completing the baseline survey, parents in the intervention group were invited to subscribe to the WeChat public account ‘Moya Nursing’ using their smartphones. The programme consists of three sections: knowledge acquisition during the five intervention periods, daily skill learning and interactive activities (see figure 2). Only parents in the intervention group are eligible to participate, thereby minimising confounding factors.

Figure 2. ‘Moya Nursing’ WeChat public account interface example. (a) First module: five intervention periods. (b) Example content of baseline visit. (c) Example content of pretransition period. (d) Example content of preparation period. (e) Example content of post-transition and long-term adaptation periods. (f) Second module: daily life skills example. (g) Third module: real-time interactive space. (h) Example content of real-time interaction. (Images reproduced with permission from the project development team.).

‘Moya Nursing’ (translated from the Chinese name ‘萌芽护航’) is a non-commercial WeChat-based program developed by using a structured, evidence-based and user-centred approach. It aims to support parents during the transition and caregiving process after discharge from the NICU. The content is organised according to the KTM, with five modules aligned with key caregiving stages: admission (T0), hospitalisation (T1), discharge day (T2), 1 week after discharge (T3) and 1–3 months after discharge (T4). All materials are evidence based and referenced from national and international guidelines, as well as peer-reviewed literature.

The programme was pilot tested with six parents to assess usability, feasibility and clarity, and was revised accordingly. An overview and sample screenshots of the WeChat-based intervention platform are provided in online supplemental file 1.

Personalised and real-time support

This study uses a WeChat chat to deliver personalised, real-time interventions. Parents receive tailored guidance and immediate feedback based on assessments, with content adjusted to their needs. Real-time data from parents and infants allow the intervention team to offer personalised support, such as on anxiety management and caregiving. Parents can also communicate one on one with the care team for instant help. This approach enhances self-efficacy and readiness for discharge.

Outcome indicators

This study encompasses three primary outcome indicators and three secondary outcome indicators, aiming to provide a more objective and comprehensive evaluation of the experiment’s feasibility. While most outcomes rely on self-report, we mitigated this by incorporating objective measures, such as breastfeeding rates, readmission rates and infant growth indicators.

Primary outcome indicator 1

Discharge readiness of parents of preterm infants. This study uses the Chinese version of the Readiness for Hospital Discharge Scale-Parent Form^{24 25} to assess parents’ discharge readiness across four dimensions: well-being, disease knowledge, coping ability and social support. Higher scores indicate better preparedness. The scale has demonstrated good reliability, with the Cronbach’s α coefficient ranging from 0.78 to 0.92. It effectively evaluates both predischarge preparedness and postdischarge coping ability of parents, helping to identify gaps in knowledge, skills or psychological readiness. This, in turn, facilitates a smoother transition from hospital to home care for premature infants.

Primary outcome indicator 2

Parental self-efficacy is assessed using the Chinese Parent Self-Efficacy Scale.²⁴ With 10 items, higher scores reflect greater self-efficacy. The Cronbach’s α coefficient is 0.91. This scale identifies parental support needs in caregiving, such as nursing skills and emotional support, forming the basis for personalised nursing interventions.

Primary outcome indicator 3

The study measures breastfeeding rates, readmission rates and growth indicators21,23 to evaluate the impact of parental discharge readiness and nursing interventions, reflecting the long-term effects of the intervention. Growth data—including weight, head circumference and length—will be collected from medical records during routine outpatient visits at 1 week, 1 month and 3 months after discharge. Before discharge, parents will be educated on breastfeeding, growth monitoring and illness management. Nurses involved in follow-ups will receive standardised training to ensure the accuracy of data.

Secondary outcome indicator 1

Anxiety is assessed using the Self-rating Anxiety Scale.²⁵ Scores below 50 indicate no anxiety, 50–59 mild anxiety, 60–69 moderate anxiety and above 69 severe anxiety. The Cronbach’s α coefficient is 0.931. Tracking anxiety at different stages helps analyse emotional adaptation and the factors affecting stability, guiding the optimisation of interventions during the discharge transition.

Secondary outcome indicator 2

Family caregiving ability is assessed using a self-assessment questionnaire²⁶ that evaluates knowledge, skills and attitudes in caregiving, with 18 items and scores ranging from 18 to 90. Higher scores indicate stronger abilities. The Cronbach’s α coefficient is 0.958. This tool helps assess caregivers’ strengths and areas for improvement, supporting the development of effective interventions.

Secondary outcome indicator 3

Satisfaction with continuity of care services is assessed using a 20-item survey developed by Pan.²¹ The survey covers nurse demeanour, nursing competence, humanistic qualities and overall satisfaction, with a total score range of 20–100. Higher scores reflect greater satisfaction. The survey helps identify strengths and weaknesses in care services, supporting the analysis of primary outcomes to validate the effectiveness of continuity of care.

Sample size calculation

This study uses the parental discharge readiness score as the primary metric for determining the sample size. The sample size was estimated using the two-sample mean comparison formula 1,²⁷ where n_₁ and n_₂ represent the sample sizes for the two groups, σ is the population SD (estimated using s) and δ is the target difference between group means. The values of z_α/2 and z_β correspond to the standard normal distribution for a significance level of α (0.05) and a type II error probability of β (0.10), with z values of 1.96 and 1.28, respectively. Based on the study,²⁸ S/δ=1.309, yielding n_₁=n_₂=36. To account for a 10–15% dropout rate, 42 participants are needed per group, totalling 84 participants. Sample size estimates based on self-efficacy scores were smaller; therefore, the final sample size was determined by discharge readiness.

${\displaystyle {\mathrm{n}}_1={\mathrm{n}}_2=2\times {\left\{\frac{\left({\mu }_{\alpha }+{\mu }_{\beta }\right)s}{\delta }\right\}}^2⟶(1)}$

Recruitment and randomisation

The study used a randomisation concealment method to select preterm infants and their parents admitted to the NICU of a tertiary hospital. On admission, participants were randomly assigned to either the intervention group or the control group, with 42 participants in each group, using a concurrent randomised controlled trial design. Randomisation was carried out by an independent research assistant (who was not involved in the study). Non-repeating random numbers were generated using SPSS V.27.0 statistical software. The researchers received sequentially numbered, opaque, sealed envelopes, each containing a card with a number indicating either 1 (intervention group) or 2 (control group).

To minimise the potential influence of intergroup information exchange on the intervention effects, a strategy of separating visiting times was implemented in alignment with the hospital’s existing visitation policy. Following random group allocation using a computer-generated sequence, infants in the intervention and control groups were, where feasible, assigned to even and odd-numbered beds, respectively. This corresponded to different visitation days—Tuesdays and Fridays for even-numbered beds, Mondays and Thursdays for odd-numbered beds—based on standard hospital operations. This approach enabled the research team to minimise potential contamination while preserving the integrity of the randomisation process.

Blinding

Due to the nature of the study, data collectors and data analysts will be blinded to group allocation. This will help avoid any bias that might arise from the data collectors’ subjective influence on the authenticity of the data. Additionally, all medical staff will remain unaware of the group assignments to minimise potential research biases further. If the principal investigator decides to unblind the study, they will verify the participant’s assignment and inform the attending physician, who must maintain the participant’s confidentiality from the research team. A flow diagram outlining the randomisation and intervention allocation is shown in figure 3.

Figure 3. Consolidated Standards of Reporting Trials (CONSORT) flow diagram.

Data collection

• Day of admission: researchers guide parents to fill out general information forms, caregiver capabilities, self-efficacy and anxiety level scales.

• 24 hours before discharge: parents complete discharge readiness, caregiver capabilities, self-efficacy and anxiety level scales.

• 1 week, 1 month and 3 months after discharge: researchers collect data via phone follow-up, home visits or outpatient visits on self-efficacy, continuity of care service satisfaction, breastfeeding rates and unplanned readmission rates.

The complete study schedule and data collection time points are presented in table 2.

Table 2. SPIRIT flow diagram.

Activity	Study period
	T0	T1	T2	T3	T4
Enrolment
Eligibility screen	×
Informed consent	×
Randomisation	×
Interventions
Information support	×
Professional support	×	×	×
Stress and coping		×
Parent-child role development				×
Social support			×	×	×
Measures
Demographics	×
Readiness for discharge			×
Self-efficacy	×		×		×
Breastfeeding rate, readmission rate and growth indicators				×	×
Anxiety	×		×		×
Family caregiving ability	×		×
Satisfaction				×	×

SPIRIT, Standard Protocol Items: Recommendations for Interventional Trials.

Data organisation

Data are entered using EpiData V.3.1 software with double entry by the researcher and a graduate student, followed by verification.

Statistical analysis

Appropriate statistical methods are employed, with standard distribution variables analysed using t-tests or analysis of variance, and non-normal or ordinal data analysed using rank-sum tests. Multivariate analysis employs multiple linear regression, with a significance level of p<0.05. Repeated measures data (eg, parental self-efficacy, infant weight gain) are analysed using linear mixed-effects models. Survival analysis, including Kaplan-Meier curves and Cox regression, is employed to examine readmission rates and breastfeeding duration. Missing data will be handled through multiple imputation to minimise bias, with imputed data verified and sensitivity analysis conducted in conjunction with complete case analysis. Python and R software ensure the accuracy and applicability of results.

Quality control and quality assurance

To minimise intervention contamination, visitation times for parents in the intervention and control groups are scheduled separately, thereby preserving the integrity of randomisation. A standardised intervention manual ensures consistency, and all research staff receive thorough training. A double-entry system ensures data accuracy, with regular checks for completeness. The study adheres to the Consolidated Standards of Reporting Trials guidelines to ensure transparency and completeness in reporting.

Ethics and dissemination

Research ethics approval

The study was approved by the Ethics Committee of the First Affiliated Hospital of Shantou University Medical College on 27 September 2024 (ID: SDFY-B-2024-185).

Consent

Participants receive detailed information about the study and intervention prior to data collection (see the online supplemental appendix for the consent form). Informed consent, as outlined in the Declaration of Helsinki, is required for participation in this study.

Plan for dissemination of study findings

The findings of this study will be disseminated through peer-reviewed journals, academic conferences and hospital educational platforms.

Patient and public involvement

Patients and the public were not directly involved in the study design or recruitment. However, the intervention builds on prior research on parents’ needs and experiences. Parent and provider feedback helped shape the WeChat program to enhance its usability. Findings will be shared with participants and stakeholders to support future improvements in neonatal discharge care.

Discussion

Despite the widespread variation in evidence-based practices for supporting parents of preterm infants, individual and institutional barriers have hindered the adoption of effective interventions.²⁹ This study addresses these challenges by integrating intelligent interventions based on KTM and JITAI theories, offering personalised, real-time support during the transition from hospital to home. Unlike traditional discharge plans that often lack tailored follow-up and dynamic guidance, our approach adapts to parents’ evolving needs, enhancing self-efficacy and discharge readiness while potentially reducing early readmissions. This area has often been overlooked in previous research.

Implementation challenges, such as limited digital literacy, varying provider engagement and institutional constraints, were mitigated through structured support, including provider training, ongoing coaching and feedback mechanisms. This proactive strategy ensures the intervention’s sustainability and scalability in real-world neonatal care. The findings are expected to provide valuable evidence for clinical guidelines, advancing the integration of digital health solutions in neonatal care and improving long-term outcomes for preterm infants and their families. Building on the findings of this single-centre study, future research will include multicentre trials to enhance generalisability and further validate the intervention’s effectiveness across diverse settings.

The content reflects the authors’ views and not necessarily those of the funder.