Abstract
Objective
To explore the application effect of multidisciplinary collaborative nursing intervention based on King's Goal Attainment Theory on medical transition readiness in adolescents with chronic kidney disease (CKD).
Methods
A total of 88 adolescents aged 15–18 years with CKD admitted to the Department of Pediatrics of a tertiary Grade A hospital from April 2025 to September 2025 were selected. Participants were randomly divided into control group and intervention group using a random number table, with 44 cases in each group. The control group received routine pediatric nursing, while the intervention group received additional nursing intervention for medical transition readiness based on King’s Goal Attainment Theory combined with multidisciplinary team (MDT) collaboration. The intention to participate in health care, self-management ability, and medical transition readiness were compared between the two groups before intervention and 6 months after intervention.
Results
After 6 months of intervention, the total score of intention to participate in health care in the intervention group (139.18 ± 20.84) was significantly higher than that in the control group (136.74 ± 21.92), with a statistically significant difference (*t* = 3.064, P = 0.005). The total score of self-management and medical transition readiness in the intervention group (60.41 ± 10.85) was significantly higher than that in the control group (58.25 ± 11.61), also with a statistically significant difference (*t* = 2.799, P = 0.01). Scores in all dimensions of the intervention group were significantly higher than those of the control group (all P < 0.05).
Conclusion
Multidisciplinary collaborative nursing intervention based on King’s Goal Attainment Theory can effectively improve the intention to participate in health care, self-management ability, and medical transition readiness in adolescents with CKD, demonstrating clinical application value.
Keywords: adolescents, chronic kidney disease, King's Goal Attainment Theory, medical transition, multidisciplinary collaboration, self-management
Introduction
Chronic kidney disease (CKD) is a common urinary system disease in children. The prevalence of CKD in children aged 0–19 years is [15.0–126.7]/1,000,000, and more than 90% of affected children can survive into adulthood (1, 2). The period of 15–18 years of age is a critical stage for the medical transition from pediatric to adult healthcare (3). Currently, medical transition preparation for adolescents with CKD in China mainly relies on conventional health education, which is often a one-way transfer of knowledge, lacking systematic, individualized, patient-centered whole-course intervention. Furthermore, inadequate connection between pediatric and adult departments and weak multidisciplinary collaboration make it difficult to meet the core needs of physical and psychological development and independent care in adolescents (4). Insufficient transition preparation can easily lead to poor treatment adherence, increased risk of complications, and serious long-term prognosis and quality of life (5).
King’s Goal Attainment Theory (6) emphasizes perception, interaction, communication, and cooperation as its core elements, advocating that healthcare providers and patients jointly set health goals and achieve health outcomes collaboratively (7, 8). This aligns well with the core requirements of the transition period for adolescents with chronic diseases — shifting from passive care to active participation and from dependence on family to independent management. This study combines this theory with multidisciplinary collaboration to construct an intervention program for medical transition readiness and explore its application effects, as reported below.
Methods
Participants
During the study period, 434 adolescents with CKD were treated at our center, of whom 88 met the eligibility criteria and were enrolled in the study. Adolescents aged 15–18 years with CKD admitted to the Department of Pediatrics of a tertiary Grade A hospital from April 2025 to September 2025 were selected. Inclusion criteria: ① meeting the 2022 CKD diagnostic criteria (1) with estimated glomerular filtration rate (eGFR) stage 2–4; ② conscious with normal communication ability. Exclusion criteria: ① combined severe heart, lung, liver, or other organ failure; ② post-renal transplantation, undergoing dialysis, or in acute exacerbation stage; ③ severe mental or psychological disorders.
Sample size was calculated based on previous studies (9) with α = 0.05, 1−β = 0.90, and a 20% loss to follow-up, resulting in 44 cases per group. Participants were randomly divided into intervention group and control group (n = 44 each) using a random number table.
Intervention group: male 16 (36.4%), female 28 (63.6%); age 15–18 years, mean (16.37 ± 0.64) years; education: junior high school 10 (22.7%), senior high school 27 (61.4%), college in progress 7 (15.9%); eGFR stage: stage 2 in 18, stage 3 in 19, stage 4 in 7; disease duration 1–6 years, mean (3.12 ± 1.05) years; main treatment regimen: glucocorticoid alone 15, glucocorticoid+biologic agent 11, glucocorticoid + immunosuppressant 13, glucocorticoid + immunosuppressant + biologic agent 5.
Control group: male 19 (43.2%), female 25 (56.8%); age 15–18 years, mean (16.91 ± 0.47) years; education: junior high school 13 (29.5%), senior high school 20 (45.5%), college in progress 11 (25.0%); eGFR stage: stage 2 in 16, stage 3 in 21, stage 4 in 7; disease duration 1–5.8 years, mean (3.08 ± 1.12) years; main treatment regimens: glucocorticoid alone 14, glucocorticoid + biologic agent 12, glucocorticoid + immunosuppressant 12, glucocorticoid + immunosuppressant + biologic agent 6.
No significant differences in baseline characteristics were found between the two groups (all P > 0.05) (Table 1). All participants and their legal guardians provided written informed consent before enrollment. The study protocol was reviewed and approved by the Ethics Committee of Jinling Hospital, Affiliated Hospital of Nanjing University Medical School (Approval No. 2024DZSJJ-054). All methods were performed in accordance with the Declaration of Helsinki and relevant institutional guidelines and regulations.
Table 1.
Baseline characteristics of participants.
| Indicators | Intervention group（n = 44) | Control group（n = 44) | Statistical values | P |
|---|---|---|---|---|
| Male/Female | 16/28 | 19/25 | χ² = 0.562 | 0.453 |
| Age | 16.37 ± 0.64 | 16.91 ± 0.47 | t = 1.892 | 0.062 |
| Level of education | χ² = 1.215 | 0.545 | ||
| Junior High School | 10 | 13 | ||
| High School | 27 | 20 | ||
| Associate degree | 7 | 11 | ||
| eGFR staging | χ² = 0.217 | 0.897 | ||
| Stage 2 | 18 | 16 | ||
| Stage 3 | 19 | 21 | ||
| Stage 4 | 7 | 7 | ||
| Duration of illness | 3.12 ± 1.05 | 3.08 ± 1.12 | t = 0.174 | 0.862 |
| Treatment Plan | χ² = 0.186 | 0.98 | ||
| Glucocorticoid alone | 15 | 14 | ||
| glucocorticoid + biologic agent | 11 | 12 | ||
| glucocorticoid + immunosuppressant | 13 | 12 | ||
| glucocorticoid + immunosuppressant + biologic agent | 5 | 6 |
Study methods
Control group
On day 1 of admission, the responsible nurse taught patients and families proper urine collection methods and provided guidance on diet and medication. From day 2, disease-related education and appropriate exercise guidance were provided. One day before discharge, the nurse assessed the patient's disease knowledge, especially medication precautions, dietary principles, and exercise amount, and instructed them to follow up regularly and respond to emergencies. Telephone follow-up was conducted 2 weeks after discharge to monitor vital signs, urine testing, urine output, medication adherence, and remind of regular follow-ups.
Intervention group
MDT team formation
An 8-person MDT team was established, including 2 associate chief physicians, 2 head nurses, 1 senior nurse, 1 dietitian, 1 pharmacist, and 1 nurse. Uniform training and clear division of responsibilities were implemented. Physicians were responsible for disease assessment, treatment planning, and dynamic monitoring of disease status. Head nurses oversaw overall intervention coordination and quality control. The senior nurse performed motivational interviews, health education, and follow-up throughout the intervention. The dietitian developed and supervised individualized diet plans. The pharmacist provided medication education and adherence management, optimized regimens, and monitored adverse reactions. The nurse assisted with daily care, data collection, and follow-up records.
Intervention development and standardization
The intervention plan was developed through systematic literature review, two rounds of Delphi expert consultation, and a pilot study.
Expert consultation: 11 experts from five fields (medicine, pediatric nursing, clinical nutrition, clinical pharmacy, chronic disease nursing management) participated in two rounds of Delphi consultation. Response rates were 100% in the first round and 90.91% in the second round. Expert authority coefficient Cr = 0.83 (academic level coefficient 0.85, judgment basis coefficient 0.83, familiarity coefficient 0.81). Kendall's W = 0.272, P < 0.001, indicating good expert consensus. Based on expert feedback, 7 unreasonable intervention items were removed, and 12 implementation details across 6 intervention phases were refined.
Pilot study: Five eligible adolescent CKD patients participated in the pilot study. Implementation challenges included mismatched hospitalization days and intervention timing, rigid communication formats with adolescents, and difficulty controlling home follow-up duration. Adjustments were made to intervention timing, single-session duration, and follow-up frequency, resulting in the final 6-phase standardized medical transition preparation intervention (perception, interaction, collaboration, goal attainment, support, consolidation). Average hospitalization was 6 days.
Quality control indicators
Intervention quality was monitored by the head nurse using an intervention execution record form. All MDT team members received standardized training and passed assessments (training pass rate 100%). MDT quality control meetings were held every 2 weeks. Intervention consistency was evaluated, with intervention execution rate 100% and protocol adherence rate ≥95%. Follow-up response rate after discharge was 100%, and patient intervention adherence rate was ≥90%.
Definitions
Intervention execution rate: completed intervention items/planned items×100%.
Protocol adherence rate: fully compliant intervention items/total checked items×100%.
Patient intervention adherence: patients completing ≥3 of 4 requirements (medication check-in, home diet adherence, scheduled follow-up, peer group participation).
Outcome measures
Intention to participate in health care questionnaire
The Chinese version adapted by Wu (10) was used. The questionnaire consists of 33 items across 6 dimensions: participation in medical decision-making (3 items), information interaction (9 items), treatment and care (10 items), appeal (3 items), diagnostic decision-making (5 items), and supervision (3 items). Items are scored on a 5-point Likert scale (1 = very unwilling to 5 = very willing). Total score range 33–165, with higher scores indicating better participation intention. The Cronbach's α coefficient of the questionnaire was 0.943.
Chinese version of the self-management and transition readiness questionnaire (STARx)
The STARx questionnaire, originally developed by Ferris et al. (11) for adolescents with chronic diseases, was used. The Chinese version has 18 items and 4 dimensions: medication management, health participation, patient-provider communication, and disease knowledge. The Cronbach's α coefficient of the total scale was 0.83. Items are scored on a 5-point Likert scale, with higher total scores indicating better transition readiness.
Statistical analysis
SPSS 21.0 was used for data analysis. Continuous data were tested for normality (Shapiro–Wilk test, W > 0.05) and homogeneity of variance (Levene's test, F > 0.05) and presented as mean ± SD. Paired t-tests were used for within-group comparisons before and after intervention. Independent-sample t-tests were used for between-group comparisons. Categorical data were presented as numbers and percentages, and chi-square tests were used for between-group comparisons. α = 0.05, and P < 0.05 was considered statistically significant.
Results
Intention to participate in health care
Before intervention, no significant differences were found between the two groups in total score and dimension scores of intention to participate in health care (all P > 0.05). After 6 months of intervention, both groups showed significant improvement (all P < 0.05). The intervention group had significantly higher scores in all dimensions and total score compared to the control group (P < 0.05) (Table 2).
Table 2.
Comparison of scores for intention to participate in healthcare between the two groups before and after the intervention (x ± s, points).
| Dimension | Category | Before the intervention | After the intervention | Within Group P | Between Groups P |
|---|---|---|---|---|---|
| Healthcare Decisions | intervention group | 13.00 ± 1.96 | 14.70 ± 1.03 | <0.001 | <0.001 |
| control group | 12.81 ± 1.92 | 13.22 ± 1.81 | 0.019 | ||
| Information Exchange | intervention group | 37.33 ± 5.34 | 38.44 ± 5.01 | 0.001 | 0.001 |
| control group | 37.22 ± 5.85 | 37.67 ± 5.62 | 0.001 | ||
| Treatment and Care | intervention group | 41.22 ± 7.19 | 42.22 ± 6.89 | 0.03 | 0.045 |
| control group | 41.14 ± 7.86 | 41.71 ± 7.35 | 0.026 | ||
| Demands | intervention group | 11.29 ± 2.85 | 12.07 ± 2.36 | 0.023 | 0.026 |
| control group | 11.22 ± 2.87 | 11.51 ± 2.62 | 0.043 | ||
| Clinical Decision-Making | intervention group | 20.44 ± 3.44 | 21.59 ± 2.77 | 0.01 | 0.01 |
| control group | 20.29 ± 3.29 | 20.85 ± 3.03 | 0.006 | ||
| Interpellation and Oversight | intervention group | 12.51 ± 2.37 | 13.55 ± 1.78 | 0.012 | 0.011 |
| control group | 12.37 ± 2.23 | 12.96 ± 1.87 | <0.001 | ||
| Total score | intervention group | 135.92 ± 22.17 | 139.18 ± 20.84 | 0.003 | 0.005 |
| control group | 136.07 ± 21.95 | 136.74 ± 21.92 | 0.026 |
Self-management and transition readiness
Before intervention, no significant differences were found between the two groups in STARx total score and dimension scores (all P > 0.05). After 6 months, both groups showed significant improvement (all P < 0.05). The intervention group had significantly higher scores in all dimensions and total score compared to the control group (P < 0.05) (Table 3).
Table 3.
Comparison of self-management and transition to primary care scores between the two groups before and after intervention (x ± s, points).
| Dimension | Category | Before the intervention | After the intervention | Within Group P | Between Groups P |
|---|---|---|---|---|---|
| Drug Management | intervention group | 21.74 ± 3.47 | 23.25 ± 2.19 | 0.002 | 0.004 |
| control group | 21.59 ± 3.28 | 22.44 ± 2.77 | 0.001 | ||
| Health Engagement | intervention group | 15.62 ± 5.06 | 17.11 ± 4.77 | 0.007 | 0.007 |
| control group | 15.55 ± 4.95 | 16.11 ± 4.84 | 0.005 | ||
| Doctor-Patient Communication | intervention group | 12.77 ± 3.77 | 14.29 ± 2.94 | 0.003 | 0.005 |
| control group | 12.88 ± 3.69 | 13.25 ± 3.41 | 0.022 | ||
| Disease Information | intervention group | 7.07 ± 2.35 | 8.18 ± 1.64 | 0.003 | 0.004 |
| control group | 7.06 ± 2.25 | 7.59 ± 1.82 | 0.004 | ||
| Total score | intervention group | 57.22 ± 12.37 | 60.41 ± 10.85 | 0.011 | 0.01 |
| control group | 56.96 ± 12.33 | 58.25 ± 11.61 | 0.005 |
Discussion
Multidisciplinary nursing intervention based on King’s Goal Attainment Theory improves transition readiness in adolescents with CKD
After 6 months, the intervention group had significantly higher STARx total and dimension scores than the control group (P < 0.05), indicating that the MDT intervention based on King's theory systematically improves medical transition readiness in adolescents with CKD. This trend is consistent with the findings of An Liqiao et al. (12), confirming the effectiveness of MDT models in improving transition readiness in adolescents with chronic diseases. Compared to conventional MDT interventions focusing primarily on disease management and health education, our intervention simultaneously targeted intrinsic participation motivation and external professional management, better aligning with adolescent psychological development and enhancing patient initiative.
Adolescents with CKD often have insufficient disease knowledge, poor self-management, and anxiety about adult healthcare settings. Conventional one-way education is inadequate (13). This study overcomes the limitations of previous interventions that focused only on knowledge and skills (14, 15). Using King’s theory (perception, interaction, collaboration, goal attainment) as the framework, we integrated psychological support, family guidance, and cross-departmental connections. The sequential mechanism of psychological arousal, self-efficacy enhancement, independent decision-making, and behavior consolidation shifted care from passive education to collaborative goal attainment. MDT collaboration integrated disease management, medication guidance, and nutritional support, compensating for shortcomings of traditional nursing models.
The perception phase accurately identified individual needs and transition barriers, awakening autonomous willingness. The interaction phase built trust and enhanced disease mastery through two-way communication. The collaboration phase strengthened patient agency through shared goal setting. The goal attainment phase translated motivation into stable behavior through practical training. The support and consolidation phases provided a full-cycle closed-loop system. This approach aligns with adolescent identity development, effectively reducing family overprotection, stigma, and environmental fear, upgrading transition readiness from knowledge memorization to internalized competence. Future clinical practice should develop stratified assessment tools based on STARx, standardize training modules such as scenario simulation and behavior check-ins, and promote routine pediatric-adult joint clinics.
The intervention improves intention to participate in health care in adolescents with CKD
After 6 months, the intervention group had significantly higher total and dimension scores for intention to participate in health care than the control group (P < 0.05). This finding aligns with Yu Genzhen et al. (16), confirming that individualized assessment and interactive interventions effectively improve participation intention. Adolescents with CKD are in a critical stage of identity vs. role confusion, and disease stigma, transition anxiety, and family over-dependence together inhibit participation intention (17), which conventional one-way nursing fails to address.
With King’s theory as the core, our intervention established a closed-loop system of cognitive arousal, emotional support, autonomous participation, and behavioral consolidation. Multidisciplinary assessment identified participation barriers, two-way communication reduced anxiety and increased confidence, shared decision-making strengthened patient agency, and scenario simulation and positive reinforcement translated intention into stable behavior. Family role adjustment, encouraging parents to appropriately let go, provided crucial social support for adolescent autonomy, enabling the shift from “passive compliance” to “active engagement.” MDT collaboration supported the intervention by providing consistent, multi-disciplinary information on disease, medication, and nutrition, enhancing understanding and trust. Shared decision-making models and visual decision aids should be promoted in clinical practice.
Practical significance in China
Transition preparation nursing for adolescents with CKD in China is still in early stages, often limited to discharge guidance and short-term follow-up, resulting in fragmented interventions, inadequate cross-departmental connections, and lack of individualized whole-course management. Our theory-guided, MDT-based, 6-phase closed-loop intervention is more systematic, continuous, and professional than traditional models, offering a replicable, quality-controllable, and generalizable practice template for pediatric nephrology departments in tertiary hospitals, with important implications for standardizing transition preparation for adolescents with chronic diseases in China.
Conclusion
Multidisciplinary collaborative nursing intervention based on King’s Goal Attainment Theory significantly improves intention to participate in health care, self-management ability, and medical transition readiness in adolescents with chronic kidney disease, providing a scientific, standardized, and feasible practice plan for transition preparation in this population.
Limitations and future directions
This study is a single-center RCT with a limited sample size. Outcome measures rely mainly on subjective scales, lacking objective indicators such as renal function and actual transition success rates. Moreover, the MDT model may be difficult to generalize in primary care settings due to human resource and cross-departmental collaboration constraints. Future studies should conduct multicenter, large-sample, long-term follow-up research with objective outcome measures. A simplified, stratified version of the intervention should be developed for primary care settings to further improve the transition preparation nursing system for adolescents with CKD in China.
Funding Statement
The author(s) declared that financial support was not received for this work and/or its publication.
Footnotes
Edited by: Vera Hermina Koch, University of São Paulo, Brazil
Reviewed by: Lucimary de Castro Sylvestre, Pontifícia Universidade Católica do Paraná, Brazil
Arnauld Kaufman, Federal University of Rio de Janeiro, Brazil
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.
Ethics statement
The studies involving humans were approved by Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University(2024DZSJJ-054). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.
Author contributions
LJ: Writing – review & editing, Writing – original draft. SB: Writing – review & editing, Writing – original draft. JQ: Writing – original draft. RC: Writing – review & editing. ML: Writing – original draft. XX: Writing – original draft, Writing – review & editing.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that generative AI was not used in the creation of this manuscript.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.