Ruijuan Wu; Lucai Jia; Biyu Ding; Ying Li; Yaqing Cao; Zhaojun Shi; Yanfang Yang

doi:10.4040/jkan.24147

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Impact of an integrated disease-specific nursing care model on parental anxiety and depression in severe hypospadias patients in China: a randomized controlled trial: Ruijuan Wu¹, Lucai Jia¹, Biyu Ding¹, Ying Li¹, Yaqing Cao¹, Zhaojun Shi¹, Yanfang Yang¹; DOI: https://doi.org/10.4040/jkan.24147
Published online: August 12, 2025

Department of Urology, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China

Corresponding author: Ruijuan Wu Department of Urology, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, 33 Longhu Waihuan East Road, Zhengzhou, Henan 450018, China E-mail: wrj63963705@163.com

• Received: December 19, 2024 • Revised: March 16, 2025 • Accepted: June 21, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License (http://creativecommons.org/licenses/by-nd/4.0) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium.

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Abstract
Introduction
Methods
Results
Discussion
Conclusion
Article Information
References
References

Abstract

Purpose
This study aimed to explore the effects of an integrated disease-specific nursing care model on alleviating perioperative and post-surgical anxiety and depression in parents of children with severe hypospadias.
Methods
Parents of children with severe hypospadias were recruited and randomly allocated into a control group (n=93), which received standard nursing care, and an intervention group (n=87), which was given an integrated disease-specific nursing intervention in addition to standard care. Parental anxiety and depression were measured using the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) at admission, discharge, and 6-month follow-up post-surgery.
Results
A linear mixed-effects model showed that SAS and SDS scores in the intervention group decreased to a significantly greater extent over time, from admission to follow-up, compared to the control group. Post-hoc analysis showed a trend for increased parental anxiety and depression among patients with complications at discharge and follow-up for the control group. Meanwhile, the intervention group exhibited a trend for decreased parental anxiety and depression among patients with complications at discharge and follow-up.
Conclusion
The integrated disease-specific nursing model significantly alleviated parental anxiety and depression over time compared to standard care, highlighting its effectiveness in supporting families of children with severe hypospadias. Notably, the intervention appeared to mitigate the negative emotional impact of postoperative and follow-up complications, suggesting its potential as a targeted approach to improve both emotional well-being and overall care outcomes.
Key words: Anxiety; Depression; Hypospadias; Nursing care; Patient-centered care

Introduction

Hypospadias is a condition where a male baby is born with the opening of the urethra located on the underside of the penis. It is one of the most common birth defects of the urinary and genital systems in male children, occurring in approximately 1 in 150–500 births. The prevalence of severe hypospadias has been reported to be increasing in recent years, necessitating more complex surgical interventions [1,2]. Severe hypospadias refers to cases where the urethral meatus (opening of the urethra) is located on the scrotum or perineum (area between genitals and anus), causing penile curvature and leading to difficulties with urination [3]. Surgery is currently the only treatment option for severe hypospadias, and it is technically challenging with a high risk of complications, which include urethral strictures (narrowing of the urethra), urethral fistulas (abnormal openings), urethral diverticula (formation of abnormal pouch or sac), glans dehiscence (separation of the head of the penis) and recurrence of penile curvature [4-6]. To prevent complications like urethral strictures, indwelling catheters are often left in place for 1–2 months after surgery.

Perioperative and post-surgical complications can often increase anxiety and depression, particularly among parents [7,8]. Recurrence of complications may require further surgical intervention or prolonged catheter use, affecting the child’s quality of life and often leading to significant anxiety in parents. Post-surgical and post-discharge experiences can also affect the patient’s mental health [9,10]. For example, in low- and middle-income countries, such as Tanzania, it was found that a lack of information on how to manage indwelling catheters had a negative influence on positive living at home [9]. Post-surgical complications and at-home factors in children can, in turn, affect parental well-being due to the established link between parental mental health and the child’s health status [11-13].

Enhanced and integrated care from healthcare personnel can play a large role in improving the negative emotions of parents through the perioperative and post-surgical process. Integrated nursing care is a holistic, patient-centered healthcare approach that addresses the physical, emotional, social, and informational needs of the patient in an ongoing and cohesive manner. A multidisciplinary team is coordinated, usually by nurses, to ensure that the appropriate services are cohesively delivered and that team members are synchronized according to the patient’s healthcare plan. The inclusion of families in this healthcare approach can be essential, especially in pediatric cases. Parents play a critical role in the child’s recovery, and their emotional state can directly impact the child’s healing process [14,15]. Studies have shown that integrated care models not only provide comprehensive medical knowledge to parents but also can enhance nursing services to meet the specific needs of patients and their families [16,17]. In turn, interactive or supportive education and attention to emotional needs can lower the anxiety of parents with hospitalized children [18-23].

This study investigated the effects of an integrated care model on alleviating the negative emotions of parents whose children underwent surgery for severe hypospadias. We hypothesized that an integrated disease-specific nursing care model would significantly reduce parental anxiety and depression during the perioperative and post-surgical periods.

Methods

1. Study design

A randomized controlled trial was conducted to determine the effects of integrated nursing care on the psychological outcomes of parents of children with severe hypospadias. Parents of severe hypospadias patients who required surgery were randomly allocated to an intervention group receiving integrated nursing care or a control group receiving standard nursing care. This study was nonblinded for the participants, caregivers, and clinical researchers. Only the statisticians assessing the outcomes were blinded.

2. Study participants

From January 2021 to January 2023, children diagnosed with severe hypospadias and their parents were recruited from Children’s Hospital Affiliated to Zhengzhou University to participate in the study. Informed consent was obtained from all parents upon recruitment.

The inclusion criteria consisted of (1) children diagnosed with type III (penoscrotal) or type IV (perineal) hypospadias; and (2) patients who had fixed caregivers available. The exclusion criteria consisted of (1) children with cryptorchidism or sexual development disorders; (2) children with severe congenital diseases; and (3) parents with severe mental or cognitive disorders.

Sample size was determined based on a linear mixed-effects model for repeated measures, consisting of two groups and three time points that measured anxiety and depression scores. Sample size calculations assumed an effect size of 0.4, a Type I effect size of .40, a Type I error (α) of .05, statistical power of .80, and intraclass correlation of .70. The minimum number of participants required per group was 79.

During the study period, 219 children with severe hypospadias were admitted. Of these, 200 patients were recruited based on eligibility (Figure 1). Before randomization and allocation, participants were excluded due to parents being unable to stay for the duration of the study. At admission, participants were dropped from the study as the questionnaires were not timely administered to the parents. No participants were lost at discharge. After the study, it was discovered that some participants did not properly fill out the questionnaire. The invalid scores were considered missing completely at random, and a complete case analysis was performed to ensure that all included cases had no missing data. In total, the statistics of 180 participants were used for the study, with 87 cases in the intervention group and 93 in the control group.

3. Randomization and allocation

Upon admission, participants were randomly divided into an intervention group and the control group, using a random number table generated in Excel. The allocation ratio was 1:1 and allocation were concealed using an opaque, sealed envelope prepared by an independent nurse not involved in participant enrollment.

4. Intervention and control procedures

The control group received standard nursing care, which consisted of admission, preoperative and postoperative care, whereas the intervention group received a specially designed integrated disease-specific nursing care model. The intervention was a structured, disease-specific integrated nursing care model involving psychological support, education, and multidisciplinary collaboration. Both groups received standard surgical and perioperative management by the pediatric urology team. The surgeries were performed by 2–3 fixed surgeons, all of whom were associate chief physicians. A comparison between the control and intervention groups is summarized in Supplementary Table 1. Each group received the following care:

1) Admission care

(1) Control group

Upon hospital admission, the assigned nurse provided a warm orientation and conducted comprehensive health education. The patient and their family received an introduction to the hospital environment, including instructions on using ward facilities, the location and operating hours of restrooms, and the office areas of medical staff. The nurse demonstrated the correct use of bed rails, including how to raise, lower, and lock them, while emphasizing safety precautions to prevent falling, slipping, and burns during hospitalization. Preoperative instructions were provided according to parental comprehension levels. Parents with a strong understanding received concise medical explanations supplemented with images and texts, highlighting the importance of avoiding crowded areas to reduce the risk of infection. Parents with lower comprehension levels received simpler explanations with real-life examples, such as cases where infections from inadequate precautions led to surgery delays. Parents were advised to ensure their child followed a regular diet that was rich in protein and vitamins, including eggs, milk, fresh vegetables, and fruits. Adequate sleep (8–10 hours/night) was also encouraged to boost immunity and prevent infections.

(2) Intervention group

In addition to the routine care described above, the intervention group received enhanced integrated care through a structured multidisciplinary team. The responsible nurse introduced themselves to the parents, fostering trust and laying the groundwork for adherence to instructions. The head nurse coordinated care delivery and conducted weekly evaluations of the team-based protocol. The attending physician was introduced promptly to the family. A dedicated health educator provided daily disease-specific education and tailored emotional support to parents, adjusting language complexity and educational tools according to the parent’s educational background and psychological state. For pessimistic or anxious parents, the educator provided empathetic listening, guidance, and affirmation.

(3) Contribution to outcomes

By tailoring communication to parental comprehension and emotional needs, and supplementing standard health education with structured team support, the intervention improved parental engagement, reduced anxiety, and laid the foundation for better adherence and outcomes throughout the hospital stay.

2) Preoperative care

(1) Control group

On the day before surgery, the assigned nurse communicated with the parents to examine their understanding of the disease and treatment. The nurse explained the causes, pathology, necessity of surgery, and the general procedure for hypospadias treatment, helping parents gain a clear understanding.

(2) Intervention group

In addition to the routine care, the integrated care team developed a nursing protocol tailored to the specific type of hypospadias based on pediatric care guidelines and updated clinical literature. The head nurse ensured that all team members followed this patient-specific plan. The health educator continued daily education to alleviate parental anxiety and foster understanding of the surgical process. For parents with different educational levels, explanations were adjusted accordingly, and emotional reassurance was provided to those with high anxiety.

(3) Contribution to outcomes

Personalized disease education and an individualized nursing protocol increased parent confidence and reduced psychological burden before surgery, leading to improved surgical preparation and compliance.

3) Postoperative care

(1) Control group

Parents received dietary guidance to provide soft, easily digestible foods like millet porridge and soft noodles, while avoiding spicy, greasy, and irritating foods. Nutrient-rich foods were gradually introduced. Parents were guided to assist their child in gentle movements, such as in-bed repositioning and later walking within the ward. The nurse explained medications, including names, dosages, and precautions. Catheter care instructions included avoiding kinks or compression and monitoring urine color, volume, and clarity. The assigned nurse monitored glans circulation and urine output and conducted shift handovers to ensure prompt detection of complications like flap necrosis or catheter blockage.

(2) Intervention group

Routine care was provided as above, but supplemented with a team-based approach. The responsible nurse ensured day-to-day adherence. The anesthetist visited daily to assess the child’s pain levels and adjusted analgesic regimens if necessary. Parents were taught distraction techniques to alleviate postoperative pain. A “token reward system” was introduced to enhance the child’s cooperation with care activities—children received tokens for tasks like drinking fluids or cooperating with wound care and could trade them for small rewards (Supplementary Figure 1A) [8]. The health educator continued daily emotional support and education. The nursing protocol emphasized a balanced, protein-rich, and fiber-containing diet, hydration, and catheter maintenance.

(3) Contribution to outcomes

Enhanced pain control and emotional support minimized discomfort and behavioral resistance. The token system improved patient compliance, and consistent multidisciplinary monitoring helped prevent complications and promoted faster recovery.

4) Post discharge and follow-up

(1) Control group

Standard discharge guidance was given, including information on diet, catheter care, and activity restrictions. Follow-up relied on routine telephone check-ins.

(2) Intervention group

A comprehensive, structured follow-up system was implemented using a WeChat group (Tencent Holdings Ltd.) supported by attending physicians, nurses, and health educators (Supplementary Figure 1B). Scheduled phone calls were supplemented by real-time responses in the group chat. Parents received video tutorials and online classes on catheter care, signs of infection, and dietary management. They were instructed to monitor urine color, output, and clarity and contact the care team immediately in case of abnormalities. The group also helped parents secure catheters during daily activities and emphasized proper drainage bag replacement. An information review team ensured all shared content was medically accurate. The health educator maintained emotional support post-discharge.

(3) Contribution to outcomes

Timely, professional online support enhanced home-based care, reduced complications, and maintained treatment adherence. Ongoing emotional reassurance and interactive communication helped reduce parental stress and improved overall patient recovery.

(4) Details on the use of the WeChat platform

A strict information review process was established to ensure that all content shared in the group was accurate and professional. An information review team, consisting of the attending physician and dedicated health educator, evaluated the content before publication. Within the WeChat group, responses and dissemination of information was conducted in real time based on parents’ inquiries and needs, ensuring timely responses.

High priority was given to protecting the privacy of patients and their families while using the WeChat platform. All personal information related to the child, such as medical records and photos, was encrypted and used only for internal communication among medical staff. Parents were explicitly informed about the privacy protection policies to alleviate any concerns.

After discharge, the WeChat platform served as a crucial tool for continuing care. Medical staff regularly organized online Q&A sessions within the group at fixed times each week to address parents’ concerns regarding postoperative care. Additionally, parents actively shared their caregiving experiences and insights, fostering a supportive and cooperative environment.

5. Instruments

At admission and discharge, responsible nurses administered questionnaires for assessing parental anxiety and depression. Six months post-surgery, follow-up nurses conducted another survey using electronic questionnaires distributed via the online messaging platform, WeChat. Parental negative emotions were assessed using the Zung Self-Rating Anxiety Scale (SAS) and Zung Self-Rating Depression Scale (SDS). Each scale consists of 20 items rated on a 4-point scale. Higher scores indicated a more severe negative emotion. These two scales have been widely used in literature, showing good factor structure, reliability, convergent validity, and discriminant validity [24-26]. Based on Cronbach’s alpha, the internal consistency of SAS among various studies was reported to have an alpha coefficient between .82–.84 and SDS was reported to have an alpha coefficient between .79–.86, indicating acceptable to good reliability [27-29]. Specifically, for parents of children in China, the Cronbach’s alphas of SAS and SDS were .84 and .86, respectively [29].

6. Data management and statistical analysis

Data was gathered by two designated research nurses. Baseline data included age, disease type, parent’s education level, residence, and baseline SAS and SDS score at admission. Outcomes included the type of surgery, number of surgeries, perioperative complications, complications at 6-month follow-up, and the SAS and SDS scores at discharge and final follow-up. The SAS and SDS were administered upon admission (pre-intervention) and again at discharge (post-intervention). Six months after surgery, follow-up assessments were conducted through electronic questionnaires distributed via WeChat, facilitated by the health educator.

Normality of the data for continuous variables was determined through the Shapiro-Wilk test and visual inspection (Q-Q plots and histograms). The Student t-test was used for normally distributed data, while the Mann-Whitney U test was used for non-normally distributed data. For categorical data, comparisons were made using the chi-square test if the data met the appropriate assumptions or Fisher’s exact test otherwise. A linear mixed-effects model (LMM) was used to assess anxiety and depression over time. LMM was chosen to examine longitudinal data that included both fixed effects (group, time, and their interaction) and random effects (variability across individual parents). LMMs are capable of modeling random slopes, accounting for the rate of change in anxiety or depression for each parent over time. LMM was preferred over repeated analysis of variance (ANOVA) because some data did not meet the assumption of normality, and LMMs are more robust to non-normal distributions. Furthermore, the longitudinal data were measured over unequal time intervals, thus not meeting the assumption criteria for repeated ANOVA.

Post-hoc pairwise comparisons consisting of between-group and within-group comparisons were performed to examine the significant group-by-time interactions identified by LMM. Differences in SAS and SDS scores between the two groups and changes in score levels over time were examined, allowing for further insight into the temporal effects of integrated nursing care.

Multiple linear regression (MLR) was conducted for SAS and SDS scores at each time point to determine potential factors that affected anxiety and depression. MLR was chosen for its ease of interpretability and its ability to identify potential predictors of outcomes that can be modeled as linear relationships. The independent variables used to analyze depression and anxiety scores at admission were age, education, and residence. The independent variables used to analyze depression and anxiety scores at discharge were age, education, residence, disease type, length of hospital stay, surgery type, number of surgeries, and perioperative complications. The independent variables used to analyze depression and anxiety scores at 6-month follow-up were age, disease type, education, residence, and complications at follow-up.

GraphPad Prism ver. 9.4.1 (GraphPad Software) and IBM SPSS ver. 21.0 (IBM Corp.) were used for statistical analysis and to create graphs. p<.05 was considered statistically significant.

7. Ethical consideration

This study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethical Review Committee of Children’s Hospital Affiliated to Zhengzhou University (2021-K-H300, 2020-12-17). This trial was registered under the Chinese Clinical Trial Registry (ChiCTR2500100859). Informed consent to participate and publish this study was signed by the parents. All parents were fully informed of the study’s objectives, procedures, potential risks, and benefits using both written and verbal explanations. All personal identifying information was de-identified and data was stored on the hospital’s password protected computers, only accessible by relevant research personnel.

Results

1. Baseline and post-surgical characteristics

There were no significant differences in baseline characteristics, including age (p=.822), disease type (p=.466), education level (p=.887), residence (p=.808), and baseline SAS (p=.079) or SDS (p=.236) scores between the intervention and control groups (p>.050) (Table 1). Baseline scores for SAS and SDS in the control group were 56.90±6.11 and 58.13±6.23, respectively, and 58.54±6.31 and 56.92±7.41 for the intervention group, respectively.

Surgical outcomes and complications are presented in Table 2. No significant differences were found in the surgery type (p=.829), number of surgeries (p=.910), perioperative complications (p=.608), or complications (p=.143) at follow-up between the two groups. At both discharge and follow-up, the intervention group had significantly lower SAS and SDS scores compared to the control group, indicating that the application of the integrated disease-specific nursing care model was effective in reducing anxiety and depression in parents. At discharge and follow-up, SAS scores in the intervention group were 51.77±5.30 and 46.36±5.12, compared to 53.71±5.43 and 52.06±5.09 in the control group (p=.017 and p<.001, respectively). At discharge and follow-up, SDS scores in the intervention group were 52.69±6.05 and 49.46±5.42, compared to 55.24±5.82 and 53.40±5.06 in the control group (p=.005 and p<.001, respectively).

2. Analysis of parental anxiety and depression

1) Impact of time point, group, and interaction effects on depression and anxiety scores

The linear mixed-effects model for depression and anxiety scores revealed that the fixed effects, including time point, group, and their interaction (time point*group), were all statistically significant with a p-value <.05 for both SDS and SAS scores. These results indicated that depression and anxiety decreased over time from admission to discharge to 6-month follow-up. Furthermore, the rate of decrease in depression and anxiety between the intervention and control group were significantly different, where integrated care led to a faster decrease in depression and anxiety over time.

The mean difference in SAS scores between the intervention group and control group at admission, discharge and follow-up were –1.64 (95% confidence interval [CI], –3.27 to –0.003; p=.050), 1.94 (95% CI, 0.31 to 3.57; p=.020), and 5.71 (95% CI, 4.07 to 7.34; p<.001), respectively. The mean difference in SDS scores between the intervention group and control group at admission, discharge and follow-up were 1.21 (95% CI, –0.56 to 2.98; p=.179), 2.55 (95% CI, 0.78 to 4.31; p=.005), and 3.94 (95% CI, 2.17 to 5.71; p<.001), respectively.

The mean decrease in SAS and SDS within-group between admission and discharge for the control group was 3.19 (95% CI, 1.23 to 5.16; p<.001) and 2.89 (95% CI, 0.77 to 5.02; p=.003), respectively. The mean decrease in SAS and SDS within-group between admission and discharge for the intervention group was 6.77 (95% CI, 4.74 to 8.80; p<.001) and 4.23 (95% CI, 2.03 to 6.43; p<.001), respectively. The mean decrease in SAS and SDS within-group between discharge and follow-up for the control group was 1.65 (95% CI, –0.32 to 3.61; p=.134) and 1.84 (95% CI, –0.29 to 3.96; p=.114), respectively. The mean decrease in SAS and SDS within-group between discharge and follow-up for the intervention group was 5.41 (95% CI, 3.38 to 7.45; p<.001) and 3.23 (95% CI, 1.03 to 5.43; p<.001), respectively.

2) Post-hoc comparisons of SDS and SAS scores between groups

Post-hoc comparisons using the estimated marginal means showed that there was no significant difference in baseline SDS scores (p=.179) between the two groups as seen in Table 3, but mean depression levels were significantly higher in the control group at discharge (p=.005) and 6-month follow-up (p<.001). There was borderline significance between the baseline SAS scores of the two groups (p=.050), where mean anxiety levels were lower in the control group. However, at discharge (p=.020) and follow-up (p<.001), mean anxiety levels ended up significantly higher in the control group compared to the intervention group.

3) Within-group changes in depression and anxiety over time

Within-group comparisons showed that both SDS and SAS scores significantly decreased in the intervention group between each time point (p<.05) (Table 4). For the control group, anxiety (p<.001) and depression (p=.003) significantly decreased from admission to discharge, but there was no significant difference in anxiety and depression scores at discharge and 6-month follow-up (p>.05).

4) Regression analysis of predictors for anxiety and depression

Multiple linear regression analysis showed that none of the independent variables were significantly associated with anxiety or depression at admission for both groups, as all p-values exceeded .05. In both groups, occurrence of perioperative complications was associated with higher levels of depression at discharge. At final follow-up, post-discharge complications were associated with both higher levels of anxiety (p=.009) and depression (p<.001) for the control group, but not for the intervention group. Figure 2 shows the direct comparison of the mean SAS and SDS scores for parents of patients with and without complications.

Discussion

The treatment for hypospadias is complex and multifaceted, posing long-standing challenges in pediatric urology [30]. Surgical correction is the only definitive treatment, but it is associated with a high risk of complications, which can affect long-term outcomes [4-6]. Given that the patients treated at children's hospitals are primarily young children, parents often experience significant anxiety, stress, and confusion, especially in cases of severe hypospadias [31]. Parental concerns about surgical success and potential complications contribute to heightened levels of anxiety and negative emotions [7,8].

Our study demonstrated that an integrated disease-specific nursing care model effectively alleviated parental anxiety and depression over time. The occurrence of perioperative and post-discharge complications was associated with significantly higher levels of depression in parents that received routine nursing care at discharge and follow-up. On the other hand, parents of patients who experienced complications and received integrated care showed significantly lower levels of depression compared to those whose children had no complications, within the same group.

To the authors’ knowledge, only one other recent, retrospective study has specifically examined the effects of an integrated medical and nursing intervention on families with children who have a genitourinary disorder. Li et al. [16] retrospectively examined the effects of integrated care on 38 pediatric patients undergoing correction surgery for concealed penis, where they were able to reduce patient pain, improve comfort levels, lower the risk of complications, and increase parental satisfaction after correction surgery compared to the control group receiving routine care (n=38). Comparatively, their intervention method only spanned the duration of the inpatient stay whereas our intervention included electronic monitoring of patient well-being after discharge, expanding the intervention period over the course of 6 months. Furthermore, the focus of our study mainly investigated the mental health of parents. Li et al. [16] also utilized proactive techniques to mitigate pain, such as using distraction techniques (music or cartoons), and concentrated on complication prevention by focusing on wound positioning and microcirculation improvement.

A study by Karaburun et al. [22] applied the use of audiovisual information to reduce parental anxiety prior to hypospadias surgery. The authors compared the use of audiovisual information sessions against a control group that applied classic verbal information. State-Trait Anxiety Inventor–State Anxiety forms were administered to parents at three time points: before intervention, after two informational consultations, and 14 days post-operation where the study was ended. While the anxiety scores of both groups decreased after the second consultation, the audiovisual group had significantly lower anxiety. Thus, in our study, it is likely that the supplementary support provided by the health educator in addition to audio and visual information received through the WeChat group improved parental anxiety and depression.

A study by Zhao and Wang [32] retrospectively examined the use of integrated nursing care based on the Medical Alliance Model, analyzing 120 coronary heart disease patients who underwent percutaneous coronary intervention. The researchers measured the self-efficacy, self-management ability, and incidence of postoperative complications between a control group receiving routine perioperative nursing care and an observation group receiving routine care in addition to integrated nursing. They found that integrated nursing care improved the self-efficacy, self-management ability and lowered the incidence of postoperative complications in the observation group. Their integrated care model also had psychological and nutritional assessments, family education with the use of simple language, and monitoring of patients into follow-up. However, their use of WeChat was to enable real-time communication between team members rather than between parents or patients as in our study. Furthermore, they had bi-monthly lectures and conducted home visits whereas in our study, follow-up monitoring was conducted through WeChat rather than home visits.

The adoption of various forms of integrated care, including family-integrated and family-centered nursing care, has been on the rise in recent years, particularly in settings involving transitions during pregnancy, parenthood, and pediatric hospitalization. These approaches have consistently demonstrated effectiveness in reducing parental stress, anxiety, and depression, while simultaneously improving clinical outcomes in hospitalized neonates and infants [33-35]. Similar to our study, family-centered care models emphasize active parental involvement, information delivery through booklets or mobile apps, individualized daily care plans, equity in care, and a holistic approach that incorporates physical, psychological, emotional, and social needs. By encouraging collaboration between healthcare providers and families, these interventions empower parents with knowledge and skills, enhancing their sense of competence in caregiving [36]. Additionally, methods in patient-centered care, such as patient education, promoting mental health, improving the quality of care, improving patient adherence and satisfaction, and preventing or reducing complications have also been shown to yield direct mental health benefits, including reducing symptoms in people with depression and anxiety disorders [37,38]. The combination of personalized information, emotional support, and equitable care delivery may thus alleviate psychological distress by promoting a sense of trust between families and healthcare providers, thereby reducing the emotional burden of hospitalization on parents.

Although statistical significance was not reached in all cases (likely due to an insufficient sample size), parents of patients who experienced complications in the control group had higher levels of anxiety and depression, whereas parents of patients who experienced complications in the intervention group had lower levels of anxiety and depression. This trend suggests that integrated care might mitigate the psychological impact of surgical complications on parents. The decrease in anxiety and depression could possibly be attributed to the increased attention, support, and information delivery by healthcare workers to families of children with complications in the intervention group. Studies have shown that limited information on anesthesia procedures and surgery-related complications can significantly affect the anxiety of parents [39,40]. On the other hand, appropriate delivery of information on pain reduction, sufficient education on potential complications, and preoperative education on the disease and treatment have been shown to mitigate anxiety in both patients and parents [21,41-44]. Thus, parents receiving additional communication with a health educator and anesthetist in the intervention group in this study may have had a large effect on preventing parental anxiety in hypospadias cases that had post-surgical complications. Although less studied, similar research has shown that families with children undergoing hospital procedures who have greater access to information may experience lower levels of parental depression [44,45].

The effectiveness of our intervention may have been further enhanced by the use of online communication platforms, which have been widely studied in medical settings. One meta-analysis investigating the effects of WeChat-based continuous care found that it was able to improve depression, anxiety, social function, and cognitive function in cancer patients across 18 randomized controlled studies [46]. The use of WeChat during hospital stays was also able to improve parental anxiety and satisfaction due to its accessibility, convenience, and ability to communicate with healthcare workers [47]. WeChat has additionally been used by parents at home to communicate with healthcare workers when their children were hospitalized, such as during the COVID-19 (coronavirus disease 2019) pandemic [44]. Thus, online communications platforms can serve multiple functions, offering swift, convenient, long-distance communication in addition to various modes of information delivery. The integrated care model in our study took advantage of both these facets through information delivery of online brochures and pamphlets in addition to monitoring the status of the patient.

To further reduce the risk of catheter-related complications, parents were advised to ensure the child maintained adequate hydration, which helps flush the urinary system and prevents infections. The WeChat group also provided advice on recognizing early signs of infection, urethral discharge, and encouraged parents to seek prompt medical attention when needed. This proactive approach to addressing daily caregiving concerns effectively alleviated parental anxiety and minimized the risk of serious complications. Through diverse educational content and personalized Q&A services, the WeChat platform played a crucial role in enhancing parents’ understanding of hypospadias, which included information on disease management and essential caregiving practices. Additionally, real-time interaction with medical staff provided timely emotional support, helping to alleviate anxiety and stress by ensuring parents were able to receive immediate responses to their concerns. Lastly, the platform’s real-time monitoring and reminder functions reinforced adherence to medical guidance and helped instill confidence in parents caring for their children.

Improvements in perceived control, social support, self-efficacy beliefs, and emotion regulation have been shown in the literature to positively affect parental anxiety and depression [48-50], which was likely enhanced by the use of the WeChat platform. The online chat platform created a distinct advantage by allowing for improved access to post-discharge support, enabling continuous and asynchronous communication, and allowing parents to access information at their own convenience or based on their own personal concerns. The information sessions could also help parents become more self-sufficient and improve their caregiving competence. Using structured educational content that was delivered through the online platform, parents were also able to revisit the information at their own pace, which could also improve retention and compliance. An increased sense of safety and reassurance could also be established as they had an online multidisciplinary team to rely on, which provided timely check-ins and offered prompt responses, thereby reducing perceived isolation, helplessness, or anxiety. As opposed to traditional care which ends at discharge, the continuation of care essentially prolonged the intervention over the recovery period, which was possibly aligned with the period where anxiety or depression could persist or re-emerge. The differences in parental anxiety and depression at both discharge and 6-month follow-up suggested that the WeChat platform was not only a communication tool, but also a vital component of the intervention’s therapeutic effect. Without this continuous and real-time support, the control group may have experienced higher levels of uncertainty, leading to psychological distress. Thus, it is reasonable to conclude that the online communication platform enhanced the efficacy of the integrated nursing model by providing continuous care, enhancing parent engagement, and reinforcing key caregiving behaviors during the post-discharge period.

Overall, our study addressed all four of the factors in Bandura’s self-efficacy theory [51], where a person’s confidence in their abilities can be established through the development of mastery experiences, vicarious experiences, social persuasion, and emotional states. These four elements were respectively enforced through: the WeChat-based guidance, which enabled mastery of caregiving tasks and allowing parents to strengthen their confidence; shared questions and video demonstrations supported observational learning; regular feedback, verbal encouragement and reassurance reinforced parents’ belief in their ability to care for their child; and ongoing emotional support with regular check-ins and guidance reduced distress, thereby promoting better anxiety and depression outcomes. The integrated nursing model also ties into other theoretical frameworks, such as the stress and coping theory by Lazarus and Folkman [52] where a parent taking care of their child in a hospital environment could be seen as taxing or exceeding their coping resources. The integrated nursing model thus provides parents with a manageable situation by improving problem-focused coping (giving them caregiving skills) and emotion-focused coping (providing support through WeChat).

Limitations of this study included the lack of blinding and potential bias in the use of self-reported measures, which may have introduced a risk of performance and response bias. A placebo effect may have occurred for parents receiving the integrated disease-specific nursing care as they may have expected better outcomes due to the increased attention and specialized support, leading them to report lower SAS and SDS scores.

Observer bias may also have taken place as healthcare providers delivering integrated care may have subconsciously provided more reassurance and emotional support to the intervention group during overlapping services. This additional support may have unintentionally influenced parents’ self-reported anxiety and depression levels, leading them to report more favorable outcomes. Given the nonblinded nature of the study, healthcare providers’ expectations of the intervention’s success may have subtly shaped their interactions with parents, reinforcing positive perceptions and potentially skewing the results. Consequently, the self-reported measures may not have fully reflected on the true impact of the intervention, but rather the emotional and psychological influence of receiving increased support and attention due to observer bias. Moreover, objective measures rather than self-reported measures can be used to limit the bias of participants. Instead of standard care, the control group could also have received a sham intervention where they receive additional support without the disease-specific elements, thus allowing for blinding of the participants and avoiding a potential placebo effect.

This study would also have benefited from additional psychological outcomes, such as parental coping mechanisms, resilience, or quality of life to achieve a more comprehensive understanding of the intervention’s impact. Lastly, in the subgroup analysis, some subgroups were too small, making it too underpowered to confirm if the resultant trend was meaningful, and thus the trend was not included. The trend of complications negatively affecting parental anxiety, for example, was non-significant possibly due to the low number of patients who had complications. However, as previously mentioned, studies in literature have found significance for this trend. Future studies can examine psychological outcomes for both patients and parents, and integrated care models can be further optimized through comparative studies with alternative models. For example, the effectiveness of digital or telehealth-based follow-ups can be compared to community-based care where local healthcare providers are assigned to follow-up on post-discharge care.

Conclusion

In conclusion, this study demonstrated that the integrated disease-specific nursing model significantly alleviated anxiety and depression among parents of children with severe hypospadias, particularly in those whose children experienced postoperative complications. The comprehensive approach, which included tailored psychological support, individualized education, and continuous follow-up, enhanced parental involvement in the child’s care and contributed to greater emotional well-being. By addressing both the medical and psychological needs of families, this model not only improved parental satisfaction, but also fostered a supportive environment conducive to better recovery outcomes for the child. These findings highlight the value of the specialized integrated nursing model as an effective and adaptable clinical practice, making it a promising approach for broader implementation in pediatric urology and other complex pediatric conditions.

Article Information

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

Acknowledgements

None.

Funding

This research received no external funding.

Data Sharing Statement

Please contact the corresponding author for data availability.

Supplementary Data

Supplementary data to this article can be found online at https://doi.org/10.4040/jkan.24147.

Supplementary Table 1.

jkan-24147-Supplementary-Table-1.pdf

Supplementary Figure 1.

jkan-24147-Supplementary-Figure-1.pdf

Author Contributions

Conceptualization or/and Methodology: YY, RW. Data curation or/and Analysis: RW, LJ, BD, YL, YY. Funding acquisition: none. Investigation: RW, LJ, BD, YL, YC, ZS. Project administration or/and Supervision: YY, RW. Resources or/and Software: YC, ZS. Validation: RW, LJ, BD. Visualization: LJ, BD. Writing: original draft or/and Review & Editing: RW, LJ, BD. Final approval of the manuscript: all authors.

Figure 1.

CONSORT flow diagram of participant enrollment.

Figure 2.

(A–D) Mean differences in depression and anxiety scores between the control and intervention groups at discharge and the 6-month follow-up. SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale. **p<.01. ***p<.001.

Table 1.

Baseline characteristics of children with hypospadias and their parents

Characteristic	Control (n=93)	Intervention (n=87)	U	t	χ²	p^a)
Age (yr)	5.3±2.93	5.3±3.07	3967			.822^b)
Meatal location					2.55	.466
Glans	21 (22.6)	13 (14.9)
Penile	51 (54.8)	57 (65.5)
Penoscrotal	17 (18.3)	13 (14.9)
Perineal	4 (4.3)	4 (4.6)
Parent education level					0.64	.887
Junior high school or below	12 (12.9)	8 (9.2)
Senior high school	50 (53.8)	48 (55.2)
Undergraduate	24 (25.8)	24 (27.6)
Graduate	7 (7.5)	7 (8.0)
Residence					0.06	.808
Urban	68 (73.1)	65 (74.7)
Rural	25 (26.9)	22 (25.3)
Baseline SAS	56.90±6.11	58.54±6.31		1.77		.079
Baseline SDS	58.13±6.23	56.92±7.41		1.19		.236

Values are presented as mean±standard deviation or number (%).

SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale.

^a)The chi-square test was used for categorical variables and the Student t-test was used for continuous variables unless otherwise stated. ^b)By Mann-Whitney U test.

Table 2.

Treatment outcomes, postoperative complications, and parental SAS/SDS scores

Variable	Control (n=93)	Intervention (n=87)	U	t	χ²	p^a)
Surgery type					0.05	.829
Single-stage	76 (81.7)	70 (80.5)
Double-stage	17 (18.3)	17 (19.5)
No. of operations					0.01	.910
1	85 (91.4)	80 (92.0)
2	8 (8.6)	7 (8.0)
Perioperative complications	30 (32.3)	25 (28.7)			0.26	.608
Complications at follow-up	14 (15.1)	7 (8.0)			2.14	.143
Discharge
SAS	53.71±5.43	51.77±5.30		2.42		.016
SDS	55.24±5.82	52.69±6.05	2,976			.005^b)
Follow-up
SAS	52.06±5.09	46.36±5.12	1,560			<.001^b)
SDS	53.40±5.06	49.46±5.42	2,144			<.001^b)

Values are presented as number (%) or mean±standard deviation.

SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale.

^a)The chi-square test was used to compare categorical variables and the Student t-test was used to compare numerical variables unless otherwise indicated. ^b)By Mann-Whitney U test.

Table 3.

Post-hoc comparison of anxiety and depression scores between intervention and control groups at each time point

Time	Mean difference in SAS score between intervention and control groups			Mean difference in SDS score between control and intervention groups
Time	Mean (95% CI)	t	p^a)	Mean (95% CI)	t	p^a)
Admission	–1.64 (–3.27 to –0.003)	–1.95	.050	1.21 (–0.56 to 2.98)	1.39	.179
Discharge	1.94 (0.31 to 3.57)	2.34	.020	2.55 (0.78 to 4.31)	2.83	.005
Six-month follow-up	5.71 (4.07 to 7.34)	6.79	<.001	3.94 (2.17 to 5.71)	4.33	<.001

CI, confidence interval; SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale.

^a)Adjustment for multiple comparisons: Bonferroni.

Table 4.

Post-hoc comparison of within-group changes in anxiety and depression scores over time

Group	Mean decrease between admission and discharge			Mean decrease between discharge and 6-month follow-up
Group	Mean (95% CI)	t	p^a)	Mean (95% CI)	t	p^a)
Control (SAS)	3.19 (1.23 to 5.16)	3.19	<.001	1.65 (–0.32 to 3.61)	1.65	.134
Control (SDS)	2.89 (0.77 to 5.02)	2.67	.003	1.84 (–0.29 to 3.96)	1.7	.114
Intervention (SAS)	6.77 (4.74 to 8.80)	6.54	<.001	5.41 (3.38 to 7.45)	5.22	<.001
Intervention (SDS)	4.23 (2.03 to 6.43)	3.77	<.001	3.23 (1.03 to 5.43)	2.88	.001

CI, confidence interval; SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale.

^a)Adjustment for multiple comparisons: Bonferroni.

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Impact of an integrated disease-specific nursing care model on parental anxiety and depression in severe hypospadias patients in China: a randomized controlled trial

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Impact of an integrated disease-specific nursing care model on parental anxiety and depression in severe hypospadias patients in China: a randomized controlled trial

Figure 1. CONSORT flow diagram of participant enrollment.

Figure 2. (A–D) Mean differences in depression and anxiety scores between the control and intervention groups at discharge and the 6-month follow-up. SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale. **p<.01. ***p<.001.

Figure 1.

Figure 2.

Impact of an integrated disease-specific nursing care model on parental anxiety and depression in severe hypospadias patients in China: a randomized controlled trial

Characteristic	Control (n=93)	Intervention (n=87)	U	t	χ²	p^a)
Age (yr)	5.3±2.93	5.3±3.07	3967			.822^b)
Meatal location					2.55	.466
Glans	21 (22.6)	13 (14.9)
Penile	51 (54.8)	57 (65.5)
Penoscrotal	17 (18.3)	13 (14.9)
Perineal	4 (4.3)	4 (4.6)
Parent education level					0.64	.887
Junior high school or below	12 (12.9)	8 (9.2)
Senior high school	50 (53.8)	48 (55.2)
Undergraduate	24 (25.8)	24 (27.6)
Graduate	7 (7.5)	7 (8.0)
Residence					0.06	.808
Urban	68 (73.1)	65 (74.7)
Rural	25 (26.9)	22 (25.3)
Baseline SAS	56.90±6.11	58.54±6.31		1.77		.079
Baseline SDS	58.13±6.23	56.92±7.41		1.19		.236

Variable	Control (n=93)	Intervention (n=87)	U	t	χ²	p^a)
Surgery type					0.05	.829
Single-stage	76 (81.7)	70 (80.5)
Double-stage	17 (18.3)	17 (19.5)
No. of operations					0.01	.910
1	85 (91.4)	80 (92.0)
2	8 (8.6)	7 (8.0)
Perioperative complications	30 (32.3)	25 (28.7)			0.26	.608
Complications at follow-up	14 (15.1)	7 (8.0)			2.14	.143
Discharge
SAS	53.71±5.43	51.77±5.30		2.42		.016
SDS	55.24±5.82	52.69±6.05	2,976			.005^b)
Follow-up
SAS	52.06±5.09	46.36±5.12	1,560			<.001^b)
SDS	53.40±5.06	49.46±5.42	2,144			<.001^b)

Time	Mean difference in SAS score between intervention and control groups			Mean difference in SDS score between control and intervention groups
Time	Mean (95% CI)	t	p^a)	Mean (95% CI)	t	p^a)
Admission	–1.64 (–3.27 to –0.003)	–1.95	.050	1.21 (–0.56 to 2.98)	1.39	.179
Discharge	1.94 (0.31 to 3.57)	2.34	.020	2.55 (0.78 to 4.31)	2.83	.005
Six-month follow-up	5.71 (4.07 to 7.34)	6.79	<.001	3.94 (2.17 to 5.71)	4.33	<.001

Group	Mean decrease between admission and discharge			Mean decrease between discharge and 6-month follow-up
Group	Mean (95% CI)	t	p^a)	Mean (95% CI)	t	p^a)
Control (SAS)	3.19 (1.23 to 5.16)	3.19	<.001	1.65 (–0.32 to 3.61)	1.65	.134
Control (SDS)	2.89 (0.77 to 5.02)	2.67	.003	1.84 (–0.29 to 3.96)	1.7	.114
Intervention (SAS)	6.77 (4.74 to 8.80)	6.54	<.001	5.41 (3.38 to 7.45)	5.22	<.001
Intervention (SDS)	4.23 (2.03 to 6.43)	3.77	<.001	3.23 (1.03 to 5.43)	2.88	.001

Table 1. Baseline characteristics of children with hypospadias and their parents

Values are presented as mean±standard deviation or number (%).

SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale.

^a)The chi-square test was used for categorical variables and the Student t-test was used for continuous variables unless otherwise stated. ^b)By Mann-Whitney U test.

Table 2. Treatment outcomes, postoperative complications, and parental SAS/SDS scores

Values are presented as number (%) or mean±standard deviation.

SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale.

^a)The chi-square test was used to compare categorical variables and the Student t-test was used to compare numerical variables unless otherwise indicated. ^b)By Mann-Whitney U test.

Table 3. Post-hoc comparison of anxiety and depression scores between intervention and control groups at each time point

CI, confidence interval; SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale.

^a)Adjustment for multiple comparisons: Bonferroni.

Table 4. Post-hoc comparison of within-group changes in anxiety and depression scores over time

CI, confidence interval; SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale.