Preterm birth, defined as delivery before 37 completed weeks of gestation, accounts for approximately 11% of all live births worldwide and remains a leading cause of neonatal morbidity and mortality (1). Despite significant advancements in neonatal intensive care, which have markedly improved the survival rates of preterm infants, the consequences of prematurity mainly extend well beyond the neonatal intensive care unit (NICU). These infants are at the elevated risk of a broad range of complications, including respiratory distress (2), feeding difficulties (3), neurodevelopmental delay (4), and growth restrictions (5). Moreover, parents, particularly first-time caregivers, undergo notable psychological strain during their infant's prolonged hospitalization (6).

The NICU's environment, characterized by high-intensity medical interventions, unfamiliar technologies, and limited opportunities for parental involvement, is inherently stressful. Studies have consistently shown that parents of preterm infants frequently experience elevated levels of anxiety, depression, and post-traumatic stress symptoms (7, 8). These psychological burdens may not only impair parental mental health, but also hinder the development of effective parent-infant attachment and reduce caregiving confidence, ultimately influencing the infant's developmental trajectory post-discharge. Fathers, historically underrepresented in neonatal research, are increasingly recognized as being equally vulnerable to emotional distress. However, they mainly receive inadequate support and are frequently excluded from neonatal care processes (9).

Traditional NICU-based models predominantly concentrate on healthcare professionals delivering care while parents’ passive, observational roles are noteworthy (10). In these models, parental participation is often restricted to minimal caregiving tasks, such as diaper changing or limited breastfeeding, typically during the final days prior to discharge (10). This limited engagement contributes to parental feelings of helplessness and unpreparedness, and it may lead to reduced caregiving competence at home, increased risk of readmission, and delayed recovery for the infant. To address these limitations, Family Integrated Care (FICare) has emerged as an innovative and family-centered model of NICU care (10–12). Originating in Canada and increasingly implemented globally, FICare was designed to empower parents through structured education, hands-on training, and active participation in the care of their hospitalized infants (10–12). Under FICare, parents are integrated into the care team, participating in both routine and specialized care activities under the supervision of trained NICU staff. The model also incorporates peer support, emotional counseling, and ongoing lactation guidance, thereby promoting parental self-efficacy, improving parent-infant bonding, and potentially enhancing neonatal outcomes.

Evidence from previous research demonstrated that FICare is associated with improved neonatal parameters, including shorter time to full enteral feeding, greater weight gain, higher exclusive breastfeeding rates, and reduced length of NICU stay (11, 13). Additionally, preliminary studies have reported that FICare may ameliorate maternal stress and depressive symptoms during hospitalization (14). However, despite these promising findings, substantial gaps remain in the literature. Specifically, few studies have rigorously assessed the comprehensive psychological outcomes, including trauma, anxiety, depression, and stress, in both parents using standardized measures across multiple timepoints. Furthermore, discharge readiness, a critical determinant of post-discharge success and caregiver competence, has been underexplored in association with family-centered interventions. Most existing studies have also emphasized maternal outcomes, often neglecting the equally important paternal experience.

Hence, the present prospective controlled study was conducted at the NICU of Nantong First People's Hospital, a tertiary care institution located in Nantong, China. This hospital serves a diverse patient population, including families from both urban and rural areas, representing a broad spectrum of socioeconomic backgrounds. The study aimed to evaluate the effects of a structured FICare program on parental psychological outcomes and discharge readiness in a cohort of 84 families with preterm infants admitted to the NICU.

This prospective controlled study demonstrated that FICare could significantly improve psychological outcomes and discharge readiness among parents of preterm infants, while also promoting earlier achievement of nutritional milestones in infants without prolonging NICU stay or increasing respiratory support requirements. These findings support the growing body of evidence that structured, parent-inclusive models of NICU care yield both psychosocial and clinical benefits for families of premature infants.

A key finding of this study is the significant reduction in psychological distress, specifically trauma symptoms, anxiety, depression, and stress, in both mothers and fathers in the FICare group, as assessed at three months postpartum. Compared with parents receiving standard care, those participating in FICare had markedly lower rates of clinically significant trauma (TSQ and PCL-5 positive), and fewer exhibited moderate-to-severe symptoms on DASS-21 subscales. This result likely reflects the protective psychological effects of early and sustained parental involvement in the NICU environment. Through structured education, practical caregiving experience, and supervised participation in decision-making, FICare empowers parents, enhances their perceived control, and reduces helplessness, recognizing as factors that may mitigate stress and trauma (19, 20). In contrast, standard care, which limits parental interaction and relegates caregivers to passive roles, may exacerbate psychological distress by reinforcing feelings of exclusion and uncertainty. The psychological impact of preterm birth on parents, particularly during and after a prolonged NICU stay, has been well-documented in the literature. Numerous studies have demonstrated that parents of preterm infants are at significantly higher risk of developing PTSD, depressive symptoms, anxiety, and chronic stress compared with parents of term infants (8, 21–23). These symptoms often originate from the sudden and traumatic onset of premature birth, compounded by uncertainty about the infant's prognosis, unfamiliar medical environments, and a loss of perceived parental role (8, 21–23). Maternal mental health outcomes have traditionally received the most attention; however, emerging evidence demonstrates that fathers also experience a significant emotional burden, although it is mainly internalized or underreported (24–26). Persistent psychological distress in parents has been associated with poorer parent-infant bonding, reduced caregiving competence, and long-term adverse effects on child socio-emotional development (24–26). This study is one of the few to specifically evaluate paternal psychological outcomes, an often underrepresented aspect of NICU research. Fathers in the FICare group, similar to mothers, experienced significant mental health benefits. This may be attributed to the inclusion of both parents in training sessions and caregiving routines, providing shared understanding, emotional support, and parity in caregiving responsibilities. Comprehensive family-centered care models may play a critical role in interrupting the trajectory from NICU-related stress to long-term psychological morbidity, highlighting the importance of integrating mental health support into neonatal care practices.

Another key finding is the significantly greater discharge readiness in the FICare group, as reflected by higher scores on validated parental readiness scales. Both mothers and fathers in this group outperformed controls across all domains, including feeding, hygienic care, and perception of infant condition. These findings likely stem from the structured, hands-on FICare training, emphasizing skill-building, knowledge reinforcement, and psychological preparation. One-on-one support, peer mentoring, and supervised practice further enhanced parental confidence. In contrast, limited and inconsistent involvement in the standard care group, especially minimal paternal participation, may account for the observed differences. Discharge readiness is a critical component of the transition from hospital to home for families of preterm infants (27–29). It not only involves the acquisition of practical caregiving skills, but also the psychological preparedness and confidence required to assume full responsibility for infant care. It has been demonstrated that inadequate discharge preparation is related to the increased parental anxiety, reduced caregiving efficacy, and higher rates of unplanned healthcare utilization following NICU discharge (30–32). Mothers and fathers often report feeling overwhelmed by the sudden shift from a highly monitored environment to home-based care, particularly when they have had limited involvement during hospitalization (32). Interventions that provide structured education, hands-on practice opportunities, and emotional support, such as FICare, may enhance discharge readiness by promoting competence, reducing uncertainty, and promoting parental autonomy. Importantly, the inclusion of both parents in discharge planning is essential, as shared caregiving responsibility contributes to better family functioning and infant outcomes in the post-discharge period.

With respect to infant clinical outcomes, FICare was associated with significantly better nutritional parameters, including earlier initiation of enteral feeding, faster progression to full enteral feeds, earlier introduction of breast milk and direct breastfeeding, and higher discharge weight. These findings align with those of previous studies, indicating that parental presence and involvement may positively influence feeding outcomes and growth in preterm infants (33–35). The mechanism by which FICare improves nutritional outcomes is likely multifactorial. Active maternal participation enhances early and consistent breast milk expression, while timely skin-to-skin contact (kangaroo care) promotes thermoregulation, metabolic stability, and feeding tolerance (35). Moreover, repeated parental presence may enable better cue-based feeding and improve the coordination of infant suck-swallow-breathe reflexes, contributing to more efficient oral feeding development. Importantly, despite these outcomes, no significant differences were found in respiratory support duration (e.g., mechanical ventilation and CPAP) or length of NICU stay between the two groups, suggesting that the clinical safety and stability of infants were not compromised by the increased parental involvement. This finding challenges previously reported concerns that non-professional caregiver participation might interfere with clinical workflows or increase the risk of nosocomial complications (36, 37).

The mode of delivery can significantly impact maternal physical recovery, emotional well-being, and psychological outcomes. In the present study, 80.95% of mothers in the control group had a vaginal delivery, while 19.05% had a cesarean section. In the FICare group, 66.67% had a vaginal birth, and 33.33% underwent a cesarean section. Vaginal delivery is generally associated with quicker recovery, while cesarean sections involve longer recovery time, increased discomfort, and a higher risk of complications, leading to higher levels of stress, anxiety, and feelings of inadequacy. Mothers who undergo cesarean delivery may experience postnatal depression, anxiety, and trauma more frequently, partly due to a perceived loss of control during the birth process. This may also limit their early involvement in infant care, leading to feelings of detachment. In contrast, vaginal delivery typically promotes faster recovery and greater involvement in newborn care, promoting better psychological outcomes and discharge readiness.

It is important to consider that the Chinese cultural context may influence parental experiences and psychological outcomes in the NICU setting. In traditional Chinese culture, the family unit is highly valued, and parental roles are often more clearly defined, with a strong emphasis on the mother's responsibility for caregiving (31, 34). This cultural context may influence both the psychological distress parents experience and their readiness for discharge. For instance, mothers may feel an elevated sense of guilt or inadequacy if they are unable to care for their infant in a culturally prescribed manner, especially if their involvement is limited by NICU protocols (22). This can exacerbate feelings of stress and anxiety, particularly in the absence of comprehensive, family-centered care. Conversely, FICare's approach, which encourages active involvement from both parents, may alleviate these concerns by empowering mothers and fathers with the skills and knowledge they need to feel confident in their caregiving roles, thereby improving discharge readiness. In Chinese society, paternal involvement in caregiving has historically been more limited compared with Western cultures, where shared parenting responsibilities are more commonly practiced (29, 30). However, this study demonstrated that fathers in the FICare group experienced significant improvements in psychological outcomes and caregiving competence. These findings demonstrate that expanding paternal involvement in the NICU, as found in FICare, could have particular cultural significance in China by challenging traditional gender roles and promoting a more equitable distribution of caregiving responsibilities. The psychological benefits for fathers, including reductions in anxiety, stress, and trauma symptoms, may reflect a shift toward more active and shared parenting roles that align with evolving attitudes toward fatherhood in contemporary Chinese society. However, in the context of Chinese families, discharge readiness may also be influenced by the presence of extended family members. In China, it is common for grandparents or other relatives to play a significant role in childcare (21). Thus, while FICare programs that emphasize parental involvement are beneficial, they may need to consider the dynamics of extended family support systems. For example, the cultural expectation for maternal and paternal roles may be altered by the presence of grandparents or other family members in the caregiving process (26). This cultural factor may affect how parents assess their own readiness for discharge and caregiving confidence. It is important that FICare interventions in China integrate family-centered approaches that acknowledge and involve extended family members in the caregiving process, enhancing parental confidence and ensuring a smooth transition from hospital to home. In Chinese culture, the mode of delivery is often regarded as a significant event, and the mother's emotional response to it can have lasting effects on her sense of identity and motherhood (36). Understanding these cultural implications can help healthcare providers with more empathetic support and care for mothers, particularly those recovering from cesarean sections, ensuring that they feel supported in their caregiving role.

This study has several limitations that warrant consideration. Firstly, the study was conducted at a single tertiary NICU center, which might limit the generalizability of the findings to other institutions with different patient populations, staffing models, or resources. Secondly, the nature of the intervention precluded participant and provider blinding, increasing the risk of performance and detection bias, especially for subjective outcomes, such as psychological assessments. Thirdly, psychological outcomes were evaluated only up to three months postpartum; longer-term effects on parental mental health, caregiving confidence, and infant developmental outcomes remain unknown and warrant further longitudinal investigation. Additionally, both the control and FICare groups had relatively small sample sizes, which might limit the statistical power of the analyses and the ability to detect smaller effect sizes. The small sample size could also reduce the generalizability of the findings, as the results might not fully reflect the diversity of NICU populations across different settings or regions. Larger, multicenter studies are needed to confirm these findings and assess their applicability to broader populations. Furthermore, the questionnaires in this study were self-translated by the authors instead of using validated Chinese versions. Future research should use validated Chinese versions or employ a professional translation and validation process to ensure accuracy and cultural relevance.

This study demonstrated that FICare could significantly improve psychological outcomes and discharge readiness among parents of preterm infants in the NICU. Compared with standard care, FICare reduced symptoms of trauma, anxiety, depression, and stress in both mothers and fathers, while also enhancing caregiving competence and readiness for discharge. Infants in the FICare group achieved nutritional milestones earlier and had higher discharge weights, without prolonged NICU stays or increased respiratory support. These findings highlight the clinical and psychosocial value of FICare and support its broader implementation in NICU settings. Further multicenter, long-term studies are warranted to validate and expand these results.