Journal of Neonatal Nursing xxx (xxxx) xxx

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Journal of Neonatal Nursing

journal homepage: www.elsevier.com/locate/jnn

The effect of telenursing on the rate of newborn readmission

Sara Gholami a, Azam Shirinabadi Farahani a, *, Fatemeh Alaee Karahroudy a,
Farzaneh Moghadam a, Nasrin Boromandnia b, leila khanali Mojen c
a
Department of Pediatric & Neonatal Intensive Care Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
b
Department of Biostatistics, School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
c
Department of Medical Surgical Nursing, Nursing & Midwifery School, Shahid Beheshti University of Medical Sciences, Tehran, Iran

A R T I C L E I N F O
Background: Unplanned readmission is a common and costly problem. A large percentage of premature infants
Keywords: need readmission during the first year of life, which indicates insufficiency in providing the necessary care. Thus,
Premature infant providing supportive care, such as telenursing, seems to be essential. Therefore, this study has been conducted to
Telenursing determine the effect of telenursing on the rate of readmissions in premature infants.
Readmission Methods: This quasi-experimental study was conducted on 288 mothers with premature newborns. Mothers were
Neonatal intensive care unit randomly assigned to intervention and control group after their infants’ being discharged (144 mothers in each
group). In the intervention group, training was provided through telenursing every 6 days. The control group
only received the ordinary care. One month after the infant’s being discharged from the hospital; both groups
were surveyed regarding readmission through calling them. Data analysis was performed by SPSS software
version 21.
Results: 56 newborns (38.9%) in the control group and 22 (15.3%) in the intervention group had been read­
mitted. A significant difference was observed between the readmission rates in these two groups through Chi-
square test (P < 0.05).
Conclusion: The implementation of educational intervention through telenursing reduces the readmission rates in
premature infants. Considering that the provision of this service is inexpensive and easy, it can be considered as a
strategy to reduce readmission rates.

1. Introduction 8 weeks of discharge (Vohr Br et al., 2012, Ambalavanan et al., 2011,

Each repeated and unplanned admission of an infant to the NICU is
defined as readmission (Dashti et al., 2015) which can last from a few
days to some months depending on the infant’s medical condition or
degree of prematurity. Unplanned readmission is a common and costly
problem. One of the reasons of increased health care costs is the read­
mission of infants who have been discharged from NICU and admitted
again within 30 days of discharge (Allaudeen et al., 2011). The reason is
that the cost of readmission of premature infants is high and even higher
than the cost of initial admission and hospitalization (Mourani et al.,
2014; Schiltz NK et al., 2014).
Premature infants will be exposed to more risk with each read­
mission (Vohr Br et al., 2012). The result of research shows that 45% of
extremely low birth weight. Infants are readmitted within 18–22 months
after their discharge from the hospital and 23–49% of infants fewer than
32 weeks will be readmitted during their first year of life, and 39.9% of
premature infants require readmission due to different problems within
Aykanat GB and Cimete G, 2017). In Iran, 39.6% of infants have
required readmission within one month after their discharge, 26.6% of
which has been due to jaundice (Dashti et al., 2015, Kavehmanesh et al.,
2008). 36.5% of the babies have been readmitted due to respiratory
diseases until the end of their second year of life (Elisabeth et al., 2014).
According to a study conducted in New South Wales, Australia, one in
every six premature babies discharged needs to be readmitted. (Lain
et al., 2014). This high rate of readmissions may indicate inadequate
care or the poor quality of the provided care (Fischer et al., 2014).
Since readmission is a variable adverse event and an important in­
dicator in measuring the quality of care provided to premature infants,
as well as a bitter experience for newborns and their parents, it has
recently been given special attention and some methods are suggested to
reduce it (Dashti et al., 2015). One of the most effective ways to prevent
the harms caused by hospitalization is to involve the parents actively in
the process of providing care for their infants and to empower them
(Goyal et al., 2013, Aliabadi et al., 2011). Therefore, providing

* Corresponding author.
E-mail address: farahani1381@yahoo.com (A.S. Farahani).

https://doi.org/10.1016/j.jnn.2021.03.001
Received 25 May 2020; Received in revised form 15 February 2021; Accepted 8 March 2021
1355-1841/© 2021 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Sara Gholami, Journal of Neonatal Nursing, https://doi.org/10.1016/j.jnn.2021.03.001
S. Gholami et al.
family-based supportive care in NICUs can be one of the factors that lead
to the reduction of the number of readmissions, because it involves the
family in decision making and providing care for the infant right after
birth. Thus, the parents are considered as the primary caregivers and
cooperate with the treatment team in preparing and implementing the
care plan for the infants (Aliabadi et al., 2011). The care plans that are
also continued after discharge are provided in different ways. One of the
most effective methods applied by nurses is counseling (Isetta et al.,
2013). Telenursing is one of the most effective counseling methods. This
method is economical leads to an increase in the quality of care services,
reduces the healthcare system’s workload (Glinkowski et al., 2013;
Souza-Junior VD et al., 2016; Ghorbanzadeh et al., 2017) and is used in
most countries throughout the world (Isetta et al., 2013). Regarding the
fact that after the infants’ discharge, the parents will be responsible for
their health and since the infants’ health may be affected by the parents’
lack of communication with medical centers and their not being
informed about the process of care plan, post-discharge conditions can
be resolved by providing facilities like telenursing (Nguyen et al., 2013).
Many studies have Explore the benefits of applying telenursing for the
patients and their families (Asghari et al., 2021; Isetta et al., 2013.
Readmission is an important indicator of the quality of care provided
to premature infants. This type of hospitalization is also a costly problem
for the family and for the health care system, and a bitter accident for the
family, especially the mother, which causes anxiety and worry in them.
In Iran, after infants are discharged from NICU, continuation of care is
possible only through the presence of family members in the hospital.
On the other hand, due to the increase in the birth rate of premature
infants, and considering the fact that a high percentage of these infants
experience readmission due to various medical and therapeutic reasons
the present study has been conducted on premature infants who are
more at risk to determine the effects of telenursing on their readmission,
after their discharge from NICU.
2. Methods
This quasi-experimental study has been conducted by convenience
sampling from mothers with premature infants in the NICUs of the two
educational hospitals affiliated with Qazvin University of Medical
Sciences.
2.1. Sample size
The sample size was calculated to be 288, based on the Sample Size
Formula and considering the number of NICU beds in each hospital, the
readmission prevalence, and the dropout rate. After convenience sam­
pling according to the inclusion criteria, 220 and 68 mothers were
chosen respectively from Kowsar and Qods hospitals. They were placed
into control and intervention groups randomly and based on medical file
number (odd and even). Sampling was done from May till the end of
August. Inclusion criteria were mothers whose infants were premature
and hospitalized in one of the NICU’s in selected hospitals only because
they were premature (not because of an abnormality or disease in the
premature infant). The exclusion criteria involved mothers who lost
their infants during the study or those with whom it was not possible to
keep in touch by phone after their infants were discharged.
2.2. Research instrument
In this study “Mothers and Infants Demographic and Clinical infor­
mation Form” and “Awareness Assessment Checklist” were used.
- Mothers and Infants Demographic and Clinical information Form:
This form was designed by the researcher and had a total of 19
phrases.
o Mother’s Demographic and Clinical Information Form: This form
measures items such as maternal age, underlying medical history,
2
Journal of Neonatal Nursing xxx (xxxx) xxx
type of delivery, number of children, medical history during
pregnancy, preterm delivery history, marital status, education
level, type of occupation, and economic status of mother and
family.
o Infant’s Demographic and Clinical information Form: This form
also measures items such as the baby’s age, sex of the baby, fetal
age, birth weight, multiple births, length of initial hospitalization,
oxygen demand, type of milk consumed, amount of milk consumed
in the infant.
- Awareness Assessment instrument: which included 22 phrases on the
infant’s general health at home including nutritional status, sleep
patterns, bathing, perineal care, taking medications, medicine com­
plications, next visit to the physician’s, dressing care and infection
control procedures. This tool was made by a researcher and was
based on the materials in the educational package.
The validity of the above instrument were assessed by ten neonatal
specialists as well as the faculty members of the Nursing and Midwifery
faculty members. In the “Awareness Assessment Instrument”, content
validity ratio was calculated. The statements with a validity of less than
80% were omitted. To determine the reliability, the test-retest method
was used. The instrument was completed by 15 mothers with inclusion
criteria and two weeks later they were completed again and the intra-
class correlation coefficient was calculated. This rate was estimated at
85%, which is appropriate (Fitzpatrick JJ and Kazer WM, 2012).
3. Method of intervention
24 h prior to the infant’s discharge (after the physician’s oral order
for discharge or negotiations with the parents to discharge the infant), a
30-min debriefing session was held in mothers’ presence at infants
bedside. After mentioning the goals of the study and obtaining their
written consents for participating in the study, the mothers were asked
for their phone numbers in order to provide them with telenursing as
well as probing the readmission status. Demographic information of
mother and infant was measured using " Mothers and Infants De­
mographic and Clinical information Form” and the level of awareness of
mothers of the two intervention and control groups was measured using
" Awareness Assessment instrument”. The infant’s referral to the hospital
was considered as readmission, if the infant was hospitalized for at least
one night and the second admission was unplanned and occurred with a
minimum time gap of more than one day after the initial discharge. A
telephone line was also provided for the mothers in the intervention
group so that they could call the researcher in order to address their
unforeseen needs regarding care provision for the infant. At the same
meeting, the mothers and infants’ characteristics were collected using
“Mothers and Infants Demographic and Clinical information Form”.
In the intervention group, consultation was provided in the form of
telenursing by a researcher who was a NICU nurse, based on the pro­
vided educational package. The contents of this package were prepared
in accordance with the booklet of Care and Maintenance of Premature
Infants (developed in cooperation with the Department of Newborn
Health and Iran Neonatal Medicine Association) and the neonatal
intensive care nursing’s curriculum. The validity of the educational
package were assessed by ten neonatal specialists as well as the faculty
members of the Nursing and Midwifery faculty members. This educa­
tional package was presented during 5 sessions, respectively, as follows:
• First session: Breastfeeding techniques and diet
• Second session: Changing the infant’s position, and its rest and sleep
patterns
• Third session: Skin and perineal care
• Fourth Session: Medications, medicine complications
• Fifth session: Dressing care (if any), infection control procedures, and
the next visit to the doctor’s office
S. Gholami et al. Journal of Neonatal Nursing xxx (xxxx) xxx

Mothers in the intervention group were contacted 3–4 days after Table 2
their infants’ discharge. These phone calls training session lasted 10–20 The distribution of some demographic characteristics of premature infant’s
min and were made every 6 days. Finally, they were contacted 5 times. mothers of admitted to neonatal intensive care units in control and intervention
First, mothers were questioned on the material discussed during the groups of in selected hospitals in Qazvin.
previous session and their level of awareness was examined by the Groups Control Intervention P-
“Awareness Assessment Instrument”. Then the mothers’ questions were Group Group value
answered, and after the elimination of any ambiguity, training was done Variables Frequency Frequency
according to the educational package. Finally, the score of parental in­ (Percentage) (Percentage)
formation during tele-nursing was calculated and the data were
Age (year) > 20 10 (6.9) 9 (6.3) 0.054
analyzed.
21–30 80 (55.6) 73 (50.3)
Since consultations were provided through telenursing and individ­ 31–50 54 (37.5) 62 (43.4)
ually, the mothers in the control group were unaware of the educational Level of Less than diploma 57 (39.5) 48 (33.3) 0.477
contents presented to the intervention group. After the infant’s Education Diploma 64 (46.4) 69 (27.9)
discharge, the control group received only the ordinary care. One month University 23 (16) 27 (18.8)
education
after discharge, the mothers in both groups were contacted to see if the Number of 1 48 (32.6) 71 (50.7) 0.451
infants had been readmitted and to get information about the number of Children 2–3 90 (62.5) 66 (47.1)
readmission times. Also, the level of awareness of mothers in the 4 and more 6 (4.2) 3 (2.1)
intervention and control groups was measured again using “Awareness Type of Cesarean Section 48 (33.1) 32 (21.8) 0.036
Delivery Normal Vaginal 96 (66.9) 112 (78.2)
Assessment".
Delivery
Data analysis was performed by SPSS software version 21. The
confidence interval level was considered 95% with a p-value of less than
0.05.
Table 3
Logistic regression model for factors associated with readmission of premature
4. Results
infants.

In order to investigate the effect of telenursing on readmission rate, Regression Model QRa SDb P- 95% CIc
value
first, both control and intervention groups were studied in terms of their Variable
demographic characteristics and the variable homogeneity. In the con­ Birth weight 1.000 0.000 0.137 0.999–1.000
trol and intervention groups, respectively 53.5% and 57.6% of the in­ length of initial hospitalization (day) 1.006 0.015 0.709 0.976–1.037
fants were female. The mean weight of the infants was 2451 ± 98 g in Number of Children 0.532 0.208 0.002 0.354–0.800
the intervention group, and 2391 ± 28 g in the control group. Some Type of Normal Vaginal 0.800 0.346 0.519 0.406–1.576
delivery Delivery
demographic characteristics of the newborns and their mothers in both Cesarean Section Reference Group
control and intervention groups are presented respectively in Tables 1 Level of University 0.384 0.480 0.046 0.150–0.958
and 2. Since there were significant statistical differences in some vari­ Education education
ables in the control and intervention groups, standardized logistic Diploma 0.727 0.333 0.338 0.378–1.396
Less than diploma Reference Group
regression was calculated to control and eliminate their confounding
effects in studying the impact of telenursing on newborns’ readmission. a
Odds ratio.
b
Results are presented in Table 3. Among the factors included in the Standard Error.
c
regression model, the number of children and the mother’s level of ed­ 95% Confidence Interval.
ucation had a significant correlation with the readmission of infants. The
level of mothers’ awareness was evaluated in each of the 5 stages using increased during the sequential sessions (Fig. 1). The impact of tele­
ANOVA with repeated measurement. The results showed that in the nursing on the rate of newborns’ readmission was evaluated by per­
intervention group, the score of parental awareness of the infant care has forming Chi-square test. The results indicated that the readmission rate
was higher in the control group than the intervention group, which
shows the effect of telenursing on reducing the rate of infants’ read­
Table 1
mission (Table 4).
The distribution of some demographic characteristics of premature infants
admitted to neonatal intensive care units in control and intervention groups of in
selected hospitals in Qazvin.
Groups Control Intervention P-
group group value

Variables Frequency Frequency

(percentage) (percentage)

Gestational age (week) > 27 29 (20.2) 12 (8.5) 0.054

27–32 45 (31.2) 53 (37.6)
32–34 23 (16) 23 (16.3)
34–37 33 (22.9) 29 (20.6)
37 > 13 (9.7) 24 17)
Sex Female 77 (53.5) 83 (57.6) 0.477
Male 67 (46.5) 61 (42.4)
Birth weight (week) > 1000 9 (6.3) 9 (6.3) 0.451
1000–1500 23 (16) 26 (18.1)
1500–2500 61 (42.7) 66 (46.2)
2500 > 51 (35) 43 (29.4)
length of initial > 10 34 (23.9) 39 (27.1) 0.036
hospitalization (day) 10–20 49 (34.5) 70 (48.6)
20–26 14 (9.9) 19 (13.2)
Fig. 1. Mothers’ knowledge score after the discharge of the premature infant
26 > 47 (31.7) 16 (11.1)
from the NICU and after each telenursing session.

3
S. Gholami et al.
Table 4
Comparison of the rate of readmission in premature infants in control and
intervention groups.
Group Intervention Group Control Group
Readmission Frequency (Percentage) Frequency (Percentage)
Yes 22 (15.3) 56 (38.9)
No 122 (84.7) 88 (61.1)
Total 144 (100) 144 (100)
P-value = 0.0123
5. Discussion
Present study was done to evaluate the effect of telenursing on the
rate of newborns’ readmission.
In regression model, no significant correlation was observed between
the length of initial hospitalization in NICU and the readmission of
premature infants. Besides, the results of some studies indicated that
there is no significant correlation between the duration of hospitaliza­
tion and readmission (Dashti et al., 2015, Kavehmanesh et al., 2008,
Goyal et al., 2013). But Harron and colleagues showed that with an
increase in the length of hospitalization, readmission rate would in­
crease noticeably (Harron et al., 2017), and some studies found that by
decreasing the length of initial hospitalization (less than 48 h post­
partum), readmission rate increases as a result of jaundice (Habib HS,
2013b; H. S. Habib, 2013a). Explaining these contradictory findings, it
can be said that in the present study, only infants who were hospitalized
in the intensive care unit due to prematurity were included in the study.
In other studies, neonates with congenital anomalies and disease were
also part of the sample.
The birth weight of infants did not have any impact on readmission.
Some other studies did not find a significant relationship between birth
weight and readmission, either (Kavehmanesh et al., 2008, Kandi Kele M
et al., 2014). However, in another studies, a significant correlation be­
tween low birth weight and readmission rate has been reported (Bentz
et al., 2018). In the present study, a small percentage of infants were
extremely low birth weight (less than 1000 g) and therefore weight was
not an effective factor in readmission.
In the presented model, the type of delivery did not have any impact
on readmission rate. However, Metcalfe et al. showed that the type of
delivery has been effective and the readmission rate after a Normal
vaginal delivery with a one to two-day hospital stay has been lower than
its rate after a cesarean delivery (Metcalfe A et al., 2016).
The mothers’ level of education and the number of their children had
a significant correlation with the infants’ readmission. The chances of
the infants undergoing readmission is reduced by 27% for mothers
holding a diploma, and 61% for mothers with academic educations
compared with mothers with an under-diploma educational level. Since
education can raise awareness and lead to higher social status, it seems
that parents with higher levels of education have more awareness and
knowledge to provide care for their infants which results in a reduction
in the number of infants’ readmissions. Mothers with higher education
raise their awareness through reading relevant articles and searching on
the Internet. A higher awareness of the therapeutic process plays an
important role in reducing the number of readmissions (Kamei et al.,
2013).
In families with one more child, the chances of readmission decline
by about 46%, which is probably the result of mother’s more knowledge
and experience in taking care of the infant.
In the present study, the intervention was received in the form of
telenursing in 5 sessions, during which mothers’ scores of knowledge
were measured. The results showed that the mothers’ mean scores of
infant care knowledge had increased during the sequential sessions.
These findings are consistent with the results of Isetta and her col­
leagues, as it also shows an increase in the score of knowledge during
successive sessions (Isetta V et all. 2013). Parents’ adequate education
4
Journal of Neonatal Nursing xxx (xxxx) xxx
and trust in their ability to take care of the infant, the relationship be­
tween the nurse and parents after the infant’s discharge, and providing
appropriate follow up services in outpatient centers after discharge are
among factors which cause a decrease in the readmission rate of pre­
mature infants in other countries (dashti et all. 2015). In the present
study, the lowest score of mothers’ awareness was associated with the
feeding the infant. Occasionally, mothers did not have enough knowl­
edge about feeding their infants regardless of their levels of education
and age. Breathing problems, jaundice and nutrition issues are respec­
tively the most common factors causing readmission among premature
infants (Akbarian et al., 2017).
The present study showed that the readmission of premature infants
and the number of its occurrence is lower in intervention group than in
the control group. Additionally, Isetta et al. reported a significant
decrease in the rate of readmissions in the intervention groups during 4
weeks of Communication and telephone counseling, which is in line
with the findings of the present study (Isetta V et all. 2013). The results
of another research showed that providing a codified education program
for the family members and supporting the family after discharge results
in a significant decline in the rate of readmission of extremely low birth
weight premature infants (Vohr BR et all. 2013). Investigations on the
effect of parental involvement in taking care of premature infants
following telephone consultation given by nurses showed that the
readmission rates after 4 and 6 weeks had been 24% and 8% respectively
(Akbarian M et all. 2017).
In addition, Aliabadi et al. showed that promoting maternal
involvement in providing care for infants admitted into NICU reduces
the number of readmissions and the average length of their initial hos­
pitalization (Aliabadi et al., 2011). Therefore, it seems that improving
the quality of care provided for extremely low-birth-weight and pre­
mature infants and paying more attention to discharge planning,
training parents and supporting the family after the infant’s discharge
are effective in removing or reducing the impacts of infants’ prematurity
and low birth weights on their readmission. Since after the infant’s
discharge, the parents are responsible for its health, and according to the
fact that sometimes due to the lack of communication with medical
centers, the lack of knowledge about the treatment plan or medications,
the infant’s health may be affected, the development of telenursing will
correct care deficiencies and will result in the reduction of infants’
readmission rate (Kamei T et all. 2013).
5.1. Limitations
The mothers who entered the study referred to these hospitals from
different parts of Iran, and after discharge from the hospital, due to the
distance or some other problems, some of them lost contact with the
researcher. Even though the telephone call was paid for by the research
team, they no longer contacted the researcher for advice and training,
therefore One of the most important limitations of this research was the
lack of researcher’s access to all samples, due to the reasons such as the
participants’ not responding researcher’s calls aiming to determine the
number of readmissions, or the wrong telephone numbers of some
samples, which led to an increase in the length of study in order to
achieve the desired sample size. In this way, many examples of research
have been eliminated in such a way that a lot of time has been spent on
replacing them, and completing the training sessions through tele-
nursing.
6. Conclusion
The results showed that telenursing was able to reduce the rate of
readmission in premature infants. Considering that the provision of this
service is inexpensive and easy, its use is recommended by the health­
care staff in providing advice to parents of premature infants. It is also
suggested that perform family training through telenursing and other
communication tools such as designing web pages and using the
S. Gholami et al.
Internet, also training be provided prior to discharge time and even from
the moment of infant’s hospitalization, and the results be compared with
the time when the training is provided at the time of discharge. It is also
recommended that the results of using other instructional tools along
with telenursing be also investigated and compared with the results of
the current study.
Funding
This project is the result of an approved research work at the Shahid
Beheshti University of Medical Sciences.
Declaration of competing interest
The authors declare no conflict of interest in this study.
Acknowledgements
This study is conducted as a part of a Master’s degree thesis in
Neonatal Intensive Care Nursing and the research project approved by
the research council of Shahid Beheshti University of Medical Sciences
(SBMU2. REC.1394.105). The authorities of hospitals under study and
the parents participating in the research are highly appreciated.
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