Why Good Intentions Are Not Enough: What Really Drives Developmental Care for Preterm Infants

Every year, between four and sixteen percent of newborns around the world arrive early, before thirty-seven weeks of gestation, and their survival increasingly depends not only on ventilators and incubators but on something far subtler: the way nurses handle, position, and respond to them in the fragile first weeks of life. A new study from South Korea, published in the open-access journal Heliyon, has now mapped the psychological machinery behind one of the most important nursing behaviors in the neonatal intensive care unit, or NICU, and the results challenge a long-standing assumption in medical education. Knowing about developmental support care, the researchers found, is not what makes nurses actually deliver it. What matters is a chain of motivation, intention, and hard-won clinical competence.

The stakes could hardly be higher. Neonatal medicine has made astonishing progress in keeping the smallest infants alive. In the United States, survival of extremely preterm infants rose from 76 percent for those born between 2008 and 2012 to 78.3 percent for those born between 2013 and 2018, according to the Neonatal Research Network. South Korea’s trajectory is even more dramatic: the survival rate of very low birth weight infants climbed from 38.3 percent in the 1980s to 89.3 percent in 2020. But survival is only the first act. Preterm infants who escape the NICU often face lifelong challenges in cognition, motor function, and behavior, and the quality of care they receive during their hospital stay is closely linked to their long-term prognosis and quality of life.

Developmental support care, abbreviated DSC in the research literature, encompasses a broad range of interventions designed to minimize the stressors of life outside the womb. It includes careful positioning, management of light and noise, protection of sleep, modulation of sensory stimulation, pain and stress management, and support for the infant’s emerging interactions with parents. The most rigorously validated structured program is the Newborn Individualized Developmental Care and Assessment Program, or NIDCAP, which originated in the United States and individualizes care to each infant’s behavioral cues. More recently, European units have embraced Infant- and Family-Centered Developmental Care, which extends these principles to parents as partners. Studies suggest such programs can shorten hospital stays, reduce post-discharge complications, lower stress for infants and families, and improve long-term developmental outcomes.

Yet in South Korea, these structured programs have not been widely adopted. Developmental care in Korean NICUs is largely delivered at the level of individual nurses or individual wards, and surveys have found that more than half of Korean NICU nurses have never received formal training in DSC, while most of those who did received only a single session. The result is a workforce with uneven knowledge and limited practical skills in exactly the interventions that matter most for preterm infants’ developing brains. Understanding what actually drives nurses to perform developmental care, rather than merely to endorse it in principle, became the central question for Haeryun Cho and Mihae Im, the researchers behind the new study.

To answer it, they turned to one of the most successful frameworks in behavioral psychology: the theory of planned behavior, developed by Icek Ajzen in 1991. The theory holds that the most immediate predictor of any behavior is the intention to perform it, and that intention itself is shaped by three forces: attitudes, meaning a person’s evaluation of whether the behavior is worthwhile; subjective norms, meaning the perceived expectations of colleagues, supervisors, and the organization; and perceived behavioral control, meaning the sense that one is able to overcome barriers and carry the behavior out. The framework has successfully predicted nurses’ care behaviors during the COVID-19 pandemic, hand hygiene among nursing students, and pediatric nurses’ intravenous fluid administration, but it had never been rigorously applied to developmental care in the NICU.

Cho and Im added a crucial extension. Intention, they reasoned, is motivational, but motivation alone cannot translate into action without capability. They therefore positioned nursing competence, a measure integrating knowledge, skills, and attitudes across domains such as environmental support, parental support, interaction, and critical thinking, as a mediator between the psychological constructs and actual performance. Knowledge was placed upstream as a cognitive antecedent to competence. The team surveyed 188 nurses from six Level III or IV NICUs in university hospitals across Seoul, Gyeonggi, Jeolla, and Gyeongsang provinces, each with at least two years of clinical experience, using validated scales for knowledge, attitudes, subjective norms, perceived behavioral control, intention, competence, and performance, and then tested their hypothesized model with path analysis.

The statistical results were striking. The final modified model explained 62.5 percent of the variance in developmental support care performance, with competence emerging as by far the strongest direct predictor, carrying a standardized coefficient of .72. Intention did not influence performance directly; instead, it worked through competence, with a strong path coefficient of .48. Attitudes, subjective norms, and perceived behavioral control all shaped intention, with coefficients of .31, .33, and .35 respectively, meaning that nurses performed developmental care not because of perceptions or external expectations alone, but because a preformed intention strengthened their competence and led to practice. The model also explained 46.5 percent of the variance in competence itself, with intention again the dominant influence.

Perhaps the most counterintuitive finding concerned knowledge. Nurses scored an average of 82.87 out of 100 on the knowledge test, yet knowledge showed no significant association with either competence or performance. The authors offer several explanations: the scale primarily measured declarative, factual knowledge rather than the procedural knowledge embedded in clinical practice; the high average score suggests a ceiling effect that restricted variance; and without the organizational scaffolding of structured programs like NIDCAP, which South Korea has not adopted nationally, knowledge alone may simply be insufficient to change behavior. Perceived behavioral control, similarly, showed no direct effect on performance, which the researchers interpret as a signal of insufficient institutional and environmental support in Korean NICUs.

The practical implications reach well beyond Korea. If competence is the gateway through which intention becomes action, then traditional one-way lectures are the wrong tool. The authors point to evidence that training through hands-on clinical experience, simulation, case-based learning, and even virtual reality can improve developmental care performance, and they argue that education should be redesigned to build motivation and intention through goal setting and self-directed practice, then convert that motivation into capability through competence-based strategies. Because subjective norms matter, organizational culture is not a luxury: peer expectations, manager attitudes, institutional guidelines, adequate staffing, and even reimbursement structures for developmental care all shape whether intentions survive contact with a busy shift.

The study’s authors are candid about its limitations. Both competence and performance were measured by self-report from the same participants, raising the possibility of common method bias and conceptual overlap between the two constructs; the attitudes scale showed internal consistency slightly below the conventional threshold; convenience sampling limits generalizability; and data were collected in 2020, during the COVID-19 pandemic, when workloads and priorities in Korean NICUs were under unusual strain. The modified model’s global fit indices were also imperfect, warranting cautious interpretation. Even so, the core message stands with unusual clarity for a field often dominated by fragmented descriptive studies. Saving a preterm infant’s future is not a knowledge problem to be solved with another lecture. It is a motivation-and-capability problem, solved by building nurses’ conviction, surrounding them with a culture that expects developmental care, and giving them the competence to deliver it, one carefully positioned, gently handled infant at a time.

Subject of Research: Determinants of neonatal nurses' developmental support care for preterm infants based on the theory of planned behavior

Article Title: Neonatal nurses’ developmental support care for preterm infants in South Korea: Path analysis based on the theory of planned behavior

Article References: Cho, H., & Im, M. (2026). Neonatal nurses’ developmental support care for preterm infants in South Korea: Path analysis based on the theory of planned behavior. Heliyon, 12(15), Article e45537. https://doi.org/10.1016/j.heliyon.2026.e45537

Image Credits: AI Generated

DOI: 10.1016/j.heliyon.2026.e45537

Keywords: preterm infants, developmental support care, NICU nurses, theory of planned behavior, nursing competence, South Korea, NIDCAP, behavioral intention, path analysis, neonatal intensive care, nursing education, family-centered care