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- v.373; 2021
Future of Nursing
How the nursing profession should adapt for a digital future, richard g booth.
1 Arthur Labatt Family School of Nursing, Western University, London, Canada
2 Centre for Addiction and Mental Health, Toronto, Canada
3 School of Nursing, Texas Tech University Health Sciences Center, Lubbock, USA
4 School of Health in Social Science, University of Edinburgh, Edinburgh, UK
Ana Laura Solano López
5 University of Costa Rica, San José, Costa Rica
Transformation into a digitally enabled profession will maximize the benefits to patient care, write Richard Booth and colleagues
Digital technologies increasingly affect nursing globally. Examples include the growing presence of artificial intelligence (AI) and robotic systems; society’s reliance on mobile, internet, and social media; and increasing dependence on telehealth and other virtual models of care, particularly in response to the covid-19 pandemic.
Despite substantial advances to date, challenges in nursing’s use of digital technology persist. A perennial concern is that nurses have generally not kept pace with rapid changes in digital technologies and their impact on society. This limits the potential benefits they bring to nursing practice and patient care. To respond to these challenges and prepare for the future, nursing must begin immediate transformation into a digitally enabled profession that can respond to the complex global challenges facing health systems and society.
Many exemplars show how digital technologies already bring benefit to nursing practice and education. 1 For instance, telehealth programs where nurses provide daily monitoring, coaching, and triage of patients with several chronic diseases have helped reduce emergency department admissions. 2 Mobile devices, in particular smartphones and health applications, are enabling nurses to offer remote advice on pain management to adolescent patients with cancer 3 4 and supplement aspects of nursing education by providing innovative pedagogical solutions for content delivery and remote learning opportunities. 5
The development and application to nursing of systems based on AI are still in their infancy. But preliminary evidence suggests virtual chatbots could play a part in streamlining communication with patients, and robots could increase the emotional and social support patients receive from nurses, while acknowledging inherent challenges such as data privacy, ethics, and cost effectiveness. 6
Digital technologies may, however, be viewed as a distraction from, or an unwelcome intrusion into, the hands-on caring role and therapeutic relationships that nurses have with patients and families. 7 This purported incompatibility with traditional nursing ideals, such as compassionate care, may explain some nurses’ reluctance to adopt digital approaches to healthcare. 8 9 In addition, nursing’s history was as structurally subordinate to other healthcare disciplines, 10 and the profession is still cementing its relationship and leadership in health systems.
The specialty of nursing informatics has long advocated for the integration of technology to support the profession, but it has comparatively few practitioners globally. Nursing informaticians are predominantly based in the United States, where the discipline seems to have originated, but many other countries and regions are expanding their digital nursing workforce and involvement with informatics. 11 12
Slow progress in some areas has been due to a lack of leadership and investment that supports nurses to champion and lead digital health initiatives. Globally, uncertainty remains regarding the next steps the nursing profession should take to increase and optimize its use of digital technology. This challenge is exacerbated by the global diversity of the profession, including unequal access to resources such as technological infrastructure maturity and expertise. Huge differences exist among countries and regions of the world in terms of the digitalization of healthcare processes, access to internet connectivity, and transparency of health information processes.
Selected technologies: benefits and challenges
The nursing literature contains many analyses of digital technologies used to support or extend the profession, including practice (eg, hospital information systems, electronic health records, monitoring systems, decision support, telehealth); education (eg, e-Learning, virtual reality, serious games); and, rehabilitative and personalized healthcare approaches (eg, assistive devices sensors, ambient assisted living). 1 T able 1 summarizes the potential benefits, challenges, and implications of emerging innovations to practice.
Benefits, challenges, and implications of selected digital technologies in nursing
The table is not exhaustive, but the diversity of topics researched shows the profession recognizes the value and challenges of digital technologies. Given the evidence, for the profession to make further progress we recommend five areas for focused and immediate action. These recommendations should be qualified in light of regional context and professional background owing to global heterogeneity in nursing and the inclusion of digital technologies into healthcare.
Reform nursing education
We must urgently create educational opportunities at undergraduate and graduate levels in informatics, digital health, co-design, implementation science, and data science. 39 These should include opportunities to work with and learn from computing, engineering, and other interdisciplinary colleagues. For instance, nursing will need a critical mass of practitioners who understand how to use data science to inform the creation of nursing knowledge to support practice. 40 These practitioners will also need savviness and courage to lead the development of new models of patient care enabled by digital technologies. 41 42
Determining how, where, and why technology like AI should be used to support practice is of immediate interest and a growing competency requirement in health sciences and informatics education. 43 Nursing education should evolve its competencies and curriculums proactively for the increasing use of digital technologies in all areas of practice 39 while incorporating novel pedagogical approaches—for example, immersive technologies such as virtual and augmented reality—to deliver aspects of simulation based education. 44 45
Recently, the American Association of Colleges of Nursing released core competencies for nursing education, explicitly identifying informatics, social media, and emergent technologies and their impact on decision making and quality as critical to professional practice. 46
Build nursing leadership in digital health
All levels of nursing leadership must advocate more actively for, and invest resources in, a profession that is both complemented and extended by digital technology. The profession needs to evolve its use of digital technology by continuing to champion and support nurses to become knowledgeable in, and generate new scientific knowledge on, data analytics, virtual models of care, and the co-design of digital solutions with patients, differences across contexts and regions permitting.
Advancement of leadership competencies in existing informatics technologies, such as clinical decision support systems, electronic health records, and mobile technologies, is also essential: these kinds of systems will undoubtedly come with increasing levels of AI functionality. Possessing a critical mass of nursing leaders who understand the intended and unintended consequences as well as opportunities of these kinds of technologies is vital to ensure the quality and safety of nursing.
The increasing presence and recognition of the importance of chief nursing informatics officers is a step in the right direction. 47 Further, providing opportunities for nurses of all specialties to contribute to the development and implementation of digital health policies, locally and nationally, could increase future use of digital technologies in nursing.
Investigate artificial intelligence in nursing practice
The influence of AI on human decision making and labor are areas in need of immediate inquiry to support nursing practice for the next decade and beyond. AI technologies could provide the profession with huge benefits in data analytics and advanced clinical decision support.
Although many of the purported potential benefits of AI (eg, improved patient outcomes, streamlined workflow, improved efficiency) have yet to be fully shown in nursing research, 6 it is inevitable that AI technologies will be used more regularly to support and extend nurses’ cognitive, decision making, and potentially labor functions. 15
These opportunities bring new and dynamic practice considerations for nursing and interprofessional expertise. One example relates to the potential automation of inequity and injustice within systems and decision support tools containing AI 48 49 : self-evolving algorithms in systems sometimes unintentionally reinforce systemic inequities found in society.
Increased use of AI also brings novel policy, regulatory, legal, and ethical implications to the fore. The nursing profession must examine its role, processes, and knowledge against emerging ethical frameworks that explore the opportunities and risks that AI and similar innovations bring, while advocating for patient involvement in AI development and application. Floridi and colleagues offer tenets regarding AI development and the ethical considerations in using such innovations in their call to develop AI technology that “secures people’s trust, serves the public interest, and strengthens shared social responsibility.” 50 They also advocate that as guiding principles, AI should be used to enhance human agency, increase societal capacities, cultivate societal cohesion, and enable human self-realization, with an emphasis on instilling and reinforcing human dignity. 50 Further research, funding, and thought leadership in this domain are needed to help support the development of new practice policy, regulatory frameworks, and ethical guidelines to guide nursing practice.
Re-envision nurse-patient relationships
The profession must reframe how nurses interact with and care for patients in a digital world. The sheer variety of “do-it-yourself” health and wellness applications (eg, personalized genetic testing services, virtual mental health support), mobile and social media applications (eg, mHealth, wearables, online communities of practice) and other virtual healthcare (eg, telemedicine, virtual consultations) options available to consumers is impressive.
All this may seem antithetical toward the traditionally espoused nursing role—therapeutic relationships in physical interactions—but patients are increasingly empowered, connected to the internet, and demanding personalized or self-management healthcare models that fit their busy and varied lifestyles.
To maximize its impact on patient care, the profession should continue to develop virtual care modalities that exploit internet and mobile technology, drawing on its experiences with telehealth and remote models of care. 51 These care models might also be extended through virtual or augmented reality technologies or integrated with assisted living or “smart home” systems, 52 and potentially other precision and personalized healthcare solutions that leverage genomic and other biometric data.
Care approaches, interpretations of privacy, and technological interoperability functionalities should be co-designed among the interprofessional healthcare team, patients, and carers 53 and available where patients want them, ideally in both physical and digital realms. Deeper discussions and scientific research regarding access, cost, electronic resource use or wastage, and equity implications of the increasing digitalization of nurse-patient relationships will also need to be thoroughly explored.
Embrace digital practice
The profession requires a cultural shift. Its membership and leadership must demand the evolution of digital systems better to meet contemporary and emerging needs.
Too often, technology to support nursing is poorly configured, resourced, or not upgraded to respond to practice and societal trends. Nurses still commonly use practice systems that are lacking basic usability (eg, contributing to alert fatigue, reinforcing disruptive workflow processes) or generate added documentation burdens because of poor configuration and optimization. 54
There is huge variation globally in access to, integration of, and sustainability of digital technology. 55 56 57 Solutions vary and are context specific. Renewed awareness of digital technology’s use brought about by the covid-19 pandemic offers an impetus for change that nurses should embrace.
Tasks undertaken by nurses that do not add enough value to patient care present opportunities for partial or full divestment, 58 and may be better integrated into future technology enabled processes or delivered by other care providers.
The profession should revisit cultural interpretations of how technology such as drones, robots, and other AI enabled systems can be considered complementary to nursing practice and process, rather than as competition or adversaries. Collaboration with technology developers, providers, and patients will be essential to ensure success.
Although some outdated nursing activities and processes made redundant or less relevant will likely be missed by some in the profession, digital technology provides opportunities to support new models of care and approaches to nursing practice. We must not allow cultural and historical interpretations of nursing to upend or impede progress.
How nursing can stay relevant
Nurses entering the profession today will undoubtedly witness substantive disruption and change from digital technology by the time they are mid-career. 59 Without immediate action, the nursing profession stands to miss a remarkable opportunity to generate new roles, knowledge, and relationships within future health systems and societies saturated by digital technologies.
Nursing will continue to offer value and importance to healthcare systems in the coming decades. However, the profession must consider its role, knowledge, and relationships with technologies and patients to remain relevant in digitally enabled societies and healthcare systems and continue to provide compassionate care in a digital world. Without proactive strategic self-reflection, planning, and action, nursing will fail to control its trajectory across the chasm separating the past, present, and future of practice.
- Nursing must accelerate the transformation to a digitally enabled profession by investing in informatics education, research, and practice
- Nurses should upskill in data science and other digital health topics to ensure emerging technologies such as AI are developed appropriately and safe for nursing practice and patient care
- Nursing must invest in and lead digital health developments and collaborate with others to develop and deliver digital tools that patients and the public need
- Nurses should champion informatics across all areas of professional practice, create leadership opportunities in digital health, and inform health policy in this area
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.
This article is part of a series commissioned by The BMJ for the World Innovation Summit for Health (WISH). The BMJ peer reviewed, edited, and made the decision to publish. The series, including open access fees, is funded by WISH.
Why Nursing Research Matters
- 1 Author Affiliation: Director, Magnet Recognition Program®, American Nurses Credentialing Center, Silver Spring, Maryland.
- PMID: 33882548
- DOI: 10.1097/NNA.0000000000001005
Increasingly, nursing research is considered essential to the achievement of high-quality patient care and outcomes. In this month's Magnet® Perspectives column, we examine the origins of nursing research, its role in creating the Magnet Recognition Program®, and why a culture of clinical inquiry matters for nurses. This column explores how Magnet hospitals have built upon the foundation of seminal research to advance contemporary standards that address some of the challenges faced by healthcare organizations around the world. We offer strategies for nursing leaders to develop robust research-oriented programs in their organizations.
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
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Kelley Kilpatrick makes the invisible visible
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Kelley Kilpatrick, RN, PhD, likes to say that her research makes the invisible visible. Recognized internationally as an expert in studying the roles and impact of advanced practice nurses on interprofessional team functioning and quality of care, Kilpatrick is Associate Professor at the Ingram School of Nursing (ISoN) and holder of the Susan E. French Chair in Nursing Research and Innovative Practice. As she explains, the roles of clinical nurse specialist and nurse practitioner are often misunderstood, not just on the part of the general public, but often by policy makers and healthcare teams. Published in peer-reviewed journals, her findings are changing these perceptions here at home and abroad. We sat down with Prof. Kilpatrick to learn more about the impact of her work and the challenges and rewards of a career in nursing research.
Tell us a bit about your nursing background.
I was attracted to nursing because of its hands-on approach to providing care. After earning my bachelor’s degree, I worked for several years in the intensive care unit, which really suited me. The environment of the ICU is one in which you are working as part of a team caring for an unstable patient while supporting families in challenging situations. When I went to graduate school, I wanted to study these dynamics further. After earning my PhD in Nursing at McGill in 2010, I did a post-doctoral fellowship at McMaster University (2011) at the Canadian Health Services Research Foundation/Canadian Institutes of Health Research Chair Program in Advanced Practice Nursing. I continued my research as a faculty member at the Université du Québec in Outaouais before being recruited to the Université de Montréal. I joined the ISoN in 2019.
What attracted you to the ISoN?
With the support of Mr. Richard Ingram and the Board of the Newton Foundation, the School had established the Susan E. French Chair in Nursing Research and Innovative Practice. The vision of the donor was to showcase the vital contributions of nurses to healthcare – a vision that I share wholeheartedly. This endowed Chair has afforded me and my team the exciting opportunity to develop and validate tools that measure the impact of well-designed and well-implemented advanced practice nursing roles and to publish these findings in high quality peer-reviewed journals. Now that the Chair has been renewed for another five years, in our second mandate, we want to continue building on our results. For example, there is a big gap in the current understanding of how decisions are made around the workload of nurse practitioners (NPs). We have identified factors that influence how much time it takes to evaluate a patient such as whether this is a first visit, the reason for the consult, whether there are mental health issues etc. We are seeking to understand the effects of this workload on patient care and to help determine the optimal number of patients NPs should see per day.
What are the most rewarding aspects of a career in nursing research?
It is so rewarding to interview patients and their families and to hear personal stories of how much they appreciate being cared for by advanced practice nurses (APNs) who took the time to answer their questions. We’ve seen how, in many cases, patients who feel understood and supported have improved care outcomes. APNs are uniquely positioned to provide this combination of specialized knowledge and support. Hearing directly from other members of the healthcare team about how APNs support the overall functioning of the team is equally rewarding. I also enjoy supervising graduate students’ research projects and teaching a graduate course in Leadership and Health Policy, where I encourage students to select the policy issues they want to explore.
What is the one finding in your research that surprised you the most?
I was surprised to discover just how much of an impact well-developed APN roles can have on the team and on healthcare outcomes. In our study on NPs in long-term care, published in the journals Journal of Advanced Nursing, BMC Nursing and Nursing Outlook , we found a 12% reduction in medications given to fragile patients, which resulted in a decrease in complications such as falls, use of restraints and transfers to the Emergency Department as well as significant cost savings to the healthcare system because of the consistent follow-up by NPs. Some patients were able to recognize their family members for the first time in a long time! We have conducted a similar study in the homecare setting and have found similar results where planned follow-ups by the NPs reduced transfers to the Emergency Department.
What are the most challenging aspects of a career in nursing research?
The uncertainty and competitiveness of securing funding is a major challenge. That is why I am deeply grateful to Mr. Ingram and the Newton Foundation for endowing the Susan E. French Chair.
What are you most proud of and why?
The role of nurse practitioner is still being defined here in Quebec and is only just beginning to emerge in other parts of the world. I’m proud that the work of my team is helping to inform policy on how best to integrate advanced practice nurses in the healthcare system. We recently completed two large research reviews synthesizing existing research on APN roles and found that almost all indicators point in favour of including advanced practice nurses such as NPs and clinical nurse specialists in healthcare teams.
“A mixed methods quality improvement study to implement nurse practitioner roles and improve care for residents in long-term care facilities.”
“Patient and family views of team functioning in primary healthcare teams with nurse practitioners: a survey of patient-reported experiences and outcomes.”
“Identifying indicators sensitive to primary healthcare nurse practitioner practice: A review of systematic reviews.”
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Ingram school of nursing.
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- Published: 20 February 2024
Educating the nurses of tomorrow: exploring first-year nursing students’ reflections on a one-week senior peer-mentor supervised inspiration practice in nursing homes
- Daniela Lillekroken ORCID: orcid.org/0000-0002-7463-8977 1 ,
- Heidi M. Kvalvaag 1 ,
- Katrin Lindeflaten 1 ,
- Tone Nygaard Flølo 1 ,
- Kristine Krogstad 1 &
- Elisabeth Hessevaagbakke 1
BMC Nursing volume 23 , Article number: 132 ( 2024 ) Cite this article
Worldwide, the healthcare system stresses a severe deficit of nurses because of elevated levels of work-induced stress, burnout and turnover rates, as well as the ageing of the nursing workforce. The diminishing number of nursing students opting for a career in nursing older people has exacerbated this shortage. A determining factor in the choice of a career within the field of residential care for nursing students is educational institutions offering students learning opportunities with positive learning experiences. Therefore, educational institutions must develop programmes that employ student active learning methods during clinical periods. Although much focus has been given to the development of new educational programs, insufficient consideration has been given to the value of peer mentoring and students’ interactions during the clinical placement at nursing homes. The aim of the present study is to explore first-year nursing students’ perceptions and experiences with peer mentoring as an educational model during their inspiration practice week at nursing home.
The study employed a qualitative exploratory and descriptive research design. Data collection took place in October 2022 using focus group interviews. A total of 53 students in their first year of the bachelor’s programme at the Oslo Metropolitan University participated in eight focus group interviews. The data were analysed following the principles of inductive content analysis.
The analysis resulted in one main category, ‘Being inspired—keep learning and moving forward’, representing first-year nursing students’ common perceptions of being mentored by third-year students. The main category is supported by two categories: ‘Closeness to the mentor’ and ‘Confidence in mentors’ professional knowledge and teaching and supervision methods’, which are interpreted as the drivers that enabled first-year students to learn more about nurses’ roles and responsibilities in the nursing home.
Mentorship enhances the learning transfer from third-year nursing students over to first-year nursing students by providing them with real-world exposure and guidance from their more experienced peers. This hands-on approach allows them to bridge the gap between theory and practice more effectively, boosting first-year nursing students’ confidence and competence in nursing and caring for older people living in nursing homes.
Peer Review reports
Nursing is one of the main professions that provides care to older people [ 1 ]. To meet society’s challenges of providing quality healthcare to older people, knowledgeable and skilled future generations of nurses are needed [ 2 ]. International research reveals that one of the key challenges for nursing in residential care is recruiting and retaining knowledgeable and skilled nurses [ 3 ]. Although nursing students have positive [ 4 ], or moderately positive attitudes towards nursing older people [ 5 ], they generally do not see caring for older people as an interesting area of their future careers [ 6 ]. Students may lack the motivation to study and work in this field; therefore, it is necessary to increase the attractiveness of working within the gerontological nursing field [ 7 ].
Generation Z nurses, born 1995 or later (aged ≤ 24 years of age), have introduced new expectations and ideals of life and work into the nursing profession [ 8 ]. People belonging to generation Z exhibit traits such as tolerance, respect, social-change oriented, collaboration and confidence but with caution while embracing diversity and growing up with friends from various ethnic backgrounds [ 9 , 10 ]. To meet their expectations and retain them into the nursing profession, it is vital to design educational programmes and work conditions accordingly. Moreover, to ensure that graduating nurses possess the necessary levels of gerontological nursing competence, nursing education programmes must prepare future nurses accordingly. This implies that faculties must emphasise the importance of having gerontological nursing knowledge and competences among nursing students right from the early years of training [ 11 ]. This may contribute to providing comprehensive education to nursing students and instil a positive attitude towards nursing older adult patients [ 7 ].
Nursing education in Norway, as well as in other European countries, complies with the European Union’s (EU) directives [ 12 , 13 ], and is completed in accordance with the Bologna Process [ 14 ], requiring bachelor’s and master’s degrees as the norm. This means that it takes 180 ECTS (European Credit Transfer System) to obtain a bachelor’s degree and a further 120 ECTS to complete a master’s degree. In Norway, nursing education consists of at least 4,600 h, including theoretical knowledge and clinical practice, in which clinical practice represents half of the education period; therefore, clinical practice must cover a minimum of 2,300 h [ 12 ]. As required by the EU [ 12 , 13 ], theoretical and clinical studies alternate during these three years, and students intertwine theoretical and clinical knowledge during lectures, seminars, workshops and clinical periods conducted in different clinical contexts. After attending a three-year nursing education programme, the student achieves a bachelor’s degree in nursing as a registered nurse (RN) with competence at a general level. For students to obtain a nursing degree, they must demonstrate the knowledge and ability required in the national goals to become RNs at the end of their education, consisting of three main goals: knowledge, skills and general competence [ 15 ].
Since 2020, Oslo Metropolitan University [OsloMet], as well as other Norwegian universities, has implemented a new bachelor’s programme in nursing. The programme aims to qualify candidates for practicing professional nursing based on up-to-date evidence-based knowledge, professional suitability and respect for human autonomy and participation [ 16 ].
To educate knowledgeable and skilled nurses to meet Norwegian society’s healthcare challenges, knowledge and skills of how to provide better and safer fundamental care are part of the curriculum of the first year during the bachelor’s programme in nursing [ 15 ], and clinical placements in nursing homes where students learn to plan and provide fundamental care to older people are mandatory courses [ 12 , 17 ]. During the course ‘Theoretical Foundations of Nursing’ (SYK1000) that is taken in the students’ first term, the first-year students have a one-week clinical period (inspiration practice) in nursing homes. This one-week inspiration practice period is in addition to their six-week clinical placement during the second term. The focus of the inspiration practice is to observe and gain knowledge about the nurse’s role and responsibilities in nursing homes, including planning and participating in providing fundamental care to nursing home residents. During this period, the third-year nursing students attend the clinical period ‘Nursing Patients with Complex Health Challenges’ (SYKPRA60) in nursing homes. One of the learning outcomes of this course is related to students developing skills and knowledge about learning, mastering and changing processes, as well as supervising and teaching patients, next-of-kin, students and healthcare personnel. To pass the clinical period, as a mandatory learning activity, the third-year students will supervise, plan and carry out supervision for one or a group of two to three first-year students in cooperation with the nurse preceptor and nurse educator from the university [ 16 ], hence employing peer mentoring as a learning and teaching method during the clinical period at nursing home for both student groups.
Mentoring is an encouraging and supportive one-to-one relationship with a more experienced worker or peer student and is characterised by positive role modelling, promoting aspirations, positive reinforcement, open-ended counselling and joint problem-solving [ 18 ]. Peer mentoring is a relational process where a more experienced individual (mentor) contributes to the professional and personal development of a less experienced individual (mentee) [ 19 ]. This approach aligns with the educational philosophy of peer-assisted learning, which engages students in the teaching process [ 20 ]. However, it is worth noting that the term ‘peer mentoring’ lacks a consistent definition [ 21 ]; therefore, various interchangeable terms, such as ‘peer learning’, ‘peer coaching’ and ‘near-peer teaching’, are utilised in the literature [ 22 ]. In the present study, ‘peer mentors’ or ‘mentors’ refers to senior nursing students possessing more extensive experience than their junior counterparts, the ‘mentees’, and ‘peer mentoring’ refers to the process of learning transfer from mentors to their mentees.
The inspiration practice period has been implemented to provide first-year students with insights into the nurse’s role and responsibilities in nursing homes, hence, to prepare them for their first clinical placement period at nursing home and all subsequent clinical periods throughout their education. This preparation aims to prevent the occurrence of what is termed ‘reality shock’ [ 23 ], a phenomenon that may lead to negative consequences for their continuing nursing education and influence their choice of whether to pursue a career in nursing [ 24 ].
Despite the growing number of studies revealing the importance of the professional development of nursing students in clinical studies, little is known about the peer mentoring process used by students in learning from each other in higher education [ 25 ]. Results from previous studies reveal that peer mentoring increases mentees’ integration, academic success, class retention, self-esteem, psychosocial wellness, reduces anxiety in clinical setting, increases self-worth for both the mentee and the mentor [ 26 , 27 , 28 , 29 , 30 ]. Furthermore, positive outcomes for mentors have been observed, ranging from enhanced problem-solving abilities to heightened coping skills [ 31 , 32 ]. Recently, results from a longitudinal study indicate that a one-on-one mentorship program is beneficial for the retention of new graduate nurses, particularly during the first year [ 33 , 34 ].
Learning environment quality in clinical placement is vital for how nursing students achieve competence through reflection on their experiences [ 35 ]. Similarly, positive learning experiences in residential care are vital for their future choices regarding where to work and therefore crucial for employers striving to recruit newly qualified nurses. Facilitating optimal clinical mentoring is therefore of high priority in nursing education [ 36 ].
As shown above, although peer mentoring has been reviewed in many studies, several gaps on the effects the mentor program has in the context of nursing home as teaching and learning context remain. Specifically, no programs focus mentoring on a targeted discipline or degree of interest to cultivate specific gerontological professional development. Because of this, there is a lack of literature focusing on the first-year experience of a nursing student. Likewise, there is limited available research exploring the benefits of mentoring specifically for first-year nursing students during the clinical placement at nursing homes as a learning context. Therefore, the aim of the present study is to explore first-year nursing students’ perceptions and experiences with peer mentoring as an educational model during their inspiration practice week at nursing home.
To the best of the researchers’ knowledge, the application of peer mentoring as a learning and teaching strategy for first-year students within the context of nursing home learning is a novel approach. Therefore, the application of innovative and active learning strategies in clinical settings necessitates educational research. For the present study, the theory of learning transfer described by Wahlgren and Aarkrog [ 37 ] was chosen as the theoretical framework. The theory of transfer of learning is defined as the application or adaptation of previously learned knowledge, skills or understanding to new situations or contexts. Moreover, it involves the ability to make connections and use what a student has learned in one context to solve problems or understand concepts in different contexts. However, little is known about the processes used by students to transfer learning from each other and to apply or adapt knowledge to practice.
The theory of transfer of learning is influenced by three factors that may be seen as facilitators or barriers that promote or hinder students’ learning in clinical settings: (i) person-related transfer factors, which include motivation, the ability to set goals, having confidence and knowing how to apply the new knowledge and reflecting on how to apply the new knowledge [ 38 ]; (ii) teaching-related transfer factors, which refer to how the ‘teacher’ organises the learning situation, by, for example, giving theoretical and examples and demonstrating how to apply theoretical knowledge into real-life situations [ 38 ]; and (iii) factors related to the situation where the knowledge is applied [ 37 ], such as the context of where the knowledge is applied, that is, willingness to include the workers’ new knowledge and skills in the workplace, leadership characterised by openness to positive changes and willingness of using the necessary resources. During the analysis, the content of the processes described by students when learning from each other revealed similarities with the theory of transfer of learning [ 37 ]; therefore, the researchers decided to choose this theory as a framework for discussing the study’s findings.
Aim of the study
This study aims to explore first-year nursing students’ perceptions and experiences with peer mentoring as an educational model during their inspiration practice week at nursing homes.
The present study has a qualitative exploratory descriptive design [ 39 ]. The design was appropriate because it allowed the researchers to contextualise how the first-year students perceived peer mentoring and nursing home as learning environment and their role as mentees within the context of nursing home, thus providing a picture of what naturally occurred between the mentors and mentees.
The study was conducted at Oslo Metropolitan University during the one-week inspiration practice at nursing homes for first-year nursing students.
Study population and sampling
All the students enrolled in the first year of the bachelor’s programme in nursing at the Department of Nursing and Health Promotion in the academic year 2022–2023 were informed about the study and invited to participate. All six researchers were engaged in providing information about the study and in the process of recruiting potential participants.
The students were provided with verbal and written information about the study during a face-to-face first meeting before and after inspiration practice week. For inclusion, the students should: (i) be enrolled in the academic year 2022–2023, (ii) voluntary to attend the study, (iii) agreed to be recorded during the interviews. If the students were interested and expressed their wish to participate, they were asked to contact the researchers by email and agree upon the date for the interview. When distributing the participants in focus groups, to make the participants feel confident and comfortable during the interviews, the researchers considered the students’ class affiliation and formed groups with students belonging to the same class, thus fostering a sense of familiarity and ease among the participants.
Of a total of 488 students enrolled in the academic year 2022–2023, only 53 expressed their interest and agreed to participate. The ages of the participants ranged between 19 and 54 years. Although most had no work experience in the field of healthcare/nursing, some had up to 13 years of clinical experience working in nursing homes or home care. The researchers strived to provide a gender balance among the participants; therefore, an equal proportion of female and male participants was encouraged to participate. Even so, only seven participants were males. As the research literature has demonstrated, nursing is a female-dominated profession with individuals still choosing gender role stereotypes for their careers [ 40 , 41 ] This may explain the large number of females among the participants.
Data were collected during the fall semester of 2022, one week after the students conducted their inspiration practice week. Eight focus group interviews were conducted to collect data during October– November 2022. Focus groups involve people with similar characteristics coming together in a relaxed and permissive environment to share their thoughts, experiences and insights [ 42 ]. The choice of using focus group interviews as data collection methods was because allows participants share their own views and experiences, but also listen to and reflect on the experiences of other group members [ 42 ]. This synergistic process of group members interacting with each other promotes and refines participants’ viewpoints to a deeper and more considered level and produces data and insights that would not be accessible without the interaction found in a group [ 42 , 43 ]. Prior to conducting the interviews, a semistructured interview guide inspired by peer mentoring in nursing literature was developed and used to guide the interviews. The interview guide used in the present study was developed based on recommendations from previous studies for further research to achieve a comprehensive understanding of how peer mentoring can be effectively employed in the context of nursing home [ 22 , 23 , 26 ]. The themes and questions that were posed during the interviews are presented in Table 1 .
The number of participants in each focus group ranged between 3 and 12. Depending on the number of participants in each focus group and on their verbal dynamism during the interviews, each focus group interview lasted between 30 and 55 min. The focus group interviews were held in a quiet classroom after a seminar class. As recommended by Krueger and Casey [ 42 ], the researchers planned to conduct each focus group interview in pairs. However, because of the busy work schedules among researchers, only two focus group interviews were conducted by two researchers, one acting as a moderator and the other as a ‘secretary’. While the moderator’s role was to pose questions and follow up the answers, the secretary’s role was to take notes, observe the group dynamic and use the recording device. During the interviews, the participants were encouraged to talk openly, share their thoughts and experiences with one week of inspiration practice in a nursing home and offer suggestions for improvement for the course. Hence, the participants offered deep and rich answers that contributed to the detailed expression of opinions.
All eight focus group interviews were digitally recorded and transcribed verbatim by the researchers immediately after completion. Except for one researcher (KK) who transcribed four focus group interviews, all authors transcribed each one to two focus group interviews. However, depending on the length of the interviews and the richness of the dialogs, the transcription process lasted between 6 and 8 weeks. The data generated from eight focus group interviews consisted of 106 A4 pages taped with 1.5 line spacing and Times New Roman font size. The analysis process has additionally taken eight weeks.
When conducting a focus group interview, it is the group rather than the individual that is the focus of analysis because data generated from focus groups represents situated accounts that can provide in-depth insights into contextualised social interactions [ 43 ]. The transcripts from the interviews were analysed following the three steps of inductive content analysis outlined by Kyngäs [ 44 ]: preparation, organising and reporting the findings.
As part of the first step, data analysis began during data collection through careful group moderation. By following transcription, reflexive engagement with the data enabled researchers’ familiarity with it as a whole before the coding process. The empirical data generated from eight focus groups were analysed independently by two researchers (DL & HK) to identify the key categories coded onto transcripts. At this step, the coding process helped reduce the amount of data. These codes were subsequently subjected to a more detailed subcoding of meaningful content, such as one word or a shorter sentence. At this step, no theoretical understanding influenced the selection of the units of analysis. Unit selection was based on the themes from the interview guide and derived from the data. Both authors then met and discussed the similarities and differences between the coded data from each interview, sharing their overall understanding of the data. If discrepancies occurred, they were solved by discussing before making a final decision.
In the second step, the researchers discussed, analysed and decided which codes should be grouped together into subcategories and determining the hallmarks of the categories. Following a discussion about the open coding process, a coding tree was developed to facilitate comparisons within and between groups. To validate and maximise the trustworthiness of the initial findings, a descriptive overview of the final analysis was presented to the other researchers, that is, the coauthors of the present paper, to confirm that it was a realistic interpretation of their views. For example, the code ‘following the mentors everywhere’ has gradually been incorporated into the subcategory ‘Spending time with mentors.’ In this step, influenced by the learning transfer theory [ 37 ] this subcategory was further placed under a category labeled ‘Closeness to the Mentor.’ It was interpreted as a person-related factor that facilitates learning transfer, thereby inspiring first-year students to continue learning and moving forward.
The third step was to present the findings by describing the content of the subcategories and categories as supported by participant quotes. An example of the coding tree is shown in Table 2 .
Rigour of the study
Rigour was ensured by employing several strategies. First, to ensure trustworthiness and rigour, the criteria described by Lincoln and Guba [ 45 ], known as credibility, dependability, confirmability and transferability, were employed.
To ensure transferability and dependability, the researchers clearly described the study’s theoretical framework, the recruitment and the characteristics of the participants, the research context, data collection and analysis processes so that readers could assess whether findings were applicable to their specific contexts and, if desired, repeating the study.
The data analysis was iterative and continued until all members of the research team agreed on a relevant and trustworthy formulation of the categories. To enhance trustworthiness, the consistency and dependability of data analysis was optimised by researcher triangulation. Two members of the research team (DL & HK), who independently coded interview transcripts and managed the coding and developed categories and subcategories that were assessed, verified and amended by all the members of the research team. Discrepancies in the coding were resolved through discussions until a consensus for each interview transcript was reached.
Confirmability is ensured by researchers presenting quotes from the participants that support the findings. The researchers strived to accurately represent the information provided by the participants, hence indicating that the interpretations of the data were not invented or based on preconceived notions.
In qualitative research, reflexivity should be oriented towards personal, interpersonal, methodological and contextual issues in the research [ 46 ]. Personal reflexivity refers to researchers reflecting on and clarifying their expectations, assumptions, and conscious and unconscious reactions to contexts, participants, and data [ 46 ]. The research team was composed of six women, all of whom had teaching experience with and knowledge of the first-year curriculum. Five of the research team members had experience with designing and conducting qualitative studies and collecting and analysing qualitative data. Although the analysis was performed by two researchers, all the researchers brought important contextual knowledge and insights to the analysis discussion, thus strengthening the study’s dependability. However, the researchers’ professional backgrounds as nurse educators who had knowledge of the curriculum and the course’s expected learning outcomes could address certain topics or follow-up questions during the focus group interviews, thus influencing the answers. Therefore, to minimize bias, the researchers discussed their prior experiences with interviewing, reflected on how questions were asked, and simultaneously managed their assumptions around how participants thought about and experienced being in the one-week inspiration practice.
Interpersonal reflexivity refers to the existing relationships and power dynamics between researcher and participants [ 46 ]. The participants in this study were first-year students, and some of the researchers who conducted the interviews were their teachers. Consequently, during the interviews, the power balance between researchers and participants could result in participants feeling that they were being evaluated, potentially leading to a focus on more positive experiences. To avoid this, researchers reinforced to participants that their participation is voluntary and that their answers will not influence their study progression. Moreover, during the interviews, researchers encouraged quieter participants to answer and allowed for differences of opinion.
Methodological reflexivity refers to researchers critically consider the nuances and impacts of their methodological decisions [ 46 ]. To strengthen methodological reflexivity, researchers discussed whether the study’s aim aligns with the chosen design and whether the data collection method and interview guide will generate data to answer questions posed during the focus group interviews. Another method to enhance methodological reflexivity was discussing the theoretical framework’s relevance to the study. After considerable discussions, the researchers decided to choose the theory of learning transfer [ 37 ] as it was considered the best theory to inform the data.
Contextual reflexivity entails researchers understanding the unique setting of the study [ 46 ]. To strengthen the study’s contextual reflexivity, researchers discussed which aspects of the context could influence the research and people involved, as well as how the research impacts the context. The study was conducted at a Norwegian university, and participants were enrolled in the first year of the nursing bachelor’s program. Although the interview guide was inspired by previous literature on peer-mentoring, the questions posed were developed to gain knowledge about students’ experiences with a one-week inspiration practice at a nursing home. This means that the research was influenced by the curriculum and mandatory courses conducted at this university. During discussions, some researchers mentioned that most focus group participants reflected on their clinical development and were looking forward to their turn being a mentor for first-year students. It was evident that this study also had a positive impact on participants.
The present study was granted approval to be conducted from the researchers’ institution, Department of Nursing and Health Promotion at Oslo Metropolitan University and from the Norwegian Agency for Shared Services in Education and Research (Sikt/Ref. number 334855). The study was conducted in accordance with the Helsinki Declaration [ 47 ]. Informed consent, consequences and confidentiality were all obtained and maintained. All participants received verbal and written information about the study and written informed consent was obtained from all the participants prior to data collection. The participants were also informed that they would not receive any financial or other benefits for participating in the study. All participants were assured that, should they choose to withdraw from the study at any time and for any reason, there would be no negative consequences for their education at the university. Nevertheless, the researchers were mindful of the students’ potential vulnerability due to their role as students, which might discourage them from withdrawing. However, despite no reported discomfort during interviews, the potential for discomfort or reluctance to express negative experiences exists. Therefore, before each focus group interview, the students were reminded of their option to withdraw from the interview, providing them with additional opportunities to assent to or withdraw from the study. None of the students who agreed to be interviewed reported any discomfort during the interviews, and none chose to withdraw.
Following data analysis, one main category was generated, ‘Being inspired—keep learning and moving forward’, which was interpreted as the first-year nursing students’ common perception of being supervised by third-year students for one week of inspiration practice at nursing homes. During the interviews, the first-year students mentioned several times that they perceived third-year students as their mentors. To differentiate between first-year students and those in their third year, the third-year students will be referred to as ‘mentors’ throughout the manuscript.
Two categories—(i) ‘Closeness to the mentor’ and (ii) ‘Confidence in mentors’ professional knowledge and teaching and supervision methods’—were interpreted as the drivers enabling first-year students to learn more about nurses’ roles and responsibilities in nursing homes. Each category is supported by several subcategories.
In the following section, the findings are presented with excerpts from the participants’ statements. The statements end with a number representing the code each participant (i.e., P1) and focus group (i.e., FG2) were given before conducting the focus group interviews, meaning participant 1 in focus group 2.
Closeness to the mentor
This category was supported by four subcategories: spending time with mentors, perceiving mentors as role models, feelings of insecurity and mutual learning– learning from each other.
Spending time with mentors
The first subcategory was related to the time first-year students spent with their mentors. Because the mentors could allocate more time to spending with the first-year students, this time allowed mentors to share formal and informal knowledge and create learning opportunities for first-year students. Being close to the mentor and spending time together was decisive for several first-year students to experience a positive relationship with their mentor. This positive mentor-first-year student relationship was highlighted as one of the participants’ positive experiences in the inspiration practice. They experienced that their mentors were aware of their own roles and responsibilities and encouraged first-year students to follow them everywhere to gain insights into how it is to be a nurse employed at a nursing home. One of the participants said the following:
We were following the mentors everywhere… They explained us everything… However, we were only six students at that nursing home, so we get one mentor each… and I followed my mentor all the time, and she explained me a lot about how to help the resident with personal hygiene or how to use a Hoyer lift to help the resident to move from bed to wheelchair. I feel that I learned a lot.… (P4, FG1).
Other first-year students were grateful that, by being with mentors, they had the opportunity to be introduced to more complicated procedures, such as changing a stoma bag or measurements of vital signs or even weighing the residents. One participant shared her experience:
Yes, we have experienced a lot! We contributed to making breakfast and served it, we helped residents with personal hygiene… we weighed the residents and documented in their journal, and we learned how to document everything we did to or with a resident, in generally… However, I learned a new word: stoma and… [stoma bag]. I observed how my mentor changed the stoma bag to a resident. You know, I get the opportunity to meet the residents face-to-face and the life at that ward. (P1, FG3)
The first-year students stated that, with this type of supervision, they would be much more likely to reach their learning outcomes for the inspiration practice. One of the participants stated the following:
I feel that, for me, everything was good. They [mentors] showed us that they have knowledge… they were very open and receptive if we had some questions: ‘Just ask me!’ and they were honest if they could not provide the answer. It wasn’t like at school: ‘Use the contact form’ [laughter]… we got the answer at once, so this was OK. They were also very creative. They made cases about things we already had knowledge about, and I learned to use several measurement instruments, such as QSOFA [Quick Sepsis Related Organ Failure Assessment] and this kind of thing.… (P1, FG8).
Perceiving mentors as role models
The second subcategory was related to first-year students perceiving the mentors as role models. Being close to the mentor, the first-year students could engage in informal discussions, hence finding that mentors were people who had been in their shoes, who had journeyed close to where they wanted to be and who had made their own mistakes in their learning but also gained practical knowledge. They perceived mentors as someone who was close enough to them, willing to share their wisdom and experience, and could help them avoid certain pitfalls. These perceptions contributed to developing a positive relationship with the mentors, which positively influenced their learning. One of the participants said the following:
I am happy that my first encounter with practice was through third-year students. It is not a long time since they were in our situation, so they know how it feels. They explain in an easier way… and you get a kind of insider information… yes, they provide us with information that nurses don’t say because they believe that we already know things… I think that because they were in this situation, they explain or teach us things in the same way they wish they have been told… They have established good routines for learning to achieve learning outcomes.… (P3, FG5).
Feelings of insecurity
The third subcategory was related to feelings of insecurity among first-year students. Several first-year students asserted that they were not confident when they had to help the residents with their fundamental needs, such as toileting, changing diapers, personal hygiene or eating and drinking. One of the participants shared her experience:
I have never assisted someone with personal hygiene before… It was quite an experience…I felt hesitant, but I had to manage somehow… (P4, FG2).
Being close to the mentor offered opportunities to seek support. They appreciated that mentors accepted their insecurity, lack of experience and theoretical knowledge limitations. One of the participants said the following:
Going together with my mentor, I felt safe to fail… [laughter]. I am happy that I gained the opportunity to try and experience the challenges that came with… They asked questions and they sensed that we were not sure about the answer, but we gradually became confident when they ‘pushed’ us to try it on our own.… (P3, FG6).
Mutual learning– learning from each other
The last subcategory was related to the learning process as a mutual process. Some of the first-year students had clinical experience in healthcare services as healthcare assistants. This placed expectations on the inspiration practice period, and although these students knew the field very well, they were impressed by the amount of practical knowledge they gained during this week. However, being close to the mentor offered opportunities to learn from each other. When the mentors could not answer their questions, they experienced that they searched for knowledge and together agreed about the correct answer for the given situation. The participants experienced that learning was a mutual process, and it did not happen only from mentors to them but also vice versa, as one of the participants said:
Yes, we had a positive dialogue about knowledge… sometimes it was funny to see… I think that it was a positive experience for both of us [to share knowledge], that when we asked questions, they had to search for the answer… and figure it out together… This would not happen with a nurse that has 20 years’ experience that knows the answer: ‘that is it!’… (P1, FG4).
Confidence in mentors’ professional knowledge and teaching and supervision methods
This category was supported by two subcategories: mentors’ theoretical and practical knowledge and skills, and mentors’ ability to apply diversity in didactical and pedagogical methods.
Mentors’ theoretical and practical knowledge
The first subcategory relates to the first-year students’ perceptions of mentors’ professional competence, which can be defined in theoretical knowledge, skills and general competence. The first-year students were positively surprised about their mentors’ amount of theoretical and practical knowledge. This contributed to motivating first-year students to be curious and wanting to learn more. Several first-year students asserted that their expectations for the inspiration practice week were fulfilled because of the supervision they gained from mentors, hence assessing mentors as ‘competent’, meaning ‘knowledgeable and skilled’. One of the participants said the following:
I was quite content with my mentor… She [the mentor] had so much knowledge… it seemed that she worked there [at nursing home] for 10 years… I was motivated by that because I noticed how much they [mentors] have learned during these three years.… (P3, FG6).
Other first-year students reported that they got answers no matter what they asked. They were surprised by the mentors’ theoretical knowledge and how they could provide them with examples of the application of theory in real patient situations. This contributed to an increase in first-year students’ self-confidence. One of the participants described his experience as follows:
Our mentors were very knowledgeable and skilled… They provide us with answers… I was surprised how much knowledge a third-year student could gain through education… As third-year students, they were so well prepared to work and to meet patients in the clinical field.… (P10, FG5).
Other participants were impressed by mentors using professional language during formal and informal conversations and by the clinical gaze they developed. One participant stated the following:
… and they communicate with us by using professional terms… such as… I don’t remember all of them now, but they [mentors] mentioned frontal lobe, and other [laughter]… and yes, ‘she’s got Alzheimer’s [referring to a nursing home resident]… it’s only a name for me… but, you know, Alzheimer’s means that the woman has dementia… (P5, FG7).
The mentors’ practical skills were also praiseworthy among first-year students. They observed and learned from mentors how to use different medical instruments and measure vital signs/National Early Warning Score (NEWS) or the level of haemoglobin or insulin on real patients and then documenting the results. One participant said the following:
I could see that they [the mentors] were knowledgeable and skilled… when they presented and demonstrated for us, they knew what they were doing and talking about… They taught us and demonstrated different measures, and when we asked them, they answered us… yes, they were professional.… (P2, FG7).
A skill that first-year students could easily perceive as a challenge was communication with residents who had a cognitive impairment. However, several first-year students were impressed by the mentors’ communication skills. Many were surprised by the ethical challenges imposed by communication with people with dementia. Others noticed how respectful mentors were when asking the residents for permission to bring into the resident’s room another person who would assist the resident with personal hygiene or toileting. One of the participants expressed this as follows:
He [the mentor] I had was very good at communicating with the residents… he always asked them if we could enter the room to observe or help with the provision of personal hygiene.… (P2, FG8).
Mentors’ ability to apply diversity in didactical and pedagogical methods
The second subcategory was related to first-year students’ perceptions of the mentors’ ability to teach and supervise them and the diversity in didactical and pedagogical methods employed. The participants were content with the mentors’ explanations and demonstrations of all the work tasks a nurse has during a working day at a nursing home. Because the first-year students were not aware of what they should ask about, they particularly liked when their mentors provided them with knowledge without being asked for it or just demonstrated how the medical instruments or personal lift-assist device functioned. For most of them, this was perceived as the most appreciated first-hand knowledge, which mentors ‘just shared’ with them. They were also encouraged to ask questions and eventually provided additional answers if they could. One of the participants explained this as follows:
When we asked the mentors ‘Why are doing in this way and not in another…’, they always had good answers grounded in theory or in their prior clinical experiences… They acted very confident, so we also felt confident in what we were doing.… (P5, FG1).
Most of the participants were content with mentors’ methods of teaching or supervising them and giving feedback. They appreciated when mentors supported and encouraged them to learn things and become independent, but also to try new things and teach them how to do it. They appreciated being told what and how to help the resident prior to entering the resident’s room, not just being told what they had to do while the resident observed and listened, thus making them uncomfortable (i.e., during the provision of personal hygiene for a resident). One participant shared his less positive experience with providing personal hygiene to a female resident:
I had to ask my mentor how I should wash her body, and when I came to her breasts, I became very uncomfortable, but the mentor said to me, ‘Just lift her breasts and wash under and dry gently… it is OK’, and then I did it, but it was a strange experience.… (P3, FG7).
Another participant gladly shared her positive experience of being taught different procedures and routines regarding hygiene routines:
We had an interesting overview of hygiene routines at the ward, and then, we went through infection control equipment, and we had to take on and off, to learn these routines… We also learned how many times, how and when we had to use disinfecting alcohol on our hands and the order of taking on and off all that infection control equipment… a kind of ‘learning by doing’… (P1, FG2).
Another learning method that was much appreciated by first-year students was mentors asking questions during a procedure that engaged first-year students to reflect on knowledge before answering. One participant said the following:
When we got out of the resident’s room, they [mentors] asked us if we would do anything different.… (P3, FG7).
Because of the limited number of nursing homes that could have both first- and third-year students at the same time in the clinical field, a few of the first-year students had to complete their inspiration practice week by being two or three days at school or/and the department’s simulation learning environment and only one or two days in the nursing home. Although these students expressed that they learned a lot from their mentors, their expectations for inspiration practice week were not as positive as they expected to be. Some asserted that they got limited or almost no insights into the nurse’s role and responsibilities in the nursing home. One of the participants revealed her experiences in the department’s simulation learning environment:
Together with a few other students from my group, we were at the school’s simulation environment… They [mentors] had a good plan for us. The first day began with measuring vital signs on each other. and we could do it many times. They created several patient cases where we could measure and document NEWS for each case… Then, we learned to change the sheets on the bed while a ‘patient’ was lying there… I felt that I learned a lot, and I am content with how mentors taught us different procedures; however, I wish I could have been at a nursing home because, personally, I have no clinical experience; it would have been useful to get insights into the nurse’s role and responsibilities at nursing home before we start the clinical period at nursing home.… (P3, FG6).
During the focus group interviews, those first-year students who completed the inspiration practice week at the school’s simulation learning environment revealed some learning and teaching methods employed by their mentors, asserted as being very creative. The mentors could not offer learning activities regarding some procedures that could be done in real life (i.e., changing wound dressing on a resident’s leg ulcer); therefore, they had to think outside the box and create situations that could contribute to learning. One of the participants explained this as follows:
They [mentors] drew a ‘wound’ on their own leg and, by following the procedure, they changed the wound dressing on each other to demonstrate us how to change a leg ulcer dressing. I have to say that I learned a lot, although the wound was ‘fake’… [laughter]. (P2, FG7)
The aim of the present study was to explore first-year nursing students’ perceptions and experiences with peer mentoring as an educational model during their inspiration practice week at nursing homes. The analysis of the empirical data revealed that first-year students were inspired by their mentors, an inspiration that contributed to their learning progression.
As the findings have revealed, as a learning process, peer mentoring facilitates the transfer of learning by mentors designing instructional activities, thus encouraging first-year students to make connections between the theoretical knowledge they gained at school and the simulation learning environment and practical knowledge within new and real patient situations.
The findings from the current study have revealed first-year students’ descriptions of how mentors provided them with explicit instructions on how to apply knowledge or skills, thus engaging them in problem-solving activities that required learning transfer. Through these instructions, the mentors transferred learning over to first-year students, hence enabling their reflective thinking within the context of a nursing home. Moreover, acting as role models, being available and allocating time to be together with first-year students, the mentors were perceived as knowledgeable and skilled, features that contributed to enhancing first-year students’ motivation to search for new and more knowledge and, thus, to achieve learning outcomes. These features can be understood as person-related factors, which Wahlgren and Aarkrog [ 37 ] described as one of the factors facilitating learning transfer. Moreover, a person-related transfer factor was positively related to those participants who had previous clinical experience. As the findings have revealed, if the mentors could not answer the questions, the experienced participants, based on their previous clinical experience, suggested solutions; thus, learning was transferred the other way around, from the first-year students to mentors, with learning perceived as a mutual process [ 48 ].
In the present study, the first-year students showed receptiveness to acquiring knowledge and were concerned with making the most of the inspiration practice week. Their interest in learning was strengthened by mentors’ knowledge and abilities in providing instructions. This finding is similar to and supports the findings from previous studies demonstrating that peer mentoring contributes to students’ engagement and increases their cognitive skills, self-confidence, autonomy, clinical skills and reasoning [ 22 , 49 , 50 ].
The mentors’ specific knowledge about nurses’ roles and responsibilities in nursing homes, different procedures and communication challenges with people with cognitive impairment enhanced trust and the credibility of mentors’ preparedness for inspiration practice week. This led to first-year students’ trust in mentors’ ability to transfer learning. The participants’ curiosity and desire to gain insights into real-life patient situations have enabled their willingness to engage in learning activities. In the current study, the mentors adopted an active role when teaching and supervising first-year students. As the participants described, the mentors gladly shared their knowledge, demonstrated how to perform procedures and had informal and formal discussions about how first-year students could implement theory into practice. Similar to previous studies, which have demonstrated that learning with an equal peer facilitates making friends and developing relationships [ 25 ], hence reducing nursing student anxiety in the clinical setting [ 29 ] and promoting learning, the findings from the current study have revealed that the participants leaned on their mentors and felt safe and could trust their mentors. Although a few felt uncomfortable being exposed to new challenges (i.e., providing personal hygiene or helping residents with toileting), most of the participants stated that the mentors’ feedback given both during and postprocedure performance contributed to increasing their self-confidence when performing measures of vital signs or other procedures. These features resonate with Wahlgren and Aarkrogs’ [ 37 ] teacher-related transfer factor which emphasises the mentor’s ability to organise learning situations by including demonstrations, providing examples from theory and practice and reflecting on possible applications in real-life patient situations.
As suggested above, although person- and teacher-related transfer factors facilitated transfer learning, the situation-related factor raised some challenges. Despite the results from one study [ 51 ] demonstrating that nursing homes as a clinical placement will not add something new to students’ skills and competencies required for their future practice, other studies [ 35 , 52 ] have demonstrated that, in general, learning in a clinical context can affect nursing students’ learning outcomes and satisfaction, as well as influence their choice of future career. Although simulation may prepare students for clinical learning environments, there is no comparison to the learning that comes from nursing patients in a real clinical context and from a simulation learning environment at school [ 53 ].
The findings from the current study revealed that not all the students were content with the learning context during their inspiration practice week. Some first-year students, together with their mentors, used the department’s simulation learning environment and even classrooms as a learning context for two or three days or even for the entire week. In this situation, it is reasonable to think that situation-related transfer factors [ 37 ] posed some challenges, and they were not related only to mentors’ pedagogical methods, but also to the programme’s readiness to inspiration practice week and the leadership of the related factors of the nursing home (i.e., not being able to provide enough placements). If the first-year students and their mentors had the necessary theoretical knowledge but could not apply it in a real-life patient situation, the person-related transfer factors could also be challenged. Although none of the participants expressed that using the department’s simulation learning environment as a learning environment was worthless, some hinted at their disappointment. The lack of situational transfer factors seemed to negatively affect the participants’ motivation to gain knowledge. However, as the participants asserted, their mentors’ creativity contributed to creating potential patient situations similar to those in real life. They also encouraged first-year students to simulate different patient conditions and perform different procedures, thus creating opportunities for first-year students to apply theoretical knowledge and improve their skills. This supports the idea that, despite a lack of situational transfer factors, the transfer of learning was supported by mentors’ teacher-related transfer factors rather than situational transfer factors.
Finally, being a first-year student supervised by knowledgeable and skilled third-year students can contribute to first-year students mirroring themselves and their knowledge with their peers. Thus, first-year students can become more aware of themselves as professionals and develop an understanding of the nurse’s role and responsibilities in the nursing home. Consistent with results from previous studies, the results of the present study suggest that peer mentoring facilitates the development of self-understanding in students [ 25 , 26 , 32 , 36 ], which is essential for first-year students to gain a positive attitude towards nursing older people. The findings from the present study have suggested the use of peer mentoring in nursing education with structured training and supervision. Moreover, as the findings have indicated, peer mentoring facilitates learning transfer from mentors to mentees and provides valuable leadership experience for third-year students as mentors. In addition, mentoring may enhance a first-year student’s opportunity to be mentored and provide mentoring in the future.
Implications for nursing education and clinical practice
Peer mentoring, as a teaching and learning method, can be applied to enhance nursing curricula and clinical practice in several ways. Firstly, incorporating successful peer mentoring strategies into the curriculum can foster a collaborative and supportive learning environment among nursing students. The perceived closeness between mentors and first-year students suggests that fostering strong mentor– first year student relationships can serve as a driver for effective learning in the context of nursing homes. This closeness may create an environment that facilitates open communication, trust, and a sense of support, which are essential elements in the field of nursing. Additionally, the confidence instilled in first year students regarding their mentors’ professional knowledge and teaching and supervision methods can directly impact the students’ understanding of nurses’ roles and responsibilities in nursing homes. In clinical practice, the findings from the study can be used to promote mentorship programs that facilitate knowledge transfer and skill development among nurses and among senior and novice students during their clinical periods. Lastly, the study highlights first-year students’ overall positive experiences with peer mentoring program. This positive experience can help change students’ attitudes towards nursing older people, making it an interesting aspect of their future careers.
Strengths and limitations
The present study has several limitations that must be considered when interpreting the findings. First, although many students were invited to participate, the study was limited by a relatively small sample size restricted to students from Oslo Metropolitan University, hence limiting the findings’ national and international transferability. However, one strength may be that the findings and issues raised are relevant for both national and international nursing education programmes that apply the peer mentoring teaching and learning model in clinical placements. Another limitation may be the sample size and data saturation. As a concept, data saturation in qualitative research has been subject to several discussions arising from a variety of conceptual understandings [ 54 ]. Although the sample size posed some limitations, the richness in the participants’ descriptions was a strength, thus contributing to enhancing the information power [ 55 ]. Another limitation may be related to the researchers not being able to conduct member checks to improve the credibility of the data. For practical reasons, it was impossible to gather the same sample of students to validate their statements. However, during the focus group interviews, the participants were asked to provide detailed answers and were given the necessary time to reflect and express their experiences, thus confirming and or disagreeing with each other’s perceptions. Furthermore, potential research biases should be acknowledged given that the data collection and analysis were conducted by all researchers who were nurse educators employed at the same university as the students, hence entailing a prior understanding of the research context. However, the researchers were not involved in the students’ inspiration practice period, which may have limited the research bias regarding data collection. Another limitation may be its specific theoretical framework [ 37 ]. We are aware that other researchers, by using another theoretical framework, would probably discuss the findings accordingly and, hence, interpret the findings differently.
To the best of the researchers’ knowledge, this is the first study exploring first-year nursing students’ experiences with one week of inspiration practice at a nursing home by employing peer mentoring as a teaching and learning method. The findings revealed that first-year students were inspired by their senior peers to keep learning and moving forward. By being close to their mentors and having confidence in their professional knowledge and teaching and supervision methods’, learning was easily transferred from the third-year students to first-year students. Moreover, person-related, teaching-related and situation-related factors were perceived as drivers that positively influenced students’ learning in nursing homes.
The findings have indicated that first-year students had both positive and less positive experiences with attending a one-week inspiration practice at nursing homes. The challenges with inspiration practice were related to situation-related learning transfer factors, such as clinical field not providing enough placements; therefore, the third-year students had to improvise and be creative. However, despite some challenges, mentorship during the one-week inspiration practice offered significant advantages to both mentors and mentees. To fully harness these advantages, we recommend that first-year educational programmes implement person-centred care for older people into the educational curriculum. This should include a one-week compulsory inspiration practice placement in settings exclusive to older people, such as nursing homes. Moreover, peer mentoring as a teaching and learning method, with themes especially designed to focus on nursing and caring for and with older people, offers first-year students insights into nurses’ roles and responsibilities at nursing homes. We believe that such a programme can prevent ‘reality shock’, reduce dropout rates, enhance academic achievements and cultivate personal and professional qualities in students at all levels of their education programmes. More research is needed to explore how peer mentoring is experienced by students enrolled at different levels of Bachelor of Nursing Education and may contribute to their preparation to care for older people in nursing homes.
The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.
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We would like to thank all the students who participated in the focus group interviews, thus contributing to data collection. We further thank the Department of Nursing and Health Promotion at Oslo Metropolitan University and the University Library for giving their approval and for supporting the publication fee of this article.
This study received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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Daniela Lillekroken, Heidi M. Kvalvaag, Katrin Lindeflaten, Tone Nygaard Flølo, Kristine Krogstad & Elisabeth Hessevaagbakke
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D.L. contributed to study conception, data collection, analysis and wrote the main manuscript text; H.K., K.L., T.N.F., K.K., & E.H. contributed to data collection and analysis. All authors reviewed the manuscript.
Correspondence to Daniela Lillekroken .
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The study was approved by the Norwegian Agency for Shared Services in Education and Research (Sikt/Ref. number 334855) and by the leader of the Department of Nursing and Health Promotion at Oslo Metropolitan University. This study does not aim to gain insights into participants’ health status, sexuality, ethnicity and political affiliation (sensitive information); therefore, the study is exempted from ethical approval from the Norwegian Regional Committees for Medical and Health Research Ethics because no health information or patient data are registered. This study was performed according to principles outlined in the Declaration of Helsinki and in accordance with Oslo Metropolitan University’s guidelines and regulations. The data were kept confidential and used only for this research purpose. To protect the anonymity of the participants, participant characteristics are not elaborated upon in the paper. The researchers provided verbal and written information about the study. Written voluntary informed consent was obtained from all participants prior to data collection.
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Lillekroken, D., Kvalvaag, H.M., Lindeflaten, K. et al. Educating the nurses of tomorrow: exploring first-year nursing students’ reflections on a one-week senior peer-mentor supervised inspiration practice in nursing homes. BMC Nurs 23 , 132 (2024). https://doi.org/10.1186/s12912-024-01768-5
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DOI : https://doi.org/10.1186/s12912-024-01768-5
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Published on 16.2.2024 in Vol 12 (2024)
“Internet+Nursing Service” Mobile Apps in China App Stores: Functionality and Quality Assessment Study
Authors of this article:
- Shuo Yuan 1, 2, * , MSN ;
- Min Liu 1, * , MSN ;
- Yuqi Peng 1 , MSN ;
- Jinrui Hu 1 , MSN ;
- Bingyan Li 1 , MSN ;
- Xia Ding 3 , BPS ;
- Lunfang Xie 1 , PhD
1 School of Nursing, Anhui Medical University, , Hefei, , China
2 Department of Cardiology II, Anhui No.2 Provincial People’s Hospital, , Hefei, , China
3 Nursing Department, Anhui No.2 Provincial People’s Hospital, , Hefei, , China
*these authors contributed equally
Lunfang Xie, PhD
Background: As the Chinese society ages and the concern for health and quality of life grows, the demand for care services in China is increasing. The widespread use of internet technology has greatly improved the convenience and efficiency of web-based services. As a result, the Chinese government has been implementing “Internet+Nursing Services” since 2019, with mobile apps being the primary tools for users to access these services. The quality of these apps is closely related to user experience and the smooth use of services.
Objective: This study aims to evaluate the functionality, services, and quality of “Internet+Nursing Service” apps; identify weaknesses; and provide suggestions for improving service programs and the research, development, improvement, and maintenance of similar apps.
Methods: In December 2022, two researchers searched for “Internet+Nursing Service” apps by applying the search criteria on the Kuchuan mobile app monitoring platform. After identifying the apps to be included based on ranking criteria, they collected information such as the app developer, app size, version number, number of downloads, user ratings, and number and names of services. Afterward, 5 trained researchers independently evaluated the quality of the apps by using the Chinese version of the user version of the Mobile App Rating Scale (uMARS-C). The total uMARS-C score was based on the average of the five evaluators’ ratings.
Results: A total of 17 “Internet+Nursing Service” apps were included. Among these, 12 (71%) had been downloaded more than 10,000 times, 11 (65%) had user ratings of 4 or higher, the median app size was 62.67 (range 22.71‐103; IQR 37.51-73.47) MB, 16 (94%) apps provided surgical wound dressing change services, 4 (24%) covered first-tier cities, and only 1 (6%) covered fourth-tier cities. The median total uMARS-C score was 3.88 (range 1.92-4.92; IQR 3.71-4.05), which did not correlate with app store user ratings ( r =0.003; P =.99). The quality of most apps (11/17, 65%) was average. Most apps (12/17, 71%) were rated as “good” or above (≥4 points) in terms of information quality, layout, graphics, performance, and ease of use; however, the vast majority of apps were rated as “fair” or even “poor” (<4 points) in terms of credibility (14/17, 82%) and demand (16/17, 94%).
Conclusions: “Internet+Nursing Service” apps need to broaden their service coverage, increase service variety, and further optimize their service structure. The overall quality of these apps is generally poor. App developers should collaborate with medical professionals and communicate with target users before launching their products to ensure accurate content, complete functionality, and good operation that meets user needs.
People are increasingly inclined to use health care apps to manage their health due to these apps’ cost-effectiveness, convenience, and speed in accessing health information [ 3 - 5 ] and ability to provide evidence-based health information for better health guidance [ 6 ]. There are several popular health care apps in China. According to a report on Statista, as of December 2022, the most popular medical app in China was Ping An Good Doctor—a health care platform owned by the Ping An Insurance Group—with almost 23 million monthly active users [ 7 ]. The mobile portal provides real-time medical consultations, web-based appointment booking services, and a health-related discussion forum.
As people become more health conscious, the demand for health care services is increasing. To alleviate the pressure on offline medical institutions and meet the needs of the public, China launched “Internet+Nursing Services” [ 8 ]. These services are provided by registered nurses from fixed medical institutions and operate on a web-based app and offline service model. They are designed to serve discharged patients or special populations with medical conditions and limited mobility [ 9 ]. Since 2019, “Internet+Nursing Service” organizations in China’s provinces and regions have been actively providing services to countless older adults living at home, pregnant women, infants, and young children who have difficulty with leaving their homes. These services have received unanimous positive reviews [ 10 , 11 ]. The “Internet+Nursing Service” model integrates nursing services with internet technology, using internet IT to break the spatial limitations of traditional medical treatment. It can meet the multilevel nursing care needs of service users, allow for personalized and continuous care, alleviate social problems that result in difficulties with visiting a physician, improve the quality of life of service users, and broaden the channels of communication between nurses and patients [ 12 ].
Patients place orders through an app, and managers dispatch orders based on various factors, such as web-based nurses’ qualifications, professionalism, and distance. Platform nurses receive orders within a specified period of time and travel to patients’ homes to provide services, including routine nursing operations (eg, intramuscular injections, intravenous injections, urinary catheterization, gastric tube insertion, and blood sample collection), as well as specialty care (eg, peripherally inserted central venous catheter medication exchange, wound stoma care, and neonatal examinations). By downloading high-quality “Internet+Nursing Service” mobile apps, users can quickly access the care services they need without leaving their homes. However, low-quality apps may not only affect the user experience but also make it impossible for users to obtain the care services they need.
As people become increasingly dependent on smartphones and apps, they are also becoming more concerned about the quality of apps. Users not only expect apps to function properly but also have high expectations for their aesthetics, security, and personalization settings [ 13 ]. App quality issues can affect the user experience, determine whether users continue to use the app, and even lead to economic and property losses for both the users and the app development departments. mHealth apps are a special type of app, and studies have shown that factors such as usability, navigability, accuracy of information, and security all affect the user’s experience with and evaluation of an mHealth app. If an mHealth app is of low quality, users may doubt its usefulness and effectiveness, which can even lead to users obtaining low-quality health services and generating erroneous health management concepts that affect their health beliefs and behaviors [ 6 , 14 , 15 ].
In recent years, various software development organizations have been paying more attention to improving app quality, but there are still deficiencies [ 16 ]. The quality of an app is mainly judged by checking user ratings and reviews on app stores. However, the actual quality of an app can be unclear, and it is impossible to know whether an app’s functions are comprehensive or whether its content is scientific based on the data displayed on app store pages. Therefore, it is necessary to objectively evaluate the quality of medical and health apps to identify shortcomings in their development; promote their continuous improvement; improve their applicability, usage experience, and compliance (eg, compliance with data protection laws); and allow users to use apps that are of high quality, are reasonably designed, and are safe to use. There are various methods for evaluating the quality of medical apps, which are also known as mHealth apps . According to a study by Stoyanov et al [ 17 ], the quality of mHealth apps is evaluated based on different categories, including engagement, functionality, aesthetics, information quality, and subjective quality [ 18 ]. There are various methods for evaluating mHealth services, such as the use of questionnaires, the conduction of interviews, and observation [ 18 ]. A systematic review by Nouri et al [ 19 ] identified the following seven main classes of assessment criteria for mHealth apps: design, information and content, usability, functionality, ethical issues, security and privacy, and user-perceived value. These criteria can be used to assess the quality of a medical app.
Most studies on “Internet+Nursing Services” focus on service effects [ 20 - 22 ], the establishment of service quality index systems [ 23 ], risk management strategies [ 24 , 25 ], and the demand for services from various groups [ 26 - 28 ]. However, there is little attention paid to the quality of “Internet+Nursing Service” apps and a lack of studies that use evaluation tools to objectively evaluate these apps’ quality and functions. The aim of this study was to review the “Internet+Nursing Service” mobile apps that are available on China’s app stores and evaluate their quality.
Selection of the “Internet+Nursing Service” Apps
We used the Kuchuan mobile app monitoring platform (Beijing Kuchuan Technology Co.) to monitor data from the iOS and Android app stores. This platform provides real-time information about mobile app developers, the latest versions of apps, and the number of app downloads. Two researchers searched for apps that were available as of December 1, 2022, using the keywords “Internet+Nursing Service,” “Home Nursing,” “Nurses at Home,” “online nurse,” and “shared nurse.”
The inclusion criteria for the apps were (1) apps with content that includes home nursing services, (2) apps categorized as health care apps, (3) apps in Chinese, (4) free apps, and (5) functional apps. The exclusion criteria were (1) non–user-side apps, (2) old versions of the same app, (3) apps with different names but the same content, and (4) duplicate apps.
Two researchers independently screened the apps based on their names, profiles, and display images. They then discussed their findings to finalize the list of evaluated apps ( Figure 1 ).
Selection of a Standardized Rating Scale for Mobile Apps
We used the Chinese version of the user version of the Mobile App Rating Scale (uMARS-C), and we obtained authorization from the authors of the uMARS-C [ 29 ]. Adapted from the Mobile App Rating Scale (MARS), the user version of the MARS (uMARS) has been used for assessing a wide variety of apps, including apps for mental health [ 30 ], rheumatology patient management [ 31 ], cancer risk assessment [ 32 ], and hospital registration [ 33 ]. The uMARS-C includes 14 objective items that are rated on a 5-point Likert scale and divided into the following three dimensions: engagement, functionality, and information. Dimension scores are calculated by dividing the total entry score by the number of entries, and the uMARS-C total score is calculated by dividing the total dimension score by the number of dimensions. According to the rating scale, a uMARS-C total score of 1 indicates poor quality, a score of 2 indicates inadequate quality, a score of 3 indicates fair quality, a score of 4 indicates good quality, and a score of 5 indicates excellent quality.
The uMARS-C has good reliability and validity, with a Cronbach α coefficient of 0.890 and dimension Cronbach α coefficients ranging from 0.853 to 0.895. The test-retest reliability value is 0.967, the item content validity index ranges from 0.78 to 1.00, and the scale content validity index/average is 0.969.
Process of Evaluating “Internet+Nursing Service” Apps
A total of 5 researchers—2 nurses with more than 5 years of experience in their roles, 2 graduate nursing students, and 1 professional internet engineer with more than 7 years of experience in their role—assessed the quality of the apps. Before the evaluation, we made sure that each researcher properly understood and was familiar with the uMARS-C. To ensure their understanding of the scale, they downloaded and assessed 2 mHealth apps that were not included in this study. When there was a difference of more than 2 points in dimension scores or total scores, they discussed until reaching a consensus. The researchers then downloaded the apps that were included in the final analysis onto iOS and Android smartphones. After downloading the apps, they used each app for at least 10 minutes and independently evaluated the ease of use, performance, security, and settings of each app, using the uMARS-C. Basic app information was collected from the app store download page, including the app developer, app size (in MB), version number, number of downloads, user ratings (ranging from 0 to 5), and number and names of services, among others. Some app download data were missing because the iOS app store did not provide these data. The researchers also graded the service coverage cities based on the categorized statistical service items in the Beijing Internet Home Care Service Item Catalog (2022 edition) [ 34 ] and the city class divisions in the 2022 China’s City Business Attractiveness Ranking [ 35 ].
We used EpiData 3.1 (EpiData Association) for data entry and SPSS 24.0 (IBM Corp) for statistical analysis. Nonnormally distributed measurement data were expressed as medians and quartiles, while count data were expressed as numbers and percentages. The uMARS-C dimension scores for each app were averaged across the five raters, and the final scores were calculated by using the scale’s formula.
This study did not involve human subjects, clinical trials, and vulnerable groups and was therefore exempt from ethical approval.
Characteristics of Selected Apps
Our search found a total of 39,982 apps (iOS: n=209; Android: n=39,773). After initial screening based on the inclusion and exclusion criteria, we downloaded 26 apps. After using them, we excluded 8 apps that were not working properly, leaving a total of 17 apps, which were included in this study ( Table 1 and Multimedia Appendix 1 ). Of these 17 apps, 4 (24%) were released by medical institutions and 13 (76%) were released by corporations ( Table 1 ). Further, 12 (71%) apps had been downloaded more than 10,000 times, with Champion Nurse having the highest number of downloads (n=37,321,776). The median app size was 62.67 (range 22.71-103; IQR 37.51-73.47) MB. App store user ratings ranged from 2.8 to 5.0, with 14 (82%) apps being rated 3.0 or higher and 11 (65%) apps being rated 4.0 or higher. In terms of service coverage, 4 (24%) of the “Internet+Nursing Service” apps covered first-tier cities, including Beijing; 8 (47%) covered new first-tier cities; 4 (24%) covered second-tier cities; and 1 (6%) covered fourth-tier cities.
a Download count for Android apps only.
Categories of Nursing Services Provided by Apps
The 17 apps provided at-home nursing services, including intravenous injection, intramuscular injection, and nebulized inhalation services, among others. These services were classified as Health Assessment and Guidance , Clinical Nursing , Maternal and Infant Nursing , TCM (traditional Chinese medicine) Nursing , Specialty Nursing , Hospice , and Rehabilitation Nursing services per the categories in the Beijing Internet Home Care Service Item Catalog [ 34 ]. Any services that were not in the catalog were classified as uncategorized items .
Of the 17 apps, 16 (94%) provided surgical wound dressing change services ( Clinical Nursing category), 15 (88%) provided services for the maintenance of peripherally inserted central catheters ( Specialty Nursing category), 14 (82%) provided maternal and infant nursing services ( Maternal and Infant Nursing category), and 10 (59%) provided TCM nursing services ( TCM Nursing category) and disease rehabilitation guidance ( Rehabilitation Nursing category). Further, 4 (24%) apps provided hospice care services ( Hospice category), 3 (18%) provided health assessments and guidance ( Health Assessment and Guidance category), and only 1 (6%) app provided gastrointestinal decompression, previsit physical examination, conjunctival capsule irrigation, T-tube drainage care, and family room services (uncategorized items).
Quality of the “Internet+Nursing Service” Apps
In our study, the Cronbach α coefficient of the uMARS-C was 0.871, and the dimension Cronbach α coefficients ranged from 0.761 to 0.811. Based on the uMARS-C scores, of the 17 apps, 1 (6%) was rated as “poor,” 11 (65%) were rated as “fair,” 5 (29%) were rated as “good,” and none were rated as “insufficient” or “excellent.” The median total score for the “Internet+Nursing Service” apps was 3.88 (range 1.92-4.92; IQR 3.71-4.05; Figure 2 ), with Champion Nurse having the highest score (4.92) and Health WuHan having the lowest score (1.92). There was no significant correlation between app store user ratings and total uMARS-C scores ( r =0.003; P =.99). The median information dimension score was 3.97 (range 1.86-5.00; IQR 3.57-4.29), the median functionality dimension score was 3.95 (range 1.25-5.00; IQR 3.25-4.50), and the median engagement dimension score was 3.80 (range 1.00-5.00; IQR 3.33-4.33; Figure 3 ). A heat map comparing the scores of each entry in the uMARS-C for the 17 “Internet+Nursing Service” apps showed that Health WuHan scored below 3 points in most entries (11/14, 79%; Multimedia Appendix 2 ). Further, 14 (82%) apps scored below 4.0 points in the Credibility entry, indicating an average or poor level; 16 (94%) scored below 4.0 points in the Demand entry; 14 (82%) scored at a good or above level in the Quality of Information entry; and 12 (71%) scored at a good or above level in the Layout , Graphics , Performance , and Ease of Use entries.
As internet technology continues to develop, all industries are integrating the “Internet+” model to promote innovation and development [ 1 ]. However, unlike services in other industries, “Internet+Nursing Services,” as web-based health care services, are characterized by the high risks and high professionalism of the medical industry, as well as the special risks associated with mHealth [ 25 ].
There are several risks associated with “Internet+Nursing Service” apps. One of the risks is that technology barriers can prevent some patients from accessing telehealth services. These barriers can include a lack of access to the internet, a lack of access to the necessary devices, or difficulty with using the technology. Another risk is that there may be issues with insurance coverage for telehealth services, as well as regulatory obstacles that can limit the use of telehealth [ 36 ]. Therefore, it is necessary to strengthen the supervision of “Internet+Nursing Service” apps and strictly control all aspects. “Internet+Nursing Services” are human-centered services and aim to improve health. Therefore, “Internet+Nursing Service” app design should fully consider user characteristics and needs. In this study, we downloaded and used “Internet+Nursing Service” apps, evaluated them from a user perspective, and rated them objectively based on our usage experience.
Most apps (16/17, 94%) provided services in first-tier cities, new first-tier cities, or second-tier cities, with only 1 app providing “Internet+Nursing Services” in a fourth-tier city. The “Internet+Nursing Service” scope does not yet cover remote areas and townships. Data from China’s seventh national census show that the rural population consists of about 509.79 million people, accounting for 36.11% of the total population [ 37 ]. However, 80% of medical resources are concentrated in medium- and large-sized medical institutions in medium- and large-sized cities, leading to an imbalance between the demand for care and the supply of care resources for the grassroots population [ 38 ].
Providing high-quality nursing resources and services is key to improving the health and quality of life of people at the grassroots level. Medical institutions at all levels should actively promote the distribution of medical resources to enhance access to basic medical and public health services. Therefore, “Internet+Nursing Service” apps should integrate medical resources and promote a 3-tier “hospital-community-family” linkage to bring professional nursing services into the homes of grassroots people. This would encourage more medical institutions to provide home care, expand the scope of services, make full use of medical resources, and address the imbalance between the supply of and demand for medical resources.
Our study found that “Internet+Nursing Service” apps provide a limited number of service programs—mostly routine care programs—with few special care programs, such as psychological care, hospice care, and child care programs. Only 4 of the 17 apps provided hospice care services, and none provided psychological care services, despite the high demand for these programs. In one study, it was found that 92.3% of the older adult population in urban and rural areas needed psychological comfort [ 39 ], and in another study, 10.32% of housebound older adults believed that hospice care should be carried out [ 40 ]. Further, as the concept of childbearing changes, people are pursuing more scientific and specialized childcare, and child health care and nursing have become more emphasized. Research has shown that providing nutritional guidance, growth and development guidance, and child psychological care to families of preterm infants through “Internet+Nursing Service” platforms could promote the growth and intellectual development of preterm infants [ 41 ]. Medical institutions in each region should have an in-depth understanding of the needs of service users and the characteristics of different groups of people. They should gradually expand the list of “Internet+Nursing Services” by taking into account the actual situations of medical institutions and the local medical resources to optimize the structure of service items and meet the needs of service users.
The total quality scores of the 17 apps ranged from 1.92 to 4.92, with 1 (6%) app rated as “poor” and 11 (65%) rated as “fair,” indicating that the overall quality of “Internet+Nursing Service” apps was not good. This may be related to the fact that app development engineers do not fully understand the medical industry. Most “Internet+Nursing Service” apps (9/17, 53%) were developed by corporations, and the developers may not have taken into account the specificity of medical software before development. They also may not have communicated well with medical staff during app development or understood the content and characteristics of “Internet+Nursing Service” apps.
The process of target user evaluation not only strengthens the interactions between users and the software but also identifies weak points (ie, from user feedback) that developers may have missed [ 42 ]. Our researchers found that some apps had problems, such as crashes and the inability to log in during use, which affected the user experience. Therefore, research and development organizations need to conduct premarket research and postmaintenance work to ensure the smooth operation of platforms.
From the heat map ( Multimedia Appendix 2 ), it can be seen that most apps (12/17, 71%) scored at a good or above level in terms of the Layout , Graphics , Performance , and Ease of Use entries. This indicates that most app development teams pay more attention to the visual effects, ease of use, and smoothness of their apps. However, of the 17 apps, 14 (82%) had average scores of less than 4.0 in the Credibility entry, and 16 (94%) had average scores of less than 4.0 in the Demand entry, indicating average or even poor performance in these areas. During the evaluation, our researchers found that some app development teams did not clearly label the source or publisher information when publishing health science articles or videos. This may cause users to doubt the authenticity, authority, and reliability of the articles when reading them, affecting their ability to build health knowledge and manage their own health [ 43 ]. It is important to publish health science articles with scientific evidence and to clarify the sources, authors, time of publication, and applicable populations of standardized content to increase the credibility of information. In terms of meeting user needs, we found that most apps provided information from health science literature in text form, with content mostly focused on introducing services, medical institutions, and health care experts. We also noted that after content was published on an app, the content was not updated for a long time. Some apps also only had 2 to 3 articles and could not meet user needs. Therefore, in addition to not meeting user needs in terms of service programs, there are also deficiencies in providing up-to-date and relevant health information.
App developers can improve the credibility of health science articles and videos by taking several steps. First, they should ensure that the information provided is based on scientific evidence and comes from reputable sources. This can be done by clearly labeling the sources, authors, time of publication, and applicable populations of the content. Second, they should regularly update the content to ensure that it is current and relevant. Third, they should provide references or links to the original sources of information, so that users can verify the accuracy of the information. By taking these steps, app developers can increase the credibility of their health science articles and videos and help users build their health knowledge and manage their own health.
Health science popularization should aim to provide basic concepts and knowledge in the field of health, with a focus on healthy lifestyles and behaviors. Health science content should be regularly updated to keep up with social hot spots, seasonal changes, and the occurrence of epidemics to provide users with the most up-to-date and relevant information. To achieve this, app development teams should conduct market research to understand the needs and characteristics of their users, including users’ cultural levels and reading habits. They should also keep track of social hot spots, seasonal changes, and other factors to provide relevant health policies, basic medical knowledge, diet and exercise guidance, psychological guidance, and knowledge regarding disease prevention or first aid in daily life. In addition to providing information in graphic form, app developers can also use video and audio formats to present health science information from multiple angles, dimensions, and levels to meet the needs of users at different levels. By providing accurate and scientific health information in a timely manner, app developers can help users improve their health knowledge and quality of life.
Our study found no correlation between uMARS-C ratings and app store ratings, suggesting that app store ratings do not reflect the quality of apps. This may have been due to the small number of app store ratings, differences in app store rating mechanisms, developer marketing strategies, or users’ preferences (eg, app favoritism among users). If the quality of apps is judged solely based on app store ratings, users may download low-quality apps, thereby affecting their usage experience and even causing them to distrust care services. Additionally, health care professionals may be unable to accurately recommend high-quality apps to patients or their families. This further demonstrates the necessity of evaluating the quality of “Internet+Nursing Service” apps by using objective rating scales.
This study has several limitations. First, we only searched for “Internet+Nursing Service” apps that were updated until December 1, 2022, and did not consistently track the uploads and downloads of related apps. Second, we only used iPhone, Huawei, and Xiaomi phones to download and evaluate apps and did not use other systems, such as Meizu, Samsung, and Windows phones. During app development, the development team may modify app functions for different systems due to differences in system algorithms, resulting in differences in app functions. Therefore, future research should take system differences into account and conduct more comprehensive quality evaluations of apps for different systems. Third, there were only 5 researchers in this study; all were under the age of 30 years and had a high level of e-literacy, which may have introduced bias in entries, such as the Ease of Use entry, during the evaluation process. However, older people, who are the main target of “Internet+Nursing Services,” have varying levels of e-literacy and may have different understandings and judgments of an app’s ease of use. Therefore, future studies may consider including evaluators with different backgrounds and health literacy levels.
In this study, we used the uMARS-C to evaluate the quality of “Internet+Nursing Service” apps. We found that the service coverage of these apps was concentrated in first-tier cities (eg, Beijing and Shanghai), new first-tier cities, and some second-tier cities, with a limited number of service items and a need to optimize the structure of service items. The quality evaluation results showed that the quality of apps was not good, especially in terms of information credibility and meeting users’ needs. Further, the scale scores did not correlate with app store scores. Therefore, “Internet+Nursing Service” app development teams need to pay attention to improving the quality of their apps. Before releasing an “Internet+Nursing Service” app, they should fully understand the needs of their target users, as well as the characteristics of this type of app, and communicate with relevant professionals in the field. They should also orient the release of health knowledge in the app toward user needs and improve the credibility and readability of content. After releasing an app, it is necessary to maintain and update it to ensure its normal operation and the timely updating of health education content.
We would like to thank three other researchers (Guanghan Zhang, Ying Liu, and Liping Fan) for their participation. This work was supported by the Key Project of Natural Science Research in Colleges and Universities of Anhui Province (grant KJ2021A0255).
Conflicts of Interest
Details of the 17 “Internet+Nursing Service” apps.
Heat map of the average scores for each item and app. The colors range from blue (worst score) to white (best score).
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Edited by Lorraine Buis; submitted 28.08.23; peer-reviewed by Eveline Prochaska, Florence Carrouel; final revised version received 07.01.24; accepted 11.01.24; published 16.02.24.
© Shuo Yuan, Min Liu, Yuqi Peng, Jinrui Hu, Bingyan Li, Xia Ding, Lunfang Xie. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 16.2.2024.
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